FAQ: Delivering at Duke

What is an “epidural?”

An epidural refers to a method of controlling pain during a woman’s labor.  A thin plastic catheter is placed in your lower back. Medicines are then given through the catheter that lowers the amount of pain you feel from your contractions. We can keep giving these medicines to reduce your pain until you deliver your baby. Sometimes stronger medicines are given in an epidural so you won’t feel pain even during an operation, like a Cesarean delivery.

What is a “spinal?”

A spinal is a single injection of medicines given through a needle in the lower back. Once the injection is given, the needle is removed, and the lower part of the body becomes numb. This can be used for surgical procedures of known length, like a Cesarean delivery. Sometimes your anesthesiologist will combine a spinal with an epidural for faster pain relief during labor.

How are these procedures performed?

We will have you curl your lower back, either while sitting or lying on your side. We will then clean your back to prevent infection, and numb the skin. The more you sit still, the easier and safer it will be to place. We will then put a needle into the epidural or spinal space. During this part, you should only feel pressure with little or no pain. We will explain each step. One birth partner may remain in the room with you during the procedure, but we ask that they wear a mask and a hat, and hat and remain seated during the procedure.

Will these procedures affect my baby?

By using medicines that work directly on your nerves in your back, we keep the medicines away from the baby. Generally, very little medicine ever reaches your blood stream or the baby, even after many hours of labor. The medicines used in the epidural could lower your blood pressure and if not treated, this can affect your baby’s heart rate. Your nurse and your anesthesiologist will watch your blood pressure closely after your receive your epidural to try to prevent this. If needed, they can immediately treat your condition with medications and extra fluids.

When can I get an epidural?

Except in rare circumstances, you can get an epidural at any time after you go into labor. You do not have to wait until you are dilated a certain amount or have received a certain amount of IV fluids to receive an epidural. Studies have shown that an epidural does not significantly slow down labor.

What can I expect from my epidural?

Expect to feel a little numb, but not all at once. Your legs and belly may feel like they have “fallen asleep,” and your legs may feel weak and heavy. It takes about 10-15 minutes after giving the medicine for you to be comfortable. Your contractions will first seem shorter, and then they will drift away.

Expect to feel something. You may feel tightness or pressure, especially close to delivery. The ability to feel pressure allows you to know when it is time to push.

Expect to need some fine-tuning. Many women will need an increase in medicine as labor continues. Less than one out of 10 women may be numb only on one side or not at all; we will adjust the epidural to try to help. Rarely, we may need to replace your epidural to make it work.

Expect to stay in bed and drink/eat clear liquids. The epidural medications can make your legs weak during your labor, and we ask that you remain in bed while your epidural is running and until the effects have worn off to keep you and your baby safe. You will probably have a catheter in your bladder after your epidural. We also ask that you eat or drink only clear foods/beverages such as broth, juices, gelatin or popsicles.

What happens if I need a Cesarean delivery?

If you already received an epidural, we can usually put stronger medicine in the epidural that makes you numb. If you did not receive an epidural, we can place a spinal. Either way, you will be numb from your chest down to your toes for a few hours. In emergency situations, or if you cannot have an epidural or spinal, we may need to give you general (asleep) anesthesia for your Cesarean delivery.

Are there any risks?

It may not work as well as we want. We may need to adjust or fine-tune the epidural or replace it (see above).

It may lower your blood pressure. We will watch your blood pressure closely, especially right after we give the medicine. We can treat your blood pressure if needed.

About one out of 100 women will get a headache after they have their baby. This headache usually goes away on its own, but if necessary, you can request medications that are considered safe even if you are breastfeeding. You may need other treatments to make it better; your anesthesiologists will discuss this with you if needed.

Are there pain relief options other than the epidural?

If you cannot have or don’t wish to receive an epidural, there are non-medicinal options (including breathing techniques, massage, heat packs and water baths), as well as pain medicines (such as morphine or fentanyl) delivered through your IV that can help reduce the pain of labor. At Duke University Hospital, we also offer patient-controlled intravenous analgesia (PCIA) with fentanyl.

Comparing types of labor pain relief

Q&A adapted from the Society for Obstetric Anesthesia and Perinatology & Obstetric Anaesthetists Association.

What is a cesarean delivery or c-section?

A c-section is performed in an operating room by obstetric doctors. There are certain times when a surgery may be a safer option than vaginal delivery for you or your baby. They make an incision on your belly and uterus, and then deliver the baby and placenta.

Why do some women need c-sections?

One in three babies are delivered by c-section. They occur for many medical reasons, including a prior c-section, breech position, a stressed baby, or other specific mom or baby health conditions. Most c-sections are planned ahead of time while others are more unexpected and can be an emergency. This can even happen after labor because of sudden stresses or if labor has stalled. If you need a c-section, your obstetrician would tell you why they think it is important and ask for your signed permission first.

What to expect when having a cesarean delivery?

If your c-section is planned, you will be notified of the date during one of your clinic visits late in your third trimester. On the evening before your surgery, a nurse from the labor and delivery floor will call and advise when you should plan to arrive at the Duke Birthing Center. The nurse will give you specific instructions for fasting before surgery – it is very important to follow these exact guidelines – your stomach needs to be empty for surgery, or your surgery may be postponed.

Some of these instructions may include:

• Do not eat any food after midnight on the night before your c-section.
• Drink only water, apple juice, or clear electrolyte drinks up to two hours before arriving at the hospital. No added sugar or milk is acceptable.

Where do I arrive?

The Duke Birthing Center is located on the 5th floor of Duke University Hospital. Please visit https://www.dukehealth.org/locations/duke-birthing-centerf or more information about the facilities and parking.

What should I expect before surgery?

