Obstretic Anesthesia | Information for Patients
- Our philosophy
- Fear of the unknown
- Rationale for using Epidurals and spinals
- Epidural vs. spinal
- The "walking" epidural
- Epidural and spinal controversies
- Cesarean delivery
- Pain relief after cesarean
- Staff and coverage
We believe that every woman has the right to a safe and comfortable delivery. We are fortunate to live in an age where advances in pain relief techniques have made this possible. At the same time, we recognize that many people do not take advantage of modern pain relief techniques because they do not fully understand them, or are frightened of them. As a result, many women needlessly suffer labor pain, as their forebears have done since time immemorial.
This need not be the case. We believe that women in labor are entitled to the same quality of pain relief that we offer to other patients suffering from pain. We agree wholeheartedly with the opinion of the American College of Obstetrics and Gynecology, that: "There is no other circumstance [other than labor] where it is considered acceptable for a person to experience severe pain, amenable to safe intervention, while under a physicians care.... Maternal request is sufficient justification for pain relief during labor."
Anesthesiologists are pain management specialists, and we serve as consultants in the Labor and Delivery Suite. We work with your obstetrician to help you through the birthing process. If you desire pain relief for your labor, and your obstetrician agrees, we will be happy to assist you. The information presented here is designed to introduce you to our services and to provide a brief overview of your options for pain relief provided by the obstetric anesthesiologists at Tisch Hospital. We encourage you to seriously consider your options for labor pain relief before your labor begins.
There is much unwarranted fear among the general public regarding epidurals and spinals. This fear is often based on the unknown--a lack of information, or worse, inaccurate information. The fact is that today, epidurals and spinals are extremely safe and effective for the overwhelming majority of women. Although there have been many recent advances in the science and art of providing pain relief for labor and delivery, public perceptions have not always kept pace with these advances.
The best way to allay your fears is to learn more about your options, and about the state-of-the-art labor pain relief techniques that we routinely use at Tisch Hospital. You will need this information to make a reasoned decision about how you want your labor pain managed. It may be that you decide not to have us assist you--obviously the choice is yours. But before you can make that decision, you need to consider all of the facts in a non-pressured setting. That is why we strongly suggest that you learn about what is available and carefully consider your options before your labor commences.
There are two basic approaches for using medication to manage labor pain. The old-fashioned way involves the use of systemic narcotics, such as Demerol®. The term systemic refers to the fact that the medication acts in your whole "system," or body. The Demerol® is injected into a vein or muscle so that it can travel through the bloodstream to work in your brain where it "numbs" the pain. In contrast, the pain relief techniques that we recommend, epidurals and spinals, are known as regional anesthetics. This is because the medication is administered into a specific "region" of your body to numb the pain arising from the uterus (during the first stage of labor) and vagina (during the second stage of labor).
In sharp contrast to systemic medications, which act in your brain and produce drowsiness and sedation in addition to pain relief, the epidural or spinal medication acts locally on the nerves that transmit pain from the uterus and vagina. The result is that you will be comfortable and alert, so that you can fully participate in the birthing process. Another advantage of the epidural and spinal techniques is that a relatively small dose of medication is required to relieve the pain. Therefore, less medication will be transferred to your baby than if you were to receive systemic narcotics.
A common question is: "What is the difference between an epidural and a spinal?" Both techniques are quite similar, as they involve blocking transmission of pain signals close to their point of origin. Each technique (epidural, spinal, or the combined spinal-epidural) has particular advantages and disadvantages. One of the advantages of the epidural technique is that medication can be administered continuously through an epidural catheter (a thin plastic tube) by connecting it to an electronic pump. In this way, pain relief can be continued throughout labor and delivery, and for management of postoperative pain should a cesarean be necessary.
Spinal techniques and combined spinal-epidural techniques have their own distinct advantages. For example, spinals take effect more quickly than epidurals. The type of pain relief technique you will receive will be tailored to suit your needs. In some circumstances, an epidural may be the best choice and other times the spinal or combined spinal-epidural technique may be most appropriate.
One of the most significant advances in recent years in obstetric anesthesia has been the evolution of the so-called "walking" epidural. With this method, a combination of medications is administered which act together to relieve your pain while preserving your muscle strength. In this way, you will be more likely to push effectively during the second stage of labor. In fact, you may even be able to walk during labor. However, because most laboring women have little desire to walk around at this time, except perhaps to the bathroom, this technique has been more appropriately referred to as "epidural lite."
These new "lite" epidurals are very different from the old-fashioned epidurals, which routinely produced significant leg muscle weakness. We have been using these new types of epidurals for years, and we continue to refine them, in order to improve the quality of pain relief while minimizing the likelihood of muscle weakness. That is one of our primary goals: To provide you with excellent pain relief while preserving your muscle strength so that you will have the strength to push effectively.
Were it so simple, it would be a breeze! However, not everyone is as enthusiastic about epidurals and spinals as are obstetric anesthesiologists. You may have heard about some of the controversies regarding regional pain relief techniques for labor. For example, some believe that epidural pain relief can not be administered until the cervix reaches a certain degree of dilation. As anesthesiologists, we do not hold this opinion. On the contrary, we believe that the epidural catheter should be placed as soon as it is determined that labor has commenced, and that the patient is definitely being admitted to the hospital.
