Preggie Pals
Epidurals, Spinals and Pain Medications

Please be advised, this transcription was performed from a company independent of New Mommy Media, LLC. As such, translation was required which may alter the accuracy of the transcription.

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David Gambling : If you are like most women, the pain of labor and delivery is one of the things that worries you when having a baby. Sometimes, medications, whether planned or spontaneous, is needed. So what are your pain relief options? I'm Dr. David Gambling, an anesthesiologist with Sharp Mary Birch Hospital for Women and Newborns in San Diego, and this is Preggie Pals, episode 39.

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Sunny Gault : Welcome to Preggie Pals, broadcasting from the Birth Education Center of San Diego. I'm your host, Sunny Gault. Are you a member of the Preggie Pals Club? Our members have access to all of our archived episodes, plus bonus content after each new show and special giveaways and discounts. And thanks to our partnership with Pregnancy Magazine, our members also get a free one year subscription to Pregnancy Magazine. You can visit our website for more information and to sign up. Let's meet our panelists, we've got two of them today, one is joining us here in the studio, and one is over the phone, so Rachel, let's start with you.

Rachel Adams Gonzales : Hi, my name is Rachel Adams Gonzales, I am 29, and a product consultant for doTERRA Essential Oils. I am due April 10th with my second, a girl. My son will be three just before I'm due, and I had an unmedicated water birth with my son, and we're planning a home birth this time around, so I'm curious to hear about all these pain management options I don't know anything about.

Sunny Gault : It's always good to have the information, just in case, right?

Rachel Adams Gonzales : Yes.

Sunny Gault : OK, and Michele is joining us once again, over the phone. Michele has been a panelist on our show before, welcome, Michele!

Michele Farry : Hi Sunny! My name is Michele and I am 34 years old, I design wigs for women with cancer and run a wig education program, wigedu.com. I am due in a week or so, and the gender of my baby is a little boy, Usher. I have a son who is almost ten, and I had a hospital birth with him.

Sunny Gault : OK, and Michele, tell us a little bit more about your experience with having pain medication for labor and delivery.

Michele Farry : When I had my son, I had my water break with no contractions, and was induced. Made it to seven centimeters, I really wanted to go natural, but I couldn't do it and I requested an epidural. They tried three different times and it was unsuccessful, and I did have some minor complications after that, a very soar back. So I'm a little nervous about having that experience again.

Sunny Gault : Alright, well thank you ladies for joining us on today's show.

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Sunny Gault : OK, before we kick off today's show, there is an interesting headline I want to talk to you guys about, as part of our news headlines segment. All of these articles are also on our Preggie Pals Pinterest board if you want to check them out. So this one – of course everyone is talking about Kate Middletone and her pregnancy, the poor thing has undergone a lot already being hospitalized, but I found this funny article that is making waves on the Internet and want to read it to you guys. The headline is, “Kate Middletone is Pregnant. 6 Ways Her Pregnancy Will be Different than Yours”, and the subheading is, “Royalty has its Privileges”. So the first thing they say is morning sickness. “Kate reportedly suffering from morning sickness is in the hospital, being carefully monitored and tended by some of the world's most renowned physicians. You start bringing a paper bag along on your morning commute and become adept at barfing into it at red lights.” Maternity fashion is second one, “High-profile designers from around the globe are salivating at the chance to clad the royal bump. Your pregnancy wardrobe consists of a few stretchy things from Target, a bag of miscellaneous used maternity clothes purchased on eBay, and some really ugly hand-me-downs from your cousin Janet.” The third thing, the big day. “International media outlets will hurriedly scrap regularly scheduled programming and redesign their front pages at the first rumor of royal labor pains. Starting about a week before your due date, your mom and best friend will begin to regularly pester you with some variant of, “Have you had that baby yet?” I think another version of it would be people on Facebook saying, “OK, it's your due date, have you had that baby yet?” Number 4, baby names. “Kate and William will be somewhat constrained by royal tradition as to choice of baby names — though they will have a bunch of slots to fill; note that paternal grandpa was christened Charles Philip Arthur George. You have free reign to go nuts if you want. Welcome Charo Hayseed Cinnabon Snooki!” So I guess we have more options, right? And the fifth one is capturing the moment, “From almost the moment Kate and William’s baby is born, he or she will be professionally photographed in a variety of outfits and settings, appearing on commemorative tea towels, silver spoons, coffee mugs, key-chains, and any other item imaginable. You will have lots of baby pictures on your iPhone.” Which is so true, because I was looking to my iPhone the other day and I'm like, “Oh my gush, this thing is just filled with stuff from my kids”

David Gambling : We could add another element to this, which gives new meaning to term “crowning”.

