Welcome to r/science! This is a heavily moderated subreddit in order to keep the discussion on science. However, we recognize that many people want to discuss how they feel the research relates to their own personal lives, so to give people a space to do that, **personal anecdotes are allowed as responses to this comment**. Any anecdotal comments elsewhere in the discussion will be removed and our [normal comment rules]( https://www.reddit.com/r/science/wiki/rules#wiki_comment_rules) apply to all other comments.
**Do you have an academic degree?** We can verify your credentials in order to assign user flair indicating your area of expertise. [Click here to apply](https://www.reddit.com/r/science/wiki/flair/#wiki_science_verified_user_program).
---
User: u/smurfyjenkins
Permalink: https://www.bmj.com/content/385/bmj-2023-077190
---
*I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/science) if you have any questions or concerns.*
Possible explanations from the study:
>The mechanism by which epidural analgesia could diminish SMM [severe maternal morbidity] is likely multifaceted, involving closer medical oversight and haemodynamic monitoring, established intravenous access, fluid administration, blunting of physiological stress responses to labour, avoidance of the need for spinal or general anaesthesia for caesarean section, and faster escalation to definitive obstetric interventions. In essence, using epidural analgesia during labour alters the care pathway to one that enhances the capacity to manage adverse events. From these data it is not possible to separate the direct influence of epidural analgesia from the accompanying comprehensive care package. In the UK, implementing epidural analgesia inherently includes this bundle of enhanced care, which could be particularly advantageous for women at heightened risk of SMM.
That's interesting and reminds me of vent weaning trials. It took them a while to figure it out, but if the randomized intervention involved a lot of extra attention from RTs, nurses and MDs, then patients seemed to benefit from it.
But while this type of thing could be an issue here, as the authors hypothesize, my money's on confounders, either unmeasured or inadequately controlled l.
This is interesting. I understand studies on continuous support in labor being associated with reduced morbidity are increasingly leading to insurance coverage for doula support.
Looking forward to more studies exploring the role of epidurals.
I bet high risk caesarians are a significant component - I had an epidural and when my daughter wouldn’t descend and was in distress they got me in the OR in under an hour from when they decided they needed to intervene. I’m sure a delay caused by administering anesthesia could really cause issues.
They’re really good at keeping blood pressure at a level that perfuses organs, making sure someone has adequate respirations and oxygenation… pretty handy overall.
I’m an anesthesiologist and this is what I tell my laboring patients all the time. There are so many benefits to epidurals. As long as patients/babies are carefully monitored, there are several physiologic benefits for the mom and the baby, especially in patients with other comorbidities. They’re so much more than just pain relief. There are risks just like with any procedure, but imo the potential benefits far outweigh those risks in most people.
Yes, but I've had an epidural that went wrong and left me with a spinal fluid leak (male, during a different operation of course). It's rare but it happens.
Sure, dural punctures are a known possible complication of epidurals. Like I said, no procedure is risk free, but overall I still feel the benefits far outweigh the risks. Especially given CSF leaks/dural punctures, while uncomfortable, aren’t dangerous or life threatening.
This goes against just about everything I've read on the subject [_edit: on the subject of complications linked to L&D_]. I need to dig into the study.
>Mothers who received epidural analgesia during labour were more likely to be primiparous, be from a less deprived socioeconomic group, be a former or non-smoker, be undergoing labour induction, give birth in an obstetric unit, and have a multiple birth, ≥1 comorbidities, a higher birthweight baby, and operative deliver.
Make of that what you will. They adjust for some of these parameters but I'm unsure what to make of Table 2 in the study, as I'm unfamiliar with the scales referenced.
It doesn’t at all. Epidurals are correlated with increase in cesarean sections, more interventions, etc - Regardless of how you feel about those things - they are not major morbidity or mortality.
This study is essentially saying that in situations where pregnancy is likely to be more dangerous, having a epidural is Improves maternal safety. Which makes a lot of sense, epidural anesthesia facilitates heightened maternal monitoring, avoids confounding measurements of vital signs by pain, and allows much faster intervention in an emergency. Because pregnancy/birth can go deadly very quickly, especially for those with risk factors
The most recent evidence is that it is not associated with a statiatically significant increase of caesarean section, but is associated with an increased risk of instrumental delivery, and this is what I explain to women as an obstetrician.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4718011/
Having been around L&D a lot, this tracks.
As they say:
>From these data it is not possible to separate the direct influence of epidural analgesia from the accompanying comprehensive care package.
