OB questions

1. General anesthesia is not an option for a mom in labor expecting a normal vaginal delivery. As a rule, GA is the last option we choose for c-section. There are a lot of reasons for this, but suffice it to say it is safer for both mom and baby to have the section done under some type of regional anesthetic where ever possible.

2. There are a lot of myths out there about epidural anesthesia in general, and specifically for labor. Some are based on a small kernel of truth, while others are purely wrong. As an anesthesia provider, I would not offer any type of procedure to any patient having a baby if I thought there was a significant chance of injury. Not to say that epidurals are completely risk free, they are not. But in the final analysis, it comes down to a risk/benefit analysis, with you making the final decision. Go over the risks with your anesthesia provider. Then make an educated decision about how you want your labor to go. It is, after all, your day.

3. Your post seems to indicate that you are planning for a section. Is that the case? As a rule, I don't generally do spinal anesthetics for labor patients. They are a "one shot" deal, and once they have worn off, there are only two options. Do another intrathecal injection, or deal with the pain until delivery. With epidurals, we leave a small, flexible (usually 20 gauge) catheter in the back, that can easily be redosed. We can also start a continuous infusion into the epidural catheter. On the other hand, I like doing a CSE (combined spinal-epidural) for my patients having a scheduled section. I get the advantage of the dense block of the spinal for the section, and leave an epidural catheter for post operative pain management.

4. For labor patients, I generally don't use lidocaine. Though it produces a dense sensory block, it also produces a pretty dense motor block, leaving the laboring patient almost entirely unable to push. OB docs get a bit testy when that happens. Where I am currently practicing, I use marcaine, generally 0.25%, in the initial bolus dose, then run an infusion of 0.1% marcaine with 2 mcg/cc fentanyl. It works nice, and leaves the parturient able to push when the time comes. I have also used ropivicaine, which has some motor sparing properties, but is VERY expensive.

5. A word about spinal/epidural narcotics: As a rule, when administered to patients with real pain, narcotics do not seem to cause any problems with readdiction. They simply treat the pain. When administered intrathecally or to the epidural space, narcotics do not have the same effect as they would if administered IM, IV, or orally. They attach to the pain receptors in the CNS, but do not seem to cause any of the euphoria associated with other routes of administration. Hence, readdiction is not a problem. However, I understand your concerns. Voice them to your anesthesia provider. It should not be a problem to completely avoid epidural or intrathecal narcotics, if that is your wish.

6. "Epidurals seem to have long term effects." It's hard to address this without knowing what you are referring to. I'd need more information to address this concern.

Kevin McHugh, CRNA

Jenn

I'm a little short of time, but will try to answer some of your main points:

I was so drugged that I am still experiencing w/d symptoms. Alot of doctor's think I'm crazy but I know enough and seen enough people (research and addiction doctor's) to know better.

I am sorry for the things you have gone through. Remember that those of us who do anesthesia for a living specialize in pain and pain management. Yes, it is possible for you to still be feeling the repercussions of addiction, and your anesthesia provider needs to be aware of that.

I am planning for a natural birth but want to be prepared just incase something was to happen. This would better prepare me and not make me go off the deep edge. When I am prepared, I handle things much better.

So do most people. Honestly, I wish I had more patients like you, willing to take the time to become educated before their labor. You are giving not only yourself time to prepare, but your anesthesia provider as well.

I worry about fentanyl b/c of it's strength. It is stronger than heroin.

Fentanyl is a very potent narcotic, no doubt. That's why it is dispensed and dosed in micrograms, rather than milligrams. As a rule, with epidurals, if I use any fentanyl, I'll put 100 micrograms (1/10th of a milligram) in with the local anesthetic dose. Generally though, I don't use it in my bolus doses. In spinal anesthetics, I use 25 micrograms as an adjunct to the local anesthetic. These are pretty small doses, and are given in either the intrathecal or epidural space. And, as I said, narcotics given in these spaces have a much narrower effect than if they were given PO/IM/IV.

I also worry about how the drugs would affect my CNS system since it is so fragile.

This is a difficult concern to address. I have never had a patient have a severe problem as a result of using spinal or epidural narcotics. I have had some patients complain of itching, but have found 4 mg of Zofran works wonders to treat it. These are tried and tested techniques.

I can't take nausea meds with the anesthesia either b/c of the link to tardive dyskinesia/dystonia. Phenergan, reglan, etc. I would like to know which ones cause the least side effects and don't have long term side effects.

I use reglan only occasionally, and phenergan never. Zofran is a much more effective drug to treat nausea, and as an H2 blocker, does not seem to have the effects related to tardive dyskinesia that the others do.

I know of several people who have had epi's and have permanent nerve damage and soreness for months. Thanks for listening.

Well, I have done literally hundreds of epidurals and spinals, and know of none of my patients with c/o long term soreness, or worse, permanent nerve damage (but I am not discounting reports you have). I have seen some soreness related to bruising at the epidural or spinal insertion site. That lasts at most a couple of weeks. Now, I have talked with patients complained of back pain weeks, even months after their first epidural, and who blamed that pain on the epidural. However, after talking with those patients, what I have found is that the pain they experience is not even near the site where the epidural was inserted. Mostly these are young women with little to no knowledge of labor or of early motherhood. On arriving home, they resumed normal activities (work, housework, laundry, caring for the new baby, etc). Owing to the fact that the mom's body is tired from 9 months of pregnancy and labor, and all the work they try to do in the immediate post partum period, they experience their first back muscle spasms, which are quite painful. Not having had these before (its amazing what a young body can do without too much damage), they attribute the back pain to the epidural.

As I hinted at before, if even one tenth of the stories floating around out there about how "my husband's sister's third cousin four times removed best friend's sister got an epidural and was paralyzed from the nasal hair down" were true, we would have stopped doing epidurals, particularly for labor patients, a very long time ago. That isn't to say there are not bad outcomes from spinal and epidural anesthesia, there are. But they are not nearly as frequent or prevalent as some people would have you believe. But again, take your concerns to your anesthesia provider, and let him/her help you sort through your options. You will come out feeling much better informed, and must more able to make decisions about what you want to do.

Let me know how it goes.

Kevin McHugh

I have a serious and honest question and really hope it doesn't get taken the wrong way. Have you considered trying for a birth with NO painkillers? Then you won't have to worry about any of that.

I mean, what if you go into labor and things work out well for you and you can handle it... it just seems from your post you are absolutely sure you are going to need something and may even have a c-section. IMO you doom yourself if you think about it like that.

I'm commenting because I did the same thing. When I had my first baby I was convinced I was going to the hospital and getting an epidural.. and I did. I had a very bad experience and later became a birth doula to educate myself as much as I could about birth. My next baby, I went for the support of a midwife and doula and had a natural childbirth. Truthfully, it was 100% better than the first, faster recovery, everything.

I know you are trying to get everything organized regarding anesthia but for your sake, I really hope you don't end up needing anything! Seems like it would just be easier.

EDIT:
CRIPES! I totally missed your reply to Kevin. TOTALLY! So, you are planning for a natural birth and are just getting prepared in case things go awry. Preparation is great! However, may I please suggest you find a doula in your city to HELP you achieve this natural childbirth? If money is an option there are LOTS that will volunteer and help you. And no, doulas are not anti-med nazi's. Find one that is kind, gentle, and very accepting to your plans.