You're 34 weeks along, filling in the pain relief page of your birth plan, and "epidural" feels like a bet on a labor you haven't met yet. Depending on who you ask, it was the best call of their labor or the reason everything slowed down.
This guide sets out the epidural pros and cons as the evidence states them, then covers timing, duration and every alternative on a typical birth plan. ACOG calls the epidural the most common form of labor pain relief in the United States, and says you don't need to decide until you're in labor.
An epidural may relieve labor pain better than non-epidural methods (Cochrane, 2018) and does not raise your chance of a cesarean (ACOG). The trade-offs are an IV, continuous monitoring, less freedom to walk, and higher odds of low blood pressure and fever. "Open to an epidural" is a complete plan.
Key Takeaways
- You can decide in labor. ACOG says the choice can wait, and that it's OK to change your mind.
- Timing is flexible. ACOG and the American Society of Anesthesiologists (ASA) say an epidural can start early or late in labor.
- The downsides are specific. Cochrane links epidurals to more low blood pressure, leg weakness, fever and trouble peeing.
- Alternatives carry little risk and mixed evidence. ACOG says no non-drug method has been found to harm you, your baby or labor's progress, though few are well studied.
How an Epidural Works
An anesthesiologist or another specialized clinician numbs a patch of your lower back while you sit curled forward or lie on your side, then threads a thin tube (a catheter) through a needle. The needle comes out and the tube stays. Medication, usually a local anesthetic mixed with an opioid, goes through it as needed (NHS).
For an epidural in a normal delivery, ACOG says you lose some feeling in your lower body but stay awake, alert and able to push.
You may also hear about a spinal block, a single fast-acting injection, and a combined spinal-epidural (CSE), which pairs a spinal dose with an epidural catheter (ACOG).
Epidural Pros and Cons at a Glance
| What the evidence says | Source | |
|---|---|---|
| Pain relief | May beat non-epidural methods, with higher satisfaction (low-quality evidence) | Cochrane, 2018 |
| Cesarean | No increase | ACOG; Cochrane |
| Forceps or vacuum | More likely overall; not clear in trials after 2005 | Cochrane |
| Labor length | Longer than with opioids per Cochrane; the ASA sees no credible evidence it slows labor | Disputed |
| Side effects | More low blood pressure, leg weakness, fever and trouble peeing | Cochrane |
| Mobility | You can move but may not walk; continuous monitoring | ACOG; NHS |
| Your baby | Low overall risk; short-term effects possible with opioids | ACOG |
Epidural Pros
Strong pain relief. The NHS says an epidural gives complete pain relief in most cases. The 2018 Cochrane review of 40 trials and more than 11,000 women found lower pain scores and higher satisfaction than with opioids, though it rated that evidence low quality.
A clear head. The NHS says an epidural should not make you sick or drowsy, both known side effects of opioid shots (ACOG).
No extra cesareans. ACOG says pain medication does not increase the likelihood of a cesarean, and Cochrane found no effect on cesarean rates or long-term backache.
Ready if plans change. For a cesarean, ACOG says the epidural dose can be increased to numb your lower body for surgery. It also says labor pain medications have no long-term effects on the baby.
Epidural Cons and Side Effects
Compared with opioids, Cochrane found people with an epidural had more low blood pressure, leg weakness (motor blockade), fever and trouble emptying the bladder, plus longer labors and more oxytocin. Cochrane calls the labor-length and leg-weakness findings highly variable, probably tied to higher anesthetic doses in some trials, and the ASA says there is no credible evidence an epidural slows labor. Treat labor length as an open question.
Forceps and vacuum. Across all trials, epidurals raised the chance of an assisted vaginal birth, but in trials after 2005, with lower-dose epidurals, the difference was no longer clear. Pushing advice also differs: ACOG supports pushing at the start of the second stage for first-time parents with an epidural, while the NHS describes waiting for the baby's head to come down.
Other side effects. ACOG lists itching as common when opioids are in the mix, headache and soreness as less common, and shivering among other possible effects. The NHS puts the headache risk at about 1 in 100, treatable. ACOG calls serious complications, such as nerve injury, very rare, and the NHS notes an epidural is not always fully effective.
Your baby. ACOG rates the overall risk as low. With opioids in the epidural, it notes a higher chance of short-term effects such as breathing problems, drowsiness and reduced breastfeeding.
