Epidural Analgesia for Pain Management in Labor

One of the biggest choices people make about while learning about birth is their preference for an unmedicated birth or birth with an epidural. There is no wrong choice here. What you choose and how you birth will be influenced by your life experiences, your values, and how your labor unfolds, which is not something we can control.

People who choose unmedicated, physiologic birth often cite a few reasons. Physiologic birth is labor and delivery that unfolds on its own, guided by the body's natural hormones and instincts, without pain medication, anesthesia, or routine interventions like continuous invasive monitoring or induction. It can happen at home, in a birth center, or in a hospital. The setting doesn't change the definition; the absence of medication and unnecessary intervention does. Spinning Babies describes this approach as trusting the body's innate ability to give birth when it has “balance, space, and respect.”

You might be someone who does not want to experience the intensity of labor and the altered state that comes with it. While the argument for control can go either way for unmedicated or epidural, I do see that for some people, having an epidural allows them to feel more present and in control of the experience.

Whatever your intentions are, it is a good idea to prepare for both and to be well-informed about what both unmedicated and medicated birth entail. Your baby may ultimately be the decider here. Some labors will move so quickly that you won’t have time for an epidural. Sometimes epidurals don’t work. I also encourage anyone who is planning an epidural to labor as long as possible without one to limit the side effects and risk of a labor dystocia (stall) that requires more intervention. On the other hand, you may be the most prepared to have an unmedicated, physiologic birth, with all the tools to manage the sensations, but you may have a labor longer than is sustainable to be unmedicated. Going several nights without sleeping is not going to help your birth progress, so if you have been in active labor for more than 24 hours without any sleep and you are not close to birth, this is probably a good time to utilize an epidural. For some people with a hypertoned (tight) pelvic floor, they may experience a stall at the midpelvis because the muscles are not allowing baby to pass through, in which case an epidural can relax these muscles and actually help your labor progress. Sometimes you just need sleep to have the energy to push a baby out.

The big message here: choose what will be most empowering for you and what aligns with your values, but prepare for both unmedicated and medicated birth.

Let’s take a look at the studies now.

Why do people choose unmedicated birth?

A doctoral research study that asked birthing people directly why they chose an unmedicated birth found their

answers clustered into a few consistent themes (4):

1. A sense of empowerment and rite of passage

Many people described giving birth without medication as one of the most powerful experiences of their lives. Others spoke about how the sense of strength and self-trust they gained stayed with them long after the birth itself.

2. Trust that the body is built for this

Many people expressed real conviction that their bodies were designed to labor and give birth, and that the pain of labor has a purpose, guiding them toward positions and movements that help labor progress (4). Body Ready Method describes this directly: birth is guided by “natural hormones and instincts that have been fine-tuned over tens of thousands of years of evolution” (2).

4. Wanting to avoid a cascade of intervention

For many people, fear of the epidural itself, and where it might lead (continuous monitoring, Pitocin, reduced mobility, and possibly more intervention), outweighed their fear of labor pain (4). Staying mobile and free to change positions was frequently described as more important to them than avoiding pain.

5. Feeling in control of their own birth

Across every theme, one thread repeats: people equated “unmedicated” with staying in charge of their own bodies and decisions, rather than having the process happen to them. Clinical sources echo this. Many people feel more empowered and in charge of their birth without routine interventions, and that sense of control can itself reduce the experience of pain (6).

What the Research Says About the Benefits

• A natural cascade of hormones released during unmedicated labor supports pain coping, bonding with the baby, and faster postpartum recovery (2, 7).

• Without medication, sensation and alertness stay intact, which can help a person actively participate in and direct their own pushing stage (6).

• The pushing stage tends to be shorter, and freedom to move and change positions can ease both labor and delivery pain (6).

• Eating and drinking are usually not restricted, unlike in some medicated hospital labors (6).

