Thinking about an epidural during labour??

There is much written and spoken about with regard to the use or otherwise of the Epidural Block (EB) for pain relief in labour. Lots of misconceptions and misinformation. In this brief blog I will endeavour to cover what I believe are a few of the important facts to know about EB in labour.

What is it?
It is a form of pain relief in labour which is administered by an anaesthetist. A fine plastic tube (epidural catheter) is inserted via a needle in the lower part of the back. Only the plastic tube remains. The needle is removed. Local anaesthetic medication is inserted via the plastic tube and this blocks the pain signals coming from the uterus each time there is a contraction. The local anaesthetic medication is administered by continuous infusion during labour and therefore remains effective for the remainder of the labour or until it is ceased. The amount of pain relief can be adjusted by altering the local anaesthetic infusion rate. Once it is turned off it usually takes 2-3 hours to completely wear off.

What are the good things about EB in labour?
It is by far the most effective form of “pain relief” in labour. Other options (eg gas, pethidine/morphine) assist with pain management but EB reduces the pain significantly, by about 90% or more in most women. No other option comes even close to this.

What are the bad things about EB in labour?
Serious complications associated with epidural are extremely rare. You are at greater risk of serious injury driving around in your car than you are of having a serious complication from an EB. The most common significant complication of EB is a thing called a “spinal tap” which is where the epidural needle accidentally makes a small hole in the sac which contains your spinal fluid, this is not a dangerous problem but it can cause a severe headache. It occurs in about 1 in 200 EB or less and will often be noticed by the anaesthetist at the time. If this happens you would need to lay flat on your back for the first 24hours after the birth. This can be a real nuisance if it occurs. Sometimes the anaesthetist will perform a second small procedure to fix this problem if it does not fix itself in the first day or 2. It does not have any long term consequences.
Forceps or vacuum assisted births occur about twice as often in women who have had an EB compared with those who have not. This is due to the EB taking away some of the sensations that would help you to push effectively. However most women with an EB will deliver normally, without the need for either forceps or vacuum.
There is a small chance that the EB might not work as effectively as hoped for. Even in the hands of a skilled anaesthetist there are some women in whom it is very difficult to administer a fully effective epidural. Sometimes this can be predicted in advance.
Women who might experience difficulty with epidural insertion
– history of previous back surgery
– known spinal abnormalities
– history of serious back problems
– obesity: especially women with a BMI > 40
If you have any of these problems and you are considering an epidural in labour you should discuss this with your obstetric care provider and perhaps consider seeing an anaesthetist in the latter part of pregnancy to discuss the relevant issues.

Some of the myths about epidurals:
Epidurals cause long term back pain“: there is clear evidence that this is not true
Epidurals slow down the progress of labour“: quite the contrary in many women, once they are pain free and more relaxed the labour often progresses more quickly. EB can however make the pushing part of labour take longer, as mentioned above.
Epidurals are dangerous“: as mentioned above, EB is only administered by a skilled anaesthetist and is a very safe pain relief option for both mother and baby.
You can walk around with your epidural“: we do not allow “walking” epidurals, it can be dangerous to try and walk if you can’t feel where your legs are! Once you have an EB you will need to remain on the bed for the remainder of the labour. Usually there will be a catheter inserted into your bladder to drain urine, as most women with an epidural find it hard to tell if their bladder is full or not. Once the EB has worn off the bladder catheter will be removed.
Don’t leave it too late or you will miss out“: if it appears that you are likely to be ready to give birth to your baby within the next hour (can be very hard to predict) then purely from a practical point of view there is very little benefit in trying to insert an epidural. If you have made it this far without an EB then essentially you have made it.

Take home message:
Epidural block provides an effective and safe pain relief option for women in labour. Whether you choose to have an EB in labour or not is entirely a personal decision. It is a good thing to have thought about your pain relief options prior to labour and perhaps to have a few thoughts as to how you might like to approach things but it is good to be quite flexible also because it is very hard to predict in advance how your labour will progress and how the contractions will feel for you, especially if this is your first labour!

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