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Dr Marlena du Toit

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Epidural anaesthesia

Childbirth is a natural process; it causes pain for most women. Breathing exercises and relaxation techniques may help, but many women will still need medical assistance to control or reduce pain.

If labour pains become severe, your obstetrician may prescribe an opioid injection or other medication. In some cases, these medicines will be inadequate or may adversely affect the baby of your health and in such a case, your obstetrician may recommend epidural anaesthesia for pain control.

Epidural anaesthesia has been used during the past 40 years for millions of women and has an excellent safety record when administered by specialist anaesthetists or other specially trained medical practitioners. Doctors regard it as the most effective means of reducing the pain of childbirth. Epidural anaesthesia is a reliable technique which can achieve continuous pain relief in most women.

Patient surveys report that about 95 women out of 100 women are pleased with pain relief. The epidural is very effective in relieving backache and contraction pains, but may allow the mother to feel some sensation at the time of delivery when her cooperation may be required.

Technique

The anaesthetist first numbs a small area of the lower back by injecting a little local anaesthetic under the skin. Using a special needle, the anaesthetist inserts a thin plastic tube (catheter) through the spinal ligaments between two vertebrae in the lower back.
The catheter is positioned so that its end is in the epidural space between the vertebrae and area surrounding the spinal cord. The needle is removed, and the outer end of the catheter is taped to the woman’s back. The catheter is made of very soft, flexible plastic so it does not injure the spinal cord or nerves.
A local anaestetic is in jected through the catheter into the epidural space to temporarily numb the spinal nerves in much the same way as a local anaesthetic numbs of the face during dental treatment.
Some anaesthetists use a morphine-like opioid painkiller mixed with the local anaesthetic to enhance its effectiveness.
Once the catheter is in place and the anaestetic solution is injected, pain relief takes about 10 minutes. The catheter remains in place throughout labour. Pain relief during labour is maintained by
  • Occasional top-up doses administered by the anaesthetist of nursing personnel, or
  • A pump, which slowly delivers a continual dose, or
  • The patient, who is able to determine how much pain relief she want; this is called “patient – controlled-epidural-analgesia”
Typically, the first dose wears off after one or two hours. As each woman reacts differently, it is not possible to predict how much epidural anaestetic a patient will require during labour. The catheter is usually removed immediately after labour unless other procedures become necessary.

Other benefits of epidural anaesthesia

  • An epidural usually does not cause sedation, which is important for women who want to be alert during their birth experience.
  • For medical reasons, an epidural may be necessary in some cases of premature labour, delivery of twins or mothers with high blood pressure.
  • The epidural can reduce the stress caused by pain. As the woman relaxes, breathing and blood pressure return to normal, the workload on the heart is less, and blood flow to the uterus improves in most cases, this improves the well being of the baby.
  • As the catheter stays in place, more epidural anaestetic can be administered easily if another procedure becomes necessary, such as forceps-assisted delivery, caesarean section, or removal of a retained placenta.
  • After delivery, it may be possible to continue the use the epidural for further pain relief, especially after caesarean section.

The decision to have an epidural

Decisions about an epidural anaestetic are made after discussion with your anaesthetist and obstetrician. Although the choice is normally up to the mother, the obstetrician may recommend an epidural for medical reasons. Any decision should not be made in a rush, but rather when you are satisfied with, and understand the information you have received.
Your anaesthetist cannot guarantee that an epidural will always be completely successful, that it bears no risk, or that you will be satisfied with the degree of pain relief. Although many mothers have made up their minds in advance, others prefer to wait until labour is underway and they decide whether they want an epidural.
If you decide to have an epidural, your anaesthetist may ask you to sign a consent form. Read it carefully. If you have any questions about the consent form, ask the anaesthetist.

Before the epidural anaestetic

Your anaesthetist needs to know your complete medical history, as well as details of allergies and medication which you may be taking, including insulin, blood thinners such as warfarin, and common medications such as aspirin. Your obstetrician and anaesthetist will advise you about any medications which you may need to continue or stop taking.
Tell your anaesthetist if you have had:
  • An allergy or bad reaction to local of general anaesthetic drugs, codeine, morphine any pain killers, antibiotics or any other medicine.
  • A bleeding disorder or easy bruising
  • Long term or recent illness, or a heart disorder
  • Surgery to the lower back.

Possible side effects and complications of epidural anaesthesia

Epidural anaesthesia is safe and effective, but does have risks. Serious problems during or following epidural anaesthesia are uncommon. Despite the highest standards of training and practice, side effects and complications are possible, not only with epidural anaesthesia but also with all types of procedures and treatments in modern medicine. While your anaesthetist is highly trained and makes every attempt to minimise risks, complications may rarely occur which could have permanent effects.
When informing a patient about any type of anaesthesia of treatment, it is no usual for a doctor to discuss in great detail all the possible side effects or rare, serious complications. The following possible risks are listed to inform you, not to alarm you. It is important to remember that even the most natural childbirth with no medical assistance can still carry risks for both mother and baby.

Common side effects for the mother

  • Legs may feel heavy, weak and numb, leading to restricted mobility during labour
  • Difficulty passing urine may require a bladder catheter, which carries a small risk for a urinary tract infection.
  • A decrease in blood pressure: this may be treated with medication or intravenous fluids if necessary.
  • Shivering, nausea and vomiting.
  • Backache is common after pregnancy and labour, whether or not an epidural has been given.
  • About five women in every 100 having an epidural anaesthesia may have some pain at delivery. Your anaesthetist may top up the epidural at this time.

Possible complications for the mother

  • In some patients, precise placement of the epidural catheter by the anaesthetist can be difficult, especially if the patient is short or obese.
  • In about one every 100 women who opt for the procedure, the area may be punctured by the needle, and cerebrospinal fluid may leak into the epidural space. This leak may cause a moderate to severe headache which usually responds to simple treatment. If untreated, this headache may last for four to five days. Although temporary, it can be severe enough to interfere with breastfeeding and routine antenatal care of the baby. In the unlikely event of this complication, your anaesthetist will advise appropriate treatment.
  • Some earlier studies suggested that epidural anaesthesia any prolong labour and may increase the likelihood of an assisted delivery, episiotomy of caesarean section. However more recent studies have disputed this. Even if an epidural does affect a particular labour, there is no evidence that this will harm the mother or baby in a properly managed labour. In most situations, the epidural offers real benefits to both mother and baby.
  • Allergic reaction to the local anaesthesia. This is extremely rare

Serious complications

Serious complications are very rare. Anaesthetists are specially trained to recognise and promptly treat situations which may be life threatening or permanently debilitating.
  • The site of puncture and the region surrounding the spinal cord can become infected. This is a serious condition requiring treatment with antibiotics or, rarely, surgery.
  • The local anaesthetic solution may be injected inadvertently into a blood vessel, causing dizziness, a metallic taste in the mouth, and in extreme cases, convulsions and heart problems.
  • Reports in the world’s medical journals have linked permanent paralysis and death to epidurals, but the cases are so rare in modern practice that the precise risks are not known.
  • Temporary damage to nerves outside the spinal cord any occur in about one in 3000 women. Virtually all of these cases heal within 12 weeks. The temporary nerve damage may be caused by the labour rather than by the epidural procedure.

Possible complications for the baby

  • Local anaesthetic and opioid medication appear to have little or no effect on the baby. Reports of toxic effect of local anaesthesia and opioid drugs have been largely discounted.
  • If labour becomes prolonged or blood pressure falls, the baby may become distresses, possibly leading to medical intervention such as an assisted delivery of caesarean section.