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Pain Management during Labor & Delivery.

Please note that the following guidelines apply to most but not all of the patients. These are general guidelines only. Specific conditions may require specific needs. Please contact the pre-op nurse or anesthesiologist if you have any questions.

bullet What are the options for control during labor?
bullet Who is an Anesthesiologist?
bullet What are Epidural and Spinal Analgesia? How do they differ?
bullet What can I expect from Epidural or Spinal Analgesia?
bullet What is it like to have an Epidural or Spinal? Does it hurt?>
bullet Does the medication affect the baby?
bullet Is there ever a time when I shouldn't have an Epidural or Spinal?
bullet Do Epidurals and Spinals always work?
bullet When can I have Epidural or Spinal Analgesia?
bullet How long will the Analgesia last?
bullet What happens if I need a C-Section?
bullet What are the problems and complications that can occur with Epidural or Spinal Analgesia?
bullet What about cost?

What are the options for control during labor?

Several options for analgesia (pain relief are available to you. We encourage you to discuss them with your obstetrician or family physician.

PREPARED CHILDBIRTH OR LAMAZE TECHNIQUES
These relaxation and breathing techniques are designed to help you manage the discomfort of labor and delivery. They are best learned in childbirth education classes.

PAIN MEDICATIONS
There are several medications now available which obstetricians generally consider safe for use during labor. Although they may not provide total relief, these medications can reduce pain significantly with relatively few side effects to you and your baby.

EPIDURAL AND SPINAL ANALGESIA
These techniques, which involve care by an anesthesiologist. use local anesthetics and/or narcotics on or around Spinal nerves to help control the pain of labor and delivery.

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Who is an Anesthesiologist?

An anesthesiologist is a physician who specializes in the treatment of pain and the methods used to make a patient unable to sense the pain associated with surgery. Anesthesiologists are fully trained physicians who have completed medical school and 4 years of residency training in their field, just as your obstetrician has done. All the anesthesiologists at Redding Medical Center are Board Certified or Board eligible by the American Board of Anesthesiology. The techniques and medications anesthesiologists use daily in surgery are readily adaptable to labor and delivery.

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What are Epidural and Spinal Analgesia? How do they differ?

Epidural analgesia is an anesthetic technique in which a needle is passed between the vertebra of the Spinal column and into the space just outside the dural membrane (which surrounds the Spinal cord, Spinal nerve roots, and the Spinal fluid). Local ansthetics or narcotics placed in the Epidural space cross the dural membrane into the Spinal fluid and reach the Spinal cord and where they produce pain relief.

Spinal analgesia is administered when the needle is advanced past the Epidural space and through the dural membrane into the Spinal fluid. Since the medication is placed directly into the Spinal fluid, less drug is required to produce its effects.

A thin plastic tube or catheter may be placed through the needle in the Epidural technique to allow reinjections to customize pain relief. The needle is withdrawn and the catheter is left in place. The use of this catheter is referred to as "continuous Epidural" technique.

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What can I expect from Epidural or Spinal Analgesia?

Pain relief from Epidural or Spinal analgesia is usually more complete and intense as compared to the other forms of labor analgesia. Most women notice a pressure sensation with their contractions; this pressure sensation is an important mechanism that keeps labor progressing.

If narcotics alone are injected, there is usually not numbness or weakness of muscles. You may move about in bed and get up to go to the bathroom as allowed by your obstetrician and labor nurse. Some women will have some itching of the nose and face from the reaction of the narcotics; some may have occasional nausea. But these effects are usually mild and are helped by time or
by specific medications.

If local anesthetics are combined with the narcotic to provide more intense pain relief, you may develop numbness from the top of your abdomen down to your feet. Usually you can still move your legs, but they may become weak and difficult to control; rarely your baby may need additional help being born if you are unable to "push" well at the time of delivery.

You may also be unable to empty your bladder properly. You will not be able to get out of bed to walk during the time the local anesthetic is effective. These effects are normal responses to the local anesthetic and disappear as the medications wear off. Epidural or Spinal analgesia may be combined with other pain control methods to make your labor and delivery more comfortable.

