Demystifying Epidurals and Labor Anesthesia with Dr. Bella Speight, MD (Rerun)

0:00 Welcome to the Birth Journeys podcast. I'm your host, kelly Hoff, bsn RN. I am a wife, a mother of two and a nurse specializing in the care of women and newborns. In this podcast, we will share powerful journeys of birth givers with the goals of lifting the veil on the birth experience, healing through sharing and beginning an open conversation to strengthen trust and promote transparency between birthing people and healthcare providers. Today, I have with me Dr Bella Spate. Dr Spate is a board certified anesthesiologist who I've worked with for many years. She is the mother of two and she is here today to share with us everything she wants new moms to know about epidurals and labor anesthesia.

0:43 Dr Spate, take it away. Hello. So hi, I am Dr Bella Spate. I am a board certified anesthesiologist. I do. What does that mean? The anesthesiologist is the person that comes in when you're screaming in labor and you need some pain relief. Usually you'll see a light behind us. No, that's just the door opening as we walk in the room. Now it is heaven. It is heaven coming down to escort you into the room and take away everyone's pain. So you know, usually we are met with a warm reception, but it's not infrequent that there is a good amount of apprehension about what to expect with an epidural. There are a lot of moms who have questions am I doing this too soon? Am I the only one getting one?

1:23 Is this the right decision? And all those questions and thoughts and feelings are normal. So let me just tell you a little bit about what it means to get an epidural. So, as far as labor pain is concerned, I would classify labor pain as one of the worst human pains imaginable. 10 out of 10 pain, don't let anyone tell you anything different. Okay, I see patients in pain all the time and there are very few things to compare to a woman in labor. The gold standard for pain relief is the epidural. Now people ask do I have to get an epidural? My mom didn't have an epidural and she had seven kids. No, you don't have to get an epidural. It is absolutely your choice. It will likely be offered to you by your nurse, even by your obstetrician, when they see that you're in excruciating pain.

2:05 But an unmedicated delivery is always an option. I tell people you can have an unmedicated delivery. The same way you can have an unmedicated headache, stomach ache or fracture, your choice. But you can also take a Tylenol and you can also get your fracture fixed and get some real pain medicine. So the epidural, how it works and what we do. So as an anesthesiologist, I would come into your room once you said that you would care to have some pain relief for your labor and go through the risk and benefits of an epidural. The risks are really, for the average healthy patient, very minimal. There's a lot of urban legends out there about epidurals. One of the questions I am asked most frequently and one of the most prevalent urban legends is will I be paralyzed from this epidural?

2:49 And the answer is a resounding no. Are there any stories or cases of patients being paralyzed from getting an epidural? In the literature there are stories, because there are always stories of people that had a lot of confounding factors, meaning a lot of other things going on that led to them having a problem after an epidural placement, and those things do not apply to pregnant women most of the time. If you are on some sort of prescription blood thinner, that will usually be in your medical history and we would have to time when we would put an epidural in because your risk for having a bad event after that would go up. If you are a normal, healthy, laboring pregnant woman, not on blood thinners, do not have a major infection going on on your back or within your body, you're not in septic shock, there's no reason that you couldn't have an epidural and no one would offer you an epidural if you met the above criteria anyway, what is the placement of the epidural?

3:42 The things that are important for getting an epidural usually would be the way that you sit in our position. Anesthesiologists and your nurse will often ask you to sit on your bed and curve your body into a Uncomfortable position around your belly usually we say the shape of a letter C, the position of a shrimp, bad posture, everything your mom and grandma ever told you not to do will behoove you when it's time to get an epidural. So really curve. You're gonna really get into an awkward position and posture. While the anesthesiologist does a sterile Preparation of your back, they clean your back off with something cold and wet. It's usually a sterilizing soap or disinfectant, a little bit of both and then they'll put up a plastic drape, just again to keep the area nice and clean and sterile.

4:24 Then what you usually feel is what we call it beasty. Now, beasty that's pretty subjective, so I'm not gonna lie to you. It's a little bit of an ouch, but it's a three second ouch and you can handle it, definitely worth the payoff of the epidural. So you get a little pinch in your back and then what you typically feel honestly is a lot of pressure. I have had an epidural. I've placed a lot of epidurals. Really. For the most part you'll feel pressure. Occasionally there's a little pinch or a little shock, and usually the Idea or the shock of the shock is worse than the actual pain of the shock, because you're expecting something bad to happen and you feel this little zip and you're like that's it, I knew it, this is the moment and it's not. It's just as we're trying to find the place to put the epidural.

