What Is An Epidural

According to the American Heritage Dictionary, an epidural is: Anesthesia produced by the injection of a local anesthetic into the epidural space of the lumbar or sacral region of the spine, inducing regional anesthesia from the abdomen or pelvis downward and used especially to control pain during childbirth.

In laymen’s terms, it is an injection an anesthesiologist administers during one of the stages of labor known as active labor and it goes directly into the spine, blocking pain to the brain almost immediately. It is very similar to what they use in cesarean sections. Once the epidural is administered you may not feel much relief for the first few minutes, but you will. Once it kicks in and you feel your body relax, you will be able to sleep or chill out for a little while, until you are dilated enough to begin pushing. Sometimes the anesthesiologist administers enough where you can still move your legs and feel pressure during contractions, but no pain. Other times the medicine is too strong for you to even lift up your foot, and you feel absolutely nothing during labor and delivery.

How Is An Epidural Administered?

Epidural Review

*Note, before an epidural is administered, if they have not already, they will start you on IV fluids. This is to prevent low blood pressure, a side effect some women experience with an epidural.

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As a childbirth educator who usually sees women only during the last ten weeks of pregnancy, I sometimes feel like a voice in the wilderness, as I may be the first and only person they encounter who perceives childbearing without drugs as a normal and achievable thing.

The terms "epidural," "epidural block," "epidural anesthesia," "epidural analgesia," and "walking epidural" refer to a procedure in which pain-relieving drugs are injected into the epidural space in the spinal column. The effects (amount of pain relief, loss of movement, side effects) depend to a great extent upon which drug is injected and at what dose.

Of course, the main attraction of an epidural is pain relief, and in this regard the epidural is far more effective than intravenous narcotics and other methods. Other perceived benefits include the fact that the birthing mother can maintain her composure and clear- headedness, and recapture a more "normal" appearance, regaining the ability to think and converse normally. She can rest, especially in a prolonged labor; often she can sleep for a few hours while her cervix continues to dilate. Further, epidural narcotics and/or lighter doses of anesthetic allow the mother more mobility and cause fewer side effects than heavier doses. Finally, although epidural drugs do pass through the placenta to the baby and cause some subtle side effects, the immediate harmful effects on the newborn associated with the other common choice of drugs for labor pain-intravenous drugs (respiratory depression and poor muscle tone) do not occur with an epidural.

From the practitioner's viewpoint, epidural use has many benefits. It gives the obstetrician more control in managing labor as he or she prefers, and allows for the painless administration of other interventions or surgery (such as oxytocin, manual dilation of the cervix, fundal pressure or massage, vaginal stretching, forceps use, vacuum extraction, episiotomy, or cesarean), which would be unbearable without anesthesia. Nurses are less troubled by patients who are free from pain. Further (and this is a significant factor in the economics of health care), increased use of labor anesthesia provides employment to obstetric anesthesiologists. In sum, epidurals have been seen by many as something of a panacea in obstetric care. However, it is not that simple.

Ever since regional anesthesia was introduced into obstetrics in the 1940s it has been touted as "safe and effective" by those who administered it. With use, however, side effects became apparent.

Anesthesiologists have responded to the revelation of undesirable risk factors with new approaches, drugs, dosage regimens, and techniques. Most of these side effects have unfortunately been discovered only after the technique or drug has caused harm. This was the case with bupivacaine (a common anesthetic for epidurals) in the 1970s, when the high concentrations of anesthetic that were standard at the time were mistakenly injected into some women's veins instead of into the epidural space, causing the deaths of several of these women from cardiac arrest. This led to a major public outcry and an eventual ban of this concentration in obstetrics.

Another example of the harmful effects of epidurals is the recent recognition by obstetricians and anesthesiologists that with an epidural, labor is more likely to slow down, and to require pitocin, forceps or vacuum extraction, or cesarean delivery. Many research reports were published in the 1990s associating epidurals (especially those given early in labor) with cesareans for dystocia (failure to progress or arrest of labor). Practitioners are beginning to realize that epidural labors must be managed differently from unmedicated labors, in order to prevent the higher cesarean rate that occurs when an epidural is used.

A third example is the recently reported connection between epidurals, maternal fever and newborn intensive care admissions, sepsis evaluations, and antibiotic use. Since 1989 numerous studies have reported time-related increases in body temperature in women with epidurals. When fever occurs in the mother, the caregiver must assume that infection is present in both mother and baby, and testing and treatment for infection are begun. These findings, reported by numerous reputable researchers, have been downplayed and denied by the majority of anesthesia practitioners.