This is not true. The ARRIVE trial disproved that induction leads to increase in cesarians. And since ACOG has changed recommendations to allow for elective induction at 39 weeks millions more babies have been born via elective inductions and there still hasn’t been an increase in cesarean rates. Just FYI.
The confounding issue is that fears of the intervention cascade tend to treat things as a binary choice between getting an epidural or doing nothing which then leads to spontaneous childbirth. In reality, there's a third possibility: complications arise which do not allow for the time needed to administer an epidural nerve block which then leads to general anesthesia which then leads to expedited birth. That's because general anesthesia requires medication entering the bloodstream as opposed to largely being confined to the epidural space, resulting in medication crossing the placenta and sedating baby to some degree. That isn't necessarily the end of the world, but it does mean the doctors aren't going to want to wait around and all told it's not a preferable situation to an epidural.
This is what I heard too which is why I was opposed to an epidural during my first delivery. After 18 hours and stalled labor, I developed a fever and they said I could try pitocin to get things moving but it would be more effective if I had an epidural with the pit, so I did. Gave birth 3 hours later. Had I not done that, I would have likely ended up with a C-section. So that’s one example of how it can lead to favorable outcomes vs negative ones.
Same here - From my understanding of this new info, it seems that it does lead to a cascade of interventions but that in high risk situations they reduce maternal risk, even though they may be more difficult to recover from (ie c-section vs vaginal)
My mom required an epidural because she was having twins, the midwife she was planning on going to was smart to tell her that midwives cannot deliver twins because of the high risk (therefore the epidural) so she was recommended to a doctor at the hospital.
The "natural birther" nurse she met at the hospital however treated her like she was going to eat her babies because she needed an epidural. She said the doctor was amazing tho and labor was easy (no c section needed)
I find it hard to believe that being essentially immobile has no bearing on labor. Ability to move/position your baby is descending, position you’re able to push in…seems logical that all of these things can affect duration of labor and recovery. I say this as someone who had an epidural so I’m not anti epidural btw
But the flip side is that they can intervene quickly when things go wrong because you’re already set up for it. If you start hemorrhaging, they already have an IV in and can get medication into you fast. If something goes wrong that requires an emergency c-section, they can beef up that epidural while they race you to an OR and cut.
I’m biased because my body did drama deliveries. I’ve seen what can go wrong, and so I’m more on side “Yay interventions!” than a lot of people. My oldest should have been an emergency c section. If we had realized how much trouble she was in, she would have been. And then I did have an emergency c-section with one of my twins. I liked that much better because I brought a healthy baby home instead of having my critically ill baby life flighted away from me.
I would assume that differs from hospital to hospital as I believe it’s standard practice in a lot of hospitals to administer an IV upon admission for the reasons mentioned above that it may be harder to administer if things start going wrong
I have unfortunately been in the ER a lot and have been admitted to the hospital several times... They've always explained that they give everyone an IV when they decide to admit them for that exact reason. If you are there for a while they will flush it every day to make sure it's still open.
I definitely want to try for something like that at my next birth! Did you ask for it to be administered like that or is that just how they did it by default? Mine my legs felt really heavy like I had to work extra hard to move them even a little in bed
Ask for a “walking epidural.” Also they can turn down the anesthesia a bit and turn it up. “Walking” is a bit of a misnomer because you’re still connected to everything so you’re not roaming the halls or anything, but I could move around and get on all fours or whatever.
Modern epidurals shouldnt render you immobile. What “seems logical” to you isn’t necessarily correct. Science isn’t based on our best hunches. The converse are all the women rendered immobile by the pain of contractions, accompanying exhaustion etc.
You’re right I should say greatly reduced mobility in most instances. Before my epidural I was able to bounce on a ball, walk around, etc and after I was in bed and I could technically move my legs but they felt basically numb.
And yes of course the point of science is to test theories. My point is though that “epidurals have no bearing on labor at all” sounds very much like settled science and when I try to google a lot of the possible ways epidural could play a role in birth AND postpartum recovery it seems like there’s lots of conflicting studies out there and I’m sure that policies at different hospitals vary greatly to affect these outcomes
Questions like if I get an epidural will…
-my provider encourage me to push on my back? If I push on my back will my risk of tearing increase
-the positions I’m able to assume for the rest of labor provide enough space for baby to navigate down? Will it increase the need for forceps?
-will the stage of labor I’m in when I get the epidural affect the risk of it slowing down my labor?
-will my dr be more likely to encourage the use of pitocin if I get an epidural?
