Informational decision aid
about childbirth with or without
epidural anesthesia

Finding a Way
to Relieve Labor Delivery Pain
That is Right for You

2nd edition, 2022

There are several ways to relieve labor pain duringchildbirth, each with its own advantages anddisadvantages.
This informational aid is intended to help pregnant
women planning on having a natural vaginal delivery
make an informed decision about whether to give birthusing epidural anesthesia.

※ An “Aid” is a tool related to decision-making that can be used in cases where there are

multiple options for treatments or examination, each with their own benefits and risks.

Contents

STEP 1：Learning how to make an informed
decision・・・・・・・・・・・・1

STEP 2：Learning the pros and cons of each
option・・・・・・・・・・・・・・・・・・4

STEP 3：Setting clear priorities for decisionmaking ･････・・・・・・・・・ 29

STEP 4：Making yourdecision・・・・・・・・・・・・・・・・・・・・・・32

Anesthesia use during childbirth can be administered by using
several methods, which may include the use of epidural
anesthesia, spinal anesthesia, or both. Epidural anesthesia is a
popular choice in Japan.

STEP１

Learning how to make an informed decision● How is this Aid used for making an informed decision?
There are different options for vaginal delivery during childbirth, each with its
own advantages and disadvantages.
This Aid is intended to help pregnant women planning on having a vaginal
delivery make an informed decision about whether to give birth using epidural
anesthesia.

This Aid consists of the following steps.
When reading this Aid for the first time, please read the steps inorder.

STEP１

Learning how to make an informed decision

P１～P3

STEP２

Learning the pros and cons of each option

P4～P28

STEP３

Setting clear priorities for decision-making

P29～P31

STEP４Making your decision

P32～P34

1

Learning how to make an informed decision

STEP１● How to use this Aid for making an informed decision
Let's find out if this Aid is helpful for you.
This Aid is not intended to promote one option over another. This Aid wascreated for the purpose of helping you to choose the method of relieving labor
pain during childbirth that is right for you. Reading the contents of this Aid will
help you to gain a more correct understanding and think about your priorities
for making a decision, thereby facilitating communication with doctors,
midwives, family, colleagues and friends, and women who have alreadyexperienced childbirth.

This Aid was created for the following women.

Who this Aid is for:
 Women planning on having a vaginal delivery（Women notplanning to have a Caesarean section）
 Women not sure about epidural anesthesia

This Aid is not for women with the following conditions:

Women requiring in-person consultations with a doctor

Women who have been recommended to have a Caesarean
section by doctors



Women who have been recommended to have an epidural
anesthesia by doctors (those with heart disease, pregnancyinduced hypertension, etc.)

2

STEP１

Learning how to make an informed decision

Let's find out how you want to be involved in choosing a childbirthdelivery method.
What is most important is “how you go about making a decision”.
There are 3 approaches you can take when making a decision.
Let's find out which approach you want to take when making your decision.

(a) Like to make my own decisions based on sufficient information(b) Like to make decisions together with health professionals and my family(c) Like to have someone else, such as a doctor, a midwife, or a family
member make decisions for me

This Aid will be helpful to those who choose option (a) and/or (b). Please
continue onto the next page.
If you wish to have someone such as a doctor, a midwife, or a family member
make decisions for you, as in option (c), you may find information in this Aidless useful.
If you choose option (c), you can still use this Aid by reading it together withyour family to check if the method chosen by your doctor is right for you.

3

Learning the pros and cons of each option

STEP２(basic knowledge of vaginal delivery)●経腟分娩のおおまかな流れ● General process of vaginal delivery
This Aid is particularly focused on making the decision between “epidural
anesthesia” and “no epidural anesthesia” in the generalprocess of vaginal delivery.

Baby is positioned head
down.

Suitable for vaginal delivery
No experience with
Caesarean section or uterus surgery.
Not having placenta previa, etc.

Using noUsing epidural

epiduralanesthesia

anesthesia

During vaginal delivery, when labor starts, the uterus receivescommands from the brain that causes periodic tightening and relaxingof the uterine muscles, thereby opening the cervix to push the baby
downward through the birth canal.
This process is common both during epidural anesthesia and no epidural
anesthesia.

4・How do you manage pain when no epidural anesthesia is used?
Spontaneous delivery is a method without the use of anesthetics. Methods ofrelieving labor pain include applying a hot pack or ice pillow to the back,applying pressure around the back and anus, and rubbing or patting. Thesemethods are considered effective in relieving labor pain as they gently act on
the neural circuits for pain.

・How do you manage pain during the use of epidural anesthesia?
Epidural anesthesia is a method of relieving labor pain that requires theinsertion of a thin tube called a catheter into the epidural space near the
spinal cord of the back and injecting local anesthetics upon request by the
pregnant women who is experiencing increasing labor pain. Injected
medicines act on nerves around the epidural space and prevent pain byblocking the nerves that transmit pain from the uterus, the vagina, the vulva,
and the perineum.

5

STEP２

Learning the pros and cons of each option(basic knowledge of vaginal delivery)● What is labor?
The smooth delivery of a baby requires uterine contraction to push the baby out.
This uterine contraction is also known as labor.
Labor causes the cervix to gradually dilate, which helps the baby to graduallydescend into the canal. Labor pain occurs regularly and becomes graduallystronger. When the cervix is fully dilated, the baby can pass through the cervix
and move into the birth canal.
Although there is variation in the periods and durations of labor amongindividuals, it is generally known that it takes women who are giving birth for the firsttime between 11 and 15 hours on average and women who have already given
birth between 6 and 8 hours on average to give birth after experiencing regularlabor.

● Steps and progression of childbirth
The longest period is when the cervix is dilating to the complete level after labor
starts. It is generally known that this step takes women who are giving birth for the
first time between 10 and 12 hours and women who have already given birth
between 5 and 6 hours.
As the childbirth progresses, each contraction becomes longer and more intense
and the intervals between contractions become shorter.
When the cervix is dilated to the complete level, the intervals between
contractions become even shorter. It is known that it takes women who are giving
birth for the first time between 1 and 2 hours and women who have already given
birth between 30 minutes and 1 hour to give birth after the cervix is dilated tothe complete level.
While the uterus contracts, the midwife tells the mother to "push" and themother pushes to bring the baby out on that cue. The contractions and pushingforce cause the baby to gradually descend through the birth canal.
When the baby's head is almost out, the mother stops pushing and starts taking
quick shallow breaths. After a short period, the baby is born.
Mild contractions begin 5 to 20 minutes after the baby is born and the placenta
is delivered to complete childbirth.

