After carefully researching her options, Maria Andrews* knew she wanted an epidural to help ease the pain of labor. She discussed her decision with her doctor during prenatal visits. Andrews' doctor assured her that she would get an epidural when she started feeling pain.

The night her water broke, however, the doctor on call had other plans.

"She asked me what I wanted to help control the pain," Andrews says. "When I said I wanted an epidural she laughed and said, 'You and every other woman.' I had to endure several hours of excruciating pain because she said I was not dilated enough."

Andrews' doctor came on shift the next morning and ordered an epidural. A couple of hours later, Andrews delivered her baby.

"My doctor said the epidural helped me relax and move the labor along," Andrews says. "I was amazed that two doctors in the same practice could feel so differently."

To Wait
Or Not to Wait

Many obstetricians have been reluctant to give epidurals to women in labor until their cervixes were dilated to at least 4 or 5 centimeters, which often doesn't occur until a woman is in active labor and experiencing intense labor pains. Ideally, a woman should be dilated to 10 centimeters to deliver a baby. Past research associated epidurals with the slowing down of labor and increasing the risk of caesarean section.

But a new study in the Feb. 17 issue of the New England Journal of Medicine found that epidurals didn't increase the risk of C-section in patients who received them in early labor. And patients who received epidurals in early labor delivered an average of 80 minutes earlier than patients who received them later in labor.

"This study shows that women should have pain relief as soon as they need it, including in early labor," says Dr. Larry Gilstrap, chairman of the Department of Obstetrics and Gynecology at The University of Texas Medical School at Houston.

Women in the Northwestern University study were divided into two groups. The women in the first group were given a spinal anesthetic when they first started experiencing pain. When the pain increased, they were given an epidural. An epidural delivers pain medication through a long, plastic tube that is placed just outside the membrane that borders the spinal cord.

The women were dilated less than 4 centimeters. Some were only dilated an average of 1 to 2 centimeters. Women in the comparison group were given intravenous dosages of hydromorphone, a morphine-like pain medication, when they first requested pain relief. They did not receive an epidural until they were at least 4 cm dilated.

The study involved 750 women, and is considered a large and well-designed randomized study on epidurals. Gilstrap says the results add weight to what many OB/GYNs suspected all along.

"It has been the policy and philosophy of the American College of Obstetricians and Gynecologists that a woman's request for pain relief is an indication that she should receive it," he says.

Method Targets Pain

Epidurals administer pain medication and an anesthetic directly into the space between the wall of the spinal canal and the sheath covering the spinal cord. The medication numbs the area of a woman's body below the waist. The level of medication can be adjusted to decrease or increase sensation when needed, for example when the patient needs to push. Epidurals may also help relax women experiencing painful labor.

"When you give a woman an epidural, you take away a lot of her pain and her anxiety, which helps decrease the amount of adrenaline and epinephrine her body produces," Gilstrap says. "A decrease in anxiety and adrenaline may help labor progress."

Epidurals are one of several pain control methods a woman can choose, and not every woman can have an epidural.

Women with specific types of back problems may not be able to receive an epidural. Dr. Jeffrey Katz, professor of anesthesiology at the UT Medical School says that women who have had surgery in the lumbar (lower back) region-where the epidural is inserted-"are less likely to benefit from it because the epidural is technically more difficult to perform and often doesn't work as well."

Certain blood-clotting disorders make epidurals or any spinal anesthesia less safe. "Women who do not clot well run the risk of excessive bleeding into the epidural space," Katz says. He also cites any skin infection over the area of insertion as a valid contraindication for an epidural.

And, in some cases, circumstances of labor may make it unsafe for some women to have an epidural.

GIMME MY EPIDURAL!

As each pregnancy is unique, so are each doctor's views on when to administer an epidural. Gilstrap advises discussing your preferences with your doctor during your checkups. If your doctor is in a group practice, be aware that another doctor may make the decision if he or she is on call. Ask your doctor to record in your chart that you want an early epidural, when safe. If your doctor doesn't seem to take your concerns seriously, find another doctor.

"It is important for patients to know that physicians work for them, and not the other way around," Gilstrap says. "Patients should ask questions when they want to, as many questions as they want to and feel like they are in control. They are in control of their pain."

* names changed to protect privacy

 

UPDATED: 5-06-2005

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