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Friday, January 10, 2014

Let's Get some epidural ...

What is an epidural?

During an epidural, painkilling drugs are passed into the small of your back via a fine tube. It is a regional anaesthetic, so the drug is injected around the nerves that carry signals from the part of your body that feels pain in labour. It will numb your tummy and provide you with very effective pain relief.

In the UK, epidurals and spinals must be given by an anaesthetist. About 30 per cent of women have an epidural or spinal during labour or after the birth (CQC 2010).
How is an epidural given?

Your anaesthetist will give you an injection in your lower back and then guide a hollow needle between the small bones in your spine.

The needle goes into the space between the layers of tissue in your spinal column (the epidural space). A fine tube (catheter) is then passed through the needle and the needle is removed. The tube is taped up your back and over your shoulder.

Try to keep very still while your anaesthetist sets up the epidural. While on your side or sitting on the edge of the bed, you'll be asked to lean forward. This opens up the spaces between the bones of your spine.

Concentrate on your breathing to help you to keep still. Breathe in deeply through your nose, and sigh out slowly through your mouth. Hold hands with your birth partner, if you have one, and keep eye contact with him.

Epidural painkillers may be given as:

Injection with top-ups
Painkillers are injected into the tube to numb the lower part of your tummy, and your contractions should no longer be painful. As the epidural begins to wear off, you can have top-ups which last between one hour and two hours.

Continuous infusion
An epidural catheter is set up, with the other end of the tube attached to a pump. This continuously feeds the pain-relieving epidural solution into your back. You can also have stronger top-up doses of local anaesthetic, if you need them. Sometimes the pump is under your control. This is called patient-controlled epidural analgesia (PCEA), but is only available in some hospitals.

Combined spinal epidural (CSE)
This injection contains a low dose of pain-relieving drugs (a mini-spinal) and works more quickly than an epidural alone (NCCWCH 2007: 128, Simmons et al 2007). At the same time, the anaesthetist will insert a catheter.

When the mini-spinal injection starts to wear off, your anaesthetist will pass the epidural solution through the tube to give you ongoing pain relief. She will then check that your pain relief is working by using a cold spray or an ice cube on your tummy and legs, to see if you can feel it. If you can feel the coldness of the spray, your epidural may need to be adjusted or reinserted.
How does it work?

The anaesthetic deadens the nerves that are carrying pain signals from your uterus (womb) and cervix to your brain.

Most hospitals use low-dose epidurals that contain a mixture of painkilling drugs, usually a local anaesthetic, bupivacaine or levobupivacaine, and an opioid (fentanyl).

A low-dose epidural may allow you to have some sensation in your legs and feet. However, only a mobile epidural, which requires extra staff to monitor you, allows you to move about.
When should I have it?

You can have an epidural at any point in your labour (NCCWCH 2007: 115). Most women request it when their contractions are getting strong, often when their cervix has dilated to about 5cm (2in) or 6cm (2.4in).

You may be offered an epidural if your labour has to be speeded up with a Syntocinon drip. This is a synthetic version of the hormone oxytocin, which makes your cervix dilate and your contractions intensify. You may need extra pain relief, because this can make your contractions difficult to cope with (NCCWCH 2007: 238).

Once your epidural is in place, it can stay in until after your baby is born and your placenta is delivered. It can also provide pain relief after the birth if you need stitches (NCCWCH 2007: 121).
How might an epidural affect my baby?

If your blood pressure drops (Anim-Somuah et al 2011, Jones et al 2012, OAA 2008), it may affect the flow of oxygen to your baby. Before starting your epidural a small tube (intravenous cannula) will be inserted into your hand or arm. This is so fluids and drugs can be fed through if your blood pressure falls later on (NCCWCH 2007: 110, 115).