6

Learning the pros and cons of each option
STEP２(basic knowledge of epidural anesthesia)● Timing of epidural anesthesia use⚫

Epidural anesthesia is administered when labor pains become stronger. A
midwife predicts the progress of labor when the pregnant woman wishes toalleviate the pain. The timing of administering epidural anesthesia may
differ depending on whether the women has given birth before. Birthcenters may have their own standard timing of when they administer
epidural anesthesia.

● Steps for providing epidural anesthesiaa) The pregnant woman lies on her side or
takes a sitting position, and arches her back on adelivery bed.
b) A disinfectant is applied to the back and local
anesthesia is applied to the part of the body where theneedle will be inserted. This operation causes a brief pricking
sensation such as when one receives an injection.

c) A thick needle (the epidural needle) for placing a tube inside, called a catheter, is inserted
into the woman’s back. This action causes a pressure sensation, but almost no pain due toeffects of the local anesthesia.
d) When the needle tip reaches the epidural space, a thin tube (catheter), which is inserted
through the needle, is threaded through into the epidural space. The needle is thenremoved so that only the catheter stays in the epidural space.
e) Anesthetics are injected through the catheter.
f) It takes approximately 20 to 30 minutes to relieve labor pain after the epidural injection.
g) After the catheter is inserted, a certain amount of anesthetic is continuously injectedusing an injection pump.
Epidural anesthesia relieves labor pain by numbing body parts
below the belly button without making you sleep, thus allowing you
to be fully conscious during childbirth.
When pain before the administration of anesthesia is rated as
10/10, labor pain is reduced to approximately 1 to 3. You may feelsome tightness in your stomach, but this varies from individual toindividual.Using low doses of anesthetic does not make you feelcompletely numb. You may still feel the pressure of contractions
7
around the buttocks as childbirth
progresses.

STEP２

Learning the pros and cons of each option● How are delivery methods chosen by women who have already given birth?

Reasons for choosing no epidural anesthesia
58.4%

自然が良いと思うから

Prefer a natural birth

46.6%

乗り越えられると思うから
Being confident to birth without
epidural anesthesia

41.6%

1回は陣痛を体験しようと思うから
Wish to experiencelabor pains at least once
前回の出産体験（自然分娩）がPrevious satisfying
childbirth experience

9.2%

Wish to avoid medical
intervention
医療介入が嫌だから

7.1%

良かったから

0%

20%

40%

60%

80%

"Other reasons" to choose not to have epidural anesthesia include:
・High costs of epidural anesthesia ・Short delivery time in a previous childbirthexperience ・Recommended by family members ・Disliked previous childbirthusing epidural anesthesia
・家族に勧められたから・前回の無痛分娩の体験が嫌だったから

Reasons for choosing the use of epidural
anesthesia
73.8%

体力を温存したいから

Preservation of physical strength

痛みが嫌だから、痛みが怖い、痛みに弱い

52.6%

To avoid pain, being
afraid of pain, sensitive to pain,
痛みに耐えられる自信がないから
or not confident in bearing pain41.3%

高齢妊婦だから

Delayed child-bearing
22.5%

Recommended友人・知人に勧められたから
by friends or colleagues
前回の出産体験（自然分娩）がPrevious tough childbirth experience with no use of
つらかったから
epidural anesthesia

19.2%
0%

20%

40%

60%

80%

"Other reasons" to choose using the epidural anesthesia option include:
・Recommended by family and doctor・Used epidural anesthesia in previous
childbirth・Being told that there will be a quicker recovery from childbirth・Simply
thought using epidural anesthesia will be good.
Reference: Shishido, E., & Horiuchi, S. (2018). Hope of delivery using epidural
anesthesia during labor compared with no anesthesia and delivery outcome.
Maternal Health. 59(1), 112－120.

8

STEP２

Learning the pros and cons of each option● Comparison of the benefits and risks between epidural
anesthesia and no epidural anesthesia
Let's compare the benefits (advantages) and risks of each option
PointsNo epidural anesthesia

Epidural anesthesia

Labor pain-relieving effects

Limited effects

Highly effective

What to expect during
delivery・You have to remain on a delivery bed.
・Eating and drinking are restricted.
・You cannot go to the bathroom andwill need to urinate through a tube
・You will be able to walk around(catheter).
freely.
※Depending on the sensation and・You will be able to eat and drink
freely.
movement of the lower limbs, the・ You will be able to go to the
response may differ depending on thebathroom.
facility, such as walking, moving to
the toilet by using a wheelchair, orinserting an indwelling bladdercatheter.

Analgesic side-effects――――――

Local anesthetic, intoxication anaphylactic
shock, postdural puncture headache,
low blood pressure, fever, itchy skin, etc.

Impact on labor――――――

・More chance of instrumental labor
・More blood loss at labor

Caesarean section

No substantial difference in possibility of having a Caesarean section
Applied anesthetics can be used for

Additional treatments for
Caesarean section

Requires additional anesthetic
treatments

Impact on newborns

None

Some
＊See Pages 23-25

Costs

Regular delivery fee

Regular delivery fee＋
Epidural anesthesia delivery fee

Caesarean section

The side-by-side comparison makes it easy to understand the benefit(advantages) and risks of each method.

9

STEP２

Learning the pros and cons of each option(medical knowledge about delivery methods)● Side-effects of epidural anesthesia
If you choose epidural anesthesia as compared with no epidural
anesthesia or other methods using painkillers, these are the possible
side-effects:⚫

Possibility of additionally requiring labor induction increases by 1.1-fold.

⚫

Risk of causing fever during delivery increases by 2.5-fold.

⚫

Risk of causing hypotension during delivery increases by 11-fold.

⚫

Risk of causing nausea and vomiting during delivery increases somewhat.

⚫

Anesthetics may cause itching around the chest during delivery.

