Pregnancy & Birth
Coping with Labor Pain: Epidurals and Spinals
“Epidural” and “spinal” refer to the areas where pain medicine is placed. In an epidural, medicine is infused into the area right outside the spinal canal (the epidural space); in a spinal, medicine is placed inside the spinal canal, where the spinal fluid is. Today there are epidurals, spinals, and combined spinal-epidurals.
Different medicines may be delivered by spinal injection or epidural catheter. How you will feel depends in part on the characteristics of your labor and the dose of local anesthetic (numbing) medicine and/or narcotic that is used. If narcotics are used in an epidural or spinal, they affect the nerves directly (unlike when they are used for systemic medication). You generally won’t feel the dizziness or other negative systemic effects you might get with an IV or injection, just less pain.
Some anesthesiologists say it is normal to feel about 80 percent relief if the medicine is working correctly. You will still feel your contractions, but for the most part they will feel like pressure, not pain.
The type and amount of medicine—narcotics, local anesthetics (numbing medicine), or a combination—affect your mobility. When relatively low concentrations of local anesthetics and/or narcotics are used, as is now common practice, you will be able to move your legs. You may even be able to walk, although you may need continuous assistance to do this and some hospitals will not allow you to walk because of safety and legal liability concerns.
To place an epidural or spinal, an anesthesiologist or nurse-anesthetist first numbs a small area of skin on your back. For an epidural, she or he uses a needle to place a catheter (a tiny, flexible plastic tube) into the epidural space. With the catheter in place, medicine can be infused through a pump that controls the dose and the rate throughout your labor. In “patient- controlled” epidural anesthesia, you have a button that activates the pump when you push it. (It has controls that won’t allow you to overdose yourself.)
A spinal is usually used for short-term pain relief. Spinals are often used for cesarean sections, and sometime for forceps or vacuum extractor births. A lower dose of medicine is put into the spinal for women in labor. In a spinal, the medicine is injected in a single dose, instead of being given continuously. In order to get the medicine into the spinal space, a very thin needle is used.
In some hospitals, a one-time dose of medicine is injected into the woman’s spinal fluid and then a catheter is left in place in the epidural space for use when the spinal medicine wears off. This is known as a combined spinal-epidural. The advantage of the combined spinal-epidural is that if relief from the spinal wears off before the birth, the anesthesia staff can add anesthetics to the epidural catheter instead of having to give you another shot.
An epidural or a spinal will be accompanied by continuous electronic fetal monitoring of the baby. In addition, women who have an epidural will have an IV. Most women will need a temporary urinary catheter to empty the bladder, as well as equipment to monitor blood pressure.
Your ability to move and change positions in labor may help the baby to descend and assume a good birth position. Because epidurals and spinals can limit this, and have other potential adverse effects (listed on facing page), you may wish to avoid the medication unless and until you feel you can’t go on without it. This is what author Penny Simkin calls “late and light” medication.
If you are having your first baby and want an epidural, it would be unusual to wait so long that you would not have the time to have one. If you are having your second or third baby, labor can be fast; depending on where you are in your labor, a combined spinal-epidural might be appropriate because the spinal part would give you more immediate relief.
|I thought that I was going to die—literally DIE—before I got my epidurals. I would have killed my husband and my midwife if they had tried visualization, aromatherapy, or something similar on me while I was waiting the hour for my epidural. I was too busy concentrating on not dying. The good experiences I had in my two labors were after the epidurals. Before just totally sucked because of the pain. I believe in using the safest pain medication available if you want it. As my stepmother put it, “They don’t give out prizes for suffering.” My mother had me naturally and said it was a mistake that she did not repeat with my younger sister. I planned on having epidurals with both my children, but I was not prepared for how badly labor hurt up until the point I got the epidurals. |
Advantages and Disadvantages of Regional Medicines
The greatest advantage of epidurals (and spinals) is that they can take away the greater part of the pain women feel in labor and while giving birth. An epidural can provide much needed rest for an exhausted mother, especially when other approaches to getting that rest have failed. An epidural can be helpful in the case of a very long labor. Psychological issues or individual circumstances may make experiencing the physical sensations of labor too difficult for some mothers at some point. Finally, some women choose epidurals simply in order to eliminate most labor pain.
The disadvantages of regional medications used for labor pain are:
- Sometimes the insertion of the epidural is ineffective and the process has to be repeated. Because of differences in the anatomy of the epidural space and the positioning of individual catheters, you may not get any relief in a small area of your abdomen or back (an “epidural window”). Sometimes such areas can be anesthetized with higher doses of medication.
