Dr. Zevy Hamburger returns to Healthful Woman to explain epidurals: how they work, how they are administered, and the advantages of different types of pain relief during labor and delivery. Plus, he gives an update on his experience at Mt. Sinai Hospital through the Covid-19 crisis.
Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy and wellness. All right, Dr. Zevy Hamburger, welcome back to the “Healthful Woman” podcast. How you doing?
Dr. Hamburger: I’m doing great. Thanks for having me again.
Dr. Fox: Fantastic. So last time you were on was in April, and we were talking about COVID and the front lines, which was a very well-received and popular podcast. I think everyone, first of all, was just stuck at home with nothing to do so they said, “We’ll listen to these guys.” And also, I think that your insight and your story really resonated with people about what was going on. So how has that been in the hospital over the past, I guess, six, seven months?
Dr. Hamburger: I’m happy to report that we’ve returned to kind of business-as-usual labor and delivery except that we have, obviously, patients who are testing positive for COVID. But my role has really went back to that as an anesthesiologist instead of that of a critical care physician. We’re obviously prepared for what may come now we’ve had a lead time so we can be ready. But hopefully, those nightmare scenarios never come to bear.
Dr. Fox: Yeah, it’s sort of a really interesting thing. I sort of feel like we’re standing on a seesaw where, on the one hand, we all know that it can get really bad really fast in terms of infections. And on the other hand, everyone sort of sees this idea of the vaccine coming and maybe that’s gonna improve things and maybe improve them quickly or slowly. We just don’t know which direction it’s gonna go and everyone’s sort of like waiting to see each day.
Dr. Hamburger: You’re absolutely right. And I think, again, like as a society, as a group, we kind of have to determine our own risk benefits and what we’re gonna do, but the vaccine really is kind of a light at the end of the tunnel. And I’m hopeful that many, if not all, people will go out and get it. I’m planning on getting one as soon as it’s offered, even though I probably still have some native immunity for my own infection. I’m a big believer in vaccination, especially when the disease is just ravaging the country.
Dr. Fox: Oh, yeah. I’m also, I’m first in line. I mean, I’ll get it as soon as they let me get it. I mean, obviously, they’re gonna give it to the people a little more critical than me first, and whenever my turn is up, go for it. I’m ready.
Dr. Hamburger: Exactly.
Dr. Fox: I hope a lot of people have that philosophy other than those who really can’t get vaccines because the more of us who get vaccinated, we’re not only gonna protect ourselves, but also all those who can’t get vaccinated potentially. And so that’s how vaccines work. Excellent. Well, today we’re gonna talk about something a little more in your wheelhouse over the course of your training. And basically, we’re gonna talk about epidurals. It’s more than just epidurals, obviously, and we can call it regional anesthesia. But you do a lot of these, you and your team do, all day every day on the labor floor, epidurals for women in labor. How much of your OB anesthesia work would you say that is?
Dr. Hamburger: Much of what I do is monitoring and placing epidurals. It’s about 70% of what I do on the labor floor. The other 30% is monitoring patients with coexisting diseases, people who are sick with other medical problems, and really working hand-in-hand with my OB colleagues to make sure that both the mother and the baby make it through delivery safely. Comfort is obviously very important to all of us, but safety is always paramount. And I’m part of that treatment team to make sure that people stay safe while they’re having a baby.
Dr. Fox: Right. So in terms of an epidural, how would you explain to somebody exactly…what are you doing when you administer an epidural? How does it work? How do they get pain relief? What do you do? Where does the needle go? Step-by-step, basically.
Dr. Hamburger: An epidural is just a thin plastic tube that goes in someone’s back, outside and below the spinal cord. The spinal cord actually ends higher up from where we’re placing epidurals for labor. And what we’re doing is we’re instilling a mixture of a local anesthetic and an opioid into this space where nerve roots run, where they live. And we fill this space with this medication, with this fluid, and it bathes these nerve roots in this low concentration of medication and that provides pain relief in almost like a band-like pattern. The beauty of this technique is that it’s regional. It’s localized anesthesia, as opposed to me giving injections of morphine in someone’s vein, or inhaled medicines to their lungs, where it affects the entire body, goes to your brain, causes euphoria, causes sleepiness, causes other types of side effects. With a regional anesthetic, an epidural or a spinal or nerve blocks, we’re really targeting the nerve that sense the pain, and that’s really it.
And so that’s where a lot of the benefits come from epidurals. The placement of an epidural, it’s a procedure that requires sterile technique. What we do is we actually find that very fine line, that thin spot in the back with tactile feedback, using our hands. We line it up by looking with our eyes and looking at the superficial landmarks, the bones that are there. And then really, once we’re past those, the skin, a little deeper than the bones that are there, it’s really based on the feedback that we get in our hands when we’re placing it. We’re really aiming for a very thin line that’s there, hoping not to go too shallow or not too deep so we can get the most effective pain relief for people in labor.
