Regional Anesthesia - Epidural Pain Relief and Your Birth Plan

By: Aunt Doula (11/25/2022)

One of the strongest forms of regional pain relief options in labor is known as the epidural. While the process is roughly understood, and many people have heard about them, the details are often hazy at best. To begin we will go over what the procedure entails and then go over the pros, cons, and risks during labor of electing for an epidural. One of the biggest pre-cursors to an epidural is an induced labor, as the contractions strength are artificially intensified.

The Procedure

The procedure itself takes about 20 minutes and is performed by an anesthiseologist. You will be on your side on your birthing bed and need to remain very still, even through contractions. The anesthesiologist will be placing a thin tube (a cannula) into your epidural space of the spinal fluid filled sac that traverses your entire spine. This sounds very disconcerting and may even strike you as very dangerous, however it is performed quite frequently by extremely trained providers. The tube is inserted like an IV except it will be going between the vertebra in your spine instead of a vein - the tube will be inside the needle and then the needle will be removed from your back after the cannula is placed. The cannula is flexible, small and you won't be able to feel its presence. This procedure's goal is to allow the labor team to provide medication that will numb your abdomen and lower body to provide pain relief. The tubing that connects to the cannula will be taped securely to your back and you needn't worry about laying on the tubing. The relief you will feel happens rapidly once the medication is delivered to the epidural space.

Once you have an epidural, the required monitoring goes up. By electing to have an epidural, you are accepting that the level of monitoring and interventions will increase and some will be relatively difficult to deny. The things that are considered mandatory and standard after receiving the epidural include:

• Fetal heartrate and contraction monitors
• Blood pressure cuff and pulse oximeter
• You may be given oxygen at least temporarily
• An IV drip of pitocin is likely going to be required as epidurals can slow labor progress down.
• A urinary cather will be placed as you will not be able to walk to the bathroom safely or feel if your bladder is full.

Conditions to meet for epidural administration

There are not always hard and strict rules that dictate when you can receive an epidural, however there are suggestions of particular milestones of labor to reach for the most ideal outcomes to be achieved. Certain hospital policies may exist, so it's important that you ask if there are restrictions on when an epidural can or cannot be administered. The general conditions that are suggested include:

• Fetal station of at least zero
• Dilation of 5-7cm (this may not apply at your center - it is a marker that is on its way out)
• Active labor is well established
• Laboring person understands the pros/cons/risks/and how to request the epidural be turned down or off

You want baby to ideally be at least zero station, your cervix to be fully effaced, and some doctors may suggest you be dilated to a certain extent to reduce the chances that your labor could stall. Getting an epidural too early in your labor comes with significant additional risks to you and your baby, increased rates of labor augmentation and need of c-section. If you are denied an epidural by anyone on your labor team, insist that they inform you why you cannot receive it and if they cannot explain the reasons, ask to speak to an anesthestiologist. It is almost never too late to get an epidural unless that baby is crowning!

The way an epidural feels

Classic epidurals that are working as intended do make you numb, it ideally will make you unable to feel pain from your contractions, but it also makes you unable to feel your legs and feet. This can be disorienting or unexpected, it can cause some people to experience a sense of panic if they aren't ready for it.

Often the only way for you to be aware of a contraction is to place your hands on your abdomen and externally feel when your uterus is contracting when your abdomen becomes tight to help you know when to push effectively, or if you have a labor partner that can watch the tocometer readout that shows when a contraction begins.

It is important that you understand that while ideally you won't feel pain, you may still be able to feel sensations, sometimes described as pulling or tugging. Many people still feel what they describe as a general pressure in their abdomen, back and/or pelvis. Some people can wiggle their toes, others cannot. Many laboring people also still feel the pressure and stretching associated with the crowning of the baby (when the fetal head is initially emerging through the vaginal opening) sometimes called "the ring of fire."

A classic epidurals goal is for you to be numb from ‘Nipples to Knees’ literally! If your pain becomes unmanagable, epidurals provide relief that can be vital to being aware and focused for your delivery. There is no shame in receiving an epidural, however you should understand the risks and drawbacks to having one now so you can make an informed decision at the hospital.

Similar Forms of Epidurals

-- A 'walking epidural' is still a very effective method of pain control, tho most people cannot walk when it is administered. The primary difference between a walking and a classic epidural is a different medication cocktail and a different dosage in order for the laboring person to balance adequate pain control with the experience of labor as they choose.

