Labor and delivery

Epidural: An option for you?

By Jennifer Newton Reents

* Some names and identifying details have been changed to protect privacy.

"Get the epidural!" said every single one of my friends with kids. I expected to. I planned to. I didn't get to. For many women, an epidural is not an option.

When our babies decide to come quickly—I went from 5 to 10 centimeters in 35 minutes—often there is no chance for pain relief. Like many others, I unexpectedly ended up with a natural childbirth. I assumed an epidural was an option at my quiet, 66-bed hospital. I assumed an anesthesiologist would be at my beck and call, waiting to make my pain disappear. But as it turns out, assuming is foolish: The anesthesiologist was actually 35 minutes away, had to be paged, and didn't have the medication anyway.

What is an epidural?

An epidural is a regional anesthetic (painkiller). To administer it, the anesthesiologist inserts a needle into an area near the spinal cord known as the epidural space. The anesthesiologist then threads a soft catheter into that space, removes the needle and tapes the catheter into place. Then, local anesthesia is administered continuously through the catheter and adjusted as needed. Across the US, about 50 percent of women use epidurals during childbirth, according to Dr Jun Zhang, PhD, MD, of National Institute of Child Health and Human Development's Division of Epidemiology, Statistics and Prevention Research. Some hospitals, particularly larger ones, have epidural rates as high as 85 percent.

Many smaller and rural hospitals, however, are choosing not to offer epidurals because they simply can't afford to keep an anesthesiologist on staff full time. These specialists must be paged when they are needed. And some smaller hospitals only offer other forms of pain relief, such as intrathecals, narcotics to "take the edge off" through an IV or injection and spinal blocks, which use less medication and are injected once into the spinal area.

It's wise to carefully explore your pain relief options for pregnancy and birth. But all your research may not matter if you don't check with your caregiver and your hospital to find out what's available first. Don't assume you will be given an epidural when you ask. Know your options.

A trend?

Dr. David Birnbach, chief of women's anesthesia and associate director of the Institute for Women's Health at the University of Miami School of Medicine in Miami, Florida, says there is a trend toward small and rural hospitals not offering epidurals. "Typically, a hospital must have between 1,500 and 2,000 deliveries a year to afford an anesthesiologist for the maternity ward. In many [smaller] hospitals, an anesthesiologist will be called from the main operating room to come to OB as soon as he or she is available—and that may vary from minutes to hours, depending on logistics."

Crystal O'Hara, like many first-time expectant moms, didn't know what to expect during labor. Though she'd planned on a natural childbirth, she also kept her mind open about using pain medication. "I had a very difficult labor," says O'Hara, who lives in central California. "I went into labor on a Wednesday night, and I didn't have my son until Saturday morning. I was in active labor for about 26 hours. About 15 hours into the ordeal, I was begging for an epidural. I had written on my birth plan that my idea was not to have one, but if I asked for one, I meant I wanted it."

She learned during labor, however, that the hospital provided only intrathecals for childbirth. O'Hara says she was never offered even this type of relief. She remains upset that she had to endure so much pain. "If I ask for an epidural or other pain medication, my choice should be honored," she says. "No one can judge how much pain another person is in."

Dr. Joy Hawkins, president of the Society for Obstetric Anesthesia and Perinatology (SOAP) and director of obstetric anesthesia at University of Colorado Hospital, says she believes a shortage of anesthesiologists across the US may be one reason smaller hospitals are not able to offer epidurals to laboring women. "In some ways, a 24-hour labor analgesia service is like running a trauma service. Some small hospitals don't do that either, for the same reasons," says Dr. Richard Smiley, chief of obstetric anesthesia at Columbia-Presbyterian Medical Center in New York City.

