The Truth About Epidurals: What Your Doctor Won't Tell You

You have probably heard of an epidural being used to provide pain relief during labor; after all, an estimated 50% of women who choose a hospital birth opt to get one. However, most women are not fully aware of the risks associated with this popular form of pain relief. For any medical procedure, informed consent is not only an ethical obligation, is it a legal requirement to ensure that the patient fully understands the implications and is given the option to decline, or opt for an alternative. In this article, we will explore both the benefits and the lesser known risks and possible complications.

But first, let’s explore the what.

What is an epidural?

There are two types of epidurals. First, the standard epidural – a catheter placed in the lower spine where medication is administered by pump or periodic injection. The most common medications given are a narcotic such as fentanyl or morphine, combined with an anesthetic such as bupivacaine, chloroprocaine, or lidocaine. These medications each have their own possible side effects. A secondary type of epidural is a CSE (combined spinal-epidural) also known as a “walking” epidural. This involves a small amount of medication injected into the spinal fluid to numb the lower half of the body (also known as a “spinal block”). This begins to work quickly but only lasts an hour or two, and typically only given once during labor. Once the spinal block wears off, the epidural continues to provide pain relief.

Now that we know what an epidural is, let’s explore the benefits. The most obvious benefit is pain relief. As labor progresses, the medications and dosages remain adjustable. With intensifying contractions, the anesthesiologist will be able to provide more medication, or different medication, if necessary. You will also remain awake and alert during labor - or not, as pain relief can offer an opportunity to rest as you dilate. However, there is a caveat - along with numbness comes the inability to feel contractions, which we will explore in the next section. Lastly, one of the most commonly mentioned benefits is hinged on a hypothetical situation: should you need an emergency caesarian, the epidural is already placed. In the event of an emergency, placing an epidural is nearly impossible, and so it sometimes becomes necessary to use general anesthetic, or “going under” - being put completely asleep. So, while this is often used as a selling point for epidurals, what most women do not know is that having an epidural in the first place can increase the risk of having a caesarian!

Which brings us to - the risks. Surprisingly, there is a long list of risks associated with epidurals, most of which women are never informed. As mentioned, the first is increased risk of caesarian section. This is because of the inherent nature of the medication - with the anesthesia, comes numbness, and the reduced ability to feel contractions and work with them, as stated above. Though this seems beneficial, it often results in coached pushing, or inability to push completely. This may also affect the baby’s position due to the relaxation of the pelvic muscles. These factors can sometimes lead care providers in a rushed hospital environment to recommend a caesarian due to “failure to progress”, or lead to other interventions such as a delivery with forceps. Additional risks and side effects listed in the literature are: drop in blood pressure, headaches, tinnitus, backache, nausea, difficulty urinating (which may cause a blockage that makes delivery difficult, necessitating other interventions, or result in a retained placenta), increased temperature, nausea, itching, tremors, infection, and, in rare cases, nerve damage.

Other things to consider when deciding if an epidural is right for your birth:

• An epidural takes about 10-15 minutes to place, and during this time you will likely need to be completely still (while you are having contractions!) As a side note, hospitals will often send women in early labor home, but placing the epidural becomes more difficult as labor progresses, and there reaches a certain point in labor where it is too late to place at all.

• Once placed, pain relief typically takes 20 minutes

• The medication crosses the placenta (which may result in fetal distress, depressed respiration, or difficulty latching)

• The hospital may restrict your ability to eat or drink in labor

• You may also be required to have an IV placed

• Limited mobility (this includes standing, walking, and delivery positions. The inability to move may hinder the progression of labor, and being forced to deliver in the lithotomy position may result in complications like tearing or interventions like forceps as the woman works against gravity and a smaller pelvic opening.)

• The possibility of incomplete numbness (if this occurs, and the woman is recommended to proceed to a caesarian, she will need to go under general anesthetic)

  
  

With that, I will leave you with some homework. There are alternatives - and of course, each comes with it’s own set of risks and benefits (hence, the homework). These alternatives are:

• Entonox (gas and air)

• Opioids delivered through an IV directly into the bloodstream

• Sterile water injections

• TENS machine

• Hydrotherapy (laboring in water)

• Movement!

• Rebozo

• Aromatherapy

• Birth comb

• Birth ball

  
  

Now that you have a complete picture of what an epidural entails, you are empowered to make your own decision. It is up to each individual woman to asses the risks and benefits for herself. When making decisions, it is helpful to remember the BRIAN acronym - benefits, risks, intuition, alternatives, and results of doing nothing. For any decision, ask yourself what feels right, and what matters most to you in your birth. Happy delivery!