References

1. Body Ready Method. Empowering Yourself Through Education: Understanding Physiological Birth and Reclaiming Your Birth Experience. bodyreadymethod.com, 2024.

2. Same source as above (Body Ready Method, 2024), citing: Buckley, S.J. (2015). Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care. Childbirth Connection Programs, National Partnership for Women & Families.

3. Spinning Babies. What Is Physiological First Birth? spinningbabies.com/what-is-physiological-first-birth/

4. Wegelt Heinz, S. (2011). Why Women Choose Physiologic Birth and What They Believe Supports the Choice. DNP Clinical Inquiry Portfolio, Oregon Health & Science University.

5. CU Medicine (Denver, CO). Natural Birth. cumedicine.us/services/natural-birth6. Same source as above (CU Medicine, Natural Birth).

7. Uvnäs-Moberg, K. (2013). Oxytocin: The Biological Guide to Motherhood. Amarant Förlag. (cited via Body Ready Method, 2024)

8. Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). Leading Nursing Journal Explores Importance of Normal Physiologic Childbirth, May 2016. awhonn.org

9. Lothian, J.A. (2009). Promoting Optimal Care in Childbirth. The Journal of Perinatal Education, 18(4), 32–34. (cited via Body Ready Method, 2024)

Why do people choose epidurals?

Many people choose an epidural simply because it offers the most effective pain relief available in labor. A Cochrane review of over 11,000 people found it relieves pain more effectively than opioid medication, with more people rating their relief "excellent or very good" (Anim-Somuah et al., 2018). For some, the appeal is also about conserving energy for a long or difficult labor, staying rested and clear-headed rather than exhausted by contractions, or simply feeling calmer once the physical intensity is under control. Others choose it because a medical reason makes it the safer or recommended option. Conditions like preeclampsia, an anticipated long induction, or a prior difficult birth experience may influence this choice. For many, it's less a philosophy than a practical, in-the-moment decision: labor turned out to be more painful or longer than expected, and pain relief became the right call at that point. As the joint ACOG/ASA statement puts it, a parent’'s own request is sufficient reason to receive pain relief in labor, there's no need to justify the choice beyond that.

What is an epidural?

Epidural (epidural analgesia): A form of regional pain relief for labor in which an anesthesiologist injects numbing medication through a thin catheter placed in the lower back, into the space just outside the membrane surrounding the spinal cord (the "epidural space"). It blocks pain signals traveling from the uterus and birth canal to the brain, numbing the lower body from roughly the belly button down while usually leaving the person awake, alert, and able to feel pressure and push.

The steps to recieving an epidural are:

1. IV line and fluids: Before the epidural is placed, an IV line is started in the arm and a bag of IV fluids is run in. This helps prevent the drop in blood pressure that the medication can cause.

2. Positioning: The laboring person sits up and curls forward over a pillow, or lies on their side curled into a C-shape. Either position widens the spaces between the vertebrae, which makes it easier for the anesthesiologist to find the right spot.

3. Cleaning and numbing the skin: The lower back is cleaned with antiseptic. A small amount of local anesthetic is injected just under the skin to numb the area where the epidural needle will go. This is usually the only part that stings.

1. Placing the epidural needle: The anesthesiologist inserts a hollow needle between two vertebrae in the lower back, guiding it into the epidural space, which is just outside the membrane that surrounds the spinal cord and fluid (this is deliberately not the spinal space itself).

1. Threading the catheter: A very thin, flexible plastic tube (the catheter) is threaded through the needle into the epidural space, and the needle is then withdrawn, leaving only the catheter in place. It's taped along the back so it stays put through the rest of labor.

1. Test dose and first dose: A small test dose is given first to confirm the catheter is in the right place and not in a vein or in the spinal fluid. Once confirmed, the full initial dose is given through the catheter.

1. Ongoing dosing: Pain relief typically builds over 10–20 minutes. From there, medication is maintained through the catheter. Typically, a bolus (dose) of medication is administered every 40 minutes, with a patient-controlled pump (PCEA) the laboring person can trigger for extra relief also available.

