Epidural Anaesthesia
While every woman who gives birth goes through the same fundamental process, each woman’s experience is complex and subjective. Labour is an emotional experience that has both physiological and psychological factors. For many women, anticipating the pain of childbirth can be intimidating.
Today there are many methods of pain relief. While some women feel strongly that they want a ‘natural birth’ without medication, others are happy to accept the assistance modern medicine can provide. Epidural anaesthesia is a common and effective method for relieving pain during labour.
In the 21st century, doctors are far better equipped to assist during childbirth than they were during the 16th century. Although the health and safety of mothers and their babies has greatly improved thanks to developments in medicine, and women now often survive situations that would have been life-threatening in the past, we still have much to learn about how best to support women through childbirth. Labouring women are now much more involved in the process of giving birth as shown by the popularity of doulas and midwives and by the now common idea of the ‘birth plan’ in which an expectant mother thinks through and writes down her hopes and expectations of the experience of childbirth. Women’s voices have been ignored in the past and we are now listening better.
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Childbirth is unpredictable, as are our reactions to it. Each woman must weigh the options for pain relief and do what she feels will be best for her and for her baby. The best place to start is to learn about what to expect and about the medical and non-medical options for easing labour pains.
Pain during labour
Childbirth generally takes from 12 to 24 hours for first-time births; for women who have given birth before, it usually lasts from 8 to 10 hours. These numbers, however, are statistical averages. Some babies are born in just a few minutes while others keep their mothers in labour for days.
Childbirth is generally thought of as having three stages:
- dilation of the cervix up to approximately 10 cm (early, active, and transition labour)
- active pushing and the delivery of the baby
- delivery of the placenta
While the pain of labour comes predominantly from uterine contractions, the pain a woman feels will change as childbirth progresses. As the first true contractions begin, the cervix also begins to dilate. These contractions are generally felt as an intense tightening throughout the abdomen. Early labour can last up to six hours. As the cervix continues to dilate, the contractions grow longer, stronger, and more frequent. Active labour typically lasts from two to eight hours.
The pain tends to be most intense as the cervix reaches full dilation and can be felt in the entire torso and pelvic area, lower back, groin, and thighs. Transition labour, or the final approach to full dilation typically lasts no longer than an hour.
At this point the mother begins to feel ‘the urge to push’ and the intense pain of the contractions that open the cervix are supplanted by the intensity of ‘bearing down’ to move the baby along the vaginal opening and into the world. While the pain continues, pushing also helps to relieve the pressure. Pushing labour pain can last anywhere from a few minutes to several hours.
When the baby’s head is coming through the vaginal opening, the tissue between the vaginal opening and the rectum—the perineum—can sometimes tear. In fact, superficial and second-degree tears are quite common and with everything else going on, a woman may not even know she has torn her perineum until after the baby is born. Third- and fourth-degree tears are deeper and require careful stitching and appropriate after care. In some cases, the doctor or midwife can perform a controlled incision, or episiotomy, to prevent a potentially more damaging rupture. If properly cared for, even severe tears will heal in a matter of weeks.
The final stage of labour is the delivery of the placenta, which involves some continued contractions and cramping and can last around half an hour but compared to what the mother just experienced and the relief of having delivered a child, it is a minor event. These final contractions also help the uterus to begin shrinking and seal off the blood vessels that have fed the baby in utero.
How much pain a woman experiences depends on objective and subjective factors, including the baby’s size and position in the pelvis (whether the baby is face up or face down, coming headfirst or breach), the speed of the labour, the strength of the contractions, and the mother’s emotional state, preparedness, pain tolerance, fatigue, and support system. Complications will also change the experience.
Pain relief
There are a number of alternatives for pain relief that do not rely on medication. These include relaxation exercises, breathing techniques, acupuncture or acupressure, massage, the injection of sterile water under the skin, heat or ice packs, yoga, walking, changing positions, using a birthing ball, showering, water immersion, and support from a loved one or doula.
Medical assistance is not always necessary in childbirth and there can be various personal, religious, or other reasons for choosing alternatives. However, many women benefit greatly from the help modern medicine can offer. Medical pain relief includes the epidural block, the spinal block, the pudendal block, nitrous oxide or ‘laughing gas’, or opioids. Each method has its pros and cons.
Pain, and even the fear of pain, can worsen pre-existing health conditions such as high blood pressure, and heart and lung conditions.
