Suzzie Vehrs is a Birth Arts International Certified Birth Doula passionate about helping moms create healthy, happy birth experiences + have a full recovery afterwards.

Can Epidurals Increase The Risk Of A Surgical Birth?

Looking for evidence on epidurals and c-sections can feel very overwhelming. Especially if you know you are going to be team epidural either way. I had an epidural in my daughter Zoe’s birth. I also had a c-section for her birth.

And you know what, I still know, of all the decisions I made during that experience, one choice I do not question is getting the epidural. It was the right decision for me at the moment.

I have no regrets about making sure my needs for pain management were met.

But that’s my experience. Since then, I’ve supported hundreds of other moms through the birth process. And, I do believe that information from lots of mothers is much more valid than information from one source. So let’s look at some data.

The Listening Mothers Survey On Inductions And Epidurals

You can see from this chart, that epidurals do increase the risks for c-sections. This is called the cascade of interventions – when one thing leads to another, which results in a surgery. That is one of the reasons people even wonder about the best time to get an epidural. Are there things you can do to reduce your risk for a c-section, even if you are choosing and epidural? The answer is yes!

We even have a special track inside of our birth class for epidural moms to teach you how to adjust best practices to your birth once you have an epidural.

And, if you are still deciding on an epidural or not and you’d like to get a more comprehensive overview of the pros and cons, make sure to watch our video about that. It’s a bit long, but I promise it will give you all the data backed answers to your questions.

Delaying an Epidural Vs Getting One Right Away

Okay, we are about to dive into some conflicting data about the timing of your epidural and if it matters when it comes to reducing risks of a surgical birth. On the bright side, a 2014 meta analysis concluded that timing of an epidural doesn’t really matter. Get it early, get it late, it won’t change your odds for a surgical birth.

That said, this does not exactly line up with my experiences as a doula, and it is not reflected in what actually happens in births. It’s also the wrong question to be asking in my mind.

Let’s go back to the listening mothers survey of actual birth results in California and see what happened. From this data, we don’t have exact data on timing of epidurals, but we do have data on when mothers came into the hospital.

You can see that the less dilated moms were when they came to the hospital – the higher the c-section rate. If moms came into the hospital at 4 centimeters or more, the c-section rate was 11% or less.

Moms that were at the hospital sooner, who were able to get epidurals sooner, and other interventions such as IV fluids sooner, had much higher c-section rates.

One simple rule of thumb for avoiding a c-section when using an epidural, stay at home as long as possible.

When To Go To The Hospital + When To Get Your Epidural

In general, a simple rule to follow for a low risk mom is to stay at home as long as possible. If you are timing your contractions, the earliest moms can get admitted at the hospital is typically when their contractions have reached a 5-1-1 rule. This means contractions are 5 minutes apart from the start of one to the start of the next, a minute long and have been that way for an hour.

If you are staying home as long as possible, most care providers will support moms in following a 4-1-1 rule as well. This means waiting to go in until contractions are four minutes apart from the start of one to the start of the next one.

Don’t worry, unless you labor is changing rapidly, 4-1-1 will still get you to the hospital in plenty of time.

It’s not usually until they are 2 minutes apart that you risk giving birth on the side of the road!

In my experience, if a mom is at the 5-1-1 rule, she will be 1 to 3 cm when we get to the hospital. Or, she will be there soon. If we followed the 4-1-1 rule, she will likely be about 4-6 cm dilated.

If you are in doubt about going to the hospital or not, call your provider and ask for their advice.

The average length of labor (from the onset of regular contractions to birth) was reported in the Listening Mother Survey as 13 hours. And for first time moms, the average is even longer, at 17 hours. So in most cases, there’s no rush.

But Wait…Didn’t You Say Timing Of Epidurals Doesn’t Matter?

You are right, there are plenty of studies that show that it doesn’t matter if you get an epidural early in labor or late in labor. But – these studies are actually a bit misleading.

There is a detailed explanation on the Lamaze website.

