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Epidurals, c-sections, and the like.

Loves Vintage

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megumic|1313121221|2989095 said:
MonkeyPie|1313113878|2989003 said:
stephb0lt|1313113229|2988991 said:
MonkeyPie|1313113034|2988989 said:
I don't get the not moving thing! It's common knowledge that for most women walking hurries labor along, gravity and all. So I don't get why they try to keep so many of us in bed, prone and feeling worse than we otherwise would. This didn't apply to me since every time I'd walk, my contractions would all but stop, so laying/sitting worked better for me. But then everything about my experience was backward!.

I wonder how much of it is tied to CYA policies again - I'm curious for the women that have been there how much fetal monitoring they were required to have, and how that impacted their ability to move around if they so desired.

That's a thought. They are totally ok with you walking around the hospital in full labor, as long as you aren't admitted yet. Once they admitted me, I got an IV right away (but they knew my blood sugar and stuff was low since I had already passed out in the shower, so mine may not count) and I got the band around my belly to monitor contractions and Micah's heart rate. I could have gotten up and walked with them, though, because I could have pulled the little stand around with me since it was small. I just didn't want to!

From my research it's the IV and the fetal heart rate monitor keeping you tied to a bed. Perhaps just hospital policy as well. Plus the nurses want you to stay put where they can control everything. I've heard that there are new wireless fetal heart rate monitors that will permit more movement, but not sure how widely they are used. Plus, some monitors are small needles inserted through the vagina into baby's skull which would certainly prevent movement. It's my understanding that most US hospitals require constant fetal monitoring, despite the research that it does not improve outcomes.

Promise to post research links tomorrow...too tired. However, Pushed by Jennifer Block is a great read. Certainly a skewed view, but relies on solid research and very informative even for skeptics.

I had the wireless fetal monitor that you referenced. That's what I referred to (above)as the monitor with the battery pack. Sounds like MP had the same since she was able to walk around with her monitor. I also had an iv, and just walked around with the iv pole, to which the battery pack also attached. Neither the monitor nor the iv kept me tied to the bed. I do think it depends on your hospital, and what is available. I have not heard of the needle-through-vagina-into-baby's-skull monitor that you mentioned? Perhaps it's more commonly referred to as an internal monitor?

Regardless of whether outcomes, in general, are improved by monitoring, in my case, I wouldn't have had it any other way. The monitor was a minor inconvenience to me that provided important information about my baby's well-being. That is not something I would ever have declined. But, again, everyone is different.
 

centralsquare

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puppmom|1313080821|2988606 said:
MP, I only regret my epi because it didn't work! I'm guessing I wouldn't be saying I wish I hadn't had that if it had actually made a dent in the pain. :lol:

We're just beginning to TTC so I've got a lot to learn...never realized the epidural couldn't work?? Why not??
 

jstarfireb

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icekid|1313092913|2988755 said:
I am curious about what exactly you believe are the associated risks of an epidural? The risks truly are quite minimal. A headache, like MP had, can happen but is usually not as prolonged.

I am an anesthesiologist and place epidurals for a living (and had an excellent one during my labor!) There is a lot of misinformation here. While certainly most women do not NEED an epidural for childbirth and going without is an absolutely valid choice, I do not want women to be scared away from it either due to misconceptions.

There really is no "too late" for an epidural. I've had patients completely dilated and effaced hold that baby in until we could place their epidural. Some places will not place it too late in labor just due to time constraints, though.

A "walking epidural" basically means that you are getting a lower concentration of local anesthetic medicine. Therefore you do not generally get as profound leg weakness and can still be mobile. Yes, I am sure there is a medico-legal issue regarding laboring patients with epidurals walking.

MP- I wish you had gone for the blood patch too. They generally make a great difference for these kind of headaches.

Let me know if there are other questions. Epidurals are great if you want one. And if you don't want one, that is great too.

Just chiming in because I am also an anesthesiologist, sort of...I'm still in training as a resident. And icekid, I didn't know we were in the same field!

