The epidural has become the most common method of pharmacological pain relief chosen by laboring women in the United States. An epidural can be used for spontaneous vaginal births, forceps- and vacuum-assisted births, as well as Cesarean births. Women often choose the epidural because they know it claims to offer total pain relief in labor.
But what really is an epidural? Many women make the choice to have an epidural without knowing the answer to that question.
What Is an Epidural?
According Dr. Joy Hawkins, director of obstetric anesthesia at University of Colorado School of Medicine in Denver, “The epidural rate is about 51 percent nationwide, with tremendous variation between hospitals.”
There are three types of anesthesia: local, regional and general. Local anesthesia requires an injection of numbing medication that affects a very small area of the body. General anesthesia requires gas and intravenous sleeping drugs that ensure that the patient will not be awake during a procedure (example: major surgery). Regional anesthesia is when medications are used to numb an area (or “region”) of the body while allowing the person to remain awake. Spinals and epidurals are examples of regional anesthesia.
The American Association of Nurse Anesthetists says that “the ideal anesthetic should provide enough pain relief to allow you to deliver your baby with minimal pain and anxiety, leaving you free to fully participate in the experience.”
How Is It Done?
During a spinal, medication is given through a needle or small plastic tube (catheter) directly into the subarachnoid space, which is the part of the spinal column that contains the cerebral spinal fluid. Numbing medication given via the spinal route is very fast acting, and the patient starts to feel numb immediately.
During an epidural, medication is given through a needle or catheter directly into the epidural space that is the part of the spinal column just outside the space that contains the spinal fluid. Numbing medication given via the epidural route is slower acting than the spinal. It usually takes about 15 minutes for the patient to feel numb.
What Medications Are Used?
A combination of local anesthetics and narcotics are used in both spinal and epidural regional anesthesia. The drugs prevent pain messages from being sent from the lower region of the spinal cord to the brain. Pain relief is achieved by the drugs acting on the sensory nerve fibers. The local anesthetics that are most commonly used are bupivacaine or ropivacaine. The narcotics that are most commonly used are fentanyl and sufentanil.
What Is a Walking Epidural?
A “walking epidural” is actually a combined spinal epidural. During a combined spinal epidural, two needles are used. The needle used for the epidural is inserted into the epidural space first. Then a longer, narrower needle containing medication is inserted through the epidural needle into the spinal (subarachnoid) space. After the medication is injected, the spinal needle is removed. The numbing effects of the medication are felt immediately. The epidural needle remains in place until after the epidural catheter is inserted. A continuous infusion of medication can be run through the epidural catheter to keep the patient comfortable throughout her labor.
Why Is It Called a Walking Epidural?
During a combined spinal epidural, the dose of the drug used in the subarachnoid space is much smaller than that used during a regular epidural. Dr. Hawkins says that all labor epidurals are walking epidurals: “All that means is that they are designed not to affect the muscle strength in the legs,” she says.
Because the dose of the drug used is smaller, there is little or no interference with motor function. This means, in theory, that the patient will be able to walk. But do laboring women walk with a walking epidural? Dr. Hawkins thinks the answer is determined by hospital policy. “Whether a woman is allowed to walk is a cultural question dependent on the culture in the hospital where she delivers,” she says. “In other words, the anesthesiologist is perfectly capable of providing an epidural which allows her the ability to walk, but it will be up to her obstetrician, midwife, labor nurse and hospital policy whether she is actually allowed out of bed.”
Real-Life Epidural Stories
Susan Varisco, a mother of two in Brooklyn, N.Y., had epidurals with both deliveries. She felt that her first epidural (in 1995) was “too strong.” So with her second child, Varisco requested that the epidural be mild. “I could still feel the contractions, but they were definitely less painful,” she says. She was happy with her birth experience and the epidural she had with her second birth. “I would recommend it,” says Varisco. “It was totally worn off by the time I was pushing so it didn’t hamper my pushing at all.”
Katie Donovan, of Wilmington, Del., has six children. She had epidurals with the first four births. While recovering in the hospital after her fourth birth, Donovan’s roommate suffered from a severe headache related to the epidural she had received. “She was in so much pain, it totally freaked me out,” says Donovan. “I decided after seeing her suffer that I would never have an epidural again.”
So she didn’t. With her last two children, Donovan had no medications. “The recovery was so much easier when I didn’t have an epidural,” says Donovan. “I think if doctors were just more encouraging and said things like ‘You know you can do this,’ that women wouldn’t need so many epidurals.”
What Do I Need Before I Get an Epidural?
If a woman decides she wants an epidural, there are several things that need to be in place prior to the actual procedure.
She will be attached continuously to a fetal monitor. It is necessary to monitor the baby’s heart rate very closely during the administration of an epidural. She will also have an intravenous line inserted to allow infusion of intravenous fluids necessary prior to the epidural as well as to give the anesthesiologist access to the intravenous route in case IV medications are necessary.
There is a debate about when in labor a woman can receive an epidural. Some argue that the epidural should not be administered until the woman is in a good labor pattern (regular contractions) so as not to require other interventions to speed up a labor that was inhibited by the administration of an epidural too early. Others argue that epidurals do not affect the progress of labor. More research needs to be done to clarify this. Meanwhile, the time at which a woman receives an epidural in labor is determined by her practitioner and the birth setting.
The process of labor has its rewards and its challenges. The rewards are obvious: A new life greets you at the other side of childbirth. The primary challenge of labor for most women is how to deal with the pain. Many women choose to have epidurals to deal with this challenge. Knowing more about epidurals will help women make educated decisions about their care during childbirth.
Epidural Side Effects and Treatments
- A drop in the mother’s blood pressure – The mother’s blood pressure is monitored frequently after the administration of medication. A woman is usually given a fairly large amount of fluid through her IV before the epidural is inserted. Medications are also used by the anesthesiologist to treat the mother’s drop in blood pressure.
- Change in fetal heart rate related to the mother’s drop in blood pressure – Treating the mother’s drop in blood pressure helps treat this problem. Position changes and oxygen administration to the mother are also used to treat a drop in the fetal heart rate.
- Inability to urinate – Insertion of a foley catheter to aid in keeping the bladder empty.
- Itching – Usually subsides on its own. Can be treated with medicated lotion.
- Prolonged second stage (pushing phase) of labor – Nothing
- Dural puncture leading to spinal headache – If the headache persists, the anesthesiologist will do a procedure called a blood patch to fill the puncture.