Labor & Delivery.
Labor is unique to every woman. Many factors influence the mother’s experience, including her pain tolerance, the size and position of the baby, how well labor is progressing, and prior birth experiences. While some women are able to cope with labor using only breathing and relaxation techniques, many choose to combine these methods with pain medications or an epidural. PAA, in partnership with your obstetrician and obstetric care team, is dedicated to managing your labor and delivery pain with a primary focus on the safety of both mother and baby. We are actively involved in the pre-anesthetic assessment of each patient’s maternal health, ensuring the right pain management plan is in place. Then, throughout delivery, we work alongside the obstetrician to provide the highest level of safety and comfort or provide anesthesia for surgical delivery, if needed.
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An epidural is the most effective form of pain relief during labor. An epidural is a tiny plastic tube that is inserted into the back next to the spinal cord. Local anesthetics and other medications are administered through the epidural to “block” pain messages that travel from the uterus and cervix through the spinal cord to the brain, significantly reducing pain during labor while allowing the patient to remain awake and able to participate in delivery.
Epidurals allow for continuous medication during labor. If pain increases, patients can automatically administer extra medication with the push of a button. For patient safety, the machine has a mechanism that ultimately limits the amount of medication. Epidurals also can be used to quickly administer additional medicine for anesthesia during surgery, should a cesarean section or other surgical procedure become necessary.
As we strive to balance each patient’s comfort, safety, and ability to push effectively for delivery, it is important to remember that an epidural will not eliminate all feeling or discomfort during labor.
How is an epidural administered?
The anesthesiologist will administer the epidural in the lower part of the back, known as the lumbar area. The skin will be cleansed with an antiseptic solution; then, a local anesthetic will be injected to numb a small area of the lower back. The numbing medicine stings for only a few seconds. Afterward, patients usually just feel pressure.
Patients will be asked to hold very still while the anesthesiologist sets up the epidural. While lying on your side or sitting on the edge of the bed, you will be asked to lean forward, almost as if you are trying to touch your nose to your belly button. This opens up the spaces between the bones of your spine. Concentrating on your breathing will help you to relax and remain still during the procedure. Breathe in deeply through your nose, and sigh out slowly through your mouth.
Next, the anesthesiologist will place a special needle in the epidural space (a long, sleeve-like space inside the bony vertebral column, but outside the spinal fluid sac). A tiny flexible tube called an epidural catheter is threaded through the needle, then the needle is removed and the catheter is taped in place, remaining until after the birth. A brief tingling sensation sometimes occurs in the back or legs.
As needed, nurses will help patients adjust position after the epidural is administered, in order to help the epidural function properly and prevents a pressure sore from developing on the numbed area. Patients remain in bed after an epidural has been administered, as the legs are likely to feel weak or heavy. Most patients receive a catheter to prevent trips to the bathroom. Catheters are typically placed in the bladder once the patient is numb from the epidural and in most cases is only required for a short time.
When will my epidural be administered?
Patients may have an epidural any time during active labor. The appropriate time is unique to each person. Most women request an epidural when contractions become strong, often when the cervix has dilated to about 5cm.
How quickly will the epidural work?
Pain relief generally occurs within 10 to 20 minutes after receiving the epidural. First contractions will begin to feel shorter; then contraction pains will become much less intense. Throughout your labor, your comfort will be monitored by your nurses and physician anesthesiologist and medications adjusted, if necessary. It is important to remember that an epidural will not eliminate all feeling or discomfort during labor.
Will the epidural affect my baby?
There is considerable evidence that uncomplicated regional analgesia is safe for the baby. Many experts believe that relief of severe labor pain and stress may actually benefit the baby. Epidural or spinal analgesia relaxes the mother while avoiding the sedative effects of the alternative narcotic drugs. Throughout labor, the baby’s heartbeat will be monitored continuously, including after the epidural is placed. Temporary changes in the fetal heart rate occur frequently in normal labors and can occur with both regional blocks and narcotic medications. These changes are not typically associated with any long-term effects.
Will an epidural slow down the birthing process?
