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The Massachusetts General Hospital Division of Obstetric Anesthesia answers questions about pain management options during childbirth.
The process of labor and childbirth is unique and unpredictable for each woman. The degree of labor pain depends on factors such as your level of pain tolerance, the size and position of your baby, the strength of your uterine contractions and your prior birth experiences. Some women can control the pain with the breathing and relaxation techniques taught at childbirth classes. If more help is desired, many options are available for the management of labor pain. Some of these options involve the participation of the anesthesia team. Your wishes and medical conditions will determine which specific options are most appropriate for you.
An epidural is shorthand for epidural catheter. A small tube (catheter) is placed near the spinal nerves (epidural space) so that pain medications can be administered. The medication consists of a combination of local anesthetics (numbing medications) and opioids (narcotics). It reduces the sensation of pain in the lower half of your body while still allowing you to actively participate in your baby’s birth. Epidurals are common for childbirth because very little medication enters your blood stream; you do not feel sleepy and there is very little transfer of medication to your baby.
You will be asked to either sit on the edge of the bed or to lie on your side and to curl yourself in a ball as much as you can. The anesthesiologist will cleanse your lower back with a sterile solution and then inject a local anesthetic to numb a small area of the skin. A special needle is then used to locate the “epidural space,” which is just outside the sac that holds spinal fluid. A tiny plastic tube, called an epidural catheter, is passed through the needle. Although many women are concerned that this procedure will be painful, most patients report that receiving an epidural hurts less than a standard intravenous placement. Occasionally, the catheter will brush against a nerve and cause a brief tingling sensation down one leg (similar to the feeling of “hitting the funny bone” in your elbow). Once the catheter is properly positioned, it is taped in place. An electronic pump is attached to the catheter to deliver medication continuously until the baby is born. The medication surrounds the nerves in the epidural space and reduces the sensation of pain.
Epidurals are placed under sterile conditions. Family members and visitors will be asked to wait outside while the procedure is performed.
Yes, we provide you with patient-controlled epidural analgesia (PCEA), which means that you will have a button to push to give yourself additional pain relief as you need it. A small amount of pain medication will continuously flow into your system, but you will control most of your own pain relief. When you feel discomfort with your contractions, you can push the button. We recommend patients do not wait to push the button because the medication takes time to work.
One of the most important things for you to know is that epidural medications do not work right away. If you are still uncomfortable 20 minutes after an epidural is placed, let your nurse know. Once you are comfortable, you can give yourself more medicine as you need it. The pump will not allow you to overdose. It is normal to feel tingling or numbness, heaviness in your legs or to be unable to move normally. However, if you have numbness or tingling in your hands, a sense of shortness of breath, or feelings of lightheadedness, dizziness or nausea, call your nurse so that she/he can check on you. Sometimes these symptoms are normal, but they can be the first early warning signs of a problem.
This is a decision that will be made by you, your obstetrician or midwife, your nurse and your anesthesiologist. In most cases, the obstetrician or midwife will want to make sure that you are in active, progressing labor before an epidural is placed. Your medical condition, and other factors related to your labor, will be taken into account.
It is never too late to consider having an epidural. However, it typically takes anywhere from 15 to 30 minutes (or longer in some cases) to place an epidural, and it typically takes about 20 minutes after placement until maximum effectiveness is achieved. If the birth of your baby is very close, there may not be enough time to perform the procedure or for you to receive the maximum benefit.
Pain relief begins to occur about five minutes after the epidural is placed; maximum effectiveness is achieved after about 20 minutes. As the epidural takes effect, you may notice that your contractions seem shorter because you only feel the peaks. You may also notice that your legs become warm and that your toes tingle. You should still be able to move your legs. You should feel contractions as pressure or tightening in your abdomen, without pain. For some of the time after the placement of the epidural, you may be unable to tell that the contractions are happening at all.
We use diluted (low dose) medications so that you may remain alert to continue pushing during labor. Nevertheless, in some cases you may lose the natural urge to push. Therefore, you may be asked to make a conscious effort to push, and may need help from your nurse, midwife or obstetrician in order to time your pushing with contractions.
The epidural block can be extended for as long as you need it. If additional medication is necessary, it can be given through the catheter. In most cases, any numbness from the epidural will wear off within a few hours of the baby’s birth. When the catheter is removed, all that you will feel is the tape being pulled off your back.
Occasionally, spinal analgesia is used for pain relief during labor. A spinal block is performed in the same part of the back as an epidural. Usually, no catheter is used for a spinal, so only one dose of medication is given. The effect of the medicine is very rapid. Sometimes, an epidural catheter is placed at the same time as the spinal, so that the epidural can be used to give more medication when the spinal wears off. This is called the combined spinal-epidural technique. Your anesthesia team can help you decide what is most appropriate for your situation.