5:05 There are some Little peripheral nerves in the area, nothing that will cause catastrophic damage. Usually that give us feedback as to where we need to go. So we keep going and putting that pressure in your back till we find the exact perfect spot. Then we put in the epidural catheter. What is an epidural catheter? It's a skinny, skinny straw. It's tinier than the IV that you'll have placed in your arm or hand at that time and it stays in a location called the epidural space and that's where we put the medication in that you're gonna get for the rest of your labor. Once that catheter is in place, we tape it, we secure it nice and flat on your back. You barely feel it. After the tape is put on, you can lay flat on your back. You can move around in your bed. You can't get out of bed, but you can move around in your bed to wiggle and watch TV and reposition yourself, and then your Anesthesiologist, sometimes the nurse, will start an infusion of medication that keeps going the entire time you're in labor.

5:56 So that's another question I get frequently. Once women get relaxed and feel that good epidural Comfort, they start to panic like I feel so good right now. How long is this gonna last? And we let them know it lasts the duration of your labor until the baby is born. Some of the other questions people have how much of this medicine is gonna get to the baby? Very, very little of what we give you in the epidural. And when I say little, I'm talking about micro, microscopic amounts that don't go to the baby's brain. They're not. It's not sedating. Your baby's not gonna come out tired or groggy because you got an epidural. They're not getting the medicine that you're getting because this is going into a different part of your body's system.

6:37 Women do tend to get very, very relaxed after they get an epidural and they think, well, I don't know, I got an epidural and I got super sleepy, so you're telling me this isn't make it going to my brain and my baby. But I know I got super tired and went to sleep so something is off. So the explanation for that kind of simple what the epidural does it works by kind of quieting your sympathetic nervous system. So all of that gets toned down and your parasympathetic nervous system takes, takes over. The sympathetic is fight or flight, the parasympathetic is rest and digest. So you get that rest, that Total body relaxation, and you've just been in some of the worst pain of your life and been extremely tense. So when all of a sudden all of your muscles relax and your body becomes totally relaxed, you do feel a relief.

7:21 And it is not uncommon for women to get very tired or sleepy or to finally be able to appreciate how hard they've been working up until that point. I tell my patients if you get sleepy and you want to take a nap, take a nap, because that epidural sleep is one of the Best sleeps that you can get on the planet. Another thing that can happen, in addition to just feeling very relaxed after getting me up a door place, is your blood pressure can go down quite a bit. So, yeah, your blood pressure has been up, you've been tense, you've been in labor or you've just been sitting there and you were just ready for your epidural, that same parasympathetic nervous system we're talking about kind of makes your blood vessels relaxed too. So where everything was tight, if you think about, like tight hose, when you're squeezing it, if you kind of let go, that pressure goes down, all your blood pressure goes down and that's not always a bad thing.

8:07 But if it gets too low then there's not enough pressure to get the blood circulating to your baby. So you'll notice that your blood pressure goes down and sometimes the baby's heart rate can go down. So we will give you a lot of times blood pressure medicine, extra fluid through your IV, things like that, to kind of get your blood pressure back up any. And all anesthesiologists and labor and delivery nurses know that this is something that happens and we prepare for it usually by giving you a lot of fluid before you get your epidural and having those blood pressure medicines readily available and stabilize you. It's kind of like you know, when the plane first takes off and there's a little turbulence, sometimes you kind of have to Settle through that initial period so that you can coast the rest of your labor. That, for the most part is how epidurals work, and Most women are very happy to have had that experience.

8:54 So I have a couple questions for you. Okay, when we finish the epidural during the recovery period, we usually have women lay flat with a little tilt. Can you kind of explain why we do that? Yeah. So we like you to lay flat because the epidural. There are different medications that we use for the epidural and some of them, without getting too technical, some of them kind of stay in the same place, some of them move by gravity, some of them tend to move downwards with gravity or just kind of stay where they are. What we try to do is keep you nice and even so that the epidural can evenly distribute to every side of your body. If we lay you completely on your left side then you may get numb only on one side. So imagine not feeling any contraptions on your left but feeling all the contraptions on your right.

