Epidural Block and General Anesthesia
An epidural is a medical procedure that is done in labor, that stops pain by injecting an anesthetic into the lower spinal cord by preventing transmission of pain signals. An epidural given for labor makes a mom numb from umbilicus down. Epidurals given for c-sections are much stronger and reach the breastbone.
Mothers choosing to have what they think will be a “painless” delivery, may be in for a shock. There is no doubt that epidurals have a place that is very needed in biotechnical intervention for mom and baby. However, perhaps moms are not really given the total potential picture of what birth via an epidural might mean for them and their baby. Should epidurals be used like Tylenol or simply a way to “get around” the “pain” of childbirth? In our society, pain is anathema. It is no surprise that woman are choosing to medicate themselves and their babies to escape it.
The beauty of birth is simple and character-stretching. What a loss to the total picture of motherhood “escaping” the sensations of birth can be. However, some moms are not able to vaginally give birth without help. In that regard, I am truly thankful that an epidural is an option over a c-section. Here are some eye opening facts that might cause a mom to rethink the fast-becoming-tradition of the epidural in childbirth in America.
Epidural analgesia can happen 2 ways: lumbar and caudal, depending on the site used when approaching the epidural space.
The epidural space is situated around the dura mater and contains blood vessels and fatty tissue as well as the spinal nerves which pass through it. The aim of the anesthetist is to introduce local anesthetic solution into the epidural space so that it will surround the fibers of specific spinal nerves, numbing them an achieving a selective block of those nerve felt during birth.
Medication types
Lingocaine – effective sooner, but lasts much less time. Unsuitable for total labor, as too much medication would be needed to be effective and risk toxicity. It is used in conjunction with other meds for a short period before the main meds take effect.
Bupivacaine (Marcain) – Effective within 10 – 20 mintues. Lasts about 2 hours.
Opiates: diamorphine, morphine, and pethidine are common. They are not as effective as might be hoped in relieving the pain of labor
Lumbar block:
Most common – anesthetic introduced between lumbar vertibra 3 and 4 or 2 and 3.
Single shot epidural – local anesthetic is introduced using a Tuhoy needle, but no catheter in inserted for continued medicating.
Continuous technique – a fine polyethylene or nylon catheter is inserted into the epidural space so that further doses of local anesthetic may be given when needed.
Caudal block:
Not as popular as it used to be. It is harder to secure an epidural catheter safely and comfortably. A larger amount of anesthetic solution is required in order to give effective analgesia. Woman is required to be in the knee chest position and this is not comfortable during labor. The epidural needle is introduced between the sacral hiatus. Toxicity is more common, because of the larger amount of anesthetic needed.
Request from the mother used to be the most common reason for giving this route of analgesia. Now, many hospitals give epidurals routinely and it is expected that a mom will wish for one. However, safety should always be the first consideration.
Narcotic Epidurals:
Narcotic epidural – Some of the anesthetic is replaced with a narcotic to maintain good pain relief, while reducing some of the side-effects of the anesthetic.
Walking epidural –The anestheologist either injects narcotic only or injects an ultra-low dose of anesthetic. With pure narcotic, you can indeed walk. With anesthetic, you need help, despite feeling normal. The epidural effects muscle strength, ability to sense balance and reaction time to correct imbalance. Most woman find walking epidurals to be inadequate pain relief.
Combined spinal- epidural – Anesthesiologist injects an initial dose of narcotic or anesthetic beneath the outermost membrane covering the spinal cord and inward of the epidural space. The needle is left in place should additional medication be wanted later. Commonly, the spinal injection is narcotic and some, but not total, pain relief is obtained. But unlike the epidudral, some mobility is maintained.
What are the potential problems with an epidural?
Hypotension – Local anesthetic solution blocks the transmission of nervous impulses along the motor and sensory nerves. It also has an effect on the sympathetic nervous system. A vasodilation of the blood vessels will lead to a further drop in blood pressure. Typically the systolic pressure <100 is noted in up to 50% of the woman following having an epidural. This can be particularly dangerous in cases where the baby is already at risk from mom’s high blood pressure, toxemia, or prematurity.
