01/16

2013

5

Comments

epidural

And Now a Word From an Anesthesiologist

I’m a minimal-intervention kind of gal. I avoid medicine and medical treatment unless absolutely necessary. Childbirth did not qualify as a case in which either were absolutely necessary, so I had my son without drugs (it didn’t work out with my daughter. Long story). But I expected a lot of pressure from the healthcare professionals to “just get the epidural” and was distrustful of  my OB and the anesthesiologist on call before I was even in labor. Based on my wariness of physicians, it might come as a surprise to some to hear that one of my best friends, Rachel, is an anesthesiologist.

My fears about being pressured into medicated birth were extreme (if you have seen The Business of Being Born, you’ll get why), but not uncommon among women choosing a natural birth. I asked Rachel if she’d participate in a Q&A post to share what she, as an anesthesiologist, wants more women like me (ie, women who are righteously committed to unmedicated birth and are distrustful of physicians and anesthesiologists) to know about epidurals. The misconceptions she wanted to correct, the information she knows to be true, and the doctor’s side of things. She was more than happy to oblige. Her answers were great. I should have done this before having my kids, as then maybe I would not have feared being pressured into medicated birth the way I did.

In the interest of full disclosure, I should mention that Rachel is currently pregnant with her third child, and she is striving for natural childbirth. Not because she doubts epidurals or other options for pain relief, but because it is a personal goal of hers. I should also add the disclaimer that you should talk to your own doctor or midwife about your goals for childbirth and how you can achieve them.

And now, a Q&A between a woman (ahem, me) wanting natural birth and Rachel Cappuccino, MD.

I don’t want an epidural. Can I tell my husband to turn the anesthesiologist away at the door?

This was on an episode of “A Baby Story” on TLC and I took issue with it. The anesthesiologist is not lurking at your door to try to force an epidural upon you. He/she is probably working elsewhere, eating lunch, or sleeping and will come to your room only when summoned.

I changed my mind. I want the epidural. What if the anesthesiologist won’t give it to me?

No one is going to actively deny you pain medication.  There are circumstances where it may take some additional time until the anesthesiologist can perform the epidural. If the labor ward is busy, you may be “in line” behind other women who are getting epidurals or are in the operating room for a c/section. The anesthesiologist may be needed in several places at once. Keep this in consideration. You may have heard that it was “too late” for someone to get their epidural, and that can happen. The only time we say that is if there is actually not enough time to perform the epidural and get it functioning before the baby is crowning.

How long will it take until I feel better?

After the initial injection, you can start feeling relief almost right away.  It may take up to 20 minutes for full relief, but even a small change at that time will be significant. Please remember that you will still feel pressure, especially as the baby descends, so you will still feel the urge to push.

Can I get a “walking epidural?”

Once you get an epidural, you will be confined to bed with fetal monitoring. Although there are local anesthesia medications which allow you to have some motor function of your legs while blocking the sensory fibers (hence blocking pain), you ought not try to walk when your legs are weak and/or numb. You would be much more likely to fall and hurt yourself or your baby.

What risks should I really be concerned about?

The most common risks to consider are back pain, headache, and a failed or partial epidural.

–   Back pain is common after pregnancy. Your body has gone through many changes, and the ligaments have stretched. There may be some additional (temporary) localized pain at the site of the epidural due to tissue trauma from the needle passing through to the epidural space. This should not be more significant than a bruise. Lasting back pain likely has more to do with the strain of pregnancy than the epidural, but studies are not clear on this.

–   Headache occurs approximately 1% of the time. This happens when the needle nicks the dural membrane and some of the spinal fluid leaks out.  Please bear in mind that if a “wet tap” occurs, you are much more likely to have a headache (>50%). This is an unfortunate risk of an epidural due to the nature of the procedure. It can happen to the best of practitioners. I was told in my residency that if I hadn’t gotten a wet tap yet, then I hadn’t done enough epidurals.  It doesn’t occur often, but the one I had in my first few years of practice was directly due to the patient jumping during a critical part of the procedure. PLEASE, do not move during your epidural. Hug a pillow, hold the labor nurse, and warn the anesthesiologist if a contraction is starting so he/she can pause and wait until it passes, or finish quickly.

This headache feels much better lying down and worsens suddenly with sitting or standing.  Rest, fluids and caffeine can make symptoms better until the body heals the nick/hole and replaces the spinal fluid that has been lost; however, in severe cases, an epidural blood patch can be performed. This is when some of your own blood is taken in a sterile fashion and then injected into your epidural space. The clotting factors in your blood may help to close up the hole faster, and the volume of blood injected can provide some instant relief by putting pressure on the hole.

–   Partial/Failed Epidural: These procedures are done without x-ray guidance. There is a very characteristic feel when the needle passes into the epidural space, and the anesthesiologist tests to be sure that the needle is in the right place. A catheter is threaded through the needle into the epidural space. However, because it is blind and the tests may not be perfect, and because the catheter might “wander” once it has gone out of the needle, your epidural can wind up being one-sided or ineffective. You may also experience “windows” where one part is not as well numbed as the others. This can be due to “webs” within the epidural space preventing the medication from reaching certain areas, or the myelin sheath covering a nerve. Greater volume of medication, stronger local anesthetic medications, or even a new epidural may be helpful in these situations.

Will I be paralyzed? My sister’s friend’s cousin’s friend’s friend got her epidural and now she can never walk again.

