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Epidural - Benefits & Side Effects of Anesthesia During Labor

An epidural is the most common type of anesthetic used for pain relief during labor. Here’s what you should know before having an epidural, including information that dispels some common myths.

If you choose to have an epidural, an anesthesiologist will insert a needle and a tiny tube, called a catheter, in the lower part of your back. The needle is removed and the catheter left in place for delivery of the medication through the tube as needed. You can begin an epidural at any time during your labor — in the beginning, in the middle, or even toward the end — in consultation with your physician.

The anesthesiologist will numb the area where the epidural is administered, which may cause a momentary stinging or burning sensation. But because of this numbing, there is very little pain associated with an epidural injection. Instead, most patients will feel some pressure as the needle is inserted.

An epidural provides anesthesia that creates a band of numbness from your bellybutton to your upper legs. It allows you to be awake and alert throughout labor, as well as to feel pressure. The ability to feel second-stage labor pressure enables you to push when it’s time to give birth to your baby. It can take about 15 minutes for the pain medication to work.

You can continue to receive pain relief through an epidural for as long as you need it. The amount of medication you receive through the epidural can be increased or decreased as necessary.

There is no credible evidence that it does either. When a woman needs a C-section, other factors usually are at play, including the size or position of the baby or slow progression of labor due to other issues. With an epidural, you might be able to feel contractions — they just won’t hurt — and you’ll be able to push effectively. There is some evidence that epidurals can speed the first stage of labor by allowing the mother to relax.

The amount of medication that reaches the baby from the epidural is very small, and there is no evidence that it causes any harm.

Epidurals are very safe; serious complications are extremely rare. However, as with all medications and medical procedures, there are potential side effects:

• Decrease in blood pressure – The medication may lower your blood pressure, which may slow your baby’s heart rate. To make this less likely, you will be given extra fluids through a tube in your arm (IV), and you may need to lie on your side. Sometimes, your anesthesiologist will give you a medication to maintain your blood pressure.
• Sore back – Your lower back may be sore where the needle was inserted to deliver the medication. This soreness should last no more than a few days. There is no evidence that an epidural can cause permanent back pain.
• Headache – On rare occasions, the needle pierces the covering of the spinal cord, which can cause a headache that may last for a few days if left untreated. If this situation arises, discuss the treatment options with your anesthesiologist.

A spinal block is sometimes used in combination with an epidural during labor to provide immediate pain relief. A spinal block, like an epidural, involves an injection in the lower back. While you sit or lie on your side in bed, a small amount of medication is injected into the spinal fluid to numb the lower half of the body. It brings good relief from pain and starts working quickly, but it lasts only an hour or two and is usually given only once during labor. The epidural provides continued pain relief after the spinal block wears off.

Anesthesiologists are committed to patient safety and high-quality care, and have the necessary knowledge to understand and treat the entire human body.

Childbirth pain relief

Since ancient times, people have perceived pain during childbirth as an evil, attributed it to punishment coming from supernatural forces. To appease these forces, amulets were used or special rituals were performed. Already in the Middle Ages, decoctions of herbs, poppy heads or alcohol were tried to anesthetize childbirth.

However, the use of these drinks brought only minor relief, accompanied by serious adverse events, primarily drowsiness. In 1847, the English professor Simpson first used ether anesthesia to anesthetize childbirth.

Physiological basis of labor pain. Typically, contractions are accompanied by pain of varying severity. Many factors affect the pain in childbirth, their intensity, truly painless childbirth are rare.

Pain during contractions due to:

1. 1. Cervical dilatation.
2. 2. Contraction of the uterus and tension of the uterine ligaments
3. 3. Irritation of the peritoneum, the inner surface of the sacrum due to mechanical compression of this area during the passage of the fetus.
4. 4. Pelvic floor muscle resistance.
5. 5. Accumulation of products of tissue metabolism, formed during prolonged uterine contraction and temporary violation of the blood supply to the uterus.

