Is epidural the best of all words – no pain but full consciousness?
(Yerby, 2000). Discuss
During pregnancy many women give some thought on what they will do to cope with labour pain. Some women aim to have the most natural type of birth, with the least possible pharmacological interventions. Others request a pain free labour, such as opting for an epidural anaesthesia as a type of pain relief. But do women actually know about the risks epidural anaesthesia can create for them and their baby? Or do they opt for it just because they heard other mothers say that it was the best?
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Epidural anaesthesia is a type of regional anaesthesia which is rapidly increasing in its popularity. Epidural works by blocking nerve conductions from the lower spinal segments, resulting in a decreased sensation in the lower half of the body, while at the same time the mother is still awake and conscious (Fraser & Cooper, 2009).
The drug is administered in the lower back, into the epidural space, specifically in the lumbar region between lumbar 1 and 4. This is achieved by cautiously inserting a Tuohy needle through the lumbar intervertebral space. Once the epidural space is reached, a catheter is threaded through the needle, which will facilitate the administration of the drug either by bolus top ups or continuous infusion. Once epidural is injected, it will start to exhibit its effect within approximately 20 minutes (Johnson & Taylor, 2011).
Indications for using epidural anaesthesia
There is no absolute indication for opting for epidural anaesthesia, however clinical instances may include:
Maternal request: mothers now acknowledge the fact that they can give birth with the least possible amount of pain. Today the majority of parents already have a plan in mind of what they wish and request for their birth experience. Having ongoing accessibility to internet encourages parents to search for types of pain relief, allowing them to make their own choices of what they think is best for them. Upon searching and from what they hear from other mothers, they are actually believing that epidural is one of the best choices of pain relief medication (Johnson & Taylor, 2011).
Pain relief: prolonged labour can be very tiring and stressful for the mother. Having an epidural can help in reducing the continuous stress of contractions and can possibly help the mother to relax, making her able to conserve energy for later use during the active phase of the second stage of labour (Johnson & Taylor, 2011).
Hypotension: epidural has the potential to lower down the blood pressure. This can be used as an advantage for women who suffer from high blood pressure. Thus this anaesthesia can possibly stabilise the blood pressure during labour, aiming to reduce complications (Johnson & Taylor, 2011).
Preterm labour: epidural aims to decrease the sensation of powerful contractions and so can be opted for to possibly lower the desire to push during a preterm labour. Use of such anaesthesia depends on the specific condition of the mother and the baby (Johnson & Taylor, 2011).
Side effects of epidural anaesthesia on the mother
Opting for an epidural can deliver a good experience amongst many women. Mothers are able to rest and relax from the painful contractions while at the same time they are awake and conscious. However, opting for this anaesthesia is very likely to be the beginning of a ‘cascade of interventions’. This means that birth can be transformed into a very medicalised experience, ending up with the mother feeling that she has lost control over her own birth experience. In fact, the World Health Organization states that, “epidural analgesia is one of the most striking examples of the medicalisation of normal birth, transforming a physiological event into a medical procedure.”
Generally, decision of opting for such a pain relief is made without the mother’s awareness of the possible complications it can create.
Hypotension: Studies show that epidural can be the cause of a sudden drop in blood pressure. Although the drug is injected around the spinal cord, there can be a degree of the anaesthesia that passes into the maternal blood stream, with the consequence of lowering the blood pressure (Healthline Editorial Team, 2012).
This in turn would require, prompt venous access in order to administer fluids to quickly correct the blood pressure. Low blood pressure will result in less oxygen reaching the baby, which upon prolonged exposure can result in hypoxia of the baby. In much more severe cases, medications and oxygen may also be required in order to maintain a stable condition (Mehl-Madrona & Mehl-Madrona).
Delayed labour: Studies have shown that epidural anaesthesia, can be the cause of slowing down labour process. This is mainly due to the interaction of the drug with the birthing hormones. Epidural anaesthesia tends to decrease the production of oxytocin (Rahm, Hallgren, Hogberg, Hurtig & Odlind, 2002). Oxytocin is one of the main hormones of labour, that is episodically released from the posterior Pituitary gland in order to stimulate the uterine myometruim to contract and retract, facilitating the foetal ejection reflex of birth (Fraser & Cooper, 2009).
