Epidural and Spinal 

What are the major variations of this type of analgesia?

• epidural: The anesthesiologist or anesthetist inserts a needle into the epidural space, which lies between the tough, outer membrane that covers the spinal cord and the next deeper membrane. A tiny tube or catheter is threaded through the needle. The needle is removed and the anesthesiologist or anesthetist injects an anesthetic similar to those used in dentistry or, in most hospitals today, a mixture of anesthetic and narcotic (narcotic epidural) into the catheter.
  • continuous infusion: The catheter is attached to a syringe driven by a pump that gradually delivers a continuous dose. This technique is the standard because it provides steady labor pain relief.
  • intermittent top-ups: The anesthesiologist or anesthetist returns to inject more pain medication into the catheter when the dose wears off.
• "walking" or "light" epidural: The anesthesiologist or anesthetist may inject narcotic only, a very low dose of anesthetic, or a combination of the two in an attempt to achieve complete mobility with good labor pain relief. These variations are intended to leave some sensation and ability to move the legs. However, many women with such epidurals never walk, even when encouraged to do so. It was hoped that these innovations would achieve equally good labor pain relief while reducing adverse effects, but many women still experience undesired effects.
• combined spinal-epidural: The anesthesiologist injects pain medication (usually a narcotic, occasionally an anesthetic) into the space that lies deeper than the epidural space ("spinal"). The anesthesiologist then pulls outward into the epidural space, threads a catheter into the epidural space, and removes the needle. The spinal cannot be repeated, but the catheter remains for an epidural should you want additional labor pain relief later.

What is involved in having an epidural or combined spinal-epidural?

• an IV (intravenous drip): you will be given about a quart of IV fluid before the epidural is administered
• continuous electronic fetal monitoring (EFM)
• frequent monitoring of blood pressure, usually with an automatic blood pressure cuff that periodically self-inflates and records the results.

• IV Pitocin (oxytocin), a drug to make contractions stronger
• drugs to combat a drop in blood pressure
• a urinary catheter for inability to pass urine
• a vacuum extraction or, less likely these days, a forceps delivery.

• cesarean section.

• blood drawn to evaluate for infection and possible treatment with antibiotics.

What are the advantages of an epidural?

• is the only labor pain relief technique that can completely eliminate pain
• without narcotics (a plain epidural) doesn't affect consciousness.

What are the drawbacks of an epidural?

• requires the presence of an anesthesiologist or nurse anesthetist: this means an epidural may not be readily available when you want it
• involves delay in obtaining relief: even when the anesthesiologist or anesthetist is in the hospital and not busy elsewhere, it can take an hour from your request to the time when the procedure is done and the medication takes effect
• changes the experience of labor: it converts labor and birth from a normal life experience in which you are an active agent to one in which the equipment (IV, Pitocin pump, epidural pump, electronic fetal monitor, blood pressure cuff, etc.) is the center of attention
• may interfere with your ability to move about: it numbs much, if not all, sensation in the belly, genitals, and legs, and you may feel groggy if it contains narcotics; these effects can prevent you from activities that may help labor progress
• requires or increases the need for other procedures: see the list of procedures, above, that are routinely used or more likely to be used to monitor, prevent, or treat side effects; each of these may introduce its own possible adverse effects
• can cause episodes of low blood pressure: this is a problem because it reduces your baby's oxygen supply
• can cause itching: this is a common, but generally mild, side effect if narcotics are given
• may interfere with the pushing phase of labor: you may have difficulty pushing your baby out, and this phase may be lengthened
• can lead to serious tears in your perineum: this is the tissue between your vaginal and anal openings (this is probably due to increased use of vacuum extraction or forceps)
• can cause adverse behavioral effects on the newborn
• can cause newborn jaundice
• can cause life-threatening complications (dangerously low blood pressure, respiratory or cardiac arrest, severe allergic reaction, convulsion): the odds may be as high as 1 in 4,000 to 1 in 3,000 cases.
• can cause maternal fever: the longer you have the epidural, the more likely you are to run a fever, which can have its own consequences:
  • developing a fever appears to increase your likelihood of birth by cesarean section, vacuum extraction, or forceps
  • fever in the mother may be associated with more babies being born in poor condition and an increase in newborn seizures
  • because fever raises the possibility of infection, babies of mothers with fever are more likely to be evaluated for infection; this involves drawing blood, and may involve precautionary antibiotics through an IV (intravenous) line; mothers and babies may be separated during these procedures

I haven't heard anything about drawbacks to an epidural; in fact, the hospital, my doctor, and even my childbirth educator have nothing but good things to say. Why might this be?