The best way to find out is to call your health insurance company. The number should be listed on your health insurance card. Every health insurance provider has many different plans and they can tell you best what is covered.

We work at Northwestern Medicine Central DuPage Hospital in Winfield, at Northwestern Medicine Surgery Center in Warrenville, and at The Center for Surgery in Naperville, IL.

The word “epidural” is an adjective referring to an anatomical space. The word “catheter” is a noun referring to a thin, flexible, and hollow tube. An epidural catheter is one of the options available to some women for labor pain relief. Although erroneous, it has become customary to refer to an epidural catheter simply as an “epidural.” To place an epidural catheter, an anesthesiologist will place a needle in between the vertebrae of your spine (in between the bony prominences you might be able to feel on your back). The needle will be used to find the epidural space, which is the space just outside of the dural membrane (see picture). The dural membrane surrounds your spinal cord and is filled with cerebral spinal fluid (CSF). An epidural catheter can be placed in the epidural space in order to deliver medications, usually a local anesthetic with some opioid (numbing medicine mixed with some pain medicine). The medication travels through this space and to your nerves, where it acts to interrupt the transmission of pain signals, giving you pain relief. The needle is removed once the epidural catheter is placed, and the catheter is taped to your back (see picture), where it remains for the rest of your labor. Neither needles nor anything sharp will remain in your back, so you are able to roll over and reposition yourself during your labor. A “spinal” is very similar to an epidural. The main difference is where the medication is delivered. While an epidural catheter deposits local anesthetic into the epidural space, with a spinal the anesthesiologist administers a single dose of medication into the fluid surrounding the spinal cord. This is done by inserting a very small needle through the dural membrane (see above). The placement of a spinal anesthetic is below where the spinal cord ends (see image below), at a level where it is safe. A spinal is often used for a scheduled cesarean section. A combined spinal epidural (CSE) is the anesthetic we most commonly administer to patients for pain control during labor at Northwestern Prentice Women’s Hospital. As the name suggests, this is a technique that combines the two procedures that are described above, a spinal and an epidural. The spinal portion of the procedure is done through the epidural needle, so getting a CSE does not mean that you will require multiple injections.

“PCEA” stands for “Patient Controlled Epidural Analgesia.” The word “analgesia” means pain relief. A PCEA is a means to allow you to control your own pain relief during labor. At Prentice Women’s Hospital, we utilize a PCEA device that delivers a continuous dose of medicine through the epidural catheter; in addition to that, a button is provided to you so that you can give yourself additional medication during labor, if necessary. The benefit of a PCEA is that it keeps you comfortable while limiting the total dose of medication, which accomplishes two things: 1) it avoids making you so numb that it causes weakness (so-called “motor block”) and 2) it prevents you from overdosing on local anesthetics. In other words, you cannot get too much medicine from pushing the button when you have pain. We believe that the PCEA is an important part of your comfort during your labor and we encourage you to push “the button” whenever you are feeling pain. When the epidural pump delivers the extra dose of medication, it is not instantaneous - it takes about 10 to 15 minutes to kick in. You can give yourself an extra dose once every 10 minutes and 3 times in an hour. For most patients, it is necessary to give yourself extra medication to maintain comfort.

Yes! Please follow this link for a video of epidural catheter placement.

Not everyone is a candidate for an epidural for labor pain relief. Your anesthesiologist will need to decide if there are any medical reasons that you are unable to get an epidural catheter. Most healthy women with uncomplicated pregnancies are able to safely receive an epidural catheter. Some specific reasons that an anesthesiologist will not be able to offer you an epidural catheter include: 1) an infection at the site of the catheter placement; 2) some blood clotting disorders (called “coagulopathies”), including those involving platelets (this will depend on your blood levels as well as the specific type of platelet disorder) or those pharmacologically induced by blood thinning medications (some patients on blood thinning medications can safely receive an epidural catheter, depending on the type of medication and the time of the last dose - see section called, “I am on blood thinning medications. Can I get an epidural?”); 3) elevated brain pressures (rare in pregnant ladies); 4) severe dehydration (uncommon on the labor and delivery unit); 5) your refusal (which seems obvious).

If it is determined that you are not able to safely receive an epidural catheter, you may still have some options for pain relief. Your obstetrician may offer you oral or intravenous (IV) pain medications, either in single doses or by a method called Intravenous Patient-Controlled Analgesia (PCA). With the latter method, you are able to dose yourself intermittently with IV pain medications by utilizing a button. At later stages of labor, your obstetrician may be able to perform some procedures for pain relief; these are techniques called nerve blocks, which is similar in principle to what dentists do when they numb your mouth for a procedure. The nerve blocks that your obstetrician performs can alleviate some pain, but they are not expected to relieve all pain to the point of complete numbness, and you will likely still experience pain with contractions.

