What to Expect

What are spinals and epidurals?

During labor and delivery, it is our goal to give patients the best possible pain relief, in the safest and most effective manner possible. Currently we can give the most relief with the smallest amount of medicine using spinals and epidurals. These techniques are essentially injections given in the lower back. They are very safe, very well tolerated and we place thousands of them every year. A spinal involves a single injection of medicine into the spinal fluid using a very small needle. Spinals are at times used for labor, sometimes in combination with epidurals, and most often for cesarean section. Lumbar epidurals are the most common form of pain relief during labor. A special needle is used for epidural injection. Through this needle, a very small medication line is placed into the lower back. That line is then used to give continuous medication and pain relief for the duration of labor and delivery. For both spinals and epidurals the strength of the effect is determined by the strength of medication administered and can very from mild pain relief to total anesthesia and temporary elimination of all sensation from the nerves serving the uterus, abdomen and below. Therefore, a significant benefit of epidurals is that they can be used for safe and rapid anesthesia if there is a need for emergent cesarean delivery.

When should I have my epidural placed? Will an epidural slow down my labor?

Epidurals can be placed with great effect at nearly any point during labor. Ultimately, the decision about when to place your epidural will be between you and your Obstetrician. It is our philosophy that epidurals should be placed as early as possible, based on available evidence about the effects of epidural medications on the progress of labor. Current studies show that standard epidural medications have no effect on the duration of the first stage of labor (from the onset contractions to complete cervical dilatation.) Some studies have shown that the second stage of labor (from complete cervical dilatation to delivery) may be prolonged by a few minutes. However, recent evidence suggests that early administration of epidurals may shorten labor overall. It is easiest to place the epidural catheter (medication line) before contractions become significantly painful, when it is easy for a laboring woman to sit still and cooperate with the procedure. With this in mind, it is even possible to place the epidural catheter without starting the epidural medications. That way the procedure is done, the catheter is in, and when contractions become painful, the medications can simply be administered.

Will the epidural affect my baby?

Epidurals have been shown to be safe for your babies. Epidurals provide significant pain relief with very small amounts of medication. In fact, the relief provided by epidurals has the benefit of decreasing fetal exposure to maternal stress hormones. This is in contrast to the option of taking systemic pain medicines during labor which requires much higher doses, and affects both the mothers whole body as well as the baby’s.

Can I become paralyzed from an epidural?

Paralysis or nerve injury from labor epidurals or spinals, placed in the lower back, is exceedingly rare. It is even more rare than for spinals and epidurals overall that may be placed along the entire length of the back and neck. In the lumber (lower back) region, the spinal cord is no longer a solid structure but has divided into a collection of small spinal nerves that are floating in the spinal fluid. The mobile nature of these nerves allows them to move out of the way in the rare instance that a needle may contact them, further reducing the risk any direct nerve trauma. Additionally, our Anesthesiologists place thousands of labor epidurals every year. We take these procedures very seriously, perform them with great care and want every patient, especially our laboring mothers, to have a positive labor experience free from complications. Careful attention is paid to anything that could increase the risk of an adverse outcome, especially the risk of bleeding along the spinal canal. If you have been taking any “blood thinners” or special injections during your pregnancy it is important to discuss these medications with your anesthesiologist and the hospital staff.

Please also see: What to Expect During Surgery

Can I walk with my epidural?

Though it is possible to walk with certain epidural medications, during labor we do not allow patients to walk after the epidural medications are administered. This practice is true at most institutions. Extra precautions are taken in the setting of labor. If you should require a cesarean section or have other abdominal surgery, an epidural can be set up that allows ambulation. However, this method would be determined by the anesthesiologist on a case by case basis.

Can I eat and drink after my epidural is in place?

We ask that you do not eat or drink, other than ice chips, after placement of the epidural and administration of the epidural medications. Just like before surgery, this restriction is for your safety. An empty stomach decreases your risk of pulmonary aspiration (stomach contents getting into your lungs), nausea and vomiting. Food or certain liquids in the stomach put you at risk for aspiration if you need general anesthesia for emergency purposes or if you need emergency surgery, even cesarean. We take many precautions to ensure your safety around the time of your delivery.

What happens if I need a C-section?

