Epidural during Labor for Pain Management
- How often epidurals during labor are used, and the difference between epidurals, spinals, and combined spinal epidurals (CSEs)
- The benefits of epidurals, spinals, and CSEs
- The potential risks and side effects of epidurals, spinals, and CSEs for mother and baby
We want to let you know that new evidence has come out since we recorded this!
There was an updated Cochrane review published in 2018 that looked at 40 different studies, with over 11,000 participants. In these studies, they compared people receiving epidurals, spinals, and CSEs to those who were either receiving no pain medication or were receiving injections in their arm of temporary pain medications. Most of the people in the studies who did not receive epidural-type pain relief were receiving injectable opioid medications for pain management.
They found that epidural-type pain relief methods lowered pain on average about two to three points when you’re looking at a zero to 10 scale, with zero being no pain and 10 being the worst pain possible.
More people using epidurals reported their pain relief to be “excellent or very good.” So, epidurals may be more effective at reducing pain and increasing maternal satisfaction with pain relief compared to non-epidural methods of pain relief. Only one trial with about 332 people reported on overall satisfaction with the childbirth experience, and they found no difference in satisfaction rates between those who had epidurals and those who had injections of temporary pain medications.
People with epidurals experienced less nausea and vomiting and had less risk of breathing problems requiring oxygen compared to the people receiving opioid medications.
There was no difference between people in the epidural or opioid groups for postnatal depression, headaches, itching, shivering, or drowsiness.
There were also no differences in newborn intensive care unit admission and Apgar score less than seven at five minutes. Babies born to mothers who used epidurals were less likely to have received naloxone (a medication designed to reverse the effects of opioid medications).
The 2018 Cochrane review found that people with epidurals were more likely to experience low blood pressure and were also more likely to have a fever during labor. And they had more urinary retention, where a catheter is inserted into your bladder to drain your urine throughout the rest of labor.
They were more likely to experience something called heavy motor-blockade. That means that your legs might become so heavy and difficult to move that you can’t really move the lower part of your body.
Importantly, people with epidurals had longer first and second stages of labor and were more likely to have oxytocin augmentation to speed up labor.
People in the epidural group were more likely to experience forceps/vacuum-use to help the baby come out at the end of the pushing phase. This type of birth is more likely to cause severe tears in your perineal area. However, when the authors restricted the data to only recent studies (since 2005), they no longer saw this increase in risk. So it could be that lower concentrations of local anesthetic and more modern epidural techniques have helped to reduce the risk of forceps/vacuum-use.
There was no difference in Cesarean rates, including the risk of Cesarean for fetal distress or for labor dystocia. However, in both groups, the rate of Cesareans was only 11% to 13%. That is much lower than is typical in many birth settings! And since epidurals do appear to slow labor (longer first and second stages of labor and more oxytocin augmentation), it’s possible that the risk of Cesarean could increase with epidural-use in some practice settings in the real world (outside of the clinical trial setting). This means that with epidural use, it’s especially important for care providers to follow best practices that help to prevent Cesareans!
Anim-Somuah, M., Smyth, R. M. D., Cyna, A. M., et al. (2018). Epidural versus non-epidural or no analgesia for pain management in labour. Cochrane Database of Systematic Reviews 2018, Issue 5. Art. No.: CD000331. Click here. Free full text!
- American College of Obstetricians and Gynecologists (2017). Obstetric analgesia and anesthesia. Practice Bulletin No. 177. Obstet Gynecol; 129:e73 – 89.
- American College of Obstetricians and Gynecologists (2019). Obstetric analgesia and anesthesia. Practice Bulletin No. 209. Obstet Gynecol; Vol. 133, No. 3:e208-e225.
- American Society of Anesthesiologists (ASA). Types of Pain Relief in Labor and Delivery. Accessed online on October 2, 2017.
- Anim-Somuah, M., Smyth, R. M., and Jones, L. (2011). Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev(12), CD000331.
- Chaillet, N., Belaid, L., Crochetière, C., et al. (2014). Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Birth, 41(2), 122-137.
- D’Angelo, R., Smiley, R. M., Riley, E. T., et al. (2014). Serious complications related to obstetric anesthesia: the serious complication repository project of the Society for Obstetric Anesthesia and Perinatology. Anesthesiology, 120(6), 1505-1512.
- Hawkins, J. L., Chang, J., Palmer, S. K., Gibbs, C. P., & Callaghan, W. M. (2011). Anesthesia-related maternal mortality in the United States: 1979-2002. Obstet Gynecol, 117(1), 69-74.
- NHS Choices. (2017). Epidural risks and side effects. Accessed online on October 2, 2017.
- NHS Choices. (2017). Pain relief in labor. Accessed online on October 2, 2017.
- Nucleus Medical Media (2009). Video: Epidural & Spinal Anesthesia. Accessed online on October 2, 2017.
