When can I have pain relief?

The decision to receive an epidural anesthetic is between you, your obstetrician/midwife, and your anesthesiologist. Epidural analgesia is generally given when you have begun active labor with regular painful uterine contractions. We recommend that if you are even minimally interested in getting an epidural, you ask to see the anesthesiologist in advance. This will allow the anesthesiologist to obtain your complete medical history and to perform a physical exam. Most importantly, you can discuss your pain relief options before you are in severe pain. Telling the anesthesiologist your preference, or signing a consent form for anesthesia does NOT obligate you to get an epidural anesthetic. You may later decide that you would rather have natural childbirth or another method of pain relief. 

Many factors determine when you can get an epidural, including the position of the baby in the birth canal, or whether this is your first baby or a later child. Some obstetricians/midwives would prefer that you be dilated at least four centimeters prior to getting an epidural. These obstetricians/midwives believe that an early epidural may slow your labor, but the available data on this topic is controversial. Certain medical conditions, however, may favor earlier commencement of epidural analgesia. Once the obstetrician/midwife gives his/her permission for you to get an epidural anesthetic, the anesthesiologist will place the epidural. If you have not seen an anesthesiologist in advance, an abbreviated history and physical, and consent for the procedure will be obtained. 

It is almost never too late to get an epidural unless the head of the baby is visible (crowning). Even if you initially attempted natural childbirth and never saw an anesthesiologist, you may change your mind later on if you find labor to be extremely painful. It is our recommendation that you attend childbirth education classes and listen to a lecture about the available forms of pain relief. It is important that you keep an open mind and be flexible throughout the prenatal period and labor itself. Different people experience labor differently, and being flexible provides the maximum benefit for you and your baby.

Recent opinion of American college of Obstetricians and Gynecologists: Issue date, February 2002:

Various studies report conflicting data with regard to the level of risk of cesarean delivery for nulliparous women (women with first pregnancy) who receive epidural analgesia before 5 cm of cervical dilatation. As a result some institutions are requiring that laboring women reach 4-5 cm of dilatation before receiving epidural analgesia. It is unclear whether these institutions have developed local protocols that are sensitive to patients' needs. Labor results in severe pain for many women, and there is no other circumstance where it is considered acceptable for a person to experience untreated severe pain, amenable to safe intervention.  Therefore , the American College of Obstetricians and Gynecologists wishes to reaffirm the opinion published jointly with the American Society of Anesthesiologists that while under a physician's care, in the absence of medical contraindication, maternal request is sufficient medical indication for pain relief during labor. Decisions regarding analgesia should be coordinated among the obstetricians, the anesthesiologist, the patient, and support personnel.

References: Practice guidelines of obstetric anesthesia. Anesthesiology 1999;90:600.