More than 3600 babies are born each year in Henrico Doctors’ Hospital. It is our wish to make this special event in our patients’ lives a happy and pleasurable experience.

Our anesthesiologists provide pain relief to 90% of our patients in labor. However, we realize that it is often difficult to take in all that the anesthesiologist has to say when you are having pain from contractions. The following answers to commonly asked questions may give you the information to better understand pain control in labor.

Should I expect pain during labor?
Most mothers will experience a certain amount of discomfort during labor. The degree of pain felt will depend on many factors. Your tolerance for pain, how strong your contractions are, and the position of the baby may all influence the amount of pain you feel. Each labor and each patient is different. Fortunately, there are many options available to control your pain and you should choose the most suitable one for you with the help of your obstetrician and your anesthesiologist.

What options are available for control of pain during labor?
Some mothers have satisfactory control of pain in labor by using breathing exercises and relaxation techniques. You can learn these techniques, like the Lamaze Method or hypnosis, by attending classes in the months prior to your delivery.
If the pain relief provided by these techniques is inadequate, then alternative methods are available to help you have a more comfortable childbirth experience. Pain relievers can be injected intravenously to dull the pain but will not take it away completely. Also, there is a tendency for these drugs to make you and baby sleepy, so they are used sparingly during labor. Occasionally, close to the time of delivery, your obstetrician may inject numbing medication into the vaginal area to ease the discomfort of delivering the baby’s head. Many women, however, choose to have Epidural Analgesia to ease the pain during labor because of the excellent quality of pain relief it provides.

What is an Epidural Block?
The nerves from the womb and abdomen enter the spinal cord in the lower back and then pass upwards in the spinal cord to your brain. In your back, the spinal cord is protected by bones, your vertebrae, and by a tough membrane called the dura mater. Inside this membrane, the nerves are further protected by spinal fluid. An epidural block places numbing medication just outside the dura membrane, hence the name epi-dural. The numbing medication washes the nerves in the area and reduces painful sensations from your belly.

How is the Epidural Block performed?
The Epidural Block is performed in the lower back. It may be placed with you sitting or laying on one side. The procedure is performed under sterile conditions, so your anesthesiologist will prepare your skin with antiseptic first. Next, you will feel a little pinch from an injection to numb the skin. Then, a small needle is inserted between the bones in your back into the epidural space. Once the tip of the needle is in the epidural space, a small plastic tube called a catheter is inserted through the needle into the epidural space. Occasionally you may experience an electric tingle going into one leg as the catheter goes in. Then, the needle is removed, leaving the catheter behind. Since there isn’t anything sharp under the skin, you may lay on your back and turn from side to side with no fear of hurting anything. The catheter is connected to a small pump to deliver pain medication during the rest of your labor.

How long does it take to work?
Most mothers experience significant relief of pain within 5 to15 minutes. This is the length of time it takes for the numbing medication to penetrate the nerves. During this period your nurse will measure your vital signs, particularly you blood pressure, every 3 to 5 minutes as the epidural has a tendency to transiently lower your blood pressure. Your baby’s heart rate will be monitored continuously also.

What does it feel like as the block takes effect?
The most dramatic change should be that your labor pains diminish and then disappear. You may still be aware of pressure sensations during your contractions. Depending on the strength of medications used in the epidural space your legs may also feel numb or heavy.

What is a Combined Spinal-Epidural (CSE)?
Your anesthesiologist may decide to use a Combined Spinal-Epidural if he feels that immediate pain relief is a high priority. During the performance of the Epidural Block, a second very small diameter needle is inserted through the epidural needle, through the epidural space and into the spinal fluid. A small dose of numbing medication or narcotic, or perhaps a combination of both is injected. The Epidural Block is completed in the usual fashion with the placement of an epidural catheter for future doses of medication. The medication injected into the spinal fluid has a very rapid effect on the spinal cord and the mother experiences almost immediate relief from pain.

What is a Walking Epidural?
When the CSE technique is used in the early stages of labor, there may be no numbness or weakness in the legs. This might allow the patient to get up and walk around. For the safety of our mothers and their babies, we do not allow women who have received any epidural or spinal block to walk until the medicines have worn off.

How long will the Epidural last?
Medication will be delivered continuously throughout your labor for as long as is necessary using the epidural catheter. After the birth of your baby, the epidural catheter is removed and the block will wear off in the course of an hour or two.

