Epidurals
There is almost always a trade-off when medications and interventions are used during labour. Each family must know and consider the potential benefits and risks and apply them to their own circumstances.
This blog is sprinkled with many links to short videos providing lots of information, perspectives and things you may really want to know! Dive in!
BENEFITS OF AN EPIDURAL
• When the birthing person is managing pain well and progress is normal, the risks of an epidural outweigh the benefits. If, however, the labouring person is exhausted, in extreme pain or requires painful interventions, the benefits may outweigh the risks.
• Epidural anesthesia or analgesia provides relief or reduction of labour pain without affecting the labouring person's mental state. It enables an exhausted person to relax or sleep during labour and calms a person who is anxious and tense because of pain. Once an epidural catheter is in place, additional medication can easily be administered as needed, providing prolonged and consistent pain relief. Click here to watch an interesting perspective on what it’s like Labouring with an Epidural.
• Some prolonged labours, probably those slowed by anxiety, speed up with an epidural. Anxiety can cause excessive production of the labouring person's stress hormones such as epinephrine and norepinephrine, which slow contractions. By allowing the labourer to rest without pain, the epidural removes their anxiety and labour progress may improve. If not, synthetic oxytocin may be administered painlessly. Since epidurals often lower blood pressure, this may benefit some people with pregnancy-induced hypertension. Click here to watch a clip about how an epidural works - What you need to know!
• Epidurals are also useful for caesarean births, making it possible for the birthing person to remain alert and involved while free from pain. It enables them to avoid general anesthesia, which is considered to carry greaterrisks.
**As a note, it can take some time to get set up to get an epidural even before the anesthesiologist joins you to administer the procedure. Check out this little video about some of the preparation required to get an epidural.
Undesired effects on pregnant person
• Inadequate pain relief (up to 10%). "Patchy" coverage - some parts of the belly still feel contractions or the epidural only takes to one side. Often this can be remedied with position changes, but sometimes more medication or redoing the epidural is needed.
• Rise of the birther's oral and vaginal temperature, beginning within one hour after administration of the epidural, which may lead to treatment of the birth and baby for non-existent infection. This effect may be dose-related.
• Drop in the birther's blood pressure treated with position changes, oxygen and possible vasopressors (less likely if a bolus of IV fluids is given before the epidural).
• Short or long-term postpartum backache from bruising caused by the injection or from ligament strain caused by prolonged time spent in a damaging position or inappropriate movement (for example, extreme passive flexion of the birther's trunk, hips and knees during the second stage, or sudden vigorous movements of the birther) while their muscles are relaxed and their back is numb (up to 19%). Long- term backache is almost twice as likely to occur with an epidural than without.
• Possible unintentional spinal block and resulting spinal headache requiring days of bed rest and a blood patch.
• Shivering may be reduced with lower doses, by warming of the anaesthetic before administration, or by adding narcotics to the anaesthetic.
• Mild to severe itching of the skin (with narcotics).
• Retention of urine, requiring a bladder catheter.
• Birther feels detached from the process and becomes an observer; others may reduce emotional support. The nurse can no longer assess labour progress by observing the birther and must rely more on the monitor and vaginal exams.
• Problems caused by human error or maternal structural anomaly, such as inability to place catheter properly; inadvertent injection of anaesthetic into a blood vessel; or too much anaesthesia, affecting respiration and swallowing (rates vary with skill of the practitioner and anatomy of the birther).
• Rare complications, such as residual numbness or weakness from needle injury to nerves (almost 1 in 10,000), delayed respiratory depression with epidural narcotics (up to 12 hours later), and brain damage and death (extremely rare).
Learn more about the Procedure of getting an Epidural!
Undesired effects on LABOUR
• May slow labour, requiring augmentation by breaking waters and or synthetic oxytocin; and has been found to increase the chances of a caesarean delivery in primigravidas (first time birthers) by two or three times.
• Often slows second stage (pushing) by reducing or eliminating the normal surge of oxytocin; and by reducing pelvic floor muscle tone, which may lead to more deep transverse arrests or persistent occiput posteriors (sunny side up). In addition, forceps or vacuum extractors are required more often (20-75%). Delaying pushing until the fetal head is on the perineum reduces the need for forceps. Even though this approach lengthens the second stage, it does not increase the incidence of fetal distress.
Undesired EFFECTS on A fetus (baby in utero)
• Abnormal heart rate patterns, requiring oxygen to the birther, position changes and possible caesarean delivery.
• Increased likelihood of newborn septic workup, IV antibiotics and isolation in the nursery if the birther develops an "epidural fever" that causes fetal tachycardia or newborn fever.
• If the fetus is already stressed greater amounts of the medication are "trapped" in the fetal circulation, leading to more pronounced newborn effects (see below).
Undesired on A newborn
• Short-term (six weeks or less) subtle neurobehavioral effects, such as irritability and inconsolability and decreased ability to track an object visually or to shut out noise, bright light. There are no data on potential long-term effects.
• Possible less efficient or less organized initial rooting and suckling behaviour. Nurses have reported more difficulties in feeding babies whose birthers had an epidural when compared to unmedicated babies.
• Decreased infant responsiveness may lead to long-term consequences for the parent-infant relationship. Parents should be counselled to give their babies time to recover from the birth and medication and should avoid a label of "difficult child" or "incompetent parent."
This article has been reproduced with the permission of Penny Simkin. * This article has been altered in some places from the original to provide more inclusive language.
DECISION MAKING ABOUT medication & getting AN Epidural
If you're having some conflicting thoughts about getting the epidural or medication during labour, these are a few questions that may help you organize your thoughts:
• Why/why don't you want the epidural?
• What messages have you heard about the epidural?
• How do you feel about the benefits and risks of the epidural?
• How would you feel if you decided prenatally that you wanted/did not want the epidural and that changed during labour?
• How does your partner/ birth partner (family or friend supporting you) feel about the epidural?
• Getting an epidural “too early” can impact your labour - get more info here!
• If you’re worried about missing your opportunity to get the epidural - watch this video!
If I Ask For the Epidural, I Want My Support Team To:
The following statements can be discussed and decided prenatally so that your team know how to support you in labour.
• Encourage me to keep going no matter what.
• Talk me out of it, unless I use a release word.
• Ask me to try ____ more contractions and then ask me again.
• Ask me to wait ____ more minutes and then ask me again.
• Remind me to ask for a cervical check before deciding if I want the epidural.
• Remind me to wait until my cervix is ____ cm dilated
• Help me get an epidural when my cervix is ____ cm dilated.
• Help me get an epidural as soon as I ask.
Have you got questions about medications and getting an Epidural? Do you want to discuss how can you advocate for your preferences? Be in touch!
