Epidural – Is it right for you?

Epidural Anaesthesia is an effective and popular form of pain relief for women during labour and childbirth. The epidural is an injection which is inserted into your spine in the lower back into an area called the ‘epidural space’. Epidurals are performed by Anaesthetists, who are specially trained doctors who provide pain relief for surgical procedures or childbirth.

The epidural numbs your nerves to stop you from feeling pain in the lower torso and pelvic region. The epidural will numb your pelvic area and legs. For this reason, you will need to have a catheter during your labour and for a few hours following the birth of your baby.

Epidurals can provide excellent pain relief and can be “topped up” or turned down depending on the length or circumstances of your labour. In some instances, the epidural does not work or the effects are only partial. The Obstetric Anaesthetists’ Association estimates that 1 in 8 women who have an epidural will need other forms of pain relief.

Though common and generally felt to be a safe pain relief option, like all medical procedures, epidurals have benefits and risks associated with their use. It is important to understand these issues before deciding if the epidural is for you.

Women’s Thoughts on Epidurals

“I found the epidural fantastic. I was incredibly nervous going into labour and I was not coping well at all from very early on. I had the epidural at 3cm and was able to calm down and rest. I was lucky in that it didn’t affect my labour or birth at all. I was 10cm within a few hours, the midwife gave me an hour to let the head come down and turned the epidural down for the pushing. I was able to feel pressure of contractions this way so I knew when to bear down. My baby was born within a half an hour. I had a second degree tear which healed fine. For me, the epidural was invaluable and I would not do it without it.”

And:

“I have no problems with the epidural. I had hope to go without it but I know its there if I need it. I do think sometimes its over-used or pushed onto mums. This is just going on what friends say though. I think it should be up to us to say we want it, rather than being constantly asked do we need it.”

And:

” I had the epidural on my first. At the time I felt I really needed it and I felt really distressed, but once I had it, I actually felt more out of control. It only worked on one side and I was stuck on the bed. I hated having a catheter afterwards too. In hindsight, I did not need it, but just needed better support to help me through it. I never had it again (have 3 children).”

And:

” The epidural worked great for me. Too well. I am the classic example of epidural and cascade of interventions. I am planning on going without it this time”

And:

“I tried everything over my long induction. gas and air made me sick, pethidine was awful I was completely out of control. I was really upset to get the epidural but once I had it, it was great. the only thing I wish they told you was that afterwards you are so swollen – I couldn’t wear shoes for over a week! And also, I know its rare, but I did have backpain in the needle site for a long time after. I knew exactly where the needle went in and my back felt weak, if that makes sense. I’d still have it again though”

And:

“I went into my labour thinking there is no way I am having an epidural. I wanted a straightforward birth and I felt that the risk of having an epidural just wasn’t worth it. It has nothing to do with medals or bragging like some people suggest, but down to the fact that I wanted to give myelf and my baby the best possible chance of being health at the end of it all. I had too many friends go down the epidural route and ended up with every intervention under the sun. The lucky ones had a Caesarean….forceps can take years to recover from. I had a long hard labour using the shower and gas and air. No complications and normal delivery. I am delighted with my choice but it wasn’t easy. I completely support women who want the epidural, I just knew it wasn’t the choice for me.”

Epidural changes to your labour

Something alot of mums don’t know, once you have an epidural, it changes how your labour is managed by your care team. With an epidural, your risk status changes to high risk, even if you were a previously low risk woman. The reason for this is that epidurals instantly introduce additional risks to your labour which were not present before. One study showed that the main reason for a change in risk status in labour (from low to high risk) was the use of an epidural.

When using an Epidural you will have an IV with fluids prior to the epidural being sited. You will also have a catheter and will be required to have continuous Electronic Fetal Monitoring (EFM), known as a CTG. The CTG measures your baby’s heart rate and has been shown to have a high rate of false positives, increases instance of a Caesarean Section. If having an epidural, you are more likely to require oxytocin (a drug used to make your contractions stronger), which some babies don’t tolerate.

Though there are risks associated with the epidural, not all women will experience this. For a woman who is finding labour distressing, is tired, or chooses an epidural for other reasons, the benefits may well out-weigh the risks. It is up to each woman to weigh up the evidence and make the best choice for her and her baby.

As with all tests, procedures, and treatments, you will be required to consent for an epidural. Your care team should go through all the benefits (the advantages of the epidural), the risks (the disadvantages of the epidural), implications (associated risks of the epidural) and possible future consequences of the epidural, in order for you to make an informed decision. Labour is not necessarily the best time to hear this information for the first time, so it is recommended you discuss the epidural, and other care options, with your care team at your ante-natal appointments. A birth plan can be an excellent way to initiate this discussion.

You will be required to provide written consent for the epidural, which means you will have a form to sign. If at any time you need anything explained to you, please ask. It is important that you understand what you are signing and consenting to.

The following are some of the benefits (advantages) and risks (disadvantages) of using an epidural in labour.