• After changing into a hospital gown, a nurse will check you in and prepare you for surgery.
• An intravenous catheter (IV) will be placed so that we can give you medicine and fluids during surgery. Occasionally, we will place two IVs if there is a higher risk for surgical complications.
• You will meet the obstetric and anesthesia teams that will be taking care of you during the surgery.
• You may meet other pediatric and ancillary staff who will provide you with important information or offer participation in ongoing research studies. It is important to note that the labor and delivery floor is dynamic with urgent deliveries 24 hours a day. It is not uncommon to have to wait beyond your scheduled time due to urgent or emergent deliveries that may be occurring on the floor.

What types of anesthesia are provided for a c-section?

There are two main types of anesthesia. You can either be awake and numb (a neuraxial anesthetic) or asleep (a general anesthetic). Typically, if you have a c- section, you will have a neuraxial anesthetic. This is where you are awake, but you can’t feel any sensation from your breasts down. This is usually safer for you and your baby and allows both you and your partner to experience the birth together. There are three forms of regional anesthetics. These are spinal, epidural and combined spinal epidural anesthetics—the anesthesiologist will discuss the best options for you on the day of surgery.

A spinal anesthetic may be used in planned or emergency c-sections. The spinal cord that carries feeling from your body to your brain is contained in a sack of fluid inside your backbone. The anesthesia team will inject “local anesthetic” or “numbing medicine” inside this sack, using a very small needle. This method works within minutes and lasts a couple of hours.

An epidural anesthetic is when a thin plastic tube or catheter is placed next to the nerves in your backbone with a needle; medicine to numb the nerves can be injected through the tube. An epidural is often used for labor pain, so if you need a c-section and have an epidural already, the anesthesia team can quickly top up the epidural by giving a stronger local anesthetic solution to prepare you for surgery.

A combined spinal-epidural anesthetic (or CSE) is a combination of the two. The spinal makes you numb quickly for the cesarean section. The epidural can be used to give more numbing medicine if needed, such as for longer surgeries.

General anesthesia means you will be asleep while the obstetrician performs the c-section. General anesthesia, while safe, does have higher risks in pregnant women. In addition, any medicines we give you may go to your baby, so there is a chance your baby may be sleepy when born and may need some help breathing. If this happens, it almost always improves quickly after birth. For these reasons, we avoid general anesthesia for pregnant patients when possible. Some women aren’t candidates for neuraxial anesthesia because of certain medications used for specific neurological or bleeding disorders.

Will my partner be able to come with me?

As long as you are awake for surgery, your partner will be able to sit by your side after your anesthesia block has been placed and you have been prepared and cleaned by the surgeons. Your partner will be dressed in proper surgical attire to maintain the sterility of the operating room. Your partner will be allowed to bring a camera for photographs. Video is not allowed in the operating rooms. It is important to follow the instructions given by the anesthesiologist at all times for you and your partner’s safety. In any type of emergency, your partner may be asked to return to the waiting area so your doctors are able to work more efficiently.

What will happen in the operating room?

Unless you already have an epidural from labor upon entering the operating room, we will have you sit up on the operating table. We will connect monitors that will tell us your vital signs (blood pressure, pulse, oxygen levels) during surgery. We will place the neuraxial block and quickly lie you down to help develop the block. The nurse and obstetricians will clean your belly and vagina with sterile soap while a drape will be put up to make sure it stays sterile. Once the obstetricians are ready to begin surgery, we will escort your partner into the operating room to join you by your side. After your baby is delivered, the baby team will check your baby. When safe, the nurse will bring your baby to you and your partner. Sometimes, the baby will need to stay with the baby team for continued monitoring and care.

In the rare event you need an emergency general anesthetic, we will prepare you quickly for surgery. We will place an oxygen mask over your nose and mouth to breathe. We will then administer medicines to get you safely to sleep and place a breathing tube in your windpipe. After the surgery is finished, we would wake you up.

Can my baby stay with me?

After your baby is born and the cord is cut during surgery, your baby will be handed to the pediatrician and moved to the baby warmer, just steps away from you. In the minutes after birth, the pediatrician will check your baby. Then your baby will be swaddled in a warm blanket and hat. If your baby is healthy and stable, he or she will be brought to you and your partner. When possible, your nurse will help with skin-to-skin contact between you and your baby, and will help you begin breastfeeding if desired. Your baby may remain with you, but will occasionally need to be checked by the nurse to make sure they are stable and safe. Sometimes, babies need to go to the Neonatal Intensive Care Unit (NICU) for care and observation.

How long is the surgery?

Usually it is 1.5 to 2 hours.

What is the recovery period like?

Immediately after surgery, your nurse will monitor your vitals and status while you recover from anesthesia and surgery. Your nurse will also check for postpartum bleeding, which is a very important step for your safety. After an hour or so, you will be transferred to a private postpartum room where you will remain for the duration of your hospital stay.

Will I be in pain during recovery?

We will work closely with you for pain management. During surgery, you will receive pain killers through suppository, IV, or through the neuraxial block. Unless there are contraindications, we will give you acetaminophen (Tylenol) and non-steroidal anti-inflammatory medicines, such as ibuprofen, around the clock during your hospitalization. If you have additional pain, we will also prescribe an opioid pain killer, such as oxycodone, as needed. A reasonable goal is mild pain at rest, and moderate pain with movement. However, it is important to have enough pain relief so you can walk. Mobility is an important component in the prevention of blood clots after surgery.

When can I go home?

Typically, women leave the hospital 1-3 days after surgery. You will need to pass certain safety goals, such as control of pain and nausea, ability to eat and drink, and feel comfortable with self-care at home.

Q&A adapted from the Society for Obstetric Anesthesia and Perinatology & Obstetric Anaesthetists Association.