Shabbos on the Labor & Delivery Ward

“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)

Ever since Chava was cursed “In pain you shall bear children” (Bereishis 3:16), labor pains have been an inseparable part of childbirth. In the last several decades, women have benefited from the advent of epidural analgesia to provide significant pain relief during labor and delivery. Perhaps this is a portent of the forthcoming redemption when, as the Pasuk states, labor pains will cease to exist: “Before she even feels her labor pains she will give birth; before any suffering comes to her she will deliver a boy” (Yeshaya 67:7).

Though, as stated, labor pains are an integral part of childbirth and do not constitute a Sakana, it is clear that Shabbos may be desecrated to place an epidural catheter and administer medications through it. Though the pain may not pose a danger to life, it certainly upsets the parturient mother’s state of mind, particularly today when women are well aware of the option of an epidural. If so, Issurim may be violated due to the principle of “Yesuvei Da’ata” – calming and reassuring a woman in labor (Shulchan Aruch, O.C. 330). Additionally, epidurals allow women to conserve or regain their strength for delivery.

However, although the Halachic position seems clear, there is an interesting discussion between Rav Shmuel Wosner zt”l^[1] and the Pnei Menachem zt”l^[2] about the subject.

In 5755, the Pnei Menachem corresponded with Rav 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.^[3] However, he wanted Rav Wosner’s opinion about epidurals on Shabbos, given that it constitutes a Melacha d’Oraisa. He noted that it likely was necessary for Yesuvei Da’ata.

Rav Wosner’s response (which was later printed in Shevet haLevi 9:75) is fascinating. He agreed that the Sakana posed by an epidural is insignificant. He also dwelt on the Pnei Menachem’s apparent stress on “Mekasheh Leileid” that seems to discriminate between a women already in the process of birth and one at an earlier stage:

… 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. But many go to give birth with the intent to receive this injection. I don’t believe that is a Mitzva; I protest it.

Concerning the Issur of causing bleeding, Rav Wosner first notes that not every injection constitutes a Melacha d’Oraisa. While intravenous injections usually constitute a Psik Reisha of bleeding, intramuscular 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^[4], there are likely to be other Melachos violated in the course of placement.

Rav Wosner then establishes an important principle regarding Yesuvei Da’ata:

The following are the words of the Rambam, Hilchos Shabbos Perek 2: “If she needs a candle when crying out due to her labor pains, we light a candle for her, even if she is blind, because her mind is calmed by the [presence of the] candle”… At any rate [the Rambam’s ruling is] only when she cries out due to her labor pains. Certainly, if there is already bleeding, it should be done. But before that stage, we have not heard that it should even constitute Yesuvei Da’ata…

Rav Wosner’s distinction correlates with a distinction drawn by the Shulchan Aruch in Siman 330. A Yoledes is essentially a Choleh sheYesh Bo Sakana, thus Shabbos may be desecrated on her behalf. Chaza”l describe three signs that indicate the birthing process has begun (see below); before this stage, one may desecrate Shabbos to prepare for the birth only in the presence of clear indications that it is imminent. For example, if she has regular, steady contractions that are increasing in strength such that physicians would recommend that she go to the hospital, she may desecrate Shabbos to do so. The same applies if her membranes rupture (aka “her water breaks”).

When she reaches the hospital, any activities necessary to prepare for birth may be performed such as applying monitors, starting an IV for infusion of fluids and medications, indicated blood tests, and summoning a midwife or obstetrician. One may desecrate Shabbos to perform these actions, not because the woman is already considered to be a Yoledes, but because she needs to be prepared for delivery; she may be endangered if these are not performed. Other activities that are not needed to prepare for the birth are prohibited.

A woman is only considered a Yoledes 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 that all of her needs are being addressed. For example, a light may be switched on so that she feels that the medical staff can see what they are doing properly (this is even permissible if she is blind.) One may boil a cup of tea for her or prepare her bed. (However, a Shinui should be employed or a non-Jew enlisted, if possible. We will not elaborate on this here.)

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 implies that the leniency is only due to the difficulty in tolerating the labor pains or because they endanger her due to weakness or sickness. He then compares epidural analgesia to analgesic medications administered to a Choleh sheYesh Bo Sakana that do not have a curative effect but merely alleviate his pain. He explains that this constitutes “Tzarchei Choleh – the needs of the patient”; we will elaborate on this definition below.

The Shulchan Aruch (O.C. 328:4) issues a ruling based on the Magid Mishna in the name of the Ramban that one may desecrate Shabbos for a Choleh sheYesh Bo Sakana not only to save his life, but also through actions that are needed, even though it would not be a Sakana if they were not performed. This applies to any endangered patient, not only to a Yoledes.

The Biur Halacha discusses this ruling at length. He proves that many Rishonim disagree and hold that one may only desecrate Shabbos if those actions are necessary to save the patient’s life. His well-known conclusion is that one should only rely on the Magid Mishna’s position to permit Issurim d’Rabbanan.

The Poskim that followed the Biur Halacha carefully examined his argument that many Rishonim dispute the Magid Mishna’s ruling. In fact, Rav Wosner himself (Shevet haLevi 8:71) raises doubts about it. At any rate, he asserts that an epidural during active labor falls into this category – it is a patient need, but, if it were withheld, the patient would not be in Sakana. 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.”

Rav Wosner’s response is somewhat surprising. It seems logical that when a woman enters active labor, any actions that provide Yesuvei Da’ata should be permitted l’Chatchila, even if she is strong, healthy, not suffering greatly, and not crying out in pain. Is the Yesuvei Da’ata brought about by an epidural any less than that brought about by a cup of hot tea or adjusting the air conditioning?!

The Pnei Menachem, in his reaction to Rav Wosner’s response (printed in Otzar Michtavim 2), noted that if a Yoledes suffers from mental illness and is at risk for acute depression (which constitutes a Sakana according to many Poskim), or if she has significant heart disease, and if she is not given an epidural her life will be endangered, it should be more readily permitted.

This is also an astonishing comment. Why is there a need for the condition that the Yoledes’ life will be endangered when an epidural should be permitted due to Yesuvei Da’ata?

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.

[1] R’ Wosner zt”l (1913-2015) was the Av Beis Din and Mara d’Asra of the Zichron Meir neighborhood and the Rosh Yeshiva of Yeshivas Chachmei Lublin in Bnei Brak. He was considered one of the Poskei haDor and published 11 volumes of Shu”t Shevet haLevi during his lifetime, along with numerous other Sefarim.

[2] R’ Pinchas Menachem Alter zt”l (1926-1996) was the son of the Imrei Emes, and became the seventh Rebbe of Ger after the passing of his brother R’ Simcha Bunim (the Lev Simcha) in 1992.

[3] For a more detailed treatment of the risks of epidural analgesia see Asya 65-66, Essay by Rav Yoel and Dr. Chana Katan.

[4] [Editor’s note: From a practical perspective, placement of an epidural catheter would be considered Psik Reisha for bleeding at the insertion site.]