We do not have strict rules about the timing of epidural catheter placement. Most women request an epidural for pain control when they feel like their level of pain is too much to handle without some help. This level of pain may be related to how long you have been in labor or how much your cervix is dilated, or on something else entirely. Pain is a very personal feeling and thus, everyone has a different threshold at which they might feel comfortable continuing labor without epidural pain control. It is almost never “too late” to receive an epidural catheter. As anesthesiologists, our primary concern with placing an epidural catheter in someone who is 10 cm dilated and has an urge to push is that she may not be able to sit still for long enough for us to safely do the procedure. Obviously, many women in this situation are able to safely receive epidural catheters, but safety is always our paramount priority, so the decision to perform the procedure will need to be made on an individual basis. There are some practitioners who believe that patients need to wait until they are 4cm dilated before they can receive an epidural catheter. The thinking is that placing an epidural catheter any earlier can increase the risk for cesarean section. A landmark study performed at our institution(1) has demonstrated that this is not the case. On the contrary, we found that early epidural catheter placement does not increase the rate of cesarean delivery, and it provides better pain relief and results in a shorter duration of labor than systemic (intravenous) pain relievers. As a result, in our practice at Northwestern Prentice Women’s Hospital, we allow epidural catheters to be placed even at early stages of labor, and we do not withhold placement based on arbitrary cervical dilation. 1. Wong CA, Scavone BM, Peaceman AM, et al. The risk of cesarean delivery with neuraxial analgesia given early versus late in labor. N Engl J Med. 2005 Feb 17;352(7):655-65.

Epidural catheter placement is a medical procedure; as such, there are risks and benefits involved. The most significant benefit is that epidural catheters provide the most effective form of labor pain relief that modern medicine has to offer - it is superior to intravenous or oral pain medications, acupuncture, or massage therapy during labor (1, 2). Severe neurologic injury causing permanent paralysis is an extremely rare complication of epidural catheter placement. Causes of this type of injury include epidural hematoma (a blood clot), epidural abscess (an infection), or direct injury of the spinal cord. Over the period of a year, it is more likely to suffer a fatal car accident than it is to suffer a permanent injury from an epidural catheter or epidural catheter placement (3). The decision to have an epidural catheter is a very personal one that is made on an individual basis, so if a patient and her anesthesiologist believe that the benefits of superior pain relief with an epidural catheter outweigh the exceedingly low risk of injury, a catheter may be placed. The vast majority of patients fall under this category. An epidural catheter is not a requirement for labor and delivery, so if a patient is uncomfortable with the low but existent risk of injury, she certainly does not need to have an epidural catheter placed for labor pain relief. 1. Howell CJ, Chalmers I: A review of prospectively controlled comparisons of epidural with non-epidural forms of pain relief during labour. Int J Obstet Anesth 1992; 1:93-110. 2. Paech MJ: The King Edward Memorial Hospital 1,000 mother survey of methods of pain relief in labour. Anaesth Intensive Care 1991; 19:393-399. 3. Ruppen W, Derry S, McQuay H, Moore RA. Incidence of Epidural Hematoma, Infection, and Neurologic Injury in Obstetric Patients with Epidural Analgesia/Anesthesia. Anesthesiology 2006; 105:394–9.

For most women, the most uncomfortable part of the experience is when we use a local anesthetic called lidocaine on the skin of the back. It is the same medication that is used during placement of your IV. We use local anesthetic in order to make the rest of the epidural procedure more comfortable. We warn you before we administer the local anesthetic, and the sensation lasts less than 5-10 seconds. Some people describe it as a sensatoin of burning, similar to a small bee sting. After the burning goes away, during placement of the epidural catheter, some people feel nothing at all, but the most common thing that patients feel is intense pressure. This intense pressure is usually not painful, but at times can be uncomfortable. If you feel a sharp or poking sensation at any time during the placement of the epidural catheter, please tell your anesthesiologist where you feel the pain. That is usually an indication that you need more numbing medication. He or she will be able to give you more numbing medication and can then better direct their efforts to find the correct space.

The time needed for your anesthesiologist to place an epidural depends on a number of things. The part of the procedure where we clean your back, set up the epidural kit, and draw up medications takes about 3 - 5 minutes on average. From the time that everything is prepared to the time you get the first dose of medication takes anywhere from between 2 minutes to greater than 30 minutes. The factors that impact this time include your positioning (how much you can flex your back), the shape of your spine (whether or not you have scoliosis), and our ability to find body anatomical landmarks on your back and hips. A higher body mass index(weight in kilograms/ height in meters squared) has been associated with increased difficulty in the ability of an anesthesiologist to feel bony landmarks and with patient difficulty in back flexion, and therefore may be associated with a longer time for epidural catheter placement (1). 1. Ellinas EH, Eastwood DC, Patel SN, et al. The effect of obesity on neuraxial technique difficulty in pregnant patients: a prospective, observational study. Anesth Analg 2009;109(4):1225-1231.

The word “epidural” is very nonspecific. A typical “epidural” on labor and delivery at Prentice Women’s Hospital usually refers to a “combined spinal-epidural” (see “What is an epidural? What is a spinal? What is a combined spinal-epidural (CSE)? How do these work?”). You may have read or heard about so-called “walking epidurals” where you can get up and walk around after your anesthesiologist places an epidural catheter. At Prentice Women’s Hospital, we run our epidural medications at very low concentrations; this does allow for enhanced mobility, including the ability to walk around. However, under most circumstances, it is difficult for care providers to consistently provide the necessary safety measures to allow long periods of walking to occur. For this reason, your nurse may advise that you refrain from walking around after your epidural catheter has been placed. (See “Can I walk with an epidural? Can I shower with one? Can I go to the bathroom?”)

We prefer that you refrain from eating while you are with us on labor and delivery. Eating doesn’t affect the medication that we give you through the epidural catheter. However, because there is always a small but existent risk for an emergency situation with you or your baby during labor and delivery, we think it is safer to avoid food for those few hours you spend with us. You may be able to drink liquids and have ice chips, at the discretion of your obstetrician. After delivery of your baby, your nurse will tell you when you may eat.

