All About Epidurals

Nowadays it is extremely rare to find a pregnant individual who has not heard the term “epidural”.  But what exactly is an epidural?  How do they work?  What are the side effects of an epidural?  Why do people talk about them so much?  Do doulas help people who get epidurals?  Penny Simkin is one of the most well-known birth researchers.  She wrote many of the resources I pulled from to create this blog post and did a wonderful video for those who are planning an epidural (or, in my opinion, anyone who wants to know more about epidurals).  

What is an epidural?

An epidural (also known as an “epidural anesthesia or analgesia block”) is an injection of “suitable local anesthetic agent (e.g. bupivacaine, ropivacaine), an opioid analgesic (e.g., fentanyl, sufentanil), or both into the epidural (peridural) space.  Injection is made between the fourth and fifth lumbar vertebrae for a lumbar epidural block.”  In other words it is an injection of drugs that blocks the nerve impulses to the brain from the lower spinal segments.  The drugs found in the epidural can vary and the combination can cause varying levels of mobility.  If an opioid is used in combination with a local anesthetic then it is likely the individual will have more mobility than if the anesthetic is used alone.

How is it inserted?

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In order to inject the drugs into your body the anesthesiologist must first be called to the room by the doctor or nurse.  This may take some time and nurses may use this time to start IV fluids if they have not already been started.  When the anesthesiologist does arrive they will need the patient to sit on the edge of the bed (or lie on their side - which I haven’t seen as much) hunched over with their chin to their chest, arms close to their chest and back out like the Hunchback of Notre Dame.  

Sometimes in order to get the patient into this position they will have the patient hug a pillow or position the patient into an epidural positioning device.  This device reminds me of some of the devices that one might see at the eye doctor to get the best position on the eyes. The epidural positioning device has a place for the birthing individual to rest their head, arms and feet.  

When everyone is in position, the anesthesiologist prepares the area by getting their materials ready and cleaning the spot they will be inserting the needle into.  They then numb the area around where they’re going to inject the needle.  While the needle is being inserted it is extremely important for the birthing individual to hold still “so as to prevent misplacement, neurologic injury, or hematoma formation”.  If the needle is improperly placed they may need to inject it a second time.  Once the needle is inserted a catheter is threaded through the needle until its tip is in the epidural space and the needle itself is removed and the catheter is taped in place on your back.  Then a test dose is injected to be sure the catheter is in the right place.  Most of the hospitals I have been to in the area use patient-controlled epidural analgesia which includes a programmed pump that allows the woman to control the dose of drugs they are receiving.

What are the benefits of epidurals?

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  1. Epidurals are considered to be “the most effective pharmacologic pain-relief method for labor that is currently available.  As a result, it is the most commonly used method for relieving pain during labor in the United States and its use has been increasing.  Nearly two thirds of American women giving birth choose epidural analgesia”.  
  2. Provides comfort and relaxation
  3. Birthing individual is able to be alert and participate in the birth
  4. Birthing individual can move most of their body.
  5. Does not increase blood loss
  6. Dosage of medications can be modified to give birthing individual more movement or relieve more pain as need be
  7. Extreme fear or distress in birthing can prolong labor and decrease blood flow.  Epidurals can relieve these extremities and allow for labor to progress.

There is a debate over whether epidurals do or do not affect the rate of cesarean births. Some, for example, say that epidurals themselves do not impact the number of cesarean births.  Others believe that all of the other interventions that come along with an epidural can cause increased rates of cesarean births and therefore the increased rates should be attributed to epidurals.

What are the disadvantages of epidurals?

Many, if not most of the side effects of an epidural are not caused directly by the epidural.  As the Labor Progress Handbook explains, some side effects “may be created or exacerbated by management that necessarily accompanies it”.

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  1. An epidural affects the nerves communicating with the brain from the point of the epidural and beyond.  It therefore will affect communication with the bladder, pushing muscles and legs, making it difficult to feel or move these body parts or producing feelings of heaviness and numbness.  Because of this hospitals require birthing individuals to receive uterine catheters and stay in bed after receiving the epidural.  Frustration or discomfort may build from keeping the body in a limited number of positions.  Urinary catheters can cause urinary tract infections.
  2. Epidurals may decrease your blood pressure, which can slow baby’s heart rate.  Therefore care providers monitor the birthing individual’s blood pressure and the birthing individual may need to wear an oxygen mask to raise the baby’s heart rate.
  3. Itching is a common side effect of opioids, especially fentanyl, that may be in the epidural.
  4. Birthing individuals who have had an epidural for a long time have a higher rate of fever since they have difficulty regulating heat and cold.  Fevers in the birthing individual can affect the temperature of the baby.  If the birthing individual does get a fever they will most likely be prescribed antibiotics in attempt to combat potential infections.  If these antibiotics are needed postpartum the baby may need to spend some time in the NICU or nursery.  
  5. Nausea is common if the opioids reach the central nervous system.  Additional medication may be prescribed to combat the nausea.
  6. IV fluids are given with an epidural.  The more fluids in your body the greater likelihood of swelling (including your breasts) which may make breastfeeding more difficult.
  7. Studies have shown an increase in the use of pitocin, forceps and vacuum delivery with epidurals.  Epidurals typically slow labor by making it difficult for your body to produce oxytocin and thus needing synthetic oxytocin (pitocin) to maintain labor progress.
  8. If the epidural medication is injected into the wrong place then there is a chance of respiratory arrest.  

Resources I used while writing this article: