Epidurals: The Good, The Bad, and The Ugly

I’m pleased to host anesthesiologist and suspense author, H.S. Clark, as he discusses his thoughts on epidurals. Very informative post. I hope you’ll check out his medical thriller Secret Thoughts available on Amazon. 

On the morning on April 7, 1853, a little known innovative physician, Dr. John Snow, was called to Buckingham Palace to administer Chloroform anesthesia to Queen Victoria for the birth of her fourth child, Prince Leopold. The Prince was healthy, and the Queen did not feel the pain of childbirth. That was the beginning of the end for “natural” childbirth, and the dawn of modern anesthesia for labor and delivery.

Buckingham Palace
Now, 25% of mothers give birth by Caesarian section, and 75% of the remaining vaginal births receive either a spinal or epidural anesthetic, so that leaves less than 20% to experience “natural” childbirth. We know now that the designation “natural” does not mean medically superior. The pain and stress of labor and delivery raises maternal blood pressure, increases circulating adrenaline, impairs breathing, and interferes with muscle control and fetal descent, all to the detriment of both mom and her unborn baby. Pain also leads to expulsive deliveries that increase the occurrence and severity of pelvic lacerations.

We’ve now progressed from Chloroform to the use of epidural anesthesia. Small amounts of local anesthetic placed in the lower back near the spinal nerves set up a regional block of the bottom half of the body. It’s like two cops stopping all the highway traffic with a roadblock. Modern epidural anesthesia reduces stress for mom and baby, which is especially helpful if the baby is medically compromised. Epidurals are used not just for pain control, but also as an active tool to manage labor and delivery, and to provide flexible options, safety, and control that is not possible during “natural” childbirth. Unlike the early days of epidural anesthesia, modern epidural methods do not slow labor, have minimal effects on the unborn child, and often help to speed labor and fetal descent.

But in medicine, there is always a down side. Epidurals are wonderful, when they work. Even in the most skilled of hands, epidurals are highly technical, difficult to place and maintain, sometimes marginally effective, and frequently fail. They are best placed after the labor is well established, usually at 3 to 5 cm of cervical dilation. If labor is rapid, there may not be adequate time to place an epidural. Minor complications include a 1% chance of a migraine-like headache that may require treatment, and the rare possibility of nerve damage, seizures, infection, or other life threatening problems. Techniques, drugs, equipment, and monitoring used during an epidural anesthetic are all geared toward preventing complications.

Epidurals are usually an elective choice, but not always. There are labor situations in which epidurals may be mandatory for the safety of both mom and baby. Anesthesia for childbirth is unique because the anesthesiologist must treat two patients at once, each one with very special needs. Epidurals are used by default, because other methods of pain control have unacceptable effects on mom or her unborn child. The delicate balance between pain control and safety during labor and delivery is like a tightrope walk. I wonder if Dr. John Snow realized what he started on that foggy April morning in London.
Secret Thoughts Book Trailer:

H.S. Clark is a mystery writer, physician, anesthesiologist, and the author of Secret Thoughts: a Medical Thriller, set in Seattle. His thrillers are ultimately about the interface of ethics and medicine, and the human struggle for health and wellness. The technology he writes about is 99% cutting edge fact mixed with a 1% glimpse into the future. He showcases the abuses of medicine in order to focus attention on the wonders of medical achievement. Mostly, he wants the reader to enjoy the journey. You can connect with H.S. at his website at:
Secret Thoughts: a Medical Thriller is available for immediate download from Kindle, and in paperback from Amazon http://goo.gl/UWLVR  

Put me to Sleep: Anesthesiology

I’m so pleased to host a new guest blogger, Dr. Kate O’Reilley, anesthesiologist extraordinaire. Today, she’s talking about an anesthesiologist’s main job– putting you to sleep– in a good way!
Welcome, Kate!

Anesthesia is all about passing gas (no pun intended!)  The most common anesthesia gases administered in operating rooms today include Sevoflurane, Desflurane, Isoflurane, and Halothane.  The gases, which are also referred to as volatile anesthetics, can be given to a patient in one of two ways. The first method involves the anesthesiologist simply holding a mask over the patient’s face and having the patient spontaneously breathe in a mixture of gas and oxygen. The second method employs the use of a ventilator that is attached to a breathing tube inserted into a patient’s airway.  Similar to the first method, the ventilator delivers a mixture of volatile anesthetic and oxygen to the patient’s lungs.

All of the anesthetic gases have similar effects. They cause sedation, muscle relaxation and amnesia – the three components to an ideal general anesthetic. The gases have slight differences in how they are metabolized, toxicities, dosages, and degree of cardiovascular depression.

Induction of anesthesia is simply the process of taking a patient from an awake, conscious state to a state of unconsciousness. With adults, this process is usually achieved through the intravenous administration of a series of drugs. Once the patient is unconscious and a breathing tube is placed, the anesthesiologist turns on one of the gases to an appropriate concentration, and uses the gas to maintain anesthesia during the operation.

With children, we rarely have the luxury of a preoperative intravenous line. It’s simply too difficult and traumatizing to place an IV in the little rascals while they’re awake. As a result, anesthesia in children is often induced with gas instead of drugs. Once the child is asleep, an OR nurse places and IV and surgery commences.

Watching a patient being anesthetized by gas alone is an interesting process. It’s the only time one is able to see the distinct stages of anesthesia. The first stage of anesthesia is a state of voluntary excitation and euphoria. It lasts from when the patient is awake until they are rendered unconscious.  Until the patient is unconscious, their movements are purposeful and they can follow commands.  Stage 2 of anesthesia is a stage of involuntary excitation. In this stage, patients my flail their arms and legs, giving the appearance of being combative or agitated. However, they are completely unaware of their actions. When parents accompany their children to the operating room for induction, this stage is usually unsettling for them to witness. The third stage of anesthesia is the stage of surgical anesthesia. In this stage, the patient has reduced muscle tone and will not respond to surgical stimulation. This is the stage where we want patients to be during the operation.  Stage 4 of anesthesia is where we aim not to be. It is the stage where there is severe cardiovascular and respiratory depression. If allowed to persist, this stage could result in death.

So once the patient’s surgery is done, how do we get rid of the gases? We simply turn the gas off.  Over time, the patient breathes off the gas and eliminates it from their bloodstream. Often times, as patients wake up, we will see the stages of anesthesia in reverse. As patients pass through the second stage, they often need to be restrained in order to protect them and the operating room staff from injury. Once a patient returns to stage 1, they may continue to be groggy and somewhat disoriented, but they should be able to follow simple commands. Only once a patient has returned to stage 1 is it safe to remove a breathing tube.

I hope that helps explain a little about anesthesia gases and how they work.  If there are any questions, always feel free to email me at kateoreilley@gmail.com.

Kate O’Reilley, M.D. is a practicing anesthesiologist in the Rocky Mountain region.  In addition to being a physician, she has also written two books, both of which are medical thrillers.  She plans on releasing her first book, “It’s Nothing Personal” in the near future. When not writing, blogging or passing gas, Kate spends her time with her daughter and husband. Together, they enjoy their trips to Hawaii and staying active. Please visit her at her website, http://www.kateoreilley.com/ , and her blog www.katevsworld.com.