For one thing, six of nine studies didn’t actually even compare early epidurals vs late epidurals. The early group asked for epidurals on average at about 3.5 centimeters, and the late group asked for epidurals on average at 4 cm. Clearly this is not enough difference to actually conclude timing doesn’t matter.

And, the c-section rates in some of these studies were astronomically high. In fact, in one of the larger studies, c-section rates for moms in both groups were close to 50%. These moms started labor on their own. If we look at another study where moms were induced, over 60% of moms in both groups had c-sections.

Instead of applying their findings to best practices in labor, we should conclude that poor care will result in surgical births, no matter what choices a mom makes.

The Timing Of Your Epidural Isn’t As Important As The Hospital You Choose

One thing that is evident through this mixed bag of research is that the location you give birth at really matters. There are hospitals where less than 7% of first time, low risk moms have surgical births and others where over 70% of first time low risk moms have a c-section.

If preventing surgery is your goal, instead of thinking about when you get an epidural, look up the hospitals in your area and make sure you go to the one that gets the best results.

You can find out how to look up your hospital’s c-section rate here.

My Take As A Doula – Early Or Late Isn’t The Right Question

Most of these studies really focus on the timing of an epidural with dilation, with the caveat that most moms in these studies are really only actually getting the epidural between 3 and 4 cm on average. So – we don’t really have data on moms that get epidurals early vs late. We have studies on moms getting epidurals at 3-3.5 centimeters compared to 4 cms.

We need studies that look at moms an c-section rates at each cm of dilation. Unfortunately, those don’t exist yet.

But in my opinion, this is the wrong question anyways. Because moms will reach plateaus of pain at different times. And pain level is what I think moms need to consider when they are in labor.

Let’s Look At The Pain Scale

Epidurals are essentially a pain management tool, so when we talk about when to get an epidural, we should really be talking about what level of pain you are experiencing. However, pain does not always correlate with dilation.

The diagram above shows pain from a scale of 0-10. Though it can be hard to quantify pain, usually moms can look at this and state where they are. And, often, as an observer, our guess from looking from the outside often matches with what moms say. Intensity in labor is intensity in labor and just like any other pain, it has a ‘look’ to it.

Four Moms At 3 CM Dilated – Is An Epidural Right?

Let’s look at three moms at 3 cm dilated and how different their stories are.

Situation 1: No Pain, No Contractions, But Dilated Past 3 CM

Sarah is having her third baby. She goes to her 40 week prenatal appointment and has a cervical check. Her midwife tells her she is 3.5 cm dilated. She isn’t even in labor, she had some cramps, but definitely no contractions, but her body is making moves towards birth. This is a moment to celebrate – but since she isn’t in labor, doesn’t have contractions and isn’t experiencing pain, does it make sense to get an epidural because she’s at a certain dilation? Of course not. When she goes into labor, it starts quickly, and she has her baby in 5 hours.

Situation 2: Light Pain, Light + Infrequent Contractions, Dilated To 2 CM

Lee is having her first baby, she has been having prodromal labor for days. It’s not that intense, but these period cramps coming and going are annoying. She hasn’t really slept in days, so she goes to the hospital to see what she should do. She is 2 cm dilated.

Her contractions are still not close, strong or frequent, but just enough to keep her awake. Her midwife gives her medicine to help her sleep.

10 hours later, she wakes up in full labor. By the time she gets back to the hospital she is 6 cm dilated and opts for an epidural, because she actually is having contractions that are long, strong, and adequately close together. She meets her baby 8 hours later.

Situation 3: Lots Of Painful Contractions, Labor Augmentation With Pitocin, High Pain, Only 0.5 CM

Rachel’s water broke but her contractions didn’t start right away. As time goes by, she does start to have contractions. She’s having too many contractions to use misoprostol or other pills prescribed by her doctor to increase contractions. But she’s not having enough to be in active labor.

