It’s your body, it’s your baby. The better informed you are about epidural and spinal anesthesia, the smoother and more pleasant the whole birth experience will be.
Every year 4 million women in the U.S will have a baby, and many of them will receive an epidural or spinal to decrease labor pain. In my experience as an anesthesiologist, most women can’t wait for their epidural to be placed. About five to ten minutes after the epidural is inserted and their pain has dropped from a “10” to a “2,” I pretty much become the most popular guy in the room for a little while!
But many of these women, particularly if it’s their first delivery, don’t have much of an idea as to what a labor epidural is or how it works — they just know they want their epidural now. Thus, it’s worth spending a little time going over the subject from an anesthesiologist’s point of view since the epidural is almost always going to be placed by an anesthesiologist (an MD) or a nurse anesthetist (a CRNA).
The Basics
Your spinal cord is bathed in a fluid called CSF (short for cerebral spinal fluid).
Around this fluid is a thin covering a lot like Saran wrap called the dura.
As the uterus contracts, it sends messages through very tiny little nerve roots — like electrical wires — to the spinal cord. These messages then travel up to the brain, which interprets them as pain (really bad pain).
By numbing or in some other way interfering with the spinal nerve roots, the messages don’t make it to the brain (like cutting the cord in old time telephones). Your uterus is still contracting really hard, but you don’t feel it.
Epidurals are tiny soft tubes placed outside the dura and used to inject small amounts of numbing medicine and also often very small amounts of narcotics. The numbing medicine and narcotics then diffuse across the dura into the CSF and then into the nerve roots. This is incredibly effective in blocking the transmission of pain.
Sometimes anesthesia providers go one step further: they actually pop a small needle through the dura right into the CSF. In this way they can use even tinier amounts of numbing medicines and narcotics. This is called a spinal and the needle is much, much smaller than the epidural needle.
Messages can be blocked with either a spinal or an epidural or sometimes both: the spinal leads to almost instantaneous pain relief but the epidural (since it’s a little tiny tube connected to an infusion pump) can be used for hours and hours. On the other hand, the spinal is only one “shot” and then the tiny needle has to come out; the effects of the spinal wear off after an hour or two but if you have a long labor the epidural stays in as long as it’s needed.
The two techniques are usually classified under one heading as neuraxial analgesia, which means placing medicines around the spinal cord nerve roots.
If you’re having neuraxial analgesia for pain relief during childbirth, you’re having either a spinal, an epidural, or a combination of both.
The Good
You don’t have to have neuraxial anesthesia. Maybe you prefer “natural childbirth” or maybe the anesthesia provider is busy with another patient and isn’t available or maybe you don’t want the extra bill from the anesthesia provider. Maybe a prior experience wasn’t so hot (we’ll discuss below) but most women do opt for the neuraxial route.
When neuraxial analgesia works, and in experienced hands that’s more than 95% of the time, there is absolutely no better technique for effectively eliminating labor pain. The change in the expectant mother’s demeanor in minutes is remarkable: from crying and yelling at her partner and in such pain she’s barely able to talk to transforming back to her normal self. It’s really gratifying.
Obstetricians usually let the epidural run until mom is ready to push, and then turn it off.
But wait, there’s still another amazing benefit of an epidural that many women don’t appreciate. The U.S. has a C-section rate of about 30%, which means roughly 1 out of 3 moms will end up with a C-section. This might be because you’ve been pushing for hours and nothing is happening, it might be because your team isn’t happy with the baby’s heart rate, it may be because you’ve had a prior C-section, it may be because your baby wants to come out feet first, or for many other reasons.
If your obstetrician calls for a “section,” you’re pretty much all set. All your anesthesia provider has to do is push a much stronger mixture of numbing medicine and narcotics through your already in-place epidural tube. While they’re pushing you down the hall, he or she is injecting the medicine and by the time they start the operation, you’re all numb from the belly down but still awake. You won’t have to go to sleep (more dangerous) and your baby won’t come out sleepy; moreover, almost always your significant other can come in the operating room, too, to squeeze your hand and share the experience. And then you both can hear the baby’s first cry and see him or her right after they come out.
It’s really a beautiful experience.
The Bad
To put in an epidural, a pretty big needle is used and once it is placed in the right spot, the epidural tube or catheter is threaded through the needle and the needle is removed over the catheter. The catheter is then connected to an infusion pump, which is set to give a constant flow of medicine and can be used as long as needed. Most infusion pumps also have a button which mom can press if she wants a little more pain relief (a top-off). It’s all very slick. With the spinal technique, you use a much smaller needle but no catheter. As we said, the spinal works quicker but wears off over time.
So what’s the bad?
Most women, but especially those who have never had neuraxial analgesia, have heard horror stories about the great big epidural needle (true). They also might have heard that if they move when the epidural needle is put in they could be paralyzed (false).
The best way to get some peace of mind is to meet with your anesthesia team weeks before your due date (a part of the ASA perioperative surgical home process).
In reality, in the hands of an experienced anesthesia provider, most women never even feel the needle go in. The doc first uses a really, really tiny needle to make a skin bump of numbing medicine on the back. I always tell anxious women to count to three out loud. Then before I use the tiny needle, I say, “When I tell you, start counting to three again, and when you get to ‘three,’ the pain from the tiny needle will be all gone.”