Moving, Positions and Monitoring With an Epidural
ACOG says you can move with an epidural but may not be able to walk. The NHS describes an IV drip, continuous monitoring with a belt around your belly, and sometimes a bladder catheter. Some hospitals offer lower-dose "walking" epidurals, which the NHS notes need wireless monitoring that many units lack.
The WHO recommends encouraging people with an epidural to give birth in the position of their choice, upright included, though ACOG cites a 2017 trial in which first-time parents pushing upright with a low-dose epidural had fewer spontaneous births. If you've picked kneeling, all fours or water birth in Bloom's positions step, ask which your hospital supports once an epidural is in.
How Long Does an Epidural Last?
A labor epidural lasts as long as the catheter stays in: the ASA says you can receive pain relief through it for as long as you need, with the dose adjusted as labor changes. A nurse can top it up, or you may have a pump that lets you control the supply yourself (ACOG; NHS).
- Starting: about 10 minutes to place and another 10 to 15 minutes to work (NHS).
- Single-shot spinal: an hour or two (ACOG).
- After it's stopped: the NHS says numbness usually lasts a few hours. You'll rest lying or sitting until feeling returns to your legs, which can take a couple of hours.
If pain returns or relief feels patchy while the catheter is in, tell your nurse, since the NHS notes an epidural may need adjusting.
When Can You Get an Epidural?
You may hear that you have to reach a certain point in labor first. ACOG says an epidural may be given soon after contractions start or later, and the ASA says even toward the end, in consultation with your physician. ACOG's clinical bulletin adds that, absent a medical reason against it, your request is reason enough.
There's no single best time to get an epidural during labor, but some practical limits are worth raising before your due date:
- It takes time. Relief builds over 10 to 20 minutes once the medication starts (ACOG). If labor is moving fast, ask whether a spinal or CSE could work sooner.
- Someone has to be free to place it. The NHS suggests checking whether an anesthesia provider is always on the unit.
- Your health history. ACOG's guidance allows for medical contraindications, so raise any conditions at a prenatal visit, not in triage.
ACOG notes that admission may be delayed in early labor when you and your baby are doing well. Our contraction timer logs the pattern your provider may ask about, and the 5-1-1 rule guide covers when to head in.
Alternatives to an Epidural
Every option below appears in Bloom's pain relief step. ACOG's 2019 guidance notes that few non-drug methods have been studied enough to rank, and that methods can be combined or used in turn.
Nitrous Oxide
Nitrous oxide (laughing gas) is mixed with oxygen and breathed through a mask you hold yourself, starting about 30 seconds before a contraction. ACOG says it eases anxiety so pain is easier to cope with, without numbing it, and calls it safe for you and your baby. Any dizziness or nausea passes within minutes. The NHS says it won't remove all the pain, and ACOG notes that some hospitals offer it, so ask about yours.
TENS Unit for Labor
A TENS unit sends mild electrical pulses through pads on your lower back, and you control the strength (NHS). A 2009 Cochrane review of 17 studies with 1,466 women found similar pain scores with and without it, no reported harms, and many women willing to use it again. The NHS says it hasn't been shown to help in active labor and is probably most useful early on, including at home. Ask whether your hospital provides units or lets you bring one.
Sterile Water Injections
A clinician injects small amounts of sterile water into or under the skin of your lower back for back pain in labor. In a 2012 Cochrane review, every study reported bigger pain reductions than with placebo, but the data couldn't be pooled and the authors found little robust evidence that it works. The injections sting briefly, and the review found no difference in cesarean rates.
Water: Bath or Shower
A 2018 Cochrane review of 15 trials with 3,663 women found that laboring in water during the first stage probably means fewer epidurals, with no evidence of extra harm to you or your baby. ACOG agrees it lowers first-stage pain scores. Giving birth in water has less evidence and sits separately in Bloom's positions step. Ask whether labor rooms have a tub or shower you can use.
Massage, Heat and Movement
A 2018 Cochrane review found low-quality evidence that massage reduces first-stage pain and very low-quality evidence that warm packs reduce pain and shorten labor. The WHO recommends massage, warm packs and relaxation techniques such as breathing for women who want pain relief, and encourages movement and upright positions in low-risk labor. ACOG suggests a partner massage with tennis balls.
Acupuncture
A 2020 Cochrane review of 28 trials found acupuncture may make little or no difference to pain intensity compared with sham treatment, but may raise satisfaction and probably reduces use of pain medication. Most of the evidence is low or very low certainty. The NHS says most UK hospitals don't offer it, so ask whether yours allows a trained practitioner.
