Why is an epidural done?

:
An epidural can be done for regular labor and childbirth, induced
labors (induction), a forceps or vacuum delivery or even a cesarean
section. You can learn more about epidural anesthesia from your
childbirth class instructor.
Childbirth Class and the Epidural
How is an epidural done?:
An epidural is usually done with you on your side or sitting up, but in
these positions you curl up tightly over your pregnant abdomen to
give the anesthesiologist the best view of your spine. The area of the
bac is then washed with a very cold cleansing solution. You are then
numbed with a local anesthetic to minimi!e the pain you feel from the
actual epidural needle going in. A test dose is delivered to be sure
that the medication is going into the right space. The needle is
removed and a thin, plastic catheter is left in your bac and taped
down for security.
Can my husband stay with me"
Epidural #tep by #tep
How will the epidural give me pain relief?:
$f the test dose given is good, then you are hooed up to a bag of
medications that will flow continuously until remove catheter from
your bac. This medication can be changed or altered depending on
your needs.
%est Epidural
&hat to 'o &hen the Epidural 'oesn(t &or
&aling Epidurals
'rugs for %irth"
How does it feel to have an epidural put in?:
The actual procedure is described anywhere from uncomfortable to
very painful. $t can be hard to lean over while pregnant and having
contractions. The local anesthesia hurts more than the epidural
needle, because at the point which the epidural needle goes in, you
are numb. )ost women describe the epidural needle as feeling more
lie pushing and shoving. *ccasionally the needle will touch a nerve
causing your leg to +ump or you may feel a shooting pain. This is
normal and does not mean you are paraly!ed.
What will I feel with an epidural during labor?:
&hat you feel will depend on the combination of medications, how far
along you are in labor and various factors. #ome women feel the
contractions but do not e,perience it as pain. *ther women report
that they feel nothing from their nipples to their nees. %e sure to tal
to your anesthesiologist about what you want to feel and see if they
can wor with you.
-ow to #upport a &oman with an Epidural
.ushing with an Epidural
Epidural %irth #tories
What happens after I give birth?:
After you have given birth, the epidural catheter is removed by
removing the tape around it and pulling the catheter out. You may still
e,perience numbness in your legs for several hours. *ccasionally
mothers will feel wea in the legs or even numb for longer periods of
time. %ac pain may also occur at the site of the epidural.
After an Epidural
What are the risks of an epidural?:
The riss of an epidural are numerous. The complications that are
most common are things lie a drop in mom(s blood pressure, which
can usually be /uicly treated by medications and position changes.
*thers lie fetal distress, fetal malpositioning, increase in the
cesarean rate are also common with epidurals, but corrections
re/uire various procedures. .aralysis, numbness, nerve in+ury and
infection for mom are really rare but do occur.
#pinal -eadache
Epidural 0acts
Can everyone have an epidural?:
1ot everyone can have an epidural. There may be reasons that are
physical to you or staff related as to why an epidural may not be for
you.
2 3easons You Can(t -ave an Epidural
&hat about a low bac tattoo and epidural"
When can an epidural be done?:
#ome hospitals, doctors or midwives may have a policy to only
provide epidural anesthesia after a certain point in your labor. This is
meant to help insure that your labor does not slow down or stop
because of the epidural. $t may also decrease your riss of certain
complications. %e sure to as what your practitioner and hospital(s
policies are about when you can get an epidural. .rior to getting an
epidural you can use other forms of pain relief lie comfort
measures and $4 medications to help you cope with labor.
$s it ever too late to get an epidural"
.ain 3elief on 'emand
What if I don't want an epidural?:
$f you do not want to have an epidural you do not have to have one.
)any mothers choose to use various techni/ues to get through labor
without using any medication. 5sing a doula is also nown to help
reduce the lielihood that you will want an epidural.
http677pregnancy.about.com7od7epidurals7p7epidural.htm
pidural Analgesia uring !abor
3*%E3T '. 4$1CE1T, 83., ).'. and 'A4$' -. C-E#T15T, ).'.,
5niversity of Alabama #chool of )edicine, %irmingham, Alabama
Am Fam Physician. 9::; 1ov 9<=<;(;)692;<>92:?.