Dural Tap - If the anesthetist inadvertently punctures the dura matter, this in known as a dural tap. It is usually recognized when a few drops of cerebrospinal fluid leaks through the Tuhoy needle when inserting the catheter. The anesthetists will usually reinsert the epidural cath in an adjacent space… and then a planned forceps delivery or vaccume suction delivery is planned to avoid the CSF being forced through the puncture hole. A headache resulting from a dural tap will resolve be itself within a week… but what a week that will be! The pain can be incapacitating. Lying flat will give considerable relief, but this does not help the woman, who should be enjoying her new baby feel better. Instead, the lasting memory that should have been sweet, is now replaced with trying to get through the after effects of her caudal
Placement risks – there are risks surrounding the placement and use of anesthetic in the epidural region, may out weigh the segment of time that we are “pain free” In fact, in a light general anesthetic, a mom may be totally aware of what is going on around her, but is paralyzed and cannot speak.. This can be terrifying.
Malposition of baby’s head - The use of epidurals early in labor have been associated with malpositions of the baby’s head. This is due to the lack of good muscle tone that guides the baby’s head in to the path for birth. Posterior positions are more common and may be compacted into the posterior pelvis, resulting in asyclitism.
Fetal distress – About one in ten babies will experience an episode of seriously abnormal heart rate as a result of the epidural.
Mixing meds – the incidence of adverse effects goes up when mixing different kinds of medication. Almost always, moms have had some drug already such as Pitocin, a narcotic, or even a different type of epidural. Every variation in drug or drug combination or dosage could affect mothers babies and even different labors differently.
Fever - Fever becomes more likely the longer an epidural is in place. Because fever is a symptom of infection, babies of mothers who run fevers will likely need to have a septic work-up and kept in the nursery for observation.
Unkown possible side effects on newborn behavior – We know that epidural anesthetics get into the baby’s circulation, but we have little data on what effects they might have.
Nausea –
Severe postpartum headache – improvements in technique may be reducing the risk.
Maternal respiratory depression – This is due to the narcotic. Reported to occur as one in a thousand cases, and it can be life-threatening.
Here are some disadvantages to a loss of sensation a mom may want to think about before asking for an epidural.
Impaired bladder function – marked bladder distention occurs when there is a loss of the sensation to void. A catheter may be inserted, which raises the risk of an infection and postpartum voiding difficulties. Woman are encouraged to attempt voiding right after an epidural, but often they are unable to electively control the action of the sphincter. When using a catheter, it needs to be removed before the baby’s head is nearing the perineum.
Marked perineal pain
Backache, which may be due in part to local bruising where the Tuhoy needle was introduced! Especially if the anesthetist had difficulty locating the epidural space.
A mom may not be aware if her bladder becomes full and may find it difficult to impossible to go to the bathroom and pee.
Even if the epidural is well managed, she may face an increased likelihood of a forceps delivery because she cannot feel an urge to push.
Immobile legs. If not positioned with care, can have nerve damage and pressure.
Please consultant with an anesthesiologist before a decision is made to have an epidural if you have any of the following.
1. Scoliosis, spina bifida or other spinal column abnormalities
2. Previous back surgery
3. Pre-existing arthritis
4. Pre-exising tracheoostomy
5. Pre-exsisting neurologic or neuromuscular disease (like multiple sclerosis or muscular dystrophy)
6. Pre-exsisting cardiac disease
7. Pre-exsisting pulmonary disease (other than mild asthma)
8. Low platelet count (>100,000) or use of heparin in pregnancy
9. Pre-exsisting coagulations
10. Any history of problems with epidurals or other anesthetic
11. Allergy to anesthetics
12. Morbid obesity
13. Suspected diffucult airway
14. Severe anxiety regarding regional analgesia
Reasons to opt for epidural anesthesia:
Abolishing pain without affecting
consciousness. It is the only pain relief method that can do this.
Allows rest or sleep in an exhausted mom. This can benefit long or
difficult labors.
If a mom has a marginally contracted pelvis or very tense perineal muscles, relieving the pain element may bring about enough muscle relaxation to have a vaginal birth, instead of a c-section.
When labor progress (dilation) has stopped, usually epidurals slow labor down, but it can help labors that have gotten stuck by producing profound relaxation.