Dr. Fox: Right. And how would that differ from a spinal?
Dr. Hamburger: So a spinal anesthetic differs in that it’s a single shot of medication, a little bit deeper than an epidural. With a single shot of medication, you have a finite time period for how long it lasts. With an epidural, we leave a small plastic tube behind so we can continue the medication indefinitely. Often the techniques are combined in what we call a combined spinal-epidural all through the same needle in order to give a dose of medication upfront to provide rapid pain relief, or provide rapid anesthesia for a cesarean delivery, and then leave that plastic tube behind so we could prolong the anesthetic as needed. Even though there’s two separate techniques, they’re often done together. Even though they’re two separate techniques, they’re actually quite similar.
Dr. Fox: Right. From the patient’s perspective, right, she would not know if she’s getting a spinal or an epidural because she’s in the same position. The anesthesiologist is cleaning the back the same way and numbing up the skin the same way, putting this, you know, a very similar needle in the same spot. But from your end, when you’re doing an epidural, where “epi” means “outside of,” you sort of stop before you puncture the actual sack, right, the dural sac, and that’s where you leave that catheter below the spinal. You actually intentionally go into the sack with a smaller needle and leave medicine behind, correct?
Dr. Hamburger: Exactly. That’s how they’re technically different. You’re correct in that the feeling during placement is pretty similar. It’s a pressure sensation that usually takes about 10, 15 minutes to get to the right spot. But the feeling is pretty similar between the two for the person who’s getting the procedure.
Dr. Fox: Right. And the other thing is, for people who have heard of the term like a spinal tap, which is essentially the same thing as a spinal procedure that you’re talking about, but in that situation, the goal is actually to remove some of the spinal fluid for testing, like to check if someone has meningitis or something like that. Whereas in your situation, your goal is to insert a medication into that area, but it’s exactly the same procedure.
Dr. Hamburger: Exactly. So technically speaking, they’re quite similar. We’re using a very, very fine, blunted needle to actually enter that last layer. It’s called the dura mater, which is what keeps the fluid that bathes the spine and the brain inside. We’d pass that needle through. First, we can sample if we need to, but generally, we’re just injecting medications. A spinal tap, it’s the same exact procedure, they’re just removing it. With an epidural, our goal is actually not to violate that last layer with the epidural needle itself just because it’s a little larger, but that’s always a risk whenever we do an epidural. But the goal is not to violate that last layer.
Dr. Fox: Right. And so in terms of this procedure in labor for pain relief, you’re saying one of the big benefits is that it’s sort of localized to the nerves instead of going in her entire system through the bloodstream. But I wanna sort of expand on that a little bit. So why is that better? Meaning yeah, I guess it’s, one might say, “Well, what do I care if I get a little sleepy and go to sleep during labor a bit if I get something intravenous?” So what are the real advantages of doing it this way as opposed to giving her something like morphine, for example, like an intravenous drip?
Dr. Hamburger: There are always other options. The reason why epidurals are often superior is the level of pain relief that you could achieve with an epidural is far greater. And that’s just because when someone is pregnant, it’s risky to really knock someone out with sedation or a larger dose of morphine enough to really control the intense pain that labor can present. Obviously, everyone experiences labor pain differently. You and your neighbor may have completely different experiences. You may feel the pain differently, but the labor epidural will block the pain significantly more than pretty much anything else out there.
The other added benefit of the epidural besides for superior pain relief without making you sleepy, or much less sleepy, is the fact that we can actually use the epidural not just for analgesic, for pain relief, but for anesthesia for real surgery if there’s an emergency. So if someone has an epidural in their back, and it’s been working well throughout labor, and now, god forbid, there’s an emergency and you need a stat cesarean delivery, we can often utilize the epidural that’s already there, that tube already there, give a stronger dose of medication and keep them awake for the cesarean delivery, providing a profound numbness for an actual operation. So we use epidurals for very good pain relief, but also for safety on labor and delivery.
Dr. Fox: Right. And I think that a lot of people, they may not realize that for women who are pregnant, there is a real risk to being put to sleep for surgery. I mean, most people who have it are gonna do fine through it and afterwards, but there’s a little bit risk when you’re asleep. There’s a risk of sort of the contents coming out of your stomach and what we call aspirating into your lungs. And so, pretty much all of us prefer that patients who are having cesareans have it under either an epidural or a spinal, unless we think there’s another reason they would have to be put to sleep. And it’s really different, also her experience of the labor and the birth between being awake and being asleep when your baby’s born.