At Prentice Women’s Hospital, it is the policy of the Anesthesiology Department that family members are not permitted to stay in a patient’s room while the anesthesiologist places an epidural catheter. We ask family members to step out of the room because an epidural is a sterile procedure and we want to minimize the risk of infection. If it is okay with the patient, family members can be present during discussion of medical history and for the explanation of risks, benefits, and how an epidural catheter is placed. Family members are asked to leave the room for about 20-30 minutes or until the epidural catheter placement is complete and the patient is comfortable. In some instances, we may request that the family members take a cell phone with them in case we would like to call them back to the room earlier than anticipated.

You may have read or heard about so-called “walking epidurals” where you can get up and walk around after your anesthesiologist places an epidural catheter. At Prentice Women’s Hospital, we start our epidural medications at very low concentrations; this does allow for enhanced mobility, including the ability to walk around. However, under most circumstances, it is difficult for care providers to consistently provide the necessary safety measures to allow long periods of walking to occur. In addition, it is possible that in spite of us starting off the epidural medication at low concentrations, your dose may need to be increased, and that might make some patients feel that their legs are weak and/or numb. For this reason, your nurse may advise that you refrain from walking around after your epidural catheter has been placed. This does not mean that you have to lie still in one position - in fact, we encourage you to reposition yourself from side to side as often as you feel comfortable.

Our goal in placing an epidural catheter is that we will control your pain for the entire labor and delivery process. This does not mean that you will feel nothing during labor. We expect and desire that you will feel pressure with contractions and increasing pressure as your baby moves towards delivery. Most of our patients receive a “combined spinal-epidural” for pain control during labor. (See “What is an epidural? What is a spinal? What is a combined spinal-epidural (CSE)? How do these work?”) The first dose (spinal dose) will start to work almost immediately. Within about 2 minutes after the spinal dose you will start to feel warmth and tingling in your feet or legs and usually within 5 minutes you will notice that your contractions are shorter and less intense. At that point you may not feel the contractions at all. The spinal dose of medication gets you the numbest and the most comfortable that you will be during the entire labor. This should keep most women comfortable for about 90 minutes. As soon as your anesthesiologist places the epidural catheter, you will begin to receive medication through the catheter. The intensity of numbness with the epidural infusion might be less than the intensity of numbness you may have experienced with that first spinal dose. We continue this infusion of medication until the time of your delivery. Therefore, the pain relief should last as long as your labor lasts. The dose may need to be adjusted if you experience breakthrough pain, at which time, you may ask your nurse to contact the anesthesiologist on duty to come in and assess your pain medication requirements. When it is time for you to leave the labor and delivery floor and go to a postpartum room, your epidural catheter and all the tape that was used to keep it in place will be removed, provided it is safe to do so. Therefore, the epidural catheter typically stays in for the duration of your labor up until the time of your transfer from the labor and delivery floor to your discharge to a postpartum room.

As a medical procedure, epidural catheter placement confers some risks which must be weighed by the benefits of pain relief. After the uncomplicated placement of a spinal anesthetic, an epidural catheter or a combined spinal-epidural, there is about 0.5-0.8% risk (less than 1 in 100) of a “spinal headache”. This is a specific type of headache that is positional- it is usually severe when sitting up or standing and gets significantly better or goes away completely when lying down. If for some reason your anesthesiologist thinks you are at increased risk for this type of headache, he or she will discuss treatment options with you. Very rarely there are severe complications to the placement of a spinal, epidural or combined spinal-epidural. Anytime something penetrates the skin, there is a risk of bleeding or infection. This risk exists even though we use sterile techniques when performing these procedures and despite the fact that the vast majority of patients have no increased risks for bleeding. However, the risk is quite small - less than 1 in 200,000 (1). Also see the section called, “Is it dangerous to have an epidural?” Sometimes after delivery, patients experience so-called “peripheral nerve palsies” in which leg or foot weakness or sensory disturbances are experienced and epidural catheter use is often blamed for these palsies. However, it is important to note that these palsies are not related to the epidural catheter. Ladies who are at higher risk for obstetric nerve palsies are those who have never delivered a baby before, those who have a prolonged second stage of labor (the time between 10cm of cervical dilation until delivery of the baby), those with large babies (called “macrosomia”), and those who assume extreme hip flexion (wherein thighs are against the abdomen) during labor (see picture). Neuraxial anesthesia, i.e. epidural catheter use, is not associated with a higher risk for obstetric nerve palsies in and of itself (2). 1. Moen V, Dahlgren N, Irestedt L. Severe neurological complications after central neuraxial blockades in Sweden, 1990-1999. Anesthesiology 2004; 101:950-9. 2. Wong CA, Scavone BM, Dugan S, et al. Incidence of postpartum lumbosacral spine and lower extremity nerve injuries. Obstet Gynecol 2003; 101:279-88.

The typical side effects associated with the placement of an epidural catheter and the medication we administer through it are very minor. We expect that your blood pressure will go down slightly after we start giving you medication. To account for this, we give you some fluid through your IV and we also have medication available to raise your blood pressure if we feel it is necessary. The second common side effect is itchiness. Itchiness is not limited to the area on your back where we place the epidural catheter; in fact it can be all over your body. The good news is that if you get itchy it will likely last only for an hour or two. It does not necessarily indicate an allergic reaction - in fact, most of the time, it is not an indication of an allergy. We recommend that if you do experience itchiness, you avoid using your fingernails to scratch. This is because you may injure yourself more than you realize, since the numbness from the epidural medication can make it difficult for you to know how hard you are scratching. There are medications available to help you with the itchiness, so if it ever becomes more bothersome than pain, please let your nurse know. The third common side effect is a bruise-like feeling experienced after the epidural catheter is removed, located at the site in your back where the epidural catheter was placed. Think of this bruise as similar to the bruise you get in your arm after a flu shot or a tetanus shot. The insertion site may be sore or tender for a day or two but will resolve on its own.

