Epidural anesthesia is the most popular method of pain relief during labor. More women request an epidural by name than any other method of pain relief. More than 50% of women giving birth at hospitals use epidural anesthesia.
As you prepare yourself for “labor day”, try to learn as much as possible about pain relief options so that you will be better prepared to make decisions during the labor and birth process. Understanding the different types of epidurals, how they are administered and their benefits and risks, will help you in your decision-making during the course of labor and delivery.
What is epidural anesthesia?
Epidural anesthesia is regional anesthesia that blocks pain in a particular region of the body. The goal of an epidural is to provide analgesia, or pain relief, rather than anesthesia which leads to total lack of feeling. Epidurals block the nerve impulses from the lower spinal segments. This results in decreased sensation in the lower half of the body. Epidural medications fall into a class of drugs called local anesthetics, such as bupivacaine, chloroprocaine, or lidocaine. They are often delivered in combination with opioids or narcotics such as fentanyl and sufentanil in order to decrease the required dose of local anesthetic. This produces pain relief with minimal effects. These medications may be used in combination with epinephrine, fentanyl, morphine, or clonidine to prolong the epidural’s effect or to stabilize the mother’s blood pressure.
How is an epidural given?
Intravenous (IV) fluids will be started before active labor begins and prior to the procedure of placing the epidural. You can expect to receive 1-2 liters of IV fluids throughout labor and delivery. An anesthesiologist (specialist in administering anesthesia), an obstetrician, or nurse-anesthetist will administer your epidural. You will be asked to arch your back and remain still while lying on your left side or sitting up. This position is vital for preventing problems and increasing the epidural effectiveness. An antiseptic solution will be used to wipe the waistline area of your mid back to minimize the chance of infection. A small area on your back will be injected with a local anesthetic to numb it. A needle is then inserted into the numbed area surrounding the spinal cord in the lower back. After that, a small tube or catheter is threaded through the needle into the epidural space. The needle is then carefully removed, leaving the catheter in place to provide medication either through periodic injections or by continuous infusion.The catheter is taped to the back to prevent it from slipping out.
What are the types of epidurals?
There are 2 basic epidurals in use today. Hospitals and anesthesiologists will differ on the dosages and combinations of medication. You should ask your care providers at the hospital about their practices in this regard.
• Regular Epidural: After the catheter is in place, a combination of narcotic and anesthesia is administered either by a pump or by periodic injections into the epidural space. A narcotic such as fentanyl or morphine is given to replace some of the higher doses of anesthetic such as bupivacaine, chloroprocaine, or lidocaine. This helps reduce some of the adverse effects of the anesthesia. You will want to ask about your hospital’s policies about staying in bed and eating.
• Combined Spinal-Epidural (CSE) or “Walking Epidural”: An initial dose of narcotic, anesthetic or a combination of the two, is injected beneath the outermost membrane covering the spinal cord, and inward of the epidural space. This is the intrathecal area. The anesthesiologist will pull the needle back into the epidural space, threading a catheter through the needle, then withdrawing the needle and leaving the catheter in place. This allows more freedom to move while in the bed and greater ability to change positions with assistance. With the catheter in place you can request an epidural at any time if the initial intrathecal injection is inadequate. You should ask about your hospital’s policy on moving around and eating/drinking after the epidural has been placed. With the use of these drugs, muscle strength, balance and reaction are reduced. CSE should provide pain relief for 4-8 hours.
What are the benefits of epidural anesthesia?
- Allows you to rest if your labor is prolonged
- By reducing the discomfort of childbirth, some woman have a more positive birth experience
- Normally, an epidural will allow you to remain alert and be an active participant in your birth
- If you deliver by cesarean, an epidural anesthesia will allow you to stay awake and also provide effective pain relief during recovery
- When other types of coping mechanisms are no longer helping, an epidural can help you deal with exhaustion, irritability, and fatigue. An epidural can allow you to rest, relax, get focused and give you the strength to move forward as an active participant in your birth experience.
- The use of epidural anesthesia during childbirth is continually being refined and much of its success depends on the skill with which it is administered.
What are the Disadvantages of epidural anesthesia?
- Epidurals may cause your blood pressure to suddenly drop. For this reason your blood pressure will be routinely checked to help ensure an adequate blood flow to your baby. If there is a sudden drop in blood pressure, you may need to be treated with IV fluids, medications, and oxygen.
