A big thank you to Janelle Durham for compiling the results of so many studies in one place.
How many of you know all about epidurals? Do you know all of the possible side effects? Do you know what good things that they can do? Do you know what can happen when things do go bad? And do you know the medical interventions that they can cause? Do you know when they are truly needed or when they aren’t actually needed and can be detrimental to your labour?
In this blog post I will be addressing all of these questions and more and supplying the most current (at the time of writing this) risk percentages in easy to understand explanations without all of the medical jargon (apart from the actual name of things like artificial rupture of membranes, where I also supply an explanation in layman’s terms).
What is an epidural and what does it do?
Epidural anaesthesia is a form of anaesthesia that blocks pain in a particular region of the body. The goal of an epidural is to provide pain relief rather than anaesthesia which leads to total lack of feeling, however many epidurals end up being quite strong and take all feeling away. Epidurals block the nerve impulses from the lower spinal segments which results in a decreased or completely numbed sensation in the lower half of the body. Epidural medications fall into a class of drugs called local anaesthetics. They are often delivered in combination with opioids or narcotics in order to decrease the required dose of local anaesthetic. This produces pain relief with minimal effects. These medications may be used in combination with other drugs to prolong the epidural’s effect or to stabilize the mother’s blood pressure. There are two types of epidural – the “numbing” epidural that numbs the lower half of your body, and the “walking” epidural, where after the initial dose only 1 of the drugs used in an epidural is administered, which reduces the amount of sensation to the lower half of the body while still allowing movement and the ability to feel contractions (in effect it takes the edge off the pain so that you can manage it successfully).
Will an epidural affect my baby?
Yes it will. The drugs used in an epidural travel through the blood stream, go through the placenta and go into your baby’s blood stream. In some cases the drugs used in the epidural can make the baby very sleepy after birth which can impact latching and sucking (if you are breastfeeding) and affect how much of the bottle the baby drinks and how well it sucks (if you are formula feeding). Sometimes the epidural drugs can make your babies heart rate go up really high (180 beats per minute or higher) or really low (under 90 beats per minute), this is classed as distress and in the majority of cases a cesarean is needed quite quickly to get the baby out safely.
What are the side effects of having an epidural and how common are they?
An epidural can lower your blood pressure which in turn can reduce your baby’s heart rate and reduce the amount of oxygen that baby gets. You are approximately 74.2 times more likely to have this happen than someone who does not have an epidural (depending on which study you read you have up to a 50% risk of this happening with an epidural).
An epidural can cause you to develop a fever (raised temperature above 38 degrees Celsius). You are 5.6 times more likely to develop a fever than someone who doesn’t have an epidural (depending on which study you read you have a 4%-24% risk of this happening with an epidural, some studies showed that 95% of those with epidurals developed a fever).
An epidural may cause uncontrollable itching, especially when an opioid (a drug made from opiates and their derivatives for example anything with morphine or codeine in it) was included in the medication. An average of 62% of women with an epidural with opioid medication included experienced itching of various intensities. Without the opioid only up to 4% of women experienced itching with most cases appearing to be mild and very few mums requesting treatment for the itching.
An epidural can cause sedation or drowsiness. The Mayberry study showed that an average of 21% of women with an epidural experienced this.
You may need augmentation with pitocin or similar induction drugs if you have an epidural. The Mayberry study showed that women with an epidural were 2.8 times more likely to need augmentation of their labours if they had an epidural.
If you have an epidural you will be more likely to need an assisted delivery (ventouse/vacuum or forceps delivery). In the Lieberman compilation of 16 individual studies it showed that an average of over 50% of women with an epidural were unable to push their babies out without the assistance of the ventouse (vacuum extraction) or forceps.
According to Thorp’s study of 93 women (only 1 woman in the non-epidural control group opted for an epidural) you are 11 times more likely to end up with a caesarean section with an epidural than a woman without an epidural. Lieberman et al (1996), found that there was a 17% risk of caesarean from an epidural.
An epidural may increase your risk of having a post partum haemorrhage, the Lieberman study showed that women who had an epidural where twice as likely to have a post partum haemorrhage than women who didn’t have an epidural (10% with epidural compared to only 5% without an epidural).
You may experience a severe headache after birth. These can last for as little as 8 weeks, or as long as 8 years after birth. This is caused by a small leak of spinal fluid into your blood (also called a dural puncture) and can be fixed with a blood patch where a small amount of your own blood is injected into the epidural space and can relieve the headache.