⚫

Risk of causing difficulty in urination after delivery increases by 4.72-fold.

⚫

Severe headache may occur after delivery in 1 to 3 out of 100 pregnant women.

Reference: Anim-Somuah, M., Smyth, R. M., Cyna, A. M., & Cuthbert, A. (2018).
Epidural versus non-epidural or no analgesia for pain management in labour.
Cochrane Database of Systematic Reviews.
Reference: Kawasoe, I., & Kataoka, Y. (2020). Prevalence and risk factors forpostpartum urinary retention after vaginal delivery in Japan: A case-control study.
Japan Journal of Nursing Science, 17(2). doi:10.1111/jjns.12293

The following side-effects occur on rare occasions:⚫

Temporary loss of feeling or strength in parts of your lower bodymay occur in 1 out of 550 pregnant women.

⚫

Life-threatening complications may occur.

⚫

Death may be caused by anesthetics.

Reference：Paech, M. J., Godkin, R., Webster, S. (1998). Complications of obstetricepidural analgesia and anaesthesia: A prospective analysis of 10995 cases.
International Journal of Obstetric Anesthesia, 7(1), 5-11.
Reference: Unno, N., & Itakura, A. (2017). Examination of the safety of labor
analgesia. 2017 Ministry of Health, Labour and Welfare Promotion of Special
Research Project "Study of the actual situation of labor analgesia and building asafety management system."

10

STEP２

Learning the pros and cons of each option★ Caesarean section
The number of Caesarean sections did not differ between the no
epidural anesthesia group and the epidural anesthesia group.
No epidural

Epiduralanesthesia

anesthesia

Primiparous
women

9 out of 100 deliveries by

12 out of 100 deliveries by

Caesarean section in the no

Caesarean section in theepidural anesthesia group.

epidural anesthesia group.

1out of 100 deliveries by
Caesarean section in the no
epidural anesthesia group.

2 out of 100 deliveries byMultiparous
women

Caesarean section in theepidural anesthesia group.

Reference：Kurakazu, M., Umehara, N., Nagata, C., Yamashita, Y., Sato, M., Sago, H. (2020).
Delivery mode and maternal and neonatal outcomes of combined spinal–epidural analgesia
compared with no analgesia in spontaneous labor: A single-center observational study inJapan. Japan Society of Obstetrics and Gynecology, 46(3), 425-433.

11

Learning the pros and cons of each option

STEP２★ Instrumental delivery
Instrumental delivery is more commonly used for the epidural
anesthesia delivery group than the no epidural anesthesia delivery group

Primiparous

No epidural
aaanesthesiaanesthesiaaanesthesia

Epiduralwomen

13 out of 100 women required
instrumental delivery in the no

34 out of 100 women required
instrumental delivery in theepidural anesthesia group.

epidural anesthesia group.
Multip
arous
wome
n

4 out of 100 women required
instrumental delivery in the no
epidural anesthesia group.

11 out of 100 womenrequired instrumental delivery
in the epidural anesthesia
group.
12

＊Instrumental delivery is:a method for hastening delivery that is performed by using a tool such as asuction cup or forceps when childbirth fails to progress smoothly. Instrumental
delivery provides greater benefits for the mother and baby than letting naturaldelivery continue.
“Vacuum assisted delivery” is a method in which a suction cup is
attached to the baby's head and delivery of the baby is vacuum assisted byapplying negative pressure.
“Forceps assisted delivery” is a method in which the forceps areused to hold the baby's head and pull out the baby. Performing instrumental
delivery sometimes requires episiotomy (a method in which the perineum is excisedby scissors for enlarging the
opening). Further, possible risks of instrumental delivery to the baby include
cephalohematoma, which is a hemorrhage found between the skull and periosteum,and facial and scalp injuries occurring during the delivery. Other risks tomothers are known to be larger wounds and increased risk of wound
infections and 3rd and 4th degree lacerations.

Forceps-assisted delivery

Vacuum-assisted delivery

Reference ： Shishido, E., & Horiuchi, S. (2018). Hope of delivery using epidural
anesthesia during labor compared with no anesthesia and delivery outcome.
Maternal Health. 59(1), 112－120.
Reference：Kurakazu, M., Umehara, N., Nagata, C., Yamashita, Y., Sato, M., Sago, H.
(2020). Delivery mode and maternal and neonatal outcomes of combined spinal–
epidural analgesia compared with no analgesia in spontaneous labor: A singlecenter observational study in Japan. Japan Society of Obstetrics and Gynecology,
46(3), 425-433.

13

STEP２

Learning the pros and cons of each option★ Blood loss
Blood loss is more common in the epidural group than in the no
epidural group. The amount of bleeding during labor could be morethan 500 mL in the no epidural anesthesia group.
No epidural anesthesia

Epidural anesthesia

30 out of 100 women had >500 mL
blood loss during labor in the no
epidural anesthesia group.

38 out of 100 women had >500 mL
blood loss during labor in theepidural anesthesia group.

Primaparous
women

Multiparous
women

21 out of 100 women had >500 mL
blood loss during labor in the no
epidural anesthesia group.

14

28 out of 100 women had >500 mL
blood loss during labor in the epidural
anesthesia group.

Blood loss during labor is the total amount of blood loss until twohours postpartum. In general, >500 mL of blood loss is considereda large amount of bleeding.

Reference: Kurakazu, M., Umehara, N., Nagata, C., Yamashita, Y., Sato, M., Sago, H. (2020).
Delivery mode and maternal and neonatal outcomes of combined spinal–epidural analgesia
compared with no analgesia in spontaneous labor: A single-center observational study in Japan.
Japan Society of Obstetrics and Gynecology, 46(3), 425-433.

Q&A Corner
Q. Why is instrumental delivery common during no epidural anesthesia labor?
Answer①

When no epidural anesthesia is used during labor, labor pain may belessened after administration of anesthetic. When the labor slows down, it
takes time for the baby to be born, so it is said that there will be more cases
where a labor-promoting agent is used to progress the labor, or if the baby's
head does not come down, support by instrument delivery is required.