- Shipley, C. (2013). Video: Epidural Spinal Anesthesia. Accessed online on October 2, 2017.
- Shnider, S. M., Abboud, T. K., Artal, R., et al. (1983). Maternal catecholamines decrease during labor after lumbar epidural anesthesia. AJOG, 147(1):13-15.
- Simmons, S.W., Taghizadeh, N., Dennis, A.T., et al. (2012). Combined spinal-epidural versus epidural analgesia in labour. Cochrane Database of Systematic Reviews, Issue 10. Art. No.: CD003401.
View the transcript
Hi, my name is Rebecca Dekker. I’m a Nurse with my PhD and the Founder of Evidence Based Birth®. In this video, we’re going to talk all about epidurals. So in this video, we’re going to talk all about what epidurals are, and what evidence says are the benefits and risks of having an epidural during labor.
An epidural is also sometimes called an epidural block. This is when a catheter is placed in your lower back in an area right beneath where the spinal cord ends. An epidural can cause some loss of feeling and numbness in the lower part of your body, but the person who’s in labor remains fully awake and alert.
Today, more than 60% of people giving birth in the US have either an epidural or a spinal block during labor. A trained care provider gives you an epidural by using a small needle to go into your back, and over on top of that needle is a small catheter that’s a small plastic tube. The needle is used to guide the small plastic tube into that epidural space in your back. Drugs given through that small plastic tube or catheter can help with pain during labor. More drugs or stronger drugs can also be given through that tube if you end up needing a cesarean, forceps or vacuum delivery.
Now, after they get the plastic tube in your back, they remove the needle so it’s just the thin plastic tube in your epidural space. An epidural takes about 10 minutes to set up and takes about 10 to 15 minutes to start working. It doesn’t always work well at first and sometimes your medications may need to be adjusted so that you get the pain relief during labor you’re looking for.
Epidurals vs. Spinal Blocks
A spinal block is somewhat similar to an epidural. It’s given as an injection in your lower back, but it’s given with a much smaller, thinner needle, and with a much smaller dose of the drugs. The drugs are injected into a sac of spinal fluid that’s right below the spinal cord in your back, and it causes a loss of feeling in your lower body. A spinal block is usually only given once during labor and it provides immediate pain relief instantaneously, but it’s only good for about an hour or two. Stronger drugs with a spinal can also be used to block all feeling during a cesarean.
Combined Spinal Epidural Block
You can also combine these two treatments into one and that is called a Combined Spinal-Epidural block or sometimes abbreviated CSE. With this method, you get both the benefits of both methods. The immediate pain relief of a spinal is there and then you get the continuous pain relief of an epidural. Lower doses of medications can sometimes be used in the CSE, and so this is what people are referring to when they’re referring to a walking epidural, because you have lower doses used, you may be able to retain some mobility.
However, there was a Cochrane review where they combined a whole bunch of research on CSEs and traditional epidurals, and they found actually no difference in how mobile you are with an epidural versus a CSE.
Benefits of using an Epidural during Labor
Epidurals, spinals, and CSEs all carry pretty much the similar benefits and similar side effects. As I’m talking about side effects, they apply to all of these methods. The main benefit of an epidural during labor is that it is considered the most effective form of pain relief.
There was a Cochrane review that looked at 38 different studies, with nearly 10,000 participants. In these studies, they compared people receiving epidurals, spinals, and CSEs to those who were either receiving no pain medication or were receiving injections in their arm of temporary pain medications. They found that epidural-type pain relief methods lowered pain on average about three and a half points when you’re looking at a zero to 10 scale, with zero being no pain and 10 being the worst pain possible. An epidural was effective by lowering that about three and a half points.
Epidural-type pain medications are also safer for the baby, compared to giving pain medications through an IV. Only two studies of about 360 people reported on satisfaction with epidurals, and they found no difference in satisfaction rates between those who had epidurals and those who did not.
Another benefit of epidurals during labor that is not mentioned in some of these studies, but anecdotally you hear a lot, is that if somebody is really tired or exhausted from labor, epidurals can help them rest and relax, and get some much needed sleep if they’ve been having a long labor.
Having an epidural in place during labor may benefit people at high risk of needing an emergency Cesarean. If an emergency Cesarean is necessary and the laboring person already has a functioning epidural in place, the existing epidural can be used for the surgery by simply adding a higher concentration of medication. According to ACOG, converting an epidural to a higher concentration takes about 10 minutes and it can be done during preparation for transport to the operating room. On the other hand, if the mother is laboring without an epidural and an emergency Cesarean is necessary, she will need either spinal anesthesia or general anesthesia before the surgery. In expert hands, spinal anesthesia takes only 8 minutes to reach the right level of block for the surgery (ACOG, 2019). However, it’s possible that there could be problems placing the block, which could cost time during the emergency. So in that case, it would be an advantage to have an existing epidural. General anesthesia, used with only 5.6% of Cesareans in the U.S., is the quickest method to use in an emergency, but it increases risks of complications (D’Angelo et al. 2014).
