25 Jul The 10 Most-Frequently Asked Questions About Epidurals
Dr Penelope Law reassures mums-to-be about epidurals.
The idea of epidural anaesthesia understandably worries many women. This is partly because few relish the thought of a needle being inserted into their back so close to their spinal cord, and partly because they may have heard or read stories that are alarming. Below is a list of questions I am most often asked regarding the safety and possible side effects of epidurals. I hope that by answering them in detail, you are reassured about what an epidural involves.
Can I ask for an epidural even if I said in my birth plan that I didn’t want one?
Yes, you can change your mind once you are in hospital and fully in labour. No one will mind – in fact, this happens quite a lot!
How late in my labour can I request an epidural?
You can have an epidural at any point in the first stage of labour – the only limiting factor is your ability to keep still while it is being administered, so this is why it needs to take place before the second (pushing) stage begins. An epidural can take up to an hour to set up and become effective, so if you are progressing quickly through the first stage, you could find that by the time you really feel like you need pain relief, your labour is almost over. In addition, apart from the time it takes to set up, your epidural could be delayed if another woman requests one at the same time. For these reasons, it is a good idea, if you are starting to struggle with the pain from your contractions, to say sooner rather than later that you may require an epidural.
Will I be put under pressure to have an epidural?
The short answer is ‘no’. However, you may be offered one if you are planning a vaginal breech delivery or your baby is in a posterior position, because these labours are usually longer and/or more complicated. Similarly, if you are being induced with a syntocinon infusion, you will also be offered an epidural, sometimes before the start of the procedure, because the contractions can be very powerful from the start. And if this is your first labour, you may be offered the chance to consider an epidural at some point. This is simply because the that you are already having trouble managing the contractions and there may still be quite a long way to go in the first stage. They are therefore informing you that it might be a good time to think about an epidural before you miss the opportunity and it is too late. However, it goes without saying that the final decision is always up to you.
What are the risks of damage to my spine?
Spinal damage caused by an epidural remains one of the greatest fears.
Fortunately, the latest research shows unequivocally that epidurals are extremely safe.
The study looked at all groups of patients given this sort of anaesthesia, ranging from women in labour through children to frail, elderly patients (who often have epidurals because general anaesthesia is too risky for them). It concluded that in every (rare) case where death or injury occurred, the complications were the result of the patient’s condition, rather than mistakes by the medical team and, in most cases, the patient was elderly. If you are worried about moving during a contraction while the needle is being threaded into the epidural space, you can rest assured that anaesthetists are extremely used to this and stop what they are doing at the start of every contraction and only continue once it has fully subsided. Furthermore, it is extremely rare for the catheter to move inside your spine and if it did, the medical team would realise this at once because the area of numbness would change.
Indeed, it is virtually impossible for an epidural to injure or paralyse you.
Will the epidural hurt?
Not as much as the contractions! The only thing you will feel is the small injection of local anaesthetic in your lower back to numb the skin in preparation for the insertion of the epidural needle. The process itself only causes mild discomfort, although it is true that some women do tense up considerably in anticipation of the procedure.
Does the epidural sometimes fail to block the pain?
Occasionally, a part of your abdomen or thigh remains unaffected by the anaesthetic; very rarely, one half of your abdomen is not effectively blocked. This is because everyone has a slightly different nerve pathway distribution, which is usually asymmetrical. You will notice this immediately, and the anaesthetist will gently move the tube in your back or ask you to change position so that the drug can reach all the nerves required to anaesthetise you completely. Very rarely, the catheter needs to be taken out and repositioned completely, but this only takes a few minutes. I also want to stress that, if you are having a Caesarean section and have had an epidural, CSE or spinal block, you will be checked extensively by the anaesthetist before the operation takes place to ensure you are fully anaesthetised. Often, they will ‘pinch’ the skin over your abdomen to reassure you that, even though you feel some pressure, you will not sense pain.
Can I still push my baby out?
Contrary to what many people believe, you can still push during the second stage even if you are completely numb and cannot feel your contractions. Your midwife can tell when each contraction is about to start, because she will be interpreting the information on the CTG and will also have a hand on your abdomen, so will be able to feel when it is tightening up. She can then let you know when you should push. If possible, your epidural (or any top-up) will be timed so that it has worn off a little prior to the second stage. In this way, you can feel your abdomen tensing up at the start of each contraction but are not in any pain. It is true that you may push less effectively if you are completely anaesthetised, but it is certainly still possible to push sufficiently well to get your baby out.
Am I more likely to have an assisted (instrumental) delivery or a Caesarean section if I have an epidural?
Studies indicate that having an epidural in the early stages prolongs labour and increases the chance of further medical intervention such as an instrumental delivery by 40 per cent, but not of a Caesarean section. This is because if it is your first labour and you cannot feel contractions, it is difficult to push effectively.
Is there a risk of backache after the birth?
A lot of research has been carried out to see if epidurals lead to a higher incidence of postnatal backache. The conclusions of some studies indicate that this might be the case, whereas others contradict these findings and state that back problems are more likely to stem from a long, difficult labour or an assisted or Caesarean delivery than from the procedure itself. Postnatal back pain can also be caused by the fact that, during the latter part of the pregnancy, the lumbar region, spine and pelvic areas (including the sacroiliac joints at the base of the spine) were under considerable strain as a result of the increasingly heavy uterus. Weakened back and abdominal muscles, as well as tendons and ligaments that have been softened in preparation for the birth, are also a contributory factor (not to mention poor posture when lifting the baby or carrying the baby on one hip, manoeuvring the pushchair, slumping when breast-/formula feeding and general exhaustion…)
Are there other side effects of an epidural?
A small percentage of women suffer from headaches following an epidural. Usually, this happens because the needle has accidentally punctured the dura, the membrane surrounding the spinal cord. The pain is caused by a small amount of spinal fluid leaking out and is usually relieved by lying down. Some women also find that they have a slight tingling or numbness in one of their limbs.
I would like to stress that all these symptoms are temporary and, although they sound alarming, they are nothing to worry about and will usually disappear within a few days or, in rare cases, within a few weeks.
Your anaesthetist will see you the day after your delivery to make sure you have none of the above problems. Should you have a persistent headache at home, you should always mention this to your midwife or call the delivery suite, as you may need to come back for a further consultation.
Excerpt from Expecting A Baby? by Dr Penelope Law and Consultant Editor Dr Sarah Clements, published by Hardie Grant Books.