Birth Plans

Epidural

Epidural and spinal are general terms for techniques for administration of pain medications. They refer to the location of the administration, either the epidural or spinal space. There are a variety of medications that are administered by regional block techniques, and there are variations in how the medications are administered including combining two or more medications.

The number of women who use an epidural during labor varies around the world, and even in different hospitals in the same area. Because it is an advanced anesthetic technique, it is only available to women in developed countries and in some countries is only available to the wealthy. The World Health Organization does not consider an epidural to be essential for care in normal birth.

According to the statistics from each individual governments, New Zealand has a 24.2% epidural rate; Canada has a 45.4% epidural rate. Other governments do not report the use of epidurals in an easy to use format. However, it is important to remember that different areas within the same country can have very different statistics. The Listening to Mothers II survey reported a 76% epidural rate among women giving birth vaginally.

The Process

Before you can receive an epidural medication, your blood will be drawn and evaluated. This is usually done upon admission to the hospital. If you have not already, you will begin receiving IV fluids to prevent a drop in blood pressure. You will be attached to an electronic fetal monitor to obtain a baseline strip recording of your baby's heart rate. The monitor will remain attached to you until your baby is born. It can be helpful to include any special information that may affect your satisfaction with an epidural in your birth plan. This may include drug allergies, unplesant reactions or a history of substance abuse or aquired tolerance. This information helps the anesthesiologist plan medications and doses.

Once everything is set up, you will need to get into a position either lying on your side or hunching over so your back is arched. You must not move during the procedure which will last about two contractions (5 to 10 minutes). Your back will be washed with an antiseptic and covered with a sterile drape. You will receive a small amount of anesthetic to numb the injection sight. Once your skin is numbed, a large needle is pushed between two of your vertebrae just above your waist. The anesthesiologist will guide the needle into the correct spot, and then test to make sure the needle is properly positioned. Once the needle is in the right space, a thin flexible tube is fed through the needle. The needle is withdrawn, leaving the tube in place. The medication is inserted through the tube, and the tube is looped and taped to your back to ensure it does not pull out.

After the tube is in place you will be assisted into a comfortable reclining position. You will be asked to rate the effectiveness of the pain relief, and depending on your questions you may receive more medication or be shifted to a different position. Depending on the preference of your care team, your tube may be connected to a pump that continuously infuses more medication into the epidural, or you may receive top up doses at regular intervals.

Effectiveness in Labor

When it comes to relief of labor pain, everyone agrees epidurals are the best medication for the job. But when the question of how an epidural affects labor is asked, a variety of points of view compete for attention. In fact, there is some heated disagreement on epidurals in childbirth.

Part of the problem lies in the fact that an epdural is a process for administering medications - not a medication itself. So two women receiving epidurals in two different hospitals at the same time could have very different experiences. The amount and type of medications vary as much as the policies around epidural use. Unfortunately, it is difficult to draw conclusions about the combined effects of such a variety of procedures.

The second part of the problem is in the research itself. Most research into pain medication use for labor is interested in how well the medication eliminates the pain. Side effects are usually a secondary issue, if the research looks at them at all.

In order to find out more about the effects of epidurals on labor, the Maternity Center Association included reviews of epidurals in its project into the nature of labor pain and its management. As a part of the project, two separate teams of researchers investigated the effects of epidurals on childbirth, and a third researcher reviewed the most common side effects.

Where they agree

The two review groups agreed that women who used epidural pain relief were more likely to have a longer second stage of labor (pushing), more likely to need forceps or vacuum extraction and more likely to have a fever.

Where only one team explored

Some effects of epidurals were only investigated by one team or the other, so were only found by one team. Among these effects of epidurals are:

The researchers also found that epidurals may be associated with:

Where they disagree

In four areas the teams came to different conclusions:

Why did they find different results? Each team set its own criteria for what studies could be included in the project. A study that may have been acceptable to one team may have been unacceptable to another. Because they used different sets of research they found some contradictory results.

Side Effects

In examining the most common side effects, the research team focused on the effects of the "light" or "walking" epidural. They found a wide range of frequency in side effects.

The -caine derivatives include mepivacaine, chloroprocaine, bupivacaine, lidocain and ropivacaine, and may be used for an epidural or a spinal. These medications are injected into the epidural space by a catheter and may be given as a continuous drip.They may cause you to feel relaxed, help you to sleep and cause a loss of sensation in the lower half of your body.

Possible side effects of -caine derivatives include maternal fever, decrease in blood pressure, slowing of labor, reduced urge and ability to push, increased use of forceps, vacuum extractor or cesarean birth, fetal heart-rate changes, or subtle changes in newborn reflexes.

Narcotics include meperidine, morphine, fentanyl and sufentanil. These medications are used for the "walking epidural." They give long term pain relief while preserving some muscle strength to allow you to move in bed and possibly stand or walk. Possible side effects of narcotics include nausea, vomiting, urine retention, itching, and fetal heart-rate changes.

