I coined the term ‘alternidural’ a few years ago when I learned that some midwife friends at a US Birth Centre have coined related term; the “aquadural”. The term may be unfamiliar; the concept is not. Offering labouring women an aquadural is another way of inviting them to get into a bath of warm water. But how much more important – and technical – an aquadural sounds than a boring old bath! It has a scientific ring about it, which might make it appeal to those women who have grown used to technological ways of living and coping with the world.
Perhaps it is just the first in a series of words which will develop to put the time-honoured ways of helping women in labour into a more modern context. In just a few years time, women might be discussing whether they will use electrodural (TENS) or aromadural (essential oils) methods, perhaps in combination with respirodural breathing techniques. Of course, none of these techniques have very much to do with the dura mater, for which the epidural was named, but they will have been brought back, at least linguistically, to retake their place beside the epidural, which has reached epic levels of popularity in labour wards.
Whether we feel it is OK to repackage those ways of coping with labour which present alternatives to the epidural is a matter of individual opinion. Some midwives might feel that anything which opens up more options to women is a good thing, while others may think that we should not be technicalising the nontechnical, through language or any other means. I am certainly bothered by the fact that the epidural is now considered by many people as the ‘normal’ choice, with non-pharmacological coping methods, some of which have served women for thousands of years, seen as ‘alternative’.
Yet perhaps we can all agree that we need to be doing something to address the (still) rising epidural rates if only in the light of the way this impacts on women’s labours and birth outcomes. We have known for a long time that epidurals slow labour down and that women with epidurals are more likely to be given synthetic oxytocin (Howell 2003). A Swedish study (Rahm et al 2002) has now confirmed that this may well be the direct result of epidural’s lowering of plasma oxytocin, thus removing from the woman’s body one of the key birth hormones.
A Norwegian study published in the same journal showed acupuncture to be effective in reducing the experience of pain in labour, reducing the need for pharmacological analgesia and shortening the time a woman spent in labour (Skilnand et al 2002). Both of these interventions involve needles and skilled practitioners; both will be perceived as too interventionist and therefore unpleasant by some women (and midwives), and technologically effective and thereby positive by others. But, for any number of reasons, epidural is widely available in almost all hospitals where women give birth; acupuncture in only a handful.
It is not simply a question of asking whether women are being given information about the pros and cons of epidurals and other methods of coping with labour. As we know, there are many, many more factors that influence a woman’s decision than the ability (and inclination) of the woman’s midwife and other supporters to ‘be with’ her. Yet this is one factor that can sometimes make a difference. One group of midwives who were working a night shift together on a labour ward made a decision at the beginning of the shift that they would see if they could achieve a 100% nonepidural rate during the night. They achieved this, not by denying epidurals to women who wanted them, but by effectively supporting labouring women, and offering a range of alternatives at the points where women might normally have started feeling the need for an epidural. I suspect those midwives might have had fewer tea breaks than normal that night, but left the hospital in the morning with a much greater sense of satisfaction.
We all understand that there are some women for whom epidural is the only option. And if women know and understand the potential implications – both negative and positive – of epidural analgesia, then they are making an informed choice, which we should support. But we also know that there are methods of helping women cope with the sensations of labour which can be as effective as epidural but without the potential for negative consequences. And, perhaps most importantly, that some women are ‘choosing’ epidural without having full information about the pros, cons and the failure rate of this procedure and before they have a chance to learn about the alternatives.
I don’t profess to have any answer to this, particularly given that I haven’t really said anything here that hasn’t been said before. But things don’t seem to be changing, and if it would help to start offering women various kinds of alternidurals as part of the smorgasbord of coping techniques, then maybe we should give that a go.
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A version of this article was originally published as Wickham S (2003). Alternidurals. TPM 6(7):47.
Howell CJ. (2003) Epidural versus non-epidural analgesia for pain relief in labour (Cochrane Review). The Cochrane Library, Issue 1, 2003. Oxford: Update Software.
Rahm V-A, Hallgren A, Hogberg H et al (2002) Plasma oxytocin levels in women during labor with or without epidural analgesia: a prospective study. Acta Obstet Gynecol Scand, 81: 1033-39.
Skilnand E, Fossen D and Heiberg E (2002) Acupuncture in the management of pain inlabour. Acta Obstet Gynecol Scand, 81: 943-948.