9:35 That would be pretty miserable. So we try to lay you flat so that all the medication can distribute evenly. We do tilt you somewhat because we do want to relieve some of the pressure on your major, our blood vessels, so that your blood can still continue to circulate through your body. And then after that 20 minute period, it's okay to position on the sides and do all those things we just kind of pay attention to if we start to wear off on one side. Absolutely so 20 minute period, once we've established that the epidural is working evenly on both sides. The other thing I didn't mention is that, yes, there is such a thing as a one-sided epidural. So sometimes when epidurals are placed that epidural catheter I mentioned earlier we put it in, but once it's in your body we can't really we can't see the tip of it.

10:16 So we're putting it in based on your anatomy and our training and the feel we expect it to be where we leave it. But occasionally those catheters can wiggle or move or migrate a little bit inside your body and then the medicine is going more sort of one side or the other. We want to make sure that you have an epidural that's placed well, that's working on both sides. So we want to keep you nice and even make sure everything's working. Both sides are getting numb. And then, once we've established that your epidural is kind of set up, as we say, then you can definitely you can set up and watch TV, you can sit up in a chair position, lay on your side. As long as the medicine keeps working evenly, you can be in any position you want. And then it's not the end of the world if we have a one-sided epidural. There's things that we can do to kind of rectify that situation, right.

10:59 Oh, absolutely. If you have a one-sided epidural, there's a lot of troubleshooting we can do for most. You know epidural issues, whether that be the epidural is kind of one-sided or you feel maybe it's not going up high enough, or it's, or you're too numb. That's another thing women sometimes complain about. We can troubleshoot and adjust the dosing of the epidural, adjust the positioning of the patient. There are a lot of things we can do to try to get your epidural working. Or, as I often will tell patients, if we've done all of the usual troubleshooting and you're still uncomfortable, it's okay to have that epidural replaced. Don't be afraid to sit up and get another epidural. Most likely you're going to get a bill for your epidural. You should make sure that it works for you. So don't feel like you're being a nuisance.

11:39 Don't be afraid to speak up and advocate for yourself. If you're asking for an epidural, it means that you would like to have pain relief during your labor and your delivery and you deserve to have that option optimized for you. Yeah, that's so true. So after the epidural we've had our baby, we've repaired anything that might have gone on down there. How long should someone expect for it to take before they can get up and walk safely? Well, first of all, if you have an epidural, do not ever attempt to stand up, walk, move, go to the bathroom. I know a lot of us are like independent women and we're used to doing everything and getting it done, but now is not the time.

12:20 Definitely ask for help. You may take up to four hours for an epidural to completely resolve. So you need to be assessed by your nurse before attempting to do anything. So let them see if you have the full strength back in your feet and your legs and if you're ready to stand up. I mean, for a lot of women it wears off much faster than that, but it can take up to that long and a lot of times you may think or feel like you're strong enough to stand up, but you're actually not strong enough to stand up unassisted and you don't want to injure yourself immediately postpartum because who's going? to help you take care of your baby Very important points. So say, we have an epidural and we were planning on having a vaginal delivery, but then some stuff went down and now we need a C-section.

13:02 What can we do if we have the epidural in and we need to get a C-section? So this is another talking point. Occasionally, you know, women are not sure if they want to have an epidural and they may be trying to have a vaginal birth after cesarean. Or maybe they have a large baby and they've been told, you know, this delivery may be difficult or not work. So they kind of have a little bit of knowledge beforehand. Some women don't know when they come in and they are having a nice normal labor and they immediately have to go to the operating room because something changes during labor. If you have an epidural in place and you're any of the above patients, then you significantly increase the chances that we can just give you a different and stronger medication through your epidural so that you can have your C-section awake and be present for the delivery of your baby.

13:51 If you do not have an epidural in place, more than likely in any sort of emergency situation emergency C-section or labor that turns emergent we would have to put you to sleep under general anesthesia. That means we would take you to the operating room, we would put a breathing tube in, put you on a ventilator and we would wake you up once everything was completed with the delivery and your body was completely repaired and all of your dressings are on. There's nothing wrong if you have to be asleep for your delivery because that's the safest way to bring your child into the world and to keep you alive and healthy for that process, then you go to sleep for your delivery. But if you have the option to have the epidural, not to have to have a general anesthetic and potentially be present and be less groggy and awake post delivery, then you want to consider having that epidural in place.