If a mom has to have a c-section, an epidural instead of a general anesthetic is much better , because mom can see and cuddle her baby right away and can be up and about fairly quickly in the postoperative period. In addition a mom is not subjected to the risks of a general anesthetic. However, epidural anesthiesia for a c-section must be more profound and extensive than for labor. Sensation is blocked to the level of her nipples (T4) and a good block is required in the pelvic area. If the motor block rises above the level of T6, the mom may have difficulty breathing.
If a mom is emotionally scarred from sexual abuse and cannot handle vaginal birth sensations, can be another reason to opt for an epidural.
General anesthesia – General anesthesia is a type of anesthesia where you are put in deep sleep. It is the most common type of anesthesia. It is also known as "being put under", "put to sleep", and "completely out".
Minor side effects from general anesthesia and surgery are common. These include nausea, sore throat, headache, muscle aches, or a generalized "hang-over" type feeling. Fortunately these are most often not serious and resolve on their own in hours or a few days after surgery.
One of the most common questions is, “Will I have to have a tube down my throat.” The answer is, yes. The medication that makes you unconscious also inhibits you from breathing adequately. The anesthesiologist must assist a patient to breathe during the course of the c-section. This is most often accomplished by placing a small breathing tube (endotracheal tube or Laryngeal Mask Airway -LMA) into the windpipe (trachea) after anesthetization. The endotracheal tube or LMA is most often removed while patient is waking up and therefore most people do not have any recollection of this event.
An IV is also needed. The intravenous line is the means by which the anesthesiologist can deliver medications and fluids necessary to safely perform the anesthetic. Post-operatively the I.V. line is maintained to continue fluids and deliver pain medications as necessary.
Reasons to opt for a general anesthesia
Baby is in danger and needs an immediate c-section.
Birth mom needs planned, additional abdominal surgery after a c-section, that requires the deep stillness general anesthetic produces.
Conclusion:
An epidural can transform what otherwise would be an awful birth experience into a positive one. In some cases, an epidural seems to promote progress in a labor that seems stuck.
Although having an epidural does relieve a woman of the discomfort of labor and birth, many woman are unprepared for the lack of control they feel physically. The fact that they cannot move their legs very readily or control their bladder, the need to be attached to all kinds of wires, multiple machines and IV leads may make birth seem very much like an illness instead of a birth. This has a profound consequence of how a birth mom views her birth, herself, her partner, other support people and medical care givers.
Because epidurals eliminate pain, the endorphin rush at the birth is eliminated too. Being passive in the birth process, instead of an active participant, causes some of the “I did it!” personal accomplishment to diminish. If the epidural results in a vacuum or forceps extraction or c-section, moms may also have a harder time dealing with a sense of loss of accomplishment. This can especially be true if her goal was to have an unmedicated birth.
It is important to note that doctors who use fewer epidurals for their patients also were more inclined to spend more time with them in labor and to use intermittent fetal monitoring. Those doctors who use epidurals as a standard of care might be using epidurals as a way of mechanizing birth. It cannot be denied that those doctors who have the lowest epidural rate started them at a more advanced cercial dilation. They had moms who had shorter labors, fewer forceps and c-sections and fewer admissions of newborns to the special care units.
Can we totally prepare and inform a mom who is considering a epidural birth? Probably not, just as we cannot totally prepare a 1st time mom for the sensations of labor and how much work it really is to push a baby out. Yet, if more doctors were inclined to share with their patient the truth about what having an epidural means and account for the loss of that special part of motherhood, maybe more woman would think twice about having them.
Myles textbook for midwives 11th edition
Edited by V. Ruth Bennett and Linda K. Brown
Published by Churchill Livingstone
Varney’s Midwifery 4th Edition
PreciousPassage.com by Henci Goer
The following is an information article written by me for my moms about epidurals, general anesthesia and natural child birth.
Information on Epidurals,
General Anesthesia
and Natural Birth
This information is shared to help you make an informed decision regarding the birth of your baby. As a mom-to-be, where and how you give birth, and who is with you, is a very important decision. Your choices affect you and your baby’s health and safety.
Important to note: Your body is created by God to give birth. From the moment you became pregnant, your body started preparing for the miraculous event that allows you to cradle your baby in your arms instead of your tummy.
A woman’s need for medication varies, in accordance to her pain threshold and on the amount of anxiety and tension she has. (And their effect on the intensifying amount of pain.)