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Sunny Gault : Today we're exploring your pain relief options during labor and delivery. Even you are planning a natural birth, it's important to now your options, just in case. Our expert today is Dr. David Gambling, an anesthesiologist with Sharp Mary Birch Hospital for Women and Newborns in San Diego. Dr. Gambling, welcome to Preggie Pals!

David Gambling : Thank you!

Sunny Gault : OK, so, Dr. Gambling, do most women choose pain medication during labor and delivery? Do we know the stats on that?

David Gambling : In our hospital, the short answer is yes, they do. I think most women to do without, it's not until they are actually in labor that the decision is made, because they make an informed choice at that time.

Sunny Gault : How important is it for women would you say to know their pain threshold before going into labor and delivery to be able to make this choice regarding pain medication?

David Gambling : Again, I'm not sure until you test your pain threshold you know what your pain threshold is, I think some people have an idea, “Yes, I'm pretty good with pain”, but to be honest, I'm not sure that you can know your pain threshold properly and I don't think it's important to know what your pain threshold is.

Sunny Gault : OK, so don't worry about that. We hear about systemic medications. What are some of those medications?

David Gambling : In our hospital, we use intervenous Fentanyl, which is a synthetic opioide potent pain killer, that is used prior to receiving and epidural or to the exclusion of the epidural, there are some people that will do very well with just a small dose of Fentanyl, and others, as labor progresses, require stronger pain relief. What most of the ladies that I talked to about this say is that it takes the edge off the pain, doesn't totally get rid of the pain. There are other agents such as Stadol, or Butorphanol, Demerol, otherwise known as meperidine, and Nubain or nalbuphine, those are agents used in other hospitals. Stadol and Nubain are classified as agonist-antagonists opioids, it's felt that they are less likely to cause side effects to the baby, one of the big concerns about using intervenous narcotic pain killers is that it can depress the respiration of baby at birth, if given soon enough to the birth. Fentanyl is pretty good in that regard, we don't see depressed babies from the Fentanyl, usually because enough time has elapsed for the drug to be metabolized and not have an effect on the baby.

Sunny Gault : Do you have to administer all of these agents, or is this something that a nurse in a room can get to the patient?

David Gambling : These are medications that the nurse administers, we don't require an anesthesiologist to receive these drugs.

Sunny Gault : I know that a lot of times women arrive at the hospital prior to being able to be admitted, because they may feel pains or whatever and decide to go. And when they test them, they are not quite dilated enough to be admitted into the hospital. Can any of these agents be given to soon to be patients, before they are admitted to the hospital? Or are talking about only once you are administered to a hospital?

David Gambling : These drugs are administered within the hospital, they are potent narcotics, they are controlled substances, they won't be given until the patient is admitted into the hospital. So we're not going to give somebody one of these drugs and then let them go home.

Sunny Gault : Right, but if they were staying there – in my instance, with my first born, I arrived at the hospital and I wasn't quite dilated enough, and they thought that if I did some walks for about an hour, walk around a bit, I would be dilated, and that is what happened. But I'm just wondering, the pain seemed pretty intense to me when I first arrived. If you know you are going to be admitted, then you are going in that direction. Maybe it depends on the hospital and what they are willing to do, but can you ask for something at that time, or do you just need to wait?

David Gambling : In our hospital, you would just need to wait. If you had pain that it was judged you could walk it off, walk around with you husband and do breathing exercises, and you wouldn't be given an intervenous pain killer, that would come the time you are admitted to the labor room, and there was access to monitoring.

Rachel Adams Gonzales : Dr. Gambling, I was wondering, is there any side effects after you deliver from these medications? Like constipation, or things that may deter you from choosing those over an epidural?

