Rosemarie Gearhart
It's one of the most charged decisions a woman faces in childbirth: Whether to have a pain-relieving epidural or to try to hold off and have a drug-free birth. Many proponents of natural childbirth paint the epidural option as a choice with many negative consequences, including slowing down labour and separating a woman from the experience.
But a new study out of Australia has found that an epidural may play a positive role in women's health long after the baby is delivered by reducing damage to the pelvic floor muscles.
Australian researchers used two sets of ultrasonic imaging on a group of almost 500 women undergoing their first pregnancy and planning vaginal birth - one taken during pregnancy and one three to four months after childbirth.
Because damage to a woman's pelvic floor muscles during childbirth is known to be a risk factor for future health problems including collapse of the pelvic organs (pelvic organ prolapse) and incontinence, the researchers wanted to see whether style of birth played a role.
Of the 488 women in the study, published last week in the British Journal of Obstetrics and Gynaecology, about 13 per cent experienced "avulsion," or tearing, of their "levator," or pelvic floor muscles. Women who had had an epidural had a lower incidence of tearing. A forceps delivery was associated with the greatest risk of injury. (Not surprisingly, the women who had undergone a caesarian section had no pelvic floor injuries.)
Co-author Clara Shek of the Nepean Clinical School of medicine at the University of Sydney suggested the epidural may prevent premature pushing, which is known to cause damage. Another potential explanation may be that the muscles are simply relaxed and less likely to suffer trauma.
The study results may be heartening news for those who have had or are considering an epidural, which is a local anesthetic delivered by an injection into the lower back.
Canadian parenting blogger Catherine Connors is unabashedly pro-epidural after experiencing her second labour without one. "Having done it both ways, there's no reason to go through that kind of pain," she says. "If I'd known that epidurals might have such a preventative effect I wouldn't even have considered going without."
And she might have discussed the issue with her doctor before the birth of her second, a birth which resulted in muscle tearing and a nearly two-year recovery.
"Not only has recovery been a nightmare, I live in fear of incontinence or uterine prolapse," says Ms. Connors, who has used graphic humour to deal with her experience on her blog, Her Bad Mother.
Ottawa obstetrician Vyta Senikas says it's rare for epidurals to be discussed as having any benefits other than pain relief. Dr. Senikas, associate executive vice-president of the Society of Obstetricians and Gynaecologists of Canada, says that while this study in particular will have no immediate effect on childbirth practices it could add to the various factors obstetricians weigh in giving advice to their patients.
In some cases, reducing pain allows the body to proceed with childbirth.
"There are certain women for whom the pain is so great that they tense themselves up and when they get the epidural and totally relax and go to full dilation in no time."
At the end of the day, there is a balancing act, risks to benefits, she says. And the pelvic floor is the big concern after childbirth. Women can begin to face incontinence problems quite young, in their 40s. "These can be humiliating issues to be faced with."
And, she says, obstetricians are trying to address some of the past criticisms of epidurals. The majority of studies that have shown negative effects, such as an increased likelihood of a vacuum or forceps intervention, refer to older, stronger epidural formulations.
Newer "walking epidurals" allow women to still have sensation in their lower body. Obstetricians are now cognizant that it's not a good idea to give an epidural too early because it can affect the urge to push; it's better to wait until a woman has the urge to push to both save her energy and reduce the risk of injury. The presence of an additional care provider, a partner, a doula or a coach also helps tremendously, she says.
Some observers suggest that it may not be the epidural per se that helped the women in the Australian study, but pain control in general.
"I think you could substitute 'adequate pain control' for 'epidural,' " says Mark Sloan a pediatrician and author of Birth Day: A Pediatrician Explores the Science, the History and the Wonder of Childbirth. "A fairer study would be epidural versus adequately managed pain other ways."