14:41 Which option is generally safer? Yes, thank you, I was gonna get there. But yes, in addition to wanting to just be present for the delivery, general anesthesia in pregnant women is never an ideal scenario. There have been historically cases of pregnant women being much more difficult to place breathing tubes in which can turn a situation from something that we do routinely to something that is much more urgent, emergent and dangerous. So we try to be prepared for all scenarios. I would definitely recommend especially a woman who maybe is trying a vaginal after Cesarian are a higher risk for ending up in the operating room to strongly consider placing an epidural prior to needing one emergently.

15:22 That's the other thing If we get into an emergency situation. Most emergencies don't leave any time for us to put in an epidural at the last minute. So this is a procedure that standardly would take, you know, anywhere from 15 to 45 minutes, depending on the patient's anatomy and just how difficult it is or easy it is to place the epidural, so you don't have 45 minutes in the emergency. So then, if you are in a C-section, that you'd have to dose the epidural, what is the difference between the recovery for that versus the recovery from general anesthesia? Another really wonderful reason to have an epidural in place is the medication that we can give you through your epidural and the way that medication impacts you. So if we're using an epidural for your delivery, we basically make you extremely numb up to about your nipple area so that the obstetrician can perform the surgery and you don't feel it.

16:15 We also can give you some strong narcotics through the epidural, so when the medication goes to the epidural you don't get the same type of sedative effects to your brain that you would get if we gave it through your IV. We have a really strong pain medicine that we use a lot of times in labor and delivery. That lasts about 24 hours and gives you a nice kind of baseline pain control. A lot of women don't have to take much more than Tylenol in addition to that, so it really makes for a faster and more awake and present postpartum period General anesthesia we do have to give you everything through the IV typically, so that means you would be a lot more groggy when you wake up.

16:57 We can't give you that long-acting epidural pain medicine that lasts for 24 hours when you're asleep under general anesthesia, so then when you wake up you're having to take much more pain medicine, iv pain medicine, oral pain medicine Again, it's not a bad thing, but when you're dealing with a non-sleeping baby and you just had surgery, the less medicine, the less opiates that you need to take, the better, because opiates can cause constipation, itching, nausea and being constipated after just having a baby. It's just if we can avoid these things, it would be ideal. So, while you're making your birth plan and thinking about things, I know that the epidurals can be scary or an intimidating option, but there's more to the epidural than just the immediate pain relief of labor.

17:42 And then, what's the difference between an epidural and a spinal? Another fun one. So the epidural is what we use for labor and delivery. It's a larger needle that we used to put it in honestly and it sits into a part of your body anatomically called the epidural space. There's no way I could describe that to you in an audio. I would encourage Google to see where the epidural space is. That's where an epidural is. A spinal goes into a layer a little bit deeper and works much faster and much more intensely. So you get very numb very quickly with a spinal and that enables us to do surgery.

18:25 We usually will use a spinal when we know for a fact we're going to the operating room. So a woman with a scheduled C-section. We also do spinals frequently for joint replacements, hips and knees. If your grandma or mom whomever maybe had a hip or knee replacement, they probably got a spinal, at least in America. The another interesting difference between epigirls and spinals because the spinal needle is much smaller, you have a lower risk of getting what we call a spinal headache, which kind of is confusing, because I'm talking about a spinal not causing a spinal headache, but it's really just semantics, it's the language. So one thing that we didn't talk about when I was discussing epigirls were the risks.

19:09 I reassured you that you would not get paralyzed. I didn't really say why. So when we put an epigirl in, we put it below the spinal cord. So there's a part of your spinal cord it starts out as kind of a thick cord and then at the very bottom it turns into like spaghetti. We call that the cauda equina. If you've ever taken like a skewer and tried to spear spaghetti noodles in a pot of boiling water, you'd notice that you can't really hit any of those noodles. You're kind of floating and moving around. The same applies to your cauda equina. If you're putting a needle down there, it's very difficult and basically impossible to hit any of those nerves down there.