David Gambling : That's a good question. There are side effects associated with these medicines. Fentanyl can cause nausea, any of the narcotics can cause nausea. Long-term use of narcotics can cause constipation, but it's not a common side effect that we see from short-term use during labor. Some of the medicines such as Fentanyl can cause itching, dizziness and nausea we see not uncommonly, and you need to be aware of that when you request that type of medication. Drugs like Stadol or Butorphanol are a little weird, they can give you what's known as a dysphoric reaction, an out of body experience, which can be quite unpleasant when you see yourself from the ceiling, so I would be careful. We don't use those drugs anymore, we tried them for a while back in the 80s, but didn't find them to be particularly effective, and actually unpleasant to some individuals.

Sunny Gault : For the medication that we've already discussed, can you have those throughout your labor and delivery experience, or is that primarily just in a certain stage of labor?

David Gambling : You can have them throughout the course of your labor, if they do the job for you. However, for a large number of women, they find in early labor and latent phase and they do take the peak of the pain away, but they don't get rid of all the pain. It may be enough for some individuals, and we do have ladies that go all the way through with intervenous narcotics alone.

Sunny Gault : And you may have to have multiple doses of these drugs, right? Depending on how long your labor is.

David Gambling : Exactly. They are given through doctor's orders by the nurse within the safe limits, but you can get multiple doses, and in some hospitals the drugs can be administered through a pump, an intervenous pump with a patient controlled button capability, so that you can administer small dozes to yourself throughout labor. And that's an option for women who have an absolute contraindication to having an epidural.

Sunny Gault : But only in that case?

David Gambling : Not necessarily, there may be some centers set up to provide women with intervenous patient controlled medicine, that's a viable approach. But it needs to be discussed beforehand.

Sunny Gault : The big one that we hear a lot about especially for first time birth is an epidural. Walks us through what an epidural is and what it's supposed to do to the body.

David Gambling : I think it's important before you even come in to the hospital and labor that you had some education on epidurals, and it's readily available through hospitals, through doctors' offices, through websites such as this. Most hospitals have a video information program as well that you can watch in earlier labor. An epidural is an invasive technique, it requires the expertise of an anesthesiologist to be perform under strict aseptic conditions. So we are very careful, everyone wears masks, gloves, it's a standard procedure. It involves the injection of local anesthetic, a narcotic mixture into the epidural space, through a needle. I can walk you through the procedure briefly, it involves – in our hospital, anyway – the lady sitting up, hugging onto a pillow, arching her back out in a C-shape, with her shoulders and her chin down, keeping very still with a support person in front of her to give her encouragement and physical support. She is receiving an intervenous infusion of a saline solution at the same time, to compensate for a drop in blood pressure that we see after the epidural has been induced under local anesthetics, in the lower back, between usually the third and fourth lumbar vertebrae, the local anesthetic is injected with a tiny needle, and that numbs the area. It's like going to the dentist, when you're having work on your teeth, once it's numb, you might feel some touch and pressure, but no pain. Then through that numb area we insert an epidural needle, and people always want to see the needle, they think it's going to be a big needle, everyone's concerned about it, but it's actually not a particularly long needle, and not all the needle goes into the back. In the average individual, we are talking about four centimeters from the skin to the epidural space. Once we've hit the epidural space, and that is the space to which nerves supply sensation from the womb to the spinal cord, and we bay those nerves with a local anesthetic mixture and then create numbness in the back and around the tummy that allows a pain free labor after. Once we've found the epidural space, we thread a tube into the space and leave that in there, take the needle out, and that is a conduit for further future administration of the drug, and we use a continuous infusion of drugs, so as to keep you comfortable for the length of your labor, because obviously we don't know how long your labor will be. In our institution, on average, the labor lasts about six hours after the epidural is inserted, it could be shorter, it could be longer. We tape that tube to your back so it doesn't get dislodged, and we lay you on your side, you are usually comfortable within, depending on the technique used, and we are going to address different types of techniques, anywhere from 5 to 20 minutes to get totally comfortable.

