Childbirth is often accompanied by intense pain, making pain management during labor an important aspect of obstetric care. Labor epidurals are typically used for pain relief during labor and differ from other neuraxial forms of anesthesia, though each has its own unique set of benefits and drawbacks.
Labor epidurals are the most commonly used form of pain relief during childbirth. They involve the injection of local anesthetics and sometimes opioids into the epidural space, the outer membrane of the spinal cord. This type of anesthesia provides pain relief while allowing the patient to remain conscious and participate in the birthing process 1. Epidural catheters are often used to allow clinicians to continue providing anesthesia over a longer period of time, compared to a single-shot injection.
Epidurals provide significant pain relief, allowing the patient to stay alert and comfortable throughout labor. The dose can be adjusted to ensure optimal pain control while minimizing side effects. While sensation in the lower body is reduced, some degree of motor function is preserved, allowing the patient to push during delivery 2,3. However, there are several disadvantages. First, the procedure may take 10-20 minutes for the epidural to take effect. In addition, an epidural can lead to itchy skin, headaches, or feeling sick. Epidurals can also cause a drop in blood pressure, requiring close monitoring 4.
Spinal anesthesia, another form of neuraxial anesthesia alongside labor epidurals, involves the injection of local anesthetics into the subarachnoid space, where the cerebrospinal fluid resides. It is typically used for cesarean deliveries or in situations requiring quick, profound anesthesia. Pain relief begins almost immediately as it completely numbs the lower half of the body. In addition, the procedure is technically easier to perform than an epidural and does not require continuous monitoring of drug infusion 5,6. The effects, however, last for a limited time, generally around 1-2 hours, making it less suitable for prolonged pain. Furthermore, there is a small risk of developing a post-dural puncture headache, which can be severe 7.
The CSE technique combines the benefits of both epidural and spinal anesthesia. Initially, a spinal injection provides rapid pain relief, followed by the placement of an epidural catheter for continuous pain management. The spinal component of CSE offers immediate relief, while the epidural ensures prolonged pain control. In addition, an epidural catheter allows for dose adjustments, catering to the progression of labor. The combination of techniques also often requires a lower dose of anesthetics, potentially reducing side effects 8,9. However, the procedure is technically more demanding, requiring skilled practitioners. Additionally, while reduced, the risk of spinal headache and hypotension remains 10–12.
When comparing labor epidurals to other forms of neuraxial anesthesia, healthcare providers should consider each method’s unique strengths and limitations. The choice of anesthesia should be guided by the clinical scenario, patient preference, and the expertise of the healthcare provider.
References
1. Birth: Learn More – Epidurals and other medications to relieve labor pain – InformedHealth.org – NCBI Bookshelf. Available at: https://www.ncbi.nlm.nih.gov/books/NBK279567/. (Accessed: 18th August 2024)
2. Epidural: What It Is, Procedure, Risks & Side Effects. Available at: https://my.clevelandclinic.org/health/treatments/21896-epidural. (Accessed: 29th July 2024)
3. Epidural – Benefits & Side Effects of Anesthesia During Labor | MFTM. Available at: https://www.asahq.org/madeforthismoment/pain-management/techniques/epidural/. (Accessed: 18th August 2024)
4. Epidural – NHS. Available at: https://www.nhs.uk/conditions/epidural/. (Accessed: 29th July 2024)
5. Spinal anaesthetic | NHS Fife. Available at: https://www.nhsfife.org/services/patients-carers-and-visitors/preparing-for-surgery/general-information-about-your-anaesthetic/spinal-anaesthetic/. (Accessed: 18th August 2024)
6. Spinal Anesthesia – NYSORA. Available at: https://www.nysora.com/techniques/spinal-anesthesia-2/. (Accessed: 18th August 2024)
7. Spinal Anesthesia – StatPearls – NCBI Bookshelf. Available at: https://www.ncbi.nlm.nih.gov/books/NBK537299/. (Accessed: 29th July 2024)
8. Combined Spinal-Epidural Anesthesia – NYSORA. Available at: https://www.nysora.com/topics/regional-anesthesia-for-specific-surgical-procedures/abdomen/combined-spinal-epidural-anesthesia/. (Accessed: 28th April 2024)
9. Ranasinghe, J. S., Steadman, J., Toyama, T. & Lai, M. Combined spinal epidural anaesthesia is better than spinal or epidural alone for Caesarean delivery [2]. Br. J. Anaesth. 91, 299–300 (2003). doi: 10.1093/bja/aeg596.
10. Rawal, N., Holmström, B., Crowhurst, J. A. & Van Zundert, A. The combined spinal-epidural technique. Anesthesiol. Clin. North America 18, 267–295 (2000). doi: 10.1016/s0889-8537(05)70164-4.
11. Combined Spinal Epidural (CSE). Available at: https://www.asra.com/news-publications/asra-updates/blog-landing/legacy-b-blog-posts/2019/08/07/combined-spinal-epidural-(cse). (Accessed: 28th April 2024)
12. Combined Spinal–Epidural Anesthesia | Anesthesiology Core Review: Part One Basic Exam | AccessAnesthesiology | McGraw Hill Medical. Available at: https://accessanesthesiology.mhmedical.com/content.aspx?bookid=974§ionid=61588357. (Accessed: 18th August 2024)