3elated Editorial
"pidural analgesia is a commonly employed techni#ue of
providing pain relief during labor$ %he number of parturients
given intrapartum epidural analgesia is reported to be over &'
percent at many institutions in the (nited )tates$ %he procedure
has few contraindications* the primary ones being patient
refusal* maternal hemorrhage and coagulopathy$ Induction of
epidural analgesia in early labor remains controversial$ However*
many physicians induce analgesia as soon as the diagnosis of
active labor has been established and the patient has re#uested
pain relief$ %he most common complications occurring with
epidural analgesia are maternal hypotension and postdural
puncture headache$ +etrospective studies have demonstrated
an association between epidural analgesia and increases in
duration of labor* instrumental vaginal delivery and cesarean
section for labor$ However* several recent prospective studies
have concluded that epidural analgesia does not adversely
affect the progress of labor or increase the rate of cesarean
section$ %hese remain controversial issues among practicing
physicians$
Superficially, obstetric anesthesia appears to be a simple field with a
limited range of interest, but it is a deceptively demanding
subspecialty. Not only are two patients involved in each anesthetic
administration, but also the dynamic events of normal labor require
that the muscles concerned with delivery retain their power and
coordination to the full.
@@.hilip %romage
9
3e/uests from patients and obstetricians, coupled with an increased
number of providers who have e,pertise and interest in regional
anesthesia for obstetrics, have resulted in a substantial increase in
the use of epidural analgesia during childbirth over the past two
decades. A recent survey of obstetric anesthesia in the 5nited #tates
indicated that the percentage of women given intrapartum epidural
analgesia increased from ?? percent in 9:;9 to <9 percent in 9::? at
hospitals performing at least 9,<AA deliveries annually.
?
#imilar
increases occurred in hospitals with <AA to 9,<AA births per year
(from 9B to BB percent) and in those with less than <AA births per year
(from : to 92 percent). Creater involvement by anesthesiologists
appears to be responsible for much of the increase in larger
hospitals. *n the other hand, greater participation on the part of both
anesthesiologists and certified registered nurse anesthetists has
contributed to an increased use of epidural analgesia in smaller
facilities.
The increased availability of epidural analgesia and the favorable
e,periences of women who have had painless labor with epidural
bloc have reshaped the e,pectations of pregnant women entering
labor. As more parturients demand pain>free labor, it is important that
physicians managing labor have a clear understanding of the benefits
of !"able #$, contraindications to and riss of epidural analgesia.
TA%DE 9
Advantages of "pidural Analgesia
.rovides superior pain relief during first and second stages of
labor
0acilitates patient cooperation during labor and delivery
.rovides anesthesia for episiotomy or forceps delivery
Allows e,tension of anesthesia for cesarean delivery
Avoids opioid>induced maternal and neonatal respiratory
depression
Pain of Parturition
4isceral distention originating from rhythmic uterine contractions and
progressive cervical dilatation causes much of the pain e,perienced
during the first stage of labor. Afferent impulses from the cervi, and
uterus are transmitted to the spinal cord via segments T9A>D9. This
usually produces pain over the lower abdomen and /uite often
causes pain over the lower bac and the sacrum as well. )ore than
two thirds of unanestheti!ed women described their pain intensity
with terms such as Edistressing,F EhorribleF or Ee,cruciatingF at some
point during the first stage of labor.
B
Although the second stage of
labor is briefer than the first, the pain is usually more intense.
.erineal pain due to stretching of the vagina, vulva and perineum is
superimposed on the pain of uterine contractions. #econd>stage pain
is principally somatic in nature and is transmitted through the spinal
#?>G segments.
#ome women have e,cruciating pain during childbirth, whereas
others e,perience only mild discomfort. #everal variables may help
physicians predict which parturients are more liely to have severe
pain during labor and delivery, allowing them to now which patients
would potentially receive the greatest benefit from continuous
epidural bloc. #ome factors shown to correlate with greater pain
during labor and delivery include the following6 nulliparity, intravenous
induction or augmentation of labor with o,ytocin (.itocin), younger
maternal age, low bac pain during menstruation and increased
maternal or fetal weight.
G@2
*f these, nulliparity and administration of
intravenous o,ytocin are the most useful predictors of women who
may have more intense labor pain.
'ecreased labor pain may be anticipated in women who have
attended childbirth classes and in those who have performed aerobic
conditioning e,ercises during pregnancy.
2,;
Preliminary Considerations
The American #ociety of Anesthesiologists has published guidelines
for regional anesthesia in obstetrics.
:
The guidelines state that
anesthesia should be provided only by practitioners with appropriate
privileges in facilities where resuscitation e/uipment and drugs are
immediately available. This e/uipment should include sources of
o,ygen and suction, e/uipment to maintain an airway and perform
endotracheal intubation, a means of providing positive pressure
ventilation, and drugs and e/uipment for cardiopulmonary
resuscitation. The guidelines also advise that regional anesthesia not
be given before the patient has been e,amined and the maternal and
fetal status and progress of labor have been evaluated by a physician
with obstetric privileges. 0urthermore, a physician should be readily
available to manage obstetric complications that may arise during
induction or maintenance of epidural analgesia.
