January 2008 - Monthly Feature

Recently, I have received many questions about epidurals and about some of the risks and benefits, and I could not believe how much inaccuracy and misinformation there is on the Internet surrounding this topic. Therefore, over the next several months at the “Ask the Doctors” forum, I hope to highlight and clarify some of these issues. This month, I’ll take you through some of the basics…

What is an epidural?

An epidural is a procedure that numbs pain fibers and prevents transmission of pain signals to the brain. The name ‘epidural’ comes from its place of delivery into the body, “the epidural space” which lies in front of the spine (see picture). It is not required in any way for the process of having a child, and many women elect to forego an epidural, as there are other methods and alternatives for enduring labor.  I believe that it’s helpful to just know that it's available as the thought of a backup for pain control reduces the anxiety and fear of childbirth.

It is important to remember that an epidural can take up to about half an hour to be administered and start having an effect. An epidural can be given at any stage during labor, but may be limited by a woman’s ability to sit or lie still for the procedure. Although many people debate that an epidural medicalizes the birthing process, it is presumed safe for mother and baby. There is no evidence that the use of epidurals affects the oxygen delivery or the neurobehavioral activity or development of the baby.

There are few reasons that a women would not qualify for the placement of an epidural during labor. These include patient refusal, active bleeding, infection in the blood, infection at or near the site of needle insertion, and problems related to blood clotting or taking blood thinners (anticoagulants). A thorough examination by an anesthesiologist should be required before any epidural is considered or placed. 

What are the advantages/benefits of an epidural for labor?

Pain relief (partial to complete) - A good epidural will relieve the pain associated with labor without removing the sensation of pressure that a woman requires to labor. Most anesthesiologists will start with a standard dose of anesthetic and specifically tailor it to each patient. The more anesthetic that is delivered, the denser the epidural becomes to the extent that a temporary numbness an inability to move the legs can occur, which can actually delay childbirth.  Therefore, I encourage all women to have realistic goals about an epidural… “pressure not pain” and keep a close communication with their anesthesiologist about the levels of their comfort.

• Increased wakefulness and alertness – The effects on epidural are typically localized rather than systemic, so while a patient is provided with pain relief during their labor they will be awake and alert. In addition, as their pain in well controlled, a women can rest if they want (or even sleep!) as their cervix dilates. As a result, they will have more energy when it comes time to push.

• Effects are localized – Unlike receiving systemic narcotics, which a patient would get through an IV or pill form, the effects of an epidural remain targeted to the area in need, without significantly affecting other areas of their body. This allows less medication to be administered which is safe for the baby and the mother.

• Can be used for caesarean section – In the event that a c-section is needed after a failed trial of labor, a working epidural can be dosed in higher concentrations to provide anesthesia. This would prevent the need for general anesthesia, and allow a woman to be awake for their c-section. (An epidural is different from a “spinal” and will be discussed in a future topic in upcoming months.) The epidural can also be used as the anesthetic for other procedures after labor (i.e. tubal ligation).

• May relieve anxiety and facilitate a prolonged labor - Anxiety related to the birthing experience and pain can cause an excess production of stress hormones in a mother, which can ultimately slow contractions. In this case, an epidural could help facilitate labor by alleviating pain and anxiety by allowing a patient to rest, as their labor progresses.

Debunking Epidural Myths

There are many myths surrounding epidurals; although I am not entirely sure where they come from, many have been disproved in recent clinical research. I feel it is important to discuss these myths as many women believe them and are persuaded to forego their epidurals because of them…

One of these statements are that “epidurals cause a prolongation of Labor” (56 minutes to be exact) and the “increased use of pitocin”  (a medication used to enhance and promote uterine contractions).”  These statements come from several research studies were different groups of women were compared. However, it is impossible to establish a direct link as the women who were compared in the epidural group were more likely to be having their first child, come to the hospital earlier, have a higher fetal station (location within the birth canal), deliver larger babies, and have smaller pelvic outlets; all factors that independently cause longer labors.

There is also the concern of timing for an epidural. It was previously thought that an epidural placed too early in labor could increase the risk of caesarean section. This has been disproven, and a woman can reasonably receive an epidural at any point during labor, provided there is enough time and she is willing to lie still for the procedure.  Another concern is regarding chronic back pain following the placement of an epidural. Epidural anesthesia does not appear to be associated with chronic back pain, and any discomfort of the back is believed to be due to the stress of labor.

Finally, there was a concern at one point that the use of epidurals was associated with babies having difficulty "latching on" leading to breastfeeding difficulties. This has been disproven, and there is currently no evidence that the use of epidurals causes a problem with breastfeeding of the neonate.

What are the disadvantages/risks of an epidural for labor?

• Higher incidence of “assisted deliveries” – Although the use of epidurals does not increase the rate of c-section, it does increase the possibility for an “assisted delivery” requiring the use of forceps or vacuum extraction to help deliver the baby.

• Effects on blood pressure - The medications used in epidurals may cause a decrease in blood pressure. For this reason your blood pressure is routinely checked and may require treatment with IV fluids, medications, and oxygen. If you develop nausea or lightheadedness with your epidural, it may be a sign that your blood pressure requires evaluation and you should contact your nurse or physician immediately. 

• Headache – A postdural puncture headache (PDPH) or “spinal headache” can occur if the epidural needle is inadvertently inserted through the epidural space into dural area.  The risk of accidental dural puncture occurs 1.5% of the time, but only half of these (0.75%) result in headache.  A PDPH can occur as early as one day and as late as seven days after dural puncture and lasts anywhere from12hrs to seven days.  If symptoms persist, a special procedure called a “blood patch”, an injection of your blood into the epidural space, can be done to relieve the headache. (The topic of PDPH will be covered in a future month at “Ask the doctors”.)

• Fever – The use of epidurals is associated with an elevation in temperature in approximately 15% of women with epidurals. This increase in temperature is not believed to be from infectious causes and consensus among most obstetricians is that no treatment be initiated. 

• May not work effectively – Occasionally an epidural does not work effectively and a woman may still feel pain, or pain on one side. In this event, different medications can be administered, but may ultimately require replacement of the catheter.

• Meningitis – Meningitis is an inflammation of the membranes that cover the brain and spinal cord, which is a serious but treatable complication. The risk of meningitis is the most common of the “rare neurological complications” occurring in an estimated 1 out of 100,000 patients or at a rate of 0.001%.

•  Epidural Hematoma – Another rare complication is the accumulation of blood in the epidural space that can cause neurological symptoms. This is a surgical emergency and is typically linked to the concurrent use of blood thinners (anti-coagulants); One of the reasons that women on blood thinners (anticoagulants) are typically not candidates for epidurals.

I hope you enjoyed this month’s topic at Ask the doctors, and if you have any questions or comments please forward them to askthedrs@thebumblecollection.com . Remember you can also submit any questions to the website through the “Ask a Question” link located here. See you next month!

Sincerely,

Dr. Sal Maya

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