Dr. Hamburger: Absolutely. And I’m not sure how many people recognize it, but on many busy labor and delivery, especially on ours, whenever we have a patient who has any risk factors for needing a cesarean delivery, or having bleeding, or really almost any other risk factor…a colleague’s actually come over to us and asked us to do epidurals earlier in the course of their labor, because I think it really helps people take a deep breath that…or, in the right place, the patient has this level of protection in case we have to make this decision to do a cesarean delivery, that no one takes lightly. But at least we know that our ducks are in a row, that we have this device ready to go. One less thing to worry about.
Dr. Fox: Yeah, I mean, in some people, if you know it’s more difficult to place someone who’s maybe a little heavier or someone who has a curved back like scoliosis, those are more challenging on your end to place. It always makes us feel more comfortable if they’re in earlier so you’re not trying to put them in emergently. Or, like you said, for example, for our twins, or for people who’ve had a prior cesarean, where the risk might be a little bit higher of needing a cesarean and laboring. We don’t mandate an epidural, but it changes maybe the risk-benefit balance for some women who are potentially considering not getting an epidural, just something else to think about.
Dr. Hamburger: And it’s something to discuss earlier on in the pregnancy, which I know your team always does. But it’s important when you’re building a delivery plan, when people are thinking about how they want their experience to go, to really factor in that the epidural is obviously there for pain relief, but there’s other reasons to get them as well, when you’re making your decision about whether or not you want one for your labor.
Dr. Fox: Right. And one of the other nice things about an epidural or a spinal as compared to intravenous is, in addition, when you give an intravenous to the mother’s entire body getting it, those medications do go through the placenta and the baby gets them. And so when people always ask, “Well, is my baby gonna get the medicine?” we’ll say, “Well, not if you get an epidural or a spinal,” because then it’s just in your nerve space and the baby doesn’t see any of that. The only effect the baby might see is if it maybe changes your blood pressure and that sort of secondarily, the baby sees that. But no direct medicine to the baby when you get a spinal or epidural.
Dr. Hamburger: Absolutely. Some medicine is always gonna be absorbed, but it’s not clinically relevant. It doesn’t really have an impact that we notice upon delivery as opposed to giving larger doses of morphine, which you’ll need for the second stage of labor, for the pushing part, or just when you start to progress in which those medications all cross and babies come out sleepy, almost a little bit under, like anesthesia, which is safe for a baby to have anesthesia. But it’s definitely more challenging upon delivery because we really have to watch the breathing extra carefully at that point.
Dr. Fox: Right. When moms get general anesthesia, meaning they get a full dose of medicine to put them to sleep and then they get a tube in the throat to help them breathe and we deliver the babies, sometimes the babies are born with the same effects that the mother would have. The baby is sleeping, the baby needs some assistance in breathing. And it’s temporary and the baby’s gonna be okay. But sometimes those babies have to go to the intensive care unit to be monitored until the medication is out of their system. And that’s again, it’s a bummer, if your baby has to go to the NICU because he or she is sedated. If that has to be done, it has to be done. But if it’s avoidable, that’s always nice. One of the other things which is again, something that a lot of women might not know, particularly if they’re having a cesarean, is if they have an epidural or a spinal, you’re able to give them the medicine that’s gonna help them after they deliver, correct?
Dr. Hamburger: Well, that’s another big benefit. Whenever we get to do regional anesthesia, spinal injection or epidural injection, and a cesarean is necessary, we include a dose of medicine, or actually a very, very small dose of morphine, that works very differently when it goes in your back than when it goes in your vein. [inaudible 00:14:43] a shot of morphine, what we’ve been talking about up until now, it causes a bit of euphoria. It causes a bit of sleepiness and drowsiness. But when it’s given in the back, instead of just lasting two or three hours, this very small dose actually can last up to 20 to 24 hours, providing some level of pain relief for the operation itself. The main side effect from that is itchiness and nausea. It’s rare to cause sleepiness or any of the other complication that intravenous morphine causes, but likely, much less than intravenous agents would. And so getting that dose of medicine can really help someone on their path to recovery because it helps them feel better for longer without a lot of the other side effects from other types of painkillers.
Dr. Fox: Yeah. Ironically, when we talk to women about their recovery after cesarean, the first 24 hours after delivery tend to be a lot easier than the next 24 hours. Because those first 24 hours, they don’t tend to have a lot of pain because they still have that what we call Duramorph or the morphine in the dural space. And once that wears off, sort of on the second day after surgery, that’s when they tend to have a little bit more pain, which is surprising to women unless you let them know in advance that that’s how it’s gonna be.
Dr. Hamburger: The whole point of this obviously, is for pain relief. But taking away pain also improve safety and outcomes because if your pain is improved in the first 24 hours, you’re gonna breathe deeper and prevent pneumonia. If your pain is improved in the first 24 hours, you’re gonna get up and walk and promote healing and prevent blood clots. So pain relief is obviously, very important for people because it affects their experience, but also medically, it makes a big difference to have less pain so your recovery is safer.
