The folks at Cochrane Reviews have just crushed a number of the most cherished myths of natural childbirth advocates:

Pain during childbirth is arguably the most severe pain some women may experience in their lifetime. Epidural analgesia is an effective form of pain relief during labour… We conclude that for first time mothers in labour who request epidurals for pain relief, it would appear that the time to initiate epidural analgesia is dependent upon women’s requests.

That’s three dead myths in only 3 sentences:

1. Contractions aren’t surges but the most severe pain experienced.

2. Epidurals are very effective in managing that pain.

3. A woman should get an epidural when she asks for one since the timing has no impact on outcome.

The Review, Early versus late initiation of epidural analgesia for labour, was published yesterday.

The authors explain the methodology and findings:

We included nine studies with a total of 15,752 women.The overall risk of bias of the studies was low, with the exception of performance bias (blinding of participants and personnel). The nine studies showed no clinically meaningful difference in risk of caesarean section with early initiation versus late initiation of epidural analgesia for labour (risk ratio (RR) 1.02; 95% confidence interval (CI) 0.96 to 1.08, nine studies, 15,499 women, high quality evidence). There was no clinically meaningful difference in risk of instrumental birth with early initiation versus late initiation of epidural analgesia for labour (RR 0.93; 95% CI 0.86 to 1.01, eight studies, 15,379 women, high quality evidence). The duration of second stage of labour showed no clinically meaningful difference between early initiation and late initiation of epidural analgesia (mean difference (MD) -3.22 minutes; 95% CI -6.71 to 0.27, eight studies, 14,982 women, high quality evidence). There was significant heterogeneity in the duration of first stage of labour and the data were not pooled. There was no clinically meaningful difference in Apgar scores less than seven at one minute (RR 0.96; 95% CI 0.84 to 1.10, seven studies, 14,924 women, high quality evidence). There was no clinically meaningful difference in Apgar scores less than seven at five minutes (RR 0.96; 95% CI 0.69 to 1.33, seven studies, 14,924 women, high quality evidence). There was no clinically meaningful difference in umbilical arterial pH between early initiation and late initiation (MD 0.01; 95% CI -0.01 to 0.03, four studies, 14,004 women, high quality evidence). There was no clinically meaningful difference in umbilical venous pH favouring early initiation (MD 0.01; 95% CI -0.00 to 0.02, four studies, 14,004 women, moderate quality evidence).

Catherine Pearson at HuffPo interviewed a number of clinicians on their thoughts about the review:

“This review — performed through the rigorous Cochrane methodology — provides a high level of medical evidence that early epidurals do not extend labor time, especially the pushing stage,” Dr. Sng Ban Leong, deputy head and senior consultant with the department of women’s anesthesia and KK Women and Children’s Hospital in Singapore, wrote in an email to The Huffington Post. Leong was an author on the review.

And:

“Epidurals these days are very different from the ’80s and ’90s,” Dr. J. Christopher Glantz, a professor of obstetrics and gynecology in the division of maternal-fetal medicine at the University of Rochester Medical Center, told The Huffington Post. Many hospitals now offer lower-dose walking epidurals, which can leave women with enough strength to move throughout labor and may help them push more effectively.

And:

“The takeaway message is that when women experience labor pain, and they choose to have early epidural pain relief, they [should] be reassured that this does not have any adverse effects to their labor outcomes,” Leong wrote.

When should a woman get an epidural in labor? According to the folks at Cochrane Reviews: whenever she wants it!