Epidurals

Should I or Shouldn't I?

I love talking to patients about labor epidurals! There is so much myth, superstition, fear, misinformation and drama regarding this topic that brief discussion can provide a great deal of educational benefit to my patient.

What is an epidural?

Most people know that it's a needle in the back and that it can take away labor pain. In reality, the needle is in the back only momentarily. It is used as a guide to insert a very long, thin, hollow plastic catheter into the epidural space, a biological location just outside the spinal cord, where major spinal nerves enter and exit the spinal cord. The catheter remains in place until shortly after the delivery. Medication-either a narcotic or a novocaine-type drug-can then be injected into the catheter either with a syringe or by a continuous computer-controlled pump (like an IV pump), resulting in incredible long-lasting pain relief.

Types of epidurals

There are two main types of epidurals: the walking epidural (epidural 'light') and the traditional epidural.

At my hospital, the walking epidural has been tried many times, and I have to say, it's more like a "crawling" epidural. For this type of epidural, only a narcotic only is given. Theoretically, there is some pain relief, supposedly with minimal weakness as a side effect. However, to achieve satisfactory pain relief when labor is strong requires so much medication that walking becomes a problem, and if the labor pain isn't that bad and the patient still wants to be able to walk around, then a better option is probably no epidural at all.

Traditional epidurals use a "novocaine" type drug, sometimes with a narcotic also. The pain relief is phenomenal, and many patients consider it almost a miracle. The before and after transformation of the patient can be dramatic. Unfortunately, once this epidural is going, the patient can not leave the bed because the legs become weak and partially numb. Often a catheter is placed in the bladder because patients may also lose their sensation of needing to urinate. This is another reason why epidurals should not be given too early during labor (see myths below). The epidural is turned off after delivery and the catheter is removed. Full sensation usually returns a few hours later.

Possible side effects

Blood Pressure Drop

Epidurals are prone to causing brief, but potentially steep maternal blood pressure (BP) drops. Therefore, all patients receive IV hydration (extra IV fluid pumped into the bloodstream) before the epidural is placed. If the BP does drop, another medicine called ephedrine is quickly given IV, which usually suffices to restore normal BP.

Pain during the procedure

The back area is numbed with lidocaine, but most patients feel pushing and pressure, and then a brief electric shock when the catheter goes in. It's weird, but not dangerous, and it is VERY brief.

Lasting back pain

The injection site does hurt for a while. Sometimes a few hours, sometimes a few weeks, and rarely a few months, but I have not yet seen someone with permanent back pain from the epidural.

Post-procedure headache

This is a rare but serious complication of epidural, occurring less than one out of one hundred times. During the procedure, the introducing needle can go just a tiny bit too deep, nicking the membrane surrounding the spinal cord. This is called a dural puncture. The resulting headache is severe when the patient stands, and resolves when she is lying down. Once identified, there is a treatment called an epidural blood patch. Basically, some blood is drawn from the patient's vein, and is then injected back into the epidural space (yes, they have to perform the epidural again to do this). However, the patch can result in immediate and complete relief of this type of headache.

Epidural Myths

Myth: Epidurals can make you paralyzed.

I have seen thousands of patients who have received epidurals, and I have never seen or even heard of someone permanently injured by one, but it is theoretically possible. I also drive on the freeway and fly in airplanes knowing that there is a remote risk of death or severe injury with these activities as well. I have seen nerve stretch injuries. For example, sometimes the legs are stretched way back during the pushing phase of labor. The epidural masks the pain that would normally result if the leg stretching is excessive. Thus a nerve stretch injury in the groin or buttock area can occur.

Myth: Epidurals lead to a high risk of Cesarean.

There is some data to suggest that giving an epidural too early in labor increases the chance for a C/S. My practice now is to wait until the patient is at least 4 centimeters dilated (signaling the onset of the active phase of labor) before allowing an epidural. So far, this does not seem to increase the C/S rate. In fact, in many cases epidurals can prevent a C/S, by relaxing an otherwise anxious and suffering labor patient.

Myth: Epidurals will stop labor.

If given too early, epidurals can slow down labor. By waiting until 4 cm. dilatation before placing the epidural, this rarely happens. If the labor does slow down, we can use Pitocin to carefully and gradually bring the labor back to a "normal" pattern, or we can allow the epidural to wear off (most patients do NOT want this option).

Myth: "I won't be able to push."

There are times where the patient is so numb that she can not push, but this happens rarely. Typically, the patient doesn't FEEL the urge to push, but with good coaching she can still bear down quite effectively. I have delivered LOTS of babies to moms with great epidurals who pushed REALLY WELL, and yet didn't feel severe pain when the baby delivered. Some doctors routinely turn off epidural pumps when it's time for the patient to push. In my opinion, this is rarely necessary.

Myth: REAL WOMEN DON'T NEED EPIDURALS.

Give me a break! I have a very hard time with the political correctness of a drug-free birth as advocated by many highly outspoken individuals. Sure, if this is what you want, then GO FOR IT! But please try to avoid the holier-than-thou proselytizing that the only way to prove what a great woman and mother you are is to deliver your baby completely drug-free, surrounded by your doula, your coach, your husband, your parents and his parents, with everyone yelling all at the same time (see "a price to be paid" below).

Epidural Truths

TRUTH: Labor can be fun!

I have seen patients actually enjoy their labor and have fun because of the epidural. Patients can take naps, watch TV, enjoy music, play cards or socialize, all while their body is in booming labor! The birth itself can be nearly painless, and many patients actually sit up to watch the baby as it emerges from their birth canal.

TRUTH: Natural childbirth is just not possible for all women.

Many patients experience so much pain during labor that they actually lose themselves. They can become unrecognizable as human beings, scaring themselves and their loved ones. For these individuals, the epidural is nothing short of a miracle. To make these women feel guilty, to imply that they are bad mothers, or that they are wimps because they didn't go natural just infuriates me! Nobody can feel another person's pain, and I believe that the choice of having an epidural should not be stigmatized.

TRUTH: There is a "price" to be paid for the epidural.

There is a magic with natural childbirth that I do not see very often with epidural births. With natural childbirth, during the pushing, there is an incredible intensity in the room. The coaches are counting loudly, the patient is working hard, sweating, grimacing, maybe actually screaming and usually really hurting. Then comes the actual moment of birth. There is a searing pain, a prolonged push accompanied by a drawn out intense wail, followed by a loud and lusty newborn baby cry, whereupon the patient's wail is transformed in the same breath into a tearful shout of pain, joy and relief all at the same moment! The experience is unbelievable, and I can understand why many women are so determined to experience natural childbirth.

Summary

I hope this article helps to explain the true risks, benefits, side effects and possible complications of a labor epidural. Although I may seem to be pro-epidural, I basically consider myself pro-choice and anti-suffering. If a patient truly wants to experience a natural drug-free birth, I am all for it, but to me all births are miracles. Some are calm, some are intense. Some are natural, some are accompanied by epidural. Modern obstetrics now offers more choices and options than ever before. We should present the facts to our patients accurately and honestly and try to avoid using misinformation and political correctness as a basis for persuading patients to do what we think is right. Let the well-informed patient decide what's best for her.

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