Dr. Fox: Excellent. Now, I know you mentioned this before sort of briefly, but if someone’s curious, “Hey, what’s gonna happen when I get an epidural or a spinal?” can you take someone through it sort of step-by-step what they would experience from the time you’re done explaining to them and talking to them to the time it’s placed?
Dr. Hamburger: Absolutely. So the first thing that we do is someone from my team will come and evaluate you. That means talking about your medical history, your surgical history, allergies, problems potentially with anesthetics in the past, or family history of your problems, and make sure that you’re a proper candidate for an epidural. Sometimes we have to check different lab tests to make sure that your ability to make blood clot is normal. Once that’s all checked out and squared away, what we’ll do is we’ll have your nurse position you sitting up on the edge of the bed. The reason for that is because epidural placement relies heavily on positioning.
Now, when people sit up and someone’s behind them, it’s kind of a scary experience, especially the first time. Usually, the second time everyone’s kind of relieved because they’ve gone through it already. They know it’s not as scary as they thought originally. But the position is really the most critical element. And positioning is important because the area we’re aiming for is surrounded by a cage of bones, and positioning is what opens up the door and lets us in. It helps speed up the process drastically. And the best position is a slouch, sitting with terrible posture, really sinking into your butt, sinking into the bed as best as you can. Almost like hugging your baby inside the stomach, rounds out the lower back as opposed to arching in the lower back.
Once you’re in that position, what we do is clean your back. We use a soft sponge with some cleaning solution. We often clean it once or twice. We let that dry as we set up our equipment. When we’re all ready to start, we give a warning because we’re behind you. We feel your hips and feel your back with our fingers. Once we find a surface spot to go, we inject a very small needle into the back. We inject some local anesthesia, some numbing medicine just to numb the skin of where we’re going. Most of the discomfort from epidural placement is just that tension burn right in the beginning of it. And that’s because that’s where the pain fibers really live. It’s skin deep.
After the area is numb from that injection, we use a different type of needle, an epidural needle to find the right spot. The area is now numb. You don’t really feel any pain, but it’s a very strange pressure and clicking feeling as we’re going and finding that right spot. Since we’re aiming in between different bones, it’s very common for us to push against it and you feel kind of pushing in the back. Once we find the right spot, we ask you to kind of stay still. At this point we have the decision whether to do a spinal part of the epidural, like we said, the combined technique, or a regular epidural. But either way at this point, it’s super common to feel a small shock of electricity, almost like a funny bone feeling in one of your legs as we do the spinal injection or as we pass the plastic tube.
It’s very short lived. It should be quite temporary and it goes away in just a few moments. If it lasts longer, then we adjust things and make it go away quick. Once we’re done passing the plastic tube, we take the needle out. The only thing that’s left behind, the only thing left behind is that small thin plastic tube. It’s very thin. We secure it in the right spot and then we do a series of tests to make sure that the tip is not in the wrong spot. The wrong spot would be inside of a blood vessel or if the tip of the plastic tube ends up where the spinal medicine goes, a little deeper than the epidural are supposed to go. Neither of those things actually are really very dangerous, we just like to determine it early. If it’s in a blood vessel, we have to replace it. If it’s a little too deep, you replace it as well at that point in time. Again, not very dangerous, it just has to be identified.
Once we’re all done, we tape it up, lay you back down in bed, and then start the medications. Usually it takes about 10 or 15 minutes for the medicines to kick in once the epidural is complete. Then we spend the next few minutes monitoring your blood pressure, monitoring the baby’s heart rate which can dip after the blood pressure goes down. Often, we fix both just by fixing the blood pressure. And we also teach you how to use your infusion pump. At our institution, you get to control your epidural infusion. You get to control how much medication you get. The goal is to provide an individualized experience. So this has the best way of providing that. And then your nurse continues to watch your blood pressure for a little while afterwards and we’re available, basically, 24/7 to help manage anything and everything that comes up.
Dr. Fox: Right, in terms of what you said, the 10 to 15 minutes, that’s just for an epidural. I mean, if they have a spinal part, they’re gonna feel relief usually within a minute or two.
Dr. Hamburger: So the main difference between the techniques that combines spinal epidural or the standard epidural for pain relief during labor is the speed of onset. And so with the regular epidural, usually it takes about 15 minutes to start kicking in. Usually the full relief comes about 30 minutes below the initial placement. When we do the combined technique where we’re giving a dose of medicine a little bit further in, we give that dose and the pain relief is usually within three contractions. You have one contraction, that still feels uncomfortable. The next one is still a little uncomfortable, much shorter, and the one after, you start to feel better and then better, and then better. The tricky part is is besides for the pain relief coming quicker, the side effects of the epidural also come on quicker.