We believe that this approach of inserting the epidural catheter early in labor is sensible for many reasons. Practically speaking, it is much easier to insert an epidural catheter into a patient who is comfortable and able to cooperate than insert it into a patient who is writhing in pain. In fact, it is not even necessary that medication be immediately administered through the catheter. However, if the catheter is in place, it is then a simple matter to inject the medications through the catheter when the contractions become painful. Please realize that because the epidural "lite" technique uses such a low dose of medication, it takes about 10-15 minutes from the time of injection until the pain relief starts to take effect. You should keep this in mind when you are deciding when to have the epidural catheter inserted.
Another advantage of having an epidural catheter in place is the "insurance" it provides against your need for general anesthesia. If at any time during your labor there is a need to perform an emergency cesarean section, your anesthesiologist will simply administer a stronger local anesthetic through your epidural catheter. In this way, the risks of general anesthesia can usually be avoided for both you and your baby.
Although as anesthesiologists we are prepared to administer epidural or spinal pain relief as early in labor as you would like, the ultimate decision as to when you can receive it will be made by your obstetrician. You therefore need to discuss this matter with your obstetrician, ideally before your labor begins.
Another controversy is that the epidural will slow labor. We do not believe this to be an issue during the first stage of labor (from the onset of regular contractions to full dilation of the cervix). However, it is possible that epidural and spinal pain relief techniques may prolong the duration of the second stage of labor (from full cervical dilation until delivery of the baby) by a few minutes. Interestingly, the most recently published studies of the effect of epidural and spinal pain relief on the duration of labor have found that the duration of labor may actually be shortened by the early administration of epidural or spinal anesthesia.
The challenge of obstetric anesthesia is to render you comfortable without compromising your ability to push out your baby. If you are unable to feel any sensation of pressure during the second stage of labor, and/or if the epidural or spinal pain relief technique weakens your muscles, you may not be able to push effectively during the second stage. To prevent this, we may, in consultation with your obstetrician, slow or stop the infusion of epidural medication to enable you to regain some sensation and/or muscle strength. Because the epidural catheter remains in place, we are always able to administer additional doses should the need arise.
Everyone is unique--some women are able to push well even without feeling any pressure, while others need intense pressure to push effectively. We will individualize your pain relief to make you as comfortable as possible during the entire labor and delivery process. Ideally, the state-of-the-art "walking" epidural we use at Tisch Hospital will enable you to have a comfortable labor and delivery while preserving your muscle strength needed to push effectively.
If you already have an epidural in place for labor, and you require a cesarean, you will simply be given a stronger dose of local anesthetic through your epidural catheter to make you comfortable during the surgery. If you are scheduled to have an elective cesarean delivery, or if a cesarean delivery becomes necessary before you have epidural or spinal pain relief, four options are available:
- epidural anesthesia,
- spinal anesthesia,
- combined spinal-epidural anesthesia or
- general anesthesia.
We usually do not use spinal anesthesia alone, because it is advantageous to have an epidural catheter in place so that you can receive pain medication after the operation (PCEA). General anesthesia is usually reserved for those emergency situations in which there is insufficient time to perform regional anesthesia. General anesthesia may also be used if there are reasons that prevent you from having a spinal anesthetic or epidural anesthetic (for example, a skin infection of your lower back). Should you require general anesthesia, it will be initiated by injecting medication through your vein (i.v.). The cesarean is then performed while you are asleep. As soon as the operation is completed, your anesthesiologist will wake you up.
At Tisch Hospital, we routinely use Patient Controlled Epidural Analgesia (PCEA) to provide pain relief after cesarean. Although we are in the minority of hospitals that use PCEA routinely for post-cesarean pain relief, we do so because we believe it is the best means of postoperative pain control currently available. With this technique, we leave the epidural catheter in place for 48 hours after the cesarean. The catheter is connected to an electronic infusion pump so that you receive a continuous flow of medication. In addition, you will be given a button which will allow you to self-administer additional doses of medication, as you need them. The pump is programmed with maximal allowable amounts in such a way that it is not possible for you to overdose yourself. PCEA has many advantages over other means of providing postoperative pain relief. Being a regional technique, PCEA will make you comfortable without sedating you. Also, because the medication is delivered directly into your epidural space, only a very small amount of medication is required to alleviate your pain. The excellent quality of pain relief that PCEA provides should ease your recovery.
Since 1992, the Division of Obstetric Anesthesia of the Department of Anesthesiology has been headed by Gilbert J. Grant, MD. Dr. Grant is an Associate Professor of Anesthesiology at NYU Medical School and Vice Chairman for Academic Affairs of the Department of Anesthesiology. Dr. Grant is assisted by a staff of approximately 15 attending anesthesiologists who share a commitment to providing the highest quality state-of-the-art obstetric anesthesia available. Their innovative approach to pain management during labor, delivery, and after cesarean has provided comfort for many women who have delivered their babies at Tisch Hospital.
The physicians of the Division of Obstetric Anesthesia provide full-time coverage (24 hours per day, 365 days per year) for the Labor and Delivery suite of Tisch Hospital. Whether or not you request their assistance, you should know that they are always available to help you should you need them.