Epidurals are handed out like candy but never fully discussed in our society. If over ¾ of vaginal deliveries are happening with an epidural, then it must be safe, right?

The first recorded use of an epidural was in 1885, when New York neurologist J. Leonard Corning injected cocaine into the back of a patient suffering from “spinal weakness and seminal incontinence.” More than a century later, epidurals have become the most popular method of analgesia, or pain relief, in US birth rooms.

The research is overwhelming, though... It is just not openly shared with moms.

What is an Epidural?

Understanding the different types of epidurals, how they are administered, and their benefits and risks will help you in your decision-making during the course of labor and delivery.

• The Epidural: The anesthesiologist inserts a needle into the epidural space, which lies between the tough, outer membrane that covers the spinal cord and the next deeper membrane. A tiny tube or catheter is threaded through the needle. The needle is removed and the anesthesiologist or anesthetist injects an anesthetic similar to those used in dentistry or, in most hospitals today, a mixture of anesthetic and narcotic into the catheter.

continuous infusion: The catheter is attached to a syringe driven by a pump that gradually delivers a continuous dose. This technique is the standard because it provides steady labor pain relief.

intermittent top-ups: The anesthesiologist or anesthetist returns to inject more pain medication into the catheter when the dose wears off.

• The "Walking" or "Light" Epidural: The anesthesiologist may inject narcotic only, a very low dose of anesthetic, or a combination of the two in an attempt to achieve complete mobility with good labor pain relief. These variations are intended to leave some sensation and ability to move the legs. However, many women with such epidurals never walk, even when encouraged to do so. It was hoped that these innovations would achieve equally good labor pain relief while reducing adverse effects, but instead, women still experience the same side effects.

• The Combined Spinal-Epidural: The anesthesiologist injects pain medication (usually a narcotic, occasionally an anesthetic) into the space that lies deeper than the epidural space ("spinal"). The anesthesiologist then pulls outward into the epidural space, threads a catheter into the epidural space, and removes the needle. The spinal cannot be repeated, but the catheter remains for an epidural should you want additional labor pain relief later.

Epidural medications fall into a class of drugs called local anesthetics, such as bupivacaine, chloroprocaine, or lidocaine. They are often delivered in combination with opioids or narcotics such as fentanyl and sufentanil in order to decrease the required dose of local anesthetic. Epidural anesthesia is a regional anesthesia that blocks pain in a particular region of the body. The goal of an epidural is to provide analgesia, or pain relief, rather than anesthesia, which leads to total lack of feeling.

How is an Epidural Administered?

You will be asked to curl up on your side or sit up with your back arched outward. Your back will be washed with antiseptic and covered with a sterile drape. The anesthesiologist will numb the skin before inserting the needle. You must remain absolutely still while the needle is in your back. A catheter will be threaded through the needle and taped to your back to keep it from moving. As part of epidural management, you will also have:

• An IV (intravenous drip): About a quart of IV fluid is administered before the epidural is given.
• Continuous Electronic Fetal Monitoring (EFM)
• Frequent monitoring of blood pressure, usually with an automatic blood pressure cuff that periodically self-inflates and records the results.

What are the Benefits of an Epidural?

Many women cannot imagine giving birth without medication. Other women will require medical interventions. While a normal, healthy pregnancy and labor does not require an epidural, there can be benefits. Benefits of an epidural include:

• Allowing you to rest if your labor is prolonged.
• Reducing the pain, increasing the enjoyment of the birth (for some).
• Remaining alert and being an active participant in the birth.
• If you deliver by cesarean, an epidural anesthesia will allow you to stay awake and also provide effective pain relief during recovery.
• When other types of coping mechanisms are no longer helping, an epidural can help you deal with exhaustion, irritability, and fatigue.

What are the Risks of an Epidural?

Epidurals increase the need for synthetic oxytocin (Pitocin) to augment labor by 3 fold, due to the negative effect on the laboring woman’s own release of oxytocin. The combination of epidurals and Pitocin, both of which can cause abnormalities in the fetal heart rate (FHR) that indicate fetal distress, markedly increases the risk of operative delivery (forceps, vacuum, or cesarean delivery). With an epidural, you are more likely to require:

• IV Pitocin (oxytocin), a drug to make contractions stronger
• drugs to fight a drop in blood pressure
• a urinary catheter for inability to pass urine
• a vacuum extraction or a forceps delivery.
• cesarean section.

According to the study of 3,200 women, more than 19% who chose to have an epidural developed a fever. This number is alarming when compared with 2.4% of other women. Women with fevers were approximately three times more likely to give birth to infants who needed resuscitation measures. This fever also raises the chances of baby needing blood drawn to evaluate for infection. An Epidural may also cause:

• You may experience a severe headache caused by leakage of spinal fluid.
• After your epidural is placed, you will need to alternate sides while lying in bed and have continuous monitoring for changes in fetal heart rate. Lying in one position can sometimes cause labor to slow down or stop.
• Shivering
• Ringing of the ears
• Backache
• Soreness where the needle is inserted
• Nausea
• Difficulty urinating.
• For a few hours after the birth the lower half of your body may feel numb. Numbness will require you to walk with assistance.
• In rare instances, permanent nerve damage may result in the area where the catheter was inserted.
• Serious tears in your perineum: this is the tissue between your vaginal and anal openings (this is probably due to increased use of vacuum extraction or forceps)
• Adverse behavioral effects on the newborn
• Newborn jaundice
• Life-threatening complications (dangerously low blood pressure, respiratory or cardiac arrest, severe allergic reaction, convulsion)

First-time mothers tend to have more difficulties with epidural side effects than women who have previously given birth. 20% of women who receive an epidural end up with an unplanned c-section.

How can an Epidural Affect the Baby?

A recent study found that epidural-related fevers can lead to problems in infants, including poor muscle tone, difficulty breathing, seizures and low Apgar scores (which measure an infant's general health). An instrumental delivery is more likely when an epidural is given, and it can increase the short-term risks of bruising, facial injury, displacement of the skull bones, and cephalohematoma (blood clot under the scalp). The risk of intracranial hemorrhage (bleeding inside the brain) was increased in one study by more than four times for babies born by forceps compared to spontaneous birth. Another study showed that when women with an epidural had a forceps delivery, the force used by the clinician to deliver the baby was almost twice the force used when an epidural was not in place.

• Any medication that a woman uses during labor enters the child’s bloodstream as well via the umbilical cord. This includes pain-relieving drugs and anesthetics delivered through epidurals.
• Epidurals might make it more difficult for some babies to get into the best position for birth.
• Research shows that an epidural has a large impact on the placenta, causing it to block oxidized stresses and other important processes that are supposed to take place during labor and birth.

Breastfeeding After an Epidural

Mothers who received an epidural reported more difficulty with breastfeeding in the first week early on, and were twice as likely to give up breastfeeding within the first six months. Evidence suggests that fentanyl can interfere with infants' ability to suckle.

Despite a woman’s best efforts to have a natural, undisturbed birth, complications can occur that require medical attention. In these circumstances, whatever interventions may protect the health and safety of both the mother and baby are what should take place. At the end of the day, that is by far more important than how the baby was born.

References:

http://www.ncbi.nlm.nih.gov/pubmed/27050812: http://articles.mercola.com/sites/articles/archive/2007/01/06/epidurals-affect-a-moms-ability-to-breastfeed.aspx http://www.ncbi.nlm.nih.gov/pubmed/16235275/ http://www.ncbi.nlm.nih.gov/pubmed/10796196 http://www.ncbi.nlm.nih.gov/pubmed/27013783 http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072751/ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3622113/

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