No. At Northwestern Prentice Women’s Hospital we don’t have a rule about when a patient can request an epidural catheter placement. (See “When am I allowed to get an epidural catheter? Is it ever too early or too late to get an epidural catheter?”) There are some practitioners who believe that patients need to wait until they are 4cm dilated before they can receive an epidural catheter. The thinking is that placing an epidural catheter any earlier can increase the risk for cesarean section. A landmark study performed at our institution(1) has demonstrated that this is not the case. On the contrary, we found that early epidural catheter placement does not increase the rate of cesarean delivery, and it provides better pain relief and results in a shorter duration of labor than systemic (intravenous) pain relievers. As a result, in our practice at Northwestern Prentice Women’s Hospital, we allow epidural catheters to be placed even at early stages of labor, and we do not withhold placement based on arbitrary cervical dilation. 1. Wong CA, Scavone BM, Peaceman AM, et al. The risk of cesarean delivery with neuraxial analgesia given early versus late in labor. N Engl J Med. 2005 Feb 17;352(7):655-65.

No. There are some practitioners who believe that patients need to wait until they are 4cm dilated before they can receive an epidural catheter. The thinking is that placing an epidural catheter any earlier can increase the risk for cesarean section. A landmark study performed at our institution(1) has demonstrated that this is not the case. On the contrary, we found that early epidural catheter placement does not increase the rate of cesarean delivery, and it provides better pain relief and results in a shorter duration of labor than systemic (intravenous) pain relievers. As a result, in our practice at Northwestern Prentice Women’s Hospital, we allow epidural catheters to be placed even at early stages of labor, and we do not withhold placement based on arbitrary cervical dilation. (See also “When am I allowed to get an epidural catheter? Is it ever too early or too late to get an epidural catheter?”) Other points that the scientific community knows about how epidurals affect labor progress include the following(2): Patients receiving epidural analgesia have longer labors when compared to women receiving intravenous (I.V.) methods of childbirth pain relief. Numerous studies have shown that the difference is approximately one hour on an average. However, this may be highly variable depending on your labor pattern. Epidural analgesia does not increase the risk of cesarean delivery. Randomized clinical trials present powerful evidence that there is no added risk of cesarean delivery owing to epidural analgesia. The relationship between epidural analgesia and forceps deliveries is complex. Some studies have shown more forceps deliveries in patients with epidurals while others have not. This may be highly dependent on practice style and preferences of your own obstetrician. Patient satisfaction and neonatal outcome are better after epidural than I.V. method of childbirth pain relief. 1. Wong CA, Scavone BM, Peaceman AM, et al. The risk of cesarean delivery with neuraxial analgesia given early versus late in labor. N Engl J Med. 2005 Feb 17;352(7):655-65. 2. http://www.painfreebirthing.com/english/labor.htm

While most medications given to the mother can reach the baby, the medications we give through the epidural rarely cause negative effects on the baby. We give a combination of local anesthetic and opioid pain medication in the spinal and/or epidural, both of which can potentially cross the placenta. A major benefit of the epidural compared to oral or intravenous (IV) pain medicines is that it minimizes the amount of medication that gets to the baby. The benefit of the epidural is not what medications are given, but where they are given. When medication is deposited directly into the spinal fluid or epidural space (instead of orally or through the IV), only a very small amount gets into the maternal blood stream. By minimizing the amount of medication in the mother’s blood, we can also minimize the amount that gets to the baby. Even though only a small fraction of the medication given through the epidural gets to the baby, it may still cause direct or indirect effects. Fortunately, none of these have been shown to have clinically significant effects. Following epidural placement, the baby may experience a temporary heart rate decrease (referred to as a deceleration). However, these decelerations are not associated with bad outcomes for the baby (1,2). Opioid medications may affect the baby’s breathing after he or she is born, especially if they are given intravenously. However, the amount of opioid given in the epidural infusion is so little and the infusion so low that very little of it builds up in the mother’s bloodstream; consequently, not enough of it gets to the baby to cause breathing problems (3,4,5,6). Compared to those who received intravenous opioids, mothers who had spinal or epidural opioids had babies with better Apgar scores and evidence of better oxygenation in their blood tests (10). Occasionally after receiving an epidural, the uterus will contract very frequently, resulting in a slowing of the baby’s heart rate. Fortunately, this can easily be treated and has not been shown to result in an increased rate of emergency cesarean delivery (5,7). Any medications that get into the mother’s bloodstream can get into the breast milk; however, the small doses of medication given through the epidural do not have any significant effect on breastfeeding newborns. There are very few studies that look at the impact that epidurals have on breastfeeding success. One recent study by Gizzo et al(8) showed minimal difference in breastfeeding between women who had labor analgesia with epidurals versus those who had no labor analgesia. The only difference they found was more women in the epidural group had a first breastfeeding session of less than 30 minutes. Another study by Wilson et al(9) found no difference between women who had epidurals and women who did not have epidurals in terms of breastfeeding initiation rates or length of breastfeeding. 1. Nielsen PE, Erickson JR, Abouleish EI, et al. Fetal heart rate changes after intrathecal sufentanil or epidural bupivacaine for labor analgesia: Incidence and clinical significance. Anesth Analg 1996; 83:742-6. 2. Pello LC, Rosevear SK, Dawes GS, et al. Computerized fetal heart rate analysis in labor. Obstet Gynecol 1991; 78:602-10. 3. Bader AM, Fragneto R, Terui K, et al. Maternal and neonatal fentanyl and bupivacaine concentration after epidural infusion during labor. Anesth Analg 1995; 81:829-32. 4. Porter J, Bonello E, Reynolds F. Effect of epidural fentanyl on neonatal respiration. Anesthesiology 1998; 89:79-85. 5. Loftus JR, Hill H, Cohen SE. Placental transfer and neonatal effects of epidural sufentanil and fentanyl administered with bupivacaine during labor. Anesthesiology 1995; 83:300-8. 6. Vertommen JD, Vendermeulen E, Van Aken H, et al. The effects of the addition of sufentanil to 0.125% bupivacaine on the quality of analgesia during labor and on the incidence of instrumental deliveries. Anesthesiology 1991; 74:809-14. 7. Reynolds F, Sharma SK, Seed PT. Analgesia in labour and fetal acid-base balance: A meta-analysis comparing epidural with systemic opioid analgesia. Br J Obstet Gynaecol 2002; 109:1344-53. 8. Gizzo S, Di Gangi S, Saccardi C, Patrelli TS, Paccagnella G, Sansone L, Barbara F, D'Antona D, Nardelli GB. Epidural analgesia during labor: impact on delivery outcome, neonatal well-being, and early breastfeeding. Breastfeed Med. 2012 Aug;7:262-8. Epub 2011 Dec 13. 9. Wilson MJ, MacArthur C, Cooper GM, Bick D, Moore PA, Shennan A. Epidural analgesia and breastfeeding: a randomised controlled trial of epidural techniques with and without fentanyl and a non-epidural comparison group. Anaesthesia 2010; 65: 145–53. 10. Chestnut DH, Polley LS, Tsen LC, Wong CA. Chestnut’s Obstetric Anesthesia: Principles and Practice, 4th Edition. pp. 270.