There is no good evidence that an epidural slows down labor or increases the risk of having a cesarean section. In fact, there is evidence that epidurals can speed the first stage of labor for some women. Some experience a brief decrease in the frequency of contractions after an epidural, while labor progresses more rapidly for others, once pain is relieved and the mother is more relaxed. Most mothers find that an epidural allows them to rest more easily during labor and save energy to push effectively.
What are the risks associated with an epidural?
As with any medical treatment, side effects or complications can occur. We monitor each patient and her baby carefully and take every precaution. Because blood pressure can decrease following an epidural, patients will have an IV and be given fluids beforehand. Shivering, nausea and vomiting can occur during labor, with or without an epidural. Medication is available to help with this. Risks associated with an epidural include:
- Headaches are rare but do occasionally follow regional anesthesia; however, holding still during needle placement decreases the likelihood of a headache. Pain medication and additional treatment can be administered when necessary.
- Backaches are common during pregnancy and labor, and often continue after the baby is born. There is evidence that epidurals do not cause long-term backache, although there may be slight local tenderness for a few days.
- Very rarely, the medication in regional blocks can cause a numbing sensation in the chest wall that can make breathing feel difficult. This sensation usually disappears on its own.
- Occasionally, the epidural needle enters an epidural vein. Epidural veins can become swollen during pregnancy, much like varicose veins. If this occurs, the epidural needle or catheter is repositioned to ensure that the medication is placed where it can provide effective pain relief.
- Serious adverse reactions to drugs entering a vein or the spinal fluid are rare. When larger doses of medication are given, such as for cesarean section anesthesia, we usually begin with a small test dose.
- Life-threatening or serious complications such as unusual drug reactions, nerve damage or infection near the spinal cord are extremely rare with regional blocks. Please feel free to discuss any concerns with your physician anesthesiologist.
Will I need to make a decision regarding pain management prior to going into labor?
No. We do encourage patients to be well informed of the options, though, and address any questions or concerns ahead of time with the obstetrician and/or physician anesthesiologist. Please note that epidurals are only available in obstetrician-led Labor & Delivery units. Patients giving birth at a home or at a midwife-led unit cannot have epidurals.
What if I ask for an epidural too late?
It is never too late to ask for an epidural; however, if a patient is close to pushing it may be physically impossible or impractical to receive an epidural. Spinal analgesia is occasionally used when labor is progressing rapidly and delivery is expected in the immediate future, as it is similar to an epidural but quicker to perform. Pain relief occurs fast and lasts about an hour and a half.
If I have a high tolerance for pain, does this mean I will also have a higher tolerance to labor pain?
There is no way to accurately predict how a patient will process labor pain. Every woman experiences labor pain differently.
Does is hurt when an epidural or spinal is administered?
Your physician anesthesiologist will numb the area where the epidural or spinal will be administered. Most patients feel just a stinging sensation that lasts for a few seconds.
Can I walk around once my epidural is in place?
No. Your legs are likely to feel weak and heavy, and most delivery units do not allow patients to walk around after an epidural is in place, due to safety concerns.
If I move during the administration of the epidural, is it true that I may be paralyzed?
There is minimal risk of paralysis from modern anesthesia techniques.
How soon after my delivery can the epidural be removed?
Epidural catheters are usually removed shortly after the delivery.
Do epidurals always work?
For a small number of women, an epidural does not work adequately to block pain and instead only numbs part of the affected pain area. In this case, extra pain relief can be administered. Patients who continue to experience significant discomfort within half an hour of the epidural should notify the physician anesthesiologist. Also, please note that not everyone is a candidate for an epidural. The physician anesthesiologist will discuss health and medical conditions with each patient before performing an epidural.
Anesthesia for Cesarean Births
Most women receive a regional anesthetic (a spinal or an epidural) for cesarean births, enabling them to remain awake for the birth of their baby. For patients who already received an epidural during labor, stronger medicine can be administered through the epidural to provide anesthesia for cesarean delivery. In unique circumstances, general anesthesia may be necessary. In these cases, general anesthesia can be started quickly to make the mother unconscious during delivery. It is important that patients avoid solid food, including milk products, once active labor begins, regardless of the birth plan, because surgical births are not uncommon. Moderate amounts of clear fluids and ice chips are allowed in most normal labors.