Anesthesiology

Regional blocks are popular because they’re the most effective way to relieve pain during childbirth. The stage of labor when you receive an epidural depends upon the progress of labor, your level of discomfort and other factors. If you request epidural analgesia, your obstetrician and the anesthesiologist will evaluate you and your baby. Epidural and spinal blocks may not be good choices in some situations, such as if you are taking blood thinners, are bleeding, or your blood clotting is abnormal.

An epidural block is performed in the lower lumbar area of the back. You will be asked to sit up or lie on your side, relax and curve your back out to widen the spaces between the vertebral bones. Most of the procedure is done between contractions to minimize the time you need to keep still during contractions. First, we cleanse the skin with an antiseptic solution, and then we inject local anesthetic to numb a small area of the back. Although this stings for a few seconds, you should feel only pressure during the rest of the procedure. A special needle is placed 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, and then the needle is removed and the catheter is taped in place. A brief tingling sensation sometimes occurs in the back or legs if the catheter brushes against a nerve on insertion, but this usually lasts only seconds. Medication given through the epidural catheter surrounds the nerves passing through the epidural space, keeping you comfortable until delivery without additional procedures.

A combined spinal-epidural block (CSE) works like the epidural but produces much faster pain relief and may be recommended if labor progresses rapidly. Because it may cause less numbness than the epidural, some refer to it as a “walking epidural.” The procedure is similar to the one described for the epidural, but a small amount of medication is injected into the spinal fluid before the epidural catheter is inserted. Pain management after the initial placement is the same as for the epidural.

A spinal block is occasionally used when labor is progressing rapidly, and delivery is expected in the immediate future. Pain relief occurs rapidly and lasts about an hour and a half. The procedure is like the epidural or CSE but quicker. A small, specially designed spinal needle is used, which results in a very low risk of a headache. Because a cathete

After an epidural, pain relief occurs gradually over 10 to 20 minutes, with contractions feeling progressively shorter and less intense. A combined spinal-epidural or spinal block often provides good pain relief within five minutes.

To maintain comfort throughout labor and delivery, a low dose of medication is continually infused through the catheter until delivery has occurred. We use low concentrations of medications (“ultralight epidurals”) to avoid excessive numbness and to ensure that you are able to push effectively during delivery.

As labor progresses and becomes more intense, additional doses (“boluses”) of medication may be required. These doses may be self-administered if you are using a patient-controlled epidural analgesia (PCEA) pump, or they may be given by the anesthesia providers. While epidural blocks provide considerable pain relief, you may feel pressure with contractions and be aware of examinations by the obstetrician or nurse. Realistic expectations for pain (on a scale of 0 to 10, where 0 is no pain and 10 is the most pain you can imagine) are 0 to 2 during the first stage of labor and 0 to 5 during the second (pushing) stage of labor.

We will assess your pain and degree of pain relief at regular intervals throughout labor and recommend appropriate treatment. Occasionally, we decrease the epidural infusion rate during delivery if you feel too numb and cannot push well. Rarely, we may need to adjust or replace the epidural catheter if you do not obtain adequate pain relief despite additional doses.

Following regional anesthesia, your legs may temporarily feel warm, heavy or weak. Despite this, muscle power usually remains normal, so you can easily move around in bed. We use newer techniques and medications in our regional blocks that allow you to be comfortable with much less numbness or weakness than in the past; however you will not be permitted to walk while under anesthesia.

Many factors influence the progress of labor and the need for assisted vaginal delivery or cesarean section (C-section). In some women, contractions may briefly decrease in frequency after an epidural. In others, labor progresses more rapidly once the pain is relieved, and the mother is relaxed and stress-free. Recent studies on up-to-date regional block techniques we use have found no increased risk of C-section with epidural compared to other forms of pain relief (e.g., narcotics).

As with any medical treatment, side effects or complications occasionally occur. We will carefully monitor you and your baby and take precautions to treat common side effects and prevent problems.