Some things I wanted to reiterate...It's true that the risks of an epidural (the scariest but fortunately rarest ones being bleeding and infection) are minimal in young, healthy women. The majority of women feel that the pain of epidural insertion is not as bad as the pain of starting an IV. Large, well-designed scientific studies show that epidurals do not increase your chance of needing a C-section. They can prolong labor by about an hour on average. Occasionally certain techniques can lead to a drop in blood pressure or a prolonged uterine contraction, but these are uncommon and can be treated easily. As for other long-term effects (back pain, for example)...these are often the result of pregnancy and labor itself rather than the epidural.

As for headaches, they are a risk only if something called a "wet tap" occurs, which basically means the needle was inserted a hair too far in and penetrated the lining around the spinal cord, causing spinal fluid to leak out. This may sound frightening but isn't a terribly scary thing in and of itself, because we routinely put a needle into that same area when we do a spinal block rather than (or in addition to) and epidural. The problem is that the epidural needle is larger and not designed to go into that particular layer, so it leaves a bigger hole for fluid to leak out. This kind of headache usually lasts less than a week, but it can make you feel like total crap. The good news is that almost 100% of the time, a blood patch (and sometimes a second or third blood patch is required) is a miracle cure.

All this info above is basically the same as what I tell women in labor when I do an epidural consultation. As for timing, as icekid mentioned, there is no "too early" or "too late" for an epidural (even 10cm dilated and ready to push is OK, although you're likely to get a different technique to make it work faster, but I don't want to belabor the details too much). As for the early end, I often do consultations on patients who are getting induced but have not really experienced any labor pain yet. I generally advise them to wait until their contractions become slightly uncomfortable, maybe to about a 3 on the scale of 1-10, for several reasons:
1) In many hospitals, you won't be allowed to walk around, even with a "walking" epidural, because of medicolegal issues with fall risk. You're probably also buying yourself a bladder catheter since you won't be able to go to the bathroom or feel the urge to urinate.
2) You'll know what it feels like when the epidural works vs. isn't working, so you have a basis for comparison if you end up needing extra doses of medication or replacement of the epidural later.
3) The longer an epidural stays in, the more likely it is to be dislodged accidentally with normal movements, and it may have to be replaced before delivery.
But ultimately it should be the woman's decision, and if she wants an epidural at the beginning of either natural labor or induction or at the point where it's time to push, I'm happy to put it in at any time.

In Charbie's thread I recommended a book, "Enjoy Your Labor" by Gilbert Grant. I think it should be required reading for anyone considering their labor pain relief options. It explains medical concepts in layman's terms and focuses on taking fear and guilt out of the equation. I have no problem at all with women choosing not to have an epidural, as I feel that many different ways of giving birth (epidural or not, vaginal vs. C-section, midwife vs. OB in low-risk pregnancies) are equally valid, but it should be an informed decision based on scientific evidence rather than fear and propaganda.

ETA: Oh, one last thing. I think the reason why so many L&D nurses seem to push them is that they've seen how dramatic the change is when a woman in severe labor pain gets an epidural. She often goes from screaming and writhing in pain to calm, relaxed, and able to get some much-needed sleep. The nurses who ask about epidurals multiple times are probably just noticing how much pain you're in and trying their best to help, since epidurals are really the best medical option for labor pain relief.
 

fieryred33143

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MonkeyPie|1313113034|2988989 said:
I don't get the not moving thing! It's common knowledge that for most women walking hurries labor along, gravity and all. So I don't get why they try to keep so many of us in bed, prone and feeling worse than we otherwise would. This didn't apply to me since every time I'd walk, my contractions would all but stop, so laying/sitting worked better

fiery, do you think that next time you will be more demanding and vocal about what you want and need? I think for a lot of us, the first time is such a learning experience that we don't realize how differently it would have gone had we just spoken up.

Yes because I know better now. First time around I did research but my birthing class only went into techniques while in labor, not what labor feels like when it starts. I didn't know I was in labor when I decided to go to the hospital to check on DD due to no movement. I should have asked to go home but instead went along with their idea to induce. Granted, they had a reason to but I don't feel the reason was valid.
 

