• Emily Reul, PT, DPT

Epidurals

Hi friends! I’m sure we’ve all seen the women in labor on TV and in the movies screaming, “Give me the drugs!” They’re talking about an epidural. There are both benefits and drawbacks to having an epidural during labor and delivery and today we’re going to discuss them.


Please keep in mind that this information is for education purposes only and should not be used as medical advice. Only you and your providers can make medical decisions.


An epidural is the most widely used form of pain control during labor and delivery (Simkin, 2016). In the United States, up to 3 in 4 women receive an epidural (Butwick, 2018). An epidural is an injection into your back which helps you to stop feeling pain in your abdomen and legs. It is typically given once your cervix is dilated to 2 cm or more and takes about 15 minutes to take effect. After the epidural, you will have numbness from your abdomen to your toes. It’s important to note that the epidural will make your legs weaker than normal while it is in effect. Like with any medical procedure, there is a small risk of complications like an infection or subdural hematoma. Your provider should discuss all of the risks with you before you have an epidural.


BENEFITS OF AN EPIDURAL

There are many benefits to having an epidural during labor and delivery. Studies have shown that an epidural can help to reduce anxiety and stress during labor and can allow the individual much needed rest and sleep during a long labor (Capogna, 2007). Sometimes this rest and sleep can be crucial during labor and can help to improve the overall satisfaction of the delivery.


Since the epidural will cause a temporary paralysis (inability to contract) of the pelvic floor muscles, it may decrease the risk of pelvic floor muscle trauma during delivery (Bo, 2005). We already know that pelvic floor muscle trauma can cause many issues down the road including urine and fecal incontinence and pelvic pain.


BENEFITS OF NOT HAVING AN EPIDURAL

While an epidural can improve the birth experience, it is important to mention that it can impact the natural process of labor and delivery in a few ways.


Normally, the natural resting tone of the pelvic floor muscles helps the baby to move down the pelvis and through the birth canal in the best positions. Since the pelvic floor muscles are temporarily paralyzed with an epidural, it can increase the chance of the baby to be in a less optimal position, like occiput posterior (Lieberman, 2005).


An epidural can also decrease the Ferguson (or fetal ejection) reflex. This reflex normally gives the individual a strong urge to bear down and push which can help decrease the risk of Valsalva pushing (Roberts, 2004). This reflex can help to promote good pushing strategies and help to prevent complications Valsalva pushing during delivery like pelvic organ prolapse.


Studies have shown that pushing for more than one hour increases the risk of perineal tears during delivery and therefore increases the risk of pelvic floor dysfunction postpartum (Goh, 2018). The average length of the second stage of labor (pushing) is about 25 minutes longer for individuals who receive an epidural (Cheng, 2014).


Having an epidural has been shown to be linked to an increased need for instrument-assisted (i.e. vacuum or forceps) delivery and cesarean births (Anim-Somuah, 2018; Hasegawa, 2013; Lieberman, 2005). With instrument-assisted delivery, there is a greater change of perineal tearing and therefore pelvic floor dysfunction (Goh, 2018).


BIRTH POSITIONS AFTER HAVING AN EPIDURAL

Once you get an epidural, you will likely be confined to the bed for the rest of the delivery for safety purposes. The epidural has temporarily affected the nerves in your legs, and it is not safe to be up and walking around until the effects of the epidural have worn off.


Because being upright and active in the first stage of labor is often very helpful, you may want to talk to your provider about when the best time to receive the epidural is. Getting the epidural a little later in the laboring process can be beneficial and allow you to remain active for as long as possible, but the entire process is very complex and varies between each individual.


Since you will be confined to the bed, positions like sitting with the bed in a chair position, kneeling over an object (like a birth bar), or lying on your side can be great. Keep in mind you might need a little help from a partner to change positions, and there will likely been many wires (i.e., a fetal hear rate monitor, IV fluids, etc.) that need to be managed.




Since an epidural is given to manage pain, you may be inclined to try other forms of pain management first. Water immersion (sitting in a pool, bathtub, etc.) can be very calming and help to reduce pain (American Academy of Pediatrics, 2014). Other options can include music, changing positions, or even dancing.


Your doctor may also offer a local anesthetic drug to block the pudendal nerve. The pudendal nerve controls the sensation around your vagina and pelvic floor and is also responsible for controlling the contraction/relaxation of your pelvic floor muscles. The medication is injected into both sides of the vagina during the second stage of labor.


Regardless of what you think you want or what you plan to do during your delivery, it’s important to be prepared for plans to change—sometimes very quickly. You may decide you are not going to have an epidural, but when the time comes you may elect to have one; and that’s totally okay! On the other hand, you may be planning to get an epidural, but due to circumstances out of your control, you may not be able to get one. That’s okay, too. Having a birth plan can be very helpful, but be open to change that plan.


To learn more about pregnancy, postpartum, and the pelvic floor, check out these great resources:


For Healthcare providers, check out all our continuing education courses here to help you better serve your pregnant and postpartum clients. You can purchase courses individually or join our Ambassador Program and most of our courses are included with your membership!


Written by Emily Reul, PT, DPT


References

1. Bo K, Berghmans B, Morkved S, Van Kampen M. Evidenced-based physical therapy for the pelvic floor bridging science and clinical practice. 2nd edition. 2015.

2. Simkin P et al. Pregnancy, Childbirth, and the Newborn: The Complete Guide. DeCapo Press. 2016.

3. Butwick AJ et al. United States state-level variation in the use of neuraxial analgesia during labor for pregnant women. JAMA Netw Open. 2018;1(8):e186567.

4. Capogna G, Camorcia M, Stirparo S. Expectant fathers’ experience during labor with or without epidural analgesia. Int J Obstet Anesth. 2007;16(2):110-115.

5. Anim-Somuah M, Smyth RM, Cyna AM, Cuthbert A. Epidural versus non-epidural or no analgesia for pain management in labour. Cochrange Database Syst Rev. 2018;(5):CD000331.

6. Hasegawa J et al. Effects of epidural analgesia on labor length, instrumental delivery, and neonatal short-term outcome. J Anesth. 2013;27(1):43-47.

7. Lieberman E, Davidson K, Lee-Parritz A, Shearer E. Changes in fetal position during labor and their association with epidural analgesia. Obstet Gynecol. 2005;105(5 Pt 1):974-982.

8. Cheng Y, Shaffer B, Nicholson J, Caughey A. Second stage of labor and epidural use: a larger effect than previously suggested. Obstet Gynecol. 2014;123(3):527-535.

9. Roberts C, Torvaldsen, Cameron C, Olive E. Delayed versus early pushing in women with epidural analgesia: a systematic review and meta-analysis. BJOG. 2004;111(12):1333-1340.

10. Goh R, Goh D, Ellepola H. Perineal tears—a review. Aust J Gen Pract. 2018;47(1-2):35-38.

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This information is for awareness purposes and not individual medical advice. You should seek your own professional counsel for any medical condition or before starting or altering any exercise or fitness program.

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