Epidural and Spinal
What are the major variations of this type of analgesia?
What is involved in having an epidural or combined spinal-epidural?
What are the advantages of an epidural?
What are the drawbacks of an epidural?
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?
To begin with, what is popularly known as an epidural is correctly termed epidural analgesia. The term epidural properly refers to the space into which the anesthesiologist or nurse-anesthetist delivers the medication rather than an agent or technique. The epidural/spinal family covers a variety of medications and ways of administering them:
What are the effects of epidural analgesia on pain?
- 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.
In all but a few women, an epidural can abolish labor pain.
You will be asked to curl up on your side or sit up with your back arched outward. Your back will be washed with antiseptic and covered with a sterile drape. The anesthesiologist or anesthetist will numb the skin before inserting the needle. You must remain absolutely still while the needle is in your back. One or more tests (such as pulling back on the syringe to see if blood flows in) will be performed to make sure the needle is in the right place. A catheter will be threaded through the needle and taped to your back to keep it from moving.
Other interventions are common with epidurals to monitor, prevent, or treat possible side effects. As part of epidural management, you will definitely have:
You are more likely to require:
- 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.
Controversy exists over whether you are also more likely to have
And because you are more likely to have a fever, your baby is more likely to have
- 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.
- blood drawn to evaluate for infection and possible treatment with antibiotics.
- is the only labor pain relief technique that can completely eliminate pain
- without narcotics (a plain epidural) doesn't affect consciousness.
First-time mothers tend to have more difficulties with epidural side effects than women who have previously given birth.
- 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
In medicine, the desired effects of a drug or procedure often receive more attention than undesired effects. The unmatched effectiveness of epidurals at relieving labor pain has impressed both caregivers and women. Many caregivers also believe that new techniques and medications have minimized side effects. For these reasons, the disadvantages and potential complications are often under-recognized or seen as unimportant because they can be managed. They may also be considered an acceptable trade-off given the benefits of superior labor pain relief. Every woman needs to understand these trade-offs and make informed decisions according to her values, preferences, and options.
Most recent page update: 11/16/2012
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