MonkeyPie

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Loves Vintage|1313122683|2989106 said:
I had the wireless fetal monitor that you referenced. That's what I referred to (above)as the monitor with the battery pack. Sounds like MP had the same since she was able to walk around with her monitor. I also had an iv, and just walked around with the iv pole, to which the battery pack also attached. Neither the monitor nor the iv kept me tied to the bed. I do think it depends on your hospital, and what is available. I have not heard of the needle-through-vagina-into-baby's-skull monitor that you mentioned? Perhaps it's more commonly referred to as an internal monitor?

I had the internal monitor megumic mentioned. It isn't actually a needle - it's this little corkscrew thing that goes just under the surface of the scalp to monitor baby's heart rate if the external one is not working properly. Micah was moving so much that once they did my epi and I had a crazy reaction, the internal monitor was safer and more reliable. It also broke my water, lol. I searched Micah's head for any sign of where they put it when he came out, but never found a mark on him. It seems pretty gentle, despite how it sounds.
 

Logan Sapphire

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I also had the monitor on the baby's head. It left a tiny mark, but it went away soon, certainly within 24 hours or less.

My epidural only seemed to partially work. It worked on one side, but I could feel total pain on the other side. Odd. Anyway, b/c of that, I had a lot of movement. Also, I kept asking the nurses if I was still supposed to feel as much pain as I did and then right at the very end, they discovered no one had told me about the "pain button" that you can dose yourself with! By that time, there was no more medicine so I just declined and kept at it.

All in all, I was lucky. I had pitocin due to stalled labor, meconium, AND being GBS+ (water had broken earlier with a fantastic gush!), but I only pushed for 25 mins and out he popped.
 

partgypsy

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An anethesologist wanted to know why someone might want to avoid an epidural. Being an anestheologist, this is your bread and butter and there would be a tendency I think to underestimate the downsides.
My personal reason why I tried to avoid an epidural:
a) I'm sensitive to medications (I'm allergic to 3 medications) so the less the better
b) I wanted to avoid potential exposure of drugs to my babym either directly, or when breastfeeding (not sure what the washout is).
c) I wanted to be present, aware and in control for the labor and delivery, both physically and in sensation. It was great that the doctors and nurses could give me very specific requests for breathing, pushing, etc and I could respond to them. In a more global sense, since I knew I was going in trying to have a non-medicated birth, that really affected my state of mind going up into labor, where I tried to take care of myself and stay in shape by walking, doing prental yoga, swimming in summer so I felt physically (and emotionally) prepared. If I assumed if I was getting an epidural I might not have been so disciplined.
d) being able to walk around. A big deal. I don't think I could have gone medication-free if I had to stay in bed. Kind of ironic, that if you have to be bed-bound to get an epidural, having a medicated labor becomes a self-fulfilling prophecy. I also was able to get in the jacuzzi tub because I wasn't all hooked up (divine pain relief!)
e) Not having to wear a catheter (need I say more?).
f) Now it says the statistics do not bear out that getting an epidural increases the risks of slowed labor, c-sections but from my personal experience from people I've known, it seems that epidural is often the start of a cascade of unfortunate events. It would be interesting to compare other countries incidence of epidurals and c-section surgeries, to see if there is any correlation
g) faster recovery. My second child I went to the hospital Saturday morning, had her at 9 am, and was discharged at noon the following day. Having an epidural, maybe. Having a c-section, no.
h) one less doctor bill

Do not assume my argument means I don't feel anyone should have an epidural. But looking at rates of epidurals in the US versus other countries, I wonder why so many women here get them. For me the drawbacks far outweighed the potential pain relief. As my mom said, yes it's painful, but it's purposeful pain, and it's only for a limited amount of time. And once the baby is in your arms, all the pain vanishes :love: .
 

jstarfireb

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Hey part gypsy, you bring up some really good points. IIRC, the epidural rate in the US is about 60%, but it varies from hospital to hospital. I wouldn't say that we underestimate the downsides because we explain all the potential risks to each woman, although sometimes when a woman is in a lot of pain, she clearly isn't paying much attention to the risk/benefit discussion.