Unmedicated Birth: What to Expect
The pros and cons of natural birth come down to pain against freedom. ACOG states that labor causes severe pain for many women, and that only you know how you handle pain. On the plus side, you skip medication side effects, and ACOG says low-risk labors can use intermittent monitoring, which can allow more movement.
The main disadvantage of natural birth is the pain. ACOG notes that unrelieved labor pain can change your breathing and raise stress hormones that can affect your baby. Changing your mind late narrows the options, since IV or injected opioids may not be possible in the last hour before delivery (ACOG).
Bloom's pain relief step lists all of these. Mark what you're open to in Bloom, plus Other for anything you want to discuss, and your care team sees it on one page as a PDF or an email.
How to Write Your Pain Relief Preferences Into a Birth Plan
A pain relief line works best when it tells your nurse what to do in the moment. Three patterns to adapt:
- "Please don't offer pain medication. I'll ask if I want it." For a planned unmedicated birth. You might add: "If I ask for an epidural, please treat it as a real request."
- "Please offer options if I seem to be struggling." For the undecided. ACOG describes a coping scale that asks how well you're coping from 1 to 10, so you might add: "If I rate my coping low, remind me of my options."
- "I plan to request an epidural early." For when you already know. Add a fallback: "If there's a wait, I'd like nitrous oxide or the shower in the meantime."
Our birth plan examples show full plans built around an epidural and around an unmedicated birth, and the C-section birth plan guide covers what to request if surgery becomes part of the day. Once you're ready, write your pain relief preferences in Bloom, then add your exact wording in the Special wishes box.
Questions to Ask at Your Prenatal Visit
- Does this hospital offer nitrous oxide, tubs or showers, sterile water injections, or TENS units?
- Is an anesthesia provider on the labor unit around the clock?
- Is there a policy on how early or late an epidural can be placed?
- Do you offer lower-dose epidurals or wireless monitoring?
- If I go without an epidural, can I have intermittent monitoring?
- Does anything in my health history rule out an epidural or a spinal?
- With an epidural, does your team start pushing right away or wait?
Frequently Asked Questions
How long does an epidural last?
As long as you need it in labor. A catheter stays in your back and medication is topped up through it. After it is stopped, the NHS says numbness usually lasts a few hours.
When is the best time to get an epidural?
There is no single best time. ACOG says it can be given soon after contractions start or later, and the ASA says even toward the end. Relief takes about 10 to 20 minutes to build.
Does a TENS unit work for labor pain?
The evidence is limited. A 2009 Cochrane review of 17 studies found similar pain scores with and without TENS, and no harms. The NHS says it is probably most useful in early labor.
How painful is natural birth?
It varies. ACOG states that labor causes severe pain for many women and that only you know how you feel and handle pain. ACOG also says it is OK to change your mind about medication.
What are the disadvantages of a natural (unmedicated) birth?
The main one is pain. ACOG notes that unrelieved labor pain can change your breathing and raise stress hormones that can affect your baby. Upsides include freer movement and no medication side effects.
Do sterile water injections work for back labor?
Possibly, but the evidence is thin. A 2012 Cochrane review found studies reported greater back pain relief with sterile water, yet little robust evidence overall. Ask whether your hospital offers them.
This article is for information only and does not replace medical advice. Talk with your OB or midwife about the options that fit your health and your hospital.
Sources
- Medications for Pain Relief During Labor and Delivery. ACOG, last reviewed 2024
- Obstetric Analgesia and Anesthesia, Practice Bulletin No. 209. ACOG, 2019, reaffirmed 2024
- Approaches to Limit Intervention During Labor and Birth, Committee Opinion No. 766. ACOG, 2019
- Epidural versus non-epidural or no analgesia for pain management in labour. Anim-Somuah et al., Cochrane, 2018
- TENS for pain relief in labour. Dowswell et al., Cochrane, 2009
- Sterile water injections for the relief of pain in labour. Derry et al., Cochrane, 2012
- Immersion in water during labour and birth. Cluett et al., Cochrane, 2018
- Massage, reflexology and other manual methods for pain management in labour. Smith et al., Cochrane, 2018
- Acupuncture or acupressure for pain management during labour. Smith et al., Cochrane, 2020
- WHO recommendations: intrapartum care for a positive childbirth experience. WHO, 2018
- Pain relief in labour. NHS, last reviewed 2023
- Epidural. NHS, last reviewed 2023
- Epidurals. American Society of Anesthesiologists, 2024