② Epidural anesthetic can loosen the muscles that support the pelvis, causing
the baby to turn in the wrong direction when it is born. Even in such cases,
instrumental delivery may be performed because the delivery time may belonger.
？

Q. Why does epidural anesthesia during labor cause more bleeding?
AnswerEpidural anesthesia administration during labor often results in longer
delivery times, which can lead to tired uterine muscles and poor postpartum
uterine return. Therefore, it is said that the amount of bleeding increases. A no
epidural anesthesia labor may also increase delivery time and bleeding,depending on labor conditions.

15

STEP２

Learning the pros and cons of each option★ Postpartum urinary retention
Urinary retention is more common in the epidural group than in the no
epidural group.
Epidural anesthesia
No epidural anesthesia

2 out of 100 women had urinary

7 out of 100 women had
urinary retention in theretention in the no epidural
anesthesia group.

epidural anesthesia group＊Urinary retention is:
the absence of spontaneous micturition within 6 hours of vaginal
delivery.
In most cases, the symptom is eased within several days. Vary rarely,
the symptom continues for more than one week and requires selfcatheterization (a method in which a tube is inserted into the bladderthrough the urethra to drain urine out).
Reference ： Shishido, E., & Horiuchi, S. (2018). Hope of delivery using epidural
anesthesia during labor compared with no anesthesia and delivery outcome.
Maternal Health. 59(1), 112－120.
Reference: Yip, S. K., Sahota, D., Pang, M. W., Chang, A. (2005). Postpartum Urinary
Retention. Obstetrics & Gynecology, 83(10), 881－891.

16

STEP２

Learning the pros and cons of each option★ Satisfaction level with relief of labor pain
Satisfaction level of the epidural group is higher than that of othergroups using methods other than epidural (injection of opioids)
anesthesia with regards to relieving labor pain.
Methods other than

Epidural anesthesia

epidural anesthesia

50 out of 100 women who usedmethods other than epidural
anesthesia were satisfied with
their labor pain relief.

73 out of 100 women who had an
epidural anesthesia were satisfied
with their labor pain relief.

＊Methods of relieving labor pain are roughly divided into two types:a) Methods that use no drugs
Breathing techniques, massage, touching, heating the back by use of a hot pack,aromatherapy, shiatsu massage, etc.
b) Methods that use drugs
Use of epidural anesthesia, injection of opioids, inhalation of nitrous oxide, etc.
Reference: Anim-Somuah, M., Smyth, R. M., Cyna, A. M., & Cuthbert, A. (2018).
Epidural versus non-epidural or no analgesia for pain management in labour. Cochrane Database of Systematic Reviews.

17

STEP２

Learning the pros and cons of each option★ Satisfaction level with childbirth experience
Satisfaction level of the no epidural group is higher than that of the
epidural group regarding childbirth experience on an evaluation scaleout of 10, with a score of 8 or higher indicating high satisfaction.
No epidural anesthesia

Epidural anesthesia

86 out of 100 women who had no
epidural anesthesia were satisfied

Satisfaction level with childbirthwith their childbirth experience.

( )

出
産
満
足
度
点

60 out of 100 women who had
epidural anesthesia were satisfied
with their childbirth experience.

10
9

In the no epidural

8

anesthesia group,
women who were7

able to control their

6予測より痛くなかった
Less painful

予測通りだった
As expected

than expected

陣痛のギャップ

予測より痛かったMore
painfulthan expectedlabor pain had ahigher satisfaction
with childbirth.

Gap between expectation and experience of labor pains

Reference: Shishido, E., Yaju Y., Horiuchi, S. (2018). The gap between expectations
and realities of pain and fatigue in women receiving epidural anesthesia versus
no anesthesia. Journal of Japan Academy of Midwifery, 32(2),101-112.

18

Learning the pros and cons of each option

STEP２★ Continuous Support
Women who had continuous support from their husband, partner,
midwife, etc. are less likely to use medications for relieving labor pain(including epidural anesthesia) as compared with women who had nosupport during delivery.
With support

Without support

83 out of 100 women who had
continuous support used
medication for labor pain relief
during delivery.

96 out of 100 women who did
not have continuous support
used medication for labor pain
relief during delivery.

＊For continuous support includes emotional support (continuously attending, reassuring,
complimenting), information on relaxation and the progress of labor.
＊Drug-based childbirth pain relief includes intramuscular injection of Buscopan, etc. aswell as epidural anesthesia.

Doctor and midwife

woman in labor

partner

Reference: Bohren, M. A., Hofmeyr, G. J., Sakala, C., Fukuzawa, R. K., & Cuthbert, A.
(2017). Continuous support for women during childbirth. Cochrane Database of
Systematic Reviews.

19

Learning the pros and cons of each option

STEP２（分娩による痛み、疲労感）★Labor pain, Perineal pain, After-delivery pain
Labor pain
A higher percentage of responses for labor pain being more painful
than expected was evident in the no epidural anesthesia group.

No epidural anesthesia

42.5

Epidural anesthesia

48.5
51.5

57.5

予測通り/予測より痛くなかった
As expected/less painful than expected予測通り/予測より痛くなかった
予測より痛かった
More painful than expected

予測より痛かった

Perineal pain
A higher percentage of responses for perineal pain after childbirth
being very strong was evident in the epidural anesthesia group.

No epidural anesthesia

27.7

Epidural anesthesia

40.4
59.6

72.3

予測通り/予測より痛くなかった

As expected/less painful than expected
予測より痛かった
More painful than expected

予測通り/予測より痛くなかった
予測より痛かった＊The cause of perineal pain:
If the perineal wound created during delivery is large and deep, the pain may
increase. In addition, the condition of the wound and the degree of pain varydepending on the use of instruments and the presence or absence of anepisiotomy.

20

After-delivery pain
There is no significant difference in the level of after-delivery pain
between the two delivery groups.

No epidural anesthesia

Epidural anesthesia
24.1

19.3

75.9
80.7
予測通り/予測より痛くなかった
As expected/less painful than expected
予測通り/予測より痛くなかった
予測より痛かった
More painful than expected
予測より痛かった＊After-delivery pain:
Labor pain that occurs after the placenta is expelled from the uterus isconsidered to be after-delivery pain. The uterus contracts to prevent
blood loss by contracting the blood vessels exposed in the area where
the placenta was expelled and to decrease its size to the size before
pregnancy. Although after-delivery pain is irregular and weak, it cancontinue for approximately 3 days after delivery and it is known thatwomen who have already given birth before experience stronger pain
than women who are giving birth for the first time.
Reference： Shishido, E., & Horiuchi, S. (2018). Hope of delivery using epidural
anesthesia during labor compared with no anesthesia and delivery outcome. Maternal
Health. 59(1), 112－120.