Advantages of Epidurals

* excellent pain relief – offers full block of pain
* does not make you ‘woozy’ ‘sleepy’ or ‘out of it’ like other pain relief medications
* can make women feel more in control if they were particularly distressed prior to or during labour
* in cases of long labours, you can rest and sleep
* in cases of severe hyper-tension or pre-eclampsia, epidural can lower blood pressure

Disadvantages of Epidurals

* it changes your risk status
* in can affect the length of your hospital stay
* it is not available straight away (must wait for available Anaesthetists)
* some women feel they miss out on feeling their baby being born
* affects your mobility
* can cause low blood pressure
* can cause maternal fever
* infection
* increase in interventions – use of CTG, Oxytocin
* can affect how your push your baby out – increases the length of time pushing
* increase instances of assisted delivery (vacuum or forceps) and severe tears or cuts(episiotomy) to your perineum (the skin between your vagina and anus)
* crosses the placenta to your baby
* can affect your baby’s sleep and feeding
* can cause newborn jaundice
* can cause long-term back pain
* may cause itching

There is also some research which suggests epidural:

* may increase the length of the first stage of labour (when the cervix is dilating)
* may increase the risk of Caesarean Section

Birth Preferences With Epidural

A Cochrane Review found that women are more likely to have shorter first stages of labour (when contractions dilate the cervix) and less likely to have an epidural if they stay in an upright position. Upright positions include standing, walking, kneeling, rather than lying in a bed.

If you decide to have an epidural, speak to your care team about ways in which you can benefit from the advantages of keeping upright with an epidural. An epidural means that you will be restricted to a bed, however, this does not mean you must stay on your back. With the support of your partner and care team you can use upright positions with an epidural.

Positions to try:

* side lying position
* jack-knife position
* supported kneeling position over the back of the bed

Video: Labour Positions Epidural Before Pushing

Video: Labour Pushing Positions with Epidural

You might also discuss turning the epidural down for the pushing phase in order to have self-directed pushing. It is possible to turn it down to enable pressure for bearing down, while still having adequate pain relief.

One study showed that when women were in control of the amount of epidural they used, they used 30% less than the standard dose. The study also showed these women had similar satisfaction ratings but less assisted deliveries than the group using a standard dose.

Other Pain Relief Methods

If you are undecided on the epidural, there are many other alternatives available.

“The factor that best predicts a woman’s experience of labor pain is her level of confidence in her ability to cope with labor”(Lowe 2002).

Pain relief alternatives you might like to try in labour:

* water
* heatpack or hot water bottle
* Doula
* TENS
* relaxation methods
* massage
* holistic treatments such as acupressure, reflexology, homeopathy

Medical Pain Relief Option Alternatives:

* Gas and Air
* pethidine

Gas and Air nitrous oxide, otherwise known as “Gas and Air” is commonly used in childbirth. It works by breathing the nitrous oxide in during a contraction by either a mask over the mouth and nose, or by a mouth-piece. You may prefer the mouth-piece as it gives you more control of how much gas you take in and when. It can take a little while to get the timing right. Studies have shown that many women have high satisfaction ratings of gas and air and that it is an effective form of pain relief. The effects of gas and air wear off quickly.

Disadvantages of Gas and Air: Some women report feeling sick from using gas and air. If a woman has too high levels of nitrous oxide, it can result in unconsciousness; though the effects wear off quickly.

Pethidine is a narcotic drug which is widely used for childbirth. It is given by injection and is part of a family of drugs called Opioids. Pethidine is a similar drug to morphine and are from the same drug family. Morphine is a drug made from natural substances and Pethidine is made synthetically. Pethidine mimics the endorphins your body naturally creates. Some women feel that Pethidine “takes the edge off”. Many women who use Pethidine will go on to have an epidural.

Disadvantages of Pethidine:

* can cause nausea
* you may feel ‘out of it’ or drowsy
* can cause “depressed respiration” in labouring women; it can make your breathing slower
* Pethidine crosses the placenta
* it may cause “depressed respiration” in your baby; makes your baby’s breathing slower
* it can affect the behaviour of your baby; sleepy baby
* if your baby is sleepy, this can upset the initiation of breastfeeding
* if your baby has depressed respiration, a drug will be required to reverse the effects
* There is some research that suggests there may be a link between the use of Pethidine and addictive behaviour later in life.

For more information or to access AIMS Ireland support services, please contact support@aimsireland.com

 References:

Change in risk status during labor in a large Norwegian obstetric department: a prospective study: http://www.ncbi.nlm.nih.gov/pubmed/23362836

Epidural analgesia in labor: an evaluation of risks and benefits.: http://www.ncbi.nlm.nih.gov/pubmed/8826170

Pain and women’s satisfaction with the experience of childbirth: A systematic review: http://www.ajog.org/article/S0002-9378(02)70189-0/abstract

Putting women in control of labor pain leads to less epidural analgesia http://www.examiner.com/article/putting-women-control-of-labor-pain-leads-to-less-epidural-analgesia

Opiate addiction in adult offspring through possible imprinting after obstetric treatment. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1664218/