I was wondering if anyone could help me out on understanding the differences between using an epidural vs. a spinal (sub arachnoid) for labor and delivery pain.
I understand how they are both inserted and potential complications like Hypotension, forceps delivery, etc. but I guess I don't quite understand why you would use one over the other. I know that the spinal is easier/faster to insert but it can cause a "spinal headache" and the epidural will not, that is the only difference my book lists between the two.
I also don't quite understand how much "feeling" a woman is left with. My book says that with an epidural she will not feel pain from labor contractions, but will have pain at birth but that she won't feel the urge to push however I was observing during a labor where mom had an epidural and she could feel contractions and push with them.
I have read these descriptions from my book over and over again and it just doesn't go into much detail. If anyone can help clarify these two for me I would really appreciate it.
Seems to be a lot of misinformation in this thread, so I will try to clear up as much as I can.
Both spinal and epidural anesthesia work on the same principle, which is bathing nerves or nerve roots at or in the spinal canal with a local anesthetic medication to provide varying levels of analgesia or anesthesia for a number of different procedures. Neither depends on "vascular uptake" to be effective, though uptake into the vascular system is how the anesthetics are cleared, and why they wear off after a given amount of time.
A spinal anesthetic is a "one shot" anesthetic. A very small needle is inserted through the dura until there is a return of CSF. A small amout of local anesthetic, usually (but not always) with some narcotic, is injected, and the spinal needle is removed. Spinal anesthesia provides a very dense motor and sensory block. Depending on the volume, baricity, and type of agent injected, it can provide complete lack of feeling from about the nipple line down. (It can even go higher, but that is considered a bad thing, because respiratory muscles begin to be involved.) However, it is a one shot thing. Depending on the agents chosen for injection, duration can range from about 30 - 45 minutes, up to 90-120 minutes, and sometimes even longer. If it wears off before delivery, your only options are to deal with it, get another spinal injection, or use IV medications.
In epidural anesthesia, a special needle is used to identify the epidural space just outside of the dura. A very thin catheter is then threaded into this space, and again, local anesthetic, usually with narcotics, is administered. Again, we are attempting to block sensation at the nerve roots where they enter the spinal canal. Much higher volumes are used in epidural anesthesia. Additionally, the catheter is left in the back, so a continuous infusion of the local anesthetic medication can be administered to the catheter. Also, we can administer additional bolus doses of medication as labor progresses.
Generally, there is a greater degree of control with epidural over spinal anesthesia. I can vary the rate of infusion, and change medications to give greater or lesser levels of blockade, and by choice of medication administered, retain a greater degree of motor control, so mom can more effectively push. However, I can use epidural anesthetics to achieve a block as dense as spinal, so that surgery, to include c-section can be done on the patient with little or no discomfort. (It's not unusual to feel pressure, as when the surgeon pushes on the belly to help push the baby out, but it should NOT be painful.)
So, why do we sometimes choose spinal over epidural? Well, there are a lot of reasons. For example, I choose to give spinal anesthetics to patients having c-sections, because spinal is better for the baby than general, and mom gets to be awake when the baby is born. Additionally, time of onset is much faster with a spinal anesthetic. Generally, once I have an epidural in, I tell moms that it is going to take two to three contractions before they really start feeling any relief. With spinal anesthesia, the patient feels relief in about 10-30 seconds.
Generally, if the patient is going to have a procedure of known duration, and pain management post operatively is not going to be anesthesia's concern, we will use a spinal anesthetic. If we cannot predict the duration, or the duration is expected to be longer than can be achieved with spinal anesthesia, then epidural anesthesia is the way to go.
Having answered your question, allow me to step on my soapbox for a moment. As a CRNA, one of my pet peeves is a prejudice some nurses, physicians, and (most commonly) nurse midwives feel towards epidurals for labor and delivery. They believe (and convey to their patients) that they are somehow less of a woman if they need an epidural for labor. It is an antiquated idea, and one I believe harms women. Yes, I know, women had babies for thousands of years without epidurals. But then, we extracted teeth for thousands of years without anesthesia as well. Does it make a dental patient somehow less of a person for demanding local anesthesia before the dentist drills on their tooth?
I've actually been told by a nurse midwife that, with proper breathing and concentration (as she taught her patients) she could achieve the same level of pain control that I could achieve with an epidural. Nonsense. I don't care how much concentration or breathing you work on, you will never be able to make an incision without pain by this method. However, I can do so with an epidural.