The strength of the pain sensation depends on the individual characteristics of the threshold of pain sensitivity, the emotional mood of the woman and her attitude to the birth of the child. It is important not to be afraid of childbirth and labor pain. Nature has taken care to supply the woman with the painkillers she needs for childbirth. Among the hormones produced during childbirth, a woman's body secretes a large number of hormones of joy and pleasure - endorphins. These hormones help a woman to relax, relieve pain, give a feeling of emotional uplift. However, the mechanism for the production of these hormones is very fragile. If a woman experiences fear during childbirth, then a reflex suppression of the production of endorphins occurs and a significant amount of adrenaline (a stress hormone produced in the adrenal glands) is released into the blood. In response to the release of adrenaline, convulsive muscle tension occurs (as an adaptive form of response to fear), which leads to squeezing of muscle vessels and impaired blood supply to the muscles. Violation of the blood supply and muscle tension irritates the receptors of the uterus, which we feel as pain.

Effect of pain on the course of labor.

The uterus has a complex system of receptors. There is a relationship between painful stimulation of the uterine receptors and the accumulation of the hormone of labor (oxytocin) in the pituitary gland. The facts of reflex influences of various painful stimuli on the motor function of the uterus have been established.

Feelings during childbirth largely depend on the mental state of the woman. If all the attention of a woman in labor is concentrated only on pain sensations, a violation of homeostatic mechanisms may occur, a violation of normal labor activity. Pain, fear and excitement during childbirth stimulate that part of the nerve fibers that irritate the circular fibers of the uterine muscle, thereby resisting the pushing forces of the longitudinal fibers of the uterus and disrupt the opening of the cervix. Two powerful muscles begin to oppose each other, this brings the muscles of the uterus into great tension. The tension is of an average level and is perceived as pain. Overvoltage causes a violation of the blood supply to the child through the placenta. If this phenomenon is short-term, then the condition of the fetus does not suffer, since much less oxygen saturation of the blood is necessary for its life support than for an adult. But if this situation persists for a long time, then due to the lack of oxygen, irreversible damage to the tissues and organs of the fetus, primarily its brain, as the organ most dependent on oxygen, can occur.

The main task of pain relief in childbirth is an attempt to break this vicious circle and not bring the muscles of the uterus to overexertion. Many women prepared for childbirth manage to cope with this task on their own, without resorting to medication due to psychological stability and various psychotherapeutic techniques (relaxation, breathing, massage, water procedures). Other women simply need to provide appropriate medical attention, reducing the feeling of pain or blunting the nervous system's response to pain. If this is not done on time, then the overstressing of the uterus muscles can lead to negative consequences for the mother and fetus.

Medications used for labor pain relief must meet the following requirements:

1. Have a fairly strong and fast-acting analgesic effect.
2. Suppress negative emotions, a sense of fear, while not disturbing the consciousness of the woman in labor for a long period.
3. Do not have a negative effect on the body of the mother and fetus, slightly penetrate the placenta and into the brain of the fetus.
4. Do not adversely affect labor, the woman's ability to participate in childbirth and the postpartum period.
5. Do not cause drug dependence at the required course of drug administration.
6. Be available for use in any maternity facility.

The following groups of medicines are used to relieve childbirth:

1. Antispasmodics - drugs that reduce the tone and contractile activity of smooth muscles and blood vessels. Back in 1923, Academician A.P. Nikolaev suggested using an antispasmodic for pain relief during childbirth. The following drugs are usually used: DROTAVERIN (NO-SHPA), PAPAVERIN, BUSCOPAN. Appointment of antispasmodics shown:

- women in childbirth who have not undergone sufficient psychoprophylactic training, showing signs of weakness, imbalance of the nervous system, too young and old women. In such cases, antispasmodics are used at the beginning of the active phase of the first stage of labor (at 2-3 cm of cervical dilatation) in order to prevent labor pains and only partially to eliminate them. It is important to wait for regular steady contractions, otherwise this process of childbirth may stop.

- for women in labor, as an independent analgesic for already developed pains, or in combination with other drugs, when the cervix is ​​dilated by 4 cm or more.

