June 22, 2012

The Walking Epidural Versus The Standard Epidural

Recently I was teaching a prenatal yoga class, and as we were discussing concerns at the beginning of class, the topic of epidurals came up. One woman said that she had heard of the “walking epidural” and was quite excited about the idea of having pain relief without the consequence of losing her freedom of movement.

I explained that the “walking epidural” does not mean that she would likely still be walking the halls while receiving epidural medication. The student was a bit disappointed to hear this, but she said she was happy to have the clarification before her birth.

Let’s discuss the epidural options:

An epidural is a regional anesthesia which isolates pain relief to the lower body by blocking the nerve roots. There are two types of epidurals used for childbirth. The standard epidural and the combined spinal epidural, known as the “walking” epidural. The procedure for receiving both types of epidural are essentially the same, with subtle differences in the placement of the catheter. With the walking epidural, the epidural needle actually comes into contact with the fluid which surrounds the spinal cord. While with the standard epidural, the needle does not interact with the spinal fluid and stops just outside the “dura” space. In both procedures, the needle is removed and a catheter is left to continuously deliver pain medication to the woman.

The broad strokes of the procedure is that the woman needs to keep very still, even during a contraction. She will assume a “cat” spine (a C curve spine) and the anesthesiologist will clean her back with iodine and then place a plastic sheet over a portion of her lower back. They will administer a local anesthetic, often described as “feeling like a bee sting”. From there the anesthesiologist will proceed with placing the needle for either the walking epidural or the standard and then threading a catheter in place. The catheter is left in place and well taped to the woman’s back for the rest of her labor and delivery.

Standard Epidural
Besides the actual placement of the catheter, the two epidurals use different drugs. The standard epidural entails the use of purely local types of anaesthetics such as lidocaine (known as Xylocaine) and bupivacaine (known as Marcaine) or ropivacaine.(1) The effect of the standard epidural is a very heavy, “dead” feeling to the lower extremities, making movement challenging for the laboring mother. It is a bit more confining. The mother is still able to still shift from side to side, but will usually need some assistance in moving her body.

Combined Spinal-Epidural (CSE) or “Walking Epidural”
The “walking” epidural is a “cocktail” of narcotics, local anesthetic and epinephrine. Unlike the standard epidural, the mother still has some sensation in her lower body. This will allow for more flexibility and ease when trying to shift from one position to another. The advantage of maintaining some mobility is that it can help facilitate the baby into a more favorable birthing position, which can lead to a quicker labor. With the “walking epidural”, the mother may even be stable enough to assume a quadruped (all fours position) on the bed and do some hip movements like “cat/cow.” This is a very helpful position since it encourages optimal fetal position and takes the pressure of the mother’s back. With a “classic” epidural, the woman’s legs would be too numb to support her weight.

One disadvantage with the walking epidural is that it is slightly more technically involved than an epidural without a spinal component. In addition, there is a purposeful placement of a hole in the dura and this hole can be the cause of a headache after the spinal.(2)

Even though the combined spinal epidural touts the name “walking” it is rather unlikely that the mother will be out of bed too much. Several reasons attribute to this. First, some hospitals have the machine that administers the medication attached to the wall behind the bed. Some have it on an IV pole. So depending on what your particular hospital has set up will declare your chance of mobility. Secondly, the hospital may simply prohibit walking. For example, Brigham and Women’s Hospital clearly states that women are not allowed to walk once the epidural anesthesia begins. I speculate they are concerned about the liability they ensue should the mother’s legs not be stable and she falls while walking. I would recommend checking with the hospital to get information about their protocol. From a personal experience as a labor support doula, I have never had a client get out of bed with an epidural, just granted the freedom to move around on the bed, but not leave the bed.

Are the risks any different between a Walking Epidural and a Classic Epidural?

The side effects are pretty much the same with the exception of a higher chance of spinal headache from the walking epidural. In my own opinion, with the walking epidural there is a greater chance for varying maternal position which can help labor be more functional Also, since the mother is still retaining some awareness of her lower body, it will make second stage (pushing) easier to coordinate.

Both epidural choices will require close monitoring. This includes frequently taking the mother’s blood pressure since a drop in blood pressure is a side effect of the epidural. The mother will also have continuous IV fluids to help combat the drop in blood pressure. The mother will also receive full time fetal monitoring. If she is prohibited to moving off the bed, she will also likely receive a bladder catheter.

I hope that this explanation of the two different epidurals has made your choice easier and clarified any misunderstanding.

Happy birthing!

(2) http://www.anesthesiologyinfo.com/articles/09152002b.php
3. http://www.brighamandwomens.org/Departments_and_Services/anesthesiology/services/painfreebirthing/walking.aspx
4. http://health.msn.com/pregnancy/epidurals-and-pain-free-childbirth



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