Experiencing pain leads to increased levels of cortisol—the stress hormone. While chronically high levels or cortisol can have negative effects on the body, the stress hormone does play a role in preparing the foetus for life outside the womb.
Whether to use epidural anaesthesia is a personal choice, but it is commonly suggested if the obstetrician suspects an emergency caesarean may be necessary, if the mother is having twins, if the baby is large compared to the mother’s pelvis, or if there are other possible complications that would require surgical intervention.
Women who have decided to use this medication usually begin to think about it when cervical dilation has reached approximately 3 cm. The epidural is administered starting from a 4–5 cm dilation.
What is an epidural?
The term epidural describes a space within the spinal column. The spinal cord lies between the row of vertebrae that make up the backbone and the spinal processes or bony protuberances that protect it just below the skin. The spinal cord is surrounded by nerves and other tissues, the outermost layer of which is called the dura mater. The epidural space is the outermost part of the spinal canal, above the dura.
Epidural anaesthesia, or simply an epidural, is injected into the epidural space to block pain signals from the lower body—the lower abdomen, lower back, pelvic region, and legs. These medications are classed are local anaesthetics and include drugs such as bupivacaine, chloroprocaine, or lidocaine. They are often delivered in combination with other drugs such as fentanyl or sufentanil to decrease the required dose of local aesthetic.
The most common method of injecting epidural anaesthesia is through a catheter placed in your lower back. This can only be done by a professional anaesthesiologist who controls the dose and monitors your health during the process. First a local aesthetic is administered to numb the area, then a larger needle is used to insert the catheter which remains in place throughout labour to administer the drug as needed. Over the past twenty years or so, some hospitals have been transitioning to patient-controlled analgesia using a dosage pump with very good results.
Epidurals can only be administered in a hospital setting with disinfectants and emergency equipment at hand, so are not available for home births, at birthing centres, or for water births.
The epidural acts primarily on the spinal nerve roots to block pain stimuli.
Even with an epidural, sensation is not completely blocked, and some pain also remains. This gives the labouring mother enough feeling to participate and know when to push. It turns out that patient-controlled pumps are a good way of minimizing the dosage and maximizing the effects of epidural analgesia.
Spinal anaesthesia vs epidural
A similar method for pain relief is spinal anaesthesia. The aesthetic is injected directly into the dural sac—the membranous sheath that surrounds the spinal cord. Unlike an epidural, only one dose of the medication can be injected at a time, so a catheter is not used.
For example, in an emergency caesarean a doctor might suggest spinal anaesthesia as it works instantly. However, the effects last for only 2–3 hours. As first-time births can last for up to 24 hours, having a catheter in place can be more convenient than repeated injection.
There are no significant differences in dosage or safety for spinal and epidural anaesthesia. Epidurals are more popular due to their convenience. Some hospitals offer a combined spinal-epidural.
Advantages
Epidural anaesthesia alleviates pain without causing the muscles to lose strength. This means that you can rest from the pain but stay active and alert to participate in the labour.
Epidural anaesthesia is well-researched and generally considered safe. Pain relief during labour has various positive effects on the mother and, by extension, on her newborn child. There is some evidence that by reducing the potential for a traumatic childbirth experience using epidural anaesthesia can also lessening the symptoms of postpartum depression.
Lessening the stress responses induced by increasing pain levels, can normalize blood pressure and breathing. This is especially important if the mother has any pre-existing health conditions.
Disadvantages and possible side effects
Although the use of an epidural can shorten the first stage of childbirth it often prolongs the second active pushing stage, especially in women giving birth for the first time. And because pain relief decreases blood pressure, it might fall too low during labour. Fluids are then administered to keep the mother’s (and therefore the baby’s) heart rate stable.
Generally, the side effects of an epidural are the same as for any other local anaesthetic. The most common side effects reported include:
- a headache the next day, once the medication has worn off
- dizziness and nausea
- soreness where the catheter was inserted
- numbness on one side of the body
- fever and itchiness
An epidural numbs the lower abdomen, making it harder to feel and control the urge to urinate. This can last for about a day.
If you choose a natural childbirth or labouring in water, an epidural won’t be for you. Childbirth doesn’t require pain relief to be successful. The choice is always there. Consider your options and discuss them with your midwife, gynaecologist, or obstetrician in order to make the choice that works best for you!
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