By Dr Feras Hamati

Senior Fellow in Cardiac Intensive Care and Anaesthesia at University Hospital Southampton NHS FT

There is much to prepare for when planning for your baby’s arrival. You’re probably focused on equipping the nursery, attending Lamaze classes and maintaining your health. But are you also preparing to make important decisions regarding your pain management options during labour?

Work with your healthcare providers, including your physician anaesthesiologist, to decide which pain management methods are best for you.

You may prefer to use little or no pain medication, or you may feel that pain medication will better control and make labour and delivery a more enjoyable experience. It’s also acceptable to change methods or use a combination during your labour and delivery. Ultimately, the choice is yours.

Here, I discuss commonly asked questions about epidurals, a popular choice for many women.

An epidural is an anaesthetic technique that uses a small tube placed in the lower back to deliver local anaesthetic or other pain medication near the nerves that cause pain during labour — you do not get sleepy from this type of anaesthesia.

Will an epidural hurt?

Compared with the pain of contractions, placement of an epidural results in minimal discomfort. As the epidural is placed, you will feel a brief sting on your skin. After this, you should feel some pressure in your back during the procedure. The needle is then removed entirely. Once the epidural placement is completed, you will feel only the tape that keeps the tubing in place in your back.

Will an epidural hurt my baby?

If you have an epidural anaesthetic, your baby will be safe. The epidural will not impact your breathing or put your baby to sleep.

What can I expect on the day?

The anaesthesiologist will ask you to sit up or lie on your side, keeping the lower part of your back curved. You will be asked not to move at all during some stages of the procedure. Your nurse will help you get into the correct position. After the anaesthesiologist numbs your skin with a local anaesthetic, a needle is inserted between the bones of your spine into the epidural space and then a tiny tube (catheter) is put in place while the needle is removed.

The tube is secured in place with an adhesive and a bandage and the tube stays in place for the duration of labour and delivery. You should be comfortable and it is okay to move around in bed, but do not drag or slide on your lower back because this could accidentally pull the catheter out.

How long does it take to administer an epidural?

Placing the epidural takes about 10 minutes, with adequate pain relief starting in another 10 to 15 minutes. Placing the epidural in patients who are obese or have scoliosis may require more time. Once the epidural is in place, medicine will flow through the tubing continuously to maintain pain relief throughout the rest of your labour and the delivery of your baby. 

Does all the pain go away?

Epidurals make the contractions feel less intense and easier to manage. Some pressure may be felt in the rectum and the vagina later in labour. Being numb during labour is undesirable because you need to know when and where to push towards the end of your labour. If you start to develop a lot of pain after the epidural is in place, more medicine will be injected through your catheter. If you are too numb, your anaesthesiologist will decrease the amount of medication you are receiving. Ask your nurse to call the anaesthesiologist with any questions you have about your pain relief.

Does epidural anaesthesia always work?

The majority of patients experience significant pain relief with an epidural. Occasionally, pain relief is one sided or patchy, but the anaesthesiologist can usually do something about this, often without repeating the insertion procedure. Very rarely, there are technical problems that prevent the anaesthesiologist from getting the needle into the epidural space. These patients may not get adequate pain relief.

Does an epidural affect the progress of labour?

The first stage of labour (until the cervix is fully dilated): The effect of an epidural at this stage is impossible to predict. Labour may not be affected at all or it may slow down and a drug (oxytocin) will be needed to speed it up again; or, labour might go faster, especially in patients who develop poor labour patterns and are progressing slowly.

The second stage (the pushing stage, after full dilatation and until delivery): This stage may be slightly longer with an epidural, but there is no evidence that this harms either the mother or the baby; also, if the patient is too numb, she might not push effectively. Balance is important here so that the patient is comfortable but still feels some pressure in the rectum as well as vagina during contractions.

Misconceptions about epidurals

•Epidurals slow down the labour process

•Epidurals cause C-sections

•You can’t get an epidural until a certain level of dilatation has occurred

•Epidurals increase the risk of paralysis

Can I walk with my epidural?

The anaesthetic solution used to manage labour pain can sometimes make it difficult to walk without assistance. Be sure to check with your labour nurse before attempting to get out of bed.

What are the possible side effects of this form of anaesthesia?

•Your legs might tingle or feel numb and heavy. This is normal and will disappear soon after delivery in the majority of cases

•Your blood pressure might fall slightly, but this is easily and rapidly treated

•Some back pain might occur at the insertion site and it might last for a few days. However, no evidence exists that epidurals cause chronic back pain

•Headaches may occur after delivery in two to three per cent of patients due to the accidental puncture of the lining containing the spinal fluid. This headache can be moderate to severe, but is not permanent or life threatening. Specific treatment is available for severe headaches

•Itching, very mild sedation and difficulty urinating are also occasionally noted

•You might have temporary temperature elevations that are not significant

•Some people may have an allergic reaction which could cause long-term effects

After delivery, some women may develop minor neurologic problems (a small patch of numbness on one leg and limping). Such issues are rare and go away eventually. The exact cause might be impossible to determine and these problems might occur both with and without epidural anaesthesia. The baby’s delivery can itself cause pressure on the nerves, as can some of the pushing positions used.

Are there any patients who cannot have an epidural catheter?

Epidural catheters are not recommended for patients who: 

•Have blood clotting problems or take blood thinning medications

•Have a urinary tract infection

•Have neurologic disorders

•Have had certain types of lower back surgery

What is spinal anaesthesia?

A spinal block, like an epidural block, is an injection in the lower back. While you sit or lie on your side in bed, a small amount of medication is injected into the spinal fluid to numb the lower half of the body. It brings pain relief and starts working quickly, but it lasts only an hour or two.

A spinal block can be given using a much thinner needle in the same place on the back where an epidural block is placed. The spinal block uses a much smaller dose of the drug and is injected into the sac of spinal fluid below the level of the spinal cord. Once this drug is injected, pain relief occurs right away.

A spinal block is usually given only once during labour, so it is best suited for pain relief during delivery. A spinal block with much stronger medication (anaesthetic, not analgesic) is often used for a caesarean delivery. It can be used in a vaginal birth if the baby needs to be helped out of the birth canal with forceps or by vacuum extraction. Spinal block can cause the same side effects as an epidural block and these side effects are treated in the same way.

Combined spinal-epidural (CSE) is sometimes used when a faster onset of pain control is needed. CSE uses the same types of drugs and has similar side effects to epidural pain control.

Reprinted with permission from Family Flavours magazine