Moreover, epidural also lowers the production of prostaglandin. This uterotonic hormone is essential for cervical ripening, effacement and dilation during labour (Kresser, 2011).
As a result to this reduction of birthing hormones, the process of labour is hindered and thus upon medical decision, synthetic oxytocin known as Syntocinon is given in attempt to accelerate labour process, aiming to strengthen and increase the frequency of contractions (Fraser & Cooper, 2009). Prior to the administration of Syntocinon, amniotomy is to be performed, unless membranes were previously ruptured. Having Syntocinon infusion, requires continuous electronic foetal monitoring in order to accurately observe the foetal heart and uterine activity. This in turn restricts mobility.
The rate of Syntocinon infusion should be carefully observed in order to exclude uterine hyperstimulation. This is when having four or more contractions in a ten minute period, which in turn causes poor placental perfusion ending up with the foetus getting compromised, as blood flow between the mother and the foetus tends to decrease during contractions (Royal Cornwall Hospitals NHS Trust, 2012). In addition, if uterine hyperstimulation is ignored, it can ultimately cause uterine rupture or placental abruption. It is the role of the midwife to continuously monitor the state of the mother. Palpation of the fundus is one of the skills used to determine the strength, frequency and length of contractions, altogether with electronic foetal monitoring (Buckley, 2005).
Moreover, Syntocinon can create a feeling of lack of breath, confusion, fast and irregular heartbeats, severe headaches and chest pains.
In-coordination of Pelvic Floor Muscles: Epidural also negatively affects the strength and coordination of the pelvic floor muscles. These muscles guide the foetal head to enter the pelvis in the best position for the delivery of the baby. Lack of such coordination results in foetal malposition (Mander, 2011). Changing labour positions aids in the rotation of the foetal head, however if malposition persists, instrumental delivery is next in choice.
The decision to proceed with an instrumental delivery would increase the likelihood of performing an episiotomy, in order to enlarge the pelvic outlet to provide the necessary room for the clinician’s hands to deliver the baby (Fraser & Cooper, 2009). Episiotomy on itself can be very detrimental to the mother. Not only can it be a bleeding point, but also a source of pain and discomfort especially during urination and rest. Moreover, lack of hygiene further increases the risk of acquiring an infection (Enkin ,Keirse, Neilson, et al., 2000).
Having an episiotomy, may also instigate a feeling of uncertainty and fear of when to resume to sexual life, which ultimately may create unnecessary conflict between partners. It is the midwife’s role to give the mother advice on perineal care in order to reduce such negative incidences.
Urination Difficulties: Epidural anaesthesia may cause numbness of the bladder, this is exhibited as decreased sensation to urinate. Inability to pass urine during birth can possibly impede the rotation of the foetal head with the consequence of inadequate foetal descent (Baston & Hall, 2009).
During birth, the midwife is to encourage the mother to urinate frequently. If she is unable to do so, the midwife should look for other signs that may indicate a full bladder. Abdominal palpation is one of the skills that can be carried out to indicate such a measure.
In urinary retention, the mother may require catheterisation. A urinary catheter is inserted through the mother’s urinary orifice. This is temporarily situated in the bladder, and allows the mother’s urine to drain freely (Johnson & Taylor, 2011). The procedure of catheterisation itself may make the mother feel uncomfortable. Moreover, the catheter pipe provides the perfect pathway for the entry of bacteria possibly ending up with a urinary tract infection, especially if there is a poor level of hygiene (Fraser & Cooper, 2009).
Pyrexia: If epidural anaesthesia happens to be in place for more than 5 hours, there is an increased tendency to a rise in maternal temperature, resulting in the foetus getting compromised which is generally manifested as tachycardia. An increased maternal temperature altogether with a raised foetal heart rate could be an indication of a possible infection such as chorioamnionitis. This would require prompt action, so as to reduce the risk of adverse morbidity to the foetus. Usually an emergency caesarean section is the option (Mander, 2011). Having to follow such a procedure may create a lot of anxiety and fear amongst the parents, as suddenly they are receiving an unexpected news which leaves them confused on the health of their baby. Caesarean section is one major operation, which on its own carries a lot of risks. In fact there is a greater tendency of bleeding. Also, the mother has to cope with a lot of after pains following the procedure.