To recap, in the hands of an experienced anesthesia provided, you never even know you had a big epidural needle placed. And since a spinal needle is much, much smaller than an epidural needle, this is even less of an issue.
Now on to some stuff that’s a little worse: when the spinal or epidural needle is placed, if it isn’t centered just right, you might get an “electric shock” type of sensation down your right or left side. This is not dangerous, and the anesthesiology provider simply pulls the needle back out a little and directs it more toward the middle of your back. You might jump or even yell, but as long as the needle is pulled back out and redirected it’s not a big deal. It’s just a little bothersome for that instant.
Another problem is that even in the hands of experienced providers sometimes the epidural just doesn’t work well. Although it’s rare, sometimes the epidural has to be replaced.
A bigger deal is the so-called wet tap. Again, this is rare if your provider is experienced but still happens maybe once in 200 or 300 epidurals. A wet tap means the big epidural needle accidentally punctures the dura and then spinal fluid squirts out through the needle.
If this happens, anesthesia providers have different opinions as to what to do next. They might pull the needle out until the fluid stops coming and then thread the epidural catheter or they may start over at a different place on your back. They might even switch the technique to a spinal and use the big needle to inject medicine into the CSF.
The other big issue with a wet tap is the spinal headache. A tiny hole in the dura from a spinal needle usually closes right away and a little CSF leaks out. But with the epidural needle, the big hole in the dura doesn’t close for days or weeks and CSF keeps leaking out. Since the brain “floats” in the CSF, as the fluid leaks out, you can get a severe, incapacitating headache.
A spinal headache is very unique in that it only comes on when you stand and disappears when you lay flat. It usually doesn’t go away without a special treatment called a blood patch. About half of women who get a wet tap get a spinal headache, and until it’s fixed, you can’t sit up to hold your baby, and you feel awful.
The best way to avoid a wet tap is to use a very experienced provider at a busy labor and delivery hospital. Really experienced providers instill confidence and know how to avoid pitfalls, such as in very large women where it’s hard to feel the bones in the back to know if they’re centered.
Furthermore, the strength of the mixture of numbing and pain medicine going through the infusion pumps is usually the same for every patient. The rate of infusion might change a bit but not the strength. This is sometimes a problem since women may find their legs are too numb to move or they may be too weak to push. In these cases, the strength of the mixture can be weakened if you get the anesthesia provider to have the pharmacy do it. If the mixture is too strong, you may also have trouble urinating after the baby is born, requiring a few days (or longer) of self-catheterization.
Finally, anesthesia providers charge by the hour and the longer your epidural is in, the bigger the bill — even though once the epidural is placed and working there really isn’t anything else to do except drop by every hour or so and say hi. Bills well over $2,000 are not unusual and frequently exceed the obstetrician’s total bill. Try to reach an arrangement before going into labor, since your 20% copay on a $2,000 bill with great health insurance is still $400!
The Ugly
Very, very, very rarely can really bad things happen in labor and delivery. I mention these mainly in the name of completeness and also because there are certain things you can do to make the “almost never happens” more like “almost, almost never happens.”
Although these events are quite rare, it’s better not be an ostrich and bury your head in the sand; instead, learn about them and then don’t worry.
An epidural is placed under sterile conditions. The anesthesia provider should not only were sterile gloves but also a face mask.
Although not commonly practiced since anesthesia people frequently run from one labor epidural to another, putting on a sterile paper gown like surgeons do in surgery is also a good idea. If the epidural is contaminated by a break in sterile technique, or the skin is not carefully prepped to kill the bacteria (it’s impossible to get rid of all the bacteria), the epidural can lead to an infection called an epidural abscess. This must be treated quickly and aggressively or it can cause paralysis. Warning signs might be a high fever or severe back pain or numbness in your legs which doesn’t go away. Just as in surgery, it’s important to do everything you can to minimize the bacteria on your back.
This isn’t proven because it’s so rare, but the same chlorhexidine shower that you might take to reduce the risk of a surgical site infection sure can’t hurt if you have the time before you go to the hospital. If your anesthesia provider looks disheveled, harried, and exhausted from being up all night, make sure they take the time to put on a hat, a sterile mask, and hopefully also a sterile gown. I really need to stress an epidural abscess is incredibly rare except if it happens to you; then it’s 100% likely.
In the same way you worry about infection, a large epidural needle can sometimes nick a vein and cause bleeding. Most often this is not a big deal and stops but if you are on blood thinners or have a low platelet count (one of the types of blood cells), the bleeding can continue and lead to an epidural hematoma (a big mass of blood). As with the epidural abscess, this can lead to paralysis if not treated immediately. Thus, if you are on any type of blood thinner or know you have low platelets (like after chemotherapy), make sure sure your anesthesia provider knows.
Finally — and perhaps shockingly — the maternal death rate in the U.S. is the highest in the developed world: five times times that of Sweden and almost four times that of Canada. And 70% of the deaths come from bleeding! The most common causes of maternal mortality are preventable.
Efforts by such organizations as the California Maternal Quality Care Collaborative (CMQCC) have developed tool kits to help hospitals prepare for the unlikely but potentially devastating complications that can happen during and after delivery. You should make sure your hospital, OB-GYN, and anesthesia provider have these type of protocols in place and routinely drill with them to practice for emergencies.
This all seems like scary stuff, but you can protect yourself with these simple measures and more pleasantly welcome your bundle of joy into the world!