So the low blood pressure is usually a little bit more profound and a little bit earlier. That can cause the baby’s heart rate to go down. So we’ll monitor pretty closely after the combined technique just like we do for an epidural technique. But we usually see things quicker. There’s a little bit more itchiness upfront also with the combined technique. So the pain relief is quicker. The side effects which are similar to a regular epidural, also quicker. But often, if someone’s in a lot of pain or in advanced labor, meaning that they’re dilated more than two, three centimeters, the combined technique is really the best way to get the pain down quickly.
Dr. Fox: And then what would you discuss with people about the risks of doing an epidural or a spinal? I know they’re rare. But what are the risks we’re talking about?
Dr. Hamburger: The main risks that we discuss with people, number one, like I said, it can make your blood pressure go low and that can impact the baby, especially temporarily. But usually, when we fix the blood pressure, we can fix both you and the baby. Number two, it makes people itchy. Those are the two most common side effects. Much less common, about 1% to 2% of the time people get a unique headache, which we call a spinal headache. It’s called the post dural puncture headache. What makes the headache unique is that it’s positional in nature. Normally, it starts off about 24 to 48 hours after the epidural is placed. And when someone sits up or stands up, they have a headache in the front of their head or also in their neck. They feel neck stiffness, too. And then when they lay down, it’s all gone. They sit up, it comes back.
That positional element is what makes it unique. Most headaches people get after having a baby. And in about 40% of women that get headaches after having a baby in that first week are not this type of headache. But if it is this type of headache, we come and evaluate you and offer you treatment options. The most effective treatment option that we have is another epidural procedure called the blood patch to fix the first one. It sounds ridiculous, but that’s what works the best. But again, that’s a conversation that we have. When we’re placing the epidural after we’re done, we often have some indicator, some of the higher or lower risk of developing this headache. But for all comers, the risk is about 1% to 2%.
Low back pain happens in about 40% of women after having a baby. That really doesn’t change whether you have an epidural or not. Most back pain comes from changes in hormones after delivery, specifically a hormone called relaxin that tightens up all the ligaments in the body. People feel it in the low back because of poor muscle weakness from the pregnancy. But it’s unlikely directly from the epidural. The pain people get in the back from an epidural is usually for a day or two to touch just because, similar to when an IV comes out, there was a needle there, now it’s not. The area is just a little bit sore to touch. Permanent problems like nerve injury, bleeding infection, very, very rare but always possible. So something to keep in mind. We’re talking 1 in 100,000, but it’s always part of a risk-benefit profile to discuss the scary thing even with the things that aren’t scary.
And then, other things to consider with epidurals is that epidurals work 95% of the time quite well. Five percent of the time, an epidural’s a little bit wonky. Wonky means it’s only working on one side potentially, or there’s just a small strip, an area that’s not working so well. We can often fix that just by giving extra volume, extra doses, positioning you a little bit differently, or wiggling the plastic tube at the skin. But about 1% to 2% of all epidurals are actually replaced during labor because they’re just not working perfectly. It’s very hard to determine during placement if that’s gonna happen to you or not. There’s no way to tell because once we feel that we’re in the right spot, we put the plastic tube in and start it. That’s always a possibility, the need for replacement during labor, and that just doesn’t work 100% of the time. But that’s the case with all procedures, there is always going to be a failure rate.
Dr. Fox: And then you mentioned before about checking some blood tests and doing a history. Who would be someone who should not get an epidural or a spinal, someone you would say it’s just not safe to place?
Dr. Hamburger: There are only a handful of true contraindications. There’s been a handful of reasons where we absolutely positively will not place an epidural. The first and foremost is if someone doesn’t want one. We’re never gonna force this procedure on anyone or any procedure on anyone. We always discuss the risk-benefits. If it’s not your cup of tea, you do not have to have an epidural. There’s never gonna be pressure. We’re not there to sell them to you. We’re there to help you through your labor. Other things that we commonly encounter, if someone has a bleeding disorder. The reason why that’s a challenge, a big problem for us is that, normally, god forbid, you cut yourself on the arm. Even if someone has a bleeding disorder, you could hold pressure. It’ll take longer for the bleeding to stop, but if you just hold pressure over that cut it will stop. An epidural is behind a bunch of bones. So if we hit a vein, which is a common occurrence, about 1% of the time, normally, if you don’t have a bleeding disorder, your body will clot that off pretty quickly. It won’t cause any problem. But if you have a bleeding disorder, you can’t make a strong blood clot over that vein, and that blood can accumulate. And you can’t hold pressure because it’s behind a bunch of bones. That blood can pool, create a pocket and put pressure on nerves causing nerve injury.
And so that’s why people with bleeding disorders, we don’t place epidurals. One of the challenges is that a platelet count, which is platelets are one of the different parts of a strong blood clot, often goes down during pregnancy. It’s not directly related to pregnancy, but some people have different diseases that cause it to go down. Often, it’s not dangerous at all. People form strong blood clots. Some hospitals have specific cut offs, but many, many, especially academic centers, try to individualize the plan based on the suspected diagnosis to really determine what the safe level, what the safe number is. And then lastly, preeclampsia, which is a disease of blood pressure during pregnancy, which I know you have other podcasts on, can cause platelets to go down and blood not to make strong blood clots. And that’s true, it would be something that we check lab tests before we can actually place an epidural.
