Monday, May 13, 2013

You want to put that where??? Part I

It's L&D 1102 time and I am super excited. I've gotten some pretty awesome questions and am really looking forward to breaking it down for you guys. Today, we're talking about epidurals. It's definitely one of the things that I get lots and lots of patient questions about, so I'm really glad I also got a blog question about epidurals. When I initially sat down and started pecking out some info about mepishmurals, I quickly ended up with something my mom referred to as "textbook-ish" Well, that just wouldn't do, so I'm going to break this down into multiple epidural-related posts!

Now I know there's a cavernous divide between the natural birthers and medicated birthers and this really isn't a forum to discuss who is "right" and who is "wrong." Remember, these questions come from real people who just want to shed some light on whether or not that darn epidural needle really is the size of a number two pencil (it's not)...among other things. Now that I've gotten that off my chest, lets get started, shall we? Here's the breakdown:

Can you explain a little more about the epidural process? (Part I)

How bad does an epidural hurt? (Part II)

Does it really take all the pain away? (Part III)

Here's my disclaimer though: I'm no expert. I've been in L&D for about 6 years now, and have my inpatient obstetrics certification, but I don't know everything and I'm not an anesthesia provider. Whatever you read here can NOT be used as medical advice. I do not replace your doctor or your anesthetist, so I don't want to hear any, "but Hollie said it'd be this way." I'm simply talking from a nurse's standpoint after a few years of delivering babies in a variety of circumstances. Hopefully I can ease some troubled minds and dispel a few rumors in the process.
For starters, it's incredibly important to know that from hospital to hospital and from anesthetist to anesthetist there are lots and LOTS of differences. I've worked at 4 different hospitals now and they all run slightly different. You might have a Certified Registered Nurse Anesthetist (CRNA) do your epidural or you might have an Anesthesiologist (MD). Some hospitals have anesthetists in house 24 hours, where as some hospitals (especially smaller or more rural locations) have to call in anesthesia. Some facilities do combined-spinal epidurals (CSE), some do regular epidurals. Some anesthesia providers use narcotics in their epidurals, some don't. The point to take home here is that there are lots of variables out there in the epidural world. So, I might mention something here that doesn't happen the same way in your neck of the woods. That's just the way things are.

So lets break down the process from start to finish. Here's what a typical, healthy patient of mine would experience:
  • First things first - A patient is hurting and asks for an epidural. If there is an order for an epidural (some docs want their patients to be so far dilated prior to epidural placement), then anesthesia is notified and an IV bolus (bolus = large volume of IV fluid given over a very short period of time) is started. The anesthetist bee-bops over and spends a few minutes reviewing the patient's chart slash health history and gathers the supplies he needs for the procedure.
  • Because it's a sterile procedure, extraneous visitors are kicked out of the room (I've never witnessed this, but I've heard some hospitals kick ALL visitors out of the room-- check at your facility for their policy) and the patient is positioned for the epidural. The two most common positions for epidural placement are sitting up and side-lying. 
  • With anesthesia at the bedside, the procedure, patient's name, date of birth, and allergies are confirmed. 
  • The patient's back is scrubbed with betadine or chlorhexidine or some sort of germ-busting soap. It's cold, wet, and scratchy. A plastic drape is applied to the back... remember, sterile procedure. It also takes just a minute or so to open the epidural tray, draw up the medications and get everything prepped and within reach. 
  • The patient is helped into an ideal position, which resembles something like shoulders relaxed & down, chin tucked down, and curled around the baby (If you're side-lying, you'll also pull your knees upward, all roly-poly like). Anatomical landmarks are determined by the anesthetist by feeling hip bones and spinous processes. A nice rolled out or slouchy back makes those spinous processes easier to navigate and opens up those spaces in-between. Proper positioning is really important.
  • Local anesthesia is injected at the site of the procedure. Yowzers. This is always the most uncomfortable part as the lidocaine stings and burns for a few seconds before the area goes numb. 
  • The anesthetist then introduces the epidural needle and begins to locate the epidural space. The patient feels some amount of pushing or pressure, may feel or hear popping or cracking. It's a bizarre sensation. This is the part of the procedure where holding still in that "ideal" position is highly recommended. Since one of the characteristics of labor is contractions, the patient can expect to have a contraction or two during this part of the procedure. It's unfortunately just a grit-your-teeth and get through it kind of moment... but the sooner the epidural is in, the sooner the relief comes with it. 
  • Once the epidural space is located, a catheter (cath = flexible plastic tube) is threaded into the space. Anesthesia then tests the catheter to make certain it is in the right location and removes the epidural needle, leaving the catheter in the epidural space. The catheter is taped to the patient's back and the patient can continue to receive medications throughout the remainder of their labor. 
  • From this point, many sets of vital signs will be taken to watch changes in blood pressure and pulse. The patient is assisted back to a sort-of laying down position (think awkward pool chair pose) with a wedge under one hip to displace a heavy uterus. Medicine is pushed through the epidural catheter and slowly -but surely- the patient's bottom, legs, and abdomen grow warm, heavy, fuzzy, tingly, numb and most importantly, pain free.
  • An indwelling catheter is put in the patient's bladder to keep it emptied during labor (plus, you can't walk to the bathroom if your legs are numb) and I generally always check a cervix at this time too.
  • Once the epidural has spread evenly, provided adequate pain relief, and all vital signs are stabilized, the patient is repositioned for comfort and naps are encouraged!!
And that's all she wrote. It seems like a pretty lengthy process, but in all actuality, the procedure itself usually only takes a few minutes. The procedure for spinal anesthesia or a combined spinal epidural is different for your anesthetist, but you can expect the same basic layout of events.

Part II is coming soon and we'll talk about whether or not the actual epidural process is painful. I'll also review a few expected side effects and things to watch for. Then, for Part III, we'll discuss whether or not epidurals really take away all the pain. Stay tuned-- there's still a LOT to talk about. Seriously. I just copied & pasted like 4 more paragraphs worth of info into new blogs. So check back again soon!

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Jerika Welch said...

I wish I had come across something like this before I had my baby. I was terrified of getting an epidural. It was not near as bad as I thought it'd be. This will be mega helpful for some soon to be mamas ;)

Erika said...

This sounds horrifying. :) I just tell myself that the cramping I regularly experience from endo is at least as bad as or worse than the labor contractions and therefore labor will be no big deal and I'll go natural without a second thought. Ha. (And don't tell me if I might be wrong!!)

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