It's Not Your Mother's Epidural

The Result: Better Pain Relief Today

In the spirit of the age-old motto of medicine, "Above all, do no harm," doctors involved in obstetrical anesthesia have sought to achieve the most good through the least amount of medicine. The result is the "walking epidural," so named because a woman can get significant—even complete—relief from pain but still feel her legs enough to be able to reposition herself in bed, walk to the bathroom (thereby avoiding a bed pan "experience"), and push effectively during labor.

The walking epidural uses a combined spinal/epidural technique. It gives the guarantee of coverage that the spinal affords, plus the continued but gentle epidural treatment for pain. Use of significantly thinner needles has almost eliminated the "spinal headache" issue, and by using a continuous low dose infusion through the epidural catheter, doctors have taken care of the "wallop" factor that used to be a disconcerting effect of some epidurals.

Further refinements have incorporated the patient-controlled epidural anesthesia (PCEA), which enables a woman to fire off a little extra dose of medication by pushing a button kept close at hand as her specific pain relief needs dictate.

These developments have yielded some positive things for laboring women:

• less epidural agent is used today than before
• the patient tends to feel more "normal" because she retains control of her legs
• there is no interference with Stage II labor (pushing)
• there has been a significant drop in the incidence of rescue and intervention required during labor due to complications from anesthesia.

The older approaches to pain relief in obstetrics, seemingly maligned at the beginning of this article, have become adjuncts to the new "regional" anesthesia of the walking epidural, which puts them in a new light. As the primary method of pain relief, options like narcotics and local blocks were remarkable for their drawbacks. Use as additive pain relief in conjunction with a walking epidural, however, reveals their positive effects.

The evolution of obstetrical anesthesia has been so celebrated that many obstetrician-gynecologists are using these techniques during hysterectomies and other gynecological surgeries, as well. After all, general anesthesia basically induces a controlled coma, which can lead to a rougher post-operative experience compared to that of patients who had spinal or epidural anesthesia instead.

One "Size" Does Not Fit All

The influences of instruction, knowledge, motivation, stamina, support from partners, unique obstetrical presentations, and how each person perceives pain all factor into a woman's experience and pain relief requirements. I advise my patients to seek natural instruction even if they plan on anesthesia interventions, just as I mention to women steadfastly determined to experience anesthesia-free deliveries that they might find themselves requesting an epidural when the time comes. In the end, as I'm fond of saying, it's really not how you have the baby, it's how you raise the baby.