Other things that can impact, a lot of people have a history of low back pain before pregnancy or during pregnancy. Some people have surgeries on their back. Generally speaking, it’s rare for those to cause trouble with epidurals. That’s just because the nature of low back pain is often from disk problems, which is in the front of the spinal cord. And we’re really coming from the back of it. And if you think about it, many times back pain is treated with epidural injections. But it does cause a lot of anxiety if you have chronic low back pain or instrumentation in your back. There are other contraindications. But that’s, again, a discussion which should be personalized between you and your anesthesiologist on your day of delivery.
Dr. Fox: Right, so those are the more common ones. Now that’s for sure an amazing description of what an epidural is, and what are the risks, and what are the benefits, and what are replacements, and who gets them. I wanna go over with you just some of the common questions that are asked all the time about epidurals and some of them are maybe more in your world and some of them are more in my world. But we could talk about them together because we always function as a team. So the first thing I’m gonna ask is when is the right time to get one in labor? So someone says, “Yeah, I’m gonna get an epidural. That’s my plan, or I think I’m gonna get one. Should I get one? I’m 2 centimeters, or I’m 5 centimeters, or I’m 8 centimeters.” We get that asked all the time. What do you tell people?
Dr. Hamburger: I tell people, it’s a personal decision and it’s completely up to them. It does not matter in terms of changing your labor course when you get an epidural. It’s easier to get an epidural and sit still for 15 minutes when you’re not having very painful contractions. Especially, if you’re one of the people who epidural placement may be more challenging, if you’re a little overweight or if you have a curvature in the spine like you mentioned before, it’s definitely easier and more comfortable to get the epidural earlier. Obviously, some people don’t have a choice because they come in in rip-roaring labor and very uncomfortable, then we can accommodate that as well. So there is no too early.
Now in terms of too late, generally, unless the baby’s coming out, we generally have time to do an epidural. If it’s your third, fourth, fifth baby, that process is pretty quick. And remember, the procedure takes 15 minutes and then the pain relief, even in the fastest type of epidural that we have, the combined technique, also takes about 10 minutes. But babies can be delivered within 20, 25 minutes. There’s usually not much of a point in getting an epidural at that point in time. So again, that’s the decision that we have to make together. But anywhere between 0 and 10, it’s completely up to you. It doesn’t matter.
Dr. Fox: Yeah, I tell them the same thing. I say the right time to get it is when you want it. And if you come in and you’re in enough pain that you want one and you’re 1 centimeter, or 2 centimeters, unless we plan on sending you home, like, “Yeah, get an epidural.” And if you wanna wait because, I don’t know, you wanna labor without one or you wanna see how long you can go, or you prefer to be a little more mobile because it’s harder to walk, so fine. Then you can wait. They say, “When is it too late?” And I say, “Well, if the anesthesiologist has to deliver your baby during the epidural, it’s too late.” Other than that, not so much.
Dr. Hamburger: And that’s happened before.
Dr. Fox: Yeah, it happens.
Dr. Hamburger: It’s happened. Yeah.
Dr. Fox: And this is a change a lot of women may have heard differently. And even…I mean, just when I was training, I remember all the time, not in Mount Sinai because they were…Mount Sinai has always been really, I think, ahead of the curve with OB anesthesia for a lot of reasons. One of them is Dr. Bernstein was there for a long time and he was great. But in other hospitals I was at, the anesthesiologist would be like, “She can’t get an epidural.” I’d be like, “Why?” He’s like, “It’s too early. She’s not yet 4 centimeters,” and then someone else, “She can’t get an epidural.” “Why?” “It’s too late. She’s already seven.” I was like, “All right, so you have to be five or six. And that’s it. That’s the only time we’re placing it.” And it was frustrating. But that’s sort of how people felt. They thought if you got it too early, you’re going to cause a C-section. And if you got it too late, somehow it just wasn’t gonna be helpful. But that’s really not how we do it at Sinai, which I think is the way you do it is the correct way, I believe. Unless it’s really, really just too late because she’s gonna deliver.
Dr. Hamburger: Oh, I think so too.
Dr. Fox: Yeah, that was just a way I think to avoid doing procedures.
Dr. Hamburger: Yeah. A lot of that has to do with really two elements of epidural placement. Number one is the staffing in a hospital. So if you come to a large institution, there’s always obstetricians, there’s always anesthesiologists around there in the building 24/7 and capable of helping. When you’re coming to a smaller hospital, that may not be the case. And so therefore, epidurals may be discouraged until there’s more people around to be able to help. The other thing, which is another question that we commonly get, and I’m not sure if this is gonna be one of your questions…
Dr. Fox: Oh, I’m sure it is.
