Epidural Anesthesia During Labor and Delivery

Epidural anesthesia is an excellent way of taking away the pain of labor and delivery. Like most invasive medical treatments it has risks and benefits, but it is generally safe, has significant advantages over general anesthesia, and less anesthetic is needed than with general anesthesia. An epidural causes less stress to the cardiovascular system because there is fewer ups and down with pain relief. There are times that an epidural would not be recommended such as:

  • patients on coagulation or platelet therapy
  • long-term use of aspirin or nonsteroidal anti-inflammatory drugs
  • problems with blood clotting
  • hypovolemic shock
  • abruptio placentae
  • an infection near the insertion site for the catheter
  • history of headaches
  • history of backaches (not related to pregnancy)
  • chronic neurologic disorders
  • an allergy to the pain medicines to be used
  • a history of certain heart conditions (talk with your anesthesiologist if you know you have heart disease)
  • not being able to understand the risks and benefits or how the procedure is done well enough to give informed consent
  • not being able to cooperate during the procedure for positioning and insertion of the needle
  • being unable to give feedback about pain levels or problems
  • previous spinal surgery has scarred the epidural space
  • spinal curvature such as scoliosis is present

It is important that you learn about those risks and benefits before deciding if an epidural is right for you. Although rare, infection and neurologic injury can happen. You and your support person should discuss risks and benefits and sign a written consent form before the epidural anesthetic is given. If you do not understand the risks and benefits or how the procedure is done, an epidural is not for you.

What is epidural anesthesia?

Epidural anesthesia uses repeated doses of a local anesthetic in the epidural space of the spinal area. It numbs the nerves from the uterus and birth passage without stopping labor. A successful epidural, once administered gives you an almost pain-free awake state throughout the entire labor and birth of your baby.

Most obstetricians will consider an epidural if the mother asks for it. Epidural is often the method of choice in cases of hypertension and premature labor.

An epidural is administered by an anesthesiologist — a physician who is a specialist in anesthesia. Your labor is watched carefully before the medicine is given. A specially trained certified nurse midwife or the physician will be near by until your baby is born.

How is it done?

Woman receiving an epidural (very short movie) An epidural is usually not administered until you are in active labor. Before the procedure begins, intravenous (IV) fluids are started and 1-2 liters of fluids are given. The IVs will continue throughout labor and birth. Then, you will be asked to position yourself lying down your left side with your chin on your chest and you knees close to your abdomen or in a sitting position with your head down, your shoulders slumped and your arms out in front—this bends the vertebrae and shows bony landmarks and opens up the vertebral spaces. The sitting position is preferred because it lets the anesthesiologist see anatomic landmarks more easily and keeps the spinal cord straight. The waistline area of your mid back is wiped with an antiseptic solution to reduce the skin bacteria and lessen the chance of infection. A coin-sized area of skin on your back is numbed with an injectable local anesthetic. You need to be as still as possible while a larger needle is placed through the numbed area and into the epidural space of your spine. A small tube (catheter) is threaded into that needle, until the tip reaches the epidural space around the spinal cord. Then, the needle is removed carefully, leaving the catheter in place. A “test dose” of medicine is injected into the catheter to confirm the proper placement of the catheter. The test dose of medicine speeds up  your heart rate if the needle is in the wrong place. If your heart rate stays the same, the placement is correct and the first dose of pain medicine is given. The catheter is then taped in place to the skin on your back so more medicine can easily be injected later. Once in place, the catheter does not restrict moving side to side in bed and it can not felt in the back. The pain involved during the administration procedure may be a slight pinch or it may be painful for several minutes.

The pain medicine diffuses into the spinal cord and nerve roots that branch out from the spine. The pain medicine blocks the nerve impulses before they reach the brain. If a steroid is used it reduces inflammation.

Three to five minutes after the first dose, the nerves of the uterus begin to numb. After ten minutes you will feel the full effect and you should have complete freedom from pain. As the first dose of anesthesia begins to wear off, another dose can be given through the catheter before contractions become uncomfortable. Another dose of medicine will be given every one to two hours depending on the specific anesthetic drug(s) and the amount and strength of the medicine given.

As soon as the baby is born, the catheter is removed. The effect of the anesthesia usually wears off completely in one or two hours. At that time, you may experience an uncomfortable burning sensation around the birth canal.

Are epidurals safe?

At this time, epidurals are thought to be safe for both mother and baby. However, there are risks, and limited studies have been done. Epidurals may require other medical procedures (such as forceps), which add to the risk. The most common side effect is a sudden drop in the woman’s blood pressure. This problem occurs 1 to 2 percent of the time and can be dangerous to a woman and baby. When it happens, the medical staff is there to take quick action. Usually, they can correct the problem. Frequent blood pressure monitoring, with either a machine or by a staff member, is required after each dose of medicine. Some women find this comforting, while others find the monitoring irritating, because it disturbs the interaction with their support people.

Other complications:

  • Infection
  • Needle is inserted into the wrong space and the epidural doesn’t relieve pain
  • Loss of tone in the bladder which can require a catheterization (about 40% of the time)
  • Total spinal block can happen if the anesthetic is injected into the cerebrospinal space. Breathing is paralyzed and a drop in blood pressure. This is an emergency.

Do epidurals always work?

If the physician cannot easily locate the epidural space, it may not be possible to use epidural pain relief. This seldom happens. Sometimes labor begins so fast that there is not enough time to use an epidural. Some epidurals give “patchy” anesthesia, causing the feeling that some parts of the abdomen are numb and other parts are not.

Can anyone have an epidural?

Most women can have an epidural, although women who have had back surgery, heart or blood disorders and those who have an allergy to “-caine” medicine should discuss those problems with their physicians and anesthesiologists.

Advantages of Epidural Anesthesia

  • Freedom from more pain during labor, birth and an episiotomy if you need it.
  • Unlike some other drugs, it does not make the mother drowsy before or after delivery.
  • Limited amount of medicine reaches the baby.
  • Close monitoring by the hospital staff may give the laboring mother a sense of confidence.

Disadvantages of Epidural Anesthesia

  • The second stage of labor may be slowed down by the mother’s inability to move about and make use of gravity.
  • The mother must stay in bed on her side with her head at the same level throughout labor.
  • The mother must have constant intravenous fluids and electronic fetal monitoring.
  • The mother must have her blood pressure taken often.
  • The mother will probably need a urinary catheter, which has its own risks.
  • The baby may be delivered by forceps, which has risks.
  • The mother has little control over her body and may not feel the birth process. This can interfere with maternal-infant bonding.
  • The mother must depend totally on nurses, certified nurse midwives and doctors for basic physical needs.
  • Extremely rare, but serious medical risks exist, about which the mother and her partner must be aware.

What can be used instead of an epidural for pain relief?

There are other ways of reducing the pain of labor. Many women are helped by techniques learned in childbirth classes – relaxation, massage, positioning, visualization, distraction, focusing and breathing that are done with the support of another person. These non-drug coping skills use your own strengths and place you in control of your own body.

Epidural anesthesia is one method that can give relief from pain and discomfort in labor. It does require that you give some control to the hospital staff. It does involve risks. The final decision is yours. Understanding this procedure can help you decide what is right for you.

tags: episiotomy complications

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