In case of developed labor activity, antispasmodics do not affect the strength and frequency of contractions, do not disturb the consciousness of the woman in labor and her ability to act. Antispasmodics well help to cope with the opening of the cervix, relieve spasm of smooth muscles, reduce the duration of the first stage of labor. They do not have a negative effect on the fetus. Of the side effects, there is a drop in blood pressure, nausea, dizziness, weakness. However, these drugs have an analgesic effect is not pronounced.

2. Non-narcotic analgesics: ANALGIN, TRAMAL, TRAMADOL. The use of drugs of this group, despite the good analgesic effect, in childbirth has some limitations.

In particular, analgin, when prescribed at the very beginning of labor, can weaken uterine contractions and lead to the development of weakness in labor. This is due to the fact that analgin suppresses the production of prostaglandins, which accumulate in the wall of the uterus in order to ensure the proper functioning of the muscles of the uterus during childbirth. At the same time, when labor activity is expressed, analgin does not affect uterine contractility. In addition, analgin affects blood clotting, which can increase blood loss during childbirth. And the use of a combination of analgesics with antispasmodics shortens the duration of the first stage of labor. Contraindications for the use of analgin in childbirth are impaired renal or hepatic function, blood diseases, bronchial asthma.

In addition to pain relief, tramadol has a sedative effect, which is useful in case of a pronounced emotional component of labor pain. However, the sedative effect of tramadol allows it to be attributed to an intermediate position between analgesics and drugs. Respiratory depression in parturient women with the use of tramadol, as a rule, does not occur, rarely causes short-term dizziness, blurred vision, impaired perception, nausea, vomiting and itching. It is forbidden to use these drugs in late toxicosis of pregnancy (preeclampsia). However, the use of these drugs is limited, since with repeated injections they affect the nervous system of the fetus, cause a slowdown in the breathing of the newborn, and disrupt his heart rhythm. Premature newborns are especially sensitive to these drugs.

3. Sedatives - sedatives that relieve irritability, nervousness, and stress. These include DIAZEPAM, HEXENAL, THIOPENTAL, DROPERIDOL Hexenal and thiopental are used in childbirth as components of drug anesthesia to relieve agitation, as well as to reduce nausea and vomiting. Side effects of these drugs include hypotension and respiratory depression. They quickly penetrate the placental barrier, but at low doses do not cause severe depression in mature full-term newborns. During childbirth, these drugs are rarely prescribed. The main indication for their use is to obtain a rapid sedative and anticonvulsant effect in pregnant women with severe forms of preeclampsia.

Diazepam has no analgesic effect, so it is prescribed in combination with narcotic or non-narcotic analgesics. Diazepam is able to accelerate the opening of the cervix, helps to relieve anxiety in a number of women in labor. However, it easily penetrates into the blood of the fetus, therefore, it causes respiratory failure, a decrease in blood pressure and body temperature, and sometimes signs of neurological depression in newborns.

Droperidol causes a state of neurolepsy (calmness, indifference and aloofness), has a strong antiemetic effect. In obstetric practice has received significant distribution. However, one should be aware of the side effects of droperidol: it causes incoordination and weakness in the mother, respiratory depression and pressure drop in the newborn. With high blood pressure in a woman in labor, droperidol is combined with analgesics.

4. Narcotic analgesics: PROMEDOL, FENTANIL, OMNOPON, GHB

The mechanism of action of these drugs is based on interaction with opiate receptors. They are believed to be safe for both mother and child. They act soothingly, relaxes, while maintaining consciousness. They have an analgesic, antispasmodic effect, promote the opening of the cervix, contribute to the correction of uncoordinated uterine contractions.

However, all narcotic drugs have a number of disadvantages, the main of which is that in high doses they depress breathing and cause drug dependence, state of stupor, nausea, vomiting, constipation, depression, lowering blood pressure. The drugs easily cross the placenta, and the more time passes from the moment the drug is administered, the higher its concentration in the blood of the newborn. The maximum concentration of promedol in the blood plasma of a newborn was noted 2-3 hours after its administration to the mother. If the birth occurs at this time, then the drug causes temporary respiratory depression of the child.