Dr. Hamburger: Yeah, do epidurals slow the speed of labor and delay the delivery of the baby? And I think that’s a lot of people’s hesitation to get an epidural early. But since 2003, ACOG, the group of obstetricians and gynecologists, and maybe even earlier, really has kind of pushed away from that message. And that’s really based on the data. There’s been many, many studies, since very early studies, which suggest that maybe it delays labor. Now, almost all of the studies that I have seen, and we have meta-analyses which groups all these studies together to look for more answers, really show that it does not delay the time to delivery. It does not delay the dilation of the cervix. And even the pushing, the recipes [SP] that are now, we call them ultra-low-dose, in 2017, a large meta-analysis came out that showed that even the pushing stage is not much altered or really not altered at all for epidurals.
Some of the earlier data that suggested that maybe it was was really very skewed. A lot of times, earlier on decades ago, people would get epidurals because their pain was more or labor was stalling. And so for those reasons, they got the epidural. And then when you analyze time to delivery, yeah, it took longer because those people were in more pain. When studies were better controlled, they actually found no real difference. So that’s why it’s really a personal decision. It doesn’t really impact. It’s targeted therapy. It’s not really affecting contractions directly. And so for that reason, it’s really a personal choice.
Dr. Fox: Yeah, a 100%. I mean, we talk about this all the time with women. The older studies were not what we call randomized. They basically looked at the women who got an epidural and they compared them to women who didn’t and they said, “Well, the women who got an epidural had longer labors and worse C-sections.” Well, yeah, they got an epidural because it was more likely to be their first baby. They were having harder labors, longer labors, more painful labors, and so they got epidurals. But the reason they had higher C-sections and longer labors is because they had longer, harder labors.
The women who came in and blew through labor in two hours and pushed three times and delivered, yeah, it’s not because they didn’t have an epidural. It was just that’s who they were. When they did these studies better, not only did an epidural not prolong labor, in a lot of studies it actually shortened labor, which was interesting. I don’t tell people to get an epidural to shorten their labor, but the data points, if anything, in the opposite direction, and it does not increase the risk of C-section. Yeah, so those are two big questions we get asked all the time about slowing down labor and increasing the rate of a C-section. Can you explain what is the concept of a walking epidural? People ask that all the time. “I want a walking epidural.”
Dr. Hamburger: A walking epidural is an ultra-low-dose epidural but originally was described as that combined spinal epidural technique where we give a small dose of spinal medicine upfront. That small dose that we give at our institution is a very low dose of fentanyl, which is an opioid. It doesn’t take away any of your strength, initially. And so, in some places, you may be allowed to get up and walk around. At our hospital, we actually don’t allow people to get up and walk around, even though with our epidurals most people have preserved strength, because there’s definitely the risk of tripping and falling and it’s the last thing that you wanna go when you’re having a baby. But you may have your strength, but you may not know where all 10 toes are. Things just feel different. And so for that reason, at our institution, we don’t allow people to get up and walk around, even though we’re using the ultra-low-dose epidurals that are commonly referred to as walking epidurals.
Dr. Fox: Right. And then the question you already answered, which is common one was, will it cause chronic back pain? And like you said, I agree. It does not cause the back pain. A lot of people get back pain, and a lot of people get epidurals, but the two aren’t related. People who don’t get epidurals also get back pain. And people who do get epidurals don’t get back pain. They’re not related to each other.
Dr. Hamburger: The risk is really high. It’s 40%. Almost one in two women are gonna have low back pain starting usually about a week after having a baby and lingering for weeks on end afterwards. And people who’ve had low back pain before, it’s often worse. So when someone tells me they’ve had back pain before, I ask them if they’ve ever seen a specialist for their back pain. I also ask them to make an appointment with someone. They may have to cancel the appointment because they never end up getting the back pain, but they should already prepare for what’s coming. Because it’s very, very common after having a baby, especially vaginally, to have back pain.
Dr. Fox: Absolutely. And the last question I wanted to cover with you, how do you handle the situation? You’re at a teaching hospital. And when a patient says, “I don’t want the resident to do the epidural, I want you. I want Dr. Hamburger. He’s the man. I want you to place it.” How do you navigate that and how do you talk to patients about that?
Dr. Hamburger: So firstly, as much as I’m spending a lot of time on the labor floor, I’m not there 24/7. That’s number one.
Dr. Fox: Seems like you are.