Epidural solutions contain the opioid fentanyl, or a similar drug, which can cross the placenta. In larger doses (more than 100 micrograms), these drugs may affect your baby's breathing, or make him drowsy (NCCWCH 2007: 113).
What are the advantages of having an epidural?
It's the most effective form of pain relief during labour (Anim-Somuah et al 2011, Jones et al 2012, NCCWCH 2007: 113).
Top-ups can usually be given by an experienced midwife (NCCWCH 2007: 109) once the epidural is in place, meaning no waiting for an anaesthetist.
You may still be aware of your contractions, and have a clear mind, but you'll feel no pain.
If you have high blood pressure, it can help to lower it.
It can be topped up with stronger local anaesthetic if you need an unplanned caesarean. Though having an epidural does not increase your chances of needing a caesarean (OAA 2012).
What are the disadvantages of having an epidural?
For about one-in-eight women it doesn't work adequately (OAA 2008) and only numbs parts of their tummy. In this case, extra pain relief will be needed. If you're not pain-free within half an hour of the epidural starting, ask the anaesthetist to come back to adjust it or try again (NCCWCH 2007: 117).
Though it works fairly quickly, it takes about 20 minutes to insert and set up and another 20 minutes to work once the anaesthetic has been injected (OAA 2012). This is longer than most other types of pain relief.
It may make you feel shivery (RCOA 2009a).
It may cause itching (NCCWCH 2007: 116, 128, OAA 2008, 2012), particularly if you have a CSE (Simmons et al 2007), but it's not usually severe.
You may develop a fever (Jones et al 2012, NCCWCH 2007: 117, OAA 2012).
You will need to stay in bed, as your legs are likely to feel weak or heavy. Even if you are able to shuffle around on the bed, you won't be able to walk around. Not many hospitals offer true mobile epidurals.

Keep varying the position you are sitting or lying in. This prevents you from developing a pressure sore on the numbed area of your body.
It can affect your ability to wee, so you may need a catheter after the birth. This usually won't need to be left in, and will be used to drain your full bladder. However if you have a difficult vaginal birth or a caesarean, you may need the catheter to be left in for longer (Jones et al 2012, MIDIRS 2008: 8, NCCWCH 2007: 197, OAA 2012).
You will need more monitoring. Your baby's heartbeat will be monitored continuously for at least 30 minutes at first, and then after each top-up (NCCWCH 2007: 122). Your blood pressure will be taken every five minutes when the epidural is started, for about 30 minutes, and after each top-up. This is because the epidural can cause your blood pressure to fall (NCCWCH 2007: 117).
You're more likely to need your labour speeded up with a Syntocinon drip (Anim-Somuah et al 2011, NCCWCH 2007: 110-12, 117). However, hospital staff should give you the chance to have a longer, slower labour, before using drugs to speed it up (NCCWCH 2007: 150, 152-3).
The second stage of labour, the pushing stage, may last longer if you have an epidural (Anim-Somuah et al 2011, NCCWCH 2007: 113). You may not feel an urge to push. If this is the case, and there's no sign of your baby's head yet, waiting an hour, or until you feel the urge to push, should be encouraged (NCCWCH 2007: 121).
There's more chance of your baby needing to be born with the aid of forceps or ventouse (Anim-Somuah et al 2011, Jones et al 2012, NCCWCH 2007: 113, OAA 2012). This may be because epidurals can make it difficult for your baby to move into the best position for birth.

Your baby is more likely to end up in a posterior position by the time you're ready to give birth. This can happen even if he wasn't in that position when your labour started (Lieberman et al 2005).
There is a small risk of you having a severe headache (RCOA 2008). This can happen if the epidural needle punctures the bag of fluid that surrounds the spinal cord, causing a leak of fluid.

There is about a one in 100 chance of this happening (OAA 2008, 2012). It's usually treated by taking a small amount of blood from your arm, and injecting it into your back to seal the hole made by the needle (epidural blood patch). This is done after your baby is born.
There's a very small risk of nerve damage, leaving you with a numb patch on your leg or foot, or a weak leg (RCOA 2009b). But this rarely happens. The risk is about one in 1,000 for temporary nerve damage and one in 13,000 for permanent damage (OAA 2008, 2012).

For more information see the Obstetric Anaesthetist Association's epidural information card.
What else should I know?
Epidurals are only available in obstetrician-led maternity units (NCCWCH 2007: 113). So you can't have one at birth centres, midwife-led units, or if you have a home birth.
Maternity units equipped to give epidurals may not offer a 24-hour service. Much depends on what your local unit offers, and when your labour starts.
If you feel pain or pins and needles in your legs, tell your anaesthetist immediately, but try to stay still. This may be a sign of temporary nerve damage and that the needle needs repositioning (RCOA 2009b). Permanent damage is thankfully rare.
Not everyone can have an epidural (OAA 2012). The anaesthetist will ask you questions about your health, and if you have any medical conditions, before performing an epidural. This may affect whether or not you can have one.

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