Epidural

Forms of Pain Relief

There are many ways to lessen pain during labor and delivery including hypnosis, psychoprophylaxis  (Lamaze Method), acupuncture, massage, imaging, distraction, positioning, and other methods. However, severe pain is usually treated with either injectable narcotics or epidural anesthesia. Narcotics are often employed early in labor to provide pain relief and sleep, but the most frequently requested and used method of pain relief is epidural anesthesia. Only about 10% of laboring patients received epidural pain relief in the 1980’s. By the mid 1990’s that number had grown to over 50%. Currently 50% to 80% of labor patients receive epidural anesthesia depending on the institution and the area of the US.

Epidural Anesthesia

Epidural anesthesia is also known as regional anesthesia, epidural analgesia, or simply epidural. It usually involves the use of a combination of local anesthetic and narcotics placed in the epidural space of the lower back to numb pain fibers from the lower parts of the body and produce pain relief at the level of the spinal cord. This allows a woman to experience relief of pain and still be alert and has minimal effects on the baby and the mother’s breast milk. In the US most hospitals restrict maternal oral intake to clear liquids only during active labor and epidural anesthesia to prevent complications from aspiration of stomach contents into the lungs if a Cesarean section delivery becomes necessary.

Benefits of Epidural

According to patients, epidural analgesia provides the best pain relief along with high degree of patient satisfaction. It allows the mother to be alert yet comfortable or to sleep if desired. It may make the cervix dilate more quickly and allow labor to progress more rapidly. It makes labor pain more tolerable, especially if labor is prolonged, and is usually very safe for the mother and baby.

Adverse Effects of Epidural

Although usually safe, epidurals can produce undesired effects such as a sudden drop in the mother’s blood pressure which can adversely affect the baby. This is watched for and quickly treated if it occurs. Also, epidurals can produce nausea and vomiting, upper body itching, soreness where the needle is inserted in the back, shivering, rarely inadequate pain control, and difficulty urinating, necessitating the placement of a urinary catheter in the mother’s bladder. Very rarely a patient will have a severe headache after a spinal or epidural, this occurs less than 1% of the time. Occasionally, labor can last longer, and the numbness and weakness can be prolonged after the baby is delivered due to the epidural. Serious nerve injury or drug reactions are extremely rare, occurring about once in 200,000 births.

How is an Epidural Given?

Before an epidural is given, the patient must sign a consent after the procedure is explained. An IV is necessary because fluids are usually given into a vein when the epidural is administered. The patient is positioned with the lower back arched out in the sitting or side-lying position. The lower back is cleaned off and a small amount of local anesthesia is injected to numb the area where the epidural needle goes in. The patient must remain very still while the needle is inserted in her back. A small, flexible plastic catheter is threaded through the needle into the patient’s epidural space, and the needle is withdrawn leaving the catheter in the back. Medication is injected either continuously or intermittently into the patient’s back producing numbness and pain relief in the lower parts of the body. The catheter is taped to the woman’s back so it will not be pulled out and is hardly noticeable, causing no harm to the patient. It is removed once the baby is delivered, and the numbness wears off in one to two hours. The placement of the epidural is usually not painful, although at times the patient may feel some shooting pain briefly when the needle and catheter are placed. The epidural is usually given once a pattern of labor is established and can be given almost up until the mother’s cervix is fully dilated. In certain circumstances an epidural is not allowed, such as when the patient has an infection in the area where the needle is inserted or the patient’s blood does not clot well or if the mother is allergic to the anesthetic drugs. Once the epidural is in place the mother’s blood pressure is checked frequently, breathing, heart rate and oxygen used are monitored and the baby is watch closely for signs of distress. The nurses and anesthesiologist check frequently to make sure that the pain is well controlled. The adequacy of pain control is also assessed. Should the mother require a Cesarean section delivery the epidural can be dosed up to provide anesthesia that will allow the baby to be delivered painlessly with the mother awake.

Does the Epidural Adversely Affect the Baby?

For the most part, studies of labor epidurals show few side effects on infants. There is some evidence that initial breast-feeding may be made more difficult after prolonged epidural infusions and baby’s breathing may be affected by epidural medications.

Mother’s Choice

Choosing to have an epidural for pain relief is the patient’s decision and should be made based on desired outcomes, consideration of the risks and benefits, and the patient’s needs and wants. Being able to tolerate labor pain is a valid reason to choose an epidural and there is no shame in that. Epidurals may actually facilitate a smoother delivery. On the other hand, birthing without an epidural will obviously avoid possible adverse effects associated with an epidural.

References

1. Robin Elise Weiss, LCCE. Epidural Anesthesia for Labor and Birth – Medications for Labor. About.com: Pregnancy & Childbirth, 2010.

2. Practice Guidelines for Obstetric Anesthesia: An updated report by the American Society of Anesthesiologists task force on obstetric anesthesia. Anesthesiology, 2007, 106: 843-63.

3. Obstertic Guidelines: University of Illinois Medical Center, Chicago, IL, Policy A.25, Oct, 2008

4. Jett, J., DiGrazia, J. Epidural Analgesia (continuous). Nursing Policy E-25, LSUHSC, Shreveport, LA, 2009

5. Bogard, T. et al, Wake Forest University Department of Anesthesiology Obstetric Anesthesia Syllabus. (current, 2010-11)