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Anesthesiology Pain Relief (443) 849-2202 Congratulations! You've chosen to have your baby at GBMC, where more babies are delivered than any other Baltimore hospital. We have dedicated significant resources to ensure the comfort and safety of you and your baby. Our labor suites allow you and your family the utmost in comfort and privacy for this special event. Our fully equipped labor suites are designed to permit labor, delivery, and initial postpartum recovery to take place in the same comfortable room. Each suite has individual climate control, bathroom, windows, cable TV and a phone. A reclining chair with a foldout bed allows prospective fathers to catch a few winks during those longer labors. A dedicated OB nursing staff will be taking care of you and your baby. GBMC boasts a Level III+ NICU (neonatal intensive care unit) with a neonatologist/pediatrician in-house 24 hours a day to manage any problems that may occur in the neonatal period. Physicians Anesthesia Associates, PA. provides 24 hour coverage, 365 days a year, to the labor and delivery (L&D) suite at GBMC. A minimum of two anesthetists is assigned to L&D at all times. This means that patients will rarely wait more than a few minutes for an anesthesia consult once it is requested. A number of options are available to reduce the pain associated with labor and delivery. The choice and timing of pain relief methods will vary from patient to patient and even from pregnancy to pregnancy in the same patient. It is often said that no two pregnancies are alike. You and your doctor will decide on the best method of pain control during your labor. Intravenous and Intramuscular Medication Early in labor your obstetrician may offer you intravenous or intramuscular injection of medication to ease the pain of labor. Narcotics, such as meperidine (Demerol) or butorphanol (Stadol), are often used. Narcotics will help with mild contractions in early labor but typically are insufficient to relieve the stronger contractions associated with active labor. Narcotics administered to the mother will reach the baby through the mother's blood stream and may make the newborn sleepy, so they are avoided as delivery approaches. An anesthesiologist is usually not involved in this type of pain management. Epidural and Spinal Analgesia (regional anesthesia) As your labor progresses, your obstetrician may request an anesthesiology consult to offer you more effective labor analgesia (pain relief). Your anesthesiologist will ask a few questions about your medical history to be sure that regional analgesia is appropriate for you. Of special concern are any bleeding disorders, active infections, or prior back surgery. Timing The best timing for this type of intervention depends on a number of factors including your medical and obstetrical history. Strictly speaking, it is never too late to have a regional anesthetic but since it requires 5-10 minutes of patient cooperation (i.e., holding reasonably still) and takes 10 -15 minutes for the medicine to work, it becomes impractical when the patient starts pushing. An early epidural is recommended in patients with a higher risk of needing a Cesarean section. Once the epidural is in place, it can be quickly dosed to provide anesthesia for a C-section if that becomes necessary, avoiding any undue delay. Patients at higher risk of needing a C-section include those with a history of prior C-section, patients with pre-eclampsia (toxemia), and patients with early signs of fetal distress. The issue of whether epidurals slow labor is a controversial one. Research has suggested that first time mothers who have an epidural placed before reaching 4-5 cm of cervical dilation and engagement of the fetal head in the birth canal MAY be at risk for a prolongation of their labor. However, the widespread use of Pitocin augmentation for labor has greatly minimized this concern. Fetal Effects Any medications that enter the maternal bloodstream are able to reach the fetus. Epidural and spinal medications are not injected into the blood but are slowly absorbed from the epidural and spinal space into the bloodstream and metabolized by the mother. Actual blood levels are, therefore, very low and usually have negligible effects on the fetus. Regional anesthesia may affect the fetus by changes that occur in the mother's body. For example: As the medicine takes effect and the mother becomes comfortable, the maternal blood pressure may decline. The baby may respond to this abrupt drop in blood pressure with a transient fall in heart rate. When this occurs, it is usually treated with IV fluids and medicine to raise the blood pressure. It will resolve in several minutes as the mother's body becomes accustomed to the epidural effects. There are also beneficial affects to the fetus. The reduction in maternal pain reduces hyperventilation and the release of stress hormones, which improve blood flow to the fetus. In patients with pre-eclampsia and high blood pressure, the epidural may relax (dilate) the mother's blood vessels, improving blood supply to the baby. Late in labor, the relaxation of the pelvic muscles and the reduced urge to push allows the baby's head to descend and the perineum to stretch slowly, thereby reducing the risk of a large episiotomy or tear. Epidural technique The patient is placed in either the sitting position or on her side and asked to curl up as much as possible. This curled up posture opens the spaces between the bones in the spine and allows access to the epidural space. The lower back is washed with a sterile solution of iodine or alcohol. A small needle is used to inject local anesthetic (numbing medicine) in the skin. This injection produces a 10-20 second stinging sensation. Once this area (about the size of dime) is numb, the patient will feel mostly pressure during the remainder of the procedure. A thin flexible plastic tube is placed through the area that is numb into the epidural space and taped along the back. Test dose Once the epidural is in place it must be tested prior to its use. The test dose is designed to alert the anesthesiologist to an inadvertent placement of an epidural catheter into a vein or the spinal space. Veins are present in the epidural space, as they are