When Is It Too Late To Get An Epidural?

Epidural anesthesia is more and more frequently used by doctors and chosen by pregnant women, for both natural births as well as Caesareans. However, there are lots of information that are less known about it, such as the way the procedures is performed, when it`s not recommended, what complications may involve, and so on.

What Is Epidural Anesthesia?

Epidural anesthesia represents the regional anesthesia that blocks pain in a certain area of the body, the purpose being more of offering pain amelioration or analgesia than anesthesia, which leads to a complete deprivation of sensations. This procedure blocks the nerve impulses from the lower segments of the spinal marrow, leading to a low sensitivity in the lower half of the body. The used medication is falling in a group of drugs known as local anesthetics, such as lidocaine, bupivacaine and chloroprocaine, these coming in combination with sufentanil and fentanyl to reduce the necessary dose of local anesthetic (the pain is relieved with minimal effects), but also with clonidine, morphine and epinephrine to prolong the effect of epidural or stabilize the mother`s tension.

Epidural anesthesia is the most common method of pain relief during labor. More than 50% of women require epidural before birth.

If childbirth approaches, it`s best to know as much as possible about what pain relief options you may have to be prepared and take the best possible decisions regarding labor and delivery.

Understanding the different types of epidurals, how they`re managed, the risks and benefits can help you make the best decisions during labor and birth.

How Do They Give You an Epidural?

Before the onset of labor, the mother should be given fluids intravenously, and before the procedure is started, she`ll have the epidural installed. During labor and birth, the pregnant woman will receive 1 – 2 liters of liquids intravenously.

An anesthetist, obstetrician or nurse will administer the epidural. You`ll be asked to sit on a bed and to curl up on one side. This position is critical to preventing problems and increasing the epidural effectiveness.

An antiseptic will be used to clean the back of the waist and minimize the risk of infection. Then a small area on your back will be numbed with a local anesthetic. The doctor will introduce a needle into the numbed area round the spinal cord on the lower back.

The needle will be inserted through a tube or catheter into the epidural space. Then, the needle is carefully removed, leaving the catheter in place in order to deliver various drugs through it.

Most of the times, the procedure shouldn`t hurt because there be a tiny needle that will numb that specific area before the epidural needle will be inserted. Most women won`t mind the tiny needle, but they`ll feel the numbing drugs which are injected with the needle. It may sting for a few seconds.

When Is It too Late to Get an Epidural?

Most obstetricians will want for you to be in active labor before beginning the procedure of epidural anesthesia, meaning for you to wait until you are around 4 – 5 cm dilated and having regular uterine contractions. The main concern may be that the epidural anesthesia may slow down the uterine contractions.

Types of Epidural

Currently, there are 2 essential types of epidurals used. The doses and combinations of drugs may be different from one hospital to another. You can ask the doctor how will perform the epidural about all this:

• Regular epidural: after the catheter is fixed, a combination of narcotic and anesthetic will be administered by anesthesia with periodic injections into the epidural space. A narcotic, such as fentanyl or morphine, will be administered to replace the high dose of bupivacaine, chloroprocaine or lidocaine. This way, any possible side effects of anesthesia will be reduced.
• Combined spinal epidural: an initial dose of narcotic, anesthetic or a combination of the 2 is injected in the outer membrane that covers the spinal cord. The anesthetist will insert the needle into the epidural space through a small catheter, then withdraws the needle locally, but leaves the catheter.

This allows the possibility of making different types of movements for hours as well as a greater ability of the patient to change positions with professional assistance. When the catheter remains in the same position, the epidural can be performed in any moment, if the initial intrathecal injection is inadequate.

You should ask the physicians if you can move, drink or eat after the epidural was placed. After the drugs for the anesthesia were used, the muscle force, balance and responsiveness are reduced. Spinal epidural anesthesia should relieve pain for 4 – 8 hours.

Is It Painful to Have an Epidural?

Although there are women who fear of this procedure more than they fear the actual childbirth, after experiencing such an intervention, most claim that an epidural isn`t that uncomfortable than a contraction or IV. It`s understandable for many women to concern themselves about the needle`s size, but this ultimately doesn`t really matter. This is also because at first a much smaller needle is used to numb that particular area before the actual epidural needle is used. Most women claim they didn`t mind this initial, tiny needle. However, they do feel the numbing drugs that are injected through the epidural needle. This will generally sting for a few seconds. The epidural drugs being to work within 5 minutes and peak in 10 minutes. Thus, it will normally take around 15 minutes from when the procedure was started to feel a pain relief.

