Epidural Anesthesia

What is an epidural?

• A catheter is placed into the lumbar region of the back, between vertebrae into the epidural space. Medication is injected, typically by continuous pump infusion. May be a “caine” anesthetic or a narcotic analgesic (Fentanyl or morphine), or a combination of these.
• Some side effects may vary depending on exactly which medication is used. See Simkin, Whalley, and Keppler for an excellent discussion.
• Provides pain relief in abdomen, back, buttocks, perineum, and legs.
• The most common type of pain relief. Statistics vary widely by hospital, but rates may be as high as 75-90% of births.

Benefits of Epidurals: why would you ask for one in the first place?

• Effective pain relief (for 90-95% of women).
• Reduced pain related to contractions and to interventions such as pitocin, forceps, episiotomy, cesarean.
• Mother can remain clear-headed, think and converse normally, and can rest, often even sleep for a few hours while her cervix continues to dilate.
• May relax pelvic floor muscles, allowing cervix to dilate fully. (This is especially true if mother is experiencing a lot of anxiety because of the pain.)
• Side effects of narcotics are reduced when they’re given by epidural rather than I.V. because less drug is needed.
• Can lower blood pressure, which may be helpful for hypertension.

How is an epidural administered, what equipment is involved, and what are the side effects?

• After you request an epidural, the nurse will call the anesthesiologist. May take 15-60 minutes: Women have described this period as “the longest 30 minutes of my life”. This is because they had already decided the contractions were overwhelming, and asked for relief, and it’s hard to wait for that to come. This is the time to use all the comfort measures at your disposal. Meanwhile:

• You get into bed; you won’t be able to walk around after the epidural. Most hospitals also say no more food and water from this point on.
• An IV is started, and extra fluids are given to reduce the chance of a drop in blood pressure. The I.V. also allows for easier administration of medications such as pitocin. Pitocin augmentation is about 3 times more likely in epidural labors
• One of the common side effects of epidural is dystocia (slowed labor progress). Contractions are decreased in strength and/or frequency. Body may stop producing oxytocin. Early labor may slow or stop
• Of 8 studies reviewed by Thorp, 7 suggest epidurals are associated with longer first stage labor. This is typically treated with pitocin.
• 9 of 10 studies reviewed report a significant association between epidural and longer 2nd stage labor. (This may lead to instrumental delivery or c-section.)
• Usually a blood pressure cuff is placed to regularly monitor blood pressure. If blood pressure drops (as it does for 12% of women): more fluids, oxygen or medications.
• Temperature is checked regularly: there is a 14.5% chance of fever over 100.4 w/ epidural; chance increases after 4 hrs or more with epidural. After 7 hours with epidural, fever increases by up to 1ºC (1.8º F) per hour.
• If you develop a fever, medical staff works on the assumption that you have an infection: treatment for infection may begin. (May involve antibiotics for mom; 48 hours of observation, blood culture, and spinal tap for baby.)
• External Fetal Monitor is placed to monitor baby’s condition.
• If mother develops a fever: Baby’s heart rate may become rapid. Baby may develop a fever (30% chance with epidurals)
• If the mother is given pitocin: contractions can get too long and too strong, reducing baby’s heart rate.
• If mom’s b.p. drops: decreased fetal heart rate and decreased oxygen supply.
• Mild to severe fetal distress in 10-15% of babies after epidural. Generally these changes don’t affect the baby’s health at birth (as measured by APGAR scores), but signs of fetal distress can lead to c-section…
• One thing you can do to help: after an epidural, lie on your side rather than your back; may decrease fetal distress.
• Prepping and placing the catheter can take 15-25 minutes. Mother is sitting, or lying on her side, with her back arched. Her back is cleaned with betadine and draped with sterile towels. Local anesthetic is injected, then a large needle is pushed through the skin, then the epidural needle is placed, then catheter is placed, and the needle removed. The mother must remain completely still for insertion, even through severe contractions. The catheter is securely taped to the mother’s back, and medication is begun. May take 15-45 minutes to reach full effect.
• Urinary catheter is placed. (Can’t sense need to urinate, and full bladder may slow labor.) Bladder function may not return to normal for a day or two after birth.
• Mother may need oxygen mask, due to decreased respiratory rate.