The path you choose to facilitate your baby’s special “birthday” will set the precedence for how you feel about birth and motherhood in the future. Because of this, we suggest that you choose carefully, with heart-felt consideration. Take the time to research and find your comfort zone, so that you are relaxed on this happy day.
Please choose a professional that will listen to you. Find a doctor or midwife that takes the time to understand what you are feeling physically, and experiencing emotionally. A clearer picture of what it means to have an epidural, medicated birth or non-medicated birth, will help you make that birth decision wisely.
What is an epidural?
The “epidural” is actually a space situated around the spinal cord. The dura matter around the cord contains blood vessels and fatty tissue as well as the spinal nerves which pass through it. The aim of the anesthetist is to introduce local anesthetic solution into the epidural space so that it will surround the fibers of specific spinal nerves, numbing them and achieving a selective block of those nerves felt during birth. This procedure is only done by an anesthetist, in a hospital.
Lumbar block:
Most common – anesthetic introduced between the 3rd and 4th or 2nd and 3rd vertibra.
Single shot epidural – local anesthetic is introduced using a very small needle. No catheter is inserted for continued medicating.
Continuous technique – a fine polyethylene or nylon catheter is inserted into the epidural space so that further doses of local anesthetic may be given when needed.
Epidural anesthesia - for a c-section must be more profound and extensive than for labor. Sensation is blocked to the level of her nipples (T4) and a good block is required in the pelvic area.
Caudal block:
Not as popular as it used to be. It is harder to secure an epidural catheter safely and comfortably. A larger amount of anesthetic solution is required in order to give effective analgesia. Woman is required to be in the knee chest position and this is not comfortable during labor. The epidural needle is introduced between the sacral hiatus. Toxicity is more common, because of the larger amount of anesthetic needed.
Narcotic Epidurals:
Narcotic epidural – Some of the anesthetic is replaced with a narcotic to maintain good pain relief, while reducing some of the side-effects of the anesthetic.
Walking epidural – The anesthesiologist either injects narcotic only or injects an ultra-low dose of anesthetic. With pure narcotic, you can indeed walk. With anesthetic, you need help, despite feeling normal. The epidural effects muscle strength, ability to sense balance and reaction time to correct imbalance. Most woman find walking epidurals to be inadequate pain relief.
Combined spinal- epidural – Anesthesiologist injects an initial dose of narcotic or anesthetic beneath the outermost membrane covering the spinal cord and inward of the epidural space. The needle is left in place should additional medication be wanted later. Commonly, the spinal injection is narcotic and some, but not total pain relief is obtained. But unlike the epidural, some mobility is maintained.
Procedure for an epidural:
To start with, you must have an IV started and receive at least about a quart of fluid. This is to add to your blood volume and counter act the possible drop in blood pressure, epidural’s most common side effect.
A blood pressure cuff will be will be loosely placed on your arm and monitored closely.
An electronic fetal heart monitor will be placed on your belly or the baby’s scalp, so that any problems with your baby’s heart rate can be seen.
Next, you will either sit up on the side of the bed or lie on your side while your back is washed with antiseptic soap and covered with a sterile drape.
For the actual “poke” you will be asked to arch your back like a mad cat or a rainbow. The anesthesiologist numbs the skin a little above the waist line with local anesthetic and then pushes a larger needle through the ligament that connects the two spinal vertebrae. You must hold very still while the needle is in your back, even if you have a contractions. (You’ll probably have one or two during the procedure.)
Feeling for the loss or resistance, the anesthetist guides the needle into the epidural space. If the position is correct, a tiny, flexible plastic catheter is threaded through the needle. The needle is then withdrawn and a full dose of medication is given.
After the anesthetist feels that all is well, a catheter will be looped and taped to your back to keep if from shifting position.
To maintain anesthesia, your catheter may be connected to a syringe that is hooked to a pump that administers the medication slowly. Or, he may cap the catheter and return to inject more when pain returns. Ideally you will feel no pain, but have some control over your legs.
The procedure can easily take over an hour from the time your request is made for an epidural until the medication takes effect.