As with all drugs, the use of epidural medications carries significant risks and can cause side effects in mother and baby. The severity of these risks varies, depending on which drugs are used, at what stage in the labor the epidural is given, the total dosage of medication accumulated through the labor, the skills of the anesthesiologist, and the woman's individual reactions to the epidural. Generally speaking, the later the epidural is given, and the lower the concentration of the drug, the lower the frequency and severity of side effects will be. Besides the discomfort of administering the epidural and the fact that it may take a half hour to 90 minutes for pain relief to take effect, mothers opting for epidurals risk these side effects:

* a toxic or allergic reaction to the specific drug or drugs

* fever, which becomes increasingly likely after the epidural has been in for four hours or more

* decrease in maternal blood pressure

* decreased contraction strength and/or frequency and slowed labor progress (dystocia)

* diminished urge and ability to push

* inability to urinate

* itching and nausea if narcotics such as Sufentanyl, Demerol (Meperidine), Duramorph (morphine), Fentanyl, and Stadol are used

There is also the remote, though not unprecedented, possibility that the anesthesiologist could insert the needle into a blood vessel or the spinal canal instead of the epidural space. While it is uncommon, this human error has in some cases led to breathing difficulties for the mother, spinal headache, and, in extremely rare cases, meningitis, cardiac arrest, or even death. 1, 2, 3, 4, 5

An epidural also puts the baby at risk of the following:

* heart rate deceleration and hypoxia (decreased oxygen supply) from a drop in the mother's blood pressure

* tachycardia (rapid heart rate) and fever (from the mother's fever)

* subtle changes in newborn reflexes and neurobehavior, including in suckling

* more difficulty in self-soothing or being consoled

There may be other, possible long-term effects on the baby, but these have not been studied widely at present. (See "Epidural's Effects on Babies.")

An additional concern is that intravenous fluids are given in large quantities before and during an epidural in order to expand the woman's blood volume and prevent a drop in blood pressure. This quantity of fluids also can lead to excessive urine production, possible excessive breast engorgement, fluid overload, neonatal tachypnea (rapid breathing), and in rare cases pulmonary edema, as well as other side effects.

Having accompanied numerous women through labor and having given birth myself without drugs, I believe that epidurals represent overkill, and that the pain of a reasonably normal labor is manageable for most women with nonmedical comfort measures and appropriate support. However, I also believe deeply in the right of a woman to make her own choice. I think that women should have an opportunity to be informed honestly and completely about epidurals and also to have the chance to explore their fears of childbirth pain, and of the pain behavior they may exhibit. Women have been systematically, if unintentionally, convinced not to trust their own bodies, especially when it comes to obstetric care. Many a woman enters pregnancy confident, positive, and healthy. However, by the time she has run the gauntlet of prenatal screening and diagnostic tests (with their frequent false-positive findings), her confidence is severely undermined, and she has trouble believing that her body will perform well for her during labor and birth.

Fortunately, there are and always will be women who trust themselves-or can be helped to trust themselves-to labor and give birth, to perceive pain as only a part of the larger experience, and to discover their strength. We also must make sure that these women have access to the maternity care that supports their values. As Leslie Ann Fuchs says in her introduction, laboring women can gain great confidence and optimism in themselves through natural childbirth, as women and mothers.

Adapted from an article first printed in Birth Gazette, 931-964-3798; www.BirthGazette.com.

Notes

1. J. J. Bonica and J. S. McDonald, Principles and Practices of Obstetric Analgesia and Anesthesia, second edition (Philadelphia: Williams & Wilkins, 1995).

2. J. A. Thorp, "A Review of the Literature on Epidural Analgesia for Childbirth," Birth 23, no. 2 (1996).

3. J. A. Thorp, "Epidural Analgesia for Labor: Effect on the Cesarean Birth Rate," Clinical Obstetrics and Gynecology 41, no. 2 (1998): 449- 460.

4. E. Lieberman, "The Risks and Benefits of Epidural Analgesia During Labor," Journal of Nurse-Midwifery 44, no. 4 (1999): 394-398.

5. E. Lieberman, J. M. Lang, and F. Frigoletto et. al., "Epidural Analgesia, Intrapartum Fever, and Neonatal Sepsis Evaluation," Pediatrics 99, no. 3 (1997): 415-419.

Penny Simkin is a physical therapist who has specialized in maternity care since 1968. She is a childbirth educator, doula, doula trainer, and birth counselor. She has written many books, the most recent of which is The Labor Progress Handbook: Early Interventions to Prevent and Treat Dystocia (2000), with Ruth Ancheta. Others include Pregnancy, Childbirth, and the Newborn: The Complete Guide, with Janet Whalley and Ann Keppler, and The Birth Partner: Everything You Need to Know to Help a Woman Through Childbirth.

***Keep in mind, the advice we are giving here is instructional only, we are not medical professionals, and this is for healthy women with normal pregnancies. If you are a high risk pregnancy, or have medical problems, this would not apply to you.

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