Let’s talk about Epidurals

Welcome to your first lesson on hospital interventions in childbirth, focusing on Epidural Pain Relief in Labor.

You may have heard of epidurals as the “magic bullet” for labor pain relief, and it’s true that epidurals can provide effective pain relief – actually no sensation at all. However, like all medical interventions, it comes with its own set of risks and downsides.

First, let’s talk about how epidurals work.

An epidural is a regional anesthesia that blocks pain in a particular area of the body. In this case, it’s injected into the epidural space of your lower back, numbing the nerves that carry pain signals from your uterus and cervix to your brain. It’s administered through a small tube inserted into the epidural space in the lower back. The medication blocks the nerve impulses from the lower spinal segments, resulting in pain relief in the lower half of the body.

The procedure  is performed by an anesthesiologist. A small catheter is inserted into the epidural space in the lower back, and the medication is delivered through the catheter. The procedure usually takes about 20-30 minutes to complete.

The medication typically includes a combination of a local anesthetic (to numb the nerves) and an opioid (to provide pain relief). The result is a significant reduction in pain during labor This means you won’t feel contractions, but you’ll still be able to feel touch and move your legs. 

Advantage of Epidural

The biggest advantage of epidurals is that they can provide effective pain relief, which can be a game-changer, especially  if you’ve had a particularly long and exhausting labor. Perhaps you went to the hospital too soon in early labor and your progress has been typically slow. Finally, after hours of early labor, active labor kicks in and your surges become more intense and closer together, as they do in active labor. 

You’re already exhausted and when the midwife/doctor examines you, they inform you that you’re 4 – 5cm dilated and you can expect another 6- 8 hours of labor. You’ve already been in labor for 8+ plus hours and you’re already exhausted. So an epidural sounds like a no brainer. Plus the hospital staff are actively encouraging you to get one “why suffer?” they may say – or imply. 

Here’s why you want to be sure it’s the right choice 

An epidural given to a low risk woman with a labor that is progressing normally can very easily lead to the cascade of interventions.

Limited mobility

While getting an epidural will give you a chance to get some much needed rest, epidurals can make it harder to move around or change positions during labor, which can slow down the progress of labor.  

• An IV (intravenous) line is typically inserted into your arm or hand when you have an epidural. This is done to provide fluids and medications, and provides access for emergency medications or interventions if needed.  The reason an IV is needed with an epidural is because the medication used for the epidural can lower blood pressure, and the fluids and medications given through the IV can help prevent this from becoming a problem. The downside of this, besides the discomfort of an IV line is that you will be “tethered” to an IV line that limits your movement. 

• A catheter is a thin, flexible tube that is inserted into the bladder to drain urine. This is typically done with an epidural because the medication used for the epidural can numb the lower body, including the bladder. This can make it difficult for you to urinate on your own, so a catheter is used to ensure that your bladder is emptied regularly. The downside to having a catheter is that it can be uncomfortable, and it limits mobility because you’re attached to a bag that collects urine.

• A CTG (cardiotocography) is a machine that monitors the baby’s heart rate and your contractions during labor. It is typically used with an epidural because the medication used for the epidural can affect the baby’s heart rate. The CTG provides continuous monitoring to ensure that the baby is tolerating labor well. The downside to the CTG is that it requires you to be attached to the machine, which limits your mobility and can make it harder to move around or change positions during labor. Continuous fetal monitoring also increases the likelihood of needing interventions. See the notes below. 

Overall, these interventions are necessary with an epidural to ensure your and your baby’s safety.  However, they can limit mobility and make the birth experience feel more medicalized. You become a passive participant rather than actively involved and responsive to your labor and your baby. 

You’ve already learned how important it is to stay active in labor and how the sensations of labor guide you to move into positions that create space for your baby to move down. An epidural effectively blocks this feedback mechanism.

This could slow your labor progress or hinder your baby’s movement through your pelvis.

If labor slows down too much, additional interventions will be suggested to “speed it up” or “get things going”, such as Pitocin to augment labor. These interventions, while potentially helpful, also carry their own risks and lead to the “cascade of interventions'”. 

Ineffective pushing 

Another risk of epidurals is that they  can make it harder to push effectively, which can increase the likelihood of needing interventions like forceps or a vacuum, or even a c-section. 

TOP TIP

If you do have an epidural, you want to request that the infusion is slowed down or even stopped towards the end of labor so that you can feel the sensation of pressure, which will guide you to birth your baby effectively. This is a beautiful opportunity to use the Birth Breath you learned about in the Hypnobirthing Course. As far as possible you want to avoid directed (coached pushing) which can damage your pelvic floor and increases the need for an episiotomy (another lesson). 

It WILL take patience and it WILL require that you speak to your birth team (doctor and midwife and nurses) and inform them of your desire to birth your baby with minimal intervention.

The IV and catheter limit your movement and potentially slow progress which provides adequate indications for further interventions. The *CTG can easily be interpreted to show fetal distress which provides adequate indication for a cesarian. In both instances the indications are valid for a cesarian (a life saving procedure when mother or baby are at risk) however you may not have been at risk when the epidural was administered. 

An epidural given to a low risk woman with a labor that is progressing normally can very easily lead to the cascade of interventions.

Epidural pain relief can be a valuable tool for managing labor pain, but it’s important to be aware of the risks and downsides. It’s true that some doctors may encourage women to have epidurals because it makes you a passive participant and easier to manipulate the situation to intervene. This is one of the reasons epidurals are so popular in (private) hospitals in South Africa (besides the financial gain) and it  effectively keeps them “in charge” of your birth.

