Epidurals~ informed consent

May 4, 2018

It seems like moms either want an epidural for sure or they are clear that they don't want one but when I ask what they know about them the only common knowledge seems to be that they make you numb and it is a needle in your back. While your doctor should give you all the facts on an epidural I have found from my experience that some things are gone over quickly or not at all. In this post I am going to cover the effects of an epidural.

 

An epidural is a catheter that is placed in your spine below your T2 vertebrae, while it is placed there with a needle the needle does not stay there. The catheter will remain to give the medication one of two ways. The first is a continuous flow much like an IV drip in your arm and the other is what is called a bolest where you will have a button like a morphine pump that you can push as you need it. From my experience the type of epidural you get will have more to do with the hospital preference than anything else. Although I am sure if you have a preference you can talk to your doctor about that. 

 

Your epidural will contain drugs the most common medication that is used is fentanyl or sufentanil and sometimes they add epinephrine to boost or enhance the onset, duration or even the intensity of your epidural. I think it is important to note this because many people don’t realize that the epidural does contain opioids and opioids are transferred to your baby and can have some lasting effects which I will get into later.

 

Once you have your epidural your birth will be classified as a Medicalized birth and your birth will require some interventions these interventions are necessary because of the opioids that are used 

 

-Blood pressure monitoring - a blood pressure cuff will be added to your arm that does not have an IV and it will automatically take your BP every 15-30 min (this depends on your doctor/hospital expectations) 
-Pulse ox monitoring - since opioids can depress cardiac function 
-IV fluids - this if for a couple or reasons the most common is because the epidural can affect your bladder so they want to ensure that fluid is consistently transferring through your bladder and because the risk of a cesarean has increased and if you are taking to the OR they need to have an IV present to give you medications if needed. 
-Pitocin Augmentation - opioids and lack of movement will slow down the natural labor process so Pitocin is given to keep your contractions together and strong 
-Bladder catheter - opioids can cause your bladder to contract which can lead to a bladder infection also since the epidural is effective in numbing your sensation it is likely that you will lose bladder control 
-Fetal monitoring + contraction monitoring - just like opioids can affect your heart they can affect your babies too. Also, since Pitocin can cause intense contractions it is important to make sure your baby is removing from them well 
-Operative delivery is highly likely (vacuum, forceps or ceceran delivery) this can be attributed to you being numb and not being able to feel to push, it can also be caused from your uterus being over worked form the strength of the contractions caused by the Pitocin (remember your uterus is a muscle and muscles can get worn out)

Ok so there is a list of everything that is highly likely to happen once you get an epidural but what are some of the risks that could happen?

 

Maternal Risks with an epidural

  • Low blood pressure, sometimes requiring additional IV fluids and medication

  • Loss of bladder control; a catheter is usually inserted

  • Itchy skin (you cannot relieve that with Benadryl)

  • Feeling sick

  • Inadequate pain relief (1 in 8 mothers)

  • Spinal Headache (this is very low and based on how well trained the anesthesiologist is)

  • Slow maternal breathing

  • Infection of the skin by the epidural tube

  • Temporary nerve damage

  • Rarely, epidural use can lead to permanent nerve

     

    damage

  • Other rare complications include seizures, severe

  • breathing difficulties, and death (death is so rare that they found 0 deaths in a 10-year period of time)

  • Increase risk or vaginal tears

  • Low blood pressure

  • Fever

  • Urinary retention

  • More need for Pitocin

  • Increased risk of Cesarean for fetal distress

 

Increased risk of a cesarean for fetal destress. Why is it that an epidural would cause fetal destress? The medication in your epidural is an opioid and opioids can cause low blood pressure which can compromise the transfer of oxygen to your baby. Also, opioids cross the placenta and carry an increased risk of abnormal fetal heart rate which also leads to low Apgar scores, respiratory depression and poor muscle control and tone. This also crosses over to breastfeeding. Infants whose mothers had high dose epidurals have a harder time breastfeeding and are a fusser baby. If you had a low dose epidural this may not affect your baby.

 

It is important to know that injectable opioids have a much higher effect on your baby then the opioids that are in your epidural

 

Epidurals are the most common and effective form of pain management during labor and in the US today they are used 60-70% of the time, in fact it is assumed at most hospitals that you will get one.

 

 

References:

Types of Pain Relief in Labor and Delivery here

Practice Bulletin No. 177: Obstetric Analgesia and Anesthesia here

NHS Choices here

 

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May 4, 2018

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