Sunny Gault : But you will notice a change pretty quick, at least that was my experience, I actually had an epidural with my first born, I was feeling contractions and thank goodness I didn't have a contraction during the actual process of having the epidural, I was really concerned about that, because you are told to stay very still, it's very important, obviously, they are putting a needle into your body, but at the same time I was really worried that I was going to have a contraction and then I wouldn't be able to stay still, because that's the last thing I wanted to. Maybe it goes without saying, but why is it so important that women do stay still, and how long do they need to stay still to have this procedure?

David Gambling : Everyone has the same concern, and we always reassure them that they will keep still, in over 30 years of doing this, I've not had a problem with somebody moving in that opportune time. And that's done through constantly communicating with the lady and having a support person there, also communicating, talking them through it. And I think they understand the importance of keeping still, there is a needle that is in the spinal area, and you don't want to go too far and you don't want to hit a nerve, so keeping still is important. It's a short period of time when that's required in fact, so we just get the woman to focus and to breath deep during contraction, if she has one at the time of the epidural. Sometimes, arguably, having the epidural inserted during contraction is not a bad thing, it takes your mind of having the epidural. But, to be honest, a lot of women tell me that having an epidural puts this whole thing into perspective – it's no worse than getting an intervenous. Because the intervenous again requires a local anesthetic to start with and after that you don't really feel very much. Mostly, that's the case, there are exceptions, of course.

Sunny Gault : Michele, can you share a little bit more with us about your experience in getting the epidural?

Michele Farry : Yeah, I was just going to ask you, Dr. Gambling, it was pretty immediate that the anesthesiologists recognized that it wasn't working. I'm sure circumstances can explain certain things, but he actually made three attempts, and I was still. Are there reasons why it can be unsuccessful?

David Gambling : Statistics tell us about 1 in 100 epidurals will not work effectively, usually they work initially, and then stop working, either because the tube that you placed in the epidural space has become dislodged, or there is some anatomical reason for incomplete spread of the local anesthetic in the epidural space. There may be other reasons, technical reasons, such as spinal abnormalities. Some people have scaring in their epidural space with a septum or a band that prevents uniform flow of the local anesthetic. And I think failure of the epidural means different things to different people, did you get some relief, did you get absolutely no relief, did you get relief anywhere apart from a small area on the left lower part of your abdomen?

Michele Farry : I've had friends tell me, “Oh, you know, I had an epidural, my right side was a little bit numb, but I could still feel everything in the left”. In my case, it did have some sensation from my epidural into my body, but it really didn't do anything else. It's interesting how some women feel like they have that one side experience. Could anything been done differently or is it just this physical reaction that that particular woman was having?

David Gambling : You have to also bare in mind the experience of the operator, that does play a role, most people in our department have over 20 years of experience, and putting an epidural is a very facile procedure. However, there are people that do present technical problems, those with excessive weight, those who have instrumentation of their spinal cord for one reason or another, perhaps they've got an abnormality with the spine, those sorts of things can cause technical problems. We do have ultrasound machines now that allow us to visualize the spinal and epidural space, and we do use that to assist us in those different cases.

Michele Farry : So the big question: is it going to happen to me again? Or do you think that if I choose to try to have an epidural there are chances it could be successful?

David Gambling : It depends on the operator and the circumstances, but there is no reason why you couldn't have it. I had this discussion yesterday with a patient in fact, in a similar situation. There is no reason why on a second attempt with a good operator you couldn't have a well functioning epidural, with no residua, with no complications from the epidural insertion.

Michele Farry : OK, that's good news, thank you for telling me that.

Sunny Gault : OK, well, coming up, we're going to talk about spinal blocks. Plus, have you ever heard of an epidural spinal combination? We'll explain when we come back.

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Sunny Gault : Welcome back everyone, today we are talking about epidurals, spinals and other pain medications. Our expert today is Dr. David Gambling, he is an anesthesiologist with Sharp Mary Birch Hospital for Women and Newborns, right here in San Diego. So, in the first half we talked about different types of pain meds that you can take in addition to epidural, and now we are talking about spinals. So, Dr. Gambling, what is a spinal block?