- You may experience a severe headache caused by leakage of spinal fluid. Less than 1% of women experience this side effect. If symptoms persist, a procedure called a “blood patch”, which is an injection of your blood into the epidural space, can be performed to relieve the headache.
- After your epidural is placed, you will need to alternate sides while lying in bed and have continuous monitoring for changes in fetal heart rate. Lying in one position can sometimes cause labor to slow down or stop.
- You might experience the following side effects: shivering, ringing of the ears, backache, soreness where the needle is inserted, nausea, or difficulty urinating.
- You might find that your epidural makes pushing more difficult and additional interventions such as Pitocin, forceps, vacuum extraction or cesarean might become necessary
- For a few hours after the birth the lower half of your body may feel numb. Numbness will require you to walk with assistance.
- In rare instances, permanent nerve damage may result in the area where the catheter was inserted.
- Though research is somewhat ambiguous, most studies suggest that some babies will have trouble “latching on” causing breastfeeding difficulties. Other studies suggest that a baby might experience respiratory depression, fetal malpositioning, and an increase in fetal heart rate variability, thus increasing the need for forceps, vacuum, cesarean deliveries and episiotomies.
Common Questions About Epidurals:
Does the placement of epidural anesthesia hurt? The answer depends on who you ask. Some women describe an epidural placement as creating a bit of discomfort in the area where the back was numbed and a feeling of pressure as the small tube or catheter was placed.
When will my epidural be placed? Typically epidurals are placed when the cervix is dilated to 4-5 centimeters and you are in true active labor.
How can my epidural affect labor? Your epidural can cause your labor to slow down and make your contractions weaker. If this happens you may be given the medicine Pitocin to help speed up labor.
How can an epidural affect my baby? As previously stated, research on the effects of epidurals on newborns is somewhat ambiguous, and many factors can affect the health of a newborn. How much of an effect these medications will have is difficult to predetermine and can vary based on dosage, the length of labor, and the characteristics of each individual baby. Since dosages and medications can vary, concrete information from research is currently unavailable. One possible side effect of an epidural with some babies is a struggle with “latching on” in breastfeeding. Another is that while in-utero, a baby might also become lethargic and have trouble getting into position for delivery. These medications have also been known to cause respiratory depression and decreased fetal heart rate in newborns. Though the medication might not harm these babies, they might experience some subtle effects like those mentioned above.
How will I feel after the placement of epidural? The nerves of the uterus should begin to numb within a few minutes after the initial dose. You will probably feel the entire numbing effect after 10-20 minutes. As the anesthetic dose begins to wear off, more doses will be given–usually every one to two hours. Depending on the type of epidural and dosage administered, you can be confined to your bed and not allowed to get up and move around. If labor continues for more than a few hours you will probably need urinary catheterization because your abdomen will be numb, making urinating difficult. After your baby is born, the catheter is removed and the effects of the anesthesia will usually disappear within one or two hours. Some women report experiencing an uncomfortable burning sensation around the birth canal as the medication wears off.
Will I be able to push? You might not be able to tell that you are having a contraction because of your epidural anesthesia. If you can not feel your contractions, then pushing may be difficult to control. For this reason your baby might need additional help coming down the birth canal including the application of pressure on your abdomen at the top of your uterus and/or the use of forceps.
Does an epidural always work? For the most part, epidurals are effective in relieving pain during labor. Some women complain of being able to feel pain and/or feeling that the drug worked better on one side of the body than the other.
Questions to ask your health care providers now and at the time of delivery in the hospital:
• What combination and dosage of drugs will be used?
• How could the medications affect my baby?
• Will I be able to get up and walk around?
• What liquids and solids will I be able to consume?
When can an epidural NOT be used?
An epidural may not be an option to relieve pain during labor if any of the following apply:
- You use blood thinners
- Have low platelet counts
- Are hemorrhaging or in shock
- Have an infection in the back
- Have a blood infection
- If you are not at least 4 cm dilated
- Epidural space can not be located by the physician
- If labor is moving too fast and there is not enough time to administer the drug
Compiled using information from the following sources:
American Academy of Family Physicians, http://www.aafp.org
William’s Obstetrics Twenty-Second Ed. Cunningham, F. Gary, et al, Ch. 19.
Mayo Clinic Guide To A Healthy Pregnancy Harms, Roger W., M.D., et al, Part 2.