By RITA RUBIN
USA Today

Like maternity fashions, women’s preferred methods for labor pain relief have changed with the times.

When loose shifts with demure Peter Pan collars were popular in the 1950s, “twilight sleep,” induced with a potent combination of morphine and scopolamine, was the method of choice. As hemlines rose in the 1960s, so did interest in drug-free “natural” childbirth.

Today, when stylish pregnant women are baring their bellies in bikinis, the majority are asking for epidurals. In this technique, an anesthesiologist injects medication through a catheter inserted into the lower part of the woman’s spine, blocking nerves leading to the uterus.

Anesthesiologists as well as natural childbirth advocates say they hope that the one-size-fits-all approach to managing labor pain remains forever outmoded. They note that women’s satisfaction with their childbirth experience rests not on how little pain they felt but on whether their wishes about how to deal with it were respected.

“Pain in any other circumstance indicates something bad,” says University of Toronto nursing professor Ellen Hodnett.

“Pain in childbirth is a whole different thing,” Hodnett says. “Not that it can’t be terrible, and there aren’t ways to relieve it when it’s bad.” She was one of the contributors to a supplement examining labor pain published by the “American Journal of Obstetrics and Gynecology” in May.

Maureen Corry, executive director of the Maternity Center Association, a New York non-profit group that commissioned the articles in the supplement, says American women don’t have as many options as those in countries where midwives attend most births.

“I really don’t believe women have the full story,” Corry says. “I think they don’t have access to the full array of safe and effective methods. We need to know what’s going on in hospitals.”

To help answer that question, Corry’s group recently commissioned “Listening to Mothers,” a nationwide survey of women’s childbirth experiences. The results are to be released in late October.

For now, the main source of information about childbirth pain management in the USA is the Society for Obstetric Anesthesia and Perinatology, which surveys hospitals periodically. The group just mailed out its fourth survey, says president Joy Hawkins, director of obstetric anesthesia at the University of Colorado Health Sciences Center in Denver.

Increasing epidurals

When Manhattan psychotherapist Ellen Daniels delivered her daughter in 1981, fewer than a quarter of women who gave birth at large hospitals got epidurals.

“Those were the days of gonzo girls,” Daniels says. “We were woman warriors.” Their childbirth mantra, she says: Don’t let anyone near you with medication.

By the time she delivered her son three years later, Daniels says, her attitude had changed. Her labor was not progressing, and both she and her doctor wanted to avoid a Caesarean section. Exhausted and in pain, Daniels says, she eagerly welcomed an epidural. “I do not see that there is any glory in suffering through pain that can be combated. It makes no sense.”

Today, apparently, a majority of women would agree with her. At least half of all women who give birth in the USA get an epidural. Women who give birth at hospitals that deliver more than 1,500 babies a year are more likely to get an epidural than women at smaller hospitals. The obstetric anesthesia society’s last survey, conducted in 1997, found that the proportion of women who received epidurals for labor pain at the largest hospitals had risen to more than 60 percent, compared with only 22 percent in 1981.

On the other hand, some hospitals that deliver fewer than 500 babies a year don’t even offer epidurals because they lack anesthesiologists trained to administer them. Instead, those institutions use intravenous narcotics, which can cross the placenta to the baby. In the mother, narcotics can cause nausea, vomiting and sedation. In the newborn, narcotics have been linked to such problems as decreased alertness at birth.

Even among large hospitals, the epidural rate varies widely, Hawkins says. In New York City, for example, “the expectation there is you come in and have your epidural and you have painless childbirth,” she says. So the rate in New York hospitals is as high as 90 percent.

“I’m close to Boulder (Colo.), the ‘au naturel’ sort of place,” Hawkins says. “The expectations are different.” In Boulder, she says, the epidural rate is more like 20 percent.

And that’s fine, too, Hawkins says. “Epidurals shouldn’t be looked at as necessarily the first-line choice,” she says.

Other options

Proponents of non-drug methods of pain relief, such as baths or massage, would agree. They cite research suggesting that epidurals increase the likelihood that doctors will need to use forceps, a vacuum device or even a Caesarean section to deliver the baby because the mother is unable to push hard enough. And, they note, some studies link epidurals to fevers in mothers, leading doctors to treat their newborns with antibiotics for suspected infections.

David Birnbach, chief of women’s anesthesia at the University of Miami, questions whether such problems are caused by epidurals or simply occur more often in women who need one. Birnbach calls epidurals “the gold standard” of labor pain relief. “You can participate in the experience, you can push the baby out, and it takes the pain away.”

At least one paper in the “American Journal of Obstetrics and Gynecology” supplement concluded that newer methods, such as “walking” epidurals, don’t necessarily improve women’s childbirth experience.

Birnbach says the lower doses of painkillers used in walking epidurals bring almost immediate relief - compared with 15 minutes for conventional epidurals - without causing numbness in the legs. “When I trained, nobody could get out of bed,” Birnbach says. “Those days are gone.”

True, he says, not all women who get a walking epidural actually walk. At his hospital, Birnbach says, about a third do. Another third don’t want to, while the remainder can’t because they are hooked up to monitors or other devices that limit movement.

In a report published last month, the American College of Obstetricians and Gynecologists concludes that even women in early labor should be able to get an epidural if they want one. But “I always say try our things first,” says Penny Simkin, a Seattle doula, or labor support provider, who wrote about non-drug alternatives in the journal supplement on labor pain.

Simkin recommends touch and massage, movement and position changes. For back pain, she says, injecting sterile water in the back can provide immediate relief, possibly by stimulating the production of endorphins. When labor has progressed, baths can be soothing.

Somewhere between non-drug approaches and epidurals is nitrous oxide, or “laughing gas,” widely used by European women in childbirth. Anesthesiologist Mark Rosen, of the University of California-San Francisco, is one of only a handful of U.S. doctors who offers it.

Says Rosen, who estimates that fewer than 10 percent of his patients use nitrous oxide to take the edge off childbirth pain: “It’s not amazingly effective, but it’s a choice.”