21

★ Fatigue associated with delivery
Fatigue within 2 days after childbirth

A higher percentage of responses for fatigue being stronger than
expected was evident in the epidural anesthesia group.
No epidural anesthesia

20.7

Epidural anesthesia

35.5
64.5

79.3

予測通り/予測より疲れていない
予測通り/予測より疲れていない
As expected/less fatigue felt than expected
予測より疲れている
More fatigue felt than expected

予測より疲れている＊Postpartum fatigue:
Delivery requires a lot of energy and is extremely exhausting. It is said
that not only physical fatigue but also mental fatigue accumulates, and it
is generally said that the longer the delivery time, the stronger the feelingof fatigue after delivery.
Symptoms of postpartum fatigue include tiredness, heaviness, drowsiness,and muscle aches.

22

STEP２

Learning the pros and cons of each option★ Postpartum depression
There was no difference in the number of postpartum depressions
among mothers at 1 month after giving birth between the no epidural
anesthesia and epidural anesthesia groups.
No epidural anesthesia

Epidural anesthesia

21 out of 100 women in the

18 out of 100 women in the no
epidural anesthesia groupexperienced postpartum

epidural anesthesia groupexperienced postpartum
depression.

depression.
＊Postpartum depression is:a condition in which depression such as maternity blues (a mild depressionthat occurs transiently after delivery and is said to improve naturally)
continues for several weeks, causing problems in daily life. The incidence of
postpartum depression in Japanese is reported to be about 10–15%.
Symptoms include extreme fatigue, mood fluctuations, sleep disorders, andeating disorders. Specialized treatment is required for recovery.
Reference Uehara K, Muradate, M.,Kano N, Kaneda K, Shishido. E., Maeda, Y. (2021).
Effect of labor analgesia on postpartum depression; From analysis of perinatal center,mother-child cohort-. The 35th Congress of the Japan Academy of Midwifery.

23

STEP２

Learning the pros and cons of each option★ Bonding fatigue
There was no difference between the no epidural anesthesia andepidural anesthesia groups in terms of the number of mothers withbonding disorders at 1 month after delivery.
Epiduralanesthesia

No epidural
anesthesia

13.7 out of 100 experienced bonding
fatigue in the no epidural anesthesia
group.

15.6 out of 100 experienced
bonding fatigue in the epidural
anesthesia group.

＊Bonding fatigue is:a state in which a parent does not have the emotions (emotional bonds)
that a parent has for a child, such as adoring the baby after birth orwanting to protect it as a parent. Symptoms include indifference to thechild, rejection of the child, and feelings of anger towards the child.
Continued bonding disorders can lead to abandonment and abuse ofchildren; therefore, appropriate support is required.
Reference: ：Kano N,Kaneda K, Uehara K, Muradate, M., Shishido. E., Maeda, Y. (2021).
Effect of labor analgesia on mother-child bonding one month after delivery; From
analysis of perinatal center, mother-child cohort. The 35th Congress of the Japan
Academy of Midwifery.

24

STEP２

Learning the pros and cons of each option★ Baby's health immediately after birthMore babies with an Apgar score of <7 were found at 1 minute after
birth in the epidural anesthesia group than in the no epidural
anesthesia group.
Epidural

No epidural
anesthesia

anesthesia

Primiparous
women

3.7 out of 100 babies had an
Apgar score <7 in the no
epidural anesthesia group.

6.6 out of 100 babies had an
Apgar score of <7 in theepidural anesthesia group.

1.8 out of 100 babies had an

4.3 out of 100 babies had an

Apgar score of <7 in the no

Apgar score of <7 in theepidural anesthesia group.

epidural anesthesia group.

Multiparous
women

25

There is no significant difference between the no epidural anesthesia
group and the epidural anesthesia group regarding an Apgar score forthe baby at 5 minutes after birth.
Women who give birth for the first time
0.47 out of 100 babies had an Apgar score of <7 in the no epidural
anesthesia group.
0.78 out of 100 babies had an Apgar score of <7 in the epidural
anesthesia group.
Women who have already given birth0.11 out of 100 babies had an Apgar score of <7 in the no epidural
anesthesia group.
0.20 out of 100 babies had an Apgar score of <7 in the epidural
anesthesia group.

＊The Apgar score:
The Apgar is a numerical value that indicates the health condition of
the baby immediately after birth. Measurement of the Apgar score ismade at 1 and 5 minutes after birth. 7 points or more out of 10 points is
considered normal.
The target value for the Apgar score is 7 points or more at 5 minutes
after birth. A score of <7 means that the baby’s birth health is not what
it should be and they may require treatment.
Reference: Kurakazu, M., Umehara, N., Nagata, C., Yamashita, Y., Sato, M., Sago, H.
(2020). Delivery mode and maternal and neonatal outcomes of combined spinal–
epidural analgesia compared with no analgesia in spontaneous labor: A singlecenter observational study in Japan. Japan Society of Obstetrics and Gynecology,
46(3), 425-433.

26

STEP２

Learning the pros and cons of each options★ Hospitalization in the NICU
Women who experience epidural anesthesia deliveries are more likely
to have babies who are hospitalized in the NICU compared withwomen who experience no epidural anesthesia deliveries.
No epidural

Epiduralanesthesia

anesthesia

5.6 babies out of 100 were

10 babies out of 100 wereadmitted to the NICU in theadmitted to the NICU in the no
epidural anesthesia group.

epidural anesthesia group.

＊NICU is:a neonatal intensive care unit. It is an intensive care unit where
newborn babies are treated when they need medical help.

Reference: HФtoft D., & Maimburg R. D. (2021). Epidural analgesia birth and adverse
neonatal outcomes: A population-based cohort study. Women and Birth, 34,e286-e291.