David Gambling : A spinal block is sometimes known as a sub-arachnoid block, and if you can imagine, following the tip of your epidural needle, we've gone through skin, we've gone through a couple of ligaments in the midline, we've gone through into the epidural space; beyond that epidural space is another membrane, the dura, the dura mater, and if you pass a needle through that, you then hit spinal fluid, and you can aspirate the spinal fluid and then inject local anesthetic and narcotic combination, and that will provide what's known as a spinal block, and we use that to provide anesthesia for operative vaginal birth, such as forceps. Even early in pregnancy, we use the spinal block to have the obstetrician insert a suture in the cervix for those people with incompetent cervix, and then we commonly use spinal anesthesia these days for caesarean section.

Sunny Gault : What happens if there's an emergency C-section, where the mom has had an epidural, and trying to get the baby out, but it's not progressing and than it turns into a C-section? What kind of pain medication is administered to be able to turn what was going to be a regular vaginal birth into a caesarean?

David Gambling : Well again, statistically, I tell women that labor with an epidural that they have overall about 80% of requiring a C-section for one reason or another. Sometimes it can be an emergency, there are different degrees of emergency, urgent cases where you'd like to see the baby delivered within 30 to 60 minutes for one reason or another, and there are absolute emergencies, that require immediately delivery, because of the concern regarding the welfare of the baby or even the mother. People with an indwelling epidural catheter, that can be used then to provide anesthesia for the caesarean section. And it can work pretty quickly if it's given at a time that the decision to do a caesarean has been made. We sometimes use the indwelling epidural catheter even in emergency situations. If the catheter hasn't been working well, the anesthesiologist may just take the catheter out, and very quickly induce a spinal block. We can induce a spinal block very very quickly, possibly quicker than getting ready for general anesthetic, which is the third option. And for those people with no anesthesia, no indwelling epidural catheter, maybe a contraindication to receiving a spinal, or just absolute urgency of the case, than a general anesthetic may be required, which means going off to sleep by giving you a drug through the intervenous and then getting the baby delivered as quickly as possible.

Sunny Gault : So that would be a last case scenario? That wouldn't be something that you would offer of the top?

David Gambling : No. Over the last few decades, we have gone away from using general anesthetics for caesarean delivery for a number of reasons. Obviously, the drugs themselves have potential adverse effects on a mother and on baby, if you give the drugs long enough, you can end up with a fluffy sleepy baby, but usually that's not the case, because we have the baby delivered very quickly. There are risks to receiving general anesthetics in pregnant women, especially if they had a big meal before they get their general anesthetic, we don't want people vomiting at the time that they go off to sleep. We have certain concerns, and in our hospital it's rare that we do general anesthesia, even for emergency caesarean section. But we do do general anesthesia occasionally. Certainly not as much as we did 30 years ago.

Sunny Gault : Let's go back a little bit and talk more about the spinal block, for women who need to have a caesarean, and this is actually what I had with my second born, it was a planned caesarean due to some complications from my first, so we knew throughout the entire pregnancy that it was going to be a caesarean. Walk us through the process of what happens should it be a planned caesarean, no other drugs have been administered.

David Gambling : Planned caesareans, we do a lot of those, and once the mother and her husband have been interviewed by the anesthesiologist and all the paper work has been done we walk back to the operating room and then the process I described earlier for the epidural insertion is similar for the spinal. The patient is sitting on the operating room table, there is an intervenous in place to compensate for the low blood pressure that can occur after spinal block, especially after a spinal block, and then washing off the back with antiseptics in the lower back, and the skin usually again between the second and third lumbar vertebrae. We use a much finer needle for the spinal, a very thick needle, it's pencil point, atraumatic. And the reason for that is we find that by using smaller atraumatic needles, the incidence of what used to be a very common side effect from the spinal, which is posterial headache, is much less in these days, and the rates are 1 in 1000 today, it used to be about 15% or more, a very severe headache for a few days after a spinal. And if you talk to your mother and grandmothers, they may describe that to you. We don't see it as much today, for that reason.

Sunny Gault : How quickly does it take effect?