Will I feel any thing if I get too much medication? If a mom has received a large dose of local anesthetic solution or if some of the solution has passed directly into her circulation, she may complain of tingling or numbness of the mouth and tongue, dizziness and tinnitus. This may be followed by drowsiness, muscle twitching and slurring of speech. Alert your care giver immediately if you feel these symptoms.
What is General Anesthesia?
General anesthesia is a type of anesthesia where you are put in deep sleep. It is the most common type of anesthesia. It is also known as "being put under", "put to sleep", and "completely out".
Minor side effects from general anesthesia and surgery are common. These include nausea, sore throat, headache, muscle aches, or a generalized "hang-over" type feeling. Fortunately these are most often not serious and resolve on their own in hours or a few days after surgery.
One of the most common questions is, “Will I have to have a tube down my throat.” The answer is yes. The medication that makes you unconscious also inhibits you from breathing adequately. The anesthesiologist must assist you to breathe during the course of the c-section. This is most often accomplished by placing a small breathing tube (endotracheal tube or Laryngeal Mask Airway -LMA) into your windpipe (trachea) after you are anesthetized. The endotracheal tube or LMA is most often removed while you are waking up and therefore most people do not have any recollection of this event.
You will also need to have an IV. The intravenous line is the means by which the anesthesiologist can deliver medications and fluids necessary to safely perform the anesthetic. Post-operatively the I.V. line is maintained to continue fluids and deliver pain medications as necessary.
General anesthesia can be administered very quickly in emergency birth procedures, where the baby or mother’s life is at grave risk. Many years ago, most woman giving birth were “put totally out or partially under” so that they had no memory of the birth. Today, unless there is a need for a quick birth, this practice is ordinarily used in emergency c-sections.
What is Natural Child Birth?
Having a baby without medication is a way of sharing the experience of birth, intimately, with your baby. Many mothers share that having a baby, naturally, was the most profoundly positive, life-changing, experience of their lives.
Non-medicated Natural Birth Options:
Hospital – Having a baby in a hospital seems normal to many people. But more and more mothers are asking for better birthing facilities, better conditions and more compassionate care. A non-medicated birth option in the hospital will include on-shift labor room nurses for the first stage of labor and an OBGYN for the birth of the baby and placenta. Birth mom is usually allowed to have her support system present, unless an emergency arises. This may include her husband, visitors and a Doula. (Doula: a woman who helps a family reach their birth plan goals. Her role is to support the family unit, providing comfort, encouragement and coaching for the entire birth process.)
Hospital births may also be facilitated with a nurse midwife. Although a non-medicated hospital birth is possible, typically hospital births require adherence to hospital protocol (Routine blood work, vaginal checks for dilation, an IV, fetal monitoring, along with other vital checks, for both mom and baby.) A “non-medicated” birth in a hospital can be a good choice for mothers who are not comfortable with birthing out-side the hospital, yet desire a healthy birth experience.
Birthing center: Usually a CPM (certified professional midwife), or direct-entry midwife (non-certified) works in a birthing center setting or at the birth mother’s home. The midwife generally has 1 or two assistants. Birth mom can have the support persons of her choice. Vitals (temp, blood pressure, respirations) are more relaxed, unless there is a problem. There are protocols, but they are very mother/ family friendly. Pain medication, except for over-the-counter analgesics for after the birth, are not used.
Birth without any assistance: Some have found that having a baby is a very personal experience and have chosen to birth at home without the assistance of a professional, or even family member in attendance. We believe that some woman can have good birth out-comes without help, but the risk of negative out-comes are greater, especially in a rural community, where help is sometimes far away.
When to get an epidural?
An epidural can be used in place of a c-section. A mom’s pelvic region may be formed differently or her muscles too tight to allow a baby to be born easily. An epidural may allow a mom’s pelvic region to relax enough to let the baby to be born vaginally, instead of a c-section.
Emotional scars from sexual abuse: This can be due to both physical and/or emotional issues. It is very hard for some moms to handle vaginal birth sensations.
Pitocin induced birth: A medication called Pitocin is administered via an IV, to gradually bring about stronger and more efficient labor contractions. These contractions are not easy to work though, especially toward the end of the birth. They are very regular, and may not allow for the normal contraction pattern of 1 or 2 weaker, then 1 stronger, letting mom rest somewhat. Mom may become tired, over-whelmed and her pain tolerance may weaken. An epidural relieves the painful part of a Pitocin-induced birth, allowing her baby to be born vaginally
Epidurals can be used as a pain-reliever. Some moms are uncomfortable with the idea of birth being painful for them.
