Anesthesia: Pain Relief during Labor
Guest: Dr. Latha Hebbar – Anesthesia & Perioperative Medicine, MUSC
Host: Dr. Linda Austin – Psychiatry, MUSC
Dr. Linda Austin: I’m Dr. Linda Austin. Today, I’m interviewing Dr. Latha Hebbar, Professor of Anesthesia & Perioperative Medicine here at the Medical University of South Carolina. Dr. Hebbar, let’s talk about anesthesia for the woman who anticipates going into labor. What are her choices?
Dr. Latha Hebbar: Well, Linda, it’s a broad spectrum of options that they have, but there are a couple that are very popular. So, broadly, they can either go with non-drug options, or they have pharmaceutical and drug-related options. So, the former category, where you can have medical non-drug options, includes hypnotherapy, breathing techniques, water; birthing in a water bath, electrical stimulation; transcutaneous electrical stimulation, acupressure, acupuncture. These are some of the non-pharmacological options.
Dr. Linda Austin: Now, do we offer all of those here at MUSC?
Dr. Latha Hebbar: Well, the breathing techniques, I think they’re taught in their prenatal classes. But, we don’t offer the water birthing. So, of all those techniques, the only thing we offer here is probably the La Maze, the breathing technique.
Dr. Linda Austin: Roughly, what fraction of women these days choose La Maze, relative to some form of medication?
Dr. Latha Hebbar: I would say less than, probably, one to two percent. So, it’s not very popular in developed countries. In developing countries, it’s probably more popular. In European countries, now, underwater birthing is prevalent. But, in the United States, it’s not.
Dr. Linda Austin: Twenty to thirty years ago, the span during which I gave birth, certainly, La Maze, which is non-medicated based, was far more popular than one to two percent. So, it’s really fallen out of favor now?
Dr. Latha Hebbar: It has. I think, though, the gold standard, now, which we’re going to talk about, is the labor epidural. That has become very popular. And that’s a gold standard against which all other modalities of pain relief are compared with.
Dr. Linda Austin: And, what percentage of women get an epidural?
Dr. Latha Hebbar: The national average is about 55 to 59 percent of all laboring moms. But, at MUSC, we have a slightly higher percentage that take epidurals; about 70 percent.
Dr. Linda Austin: And so, the balance, then, choose, what?
Dr. Latha Hebbar: The other 30 percent go with medications, but it’s not delivered via epidural. It’s delivered IV, or they get an intramuscular injection of a pain killer.
Dr. Linda Austin: And, is that because they’re getting a C-section?
Dr. Latha Hebbar: Women that opt to go without the epidural do it for a variety of reasons. They’re fearful of having a needle in their back, which is the foremost reason. And, some of them have, you know, a good pain threshold, I think. They feel they can do without an epidural.
Dr. Linda Austin: I see. Well, let’s go back and talk about an epidural. What is an epidural?
Dr. Latha Hebbar: The term, epidural, refers to an anatomical space in the back. It’s actually a space which surrounds your spinal cord, but is separated from your spinal cord by a tissue, called the dura. It’s like a wrapping that separates the epidural space from the spinal cord. So, really, we’re not going anywhere near the spinal cord with an epidural. So, the epidural kind of envelops the spinal cord, and that’s where we go and drop in our medication, and it crosses over this thin barrier, called the dura, and then causes a blockage of conduction of your pain signals. And, therefore, you get pain relief.
Dr. Linda Austin: I recall, in medical school, it seemed to me to be tricky to put in an epidural. Now, you do this many times a day and, I would imagine, that, for you, it doesn’t seem tricky at all.
Dr. Latha Hebbar: It can be, even now, tricky at times. It’s a blind procedure. You go by feel. It’s the feel of the ligaments and the tissue you’re going through with the needle. So, because we go by feel, if you don’t have good landmarks, it can be a little more challenging at times. But, you know, the success rate is almost 100 percent.
Dr. Linda Austin: Yeah. You’re a pro at it. Tell us what the pros and cons are of getting an epidural.
Dr. Latha Hebbar: The most important pro is that it’s almost 100 percent pain relief. It’s definite pain relief; superior to getting a shot in your arm, or through your IV. It’s good for the baby too because it improves blood supply. Once you’re pain free, there’s less stress hormone released and, therefore, blood flow to the uterus and to the placenta is improved. And, especially in certain situations, such as preeclampsia, where there’s less blood going to the placenta, it’s extremely useful. And if you have a labor epidural in place and, for some reason, you need to have a Cesarean section, then, obviously, we can extend the epidural to provide anesthesia for the Cesarean section. You don’t have to go to sleep. You can have it done under the epidural.
Dr. Linda Austin: I see. Now, if you know that someone is going to have a Cesarean, do you do an epidural from the start?
Dr. Latha Hebbar: More commonly, we do what’s called a spinal anesthetic for a Cesarean section, if you know it’s a Cesarean section from the start.
Dr. Linda Austin: And, what is the difference between a spinal and an epidural?
Dr. Latha Hebbar: The spinal, you go beyond the epidural space; through that little envelope, the dura mater. We go beyond that and get closer to the spinal cord. So, it’s very quick-acting, unlike an epidural. An epidural takes about 15 minutes to start working because it’s got to travel some distance to get to the nerves. Whereas, a spinal, you know, you’re putting the medication right around the spinal cord and the spinal nerves. It acts, almost, in a minute or two.
Dr. Linda Austin: So, I’m sure, in emergency situations, that’s, really, the way to go.
