This article was written by Penny, a registered nurse and midwife with 20 years experience as a nurse and 10 years as a midwife. She is also a mum to two school aged children, so has been on both sides!
If you are in your last trimester of pregnancy, you may be starting to think about your birth and how you are going to cope with Labour. You may be wondering whether or not you should have an epidural In Labour? Epidurals are not the only method of pain relief but if you are wanting to know More about epidural pros and cons then read on.
What is an Epidural?
An Epidural is known as a ‘regional anaesthesic’ which means it blocks pain in a particular region, or part of the body, as opposed to the whole body. Epidurals block the nerve impulses from the lower half of the body which reduces the pain associated with labour. The types of medications that are used in epidurals are usually a combination of local anaesthetics and narcotics. These are effective at providing pain relief but allowing the person to stay awake.
How is an Epidural inserted?
- An Epidural insertion is performed by an Anaesthetist, (a doctor that specialises in pain relief). You will need to have an IV (intravenous) cannula and IV fluids via a drip started prior to the epidural insertion. This is in case your blood pressure drops after the epidural has been inserted.
- You will need to be positioned with your back arched and remain very still while either sitting up or lying down on your side. This allows the anaesthetist the best chance of getting the epidural in the correct space.
- An Antiseptic solution will be used to wipe your back to reduce the risk of infection.
- A small area of your lower back will be injected with a local anesthetic to numb it before the epidural needle goes in.
- Once the area is numbed, the epidural needle is then inserted into the epidural space, which is a layer around your spinal cord.
- Once the needle is in place, an epidural catheter is threaded through the needle into the epidural space. The needle is then carefully removed, leaving the catheter in place. The catheter is then taped to the back to stop it from being pulled out.
- After the catheter is secured, pain relieving medication can be given by either periodic injections or a continuous infusion via a PCEA (see below for more info).
What happens after my epidural?
After your epidural is inserted, the anaesthetist will give a ‘test dose’. This is where a small amount of the pain medication is injected into the epidural catheter to see that it is working. Once the anaesthetist is happy that it is working okay (and hopefully by this time you will be too), you may then be given a PCEA (patient controlled epidural analgesia). This will allow you to give yourself doses of the pain – relieving medication when you feel your need it. Every hospital is different as to what drugs and dosages they use in their Epidurals and PCEAs. This will be determined by hospital protocols and the individual anaesthetist. You will not be able to give yourself too much medication as the machines are designed to limit how much you have.
- You will have to stay in bed as you are not safe to walk, due to the effects of the epidural on your lower body. You will be able to change into different positions on the bed, though.
- Your baby will need to be monitored by continuous CTG (cardiotocograph) which monitors both baby’s heart rate and your contractions. This is to make sure baby’s heart rate has not been affected by the epidural. This can happen if mum’s blood pressure drops after the epidural is inserted.
- You will have your vital signs monitored frequently. This includes your temperature, heart rate, blood pressure, oxygen levels, breathing rate, how much you can move your legs and how high up the body the epidural is providing pain relief.
- You will need to have a urinary catheter inserted into your bladder to drain your urine as you will not be able to feel when your bladder is full.
- After all the above things are done, your progress of labour will continue to be monitored.
What are the expected effects/ side effects of an epidural?
Hopefully pain relief! This is the main reason you would choose to have one. Other expected side effects of epidural include;
- Loss of ability to walk as the nerves that make your legs move are affected by the epidural.
- Some loss of sensation in bladder and bowel, which is due to the effects of the epidural. This is why you need that urinary catheter!
- Epidurals can lower blood pressure, so you may feel faint or light headed after. If your blood pressure drops low enough it can compromise blood flow to your baby, which may cause foetal distress. This is why you need to have an IV drip running to bring your blood pressure up again if necessary, and continuous monitoring of your baby.
- Some women can experience an uneven block or ‘patches’ of pain. The epidural may work well to relieve pain on one side but not the other, or there may be patchy areas on the abdomen where the person still experiences pain.
What are the Pros of having an Epidural?
The most obvious positive of having an epidural is pain relief! If you have been laboring for a long time and you are exhausted, an epidural can give you a break for a little while and an opportunity to have a bit of a rest.
The labours that benefit most from having an epidural are:
- Posterior labours (where the baby’s back is on your back) as these labours can be more uncomfortable and take longer then if a baby is in a better position.
- Women who have a strong urge to push before the cervix is fully dilated, which they can’t control. This is usually associated with posterior labours.
- Labours that are slow to progress, (this occurs when despite having strong, regular contractions, the cervix is taking a long time to dilate)
- Labours that are being induced. Inductions can take longer and can be more uncomfortable then a labour that has started naturally. The hormone drip that is used for labour induction, can make contractions stronger and more frequent compared with a natural labour.
What are the Cons of Having an Epidural?
The main con with having an epidural is that is can delay labour progress by either decreasing the frequency of your contractions or stopping them altogether, (you may think yippee to this), but without contractions, your cervix can’t dilate and your labour won’t progress.
