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Epidural for labor - Too soon or too late?
Questions about the use of epidurals for labor are frequent. Women who have had a previous epidural often ask how soon they can get one during this labor. Other women, unsure whether they want to go this route, are concerned about when they must make the decision. Stories abound about “waiting too long” to decide and missing the opportunity to have an epidural administered. Let’s address each of these concerns and look at what recent research has taught us.
Epidural anesthesia is administered to control the pain of labor. This inherently means that a woman must be in active labor. Active labor is defined as the presence of regular, painful contractions that cause the cervix to dilate. To be sure that a woman was in active labor, epidural anesthesia has traditionally been withheld until a woman’s cervix reached about 5 centimeters dilatation. This was done somewhat arbitrarily to ensure that it was given prior to active labor, on what is called the latent phase of labor. Administration at that time was felt not to be harmful or risky, but it was felt that it could arrest labor or slow contractions to the point that labor would be prolonged.
Over the last several years many have come to realize that this was too restrictive. A woman whose cervix was undilated at the start of contractions would often be made to wait for hours, often the majority of her labor, to receive the desired epidural. Experience taught us that epidurals placed earlier, say at 3-4 centimeters dilatation, did not adversely affect labors and the trend has been toward their more liberal use earlier in the labor process. A recent medical study looked precisely at this issue. It compared labor progress in women given an epidural at 2 centimeters dilatation to that of women who received it at 5 centimeters. The study showed that labor progress was more rapid in the women who received their epidural at 2 cm. So, as we view it now, no, it isn’t too soon even at 2 cm as long as regular painful contractions are established.
When is “too late” to receive an epidural a problem? This depends essentially on how rapidly labor is progressing and how readily available is the anesthesiologist. Some women do dilate very rapidly and can arrive at the hospital fully (or nearly so) dilated. They might arrive there and not have the 30 or 40 minute window available to them that is needed to obtain an epidural. This scenario is however the uncommon exception to the rule. Most women, especially those having their first baby, dilate so slowly (say 1-2 centimeters per hour) that the epidural may be given even at 8-9 centimeters dilatation. This is especially true if cervical dilatation stops. If this happens, as it often does in first labors, then pitocin is needed to stimulate or augment labor. Epidurals are often used in this situation prior to the initiation of the pitocin and in those unusual situations where labor progresses rapidly, some women will still have time to receive a spinal narcotic. Spinal anesthetics arrest labor and are only used for c-sections. Spinal narcotics provide virtually immediate pain relief lasting about 2 hours, plenty of time for a woman laboring rapidly.
So, is it too late? Very seldom. Always ask, and know your options.