Epidural   What is it? An epidural is procedure used to make a woman more comfortable during labor. It is called an epidural because that is the space of the spine where local anesthetic is inserted. It is a local Anesthetic which freezes a person from the abdomen to the feet. The use of this technique allows the patient to be fully awake and participating in all aspects of the birthing process. The primary function is to have sensory block and keep motor function uninterrupted. How is it Done? After the Anesthesiologist takes a full history of the patient and talks to her about all aspects of the epidural (pros and cons) and telling her of the complications that may occur, it can be decided what epidural procedure is best suited when needed. The epidural can proceed when effective labor is established and the cervix is 5 to 6cm dilated. It can be done earlier if the patient is on a oxytocin drip for inducing labor or not tolerating pain well. The patient should receive 500 to 1000ml of a crystalloid solution prior to the injection of the drug into the epidural space. The patient is then placed in a sitting or lateral position with knees tucked to expose the vertebrae to the anesthetist. After infiltration of local anesthetic between L3-4 or L4-5 (see Figure 1.1) the needle is placed in the epidural space. One or more test doses of local anesthetic are then injected into the space to confirm that the needle is not in a vein or that the Dura has not been punctured. After confirmation, the epidural Catheter is guided through the needle to be left in the space and the needle pulled out over the catheter. The catheter is then taped to the mothers back in order to avoid any movement or dislodging from the back. Through this, doses of anesthetic can be administered as boluses or connected to continuous pumps. Dosing during an epidural will be in increments in order to achieve a sensory block to a level of approximately T10 (see Figure 1.1)   Who should NOT have an epidural? There are circumstances where an epidural should not be given due to various obstacles that may occur. First and foremost, refusal by the mother is of outmost importance. You cannot be forced to have an epidural by any doctor. Also, if you have any of the following conditions, an epidural will not be suitable.  Coagulation defects  Back Problems (From mild back pain to Back Surgery)  Skin lesions at the site if needle entry  Possibility previous surgery for back injuries that has altered normal spinal anatomy  Morbid Obesity This is why it is so important for the anesthesiologist to take a full history of the patient prior to the epidural.   Why have an epidural? The reasons for having an epidural are strictly up to you. Most people feel they need one because of pain tolerance Others have one because it keeps them calm If you have a planned ‘C'-Section and want to be awake for the birth of your child. Epidurals can result in near-complete pain relief in selected areas of the body not interfering with motor function.   Local Anesthesia Anesthesia describes a total loss of sensory capability wether imposed localy (epidural) or centrally (put to sleep). Anesthesia usually implies that one or more vital organ functions are under partial or total control of the anesthesia provider, meaning temporarily lost to the patient. Several factors should be considered in planning and selecting the anesthetic for labor and delivery. It is usually introduced by the obstetrician or qualified pre-natal teacher. He/she should be able to provide you with material on all aspects of anesthesia. Too often, patients receive incomplete of inaccurate information that promotes certain biases or predispositions toward certain anesthetic techniques, which may not be in the best interest of the mother or baby. Expecting mothers should always try to read more than one document on anesthesia in order to make to correct decision. Once the patient is admitted to the hospital for labor and delivery, and is thinking of getting an epidural they should expect the anesthesiologist to take a full history and physical of the patient. He should also talk to the patient in order to help her decide which type of anesthesia is best for her and her baby. According to the American PDR (physician Desk Reference) states. "Local anesthetic rapidly cross the placenta (by passive diffusion) and when used for epidural blocks, anesthesia can cause varying degrees of maternal, fetal , and neonatal toxicity. Adverse reactions on the mother and baby involve alteration of the central nervous system, peripheral vascular tone, and cardiac function.   Objectives to Consider When Selecting Anesthesia Mother should not be coerced into having epidural anesthesia The anesthetic techniques should promote patient safety and interfere with normal progression of labor. The anesthetic should provide pain relief but not interfere with the mothers participation and satisfaction of her labor. The anesthetic should not put risk on the mother or infant at any time The mother should always be informed on alternative plans should they be needed incase of problems that need immediate attention.   History of Epidural Anesthesia Epidural anesthesia was first introduced in 1901 but unsuccessful. It's first success came in 1921 when it was performed in Spain. It was introduced in the United States in 1935 and continuous lumbar epidural was developed in 1946. In the beginning, it was taught that an epidural was the best thing for laboring mothers. It's ability to freeze lower extremities enabling the mother to have a pain free birth and able to assist in the delivery of the child was great. It was also widely believed that an epidural was totally safe for the baby because it was protected from the effects of the drugs. Today, 80 years later, we are told a different story about epidural anesthesia. Through further research and new findings, it is becoming more evident that epidurals can cause problems not only to the mother but to the baby as well. Studies show that up to 90% of woman in the United States have an epidural, with that number increasing every year. It is becoming so routine that doctors don't think anything of it. But with studies surfacing on a more frequent basis, it is coming apparent that an epidural should not be so routine and that more care should be given in the choice of drugs used and reasons for it's use. Women have been giving birth since the beginning of time and epidurals have only been in existence for 80 years. Taking this into consideration, and the fact that the epidural does not in any way, save the life of a child or reduce the risk of having birth problems, in fact, it increases those odds. More education and careful consideration should be given before an epidural is ever administered.