• With narcotic epidurals, side effects may include moderate to intense itching, difficulty in urination, nausea and vomiting.
• Shivering is present in 10% of laboring women. With epidurals, the incidence raises to 33%. Although harmless, it may cause concern for mothers.
• Headache. During labor, or chronic headaches in the months after birth.
• Support people tend to move further away from birthing moms after epidural: One study showed that instead of being inches away on average before the epidural, they’re feet away afterwards. When the mom is no longer experiencing physical pain, they may assume she no longer needs support; some women report feeling emotionally abandoned by people moving away at this point.

Time for the Birth

- Can you feel the urge to push? Generally not. Medical staff will check cervix to tell you when to start pushing; and will watch monitor to tell you when a contraction comes so that you can push with the contraction.

- Can you push as effectively with an epidural? No. Abdominal muscles are weakened: normal pressures exerted during second stage are 120-135 mm Hg, with an epidural, they barely reach 100 mm Hg. Also, you can’t use your voluntary muscles as well to aid in the pushing, and you can’t move into the most effective positions (i.e. squatting)

- Does the baby rotate as well into the correct position if mom has had an epidural? No. Amongst non-epidural mothers, only 4% had a posterior baby persisting into second stage; after epidural, 19% failed to rotate.

As a result of these factors, there’s an increased risk of: forceps, vacuum extractor, and c-section. Of 24 studies reviewed, 22 studies showed a significant association between epidural and instrumental delivery; other 2 suggested an association, but it was not statistically significant. With narcotics, instrumental delivery: 3-7% With epidural: 15-53%

Thorp referred to some studies where the epidural medication was stopped once the mother reached 8 cm dilation, so that sensation would return for second stage labor. You may wish to consult with your caregiver about whether this practice is currently recommended.

Increased Risk of Cesarean

In a review of 15 available studies, 12 suggested a significant association between epidural and c-section. Risk of c-section generally found to be 2-3 times more likely with epidural.

An influence on this is what point in labor the epidural was administered. One study found that cesarean rates were 11% if epidural was given at 5 or more cm dilation, 16% at 4 cm, and 28% at 3 cm. Another study was even more striking, finding that cesarean rates increased to 26% when epidural was given at 4 cm, dilation, 33% at 3 cm, and 50% when the epidural was given at 2 cm dilation. So, the longer you can wait to have an epidural, the better.

Possible Effects After the Birth.

Backache. 10% of new moms develop a backache for the first time that lasts at least 6 weeks. Among women who’d had epidurals, the number jumps to 18%. This may be due to poor positioning during birth: women with epidurals may not be able to sense discomfort when they are in a position which is straining muscles, so support people need to pay attention to keeping mom in a comfortable, healthy position.

Medications cross the placenta and may have subtle side effects on the baby, including more difficulty in self-soothing, subtle changes in reflexes.

Decrease in maternal oxytocin during labor may interfere with oxytocin release after birth. Bonding and milk letdown reflexes may be decreased.

Some uncontrolled studies have been done, which aren’t conclusive due to lack of controls, but interesting nonetheless: unmedicated mothers reported that their babies were more sociable, more rewarding, and easier to care for. Unmedicated moms were more responsive to their babies’ cries. Women who had epidurals smiled less at their infants.

Janelle Durham, 2002

Sources: Statistics cited are from “Epidural Anesthesia in Labor: An Evaluation of the Risks and Benefits” by Thorp and Breedlove, Birth, June 1996. This was a literature review article, which summarized the results of numerous studies involving thousands of births. Other information from: Pregnancy, Childbirth, and the Newborn by Simkin, Whalley, and Keppler (1991 edition). Maternity & Women’s Health Care by Lowdermilk, Perry, and Bobak (6^th Edition, 1997). Family-Centered Maternity and Newborn Care by Celeste R. Phillips (Fourth edition, 1996). “Epidural Epidemic” by Dozer and Baruth, Mothering, July-August 1999. “What no one tells you about Epidurals” by Penny Simkin; “The Cascade of Interventions” by Pam England; and Epidural’s Effects on Babies” by Beverley Lawrence Beech, in Mothering, March-April 2000.

“So you Want An Epidural” by Kim James.

An overview of epidural side effects (a chart based on the data cited above, from 2002 and before.)

A more recent examination of epidural side effects. Written for professionals, it is more difficult to read than the information above.

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