Anesthesia Associates of Southern Connecticut

Obstetric Anesthesia FAQ's

What is the difference between an epidural and a spinal?

In a spinal anesthetic, the anesthesiologist uses a very fine needle. The needle is advanced until spinal fluid is encountered, usually at about 2 inches, at which time a single injection of medication is given. The onset is extremely rapid, and the patient has marked numbness (and leg weakness) from the waist down. This is perfect for a Caesarean Section or other surgery, but is not an appropriate anesthetic for labor. For labor, we use an epidural.

In an epidural, a needle is advanced only until the epidural space is reached. This space is reached before penetrating into the spinal fluid. A fine catheter epidural catheter is advanced about an inch into the epidural space. Medication is given through the catheter. The onset is much slower (about 15-20 minutes), and in a labor epidural, the amount of numbness and weakness is drastically less than with a spinal. This allows the mother to push effectively when the time comes.

Please see the discussion of spinal and epidural anesthesia in "Types of Anesthesia."

Who performs the epidurals and spinals?

All labor epidurals and spinals at Norwalk Hospital are performed by M.D. Anesthesiologists. Residents and CRNA's are not involved in our obstetric epidurals and spinals.

What is a spinal headache?

A spinal headache is a rather severe headache caused by continual leakage of spinal fluid from a hole made by a needle through the membrane (the dura) surrounding the spinal fluid. The classic spinal headache is a throbbing headache that appears in 24-72 hours and is made much worse by sitting or standing, and relieved by lying flat. The headaches are not dangerous, but they can last for several days.

In spinal anesthesia, the membrane (dura) around the spinal fluid is intentionally punctured to allow injection of medication into the spinal fluid. Because the needle is so fine, and because of its unique tip, the tiny puncture hole closes quickly and leakage of spinal fluid is minimized. The risk of developing a headache is about 1:100 in obstetric patients.

In epidural anesthesia, the dura is not punctured, so there should be no leakage of spinal fluid and no headache. However, occasionally, the dura is accidentally punctured, and since a larger needle is being used, a headache is much more likely. Accidental punctures are very uncommon when the epidural is done by an experienced person. At Norwalk Hospital, labor epidurals are done only by staff anesthesiologists. So you can be assured that your chance of a spinal headache is much less than the nationally quoted 1:100.

How is my pain treated after my Caesarean Section?

If you have a spinal or epidural anesthetic, a long-acting morphine preparation called Duramorph is injected either through the spinal needle at the time of placement, or through the epidural catheter after the baby is delivered. This provides about 24 hours of excellent pain relief. The doses required to achieve this pain relief are tiny, and virtually none of the morphine reaches the baby or the breast milk. The major side effects of Duramorph are itching and nausea.

If you had a general anesthetic, you will be given PCA (patient-controlled analgesia). This is intravenous medication (usually Dilaudid), that is delivered to the patient every time she pushes a button. A computer-controlled pump regulates how much is injected with each button-push and the maximum that can be given in a one-hour period. This is an extremely safe and reliable method of pain relief and is used widely in treating post-operative pain for all type of surgeries

Should I get an epidural for my labor?

That, of course, is your decision. An epidural is a safe, extremely effective method of relieving the pain of labor. Greater than 75% of first-time mothers at Norwalk Hospital have an epidural, and the vast majority of mothers getting epidurals are very happy with their decision.

Please use the information in this FAQ section along with the information in the "Obstetrics" section of the website to help you reach your decision.

Does an epidural hurt?

Most patients state that the only real pain is the "pinprick" when the local anesthetic is injected to numb the skin prior to insertion of the epidural needle. The insertion of the epidural needle is described as a pressure. Some anesthesiologists will inject a small amount of fluid through the needle before putting the catheter in.This fluid expands the otherwise empty epidural space and can cause a pressure sensation. The epidural catheter is inserted through the needle and the needle is removed. The catheter is taped along the length of your back and brought over your shoulder. The catheter is about the thickness of heavy kite string and is soft so that you cannot feel it even when lying on your back.

