How soon will it work?
When you have been prepared for your epidural, the anesthesiologist will be notified and will come as soon as he or she is able. After a brief screening interview, you will be positioned either on your side or sitting according to the preference of the anesthesiologist. The procedure for inserting the epidural will then begin. For patients with normal anatomy, this usually takes only a matter of minutes, but if the patient has an abnormality of the spine or is significantly overweight the procedure can become technically difficult and may take longer to complete. Once the epidural catheter has been successfully placed the initial dose of anesthetic medication is injected and pain relief generally ensues within five or ten minutes. Our usual practice is to begin with an initial injection and continue with an infusion of anesthetic solution that is aimed at providing continuous pain relief throughout the remainder of the patient's labor. Most patients attain adequate control of their labor pain with this technique. Sometimes during labor a patient will experience the return of labor pains at some later time. Most often this can be relieved by injecting additional doses of anesthetic solution and adjusting the continuous infusion rate; occasionally it becomes necessary to replace the epidural catheter if it appears to have become dislodged and is no longer delivering the medication to the right place.

Can it cause me to have back pain?
Back pain is a very common complaint among persons of all ages and has a number of different causes. Often it is difficult to discern the precise cause in any individual case. Back pain is a common finding in patients who have had vaginal delivery, regardless of what form of pain control is used, i.e., with or without the use of epidural anesthesia. One study examined the number of patients who complained of back pain after childbirth and found that there were equal numbers of patients with back pain after vaginal delivery in both epidural and nonepidural groups. Furthermore, there were fewer backaches among patients who had had a C-Section, and backache among C-Section patients was equally likely after general anesthesia as after epidural. This strongly suggests that, while back pain is often seen after vaginal delivery, epidurals are not a contributing cause for most patients.

What are the risks of having an epidural?
The techniques for administering epidural anesthesia that have been developed have a good track record for safety in the laboring patient. In our practice, we do hundreds of labor epidurals each month, and it is most uncommon for patients to encounter serious complications from them. While it is beyond the scope of this publication to attempt to name and exhaustively discuss every conceivable problem that is possible, the following is a brief overview of those complications that the author deems worthy of mention.

For obstetric epidurals, the most often seen complication is a fall in the mother's blood pressure. This occurs because the nerves that control the diameter of the blood vessels are blocked at the same time as the nerves carrying pain sensations. At this time there is no technique that blocks pain without also blocking these nerves. The result is that the blood vessels dilate, and blood tends to pool in the dilated vessels instead of returning to the heart. The heart thus receives less blood to pump out into the arteries, whose pressurization then drops. If the blood pressure drops to a sufficient degree, the circulation to the placenta may be compromised, causing less oxygen to be delivered to the fetus.

For this reason, after you get an epidural we institute a protocol of very close monitoring of the baby's heart rate (which responds rapidly to changes in oxygen delivery) as well as of the mother's blood pressure. If any significant changes occur, we have drugs available at our fingertips to counteract the blood vessel dilation and help restore blood pressure. Other measures such as supplemental oxygen for the mother and positioning the mother on her side (alleviating potential compression of the major blood vessels by the pregnant uterus) are also taken. When this complication occurs, such corrective actions are nearly always effective. There have, however, been isolated cases in which the administration of an epidural was followed by a drop in the baby's heart rate that did not recover with therapy, precipitating an emergency C-Section. One can only speculate as to whether or not these cases represent adverse reactions to epidural anesthesia or if they were merely coincidental to the administration of the epidural. Some current theories speculate that this effect may be related to pain relief per se and not specifically to epidural anesthesia.

Other potential complications include headache, inadequate pain control, total spinal anesthesia, seizure, and nerve damage. The headache occurs in about one to two percent of persons; perhaps five to ten percent may experience further pain during their labor, but your anesthesiologist can usually succeed in bringing most of them back under control. Trauma to nerves resulting in abnormalities of sensation or strength, usually in the legs, seems to happen about once per ten to twenty thousand epidurals and normally is not permanent although recovery times can be prolonged (in the range of weeks to months). Of note is the fact that a few patients sustain nerve problems as a result of vaginal delivery. Nerve injury in this setting can be caused from pressure by the fetal head on the nerves that course through the pelvis en route to the legs, or sometimes by stretching of nerves if the legs are held back during pushing. In patients with epidurals, these types of nerve injury are usually not recognized until after discontinuation of the epidural, when persistent numbness or weakness is noted. Fortunately, most patients rebound from this without developing permanent problems. Seizure and spinal anesthesia are considerably less common.