Will the Epidural affect my baby?
Epidural analgesia is extremely safe for both mother and baby. Studies of babies’ Apgar Scores, for example, reveal no adverse effects. In fact, unrelieved pain in labor can have a much more profound effect on your baby by lowering the amount of oxygen delivered by the placenta. It is important to remember however, that the technique requires a high degree of skill, medical knowledge and judgment to perform safely. Your anesthesiologist will remain available to track the progress of your labor and your response to the Epidural.

Will the Epidural slow down my labor?
Not by much. For a brief period following placement of the epidural, your contractions may become less frequent. However, they will resume and often become more regular and forceful which should speed up your labor. If your obstetrician has prescribed oxytocin (Pitocin) to strengthen your contractions, the contractions will continue regardless.

Will the Epidural prevent me from pushing?
No. In fact, if you have been comfortable in labor, then you will have considerably more energy for pushing when the time comes. Even if you do not have the sensation to push, your nurse will help you to time your pushing efforts with your contractions. An added benefit of the epidural is that stronger medication may be administered if your obstetrician decides it is necessary to deliver your infant using forceps.

What are the side effects associated with Spinal or Epidural Blocks?
Common side effects of epidurals are usually mild and can be minimized or avoided with careful monitoring and special precautions. It is not unusual for a patient’s blood pressure to drop slightly following an epidural. Some patients shiver while in labor or following an epidural. Although the reasons are unknown, this is usually brief and will go away without treatment. After the epidural catheter is removed, many women can feel with their hands the little spot where the epidural needle was inserted. Although the skin heals very quickly, the ligaments under the skin can take up to two months to heal.

I have a tattoo on my lower back. Can I still get a spinal or epidural?
Assuming that they are healthy otherwise, women with tattoos can still get a regional anesthetic. The concern, in theory, is that the needle tip could carry ink from the tattoo into the epidural or spinal space and cause a reaction. However, tattoo ink is hypoallergenic and is permanently fixed into the skin cells, so these risks are extremely small. A bigger concern is that the tiny scar from the needle, less than an eighth of an inch across, may disrupt the appearance of the tattoo. - Drs. Skilling & Sperry, as quoted at http://www.soap.org/media/newsletter_summer2001.pdf

Are there risks associated with an Epidural Block?
Just as there are risks associated with pregnancy, labor, and all medicines, there are risks associated with epidural anesthesia. Your anesthesiologist is a highly trained physician with specific training, skills and experience to minimize complications related to epidurals.
The most common risk, in up to 10% of patients, is that the epidural will not provide excellent pain relief. Additional doses of medicine can help, or we can simply replace the epidural catheter. Other risks include a 1% risk of headache, which can be treated (see “wet tap” section below) or allowed to resolve on its own, or the epidural catheter may enter the small veins contained in the epidural space. Both of these can be easily treated. Less than 1 in 1000 patients have serious problems like bleeding, nerve damage or long-term back pain. Overall, the risks of an epidural are very small when compared to the wonderful benefits of epidural pain relief during labor.

What is a “wet tap?”
In less than 1% of epidural block, the needle passes through the epidural space, through the dura, and into the spinal fluid. This is called a “wet tap.” The resulting hole in the dura leaks spinal fluid until the hole heals shut. Until then, a slow drip of spinal fluid can result in a headache. The headache is described as throbbing and may be severe, but it usually disappears completely when you are lying down. The headache will resolve over several days to a week and responds to drinking plenty of fluids, increasing your caffeine intake and taking pain killers like Tylenol. In some cases, the headache may warrant further treatment, which might include a blood patch. This is an epidural injection of some of your own blood at the site of the previous puncture. The blood clots and forms a seal over the hole in the dura. Relief from the headache is usually immediate.
The risk of headache increases with the size of the needle making the hole. Epidural needles are much larger than spinal needles, so the risk of getting a headache after Spinal or CSE, when medication is deliberately placed in the spinal fluid, is very small.

Some of our pregnant patients this year will deliver their babies by Cesarean Section. This section offers answers to some of the more commonly asked questions regarding anesthesia for Cesarean Section.

Which patients require a Cesarean Section?
The obstetrician will decide whether a patient requires a cesarean delivery, either before labor starts or during labor itself. Some babies are simply too large to travel easily through the birth canal, or some babies have placentas that block the opening to the womb. If the baby’s heart rate or other signals are concerning during labor, the Obstetrician may also decide to deliver the baby by cesarean rather than to continue with labor.