27

STEP２

Learning the pros and cons of each option★ Breastfeeding
The percentage of mothers who have given birth for the first time whoare exclusively breastfeeding on the 4th to 5th day after childbirth is
44.8% in the no epidural anesthesia group, whereas it is 17.2% in theepidural anesthesia group. Japanese research results show that moremothers in the no epidural anesthesia group are breastfeeding thanmothers from the epidural anesthesia group.

No epidural anesthesia

Epidural anesthesia

44.8%
55.2%

Breastfeeding
only
母乳のみ
ミルク or混合授乳

milk or mixed feeding

Breastfeeding only, milk or mixed feeding
Reference: Shishido, E., Shuo, T., Shinohara, K., Horiuchi, S. (2021). Effects of epidural
anesthesia on postpartum maternity blues and fatigue and its relation to changes in oxytocin.

Q&A corner
Q. Why are mothers in the epidural anesthesia group less likely tobreastfeed during postpartum hospitalization?
Answer:If you experience heavy bleeding during labor or feel tired after giving
birth, it may take some time for your body to move normally. Therefore,
it takes time for the mother and child to be together and bond, and thetiming for the start of breastfeeding is delayed. Breast milk is produced
when your baby sucks on your breasts, so the later you startbreastfeeding, the more delayed your milk production will be.

28

STEP２

Learning the pros and cons of each option★ Autism spectrum disorder (ASD)
Various research studies have been published on the relationshipbetween the number of children diagnosed with autism spectrum diseasein early childhood or when they are of school age and the method of birthdelivery (no epidural anesthesia or epidural anesthesia), but noconclusions have yet been reached.
According to my research results, there was nodifference in the number of children diagnosed with
autism spectrum disorders between the no epidural
anesthesia or epidural anesthesia groups.

Research C, D

According to my research results, the number ofchildren diagnosed with autism spectrum disorders
was a little more in the epidural anesthesia delivery

Researcher A, B

group than in the no epidural anesthesia delivery
group.
。

＊Autism spectrum disorder:
In the International Classification of Diseases (ICD-11), ASD is characterized by"disorders of mutual social relations / communication disorders" and "repetitive andstereotyped patterns of limited behavior, interests and activities". Autism spectrum
disorders are often diagnosed from early childhood to when children are of school age, and it
is reported that the average age of diagnosis for children in Japan is 7.3 years.
文献：齊藤卓弥. (2019). DSM-5と ICD-11B.
における神経発達症.
分子精神医学,19(4),
Reference：Wall-Wieler,
E., Bateman,T., Hanlon-Dearman,
A., Roos,L. 217-223.
L., & Butwick, A. J.
文献：倉澤茂樹,
立山清美,
大歳太郎,
中谷謙, 横井賀津志.
(2019). 日本における自閉症スペクトラム(2021).
Associationof 岩永竜一郎,
Epidural Labor
Analgesia
with Offspring
Risk of Autism Spectrum
障害の診断年齢―種別の検討―. 保健医療学雑誌. 10(1), 34-41.
Disorders. JAMA Pediatrics, 175(7), 698–705.
Reference：Mikkelsen, A. P., Greiber, I. K., Scheller, N. M., Lidegaard, Ø. (2021). Association ofLabor Epidural Analgesia with Autism Spectrum Disorder in Children. JAMA, 326(12),1170–1177. Reference：Qiu, C., Lin, J. C., Shi, J. M., Chow, T., Desai, V. N., Nguyen, V.
T., Riewerts, R. J., Feldman, R. K., Segal, S., Xiang, A. H. (2020). Association between
epiduralanalgesia
laborC.,
andIp,
riskA.,of autismspectrum
disorders in
Reference： Hanley,
G. E.,during
Bickford,
Lanphear,N., Lanphear,B.,offspring.
Weikum, JAMA
W.,
Pediatrics,
174(12),1168-1175.
Zwaigenbaum, L., Oberlander, T. F. (2021). Association of Epidural Analgesia During

Labor and Delivery with Autism Spectrum Disorder in Offspring. JAMA, 326(12), 1178–
1185.

29

STEP２

Learning the pros and cons of each option★ Childbirth delivery costs

The following summary shows the cost difference between no epidural
anesthesia and epidural anesthesia childbirth delivery

Costs

No epidural anesthesia

Epidural anesthesia delivery

Delivery admission fee

Delivery admission fee

Epidural anesthesia fee(approximately 100,000 to
150,000 yen)

＊Epidural anesthesia is not covered by private health insurance andis thus considered a private practice.
（Costs vary by birth center, hospital, etc.）30

Setting clear priorities for decision-making

STEP３

In Step 2, we reviewed the pros and cons of each option. It is important tomake a decision based on correct information as well as your own priorities thatyou set for that decision.
Once you set clear priorities for decision-making, it becomes easier for you to
ask for advice from a doctor or a midwife about your decision regarding thechildbirth delivery method.
The following pages provide a tool that allows you to decide where you place
your values and thus help you set clear priorities for decision-making. A blankspace where you can write down other points to consider is also provided.

★ Pain associated with delivery
Let us find out how important the following point are to you. On a scale of 0
to 5, with 0 being the least important and 5 being the most important, circle
the number that represents how important each item is to you.
PointsLess importantMoreimportant

Consideration for my pain tolerance level

0

1

2

3

4

5

Experiencing labor pain

0

1

2

3

4

5

Reducing labor pain

0

1

2

3

4

5

0

1

2

3

4

5

Overcoming

childbirthexperiencewith

persons supporting you

31

★ Side-effects of epidural anesthesia
Let us find out how important the following point is to you. On a scale of 0 to
5, with 0 being the least important and 5 being the most important, circle thenumber that represents how important this item is to you.
Point

Less important

Consideration for possible side-effects ofan epidural anesthesia

0

1

2

More
important3

4

5★ Effect on the delivery process
Let us find out how important the following points are to you. On a scale of 0
to 5, with 0 being the least important and 5 being the most important, circle
the number that represents how important each item is to you.
PointsLess important

Being able to freely walk, eat and drink, or
go to bathroom during delivery
Epidural anesthesia results in a longer
delivery time
Epidural anesthesia more likely results in
instrumental delivery of the baby

Moreimportant

0

1

2

3

4

5

0

1

2

3

4

5

0

1

2

3

4

5

★ Effect on the baby's health
Let us find out how important the following point is to you. On a scale of 0 to
5, with 0 being the least important and 5 being the most important, circle thenumber that represents how important each item is to you.