Does it hurt while you're putting it in?
Most patients do not experience significant discomfort during the insertion of epidural catheters. After cleansing the skin, a local anesthetic is usually injected to numb the area where the epidural will go. Local anesthetics such as this ordinarily will give a stinging or burning sensation during injection. For the average patient, this is the most uncomfortable part of the procedure, and is of only a few seconds' duration.

After the local, the actual insertion of the epidural needle is typically limited to sensations of pressure or pushing, and by some gritty, popping sensations as the needle is advanced through the tissues. These sensations are entirely normal to feel and should not serve as cause for alarm. Any discomfort during this phase is usually limited to a mild ache and easily tolerated by most patients. Of course, every individual has different tolerances to pain and some persons seem to have more discomfort during the procedure than others. However, for the average patient, the injection of the local with its momentary burning sensation is the worst part.

Will it increase my chances of needing a C-Section?
There is controversy regarding the question of whether or not the use of epidural anesthesia predisposes patients to C-Section. Numerous studies have been done to answer this question, with conflicting results. Some studies have shown that patients with epidurals are more likely to deliver by C-Section than those without. However, others have noted that the introduction of epidurals into an obstetric practice did not increase the C-Section rate. Critics of studies claiming that epidurals tend to increase the C-Section rate point out that there may be a component of selection bias, i.e., that women with difficult labors are more likely to have more pain, are more likely to request an epidural, and are more likely to have a C-Section. On the other hand, well-designed studies of large patient populations have suggested that labor epidurals do indeed increase the likelihood of Caesarian delivery. At this point in time, the answer to this question remains obscure. However, the fact that no indisputable effect has been consistently demonstrated suggests that the contribution of epidural anesthesia to the probability of C-Section, if it exists at all, is probably small.

Does my child have to have an IV?
Most often, yes, but it is usually done after the child is asleep from inhaled anesthesia gases. Occasionally it may be necessary to have the IV in place prior to going to sleep, for instance, when there is concern over the risk of pulmonary aspiration. Your anesthesiologist will make that determination when your child is assessed preoperatively.

Is it safe for children to have general anesthesia?
Yes, indeed. The risk of serious complications occurring in otherwise healthy children as a result of exposure to anesthesia is very low.

Will my child suffer from pain or nausea afterwards?
Pain and postoperative nausea may occur to varying degrees after many types of surgery; however, in most cases these effects can be foreseen and appropriate medications can be given while the child is asleep so that the impact of these conditions may be blunted. If further therapy is needed, it will be addressed during the recovery room stay.

Can I be present while my child goes to sleep?
This is not generally possible due to a variety of reasons related to hospital policy, safety concerns, and logistical considerations. If your young child fears separation then medication is available, at the discretion of the anesthesiologist, which can facilitate a peaceful trip to the operating suite.

Do you use advanced pain control methods as are used in adults?
Yes, epidurals and caudals are frequently used for postoperative pain control in pediatric patients, usually for surgeries on the abdomen or legs. Your anesthesiologist can provide you with more details.

Will someone be present to monitor my child continuously?
Absolutely! At least one member of our anesthesia care team is always present "at the head of the table" throughout the operation, and will check on your child in the recovery room. No patient of CAA's is ever left unattended during the course of an anesthetic.

How long will it be until the effects of the anesthesia wear off?
By and large, the effects of the anesthetic agents will be dissipated before the child is discharged from the recovery room. However, there may be a lingering effect from pain medications given during or after surgery. Usually these medications have a time span in the range of three to four hours.

Is there anything we should be on the lookout for after we get home?
Not as a routine. The anesthesiologist will not discharge the patient from recovery room until he or she has determined that further observation for anesthesia-related complications is not warranted.