Epidurals During Labor: Benefits and Risks

May 2, 2016

Bethanie Verduzco,

Many moms who were geared up for an unmedicated, natural labor, find that at some point during labor they might to second-guess that decision. Some will push past that point and go on to deliver without medication, and others will make the sometimes difficult call to get an epidural. This can happen for a wide variety of reasons—both medical and psychological. Epidurals can calm a mom who is anxious and not able to relax, they can be a way to rest after a long and exhausting labor, and they can lower blood pressure for a mom who’s preeclamptic. Then there’s the mystery of: what’s happening with baby? Is she in a good position or is she posterior? Is her head coming down straight or is it asynclitic? These things can absolutely affect a mom’s decision to get an epidural, as well.

Too often mamas judge themselves for choosing to get an epidural when they were hoping for a natural birth. So let’s get real: birth is tough and gritty and raw. It can be beautiful and empowering too. But the underlying theme is that it rarely goes to plan. What you decide to do during labor is your decision. Be proud that you’re already making difficult but informed choices for yourself and your baby—the first of many tough parenting decisions, right? So say no to the guilt. You’re in charge, mama. Own it.

That being said: it’s important you know the risks of the procedure, both risks to you and baby’s health as well as the situational risks—how your labor will be effected by this decision from this point on. There are many reasons why epidurals shouldn’t be taken lightly, and I’ve included some resources for further reading at the bottom of this post. But for the sake of this particular blog post, we’re focusing on what actually happens once a mom has made that educated decision to get an epidural.

So let’s say you do make that decision. What happens from that point on?

I’ll be honest, as a doula, this is oftentimes the stickiest part of a mama’s labor. Once her mind is made up, mom is already at the end of her rope. She’s decided that’s it.

But what happens next is usually pretty unexpected. The nurse responds with, “okay, hun, we need to get a whole bag of IV fluids in you and get a hold of the anesthesiologist first.” Cue: laboring mother panic. What do you mean get a whole bag of fluids? Get a hold of the anesthesiologist?! You mean it’s not going to happen right now?!

No, it’s not. It can take anywhere from 30 minutes to an hour to get a bag of fluids (if you don’t already have an IV hooked up). And the anesthesiologist might be in surgery or doing other procedures in the meantime. And, something else to consider, it usually takes about 15 minutes to feel the anesthesia after the epidural is place. So you’re looking at a possible hour+ from the point you decide you want an epidural to when you’ll actually feel the effects.

BEFORE YOU GET THE EPIDURAL:

Usually a full bag of IV fluids— from 30 minutes to an hour.
Wait for anesthesiologist on call— from 30 minutes to an hour.
continuous fetal monitoring
blood pressure monitored regularly

So once you’ve got enough fluid and anesthesia arrives, what happens next?

DURING EPIDURAL PROCEDURE:

Sometimes one support person is allowed to stay in the room during the procedure, but more often than not, support people (partners, doula, mother, etc.) are asked to leave the room and wait in the waiting room while the epidural is being placed. Just a nurse and anesthesiologist allowed to stay. Support people can expect to wait for 30-45 minutes before being allowed back in.
After support people leave, the laboring woman will be asked to sit over the side of the bed or lay on her side. She’ll then be instructed to curl over and round her back.
The anesthesiologist will clean her lower back with a sterilizing solution and then put a clear sticky tape over and around the area. The anesthesiologist will then inject a local anesthetic into mom’s lower back to numb the site. This will likely sting quite a bit.
The laboring woman will be lean forward, curling around her belly. She’s then instructed to hold her breath and sit perfectly still (which many mothers will tell you can be very hard and painful when contractions are intense).
Then a long needle is injected into the spinal column, passing through the skin, ligaments, and in between the vertebrae until it reaches the space just outside the membrane that surrounds the spinal nerves. The membrane is called the “dura,” and the space outside it is called the “epi-dural space.” The anesthesiologists will be watching to make sure the needle doesn’t pass through the dura or into a blood vessel—the long epidural needle has markings on it so that the anesthesiologist knows how far to go in. And FYI: this can still be painful even though it’s been locally numbed.
Once the needle is in place, a thin plastic catheter is threaded through the needle, about 4-5 cm into the epidural space. Then needle is actually pulled out—just the catheter remains. So important to know: the needle does not stay in your body!
After the catheter is placed, the anesthesiologist will check to see if it’s placed correctly by administering a small dose of anesthetic (usually lidocaine) into the epidural space. 3-5 minutes later, they will do a leg movement test. If the laboring woman’s leg can move, then they know it’s placed well. If her leg cannot move, it’s not in the right place and they will have to start the whole procedure over (which happens in about 5% of cases). If everything looks good, however, a bolus of anesthetic medication is administered through the catheter, and a continuous infusion of anesthetic through a drip is started. This drip can be adjusted by mom throughout the rest of her labor, numbing her body from her abdomen down. Know that it usually takes about 10-15 minutes for moms to feel the medication start to work after the epidural is placed.
The thin plastic catheter administering the anesthesia is then taped down on her back and shoulder, then on the outside of her gown, so that it has less chance of being pulled loose with movement.
A bladder catheter is then put in—remember: you won’t be able to stand up and walk to the bathroom to pee. But the catheter will go in only after you’re numb. And it will stay in until it’s time to push.
You can expect the whole procedure from the time your support people leave the room to the time they’re allowed back in, to take about 20-40 minutes.
The numbing effects of the epidural will last about 1-2 hours after delivery.