Have you ever played the game of telephone? Each time the story gets repeated, it gets changed or amplified. Remember this as you process other people’s stories.  Everyone seems to have a scary epidural story. Most of them are largely untrue. As with any procedure involving needles or scalpels, bleeding and infection are a risk. However, they are extraordinarily uncommon.  The same goes for paralysis. The spinal cord in adults ends about 2/3 of the way down your back, at the level of the second lumbar vertebra. Most epidurals are placed beneath the 4th or 5th lumbar vertebra, much lower than the end of the spinal cord.  As it ends, the spinal cord fragments off into many smaller nerves and is called the “cauda equina” (horse’s tail, because that’s what it resembles). A labor epidural is unlikely to nick any of those nerves because they are within the spinal canal, but again, remaining still will minimize the risk of the needle entering the spinal canal. Paralysis from an inadvertently deep needle puncture for a higher epidural is more plausible, but still unlikely. If there were a horrible cascade of uncommon events, it is vaguely possible with a labor epidural. I haven’t crunched the numbers, but I think you’re more likely to get struck by lightning today.

Why are they making my husband/partner leave the room?

Quite frankly, even the strongest of men can crack under pressure and stress to pass out while your epidural is being placed. I’ve seen it happen. I even made my physician husband leave the room during my epidurals. Many hospitals have adopted the policy that dads are to go the waiting room while the epidural is being placed.  This happened after a father in California lost consciousness, fell and hit his head on a radiator, and subsequently passed away.  Obviously that is the extreme and rare situation. Even if we’re just talking about a woozy dad, you don’t need that stress. Use your labor nurse. He/she has seen and done this thousands of times and can coach you through it. Dad is more likely to be a negative distraction. Prepare him for this ahead of time, and if he does wind up staying, have him stand in front of you and focus on YOU, not the procedure.

I heard that an epidural will make nursing more difficult.

This is a tough one. Unfortunately, there aren’t any reliable studies from which to draw a good conclusion. With the exception of narcotics, which I personally do not use except in minute quantities in the labor infusion, I cannot see a logical scientific reason for a link between a local anesthetic labor epidural and difficulty suckling. The medications are bathing the nerves as they come off your spinal cord and only a miniscule amount gets into your bloodstream (you won’t be likely to feel any effects other than relief). Therefore, an even tinier fraction would even possibly be available to your infant. Personally, I have had two very alert and hungry newborns after epidurals, neither of which had any issue with latching or suckling. An “n” of 2 does not make a good study, but perhaps if I have a natural childbirth next spring, I can give you a more well-rounded opinion.

Will the epidural slow my labor or lead me down the road to C/section?

In my experience, epidurals speed the first stage of labor because they allow the mother to relax – and then, she can dilate more efficiently/quickly. It can, however, prolong the pushing stage because of the loss of muscle tone.  As for the link to c/sections, I don’t have a crystal ball, but I have read studies about this.  There may be some “selection bias” – let’s make the assumption that some women who opt for an epidural are doing so because they are in extreme pain or experiencing prolonged labor. Either one of those symptoms can indicate problems with fetal position (such as a sunny-side up baby) or cephalo-pelvic disproportion (meaning the baby’s head is too big to fit through the pelvis). If those are a proportion of the women opting for epidurals, the statistics on how many of those labors turn into c/sections is skewed because they were likely to head that way whether they had the epidural or not. I won’t deny that the “cascade of intervention” is a possibility, but to some extent, you have to keep a level head and deal with each step as it comes. My educated opinion is that most people will deliver the way they would have regardless of the epidural, but a small percentage who could go either way (a tough call between vaginal and cesarean) may be pushed toward cesarean by the presence of the epidural.

So if epidurals are OK, why don’t you want one for your next child?

The reason that I want to have a natural childbirth is because I believe that my body was made to do this, I am physically and mentally ready for it, and it’s a goal I’d like to achieve. Sam once said this to me, and I understand it now. Just like some people want to run a marathon, I want to have a natural childbirth. I don’t feel there is anything wrong with choosing to have an epidural (either before or during labor), and I could and would have another one if the situation called for it. This is a very personal choice. Be informed, be open minded, and be willing to shift a little if the baby has different plans from yours – anything can happen. I would very much like to finish out a healthy pregnancy and natural delivery. If I do, I’ll give you my annotated thoughts in April after comparing experiences.

4 comments
MelindaMichelle1
MelindaMichelle1

Thank you for this article! So much fear mongering- including from those who should know better- on this topic. 

ecas
ecas

Thank you for this interview! I am a first time mom striving for a natural birth next month but should an epidural end up being part of the process, I'm much less fearful now. I do hate that my husband would have to leave the room but this is the first time I've heard the "why" explained. Thank you!

Hollow tree ventures
Hollow tree ventures

This is great info! Personally, I begged for drugs my second time (first was a c-sec) and was refused due to a low platelet condition that the anesthesiologist was the first to notice. I offered to sign 1000 releases, but no dice. I didn't even bother asking the next time; they'd already warned me in advance they wouldn't give me any drugs. Of course after it was all over, I was glad - but boy, I sure wanted some at the time!

Trackbacks

  1. […] Rachel works part-time as an anesthesiologist and is the very pregnant mother of two busy kids. She is not nearly interesting or funny enough to have her own blog, but she has plenty of interesting and funny experiences and opinions. Check out her previous RMONJ post, And Now a Word From an Anesthesiologist.  […]