Today women have the option of choosing a relatively pain-free labor and delivery by virtue of the advancements in anesthesia techniques over the last three decades. Regional anesthesia in the obstetric settings has become far safer and widely available with approximately 80% of all laboring patients in the United States receiving some form of regional anesthesia for labor and/or C-section. A minority of women still choose to have a natural birth without medication during labor regardless of the discomfort that labor may represent. Fortunately, women have the right to make their own decisions surrounding anesthesia during childbirth. We as anesthesia providers must respect each patient’s wish and expertly attend to their individual anesthetic needs when called upon to care for expectant mothers.
How is the epidural catheter placed?
After a sterile prep and draping, a local anesthetic is placed in the skin to numb the area where the epidural needle will be placed. The needle for epidural passes between the vertebrae of the spinal column to a tissue layer called the “epidural space.” Once the needle is correctly positioned, a very small plastic catheter (tube) is threaded though the needle into the epidural space. The needle is then removed and the catheter remains. The catheter is taped to the patient’s back and local anesthetics or narcotics can be continuously infused via this catheter. Placement of an epidural usually takes 10 – 25 minutes and is relatively painless. The epidural catheter can remain in place providing pain relief until delivery or the patient decides it is no longer needed.
Is placement of an epidural painful?
Epidurals are typically placed using local anesthetics to numb the skin and tissue that the epidural needle will pass through. A very small needle (often 25g.) is used to administer this local anesthetic (typically lidocaine) and is comparable to a routine injection from your doctor. Patients having an epidural for a procedure other than labor and delivery during pregnancy are typically sedated prior to epidural placement. Women receiving epidurals for labor are generally not sedated as the sedatives can reach the baby.
What kind of pain relief can I expect from my epidural?
The goal of a labor epidural anesthetic is to significantly reduce the pain while leaving enough sensation to feel pressure and push during delivery. The epidural medication generally begins to work within 5 minutes, but can take up to 15 minutes to achieve its full effect. Sometimes your pain relief may not be complete, or it may be one-sided. In most cases, changing your position, changing the dose of medication, and/or repositioning the catheter in your back resolves this. On occasion, the catheter may need to be replaced. Be sure to talk to your nurse or anesthesiologist if you have concerns about the amount of pain you feel.
Will an epidural slow my labor?
There has been much debate and research on this topic. Generally, epidural anesthesia does not dramatically affect the progress of labor and delivery. Sometimes there is a brief slowing of contractions thought to be due to the extra IV fluids given around the time of epidural placement. Occasionally, labor progresses more rapidly after the epidural anesthetic is working and you are more relaxed. One factor important for a good labor pattern is the placement of the epidural only after labor is regular and your cervix is dilating.
How am I positioned during the placement of my epidural?
Patients are generally sitting or lying on their side for epidural placement. In addition, patients are typically asked to curve their back (often called the “mad cat” position) to help open the spaces between the spine and facilitate epidural needle passage between these bones into the epidural space.
Will an epidural increase my risk for a C-section?
Current data does not support the idea that epidural anesthesia directly increases the need for C-sections in laboring patients. Statistically, a high percentage of laboring women having C-sections have epidural anesthesia. However, this is due to the fact that women who have more difficult labor (due to multiple factors including the size and position of the baby and intolerable pain) are more likely to ask for epidural anesthesia. This same group of women are more likely to require C-section for delivery because of factors unrelated to the anesthesia.
What are the most common side effects of an epidural?
The most common side effects from epidural and spinal anesthesia are:
1. Itching — this is not an allergy, but a common side effect of some of the medication.
2. A decrease in blood pressure due to the medications. This is usually counteracted with increased IV fluids and occasionally, medication. For this reason, an IV is placed prior to the epidural. Both the mother’s and the baby’s vital signs will be monitored to ensure patient safety during the epidural.
3. Shaking is a side effect which can result from the epidural medication, rapid infusion of relatively cold IV fluid, or labor itself.
What are the possible complications from epidural anesthesia?
1. Infrequently, once the anesthetic takes effect, the mother’s uterus contracts very hard. This may cause the baby’s heart rate to decline briefly, but does not harm the baby.
2. Approximately one in every 400 hundred patients receiving spinal or epidural anesthesia gets a spinal headache. Spinal headaches usually start the day after the anesthetic. These headaches can be painful, but are not life threatening and can be treated.
3. On rare occasions, the epidural medication may go into a blood vessel. A very large dose could cause a loss of consciousness or a seizure. Small doses are normally used for labor.
4. Occasionally, the anesthetic can be too strong and the patient will require breathing assistance. The anesthetist is trained to manage breathing under these circumstances.
5. Very rarely, back or nerve damage can occur.
6. While extremely rare, any anesthetic can sometimes have serious consequences. In the most severe cases, blindness, major organ damage or death may result.
What drugs are used in an epidural?
Two types of drugs are commonly used in epidurals: local anesthetics and opioid pain medicines. Local anesthetics block nerves to provide “numbness” and opioids (morphine-like medicines) alter pain nerve signal transmission and modify perception of pain. Pain medicines (opioids) mixed with local anesthetics provide superior results compared to local anesthetics alone.
Is everyone a candidate for an epidural?
Most new mothers are normal, healthy patients and can choose to have an epidural. There are some patients who may not be eligible for regional anesthesia because of co-existing medical conditions. Women who have bleeding disorders should not receive regional anesthesia because the procedure can cause bleeding into the epidural space, which may cause nerve injury. Women with severe infection can also develop nerve injury after regional anesthesia because of the introduction of bacteria into the epidural space.
Complicated back surgeries such as Harrington rods and spinal fusion can present unique challenges for the anesthesiologist and should be discussed in advance whenever possible. The anesthesiologist may need to request surgical notes or X-rays in advance of your labor. If you have a concern regarding one of these issues, we will be happy to consult with you on the phone or in person.
I am going to have a C-section. What can I expect?
A Caesarean Section (or C-section) is a surgical procedure which involves delivering the baby through an incision in the abdominal wall. Like most other types of surgery, anesthesia is administered prior to the surgery. However, because patients are encouraged to participate in the experience of childbirth, a C-section is usually performed with the patient awake, under a spinal or epidural anesthetic. Depending on the circumstances, it is usually possible to allow one other support person (such as the father) to join the mother in the operating room during the surgery. After the baby is delivered, the support person may accompany the newborn to the nursery, or they may choose to remain with the mother for the remainder of the procedure. Following the operation, the mother will be transported to the recovery room, where she will recover from anesthesia and be re-united with her newborn.
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