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Overview

In this episode, we are talking about epidurals. There are three separate procedures that can be done that are often lumped under the umbrella term, “epidural”.  The three procedures are epidurals, spinals, and the combined spinal-epidural. These medications and methods of delivery are the best solutions we have to minimize pain during labor with the least risk. Like any intervention, there are risks and benefits. This article examines the evidence on epidurals so you have the information you need to decide whether this is something you want to include in your birth. Learn about your options are for an epidural, what is involved in the procedure, how it will impact your labor and birth, the benefits, risks, and possible side effects.

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Epidural Administration

Epidural administration is a method of administering medication into the epidural space around the spinal cord. People commonly use the term epidural to describe any anesthetic drug administered in your back used for labor and birth. There are technically three different methods widely referred to as an epidural – epidurals, spinals, and the combined spinal-epidural.

Epidural

An epidural is an ideal pain medication for labor and birth because it affects the area from your belly button to your upper legs. Epidural administration allows continuous administration that your care provider can adjust for your needs throughout your labor and birth. An epidural significantly relieves pain and allows you to remain awake. Plus, you can still feel pressure which is helpful during the second (pushing) labor stage.

Spinal Anesthesia (AKA Spinal Block)

A spinal block is a one-time injection directly into your spinal fluid. This takes effect quickly, usually within about 5 minutes, and lasts about one or two hours.

Combined Spinal-Epidural

A spinal is frequently used in conjunction with an epidural to make a combined spinal-epidural. This takes effect within about five minutes, like a spinal, and then works to deliver continuous medication like an epidural.

For this article, we refer to an epidural as either solely an epidural or spinal-epidural. You will need to talk to your care provider if you want to get more into detail as to your options between just an epidural and a combined spinal-epidural. While they differ, both deliver continuous medication, and everything we are talking about today applies to both.

Medications Used in Epidurals

The medications in an epidural can be a combination of more than one drug. What medications are used, in what amounts, and how long will all depend on many factors. These include your individual needs, any allergies to medicines, your medical history, your care provider, the anesthesiologist, and the hospital. Different techniques, drugs, and doses all have different results and risks. Generally, the medication you will receive is a combination of a local anesthetic and an opioid. A local anesthetic decreases feeling in a specific area. Examples of local anesthetics are bupivacaine, chloroprocaine, or lidocaine. An opioid reduces the required dose of the anesthetic and prolongs the effects while stabilizing your blood pressure. Common opioids are fentanyl or morphine. The result is relief from feeling contractions with minimal effects.

Depending on the hospital and where you live, you may have additional drugs in an epidural. In the UK, diamorphine is also added to an epidural for a cesarean section. Diamorphine is medical-grade heroin. When you talk about medications via an epidural, you are dealing with powerful and very effective drugs.

Walking Epidural

A “walking” epidural is a lower dose of medication from an epidural that allows you to maintain more feeling. You may not necessarily be able to stand or walk. A lower dose of medication also means you have more sensation, and it may be easier to feel when you are having a contraction or when you need to push during the second stage of labor.

Patient-Controlled Epidural

You may have the option of patient-controlled epidural analgesia. Patient-controlled means the epidural has a pump with a button to push if you would like more medication. This gives you more control over the amount of medication you are receiving. You don’t need to worry about overdosing because the pump limits how much medicine can be delivered within specific time frames.

Prevalence and Availability

Epidurals are common in the United States. For the most recent year data on epidural use is available (2016) 73.5% of mothers used an epidural during labor. Keep in mind that same year, 31.9% of births were via cesarean. Epidurals are available in all hospitals in the United States and are not an option if you opt for a home birth or a birth center.

Cesarean Birth

The majority of cesarean sections use an epidural. If you deliver by cesarean, an epidural anesthesia will allow you to stay awake and provide effective pain relief during the procedure and recovery. In rare cases or emergencies, general anesthesia may be used in which you are not awake during the surgery.

Contraindications for an Epidural

There are some instances for which an epidural would not be recommended. This could be if you use blood thinners, if you have low platelet counts, hemorrhaging or in shock, or have a blood infection or an infection in your back.

How an Epidural Works

An epidural blocks the nerve impulses from the lower spinal segments resulting in decreased sensation in the lower half of the body. A tiny catheter is inserted into a space between your vertebrae and the spinal fluid. Once it is in place, medication is delivered through the tube. Epidurals may take around 15 minutes or less to take effect, and if more pain relief is needed or desired, more medication can be delivered through the catheter.

What to Expect with an Epidural

In the past, many doctors wanted you to be in active labor before starting an epidural. Their concern was that an epidural might slow down your contractions. Today, most care providers will be supportive of starting an epidural whenever you request it. It can take 30-45 minutes from when you request an epidural until it is in place and working. This procedure requires an anesthesiologist, and if one is not immediately available, it could add additional wait time.

The window of opportunity to get an epidural is until your baby’s head is crowning. It is doubtful, especially if this is your first baby, to reach that point in a short time. If you know you want an epidural the second you get to the hospital, ask for one. You also have the option of the anesthesiologist putting the catheter in place and waiting to start the medication when your labor becomes more active.

To start, the anesthesiologist will ask you to arch your back and remain still either while lying on your left side or sitting up. The position you are in during this procedure is important for preventing problems and increasing the epidural effectiveness. They will use an antiseptic to wipe your lower back to minimize the chance of an infection. Next, the anesthesiologist will numb the injection site with a local anesthetic. When this happens, you may feel a pinch and sting for about 10 seconds. The epidural needle is left in place for a minute or two until they insert a thin, flexible catheter into the epidural space. When the anesthesiologist administers the epidural, you will feel some pressure, but it should not be painful. The catheter will then be taped to your back to keep it in place and prevent it from slipping out.