An epidural is an extremely effective way of controlling pain during labor and delivery, but the goal is not to have you completely numb. While the epidural works well to reduce or eliminate the pain associated with contractions, it cannot and should not take away all sensation. It is normal and expected to feel pressure, especially as the baby’s head descends. The goal of a labor epidural is to provide pain control but to still allow the mother to have the strength to push effectively when the time comes to deliver the baby. In order to provide effective pain relief for labor, it is necessary to block transmission of pain signals to the spinal cord from the 10th thoracic vertebrae (which is roughly at the level of your belly button) all the way down to the sacral nerve roots (the nerves that enter the lowest part of the spinal cord). Because of this, you can expect to have reduced sensation to painful stimuli (like contractions) from about the waist on down to the toes. Depending on the dose of local anesthetic used, we can adjust the height and strength of the block. This is important if an epidural later needs to be used to provide anesthesia for forceps delivery or a cesarean section. When the strength of the block is increased, you are more likely to also have a motor block, meaning you may be temporarily unable to move your legs. If the epidural is being used for labor analgesia, then the goal is to titrate the medication to help with painful sensations but to avoid causing a motor block. At Prentice Women’s Hospital, we accomplish this by using a dilute solution of local anesthetic and opioid that is run at a low continuous rate. Most people can expect to feel numbness from the waist on down but should always have the feeling of pressure until after the baby is delivered.

The typical choice for anesthesia for cesarean delivery is a spinal anesthetic (see, “What is an epidural? What is a spinal? What is a combined spinal-epidural (CSE)? How do these work?”). We use this type of anesthesia for almost all scheduled cesarean deliveries because it provides a dense level of anesthesia in a reliable fashion. The exceptions to this are patients for whom surgery may take an extended period of time above the average cesarean delivery or those patients who have a contraindication to a spinal or epidural catheter placement. In those cases, your anesthesiologist will discuss other modes of anesthesia with you, including combined spinal-epidural placement or general anesthesia. Examples of patients in whom we expect surgical time might be longer than average are patients with many past cesarean deliveries (two or more), patients that have had previous abdominal surgeries other than a cesarean, or patients with past cesarean deliveries who are also going to have a tubal ligation. Examples of situations in which a patient may not be able to safely receive a spinal or epidural catheter for cesarean delivery include the following: 1) an infection at the site of the catheter placement; 2) some blood clotting disorders (called “coagulopathies”), including those involving platelets (this will depend on your blood levels as well as the specific type of platelet disorder) or those pharmacologically induced by blood thinning medications (some patients on blood thinning medications can safely receive an epidural catheter, depending on the type of medication and the time of the last dose); 3) elevated brain pressures (rare in pregnant ladies); 4) severe dehydration (uncommon on the labor and delivery unit); 5) your refusal (which seems obvious)