• Your blood pressure can decrease following a block. To reduce the incidence of low blood pressure, we place an IV and administer fluids beforehand. In addition, it is important to lie on your side as much as possible during labor to help ensure your blood pressure and blood flow to the baby remain normal.  
• A headache (about one in 100 deliveries) occasionally follows a regional block. Holding still during the epidural needle placement decreases the likelihood of a headache. Additional treatment can be given if the discomfort does not resolve with rest or pain medicines.
• Very rarely, the medication in regional blocks can cause the chest wall to feel numb and make it feel like it is hard to breathe. This sensation usually disappears by itself but may be helped by breathing oxygen.
• Occasionally, the epidural needle or catheter enters an epidural vein as these become swollen during pregnancy, like varicose veins and hemorrhoids. 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 are exceedingly rare because such low doses of medications are used.
• Shivering, nausea, and vomiting can occur during labor, with or without a regional block. If these symptoms are troublesome, medication is available to help treat them. Backache is common during pregnancy and often continues after your baby is born. There is good evidence that regional blocks do not cause long-term backache, although there may be slight local tenderness for a few days.

When larger doses of medications are given, such as for C-section anesthesia, we usually give a small “test dose” first to make sure the medication is in the right place.

Life-threatening or serious complications (such as unusual drug reactions or nerve damage due to bleeding or infection near the spinal cord) are extremely rare with regional blocks given for labor pain relief. Please discuss any concerns you may have with your anesthesiologist.

There is considerable evidence that an uncomplicated regional block is safe for the baby. Some experts believe that relief of severe maternal pain and stress may benefit the baby. A regional block relaxes the mother while avoiding the sedative effects of IV or intramuscular (IM) narcotic drugs. Temporary changes in the fetal heart rate occur frequently in normal labor and can occur with both regional blocks and narcotic medications. When not caused by other reasons, these changes are not associated with any long-term effects.

Some studies have found small increases in maternal temperature with prolonged epidural blocks that are not caused by maternal or newborn infection.

Therefore, if the mother has received epidural analgesia, a slight increase in maternal temperature does not result in our screening of the baby for infection unless other risk factors are present. A regional block will not affect your ability to hold the baby immediately after birth or to breastfeed.

If an epidural catheter is already in place when a C-section becomes necessary, it can usually be used to provide surgical anesthesia. Your anesthesiologist will inject a stronger concentration of local anesthetic through the catheter to make your abdomen and legs completely numb. Because it takes about 10 to 15 minutes to work effectively, it may not be possible to use the epidural in urgent situations. An epidural block is sometimes used to provide anesthesia even when no catheter is in place. This is performed like a labor epidural block, but it uses larger doses of stronger medicines and takes place in our operative delivery room.

Spinal anesthesia is the most common technique used for the majority of planned and some urgent C-sections. A single spinal dose rapidly results in anesthesia that lasts long enough for routine C-sections. A much smaller dose of anesthetic is needed than with an epidural block, and a small needle is used, which rarely results in a headache. In certain circumstances, we may recommend a combined spinal–epidural (as described for labor analgesia) to allow greater flexibility of dosing.

Some C-sections are so urgent that there is no time to perform a regional block. Also, regional blocks may not be a desirable choice with some maternal conditions (such as bleeding or previous spinal surgery). General anesthesia can be administered safely and quickly to make the mother unconscious during the delivery.

Pregnant women have slower stomach emptying and are at greater risk of aspiration (stomach contents entering the lungs) during unconsciousness or general anesthesia, which can result in serious pneumonia. To decrease the risk of aspiration, your anesthesiologist will take special precautions to protect the lungs, including placing a breathing tube in your windpipe after you are asleep. In addition, you will be given an antacid drink before anesthesia to neutralize any acid in the stomach. For your safety, it is important not to eat solid food (including milk products) once you are in active labor, regardless of your plans for delivery or pain relief. Moderate amounts of clear fluids and ice chips are usually allowed in normal labor. You should check with your nurse or doctor to see what is best for you.