A guide to epidurals

Your Pregnancy - - Contents -

FROM THE HI­LAR­I­OUS (“it was like eat­ing 100 hot pep­pers and poop­ing out a wa­ter­melon”) to the down­right hor­ri­fy­ing (“it felt like my spine was go­ing to break away from my body”), all it takes is a “birthing sto­ries” trawl through Google to get you think­ing about an epidu­ral.

WHAT IS AN EPIDU­RAL?

It’s a re­gional anaes­thetic that blocks pain in a spe­cific re­gion of the body – in the case of labour, the ab­dom­i­nal re­gion. Its pur­pose isn’t to block all feel­ing, but rather to numb or relieve the pain. “It’s an ex­cel­lent form of pain relief dur­ing labour,” says Dr Gavin Jones, a spe­cial­ist anaes­thetist at hos­pi­tals through­out Cape Town. Tim­ing is ev­ery­thing here. An epidu­ral shouldn’t be given too soon into labour, but leave it too late and it’s a no-go. “It’s usu­ally in­serted dur­ing the first stage of labour from four to five cen­time­tre di­la­tion,” ex­plains Dr Jones. “Once the pa­tient is nine to 10 cen­time­tres di­lated, it’s usu­ally too late.”

WHAT TO EX­PECT

The pro­ce­dure is straight­for­ward and mostly pain­less. For Lynn Robin­son, 40, a project man­ager for a Cape Town-based pub­lish­ing firm, it was en­tirely pain­less. “The doc­tor said he was go­ing to insert the nee­dle into my spine; that it was go­ing to feel like a small prick, and that I must just put my chin on my chest. But I was very calm and I didn’t feel any­thing.” Dr Jones runs through the process: “First an in­tra­venous line is set up and

flu­ids ad­min­is­tered via a drip. Mon­i­tors are con­nected, in­clud­ing a blood pres­sure cuff, which feels tight on the arm ev­ery time a read­ing is taken. “Mom is ei­ther asked to sit and lean slightly for­ward or asked to lie on her side. The lower back is cleaned with an ice- cold an­ti­sep­tic so­lu­tion, which is com­fort­ing for some and chilly for oth­ers. Then, a small nee­dle – which may sting a bit – in­jects lo­cal anaes­thetic into the skin and soft tis­sue of the back, to numb the area be­fore in­ser­tion of the larger epidu­ral nee­dle. “The anaes­thetist will then insert the epidu­ral nee­dle be­tween con­trac­tions when the mother can keep still and calm, un­til it reaches the space be­tween the lay­ers of the lower spine. Once this nee­dle is in place, the anaes­thetist can insert a small plas­tic catheter (or tube) that will re­main in place dur­ing the de­liv­ery (taped over your shoul­der) and will be used to pump the pain med­i­ca­tion into your body con­tin­u­ously. “Some­times one can feel a sharp, tin­gling, or elec­tric shock sen­sa­tion down one leg. This may be due to the catheter mak­ing con­tact with a nerve. The anaes­thetist may re­po­si­tion the nee­dle or nerve if the sen­sa­tion doesn’t sub­side,” says Dr Jones.

WHEN WILL IT KICK IN, AND FOR HOW LONG?

“Once in­serted it takes about 10 to 15 min­utes to start work­ing. If work­ing ad­e­quately, the pain from con­trac­tions can be well con­trolled,” says Dr Jones. “Once the dosage is achieved, the pain block is main­tained through hourly top­ups or an in­fu­sion.” Epidu­ral dos­ing can be ad­justed to pro­vide more or less sen­sa­tion – so you will still feel some­thing. “At one stage the pain got worse and I thought they must not be giv­ing me an epidu­ral any­more, but they were,” re­calls Lynn. “I can’t imag­ine what it would have been like if I hadn’t had an epidu­ral.” It’s only if anaes­the­sia is be­ing pro­vided for a C-sec­tion that a pa­tient feels im­mo­bile or to­tally numb from the waist down. With an epidu­ral, you should still be able to move your legs some­what, but it’s un­likely you’ll be able to walk much af­ter the epidu­ral is ad­min­is­tered – de­spite the fact many hos­pi­tals call it a “walk­ing epidu­ral”. “Once the baby has been de­liv­ered, there’s usu­ally no rea­son to keep the epidu­ral in. The catheter is re­moved and full sen­sa­tion usu­ally re­turns within a cou­ple of hours,” says Dr Jones.

IS AN EPIDU­RAL THE SAME AS A SPINAL BLOCK?

No. A spinal block is typ­i­cally used dur­ing C-sec­tions or for shorter pe­ri­ods of pain relief. It’s a once- off in­jec­tion, not a con­tin­u­ously ad­min­is­tered drip like an epidu­ral. “With a spinal block, a much smaller nee­dle is passed through the same lum­bar space into the area of spine where cere­brospinal fluid is found,” ex­plains Dr Pi­eter Roux, an anaes­thetist who works at Chris­ti­aan Barnard Me­mo­rial Hos­pi­tal and var­i­ous Medi­clinic hos­pi­tals in Cape Town. “Lo­cal anaes­thetic is in­jected, which causes a more sud­den, re­li­able and pro­found pain relief [than an epidu­ral].” This relief, how­ever, is only lim­ited to five hours.

WHAT ARE THE RISKS?

As with any type of med­i­ca­tion, there may be side- ef­fects. The most com­mon side- ef­fects ex­pe­ri­enced are: • A drop in blood pres­sure (can cause light-head­ed­ness, nau­sea and vom­it­ing, which might make it more dif­fi­cult to breast­feed as a re­sult). • Loss of blad­der con­trol (doc­tors can insert a catheter to drain the urine). • Itchy skin (caused by an opi­oid nar­cotic that is of­ten added to the epidu­ral mix­ture). • Heavy legs and a feel­ing of paral­y­sis. • Headache (oc­curs in about 1.5 per­cent of women). More se­vere but ex­tremely rare side­ef­fects are: • Tem­po­rary nerve dam­age (1 in 6 700)* • Per­ma­nent nerve dam­age (1 in 240 000)* • In­fec­tion at the site of nee­dle in­ser­tion • Seizures • Paral­y­sis • Death *Based on a re­view of 27 stud­ies (which in­cluded 1.37-mil­lion preg­nant women who re­ceived epidurals or spinal blocks).

HOW TO DE­CIDE…

“I think all moth­ers should plan their per­sonal birth plan in con­junc­tion with their cho­sen ob­ste­tri­cian,” says Dr Roux. “Your ob­ste­tri­cian will know what’s best for you based on many fac­tors: your phys­i­cal health dur­ing preg­nancy, the size of your baby, your pelvic shape or type and, to a de­gree, your pref­er­ences – af­ter all pros and cons have been ex­plained to you.” He says moms are the best ones to know their own pain thresh­old and val­ues, but to re­main open-minded since plans in the de­liv­ery room can and of­ten do change. “No one should be forced to have an epidu­ral if they don’t want one,” stresses Dr Roux. “Epidurals aren’t es­sen­tial for nat­u­ral birth, and if birth is prob­lem­atic or pro­longed, the ob­ste­tri­cian will usu­ally pro­ceed to C-sec­tion.” And re­mem­ber: epidurals and spinal blocks aren’t the only way to relieve your pain dur­ing birth. Chang­ing po­si­tions of­ten, hav­ing a mas­sage, spend­ing time in the bath­tub and us­ing ni­trous ox­ide (aka “laugh­ing gas”) can all help, too. Get the facts and choose what’s right for you.

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