In most hospital labor suites today, the most common form of pain control for the woman in labor is Continuous Lumbar Epidural Analgesia also known as a Labor Epidural. This technique involves placing a small plastic tube, or catheter, into the Epidural Space in your lower back. The epidural space is a small space that surrounds the Dura (a membrane which covers the spinal nerves and spinal fluid). The epidural space runs from your tailbone to your head. The plastic tube, or catheter, is inserted into the epidural space in your lower back, close to the spinal nerves that transmit the painful sensations during labor. After the catheter is inserted, medications can be injected through the catheter that block the sensations that pass through these spinal nerves. The catheter can remain in place as long as necessary. Therefore, medications can be given through this catheter to reduce the pains of labor throughout most of the labor process, whether that should last 20 minutes or 20 hours. The medications used may include a low dose local anesthetic and/or a narcotic. Because these medications are injected into the epidural space, they work at the spinal cord level to relieve pain and have very little effect systemically (throughout the rest of the body). The patient can be comfortable with little or no drowsiness. The anesthesiologist may give small doses to remove the pain, but still allow the mother to feel some of the contractions, or give bigger doses to take away all of the feeling of labor. The dose can be further increased to provide anesthesia for a Cesarean Section if necessary.

What is the epidural?

Spinals, epidurals and combined spinal-epidurals are regional anesthetics. A section or “region” of the body is numbed by the medicine that is injected into the spinal canal. The legs, the torso and part of the chest are the areas that become numb. What’s the difference between a spinal and epidural and a combined spinal-epidural?

The spinal cord and the nerves are contained in a sac of cerebrospinal fluid. The space around this sac is the epidural space (see section on 'Regional anesthesia'). Spinal anesthesia involves the injection of numbing medicine directly into the fluid sac. Epidurals involve the injection into the space outside the sac (epidural space). Spinals and epidurals have the same effect (i.e. numbs a large region of the body) because they both involve numbing of the nerves as they branch off the spinal cord. Since the spinal injection is more “direct”, the effect is immediate. Spinals are usually the first choice of anesthetic for women who are not in labor but need a Cesarean delivery. Epidural anesthesia takes a little longer to establish desired affect. Because a small tube (catheter) can easily be placed through a needle in the epidural space, repeated doses of medicine can be given to maintain anesthesia as long as needed. Epidurals are the primary way of relieving pain in women that request analgesia for labor. A combined spinal-epidural involves a spinal injection followed by the insertion of an epidural catheter. Quick onset can be achieved with the spinal part. Further maintenance of the anesthesia is achieved through the epidural catheter.

Depending upon one's requirements for local anesthetic medications via epidural, occasionally one can have transient weakness of legs hampering your ability to move your legs which should resolve over time. The anesthesiologist with the assistance of your labor and delivery nurse would monitor requirements of local anesthetic medications via epidural route. After making you comfortable with an initial epidural injection of local anesthetic medication, an epidural pump is usually set up to deliver a set amount of medication periodically. The pump injects epidural medications automatically until the baby is delivered. This will ensure that you are comfortable through out your childbirth process. Occasionally, however, the amount set to deliver automatically by the epidural pump may not be enough and you may feel uncomfortable contractions during the childbirth process. The anesthesiologist can make you comfortable and achieve optimum pain relief with additional epidural medications. Your labor and delivery nurse and the anesthesiologist will monitor the pain relief all through your birthing process. Combined spinal epidural techniques (CSE) can combine the advantages of each technique. Distinct advantages of CSE over the epidural are: Rapid onset, profound suppression of pain.

For an ideal position, you should arch your spine in a such a way that you push your lower back outwards. Several words are used to describe this position to patients such as "letter 'C', 'like a shrimp', 'angry cat', 'pelvic tilt', etc. See the figure to understand this position.

Sitting position: In addition to arching your back outwards, keep shoulders down without leaning to either side. Keep your chin down.

On the bed on your side: In addition to arching your back outwards, keep shoulders down without leaning forwards. Keep your chin down. You will be asked either to lie on your side or sit up and curl your back out as much as you can as shown in the preceding image. The anesthesiologist will feel bony landmarks in the lower back and will clean your back with an antiseptic solution prior to placing the epidural. A small amount of local anesthetic will be injected to numb your skin prior to insertion of the hollow epidural needle. After the needle is advanced to the epidural space, a tiny catheter (plastic tube) is inserted through the needle into the epidural space. Occasionally, some women may complain of 'very transient' tingling nerve sensation (parsthesia) of legs when the catheter brushes against the nerves in the epidural space during its passage. However, this is very transient and passes off very quickly. Once the catheter is in place, the needle is removed, and the catheter is taped onto your back. Initial medication is injected through the catheter. Some women report 'feeling cold sensation in the back while medications are being injected'. Thereafter, the medication is delivered via an automated pump until your baby is born. Since the nerves from the uterus and cervix pass through the epidural space, as explained earlier, the medication bathes these nerves and blocks the sensation of pain. The epidural can take 5-10 minutes to place, and the medication works gradually in the epidural space over next 10-15 minutes. Initially, many women notice that their pain during contractions is less intense and lasts for a shorter duration, until eventually, all they feel is the tightening feel (little pressure) of the contraction. You may not feel the contractions at all; it differs for every woman.