Just a few minor points that I want to respond to. Regarding exposure of the baby to drugs, the doses used in spinals and epidurals are much lower than the doses used for IV pain medications. Some women who don't want an epidural decide it's OK to take IV fentanyl, but the dose required for pain relief is higher, they're actually exposing the baby to a much higher risk of respiratory and neurologic depression. Of course if you take no pain medication at all, the risk is nonexistent...but there is a misconception out there that an epidural is more dangerous than IV pain medications, and it's really not. Regarding the epidural being the start of a cascade, often the epidural is not the cause, but all of the events including the need for an epidural are a symptom of a particularly difficult labor (big baby, OP or transverse lie, etc.). It may be hard to ignore personal experiences and stories, but (as you mentioned), the scientific evidence shows that epidurals do not lead to more c-sections. Regarding the speed of recovery, the number of days you stay in the hospital is usually the same whether you have an epidural or not, but your stay will be longer if you have a C-section.

I think the reason why many women get epidurals is that labor is the most intense pain most women will experience in their lifetimes. The epidural not only quiets the pain but can relax the perineal muscles, and there's also a benefit to the baby if the woman is hyperventilating because of pain and stops hyperventilating after the epidural starts working.
 

Kunzite

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jstar - I'm curious if you could answer Pupp and my question about why epis fail. I think we all go in knowing they can fail, but I want to know why they fail. :read:
 

icekid

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Pupp & Kunzite re: non-working epidural- There are a few reasons it might not work. First and foremost, if it is not in the right place for some reason (difficult placement, gets pulled out?) For pupp, 20 min generally is not long enough to feel a full effect but you should have noticed a difference by then. So that may have been why yours did not work. Also, sometimes they may not cover WHERE you are having pain, but cover different nerves instead.

Finding the epidural space is not always the most straightforward thing- you're attempting to put a needle between two vertebrae, into a POTENTIAL space- meaning, not an actual "space", but one that we can use and open up a bit with some fluid.

Kunzite- Did they have a difficult time placing your epidural?

MP- Sorry that you went through all of that! Some people just have difficult spines and it can be tough to find the tiny space between the bones that allows access to the epidural space.

OH, and about the pressure with epidural. I ALWAYS tell patients that they will still feel a LOT of pressure which is very uncomfortable, despite the epidural. Having given birth now, I can say this is DEFINITELY the case. I did not feel pain at all, had a very dense block. But wow, the pressure was intense at the end!

LV- Whether or not you have a “button” just depends on the hospital. Did they turn off your epidural when you were pushing? Maybe that is why you eventually had pain?

And the literature shows that epidurals do not increase c-section rate, so you can still have your vaginal birth and your epidural ladies :)
 

Pandora II

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I'm interested that you say that 20 minutes isn't enough for full effect.

Mine was pretty darn good straight away!

I found that you could feel a fair amount of pushing down sort of pressure. I've had spinal nerve root injections done - both with and without anaesthetic (anaesthetist said that the local hurt about as much as the nerve root shot itself - not totally convinced) and it was a very similar feeling to those, whereas the previous epidurals there was almost no pressure at all.

Btw, would having a laminectomy make it easier or harder or no difference to place an epidural?

PS. Icekid and jstar - I'm presuming that you have both seen 'The Anaesthetist's Hymn' by Amateur Transplants? :wink2: DH and I are big fans and go to see their concerts (we are surrounded by medics in our families so have absorbed enough through osmosis to understand the jokes... :rolleyes: )

If anyone else is interested... here's a link to it: http://www.youtube.com/watch?v=c1JzCDqt3BM
 

icekid

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Pandora|1313193180|2989720 said:
I'm interested that you say that 20 minutes isn't enough for full effect.

Mine was pretty darn good straight away!

They may have used a different local anesthetic for yours? The one we most typically use takes longer to set up, but lasts longer.
 

Skippy123

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icekid|1313192473|2989712 said:
OH, and about the pressure with epidural. I ALWAYS tell patients that they will still feel a LOT of pressure which is very uncomfortable, despite the epidural. Having given birth now, I can say this is DEFINITELY the case. I did not feel pain at all, had a very dense block. But wow, the pressure was intense at the end!

I can say I did feel PRESSURE and at the end a bit of pain but they told me the medicine was turned up! LOL I told them, where is that button to push, because I am going to Push it. LOL They said it was already pushed. :o I figure it is kind of good to feel something rather than nothing at all, but that is just me. It was intense at the end.