C-section: an epidural used instead of general anesthetic is much better. A mom can see and cuddle her baby right away and can be walking fairly quickly in the postoperative period. In addition, a mom is not subjected to the added risks of a general anesthetic. However, epidural anesthesia for a c-section must be more profound and extensive than for labor, and there can be more negative sensations to work through. (Feeling like you cannot breathe).
Reasons why some moms may choose general anesthetic:
Baby is in danger and needs an immediate c-section.
Birth mom needs planned, additional abdominal surgery after a c-section, that requires the deep stillness general anesthetic produces.
Birth mom wishes to have no recollection of the birth itself.
Why do moms choose natural childbirth?
After having a previous medicated birth, they may be seeking a deeper level of birth experience. Sometimes, after a first birth in the hospital, moms realize that the birth process in not an illness, and that they can birth naturally, even out of the hospital, in a birth center or at home.
Birth mom may enjoy learning about her body, her unborn baby, and the process of birth. The professional that you choose should have time to cultivate a relationship with you, her client. Ask yourself these questions when interviewing:
Do you feel rushed? Are they really listening to you and hearing your concerns? Do you feel like you are getting “brushed-off”. Are your questions being answered? Are you comfortable in their office? Can you see yourself giving birth and having them attend you?
Natural birth is statistically safer for lower-risk moms and babies.
Recovery time is quicker, assuming there are no complications.
C-section rate is lower
Breast-feeding is established immediately
Very carefully consider your choice of an epidural if…
….You are not wanting to risk a backache and/or headache, due to local bruising or bleeding where the needle was introduced into the epidural space. Occasionally the place where the needle was introduced leaks blood and causes a persistent headache for several days, which needs to be “patched” with fresh blood at the site of entry.
….You are not sure you want a forceps birth. Epidurals increase the risk of forceps delivery, which is hard on baby. Due to the lax pelvic floor muscles baby may not descend with good flexion and consequently come down sort of sideways, needing help getting out. Also, because mom has no pushing sensation, baby has a harder time descending through the birth canal without maternal effort.
.…You would like to be able to walk around immediately after the birth. A mom’s legs are immobile during an epidural style birth and for a period of time afterwards. Mother must remain in bed until epidural medication wears off.
….You have low blood pressure, have hemorrhaged with the birth so far, have cardiac disease, or allergy to anesthetics, are obese or have a blood clotting disorder. Please consult an anestheologist before considering an epidural option for birth.
…You think that an epidural will give you a “painless” birth. Mothers choosing to have what they think will be a “painless” delivery, may be in for a shock. There is no doubt that epidurals have a place that is very much needed in biotechnical intervention for mom and baby. However, perhaps moms are not really given the total potential picture of what birth via an epidural might mean for them and their baby. Should epidurals be used like Tylenol or simply a way to “get around” the “pain” of childbirth?
…You are concerned about the health of your newly born baby. All babies feel the effect of their mother’s medication to some extent. Immediately after birth, a new born will cry a little, seek comfort from mommy and even nurse within minutes of birth. Babies who have received medication crossing the placenta can be sleepy, have floppy muscle tone and are not as vigorous and alert as they could have been without the medication.
The beauty of birth is simple and character-stretching. However, some moms would not be able to vaginally give birth without help, or are not able to handle the emotional and physical workload of birth. In that regard, I am truly thankful that an epidural is an option. In addition, epidurals, and medicated birth can mean the difference between a vaginal birth versus a c-section. Once a mother has a c-section, it is much harder to find a professional, even in a hospital, to allow a vaginal birth in the future if she so wishes. VBAC’s can be done legally, but it depends on the OBGYN, method of incision and location of birth.
In addition, general anesthesia has saved many a baby’s life. Respectfully and kindly, I am very supportive of the hospital style birth and parents who choose these options.
Myles textbook for midwives 11th edition
Edited by V. Ruth Bennett and Linda K. Brown
Published by Churchill Livingstone
Varney’s Midwifery 4th Edition
PreciousPassage.com by Henci Goer