Women who have an epidural can’t be as active in labour as those who don’t. Being able to mobilise and get into many and varied positions helps labour to progress.
Having an epidural can lead to needing other forms of intervention. If contractions stop due to the epidural, then a hormone drip (Syntoncinon) will usually need to be commenced to get contractions going again. If the Sytocinon drip does not work, then you have a labour that is not progressing. Sometimes the Syntocinon drip can work too well, making contractions very strong and frequent, which can cause foetal distress in babies. However, all of these factors would be monitored closely, and can be managed.
There is an increased chance of needing an assisted delivery if you have an epidural. Some women can have difficulty pushing effectively, due to decreased lower body sensation. This means that you may need assistance with a vacuum or forceps delivery to help birth your baby. This can potentially be more traumatic for both you and baby.
Timing and Availability of Epidural?
The ideal time to have an epidural is when you are considered to be in established labour. This means when your cervix is at least 4 – 7 cm dilated and you are having regular contractions of at least 3 – 4 contractions every 10 minutes. If you have your epidural too early then it can delay your labour progress and then it may go on for a long time. However, if you are at the point where you can’t cope anymore it is okay to ask for one when you feel you need it. Likewise, if you have had previous vaginal births and your labour is progressing quickly you may need to ask for an epidural earlier to allow time for it to be done.
The other thing you will need to consider is whether there is an anaesthetist available 24/7 at your chosen birth facility. If you are birthing in a smaller maternity unit, the anaesthetist may need to be called in which can mean a longer wait to get your epidural. Some smaller rural units may not have the option of offering epidurals during labour. These would be good questions to ask at one of your antenatal appointments with your midwife/ doctor.
Effects on Baby?
Epidurals in themselves are generally considered safe for babies. However, the need for other interventions that can be necessary as a result of the epidural, can potentially have consequences for baby. E.g. Needing a Syntocinon drip, forceps or vacuum delivery, which has been discussed previously. If you also have other risk factors going into labour such as being overdue or baby not growing well, this could be compounded by the above interventions. Although there is no conclusive research, babies may potentially have difficulty with breastfeeding in the first few days as a result of an epidural.
Conditions which may make Epidurals more risky or difficult?
There are certain pre-existing medical conditions which may make performing an epidural riskier and in certain cases, should not be done at all. This list is by no means exhaustive. If you are unsure, please discuss this with your midwife/ doctor.
- Ladies who have had previous spinal surgery or who have any abnormalities of the spine
- Patients who have had difficulty with epidural insertions in previous labours.
- Ladies who have clotting disorders, e.g. Factor V Leiden, especially those who are taking drugs that stop your blood from clotting, e.g. Heparin.
- Ladies who have bleeding disorders and have a low platelet count (the factors in your blood that make it clot), e.g. Thrombocytopaenia. Another big one in this category are ladies that have developed HELLP syndrome with Pre-eclampsia.
If your care provider has identified you as being a high- risk epidural candidate, you may be offered an Antenatal Anesthetic Consultation, depending on your birthing facility. This would allow an anesthetist look over your medical history and put some extra safeguards in place if you do decide to go ahead with an epidural when you come into hospital. Not all hospitals have this available as an option though.
Adverse (serious side effects of having an epidural)?
Post-dural puncture headache: This occurs when the epidural or needle goes in too far and breaches the dura mater. This is a layer of cushioning around the spinal cord that contains cerebrospinal fluid. The spinal fluid leaks out of the hole made in the dura mater which causes neurological irritation. Symptoms may include: a dull, pressure like headache affecting any part of the head which can extend to the neck or upper back. Other symptoms may include mild hearing loss, ringing in the ears and double vision. The headaches can be associated with nausea, vomiting, photophobia (difficulty looking at light). The headache usually develops within 48 hours post epidural insertion but may occur after that. The headaches may resolve on their own in a few days or the patient may require a blood patch. A blood patch is performed by two anaesthetists. One performs an epidural, while the other takes blood from the patient so that it can be injected through the epidural site. The blood then works to plug the hole from the original epidural site once it clots. This then stops the spinal fluid leaking out and hopefully stops the headache. Dural puncture occurs in approximately 1% of epidural blocks. (Royal Australian College of Anaesthetists).
Paralysis: Neurological injury post epidural may include sensory loss, motor weakness and paraplegia. Royal Australian College of Anesthetists reports that the incidence of permanent harm which includes neurological symptoms lasting more than 6 months including death is 0.6 per 100 000 women who had an epidural in labour. Therefore the risk of permanent paralysis is very low.
You have been given a lot of information and food for thought! Hopefully now you have a better understanding of epidural pros and cons. At the end of the day its your body and your decision. If you have any concerns either before or during your labour talk to your midwife or doctor. This information is intended a guide only and does not take into account your individual circumstances. Apart from that Happy Birthing!
Australian and New Zealand College of Anaesthetists (www.anzca.edu.au/patients/frequently-asked-questions/epidurals-and-childbirth).
Dr Sarah Buckley (author of gentle birth, gentle mothering (transform.childbirthconnection.org/reports/physiology)