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Analysis

Upfront: The birth of the epidural

11 March, 2014

Upfront: The birth of the epidural

Although the first epidurals date back to the 1850s, it was nearly a century later before they were used in childbirth. Steve Ainsworth takes a look at their history.
Midwives magazine: Issue 2 :: 2014

Although the first epidurals date back to the 1850s, it was nearly a century later before they were used in childbirth. Steve Ainsworth takes a look at their history.

chloroform_inhaler_devised_in_1850

According to the King James Bible, God said to Eve: ‘I will greatly multiply thy sorrow and thy conception; in sorrow thou shalt bring forth children’ (Genesis 3:16).

In the latest Holy Bible, New International Version, that verse has become: ‘I will make your pains in childbearing very severe; with painful labour you will give birth to children’ (Genesis 3:16).

Whether written in ancient Hebrew, 17th century English or the language of the 21st century, the message is still exactly the same: ‘Childbirth is going to hurt you a lot.’

Yet thanks to modern anaesthetic techniques, childbirth today need not hurt mothers anywhere near as badly as the pains endured by their foremothers.

One of the greatest advances in anaesthesia was arguably the development of the ‘epidural’. 
Today, epidurals have been routinely used for many years and are widely accepted as an effective method of providing pain relief after surgery and during labour and childbirth.

But what exactly is an epidural? How does it work? And who was the first person reckless enough to volunteer to have a needle thrust into their spine with all the presumed attendant risk of suffering permanent paralysis?

Although the first epidurals were conceived and tried in 1853, it was not until halfway through the 20th century that epidurals were used in childbirth (Hingson and Edwards, 1943).

In the past, it is often said, many churchmen thought that any pain relief in childbirth bordered on blasphemy because it countered the word of God (Humphrey, 2008). Incense and prayer were fine, but anything else might upset divine intent.

This began to change in 1853 when Queen Victoria, who was head of the Church of England, was rendered temporarily insensible on being given chloroform during her eighth confinement (Science Museum, 2010a). Thereafter, religious opposition rapidly diminished.

Chloroform, though, was far from an ideal solution. Medical concerns about its use in childbirth were less to do with religion and more to do with the risk of death, which was not uncommon. The ideal obstetric anaesthetic was a local one; something that would render only the lower body insensible to pain.

The very same year of Queen Victoria’s confinement, French surgeon Charles Gabriel Pravaz and Scottish physician Alexander Wood independently combined the hollow hypodermic needle with a metal syringe for the very first time (Science Museum, 2010b). Wood used his syringe and needle for the management of neuralgic pains; Pravaz used his for intra-arterial injection in the treatment of aneurysms.

In 1869, 16 years after Queen Victoria first used chloroform to ease the pains of childbirth, a little known French ear, nose and throat specialist, Charles Fauvel, claimed a footnote in history by becoming the first clinician to use a needle and syringe to inject cocaine as an anaesthetic in a surgical procedure (Carney, 1965).

It would only be a matter of time before it would be used in the delivery room.

The epidural space is the space inside the bony spinal canal but just outside the dura mater (dura). In contact with the inner surface of the dura is another membrane called the arachnoid mater (arachnoid). The arachnoid mater contains the cerebrospinal fluid that surrounds the spinal cord. In adults, the spinal cord terminates around the level of the disc between L1 and L2, below which lies a bundle of nerves known as the cauda equine.

In theory, an injection of cocaine into this space might render everything further away from the brain insensitive to pain. American neurologist James Leonard Corning was the first to test the theory (Corning, 1885).

He performed a neuraxial blockade in 1885 by injecting 111mg of cocaine into the epidural space of a healthy male volunteer, although at the time he believed he was injecting it into the subarachnoid space (Marx, 1994). The volunteer had been reassured about the safety of the procedure after Corning explained that he had already tested the procedure on a dog.

In 1921, Spanish military surgeon Fidel Pagés developed the technique of ‘single-shot’ lumbar epidural anaesthesia, which was later popularised by Italian surgeon Achille Mario Dogliotti (Dogliotti, 1933).

Robert Andrew Hingson and James Southworth, both of whom worked in the Marine Hospital in New York, developed the technique of continuous caudal anaesthesia using an indwelling needle in 1941. They first used this technique in an operation to remove the varicose veins of a Scottish merchant seaman.