1. Urinary catheter is placed: a foley bulb (indwelling) cathether is inserted once numbing is complete and stays in place until pushing commences.

Medications used

Epidurals almost always combine two types of drugs:

• Local anesthetic: Numbs the nerves that carry pain signals. The most commonly used are bupivacaine, ropivacaine, or levobupivacaine. Modern practice favors low concentrations (around 0.0625–0.125% bupivacaine, or similarly dilute ropivacaine) rather than the stronger doses used decades ago, because lower concentrations relieve pain while preserving more muscle strength and mobility.

• Opioid: Added in a small dose to boost pain relief without needing more local anesthetic. Fentanyl is most common in the U.S. This combination means less numbness and motor block than local anesthetic alone at an effective dose.

An epidural comes with a package of other interventions: continuous IV fluids, continuous fetal monitoring, and a foley catheter.

Benefits and Risks of Birth with an Epidural

Benefits

• Highly effective

• Continuous pain relief through labor

• Ability to sleep during labor

Risks

• 1 in 8 people report unsatisfactory pain relief

• Can lead to more interventions and increased medicalization of birth

• Longer pushing phase, higher rates of forceps or vacuum birth

• Increased need for Pitocin augmentation

• Itchy skin, nausea, urinary retention

• Spinal headache

• Skin infection, sore back

• Restriction of movement

• Low blood pressure leading to low oxygen in fetus, requiring further intervention

• Abnormal fetal heart rate

• Low Apgar score

• Respiratory depression of the newborn

• Poor muscle tone of the newborn

• Newborn difficulty with breastfeeding

*Side effects increase with higher doses

A few more notes on epidurals:

On average, epidural analgesia is associated with a longer first and second stage of labor and more use of oxytocin to augment contractions. [2] Across the full body of evidence, epidural analgesia has not been shown to increase the overall rate of cesarean birth. [2] With an epidural, possible effects include a temporary drop in blood pressure (usually prevented with IV fluids), itching, fever, difficulty urinating (sometimes requiring a temporary catheter), and a sore lower back for a day or two at the injection site. Epidurals do not cause long-term backache. About 1 in 100 people develop a headache after the procedure, which can be treated. Depending on the dose and medication used, legs may feel heavy or difficult to move. [3,4,2]

Epidural analgesia is associated with a rise in maternal temperature during labor. Because fever is also a sign of possible infection, hospital protocols often respond to an epidural-related fever with a newborn sepsis evaluation (bloodwork, monitoring, sometimes precautionary antibiotics) even when no infection is present. This is a standard safety precaution, not evidence that something went wrong. [7]

1. California Maternal Quality Care Collaborative (CMQCC). Toolkit to Support Vaginal Birth and Reduce Primary Cesareans, with Supplement (2022).

2. Anim-Somuah M, Smyth RMD, Cyna AM, Cuthbert A. Epidural versus non-epidural or no analgesia for pain management in labour. Cochrane Database of Systematic Reviews, 2018. pmc.ncbi.nlm.nih.gov/articles/PMC649464

3. NHS. Pain relief in labour. nhs.uk/pregnancy/labour-and-birth/pain-relief-in-labour/

4. NHS. Epidural, side effects. nhs.uk/tests-and-treatments/epidural/side-effects/

5. American Society of Anesthesiologists. Made for This Moment: Labor Pain. madeforthismoment.asahq.org/pain- management/types-of-pain/labor/

6. American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine. Safe Prevention of the Primary Cesarean Delivery. American Journal of Obstetrics and Gynecology, 2014. ajog.org/article/S0002- 9378(14)00055-6/fulltext

7. Lieberman E, et al. Epidural analgesia, intrapartum fever, and neonatal sepsis evaluation. Pediatrics, 1997. pubmed.ncbi.nlm.nih.gov/9041298