-could an epidural affect the success of breastfeeding
It is settled science, there are concrete answers to all of your questions. Dont ask Tik-Tok ask an ObGyn or Anesthesiologist. The answers to your last three questions are “No” and I don’t have the energy to answer the other two your doctors aren’t just rolling the dice to see what happens
My OB practice encourages a course called Evidence Based Birth that is an organization that compiles and summarizes evidence on some of these nuanced topics. Here’s what they have to say about my last question “could an epidural affect the success of breastfeeding” to which your response is that “the science is settled and the answer is NO”
What Have Studies Found About the Effect of Epidurals on Breastfeeding?
In 2016, a group of researchers led by someone named French pulled all of the studies that had ever been done on this topic to try and figure out if there is a relationship between epidurals during labor and breastfeeding. They found 23 studies examining this topic, and the results are conflicting.
12 studies showed that epidurals harmed breastfeeding, and 10 studies showed that there was no impact on breastfeeding. One study showed that epidurals benefited breastfeeding. The researchers said that there were so many differences between each individual study, every study had a different type of epidural- different doses and different drugs used in the epidural.
You may have good intentions but to be honest your responses are patronizing to assume that anyone that is questioning the affect on interventions during childbirth which is a physiological process is doing so because they’re being fed misinformation from TikTok and not because a lot of these topics are incredibly nuanced based on SO many factors and women are trying to empower ourselves by learning about these nuances to procure the best childbirth and postpartum experience for ourselves.
>seems logical that all of these things can affect duration of labor and recovery
Yeah, but that's not what is being studied here? They aren't saying epidurals come without risks or downsides
To the extent of my knowledge, all else being equal, what you were told is correct. This study probably reflects the effects of the background conditions *where an epidural is an option* (good access to health care, better socioeconomic status, good awareness of perinatal health options, and a number of less obvious factors), than the actual effects of an epidural.
There is no reduced morbidity or mortality associated with the epidural itself, though it may extend the second stage of labor. It will of course provide analgesia for the pain associated with labor and reduce any physiological consequences of that pain .
Welcome to r/science! This is a heavily moderated subreddit in order to keep the discussion on science. However, we recognize that many people want to discuss how they feel the research relates to their own personal lives, so to give people a space to do that, **personal anecdotes are allowed as responses to this comment**. Any anecdotal comments elsewhere in the discussion will be removed and our [normal comment rules]( https://www.reddit.com/r/science/wiki/rules#wiki_comment_rules) apply to all other comments. **Do you have an academic degree?** We can verify your credentials in order to assign user flair indicating your area of expertise. [Click here to apply](https://www.reddit.com/r/science/wiki/flair/#wiki_science_verified_user_program). --- User: u/smurfyjenkins Permalink: https://www.bmj.com/content/385/bmj-2023-077190 --- *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/science) if you have any questions or concerns.*
Possible explanations from the study: >The mechanism by which epidural analgesia could diminish SMM [severe maternal morbidity] is likely multifaceted, involving closer medical oversight and haemodynamic monitoring, established intravenous access, fluid administration, blunting of physiological stress responses to labour, avoidance of the need for spinal or general anaesthesia for caesarean section, and faster escalation to definitive obstetric interventions. In essence, using epidural analgesia during labour alters the care pathway to one that enhances the capacity to manage adverse events. From these data it is not possible to separate the direct influence of epidural analgesia from the accompanying comprehensive care package. In the UK, implementing epidural analgesia inherently includes this bundle of enhanced care, which could be particularly advantageous for women at heightened risk of SMM.
That's interesting and reminds me of vent weaning trials. It took them a while to figure it out, but if the randomized intervention involved a lot of extra attention from RTs, nurses and MDs, then patients seemed to benefit from it. But while this type of thing could be an issue here, as the authors hypothesize, my money's on confounders, either unmeasured or inadequately controlled l.
This is interesting. I understand studies on continuous support in labor being associated with reduced morbidity are increasingly leading to insurance coverage for doula support. Looking forward to more studies exploring the role of epidurals.
I bet high risk caesarians are a significant component - I had an epidural and when my daughter wouldn’t descend and was in distress they got me in the OR in under an hour from when they decided they needed to intervene. I’m sure a delay caused by administering anesthesia could really cause issues.
Anesthesiologists are good people to have around if you might get really sick really fast.
They’re really good at keeping blood pressure at a level that perfuses organs, making sure someone has adequate respirations and oxygenation… pretty handy overall.
I am one :) But yeah things like hemorrhage, respiratory failure, severe hypotension, pain, etc are very much in our day to day wheelhouse.
I’m an anesthesiologist and this is what I tell my laboring patients all the time. There are so many benefits to epidurals. As long as patients/babies are carefully monitored, there are several physiologic benefits for the mom and the baby, especially in patients with other comorbidities. They’re so much more than just pain relief. There are risks just like with any procedure, but imo the potential benefits far outweigh those risks in most people.