David Gambling : A spinal anesthetic works very quickly, unlike the epidural. I tell some of my patients to expect a sense of warmth as soon as the spinal goes in, and that warmth is felt in the bottom, in the legs, in the feet, and they usually nod and say “yes, I am feeling that now”, and that's within seconds. And then they'll get a feel of numbness in their legs, and usually between 5 and 10 minutes they can't move their legs, and that's a thing to anticipate, very heavy legs for a few hours, certainly beyond the duration of the surgery. But your legs come back, and the other thing to be aware of is that we provide spinal anesthesia which gets rid of the pain of surgery. But it doesn't get rid of all sensations, so you might still be aware of touch and pressure. And when the baby is being delivered through caesarean section, the assistant surgeon does apply a lot of pressure to the uterus, to help deliver the baby through the small incision that they make. That distinction is important, it's a pain free surgery, not a sensation free surgery.

Sunny Gault : I can just share from my own experience that it was immediate, I guess I should back up, you were talking about the size of the needle. I was expecting something similar to the epidural, and I actually wasn't aware that the needle sizes were different, but that was a concern for me, because when I had my epidural, I was one of those patients that moved just a little bit. To me, it was substantial, so I was expecting that with the spinal, and it was like getting a regular shot, it was nothing. Super-simple, which was just amazing to me, because a spinal which you use for a C-section so they can completely open you up was a more simple process than an epidural. But for me that was definitely the case, and they lowered me down immediately. And I remember when I went into the operating room, initially it's very cold, 'cause they keep operating rooms very cold, and I was really cold. In the moment they inserted the spinal, I felt that warmth sensation that you were talking about, and it made for a much more comfortable experience, because I wasn't cold. So that was just one benefit, I guess you can say. And I had never had the sensation before, of not being able to feel my legs, or the lower half of my body, and it was very surreal to me, I actually had flashes of images of being paralyzed or something like that. For me it was kind of unsettling, because I thought – not that I would ever have to jump and walk out of a room when I am in surgery, but I thought that I could not defend myself, I could not get out of the situation if I needed to, almost a sense of helplessness, even though I know I was completely provided for, my husband was right there, and I knew it was the best thing for our situation. But that was one thing that kind of threw me off a little, I was like, “I'm really kind of helpless here!” I did feel the tugging and everything, and my OB warned me of that. The other thing that I wanted to bring up is that – I know some women get sick, they feel like they are going to vomit, and this was, for me, a planned caesarean, I knew that I was going to have the medication and everything, so I purposely didn't eat for an amount of time prior. And I did get sick, but I didn't get sick until after the baby came out. Is that a common thing for women to feel like they are going to vomit? And why is that, what is it in the medication?

David Gambling : It is a common occurrence, and I warn all my patients that there is a potential for them to be sick at some time, during the surgery and up to 24 hours after that. The nausea can come on as a result of low blood pressure that's associated with inducing spinal anesthesia, and we want to watch for that very carefully, and we are aggressive with treating low blood pressure, because once the blood pressure gets below a certain point, that will cause nausea. So we keep the blood pressure close to where it was before the spinal is put in, we have drugs to do that and that are used commonly in the operating room for caesarean surgery. The other element is the fact that you are having surgery in the abdomen, and it involves pain sensitive structures, visceral structures, and so you can get nausea just from having those structures pulled, so we than add other drugs to help reduce nausea that's related to the surgery in general, and those drugs include Zofran, or Ondansetron, a drug called Reglan or metoclopramide, and then we are also using a steroid called Decadron, which is very effective as well in reducing the nausea associated with the surgery, and all those drugs have minimum effect on the baby and a lot of anesthesiologists will actually administer those drugs after the baby is born anyway.

Michele Farry : I just have one quick question, did you experience anything different in the recovery, as far as the epidural and the spinal, or are they the same?

Sunny Gault : For me, for my recovery, the one thing that I noticed was for the spinal. For about 24 hours after giving birth I was very itchy, and I think they did give me something for that.

David Gambling : I can address that, because the itching would have been due to the use of spinal morphine, and spinal morphine is given with the initial spinal local anesthetic, to provide high quality pain relief after delivery, up to 18 to 24 hours, and it's a very good pain relief for that time. The downside is that on the second day of your recovery you find that you have a little more of a discomfort, especially with movement. But one of the common side effects of spinal morphine and epidural morphine, or indeed any epidural or spinal narcotic, is the itching. And that can be severe in some people. There is a range of response, and some people have no itching. Most people will have some itching that doesn't bother them. When you asked, “Has it iched you over night?”, they will say yes, “Did you get any treatment?”, they'll say no, it wasn't that bad. And then there will be a subset of individuals who have severe itching and it requires multiple treatments, including the drugs we've already mentioned, Nubain is a very good treatment for that.

