WHAT IS AN EPIDURAL?

An epidural is a medical procedure that features the administration of painkillers into the small of the back via a fine tube. An epidural is classified as a regional anesthetic. This implies that not every part of the body is affected.

The anesthetist injects the medication around the nerves transmitting the pain signals from the uterus and cervix during labor. An epidural is usually very effective in pain relief.

An epidural is usually administered by a qualified anesthetist, like Dr. Robert St. Thomas. No less than 30 percent of women have had an epidural during labor.

Most health facilities use epidurals in low-dose. Such epidurals are a combination of other drugs. The mixture usually comprises of an anesthetic and an opioid. The later usually fentanyl while the former is usually bupivacaine or levobupivacaine.

A low-dose epidural permits retention of some sensation in the legs and feet. With these, the patient should be strong enough to move around in bed and change position at will.

It is best for the patient to constantly change the position while sitting or lying. This prevents the development of pressure on the numbed area of the body.

Walking around or standing is only possible if the patient is supported by extra staff. This is known as mobile epidural.

Where are epidurals administered?

Epidurals can only be administered in the maternity unit of a health facility. The unit is usually led by an obstetrician. An epidural cannot be administered at a birth center.

Some anesthetists would be glad to administer an epidural in a hospital-based birth center, where the center stands close to an obstetrician-led maternity unit. However, the implication is that the pregnant woman would no longer receive the care offered by a midwife and would only be looked after by the obstetric team.

Maternity units offering an epidural may not render a 24-hour service. Everything depends on what the local unit offers and when the labor begins.

Most women may have an epidural, but it is not recommended for everyone. The anesthetist will have to carry out a comprehensive investigation into your medical condition before an epidural is performed.

How is an epidural given?

An anesthetist will first of all numb the patient’s back with a local anesthetic. Thereafter, a fine, hollow needle will be placed between the bones in the spine.

The needle is inserted into the space between the layers of tissue in the spinal column. This layer is known as the epidural space. An epidural catheter will be passed through the needle. Then once the tube is in place, the needle will gently be removed.The other end of the tube is taped onto the back and over the shoulder to keep it in position.

The patient is advised to keep still while the epidural is being set up. The anesthetist may ask you to lean forward while you are on your side. This creates spaces between the bones of the spine.

Focus your attention on your breathing to help you keep still. Breathe deeply though the nose, and exhale slowly through the mouth. Maintain eye contact with your birth partner if one is present.

If pain is felt in the legs, then inform the anesthetist immediately. However, maintain calm. This may signify a temporary damage of the nerve. The nerve usually repairs itself in a few weeks. Only in rare cases does permanent damage occur.

Epidurals may be administered as:

Injection with top-ups

Here, the anesthetist will inject painkillers into the tube to numb the lower abdominal region. About 10 minutes is required to set up an epidural. Another 15 minutes is required before the effects are felt. If adjustment is needed, then it may take up to 40 minutes for everything to be in place. After this, you’ll no longer have painful contractions.

As the effect of the epidural wears off, you may have additional top ups that may last an hour or two.

Continuous infusion

After the epidural catheter has been set up, the anesthetist will attach the other end to a pump. This allows continuous flow of the pain killer into the patient’s back. More potent top up doses of local anesthetic can be administered if needed. In some cases, the pump may be under the patient’s control. This is called patient-controlled epidural analgesia. However, it is not available in all health facilities.

Combined spinal epidural (CSE)

A low-dose of analgesics forms part of this injection. It has a faster action than a sole epidural medication. The injection will be administered by the anesthetist directly into the fluid surrounding the spinal cord located in the inner recesses of the back. At the same time, an epidural catheter will be inserted into the epidural space, this will be put into use much later.

When the CSE begins to wear off, the anesthetist will pass the epidural solution through the tube to relief the patient of pain. An ice cube or cold spray will be placed on the tummy or legs to check if the pain relief is working. If the patient feels the coldness of the ice, then the anesthetist may need to readjust the epidural.

Does having an epidural affect the baby?

An epidural causes a decrease in blood pressure. This implies that there will be a reduced oxygen flow to the baby. Before embarking on an epidural, the anesthetist will insert a small tube known as an intravenous cannula into the arm or hands. This is done so that fluids can be fed through if the blood pressure falls later.

The opioid drug present in the epidural may not affect the baby. It has a standard dose of 20mcg which is too weak to drowse the infant.

References

Anim-Somuah M, Smyth RMD, Jones L. 2011. Epidural versus non-epidural or no analgesia in labor. Cochrane Database of Systematic Reviews 12: CD000331. www.ncbi.nlm.nih.gov [Accessed July 2016]

CIHI. Epidural rates for vaginal delivery. Health indicator library, CIHI. Indicatorlibrary.cihi.ca [Accessed July 2016].

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