At NewYork-Presbyterian/Weill Cornell Medical Center, a team of anesthesia providers covers the Labor and Delivery Suite 24 hours a day, 7 days a week. There are about 5,500 deliveries performed annually and over 90% of our patients receive some form of pain medication during the first stage of labor.
Pain Relief for Labor and Delivery
The available options include:
- Intravenous medication
- Epidural analgesia
- Combined spinal epidural analgesia
The first method of pain relief is offered as a dose of narcotic via intravenous injection. This method may involve a continuous infusion, or a patient-controlled dosing through a pump. There are a few side effects such as nausea and vomiting. Narcotics occasionally cause the baby to be a little sleepy at birth, and pain relief is far from complete.
A more effective form of pain relief during labor is a type of regional anesthesia known as epidural analgesia. The epidural space is a very small space (about 1/8 inch) surrounding the spinal cord. Epidural analgesia means placing a local anesthetic in that space so that the anesthetic bathes the nerves on their way in and out of the spinal cord, thereby causing a feeling of numbness.
About 90% of our expectant mothers choose epidural analgesia as their anesthetic.
First, we make sure that you have no problems preventing us from using this form of analgesia. Next you will be asked to sit up and curl around your baby. Your nurse will help you and hold you in the desired position. The lower back is then cleaned with an antiseptic solution and the skin is numbed with a small dose of local anesthetic. This is done with a tiny needle and stings for only a few seconds. This step prevents the actual procedure from being painful.
The epidural needle is then inserted. You must keep as still as possible to allow the needle to be correctly placed. If the needle is advanced too deeply, a spinal anesthetic may occur. This makes the parturient more numb and makes it more difficult for her to “push” the baby out. If a spinal placement of the needle should inadvertently happen, the procedure is redone to ensure that the needle is placed epidurally. However, a headache may later occur because some fluid may be lost from the spinal space. Once the epidural space is found, a very thin catheter is inserted and stays in the epidural space throughout labor. The needle is then removed and the catheter remains in place, enabling a continuous infusion and/or repeated doses of local anesthetic to be given as needed until your baby is born. The presence of a catheter is very important as the anesthesiologist is able to control the duration and the intensity of the anesthetic as needed. For example, if you need a cesarean section, the anesthesiologist can inject a more concentrated anesthetic, strong enough for surgery. In the normal course of events following an epidural, your lower body will get a little numb and your feet “tingly” and “heavy.” The level of analgesia is kept constant until your baby is delivered after which the catheter is painlessly removed.
A common variation on epidural analgesia is combined spinal epidural analgesia, which entails placing a needle in the epidural space, then placing a thinner needle through and injecting a small dose of narcotic and/or local anesthetic into the spinal space. The epidural catheter is then threaded into the epidural space. In either case, epidural medication is administered via a continuous infusion to keep a steady level of pain relief and allow ambulation if desired.
If a patient requires a cesarean delivery, the following options are available to you:
If the surgery is not an emergency:
a) Epidural anesthesia
b) Spinal anesthesia
c) Combined spinal epidural anesthesia
d) General anesthesia
If the surgery is an emergency but you already have an epidural catheter in place:
a) Continue with epidural anesthesia
b) General anesthesia
If the surgery is an emergency but you don’t have an effective epidural anesthetic:
a) General anesthesia
b) Possibly spinal anesthesia
If the epidural is effective and you need to have a cesarean section, your anesthesiologist will inject a more concentrated local anesthetic through your epidural catheter to raise the level of numbness to the midchest.
If you don’t have an epidural, a spinal anesthetic can be performed in a few minutes with a very fine and relatively painless needle. The spinal anesthetic will make you totally analgesic (pain free) in a couple of minutes.
During a cesarean section under either epidural or spinal anesthesia, you will feel heavy and numb. You will feel some pushing and pulling during surgery but will have no pain. You will have the added advantage of being awake for your baby’s birth and having your “significant other” in the operating room with you.
If a very acute emergency arises, the only option for anesthesia for a cesarean section may be a general anesthetic. You will be brought to the operating room and asked to breathe some oxygen until the obstetrician and nurses are ready to start. Then your anesthesiologist will inject drugs through the intravenous to put you to sleep.
After a cesarean section, it is normal to experience post-operative pain. This can be handled in a variety of ways.
- Morphine (Duramorph) placed into the epidural (or spinal) space in the operating room, which gives 12 to 24 hours of pain relief.
- PCA (Patient-Controlled Analgesia): The pain medication is hooked up to your intravenous line and delivered by you at the push of a button, in carefully calculated and measured doses.
- Epidural Infusion: Pain medication is hooked up to your epidural, maintaining pain relief similar to that in the operating room while still allowing you to walk around. You control the dosage at the push of a button.