So you're on your way to the hospital to have your baby, and you are determined to have an epidural. Not that you don't already have a zillion things on your mind at this point, but here are some things to keep in mind to help make that epidural experience a positive one:
1. Tell your obstetrician and anesthesiologist about any medical issues you may have. This is soooooooo important I can't overstate it. The most important thing with an epidural is to ensure a comfortable and SAFE experience for you and your baby. Whoever your anesthesiologist will be needs to know all about your medical issues. Certain ones are particularly important to us: problems with high blood pressure during pregnancy? That tells us about risk of pre-eclampsia and possible low platelet counts. Are you taking any blood-thinning medications? Sometimes women at risk for blood clots will be on Lovenox, an anticoagulant given as a once or twice daily injection. If that's the case, the epidural placement needs to be timed around the doses. Sometimes the anesthesiologist may choose not to place it.
Other medical issues worth mentioning are anything to do with your back. If you have structural issues with your back, ie scoliosis, history of back surgery (with or without instrumentation), or simply chronic low back pain, we need to know. All of those things make placing an epidural technically difficult and may potentially decrease its effectiveness. In those situations I'm willing to try the epidural if the woman goes into it with open eyes and full knowledge that it may not work, and that I'll err on the side of stopping before doing
any harm.
2. Be nice. I know it's easier said than done when you're in the worst pain of your life, but try. Your anesthesiologist is doing the best they can, and if they're not there five minutes after you called, its probably because they're putting someone else's epidural...
3. Have the room as empty as you can possibly make it. In some hospitals, like Northwestern, the only three people in the room were the anesthesiologist, the nurse, and the patient. No dads or significant others were allowed. It's not being mean; there are practical considerations at work. First, it's a sterile procedure which means the room should be as clean and clutter free as possible. Second, if a dad faints at the (undoubtedly disconcerting) sight of a large needle in his wife's back, no one is there to help him. The nurse and anesthesiologist are obligated to the mother first. There are stories of dads fainting, hitting their heads, and going to surgery for an intracranial bleed. Third, frankly, it's unsettling having someone you don't know breathing down your neck, looking at what you're doing, or worse yet, telling you what to do.
Where I work now, the policy is up to the individual doctor. I let the dads stay if they insist, but I ask them to stand in front of the mom and hold her hand, comfort her, keep her sitting still, etc.
4. Try to hold still as the epidural is being placed. Let me preface this by saying that I am the biggest pansy on earth when it comes to pain, as are most guys. I wouldn't last 10 minutes in labor. I joke with patients that if dads had the childbearing responsibilities, the human race would've died out thousands of years ago.
That being said, it is incredibly disconcerting for me (and dangerous for you) if you move while I have a large needle in your back, within an inch or so of your spinal cord. Bad things can happen. So try really, really, really hard not to move. Labor must hurt something awful, because women, even the most squeamish ones, eventually sit amazingly still if it means the difference between getting or not getting an epidural. Just gimme five more minutes and your pain will be so much better...
5. If you're at an academic medical center, don't ask an attending to do you your epidural. The falsely enlightened ones who would come to Northwestern when I was a resident would do this, and besides being annoying, it was barking up the wrong tree. By the time I was a senior resident, I had placed literally 400 epidurals, all in a four month span. Any of the attending physicians I was working with had placed...nowhere near that many. They're way too busy supervising and doing administrative tasks and are out of practice. With all due respect to my old attendings, if you must ask someone to place your epidural ask a senior resident, or if you're really savvy, an OB fellow if there are any. Generally, though, a good old junior resident will do the job just fine.
6. Unless you're trying to go without, get the epidural as soon as you can. I'm sure any OB reading this will have a fit, but I still think it's a good idea. Before, the wisdom was that getting an epidural before you were 4 centimeters dilated would slow labor and increase the risk of c-section. But several studies have shown (including one that was completed at Northwestern, by the way) that that is not the case. You'll be comfortable for longer, and should things go awry, the epidural is there for a c-section if needed.
7. The longer you wait, the harder it is to get the epidural. The reason is simple. As your cervical dilation increases and contractions get more intense, they hurt more and it's a lot harder to sit still when the epidural is being placed. Also the strength and intensity of the contractions then are such that it is difficult to get full and quick relief from the epidural. But there's a happy corollary to this one:
8. It's never too late to get the epidural. At least it's never too late from the anesthesiologist perspective. Again, if you can sit still, we can try to place it. I remember on one occasion as a resident where I was asked to place an epidural in a woman who was pushing. They were concerned she would need help delivering by forceps and didn't want her to be uncomfortable. So she stopped pushing, sat up for the epidural, and when she got it, kept on pushing. Amazing. Now if the OB doesn't want it for their own set of medical reasons, that's another story...
9. Don't expect a miracle. In some ways, epidural anesthesia is burdened by its own success. One woman tells another who tells another that her epidural was great, and then that woman comes in to deliver, expecting to do so without a hint of pain. Needless to say, that's simply not realistic. We as anesthesiologists can dose the epidural that way, making you so numb you can't feel anything. The problem is that you won't be able to move your legs, and that will make pushing difficult if not impossible and increase the chance of c-section or instrumented delivery. The OB doctors don't like it when we make patients that numb. Sometimes things like spinal anatomy or the position of the baby can cause issues with discomfort that even the best epidural can't completely fix. The ideal is to feel the pressure of the contractions, so that you can actively push, but without the pain that came with them before the epidural.
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