All about the Epidural

History of the Epidural

The epidural was introduced to childbirth for pain relief in the 1970s. This came after a long time period of experimenting with different types of pain relief for women during childbirth dating back to the time of Queen Victoria and her choice of using Chloroform in the mid 19^th century. After this, pain relief during childbirth was more widely accepted especially in religious groups. In the early 20^th century women started being put into “twilight sleep” which would prevent women from remembering childbirth. I wonder if this form medication prevented the woman from feeling pain or did the woman just not remember the pain? All of the pain relief used in the past came with their own long lists of side effects and risks. The Epidural, although deemed as safe and effective, has its list of downsides as well.

How is it administered?

While lying on your side in the fetal position or hunched all the way over on the edge of the hospital bed in between contractions, the anesthesiologist will sterilize and numb the injection side. Then they proceed to inject a needle into your lower back into the membrane just outside of your spinal cord. A catheter (a small flexible tube) is then passed through the needle into the space in your back, the needle is removed, and the catheter is secured most likely with tape on your back. Once the catheter is set narcotics like fentanyl and morphine as well as local anesthetics similar to Novocain can be given and adjusted according to pain level and tolerance. This process is believed to be painless, while some report it is the worst part and most painful part of their childbirth experience. It should only feel like the placement of an IV according to most Doctors and anesthesiologists but some this is not the case.

During childbirth most anesthesiologists will give an epidural if you are less than 9cm and more than 3cm. It is ideal if you re 6cm dilated, they will not give you an epidural if you are close to delivery. The medication takes about 15 minutes to start working and the placement of the epidural itself takes about 10 minutes. The catheter is attached to a small pump called a PCA or patient-controlled pump, operated by a button that the mother can use to increase the amount of pain medication a few times per hour. The pump is designed to limit the amount of medication so as not to give too much.

What medication is used in an Epidural?

An epidural was, in the past, primarily morphine based. Morphine is a narcotic drug classified as an opioid that can reduce and potentially eliminate pain. Morphine is used on patients that are in severe pain, those who were just released from surgery as well as those close to death. Currently, the drug that is used is fentanyl which is an opioid that is 50- 100 times more potent than Morphine and 20-40 times more potent than Heroin. In 2020 fentanyl killed more American's than car accidents, gun violence, and suicides. There is research emerging that shows us that this drug does cross the placenta and can cause side effects to our babies. The specific dosage and drug concoction that is used depends on who your anesthesiologist is.

Risks of an Epidural

As with any medication or medical intervention there are risks associated with the Epidural some include:

• Fetal distress
• Itching
• Fever
• Soreness
• Tingling in legs
• Prolonged labor
• Increased need for operative delivery
• Low blood pressure
• Difficulty breathing
• Difficulty emptying bladder
• Headache/ Severe headache
• Failed or One-sided Epidural
• Infection
• Blood clots in spine
• Epidural fever

Along with the risks mentioned above this form of pain relief also inhibits the mother's mobility in labor. Movement is so important during childbirth; your body instinctually wants to move into certain positions typically standing or hands and knees. These positions allow your body and baby to work together with gravity to be born. They also encourage the pelvis to open in different ways, this can help progress labor if the baby isn't in the best position. Once an Epidural is administered most medical staff will encourage the mother to stay in the bed due to risk of unsteadiness and falling. Thankfully many trained doulas are familiar with and encouraging of different positions to try during labor in the bed. 

Instead of feeling the natural urge to push this stage of labor is usually initiated by the doctor after confirming full dilation (10 cm) by preforming a cervical check. Because there is less feeling and, in most cases, no feeling the mother needs to be coached on when to push. There is evidence showing that coached pushing is often less effective than physiologic pushing (our natural urge to push), the pushing stage is prolonged, and risk of severe perineal tearing increases significantly. 

It has been well known that epidurals interfere with mother infant bonding after birth which directly impacts breastfeeding. When babies are born, they need to be alert and hungry to have the drive to initially find and latch on to the breast. Babies that are born after a mother has received an epidural are more likely to be sleepy resulting in inability to latch. New evidence is emerging showing that the medication in an epidural does cross the placenta. The longer an epidural has been administered the more difficulty a baby will have at this critical time. 

The benefits of the Epidural

The Epidural is the most effective form of pain relief medication used for childbirth. It can be very helpful to an exhausted mama who has been laboring for a long time with little progression looking for rest before the pushing stage. It is also helpful to already have an Epidural placed in case of emergency c-section. This allows her to go right into surgery rather than need to be put under general anesthesia.  

What is a "walking epidural"

The “walking” epidural is a “cocktail” of narcotics, local anesthetic and epinephrine which offers relief while not completely numbing your lower half like a "regular" epidural, still allowing for motor function. Since the walking epidural is a lower dosage of medication the birthing mother will still experience different sensations in the lower body. With this version of the epidural, you can continue to move your legs freely and have freedom of movement.

While walking around may not necessarily be an option, this depends on the policies at the hospital or birthing center where you are giving birth, you can still move safely in bed! This allows for easier movement and changing of positions for comfort but also to help progress labor, in turn you are able to get into the most optimal birthing position for the baby which can lead to a quicker labor and smoother delivery. Some positions that are particularly helpful are being on all fours as well as side lying. These both promote optimal fetal positioning. Also being on all fours and rocking/ moving the hips can be very comforting during a contraction. 

There are many considerations to take into account when deciding if an epidural is right for you or not. This blog provides much information and research on the topic. However, it is always worth talking with your support team like your OB, Midwife, Doula and husband to work through any other questions you may have regarding this topic. If you're curious on why I think it's worth thinking twice about getting an epidural check out this blog.