You may develop a back ache on the first day after your epidural is removed. The few studies on this have shown no noticeable percentages in further abnormal headaches at 1 week and 7 weeks post partum, but there could always be exceptions.
What is good about having an epidural?
An epidural can block or reduce the pain from contractions.
An epidural can help you to rest and recover your energy during a long labour or a very painful labour (an induced labour involving pitocin or similar inducing drugs can be more painful than a “natural” labour so an epidural can be helpful in inductions).
It can lower your blood pressure (this doesn’t happen to everyone and is extended upon in another answer below).
It can help you to relax if you are “tensed up”.
Some women have a more positive birth experience with an epidural.
If I have an epidural what are the most common interventions that can occur as a result?
The most common interventions are:
1 – Artificial rupture of membranes (if they haven’t already broken) where the Midwife/Nurse/ObGyn breaks the amniotic sac.
2 – Pitocin/Syntocinon, an artificial oxytocin drug that is used to induce or augment labour and is used by many obstetricians to make labours go faster than they would normally may be started if the epidural causes your labour to slow down or stop. Pitocin/Syntocinon has its own risks that could be detrimental to labour and babies health as well.
3 – A caesarean section (c-sec) where the baby is cut out of your uterus. This is major abdominal surgery and in the average woman who has no complications as a result of the surgery is not fully healed until around 6 months after it occurs.
4 – Consistent Electro- Foetal Monitoring (CFM), where special pads are placed against the mothers skin to pick up the babies heart rate and another pad that picks up the contractions, these are often held in place by stretchy straps (that appear similar to seat belts), or in some hospitals this is done with the use of sticky pads similar to what is used to monitor your heart in an echocardiogram or a it can be done with a clip that is placed on the baby’s skull. This can be very uncomfortable for many mums and usually means that the mum has to remain on her back on the bed as movement can make the baby move away from the pad picking up the baby’s heart beat.
5 – A urinary catheter. Basically when you have a run of the mill (or full) epidural, and even quite often with a walking epidural, you can no longer feel when you need to do a wee. A urinary catheter is placed, with a small medical balloon attached to the end of it which is inside your bladder which is inflated to hold the catheter in place, and has a collection bag attached to it to collect the urine so that the urine doesn’t build up in the bladder. The side effects of this are discomfort for a few weeks afterwards, urinary tract infections (these don’t always happen but have been reported as a common occurrence by many mums) and the possibility of receiving a diagnosis of “obstructed labour” if the urine starts to get a rose coloured tint to it (this can sometimes be caused by baby’s head pressing on the bladder as he/she descends into the birth canal and the balloon from the catheter can cause baby to get stuck and not descend any further – in this instance deflating the balloon and repositioning it further into the bladder can help a lot – rather than being a genuinely obstructed – read stuck – baby), and incontinence. A not very common complication of having a urinary catheter is scarring and bladder damage.
When is an epidural really needed?
There are several things that could suggest that you may need an epidural.
The most common of these is exhaustion, when you are extremely tired and have been labouring for over 24 hours without sleep an epidural can be placed to allow you to “have a break” from the contractions and enable you to get some decent sleep before the big show starts.
Another time an epidural may be needed is if your blood pressure is steadily rising during labour and is getting close to dangerously high levels. One of the side effects of an epidural is lowered blood pressure, and in this instance an epidural can be very helpful. This doesn’t always work for everyone however, and in some cases it can do the opposite and make a woman’s blood pressure go even higher. No one can predict who this will work for, and sometimes it can work for one labour and not for the next labour and vice versa, so it really is a “see as you go” scenario.
Epidurals can also be easily turned into spinal blocks, so if you are attempting to have a “Natural Caesarean with trial of labour beforehand” then an epidural can work really well in helping you to avoid the pain caused by contractions to begin and making it easier for you to get a spinal block when you do go to theatre. The down side of this is that labour can stop shortly after an epidural is placed which may mean that your body doesn’t get the full effects of natural oxytocins, or it can drop your blood pressure so low that you don’t get to experience your “Natural Caesarean” in the way that you wanted to.
If you are “tensed up” from the pain then that can slow your labour down and make it last longer than it normally would. In this instance there is around a 50/50 chance that having an epidural placed can allow you to relax enough to dilate quicker than you previously were and enable your baby to be born sooner.
When isn’t an epidural needed?
1 - An epidural isn’t needed as soon as you arrive at the hospital if you and baby are happy and you are not exhausted.
2 - An epidural isn’t needed before you reach 4cm dilated.
