What is an epidural injection?
Epidural anesthesia is the most common form of anesthesia for labor. It is also used for pelvic, hip, and leg surgery. It is useful during labor because it relieves pain in the lower abdomen, back, and perineum and allows patients to be awake and alert for the delivery of their baby. The injection leaves patients numb from the chest down to the feet and is a great alternative to general anesthesia. During the procedure, epidural anesthetic medication is injected near the spinal cord and is usually given early in labor. After getting an epidural, patients should not feel any pain however patients may feel some pressure from contractions and pressure on their pelvic floor.
How is an epidural given?
Preparing for an epidural
What to expect
The entire epidural procedure takes about 15 minutes and pain relief should come within 15-30 minutes or sooner. Epidural anesthesia involves the injection of medication just outside of the sack of fluid that surrounds the spinal cord. Epidural anesthesia could be given in a single dose or the anesthetist may leave a tiny flexible tube or catheter in place just in case more anesthetic medication is required for a longer than expected procedure.
To prepare for the epidural you will have to get in position. You will be asked to either lie on your side with your knees drawn up to your tummy and your chin tucked in, or to sit up on the bed and lean forward. Both positions open up the spaces between the bones in your lower back.
I was asked to sit up on the bed and lean forward. I was given the hospital pillow to bend forward over and hug on and was told to stay very still during the whole procedure. I could see how this could be very difficult if you are having contractions. Thankfully I was not having contractions yet so staying still was not a problem for me.
Prior to receiving epidural anesthesia, the anesthetist will use an antiseptic solution to clean the area of your back where the medicine will be injected. He or she will carefully select a point to inject by feeling for specific bones in the spine. The anesthetist may or may not mark the site with a pen to show where to put the injection.
To decrease pain from the needle stick, the anesthetist may first inject a local anesthetic directly over the spot where the epidural needle will be inserted. The small amount of local anesthetic will completely block feeling in the area.
This is the only time you will feel something, it will feel like a pinch. It isn’t too bad.
Epidural needle injection
When the skin is numb, a larger epidural needle is passed into the epidural space, which is the space outside the membranes that surround the spinal cord.
When the needle reaches the correct spot, a fine plastic tube called the catheter or cannula is inserted through the center of the needle. The needle is then removed and the tube is left running from the epidural space to the outside. The tube is then held in place with adhesive tape. The anesthetist uses the tube to inject local anesthetic or other pain relief medicines directly into the epidural space when needed. After the catheter is placed in the correct location, epidural drugs are injected and slowly soak into the nerve roots of the low thoracic, lumbar, and sacral spine, and provide its analgesic effects within about 20 minutes.
Catheter being inserted in epidural needle
Your anesthetist may attach a pump to the tube so that you can have a top up when it’s needed. It may be possible to control this yourself. This is called patient-controlled analgesia (PCA).
Patient controlled analgesia (PCA)
When you have an epidural you will also be connected to various monitors to keep track of your blood pressure, pulse and the oxygen content of your blood. You will also have a catheter to collect your urine since you will not be able to get up to use the restroom if needed.
What medications are used in epidurals?
Epidural narcotics Fentanyl and Sufentanil
Both opioids and local anesthetics are used in labor analgesia. Fentanyl is usually the opioid of choice because it is relatively fast acting and has minimal side effects. Another narcotic that could be used is sufentanil.
Epidural anesthesia bupivacaine
The three main long acting local anesthetics used for epidural anesthesia are bupivacaine, levobupivacaine, and ropivacaine. The local anesthetic of choice is bupivacaine because compared to other local anesthetics, it preferentially blocks sensory over motor nerves and as a result of this it preserves leg and muscle strength. Lidocaine is rarely used because of its short duration of action. 2-chloroprocaine has a rapid onset of action and is often used for urgent cesarean delivery or rapid extension of labor analgesia.
Epinephrine is rarely used but is sometimes added to improve the effects of local anesthetics and opioids. When epinephrine is added, anesthesiologists could use lower doses of analgesia and as a result, the patient will have fewer side effects such as nausea.
What are the benefits of an epidural?
The benefits of epidurals include giving very effective pain relief that does not affect the mental state of the patient. It also gives the mom-to-be the opportunity to rest.
What are the risks of an epidural to mom?
It is important to weigh the pros and cons of an epidural. Here are the risks of having an epidural:
- Areas of pain may still exist (this is usually corrected with repositioning the patient or the catheter)
- May lower blood pressure (this also may cause baby’s heart rate to drop, and is usually corrected by giving the mother extra oxygen or fluids or by changing her position). This could be a benefit for patients with high blood pressure
- May cause shivering, itching, or nausea (can be treated with medication)
- May increase risk of fever (which can cause baby to need special procedures after birth in some cases)
- May cause soreness or bruising at administration site
- Rare but serious risks are listed on consent form
What are the risks of an epidural to the baby?
No significant risk to the baby is known, however, epidurals can impact breast feeding by reducing the baby’s initial ability to suckle.
What are the effects of an epidural on labor?
These are the effects of having an epidural on labor and delivery:
- Continuous fetal monitoring, a blood pressure cuff, pulse oximeter, and urinary catheter will be in place for the remainder of labor
- Women usually must stay in bed (this allows rest, but limits the ability to use different labor positions)
- May affect labor progress (if labor slows, Pitocin may have to be given)
- Mother may need extra help from nurses to push effectively, or the use of instruments may be needed to help with delivery
My epidural experience
Unfortunately, I received two epidurals that did not work. Both of the epidurals worked initially and then wore off. After the first epidural, I felt very nauseous and started dry heaving (since I did not eat prior to going to the hospital, I had nothing to throw up!) After the second epidural, I felt itchy. I experienced relief for a short amount of time after receiving both epidurals which was nice. I did not feel the second epidural and did not feel discomfort when they checked my cervix afterward as well. I HATED when they checked my cervix by the way but the epidural made that tolerable since I did not feel that anymore.