Her doctor would really like her to be in active labor, so they recommend starting pitocin. She agrees, and even though she’s not even 1 cm dilated, her contractions become VERY STRONG + QUITE PAINFUL. She zipped passed, 4,5, and 6 on the pain scale, and is reporting pain levels of 8 or 9.

But, she is still only 1 cm. This is a great instance where getting an ‘early epidural’ makes a lot of sense. This mom sleeps all night. She has her baby in the morning as the sun comes up.

Just because the epidural was “early” didn’t make it a bad choice for her. Because her contractions were quite strong, it was the best way for her to be able to relax and release through them.

Situation 4: Most Common, Reaches Medium To High Intensity Pain Levels, Contractions Frequent, Strong And Long

Lana went into labor on her own, contractions started like period cramps, over time they turned into more powerful waves of sensation. At first she can ignore them, then she finds comfort walking through them, then they get intense enough she can’t really talk through them anymore and walking is less helpful.

Lana goes to the hospital when her contractions are 4 minutes apart, 1 minute long and have been this way for an hour. Labor is not excruciating, but it does take a lot of focus and work. She is ready for a break.

When she arrives at the hospital, she has a cervical check and find out she is 4 cm dilated. That’s enough for her! She opts for an epidural, and guess what, after a few shows, card games and a semi nap, she meets her baby 9 hours later.

Why Is Dilation Not A Sign Of How Long Labor Will Last

To me it seems silly to consider dilation as the main factor for when to get an epidural. Moms labor very differently, and pain levels do not always match with dilation, especially before 5 cm.

You can see that each of the moms in the stories above were in very different places in regards to intensity of labor at 3 cm dilation.

Instead of focusing on what dilation a mom is at, a mom should consider, three questions:

Are my contractions long, strong and close together?
Am I okay with this level of work, or am I entering a place where I am suffering?
Would an epidural help me relax and release my body?

While I do believe most moms can do a natural birth if they want, getting an epidural or not is not a reflection of our value or how well we did labor. I encourage the moms I work with to consider their personal needs, and ask for an epidural when they need it.

My Advice For The Best Time To Get An Epidural – If Your Goal Is To Potentially Go For A Natural Birth

I know many moms who are considering a natural birth – but because they have never experienced the labor process before, they want to leave the door open for an epidural if they need it. They want to keep their options open, and that can be okay. Here’s my advice for moms considering a natural birth, but also considering an epidural if it all becomes too much.

Follow The Rule Of Thirds?

For moms who have a tentative goal of going without an epidural, I recommend they consider the rule of thirds. This is a rule to help you figure out how much powering through is enough:

1/3 of labor you should feel pretty ok, if this means that even between contractions you are coming back to your norm and either able to rest and relax or chat and walk that’s great! Keep it up. It is always our goal to help you stay here.

1/3 of labor you simply don’t like. It’s okay to not like the labor process. Some natural moms will love feeling their body move through the process, some will do it, but not like it. That’s okay too. But, you shouldn’t always be feeling down. It’s up to us, your support team to help you get back to the position above.

1/3 of your labor you hate it. It’s okay to hate your labor at certain moments, but it shouldn’t last. Whether this is a short time in transition where it feels super intense, or labor shifted and for a short time it feels impossible until you find the new thing that works for you, it’s a natural part of the process to have ups and downs. Almost everyone wants to escape labor at some point. But, you shouldn’t stay here.

What Does This Rule Help You See?

As support people, your doula and partner need to help you get back to one of the places where you feel okay or great about labor if you have a down moment. It’s okay if you feel like you’re on a bit of a ferris wheel ride as labor changes.

Going through cycles of feeling great, not liking it and hating it. Coming back to peace with the process, and recognizing the progress and purpose in the journey on the way is all a natural part of the labor process.

If you begin to feel like contractions are these angry things coming at you, and you are at war with them, and you’ve made 3 attempts to find ways to cope and it’s just not working. Get the epidural.