SOME THINGS TO CONSIDER BEFORE MAKING THE CALL:

Oftentimes the anesthesiologist will not automatically be explaining things to you as you go. Make sure to ask them to give you a play by play if that’s something you think you will want/need to feel comfortable and in control.
A “good epidural” is one where mom can still feel pressure, still feel a contraction and still have the urge to push. But this is ideal and doesn’t always (or even usually happen). In reality, the pushing stage can be just as difficult, if not more so, with an epidural. With sensation gone, you might not be able to feel where to push, which can make this stage longer, less efficient and can wear a laboring woman out. As a result, there’s a higher risk of forceps or vacuum extractor deliveries with an epidural.
It’s not unusual for moms to feel the epidural working on one side but not the other. So remember: epidurals work by gravity. So lying on the non-numb side is the trick to getting more even coverage (and then switching sides again when that feeling reverses).
You will likely be confined to your bed after you get an epidural. You won’t be able to walk around, squat, lunge, take a shower or bath, or get into different birthing positions that help baby move down efficiently. So you’ll need to have support from your nurse and support people to help you move from side to side every 30 minutes so that labor can progress. Ask your nurse if she or he can set you up with a peanut ball while you’re on your side. These are amazing tools for labor—especially for a woman on an epidural! They can lower your chances of having a cesarean by 80%! You might also be able to try a supported hands-and-knees position or sitting upright near a 90 degree angle and dropping the foot of the bed down, letting gravity work for you.
There’s also a risk that the epidural can slow labor down or stop it completely. This usually happens earlier in labor (before 5cm), but I’ve seen it happen later too. If labor begins to slow or stagnate, hospital staff will want to start Pitocin to get your contractions going again. But this is also not without risks—do your research on Pitocin. If you’re considering an epidural, know these two are closely connected and what possible outcomes are.
Babies do feel the effects of epidurals, and there is some research to say that the baby’s drug levels may even be higher than the mother’s drug levels at birth. Babies whose mothers get epidurals might also become lethargic in utero, which can effect how their positioning for delivery. This can carry over to breastfeeding, as well. Babies with epidurals take longer to latch on and have more difficulties with breastfeeding in the early days than unmedicated babies. Epidurals have also been known to cause respiratory depression and decreased fetal heart rate in newborns.
Also when it comes to breastfeeding, it can be hard for moms to initiate a good first latch because they’re still feeling numb and can’t support baby at the breast until later on. It’s critical that moms with epidurals have extra support to help them with breastfeeding at the beginning.
I’ve supported moms with epidurals who have said that the anesthesia wasn’t actually working much at all, that it wasn’t taking enough edge off to really do anything for them. This actually happens for 10% to 15% of women. Also, it’s possible for her to feel a window of pain somewhere on her back or belly—where the epidural is working on the rest of her mid-section, but one small window is still experiencing every bit of the contraction’s intensity.
Epidurals significantly interfere with the major hormones of labor and birth, i.e. oxytocin, beta-endorphins, catecholamines. A mother’s levels of oxytocin and beta-endorphins, the lovie-feely hormones are reduced or eliminated, which can delay bonding and inhibit attachment. Also, because of a drop in catecholamines moms might have a tougher time having the energy to push baby out.
Laboring women with epidurals have longer labors—both for active labor and for pushing.
This is not a medical risk your doctor will most likely tell you about, but as a doula I know it’s important for many moms. Getting an epidural can change the feeling of your labor from something active to something passive. Many moms have told me they felt like what was before within their control, was suddenly taken away after they got the epidural. Just know: you will have to give up some of your power if you choose to have an epidural. Give up something to get something else. It’s a trade off.
Some women can get a horrible spinal headache that can last for hours or, in rare cases, days/weeks. This will happen to 1 in 100 women.
There’s also the rare possibility of permanent nerve damage at the epidural catheter site, developing an abscess or hematoma (blood clot), as well as toxic reactions in the covering of the spinal cord which could result in paraplegia.
Other risks include: shivering, ringing of the ears, backache, weakness, numbness, soreness where the needle is inserted, nausea, or difficulty urinating.

So whether or not you decide to get an epidural during labor, make sure you know how it can effect the rest of your labor, delivery and postpartum bonding time with your baby. Learn about the procedure and the risks so that you can make the best choice for you and your baby!