Sunny Gault : Real quickly, I wanted to touch on the combination of spinal and epidural. When would you get something like that?

David Gambling : Well, if you come to Sharp Mary Birch Hospital for Women and Newborns, most of the time. Most of us now are using combined spinal and epidural analgesia, or pain relief during labor, because it provides a rapid onset of pain relief. And we found, by doing some clinical research in the hospital, that it's also associated with less need for rescue medication via an anesthesiologist. In other words, it seems to imply that the placement of the epidural catheter is more accurate. Once that follows, the spinal component of the combination. Combined spinal-epidural analgesia is commonly used around North America and around the world these days, and the advantages are that you get very rapid pain relief, and probably more reliable pain relief throughout labor and delivery.

Sunny Gault : And can you request that or is that a question you should ask your hospital OB, to see which one they do?

David Gambling : I think you can have that discussion with your anesthesiologist either before or at the time of admission. There are some anesthesiologists that are not comfortable with the combined spinal-epidural technique. Both are valid and viable options, but certainly have that discussion. I will tend to use the combined spinal-epidural technique universally, and the discussion rarely comes up.

Sunny Gault : Well, thank you Dr. Gambling, for joining us today. This conversation continues for members of our Preggie Pals Club, after the show we'll talk about some of the questions you should ask your anesthesiologist.

[Theme Music] [Featured Segments: Ask the Experts]

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Any : Hi! My name is Any and I live in San Diego, California. I have a question for Leigh-Ann Webster, your Fitness and Nutrition expert. I gave birth to my first baby just over a month ago, and I am breastfeeding, and the body weight just isn't getting of like I had hoped. I want to start dieting to lose weight, but I don't want it to impact my milk supply. Do you have any suggestions? Thank you!

Leigh-Ann Webster : Hi Any! Thanks for such a great question. I think many of us moms have the same concerns after we have a baby and we want to take that weight of as fast as we can. It is really important that you keep your energy levels up throughout the day, and to keep your milk supply up, so I am going to give you a few different suggestions that will keep you loosing weight but also keep you feeling good. The first thing I would suggest is having a 20 to 30 minutes walk every day, as long as your doctor has given you permission to exercise. And while you are walking, really focus on taking your heart rate out of its comfort zone a few times. Every three minutes or so, you want to really speed up that walk for 30 to 60 seconds, and then take it back down to your comfortable level. So basically what you're doing is creating walking intervals, and this will help to increase the number of calories that you burn, and you will also start to build your aerobic endurance for future athletic endeavors that you might have. The second thing I would do is really focus on adding in lots of healthy, good calories, foods that are rich in fiber and in iron and calcium. So some suggestions would be yogurt, topped with granola, and nuts are also a really good choice, a handful is great for fiber and calcium and protein. Also, focus on adding in a lot of fruits and vegetables, you can't go wrong with that, they are low calory, nutritious, they have fiber and they taste good. The big thing is that you don't want to drop below 1500 calories, that would probably upset your energy levels, and you just want to keep that energy level up so that you have the stamina to take care of the baby and to want to go exercise and do all the other things that you probably have going on right now. So thank you so much for your question, I think that new moms, including myself when my son was younger, we all think about how can we loose weight. Take your time, enjoy the process and go for a walk! OK, thanks Any, have a great day!

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Sunny Gault : That wraps up our show for today, coming up next week, our series on childbirth preparation methods continues, as we explore hypnobabies. Thanks for listening to Preggie Pals! Your pregnancy, your way.

[Disclaimer]

This has been a New Mommy Media production. Information and material contained in this episode are presented for educational purposes only. Statements and opinions expressed in this episode are not necessarily those of New Mommy Media and should not be considered facts. Though information in which areas are related to be accurate, it is not intended to replace or substitute for professional, Medical or advisor care and should not be used for diagnosing or treating health care problem or disease or prescribing any medications. If you have questions or concerns regarding your physical or mental health or the health of your baby, please seek assistance from a qualified health care provider.

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