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Epidurals
 
Kelsey McLaughlin, PhD and Melanie Audette, MD PhD

Epidurals are the most common pain relief option used by pregnant patients during labour and delivery.

Keep reading to learn more about epidurals!

Pain management options available to pregnant patients during labour

 

Each pregnant patient and pregnancy is unique, and pain management during labour is an individual choice. Health care teams are there to support individual choices and manage pain in a way that best suits each individual.

 

There are several pain relief options available to labouring patients, including:

 

  • Epidural, spinal or combined spinal-epidural

  • Opioids

  • Nitrous oxide

  • Local/regional block

  • Non-medicated options (hydrotherapy, massage, movement and positioning)


What are epidurals?

 

Epidurals are a pain management option that is used during labour and delivery to prevent pain in the stomach and lower body areas.

 

Epidurals are a popular option for labouring patients, as they allow the patient to stay awake during labour and allow them to feel pressure when it is time to deliver the baby. In Canada, 58% of pregnant patients who had (or attempted to have) a vaginal birth had an epidural or spinal anesthesia. The rates of epidural use are increasing in Canada.

 

The majority of labouring patients who receive an epidural feel little to no pain.

 

Epidurals can also provide pregnant patients:

 

  • An opportunity to rest during labour

  • Pain relief during Caesarean sections

  • Prevent perineal pain associated with vaginal tearing during delivery and during repair following delivery

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How do epidurals work?

 

During labour, pain is caused by the uterus contracting (contractions). Pain signals travel from the uterus to the spine to the brain through nerves that connect to the spinal cord. Epidurals prevent pain signals from travelling to the brain from the spine by numbing these spinal nerves.

The spinal cord is surrounded by a membrane that provides protection, called the ‘epidural space’. The epidural space is filled with fluid. 

Epidurals allow doctors to inject small amounts of anesthetic (pain relief medications) into the epidural space around the lower part of the spine, creating numbness in the lower part of the body. These medications stay in the epidural space and do not enter the mother’s or baby's bloodstream.

One dose of medication is usually not enough to provide pain relief for the long length of labour, so a catheter is put into the epidural space and taped to the patient’s back. Pain medication can then be administered by a pump continuously throughout labour and delivery. 
 

How are epidurals administered?

 

Epidurals are administered by anesthesiologists, which are doctors that specialize in pain management. 

Patients will be asked to round their backs while lying on their left side or sitting up. The anesthesiologist begins by injecting a local anesthetic (freezing agent) into the patient’s lower back that causes numbing. This numbing reduces pain associated with the epidural injection.  

A needle is then inserted into the patient’s lower back into the epidural space near the nerves that carry pain messages to your brain. The anesthesiologist will then thread a small tube (called a catheter) into the epidural space and the needle is removed. The catheter remains in the epidural space and medications can be injected until pain management is no longer needed. 

Once the catheter is in place, medications will be regularly administered at a steady rate. Patients will also be given a button to control any additional doses of medications that may be needed; this is called a Patient Controlled Epidural Analgesia (PCEA). 

Medications can be adjusted at any time.

It takes approximately 10-20 minutes for pain relief to begin. When the catheter is removed following delivery, it can take a few hours for the numbness to wear off. Patients may feel tingling in their legs as the medication wears off. 
 

When in labour can patients get an epidural?

Epidurals can be administered at any time during labour. There are no fixed criteria for administration.

Labouring patients don’t have to reach a certain cervical dilation in order to receive an epidural. Whether or when a patient receives an epidural is based on their own individual choice.

However, epidurals cannot be administered if the patient cannot sit still for the epidural insertion, which can be the case when there are intense, frequent contractions. Secondly, if delivery of the baby is expected to occur within 20 minutes, an epidural would not deliver pain relief within this timeframe and therefore is not useful. Otherwise, a patient can receive an epidural even if they are 10 cm dilated, as long as there is enough time for the medication to become effective.

Can epidurals impact delivery?

  • Delivery times are slightly longer (approximately 10-15 minutes) in pregnant patients who have epidurals, compared to pregnant patients without epidurals

  • Epidurals do not increase the rate of Caesarean delivery

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Can epidurals impact the pregnant patient?

 

While epidurals provide effective pain relief in the majority of pregnant patients, there is a small chance that epidurals will not be effective or will not provide adequate pain relief.

 

The most common side effects (>1% of patients) from epidurals include:

  • Fever

  • Difficulty urinating

  • Drops in blood pressure

  • Itching associated with opioid medications

  • Transient back pain at site of injection

 

Rare side effects (<1% of patients) from epidurals include:

  • Severe postdural headaches

  • Spinal or epidural hematoma

  • Central nervous system toxicity

  • Spinal cord or nerves injury

Can epidurals impact the baby?

 

There are no known health impacts on the baby - epidurals do not impact fetal weight, need for neonatal ICU care or APGAR scores.

 

Epidurals do not cause autism spectrum disorder.

 

There is limited research showing that epidurals may cause transient fetal bradycardia (low heart rate) in rare cases, but this requires further research.

Consult with your healthcare provider

 

Each pregnant patient and pregnancy is unique, and pain management during labour is an individual choice. Healthcare teams are there to support each patient's decision on which pain management strategy is best for them. There are many factors to consider when discussing epidural pain relief, including:

 

  • Pregnant patient’s health (physical and mental)

  • Pain tolerance

  • Size of pelvis and baby

  • Position of the baby

  • Contraction intensity

  • Alternate pain management strategies

  • Goals of care for delivery

 

Not all patients are good candidates for epidurals. Patients are recommended to avoid epidurals if they have:

 

  • Certain drug allergies

  • Blood clotting issues

  • Infections

  • Uncontrolled diabetes

  • Certain types of medications

Conclusion

Epidurals are the most common form of pain management during labour and delivery in Canada. The majority of labouring patients who receive an epidural feel little to no pain by introducing pain medication into the patient’s epidural space. Pain management is an individual choice and should be discussed with the healthcare team.

Disclaimer

 

Every person and every pregnancy is unique. Pregnant persons should speak to their healthcare provider to ensure maternal and fetal safety. This article is meant to provide readers with current information and opinions. All medical and treatment decisions should be discussed with your healthcare provider.

This article was written by Dr. Kelsey McLaughlin and edited by Dr. Melanie Audette.