Considering that at least 60 percent of American women today have an epidural for pain relief during labor, it's surprising how misunderstood this procedure is. For starters, even doctors use the word "epidural" generically, to encompass three similar, yet distinct procedures: epidurals, spinals, and a more recently perfected procedure, the combined spinal epidural (CSE), or "walking" epidural. Because deciding whether or not to have an epidural means becoming informed about the benefits and risks well before labor begins, here are the facts to help you make sense of some misconceptions.
Reality: An epidural involves injecting pain-blocking medication into a space between the vertebrae and the spinal fluid; it usually takes about 15 minutes to work and lasts as long as needed. A spinal is an injection directly into the spinal fluid; it is given as part of the CSE technique and takes effect in five minutes. With either an epidural or CSE, the catheter that delivers the drug is left in the epidural space until the baby is born so the medication can be administered continuously.
"But what medication is given, how much and for how long all vary depending on the individual and the hospital; some routinely combine epidurals with spinals and some do not," says Laura Riley, M.D., a high-risk obstetrician at Massachusetts General Hospital in Boston. Different techniques, medications, and doses have different results and risks, so being educated about the procedures used where you will deliver can help you make a decision that is right for you.
Reality: The epidural needle is left in place for only a minute or two—just long enough to insert a skinny, flexible catheter the size of a pencil lead into the epidural space. The spinal needle is much smaller—the width of a thick piece of hair. But before this happens, the injection site is numbed with a local anesthetic, at which point you will feel a pinch and sting for about 10 seconds. You'll feel pressure, but not pain, when the epidural and/or spinal itself is given.
Reality: "One advantage of combining spinals with epidurals is that it typically allows for less medication to be given than with an epidural, so you get pain relief without total numbness," says William Camann, M.D., director of obstetric anesthesia at Brigham and Women's Hospital in Boston and co-author with Kathryn Alexander of Easy Labor: Every Woman's Guide to Choosing Less Pain and More Joy During Childbirth. This lower dose makes pushing easier than with a higher-dose epidural, reducing the likelihood of a forceps- or vacuum-assisted delivery.
Reality: "Most women do not walk with one," says Gilbert J. Grant, M.D., director of obstetric anesthesia at New York University Medical Center and author of Enjoy Your Labor: A New Approach to Pain Relief for Childbirth. Once one is given, continuous fetal monitoring and an IV are needed, and many doctors do not encourage women to walk with these, he explains. "A better name would be 'epidural lite,' because it has to do with the dose being low," Grant says.
Reality: "Any medication that you take to relieve pain will reach the baby," Grant says. "However, with an epidural, the amount that enters your bloodstream is quite small, and with a spinal, it's even smaller." While further studies are needed, the small amount of medication absorbed by the baby is not known to cause harm, says Cynthia Wong, M.D., an associate professor of anesthesiology at Northwestern University Feinberg School of Medicine in Chicago.
Reality: Epidurals are very safe for the vast majority of patients. Complications do occur, though, and can range from the short-term and bothersome to the (far more rare) long-lasting or life-threatening. The most common side effect is hypotension, a drop in maternal blood pressure that could affect the baby; this occurs more with higher doses of medication. "With treatment, hypotension has no consequences to mother or baby," Camann says. Other relatively common and treatable side effects are nausea, which affects roughly 20 to 30 percent of women who receive epidurals; and itching, which affects approximately 30 to 50 percent.
Another possibility is that the mother will develop a fever if an epidural is in place for about six hours or more; this can lead to diagnostic testing and, sometimes, antibiotics for mother and child. "With first births, about 20 percent of mothers have an elevated temperature, because the first birth is usually the longest," Camann says.
A much rarer complication is a "spinal headache" after an epidural: a severe headache following local anesthesia that gets worse upon standing upright. "This occurs in less than 1 percent of patients in this hospital, but it can last for several days and be very uncomfortable," Riley says. Other rare risks include infection, bleeding, and nerve damage near where the injection is given. If the drug is accidentally injected into the bloodstream, this can cause breathing to slow or stop, seizures, or even death. However, Camann says, "most anesthesiologists will go through a whole career and never see a case of these rare complications."
Reality: According to Wong, less than 5 percent of women have unrelieved labor pain after receiving an epidural. This can be caused by the baby's position, but sometimes the anesthesiologist simply needs to give more medication. Occasionally, the pain is relieved on only one side of the body, either because the catheter is mispositioned or dislodged or because the mother stays in the same position for too long; this problem is easily remedied. An increasingly popular option is patient-controlled epidural analgesia (PCEA); the laboring woman can control the amount of pain relief she gets, but overdosing is extremely unlikely.
Reality: Epidurals are not instantaneous. They're far more complicated than getting a shot in the butt. From the moment you ask for one to the moment you get relief, you might have to wait anywhere from a half-hour to an hour or far longer. The pre-epidural preparations include lab work, getting an IV, having at least a full liter of fluid infused, a consultation with the anesthetist, getting up to pee, signing paperwork and more.
When all that is done, you can get your epidural—but what if the anesthetist is busy putting in another woman's epidural? What if he's needed in the operating room and the stand-by anesthetist has to come to the hospital from home? What if you're only a little bit dilated and in minor pain and another mother is speeding through labor and in serious pain? She goes first, even if you put in your request before she did. While every effort will be made to ensure you get your epidural ASAP, don't expect it to be an instant deal. It takes time, and this is one area where you don't want your doc to take shortcuts.