Furthermore, following delivery the baby is most probably admitted to the neonatal intensive unit for investigations regarding the possibility of infection. This early separation surely creates a lot of fear and uncertainty in the newly parents.
Limited Mobility: Since epidural numbs the body from the waist down, it creates a lot of restrictions in mobility. Nevertheless, it is very likely that continuous foetal monitoring is required to monitor the baby and uterine activity. This restricted mobility does not help in the physiology of normal labour (Baston & Hall, 2009).
Other side effects of epidural anaesthesia may include: pruritus, generalised itching of the skin, nausea, vomiting, shivering, headache, permanent nerve damage, heart and breathing difficulties.
Side effects of epidural anaesthesia on the baby
As discussed earlier, epidural can be the cause a variety of side effects on the labouring women, nonetheless, the baby is also very likely to be negatively effected.
When epidural is injected, there may be a degree of the drug that enters the maternal blood stream. Blood eventually passes through the placenta, with the consequence of drug components ending up into the foetal circulation. Studies show that the degree of drugs in the foetus can reach levels that are equal to or even higher than that in the maternal blood stream. In addition, the elimination process of a newborn is still quite immature, with the consequence of taking longer for the drug to be eliminated from the body.
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Foetal distress: this is the commonest side effect of epidural. As discussed earlier, epidural tends to lower down the maternal blood pressure with the consequence of decreasing the amount of oxygen and nutrients that reach the foetus. This phenomena is better known as foetal distress. This is commonly manifested as bradycardia as well as abnormal variations in the foetal heart rhythm (Lohse, 2015). This distress puts the baby and the mother at greater risk of intervention, which may include opting for instrumental or operative delivery. Such choice depends on the explicit condition of the mother and baby.
Furthermore, the baby is also prone to experience difficulties after birth, which may include:
Breastfeeding difficulties: Epidural drug components are likely to interfere with the release of oxytocin. This hormone plays an important role in the let down reflex of breastfeeding; when the baby sucks, oxytocin is released which positively feedbacks to release even more oxytocin which in turn altogether with the aid of other hormones, milk is released (Amis & Green 2008).
Epidural anaesthesia also has the tendency to effect the baby’s neuro-behavior. The newborn may show signs of drowsiness, difficulty in latching and sucking which will make breastfeeding far much more difficult to establish (Amis & Green 2008). This will require more intensive care and time to acquire efficient breastfeeding, which may put the mother under great stress and anxiety.
Poor condition: as stated earlier, epidural anaesthesia may cause maternal fever during labour. This in turn affects the baby’s condition in having poor muscle tone, may require resuscitation immediately after birth, and to a greater extent may experience seizures. This all sums up to a low apgar score at birth (Buckley, 2010).
Having said that, the baby may be admitted to the neonatal intensive care for more intensive observation in order to stabilise and maintain his/her condition. This early separation from the parents surely interferes with bonding. It may even create a sense of anxiety and stress in the parents; being greatly concerned on the heath of their child. It is the role of the midwife to inform the parents on the daily condition of their baby and as much as possible find measures and ways to make them feel reassured and closer to their child (Buckley, 2010).
Other side effects seen in infants are: rapid breathing and low blood sugar levels.
As we midwives are knowledgable of all the risks this pharmacological pain relief brings with it, it is our role that during labour we suggest other methods of pain relief, possibly non pharmacological ones. If the mother happens to request for pharmacological ones, we should make her aware of all the benefits and risks, and in this way we enable the mothers make an informed choice.
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Rahm, V., Hallgren, A., Hogberg, H., Hurtig, I., & Odlind, V. (2002). Plasma oxytocin levels in women during labor with or without epidural analgesia: A prospective study. Acta Obstet Gynecol Scand 81.
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- Danica Chetcuti
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