Epidural Benefits

The most significant benefit of an epidural is the ability to block or decrease pain. As far as medication to minimize the pain that can accompany contractions during labor, an epidural is the most used and the most effective medication and delivery system available today. There are also other reasons you may choose to opt for an epidural.

An epidural can also allow you to rest. This could be a big benefit if you have had a particularly long labor. Labor is a marathon and can be exhausting. Some moms are even able to sleep through some of their earlier labor with an epidural. Another benefit is that an epidural does not knock you out, so you will still be alert and actively participating in your birth. As your needs change during labor, the type and amounts of medications can be adjusted.

Epidural Effectiveness

According to one study, 98.8% of participants reported adequate labor anesthesia with an epidural. A tiny percentage of expecting mothers may not find the relief they are looking for with an epidural.  Initially, 12% of epidurals failed, and most were able to be corrected with adjustments. Some scenarios in which an epidural may not be very effective is if the baby is in an especially uncomfortable position. Occasionally, the epidural may only be working on one side of your body. This is caused by the catheter not being appropriately positioned, becoming dislodged, or if you remain in the same position for too long. Your anesthesiologist can quickly correct most of these issues. In some cases, if your epidural is not adequate, you may require a higher dose of medications. Please speak up and let your care provider know how you are feeling.

Epidural Side Effects

As with any medication, there are possible side effects that you might experience. A few of these are shivering, ringing in your ears, backache, or soreness at the insertion site. The narcotics delivered through an epidural can cause itchiness, particularly in your face. The medications used may also make you nauseous. Keep in mind you could also be nauseous from labor without an epidural.

According to the American College of Obstetricians and Gynecologists, approximately 30% of mothers with an epidural will experience a fever. Unfortunately, we do not know exactly why this happens. Having a fever does not increase your or your baby’s risk for an infection, but since a fever is a sign of an infection, it is possible you or your baby could end up with antibiotics unnecessarily.

An epidural may cause your blood pressure to suddenly drop, this happens in about 10% of women receiving an epidural. The issue with your blood pressure dropping is that it also affects blood flow to your baby. A drop in blood pressure is often treated with IV fluids, medications, and oxygen.

One side effect that affects less about 0.7% of women is a severe headache which is caused by leakage of spinal fluid. This can be treated with a procedure called a “blood patch”, in which a small amount of your blood is injected into the epidural space.

In rare instances, an epidural could affect your breathing and very rarely could cause permanent nerve damage or result in an infection. This is an overview of the side effects and this list is not specific to particular medications so you definitely want to discuss any possible side effects of the specific medications you will be given with your care provider.

Effects on Hormones

An epidural can affect the natural flow of hormones that happens during birth. The use of an epidural decreases your oxytocin levels. Oxytocin is the hormone that drives your contractions. For an in-depth analysis of how an epidural may affect hormones during labor see this article. A Cochrane review that examined studies comparing epidurals to other pain medications and non-medicated births found the use of Pitocin was slightly higher in the participants receiving an epidural.

Mobility

There is evidence that some labor positions are more effective than others. Upright and squatting positions tend to be more effective and may even reduce your time in labor. An epidural may limit your mobility and the positions you labor in due to loss of sensation and additional interventions like IV fluids, catheters, and electronic fetal monitoring.

Loss of Sensation

The medicines in an epidural decrease your sensation in the lower half of your body. This is beneficial for relieving pain but it may bring additional challenges. Depending on how numb you are with an epidural you may have difficulty telling when you are having a contraction and this can make pushing difficult to control. You may also be restricted to a hospital bed if you cannot stand safely. Thankfully, nurses and hospital staff are very helpful in assisting you with positions within your limitations.

Urine Catheter

An epidural may make it difficult to tell when you need to urinate, and you could have a catheter to empty your bladder. According to this study, about 4 out of five women who have an epidural require a catheter at some point during their labor.

IV Fluids

Epidurals are accompanied by IV fluids. To receive IV fluids you will have an IV line attached to the top of your hand that is connected to an IV pole. If for example, you need to go to the bathroom, you will be tethered to an IV pole and will need to take it with you.

Electronic Fetal Monitoring

Hospitals use continuous electronic fetal monitoring to monitor your baby’s heart rate and keep an eye on how they are tolerating labor. Electronic Fetal monitoring uses instruments to continuously record the heartbeat and the baby and the contractions of the uterus during labor. The machine used is a cardiotocograph, or CTG, and more commonly known as an electronic fetal monitor. Electronic Fetal Monitoring is most often done with a pair of belts wrapped around your abdomen. One of the belts is using a Doppler to detect your baby’s heart rate, and the other belt measures the length of contractions and the time between contractions. With continuous electronic fetal monitoring, you will be connected via wires to the CTG machine so you may not be able to move or walk around much.

How an Epidural Affects Your Baby

A big question is whether an epidural has an effect on your baby. Because there are no perfect studies with controlled test groups it is tough to assess exactly what the impact of an epidural on your baby is. Any medication that you use during labor enters your baby’s bloodstream through the umbilical cord. Many of the effects on your baby are a direct result of the possible side effects the epidural can have on you, like running a fever or having a drop in your blood pressure, and we talked about how that can impact your baby. As far as the research that I can find, epidurals have no known long-term disadvantages, but more studies and research are really needed.

Breastfeeding

The research on epidurals and their impact on breastfeeding is a little tough to dissect and there are some conflicting studies, about split in half between those that showed a negative association between epidurals and breastfeeding and about half showing no effect. It is really difficult to pinpoint a correlation between one intervention, like an epidural, with an outcome because there are so many other variables. If you are planning on an epidural and you are concerned about your baby breastfeeding take advantage of being in a hospital and ask to see a lactation consultant to really make sure you get off on the right foot with breastfeeding.

 

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