Thousands of women will have an epidural today to help them through their labor, and many of them will have a running epidural after they have their baby delivered. This is especially true in the time period for those who have had a C-Section.
There’s no doubt that epidurals have been a wonderful tool for doctors to provide patients with relief from the pains of labor and the pain and discomfort following delivery – mainly after a C-Section.
Because they have become so commonplace in hospitals throughout this country – and the world – they seem to have been taken for granted as being “safe” – not just effective. For the most part – they are safe, but they clearly have significant risks associated with them.
Some reports claim that the overall complication rate for epidurals is 23%. These complications range from very minor (e.g. some nausea, vomiting, itching, headaches) to the most major of complications – death of the mother and/or her baby. In between these two extremes lie some very devastating injuries to both a mother and her baby. Just some of those reported are damage to the mother’s spinal cord leading to motor (ability to move legs) and/or sensory (ability to feel sensations) injuries, bowel and bladder dysfunction, foot drop and a host of other potential – thankfully rare – complications.
There is a popular book that many expectant mothers have considered their bible over the years – What to Expect When You’re Expecting, which is now in it’s fourth edition, according to Amazon.com. While no doubt this has been a valuable resource for many moms-to-be, one medical author takes some exception to the section on epidurals:
Epidural anesthesia has become increasingly popular for childbirth. The popular book, What to Expect when You’re Expecting, for example, portrays epidurals as perfectly safe. The risks, however, may be greatly underplayed.
It’s been many decades (four in one instance) since I personally went through the “birthing” process as a parent-in-waiting. I must admit, I have not purchased or read the latest edition of this book so I cannot vouch that this portrayal of epidurals being “perfectly safe” is still the message of this popular book. Obviously it was at the time of the quote by this Canadian medical writer.)
What expectations do YOU have for your special day?
I suspect that many of you are like I was in envisioning what your experience will be like when the day arrives. You have your bags packed, back-up coverage in place if needed, car gassed. The moment arrives and off to the hospital you go. You register, get in your room, the fetal monitor is applied, and you pass the time remembering (or trying to remember) all those things you learned in your birthing classes. Your epidural is placed and all goes smoothly. Finally, the time comes for you to deliver your new bundle of joy. You make it through some angst of birth, see your new addition through tears of joy and relief and get ready for the onslaught of family and friends, who want to see the new arrival to your family. After you and your baby are cleared for discharge, off you go to your home, ready to begin your “new life” of nurturing, educating, parenting – aglow with images of pride, joy and a world of opportunities ahead. Hopefully, that’s exactly how we all hope it works out for you and your family.
To increase your odds that this scenario plays out, I would strongly suggest that you not take for granted the part about your epidural going smoothly. While there are probably many other questions you may think to ask – or should think to ask – here are three suggestions I have for you based on my seeing (as a lawyer) what can happen when the epidural doesn’t go smoothly.
How an epidural is performed
Here is one example available on the internet (YouTube) to show you just how an epidural is done. Unfortunately, it is a bit difficult to understand the speaker (at least for me), but having looked at several videos, I think it gives you a pretty good idea of how this procedure is performed by the anesthesiologist.
“Have you reviewed my medical history, Doctor? Is there anything else I can tell you?”
Some of the known risks of having epidural anesthesia are connected to your medical history. Sure, you’re assuming that the medical history you gave to your OB during the prenatal visits and to the intake nurse when you arrived at the hospital has found it’s way to your medical record. You’re also assuming that your medical history has been carefully reviewed by the anesthesiologist whose about to put the epidural in your back. Is it there? Has it been carefully reviewed? Ask! There are conditions (e.g. spina bifida, scoliosis, certain heart valve problems, sickle cell anemia, etc.) that can increase your risk of a complication from an epidural. Are you taking or have you recently taken any type of anti-coagulant such as heparin or coumadin? Make sure your anesthesiologist is aware if this is the case since these drugs can increase the risk of a bleeding complication. You don’t want to have a collection of blood around your spinal cord – believe me!
“When should I expect to move my legs or bend my knees? How long will I feel numb?”
In most instances, epidural are given to provide analgesia – pain relief (sensory block) during labor and at times for post-delivery (C-Section) pain relief. They are not intended to block your motor function – that is, your ability to move your legs, flex your ankles, wiggle your toes, flex your hips or bend your knees. During a C-Section the drugs being used for delivery are many times different drugs from the ones you are getting via your epidural infusion. You will have a different block so that surgery can be performed safely. You will likely have both a sensory and a motor block! You need to understand the difference.