Having scoliosis is not a so-called “absolute contraindication” to receiving an epidural catheter -- in other words, by itself, it is not a reason that you cannot have an epidural catheter for labor pain relief. Scoliosis, which is a curvature of the spine, can be mild, moderate, or severe. If you have scoliosis greater than 30 degrees, or if you have required back surgery with instrumentation for the correction of scoliosis, this is important information to relay to your anesthesiologist. Depending on the severity, it may require a visit with us prior to your coming to the Labor and Delivery Unit so that we can determine the severity of the curve, if there are any other associated conditions you might have with your muscles or nerves, and any effect the scoliosis may have had on your heart or lung function. Previous back surgery may affect the ability to place an epidural catheter, and it may also affect the quality of pain relief that an epidural catheter can provide (see, “I have had back surgery. Can I get an epidural? Will I have problems?”) Patients with scoliosis of any degree who desire an epidural catheter for labor pain relief deserve an attempt at placement. There are several challenges that scoliosis can bring to an anesthesiologist and to the patient. It can be more difficult to find the correct space (the epidural space), and thus the procedure may take longer and require multiple attempts. That can mean that the procedure can be associated with some complications, namely: a spinal headache; unsuccessful identification of the epidural space and therefore inability to place the epidural catheter; failed block and/or inadequate pain relief, including pain relief that is only one-sided and which might require replacement of the epidural catheter (repeat procedure) at some point during labor. These complications are more common in patients with a history of back surgery that included spinal fusion to a low lumbar level compared to patients with back surgery whose fusion only extends to the upper lumbar spine (1,2). The decision to use an epidural catheter for labor pain relief is a very personal one, and thus an anesthesiologist will be happy to discuss risks and benefits with you in person. 1. Crosby ET, et al. Obstetric epidural anaesthesia in patients with Harrington instrumentation. Can J Anaesth 1989; 36-693-6. 2. Daley MD et al. Epidural anesthesia for obstetrics after spinal surgery. Reg Anesth 1990; 15:280-4.

Yes, you can request an epidural catheter. A herniated disc is a common problem that many women have. The actual anatomical changes that occur from a herniated disc are separate from the location that we place the epidural catheter. An isolated herniated disc without other back issues such as scoliosis does not usually lead to difficulty in the placement of the epidural catheter, nor does it usually cause changes in how we expect the epidural infusion to act for pain relief. Women with a herniated disc may be at increased risk for one-sided or patchy numbness, but this again depends somewhat on a number of other factors. Having an epidural catheter placed should also not increase your risk for future back problems any more than a person who does not have a herniated disc, but there are some precautions that should be taken with regard to your positioning during your labor and delivery, as discussed below. If you have a herniated disc that is causing neurologic symptoms such as pain that shoots down your legs or numbness, weakness, or tingling, your anesthesiologist will want to know what the symptoms are and if they have changed during pregnancy. You should give this information when you talk to your anesthesiologist prior to the placement of an epidural catheter. It is important to share this information so a neurologic exam can be performed and a baseline established in case you have a new symptom after the numbness from the epidural infusion wears off. The placement and presence of our epidural catheter will not worsen any of these symptoms, but the process of labor and the delivery may worsen symptoms or lead to symptoms that you previously did not have. This happens because of the extreme positions that many laboring women assume. The position associated with the most risk is back flexion with hip flexion (see picture). That combination can lead to worsened disc herniation as well as stretching of other nerves. One way to try to prevent this type of injury is to try out positions that you may use during labor or the pushing process before you ask for an epidural so you can see what is comfortable when you do not have any pain medication or numbness.

Patients with a history of back surgery are certainly able to request to receive an epidural catheter. However, previous back surgery may affect the ability to place an epidural catheter, and it may also affect the quality of pain relief that an epidural catheter can provide. There are several challenges that a patient with previous back surgery can pose to an anesthesiologist and to the patient, due to changes in anatomy and possible internal scarring. It can be more difficult to find the correct space (the epidural space), and thus the procedure may take longer and require multiple attempts. That can mean that the procedure can be associated with some complications, namely: a spinal headache; unsuccessful identification of the epidural space and therefore inability to place the epidural catheter; failed block and/or inadequate pain relief, including pain relief that is only one-sided and which might require replacement of the epidural catheter (repeat procedure) at some point during labor. These complications are more common in patients with a history of back surgery that included spinal fusion with Harrington Rods to a low lumbar level compared to patients with back surgery whose fusion only extends to the upper lumbar spine (1,2). The decision to use an epidural catheter for labor pain relief is a very personal one, and thus an anesthesiologist will be happy to discuss risks and benefits with you in person. A study done at our institution has found that patients with a history of lumbar discectomy surgery at one level do not require more epidural pain medications (local anesthetics) compared to patients who have not had back surgery; however, epidural catheter placement may require more attempts compared to patients who have not had back surgery (3). 1. Crosby ET, et al. Obstetric epidural anaesthesia in patients with Harrington instrumentation. Can J Anaesth 1989; 36-693-6. 2. Daley MD et al. Epidural anesthesia for obstetrics after spinal surgery. Reg Anesth 1990; 15:280-4. 3. Bauchat J, et al. Prior lumbar discectomy surgery does not alter the efficacy of neuraxial labor analgesia. Anesth Analg 2012 Aug;115(2):348-53.

