Epidural Anaesthesia During Labour- Risks and Benefits

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As D- day approaches, every mom finds herself wondering ‘how painfulis labour?’. Labour is surely painful , however thanks to modern medical science, we now have several medication and techniques that can reduce (if not stop) pain during labour and delivery.

Epidural anaesthesia is a popular and safe method of pain relief during labour. Opting for an epidural indicates having a small amount of medicine injected in the body to produce desirable pain relief. However, like all medicines, it is important that you understand the benefits and risks involved in epidural, so that you can make an informed choice well before getting into labour.

What is an Epidural?

An epidural is a local anaesthetic that aims to provide pain relief or an analgesic effect, rather than a total lack of feeling (anaesthesia). It blocks the nerve signals from both motor and sensory nerves to reach your brain. It shields you from pain while immobilising your lower body while allowing you to stay conscious during labour. Epidural can be used for both vaginal (normal) and a caesarean delivery.

Epidural anaesthesia during labour is administered on your lower back into a small space (also called epidural space) outside the spinal cord through a hollow needle or a catheter. A catheter allows for repeat or continuous delivery of the anaesthetic medication, when needed. An epidural injection for pregnancy is designed to provide partial pain relief for women, however, the decision to opt for it is entirely up to you.

Types of Epidurals

While hospitals and anaesthesiologists differ on the dosage and combinations of medication, there are broadly three type of epidurals that are used during labour.

  • Traditional/ Standard Epidurals

Apart from the regular use of a cathedar, traditional epidural uses regular anaesthesia medications such as bupivacaine or lidocaine that eliminates pain to a great extent. It is injected around the spine creates a heavy feeling and numbs the lower body. Therefore, mothers find it difficult to move during labour. However, you will still be able to move with some help in walking or moving.

  • Spinal Epidurals/ Spinal Block

Unlike a traditional epidural, spinal epidural involves the anaesthesia being injected into the spinal cord fluid directly. This gives faster relief from the labour pain but the effect of the drug wears off after a few hours. Spinal blocks are generally used late in labour. Spinal epidural once administered also makes body movements limited.

  • Walking Epidural or Combined Spinal Epidural (CSE)

This is a combination of drugs, local anaesthetic medication and epinephrine. Unlike other epidurals, CSE allows you to have slight sensation in your lower body. Hence, mobility is not much of an issue in this case. The advantage of maintaining some mobility in spite of the motor block, potentially helps in getting the baby into a better position for faster delivery.

How is an Epidural Injection Administered?

An epidural injection is usually given during the ‘active’ stage of labour by an anaesthesiologist or gynaecologist.   You will be asked to sit at the edge of the bed, bend your back and remain steady. This position is important for preventing any complications and thereby increasing the effectiveness of your epidural medications. Another favourable position to do so is to lie on one side, bend and curl your knees to as high as you can possibly bring them. Both of these allow a good spinal curve to assess the exact location where the injection must be administered.

An antiseptic solution is applied on your skin to eradicate any chances of infection. A small area on your back is made numb by local anaesthesia administered through an injection. A needle is then directed into the area surrounding the spinal cord in your back followed by a catheter through the needle into the epidural space. The anaesthesiologist then carefully removes the needle, leaving the catheter in its place, in order to give medication as per requirement. The catheter is then safely taped on to the back to maintain its position.

Once you are through with the above procedure, there are a few ways to administer an epidural that can be adopted. All these methods are crucial to determine the amount of medicine that needs to be administered for an effective pain relief depending on your threshold and condition:

1. Epidural using a catheter: A catheter (a bendable thin and hollow tube) is put in carefully into the epidural space created by using a hollow needle. This allows the continuous or intermittent administration of medication just outside the membrane surrounding your spinal cord and spinal fluid. Your anaesthetist will first give you a “test dose” to check the placement of the catheter tube and check for any adverse drug reactions. If you do not develop any reactions, the test dose is followed by a full dose.

2. Intermittent Epidural: In this case, the medicine is given on a need basis. Based on your tolerance level for the labour pain and desired level of movement your anaesthesiologist will decide the dose .

3. Mix and Match: The anaesthesiologist mixes medicines (anaesthetics and analgesics) to match the degree of sensation and movement you want.

4. Patient-Controlled Epidural Anaesthesia: With the help of this epidural, you can regulate the amount of medication injected into the epidural tubing.

5. New Epidural Births: Also called as “walking epidurals,” this particular analgesia gives the mother freedom to stand, kneel, squat, or even walk with some help.

6. Spinal Analgesia: The newest pain reliever is known as spinal analgesia or a “walking spinal.” Only a tiny dosage of medicine is injected into the spinal fluid to reduce the agony of labour but still allows movement.

7. Low-Dose Epidurals: This is a type of combination (narco-anaesthetic) epidurals. They are designed to relieve some of the pain of labour so that an exhausted mother can relax a little and get some energy back for pushing.

How Does an Epidural Anaesthesia Work?

An epidural temporarily blocks the nerves in your cervix and uterus that carry pain signals to your brain and thereby decrease the sensation.

