It’s 3 a.m., and I’m startled awake by a phone call notifying me of two new admissions. I inhale a cup of hospital coffee that I pray was actually brewed on this shift, as I shuffle down the hall from my call room. As I round the corner, I hear the primeval screams coming from the unit and quicken my pace. Based on the wails of pain, I am expecting to see a baby crowning as I walk in the room. The patient is rocking back and forth on the bed moaning intensely as the nurses ready the room for delivery. In between contractions, I quickly check her cervix, only to discover that she is only 3 cm. She looks at me incredulously as I inform her that she is still in early stages of labor. With some expletives added in for emphasis, she 'requests' an epidural. Her original plan was an unmedicated birth, but based on the wild look in her eyes, I decided not to question her change of heart.
As I placed her epidural orders, I was called to the room next door. This was no false alarm. The patient was pushing as I walked in the room, so I quickly pulled on my gloves. This patient begged for an epidural, but as I examined her, I saw that the baby’s head was already starting to crown. "It's too late, you have to push now, but I know you can do it" I said in my best encouraging voice. "This wasn’t my plan" she cried, terrified of the unexpected experience of an unmedicated birth. Two pushes later, she was holding her sweet baby. "That wasn't as bad as I thought" she said through tears of joy.
Despite careful preparations, labors do not always go as we plan. Whether you are planning to get all the drugs as soon as you walk in the door or go completely natural, you should know the basics of epidurals.
How does an epidural work?
Epidurals work by placing a small tube in the space beside the spinal column. Medication is placed through the tube that numbs the nerves and provides pain relief to the lower part of your body, while still allowing you to feel pressure. Effectiveness of the epidural can depend on many factors including the patient’s anatomy, previous back surgeries, and the degree of experience of the provider. While some sources claim that up to 12% of epidurals don't work, a closer look at the studies reveals that when the catheters were repositioned or replaced, 98% of women felt they had adequate pain relief from their epidurals. Talking with anesthesiologists in my region, we see a failure rate of closer to 1%. Regardless, you should always be aware that there is a chance that your epidural may not work always work perfectly, or at all.
Is an epidural safe?
The thought of a needle being inserted into your back millimeters from your spinal cord is quite cringy, but nerve damage from the epidural needle is extremely rare – so rare there are not enough data points to give us an actual risk percentage. As with any medical procedure, there is a risk of complications. If the needle scratches a blood vessel as it’s placed, then bleeding can occur and blood can collect near the spine. This collection of blood can put pressure on the nerves, causing damage. The risk of this is < 1/100,000. An epidural can also cause the mom’s blood pressure to drop when the medicine first takes effect, but this can usually be quickly corrected with medication. Although scary for the mom (it makes your heart race momentarily), it rarely causes long term side effects. Infection in the spinal or a reaction to the medication used in the epidural can also cause rare complications. Nausea, itching, and headaches are more common, and simply annoying, side effects.
Epidurals are safe for babies. Only minimal amounts of the medication in the epidural reaches the baby. Studies do not show any difference in outcomes in babies born to moms with and without epidural.
Do epidurals increase the risk of cesarean section?
Whether or not epidurals increase the cesarean section rate has been a long source of debate, but the most recent data shows that they do not. Epidurals often increase the length of time you need to push because it can be difficult to feel the contractions, but in large studies the cesarean section rate is not increased.
Can you get an epidural too early or too late?
My patients often ask me if there is a point where they can’t get their epidural. At my hospital if we have time to place an IV and get your labs results; then you can get an epidural if you can remain still enough for the anesthesia team to safely place it. This is likely dependent on the facility. Sometimes labor is simply moving too fast, and there is not enough time for it to be placed or for it to take effect.
How early can you get an epidural? The textbook answer is that you can get an epidural as soon as you feel the pain is intense enough for you to need one. In real life, it seems that when epidurals are in place for extended amounts of time, they can sometimes become less effective. First labors can be very long, so I encourage my first time moms to try to wait until they are making good cervical change before they get their epidural.
Who can’t get an epidural?
If you are on blood thinners or your blood clotting factors (platelets) are low on your blood work, then it may not be safe for you to get an epidural. If you have increased bleeding when the epidural is placed this can cause serious nerve damage.
If you have had surgery on your spine or your spine is abnormally shaped (i.e. spina bifida) you may not be able to get an epidural. At our facility, the anesthesia team tries to evaluate patients before delivery and look at the x-rays so that they are aware ahead of time if epidurals are safe option for them
If you have a high fever, increased infection cells on your blood count, or even severe back acne, an epidural may not be the safest option, as introducing a needle might spread dangerous bacteria into that space and cause infection.
Do epidurals cause chronic back pain?
Epidurals can cause low back ache for a couple weeks after delivery, but are not associated with increased chronic low back pain when compared to women who labor without medication.
I have many patients who choose natural birth, and I completely support their choice. They feel empowered by the process of natural birth and want to be mobile, unencumbered by wires and IV tubing, during delivery. For those patients who change their minds mid-labor, or the women who decide on pain control medication from the start, epidurals are a generally safe, wonderful advancement in modern medicine. Whatever your preference, be aware that sometimes the labor story writes itself and the process may not go according to plan, so being prepared for either option is smart.