Labor Anesthesia

Today, we are joined by Dr. Jenny Dworzak, an anesthesiologist, who talks to us about anesthesia. 

On today's podcast we answer the following. 

1) What kinds of medication-based pain relief are available for labor?

• IV pain medications: most have short-lived effects and require repeat dosing with a limit to benefits and more side effects (itching, nausea) for mom, most can affect baby’s heart rate and breathing and may increase the need for more resuscitative efforts for baby when baby is delivered; may interfere with baby’s ability to breastfeed immediately following delivery
• Epidural: pain medication administered directly through a catheter to the nerves that transmit pain during labor. Dramatically decreases the systemic side effects for mom and makes the amount baby sees negligent. Also, because the medication can safely be given continuously it is the most effective form of pain relief during labor. 

2) If I have a high pain tolerance, is there any benefit for me to get an epidural?

• Yes, when the body has a stress response to pain, it releases substances that can slow the contractions of uterus and decrease blood flow to the uterus which houses baby. Also certain breathing patterns associated with painful stimuli can affect baby’s heart rate during labor.
• Yes, with a working epidural in place, if an emergency arises where you or baby require a C-section delivery, there is a decreased chance that you will require general anesthesia for delivery.

3) How long does placing an epidural take? 

• On average about 10-15 minutes with a few minutes for setup beforehand a few minutes for setup of the pump afterward. This can be longer in patients with anatomical variations or increased soft tissue overlying the spine. It takes another 15-20 minutes for the standard epidural medication used on our floor to have an appreciable effect on contraction intensity.

4) When should I ask for an epidural? And when is it ‘too late’? 

• This is a personal decision. Once the epidural is placed you will remain in bed and a nurse will catheterize you every 4 hours to eliminate urine from your bladder. Some moms who want to walk around their room or otherwise be more mobile prefer to wait until a significant amount of discomfort before requesting an epidural.
• On the flip side, a couple key points in considering when might be ‘too late’ for an epidural.
• A major determinant of epidural ease and success is the mom’s ability to hold a reliable still position for the duration of the procedure, which is difficult to do with increasing discomfort.
• After placement of the epidural, it may take 15-20 minutes for our standard medication to demonstrate an effect on intensity of contractions, which may not be a tolerable period of time with increasing discomfort.
• There are limited anesthesia personnel available for the floor and sometimes depending on number of emergencies, surgeries, and other epidurals on the floor, there may be a wait time from the time of your request to the placement of the epidural. To avoid disappointment and waiting in increasing discomfort, try to plan ahead and ask for your epidural before you are too uncomfortable.

5) What should I do while getting an epidural? 

• Always face forward in a straight line with your arms and legs in front of you.
• Maintain the hunchback position that your nurse and anesthesiologist will demonstrate for you.
• Sometimes your anesthesiologist may ask whether you feel they are exactly midline or more to the left or right depending on the curve of your spine and if there is soft tissue covering the spine. Answer as well as you can.

6)  Does getting an epidural hurt? 

• Before localizing the space in your back with the epidural needle, your anesthesiologist will inject local numbing medication into the skin and soft tissue overlying your bones. This numbing medication can sting slightly before it creates a numbing sensation that makes the rest of the procedure much more comfortable. Throughout the epidural you may feel pressure and manipulation but the local anesthetic will blunt sharp pain.

7) Can I be paralyzed by an epidural? 

• Extremely unlikely. A rare complication of an epidural that usually occurs in patients that have risk factors for bleeding or an inability to clot blood because they have underlying medical problems, blood count aberrancies, or are on blood thinners is an epidural hematoma, which is a bleeding collection that can compress the spinal cord. The rate of this complication is 1/160,000-190,000 epidurals.
• Neurological injury due to labor and delivery is actually more common than neurological injury due to anesthesia for labor and delivery, primarily in the form of compression nerve injuries. These include compression nerve injuries and even ischemic spinal cord injuries. Persistent neurological injury of any kind > 1 year has a rate of 1/260,000 – incredibly low and is usually associated with spinal anesthesia and medications that we don’t typically use in this hospital.

8) Is there anyone that can’t get an epidural? 

• Your anesthesiologist will make an informed decision and involve you in the process if you are not a good candidate for an epidural. If this happens, it is most likely because you have a risk factor for bleeding, an infection at the site where an epidural might be placed, active neurological symptoms or disease, or certain heart conditions.

9) What will I feel during labor if my epidural is working properly?

• You may feel pressure with contractions but a lessened intensity of each.
• You may or may not feel the urge to urinate.
• As labor progresses and the baby begins to descend, the lower nerves, which are often harder to cover with an epidural, may relay discomfort and pain.

10) When does an epidural wear off? 

• On our labor and delivery floor, we run medication through your pump every 45 minutes during labor. In addition, you have the option of pressing a button that can provide an extra bolus every 10 minutes. You will not run out of epidural medication during labor. After the epidural is paused, greatest effects of the standard medication we use in labor epidurals on our labor and delivery floor will wear off by 2 hours. Several factors, including exactly which medication was used, how long the epidural was running, how much volume of medication was in the space, and anatomical variation may cause the epidural medication effects to last a little longer.

11) What if my epidural doesn’t work? 

• There are ways we can troubleshoot why it’s not working by making sure the catheter is in the right space, giving the right amount and strength of medication, and in some cases replacing the epidural into a slightly different space if the situation calls for it. A very small % of epidurals don’t work after extensive trouble shooting. This may be because of an anatomic variation/changes due to prior injury/procedures that don’t permit the medication to spread to all the required nerves, abnormal labor patterns.

12) Will an epidural give me a headache? 

• There are many reasons for a headache developing around labor and delivery.
• About 1/100 people who get an epidural or a spinal can develop a change in their spinal column pressure due to a small hole in the covering over the spinal cord from the needle. This is a very specific type of headache that your anesthesiologist can assess you for. Most of these resolve on their own within a couple of weeks. There are also symptom treatment options including medications and patching a hole if necessary that your anesthesiologist can discuss with you.

13) Will an epidural give me a backache?

• There are many reasons for back pain surrounding pregnancy, labor and delivery. Most studies that have looked at epidurals specifically have demonstrated no difference in back pain rates in moms that received epidurals for labor pain vs those that did not in the absence of any epidural complications.

14) Is an epidural bad for baby?

• Baby sees only negligible amounts of the medications we use on our labor and delivery floor.

15) Will an epidural slow down my labor?

• There is no reproducible evidence that suggests that the current low-dose motor-sparing epidural medications that we administer on the labor and delivery floor slow labor time, increase rate of C-sections, or change outcomes in baby. There is also no reliable evidence that timing of the epidural changes labor duration.

16) Can I just go to sleep for a C-section?  

• While general anesthesia (going all the way to sleep and having an anesthesiologist take over breathing for you) is considered generally safe in young, healthy patients, being pregnant makes it far more risky for both mom and baby. So, we don’t routinely recommend general anesthesia for standard C-sections unless there is a life threatening emergency or a pre-existing medical condition that necessitates it.