3 - An epidural shouldn’t be placed after you reach 8-9cm dilated.
4 - An epidural should not be placed if your blood pressure is already lower than normal. It may make it drop even lower which will not be good for you and can negatively affect your baby.
5 - If you are in transition and start demanding an epidural (which happens more often than you would think even in mums who are labouring drug and intervention free by their own choice) an epidural should not be given. Not only will it most likely not start to work on time, but if there is enough time for it to work it can make pushing very hard and even make your pushing not be effective enough to get the baby out.
6 - If you use blood thinners then you should not have an epidural.
7 - If your platelet counts are low then you should not have an epidural.
8 - If you are hemoraghing or in shock you should not have an epidural.
9 - If you have an infection in your back then you should not have an epidural.
10 - If you have a blood infection then you shouldn’t have an epidural.
11 - An epidural should not be done if the epidural space cannot be located by the anaesthetist.
12 - If labour is progressing too fast and there is not enough time to administer the drug (mentioned in #'s 3 and 5 of this section).
Why do some doctors insist on epidurals as soon as a woman gets to hospital while in labour?
Training, hospital policy and personal beliefs. Many older doctors were trained when epidurals were considered to be “the next best thing to chloroform” (chloroform, amongst other drugs that are now not used, was used extensively in the 50’s and 60’s to effectively “knock women out” so that they wouldn’t have to be in pain or make a sound during labour and birth) and they see it as an “aid for labouring women” in a misguided belief that no woman should go through that kind of “pain”. Many also feel that women should not make a sound during labour or pushing and a full epidural is the best way to achieve that in lieu of performing a caesarean section. Newer doctors are trained differently but their personal beliefs and desire to prevent what they see as “unnecessary pain” can make them think that epidurals should be given to everyone.
I must point out that not all doctors are like this, there are many who prefer to avoid the use of an epidural if they can, and many who prefer for the woman to decide if she has one or not rather than forcing it on her.
Some hospitals have a policy of making every woman who arrives in labour between 4cm and 8cm have an epidural placed. This is not evidence based and can be detrimental to a woman’s labour and birthing experience. Hospital policy is not law however, and you always have the right to refuse if you wish to. If anyone tells you otherwise then they are not supportive of you and you can request someone else to look after you.
What can I do to reduce my risks of further intervention or any damage to my spine if I choose to get an epidural?
Have a very experienced anaesthetist administer your epidural, and ensure that the cords are placed somewhere where they won’t be underfoot. Also if you already have spine issues (bulging/compressed disks and spine damage) then it might be best to avoid an epidural altogether.
To avoid further intervention get a “walking” epidural, which only has one of the 2 epidural drugs administered to you. This way you can stay active and “feel” the contractions without feeling all of the “pain” as well. This kind of epidural is beneficial for pushing as you can still feel the surges and the pressure and can push more effectively.
Lieberman E, O’Donoghue C. Unintended effects of epidural anaesthesia during labor: A systematic review. Am J Obstet Gynecol 2002; 186:S31-68. A total of 1900 articles were examined, and evaluated for inclusion in the review based on the authors’ criteria. They limited their review to original reports in English, in peer review journals since 1980; they included both randomized trials and observational studies; they excluded studies with no control group, studies that evaluate specific drug regimens, studies that examine epidurals for anaesthesia during cesareans, studies conducted exclusively on high-risk populations, studies where population selection renders results uninformative, studies with analytic choices that make results impossible to interpret, and studies that examine outcomes only for the overall population of delivering women.
Mayberry LJ, Clemmens D, De A. Epidural analgesia side effects, co-interventions, and care of women during childbirth: A systematic review. Am J Obstet Gynecol 2002; 186:S81-93. More than 700 publications were identified; they narrowed that down to 150 studies that addressed one or more of the common side effects and co-interventions, plus 75 articles addressing relevant clinical or nursing care information related to unintended effects of epidurals. They only included prospective, randomized, controlled trials published between 1990 and 2000. These studies were then further limited by pre-established criteria: evidence of little or no crossover effect, minimal loss of subjects after random allocation to comparison groups, and satisfactory description of the randomization procedures. In the final review, they included 19 studies, with a total sample size of 2708 women.
Thorp JA, Hu DH, Albin RM, McNitt J, Meyer BA, Cohen GR, et al. The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial. Am J Obstet Gynecol 1993; 851-8.
http://americanpregnancy.org/labornbirth/ (under the section on Epidurals)