19:50 So you're not going to damage the spinal cord by placing an epidural. That's why you don't get paralyzed. As far as the spinal headache, how that occurs is when we're placing an epidural. If it goes, we're supposed to put the epidural in the epidural space. Okay, if an epidural needle goes beyond the epidural space, to where a spinal needle could go, it can cause you to lose some of your spinal fluid and that changes the pressure in your head and can cause a severe headache called a spinal headache. Spinal headaches are probably the biggest risk of getting an epidural. The biggest real risk of getting an epidural would be potentially landing yourself a spinal headache. If you get a spinal headache, what does that mean?

20:32 That means you're going to be sort of miserable for the first few days while the headache is present. Most women have what we call photophobia. You can't stand light. You're unable to sit straight up in the bed without your head feeling like it's going to explode. You need to lay flat. It's a very specific, very easily identifiable headache that comes after an epidural that's been placed a little bit too deeply. I stand and we tell patients things you can do to avoid it. Try to stay really still when they're placing the epidural. You can breathe, but don't make any major movements. Don't jump off the bed. Don't scream, don't howl. Just get into the zone. Focus, stay as still as you can.

21:14 Do your best. That's what you can do on the patient side. Sometimes everyone does everything perfectly and the spinal headaches still happen. Sometimes the patient is perfectly still, the anesthesiologist is highly skilled and does everything exactly. Due to anatomic reasons or it's usually anatomic reasons, anatomic reasons the spinal headache still happens. If it does happen, there is a treatment for it. A few different things. One you could do absolutely nothing and just wait it out. Do not recommend. But if you do that, it takes about. It can take up to two weeks of you dealing with this very excruciating headache.

21:55 Most women can't really take care of their baby when they're experiencing this headache because you need to set up to breastfeed. And you can't set up to breastfeed, you can't stand up to take a shower. It's a very miserable experience. If you have other children at home, it can be even harder to take care of yourself and or your new infant. But studies have shown that we do absolutely nothing. After two weeks these headaches go away on their own. If you want to take the most conservative approach, that would be doing nothing. I guess would be the most conservative. Going into that would be hydration. This is what we always try. First, we would hydrate. You, give you caffeine, give you headache medication. We have a medication that we use called Coacentropin. That a lot of times if we give it through the IV upfront, it can prevent the spinal headache from progressing.

22:40 And we try those things. If we've tried hydration, we've tried caffeine, we've tried medication, we've tried Coacentropin, nothing is working. You are still miserable. The gold standard for treating this is called an epidural blood patch. Blood is an epidural blood patch. That is an epidural. That is just like getting a regular epidural, but we also take blood from your body under sterile conditions. So we clean off, usually your arm, with some sterile cleanser, using sterile gloves, we take about 20 mLs of blood from you, the patient, and then we take that 20 mLs of blood and we put it into your epidural space. It sounds scary but it has been shown and it does.

23:22 It's like magic. If it's a spinal headache, that's your problem. About 94% of patients will get better immediately, within 10 minutes. If you're not one of those lucky upper 90% that get better immediately and you have to have a second epidural blood patch. I believe the numbers are like 98 or 99 percent I'm not going to square, but very high that you will be cured of your headache after the second epidural blood patch. Most people do not need a second blood patch. Most women, if you have a spinal headache requiring an epidural blood patch, will see relief after that and then you can go on with your life. So that's probably the biggest thing that we worry about is anesthesiologists placing epidurals, not paralysis, not anything crazy happening.

24:07 We are concerned that you'll get the spinal headache and then be miserable and uncomfortable and we'll have to do a second epidural to fix the spinal headache. Then if you do have to get the epidural blood patch, is it uncomfortable during the process? It's no more uncomfortable than your first epidural. So it feels exactly to the patients. It feels exactly like the first time you got an epidural. I would say the feedback I get from most women getting an epidural is that was much worse in my head. Yep, I can confirm that. Yes. The thing is fun, but it's just like the funny bone feeling that goes down your legs. It's shocking, but yeah, I really that bad. Then finally, the difference between an epidural and a spinal.

24:50 Is there any difference in how long it takes for you to get up and walk afterwards? Not really based on the medication that we would be using. I mean, I would give you the same range of time. The difference between the patients appreciate, between a spinal and an epidural is if you get a spinal you pretty much get numb, really, really, really numb immediately, can't move anything. You feel that change right away. With an epidural it's a little bit more gradual. You'll notice when patients get an epidural they'll start to feel warm and tingly and almost feel like they're floating and kind of in warm water. Then it's not uncommon for patients to still be able to move their legs when they have an epidural that's working. Now you can't stand up but you could kind of move a leg or so.