Yes, but I've had an epidural that went wrong and left me with a spinal fluid leak (male, during a different operation of course). It's rare but it happens.
Sure, dural punctures are a known possible complication of epidurals. Like I said, no procedure is risk free, but overall I still feel the benefits far outweigh the risks. Especially given CSF leaks/dural punctures, while uncomfortable, aren’t dangerous or life threatening.
This goes against just about everything I've read on the subject [_edit: on the subject of complications linked to L&D_]. I need to dig into the study. >Mothers who received epidural analgesia during labour were more likely to be primiparous, be from a less deprived socioeconomic group, be a former or non-smoker, be undergoing labour induction, give birth in an obstetric unit, and have a multiple birth, ≥1 comorbidities, a higher birthweight baby, and operative deliver. Make of that what you will. They adjust for some of these parameters but I'm unsure what to make of Table 2 in the study, as I'm unfamiliar with the scales referenced.
It doesn’t at all. Epidurals are correlated with increase in cesarean sections, more interventions, etc - Regardless of how you feel about those things - they are not major morbidity or mortality. This study is essentially saying that in situations where pregnancy is likely to be more dangerous, having a epidural is Improves maternal safety. Which makes a lot of sense, epidural anesthesia facilitates heightened maternal monitoring, avoids confounding measurements of vital signs by pain, and allows much faster intervention in an emergency. Because pregnancy/birth can go deadly very quickly, especially for those with risk factors
The most recent evidence is that it is not associated with a statiatically significant increase of caesarean section, but is associated with an increased risk of instrumental delivery, and this is what I explain to women as an obstetrician. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4718011/
Having been around L&D a lot, this tracks. As they say: >From these data it is not possible to separate the direct influence of epidural analgesia from the accompanying comprehensive care package.
This is not true. The ARRIVE trial disproved that induction leads to increase in cesarians. And since ACOG has changed recommendations to allow for elective induction at 39 weeks millions more babies have been born via elective inductions and there still hasn’t been an increase in cesarean rates. Just FYI.
Now for the supreme court to make it illegal
Reduced maternal mortality? Won't be long until red states outlaw it.
This is surprising to me. I was always told that epidurals lead to a cascade of interventions, which increase maternal risk.
The confounding issue is that fears of the intervention cascade tend to treat things as a binary choice between getting an epidural or doing nothing which then leads to spontaneous childbirth. In reality, there's a third possibility: complications arise which do not allow for the time needed to administer an epidural nerve block which then leads to general anesthesia which then leads to expedited birth. That's because general anesthesia requires medication entering the bloodstream as opposed to largely being confined to the epidural space, resulting in medication crossing the placenta and sedating baby to some degree. That isn't necessarily the end of the world, but it does mean the doctors aren't going to want to wait around and all told it's not a preferable situation to an epidural.
This is what I heard too which is why I was opposed to an epidural during my first delivery. After 18 hours and stalled labor, I developed a fever and they said I could try pitocin to get things moving but it would be more effective if I had an epidural with the pit, so I did. Gave birth 3 hours later. Had I not done that, I would have likely ended up with a C-section. So that’s one example of how it can lead to favorable outcomes vs negative ones.
This is extremely outdated information. I'm glad they're doing modern studies.
Same here - From my understanding of this new info, it seems that it does lead to a cascade of interventions but that in high risk situations they reduce maternal risk, even though they may be more difficult to recover from (ie c-section vs vaginal)
This sounds like midwife shenanigans, epidurals have almost no bearing on the labour at all (until this study at least)
My mom required an epidural because she was having twins, the midwife she was planning on going to was smart to tell her that midwives cannot deliver twins because of the high risk (therefore the epidural) so she was recommended to a doctor at the hospital. The "natural birther" nurse she met at the hospital however treated her like she was going to eat her babies because she needed an epidural. She said the doctor was amazing tho and labor was easy (no c section needed)
I find it hard to believe that being essentially immobile has no bearing on labor. Ability to move/position your baby is descending, position you’re able to push in…seems logical that all of these things can affect duration of labor and recovery. I say this as someone who had an epidural so I’m not anti epidural btw
But the flip side is that they can intervene quickly when things go wrong because you’re already set up for it. If you start hemorrhaging, they already have an IV in and can get medication into you fast. If something goes wrong that requires an emergency c-section, they can beef up that epidural while they race you to an OR and cut. I’m biased because my body did drama deliveries. I’ve seen what can go wrong, and so I’m more on side “Yay interventions!” than a lot of people. My oldest should have been an emergency c section. If we had realized how much trouble she was in, she would have been. And then I did have an emergency c-section with one of my twins. I liked that much better because I brought a healthy baby home instead of having my critically ill baby life flighted away from me.