-- A similar method known as a patient controlled epidural allows for a minimum administration of epidural medication that can be 'topped up' by the pressing of a button by the laboring person to have the most dynamic pain relief throughout their labor. Not all hospitals perform walking epidurals or allow patient controlled epidurals, so be sure to inquire in advance if these are options you want to explore.

-- A spinal-epidural, usually referred to as a 'spinal' is a short acting injection of the similar medications to a a classic epidural but there is no cannula (tube) that remains in the epidural space. This is most often used in the case of a C-section that happens without an epidural already in place. Once the injection is given, your surgeon will ensure that you are fully numb before the surgery begins.

The pros, the cons and the risks

• Pros: Epidurals have the significant pro of effectively removing inordinate levels of pain from your labor, and if your pain is too severe for you to be an active participant in your labor, an epidural is definitely worth considering. During inductions and labor augmentation with pitocin, contractions can become so intense (beyond non-pitocin contraction) that an epidural is the only way to continue with a vaginal birth.

Epidurals allow for a present and aware birth experience that can give the laboring person the labor they desire and be able to have the clearest mind once baby arrives.

Epidurals allow for significant periods of rest that are otherwise difficult to manage. Epidurals may give a laboring person the rest they need while their labor advances closer to the pushing stage.

• Cons:

The cons to an epidural can be significant and include:

• Low Blood Pressure drop that can be severe and disorienting. This is one of the more dangerous side effects that cannot be predicted.

• Tearing of the dura leading to leaking of spinal fluid leading to spinal headaches that can be debilitating and extend hospital stay.

• Increased use of induction methods that come with their own risks to you and baby.

• Impaired blood flow to the fetus due to blood pressure drops (this is why it is a dangerous side effect)

• Impaired hormonal releases and interplay necessary for

  -- Proper energy reserves and the second wind of pushing

  -- Ideal bonding between mother and baby,

  -- Proper hemorrhage control after placenta delivery.

Your risk of getting a c-section goes up with an epidural, tho it is not fully agreed by how much, it is important to note as a potential additional risk or con. An epidural reduces your ability to push effectively, as your control of your lower half has reduced and you cannot feel the contractions.

Insist that you are rotated into multiple positions atleast every 45 minutes from the placement of the epidural until delivery and request that you be allowed to attempt delivery on your side or on all fours. Remaining in the lithotomy position for birth increases back, joint and pubic symphisis injuries if your legs are over extended.

During active labor is the time when an epidural is most often asked for. Longer epidural times can lead to more complications, so it is encouraged to get as far as you can without the epidural. Delivery can still be a fantastic experience with an epidural, however you must go into any of pain relief method with your eyes wide open and your alternatives well understood.

It can take 1-2 hours or more for the epidural to wear off and for you to be able to walk, feel like you have full control over your legs, and regain full sensations. It is a narcotic administered into your spine and baby will be processing that drug just like your body – it will cross the placenta and it takes longer for the baby to clear the medication, up to 24 hours, because of their diminshed size and immature processing abilities.

Something many people are not prepared to encounter or know is possible, is that epidurals can fail or only provide insufficient or ineffective numbing. Due to the nature of the spinal placement, it is possible for you to only have half your body become numb, have partial numbing where you still feel some sensations and pain on your lower half, or for you to need a higher dose of medication administered to maintain effective pain control. If your epidural fails, it may be possible for the anesthesiologist to attempt another placement, however this is facility and doctor specific and should be addressed with the BRANN sheet if it occurs. The epidural can also be removed at any time and allowed to wear off including before or near delivery, or if it is causing side effects.

The bottom line

An epidural is a strong method of pain relief and pain control in labor. It is a gift of modern obstetric medicine, however it comes with risks and drawbacks to consider. Going into your birth knowing what can happen with your epidural is meant to prepare you, not scare you. An epidural changes a labor experience, but difference isn't diminishment! If you want an epidural, that makes it the right choice for you.

On your birth plan, you can list which type of epidural you would prefer, and when. Be sure to list if want an epidural at a certain point, as soon as possible, or only if you say a code word to your labor partner or team. A code word allows you to express your pain freely without being offered an epidural unless you have decided that it's time for an epidural. Choose a word that isn't in your natural language habits, kumquat or sasquatch, for example. This allows you to profess "Why am I not getting an epidural?!" without an anesthesiologist showing up.

Remember that you can change your mind at any time about wanting or not wanting an epidural, and by learning the most you can now, you will be empowered to do what is right for you, when it's right for you.