- You are more likely to have problems during your labor with low blood pressure,28 which may be associated with a drop in the baby’s heart rate. This may necessitate changing positions, administration of medicine to raise your blood pressure, the placement of oxygen, and perhaps placement of an internal monitor to better track the baby’s response to these actions. Your blood pressure generally comes back up without any lasting effect on you or the baby.
- This type of medication can increase the amount of time that you are in labor.29
- You may be more likely to need Pitocin, a synthetic form of the hormone oxytocin, to make your contractions stronger.30
- If you have an epidural, you may be more likely to get a fever during labor than women who don’t have epidurals. Because your providers cannot know if a fever is from an infection or from the epidural, if you get a significant fever in labor, your providers will start antibiotics and your baby may be subjected to more tests in the first hours after birth.
- You may be more likely to have forceps or vacuum delivery.31 If you have a forceps birth, you are more likely to have a serious tear (a third- or fourth-degree tear) in your vagina.32
- One or two of every one hundred women who get an epidural, and fewer than one of every one hundred women who receive a labor spinal, get a bad headache called a “spinal headache.” The headache usually doesn’t start until the next day; if it occurs, effective treatment is available.
Evidence is mixed on whether there is an association between epidurals and problems in establishing breast- feeding; such problems seem more likely to be linked to high- dose opioid epidurals than to other epidurals.33
A paracervical block involves injecting a local anesthetic into the area next to the cervix. The medicine blocks pain signals from the nerves that come from the cervix. It is an effective and relatively simple way to provide pain relief for an hour or two, before the pushing stage of labor. Paracervical blocks are not commonly performed because they can cause a decrease in the baby’s heart rate, although such a decrease almost always lasts for only a very short time and rarely causes problems for the baby.
A pudendal block involves injecting an anesthetic into nerves that will numb the perineal area around the opening of the vagina. This type of anesthesia is now rarely used during labor because of the advent of epidurals, but it is sometimes used for the pushing stage of labor, for forceps delivery, or for episiotomy repair. It provides temporary relief.
End of excerpt.
28. M. Anim-Somuah, R. Smyth, and C. Howell, “Epidural Versus Non-epidural or no Analgesia in Labour,” Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD000331. DO1: 10.1002/14651858.CD000331.pub2. [Back to text]
29. Ibid. A meta-analysis of trials involving nearly 2,400 women found that epidural analgesia prolonged labor by an average of 42 minutes in the first stage and an average of 14 minutes in the second stage, when compared with systemic opioid analgesia. See Holger Eltzschig, Ellice Lieberman, and William Camann, “Regional Anesthesia and Analgesia for Labor and Delivery,” New England Journal of Medicine 348, no. 4 (January 23, 2003): 322; Stephen H. Halpern, Barbara L. Leighton, Arne Ohlsson, Jon F. R. Barrett, and Amy Rice, “Effect of Epidural Versus Parenteral Opioid Analgesia on the Progress of Labor: A Metaanalysis,” JAMA 280 (December 23, 1998): 2105–2110. [Back to text]
30. Anim- Somuah et al., “Epidural Versus Non-epidural or No Analgesia.” [Back to text]
31. Ibid. [Back to text]
32. Ibid. [Back to text]
33. Siranda Torvaldsen, Christine Roberts, Judy Simpson, Jane Thompson, and David Ellwood, “Intrapartum Epidural Analgesia and Breastfeeding: A Prospective Cohort Study,” International Breastfeeding Journal 1, no. 24 (December 11, 2006). See also Sue Jordan, “Infant Feeding and Analgesia in Labour: The Evidence Is Accumulating,” International Breastfeeding Journal 1, no. 25 (December 11, 2006); J. Riordan, A. Gross, J. Angeron, et al., “The Effect of Labor Pain Relief Medication on Neonatal Suckling and Breastfeeding Duration,” Journal of Human Lactation 16, no. 1 (2000); A. B. Ransjo- Arvidson, A. S. Matthiesen, G. Lilja, et al., “Maternal Analgesia During Labor Disturbs Newborn Behavior: Effects on Breastfeeding, Temperature, and Crying,” Birth 28, no. 1 (2001): 5–12. [Back to text]
Excerpted from Chapter 11: Coping with Pain in Our Bodies, Ourselves: Pregnancy and Birth © 2008 Boston Women's Health Book Collective.
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