Dr. Latha Hebbar: We would prefer to do a spinal. Yes, correct.
Dr. Linda Austin: How about contraindications or reasons why a patient would not be a good choice for either an epidural or a spinal?
Dr. Latha Hebbar: The foremost would be patient refusal; that they don’t want to, because they’ve heard, or read, negative information about an epidural or spinal. But there are some absolute reasons why we would not do it. For example, if somebody is on blood thinners, we would not do a spinal or an epidural. The epidural space not only has the nerves, it also has some blood vessels in it. If you accidentally puncture one of those blood vessels; since it’s a blind procedure, and they’re on blood thinners, that’s not going to clot, and it’s going to compress the spinal cord. So, if a patient is on a blood thinner, like heparin or coumadin, then we would not do it. Or, if they have a low platelet count, we will not do it, or if they have sepsis.
Dr. Linda Austin: In other words, infection in the blood.
Dr. Latha Hebbar: Infection; right, either in the bloodstream or locally, in the back. If they have a boil or, you know, a little furuncle, where we need to go in with a needle, we would not do it. And there are some cardiac situations, some heart conditions.
Dr. Linda Austin: How about significant complications from an epidural or spinal? Are there any?
Dr. Latha Hebbar: Lack of pain relief is one complication. We inform patients about that. It’s a blind procedure. Epidural space, sometimes, can have some septations; little pockets, because of tissue. Sometimes, the catheter we put in can go sit in a little pocket and you may not get good pain relief. You can get what we all a patchy block. We have to redo the epidural sometimes. That could happen, or you can get a block on one side only. It can travel to one side, the catheter. Those are the common things we encounter. But, of course, there are some remote possibilities it can travel into a blood vessel, and you can accidentally inject into the bloodstream, or you might get a bleed and have compression of the spinal cord. But, these are all very remote possibilities. And, any time you violate the skin, you can have an infection; therefore, meningitis. Or, again, you do it aseptically, so it should not be a problem.
Dr. Linda Austin: Ever any long-term consequences?
Dr. Latha Hebbar: The only long-term consequence we’ve encountered is possible nerve injury. It’s very hard after you’ve had a baby and have some kind of nerve damage. It’s hard to differentiate that from the birthing process. Because, the position for birthing, you stretch some nerves. So, it’s very difficult to pinpoint that it was due to the epidural. So, it’s a process of elimination, whether the epidural caused it or not. But, apart from that, there’s no long-term effect from the epidural.
We do have patients with low-back pain who are a little skeptical about getting an epidural. They wonder if it’s going to make it worse. And, we always reassure them that that should not be a problem. The epidural, sometimes, is the treatment for low-back pain.
Dr. Linda Austin: I would think it would, temporarily, make it better.
Dr. Latha Hebbar: Yes. It’s very rewarding to watch patients. You go in. They’re in a lot of pain. By the time you walk out, they’re smiling. You know, it’s very rewarding.
Dr. Linda Austin: Absolutely. Now, anesthesiologists are often behind the curtain. Patients, often, don’t even get to talk to their anesthesiologist ahead of time. But, if a woman wanted to do that, could she do that?
Dr. Latha Hebbar: Oh, absolutely.
Dr. Linda Austin: Is that very common, to ask to speak to the anesthesiologist, say, in the weeks before labor?
Dr. Latha Hebbar: Yes. We accommodate that. When they come for their prenatal visit, we have some patient education material out there, in terms of pamphlets, as to what to expect from labor analgesia. We put that out last year. We’re hoping to get a Spanish translation. Every third delivery here is a Hispanic baby. So, we’re trying to get a Spanish translation of that out.
So, when they come for their prenatal visit, they can always ask to speak to an anesthesiologist if they have any more questions. But, normally, here, unless they have any other coexisting disease process, they don’t normally consult the anesthesiologist. But, it would be nice if we could see all of them and reassure them of what their options are, and to define expectations a little bit more. It’s one hundred percent pain relief, but they do, still, feel the pressure. Pressure is a sensation you cannot take away when you do an epidural. Patients, sometimes, find it difficult to differentiate between pressure and pain.
Dr. Linda Austin: How long does the anesthetic effect last after an epidural?
Dr. Latha Hebbar: We actually do what’s called a continuous epidural. So, once we identify the epidural space, we thread a little catheter into the epidural space. That stays for as long as the patient needs it, or as long it takes to deliver the baby. We have medication continuously given through that catheter via an epidural pump. So, we set the parameters on the pump and the patient gets continuous medication throughout labor.
Recently, about a year and a half ago, we started what’s called patient-controlled epidural analgesia, where the patiently actually hits a little button. She’s in a lot of pain. She goes ahead, hits a little button, and gets a little extra booster dose to tide over the contraction.
Dr. Linda Austin: And then, how long after the birth of the baby does it take for the anesthetic to wear off?
Dr. Latha Hebbar: Once we discontinue the infusion, in about 30 to 40 minutes, the epidural effect has completely worn off. That’s because the dose we use for pain relief and labor, the concentration, is very dilute. They can still move their legs. It just takes the pain fibers away. It wears off very quickly.
Dr. Linda Austin: Dr. Hebbar, thank you so much for talking with us today.
Dr. Latha Hebbar: It was a pleasure. Thank you.
If you have any questions about the services or programs offered at the Medical University of South Carolina, or if you’d like to schedule an appointment with one of our physicians, please call MUSC Health Connection at: (843) 792-1414.