Effects on the Mother

Benefits

• A reliable method used to relieve pain, with the complete loss of senses from the waist down.
• It can help control tension.
• It facilitates birth using the forceps in case of complications.
• It allows the mother to remain awake and aware during C-section.
• It removes pains to ensure a better relaxation and faster dilation of the cervix.
• It removes pains to enhance the positive feelings of the mother about labor and birth.

Disadvantages

The mother will stay for a period of time in bed with reduced mobility. If the dosage is partial (half or a quarter), the mother will be able to move her legs, sit down, even stand up, if she is able to handle the pains.

• In 10% – 15% of cases, the anesthetic isn`t completely absorbed.
• Epidural administration slows labor, so drugs may be required to main the uterine contractions.
• The mother`s tension may decrease drastically due to epidural and that`s why this method is used exactly for this purpose.
• It`s possible the mother`s body temperature to increase during epidural anesthesia, which may also increase the baby`s temperature, increasing the risk of fetal complications.
• It`s possible for the bladder emptying to become difficult; that`s why it`s used a urine probe.
• In the case of an inexperienced anesthesist, lumbar puncture might be partial. This leads to the drainage of the spinal marrow, resulting in severe headaches caused to the mother (these pains may last for a few days), which maintain until the wound is healed and the spinal marrow doesn`t leak anymore. The leakage can be stopped by injecting a small amount of her own mother`s blood in the epidural space. Once closed, there will be a wound formed over the incision, sealing it to stop flowing. If the procedure proves to be successful, headaches will disappear.
• The pelvic muscles will be relaxed by the anesthetic and, as a result, the baby`s head won`t be able to be rotated, making the usage of forceps necessary to get the baby out.
• When the epidural with full dose is performed, the mother will only feel the need to push if time is allowed to pass until the next phase of birth. It`s possible to use the forceps to get the baby out.
• The mother will benefit of mild sensations regarding the birth of her baby.
• It`s quite common to have a sensitivity in the area where the needle was inserted to apply the anesthetic.
• There`s an absence of tonicity the muscle which support the lower vertebrae, especially in the case of a full dose of anesthetic. This leads to a lack of wrist stability, and the mother`s movement might cause them to be non-aligned, leading to back pain that might last for weeks or even months after the baby is born.
• If the baby`s is affected by anesthetic, the mother may encounter difficulties with the baby, this one being hard to quench, which will aggravate breastfeeding or artificial feeding, depending on the situation. This perception may last for a few months.
• Paraplegia (paralysis of the lower limbs) is a very rare complication, but which cannot be overcome.

Effects on the Baby

Benefits

• The mother will be able to have immediate contact with the baby, making breastfeeding possible.
• Reduced fetal risks, in case that the mother`s tension during the procedure may be maintained between normal limits.
• The mother can experience positive feelings about labor, birth and the baby, if the pains are removed.

Disadvantages

• The baby will be affected by the drugs used, depending on the duration of exposure to them during delivery. Common reactions involve irritability, an inability to calm down as well as a tendency to scare rapidly. These reactions may last a few weeks.
• If any obstetric complication may appear due to epidural, this will contribute to the increase of side effects on the baby in the following weeks.
• If additional interventions are required, such as the administration of ocitocic, forceps, vacuum extraction, episiotomy or C-section, the baby will be affected by each of these procedures. – Learn more!
• Any obstetric intervention or complication occurred during the procedure will increase the possibility of separating the mother from the baby during the immediate postnatal period.

How Could the Child Be Affected by this Procedure?

• If there`s a drop in blood pressure, it might have affected the flow of oxygen to the fetus. In this case, you`ll need to insert an intravenous cannula in the hand or arm, in case blood pressure drop suddenly.

A lower blood pressure can be treated by drinking fluids introduced through the cannula to increase of blood volume.

• Epidural solutions contain opioids, like fentanyl or other similar drugs, which may pass through the placenta. In high doses (more than 100 mcg), there medications may affect the baby`s breathing or it might make him drowsy.

Useful Advice

Epidural is only performed in maternities by an anesthetist under the direction of an obstetrician, not at home. Even maternity kits cannot provide an epidural 24/24. Therefore, it`s recommended for the mother to get such a kit from a pharmacy, according to the recommendations of obstetricians, to be ready when labor triggers.

Try to remain calm when the anesthetist mounts the epidural. You`ll stay in a squatting position on one side, so you can open the space between the bones of the spine. Try to focus on your breathing: inhale slowly through your nose and exhale through your mouth. Try to keep eye contact with your partner, if he`s present.