Dr Danie Schneider
Obstetrician and Gynaecologist, Somerset West

Epidural and spinal in labour

Are there adverse consequences of pain in labour?

The pain of labour can have emotional, as well as physiological effects. These changes can have an impact on both the mother’s body and her baby.

Research has shown that unrelieved pain during labour is a risk factor for postpartum depression.

We know that hyperventilation accompanies labour pain. The resulting changes in the mother’s oxygen delivery system are usually well tolerated in healthy moms with a healthy baby, but can have a negative effect in pregnancies were the mother or baby are under stress due to underlying conditions that compromise oxygen delivery.

Animal studies have shown that stress and pain can lower oxygen supply to a fetus. These changes can have a negative effect in pregnancies were there are other conditions that compromise oxygen supply.

What factors influence the pain experienced during labour?

It is important to understand that your unique emotional, cultural, cognitive and social circumstances influence the way you experience pain. We know that the pain of labour and delivery varies between women and experience has also shown that each labour of a woman can be quite different. Sometimes the baby can lie in an abnormal position, eg oksipito-posterior and this is known to be associated with more intense pain.

Experience has shown that many women rate the pain of labour as very severe. Research has however shown that the intensity of the pain in labour is not the most important factor in determining your childbirth experience. A sense of personal control over the decisions taken in labour, however, directly correlate with the maternal satisfaction. Rational decision -making can be difficult during times of emotional stress and this can negatively impact on the birth experience.

It is therefore important that you are involved in the decision-making process throughout labour. We will discuss the different pain relief techniques in detail during antenatal consultation and your questions will be answered. This will give you time to carefully contemplate your options before labour starts. It is important to involve your birth partner as well.

What are advantages of an epidural in labour?

An epidural can reverse the additional potential negative effects that hyperventilation in response to pain can have on a high risk pregnancy. In mothers with certain heart problems or raised blood pressure, this can be very advantageous for mother and baby.

An epidural results in decreased concentrations of stress hormones that can be beneficial for mothers with heart problems and pre-eclampsia. By providing adequate analgesia the blood flow to the uterus and placenta can be improved.

By providing adequate pain relief the epidural can decrease the incidence of postpartum depression by reducing pain and anxiety.

It can be very wise to have an epidural early on in high risk labours e.g. twins, previous post-partum bleeding, pre-eclampsia, etc. The goal of an early epidural in this setting is to reduce the need for a general anaesthesia for an unplanned, but likely high risk caesarean section.


How is an epidural done?

An epidural block is a sterile procedure done by a qualified specialist anaesthetist. The procedure will be discussed with you by the doctor before commencing the process. Informed consent will be taken by the doctor. A regular intravenous drip is inserted to enable you to get extra fluid into your body before the procedure. Firstly the skin is infiltrated with a small amount of local anaesthetic, so that you should not feel the epidural.  Then a thin tube, called a catheter, is placed under the skin of your back to reach a safe level outside of your spinal column. The anaesthetist does continuous checks during this phase to enable safe placement of the epidural. It is important to sit still during this phase. Note that the anaesthetist and supporting midwife will sympathetically guide you through this process all the way.

The doctor will then inject medicine into the catheter and this numbs the nerves in your spine to block the sensation over your abdomen. The aim is to take the edge off the pain and NOT to paralyse you. Many women are still aware of the contractions, but cannot feel the actual pain. The catheter is safely secured and stays in for the rest of your labour.


What happens after the epidural is done?

Your blood pressure, as well as the strength of your epidural block sensation, is monitored throughout labour. Your baby’s heart rate will be monitored continuously. A soft catheter will be inserted to drain your bladder until the epidural is stopped.

Be aware that there is no reason to discontinue the epidural before the baby is born. Recent research has shown that this old practice has no benefit. Once the baby is delivered, the  epidural catheter will be carefully removed and your full sensation will return.


What is the difference between an epidural and a spinal?

An epidural is usually done for pain relief in labour. This is a slightly more technical procedure than the spinal. With the epidural a soft catheter is inserted in the epidural space (the negative pressure space outside of the spinal column). This is in effect similar to a drip line being inserted as the catheter stays there till removed, enabling the anaesthetist to continuously administer local anaesthetic safely for as long as desired.

During a spinal anaesthetic the anaesthetist gives a once off injection directly into the spinal column. This is very similar to a lumbar puncture procedure and is technically easier to do and takes less time than an epidural. A much thinner needle is used as no catheter needs to be inserted. We usually do this for a planned or emergency caesarean section. The block lasts a known time, usually around 4 hours.


When can I have an epidural in labour?

The decision to place an epidural primarily depends on your wishes. We can guide you in making this decision. Often factors that can be considered at this time is your parity (how many babies you have had), as well as your previous experience. We do not belief that there is any reason to fear that the epidural will slow down your labour and we therefor do not wait for a specific cervical dilatation before we administer the epidural.


What are the implications of Covid?

Covid does put additional stress on the medical system and it is important to remember this when you make decisions regarding the timing of pain relief. It is often a good idea to rather have an epidural earlier in labour when an anaesthetist is available. This often is a valuable asset when an emergency Caesarean section is unexpectedly needed, as this lowers the risk of a general anaesthetic (due to the added risks of aerosol generation for staff  in case of a failed spinal).


Can a spinal always be done for a caesarean section?

A spinal anaesthetic is generally the first choice for a caesarean section. This is a quick and safe procedure when done correctly. Sometimes unexpected technical difficulties arise that make correct placement problematic. It is important to be aware that the procedure is technically a lot more difficult if you are significantly overweight or have had pervious surgery or trauma to you spine. It is very rare for us to have an absolute contraindication for a spinal and we usually approach such problematic situations on a case-by-case basis. We would advise a general anaesthetic if you take blood -thinners or have a bleeding tendency. We also favour a general anaesthetic if we suspect technical difficulties during the caesarean section as is sometimes found with a low lying placenta.


Can I have an epidural if I have trial of labour after a previous C/S?

An epidural can provide adequate pain relief during labour for vaginal birth after a previous caesarean section. From research is does not appear that an epidural will lower your chances of a successful vaginal birth. Importantly we do not believe an epidural will mask the signs of a uterine rupture. It is important to understand that an epidural can provide adequate anaesthesia in the event of a rapid emergency procedure being indicated due to complications.


What are complications or risks of an epidural?

An epidural can lower your blood pressure and this is why you receive a drip and a bolus of intravenous fluid before the procedure to counteract the possible effect. The anaesthetist can also administer a drug that can raise the blood pressure. You will need to stay in bed and can’t walk on your own until the block has safely worn off.

Sometimes a small percentage of women develop a fever. Rarely this would need antibiotic treatment or further testing to rule out other problems that could also cause a fever.

Pruritus or an itchy skin is a common side effect. This can usually be treated with medication if desired.

Some women have a headache after an epidural, but this is rare following uncomplicated and straightforward procedures.

Rarely the block can be too high (too strong) or simply not work fully and the anaesthetist will then make alternative plans.

Bleeding at the procedure site is a rare and potentially troublesome complication. This is usually prevented by not considering the procedure in women with a risk for bleeding.

An epidural should not affect the baby negatively as long as your blood pressure is stable. There should not be any negative effect on breastfeeding