There is also some evidence that severe pain (suffering, not coping with labor) can lead to a higher maternal stress response with decreased blood flow (oxygen) to the baby. Effective pain management may reduce maternal stress reactions and improve blood supply to the baby (Shnider et al. 1983).
Those are the benefits, the main benefits have to do with pain management. What are the side effects or risks of epidurals during labor?
Risks of using an Epidural during Labor
The Cochrane review that found that epidurals are very effective with pain management during labor also found a lot of different side effects. You’re much more likely to need a forceps or vacuum delivery to help the baby come out at the end of the pushing phase. This type of delivery is more likely to cause severe tears in your perineal area.
You’re much, much more likely to experience low blood pressure, which can make you feel lightheaded or nauseous, and may require additional IV fluids or medications to manage. A drop in the mother’s blood pressure can also compromise the oxygen status of the baby. Also, there is an increased risk of needing a cesarean for signs of fetal distress if you have an epidural during labor. However, there’s no increased risk in the overall rate of cesarean in these studies in the Cochrane review, just an increased risk of needing one for the baby being distressed.
You’re much more likely to experience something what we call heavy motor-blockade. And that means that your legs might become so heavy and difficult to move that you can’t really move the lower part of your body. That doesn’t happen to everyone, but you’re much, much more likely to have that if you have an epidural.
The Cochrane reviewers also found that you’re much more likely to have a fever during labor with an epidural, lose bladder control and not be able to urinate, and so often, there’s a catheter inserted into your bladder to drain your urine throughout the rest of labor.
Also, you’re more likely to need Pitocin to speed up your labor because the epidural during labor can slow your labor down. Then, you’re more likely to have a longer second stage of labor, the pushing phase, with an epidural. We’ll cover more about pushing phases with an epidural in a separate video. Other risks and side effects from epidurals, spinals, and CSEs include feeling itchy, having itchy skin. This is a very common side effect.
Feeling sick or nauseous, although this is less common with an epidural than it would be. It’s more common if you’re are given medications through your arm through an IV. Inadequate pain relief, researchers estimate anywhere from one in eight to one in 10 people with an epidural will not have satisfactory pain management with the epidural.
About one in a 100 mothers reports a spinal headache. Epidurals can cause slowed breathing and drowsiness in the mother. The site where the needle went in could cause slight infection, but usually, those are not serious and can be treated with antibiotics. You can have a temporarily sore back from the epidural injection. Now more severe complications, things like nerve damage, seizures, severe breathing difficulty, and death are extremely rare. In fact, death from epidurals is so rare that one study during a 10 year period in the United States, found zero recorded deaths from epidurals during labor.
Interventions with Epidurals during Labor
It is important to consider how having an epidural during labor can medicalize your birth. You can think of an epidural as almost like a bundle of interventions that go along with it. It’s not just the epidural needle and the pain management.
There will likely be continuous blood pressure monitoring, oxygen monitoring with a probe on your finger. Additionally, you’ll have a cuff on your arm to measure your blood pressure, a probe on your finger to measure your oxygen level. You may need extra IV fluids. In fact, probably most people will have extra IV fluid through the IV in your arm. You’ll likely need Pitocin to help augment or speed up your labor. There is a likelyhood you’d have a catheter in your bladder. Also, you would probably need to stay on a continuous fetal monitor and contraction monitor, and you’ll have several belts strapped around your abdomen. Then you have a higher risk of needing a vacuum delivery at the end of the second stage to help get your baby out.
The bottom line is that epidurals, spinals, and combined spinal epidurals during labor are very effective ways to help manage pain. However, they do carry potential risks and side effects for the mother and the baby.
That’s it. I hope this video was helpful for you. Thanks. Bye. To learn more and subscribe to our newsletters for useful information, please visit EvidenceBasedBirth.com.
Stay empowered, read more :
Don't miss an episode! Subscribe to our podcast: iTunes | Stitcher On today's podcast, we're going to talk with EBB Childbirth Class Parent, Shelitha Owens about her inspirational home waterbirth story. Shelitha Owens (she/her) is an environmental policy manager...
EBB 229 – Evidence on Doulas: Community-Based Models, the Pandemic and Reimbursement with the Research Team
Don't miss an episode! Subscribe to our podcast: iTunes | Stitcher In today's episode, hosted by the EBB Research Team, we are sharing the audio from a private livestream we did with our Pro Members at Evidence Based Birth. We talk about three major topics related...
Don't miss an episode! Subscribe to our podcast: iTunes | Stitcher On today's podcast, we're going to talk with the founder of The Pocket Doula, Anna Balagtas, about uplifting queer, and trans-care. Anna Balagtas (she/siya) is a queer, Pinay full circle birth...