There are many reasons to experience back pain after labor and delivery, but only rarely is it truly related to the use of an epidural catheter. There is scientific evidence that mothers who deliver babies without the use of epidural catheters are just as likely to experience generalized back pain lasting a few days as those who have epidural catheters. Pregnancy itself can increase the incidence of back pain due to softening of ligaments, causing back strain. Back pain caused by use of epidural catheters is usually severe and associated with other neurologic signs, and it can be a sign of a more serious complication such as a hematoma or abscess (see sections called, “Is it dangerous to have an epidural?” and “What complications are possible with epidurals?”). Again, the risk of these occurring is very low - less than 1 in 200,000 (1). In other words, the chance of these serious complications occurring is comparable to the chance of an Earth-impacting asteroid causing a human death (2). In order to catch these rare but serious symptoms early, the anesthesiologists at Prentice Women’s Hospital routinely follow up on the day after delivery with everyone who has had an epidural catheter, or any anesthetic, for labor and delivery. Commonly, after the anesthetic wears off, women will describe a feeling of soreness in the back at the site where the epidural catheter was placed. It is usually mild, localized to just that spot, causes no other symptoms, and can be described as a sensation similar to that of a bruise or a flu shot. This is normal and expected, does not herald any serious complications, and will get better with time. Most other times, back pain or other pains after delivery can be attributed to the pregnancy or labor process themselves. The process of labor and the delivery may worsen symptoms or lead to symptoms that you previously did not have. This happens because of the extreme positions that many laboring women assume. The position associated with the most risk is back flexion with hip flexion. That combination can lead to worsened disc herniation, if present prior to labor, as well as stretching of other nerves. One way to try to prevent this type of injury is to try out positions that you may use during labor or the pushing process before you ask for an epidural so that you can see what is comfortable when you do not have any pain medication or numbness. Also after delivery, some patients can experience so-called “peripheral nerve palsies” in which leg or foot weakness or sensory disturbances are experienced, and epidural catheter use is often blamed for these palsies. However, it is important to note that these palsies are not related to the epidural catheter. Ladies who are at higher risk for obstetric nerve palsies are those who have never delivered a baby before, those who have a prolonged second stage of labor(the time between 10cm of cervical dilation until delivery of the baby), those with large babies (called “macrosomia”), and those who assume extreme hip flexion (wherein thighs are against the abdomen) during labor. Neuraxial anesthesia, i.e. epidural catheter use, is not associated with a higher risk for obstetric nerve palsies in and of itself (3). Source: Chestnut DH, Polley LS, Tsen LC, Wong CA. Chestnut’s Obstetric Anesthesia: Principles and Practice, 4th Edition. 1. Moen V, Dahlgren N, Irestedt L. Severe neurological complications after central neuraxial blockades in Sweden, 1990-1999. Anesthesiology 2004; 101:950-9. 2. Clark Chapman, Southwest Research Institute; David Morrison, NASA Ames Research Center. http://www.livescience.com/3780-odds-dying.html 3. Wong CA, Scavone BM, Dugan S, et al. Incidence of postpartum lumbosacral spine and lower extremity nerve injuries. Obstet Gynecol 2003; 101:279-88.l

Every pregnancy and labor is different, and even if you had problems with a previous epidural does not necessarily mean you will have problems this time. There are many reasons why you may have had inadequate pain relief, but most of them can be resolved or at the very least improved. One of the most common reasons for a sudden increase in pain despite having an epidural is related to the natural progress of labor. During the first stage of labor, most of the pain results from uterine contractions and cervical dilation. To cover pain related to the first stage of labor we need to block the nerve roots from the 10th thoracic vertebrae (about around your belly button) to the 1st lumbar vertebrae. As you enter the second stage of labor (often referred to as the active phase), the baby begins to descend into the lower part of the birth canal. The descent of the baby’s head results in pain related to stretching and pressure on the vagina and perineum. In order to control pain in the second stage of labor, it is necessary to block the sacral nerve roots. In addition to being lower in the spinal cord, these nerve fibers are also larger than the nerve fibers responsible for pain in the first stage. This means that if your cervix makes rapid change, you can go from being quite comfortable with the low-concentration, low-rate solution during the first stage of labor to suddenly becoming very uncomfortable as you progress into the second stage of labor. At Northwestern Prentice Women’s Hospital, we provide patients who have labor epidurals with a patient-controlled epidural analgesia (PCEA) button. The PCEA allows the mother to bolus herself with an extra dose of medication from the infusion pump, in addition to the continuous low rate. While the PCEA is a great way to provide customized pain control, occasionally a patient’s cervix makes rapid change resulting in a sudden increase in pain. This “breakthrough” pain may not be covered adequately by the infusion or PCEA. However, the anesthesiologist can increase the dose of medication by adjusting the rate and/or concentration as needed. Additionally, your anesthesiologist can give you a larger and stronger bolus dose than you can give yourself with the PCEA by giving an additional dose through your epidural catheter that is already in place (we often refer to this as a “redose”). Giving a redose is an effective way to help the local anesthetic spread down to reach the sacral nerve roots responsible for pain in the second stage of labor. It is possible that despite proper placement of the epidural catheter, you may still experience inadequate pain relief. Often, we can achieve improved pain control by adjusting the dose or giving redoses as explained above. However, for various reasons the epidural may fail and need to be replaced. If the epidural was functioning for several hours but eventually stopped working, it is likely the catheter migrated out of the epidural space. If you were initially comfortable but after two hours or less you are in pain again, it is possible the epidural was never in the right place and the initial pain relief from the spinal has now worn off. Fortunately, most patients are able to get comfortable again by replacing the epidural catheter, although this does require a second procedure. Another cause of inadequate pain relief is a one-sided block. A one-sided block may be due to the catheter position, the patient’s position, or the patient’s anatomy. Once you receive your epidural, you will need to stay in bed for the rest of your labor, and you will be encouraged to lay on your side (lying on your back puts pressure on the large blood vessels and prevents good blood flow to you and the baby). If you remain on one side for too long, you may develop an asymmetrical block that is much stronger on the down side and possibly inadequate on the up side. A one-sided block due to patient positioning can often be overcome with position changes or redoses. If the cause of the one-sided block is due to the catheter position, it may be fixed by a redose or by pulling the catheter out a small amount. Occasionally the only way to achieve adequate pain relief is to replace the catheter. The spread of medication within the epidural space may be affected by the patient’s anatomy. This may be due to something obvious, such as scarring from a previous spine surgery, or it may be caused by something previously unknown, such as presence of a connective tissue band in the epidural space. Often, improved pain relief is achieved by replacing the epidural catheter at a different level, although it may never be possible to achieve complete relief. The position of the baby’s head is a common contributor to difficult to treat labor pain, and is often experienced as “back labor.” This may cause the patient to have breakthrough pain in her back, despite well-controlled contraction pain. Often, an additional dose of opioid pain medication helps with this type of pain, but replacement of the catheter may be necessary. Source: Chestnut DH, Polley LS, Tsen LC, Wong CA. Chestnut’s Obstetric Anesthesia: Principles and Practice, 4th Edition. pp. 431,454,459