PointsLess important

The health of the baby immediately after
birth
Increased chances of a baby being
hospitalized in the NICU after birth

32

More
important

0

1

2

3

4

5

0

1

2

3

4

5

★ Effect on breastfeeding
Let us find out how important the following point is to you. On a scale of 0 to
5, with 0 being the least important and 5 being the most important, circle thenumber that represents how important this item is to you.
PointsLess important

Breastfeeding in infancy

0

1

2

More
important3

45★ Delivery costs
This section allows you to think about the costs of epidural anesthesiadelivery. Let us find out how important the following point is to you. On a scaleof 0 to 5, with 0 being the least important and 5 being the most important,circle the number that represents how important this item is to you.
PointsLess important

Private expense for delivery being high (or
low)

0

1

2

More
important3

4

5★ Others
Do you have anything else to consider? Write down your own points below.
PointsLess importantMoreimportant

⚫

0

1

2

3

4

5

⚫

0

1

2

3

4

5

0

1

2

3

4

5

⚫

33

STEP４Making your decision● Let us make sure you are ready to make a decision regarding yourchildbirth delivery method
You have learned basic knowledge and thought about your priorities
for decision-making.
Now, let us make sure you are ready to make a decision.
Check the boxes ☑ if the points are applicable to you.

*Do you know the benefits and risks of each option？
□Yes □ No*Are you clear about which benefits and risks matter most to you?
□Yes □ No*Do you have enough support and advice to make a choice?
□Yes □ No*Do you feel sure about the best choice for you?
□Yes □ No
The SURE Test © Légaré, et al.(2010)
Translation：Wakako Osaka et al. (2018)

If you answered “No” to at least one of the above four questions, you may
not be ready to make a decision yet. Is there anything else you want to do
before making your decision?
Let us determine what else you want to do by using the following checklist.

34

STEP４Making your decision● Let us determine what you want to do next before taking action●あなたがどれくらい決める準備ができているか確認しましょう。
You can set your priorities about what you want to do next before taking action bychecking off ☑ the items on the following checklist.

 None. I am ready to make my decision.
 I need to talk to (person)

about myoptions.
 I need to be clear about which advantages anddisadvantages matter most to me.
Besides that, I need to do.

Many women may be figuring out what to do and how to proceed
before making a decision regarding their childbirth delivery method.
Clarifying what you want to do with the help of the above checklist will
make it easy for you to take the next step.
If you feel that you still do not fully understand the available options,
you are encouraged to read the chapter “Learning the pros and cons ofeach option” in this Aid again, or ask your doctor for further
explanation.
If you are still uncertain about your priorities for decision-making, youare encouraged to read the chapter “Setting clear priorities for
decision-making” again or talk to people such as midwives, family andfriends, and women who have experienced childbirth before.

35

STEP４Making your decision● How do you feel now?
Check off ☑ the items that best match your feelings now about childbirth delivery
methods from the list below.

I want to have an epidural anesthesia.
Reasons（）

I would prefer epidural anesthesia if needed during delivery.
Until then, I will do my best.

I slightly favor the use of epidural anesthesia, but withminimum use. Mostly, I want to go without epidural anesthesia.

I am not sure. I need to think more about my options.
I do not wish to have an epidural anesthesia; however, I will
accept an epidural anesthesia if the pain becomes unbearable.
I want to avoid epidural anesthesia as much as possible;
however, I will accept epidural anesthesia if delivery is delayed
and it becomes difficult to proceed with vaginal delivery.
I do not want to have an epidural anesthesia.
Reasons（36）

In conclusion★ Process of developing this Aid

This Aid was created on the basis of opinions from doctors, midwives andexperts in decision-making research. Medical information described here waschecked by experts in obstetrics and obstetric anesthesia. This Aid does notinclude all medical information, but rather basic information that you shouldknow.

★ For making your own informed decision
No financial support of any kind was received from healthcare-relatedcompanies or other entities for creating this Aid (declaring no conflicts ofinterest).

There is no right or wrong decision about choosing which childbirthdelivery method to use. Sharing your values and preferences withhealthcare professionals and receiving professional opinions from themwill allow you to make your own informed choice.
★ Update of information in the “Finding a Way to Relieve Labor Painthat is Right for You” Aid
Each option has benefit and risks. This Aid was created to help you
understand the benefit and risks of each option from a medical
perspective, examine which benefit and risks are important to you
according to your values, and facilitate communication with doctors,
midwives, family, colleagues and friends, and women who have alreadyexperienced childbirth.
The contents of this Aid are revised and updated as needed. Please checkthe revision date before using this Aid.
The information published in this Aid is to facilitate communication withhealthcare professionals, and to help you organize the information you learn
and your priorities for making decisions so that you can make up your mind
about which childbirth delivery method is right for you. This information is notintended to be a substitute for the advice of healthcare professionals.
(Final revision of contents：February 20, 2022)

