Updated: July 29, 2016
Getting an epidural but curious about potential epidural side effects? Your answers are here.
Epidural Side Effects and Risks
First things first. Opponents of labor epidurals often point to a laundry list of potential side effects that can occur. And I would completely agree with these opponents that any time a medical procedure is utilized, risks are present. But they rarely occur.
To add fuel to the fire, there are potential risks even if an epidural isn’t placed. More on this later……
What your anesthesiologist is there to do is to help you decide whether the benefits of an epidural outweigh any potential risks. And this is precisely what this post is about. We want you to be an informed consumer.
Now onto the potential laundry list.
The first risk with epidurals that I usually mention is that the epidural may not work. Or, it may work but not in the way you and your anesthesiologist would like. This includes “patchy” epidurals that seem to work in some areas of your body, but not others. Also rare are “one sided” epidurals. This is obviously not desirable and not part of the plan, but it can happen (rarely). Your anesthesiologist will troubleshoot the epidural, and if its function can’t be improved, he/she may offer to replace it.
Next, a decrease in blood pressure can occur. This decrease is usually not to a level that will affect the well being of the laboring mom or the baby. In order to be vigilant, however, anesthesiologists monitor your blood pressure and heart rate throughout the placement of an epidural and at regular intervals when the epidural medicine is infusing.
Medicines infused into the epidural space can cause itching. Usually this is due to the opioid medicine (ie. narcotics) in the epidural solution. These small doses of opioids (eg. fentanyl) work synergistically with the low dose local anesthetic medicine. There are anti-itching medicines that can be given to help alleviate this problem. In addition, the opioid medicine can be removed altogether from the epidural solution. However, in some patients, the itching will continue.
Opioid medicines in the epidural space can also cause nausea and vomiting, difficulty urinating, low blood pressure, and breathing difficulties in the mother. Most women experience very little, if any, problems with these side effects. But they do exist. Your blood oxygen level is monitored constantly while your epidural is in place.
There is also the rare possibility of a “high block.” This means that the epidural medicine makes you too numb, perhaps up to the level of your hands and fingers. In worst cases, the medicine goes into the spinal space and can cause a total spinal.
A total spinal means your entire body is numb and you cannot breathe. This is very rare and if it even begins to occur, your anesthesiologist will be there to respond. You will be given sedating medicine and your breathing will be supported until the spinal medicine wears off.
Some patients may get a headache after epidural placement. The incidence of this type of headache is about 1%. These headaches can range from mild to severe. They are known as post dural puncture headaches, or as spinal headache. One distinguishing feature of this headache is that it is typically worse when standing or sitting, but goes away when laying flat.
If it is this type of headache, it can resolve on its own without treatment. Sometimes, drinking fluids and caffeine will help. Other times, oral pain medications relieve the headache. And sometimes, an epidural blood patch is performed to help resolve the pain. This is a procedure done by anesthesiologists.
An epidural blood patch involves the same process as an epidural for labor. There is an added step, though, in which blood is removed from an iv and then placed into the epidural space. Many times, a blood patch can instantly stop a post dural puncture headache. But there is also the chance that this procedure may not work as well.
If the headache continues for over a week after epidural placement, this is rare. It may be a sign that the headache has an additional causative factor or is not a post dural puncture headache at all.
This is not to downplay your discomfort by any means, but may be a sign that other diagnostic tests are in order. Also, a neurologist can be consulted. These physicians are experts in the causes and treatment of headaches.
If the epidural catheter starts to travel into a blood vessel inadvertently, the local anesthetic medicine in the epidural can cause toxicity in your body. In the worst case scenario, a large dose of the local anesthetic in your bloodstream can cause your heart to stop.
But this is why we use low concentrations of local anesthetic and why we give incremental doses of epidural medicine prior to starting the infusion. We are testing for “intravascular placement.” And even a properly functioning epidural has a risk of migration into a blood vessel at any time, so we are monitoring you for any feeling out of the ordinary.
The most feared side effect of epidurals is of permanent nerve damage. Fortunately, this is a very rare complication. Several studies have quoted the risk of permanent nerve damage after epidural placement, but the exact risk is difficult to pin down. This is because it is such a rare complication.
Labor epidurals are placed below the level of the spinal cord so as to avoid interfering with the cord. However, nerve roots exit the spine at many levels and these could theoretically be damaged during epidural placement. But that is precisely why you remain awake during your epidural placement, to allow you to tell us if something doesn’t feel right. This may be a sign that the needle needs to be redirected.
Another very rare risk of epidurals is the development of an epidural hematoma. This can potentially occur if you have a bleeding disorder or you have taken blood thinning medicines. In this case, even the tiniest of blood vessels in your back can have trouble clotting. And if a vessel is pierced and the bleeding is around or in the epidural space, an epidural hematoma can occur.
Without the emergent treatment from a neurosurgeon to drain the blood from the epidural space, an epidural hematoma can cause permanent nerve damage. This is why anesthesiologists are very keen on getting a detailed history about you prior to epidural placement. As with other potential risks, we take this one very seriously.
Contradindications to epidural placement
There are times when an epidural is contraindicated. If a patient is actively bleeding or if their vital signs are unstable, an epidural is usually out of the picture. This is because epidural placement in these scenarios may cause an even more unsafe drop in blood pressure.
If a patient has a bleeding disorder or inability to clot blood effectively, epidural placement is contraindicated.
A severe infection in the bloodstream (sepsis) or at the site of potential insertion of the epidural is of concern. Some neurologic disorders make epidurals contraindicated.
Finally, technical difficulties in the actual placement of the epidural and patient refusal are two other contraindications.
What I tell my wife about epidurals
When a labor epidural works great, it is a beautiful thing. And we all have friends and family members who swear by epidurals. They can allow for a virtually pain-free labor and delivery, so that the mom can really focus on the joy of delivering a baby.
And usually epidurals do work really well.
But sometimes they don’t work and sometimes they can have have side effects. The most common side effects we see (itching, low blood pressure) can be treated and are usually minor. On the other hand, there are serious risks, but they are very rare.
So I tell her that the potential benefits of an epidural far outweighs the risks (in a healthy patient with no contraindications). And if something out of the ordinary begins to occur, an anesthesiologist will be there right away to help out.
But in the end, I know the decision is completely up to her. And she may decide to go one way at first and end up with another decision after awhile. The goal is to have a safe labor and of course have a happy mom when it is all said and done.
Have you had a labor epidural before? Did you experience any side effects? Let us know what you think by leaving a comment below or by visiting the forum.