A post-dural puncture headache (a.k.a. “spinal headache”) is a particular headache that can occur as a result of spinal, epidural, or combined spinal-epidural anesthetic techniques. While there are multiple reasons that this may occur, the overall risk is 0.5-0.8% (less than 1 in 100) after an uncomplicated procedure. The risk can go up to 52.1% (1 in 2) if, during the procedure, an inadvertent dural puncture occurs. This is a known risk with placement of a neuraxial anesthetic, and one which we discuss with everyone during the process of obtaining your informed consent. While it is impossible to predict if a post-dural puncture headache will occur to anyone, there are some patients who may be at higher risk, namely: patients with scoliosis or patients with previous back surgery, in which cases neuraxial anesthesia placement can be challenging; patients with previous history of post-dural puncture headache (these patients are 2.3 times more likely to develop a second spinal headache than women without a history of it); anesthetic technique, including needle size and design (at Prentice Women’s Hospital, we use needles that are associated with the lowest risk for spinal headaches); multiple attempts; age (more susceptible in patients <40 years old); gender (females more likely); and weight (more susceptible in patients with lower BMIs). If an inadvertent dural puncture were to occur, we will routinely warn you of signs and symptoms to be aware of in the next 24 hours, and we will follow you for as long as you are in the hospital. We will also follow up with you with phone calls once you are discharged, since sometimes symptoms won’t arise or won’t worsen until after you are sent home. We follow you closely for several reasons: we want to make sure that the headache that you are experiencing is indeed related to the procedure, and not one of several other types of headaches or migraines that are common in the postpartum period; we want to advise you of treatment options and keep track of the evolution or resolution of your symptoms; and we want to make sure you are not developing anything more serious such as an infection or collection of blood. Source: Chestnut DH, Polley LS, Tsen LC, Wong CA. Chestnut’s Obstetric Anesthesia: Principles and Practice, 4th Edition. pp. 682-5.

Some patients require blood thinning medications, including things like aspirin (uncommon but used in some pregnant patients), Plaxix, heparin, Lovenox (or other low molecular weight heparins), or a combination of medications. If you are on blood thinning medications, you may or may not be able to receive an epidural catheter for labor pain relief. The American Society of Regional Anesthesia (ASRA) has created guidelines for the placement of neuraxial anesthesia (e.g. epidural catheters) for obstetric patients who require blood thinning medications. These guidelines are in place to help minimize the risks of bleeding when we place a spinal, epidural or combined spinal-epidural. Your ability to receive an epidural catheter will depend upon the type of medication you are on, the dose, and the last time you took it. In some cases, labwork will need to be drawn and processed before we can know that it is safe to proceed with placement of an epidural catheter; this is because some blood thinning medications affect your platelet levels, which can pose a safety risk if the levels are too low. In cases in which we know when you will come to deliver (e.g. scheduled cesarean delivery, scheduled inductions of labor) we are able to more precisely time your last dose of medication to the time you receive your neuraxial anesthetic. If you see a hematologist to manage your blood thinning medications, he or she may talk to you about switching your medications and/or timing them differently at a later point in your pregnancy. In other routine cases, your obstetrician or an anesthesiologist can help make those decisions. Ultimately, the decision to place an epidural catheter will be made between you and your anesthesiologist on the day that you deliver.

Women with a history of so-called “precipitous deliveries” have a high likelihood of repeating the same scenario on future pregnancies. In other words, if you delivered quickly with your previous child (children), it is very likely that you will delivery quickly with subsequent children, unless discussed otherwise between you and your obstetrician. In cases like these, it can be challenging to place an epidural catheter in a timely fashion, and it is sometimes necessary for you, your obstetrician, and your anesthesiologist to weigh the benefit of a brief period of pain relief with an epidural catheter against the inevitable and swift delivery of your child, at which time the pain associated with contractions will be eliminated. At other times, it is certainly possible for us to place the epidural catheter should you request it, but the ability and success of placement will depend upon multiple factors, including how far along you are in labor. For example, a patient who is 10cm dilated and ready to deliver her child may or may not be able to receive an epidural catheter for pain relief, depending upon how quickly it is thought that she will deliver, and upon how uncomfortable she is, as her comfort level may determine her ability to cooperate with the procedure such that it can be performed safely.

Yes. Although some practitioners may state otherwise, most of the time it can be done safely, especially if the tattoo is not new. There is no scientific evidence to support the idea that placing an epidural needle and/or catheter through the pigment of a tattoo will cause any harm (1). Tattoo pigments are fixed in your dermis during the healing process, and as a result they cannot be mobilized by a needle or catheter, nor can they migrate along their tracks. Furthermore, the amount of pigment used during tattoo placement is typically small, and the pigments are made of inert materials. Source: http://www.painfreebirthing.com/ 1. Opinion Statement, Society of Obstetric Anesthesiology and Perinatology (SOAP), Accessed 10 October 2012: http://www.soap.org/media/newsletter_summer2001.pdf