Sodium oxybutyrate (GHB) is used when a woman in labor needs to rest. As a rule, when the drug is administered, sleep occurs after 10-15 minutes and lasts 2-5 hours. Ether is not currently used for labor pain relief, since it significantly weakens labor activity, can increase blood pressure, and adversely affect the fetus.

Inhalation anesthesia of childbirth by inhalation of painkillers is still widely used in obstetric practice. Inhalation anesthetics are used in the active phase of labor with the opening of the cervix by at least 3-4 cm and in the presence of severe pain in contractions.

Nitrous oxide is the primary inhalant used for both obstetric and labor pain relief. The advantage of nitrous oxide is safety for the mother and fetus, the rapid onset of action and its rapid end, as well as the absence of a negative effect on contractile activity, and a pungent odor. They give nitrous oxide through a special apparatus using a mask. The woman in labor is introduced to the technique of using the mask and she herself applies the mask and inhales nitrous oxide with oxygen as needed. When inhaling it, a woman feels dizzy or nauseous. The action of the gas appears after half a minute, so at the beginning of the contraction, you need to take a few deep breaths

Trilene is a clear liquid with a pungent odor. It has an analgesic effect even in small concentrations and with the preservation of consciousness. Does not suppress labor activity. It is a well-administered fast-acting agent - after the cessation of inhalation, it quickly ceases to have an effect on the body. The downside is the bad smell.

6. Epidural anesthesia during childbirth and caesarean section

Epidural analgesia is performed by blocking pain impulses from the uterus along the nerve pathways entering the spinal cord at a certain level by injecting a local anesthetic into the space around the spinal cord membrane.

Performed by an experienced anesthesiologist. The time to start epidural analgesia is determined by the obstetrician and anesthesiologist, depending on the needs of the woman in labor and the child during childbirth. It is usually performed with established regular labor and at least 3-4 cm dilatation of the cervix.

Epidural lumbar anesthesia is performed in the lower back with the mother sitting or lying on her side. After treating the skin in the area of ​​the lumbar spine, the anesthesiologist makes a puncture between the vertebrae and enters the epidural space of the spine. First, a trial dose of anesthetic is administered, then, if there are no side effects, a catheter is inserted and the desired dose is given. Sometimes the catheter can touch a nerve, causing a shooting sensation in the leg. The catheter is attached to the back, if it is necessary to increase the dose, subsequent injections will no longer require a second puncture, but are made through the catheter.

Pain relief usually develops 10-20 minutes after the epidural and can be continued until the end of labor and is usually very effective. Epidural anesthesia is safe for mother and child. Of the side effects, there is a decrease in blood pressure, back pain, weakness in the legs, headaches. More severe complications are a toxic reaction to local anesthetics, respiratory arrest, and neurological disorders. They are extremely rare.

Sometimes the use of epidural anesthesia leads to a weakening of labor. At the same time, a woman cannot effectively push, and thus the percentage of surgical interventions (obstetrical forceps) increases.

Contraindications to the use of epidural anesthesia are: violation of blood clotting, infected wounds, scars and tumors at the puncture site, bleeding, diseases of the nervous system and spine.

Epidural anesthesia can be safely used for caesarean section. If an epidural catheter is already in place at the time of delivery and it becomes necessary to perform a caesarean section, it is usually sufficient to inject an additional dose of anesthetic through the same catheter. A higher concentration of the drug can cause a feeling of "numbness" in the abdominal cavity, sufficient for surgery

7. General anesthesia.

Indications for the use of general anesthesia in childbirth are emergency situations, such as a sharp deterioration in the condition of the child and maternal bleeding. This anesthesia can be started immediately and causes a rapid loss of consciousness, allowing for an immediate caesarean section. In these cases, general anesthesia is relatively safe for the child.

The use of any painkillers during childbirth is carried out only by obstetrician-gynecologists and anesthesiologists-resuscitators. Nurses, anesthetists and midwives follow the doctor's orders, monitor the condition of the woman in labor and note possible side effects that require a change in treatment.