25:31 Some patients can't move anything. So don't panic if you're like I can't move anything. She said I could move my leg. Some patients can, some patients can't. It's just not the term we would use. It's not as dense as a spinal. A spinal is a very dense anesthetic. We place it. It's thick, it's heavy. You get numb right away. It's very consistent, we know what we're getting. But a spinal is one single shot and it only lasts for the amount of time it lasts. So let's say three hours. One single shot, you get three hours worth of anesthesia With an epidural. It's a continuous infusion because there's that catheter that I mentioned, so we can pump medicine into it and keep giving it for 24 hours if we needed to.

26:14 So then, if you get that dense spinal, it's your pain relief that's wearing off in that three hours and then it might take a little bit longer for you to regain all your strength. Typically for the spinal, most people have their strength and back within three hours. I will tell patients, you know, when you're numb, enjoy that because you're also not feeling pain. So that's a good time to maybe get some oral pain medicine on board so that when the spinal completely wears off and you're feeling everything, you've already kind of started your pain medicine journey for the first few days. I do have a little soap box thing I want to send off. I feel strongly that we under treat postpartum pain in a lot of places in America. I think that this is one of the only surgeries I mean especially after a C-section one of the only surgeries where we actually perform surgery.

27:01 We open a woman's abdomen, remove a baby, repair an organ, sew her back together and we're like here's some. Tylenol, you should be fine. I tell patients, in the first 24 to 72 hours you may need more than a motrin and a Tylenol and that is okay. If you need to take a pain pill, take a pain pill. I had two C-sections myself and I'm very much like a tough-about kind of person. But when I was home I needed to take my oxy. I took probably about a total of maybe four pills over the course of that first week, but every time I needed to pop that pill it made a big difference for me. It was kind of miserable and suffering through it until I took a pain pill and realized I had been miserable and suffering through it.

27:43 I don't think it's necessary. I think we should encourage women. The better you feel, the better you can take care of your baby. Yeah, for sure. You absolutely should not need opiates after the first week. You should not need opiates after a week. So if it's day seven and you're still taking oxy or percocet, you need to tell your obstetrician because something is probably wrong. But on day three or four, if you need something, especially after a C-section, don't feel bad about that and take what you need. Yeah totally, but I digress no, you do not. That is very important information. But the spinal, yeah, and the epidural, everybody is a little different, you know we tell you how long it takes to wear off, but it's a range. These things are not set on a clock.

28:24 So I couldn't set a clock and say this is a three hour spinal Dang it three hours you're ready to get up and walk. At three hours we expect most patients to be recovered. If you're not in the most patient category, that's okay. That's why you have a nurse with you to assess you before you're able to get up and move and walk. If you try to do that before you're ready, you could severely injure yourself. Do not do that. Yeah, I feel like when I'm working on postpartum, I am like assessing for several hours afterwards and we're moving the legs, but also it's not necessarily the spinal's fault that we're not moving our legs as well as we did before. We have to remember that we just cut through several layers of abdominal muscle and nothing is going to work the same after you do that.

29:06 So it's super important to remember that we're not going to get up and start dancing around the room immediately afterwards. Chill yeah. Let us take care of you. That's why you're here in the hospital. Yeah, I told somebody it's okay. Yeah, Chill, you're the patient. Right, yeah, you can get back to being superwoman in about three days. Yes, use your call bell. That's what we're here for. Yeah, I knew I was asking the right person because I know you have so much to say on this topic. As a woman and a mom and an anesthesiologist, I always love it when you come in the room because the vibe is just so awesome. So thank you so much for sharing. We're all in this together.

29:48 Oh yeah, thanks for having me. Yeah, I definitely feel like with the moms and stuff, like girl I've been there, I know what it is let's get this done Like we're all in this tribe together. Right and we're all in this fabric for you. Yes, Thank you so much. To help more moms find this podcast, please be sure to subscribe and leave a review to tell me what you think. To find more information about guests from each episode, please see the show notes at birthjourneyspodcastbuzzsproutcom there. You can also learn how to follow me on Facebook and Instagram. Thank you for listening. I'm honored to be a part of your birth journey.