.ain relief alone is an ade/uate medical indication for administration
of epidural analgesia during labor. The American College of
*bstetricians and Cynecologists and the American #ociety of
Anesthesiologists have collectively published the opinion that
Ematernal re/uest is sufficient +ustification for pain relief during
labor.F
9A
Also, these groups point out that Ethere is no other
circumstance where it is considered acceptable for a person to
e,perience severe pain, amenable to safe intervention, while under a
physician(s care.F
There are few absolute contraindications to the use of epidural
analgesia during labor. Contraindications to the use of a neura,ial
(i.e., epidural or subarachnoid) techni/ue include patient refusal,
active maternal hemorrhage, septicemia, infection at or near the site
of needle insertion and clinical signs of coagulopathy!"able %$.
TA%DE ?
Contraindications to "pidural Analgesia
.atient refusal
Active maternal hemorrhage
)aternal septicemia or untreated febrile illness
$nfection at or near needle insertion site
)aternal coagulopathy (inherited or ac/uired)
The presence of a nonreassuring fetal heart rate pattern is not a
contraindication to epidural analgesia. -owever, some physicians
may be reluctant to recommend epidural anesthesia in this situation.
The prior placement of a functioning epidural catheter may allow
rapid e,tension of the bloc should cesarean delivery be re/uired for
fetal distress.
Timing Considerations
$t is uncommon for spontaneously laboring parturients to re/uest
epidural analgesia before B cm of cervical dilation. -owever, women
receiving augmentation of labor with o,ytocin may re/uest analgesia
at minimal cervical dilation. $t is appropriate to induce epidural
analgesia after the diagnosis of active labor has been established
and the patient has begun to re/uest pain relief. 3ecent data do not
support the conclusions of earlier studies that administration of
epidural bloc before < cm of cervical dilation will adversely affect the
subse/uent course of labor.
99,9?
&hile epidural bloc is not
contraindicated in advanced labor, it is less common to initiate
epidural bloc when cervical dilation e,ceeds ; cmHespecially in
parous women.
Complications
Complications of epidural analgesia are listed in "able &. Elimination
of painful stimuli and the onset of peripheral vasodilation typically
reduce maternal blood pressure during the onset of epidural
blocade. )odest decreases (?A percent or less) in maternal blood
pressure are of limited concern in a woman with a healthy fetus. )ore
severe hypotension may result in a clinically significant decrease in
uteroplacental blood flow, which could +eopardi!e a fetus with
marginal reserve. The preanesthesia intravenous administration of an
isotonic electrolyte solution (e.g., lactated 3inger(s solution, <AA to
9,AAA mD) will attenuate the decrease in maternal blood pressure that
occurs with induction of epidural analgesia. -ypotension during
epidural analgesia is treated with additional intravenous boluses of
crystalloid solution and7or administration of small intravenous doses
of a vasopressor (e.g., ephedrine, in a dosage of < to 9A mg).
TA%DE B
Complications of "pidural Analgesia
Immediate
-ypotension (systolic blood pressure I9AA mm -g or a
decrease of ?< percent below prebloc average)
5rinary retention
Docal anesthetic@induced convulsionsJ
Docal anesthetic@induced cardiac arrestJ
elayed
.ostdural puncture headache
Transient bacache
Epidural abscess or meningitisJ
.ermanent neurologic deficitJ

'()ery rare.
1eurologic complications of epidural or spinal analgesia7anesthesia
are rare. .erhaps the most common postpartum complication of
epidural or spinal analgesia is postdural puncture headache. *nce
common with spinal anesthesia, postdural puncture headache occurs
infre/uently in patients who undergo dural puncture with a fine pencil>
point spinal needle (e.g., &hitacre, #protte). -owever, most patients
who e,perience unintentional dural puncture with a 9K> or 9;>gauge
epidural needle are at ris for postdural puncture headache. The
headache is typically postural in nature and results from leaage of
cerebrospinal fluid, with the attendant decrease in intracranial
pressure and compensatory cerebral vasodilation. $n some cases
(especially in patients whose dural puncture occurred with a small>
gauge, pencil>point spinal needle) the postdural puncture headache
resolves spontaneously. Consumption of a caffeinated beverage may
provide partial relief in some patients. -owever, the definitive
treatment for persistent postdural puncture headache is an
autologous epidural blood patch (i.e., sterile in+ection of 9< to ?A mD
of the patient(s fresh blood into the epidural space, preferably at the
site of the dural puncture).