Epidural analgesia for labor pain relief

This fact sheet has been compiled to introduce epidural analgesia as a method of labor pain relief and to provide confidence in its use during labor.

There are various methods of pain relief during childbirth. Different people tolerate pain differently, so you should not be afraid to use the available methods of pain relief. For particularly severe pain, epidural analgesia is often performed, which is currently widely used and the most effective method of labor pain relief. Pain relief allows the woman in labor to relax and make the birth process more comfortable. In the maternity ward of East-Tallinn Central Hospital, up to 30% of women in labor receive epidural analgesia.

What is epidural analgesia?

The epidural space is an area in the lumbar spine through which the nerves pass, transmitting pain impulses from the uterus and birth canal. A thin catheter is inserted into the epidural space using a special needle (subsequently, the needle is removed), through which a drug is injected (local anesthetic and opioid in small doses), which blocks signals from the corresponding nerves that conduct pain impulses from the birth canal. An epidural catheter is placed by an anesthetist or resident physician.

Before inserting an epidural catheter, an intravenous cannula must be placed and saline infusion started so that you can be treated immediately if side effects occur.

Injected into the epidural space, the drug begins to work within 15 to 30 minutes. During the entire process of childbirth, additional medication can be administered through the epidural catheter; with the help of a special regulator, this can be done by a midwife or by the patient herself under the guidance of an obstetrician.

Does inserting an epidural catheter cause pain?

During the insertion of the epidural catheter, you will be asked to lie on your side or sit with your knees bent and tucked into your stomach and your chin down to your chest. This position is uncomfortable, but necessary for a successful procedure.

Before starting the procedure, a local anesthetic (local anesthetic) is injected into the appropriate area on the back, which initially causes a burning sensation, but makes the entire subsequent procedure less painful. Some women feel pressure in the back during the procedure. Usually, the insertion of an epidural catheter is less painful than the delivery itself.

What is the best time to start epidural analgesia?

Epidural analgesia is started after the onset of regular labor.

After starting epidural analgesia, is it necessary to remain in a hospital bed for the remainder of labor?

No. You can sit, stand and walk. Because epidurals can sometimes cause numbness in the legs, someone should be by your side to help if needed.

What are the benefits of epidural analgesia?

• Best pain relief.
• In total, fewer drugs are needed than with other methods of pain relief (eg, injection of analgesics into a vein or muscle).
• Very little effect on the child.
• Does not cause drowsiness.
• If an emergency caesarean section is required, then (in some cases) it will be enough to inject more anesthetic through the epidural catheter to relieve pain during the operation.

What are the disadvantages of epidural analgesia?

• Labor may be delayed. May slow down the labor period.
• There is a higher risk of using vacuum extraction in the pushing period of labor.
• Sometimes this method can cause numbness in the legs, making it difficult to walk during childbirth. In this case, the next dose can be delayed until the numbness in the legs has passed.
• Sometimes the desired analgesic effect is not achieved - in this case, you can adjust the position of an already installed epidural catheter or install a new catheter.

Is epidural analgesia suitable for everyone?

Placement of an epidural catheter is a risk for women in labor who are taking medications that affect blood clotting or who have other clotting disorders. Be sure to inform both the obstetrician and the anesthesiologist about this. Each case is considered individually.

Placement of an epidural catheter is not possible if there is a rash with signs of inflammation on this area of ​​the skin.

If there is reason to believe that it is not too long before the baby is due, you may be advised to have a low-dose spinal anesthetic instead of an epidural. This provides a faster pain relief effect that lasts for a shorter period (usually about 1 hour).

What happens if an emergency caesarean section becomes necessary?

If you have already had an epidural catheter inserted and the medication provided a good pain relief, in case of a caesarean section you will be given a higher dose of local anesthetic through this catheter, which will provide sufficient pain relief for the operation (you may still feel a stretch or pressure in the abdomen during surgery).

You will be conscious and still able to participate in the birth process.

If epidural does not work well enough during labor, it will be changed to spinal anesthesia.

What are the possible side effects and complications?