At Staten Island University Hospital in New York, about 2,700 babies are delivered each year. At this 813-bed hospital, epidurals are available 24 hours a day, and an anesthesiologist is assigned solely to the labor unit at all times, says Dr. James Ducey, director of obstetrics and maternal-fetal medicine. The hospital has about a 70 percent epidural rate. "Our philosophy about pain management in labor is educate women prior to labor about the risks and benefits of various methods and to provide what they wish at the time of birth," he says. "We also employ intravenous narcotics and hydrotherapy in a whirlpool bath. It is important to provide epidurals because [they are] a very effective method of pain control."

By contrast, when California's Sutter Davis Hospital offered epidurals, only about 10 percent of laboring moms used them, according to the hospital. Central Anesthesia Service Exchange (the company contracted to provide anesthesia) discontinued service for childbirth to the hospital in September 2001. According to newspaper accounts, this resulted from a lack of manpower and a change in requirements by its new malpractice insurance provider regarding how epidurals are to be supervised.

While Norah Ryan*, a mother in Fort Lauderdale, Florida, had an unmedicated birth with her third child, she was happy knowing she had the epidural option, even if she didn't use it. "I had an epidural once before, and it was great. I also had a natural birth, which was hard but phenomenal," she says. "When it came time to have another baby, I decided to try it without pain medication again. I got a lot of confidence from the fact that an epidural was readily available if I needed one. I could actually relax during labor much more just knowing I had that option. It was my safety net."

Plan B: alternatives to epidurals

To better prepare yourself for the unexpected twists of labor, make sure you have a "Plan B" in place to help you cope should an epidural not be available—or not advisable, given your specific circumstances. (For example, if you have a very fast labor, there may be no time for an epidural!) Take childbirth education classes and consider studying relaxation or self-hypnosis methods. Learn the risks and benefits of other forms of pain relief such as intrathecals, spinals and IV medications. (See sidebar.) And as early as possible in your pregnancy, discuss your options with your healthcare provider, and check that your insurance plan covers epidurals and pain medication for childbirth.

Dr. Smiley recommends asking if the anesthesiologist is in the hospital all the time or takes calls from home. "This matters less if 'home' is five minutes away, as in some smaller communities, but may make a big difference in an urban hospital, or some rural areas where 'home' may be 80 miles away," he says.

Dr. Smiley also suggests asking if an anesthesiologist is specifically assigned to the labor and delivery unit. "The larger the hospital and anesthesia group, the more likely to have an in-house, dedicated anesthesiologist," he says.

Most importantly, determine whether your doctor has a policy about when epidurals can be given. "Some OBs and/or labor services have formal or informal 'rules' like, 'no epidurals before 5 cm' or 'try Demerol first for an hour and then see'," he says.

"Most women expect all options to be available to them. But remember that labor and delivery units are unpredictable places," Hawkins says. "Even if an anesthesiologist is available 24 hours a day, there may be an emergency cesarean section that might tie him or her up for an hour or more That doesn't mean [your] labor pain [will be] ignored—just that things will be prioritized and a woman or baby's safety will come first. Therefore, you should investigate all your options before labor begins."

While many women opt for natural labor or choose to deliver with very little pain medication, you're the one best equipped to make the decision. Weigh the risks and benefits to decide what you think is right for your birth, your body and your baby.

Know your options long before you arrive at the hospital, and trust your instincts if they tell you to choose a birthing center or hospital with more pain relief options. As long as you know as much as possible about what to expect ahead of time, you should be able to have the final say.

Epidural benefits vs. disadvantages

Benefits

• usually provides excellent pain relief
• small amount of medication is used, so you remain alert
• mot very much medication reaches the baby
• safer than general anesthesia, if cesarean section is required

Disadvantages

• may provide inadequate or patchy pain relief
• necessitates immobility, precluding walking or other movement that may help labor's progress
• decreased pushing urge and ability
• possible shivering, itching
• usually requires urinary catheterization
• requires continuous monitoring to detect complications and/or progress
• reduces experience of birth; mother becomes observer instead of full participant

Risks to the mother

• fever
• serious drop in blood pressure
• malpresentation or malposition
• since it may interfere with progress, increased need for Pitocin
• increased need for forceps and vacuum
• Increased need for cesarean section
• severe postbirth headache
• long-term backache
• severe complications are very rare but include paralysis and death

