You’re not going to win any good-mommy awards and your child is not going to be admitted to Harvard simply because you experienced the full sensation of labor pain. If you do choose to medicate, you have a few options, including
an epidural block, which numbs you from the waist down but keeps you alert a spinal block, which is like an epidural but kicks in quicker a combined spinal epidural (CSE), also called a walking epidural a pudendal block general anesthesia
Your doctor can explain these options to you so that you can make your own decision. Here, we break them down for you.
Epidural
Epidurals are the most popular form of pain relief during labor in the U.S., with more than half of pregnant women delivering in hospitals choosing this treatment. It’s a regional anesthetic that can be given at any stage of labor to numb the abdomen and therefore block the pain of contractions, but it’s typically given when the woman is at least 4 cm dilated. This will affect sensation in your legs so that you need to remain in bed, and your baby will be closely monitored. A stronger epidural also affects sensation in your bladder, so you will need to have a catheter. If you’re considering using an epidural, inform your doctor early in labor so that she can consult the anesthesiologist. The anesthesiologist may then discuss this with you and take a brief medical history to ensure that it’s safe for you to have one. She will discuss any risks, and answer any questions that you or your partner have, all of which can save time later on if you decide to go ahead.
The Procedure
Before starting the epidural, an IV will be inserted in the back of your hand or arm, and you’ll be started on fluids. You’re given fluids during an epidural to stop your blood pressure from dropping. The doctor will then help you into position for the epidural, which will either be sitting up with your legs over the side of the bed leaning forward, or curled up on your side on the edge of the bed. The position may depend on the preference of the anesthesiologist. There are occasions when an epidural is not a good idea. These include cases where a woman has had spinal surgery or is taking blood-thinning medication. Rarely, a woman may have an infection that could be exacerbated by an epidural. Your lower back will be cleaned with antiseptic and a drape placed over the rest of your back to reduce the risk of infection. Before the epidural needle is inserted, a local anesthetic will be given into the skin and surrounding tissues. This creates a numb patch to ensure that the insertion of the large epidural needle is not painful. When the local anesthetic is injected, you may feel a scratching sensation and experience a very short-lived sting in the area between the vertebrae bones. Since it’s important for you to remain still during the procedure, the anesthesiologist will insert the epidural between your contractions. If that’s too difficult, you should try to concentrate on your breathing and remain as still as possible until the procedure is completed. You’ll feel a pushing sensation in your back while the anesthesiologist finds the very small epidural space with the hollow needle. When the space is located, a tiny plastic tube will be fed into it through the needle. The epidural needle is then removed and the tube, which is secured onto your back with sticky tape, remains in the epidural space. The tube remains in place until your baby is delivered and, because it’s thin, soft, and pliable, it’s perfectly safe to lie on the tube and move around. Once the epidural tube is in place, the anesthesiologist will give the first dose of medication through it with a syringe. Once she’s satisfied that the epidural is in the right position and is working, all other doses, or “top ups,” can be given without another injection. Your blood pressure will be taken once the epidural is in place and will be monitored for the next half an hour or so, and then regularly thereafter, including after each top up. Each dose of medication takes about 10 to 20 minutes to take its full effect and can last between one and two hours. The epidural will be topped up as required, usually around every three to four hours, to keep you comfortable throughout your labor. An anesthesiologist should be available 24 hours a day to manage any concerns or problems that may arise with the epidural.
Epidurals Late in Labor
Used late in labor, a stronger epidural may mean that you need help to push the baby out, since the pelvic floor muscles will be heavy and ineffective. In this case, your doctor will put a hand on your abdomen to feel when a contraction starts and will tell you when to push. In some cases, an assisted delivery becomes necessary. There are factors to bear in mind should you opt for an epidural late in labor. To minimize the risks, you must remain completely still during the placement of the epidural tube. If your labor has progressed too far to enable you to do this, the anesthesiologist may refuse to proceed with an epidural for your own interest. Also, if you choose to have an epidural late in labor, it may be necessary to give a high dose so that it takes effect in time, which has disadvantages.
Side Effects
There are a number of minor side effects. The medication can cause blood pressure to fall, so this will be monitored. If it does fall, you’ll be given fluids and medication, and subsequent doses may be reduced. It’s common to experience itching with epidurals, caused by an allergic reaction to the opioid component of a mobile epidural. Histamine is a substance released by the body during an allergic reaction that can cause itching. The itch can be treated, but in most cases it gets better on its own. If you develop an itch, a greater concentration of local anesthetic alone will be used. It’s not unusual to shiver with an epidural, although this is a more common side effect if a concentrated local anesthetic is used, as is the case for a cesarean delivery. Epidural pain relief can cause a rise in temperature. If this occurs, you’ll have a blood test to eliminate an infection, which can also cause your temperature to rise. You’ll be given preventative antibiotics while waiting for the blood test results, and acetaminophen to bring your temperature back to normal.