The "black point" is the point in the lower back to place the peridural catheter. Click on the "black point", you can watch short movies about epidural

When is an epidural started?

Obstetricians have different opinions as to what point in your labor is optimal to begin your epidural analgesia. Some will allow you to have your epidural as soon as you are having pain from your contractions. Some Obstetricians prefer to wait until you have established a consistent contraction pattern demonstrating that you are well into labor. Still other Obstetricians prefer to wait until you are more than 5 centimeters dilated before allowing placement of the epidural. If you are considering an epidural for control of pain during labor, speak with your Obstetrician about labor analgesia. Your hospital's anesthesia department may offer a full labor epidural service or may have limited types of labor analgesia available. Some anesthesia groups require a consultation with the patient before she goes into labor. Your Obstetrician can answer your questions about labor analgesia or put you in contact with the anesthesia group that will provide that service for you.

Which are the benefits?

Epidural analgesia provides relief or reduction of labor pain without affecting the mother's mental state. It enables an exhausted mother to relax or sleep during labor and calms the woman who is anxious and tense because of pain. Once an epidural catheter is in place, additional medication can easily be administered as needed, providing prolonged and consistent pain relief. Some prolonged labors, probably those slowed by anxiety, speed up with an epidural. Anxiety can cause excessive production of the mother's stress hormones such as epinephrine and norepinephrine, which slow contractions. By allowing the mother to rest without pain, the epidural removes her anxiety and her labor progress may improve. Since epidurals often lower blood pressure, this may benefit some women with pregnancy induced hypertension. Epidurals are also useful for cesarean births, making it possible for the mother to remain alert and involved while free from pain. They enable her to avoid general anesthesia, which is considered to carry greater risks. Epidural narcotics reduce pain without reducing other sensations or muscle function. Women can change positions more easily than with anesthetics. They remain aware of their contractions and often continue to participate; using breathing patterns and other comfort measures. For those women who wish to remain aware of their labors, epidural Taking away pain takes away the stress of labor on your heart. It allows you to breathe normally. Studies show that labor pain relief can improve the oxygen supply to your baby. Having an epidural in place also means that you have the ability to get a quick anesthetic if you need a caesarian section.

Are there any controindications?

Controindications for having an Epidural are: Bleeding disorder or on anticoagulants, Infection in area of Epidural Injection, Thrombocytopenia, Patient refusal.

Are there any side-effects?

The anesthesiologist takes special precautions to prevent complications.  Although side-effects are rare, they occasionally include the following. Some of the side effects may be specific to the circumstances of your presentation. Therefore you should discuss them with your anesthesiologists.

• Mother

Shivering: Shivering may occur and is a common reaction. Sometimes it happens during labor and delivery, even if you have not received any anesthetic medications. Keeping you warm often helps it subside.

Decreased blood pressure: You will receive intravenous fluids and your blood pressure will be carefully monitored and treated. Decreases in blood pressure are expeditiously corrected.

Mild itching during labor: This is a result of narcotics used in the epidural/spinal medications. If itching becomes bothersome, your anesthesiologist can treat it with medications. Most women find itching to be mild.

Local anesthetic reaction: While local anesthetic reactions are rare, they can be serious. Be sure to tell your anesthesiologist if you ever had any allergic reaction to local anesthetic medications.

Breathing problems: On rare occasions, the anesthetic medication may affect the chest muscles and make it harder to breathe. Oxygen can be given to relieve this and help the breathing.

Injection into veins: The veins located in the epidural space become swollen during pregnancy. There is a risk that the anesthetic medication could be injected into one of them. To help avoid unusual reactions stemming from this, your anesthesiologist will first administer a test dose of medication and you may be asked if you notice any dizziness, a funny taste, numbness of ears, dizziness or rapid heart beat.