Risks to baby

• Medication crosses placenta
• Septic workup and NICU care if maternal fever develops
• Complications due to forceps, vacuum or cesarean section delivery
• Respiratory depression
• Increased likelihood of fetal distress due to mother's low blood pressure
• Short-term neurobehavioral changes, including irritability and inconsolability

Medical pain relief options

Analgesia

Full or partial relief of pain sensations

Anesthetic

A block of all sensations and muscle movement

Combined spinal-epidural block/walking epidural

Uses both epidural and spinal techniques to provide pain relief almost immediately. Medication is injected into the spinal sac and the epidural catheter is placed. There may be less numbness with this technique, and some women are able to walk around after the block is in place. Variations of this technique are sometimes referred to as the "walking epidural."

Epidural

An anesthetic delivered by injection near the lower spine. It numbs the body below the injection, usually from the waist down. Contractions are not felt.

Intrathecal

single dose of anesthetic (instead of a continuous flow) into the fluid around the spinal cord. Less of a numbing sensation but allows the woman to feel contractions so she may push.

IV or shot

Pain-relieving medications are injected into a vein or muscle and dull (but not completely eliminate) pain. Your obstetrician usually prescribes these medications. Because they often make both you and your baby sleepy, they are used mainly during early labor and are considered by many to be the least "natural" choice for pain relief medication.

Local anesthesia

Other pain-relieving medications are injected in the vaginal and rectal areas by your obstetrician at the time of delivery. These medications are local anesthetics, which provide numbness or loss of sensation in a small area. This technique is often used to ease the pain of delivery or episiotomy. It does not lessen the pain of contractions.

Spinal anesthesia

Spinal anesthesia uses a much thinner needle than an epidural but is placed in the same location of the back. A much smaller dose of anesthetic medication is needed for a spinal block, and it is injected into the sac of spinal fluid below the level of the spinal cord. Once the spinal anesthetic medication is injected, the onset of numbness is almost instant. The development of new spinal needles has dramatically decreased the risk of headache following spinal anesthesia.

Source: American Society of Anesthesiologists

Non-medicated pain relief options

Active birth

With this method, you work with the pain, which may make labor more effective. The technique uses coping techniques often taught in childbirth education classes. Doulas or other birth assistants can help support you. With active birth, you are more in control and at less risk for medical interventions, which can make the experience very rewarding.

On the down side, there may not be enough privacy or a supportive-enough atmosphere in the hospital. Sometimes you need more help with pain, especially if you labor for a long time.

Aromatherapy

Fragrant essential oils can help you relax, improving progression and control of labor. Your partner can take an active role by massaging you with the oils. Consult a doula or other caregiver for information on other aromatherapy options.

Acupuncture, acupressure, and hypnosis

These can help reduce pain (or at least your perception of it), creating a sensation of well-being and control -- and minimizing the likelihood of medical intervention. They can be used in conjunction with other forms of pain relief. However, they require consultation with and/or administration by trained practitioners.

With acupuncture and acupressure, thin needles or firm pressure is applied to specific pressure points on the body; they're most effective if used from the beginning of labor rather than at the onset of strong pain. In hypnosis, you call upon learned techniques of deep relaxation to eliminate the fear/tension/pain cycle.

Doula

A doula is a professional labor support person, there to help you through every moment of your labor and birth. Through her training and expertise, she can offer countless ways to help relieve your pain and progress labor. In fact, moms with doulas at their sides ask for epidurals 60 percent less often than moms without. (And, even if you do end up with an epidural, your doula is there to support you and your decision.)

Water

Water—whether in a tub or a shower—can help you relax between and during contractions. Showers can be very soothing during labor. If you want to actually labor in water (known as the "midwife's epidural"), a deep tub or a pool can be used. In the hospital, pools or tubs aren't always available when needed, and not all hospitals provide access.