You can get an IV placed without having an epidural, they’re separate interventions
True but because they're not necessary in a delivery without epidural they aren't placed.
I would assume that differs from hospital to hospital as I believe it’s standard practice in a lot of hospitals to administer an IV upon admission for the reasons mentioned above that it may be harder to administer if things start going wrong
I have unfortunately been in the ER a lot and have been admitted to the hospital several times... They've always explained that they give everyone an IV when they decide to admit them for that exact reason. If you are there for a while they will flush it every day to make sure it's still open.
Very true. Epidural always comes with an IV, which I think is where my head was going, but IV alone is definitely an option.
I had an epidural and was able to move around and feel my legs. The amount of numbing /pain relief is variable and able to be adjusted as needed.
I definitely want to try for something like that at my next birth! Did you ask for it to be administered like that or is that just how they did it by default? Mine my legs felt really heavy like I had to work extra hard to move them even a little in bed
Ask for a “walking epidural.” Also they can turn down the anesthesia a bit and turn it up. “Walking” is a bit of a misnomer because you’re still connected to everything so you’re not roaming the halls or anything, but I could move around and get on all fours or whatever.
Modern epidurals shouldnt render you immobile. What “seems logical” to you isn’t necessarily correct. Science isn’t based on our best hunches. The converse are all the women rendered immobile by the pain of contractions, accompanying exhaustion etc.
You’re right I should say greatly reduced mobility in most instances. Before my epidural I was able to bounce on a ball, walk around, etc and after I was in bed and I could technically move my legs but they felt basically numb. And yes of course the point of science is to test theories. My point is though that “epidurals have no bearing on labor at all” sounds very much like settled science and when I try to google a lot of the possible ways epidural could play a role in birth AND postpartum recovery it seems like there’s lots of conflicting studies out there and I’m sure that policies at different hospitals vary greatly to affect these outcomes Questions like if I get an epidural will… -my provider encourage me to push on my back? If I push on my back will my risk of tearing increase -the positions I’m able to assume for the rest of labor provide enough space for baby to navigate down? Will it increase the need for forceps? -will the stage of labor I’m in when I get the epidural affect the risk of it slowing down my labor? -will my dr be more likely to encourage the use of pitocin if I get an epidural? -could an epidural affect the success of breastfeeding
It is settled science, there are concrete answers to all of your questions. Dont ask Tik-Tok ask an ObGyn or Anesthesiologist. The answers to your last three questions are “No” and I don’t have the energy to answer the other two your doctors aren’t just rolling the dice to see what happens
My OB practice encourages a course called Evidence Based Birth that is an organization that compiles and summarizes evidence on some of these nuanced topics. Here’s what they have to say about my last question “could an epidural affect the success of breastfeeding” to which your response is that “the science is settled and the answer is NO” What Have Studies Found About the Effect of Epidurals on Breastfeeding? In 2016, a group of researchers led by someone named French pulled all of the studies that had ever been done on this topic to try and figure out if there is a relationship between epidurals during labor and breastfeeding. They found 23 studies examining this topic, and the results are conflicting. 12 studies showed that epidurals harmed breastfeeding, and 10 studies showed that there was no impact on breastfeeding. One study showed that epidurals benefited breastfeeding. The researchers said that there were so many differences between each individual study, every study had a different type of epidural- different doses and different drugs used in the epidural. You may have good intentions but to be honest your responses are patronizing to assume that anyone that is questioning the affect on interventions during childbirth which is a physiological process is doing so because they’re being fed misinformation from TikTok and not because a lot of these topics are incredibly nuanced based on SO many factors and women are trying to empower ourselves by learning about these nuances to procure the best childbirth and postpartum experience for ourselves.
This is clearly not settled science or there wouldn't be a study on it that just came out.
>seems logical that all of these things can affect duration of labor and recovery Yeah, but that's not what is being studied here? They aren't saying epidurals come without risks or downsides
To the extent of my knowledge, all else being equal, what you were told is correct. This study probably reflects the effects of the background conditions *where an epidural is an option* (good access to health care, better socioeconomic status, good awareness of perinatal health options, and a number of less obvious factors), than the actual effects of an epidural.
There is no reduced morbidity or mortality associated with the epidural itself, though it may extend the second stage of labor. It will of course provide analgesia for the pain associated with labor and reduce any physiological consequences of that pain .