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What is it like to have an Epidural or Spinal? Does it hurt?

You will have an IV placed for fluids and medications which you may need. The anesthesiologist and labor nurse will position you correctly for the placement of the Epidural or Spinal (usually either lying on your side or sitting up). The anesthesiologist will apply an antiseptic solution to your lower back to reduce the chance of infection. A local anesthetic will be placed into the skin and into the ligaments under the skin. There may be a slight sting at the skin and a slight ache at the level of the ligaments until the anesthetic begins to work. After that, there should not be much discomfort from the actual placement of the Epidural or Spinal needle; most women will feel only a pressure sensation. If you do feel pain, let the anesthesiologist know, but try not to move during the placement of the Spinal or Epidural. Occasionally, there will be strong tingling in a hip or running down a leg. This can happen occasionally with needle placement and is not a cause for alarm; however, you should inform your anesthesiologist if it occurs.

Once the Epidural or Spinal catheter is placed, the anesthesiologist will perform several tests to assure that the catheter is in the proper position before injecting the medication to relieve your discomfort. It usually takes about twenty-five minutes to place the catheter and perform the tests. Pain relief usually begins within five to ten minutes after the medication is injected, although it may take 15-30 minutes for the full effect.

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Does the medication affect the baby?

The doses of medication typically used in labor analgesia usually do not cause any noticeable effect in your baby's Apgar scores or behavior. Your baby is exposed to drugs that are present in your blood stream; the amount of drugs present may be influenced by the dose used. The Spinal and Epidural techniques use very small doses of medications; the local and IV techniques use larger
doses. Your body will have essentially eliminated these medications before your breasts begin producing milk for breast feeding.

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Is there ever a time when I shouldn't have an Epidural or Spinal?

Yes. You may not be a candidate for Spinal or Epidural analgesia if you (1) are allergic to certain narcotics or local anesthetics, (2) have nervous system (neurological) disease, (3) have a bleeding tendency or coagulation disorder, (4) take aspirin routinely, (5) have an infection in the lower back area, (6) have had previous back surgery, (7) have a psychological disorder or a fear of needles, (8) are morbidly obese, (9) have a Spinal deformity, (10) cannot cooperate or get into a position to allow the anesthetic administration (11) are too early in your labor, (12) are progressing too rapidly, or (13) have an abnormal labor or fetal monitoring pattern. Please discuss these conditions with your obstetrician and anesthesiologist.

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Do Epidurals and Spinals always work?

These techniques usually provide good pain relief, but it is possible that they may fail to eliminate any or all of your pain. The catheter or needle must be in the proper position for the medication to work. Discomfort from labor and pregnancy and anatomic characteristics can make it difficult or impossible for you to get into an appropriate position for reliable needle and catheter insertion.

Individuals vary in their response to the medications.

Variations in the anatomy of your Epidural space and back may prevent effective pain relief. It is possible to get pain relief in some areas and not in others or on only one side of your body. Your anesthesiologist will do everything possible to make you comfortable, but sometimes complete pain relief is not possible.

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When can I have Epidural or Spinal Analgesia?

You should discuss your wishes about labor analgesia with your obstetrician or family physician during your prenatal care. Spinal or Epidural analgesia is easier to start before labor discomfort makes it difficult for you to discuss your situation or cooperate in analgesia administration. However, you may let the labor nurse and your physician know if you are interested in having Epidural or Spinal analgesia at any point in your labor.

When you can actually receive the analgesia depends on circumstances surrounding your labor pattern and assessment by your physician. At the appropriate time, an anesthesiologist will discuss the techniques with you and suggest options in accordance with your wishes and those of your physician. You may have concerns unique to you that your anesthesiologist will need to
discuss, and you should have an opportunity to ask questions. If you and your anesthesiologist agree after this discussion, preparations will be made to administer an analgesic. Although it is unlikely, an anesthesiologist may not be immediately available to administer the analgesia because of emergencies; or there might be a reason that makes if inadvisable for you to have Epidural or Spinal analgesia.

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How long will the Analgesia last?