Persistent pain in some areas/no pain relief: Sometimes the anesthetic does not reach an area leaving a "spot" which is still painful. Your anesthesiologist may change your position on the bed or withdraw the epidural catheter to relieve the pain. Occasionally the epidural catheter may need to be removed and reinserted again if you do not get adequate pain relief. Your anesthesiologist will work with you  to make you comfortable.

Paresthesias (feeling of nerve sensations): Transient "Feeling of nerve sensations/electric shock" (hitting your funny bone) can occur while inserting the epidural catheter as it brushes against the nerves in the epidural space. Although these sensations are common during epidural injections, permanent nerve damage is extremely rare. 

Back pain: You may have localized back pain from the needle insertion, which should last a day or so. On the other hand, you may experience generalized back pain, which is not necessarily attributable to the epidural. Studies have shown that mothers who have natural childbirth deliveries are as likely to experience generalized back pain lasting a few days as those who have epidurals. It seems that pregnancy itself can increase the incidence of back pain because of softening of the ligaments resulting in back strain.

Headache: There may be several reasons why you can get a headache after labor and delivery that are unrelated to epidural anesthesia. However, although uncommon, a headache may develop following the epidural block procedure (<1%). This occurs as a result of a needle hole in the sac containing fluid (spinal fluid) during the epidural procedure. Leakage of spinal fluid into the epidural space may result in headache. By holding as still as possible while the epidural needle is placed, you help to decrease the likelihood of a headache. Usually the headache occurs in about 24 hours following the epidural block. Typically, the headache occurs while you sit up and relieved by assuming lying down position. The head and neck discomfort sometimes lasting few days, often can be reduced or eliminated by simple measures such as lying flat, drinking fluids and taking pain tablets. Occasionally, a patient may need additional treatment if the headache persists, or associated with other features such as nausea,  difficulty in seeing light, or hearing noises. A major complication such as nerve damage, bleeding into the epidural or spinal space, paralysis, and infection are extremely rare events. Since epidural anesthesia involves needle placement in the back, there is a natural tendency to assume that any post-delivery nerve problem is due to the epidural anesthesia.  However, the majority of nerve problems following labor and delivery are commonly due to the impinging of the nerves by the moving baby along the birth canal, and rarely to regional anesthesia.  If you experience any weakness in the legs or other nerve problems, your anesthesiologist will help to evaluate the problem and make sure you have the proper follow-up.  

• Newborn

Usually two types of medications are used to produce effective epidural analgesia; local anesthetics and opioid (narcotic) medications. Local anesthetic medications given into the epidural space can reach the baby via mother's blood circulation. However, the amount reaching the baby is too small to have an effect on the baby's heart rate, or on the general alertness of the baby after delivery. Similarly, opioids used in the epidural injections can also reach the baby. Once again, the amount of opioids reaching the baby is much smaller when compared to the amounts reaching the baby when the mother is getting systemic (I.V) opioid medications.

Fetal Heart beat: Occasionally, within 10 to 15 minutes of epidural injection of local anesthetic or opioid, fetal (baby) heart rate may show changes such as slowing of heart rate with or without changes in heart rate pattern (decreased beat-to-beat variability) in about 30% of pregnant women. However, these baby heart rate changes are transitory, and last only 3 to 4 minutes. As long as baby's heart rate is monitored continuously (as is generally practised), and corrective measures undertaken, these transitory changes should not give rise to great concern.

Neonatal neurobehavior: Tests of neonatal neurobehavior (tests performed to assess activity of newborn) after exposure to various methods of pain-free child birth have produced conflicting results. In recent years, however, the doses of local anesthetic medications and opioids used for providing child birth pain relief via epidural analgesia have gradually decreased, and there is now general consensus that within the dose range presently en vogue, and under normal circumstances, the effects of the local anesthetics on the new born baby have little or no clinical significance. Under some circumstances, an epidural pain relief can be beneficial for the baby as is for example in pregnant women with preeclampsia (high blood pressure, swollen feet, etc). An epidural analgesia can improve blood flow to the baby during labor and delivery.

Peridural Anesthesia and C. Section

Some women who go through labor might eventually require a Cesarean delivery. This can be due to non-urgent factors (labor not progressing), or urgent factors (mother or baby’s condition is at risk). If an epidural catheter has been in place and functioning well, most of the time the anesthesiologist can put additional medicine into the catheter to make the numbness adequate for surgery. As with spinal anesthesia, it is normal for the body to feel numb from the lower chest down to the feet. Again, this is considered the right amount of anesthesia to keep you comfortable for the operation. If the epidural does not work, it may be replaced, or spinal or general anesthesia may be used. This choice depends on the urgency of the situation. This is, however, uncommon.

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