Hingson then collaborated with Edwards, the chief obstetrician at the hospital, to study the use of continuous caudal anesthesia during childbirth. Its first use in labour came on 6 January 1942, when the wife of a US coast guard was brought into the Marine Hospital for an emergency CS.

The woman suffered from rheumatic heart disease – heart failure following an episode of rheumatic fever during childhood. This led doctors to believe she would not survive the stress of labour, nor tolerate general anaesthesia, due to her heart problems. Happily, both mother and baby survived.

Now, of course, epidurals are common. But, in spite of the advances in the past 70 years, as with medical procedures, there are some risks associated with an epidural.

According to current advice from NHS Choices (2013), risks include puncture of the dura – the thickest, outermost layer that surrounds the spinal cord and brain – and infection. The risk of the dura being punctured is about one in 100, while the odds of infection, which can very rarely occur in the weeks following an epidural, are about one in 47,000 (Royal College of Anaesthetists, 2009).

Another problem with epidurals is that they are not always effective at reducing labour pain. The Obstetric Anaesthetists Association estimates that one in eight women who have an epidural during labour need to use other methods of pain relief (NHS Choices, 2013).
Also, epidurals might not be ideal, as they reduce mobility in labour and relax the pelvic floor, altering the physiology of labour. 

In 2011-12, the statistics for England and Wales (The Health and Social Care Information Centre, 2012) show that 17.1% (99,379 births) used epidural or caudal anaesthetic. And 13.6% (79,151 deliveries) used a spinal anaesthetic, which were mostly for CS deliveries. More than a third (36.7% or 213,052 deliveries) required no anaesthetic.

Epidurals may not be perfect but, for many women in labour, they are a helpful addition to incense and prayer.

Steve Ainsworth
Writer


References

Genesis. (1611) The King James Bible (1611 edition King James version). Genesis 3: 16. See: www.kingjamesbibleonline.org/Genesis-Chapter-3 (accessed 25 February 2014).

Genesis. (2011) Holy Bible, New International Version. Genesis 3: 16. See: www.biblegateway.com/passage/?search=Genesis+3&version=NIV (accessed 28 February 2014).

Carney TP. (1965) Alkaloids as local anaesthetics: In: Manske RHF. (Ed.). The alkaloids: chemistry and physiology (volume five). Academic Press: London: 211.

Corning JL. (1885) Spinal anaesthesia and local medication of the cord. New York Medical Journal 42: 483–5.

Dogliotti AM. (1933) Research and clinical observations on spinal anesthesia: with special reference to the peridural technique. Anesthesia & Analgesia 12(2): 59-65.

Hingson RA, Edwards WB. (1943) Continuous caudal analgesia in obstetrics. Journal of the American Medical Association 121(4): 225-9.

Humphrey. (2008) The deep sleep of Adam. See:
bedejournal.blogspot.co.uk/2008/12/deep-sleep-of-adam.html (accessed 20 February 2014).

Marx GF. (1994) The first spinal anaesthesia. Who deserves the laurels? Regional Anesthesia 19(6): 429-30.

NHS Choices. (2013) Epidural anaesthesia. See: www.nhs.uk/conditions/Epidural-anaesthesia/Pages/Introduction.aspx (accessed 14 February 2014).

Royal College of Anaesthetists. (2009) National audit of major complications of central neuraxial block in the UK: section 2. See: www.rcoa.ac.uk/system/files/CSQ-NAP3-Section2.pdf (accessed 20 February 2014).

Science Museum. (2010a) Queen Victoria (1819-1901). See:
www.sciencemuseum.org.uk/broughttolife/people/queenvictoria.aspx

(accessed 20 February 2014).


Science Museum. (2010b) Hypodermic syringe. See:
www.sciencemuseum.org.uk/broughttolife/techniques/hypodermicsyringe.aspx

(accessed 20 February 2014).


The Health and Social Care Information Centre. (2012) NHS maternity statistics 2011-12 summary report. See:
catalogue.ic.nhs.uk/publications/hospital/maternity/nhs-mater-eng-2011-2012/nhs-mate-eng-2011-2012-rep.pdf (accessed 14 February 2014).





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