Suffering through labor is not a labor plan I suggest. I especially want moms who are in inductions to. be open minded about using pain relief tools, as it is a different experience than the self generated contractions.

That said, most of my moms who want to go epidural free are successful. You can learn how to rock a natural birth inside my childbirth class.

Moms Who Want An Epidural ASAP

I often work with moms who tell me their goal is to get out of pain as soon as possible!

When I talk to my moms about epidurals in labor, I have them set two goals. The first goal is a dilation goal, and the second in a pain goal. Then, whichever threshold they reach first is when we start asking for an epidural.

We also talk about how to cope with contractions in early labor, and what movements they can do to help get into active labor. You can find this all in our childbirth class.

One thing is, even if you want an epidural early, you still have to be admitted into the hospital to get it. Which means you need to get to a place where your contractions are five minutes apart, a minute long and have been that way for an hour before you can be admitted to the hospital (in most cases, you can always ask if you aren’t quite there yet, but you want to be checked in.)

If we are admitted, I’m 100% okay with asking for an epidural if you feel you are ready for one. But, I typically see moms make it to 4-1-1 before requesting an epidural if they have practiced some basic coping skills before.

Moms Who Are Starting An Induction

Induction pain is different than natural labor pain. I often hear people be told before receiving Pitocin that all labor is hard, and Pitocin won’t make that big of a difference in their labor. There is a grain of truth hidden in that sentiment. But in general, I find it misleading.

It is common for moms in transition to reach levels of pain that would be 8-10 on the above scale. But, that phase of labor usually only lasts 15 minutes to 2 hours, and then a mom is pushing. Which, for most moms, feels much better.

However, when I see moms on Pitocin, I have seen them reach those high levels of pain, seen nurses get excited and start setting up for delivery, and everyone prepping for the baby to be here. Only to do a cervical check and find out a mom is still only 1 cm dilated. Just at the beginning. In those cases, labor may continue on for another 12 hours before delivery.

It may be reasonable to be at a level 9 pain for a short period of time. It is not reasonable to do that for hours and hours and hours on end.

If you can’t get the Pitocin turned back down, or it doesn’t make sense to turn the Pitocin down in your case, opt for an epidural once you realize walking and moving doesn’t help you anymore. If your mobility is gone, and being in a tub isn’t helping enough, it’s time for a break and rest! Don’t suffer your way through labor.

Another Responsibility In Inductions

For moms that are laboring without an induction, the main consideration is pain management. But, self advocacy becomes more important in inductions.

Once Pitocin is part of your birth story, it’s also important for you to be clear headed so you can advocate for your baby if you notice you are getting too much and it’s affecting them

There is a great book that can teach you how to advocate for your baby written by Gina Mundy, a lawyer that has spent decades working with hospitals and families after mistakes have been made. The book is called A Parent’s Guide To A Safer Childbirth. And it will show you the basics of advocating for yourself and your baby through labor.

Pitocin takes 20-90 minutes to reach a steady state in your body. It’s also often turned up every 30 minutes. Sometimes this means you need to advocate for it to be turned down so it doesn’t get too intense for you or your baby.

I know it seems like you shouldn’t have to do this, but truthfully, even good teams make mistakes. And too often, hospitals are understaffed, and there is too much on everyone’s plate to catch everything.

It’s important to learn to advocate for yourself if your going through an induction.

Best time to get epidural TL/DR

So when is the best time to get an epidural? When you are ready and when you want one. Ultimately, this is your birth experience. It makes no sense for you to suffer through labor. If you want to do a natural birth, then great, I want to encourage you to believe in yourself and do it.

But, if you don’t like pain and you know that you can be more present with an epidural, use it without fear. We do have a special track in our childbirth class to help you.

I have been with so many moms who have chosen epidurals and have been so happy they made that decision. If an epidural is the decision you’ve made, I’m happy for you. Enjoy the time, make some memories and I am confident you will meet your baby and build a full and happy life together.

Congratulation mama! You’ve got this!

What Is The Best Time To Get An Epidural?