If you need a Cesarean Section (C-section) for delivery of your baby, unless it is an emergency, you will most often require spinal or epidural anesthesia. The most important thing is to remain calm. The doctors and staff will guide you. Our number one goal in the end is to have healthy moms and healthy babies. C-section is abdominal surgery, though it is limited in its extent. You will need anesthesia for the procedure. Spinals and epidurals have been shown to be safer for pregnant woman than general anesthetics. Additionally, these neuraxial anesthetics (see “Anesthesia Techniques”) have the added benefit of allowing you to be awake for the delivery of your baby even for surgical delivery. If we can avoid giving you general anesthesia for C-section, we will. If you already have an epidural in place, we can give you a stronger medicine through the epidural catheter. This method is safe and fast, making it ideal for emergency situations. The stronger medicine will make your abdomen numb for the surgery. If spinal is needed, all that is involved is a small injection in your lower back. The injection is generally quick and well tolerated, and will likewise make your abdomen numb so you won’t have pain during the procedure. We often also administer spinal or epidural medicines that work to keep you comfortable in the hours and days after your surgery. After surgery, we will tailor a regimen of medications to alleviate your pain and the Acute Pain Service will see you and adjust you pain medicines as needed to allow you a rapid recovery.

What are my pain relief options during labor?

The options for pain relief during labor include focused breathing and relaxation, intravenous (systemic) narcotics, spinals and epidurals. All of these methods are safe when managed appropriately by physicians. While women have had successful labor using all of these methods, it is evident from available studies and our own experience that epidural analgesia is by far the most effective and beneficial. Intravenous medications travel throughout the entire body including the brain and the baby. The medications given I.V. are narcotics, most commonly Stadol (butorphanol) or Demerol. These medications generally require higher doses to achieve good effect and because they are systemic can result in sedation and confusion. Both intravenous and spinal medicines are likely to require redosing during labor, each lasting only 1-4 hours with each dose. Spinals and epidurals use a combination of local anesthetics (like lidocaine) and other opioids. Local anesthetics directly reduce or eliminate pain signals from nerves. Therefore, these combinations given excellent relief using very small amounts of medicine. Spinals are given with a single injection. Epidural medicine is given continuously using a very small catheter (medication line) that is placed in the back. Mothers laboring with epidurals experience less stress and use less systemic medication. Studies have shown better fetal outcomes in these patients. Additionally, as mentioned above, an epidural catheter can be used rapidly and safely to give surgical anesthesia in the event of an emergency requiring rapid cesarean delivery. There are women who do well and have successful deliveries without pain medications or epidurals. Given the significant safety, effectiveness and potential benefits of epidurals for labor, we strongly support their consideration for use during your labor.

Are there any potential side effects or risks from spinals or epidurals?

Spinals and epidurals for labor and delivery are exceptionally safe. As discussed above, the risk of nerve injury and paralysis from these lumbar (lower back) injections is exceedingly rare and unlikely. Epidurals and spinals for labor are also unlikely to affect preexisting lower back problems. In fact, epidural injections are often used to treat disc and nerve related back and leg pain. Spinals and epidurals can cause a mild bruise at the injection site. Spinal and epidural narcotics, often used in small dose combinations with local anesthetics, can sometimes cause mild itching and the local anesthetics themselves can cause a varying degree of temporary numbness in the legs and abdomen. It is this numbness that provides some of the pain relief. However, we seek to find the right balance for each patient between good pain relief and enough strength and sensation to push well at the end of labor when it is time to deliver.
Another potential side effect from spinals and epidurals is headache. There are several potential causes of headache after delivery, most of which are not related to neuraxial injections. The kind of headache related to these techniques is called a Post Dural Puncture Headache (PDPH), commonly referred to as spinal headache. These headaches are infrequent, develop in the first few days after delivery, and can occur as a normal side effect of neuraxial injections. Occasionally, epidural placement will indicate the need to watch for headache. Spinal headaches also occur unexpectedly. They can resolve spontaneously but often require another lumbar injection to treat. Treatments for spinal headache are very effective. Our anesthesiologists are skilled and experienced in the care of laboring patients and the placement of neuraxial anesthetics including labor epidurals. While the true incidence of PDPH nationwide is difficult to estimate, the rate of occurrence in our institution has been far less that available averages.