Many women have had a labor epidural. And many women have strong opinions, for and against labor epidurals. Want to learn more?
As an anesthesiologist, I have an admitted bias on this issue. Having placed epidurals on a regular basis, what I also have is an intimate understanding of the real risks, benefits, and alternatives of labor epidurals.
Whether in the hospital or online, my goal is not to convince someone to have an epidural. But there is a whole lot of misinformation out there on this topic. My hope is that when you make your decision, it is one that is truly informed and not based on scary untruths that are lingering all over the place.
A valid concern that mothers often have is how an epidural may impact the progress of labor. As of this writing, much of the evidence suggests that the fear mongering put out about epidurals is simply untrue. Epidurals have not been found to slow the first stage of labor (this is the period of regular contractions and cervix dilation that ends when the cervix is fully dilated). In fact, there is some evidence emerging that epidurals placed at less than 4 cm dilation resulted in a shorter first stage of labor, as compared to those place at greater than 4 cm dilation.
Another concern was that epidurals may contribute to increases in forceps delivery or the rate of cesarean delivery. This has also not been found to be true. And women receiving intravenous PCA (patient controlled analgesia, with narcotic) instead of an epidural were more likely to feel drowsy and nauseous. Their babies were more likely to require naloxone, a medicine used to reverse the effects of narcotic medicine.
Epidurals are associated with a longer second stage of labor. This is the period that starts with full cervical dilation and ends with the delivery of the baby. It’s sometimes referred to as the “pushing” stage. This stage has been found to last about 15 minutes longer in women with an epidural.
Women with epidurals also report the best relief of labor pains and newborns clearly do better when little or no IV pain medicine is used. These are a few of the reasons why the American College of Obstetricians and Gynecologists view “neuraxial analgesic techniques” (eg. epidurals) as the most effective and least oppressive treatments for labor pains. They also mention that a fear of unnecessary cesarean delivery should not influence the method of pain relief that is chosen.
What about any adverse effects of epidurals? Well, they are associated with an increase in maternal body temperature. There may be several reasons why this occurs, including that epidurals cause a sympathectomy. This diminishes the body’s ability to cool down by sweating, below the level of the sympathectomy. What’s also important to note, however, is that although epidurals may increase maternal temperature, they are not associated with increased infection rates for the mother or the newborn.
A sympathectomy also may cause a drop in maternal blood pressure. Once you have an epidural in place, your blood pressure will be monitored regularly. Your anesthesiologist will treat you in the case of an unsafe drop.
Epidurals can be associated with a subsequent headache. These headaches typically decrease in intensity when lying flat, but worsen on standing up. They are called postdural puncture headaches and their incidence is about 1%. If this occurs, you will likely be treated with IV fluids and caffeine.
If this does not make the symptoms go away, you may be offered an epidural blood patch. This is the definitive treatment for this type of headache, but it involves the placement of another epidural and the delivery of your own sterile blood into that epidural space. This treatment works in about 90% of cases. Headaches can be very debilitating and by no means do I want to diminish their impact on quality of life. But even with no treatment, most of these headaches will go away within a few days to a few weeks.
Another fear is that the epidural may cause back pain. What’s often overlooked, however, is that back pain is common in pregnancy. Almost half of women develop back pain during pregnancy, even without epidurals. The added weight shifts a woman’s center of gravity, increasing the risk of lordosis and putting strain on the back. This has a higher chance of occurring when there has been a larger weight gain. So this is more an issue of pregnancy, labor, and delivery and not necessarily related to the epidural. But the epidural often gets the blame.
Another great fear with epidurals is the risk for nerve damage. “Will I get paralyzed?”, I have heard some paraphrasing of this question too many times from women that are in so much pain that they want an epidural but are worried about horrible consequences. The data tells us that nerve injuries related to labor epidurals have a rate somewhere between 0.08% and 0.92%. The symptoms typically last two months or less, and there is complete recovery in almost all cases. But many women have this image in their head of a needle jammed into their back, piercing their spinal cord, and leaving them paralyzed for the rest of their lives. Never mind that epidurals for labor are placed below the level where the spinal cord ends. While I can never tell anyone that their risk of a complication is zero, what I can say is that risk of nerve injury is very small and, if it should occur, it typically resolves within a few weeks to a a few months.
There is always a small chance that an epidural will not work as effectively as we’d like. When this occurs, after some “troubleshooting”, your anesthesiologist may offer to replace the epidural. There are also certain conditions that can make epidural placement more difficult. These include but are not limited to scoliosis, a history of back surgery, and obesity.
We already have covered a lot of information here, but I do want to make just a few more quick points. Know that once your labor has progressed past a certain point, you may not be able to get an epidural. In order to place your epidural, the anesthesiologist needs to have access to your lower back with you in either a sitting position or lying on your side. This may not be possible if you are close to the pushing phase.
One topic that never seems to come up in the epidural discussion is general anesthesia. If an epidural is in place, should you need to have an urgent cesarean delivery, your anesthesiologist can bolus your epidural catheter with stronger medicine that provides surgical anesthesia. If an epidural is not in place, there may not be time to place an epidural or a “spinal” and you may have to undergo general anesthesia. Though still safe, general anesthesia is significantly riskier in a pregnant patient. It is often more difficult to place a breathing tube in pregnant women due to physiologic changes that normally occur during pregnancy. And you will not be awake for the delivery.
We have covered so much information here, and we still could go on and on. Your anesthesiologist will discuss the possibility of an epidural with you after carefully reviewing your medical history. Hopefully, you will now have more information to have a good discussion with him/her. There are risks and complications with epidurals, but for most, those risks have a small chance of occurring. Understand that your anesthesiologist is not there simply to do a procedure. We are physicians that after carefully considering your medical profile and performing a focused physical exam, will give you a recommendation on the best options for you. We are there to be your advocate and provide safe and effective pain relief.
In the end, the decision is yours. The first contraindication to the placement of an epidural is patient refusal. My hope is that your decision is made after considering accurate information. And please don’t hesitate to discuss with your anesthesiologist any questions or fears you may have.
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