What kind of anesthesia will I get if I need a Cesarean Section?
If you are already in labor and have an epidural that has been working well for pain relief, we can use that to make you numb enough for surgery. This process usually takes 15 to 20 minutes.
If you have come to the hospital for an elective Cesarean Section, then there are several possible ways of providing anesthesia: a Regional Anesthetic (a spinal or epidural) or a General Anesthetic (where you are totally unconscious.) Because Regional Anesthesia is safer for most pregnant women, General Anesthesia for Cesarean sections is very rare.
Regional anesthetics include Spinal, Epidural, or a Combined Spinal-Epidural. All of these use powerful numbing medicines (“local anesthetics”) to achieve surgical anesthesia. A Spinal is a single injection of local anesthetic medication, while an Epidural Block involves placing a small plastic tube in your back, which is then used to give medicine to keep you numb and comfortable. The Combined Spinal-Epidural, or CSE, is a combination of these two techniques. A portion of the medication for surgery is given as a regular spinal, and a portion is given as a regular epidural.

What will it feel like to get a spinal or epidural?
The anesthesiologist will ask you to expose your lower back, either by sitting on the edge of the bed or laying down on your side. After washing off your back with a cleaning solution, a clear plastic sheet will be placed over your shoulders and back. The skin will be numbed with a tiny needle to inject numbing medicine, then you will feel some pressure as the epidural or spinal needle is placed. Once the needle is in place, the spinal medicine or epidural catheter is passed through the needle and the needle is removed. The only thing left in your back is medicine from a spinal or a soft plastic tube with an epidural.

What will it feel like to have a cesarean with a spinal or epidural?
You will be awake from the ribcage up, and numb from the abdomen down. Although the incision is usually below the belly button, it has been found necessary to extend the area of numbness to the lower chest. For a period of roughly 2 hours, it will be difficult to move your legs. You may have the sensation of working harder to breathe. Your breathing will feel much better as soon as your baby is delivered. During the surgery, it is normal to feel some pulling and tugging. Some patients experience shivering early in the procedure but this usually settles down without treatment. You will be completely awake and aware of everything going on in the operating room. Hearing and holding your baby soon after birth keeps you connected to the experience, similar to the connection after a vaginal delivery. Your partner can be with you in the operating room. Your anesthesiologist will be with you throughout the procedure and will ensure that you are comfortable during surgery.
The surgery usually takes 30 to 45 minutes, and then you will return to your room in Labor and Delivery. About 2 hours after delivery, you will be transferred to your room on the post-partum ward.

What will happen if I need General Anesthesia?
If you need General Anesthesia, we will take you to the Operating Room and move you into the operating room bed. We will give you oxygen to breathe through a clear plastic mask and put our monitors on your chest, arm and finger while the surgical team washes off your belly. Once the surgeon is ready to start, we will give you powerful medicines through your IV so that you drift off to sleep. While you are going to sleep, you may feel someone’s hand on the front of your windpipe. Once you are asleep, the breathing tube is placed through your mouth into the windpipe and the obstetrician begins the surgery. When the surgery is finished, we remove the breathing tube as you wake up and then take you to the recovery room.

Why would I need General Anesthesia?
There are certain medical conditions which would make it dangerous for you or your baby to have a Spinal or Epidural anesthetic for cesarean delivery. Excessive bleeding during labor and signs of serious fetal stress are two examples of cases that require a rapid delivery. Often in these cases, we don’t have time to perform a Spinal or Epidural anesthetic. In an emergency situation, things will move very rapidly. While this can be frightening for you, please remember that all members of the team are highly skilled and our primary goal is to ensure the safety of you and your baby.

What are the risks of General Anesthesia?
While General Anesthesia remains very safe, it does pose risks to the patient which are different from those associated with Spinal or Epidural anesthesia. When consciousness is lost, food and acid often accumulate in the pregnant patient’s stomach and may spill back up into the lungs under General Anesthesia. This can cause a very serious pneumonia. For this reason your anesthesiologist will strongly advise you to have Spinal or Epidural anesthesia unless there is a medical reason to the contrary. Your partner will not be able to accompany you during the delivery.

How will the pain from my incision be treated after the Cesarean Section?
Our goal is to treat your pain both quickly and aggressively. Most patients who have a cesarean section with a Spinal, Epidural or CSE will be given morphine (DuraMorph) in the injection for postoperative pain. This morphine works on pain receptors in the spinal cord, producing long lasting and powerful pain relief. Since there is no associated numbness or weakness of your legs with this technique, you will be able to walk soon afterwards. Some patients may experience some itching. Although this is usually not severe and goes away within 24 hours, treatment is available if itching proves bothersome. In cases where DuraMorph cannot be given, your pain can be relieved by pain relievers, either tablets by mouth or medicines through your IV. A device called a PCA may be used so that you can safely give yourself small doses of pain reliever into your IV by pushing a button as frequently as you require.

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