Many of our practice anaesthetists participate in on call rosters for obstetric anaesthesia, and may be involved in your care if you are having an elective Caesarean section, or require an epidural during labour.
It a good idea to find out more about an epidural prior to labour commencing. the best time to absorb important medical information is when you are not distracted or under time pressure. The information in the links below will hopefully answer most questions you have.
Will I need an anaesthetist during labour?
Most women in labour develop significant pain with their contractions. Once simple methods of pain management have been tried but are insufficient, an epidural may be requested after consultation with your obstetrician. At this point an anaesthetist will be called to administer the epidural.
There are some circumstances where an epidural may be placed for the good of your pregnancy (eg twins, high blood pressure, prematurity, breech presentation) even you are managing your pain well.
Epidural anaesthesia provides the most effective relief for labour pain. This is where local anaesthetic is administered around the outer coverings of the spinal cord. This numbs the nerves that flow downstream from that area, leaving your lower abdomen and uterus far less sensitive to pain.
What happens during an epidural?
You will first be positioned either sitting down or lying on their side depending on your anaesthetist’s preference.
After washing the back with a very cold antiseptic solution, you will next feel your anaesthetist prodding your back to locate the relevant anatomy. Sometimes this involves a significant amount of pressure. Local anaesthetic is then injected under the skin to reduce discomfort from the procedure. This local needle is uncomfortable but leaves the area numb so that the rest of the procedure is much more comfortable.
You will then be positioned with a curved back posture, typically described as making the shape of a cooked prawn or an angry cat. By placing the chin on the chest and dropping the shoulders, the space between the vertebrae opens up to facilitate passage of the epidural needle. This can be difficult to do in labour, and particularly with contractions. Your anaesthetist will usually pause while you have a contraction, as you must remain very still during the insertion of the epidural catheter.
A fine plastic tube known as an “epidural catheter” is then threaded through the needle and left in place, while the needle is then removed.
You’re almost done – the epidural will now be secured, tested and a test dose of local anaesthetic will then be given. You should start to feel better within 5-15 minutes of the initial dose of local anaesthetic.
What happens next?
A combination of medications will then be administered by continuous flow throughout the labour to ensure the epidural is always working. Occasionally the rate of flow will be adjusted, or an extra dose given to improve the quality of your epidural.
After an epidural you will also have an urinary catheter inserted, and you will not be able to walk around the room any longer. You will also have a drip inserted prior to the epidural placement, so that emergency drugs and fluid can be administered if necessary.
When can I ask for an epidural?
As a general rule, you can request the epidural at any stage during labour provided there are no medical reasons not to, and following consultation with your obstetric team.
An epidural procedure takes between five and 30 minutes to perform, depending on your anatomy, with the onset of pain relief starting within five minutes of the patient receiving the local anaesthetic.
There may be medical reasons for placement of an epidural other than pain, such as having high-blood pressure, twins, breech presentation, pre-eclampsia, or the need for use of medications that augment and speed up labour due to slow progress.
The other factor that needs to be kept in mind is that usually, but not always, the length of labour is shorter with each subsequent pregnancy. If this is not your first labour, the window of opportunity may be shorter for the epidural to be inserted and have its effect before delivering the baby. An epidural will only be of benefit if you are still in the first stage of labour, prior to ‘pushing’. You should discuss the desire to have the epidural with your obstetrician or midwife looking after you at the time of labour. They will be able to advise you on the timing depending on the progress and status of your labour at the time.
What are the risks of an epidural?
Epidural anaesthesia is general very safe, and performed widely in across hundreds of labour wards in Australia every day. It is however a technical procedure that involves working near the spinal cord, so there are risks involved, that range from common but minor, to serious but rare.
Pain can occur, both on insertion of your epidural, as well as after your epidural has been placed. Despite using local anaesthetic to numb the area, you may still feel some discomfort during the insertion, although minor. You may also feel some shooting sensations in your legs or bottom at certain times. It is important to let your anaesthetist know if you are feeling any pain, but to try to stay as still as possible.
Ineffective epidural blocks occurs in roughly 20% of epidurals. this may range from a slightly ‘patchy’ block where some parts of you are still sore while most of you is numb, right through to a completely ineffective block. Your anaesthetist will be able to attempt to improve your block using various methods, but in a small number of cases an epidural may need to be inserted again.
Headache can occur after roughly 1 in 100 epidurals, particularly if it has been a difficult insertion. This can be a severe headache in the worst cases, but usually resolves without treatment.
Infection locally at the insertion site is possible, although sterile techniques are used to minimise the risk of this. You may also be given antibiotics to prevent infection if you end up requiring a caesarean section or other intervention, which will reduce the risk of all infections.
Nerve damage can occur but is rare. Because your legs will be numb from the epidural, and often positioned in stirrups during labour, nerves can be stretched. Nerve damage can also occur directly as a result from the epidural, particularly if you are at risk of abnormal bleeding. You will be monitored after your epidural has been removed to ensure this is not occurring.
Delayed delivery and a marginally higher Caesarean rate are associated with epidural anaesthesia.
Roughly 20% of all deliveries are by Caesarean section, and this number is generally increasing
An elective Caesarean is usually preplanned for a date around 37-39 weeks gestation where you are booked to come into the hospital like with any elective surgery. You will stay in hospital around 5-7 days.
An emergency Caesarean is usually done because your obstetrician feels that there is too much risk to the mother or baby if the birth is allowed to proceed naturally, and can be for many different reasons. They often are necessary after a long and difficult labour when there has been little in the way of progression. This is by no means a failure on the part of the mother, and is a relatively common event for first pregnancies. It may also be because of signs of foetal distress.
The vast majority of Caesareans are now done under a spinal anaesthetic, because this is the safest form of anaesthetic to have while pregnant, where risks of general anaesthetic are much higher than normal. Most parents want to be present and awake when their child is born, and a spinal anaesthetic allows for this to occur, which is a huge advantage.
Having said this, general anaesthesia is still an option used occasionally, but tends to be used more in a very time sensitive emergency. The risk of airway complications, aspiration, awareness under anaesthetic and blood pressure problems are far greater to pregnant women, so in general your anaesthetist will prefer to do a spinal to make the procedure safer for you and your baby. Please discuss with your anaesthetist if you feel strongly about having a general anaesthetic.
The third option is for an epidural anaesthetic which is very similar to a spinal anaesthetic. Epidurals for elective Caesareans are now uncommon as spinals are less technically challenging to do, less risky, are very reliable, and have a much faster onset than an epidural. Occasionally you will have a spinal and an epidural placed, for safety. If you have been labouring and already have an epidural that is working, this will commonly be used as the anaesthetic for your Caesarean. The epidural is ‘topped up’ with a very strong local anaesthetic, rendering you as numb as you would have been with a spinal anaesthetic. The local anaesthetic used during the labour tends to adequate for labour pain but not sufficient for a Caesarean, so needs to be replaced.
The placement of a spinal anaesthetic is the same as for an epidural, from the patient’s perspective, as are the risks (see the above sections). The main difference is that a spinal anaesthetic has a much lower risk of failure, and in any case, your surgeons and anaesthetist will test your anaesthetic to ensure it is working adequately before proceeding with your procedure.