9B
3are but life>threatening complications from epidural analgesia
include the following6 (9) maternal convulsions or cardiovascular
collapse after unintentional direct intravenous in+ection of a local
anesthetic and (?) total spinal anesthesia following unintentional
subarachnoid in+ection of local anesthetic. #low, incremental
administration of the local anesthetic with appropriate maternal and
fetal monitoring will produce signs and symptoms of subarachnoid or
intravenous in+ection before serious conse/uences occur. )any
physicians administer an epidural Etest doseF (e.g., B mD of 9.<
percent lidocaine LMylocaineN with epinephrine 96?AA,AAA) to detect
subarachnoid or intravenous placement of the catheter.
Induction and Maintenance of Analgesia
A method of administering epidural analgesia is outlined in "able
*.
9G
The anesthesiologist(s goal during the first stage of labor should
be to provide segmental sensory anesthesia of the T9A>D9
dermatomes. The dose of local anesthetic necessary to achieve
effective labor analgesia will depend on the intensity and location of
the patient(s pain. These in turn depend on the variables discussed
earlier, including the amount and rate of cervical dilation= the strength,
fre/uency and duration of uterine contractions= and the position of the
fetal head at the time epidural analgesia is re/uested. Appro,imately
9A mD of A.9?< to A.?< percent bupivacaine ()arcaine) or A.9?< to
A.?< percent ropivacaine (1aropin), with or without a small dose of a
lipid>soluble opioid (e.g., fentanyl L#ublima!eN or sufentanil L#ufentaN),
establishes effective analgesia with minimal motor bloc. Thereafter,
maintenance of epidural analgesia may be achieved with either
intermittent bolus in+ections, continuous epidural infusion or patient>
controlled epidural analgesia. $n most cases, analgesia may be
maintained with a solution of local anesthetic more dilute than that
used for induction.
TA%DE G
,rotocol for "pidural Analgesia in !abor
"he rightsholder did not grant rights to reproduce this item in
electronic media. For the missing item, see the original print version
of this publication.
The supine position is contraindicated in women receiving epidural
analgesia during labor. Compression of the abdominal aorta and the
inferior vena cava (aortocaval compression) by the term gravid uterus
may concurrently decrease uterine arterial pressure and increase
uterine venous pressure. Conse/uently, uterine perfusion pressure
(uterine arterial pressure minus uterine venous pressure) may be
substantially reduced even in the presence of normal brachial arterial
blood pressure measurements (concealed aortocaval compression).
&hen maternal hypotension occurs during epidural analgesia, it is
essential to verify that the patient is not supine.
The onset of fetal descent causes substantial distention of the vagina
and perineum, typically resulting in severe pain. $t is important to
ensure that the segmental e,tent of epidural analgesia has spread to
include the #?>G nerve roots to maintain analgesia during this stage
of labor. Achieving ade/uate perineal analgesia is especially
important in women in whom episiotomy or the application of forceps
is probable. Complaints of rectal pressure with progressive descent of
the fetal head should alert the anesthesiologist that sacral analgesia
may be inade/uate for delivery. &omen who progress into the
second stage of labor soon after induction of epidural analgesia
seldom have ade/uate sacral blocade and often re/uire additional
epidural boluses of local anesthetic before delivery. *n the other
hand, women who have been receiving continuous epidural analgesia
for many hours often have e,cellent perineal analgesia at delivery.
Controversial Issues
$n spite of the widespread acceptance that epidural analgesia has
achieved among many physicians and patients, disagreement
remains regarding the effect of intrapartum epidural analgesia on the
subse/uent progress of labor and the mode of delivery. #everal
retrospective studies consistently demonstrated an association
between epidural analgesia and increased durations of both the first
and second stages of labor, o,ytocin augmentation, instrumental
vaginal delivery and cesarean section for dystocia. $n these studies,
the probability of cesarean section for dystocia was reported to be
increased three> to si,>fold by the intrapartum administration of
epidural analgesia.
9<@92
5nfortunately, retrospective studies add little
to the understanding of the impact of epidural analgesia on labor and
delivery. #uch studies are biased by the fact that women who
progress rapidly through labor often have less pain and are less liely
to re/uest and receive regional analgesia.
3andomi!ed, prospective studies have produced contrasting findings
regarding the effects of epidural analgesia on labor and mode of
delivery. $t is unclear whether or not epidural bloc prolongs the first
stage of labor.
9;,9:
-owever, maintenance of profound epidural
analgesia beyond complete cervical dilation will increase the duration
of the second stage of labor or increase the probability of an
instrumental vaginal deliveryHespecially in nulliparous patients.
?A,?9
Controversy remains as to whether epidural analgesia predisposes
parturients to a greater ris of cesarean delivery for dystocia.