These anesthesia drugs (the ones given during your surgery) will usually wear-off (varies depending on the drugs and from patient to patient) in a period of 1 to 4 hours. You will typically be in a post anesthesia care unit (PACU) during your recovery phase from anesthesia.
Key: you should not be discharged from the PACU if you are unable to at least bend your knees. There is a scoring system (Bromage) that the nurses and personnel in the PACU will typically use after examining your ability to move your legs, bend your knees, wiggle your toes, flex your hips, etc. to determine if you can safely be discharged from the PACU or if you need to be seen by a specialist in anesthesia to determine if you have a potentially significant complication.
“What exactly should I expect to feel like if I have an epidural running after I deliver my baby?”
I simply cannot stress enough how important it is for you to understand exactly how you should be feeling after you have been discharged from the PACU to your room. Don’t ask your family or friends; they don’t know – unless they are anesthesiologists. There are so many free, uneducated opinions out there that are simply wrong!
One further piece of advice: do not ask the nurse what you should expect to feel like. There is absolutely no doubt that there are many very experienced and highly capable nurses out there taking care of moms. Unless you intend to ask for and analyze your nurse’s background, training and experience in anesthesia, don’t do it. The drugs used in administering epidural analgesia can vary significantly. The dosing (concentration, volume per hour, etc.) can also vary. Only a specialist in anesthesia can answer your questions correctly!
Know what to look for so that if there is some change in your condition or you start to encounter a feeling or loss of function or sensation, you can tell your nurse or doctor immediately so that you can be examined right away!
I suspect many parents are so caught up in the labor process, or are so exhausted after the delivery or so caught up in the wonderment of having their baby that these issues relating to an epidural may not be very important. If you are in your 20′s, 30′s or 40′s, how important is it to you that may not be able to walk for the rest of your life? It can happen – rarely, thank goodness, but it can happen. I have been involved in cases in which this is exactly what happened! Frankly – I don’t want to see it happen to anyone else. It is incredibly tragic for a mom, a dad and their child – trust me!
One last point before we leave this discussion on post-delivery (post-operative) analgesia. Some hospitals (the number appears to be declining due to concerns about the inadequacy of monitoring) use what is known as Patient Controlled Anesthesia epidural analgesia. Simply put, this is a device (they vary depending on the manufacturer) permits the patient to push a button a infuse a pre-determined dose of drugs (e.g. bupivacaine and fentanyl) into the epidural space for additional pain relief. A patient is actually limited as to how much drug can be used in the course of an hour (determined by what in called a lock-out interval and maximum dosing parameters per hour). While a fixed lower amount of drug flows each hour (known as the basal rate), many patients may require more relief than the basal rate provides.
That being said, if you find yourself pushing the PCA button numerous times during the course of an hour, you should bring this to the attention of your nurse or doctor. Don’t wait for them to hopefully check the machine to see how many times you pushed in the last hour (many forget to do this!). Be pro-active. If you are pushing your PCA button a number of times in the course of an hour, even though you can’t really overdose yourself because of pre-set limits by the anesthesiologist, this may be an indication that something needs to be checked. For instance, the catheter may have become displaced; the drugs may not be distributing equally; you may be having some problem that someone needs to investigate. Don’t keep hitting the PCA pump; hit the call button!
Get information about the risks, benefits and alternative to an epidural!
Having been there (i.e. childbirth) as a father four times, I know – at least from my perspective – how difficult it is to concentrate on issues such as risks, benefits and alternatives involving an epidural. Common sense tell me the ideal time to have this discussion simply cannot be while mom is in labor. If that’s the only chance you have, then fine – take the time and make the effort and have a real discussion with the anesthesiologist. Even if you just cover the 3 items I have suggested above, that will take you a long way.
I have made this suggestion before, but I’ll make it again: make arrangements to meet with someone from the anesthesia department before you get to the hospital to delivery your baby. Don’t be shy or concerned that you don’t want to bother anybody. Bother somebody! There really are an awful lot of wonderful doctors and CRNA’s, who would be willing to meet with you, educate you and answer your questions. It’s your health, your body, your future – so protect it!
There clearly are more than “3 questions” you should ask. Many of you have been through this. Many of you have medical training and experience. What questions do YOU think a mom-to-be should ask about their epidural.