Dr. Hamburger: Yeah. But number two, when our residents place epidurals, they’re under direct supervision. We’re there. We’re watching. Their hands are like our hands when we’re placing an epidural block. Our resident is not someone who really has never seen hospitals before, have never placed anything or done any procedure before. Residents, especially in anesthesia, they’re always in at least their second year of training. They’re always experienced in the main operating room to a degree. And part of training is teaching them what to feel for and how to feel. And we’re directly observing them the entire time, making sure that everything is going the same way it would be if my hands were doing it. And so when my wife came in for her labor, for her epidural, I was perfectly happy having our resident do it. And most of my colleagues kind of feel the same way, because we’re responsible for them and there’s always someone supervising.
I would encourage people to definitely consider letting residents take care of them because often, especially at other hospitals, the residents end up doing a lot of these procedures and have a very strong skill set in them. Sometimes they do more than some of the faculty who are watching them. So they may actually have done more epidurals in the past three weeks, and the faculty member may not have done an epidural in weeks on end or a month after or longer than that. So it’s definitely not a slam dunk, which way you should go. It’s always gonna be personalized. But the residents are very capable, and very caring, kind, compassionate doctors.
Dr. Fox: Yeah, I tell them the same thing. When my wife came in for labor, she was like, “Yeah, fine. Whoever.” And the resident did her epidural. And I think that most of the anesthesiologist feel that way. Most of the obese…the people who are like there and see this all the time are comfortable with the residents placing the epidural. Number one, because we know they’re really good. And like you said, I tell people the residents, like literally on a 12-hour shift, they could place 15 epidurals without even blinking, like easily. And the attending may not place any. And the attending may be watching all day. And obviously, so you’re an OB anesthesiologist. You’re there a lot. You place a bunch. But sometimes you don’t know the attending may just be covering from the main operating room and they may not have placed one in a month. And I’m sure that he or she would be great also, but it’s not like that, by definition, if you have the attending, you’re gonna have an easier…he or she’s gonna have an easier time placing it and you have a lower chance of a complication.
And that’s not what we see either. We don’t see like a higher rate of complications amongst the ones placed by residents versus attendings. It’s like you said, it’s a low rate. It’s somewhat random and you have a pretty good sense when it’s happening, who’s higher risk, who’s lower risk. But yeah, I always encourage people to have their resident do it and you’re going to get someone who’s paying very close attention to, and is gonna be looking over you the whole labor and delivery. And I would say, the risk is exactly the same, meaning it’s very safe.
Dr. Hamburger: Exactly. And like I said before, the residents who are still learning the procedure are being supervised closely, and our senior residents who’ve done many, many of them, and are much more comfortable doing them. Especially in our training program, they’ll do five or six times the number of required epidurals [inaudible 00:40:34]. It’s unbelievable. You only need, technically, I think 40 right now? They’ll push 200 to 250, which is more than some people do in their entire training, and even in the first few years as being faculty at smaller hospitals. So our senior residents, besides from being some wonderful, wonderful physicians and other ways, they’re very technically skilled and can do these better than most.
So I usually ask, when they say, “I want the attending only,” I often ask them why. Because sometimes it’s a specific reason. And if it’s a specific reason, then we can help make the experience better for them. But often, it’s just hearsay that they heard, they read on the Internet this is what should happen. But that might not actually be the right answer for where you are right now. The resident may actually be the one you want, who’s gonna watch after you. And also, a lot of times when I’m there, I’m managing the entire labor floor, it may take a little longer for me to personally come and do it, not because I don’t want to. I’m happy to take care of people. But just because I may be involved in other emergencies or supervising in other areas. And so that may just delay the care just a bit. So it’s something to consider when you’re making your decisions.
Dr. Fox: Right. This is great. And I think that the overall message I know that you give, that we give is epidurals are safe, and they’re effective, and they’re safe for the baby, and they’re optional. In some people, again, we sort of encourage it a little bit more because there’s some more benefit potentially, if they’re high risk for a cesarean, or high risk for it to be placed. But for the vast majority of women, it’s really just a choice. For all women, it’s a choice but the vast majority of women, it’s really just a choice. Like do I want one? Do I not want one? And there’s not much that goes into it otherwise. And the nice thing is you guys are there 24/7. There’s a lot of you there. I mean, I can’t turn around without bumping into one of you guys, which is great. It’s an amazing team of doctors. And I think people should be very reassured with our options for pain management and labor and for a cesarean.
Dr. Hamburger: Absolutely. And our whole goal is to individualize your care. It’s to make it your experience. And so some people may choose to have an epidural, some people may choose not to have an epidural, and some people may change their minds. And our goal is to work with you to make it your personal experience. And so there’ll never be pressure one way or the other. We’re really just there for you.
Dr. Fox: Great. Zevy, thank you so much. Thanks for coming on. Thanks for doing what you do. I’m sure I’ll see you every day for the next several years.
Dr. Hamburger: Forever, yes.
Dr. Fox: All right, thanks a lot. Thank you for listening to the “Healthful Woman Podcast.” To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s H-E-A-L-T-H F-U-L W-O-M-A-N.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day.
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