This blog series is designed to help women who are developing a birth plan join together with like-minded birthing professionals so as to have a shorter and safer labor and birth. Although written primarily for professional birth attendants, I hope information will be helpful to lay women planning their birth. Today we’ll look at the fourth “P” of my 10 “P’s” of keeping labor shorter and birth safer — pain control.
“Controlling the pain of labor without harm to (the) … labor process remains a major focus for maternity care.”(61) This focus has resulted in the escalation of epidural use, despite the fact that epidurals continue to be controversial.
Even so, meta-analysis and critical reviews are available.
“Epidural, when properly administered, provides excellent analgesia, although it is associated with prolonged labor, results in higher rates of instrument-assisted delivery, increased use of oxytocin, and possibly increased cesarean -section rate…as up to 47% of fetal heart rate tracings may be abnormal after epidural blockade.”(5)
One meta-analysis says that “recent study contains well documented data showing an approximate increase of two hours in the length of the 1st stage of labour.”(62)  A population based study says that “epidural use increases the average length of second stage of labor by 38 minutes in primiparas and 23 minutes for multiparas.”(63)
Another tact of the attack on epidurals says that “women who receive an epidural were 4.3 times more likely to have a cesarean than those who did not (17% vs 4%) … when all factors were controlled for, epidural anesthesia was associated with a 3.7 fold increase for cesarean section, and a 6.5 fold increase for failure to progress. They also had slower rates of dilation (0.5 vs 1.2 cm/hr).”(64)
However, meta-analysis data seem to confirm this criticism:  “There is a significant increase in the cesarean section rate in the three largest studies which were of sufficient size to report an incidence of cesarean section. The major reason for this seems to be an increase in the cesarean section rate for fetal distress.” (62)
“The only two trials in which relevant data were reported confirm that epidurals predispose to a two fold increase in the incidence of malrotation of the presenting part, and a four fold increase in the use of instrumental delivery.”(62)
One meta-analysis summed it up this way, “…Given such strong evidence of the effects of epidural analgesia on the dynamics of labour, a mother receiving epidural analgesia can no longer be considered to be having a ‘normal’ labour.”(62)
If this is true, then it follows that avoiding epidural, by definition, will help keep normal labor normal, at least until further study shows that different techniques dispel these criticisms.
Although whirlpool baths in labor (called by some “the midwives’ epidural”(65)) seem to have “…positive effects on analgesia requirements, instrumentation rates, condition of the perineum and personal satisfaction…”(65), all of which help keep normal labor normal; however, they may significantly lengthen labor.(65,66)
Overlooked by many maternity caregivers is the literature that says, “…Many simple, effective, low-cost methods to relieve labor pain can be initiated by nurses, midwives, or physicians with the potential benefits of improved labor progress, reduction in the use of riskier medications, (improved) patient satisfaction, and lower costs … Unfortunately, training and practice in the use of these measures are not included in the education of most maternity caregivers … This lack of knowledge is at least partially responsible for today’s reliance on drug management of labor pain.  Employing a broad range of effective and simple techniques can promote the laboring woman’s physical comfort … and labor progress.”(61)
Here’s the entire series:

• Introduction
• The Costs of Abnormal Labor
• THE 10 P’s

1. Philosophy,
2. Partners,
3. Professionals,
4. Pain control,
5. Procedures,
6. Patience,
7. Preparation,
8. Positions,
9. Payment, and
10. Prayer.

• Summary

Citations: