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Combined Spinal - Epidural (aka Walking Epidural)

Reviewed by James Brann, M.D.

Combination Spinal/Epidural

Learn about combined spinal-epidural analgesia (CSE)

OK, the day you have been waiting for has finally come, you are in labor. You think the contractions are not “so terrible” as the nurse puts you in your labor room. But, wait the contractions are getting stronger and now you are wondering how strong will the contractions become.

At this point you are thinking about that prenatal class lecture that talked about the “breathing techniques” to help with the pain. So you give them a try with your partners help. You soon realize that the breathing is not helping, so you ask for your first dose of IV pain medications. The IV pain medication did not help either; in fact it just made you feel dizzy and you started to vomit.

The contractions now are unbearable and you want the pain to just stop. You want the contractions to stop hurting, now!  Remembering back to your prenatal classes, you recall using an epidural during the intense part of labor, but it would take 10 to 20 minutes to take effect. That would never do, “I want pain relief now”.

Sounds terrible, yes it is. I have heard this scenario over and over again from many laboring patients. Only if they knew that they could get immediate and continuous pain relief with a new anesthetic technique called a “CSE” or combination spinal/epidural anesthesia technique.

What is great about combined spinal-epidural analgesia (CSE)?

The epidural and spinal analgesia combination is the most effective pain relief for labor and delivery today. The combined spinal-epidural analgesia (CSE), gives you the benefits of both.  The spinal anesthetic allows for a rapid onset (almost immediately) of pain relief and the epidural anesthetic allows for continuous pain relief throughout labor. This combined spinal (fast acting) and epidural (slower onset but greater control) anesthesia technique has led to exceptionally high levels of pain relief satisfaction.

The use of combined spinal and epidural anesthesia has risen for the past 10 years. Because of the advantages over the older single-shot spinal or epidural techniques that were limited by the duration of action and the inability to be adjusted for increasing pain.

The spinal anesthesia is easy to administer, rapid in its onset, and produces excellent pain control. The epidural, allows for smoother control of your changing pain perception.  Once the effects of the spinal anesthesia subside, the anesthesia received through the epidural portion takes over to relieve the pain. The epidural medication is regulated to provide the exact amount of pain relief desired until the baby is delivered.

How is the combined spinal-epidural analgesia (CSE) administered?

To administer a combined spinal/epidural anesthesia, a mother in labor is placed in a sitting position. Her back is cleaned and prepared with an antiseptic solution. The physician first inserts an epidural needle into the lower back.  Then, a long and fine spinal needle is inserted through the epidural needle until it reaches the fluid surrounding the spinal cord (cerebrospinal fluid). The anesthetic (pain medicine) is then administered through the spinal needle, resulting in immediate pain relief. The spinal needle is then withdrawn.

The next step is to insert the epidural catheter (thin tube) through the epidural needle; the catheter is fixed in place with tape. The epidural catheter is used to give you continuous infusions of anesthetic (pain medicine) for extend pain relief once the effect of the spinal pain medicine wears off.

Who can have a combined spinal-epidural?

The combined spinal/epidural anesthesia is indicated for all women who want rapid onset of pain relief, control over the amount of pain medicine they receive, and can be used for a scheduled cesarean sections.

What are the advantages?

The increasing popularity of combined spinal/epidural anesthesia technique is attributable to its numerous advantages. The CSE allows rapid onset of surgical anesthesia, allows for continuous pain control during a long labor or surgery and pain relief after.  It also facilitates mobility (walking epidural), while controlling pain during early labor.

Overall, because of CSE technique’s faster pain-relieving effects with minimal discomforts and side effects, it has become the analgesic of choice with laboring patients.

What are the disadvantages?

CSE may cause a sudden drop in blood pressure, which is similar to the side effect noted with other spinal and epidural techniques. If the blood pressure does drop, it is easily increased by turning you to the left side and administration of a drug to increase blood pressure (vasopressin). Decrease in blood pressure is a very common side effect.

Another disadvantage is the increased risk of a spinal headache, also known as postpartal puncture headache. The headache is relieved by lying flat and increasing caffeine intake. If the spinal headache is persistent a procedure can be done for immediate relief called a “blood patch”. The headache is a rare complication of CSE.

What are the effects on the Baby?

Virtually all medications administered during labor have the ability to cross the placental barrier and reach the baby. However, spinal and epidural anesthetics are less likely to cause side effects on the baby when compared to drugs delivered through an IV.

SUMMARY

  • CSE  (combined spinal-epidural) has become the analgesic of choice with laboring patients

  • CSE has immediate pain relief and continuous pain control throughout labor

  • CSE is a patient controlled pain management technique that actively allows you to adjust the amount of pain medication you need.

  • The term “walking epidural” is commonly used to refer to CSE

  • When compared to different classes of pain relievers CSE has the advantage of minimizing the likelihood of side effects.
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