Epidural Pain Relief
An epidural delivers continuous pain relief to the lower part of your body while allowing you to remain fully conscious. It decreases sensation but doesn't result in a total lack of feeling.
Medication is delivered through a catheter – a very thin, flexible, hollow tube – that's inserted into the epidural space just outside the membrane that surrounds your spinal cord and spinal fluid. An epidural is the most commonly used method of pain relief for labor in the United States.
To allow the catheter to be inserted, you lie curled on your side or sit on the edge of the bed while an anesthesiologist or nurse anesthetist cleans your back, injects the area with numbing medicine, and carefully guides a needle into your lower back. (This may sound painful, but for most women, it's not.)
The anesthesiologist or nurse anesthetist then passes a catheter through the needle, withdraws the needle, and tapes the catheter in place so medication can be administered through it as needed. You can lie down at this point without disturbing the catheter.
First you're given a small "test dose" of medicine to be sure the epidural was placed correctly, followed by a full dose if there are no problems. Your baby's heart rate is monitored continuously, and your blood pressure is taken every five minutes or so for a while after the epidural is in to make sure it isn't having any negative effects.
The medication delivered by the epidural is usually a combination of a local anesthetic and a narcotic. Local anesthetics block sensations of pain, touch, movement, and temperature, and narcotics blunt pain without affecting your ability to move your legs. Used together, they provide good pain relief with less loss of sensation in your legs and at a lower total dose than you'd need with just one or the other.
You'll start to notice the numbing effect about ten to 20 minutes after the first dose of medication, though the nerves in your uterus will begin numbing within a few minutes. You'll receive continuous doses of medication through the catheter for the rest of your labor.
You may also have the option of patient-controlled analgesia, which means that you can control when you get more medication via a pump that's connected to the catheter. (The amount of medication you can give yourself is limited, so there's little chance of overdose.)
After you deliver your baby, the catheter will be removed. (If you've had a c-section, sometimes the catheter is left in to administer postoperative pain medication.) Having the catheter removed doesn't hurt at all beyond the sting of having the tape pulled off.
Best Time to get an Epidural
In the past, many practitioners wanted a woman to be in active labor before starting an epidural due to a concern that it might slow down her contractions. These days, most caregivers will allow you to start an epidural whenever you ask for it.
Studies have shown that starting an epidural in early labor (compared with later in labor) is not more likely to prolong labor or lead to a c-section or other interventions such as a forceps delivery. (However, as we note later, having an epidural at all does increase your risk of a vacuum extraction or forceps delivery.)
If you arrive at the hospital before you’re in active labor and you know you’re going to want an epidural, you can ask the anesthesiologist to place the catheter as soon as you’re settled in your bed. Then you can wait to start the medication when your labor becomes active.
Or you can wait and see how you feel. It’s never too late to get an epidural unless the baby’s head is crowning. The only risk to waiting is that the anesthesiologist may be busy and you may have to wait a bit longer for her to arrive once you decide you want the pain medication.
Advantages to having an Epidural for Pain Relief during Labour
- An epidural provides a route for very effective pain relief that can be used throughout your labor.
- The anesthesiologist or nurse anesthetist can control the effects by adjusting the type, amount, and strength of the medication. This is important because as your labor progresses and your baby moves farther down into your birth canal, the dose you've been getting might no longer cover the pain, or you might suddenly have pain in a different area.
- Since the effect of the medication is localized, you'll be awake and alert during labor and birth. And, because you're pain-free, you can rest if you want (or even sleep!) as your cervix dilates. As a result, you may have more energy when it comes time to push.
- Unlike with systemic narcotics, only a tiny amount of medication reaches your baby.
- Once the epidural's in place, it can be used to provide anesthesia if you need a c-section or if you're having your tubes tied after delivery.
- You have to stay in an awkward position for ten to 15 minutes while the epidural is put in, and then wait another five to 20 minutes before the medication takes full effect. This may seem like a minor inconvenience, though, when the tradeoff is hours of pain relief.
