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Epidural Information

Choices of analgesia in labor and delivery

Several options are available for pain relief. Psychological techniques such as the Lamaze method are one option. Intravenous or intramuscular injections of narcotics such as nubain and morphine are another option. Inhalation of anesthetic gases, although still used in Europe as an adjunct to pain relief is very uncommon in the United States. Most patients at Riverside will employ several of the above options. That is, a combination of lamaze technique and narcotics until the patient is ready for her epidural. Over 75% of women in labor at Riverside choose epidural anesthesia for pain relief.

Considerations for epidurals

The epidural space surrounds that sac of fluid that bathes the spinal cord and nerve roots. Injection of local anesthetic into this space is an epidural anesthetic. For labor analgesia, the lnjection is at the lower back area. The spinal cord terminates higher up in the back so there is no danger of spinal cord damage.  There are some absolute contraindications to epidural analgesia: infection at the site of injection, problems with blood clotting, and of course patient refusal. There are relative contraindications: previous spinal surgery (fusions), severe lumbar spine problems and neurological disorders such as multiple sclerosis. Patients with contraindications can be seen in our office for consultation. Most obstetricians wait until the cervix is dilated by 4-5cm and there is a good pattern of labor, before they order epidural placement. Your skin is cleaned with an antiseptic  solution and the skin in numbed in preparation for placement. A special needle is slowly advanced  until the epidural space is entered. The small catheter, as seen in the above photograph is threaded into the space. On occasion, the catheter might brush against a nerve root on insertion. This can result in a brief electric shock sensation (paresthesia). Please let the anesthesiologist know if this happens. Test medication is given through the catheter to confirm proper placement in the epidural space. Since the onset of epidural anesthesia is slow, it will take 15-20 minutes after the initial dosing for good pain relief.

Epidural placement

Will I get total pain relief?

Low concentrations of local anesthetics are used so that patients do not become completely numb. A very complete nerve block would prevent adequate muscle strength for pushing in the second stage of labor. Generally, you will feel pressure with the contractions and most of the pain will be relieved. The epidural will be continuously dosed via an infusion pump of local anesthetic. This prevents the block from wearing off during your labor. If the pain control seems inadequate, the dosing can be adjusted.  

What are the side effects?

Labor epidurals are very safe, but any procedure can have side effects and complications. We will describe the most common ones:

• There can be a drop in blood pressure from the block. You are given a bolus of intravenous fluid prior to epidural placement to help prevent this. Your blood pressure is monitored throughout the epidural. 
• There are risks of the local anesthetic entering sites other than the epidural space. To detect misplacement of the catheter into an epidural vein, your anesthesiologist gives a small "test dose" of local through the catheter. If you develop a funny taste in your mouth, ringing in your ears or pounding chest, the catheter is likely in a vein. In this case the epidural is redone. The epidural catheter can be misplaced into the sac that holds the spinal fluid. Injection of the local into this space results in  excess nerve block. Again, small doses at placement help to detect this.
• There is a 1% or less chance of headache. It can occur when the sac that holds the spinal fluid is nicked by the epidural needle. The headache usually presents the following day. It is made worse by standing up. The initial treatment is conservative with pain medication, and large amounts of caffeinated beverages. If the headache persists, an epidural blood patch in done. In this procedure  a small amount of your blood is injected into the epidural space. In over 90% of the cases, a single blood patch cures the headache.
• Weakness of your legs results from the epidural block. Once the epidural is dosed, you must stay in bed.
• Mild low back pain post delivery is common from the epidural needle. This is usually of short duration.
• Nerve damage and infection are uncommon complications.

What is a walking epidural?

This technique involves placement of the epidural very early in your labor (less than 4 cm dilation). We have been dosing these walking epidurals with small doses of narcotic agents. Since there is some local anesthetic in the initial test dose, you must stay in bed for 20 minutes after the placement. Common  side effects of the narcotic dose include itching and mild nausea which can be treated easily. When your labor advances the epidural catheter is dosed with the usual medications for a stronger block. Another form of walking epidural uses a combined spinal/epidural technique. In this approach as small dose of local anesthetic and/or narcotic is injected into the spinal fluid (intrathecal injection). An epidural catheter is also placed for use in the later stages of labor.

Will I wait long for my epidural?

There is both a CRNA and anesthesiologist available at the labor and delivery suite 24 hours a day. In addition, back up staff is available  from the main operating room suite if needed. You can rest assured that once your epidural is ordered by the obstetrician, it will be placed as soon as possible.