Editor’s Note: This article is written from the perspective of a medical provider and does not encompass all possible scenarios and outcomes. All providers have their own methods, and you should always ask your own doctor or anesthesia provider for specific information on how medical procedures will be approached during your labor and delivery.
Epidural anesthesia is a local anesthetic delivered into your epidural space through a catheter that provides various degrees of pain control and possible immobility. Unlike spinal anesthesia, an epidural catheter allows for continuous medication to be delivered. An epidural can be given for pain control during many different surgeries (thoracic, abdominal, etc.), but for this article we will only discuss it in the context of pain control during labor.
Depending on your obstetrician group, you may be allowed to have an epidural at any point during your labor. Some more traditional practices (like mine), prefer you to wait until you are dilated around 4cm. As someone who had exclusively back labor with both my labors, I can tell you that waiting until 4cm is horrific and I wouldn’t wish that (or back labor in general) on anyone.
I’ve done many epidurals and have had two myself for both of my childbirths. Each epidural experience is different. This concept is something I try to emphasize to patients – each time you may have a different experience, but that’s OK. It’s a different labor. It’s a different provider. Different doesn’t mean something is wrong.
The process of placing an epidural is more complicated than a spinal anesthetic and may take anywhere from 10 minutes to 40 minutes (or even longer). This also doesn’t mean something is wrong.
Once the anesthesia provider gets a call from your labor and delivery nurse, he or she will come and ask you some health questions prior to starting the procedure. Your vital signs are being monitored throughout your labor, and during an epidural placement that continues to take place. Many providers ask your support person to step out of the room until the epidural is placed. There are two main reasons for this: it’s a sterile procedure, and we’ve all seen a man hit the floor at least once in our careers. One patient per room is plenty.
The anesthesia provider and nurse will then help position you on your hospital bed. It is important to maintain a slouched posture during the procedure – tucking your pelvis under in a scooping motion – because it stretches out the lumbar spinal spaces (lower back) and provides a better opportunity to find the correct location. It’s best to relax your shoulders and drop your chin to your chest. I often tell patients to think about a “mad cat” or “curled shrimp” posture.
After I assess the space in which the epidural needle should be placed, I tell patients that they will feel the “cold and wet” from the antiseptic soap used to clean off the skin. If you are allergic to topical iodine, please make sure that is in your medical chart — and it never hurts to remind the anesthesia provider as well. Then, a “big sticker” or sterile drape will be placed on your back, isolating the area from the risk of infection.
Next, you’ll feel a “pinch and a burn” or something similar to a bee sting as the local anesthetic used to numb the skin and tissues is delivered underneath the skin. The burning, stinging feeling dissipates quickly. This numbing medicine provides more comfort as the needle passes through the layers of tissue and bone until it reaches the epidural space.
Using a syringe on the end of the epidural needle, millimeter by millimeter, I move toward the epidural space. One of the reasons this procedure can be challenging is that the epidural space is a “potential space.” It doesn’t exist as a functioning entity unless medication or fluid is used to expand it. Once the syringe collapses from the negative pressure of the epidural space, I can deduce that the needle is in the correct space.
Once the epidural space is found, the epidural catheter is threaded into that space an average of 3cm. beyond the needle tip. The needle is then removed from your back, leaving only the catheter in the epidural space. In order to ensure the correct placement, a “test” dose will be given through the catheter. Since it is a blind procedure into a potential space (fun, right?), a test dose is given to check the position.
After the test dose is deemed a success, a LOT of tape will be placed on your back to ensure the catheter does not come out. (Taking the tape off after your delivery is oddly painful, more so than you’d think.) You can help prevent the catheter from dislodging by not sliding around in bed afterward. To shift positions, lift yourself away from the bed instead of sliding against the sheets.
The epidural pump will be hooked up to the catheter. Continuous local anesthetic medication will flow through the catheter, into the space, providing pain relief from the joys of labor. You will be given a button to push for additional medication (a bolus) if you need it. Depending on provider technique and preference, as well as clinical judgement, you may be numb right away or have a more gradual onset of pain relief. As a patient, you would obviously choose immediate relief, but a gradual onset may be a safer choice depending on your personal situation.
As with any medical procedure, there are certain risks and misconceptions about epidural anesthesia. The following are the common concerns, questions, and information that I talk about with my patients, as well as a few things I wish people would understand a bit better about the procedure itself.
8 Things to Know About Epidurals
1. I cannot emphasize enough: every epidural experience will be different. I tell my patients, “It may work great, it may work on one side, and it may not work at all. If it works on one side we can try a few different things to before redoing it. If it doesn’t work at all, I’ll take it out and redo it. You may feel nothing at all or you may feel some pressure throughout your labor, but that’s OK. Pressure is good, it can help you coordinate your pushes.” Many people want to feel nothing throughout their labor, but that’s not a reasonable expectation. That being said, if you’re in a lot of pain, let the nurse know. Sometimes the epidural may work great at first, but as time passes it needs adjusting.
2. The higher your BMI, the harder it can be to find the right spot. But people with a low BMI can present challenges too.
3. Headache, backache, trouble breathing, effects on your heart, and a decrease in blood pressure are all possible risks to the procedure. But you’re being monitored very closely, so if anything happens, the risk to the baby are minimal.
4. Any nerve injury or permanent numbness is very rare and more likely to be from pushing or instrument retractors than your epidural.
5. The curve of your spine changes as you get older. It may take a few extra minutes or tries to find the right spot than it did on your first pregnancy.
6. The most common question I get is “What if I have a contraction during the procedure?” I tell people to tell me if they’re having one and feel the need to move. But you probably don’t want to move because it will take longer since it’s harder to find the space in a moving target.
7. Old-time thinking was that epidurals prolong labor and increase your chance of a cesarean section. But with the current way epidurals are done (with very dilute solutions of local anesthetic), studies from Northwestern University Hospital and others have shown this to be untrue.
8. Epidurals can be left in for days, but the longer they’re in, the higher the chance that they’ll stop working.