Ditto, on the 20 mins. They also told me it would take about 20-30 mins to feel something. Interesting. Only at the end did I question if I was getting meds but then again they gave me pitocin to hurry things along because another twin momma was about to deliver which was kind of annoying that I had to be hurried along, but oh well. Thanks for posting IceKid as I wondered about epiderals too! I did find my birthing class to be super helpful with my birth.
 

MonkeyPie

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For the brief moment when my epi worked, it was instant for me, too. It was also crazy strong. I had to ask DH several times to bend my left leg for me because I felt like I needed to shift them, but had no power to do so. Completely dead. I also had the crazy shivering for awhile, which made my whole family laugh hysterically. I don't remember much of that though...lol.

It's interesting to see how basically the exact same procedure is different for everyone.
 

Kunzite

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icekid|1313192473|2989712 said:
Pupp & Kunzite re: non-working epidural- There are a few reasons it might not work. First and foremost, if it is not in the right place for some reason (difficult placement, gets pulled out?) For pupp, 20 min generally is not long enough to feel a full effect but you should have noticed a difference by then. So that may have been why yours did not work. Also, sometimes they may not cover WHERE you are having pain, but cover different nerves instead.

Finding the epidural space is not always the most straightforward thing- you're attempting to put a needle between two vertebrae, into a POTENTIAL space- meaning, not an actual "space", but one that we can use and open up a bit with some fluid.

Kunzite- Did they have a difficult time placing your epidural?

ice - Thank you so much for taking the time to answer!! So more than likely it wasn't placed properly (either through the fault of the doctor or the fault of my spine) and that's why it didn't work and also why it hurt like a %&*^%! Is that the take away? Probably not that my "body wasn't ready"? I'm certainly not looking to place blame, just trying to sort out if this guy was feeding me BS :tongue: If he had a difficult time placing the epidural, I wasn't aware of it. Other than the pain when he did it, it was quite quick. I guess this means that next time around my odds are 50/50 since we don't know if it was the doctor or my body.

And don't think I'm going to let you off without asking about jumper!! You need to get over to the NB thread and give us an update lady!!! :wavey:
 

jstarfireb

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Kunzite|1313181804|2989616 said:
jstar - I'm curious if you could answer Pupp and my question about why epis fail. I think we all go in knowing they can fail, but I want to know why they fail. :read:

Sorry, I had written so much and meant to come back to answer your question but then forgot! Icekid pretty much covered it. The epidural catheter may not have been in the right place to begin with or may have migrated out, or labor can progress too fast for the meds to catch up. Sometimes you can get one side of your body completely numb and the other still in pain, and that's usually a result of the catheter being too far into the space and migrating up one side rather than the middle. It often resolves with the catheter is pulled back about a centimeter.

This article explains it pretty well, with pics and all, and it's written by anesthesiologists for OB/Gyns (so you don't need much anesthesia-specific knowledge to understand it:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2505163/

Pandora - seen it and love it! I'm considering singing it during our department's karaoke holiday party one of these years. :tongue:

ETA: Kunzite, your take-away message sounds correct to me. "Your body wasn't ready" sounds like a lot of hand-waving rather than a real explanation...in other words, BS.
 

Bliss

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I had an awesome delivery vaginally - with an epidural. The first 10 hours I thought I could go without the epi and my goodness, near the end I realized I really really needed the relief. Being in that much pain was exhausting! But I wouldn't trade my earlier labor without the epi because it was really incredible to experience (before it got too strong) and really bonded us together. DH was really there for me, cheering me on with words, massages, love and kisses throughout and I wouldn't have experienced all of that if I had been lying on my back pushing the magic clicker the whole time. We walked, we rocked, we bounced on the birthing ball...we locked eyes. It was really intense and intimate, even though we were in a hospital room.

He and I got to see my inner strength bloom and my inner warrior goddess push through the waves. I really saw to the last inch how much my body was capable of and it was EMPOWERING!!!! RAWR!!!! I think DH thinks of me in a whole new light now!!!! He is so proud and we really fell in love all over again during that time because I've never needed anyone more and he was there for me 100%. That kind of trust will last me a lifetime. Also, I got so much admiration from him after seeing me go through each contraction with grace and strength. Hahahaha, his words. It was really beautiful...but then I hit a wall after 10 hours! Time for the epi!

