stage of labor. By the time the epidural actually sets in, they’ve probably already had their baby, but it’s variable because that second stage, some people– just depending on the size of your baby and everything else–that second stage could last up to several hours. So in that case, even if someone’s complete, if they have a large baby, or if there’s anything else that’s affecting the rapid delivery of your baby from the second stage of labor, the epidural can be very beneficial for that as well. 4 How long will epidurals last? Dr. Montgomery: An epidural is a catheter, a little tiny tube that stays in this epidural space. If you’re looking at the anatomy, your spinal cord runs up and down the center of your back, and your spinal cord is surrounded by a tough sac called the dura sac. The dura sac means “tough mother,” so you have this protective sac surrounding the spinal cord. Your spinal cord ends halfway down your back, and you have a bunch of nerve filaments that then come down all the way to your belly into your lower legs and everything else, and that’s actually the level that we place an epidural. When we’re placing the epidural, we’re placing it two levels below where the spinal cord ends, so risk for spinal cord injury or anything like that is pretty much zero. Then we thread a little catheter into that space. The epidural space is outside of that sac, and then we fill that space up with medicine, and that’s what numbs the nerves in the lower part of your body. With the catheter that stays in place, we can set that up to an infusion pump that will continuously give medicine until you’re delivered. It can last as long as we need it to last. The pump allows us to make adjustments, so if they’re very sensitive to local anesthetics and they don’t push effectively at the second stage of labor, then we can reduce our rates on our pump and allow them to have more sensation, more feeling, and more motor strength to help push and deliver the baby. If they progress through labor and they’re still really uncomfortable in the later stages, we can increase those rates. 5 Will epidurals slow down labor? Dr. Montgomery: If you look at the current literature, a lot of it looks at the first and second stages of labor. The first stage can be anywhere from
four to eight hours up to a couple days. It takes a while, especially with your first delivery. Some literature says, on average, that the epidural might increase that four to eight hours by half an hour. Right before we place an epidural because of a potential drop in blood pressure, we give a fluid bolus, which helps to offset some of that drop in blood pressure. A fluid bolus also slows down the contractions, so that could also be related to why that first stage labor might be increased just slightly. Sometimes it actually helps because it allows the patient to relax and not fight the contractions and allows the process of thinning the cervix and progressing and dilating to happen more gradually. The second stage of labor, which is from being complete until the actual delivery process, what the literature says currently, the evidence just shows it’s about a 15-minute to 20-minute change in that. So if that process can be anywhere between 10 and 3 hours, that 15 minutes is really kind of minimal. There’s no downside to having the epidural. 6 What are some of the risks and side effects? Dr. Montgomery: The number one side effect for an epidural is a drop in your blood pressure, because once those nerves in the lower part of your body become numb, they dilate, meaning they relax. The blood pulls downward so people get more lightheaded or dizzy. After we place an epidural, we’re really focused on watching the blood pressure because in a short period of time, their pressure can drop fairly significantly. I always let them know they need to communicate with their nursing staff, because we can give medications through the IV within 20 seconds to get the pressure right back up so we can avoid nausea, vomiting, all the other side effects of a low blood pressure. The next thing is any sort of allergic reaction. The risk for any allergic reactions to any of the medications we utilize is extremely rare. Local anesthetics that we use, the risk for having any sort of reaction to any of those is something that we don’t even really see pretty much ever in my practice. There’s a low dose narcotic we have in the epidural infusion; these are standard bags that we have, and we don’t have to include that. Patients that are extremely sensitive to narcotics, we can avoid that in our infusion and just
do a local anesthetic. Also, any sort of cardiac anomalies, we monitor both the baby and mother, so we can help, and those are extremely rare to have any issues. Another thing, specifically for a spinal or for an epidural, is that patients can have a bruise or lower back pain. It’s typically just a bruise and goes away like a typical bruise. Bruising can be increased when people are on products like aspirin or blood thinners. The evidence shows that the risk for lower back pain is the same in people who have epidurals and those that do not for the birthing process. A lot of people have concerns about risk for paralysis or nerve injury, and just because of the level that we go into, when we place an epidural, it really minimizes or mitigates any of that risk, because we’re going two levels below happen. One would be because maybe the practitioner who’s placing it had difficulty placing it. If that does happen, typically, what we would do is we would go back and replace it. We would take it out, reevaluate, and see if maybe they were just in the wrong tissue plane or if that medicine was not going into the epidural space where we want it to go. Occasionally, we have to replace an epidural. It’s not that common, but it does happen, and it’s not a risk or any bad outcomes resulting from that. The other thing would be some people are called hyper metabolizers. Whether it’s a genetic predisposition, they may metabolize local anesthetics faster than other people do. Typically, where you would find out about this is if people have had prior dental work done. If they had injected Novocaine in their jaw or something like that, and they said, they never got comfortable, and they had to keep injecting to get them comfortable, and they felt everything during the process. These are some subset of people that might metabolize local anesthetics faster. Now, the anesthetic or the process and the way they work still works for these people. So they just may require a much larger amount or higher doses of these local anesthetics or higher concentrations to give them the same type of benefit and same type of block that the normal general population achieve with epidurals. where the spinal cord ends. 7 Can epidurals not work on everyone? Dr. Montgomery: There would be several reasons why that may
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