Epidurals and other regional blocks are on the way up -- and for good reason.

By Rebecca Felsenthal

Pain Relief Basics

Maybe you've already decided that you're going to ask for an epidural as soon as you feel the first twinge of pain -- or maybe you've vowed to get through childbirth drug-free. Either way, you should learn about pain relief before the big day. "The more that you know about anesthesia ahead of time, the better prepared you'll be to make a smart decision," says Joseph J. Apuzzio, MD, director of maternal-fetal medicine at the University of Medicine and Dentistry of New Jersey, in Newark. Here's what you need to know.

Pain-free is back in vogue. The days of the macho mama may be over. "More and more people are asking for pain relief," says Rebecca Shaw, MD, an obstetrician at Iowa Methodist Medical Center, in Des Moines. "As drugs become safer and more effective, women are becoming more comfortable using them -- and they're less willing to be in pain during labor."

The most effective and popular solutions are regional blocks: epidurals, spinals, and combined spinal-epidurals.

Regional blocks don't make you woozy. These drugs block pain, but not all sensation, so that you remain alert, able to push, and possibly able to walk. What's the difference between a spinal and an epidural? An epidural is a local anesthetic injected into an area of your lower back just outside the spinal-fluid sac. It takes about 15 or 20 minutes to work and the anesthesiologist can leave the catheter in place to allow for top-offs. One of the upsides of epidurals is that you and your anesthesiologist can decide the strength of the dose. "Patients who are nervous can ask for an 'epidural light,' and then get more medication if they need it," says Samuel Hughes, MD, director of obstetric anesthesia at San Francisco General Hospital.

A spinal is a shot of analgesic injected directly into the spinal fluid that takes effect almost immediately but lasts only for about two hours. Spinals are often used in emergency C-sections because they're fast-acting.

It's not your mother's pain relief. Many hospitals are starting to use patient-controlled epidurals. At the press of a button, you can add more drugs. This way you don't have to wait (or scream!) for your anesthesiologist to finish the emergency C-section she's performing next door.

Another popular technique is the combined spinal-epidural (CSE). When you're given this cocktail, the anesthesiologist places a catheter in your back, shoots a little anesthesia into the spinal fluid to make you immediately comfortable, and places some anesthesia into the epidural space for longer-lasting pain relief. "The nice thing about the CSE is that it allows you to start with the smaller dose," says Joy Hawkins, MD, director of obstetric anesthesia at the University of Colorado School of Medicine, in Denver. "Then, because the epidural catheter is already in place, your doctor is able to add more as it's needed throughout your labor."

You don't have to wait. Back in the day, women in labor had to be 4 centimeters dilated before getting a regional block; doctors believed that giving medication earlier could stall labor and increase the rate of emergency cesareans. But a recent study in The New England Journal of Medicine found that this isn't true and that giving women pain relief earlier actually shaves an average of 90 minutes off of labor.

Side effects are rare and manageable. Of course there are possible side effects for any type of anesthesia. "The risk of a bad headache with a regional block is about one in a hundred," says Dr. Hawkins. "This isn't dangerous, just inconvenient, and it's easy to treat." Your doctor will monitor you to make sure your blood pressure doesn't drop, but that's something he can correct by having you lie on your side. Infection at the site of the needle is also a risk with regional blocks, as is soreness and bruising.

It's smart to stay flexible. Go into the delivery room with an open mind. "Remember that labor is an experience that you can't plan," says Dr. Hawkins. "You should prepare yourself as well as you can by taking birth classes, but you'll have to wait to see what your own experience is like." It's possible that you'll decide to go without any drugs -- but it's also possible that you'll have a difficult labor and will definitely want the meds. What's most important is that you and your baby are safe and healthy throughout your delivery.

Why Epidurals Are Not for Everyone

You're screaming for an epidural -- but the doctor says no. What's the deal?

  • You have a bleeding problem. If you have a condition that keeps your blood from clotting, like preeclampsia, or if you're on blood thinners, you might not get a regional block. There are a lot of veins in the epidural space. If your anesthesiologist nicked one, you'd be in trouble.
  • You have a skin infection. If you have cellulitis or another infection in the area where the doctor needs to insert the needle, she probably won't go ahead with the epidural for fear of spreading the infection deeper into your body.
  • Your doc can't find the spot. If you've had scoliosis, it might be more difficult for the anesthesiologist to find the right location on your spine. It can also be difficult for doctors to place regional blocks in obese women because it's harder to see or feel the spinal bones.
  • An anesthesiologist isn't available. Birthing centers and some smaller hospitals don't offer epidurals. Also, labor and delivery is always unpredictable, and you never know how many women will be delivering when you are.

The Lowdown on IV Drugs

When you get to the hospital, a nurse may start you off with an IV narcotic to take the edge off the pain until the anesthesiologist shows up for your regional block. Which meds you get depends on the hospital, but Stadol, Sublimaze, Demerol, and Nubain are the most common. Here's what you need to know about these drugs.

  • Expect some side effects. Narcotics do sedate you a bit and can make you feel woozy, so anesthesiologists use low doses that last for a short amount of time.
  • The drugs cross the placenta and enter the baby's bloodstream -- but it's not something to worry about. In low doses, narcotics won't have any permanent effects. After all, children are safely anesthetized all the time.
  • If there are complications, your doctor may not give you these meds. Sometimes the obstetrician won't want the mother to have narcotics in her bloodstream.

All content here, including advice from doctors and other health professionals, should be considered as opinion only. Always seek the direct advice of your own doctor in connection with any questions or issues you may have regarding your own health or the health of others.

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