Then allow me to address one of the areas where I receive the most questions, both from patients but also friends and families: epidurals.
Specifically, lumbar epidurals. More specifically, lumbar epidural catheters. Even more specifically, lumbar epidural catheters for labor. Why all the specifications?
An epidural derives its name from the fact that the procedure involves accessing the epidural space. This is an area that surrounds the spinal cord, but does not involve the spinal cord itself. It extends the entire length of the spinal cord. As such, the epidural space can be accessed at multiple levels: the cervical epidural space (around the neck), the thoracic epidural space (the mid-back, around the shoulder blades), and the lumbar epidural space (the lower back).
This area is accessed with a special needle. Once the needle is in the right place, medication can be injected through it, or a special tube called a catheter can be inserted into that area. No, not the tube that goes into the bladder — that is a urinary catheter. A urinary catheter is frequently utilized during labor as well, and is what most folks are referring to when they say “catheter.” But this once again highlights why the specificity of language is important.
Access of the epidural space can be performed for a variety of reasons, surgeries, and conditions. Cervical epidural injections may be utilized for neck and shoulder pain. Thoracic epidural catheters may be used for surgery on the chest. Lumbar epidurals can be used for a variety of procedures such as hip fractures, knee surgery, and abdominal surgery. But it is most commonly utilized in the lumbar area, with a catheter, for pain relief during childbirth.
All this blabbering aside, if you arrive at the hospital, noticeably pregnant, and ask for an epidural, everyone will know exactly what you are asking for.
Once the catheter is in place, an infusion of medication is started. This varies among institutions, but is typically a local anesthetic such as ropivacaine or bupivacaine (very similar to the novocaine you might receive from the dentist) with or without an opioid such as fentanyl or hydromorphone in very low doses. This helps alleviate the pain associated with the uterine contractions and cervical dilation of labor.
So that’s what it is.
Now, these are some of the most common questions I receive about lumbar epidural catheters for labor:
Will it hurt?
The answer to this is different for every woman, as women all have dramatically different pain tolerances (though those are almost universally higher than those of men, #girlpower). But no, it really shouldn’t. The anesthesiologist or nurse anesthetist will use a very small needle to numb the skin and deeper tissues. For many patients, this is the worst part, as you will feel the pinch of that needle, and the burning of the local anesthetic. It is classically likened to the sensation of a bee sting, but quickly subsides.
Then a larger needle is used to actually enter the epidural space. This is often felt as pressure, or a dull ache, but should not feel like a sharp pain. If it does, it is actually quite helpful to let the person placing the epidural know if you feel that in the left, right, or in the middle. Once the needle is in the right place, a the very thin catheter is threaded a few centimeters (classically 3-5cm) into that space. It is then secured with special dressings and tape, and connected to an infusion pump. Depending how the catheter is dosed, improvement in pain usually is noticed anywhere from 1 to 15 minutes.
Will it cause long term back pain?
Almost universally, no. Localized soreness is common for a couple of days. But long term back pain after childbirth is commonly more related to the muscular strain of pregnancy, pushing, weakness of the abdominal musculature, and positioning used when delivering the baby.
Will it paralyze me?
Again, almost universally, no. As mentioned, an epidural catheter, goes into the epidural space. As such, it doesn’t involve the actual spinal cord. Furthermore, an epidural catheter is typically placed between the levels of L3 and L5. The adult spinal cord, tends to end around L1. This means the epidural is being placed far away from the spinal cord in all directions. Permanent paralysis requires damage to the spinal cord itself, which is exceedingly hard to accomplish with a lumbar epidural catheter.
Will it cause nerve damage?
This is exceedingly uncommon as well. Because once again, we are working quite far away from any actual nerves. The incidence of neurologic injury has been reported as less than 1 in 10,000, and is typically temporary. Nerve injury is more commonly associated with the process and positioning of labor itself, with potential sites of injury including the common peroneal nerve, lateral femoral cutaneous nerve, the femoral nerve, or the lumbosacral trunk. But as always, it’s just easier to blame anesthesia.