Occasionally, insertion of the catheter is difficult. This could be because of obesity or edema which make identification of the bony landmarks difficult, or it could result from scoliosis or poor patient position. See the Obstetrics section of the website for information on proper patient position. In these cases, repeated attempts may be necessary, and insertion can be more painful. Fortunately, your epidural will be placed by an anesthesiologist; we use no residents, students, or other trainees. As a result, the vast majority of epidural placements are straightforward and cause only mild discomfort.

Removal of the epidural is completely painless, except for the removal of the tape.

Does an epidural effect the baby?

The effect on the baby is minimal when compared to the other methods of pain control, namely injected or intravenous medications such as Demerol, Stadol, Dilaudid, and morphine.

There is negligible effect from the medications used in the epidural. The main medication injected into the epidural space is a local anesthetic (usually bupivacaine or ropivacaine.) The local anesthetic does its work in the epidural space and not by being absorbed into the bloodstream. The amount of local anesthetic absorbed into the bloodstream is negligible. This means that almost none reaches the baby.

In addition, a tiny amount of narcotic (usually fentanyl) is added to the local anesthetic solution being infused into the epidural space. This narcotic greatly reduces the amount of local anesthetic necessary, thereby reducing muscle weakness to a minimum. The narcotic is absorbed into the blood to some extent, but it is such a small amount that it has no real effect on the baby.

Remember that the alternative to an epidural is injected medication which goes directly into the bloodstream.

When the epidural sets up, mother's blood pressure can drop. If it drops low enough, the baby can be affected. To minimize this drop in blood pressure, we require that our patients receive at least 1 liter of IV fluid prior to placement of the epidural. If the drop in blood pressure is significant, in spite of the fluids, it is treated immediately with a medication called ephedrine, which quickly and safely corrects the blood pressure. You will notice that your blood pressure is measured every minute or two for the first 15-20 minutes after insertion of the epidural.

When in my labor can I get an epidural?

Traditionally, obstetricians have waited until the cervix is dilated to 4 cm before allowing an epidural to be placed. However, in recent years, this guideline has been relaxing and, in fact, a very recent article in the New England Journal of Medicine showed no difference in C-sxn rates if the epidural is placed early in labor vs after 4 cm. Click here to see an abstract of the article

Do epidurals increase the chances of a Caesarean Section or forceps delivery?

It was long believed that epidurals increased the incidence of C-section and forceps delivery. You will still find the old literature quoted quite frequently. However, with improvements in drugs and techniques, particularly the advent of very-low concentration local anesthetics and continual infusions, the risk of C-section or forceps delivery is now no higher in patients receiving epidurals than in those having "natural" delivery.

Epidural anesthesia is very often used in high-risk pregnancy because of its beneficial effects on blood pressure. It is also more likely to be used in twin pregnancies and in prolonged labors. All these patients are more likely to have C-sections, because of the underlying complicated pregnancy. In addition, obstetricians are more likely to request an epidural in a patient believed to be at higher risk for C-section. All these factors skewed the data in the older studies.

Can my epidural be used for the anesthetic if I need an emergency Caesarean Section?

Yes. Having an epidural catheter in place means that a method of giving immediate surgical anesthesia is already available if an urgent or emergency C-section is necessary. This eliminates the need for an emergency general anesthetic in most cases.

If a Caesarean becomes necessary during your labor, your anesthesiologist will stop the continuous epidural infusion and inject a different medication into the epidural catheter. This stronger medication will cause your abdomen to become very numb and your legs to become very heavy, similar to a spinal anesthetic. You can then be awake, with your partner present, when the baby is born.

What are the risks of an epidural?

Epidurals are extraordinarily safe, especially in the healthy obstetric population. The risks are as follows:

