The most popular form of pain relief in childbirth today is the epidural - in fact, it is women’s number one by-name medication request. Over 50% of women giving birth at a hospital get an epidural at some point during labor. In many cases, the (usually) very effective pain relief an epidural provides can be a God-send. Everyone knows, after all, that labor is probably one of the most painful things a woman will endure, and although most women can get through a normal labor and birth without one, many choose not to. But have you ever wondered about the history of epidural analgesia? When was it discovered? When did it come into common use? How has it changed over time?
Epidurals came into use in the 1900’s, about 50 years after the discovery of inhalation anaesthesia. Back then the procedure was not used for labor or delivery and came with considerable risk when it was used. In 1909, the first caudal anaesthesia was given for labor pains, and a German obstetrician, Walter Stoeckel, reported his study of 141 cases of healthy laboring women with epidurals. His success rate (of reducing pain) was about 50%. (1)
In 1931 the first catheter was used in an epidural, which meant that further medications could be administered after the needle was removed. This made the epidural an attractive alternative to spinal anaesthesia, which had serious risks such as spinal headaches, which is described by many as a severe migraine. By the 1940’s, epidurals were being used sporadically for labor but did not gain true momentum until the 1970’s. (2)
Then in the 1970s they exploded. This was in large part due to the fact that other childbirth technology developed and doctors felt more equipped to handle the side effects that often went along with the epidural. Perhaps the biggest breakthrough in this technology was the discovery of synthesized oxytocin - the drug we know today as Pitocin.
Back then, epidurals caused contractions to slow or stop about 40% of the time. (3) With the ability to augment labor with synthesized oxytocin if this occurred, this side effect no longer seemed to be such a serious consequence, especially because synthesized oxytocin hadn’t been studied and its side effects were unknown.
It is interesting to note how, from about the 1970’s, with the advent of advanced childbirth technology (needed in part to manage the side effects of pain relief), birth began to turn from a normal process into a medical, highly managed event. I like to think of this time as the advent of the “cascade of interventions” we have today.
In addition to the discovery and use of oxytocin, electronic fetal monitoring (EFM) was made commercially available in 1968. (4) In the same year, a review of 24,863 labors in which intermittent ascultation (IA) was used came out saying that IA, which was what had been used before EFM, was not a “reliable … indicator of fetal distress” (5) That was just one more reason for everyone to get on board with EFM. With it, doctors thought they could more easily detect fetal distress, which was often a side effect of epidurals and synthetic oxytocin.
Another reason epidural use became more widespread in the '70’s was due to increasing medical competency - C-sections had become much safer and were being used more often. So, if a problem arose (like a baby in distress), doctors could more comfortably perform an emergency C-section.
The epidural wasn’t done evolving and developing, though. Until about 20 years ago, most epidurals were actually called caudal blocks because it was administered in the caudal space, which is the lowest portion of the epidural system. Though similar to today’s epidural, they were much harder to insert, had potential to puncture the baby’s head, and required high levels of medicine to work. In fact, up until about the mid 90’s, women were given such high levels of these powerful drugs that they couldn’t feel anything, which made it difficult for them to push.
Today, epidurals are generally inserted into the lumbar - low back - area of the woman’s spine, which is much easier and safer than the caudal block. There are different types of epidurals available, such as the “walking” epidural or spinal-epidural, patient-controlled epidural anesthesia, and continuous epidural, among others. There are pros and cons to each of these types of epidurals, and choosing which to use will be highly influenced by your personal preferences for pain management.
Today’s epidural is (thankfully!) a far cry from its tentative beginnings. From a 50% success rate in Walter Stoeckel’s trial in 1909 to patient-controlled epidural anesthesia, the epidural has evolved into a powerful pain reliever in labor and birth. While many women may choose not to use epidural anesthesia, it is a blessing to know that we have this effective tool as an option for the times it really is needed, instead of suffering through as women have had to do for thousands of years. That’s the beauty of birth today - you can birth as naturally as our ancestors if you so wish, but you have medical technology readily available when it’s needed. And that is worth celebrating.