Why is it taking so long?
The duration of the procedure typically varies based upon both patient and provider factors. From the time I position a patient for an epidural to the time I walk out of the room is usually less than 15 minutes. The majority of that time is spent preparing the epidural kit (that has multiple components), sterilizing the skin, taping the catheter in place, and preparing the infusion pump. I’d argue I spend less than a third of that time actually poking the patient with a needle.
I think I’m pretty damn good at placing epidurals. I’m sure some folks are better, and I guarantee a lot are worse. Some may be no worse or better…just slower. So sure, the experience and skill of the person placing it are a factor, but more so, consider the following:
This is, effectively, a “blind procedure.” We do it by feeling and identifying landmarks that give us clues about the correct place we want to go. We don’t have x-ray. Anything that distorts these landmarks increases the difficulty of the procedure — scoliosis, previous back surgery, etc. Obesity is a major factor. I’m not fat shaming, I’m not criticizing, or saying the weight of a person has any reflection on character. It is simply factual that the more obese a patient is, the more difficult it typically is to identify those landmarks, and therefore the more challenging the procedure.
Why am I still feeling everything?
The goal of a labor epidural catheter is to achieve analgesia, not anesthesia. Analgesia means pain relief. Anesthesia, effectively means numb to the point of tolerating a surgical incision. This can in fact be achieved with an epidural, for a C-Section for example, but the density of this block impairs the ability for a woman to push effectively. Which is not what you want for delivering a baby. An improvement in labor pain by 60-70% is a reasonable goal. So ask yourself, is the pain as bad as before the epidural? Is this still intolerable? Am I feeling it on one side more than another? If so, have the nurse call your friendly neighborhood anesthesiologist! We are here to help. Help may involve dosing additional medication through the catheter, repositioning the catheter, or sometimes putting in a new one. We want to make you more comfortable. That is our job. But some realistic expectations can go a long way.
Additionally, as you progress into the later stages of labor, the nerves involved are lower in the body, and are not always targeted as effectively by the epidural. It is not in any way uncommon, and it doesn’t mean your epidural “stopped working.” The good news is, if you’re feeling a lot of pressure in your bottom or feel like you need to poop, it might mean it’s time to meet your baby!
And yes, you will poop. Everybody poops. No one cares.
Can epidurals harm the baby?
No. The amount of medication that reaches the baby from the epidural is very very very small, and there is no evidence that it causes any harm.
Can an epidural slow labor or lead to a cesarean delivery?
Can anyone stay with me during the procedure?
It depends. COVID has thrown a whole knew wrench into this question. But pre-COVID, it still would depend on the hospital policy. Some allow one person. Some allow none. Whatever it is, please abide. It does not give any of us joy to dismiss your family from the room. We just want to keep everyone safe. And if you stay, please sit. With me, that’s non-negotiable. Patients’ family members have passed out while watching the epidural, and it’s possible to be seriously injured and even die from head injury. I don’t care how tough you think you are. The bigger they are, the harder they fall.
Can it be “too late” for an epidural?
Kind of, yes. It’s hard for that to be the case. But as mentioned, figure it takes about 15 minutes for the whole procedure. If you’re very far in the process, and or progressing through your labor very rapidly, and the delivery of the baby seems imminent, yes, it is possible that there is not enough time for both the procedure to be performed and the baby to be delivered safely.
But why did x, y, or z happen to my friend/sister/cousin/aunt/grandmother/Karen?
I don’t know. There’s almost no way to know. Common possibilities include speed of labor, challenging anatomy, and malfunctioning catheter. But frankly, the most likely explanation, is that every patient is different.
If it was your wife, would you want her to have an epidural?
And she did. As soon as she could possibly get it. Both times. Her body, her choice.
Can you deliver without an epidural?
Absolutely. People did it for thousands of years. And still do it all over the world. And if you want to go au naturale, you do you. But please understand, doing so doesn’t make you better, smarter, tougher, nobler, than those who don’t. As I tell my patients, the prize is the same. And it’s the best prize in the world.