Making an Informed Decision on Epidurals

I wrote this article on epidural anesthesia while I was in school, and I thought someone may find it helpful….it’s always important to consider ALL aspects of the information available!

There is much debate today over the use of epidural anesthesia during labor and delivery. On one hand they are reported to bring miraculous relief from labor pain, and yet on the other hand many different risks and complications have been reported. How much do we know about this method of pain relief? For how many years have epidurals been used? How is it administered? What are the possible risks and complications? How does it affect other facets of labor? What are the benefits? Let us take some time to look at the issue from the perspective of researchers who are representing both sides.

The history of epidural anesthesia:

According to one source, the epidural block was first introduced unsuccessfully in 1901. (1)  At that time, administering an epidural through the caudal region was being experimented with, but was a complex technique that required extreme skill. In 1921, Fidel Pages from Madrid, Spain, first reported on his successful results using the epidural space for insertion of anesthesia. As this method became more familiar, and new discoveries were made in the invention of better needles and equipment along with further understanding of anesthesia and its effect on the human body, the epidural block has become part of the modern medical world. (2)

How is an epidural administered?

Before administering an epidural, the patient must first be given an IV of crystalloid solution (in order to counter-act the hypotensive effect of the medication), and it must be determined that she is in active labor. The anesthesiologist will take a full history and determine if there are any contraindicating factors. Ideally, he will also talk with the patient about the possible risks and benefits of the procedure. Then she will be instructed to lay on her side, in a curled, arched position so that he can reach the vertebrae and insert a needle into the L3-4 or L4-5 area. (3) The patient must hold extremely still, as the epidural space is only 3-5 mm deep, and it is easy to accidentally puncture the dura, which can cause major headaches and other side effects. (4) Once the needle is inserted, it is replaced with a catheter, and a test dose is given to make sure that the dura has not been punctured and that the patient will not have an adverse reaction to the particular drug used. She must continue to lie on her side to prevent aortocaval compression and hypotension that results from being on her back, and the remainder of the anesthetic is injected. Some evidence of pain relief should occur within 5 minutes, and full effect should take place within 8-15 minutes. The catheter is then taped to the patient, and remains inserted so that more medication can be injected as needed for the duration of the labor. (5)

How does the epidural work?

The anesthesia of choice (usually a combination of two or more of the following: lidocaine, bupivacaine, mepivacaine, chloroprocaine) is injected into the epidural space (6), which surrounds the outside membrane of the spinal cord. Since the spinal cord carries signals to the brain, the nerve sensations can be numbed or blocked by filling the epidural space with anesthesia. This affects the areas just above and below the insertion spot. The amount of pain relief depends upon the type of anesthesia used, and the amount that is given. It is possible to have all sensations blocked so that the patient has no feeling from the waist down, or to have just enough pain relief to “take the edge off” and yet still allow the mother to be mobile. (7)

Advantages of an epidural:

Advantages of using an epidural block include:

–    Completely pain-free labor and birth experience is possible, while allowing the mother to remain aware of what is transpiring. (8)

–     Pain relief is constant for whatever length of time is desired.                                                                                                                  –     During a long, difficult labor, it can bring about needed relaxation to help the mother progress and give her strength by providing a chance to rest. (9)                                                                                                                                                                                  –     Should a cesarean become necessary, the entry route for anesthesia is already established, allowing the mother to remain awake during the surgery, thus enabling her to be a part of the birth and postpartum periods.                                                             –     If the mother is having trouble coping with labor pains, an epidural can help her to relax and enjoy the process. (10)

Disadvantages and possible complications:

–     Complications are reported to occur in about 23% of women. (11)

–     Safety to the baby is not proven.

–     Restricts the mother’s movement, as she must remain on her side in order to prevent complications and allow the catheter to stay in place. (12)

–     Lowers the blood pressure, which may make the patient feel nauseas and possibly vomit. This also affects the baby due to the reduced amount of blood flow through the placenta. (13)

–     There is a 15-20 % chance of the patient developing a fever, in which case further testing must be done in order to make sure the baby is not being negatively affected.

–     Changes the normal progress of labor, many times lengthening the second stage. (14)

–     Increases the possibility of other interventions: urinary function can become impaired, necessitating a catheter; second stage may be prolonged, indicating a higher incidence of oxytocin, episiotomy, forceps, and/or vacuum extraction. In addition, continuous fetal monitoring is indicated, and the mother’s vital signs must be closely observed. (15)

–     It can influence the baby’s heart rate. In one study, 8-12% of the women who used an epidural experienced low fetal heart decelerations, indicating fetal distress. (16)

–     The actual strength of the uterine contractions can be concealed, which can increase the possibility of uterine rupture, especially when oxytocin is involved. (17)

–     There is an 8% incidence of the dura being punctured during insertion of the catheter. This results in extreme headaches, which can last for up to a week, with some patients experiencing long term chronic problems. (18)

–     Occasionally there are women in which the epidural does not take, which can cause further discomfort and pain, along with subsequent loss of expectations. Some women experience numbing on one side and not the other, or in certain areas, which is a frustrating experience. (19)

–     The drugs do reach the baby, and depending on the degree in which he was affected, his muscle tone and reflexes can be altered and he may be excessively drowsy for his first hours of life. (20)

–     Many women experience long term backache, sometimes as a result of unknowingly straining muscles during labor, due to lack of feeling in the area. (21)

