Epidurals and Planned VBAC

Some studies have shown that epidural analgesia for labor increases the risk for cesarean delivery, others have not. The latest evidence from controlled studies shows that use of epidurals does not increase the risk for cesarean for women laboring for a VBAC, nor does it mask the pain or tenderness in the rare event of a uterine rupture.

Epidural analgesia for labor varies widely based on the type of drug used, the combination of drugs, the dose, the stage of labor at which it is introduced, the woman's ability to change positions in labor, and how much time a woman is given to complete her labor.

For the most up-to-date information on use of epidurals for pain relief, see Childbirth Connection's Advice on Labor Pain Relief and Effect of Labor Pain Medication Timing on Cesarean Section: NEJM Study, 2/2005

What is an epidural?

Epidural analgesia is a way of providing pain relief for labor by inserting medication into the epidural space located near the spine through a thin plastic tube. The medication numbs the nerves of the uterus and the birth canal. The mother feels the numbing effect from the waist area down to the thighs, and sometimes to the toes. The lighter the dose of anesthetic the easier it is for the mother to move around.

What is the advantage of using an epidural?

• An epidural allows the mother stay alert throughout labor and delivery.


• The baby is less heavily medicated.


• It can provide a rest period when labor is long.


• It can provide pain relief when labor is induced or augmented with pitocin.

What drugs are used?

The drugs used are often a combination of an anesthetic (such as bupivacaine) and a narcotic or opioid (such as fentanyl). The combination of drugs used and the dosage vary depending on the anesthesiologist or nurse anesthetist.

How is the procedure done?

• The mother must have an adequate amount of intravenous fluid, an IV line is inserted.


• The mother's blood pressure and the baby's heart rate are monitored at all times.


• The mother is placed on her side or asked to sit up and lean forward.


• The anesthesiologist or nurse anesthetist bathes an area in the lower back with a cleansing solution.


• A local anesthetic is injected, then an epidural needle is slowly inserted between two vertebras till it reaches the epidural space, just before the membrane that covers the spinal cord.


• The mother usually feels pressure at this time.


• An epidural catheter, thin plastic tube, is slowly threaded into the epidural space and the needle removed.


• The catheter, which feeds the medication into the space, is taped to the mother's back.


• The mother begins to feel pain relief in about 10 to 20 minutes. Her legs may feel warm or tingly and may feel heavy.


• The lighter the anesthetic dose, the more flexibility the mother has to move her legs and the easier it is to change positions.

Are there any side effects?

Epidural analgesia is usually a safe procedure, but it may carry some risks.

• A woman's ability to move around or change positions may be limited.


• The medication in the epidural may cause an erratic heart rate for the baby. Local anesthetics rapidly cross the placenta.


• Drugs can cause various degrees of maternal, fetal, and neonatal toxicity.

Studies show that use of epidural analgesia:

• May slow down labor.


• May increase the possibility for using pitocin.


• May make it more difficult for the mother to push the baby down.


• May increase the likelihood of using forceps or a vacuum extractor.


• May cause maternal fever when used for long hours.


• May make it more likely that the newborn will be screened and treated for infection.
• Some mothers experience nausea, vomiting or itching when epidural narcotics are used.


• May cause short-term urinary incontinence.

Is there a best time to ask for an epidural?

Some studies have shown that the risk for cesarean is reduced if the epidural is started after the baby's head is engaged in the pelvis and the mother waits until the cervix is dilated to 4-5 centimeters.

For more information about epidural anesthesia for labor see American Society of Anesthesiologists - Standards Guidelines and Statements.

Non-Pharmacological Methods of Pain Relief

The latest research shows that several methods, other than use of medication, are effective in reducing pain in labor.

• Moving and changing positions for labor and birth.


• Use of Touch (handholding, stroking, patting) and Massage.


• Immersion in water during active labor (as opposed to early labor) when the water is maintained at body temperature.


• Use of Intradermal Water Blocks (subcutaneous injections of sterile water).


• Continuous Labor Support by an experienced person (who provides physical comfort, such as relaxation techniques, massage, non-clinical information and advice for the laboring woman and her partner, advise on effective positions, heat or cold for pain relief, and emotional support (encouragement and reassurance).

References:

Enkin, et al 2000. A Guide to Effective Care in Pregnancy and Childbirth. Oxford University Press.

New York Academy of Medicine and Maternity Center Association. The Nature and Management of Labor Pain: An Evidence-Based Symposium. May 4-5, 2001. New York, NY.

Lieberman , E. 1999. No free lunch on labor day: The risks and benefits of epidural analgesia during labor. Journal of Nurse-Midwifery, 44(4):394-398.