Epidural medications include drugs called local anaesthetics, such as bupivacaine, chloroprocaine or lidocaine. They are usually given with opioids or narcotics so that local anaesthetics can be used less.

This produces pain relief with less side effects. Such medicines may also be used to prolong the epidural’s effect or to stabilize the mother’s blood pressure.

What is the Right Time to Have an Epidural?

There is no right or wrong time to have an epidural analgesia during labour. However, it is usually given during the active stage of labour, when you feel more frequent contractions and your cervix has dilated.

You may also be offered an epidural if your labour has to be sped up. This is done with a hormone called Syntocinon, administered in a drip which make your contractions more intense and painful.

The epidural has to remain in its place until after your baby is born . It can also provide pain relief after delivery if you need stitches from an episiotomy.

Advantages of Having an Epidural

Epidurals are a great choice to relieve labour pain better than any other medication. Women who have been administered epidural feel very less or no pain durimng labour. Other advantages are:

  • It does not significantly increase duration of labour.
  • You can stay awake and alert but you will still feel the pressure and some stretching during delivery.
  • Combined spinal-epidural (CSE) gives better results than does a standard epidural. It has lower doses of anaesthetic medications that give you more muscle strength.
  • It‘s strength can be enhanced with a local anaesthetic if needed. Though having an epidural does not increase your chances of needing a caesarean.

Possible Disadvantages of Taking an Epidural

An epidural can be used to deliver different types of local anaesthetics, which also differ in the side effects that they cause. Common epidural side effects include

  1. Itching : If that happens, changing the drug may help in solving the problem.
  2. Drop in blood pressure and fever : Even a small dose of epidural may cause a drop in blood pressure or induce fever. However, this is normal.
  3. Numbness or tingling sensation in the legs : This can create difficulties in urinating. A urinary catheter is normally used in such cases to help you urinate.
  4. Risk of spinal fluid leak: If the injection goes too deep, it can make a hole in the protective layers (dura) around the spinal cord, and spinal fluid might leak out. This may result in headaches that can last up to days. This can happen due to fluid loss.
  5. Longer duration of childbirth: Delivery may take a bit longer on an average amongst women who have epidurals.
  6. Assited delivery: Some women may feel the desire to push in spite of having an epidural. Due to the epidural they cannot feel when it is time to push, they may need assisted delivery (vacuum suction/forceps)

Does Epidural Have Any Side Effects on Baby?

In general, epidurals are safe for the baby as it is injected into the spine and not through veins. Any medication that is given to a woman during her labour surely reaches the baby’s bloodstream through the umbilical cord. This includes pain-relieving anaesthetics delivered through epidurals. But anaesthetics use drugs that are as safe as any other painkillers that are given to expectant mothers and hence do not affect the baby strongly. There aren’t any long term side effects of using epidurals.

However, since the babies’ immune system is weak, it takes more time for them to remove epidural drugs. Similarly a drop in the blood pressure of the mother due to epidural, may cause discomfort to the baby as it may affect his oxygen supply.

Is Epidural Birth Painless?

Parents have fear and anxieties involving labour pain and childbirth. Having an epidural does reduce pain, however doesn’t eliminate it completely.

On an average epidural takes about 40 minutes to work after it is injected. The process of administrating it is painful and can be quite uncomfortable. If the same medicine is used in lower concentration, it will cause analgesia which means it will only relieve the pain without causing any muscle weakness. However, if the epidural does not work, your doctor may have to administer it again.

Taking an epidural will provide some pain relief however, a ‘painless delivery’ is not entirely possible.

Can the Use of an Epidural Injection Cause Back Pain in the future?

Even after going thorugh childbirth with the help of an epidural, some women may experience mild soreness at the catheter site where the medication was injected. Using an epidural pain relief during delivery does not cause long-term back pain. While many women believe that epidural analgesia causes severe or long-term back pain, they are not related. Back pain post-delivery happens due to the pre-existing prenatal backaches or are a result of normal physiological changes during pregnancy.

Epidural and Multiple (twin) Pregnancy

It is not necessary to have a caesarean delivery with twins. Just like a single child delivery, many twins are born vaginally too. Epidurals are often recommended by doctors for pain relief in labour and also in preparation to get the second child in position for delivery.

If there are any problems, it’s practically easier for your antenatal team to deliver your babies quickly if you’ve already had an epidural.

What Happens After Delivery?

It’s important to focus on your baby’s birth during pregnancy. But it’s a good idea to also know what to expect after labour.

  1. The umbilical cord is clamped and cut, and your baby is dried and covered up to prevent catching cold.
  2. Mucus is cleared out of your baby’s face. Some babies need assistance to get their breathing normal.
  3. Bonding starts with skin-to-skin contact. Hold your baby close to you.
  4. Your baby will be examined by a paediatrician, weighed and measured, and given a band with your name on.

Once your precious bundle of joy is born, the toughest journey of your pregnancy may be over, but the process of care bringing him up will always continue. Your body starts to recover and you learn to adjust to the new role of motherhood.