throughout the body, and the tip of the epidural catheter can sometimes thread into one of these veins and must be replaced. The catheter may also be inadvertently placed into the spinal space, in which case it must be dosed with a different amount of medicine. The test dose contains a small amount of local anesthetic and epinephrine (adrenaline). When the catheter is in the epidural space, this test dose of medicine is too small to have any effect. If the catheter is in a vein the patient will experience a transient increase in heart rate and/or mild ringing in the ears. When an inadvertent spinal is in place, this small amount of medicine will cause complete pain relief and numbness in the legs within minutes. Epidural dosing Once the test dose is completed and proper placement confirmed, the epidural is dosed with a combination of local anesthetic and narcotic. This medicine will take 10 to 20 minutes to reach its peak effect, during which time each contraction will feel better then the previous one. Once a satisfactory comfort level is reached, a slow infusion will be started to maintain that level until delivery. The patient may feel some pressure with each contraction. The goal is to provide relief of pain without interfering with the mother's ability to push at delivery. An additional "delivery dose" may be needed as delivery approaches. There are times when your obstetrician may want to reduce your epidural infusion to increase your ability to push. When this happens, you may begin to feel more of the contractions. As always, our priority is your safety and the safety of your baby. Risks of regional anesthesia
Spinal technique The technique for placement of a spinal anesthetic is essentially the same as for an epidural. However, instead of a catheter being placed into the epidural space, a tiny needle is used to inject local anesthetic and/or narcotic medication into the spinal fluid. The advantages of a spinal injection are that it is generally easier to perform, highly reliable and provides almost immediate pain relief. The disadvantage is that, since it is a one time injection (i.e. no catheter inserted as with an epidural), it will only last 60-90 minutes. This makes it useful mostly for patients who present late in labor and will likely deliver rapidly. Occasionally, a combined spinal and epidural can be placed to achieve the benefits of both techniques. Nerve Injury The most common nerve injury (still rare) that occurs during labor and delivery is called meralgia paresthetica. This is only indirectly related to anesthesia. During the pushing phase of labor and delivery, the mother will be asked to pull the knees back toward the chest to help allow the baby's head to pass into the perineum. When there is prolonged pushing the legs may be in this position for some time. This may cause a pinching of the femoral nerve that passes through the inguinal (thigh) area. When this nerve is injured, it may cause numbness or pain in the thigh and even weakness in the leg. Usually recovery occurs over time but may take weeks to months. An epidural may increase the likelihood of this injury because the mother may not appreciate the awkwardness of the knee to chest position and is less likely to relax her legs between contractions. So remember to relax the legs in between contractions to avoid prolonged pressure on this nerve during labor. Anesthesia for Caesarian section Whenever possible, a regional anesthetic technique (spinal or epidural) is preferred in patients undergoing Caesarian section. Anatomic and hormonal changes that occur during pregnancy cause the pregnant patient to be at increased risk for complications with general anesthesia. Elective C-section Spinal anesthesia is often recommended for elective C-section because of its quick onset and reliability. Epidural anesthesia may also be used but takes a bit longer to achieve the necessary level of anesthesia to begin surgery. Urgent C-section An epidural, when already in place for labor, can be dosed with a more concentrated anesthetic solution to provide anesthesia for C-section. When an epidural is not in place, a spinal anesthetic is most often used to provide prompt onset of surgical anesthesia. In cases where regional anesthesia is contraindicated (i.e. unsafe), such as in a patient with a bleeding disorder, general anesthesia is required. Emergency C-section When the mother or baby is in severe life threatening distress, general anesthesia is the fastest way to provide surgical operating conditions. Under these circumstances, no time is available to initiate regional anesthesia. Fortunately, this is an uncommon situation. Risks
Sedation during C-section Sedative medications are usually withheld until after the baby is delivered so as not to sedate the baby and impair evaluation of the newborn. After the baby is delivered, the mother may request mild sedation at any time during the surgery (unless medically unadvisable). Many patients are quite comfortable and will not need or want any additional medicine but it is available to "take the edge off" while lying still for the repair and closure of the abdomen. Postoperative pain control After surgery the patient is transferred to the recovery room and is still "numb" from the anesthetic. Over the next two hours, the numbness will gradually wear off. Most patients will have their postoperative pain managed by their obstetrician. Pain medicine will be given in the recovery room as the numbness wears off. Most patients will not resume a regular diet until the following day and so their pain will be treated with intramuscular injections of narcotics until they are able to take pain medicine by mouth. In cases where the anesthesiologist is asked to manage postoperative pain, a number of options exist. Medications can be added to the spinal or epidural to provide pain relief or intravenous patient controlled analgesia may be utilized (see Acute Pain Management Service at GBMC). More Information Physicians Anesthesia Associates, PA offers a free consultation service to GBMC patients to discuss any issues or concerns you may have regarding your anesthetic care. To schedule a free consultation with a board certified anesthesiologist at GBMC, call 443-849-2202.
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