Continuous Epidural analgesia can usually be made to last as long as your labor lasts. Injections will be effective depending on the characteristics of the drug injected. Without the use of the catheter, they cannot be repeated without replacement of a needle. Toward the end of labor - when the birth of the baby is close at hand and discomfort is more intense - additional medication or techniques may be needed.

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What happens if I need a C-Section?

The type of anesthesia used for a C-Section will depend on the urgency and nature of the reason for the surgery. Continuous Epidural technique can be extended for use during a C-Section. Sometimes, however, it may be more appropriate for you to have a general anesthetic or a separate Spinal anesthetic. Our anesthesiologist will discuss the available options if the need arises.

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What are the problems and complications that can occur with Epidural or Spinal Analgesia?

When you drive a car, you know there is always a possibility of mechanical difficulties or an accident, but most of the time you reach your destination safely. The same is true with analgesia and anesthesia for labor and delivery. There are, however, possible problems or complications about which you may want to know:

Narcotics can have side effects such as nausea, vomiting, itching, or slowed breathing. These side effects can be more prominent when narcotics are administered for Epidural or Spinal analgesia. The doses chosen for you will be made to provide you with as much pain relief as is feasible while minimizing the side effects. Other medications can be used to relieve some of the side effects if they become troublesome.

Local anesthetics given in Epidural or Spinal analgesia frequently will decrease your blood pressure. For most, the drop in only slight; for others, more significant. Normally, you may not notice this change in blood pressure or you will experience mild nausea. We may need to give you additional IV fluids or medications and change your position to raise your blood pressure and counteract this effect of the local anesthetic.

Because of the small size of the Epidural space and Spinal area, an Epidural catheter may enter an Epidural blood vessel or the dural membrane containing the Spinal fluid. Medications would then enter the bloodstream or Spinal fluid. Part of the testing after catheter placement is designed to help detect these problems. Very rarely, the catheter may enter these structures after testing
has been done. If local anesthetics are injected into the bloodstream, you may experience a metallic taste, ringing in the ears, lightheadedness, or numbness around your lips.

Since the dose of medication for Epidural analgesia is much greater than that used for Spinal analgesia, you could get enough medication in the Spinal fluid to affect your breathing and blood pressure. The first symptoms would be increasing numbness in your legs and the numbness would rise from your abdomen into your upper abdomen and chest. You may need assistance while the medication is in effect, so you should inform your anesthesiologist immediately if you have any of these symptoms. Epidural or Spinal analgesia may not be effective for relieving your pain. It may not be sufficient for a C-Section if that need arises.

One of the more common complications of Epidural or Spinal analgesia in women of childbearing age is the so-called "Spinal headache." This occurs less than 1% of the time with epidurals and less than 3% of the time with Spinals. This condition is thought to result either from injected medications or, more likely, from Spinal fluid leaking through a hole in the dural membrane into the Epidural space. It may last several days or even several weeks. Since it is more likely to occur when large diameter needles are used, very small needles and catheters are used when Spinal analgesia techniques are planned. Epidural techniques, however, require larger needles or catheters for placement in the Epidural space. If either the needle or catheter passes through the dural membrane, a Spinal headache is likely.

Several methods can be used to treat this type of headache. The most reliable is an Epidural "blood patch" in which the physician places a needle in the Epidural space at the level of the dural membrane puncture and "patches" the hole by injecting your own blood into the space. The blood coagulates and seals the leak.

Soreness or aching for several days at the site of an injection can be normal.

Other complications that can occur include, but are not limited to, infection, nerve damage (including paralysis, loss of bladder and bowel function, and loss of sexual function), allergic reactions, seizures, cardiac arrest, and death. Although the consequences of these complications are very severe, they occur very rarely.

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What about cost?

Due to the risk involved, the expertise necessary to place the catheters, and the length of time needed to manage the analgesia during labor and delivery, Epidural and Spinal analgesia can be expensive and is not a free service of the hospital. The actual cost will vary depending on the anesthesiologist, technical difficulties and the length of time pain management is required. Very few insurance companies pay the total charge. If you are unsure of your coverage, you should check with your insurance company. Analgesic techniques such as Lamaze or IV pain medication ordered by your obstetrician probably would not require the services of an Anesthesiologist.

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