From Curse to Comfort: Navigating Epidural Use on Shabbos
Ever since Chava was cursed “In pain you shall bear children” (Bereishis 3:16), labor pains have been an inseparable part of childbirth. We are presented with a unique type of pregnancy pain in this weeks Parsha when the passuk explains, “But the children struggled in her womb, and she said, “If so, why do I exist?” and she went to inquire of Hashem.” (Bereishis 25:22). In the last several decades, women have benefited from the advent of epidural analgesia to provide significant pain relief during labor and delivery.
In halacha, a woman is only considered a Yoledes, or in labor, if she meets one of the following three conditions: Advanced dilation of the cervix, significant bleeding, or when she cannot walk unsupported. At this stage, she is in active labor and Shabbos may be desecrated, not only for things that are needed for the birth but for anything needed to calm her and reassure her, this is called Yisuvei Daytah (see Shulchan Aruch, O.C. 330). Some examples of this are: a light may be switched on so that she feels that the medical staff can see what they are doing properly, one may boil a cup of tea for her, or prepare her bed.
The Pnei Menachem corresponded with Rav Shmuel Wosner about epidurals for a Mekasheh Leileid – a woman experiencing difficulty in labor and delivery. He explained that during the week he recommended epidurals despite the very small chance of spinal cord injury and nerve damage because it is extremely rare, particularly if the anesthesiologist or anesthetist is an expert. Moreover, such injuries are generally treatable. However, he wanted Rav Wosner’s opinion about epidurals on Shabbos, given that it constitutes a Melacha d’Oraisa of causing the patient to bleed. He noted that it likely was necessary for Yesuvei Daytah. Additionally, epidurals allow women to conserve or regain their strength for delivery.
Rav Wosner’s response (Shevet haLevi 9:75) was that he agrees that the Sakana posed by an epidural is insignificant. He states that if she is already in the process of birth and she is experiencing difficulty, and the pain is great and intolerable for an extended period, it is obvious that it is possible and perhaps even a Mitzva to recommend it. Concerning the Issur of causing bleeding, Rav Wosner first notes that not every injection constitutes a Melacha d’Oraisa. While intravenous injections (IV) usually constitute a Psik Reisha of bleeding, intramuscular (IM) and subcutaneous injections do not. He concludes that although it is more likely to be permissible if the epidural placement were only an Issur d’Rabbanan, there are likely to be other Melachos violated in the course of placement.
Rav Wosner then explains based off the Rambam Hilchos Shabbos Perek 2 that Yesuvei Daytah is only when she cries out due to her labor pains. Certainly, if there is already bleeding, it should be done. The criterion of bleeding, as mentioned by Rav Wosner, correlates with the second of the three conditions mentioned above. His criterion of “crying out due to her labor pains”, based on the Rambam, likely correlates with the condition of advanced dilation of the cervix which is usually accompanied by extremely painful contractions. Rav Wosner concludes: At any rate, if she is already crying out due to her labor pains that are difficult for her to tolerate, particularly in the case of weak or sick women, there is room to be lenient.
Rav Wosner then concludes based off the Magid Mishna quoted in the Biur Halacha (O.C. 328:4) that an epidural during active labor is a patient need, but, if it were withheld, the patient would not be in Sakana, which would be permitted according to the Biur Halacha. He therefore rules, “With regard to our question, where she is crying bitterly due to her labor pains and, generally, blood pressure increases due to the fright, there is room to be lenient, at least in cases similar to this.”
It is interesting to point out that despite Rav Wosner’s measured response in Shu”t Shevet haLevi, in the Moriah journal (Elul 5775, Vol. 400, p. 299) he refers to his exchange with the Pnei Menachem and presents a different (and seemingly more understandable) perspective permitting an epidural on Shabbos to any Yoledes who requests one and not just one who screams out in pain.
Adapted and translated from Rabbi Yossi Sprung on medicalhalacha.org