??,?B
This
situation is illustrated by the opposing conclusions of two studies
originating from the same institution. $n the first of these studies,
3amin and colleagues
??
reported that the ris of operative delivery for
dystocia was increased nearly two>fold among women of mi,ed parity
who were given epidural analgesia rather than intravenous
meperidine ('emerol) analgesia. Two years later, #harma and
associates
?B
observed identical cesarean section rates among
women randomi!ed to receive either epidural analgesia or patient>
controlled intravenous meperidine analgesia. *ne important
methodologic difference between these two investigations was that
parturients in the latter study were analy!ed on an intent>to>treat
basis, regardless of the type of pain relief ultimately administered.
.erhaps most illuminating are data from institutions where the use of
epidural analgesia has increased abruptly over a short period of time.
3esults from these studies refute the hypothesis that increased
utili!ation of epidural analgesia is responsible for the cesarean
section Eepidemic.F
9<
0or e,ample, the introduction of an Eon>demandF
epidural analgesia service at one clinic produced a sudden increase
(from !ero to G9 percent) in the use of intrapartum epidural analgesia
but no increase in the primary cesarean>section rate.
?G
$n a similar
study, Dyon and colleagues
?<
evaluated the impact of a 'epartment of
'efense mandate allowing the vast ma+ority of military beneficiaries
to receive intrapartum epidural analgesia on obstetric outcomes at
one 5.#. Air 0orce hospital. $n the 9?>month period preceding
enforcement of the new policy, 9B percent of parturients received
epidural analgesia= the incidence of cesarean delivery for dystocia
was ; percent. 'uring the first year that epidural bloc became widely
available, <: percent of parturients were given epidural analgesia
during labor. The incidence of cesarean section delivery for dystocia
decreased (although the decrease was not statistically significant) to
< percentHdespite a B<A percent increase in the use of intrapartum
epidural analgesia.
Other Techniques
'iscovery of opioid>mediated spinal analgesia led to speculation that
spinal morphine administration would result in acceptable labor
analgesia without local anesthetic>induced sympathetic and motor
bloc. 5nfortunately, pain relief following subarachnoid administration
of morphine is often slow in onset, inconsistent in /uality (especially
during the second stage) and accompanied by a high incidence of
pruritus, nausea, urinary retention and sedation.
*n the other hand, intrathecal administration of short>acting lipid>
soluble opioids (e.g., fentanyl and sufentanil) has greater efficacy and
results in fewer side effects than administration of a water>soluble
opioid such as morphine. #pecifically, subarachnoid sufentanil or
fentanyl each produce e,cellent first>stage analgesia within five
minutes that lasts about :A minutes. Dimitations to the intrathecal
administration of a lipid>soluble opioid for labor analgesia include a
propensity for intense (although brief) pruritus, a relatively short
duration of action and an inability to produce ade/uate pain relief
during the second stage of labor.
#ome physicians have administered a lipid>soluble opioid with a very
small dose of morphine (A.?< mg) intrathecally in an attempt to
provide rapid>onset, long>acting labor analgesia with a single
in+ection.
?K
5nfortunately, this method (although offering analgesia
superior to conventional intravenous opioid techni/ues) lacs the
fle,ibility of continuous epidural analgesia and does not compare
favorably with epidural analgesia in the /uality of pain relief provided
during advanced labor.
The uni/ue ability of intrathecal lipid>soluble opioids to produce rapid
onset of pain relief during the first stage of labor clearly cannot be
e/ualed using epidural techni/ues. Thus, some anesthesiologists
facilitate the onset of labor analgesia by in+ecting a single dose of
fentanyl or sufentanil (with or without a local anesthetic) intrathecally
before placing the epidural catheter (combined spinal>epidural
analgesia). This techni/ue allows prompt onset of pain relief through
spinal anesthesia without sacrificing the fle,ibility of continuous
epidural analgesia.
Final Comment
The increased availability and effectiveness of epidural analgesia
have altered the e,pectations of many women regarding intrapartum
pain control. A significant number of parturients are re/uesting this
form of analgesia for relief of labor pain. 0amily physicians who
perform obstetrics should discuss this method of pain control with
their prenatal patients. The riss and benefits of epidural analgesia,
as well as other options for pain control, should be ob+ectively
presented to each woman well before the onset of labor. $n addition,
women can be encouraged to attend childbirth classes to help them
prepare for stresses that may arise during labor and delivery. Careful
patient evaluation, meticulous techni/ue during epidural catheter
placement and appropriate dosing of medication minimi!e the ris of
serious complications from epidural analgesia.
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