Epidural anesthesia is the most popular means for pain relief during labor. In fact, more women ask for an epidural by name than any other method of pain relief. Over 50% of women giving birth at hospitals use epidural anesthesia.
As you prepare yourself for “labor day”, learn as much as possible about pain relief options so you will be equipped and ready to make decisions throughout your birth experience. Understanding the different types of epidurals, how an epidural is administered, and the benefits and potential risks of an epidural will prepare you to make an informed decision for you and your baby as your birth unfolds.
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 complete anesthesia, which is total lack of feeling. Epidurals block the nerve impulses from the lower spinal segments resulting 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, to decrease the required dose of local anesthetic. This way pain relief is achieved with minimal effects. These medications may be used in combination with epinephrine, fentanyl, morphine, or clonidine to prolong the epidural’s effect or 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, a physician who specializes in 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. Then a needle will be inserted into the numbed area that surrounds the spinal cord in the lower back. A small tube or catheter is threaded through the needle into the epidural space. The needle is carefully removed leaving the catheter in place so medication can be given through periodic injections or by continuous infusion.The catheter will be taped to your back to prevent it from slipping out.
What are the types of epidurals?
There are 2 basic epidurals used today. However, hospitals and anesthesiologists vary on the dosages and the combination of medication they use. You will want to ask your care providers at the hospital about their protocol.
• Regular Epidural: After the catheter is in place, a combination of narcotic and anesthesia is administered through either a pump or periodic injections into the epidural space. The narcotic, such as fentanyl or morphine, is given to replace some of the higher doses of anesthetic, such as bupivacaine, chloroprocaine, or lidocaine, which helps reduce some of the adverse effects of anesthesia. You will want to find out your hospitals 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, withdrawing the needle and leaving the catheter in place. This allows you to move more freely in the bed and change positions with assistance. With the catheter in place you may decide later to request an epidural if the initial intrathecal injection is not enough. You will want to find out 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 is 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
- Relieving the discomfort of childbirth can help some woman have a more positive birth experience
- Most of the time 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 not helping any longer, an epidural may be what you need to move through exhaustion, irritability, and fatigue. An epidural may 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 perfected and much of its success depends on the care in 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 make sure there is adequate blood flow to your baby. If this happens 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 from epidural use. If symptoms persist, a special procedure called a “blood patch”, an injection of your blood into the epidural space, can be done to relieve the headache
- After your epidural is placed, you will need to alternate from lying on one side to the other 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 may experience the following side effects: shivering, ringing of the ears, backache, soreness where the needle is inserted, nausea, or difficulty urinating
- You may find that your epidural makes pushing more difficult and additional interventions such as Pitocin, forceps, vacuum extraction or cesarean may become necessary
- For a few hours after birth the lower half of your body may feel numb which 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 some babies will have trouble “latching on” which can lead to breastfeeding difficulties. Other studies suggest that the baby may experience respiratory depression, fetal malpositioning; and an increase in fetal heart rate variability, which may increase the need for forceps, vacuum, cesarean deliveries and episiotomies.
Common Questions About Epidurals:
Does the placement of epidural anesthesia hurt? This depends on who you ask. Some women describe an epidural placement as feeling a bit of discomfort in the area where the back was numbed and then feeling 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 also 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 stated above, research on the effects of epidurals on newborn health is somewhat ambiguous and many factors may be contributing to newborn health at the time of birth. How much of an effect these medications will have is difficult to judge and could vary based on dosage, how long labor continues and individual babies. Dosages and medications vary, so concrete information from research is lacking. Studies reveal that some babies may initially have trouble “latching on” among other difficulties with breastfeeding. While in-utero, they may become lethargic and have trouble getting into position for delivery. These medications have been known to cause respiratory depression, and decreased fetal heart rate in newborns. Though the medication may not harm the baby, the baby may experience 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 and dosage of epidural you receive, you may 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 wear off completely in one or two hours. Some women experience an uncomfortable burning feeling around the birth canal as the medication wears off.
Will I be able to push? You may not feel that you are having a contraction because of your epidural anesthesia. If you can not feel contractions then pushing may be difficult to control. For this reason your baby may need additional help coming down the birth canal. It may be necessary to apply pressure on your abdomen at the top of your uterus and/or use forceps to pull the baby out.
Does an epidural always work? For the most part, epidurals are effective in relieving pain during labor. There are some women who 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.
American Pregnancy Association, http://www.americanpregnancy.org