Pain Relief in Childbirth: Women Have Choices

A top pain-relief specialist at Yale Medicine busts the myths around epidural anesthesia.

Options availabe

Ferne Braveman, MD, explains the options available for women for anesthesia during childbirth.

Credit: Robert A. Lisak

5 quick facts about epidurals
  • An epidural allows pain-blocking medication to be delivered to a woman in labor via a catheter inserted in the lower back.
  • An estimated 60 percent of American women choose an epidural for pain relief during childbirth.
  • With a low dose epidural, women can still get up and walk around during labor.
  • Yale Medicine is the only facility in the state to offer around-the-clock obstetrical anesthesia service supervised by anesthesiologists with advanced training in obstetrical care.
  • An epidural delivers less medication into the patient’s bloodstream than intravenous medications or nitrous oxide, and very little of it reaches the baby.

When it comes to childbirth, many women understandably worry about pain. Some have heard frightening accounts from friends and family members of deliveries that, with each retelling, seem to lengthen by hours. Others have phobias about needles and are anxious about receiving an epidural, yet have qualms about going through labor without one.

Ferne Braveman, MD, division chief of anesthesiology at Yale Medicine and professor of anesthesiology and of obstetrics, gynecology and reproductive sciences, is familiar with those concerns.

“I always tell women to not listen to their mother or sister or friend,” she says. “No one ever tells you about their wonderful birthing experience.”

Dr. Braveman says her job is to make sure women—who today are more informed and empowered when it comes to deciding what works best for them—understand their options, including those that do not involve medications. More often than not, epidural pain relief is part of their childbirth experience.

To explore the options for anesthesia in childbirth, click here.

What is an epidural, anyway?

About 60 percent of American women receive an epidural for pain relief during childbirth. During the procedure, an anesthesiologist inserts a needle and a tiny catheter into a woman’s lower back. The catheter delivers pain-blocking medication. Women begin to feel relief “within four contractions, or 10 to 12 minutes, with peak effect after 15 minutes,” Dr. Braveman says.

The epidural infusion contains an anesthetic and a narcotic. These block pain signals in the lower part of the body. With a low dose, women can get up and walk around.

Another approach is a two-step procedure called a walking epidural. The epidural needle is placed in the same fashion as with a traditional epidural. Then the spinal needle for the walking epidural is advanced into the fluid surrounding the spinal cord and a small dose of medication is administered. The spinal needle is removed and the epidural catheter is placed in the epidural space, as with a traditional epidural. This approach delivers pain relief “almost instantaneously,” Dr. Braveman says.

At Yale Medicine, anesthesiologists with advanced training in obstetrical care supervise the obstetrical anesthesia service. “We do the most high-risk deliveries in the state,” Dr. Braveman says. “It doesn’t mean you can’t get good care elsewhere, especially if you are young and healthy. But we have a dedicated team and any wait for our care, once we are consulted, is minimal.”

Teamwork

Lori Vogt, RN, (left to right) Paula Trigo Blanco, RN, and Ferne Braveman, MD, work as a team to recommend pain-relief options to women in labor.

For high-risk deliveries, Dr. Braveman or one of her team members meets with patients before childbirth. “We come up with a plan and discuss it with the obstetrical team so that we are all on the same page when the woman comes into the hospital,” she says.

Obesity is a common risk factor that poses a number of health risks for pregnant women. Women who are obese “are more likely to need a C-section,” Dr. Braveman says. “They are more likely to have high blood pressure, diabetes and other medical problems that can complicate their pregnancy and delivery.”

Another risk factor can be the mother’s age. “Women are waiting longer and longer to have children,” Dr. Braveman says. “If you are healthy and 40, you will do just fine, but we do see more medical issues as people age.”

Epidural myths, and the truth

Whether or not the delivery is high risk, epidurals remain a source of concern for many pregnant women. This is understandable, given the importance of any medical decision associated with labor and childbirth.
In meeting with expectant mothers, Dr. Braveman says she frequently encounters a number of myths, including the widespread (but misguided) belief that an epidural can cause paralysis. She assures women that will not happen, and that the biggest complication might be a headache. “And if they do get a headache, we can treat it and manage it,” she says.

Here are some key facts about epidurals:

Epidurals are not harmful to babies

One widespread belief is that the epidural contains medicine that is a risk to the baby’s health. That is not true. An epidural actually delivers less medication into a laboring woman's bloodstream than intravenous medications or nitrous oxide, and very little of it reaches the baby, says Dr. Braveman.

“We give women a very low dose and we do it right at the nerve, which is best to control the pain coming from the uterus,” she says. “Plus, we monitor the mother’s blood pressure and the baby very closely.”

An epidural will not make labor last longer

Another common myth is that an epidural will greatly increase the labor time because it makes women feel numb and therefore unable to recognize the need to push.

An epidural does increase labor time by about eight minutes, on average. But Dr. Braveman says that is a marginal amount, “especially if you are talking over the course of eight hours.” Today’s epidurals, she says, use a very diluted analgesic combination of a local anesthetic and low-dose narcotic.

“Women can move, feel pressure, push, urinate,” says Dr. Braveman, adding that she is speaking of her own experience and observation rather than from evidence-based research. “The small increase in time from fully dilated to delivery of baby is likely due to a delay in starting active pushing. Unmedicated patients have an incredible urge to push. The urge is less intense if the patient has some analgesia.”

An epidural will not raise your risk of needing a cesarean section

Along with the belief that an epidural increases the amount of time it takes to deliver a baby, many women wrongly believe that having an epidural makes them more likely to have a cesarean section.

That is not true, Dr. Braveman says. “Poorly designed retrospective studies in the past suggested a large number of patients going to cesarean sections had had epidurals, but well-designed studies did not support this,” she says.

An epidural is not your only option for pain relief

Plenty of choices

Nurse Angelique Garay prepares for another delivery in the anesthesia workroom.

An epidural is not for everyone and is not the only choice when it comes to relieving pain, Dr. Braveman says. Many women find it relieves discomfort to sit on a birthing ball, or take a dip in a bathtub, or practice breathing and relaxation exercises they learned in childbirth classes.

Nitrous oxide, commonly known as laughing gas, is another option for pain relief in labor, one many people are not aware of. It fell out of fashion as a childbirth aid years ago for various reasons, including environmental concerns.

“But now they have developed a delivery system where the patient breathes back into the machine,” Dr. Braveman says. She says nitrous oxide can serve as a bridge to an epidural for women who don’t want one early in labor. And for a woman delivering her second or third baby, nitrous oxide might be all that she needs.

Women giving birth for the first time (68.1 percent) are more likely to receive regional anesthesia than those delivering subsequent children (57.3 percent), according to the Centers for Disease Control and Prevention.

The priority: Healthy baby, healthy mom

As much as women need to be prepared for childbirth and have choices, Dr. Braveman says she often reminds them that the outcome—a healthy baby and healthy mother—matters most.

“From the day you get pregnant to years later, nothing goes according to plan with parenting,” she says, “and the message we want to give everyone is that knowledge is power. You will have choices, but at some point during your labor, there may come a time when you have to trust your provider to do what is best.”

At Yale Medicine, Dr. Braveman says, the focus is on the patient. “That is reflected in our amazing team of doctors, nurses and anesthesiologists who work to make the healthy outcome happen,” she says.