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Getting an epidural
Jackie: Planning for an epidural, yes. I want to enjoy the last few hours. I want to enjoy her coming out.
An epidural delivers continuous pain medication to the lower half of your body.
Jackie: With the epidural, just, for a lot of women, it helps relax them. It allows their uterus to do all the work without the woman fighting against the pain. So especially at the end, when mom's exhausted, I think the epidural just helps them. Gives 'em some relief.
First, an anesthesiologist injects your lower back with numbing medicine.
Then a needle is carefully guided into your lower back.
A catheter is passed through the needle, and the needle is withdrawn.
The pain medication is administered through the catheter as needed.
Finally, the catheter is taped down so it doesn't move.
You'll feel the numbing effect about 10 to 20 minutes after the first dose of medication.
Niles: Look at the power of the epidural, hon. Now you're just all smiley and glowy.
Jackie: And now I can actually tell patients how it feels like.
See this family's live birth in its entirety: babycenter.com/live-birth-epidural
Video production by MEgTV.
How does an epidural work?
An epidural delivers continuous pain relief to the lower part of your body while allowing you to remain fully conscious. It reduces sensation but doesn't cause 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.
What's in an epidural?
The medication delivered by the epidural is usually a combination of:
- a local anesthetic (this blocks sensations of pain, touch, movement, and temperature), and
- a narcotic (this blunts pain without affecting your ability to move your legs.
Used together, the anesthetic and narcotic provide good pain relief at a lower total dose than you'd need with just one or the other, while keeping more sensation in your legs.
What is the procedure like?
Here's a step-by-step guide to what happens when you have an epidural:
- Injection prep: You lie curled on your side or sit on the edge of the bed while an anesthesiologist cleans the injection site, numbs the area, then carefully guides a needle into your lower back. (This may sound painful, but for most women, it's not.)
- Catheter insertion: The anesthesiologist then passes a catheter through the needle, withdraws the needle, and tapes the catheter in place. At this point, you can lie down without disturbing the catheter, and medication can be administered through it as needed.
- Test dose, full dose, and monitoring: 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 causing any concerning changes in these vital signs.
- Medication takes effect: You'll start to notice the numbing effect about 10 to 20 minutes after the first dose of medication, though the nerves in your uterus will begin to go numb within a few minutes. You'll receive continuous doses of medication through the catheter for the rest of your labor.
- Adjusting your medication: You may also have the option of patient-controlled analgesia, which means you can control when you get more medication through 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.
What are the advantages to having an epidural for pain relief during labor?
- An epidural provides a route for very effective pain relief that can be used throughout your labor.
- The anesthesiologist 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 down into your birth canal, the dose you've been getting might no longer be adequate, or you might suddenly have pain in a different area.
- The medication only affects a specific area, so you'll be awake and alert during labor and birth. And because you're pain-free, you can rest (or even sleep!) as your cervix dilates and conserve your energy for when it comes time to push.
- Unlike with systemic narcotics, only a tiny amount of medication reaches your baby.
- Once the epidural is 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.
What are the disadvantages?
- You have to stay still for 10 to 15 minutes while the epidural is put in, and then wait up to 20 minutes before the medication takes full effect.
- 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 in early labor, the amount of anesthetic you're given is low enough that you have normal strength and sensation in your legs and can move around without difficulty. (This is called a "walking epidural.") Often this requires a slightly higher dose of narcotic in the epidural. Still, many providers and hospital regulations won't allow you to get out of bed once you've had an epidural, whether you think you can walk or not.
- You'll need an IV, frequent blood pressure monitoring, and continuous fetal monitoring.
- An epidural often prolongs the pushing stage of labor because losing sensation in your lower body weakens your bearing-down reflex, making it harder for you to push your baby out. (According to the most recent studies, the increase in pushing time is about 13 minutes.)
- 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. There's also 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 of serious lacerations. These interventions also increase 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 if the medication doesn't manage to reach all your spinal nerves as it spreads through your epidural space and because every woman has variations in anatomy.
- 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 your dose to be adjusted or your catheter reinserted.)