Problems With Epidurals
There can occasionally be problems with the effectiveness of an epidural. The anesthetic may not spread evenly in the epidural space, which may be caused by the epidural tube sitting on one side of the epidural space. That can mean that pain relief only occurs on one side of the body. If that occurs, the anesthesiologist will try to reposition the tube and give another dose of anesthetic. If that doesn’t work, the only other solution is to redo the entire epidural. Sometimes, one spot can remain painful, usually in the groin area or low down in the front of the abdomen, which is referred to as a “missed segment.” This results from a single nerve root not being coated with the local anesthetic. Again, the anesthesiologist may reposition the tube. Sometimes, a stronger local anesthetic or an opioid is used to numb the area. If a persistent missed segment is too uncomfortable, the anesthesiologist may do a combined spinal epidural block, known as a CSE. Some women report a headache after an epidural, which can develop more than 24 hours after the delivery and tends to be at the front of the head. It’s made worse by sitting up and moving around and is much improved by lying down. This occurs in around 1 in 100 women and is caused by the epidural needle moving too far forward and cutting the dura sheath, the membrane maintaining the fluid around the spinal cord and brain. This small hole results in a loss of fluid from the sheath, which causes a headache. The risk is hugely reduced by remaining still during the placement of the epidural. In around 70 percent of women, the hole heals on its own. You will be advised to drink plenty of fluids and to take simple painkillers, such as acetaminophen and ibuprofen, and you will be reviewed at regular intervals by an anesthesiologist. If the headache persists, a procedure called a “blood patch” will be done. One anesthesiologist places an epidural needle in your back, while another takes around 20 ml of blood from a vein in your arm. The blood is then passed down the needle into the epidural space. It forms a clot that seals the hole and prevents further leakage of fluid from around your spine, therefore relieving the headache.
Spinal Block
A spinal block is similar to an epidural in that a needle is put in your back and pain relief is achieved by blocking nerves that supply the pelvic organs. In a spinal block, though, the needle is passed through the epidural space to pierce the membrane covering the spinal cord (the dura) so that anesthetic can be injected into the fluid around the spinal cord; no tubes are left in place. The needle used for a spinal block is smaller than that used for an epidural, which means it’s less painful to insert. There is still a risk of a headache as with an epidural and the side effects should be treated the same way. A smaller dose of anesthetic is needed and it works very quickly: pain relief is almost immediate. Spinal blocks are used less often because only a single dose of medication can be administered. As a result, spinal blocks are usually reserved for use during a cesarean, or for an assisted delivery when an epidural isn’t in place.
Combined Spinal Epidural (CSE)
Also called a walking epidural, a CSE involves both a spinal injection and putting an epidural in place. It’s sometimes done when problems are encountered with an epidural and is also used for a cesarean. A CSE gives pain relief throughout labor, but it’s a specialized technique and isn’t offered in all units.
Pudendal Block
This type of regional anesthesia involves injecting a local anesthetic into the vagina, where the pudendal nerves are located, to reduce pain in the vagina and perineum. The pudendal needle is quite long and thick, so before the injection is given, a cold anesthetic spray is applied to the area. The anesthetic has no effect on the baby and can be used with other medications. It takes effect very quickly and is sometimes used just before birth to aid an assisted forceps delivery.
General Anesthesia
When you start to feel contractions at home, do not reach for an aspirin to relieve your pain. Aspirin interferes with your blood-clotting ability, which means that your risk of a hemorrhage during delivery increases if you take aspirin. Bleeding problems may even develop in your newborn, and can affect your baby’s heart or blood flow. Most cesareans are conducted using regional anesthesia. In some cases, though, general anesthesia, where the mother is put to sleep, is necessary. That may be because of a failure of regional anesthesia, blood-clotting problems in the mother, an infection in the mother’s bloodstream or persistent fetal distress.
The Procedure
Precautions are taken to minimize the risks to you and your baby. You’ll be given an antacid to reduce stomach acid. Often a catheter is inserted into the bladder and antiseptic is applied to the abdomen before you’re put to sleep to minimize the baby’s exposure to the anesthetic. As the mother is put to sleep, a face mask is held tightly over her nose and mouth. Because a major risk during general anesthesia is undigested food or liquids in the stomach re-entering the mouth and going into the lungs, you’ll likely be told not to eat or drink anything once labor begins, in case you need general anesthesia. You may be able to have ice chips, though. Once asleep, an anesthesiologist inserts a tube through your mouth and down your throat so that oxygen can reach your lungs easily. So you may have a sore throat when you wake up. During the surgery the anesthesiologist cares for the mother, giving painkillers and anti-nausea medicine when needed. The baby is cared for by the doctor. Depending on hospital procedure, your partner may or may not be present for the birth. However, no hospitals allow the partner to be present while the mother is being put to sleep.
After the Surgery
The procedure takes about an hour. The mother is awakened 5 to 10 minutes afterward. The baby is kept with the mother at all times unless he needs extra care. Since general anesthesia doesn’t give localized pain relief, it’s normal to need pain relief afterward. Oral medicine will be given regularly and morphine-based medication may be given for a day or two.
The Choice Is All Yours!
Many women like the idea of natural childbirth—they see it as very empowering. But it’s not easy. Because so much anxiety is brought on by the fear of labor, you need to make a plan you’re comfortable with, so that you can stop worrying. All you really need to remember is that this is your childbirth experience. Nobody can tell you what is best for you. Discuss your options with your doctor, and then choose the approach to handling the pain of delivery that best suits you.