I waited as long as I could before getting the epi because I was afraid of stalling labor, cranking up the pitocin and ending up with a c-section. Plus, being in NY the c-section rates are insanely high so I was very nervous.

But...gotta say, once I got the epi... LIFE WAS GOOD! :lol: It amazed me that one could actually have a pain-free childbirth!!!! I could sleep! I could joke! I could smiiiiiiile. And when it was time to push, I could concentrate on the incredible moment - focus on my DH's face, memorize every emotion and say all the things to DH I wanted to before we became parents. And I remember ever detail of life, especially those final milliseconds, before our tiny angel blessed our lives and changed everything forever. It was just the most amazing thing. So in retrospect, I'm truly happy that I got the epi because I could be free from the pain, in the moment and absolutely bathed in love when I gave birth to M. I think otherwise I would have been screaming bloody murder, stressed, too tired to focus on the moment and out of my mind from the pain. Instead, I was calm and feeling blissfully happy and loved. Very Earth Mother! :love:

You ladies who delivered naturally without epis - are GODDESSES!!!!!!!! What strength!!!!! I applaud you!!!!!!

Oh - and I was afraid of the epi initially but it took seconds and took the pain away so quickly. Just like the nurse said, it was indeed a "little slice of heaven!" :naughty:
 

drk

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I'm another anesthesiologist. I didn't plan on having an epidural (was going to just do hypnobirthing), because I had control issues with letting someone else do one for me. If I could have done it on myself, I wouldn't have hesitated. An hour and a half into the bad contractions, I was asking for one. Even though mine was a hemi-block (worked on the right side only) for the better part of an hour, and then still had one painful patch on the left when it was time to push an hour after that, I was glad to have it. Unfortunately due to the stronger and higher volume of meds they gave me to try to get it working all over, I was so frozen when the time came to push (due to heart rate decels, probably from rapid dilatation and descent squeezing K's head) that I had no feeling while pushing and needed a vacuum assist to deliver. That was just bad luck.

Epidurals are extremely safe. How often they're done really depends on where you are. A small town with no anesthesia like the one I did my family practice rotation in in med school had a 0% epidural rate. If you wanted one, you had to go wait out the end of your pregnancy a couple hours away in the city. In a town with GP anesthesia covering epidurals, you might have a 30% epidural rate. At my hospital (community hospital in a big city, with lots of immigrants and lots of people having their second or more baby), I'd bet the rate is more like 50%. At the downtown teaching hospitals with lots of high risk patients and lots of people having their first, as well as 24h OB anesthesia coverage, I'm sure the rate was over 90%. It also depends what other interventions for pain relief are available. At my hopsital, they can't do Entonox because the rooms aren't sent up for the ventilation needed to do that. Patients can get nothing, a shot of morphine/gravol early on, or an epidural.

The risks I tell all my patients:
- 1 in 200 chance of a dural puncture which can give you a very bad headache for a few days (usually) after the baby is born. Can be treated with a blood patch if more conservative measures fail (hydration, bed rest, pain meds). I think my personal dural puncture rate is actually lower than that.
- 5% chance of it not working perfectly the first time I do it. I kind of pulled this number out of my a$$, but I think it's in the right ballpark based on the hundreds of epidurals I've done. Actually, I think it's probably more like 2-3%. Epidurals are done by feel alone by slowly advancing the needle through the ligaments in the spine until the resistance suddenly drops after you move out of ligament and into the epidural space. You can be tricked by some people with crappy ligaments who have a wishy-washy resistance the whole way through, though usually you can't thread the catheter if you're not really in the epidural space. When you advance the catheter through the needle, you're trying to put 3-5cm into the epidural space so that as the patient moves around, there's some extra length in there so it doesn't come out. When you put it in, it can go off to one side or out alongside one of the nerve roots. If that happens, or if the epidural space itself is divided up by fibrous tissues, the local anesthetic may not spread evenly. We can usually fix it by pulling the catheter out more and hoping it will come back more to the middle of the space, but it doesn't always work. Occasionally it has to be done a second time, in which case I'd put it in at a different level and hope it worked better there.
- your blood pressure and/or the baby's heart rate can drop after the medication takes effect. I'm not sure why exactly that happens, but we monitor for it closely and can give meds for the blood pressure or tickle the baby's head to bring up the heart rate again. It would be very very rare to need an emergency C/S because of that.
- 1:150000-1:200000 chance of an infection or blood clot putting pressure on the spinal cord and causing problems with the nerves (ie paralysis). This is serious, but should be able to be picked up by noticing that the patient's legs are becoming weaker. If diagnosed early on, the pressure can be relieved by surgery and the problem fixed. You're more likely to have a car crash coming to the hospital to have the baby.