  • Spinal Headache - the nationally quoted risk is 1:100. However, since we do not use CRNA's, residents, students, or trainees to place labor epidurals, you will have an experienced staff anesthesiologist placing your epidural. Our incidence of spinal headache is far lower than 1:100.
  • Nerve Damage - nerve damage is almost never caused by an epidural. There have been no cases at Norwalk Hospital for the past 20 years. However, it is not uncommon for patients to have minor, temporary nerve root injury from the birth process intself. This is caused by the baby's head as it descends through the birth canal. These minor nerve injuries usually just cause some numb spots on the legs, but rarely can cause some weakness. In any event, they almost always resolve within a few days. If the numbness or weakness is significant or lasts more than a day, the anesthesiologist will evaluate you as well as a neurologist.
    A nerve injury caused by a labor epidural is extraordinarily rare in obstetric patients. Nerve injuries have been reported when large volulmes of local anesthetic are injected directly into nerves. This is prevented in obstetric patients because they are wide awake, and will report pain the instant such an injection begins. The injection will be stopped and the epidural re-positiioned. We place over a thousand labor epidurals a year, and we have never had a significant neurologic injury at Norwalk Hospital.
  • Spinal Hematoma - this is another rare complication that we have never seen in an obstetric patient at Norwalk Hospital. It is caused by bleeding into the area around the spinal cord and can be extremely serious. Fortunately, this complication is basically unheard of in patients with normal blood clotting ability. It is seen (rarely) in patients who are on blood thinners (anticoagulants) or who have blood clotting abnormalities from certain diseases.
    Pregnant women generally have normal or even excessive blood clotting ability (hence the increased risk of blood clots during pregnancy). The exception to this is with the syndrome known as toxemia of pregnancy, which includes preeclampsia and eclampsia. This syndrome can cause a reduction in your platelet count or even in your clotting factors. For this reason, your obstetrician or anesthesiologist will order a platelet count or clotting study just prior to insertion of the epidural. If these studies are normal, an epidural is safe. We have never had a spinal hematoma from a labor epidural.

I am having an elective Caesarean Section. What type of anesthesia will I receive?

At Norwalk Hospital, we use spinal anesthesia for elective C-sections. If you are not allergic, we also mix a tiny amount of morphine (.25mg) into the spinal to provide pain relief after surgery. The spinal will wear off after about 2 hours, but the morphine will continue to work for about 24 hours. None of the morphine reaches the baby, in contrast to the more traditional forms of pain relief such as injections or IV medications.

Does a spinal hurt?

The anesthesiologist will place the spinal with you sitting or lying on your side. The back is prepped with an antiseptic solution (cold), and then a local anesthetic is injected - this stings and is often the most uncomfortable part of the whole process. An extremely fine spinal needle is then placed through the numbed skin and when spinal fluid is encountered, the medication is injected. 

Most of the time this is extremely quick and patients often state that it was easier than the IV insertion. As with epidural anesthesia, there are factors that might make placement more difficult (and uncomfortable.) These include obesity, significant edema (swelling) in the back, previous back surgery, and inability to hold still.

What happens after the anesthesiologist does the spinal?

The onset of a spinal anesthetic is extremely rapid, unlike the 15-20 minutes required for an epidural to set up. Complete setup of a spinal anesthetic takes 1-3 minutes. 

You will first notice a warmth in the legs, followed by complete numbness. You may be able to wiggle your toes, but that is about it. Your abdomen will be completely numb. Ideally, the level of numbness should extend to the upper abdomen or lower chest.

Because the anesthetic sets up so abruptly, the body sometimes takes a minute or two to get used to it. The blood pressure can drop to a point where you might feel light-headed or even nauseated. If this occurs your anesthesiologist will give you medication to raise your blood pressure. This entire period is usually over in the first 5 minutes.

Your abdomen will be draped for surgery, and the surgeon will test the surgical site to make sure the spinal is working. When this is confirmed, your partner will be allowed to come into the room and will sit at your right for the remainder of the surgery.

The baby is delivered fairly quickly, and the majority of the time in the O.R. is spent closing you up. After the bandages are placed, you are transported to the recovery room where you will spend about an hour, before going to your room in the Maternity Ward (Dana 4).

The spinal lasts about 2 hours, so should be starting to wear off when you leave recovery.

What if my spinal doesn't work?

Don't worry - the anesthesiologist, and then the obstetrician, will test the abdomen to insure that the spinal is working perfectly before incision is made. In the extremely rare circumstance where the spinal simply does not set up at all, it will be repeated. The likelihood of it failing a second time is almost zero.

What are the risks of a spinal anesthetic?

Although spinals are extraordinarily safe and widely used, they are not risk-free. The risks are as follows:

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