That’s OK as long as you’re OK with it. As long as you know that it doesn’t need to be that way. Remember, you are the one in charge of your body and your birth experience. You have the right to make informed choices about your medical care and to advocate for yourself and your baby.

There is no one “right” way to give birth, and the most important thing is that you feel supported, informed, and empowered  – which is why you’re here – so thank you for your time. Keep going – you’re doing great! 

For some reason the downsides of epidurals are never discussed and when interventions are required as a result of the epidural and you end up needing a c/section it’s framed as being the “life saver” and “lucky that you were in hospital” or “imagine what would have happened if you were at home” – now I’m not saying that home birth is preferable (its just another option) but I will say that epidurals are not used at home births and the c/section rate of home birth midwives in South Africa is on  average 12%. 

It’s also worth noting that epidurals are not always 100% effective, and there is a small chance that you may still feel some pain or discomfort during labor, especially if the epidural doesn’t fully take. Unfortunately when this happens, the pain sensations feel even more intense than they did before the epidural because they are felt in just one spot. When this happens, they can repeat the procedure or try alternatives to numb “that spot”.

Timing of an Epidural

Another important factor to consider if you have an epidural is the timing. 

If you are planning an epidural then you need to be in an active labor pattern (meaning you’re having at least 1 surge, lasting at least 1 minute, at least every 5 minutes for at least an hour or longer). It’s important to note that by the time you reach this stage, labor is usually exponential (meaning it naturally speeds up because there is a rhythm) so if you get to this stage and you’re coping well, you might want to consider other pain relief options. 

This is VERY IMPORTANT because too often I work with women who have decided they are going to have an epidural so they don’t need to learn any other forms of pain management or coping skills. WRONG!

You’ll still need these skills in early labor and early labor will be MUCH MORE MANAGEABLE if you have these skills.

You will feel more in control and you can plan your trip to the hospital to arrive by the time you are in active labor and ready to get your epidural. 

Too Late

I’m sure you’ve heard stories of women who requested an epidural (or opioid) pain relief only to be told that it’s “too late” and you think to yourself – that is NOT going to happen to me.

So let me explain it a bit more. When we say “too late” what we really mean (and should be saying) is “you’re almost there” and in medical terms, it means you’re in transition. In fact that’s probably the reason you’re requesting pain relief, because transition is characterised by a sudden change in behaviour and a desire to “find a way out” because it’s the most intense part of labor.

Imagine at as reaching the peak,  and considering that you’ve been experiencing rapidly increasing sensations for hours, and you’re already exhausted, this sudden increase in intensity kind of sends you over the edge. You don’t realise that you’ve reached the peak, you’re just thinking “any more and I won’t be able to manage – so just bring out the epidural”. (You’ll learn more about this in the stages of labor in the hypnobirthing course, so this is just a reminder and for context) 

The bottom line is, don’t have the epidural earlier than you need it in case you might need it later. 

In other words, if you’re managing well (with breathing, entenox, partner support or even opioids) and you’re offered an epidural, make sure that it’s what you want. Remember, if you get to transition and then request it – it means you’re about to have your baby. Just keep doing what you’ve been doing and don’t let your head get in the way and the intensity will turn to pushing and your baby will be born. 

Another thing to be mindful of – even though it won’t make sense until you experience it – is that shortly after the peak intensity you experience in transition, you will start to experience a strong urge to bear down. This is the “fetal ejection reflex” and can feel quite scary as it’s literally caused by your uterus exerting a downward pressure to “expel” your baby. This means that your focus will also shift from breathing THROUGH contractions and managing them, to  working WITH them to birth your baby.

Finally, you have something to do other than “endure” the sensations. 

A lovely analogy is a coffee plunger. Throughout labor your (very clever) uterus works to pull up and open your cervix. The muscles are working hard to dilate your cervix. When it’s completely open they change function (yes, I know amazing huh?) and start pushing down. This is where the cofffee plunger analogy comes in. You might even want to use that imagery if it makes sense to you.

By the end of this course you will know enough about about the medical pain relief options available to make an informed choice.

You will learn all about non-medical pain relief options in the Hypnobirthing course, along with an understanding of the stages of labor and what happens in your body during labor.

Make sure you complete the exercises and activities  which will guide your decision making process. 

*CTG and Fetal Distress (FYI)

When you receive a CTG reading during labor, it will typically show two main things: the baby’s heart rate and the mother’s contractions. The heart rate is the most important aspect of the reading, as it provides information about how the baby is tolerating labor.

The baby’s heart rate is measured in beats per minute (BPM) and a normal heart rate typically ranges from 110 to 160 BPM, and may fluctuate slightly throughout labor.

A CTG reading is classified as reassuring, doubtful, or pathological based on the presence or absence of accelerations, decelerations, and variability.

• A reassuring reading means that the baby is tolerating labor well, and no interventions are typically needed.
• A doubtful reading means that there are some signs of fetal distress, and the care provider may recommend additional monitoring or interventions.
• A pathological reading means that the baby is experiencing significant distress, and urgent interventions may be needed, such as a c-section.

It’s important to understand that while CTG readings can provide important information about the baby’s well-being during labor, they are not always accurate, and can sometimes lead to unnecessary interventions. 

In the next lesson, you’ll learn about opioid pain relief options. See you there! Take a break if you’re feeling a little overwhelmed with all this new info.