For a cesarean delivery, you will be taken to the operating room. You will receive either spinal, epidural or combined spinal-epidural (or rarely, general) anesthesia. In the case of a spinal or epidural, medication will be used to make your abdomen numb. Your legs will be very numb, and you may be unable to move them. Safety monitors will be placed, including a blood pressure cuff, a heart monitor and a monitor on your finger that measures how much oxygen is in your blood. You will be given oxygen to breathe via a clear face mask. Although you will be awake and able to see your baby soon after birth, you will not be able to see the surgery. During the surgery, you may feel touching, motion, pulling and pressure, but usually not sharp pain. The intense numbness will wear off a couple hours after the surgery is over.
If an epidural catheter is already in place for labor, it can usually be used for the C-section. In this case, additional medicine will be administered through the epidural. Usually there is no need for further anesthesia procedures.
If a spinal anesthetic is chosen for C-section, the spinal will be performed in the operating room while you sit or lie on the operating table. Your lower body will usually become very numb a few minutes after the spinal is performed.
During the C-section, if epidural or spinal anesthesia is used (but not in the case of a general anesthetic), your partner or support person can usually come into the operating room to experience the birth with you after you are numb and completely ready for surgery. He or she will sit next to you at the head of the operating table. There is only room for one person to join you in the operating room. He or she may be asked to leave the operating room at any time if doing so will allow the team to better care for you.
In order to help provide pain relief after the surgery, a small amount of morphine may be given through the epidural catheter or with the spinal.
Considerable research has proven that regional anesthesia is safe for both mother and baby. This type of pain relief allows the mother to be awake, with minimal effect to the baby. Scientific studies show that receiving an epidural for labor does not increase your chances of having a C-section. However, like any other medical treatment, there are risks. You should speak to your doctor if you have any concerns about the risks about anesthesia.
The most common complication with regional anesthesia is the possibility that it may not eliminate all pain. Each patient will have a different experience in terms of their pain relief, and there is often no clear explanation why. It is common to experience sensations such as touching and pressure, but not sharp pain. Most (but not all) spinals and epidurals are successful in preventing sharp pain. If you are having a c-section, your doctors will test how numb you are before starting, and will not proceed unless it appears that you will be reasonably comfortable. If you become uncomfortable or feel unwell during the surgery, you and your anesthesiologist will work together to make you comfortable while considering the safety of you and your baby.
Epidural and spinal blocks can cause a drop in the mother’s blood pressure and heart rate. Usually these effects are easily treatable. Very rarely, there can be more significant problems including infection, bleeding, seizures, respiratory or cardiac arrest and temporary or permanent nerve damage. Despite being secured with tape, sometimes epidural catheters fall out and need to be replaced. Occasionally the tape itself (or sticky materials used under the tape) can irritate the skin.
A “spinal headache” can occur after either spinal or epidural anesthesia. This is reported in one to four patients out of every hundred. The headache lasts a variable length of time, most often less than a week. There are ways to lessen the symptoms, including pain medicine and/or a specific procedure called an epidural blood patch.
Patients are sometimes concerned about backache after epidural or spinal anesthesia. It is common for pregnancy, labor and delivery to be associated with back discomfort even in patients who never receive a regional block. Many patients have some tenderness at the site of epidural or spinal placement for a few days. Scientific studies suggest that regional block does not increase the incidence of long-term backache after childbirth.
Learn about quality and safety in the Department of Anesthesia, Critical Care and Pain Medicine
Pain medications such as nalbuphine (Nubain) are sometimes given intravenously or by means of a simple injection under the skin in order to ‘take the edge off’ of labor pain. The limited degree of pain relief that systemic medicines provide may be all that is needed to make labor tolerable, but often a “regional block” (i.e. epidural or spinal) is desired.
If there is an emergency such that you need a cesarean section very quickly, there may not be enough time to perform a spinal or an epidural. Also, sometimes the spinal or epidural is not effective enough to allow for a cesarean section. In these cases, general anesthesia is used. With general anesthesia, you will be completely asleep for the duration of the surgery and woken up after the surgery is finished. Your partner will not be allowed in the operating room when general anesthesia is used, however they will be informed of your progress.
Though general anesthesia is quite safe overall, there are possible complications, including but not limited to nausea, damage to teeth, aspiration of stomach contents into the lungs, pneumonia, intraoperative awareness, nerve damage, muscle soreness, infection, bleeding and allergic reaction. It is possible for the general anesthesia given to the mother to have a temporary effect on the baby and breastfeeding may need to be temporarily delayed. If you receive general anesthesia, you will likely not have a memory of the delivery of your child, although you will typically see the baby soon after waking up.
You should not eat anything after your labor begins, regardless of your plans for delivery or pain control. Labor usually causes undigested foods to remain in the stomach for prolonged periods of time. This means that it cannot provide nutritional benefits to you and your baby. Also, should you need general anesthesia in an emergency, any food or drink taken during active labor will greatly increase your risk of vomiting and lung injury as you go to sleep. To reduce this risk, only clear liquids will be allowed once you are in labor.
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