Getting the Best Result

Understand the availability

To have an epidural you need an anesthesiologist or a nurse anesthetist to perform the technique. If no one is available, you can not get an epidural. Small hospitals may not have 24 hour in-house anesthesiology. This means if you decide to have an epidural in the middle of the night it either may not be available or you have to wait for the anesthesiologist to wake up and get to the hospital. A similar situation can occur in very busy hospitals when several women want an epidural at the same time or if the anesthesiologist is assisting a cesarean surgery. For some women, the wait is unacceptable and they choose other forms of pain relief.

To find out about the policies at the hospital you plan to give birth in, attend a tour or information night. You can ask questions about their anesthesiology coverage, how they handle busy days and what other options are available if an epidural is not immediate. You will also learn about any other policies that may limit your access to an epidural such as results from blood testing or progress in labor. Your midwife can also let you know any health issues you may have that could limit your access to an epidural.

Have realistic expectations

For most women an epidural does an extremely good job of relieving their pain. 81% of the women in the Listening to Mothers II survey said an epidural was very helpful. But keep in mind that 10% said it was only somewhat helpful and another 9% said it was either not very helpful or not helpful at all. Be sure to alert the medical staff if you feel the epidural is not as effective as you expected so they can work with you to improve your comfort.

Because an epidural is a technique, not a medication, there is a wide range of pain relief that you may feel. In general, the lower doses that allow you the ability to have some strength and movement in your legs provide less pain relief then the stronger doses that make it difficult or impossible to move your legs. Find out if you will be given the choice between more relief and lack of mobility and less relief (generally feeling pressure of contractions but not strong enough to be called painful) and some mobility.

Some hospitals offer what is called a walking epidural. The idea of using such low dose medication to allow pain relief and mobility is a good one. However, in practice very few mothers who use a walking epidural actually get up and walk. For 35-85% of mothers they either feel too weak and shaky, do not have assistance or are unable to walk because of wires and tubes attached to their body.

Understand the process

Although the image of laboring with an epidural is that it is blissfully easy and relaxing, the reality is most mothers using an epidural look more like they are in an intensive care unit than a birth center. Because of the risk an epidural adds to labor, your baby's heart rate will be monitored with an electronic fetal monitor. Most often this is accomplished with an external unit, but sometimes an internal monitor is used. The medications used in epidurals increase the risks for you too, so your blood pressure and pulse will be monitored during labor. This means in addition to the tube attached to your back you will have wires attached to either your abdomen or your vagina, a blood pressure cuff on your arm and a pulse meter on your finger.

The numbing effect of an epidural prevents you from feeling the need to empty your bladder. To ensure a full bladder does not block your baby's progress, you may require a urinary catheter (between 30 and 60% of mothers are catheterized). Because an epidural can decrease the available oxygen for your baby, you may need to wear an oxygen mask over your nose and mouth. When narcotics are used in an epidural (common in a combined spinal/epidural) about 62% of mothers experience itching all over their body.

Hospitals have different policies about eating and drinking during labor. Be sure to ask how having an epidural will affect your ability to nourish yourself.

Keep the epidural for pushing

It was once believed that an epidural needed to be shut off for pushing. Studies now lead doctors to believe there is no benefit to turning off the epidural and it causes more pain for mothers. In fact, if you keep the epidural and wait until your baby's head descends enough to be visible you not only decrease your fatigue from pushing, you also decrease the risk you will need a cesarean, forceps or a vacuum.

Accept the limitations

Epidurals are only able to change the way your body physically processes the sensations of labor. Presumably, removing the pain of contractions will improve your satisfaction with childbirth, but not always.

Four factors are consistently related to a woman's satisfaction with childbirth. These are:

The fact that pain relief is missing from this list was a surprise to the researchers, who naturally assumed pain relief was the most important factor in a satisfying birth. Instead, it appears the relationship you have with your midwife is significantly more important to your having a good birth than how effective an epidural may be. Because of this, part of having the best epidural experience possible is ensuring you have chosen a supportive caregiver who is a partner as you make decisions for birth.

References:

Declercq ER, Sakala C, Corry MP, Applebaum S. Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection, October 2006.
Enkin, Keirse, Nilson, Crowther, Duley, Hodnett and Hofmeyr. A guide to effective care in pregnancy and childbirth Third Edition. 2000. Oxford: Oxford University Press.
Goer, Henci. The Thinking Woman's Guide to a Better Birth. 1999. New York: The Berkley Publishing Group.
Simkin, Penny. The Birth Partner: Everything You Need to Know to Help a Woman Through Childbirth. 2001. Boston: Harvard Common Press.
The Nature and Management of Labor and Pain Symposium Steering Committee. The Nature and Management of labor Pain: Executive Summary. Journal of Obstetrics and Gynecology. May 2002; 186:5 S1-S15.