37

This Aid was created on the basis of aids for choosing epidural anesthesia delivery
that have been developed abroad. The references used are listed below.
＜Overseas aids used as references＞
Pain Relief for Labour: For women having their first baby.
(The University of Sydney)www.psych.usyd.edu.au/cemped/docs/Pain_Decision_Aid.pdf [2018-04-25]
Should I Have an Epidural During Childbirth?
(Healthwise Content Development Team)https://www.mottchildren.org/health-library/tn9762 [2018-04-25]＜References＞
Anim-Somuah, M., Smyth, R. M., Cyna, A. M., & Cuthbert, A. (2018). Epidural versus nonepidural or no analgesia for pain management in labour. Cochrane Database of
Systematic Reviews.
Asaba, H., & Akinaga, C. (2018). Sequence of actions for epidural anesthesia. Perinatal Care,
37(6), 528-533.
Bohren, M. A., Hofmeyr, G. J., Sakala, C., Fukuzawa, R. K., & Cuthbert, A. (2017). Continuous
support for women during childbirth. Cochrane Database of Systematic Reviews.
HФtoft D., & Maimburg R. D. (2021). Epidural analgesia birth and adverse neonatal outcomes: A
population-based cohort study. Women and Birth, 34, e286-e291.
Hanley, G. E., Bickford, C., Ip, A., Lanphear, N., Lanphear, B., Weikum, W., Zwaigenbaum, L., &Oberlander, T. F. (2021). Association of Epidural Analgesia During Labor and Delivery With
Autism Spectrum Disorder in Offspring. JAMA, 326(12), 1178–1185.
Kano N, Kaneda K, Uehara K, Muradate, M., Shishido. E., Maeda, Y. (2021). Effect of labor
analgesia on mother-child bonding one month after delivery; From analysis of perinatal center,mother-child cohort. The 35th Congress of the Japan Academy of Midwifery.
Kawasoe, I., & Kataoka, Y. (2020). Prevalence and risk factors for postpartum urinary retention after vaginal delivery in Japan: A case-control study. Japan Journal of Nursing Sci
ence, 17(2). doi:10.1111/jjns.12293
Kurakazu, M., Umehara, N., Nagata, C., Yamashita, Y., Sato, M., Sago, H. (2020). Delivery modeand maternal and neonatal outcomes of combined spinal–epidural analgesia compared with noanalgesia in spontaneous labor: A single-center observational study in Japan. Japan Society of
Obstetrics and Gynecology, 46(3), 425-433.
Légaré, F., Kearing, S., Clay, K., Gagnon, S., D 'Amours, D., Rousseau, M., O'Connor, A. (2010).
Are you SURE? Assessing patient decisional conflict with a 4-item screening test. Canadian
Family Physician, 56(8), 308-314.

38

Mikkelsen, A. P., Greiber, I. K., Scheller, N. M., Lidegaard, Ø. (2021). Association of Labor
Epidural Analgesia with Autism Spectrum Disorder in Children. JAMA, 326(12), 1170–1177.
Osaka, W., & Nakayama, K. (2014). A guide to “decide” in your own way for patientsdiagnosed with breast cancer to decide the operation methods.
Paech, M. J., Godkin, R., Webster, S. (1998). Complications of obstetric epidural analgesia andanaesthesia: A prospective analysis of 10995 cases. International Journal of Obstetric
Anesthesia, 7(1), 5-11.
Creating pictograms. http://iconarray.com/
Qiu, C., Lin, J. C., Shi, J. M., Chow, T., Desai, V. N., Nguyen, V. T., Riewerts, R. J., Feldman, R.
K., Segal, S., Xiang, A. H. (2020). Association between epidural analgesia during labor andrisk of autism spectrum disorders in offspring. JAMA Pediatrics, 174(12), 1168-1175.
Saito, T. (2019). Neurodevelopmental disorders in DSM-5 and ICD-11. Japanese Journal of
Molecular Psychiatry, 19(4), 217-223.
Shishido, E., & Horiuchi, S. (2018). Hope of delivery using epidural anesthesia during laborcompared with no anesthesia and delivery outcome. Maternal Health. 59(1), 112－120.
Shishido, E., Shuo, T., Shinohara, K., Horiuchi, S. (2021). Effects of epidural anesthesia on
postpartum maternity blues and fatigue and its relation to changes in oxytocin. Japan Journalof Nursing Science, 18(3). doi:10.1111/jjns.12406
Shishido, E., Yaju Y., Horiuchi, S. (2018). The gap between expectations and realities ofpain and fatigue in women receiving epidural anesthesia versus no anesthesia. Journal ofJapan Academy of Midwifery, 32(2),101-112.
UeharaK, Muradate, M., Kano K, Kaneda K, Shishido. E., Maeda, Y. (2021). Effect of labor
analgesia on postpartum depression; From analysis of perinatal center, mother-childcohort-. The 35th Congress of the Japan Academy of Midwifery.
Unno, N., & Itakura, A. (2017). Examination of the safety of labor analgesia. 2017

Ministry of Health, Labour and Welfare Promotion of Special Research Project"Study of the actual situation of labor analgesia and building a safety management
system."Yip, S. K., Sahota, D., Pang, M. W., Chang, A. (2005). Postpartum Urinary Retention. Obst
etrics & Gynecology, 83(10), 881－891.
Wall-Wieler, E., Bateman, B. T., Hanlon-Dearman, A., Roos, L. L., & Butwick, A. J. (2021).
Association of Epidural Labor Analgesia with Offspring Risk of Autism Spectrum Disorders.
JAMA Pediatrics, 175(7), 698–705.

39

“Finding a Way to Relieve Delivery Pain that is Right for You”. Helping pregnant women make an
informed decision about epidural anesthesia and no epidural anesthesia＜1st Edition＞
Authors
St. Luke's International Hospital, Ayame Henna
St. Luke's International University, Women's Health and Midwifery, Assistant Professor Eri
Shishido
Keio University, Chronic and Terminal Care Nursing, Associate Professor Wakako Osaka
St. Luke's International University, Graduate School, Women’s Health and Midwifery,
Professor Shigeko Horiuchi
Medical supervision
National Center for Children's Health and Development Obstetrician & Gynaecologist,
Kohei Ogawa
Date published：July. 7, 2018. Last updated：January 20, 2019.
This Aid is supported by a Grant-in-Aid for Scientific Research （Ａ）17H01613(Principal Investigator Shigeko Horiuchi）.
"Finding a Way to Relieve Labor Delivery Pain That is Right for You" Informational decision
aid about childbirth with or without epidural anesthesia.
＜2nd Edition＞
Authors
St. Luke's International University, Yumiko Arabiki
St. Luke's International University, Women's Health and Midwifery, Assistant Professor Eri
Shishido
St. Luke's International University, Graduate School, Women's Health and Midwifery,
Professor Shigeko Horiuchi
Medical supervision
National Center for Children's Health and Development Obstetrician & Gynaecologist,
Kohei Ogawa
Date published：August 31, 2021. Last updated date: February 20, 2022.
This Aid is supported by a Grant-in-Aid for Scientific Research for Young Scientists
21K1740 (Principal Investigator Eri Shishido).

＜Unauthorized copying or reproduction prohibited＞