I generally don't talk about other things (and who's really interested when all you want is pain relief):
- chance of injecting the local anesthetic into a blood vessel by accident. This is rarely serious, as most of us give a test dose that will produce symptoms of ringing in the ears, numbness around the mouth, dizziness etc before loading up the epidural. We also tend to give the epidural meds in divided doses so that side effects like that can be seen before any dangerous cardiovascular effects happen.
- chance of a total spinal - If the full dose of epidural meds were injected into the spinal fluid by accident, it could rise up and basically anesthetize the brainstem. Bad. I've never seen it happen.
- chance of a allergic reaction (very rare)

People ask about stuff like whether the epidural slows things down, or whether it can give you low back pain. Studies haven't shown either, as far as I know. If anything, I've seen cases where someone's barely progressing at all for hours, gets the epidural, is finally able to relax, and is fully dilated really quickly after that. Incidence of low back pain is the same whether you have one or not, and is more likely due to the way you're lying around while in labour.

Whether you can have a "walking" epidural or not depends on where you're delivering, and what concentration they run in the epidural. None of the hospitals I've worked at allow patients out of bed after they have an epidural, mostly for medicolegal reasons, I think.
Whether you get the button to give yourself extra or not also depends on how the hospital is set up. I'm trying to get my hospital to do it, but administration is very slow to change things, and I'm sure it will take forever to "inservice" the nurses on it before we can start.

In certain situations, an epidural is an extremely valuable tool. Patients with high blood pressure or preeclampsia should have one. High risk cardiac patients should almost all have them, as the stress of labour can be too much strain on their hearts. An epidural and vacuum/forcep delivery can allow those patients to deliver vaginally and avoid the dangers that would be involved in having a C/S. Patients pregnant with twins who plan to delivery vaginally should all have epidurals, because that epidural can mean they avoid a general anesthetic for a C/S if the second twin cannot be delivered vaginally. You can quickly top up the epidural for surgery, but might not be able to safely get a spinal in to delivery baby #2.

Most of the time, the epidural is not painful. Some go in in 1 minute without me ever running into bone (which can be achey/hurt), some take 10 min or more of me struggling to find my way through a tight space or curvy spine, with it being pretty uncomfortable for the patient when I keep running into bone. The difficult ones are not that frequent though. Position is everything. If you can slouch well (ie curl around your belly into the shape of a C, pushing your lower back out), it makes things go a heck of a lot easier. Often the only part that hurts is the skin freezing. I don't remember much at all of what the rest of it felt like when I had mine, only that I had a twinge in my right butt cheek when he put the catheter in, which must have been the catheter bouncing off a nerve root as it headed off to the right, giving me a right-sided block later on. I don't remember any pain after the skin freezing.

Really, the epidural is the best thing we have to relieve labour pain. If you don't want to be offered one, make that clear when you check in to the hospital, and any time someone new becomes involved in your care. In general, once it's in, all you'll feel is pressure as labour progresses. I find that the patients I get called back to top up (give additional meds to) are either moving very rapidly and delivery quickly after one top up, or are having some kind of dysfunction labour that is more painful than usual. If I have to top them up twice, I almost always meet them again for a C/S later on.

I'll put in an epidural for someone who's 1cm dilated if the doctors are committed to delivery the baby in the next day or so (ie they're not going to give up on an induction and send the patient home). I wish they'd call me to do the epidural for more women before they start to augment things with oxytocin, because often by the time I'm called, the poor woman is in agony and has waited for 45min to get pain relief. I'll also do one for a patient who's fully dilated as long as they can sit still for me to do it. Recently I came to do the epidural for a multip, saw how she looked during contractions, heard her say she's having a lot of pressure, and had her say no when I asked if she wanted to be checked before I started. Sure enough, by the time I was done 5 min later, they were calling for the OB to come for delivery, and just waited long enough for the meds to kick in before getting her to push. Personally, I don't think there should be a "too early" or "too late" for an epidural.

