There are many ways to lessen pain during labor and delivery including
hypnosis, psychoprophylaxis (Lamaze Method), acupuncture, massage, imaging,
distraction, positioning, and other methods. However, severe pain is usually
treated with either injectable narcotics or epidural anesthesia.
Narcotics are often employed early in labor to provide pain relief and
sleep, but the most frequently requested and used method of pain relief
is epidural anesthesia. Only about 10% of laboring patients received epidural
pain relief in the 1980s. By the mid-1990s that number had grown to over
50%. Currently, 50% to 80% of labor patients receive epidural anesthesia
depending on the institution and the area of the US.
Epidural Anesthesia
Epidural anesthesia is also known as regional anesthesia, epidural analgesia,
or simply epidural. It usually involves the use of a combination of local
anesthetic and narcotics placed in the epidural space of the lower back
to numb pain fibers from the lower parts of the body and produce pain
relief at the level of the spinal cord. This allows a woman to experience
relief of pain and still be alert and has minimal effects on the baby
and the mother’s breast milk. In the US, most hospitals restrict
maternal oral intake to clear liquids only during active labor and epidural
anesthesia to prevent complications from aspiration of stomach contents
into the lungs if a Cesarean section delivery becomes necessary.
Benefits of Epidural
According to patients, epidural analgesia provides the best pain relief
along with a high degree of patient satisfaction. It allows the mother
to be alert yet comfortable or to sleep if desired. It may make the cervix
dilate more quickly and allow labor to progress more rapidly. It makes
labor pain more tolerable, especially if labor is prolonged, and is usually
very safe for the mother and baby.
Adverse Effects of Epidural
Although usually safe, epidurals can produce undesired effects such as
a sudden drop in the mother’s blood pressure which can adversely
affect the baby. This is watched for and quickly treated if it occurs.
Other possible side effects of epidurals include:
Nausea and vomiting
Upper body itching
Soreness where the needle is inserted in the back
Shivering
Rarely inadequate pain control
Difficulty urinating, necessitating the placement of a urinary catheter
in the mother’s bladder
Very rarely a patient will have a severe headache after a spinal or epidural,
this occurs less than 1% of the time. Occasionally, labor can last longer,
and the numbness and weakness can be prolonged after the baby is delivered
due to the epidural. Serious nerve injury or drug reactions are extremely
rare, occurring about once in 200,000 births.
How is an Epidural Given?
Before an epidural is given, the patient must sign a consent form after
the procedure is explained.
The epidural process involves the following steps:
An IV is necessary because fluids are usually given into a vein when the
epidural is administered.
The patient is positioned with the lower back arched out in the sitting
or side-lying position.
The lower back is cleaned off and a small amount of local anesthesia is
injected to numb the area where the epidural needle goes in.
The patient must remain very still while the needle is inserted in her back.
A small, flexible plastic catheter is threaded through the needle into
the patient’s epidural space, and the needle is withdrawn leaving
the catheter in the back.
Medication is injected either continuously or intermittently into the patient’s
back producing numbness and pain relief in the lower parts of the body.
The catheter is taped to the woman’s back so it will not be pulled
out and is hardly noticeable, causing no harm to the patient. It is removed
once the baby is delivered, and the numbness wears off in one to two hours.
The placement of the epidural is usually not painful, although at times
the patient may feel some shooting pain briefly when the needle and catheter
are placed. The epidural is usually given once a pattern of labor is established
and can be given almost up until the mother’s cervix is fully dilated.
In certain circumstances, an epidural is not allowed, such as when the
patient has an infection in the area where the needle is inserted or the
patient’s blood does not clot well or if the mother is allergic
to the anesthetic drugs.
Once the epidural is in place the mother’s blood pressure is checked
frequently, breathing, heart rate and oxygen used are monitored and the
baby is watched closely for signs of distress. The nurses and anesthesiologist
check frequently to make sure that the pain is well controlled. The adequacy
of pain control is also assessed. Should the mother require a Cesarean
section delivery the epidural can be dosed up to provide anesthesia that
will allow the baby to be delivered painlessly with the mother awake.
Does the Epidural Adversely Affect the Baby?
For the most part, studies of labor epidurals show few side effects on
infants. There is some evidence that initial breastfeeding may be made
more difficult after prolonged epidural infusions and baby’s breathing
may be affected by epidural medications.
Mother’s Choice
Choosing to have an epidural for pain relief is the patient’s decision
and should be made based on desired outcomes, consideration of the risks
and benefits, and the patient’s needs and wants. Being able to tolerate
labor pain is a valid reason to choose an epidural and there is no shame
in that. Epidurals may actually facilitate a smoother delivery. On the
other hand, birthing without an epidural will obviously avoid possible
adverse effects associated with an epidural.
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