I'm not suggesting that every woman must or should have an epidural. In fact, with I discuss them with my patients, one of the first things I say is that "I'm not here to sell you anything." I simply provide information, answer questions, and allow the mom to make her own decisions, and I respect her ability to do that. If she chooses not to have an epidural, great. That is HER choice. By the same token, it is unfair and unethical for others to allow their prejudice to color how they talk to patients. Present patients with options, and allow the patient to make a choice, unsullied by your preconceived notions.
I also don't quite understand how much "feeling" a woman is left with. My book says that with an epidural she will not feel pain from labor contractions, but will have pain at birth but that she won't feel the urge to push however I was observing during a labor where mom had an epidural and she could feel contractions and push with them.
By the way, much of what you are writing about here deals more with the amount and type of local anesthetic used, rather than any real difference between spinal or epidural anesthestia. When I do epidurals for labor, I generally aim for complete pain management. If the mom can feel the pressure of the contraction without hurting, fine. But I can (and have) administered enough medication to provide complete sensory blockade. Meaning mom doesn't feel anything below the level of the epidural.
And your book is wrong. My goal with epidurals is to keep mom pain free throughout labor AND delivery, while leaving her able to push. We can do that.
KMchugh, thanks so much for the info -- I have a much greater understanding now. I haven't had my OB rotation yet, but I did have epidural anesthesia when I had my daughter, and your explanation matches my experience exactly. Nice to understand some of the science behind it now.
Nice explanation, Kevin. However, I don't think the nurse midwife was necessarily suggesting that she could achieve pain control for an incision. She was talking about the use of breathing and relaxation for labor pain. often proper breathing and relaxation techniques is all a woman needs. Having had two children: one without any meds or IV, I can definitely say that I really had little pain at all.
As a CRNA, it is your job to alliviate pain, especially surgical pain. There is a difference.
Nice explanation, Kevin. However, I don't think the nurse midwife was necessarily suggesting that she could achieve pain control for an incision. She was talking about the use of breathing and relaxation for labor pain. often proper breathing and relaxation techniques is all a woman needs. Having had two children: one without any meds or IV, I can definitely say that I really had little pain at all.
As a CRNA, it is your job to alliviate pain, especially surgical pain. There is a difference.
Bets
Are you really saying that "because I did it, you can too?" Since you have had children, you know what the pain of labor is, and any woman who can't withstand it like a "real woman," like you did, is a whimp? Define "often."
As close to a quote as I can recall: "I can, with breathing and concentration techniques, achieve the same level of pain control with my patients that you get from epidural anesthesia." Not true. For many patients, all the breathing and concentrating in the world will not alleviate the pain many women feel during labor. The last time I checked, something like 75% of women having babies at our hospital did so with epidural anesthesia.
Remember that pain is a subjective experience. I know that there are women who have children with little or no pain, with no medical intervention whatsoever. I think that's fine, and if you did it that way, great. However, there are other women for whom the pain of labor is intolerable, and attitudes such as "I did it without medications, why can't you?" are counterproductive and harmful to our patients.
Again, it's not my job to sell anybody anything. By the same token, its not your job to shame them into your way of thinking. Give the patient the facts, unsullied by preconceived notions, yours or mine, then let the patient decide.
It's not my job to 'sell" anyone anything either. I was stating my opinion,also. Nowhere did I say that one was a "wimp" for choosig epidural anesthesia.I work at a hospital with 2/7 anesthesia and we have a much lower epidural rate than you do: nothing wrong with either. Of course, pain is subjective, we both know that. Working with a laoring woman as I do, I know that not all women need or want any type of anesthesia. If they do, fine, if not, that's fine too. You and I are from two different ends of the spectrum and we are both patient advocates. There is o reason to throw stones and challenge. The original question that the student asked has been answered. You have never had kids and you never will be able to have any kind of appreciation for that. I can never have any appreciation for working with anesthesia because it is not my field of expertise. At no time did I say anywhere "I could do it without mes, why can't you?" Why the defensive response to my post?
I just wanted to say I really appreciate everyone's input and Kevins great explaination. I was really quite disappointed that my book felt that epidurals and spinals only deserved about a half a page each. The information that they did have was quite contradictory compared to what has been explained here and also to other references of them in the same book.