There is also another option called the combined spinal-epidural which produces near-instantanous pain relief by having a small amount of medication injected directly into the spinal fluid through a spinal needle inserted through the epidural needle. After that's in, the epidural catheter gets inserted to provide pain relief after the spinal wears off. I only tried that a couple times in my training because I don't think the added benefit is that great, and there are a couple additional risks. There's a chance of getting a spinal headache from the spinal part of it. And there's more of a chance of having a serious drop in the baby's heartrate. I figure the difference between 8-10min to feel way better vs 1min to relief just isn't worth the added risk to me. Anyone can get through 2-3 more contractions.

If you have any concerns, be sure to ask your OB and your anesthesiologist lots of questions. And be sure your health care providers are aware of your wishes with respect to pain management and interventions.

The internal monitor you're talking about is a scalp clip. It's a tiny electrode that gets screwed into the baby's scalp if there are problems with the fetal heart rate and the external monitor isn't doing a good enough job of picking it up accurately.

Whether you're able to move around while being monitored depends on what technology your hospital's got. They didn't have it where I delivered, but the nurse just did intermittent monitoring before I got the epidural, and continuous monitoring after the epidural.

Probably if I ever have another I'll try to do it without the epidural, because I now know that I progressed very rapidly. If I'd known it wouldn't be another 10 hours of agony the first time around, I might have been able to hold off.
 

phoenixgirl

Ideal_Rock
Joined
Mar 20, 2003
Messages
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Ultimately, I think my c-section was a foregone conclusion due to my pelvis shape (platypelloid), but the ob didn't really stress this. I'm sure I would have tried either way, but for me to have had any chance of a vaginal delivery, I think I would have had to have a plan for a med free, or at least very mobile, delivery. I was sort of induced -- the doc stripped my membranes at 40 weeks, and I walked around for hours. When I went in that night, I was already at 4 cm and having contractions, although I couldn't feel them. Then the doctor broke my water. At that point the contractions hurt and I was already 4 cm, so I asked for the epi.

My epidural made the room spin the first time. The anesthesiologist said, well, I know I put it in correctly because blah, blah, blah, and just left it at that. But then the nurse did something "down there," and I said, "I can feel that. Am I supposed to feel that?" and she ran out and brought him back. I think he cranked it up to make sure it worked; one of my legs went numb and I was pretty much unable to move. I got the chills, threw up, and lay there uncomfortable with the feeling of my broken water trickling around and not being really cleaned up. Not a pleasant couple of hours.

They did give me pitocin, but right after I heard somebody say, "Ooops, she's already at 10. Turn off the pitocin." So then I began pushing. Baby was occiput transverse, which I think is normal with my pelvis shape (head has to go through sideways). I pushed for a couple of hours (couldn't tell if I was doing anything - I tried to poop, basically, but because of the epi, I really had no sense of whether or not I was doing anything). Meanwhile, I kept yelling at DH to hold my leg straight, and he kept wanting to hold it at a different angle that was more comfortable for him (but I felt like it was going to fall over and was obsessed with not being able to control that).

OB tried to manipulate the head through the pelvis, but finally called the c/s. At that point it was just a relief to have the Kafkaesque experience over. Moved from a dark, sticky room to a light, bright operating room full of chipper people. I have no complaints about the c/s except that I didn't know to ask to see my daughter sooner, more, etc. Establishing breastfeeding was difficult and this time around, I want that baby with me asap.

I am going for the elective c/s this time around. With my pelvis, I think my chances of a VBAC are pretty slim, and I want to skip all the unpleasant aspects of my previous L&D. Maybe if I'd known how it would turn out, I would have gone into labor spontaneously and done a med free delivery, but honestly, I wanted that "easy" delivery that women with successful epis describe. I just don't think that was in the cards for me. Lying incapacitated on your back is no way to navigate a funky pelvis.
 
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