Having an epidural has become one of the more desired ways in the U.S. to control pain during childbirth. Despite the popularity of the epidural, most woman know little about what it is, how it works and what the real risks are. The spinal and epidural spaces are the most effective places to provide pain-relief medications.
The spinal cord carries nerves and their information up and down from the brain to just above the curve in the lower back. The nerves peel off from the spinal cord and travel to all distant parts of the body. The epidural space lies just outside of the cord, and medication placed there will seep into the nerves. To be safe, epidural and spinal needles are placed lower in the back, below the spinal cord, to reduce the chance of injury.
Unlike pain medications given by a shot or by mouth that affect the whole body, the epidural space is so close to the nerves that a tiny dose of medication can give a huge amount of pain relief. Different medical centers use different drugs, but commonly these are bupivacaine (a local anesthetic like the dentist might use) and fentanyl (a morphine-like medication). The combination of two drugs works much better then either alone, allowing smaller doses and fewer side effects. Recent studies have shown that early epidural relief does not lengthen labor, increase the risk of having a C-section or harm the baby.
Epidural pain relief is nothing like it was 40 years ago when women felt too numb and weak to push well and their ob-gyns believed that it slowed labor. The modern epidural techniques such as the “walking epidural” rely on small doses of medications that aim for pain relief without a dense block, and minimize the medications that might get to the baby.
Another new technique is the combined spinal-epidural, whereby an epidural needle is placed into the epidural space, and a spinal needle slightly thicker than a hair is inserted through it, allowing the injection of ultra-fast-acting spinal medications. This allows pain relief in advanced labor when it once was considered too late. Modern spinal needles have been redesigned to virtually eliminate spinal headache.
Unfortunately, spinal headache is the most common side effect of epidural needle placement, occurring in 1 in 100 people. It is a severe headache, but fortunately there is treatment for it (called a blood patch) and it’s usually short-lived. Back pain is very common after childbirth, even in women who do not have an epidural.
Epidural needles do not cause chronic back pain — in fact, pain specialists use epidural injections to treat patients with back pain. Epidural pain relief is not appropriate for everyone; it is a powerful medication that can be used only with safety monitors and by skilled care providers. If you have questions, speak with your anesthesia care provider about what is available near you.
Philip Hess, M.D., is Chief of Obstetric Anesthesia, Beth Israel Deaconess Medical Center, and Assistant Professor, Harvard Medical School.
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