Labor

Epidural Anesthesia

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.

The term epidural is often short for epidural analgesia, a form of regional analgesia involving injection of drugs through a catheter placed into the epidural space. The injection can cause both a loss of sensation (anaesthesia) and a loss of pain (analgesia), by blocking the transmission of signals through nerves in or near the spinal cord.

The epidural space is the space inside the bony spinal canal but outside the membrane called the dura mater (sometimes called the “dura”). In contact with the inner surface of the dura is another membrane called the arachnoid mater (“arachnoid”). The arachnoid encompasses the cerebrospinal fluid that surrounds the spinal cord.

Epidural medications fall into a class of drugs called local anesthetics, such asbupivacainechloroprocaine, 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.

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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.

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Are there any risks or negative side affects?

Complication rates with Epidural Steroid Injections are very low.

As with all injection procedures, the contrast dye contains iodine, so patients with a known allergy to iodine may have an adverse reaction. However, because the contrast is injected into a joint and not a vein, allergic reactions are rare.

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.
  • 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.
  • 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.
  • 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.)
  • 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.

Will An EPIDURAL AFFECT MY NEWBORN?

The most recent studies suggest that an epidural does not have a negative effect on a newborn (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 newborn behavior are much less than the effects of systemic narcotics.

CAN ANYONE HAVE AN 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.

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