–     Paralysis can last for up to several days (this occurs in 1/500 women). (22)

–     Postpartum problems including a higher increase of jaundice in the newborn, and an increased difficulty with breast feeding have been reported. (23)

Conclusion:

In closing, it must also be considered that pain can be a good thing. Research shows that the pain and stress of normal labor trigger the release of adrenaline and noradrenalin, which are necessary in preparing the fetal lungs to breathe air and helps to utilize the mother’s energy. Pain can be an indicator of progress, as well as a safeguard to keep the mother from assuming a position that can be harmful. When the nerves of the pelvic floor are numbed, the body is not able to make the same supply of oxytocin which causes the pushing urge. Thus the body’s natural mechanisms are altered.  Along the same lines, stress hormones cause the release of endorphins, creating a natural form of painkiller. These give the mother a type of “high” enabling her to do the work needed throughout the laboring process. (24)                                                                                                 The decision whether or not to use an epidural must be the choice of the mother, after she has been informed of all of the pros and cons on both sides. Any type of intervention is not without its risk, as we can see from this study. However, there are times when intervention is necessary, and it is important to know what the risks are when evaluating your choices. For a mother who has had a long labor without progress, and is getting tired and worn out, and epidural may be just what she needs in order for her to have a vaginal birth. At these times we are extremely grateful for medical invention and progress, but we must not forget that a woman’s body was designed to give birth, and for thousands of years this has happened without epidural anesthesia. As with any medical advancement, we must exercise caution and make wise, informed decisions concerning what is placed inside of our bodies.

Reference:

  1. 1. Mandabach, Mark G., MD; article entitled “The History of Epidural Anesthesia”. Accessed on August 29, 2007, at:     http://www.asaabstracts.com/strands/asaabstracts/abstract.htm;jsessionid=AEA7FF46297392A08B32A41CD6976656?year=2000&index=14&absnum=506
  2. 2. Franco, A.; article entitled “Current Anesthesia & Critical Care”, accessed in August, 2007, at: http://linkinghub.elsevier.com/retrieve/pii/S0953711200902643
  3. 3. Article entitled “Epidural”, accessed in Aug. 2007 at: http://www.nt.net/lerouxma/epidural.htm#history
  4. 4. Article entitled “Epidural”, accessed in Aug. 2007 at: http://www.answers.com/topic/epidural?cat=health
  5. 5. Oxhorn, Harry, Human Labor and Birth, pg. 461
  6. 6. Oxhorn, Harry; pg. 461
  7. 7. BUPA’s Health Information Team, article entitled “Epidurals for Surgery and Pain Relief”, accessed in August, 2007, at: http://hcd2.bupa.co.uk/fact_sheets/html/epidural.html
  8. 8. Kitzinger, Sheila; Complete Book of Pregnancy and Childbirth, The, pg. 242
  9. 9. Oxhorn, Harry;  pg. 462
  10. 10. Sears, William, MD; The Birth Book, pg. 177
  11. 11. Marsden, Wagner,MD; Born in the USA: How a Broken Maternity System Must be Fixed to Put Women and Children First, pg. 54
  12. 12. Sears, William,MD,  pg. 177
  13. 13. Kitzinger, Sheila, pg. 243
  14. 14. Wagner, Marsden, MD,  pg. 54
  15. 15. Wagner, pg. 55; Goer, Henci, Obstetric Myths Versus Research Realities,  pg. 250
  16. 16. Wagner, Marsden, MD, pg. 55
  17. 17. Oxhorn, Harry,  pg. 463
  18. 18. Various authors, article entitled “Epidural Anesthesia and Analgesia Are Not Impaired After Dural Puncture With or Without Epidural Blood Patch”, accessed in August 2007, at: http://www.anesthesia-analgesia.org/cgi/content/full/89/2/390?ck=nck
  19. 19. Kitzinger, Sheila, pg. 243; Sears, William, MD,  pg. 176
  20. 20. Cohen, Nancy, Open Season,  pg. 98
  21. 21. Sears, William, MD, pg. 175
  22. 22. Wagner, Marsden, MD, pg. 54
  23. 23. Goer, Henci, pg. 255; article entitled “Epidural Birth May Negatively Affect Breastfeeding”, accessed August 2007, at:  http://www.forbes.com/health/feeds/hscout/2006/12/11/hscout536503.html
  24. 24. Goer, Henci, pg. 252
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2 thoughts on “Making an Informed Decision on Epidurals

  1. Another thing to consider with an epidural is that baby might be too drowsy to nurse. It took over 48 hours for the affects to wear off of you (you wouldn’t wake up long enough to really nurse) which was very frustrating for a first time mom learning how to cope. I thought an epidural was wonderful during labor until it came time to push and couldn’t do it. So I had to just watch while they had to cut and use forceps to deliver you-no fun. Recovery was much better with natural birth-the minute the baby is out you feel like a new person and have so much adrenaline not to mention the baby aware and looking into your eyes (if the cord wasn’t around the neck, that is, but that is another story….!)

  2. Hello! Just wanted to add something to your excellent article because most people who opt for epidurals don’t know how incredibly debilitating epidural headaches can be. I had an epidural headache for three months before it was fixed with a blood patch. If anyone is contemplating an epidural, please read http://www.epidural.net/epiduralheadache.htm. Epidurals can be very useful and sometimes necessary, but if I can save just one woman going through what I did when it can be so easily fixed then it’s worth it to me!

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