- The drugs used in your epidural may temporarily lower your blood pressure, reducing blood flow to your baby and slowing 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. Also, 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. You'll have a catheter inserted into your urethra to drain urine into a collection bag during your labor.
- 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. This doesn't boost your or your baby's odds of getting an infection, but because it can be unclear whether the fever is from the epidural or an infection, you and your baby could wind up getting antibiotics unnecessarily.
- 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. However, there's controversy 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.
- About 1 in 100 women develop a spinal headache in the days after the procedure. This can happen if the epidural needle punctures the bag of fluid that surrounds the spinal cord, causing the fluid to leak. Let your provider know if you have a headache when you're upright that goes away when you're lying down. The problem can be treated with an epidural blood patch, a procedure in which blood is taken from your arm and injected into your back, where it clots and seals the hole caused by the needle. It's best if you can have this procedure done while you're still in the hospital, but you can always return to the hospital to get it done. The pain can be severe and can last for days or even weeks if not treated. Some women continue to have headaches even after treatment.
- In very rare cases, an epidural affects your breathing.
- 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. 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.
It remains controversial whether an epidural affects a baby's ability to breastfeed immediately after birth. Some experts suggest that the baby may have trouble latching on if the mother had an epidural. Others believe there are no good studies to support this conclusion.
We do know that any effects of an epidural on newborn behavior are much less than the effects of systemic narcotics.
When is the best time to get an epidural?
These days, most providers allow you to start an epidural whenever you ask for it.
In the past, many providers wanted a woman to be in active labor before starting an epidural because there was a concern that it might slow down her contractions. Some providers still prefer to wait until active labor. Nevertheless, studies have shown 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 (although having an epidural at all does increase your risk of a vacuum extraction or forceps delivery).
Is it ever too soon for an epidural?
No. If you're having trouble managing the pain in early labor, you can ask for an epidural.
Or if you want to put off the decision of whether to have an epidural, you could get some pain medication or a tranquilizer through an IV to take the edge off, and then get an epidural later in labor if you decide to. This kind of systemic pain relief can make you sleepy, so you'll need to stay in bed.
Alternatively, if you arrive at the hospital before you're in active labor and know you want an epidural later on, you can ask the anesthesiologist to place the catheter as soon as you're settled. Then you can wait to start the medication when active labor begins.
Is it ever too late to get an epidural?
It's never too late to get an epidural, unless the baby's head is crowning, says David Wlody, Chair of the Department of Anesthesiology at SUNY Downstate College of Medicine. It takes as little as ten to 15 minutes to place the catheter and start getting relief, and another 20 minutes to get the full effect.
However, in certain circumstances, it may be harder to get an epidural late in labor because:
- The anesthesiologist may be busy with other patients, so it could take longer for her to arrive once you decide you want the pain medication.
- Your labor and delivery team may urge you not to request pain relief if they think you'll deliver your baby soon. That's because the reduced sensation could make it harder for you to push your baby out and increase your odds of needing a vacuum extraction or forceps delivery. However, if the pain itself is making it hard for you to push, then getting good pain relief may actually help you deliver sooner.
- Your anesthesiologist may decide it's too risky to try to place the needle if you're unable to remain reasonably still during contractions. Luckily, most women are able to hold still, and your labor team can warn the anesthesiologist when a contraction is coming, if necessary.
Other pain relief options late in labor:
- Get a single spinal injection instead of an epidural. You can usually get a spinal block injection placed within five minutes. It'll take effect within another five minutes, giving you complete pain relief that lasts a few hours.
- Get a combined spinal/epidural. This gives you complete relief in under ten minutes from the spinal, and the epidural will be there if your labor lasts longer than another few hours or if you end up needing a c-section. (However, not all anesthesiologists are comfortable performing this procedure.)
Can anyone have an epidural?
No, 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)
- Have a bleeding disorder
- Have a blood infection
- Have a skin infection on the lower back where the needle would be inserted
- Had a previous allergic reaction to local anesthetics
Note that if you're taking certain blood-thinning medications, you can probably get an epidural but will need to be managed carefully.
If you have any concerns about whether an epidural is safe for you, discuss them with your provider during your pregnancy. Most hospitals also allow you to consult with an anesthesiologist.