What you need to know before getting an epidural
By Karen Robock
Updated Mar 05, 2018
Illustration: Stephanie Cheng
When I was pregnant with my first daughter, I was adamant I wasn’t going to have an epidural. I had asked my midwife a lot of questions—a lot of questions—and I’d done my research. I knew some studies showed this form of pain management is connected to an increased risk of other medical interventions, longer labour and even trouble breastfeeding. My mind was made up but, unfortunately, things didn’t quite go according to plan. My blood pressure spiked suddenly a few days before my due date, which meant I had to be induced, and as my labour progressed, it was deemed medically advisable to have an epidural to help lower my blood pressure. So, like about half of moms-to-be, I ended up calling in the anaesthesiologist.
Epidural anaesthesia is the most effective pain relief option used in hospital births and the most common one labouring moms ask for by name. An estimated 40 to 70 percent of first-time moms opt for this form of anaesthetic.
“In my experience, most women are really happy they got an epidural,” says Jessica Dy, an obstetrician at the Ottawa Hospital. But that doesn’t mean it’s for everyone. And sometimes plans change, says Alix Bacon, president of the Midwives Association of BC. “I encourage people to keep an open mind rather than going into labour planning to have an epidural or not have an epidural under any circumstance,” she says.
How is an epidural done?
An anaesthesiologist will ask you to sit up on the edge of the hospital bed and will wipe your back with an antiseptic to reduce the chance of infection. Next, they’ll give you a needle in your lower back with a local anaesthetic to numb the area, just like at the dentist. Then they will position a large needle between the bones of your spine in your lower back, making space for a catheter (a small plastic tube) to be inserted into the area just outside the cover of the spinal canal. A mixture of anaesthetic and an opioid like fentanyl is then injected through the catheter. It works with gravity, so you’ll be asked to lie down right away; after 15 to 20 minutes, you’ll have pain relief from the belly down.
There are essentially two kinds of epidurals. “The more common type is a low-dose infusion epidural, which is what women refer to as a ‘walking epidural,’ though we don’t really call it that,” says Dy. Once the anaesthetic kicks in, you can’t actually walk very far, but you can move around the delivery room a bit, go to the washroom and change positions more effectively when it comes to the pushing stage. A low-dose epidural means there is a low-dose constant infusion, which the patient controls by pushing a button to increase the dose whenever they feel they need it, up to a preprogrammed maximum.
The second type of epidural is a spinal anaesthetic that is delivered in one shot, designed to wear off over time. This is used mainly for planned surgery, like a C-section. Spinal anaesthesia is effective, but it doesn’t last as long as labour sometimes can, so it’s not typically used in labour, though it may still be in practice at some rural hospitals across the country, says Bacon.
What does an epidural feel like?
An epidural has the ability to completely erase pain, while other forms of pain management do just that—they help you manage or dial down the pain. During labour, practitioners often talk about pain levels on a scale of one to 10. Some options, like having nitrous oxide or soaking in a hot bath, just subtly take the edge off, bumping you from a nine to an eight, for example. An epidural, on the other hand, can take things from a nine to a zero, though there is still some sensation, which allows you to push.
“The relief was so immediate—and total,” says Toronto mom Karen Verk. “It was great because, once it took effect, I could actually rest and the contractions became a sort of flutter in the background.” According to Dy, this is one of the biggest bonuses of epidurals. “Women can’t push when they’re exhausted,” she says. Giving moms a chance to rest can be really important, especially during a long labour. “We sometimes have women come into the hospital who’ve been labouring for a long time at home or in a birthing centre without progress, and once we suggest an epidural and give her a rest, very commonly what we see is a vaginal birth resulting from that.”
Another plus: The pushing stage may be more controlled with an epidural, which can result in less tearing. “And it allows for a better job of repairing any perineal tears afterwards, because the woman won’t be squirming when you’re stitching her up,” says Dy.
Unlike some of the other forms of pharmaceutical relief, like a morphine or fentanyl drip or injection in which the medicine travels through the blood stream, there’s no conclusive proof that epidural anaesthetic has any effect on baby, since the drugs are localized to the nerves around the lower spine. There’s no increased risk of depressed breathing, a slowed heart rate or a low Apgar score (a test which measures a newborn’s well-being).
When should you ask for an epidural?
Going into her delivery, Verk wasn’t sure whether she would want an epidural, so she didn’t ask for one right away. “I had to be induced, and nobody told me how intense the contractions would be with Pitocin,” she says. “I was in so much pain that I had no mental capacity to think about what I needed or to ask for anything.” After an hour or two of intense contractions, her husband asked her if she wanted an epidural—and she was glad he did. “It took another half-hour of blinding pain before the anaesthesiologist even came in the room,” says Verk. “I just wish I’d asked for it an hour earlier.”
Picking the right moment to ask for an epidural can be tricky. “With epidurals, timing really is everything,” says Dy. For one thing, accessing the anaesthesiologist may take a while: There may be only one on call, they might not be on-site, or they could be too busy to get to you right away. “If your hospital only has one anaesthesiologist and a car accident comes in, it could be a long wait,” says Bacon. Ideally, an epidural is started when the woman is at least four centimetres dilated and in active labour (having strong and regular contractions). Contractions that are too strong or frequent can pose a problem, because the anaesthesiologist needs the woman to sit on the edge of the bed without moving a muscle in order to insert the needle—a near impossible feat if the pain is very intense. “I had a really hard time staying still,” says Verk. “I didn’t think I could do it.” If you’re almost at the pushing stage, your practitioner might tell you it will actually be faster to skip the epidural. On the other hand, you don’t want to start too early. “The longer the epidural has been in, the more likely it is to move and not provide full coverage,” says Dy.