I would never look down upon a woman who used anything for pain management, in fact I am glad to have had the experience of helping a woman with an epidural labor because I feel that when I have a child, that will be the way I go.
kmchugh
801 Posts
Seems to be a lot of misinformation in this thread, so I will try to clear up as much as I can.
Both spinal and epidural anesthesia work on the same principle, which is bathing nerves or nerve roots at or in the spinal canal with a local anesthetic medication to provide varying levels of analgesia or anesthesia for a number of different procedures. Neither depends on "vascular uptake" to be effective, though uptake into the vascular system is how the anesthetics are cleared, and why they wear off after a given amount of time.
A spinal anesthetic is a "one shot" anesthetic. A very small needle is inserted through the dura until there is a return of CSF. A small amout of local anesthetic, usually (but not always) with some narcotic, is injected, and the spinal needle is removed. Spinal anesthesia provides a very dense motor and sensory block. Depending on the volume, baricity, and type of agent injected, it can provide complete lack of feeling from about the nipple line down. (It can even go higher, but that is considered a bad thing, because respiratory muscles begin to be involved.) However, it is a one shot thing. Depending on the agents chosen for injection, duration can range from about 30 - 45 minutes, up to 90-120 minutes, and sometimes even longer. If it wears off before delivery, your only options are to deal with it, get another spinal injection, or use IV medications.
In epidural anesthesia, a special needle is used to identify the epidural space just outside of the dura. A very thin catheter is then threaded into this space, and again, local anesthetic, usually with narcotics, is administered. Again, we are attempting to block sensation at the nerve roots where they enter the spinal canal. Much higher volumes are used in epidural anesthesia. Additionally, the catheter is left in the back, so a continuous infusion of the local anesthetic medication can be administered to the catheter. Also, we can administer additional bolus doses of medication as labor progresses.
Generally, there is a greater degree of control with epidural over spinal anesthesia. I can vary the rate of infusion, and change medications to give greater or lesser levels of blockade, and by choice of medication administered, retain a greater degree of motor control, so mom can more effectively push. However, I can use epidural anesthetics to achieve a block as dense as spinal, so that surgery, to include c-section can be done on the patient with little or no discomfort. (It's not unusual to feel pressure, as when the surgeon pushes on the belly to help push the baby out, but it should NOT be painful.)
So, why do we sometimes choose spinal over epidural? Well, there are a lot of reasons. For example, I choose to give spinal anesthetics to patients having c-sections, because spinal is better for the baby than general, and mom gets to be awake when the baby is born. Additionally, time of onset is much faster with a spinal anesthetic. Generally, once I have an epidural in, I tell moms that it is going to take two to three contractions before they really start feeling any relief. With spinal anesthesia, the patient feels relief in about 10-30 seconds.
Generally, if the patient is going to have a procedure of known duration, and pain management post operatively is not going to be anesthesia's concern, we will use a spinal anesthetic. If we cannot predict the duration, or the duration is expected to be longer than can be achieved with spinal anesthesia, then epidural anesthesia is the way to go.
Having answered your question, allow me to step on my soapbox for a moment. As a CRNA, one of my pet peeves is a prejudice some nurses, physicians, and (most commonly) nurse midwives feel towards epidurals for labor and delivery. They believe (and convey to their patients) that they are somehow less of a woman if they need an epidural for labor. It is an antiquated idea, and one I believe harms women. Yes, I know, women had babies for thousands of years without epidurals. But then, we extracted teeth for thousands of years without anesthesia as well. Does it make a dental patient somehow less of a person for demanding local anesthesia before the dentist drills on their tooth?
I've actually been told by a nurse midwife that, with proper breathing and concentration (as she taught her patients) she could achieve the same level of pain control that I could achieve with an epidural. Nonsense. I don't care how much concentration or breathing you work on, you will never be able to make an incision without pain by this method. However, I can do so with an epidural.
I'm not suggesting that every woman must or should have an epidural. In fact, with I discuss them with my patients, one of the first things I say is that "I'm not here to sell you anything." I simply provide information, answer questions, and allow the mom to make her own decisions, and I respect her ability to do that. If she chooses not to have an epidural, great. That is HER choice. By the same token, it is unfair and unethical for others to allow their prejudice to color how they talk to patients. Present patients with options, and allow the patient to make a choice, unsullied by your preconceived notions.
Kevin McHugh, CRNA