- Depending on the type and amount of medication you're getting, you may lose some sensation in your legs and be unable to stand. Sometimes, particularly in early labor, so little anesthetic is needed to make you comfortable that you have normal strength and sensation in your legs and can move around without difficulty. (This is called a "walking epidural.") Still, many practitioners and hospitals won't allow you to get out of bed once you've had an epidural, whether you think you can walk or not.
- An epidural requires that you have an IV, frequent blood pressure monitoring, and continuous fetal monitoring.
- An epidural often makes the pushing stage of labor longer. The loss of sensation in your lower body weakens your bearing-down reflex, which can make it harder for you to push your baby out.
- You may want to have the epidural dose lowered while you're pushing so you can participate more actively in your baby's delivery – but it may take time for the pain medication to wear off enough that you can feel what you're doing, and there's no evidence that reducing the epidural dose actually shortens this stage of labor.
- Having an epidural makes it more likely that you'll have a vacuum extraction or forceps delivery, which in turn increases your risk for serious lacerations. The assistance of a vacuum or forceps also increases the risk of bruising for your baby. (The risks of more serious problems for your baby are relatively low.)
- In some cases, an epidural provides spotty pain relief. This can happen because of variations in anatomy from one woman to the next or if the medication doesn't manage to bathe all of your spinal nerves as it spreads through your epidural space.
- The catheter can also "drift" slightly, making pain relief spotty after starting out fine. (If you notice that you're starting to have pain in certain places, ask for the anesthesiologist or nurse anesthetist to be paged so your dose can be adjusted or your catheter reinserted.)
- The drugs used in your epidural may temporarily lower your blood pressure, reducing blood flow to your baby, which in turn slows his heart rate. (This is treated with fluids and sometimes medication.)
- Narcotics delivered through an epidural can cause itchiness, particularly in your face. They may also bring on nausea – though this is less likely with an epidural than from systemic medication, and some women feel nauseated and throw up during labor even without pain medication.
- Anesthetics delivered through an epidural can make it more difficult to tell when you need to pee. Also, if you can't pee into a bedpan, which for many people is harder than letting go on a toilet, you may need to be catheterized (have a catheter inserted into your urethra).
- An epidural raises your risk of running a fever in labor. No one knows exactly why this happens, but one theory is that you pant and sweat less (because you're not in pain), so it's harder for your body to give off the heat generated by labor.
- It doesn't boost your or your baby's odds of getting an infection – but since it's unclear at first whether the fever is from the epidural or from an infection, you and your baby could wind up getting unnecessary antibiotics.
- Epidurals are associated with a higher rate of babies in the posterior or "face-up" position at delivery. Women whose babies are face-up have longer labors, tend to need Pitocin more often, and have a significantly higher rate of c-sections. (There's controversy, though, over whether having an epidural actually contributes to babies ending up in this position – because the pelvic floor is relaxed – or whether women whose babies are in the posterior position have more painful labors and so request epidurals more often.)
- In 1 in 100 women, an epidural causes a bad headache that may last for days. This is caused by a leakage of spinal fluid. (You can reduce the risk of headache by lying as still as possible while the needle is being placed.)
- In very rare cases, an epidural affects your breathing, and in extremely rare cases it causes nerve injury or infection.
Affect on New Born
The most recent studies suggest that an epidural does not have a negative effect on a new born (as measured by his Apgar score, an evaluation routinely done immediately following birth). In fact, some studies show that babies whose moms had epidurals had better Apgar scores than babies whose moms had prolonged labors without the relief of an epidural.
Whether or not an epidural affects a baby's ability to breastfeed immediately following birth remains controversial. Some experts suggest that the baby may have trouble latching on if the mother had an epidural. Others believe there are no good studies on which to base this conclusion.
We do know that any effects of an epidural on new born behavior are much less than the effects of systemic narcotics.
Contraindications of Epidural
Not all women are good candidates for this kind of pain relief. You won't be able to have an epidural if you have abnormally low blood pressure (because of bleeding or other problems), a bleeding disorder, a blood infection, a skin infection on the lower back where the needle would enter, or if you've had a previous allergic reaction to local anesthetics. Women taking specific blood-thinning medications can't have this kind of pain relief, either.