“Whenever I talk to women about epidurals, that’s part of the reason I always tell them it’s best to go as long as you can without it,” says Dy. “If you put it in too early, it also increases the chances of slowing down labour,” she adds. A study published this fall in Obstetrics & Gynecology reported epidurals had no effect on the duration of the second stage of labour, but experts disagree. Both Bacon and Dy say that, in their experience, the pushing stage is typically longer with an epidural. “We know it changes the hormone cascade that happens, which can slow things down,” says Bacon. During labour, the brain releases oxytocin, which gives you strong contractions. The contractions cause pain, which triggers endorphins to help you feel better, and then endorphins cause the release of more oxytocin. “When we break that cycle by taking out the pain, sometimes we see the contractions space out,” Bacon says. According to Dy, women who have epidurals typically push 30 minutes to an hour longer than those who don’t.
What are common side effects of epidurals?
Epidurals are very low risk, but they do come with potential negative side effects. Here are the most common complications.
Drop in blood pressure Hypotension is the most typical side effect of an epidural. When the anaesthetic cuts off sensory input to the brain, the body’s natural response is a drop in blood pressure, says Dy. “It usually comes back up with just giving women extra fluids through the IV.” But, if blood pressure drops too far or too quickly, it can have a negative impact on the baby. When mom’s blood pressure drops, less oxygen is circulated to the placenta, which can cause baby’s heartbeat to slow. (In the rare case where mom’s blood pressure and baby’s heartbeat don’t normalize, a C-section could be ordered.) This sudden dip in blood pressure can make some women feel nauseous, but Bacon says this isn’t very common.
Headache or numbness A severe headache, also called a post-dural puncture headache, can occur if a bit of spinal fluid leaks out of the hole where the needle was inserted, causing a drop in pressure in the head. A 2011 study published in Continuing Education in Anesthesia, Critical Care & Pain estimates the risk of a dural puncture is relatively low at about 1.5 percent, and roughly half of those patients will experience a subsequent post-dural puncture headache. It’s no ordinary headache: The pain can be extreme and last for several days after delivery. In the most severe cases, a procedure called a “blood patch,” in which doctors use a small amount of the woman’s blood to block the hole, may be required. Numbness in the legs or feet or, in more extreme cases, nerve damage are also possible, but they are reported to be rare (between one in 1,000 and one in 100,000 will get nerve damage) and usually resolve within weeks or months.
Itching and shakes Women who are more sensitive to narcotic medications may experience itchiness while the epidural is in place and for several hours afterwards. This can be treated with a dose of diphenhydramine (Benadryl) given through an IV. Shaking, which is another possible reaction, can’t be treated medically but your practitioner may bundle you with more blankets to keep you feeling cozy until it wears off.
Fever Running a high temperature is the side effect that worries practitioners the most. It happens to between 10 and 15 percent of women who have an epidural. “The problem with a fever in labour is we don’t know if it’s caused by the epidural or if there is an infection brewing,” says Bacon. The practitioner will likely start a course of antibiotics and may even expedite labour with an IV dose of oxytocin in an effort to get the baby delivered as soon as possible. “In some cases, we even determine that it’s not safe to keep going, and the woman has to have a C-section,” she says. That’s because the baby’s temperature will rise with the mother’s, usually accompanied by a quickened heart rate and a range of worrisome symptoms after delivery, including difficulty breathing and lower Apgar scores.
Breastfeeding complications Although breastfeeding advocates like La Leche League have warned epidurals can interfere with breastfeeding, most research suggests this is actually because of complications from the epidural, not the epidural itself. If a woman is feeling unwell due to a drop in blood pressure or an opioid reaction, for example, she might find it difficult to begin nursing.
Instrumental birth The use of an epidural doesn’t increase the overall risk of having a Caesarean section, but it is associated with an increased risk of assisted vaginal birth, according to a Cochrane review. That means the woman might require oxytocin to keep contractions going and/or baby might need the help of a vacuum or forceps to make their way down the birth canal. The current research on epidurals and tearing is conflicting, says Bacon. “Some studies say an epidural increases the risk, while others say it decreases it, so I guess the jury is still out on that front.”
Poor pain relief It’s also possible for an epidural not to take effect right away. Sometimes the procedure has to be repeated, and even then, it may only take on one side or leave patches unfrozen. It’s difficult to say why this happens, but it does occur between five and 10 percent of the time. This happened to me: My anaesthesiologist tried twice, but I only ever felt relief on the right side of my body.
Of course, it’s impossible to control for all variables during childbirth. Having my second daughter was a completely different experience. I relied on many other forms of pain relief: changing positions often, having a massage, spending time in the bathtub and using nitrous oxide. After about six hours of active labour and tremendous coaching from my midwife, I was finally able to push my baby out on my own. The euphoria that overcame me as I pulled my baby up onto my chest and cuddled her for the first time was as intense as all the pain that preceded it. While some moms report feeling groggy or sleepy after an epidural-aided delivery, my mind was completely clear. Without an epidural, I felt everything.
Verk, on the other hand, doesn’t for one second regret her decision to get an epidural. “It made giving birth something that was really special, because without that blinding pain, I could really be present for it,” she says. “I was still able to reach down and pull him out, and it was a really beautiful experience. I would definitely do it again.”
Reasons you can't get an epidural
There are a few medical conditions that can prevent you from getting an epidural. You might not be eligible for one if…
* you have low platelet counts or are taking blood thinners
* you have an infection in or on your back
* you have a blood infection
* the anaesthesiologist has difficulty locating the epidural space (this can happen in women who are obese or have spinal issues)