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I had a student approach me recently quite perplexed about some of the limitations she may have if she decided to take an epidural. She had heard of the “walking epidural” so presumably thought that she would be able to walk.
I doubt this student is the only one who has had some confusion about the difference between a walking epidural and a standard epidural, so let’s dive in and discuss them!
What is an epidural and what does it do?
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.
How is an epidural procedure done?
A very important component of the epidural placement is the parent’s position.
The laboring person needs to be very still, even during a contraction. They will assume a “cat” spine (a C curve spine) which allows the spaces between the vertebrae to open up so that the epidural space is easiest to find.
The doctor will clean the back with iodine and then place a plastic sheet over a portion of the lower back.
An anesthesiologist will then administer a local anesthetic, often described as “feeling like a bee sting” or needle pinch. This is a numbing medication.
From there the anesthesiologist will proceed with placing the needle in the back and at this point you should feel more pressure because the numbing agent previously applied is working.
Then you will feel a cold sensation down your back. That is simply the medication getting to work!
For both, the walking epidural or the standard epidural, the anesthesiologist threads a catheter in place. This catheter is then removed and a tiny catheter is then threaded through the needle. The needle is removed and the tiny catheter is left in place and well taped to the person’s back in order to continuously deliver pain medication for the rest of labor and delivery.
Are you really walking with a “Walking Epidural”?
Some hospitals do allow more out of bed mobility than others. So always check with the facility and find out what their policies are. Many hospitals will not allow you to walk if you have any needle in your back regardless of the type of epidural given. This is primarily due to liability. If there is any issue with your proprioception (your sense of movement), balance and movement, it becomes a liability for both the parent and baby as well as the hospital.
How much can you move with an epidural?
The “walking” epidural is a “cocktail” of narcotics, local anesthetic and epinephrine which offers relief while typically still having all of your motor sensations functioning. Since the combined epidural is a lower dosage through the spinal space, there is not such a dense block of feeling so the laboring person still has some sensation on the lower body.
The combined epidural offers immediate relief while typically still preserving all of your motor sensations. You can continue to move your legs freely and have freedom of movement. Unlike with the standard epidural where there is more heaviness to your lower body.
While walking around may not necessarily be an option, you can still move safely in bed! 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 and smoother delivery.
With the “walking epidural”, the laboring person may even be stable enough to assume a quadruped (all fours position) on the bed (with a little help from the birthing team) and do some hip movements like “cat/cow.”
This is a very helpful position since it encourages optimal fetal position and takes the pressure off the birthing parent’s back.
Keep in mind, some people are less sensitive than others to the medication and some may need more medication. So even if it is a combined epidural, if they need more medication, they may experience a heavier feeling in their lower body making it harder for them to move.
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 anesthetics 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 generally 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.
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 (spine) and this hole can be the cause of a headache after the spinal injection.(2)
Is there a difference in risks between a Walking Epidural and a Standard Epidural?
The side effects are pretty much the same with the exception of a higher chance of a spinal headache from the walking epidural. In my own opinion, with the walking epidural there is a greater chance for varying maternal positions which can help labor to be more functional. Also, since the laboring person is still retaining some awareness of their lower body, it will make the second stage of labor (pushing stage) easier to coordinate.
Both epidural choices will require close monitoring. Specifically blood pressure monitoring since a drop in blood pressure is a side effect of the epidural. You will also have continuous IV fluids to help combat the drop in blood pressure and receive full time fetal monitoring. Some people also receive a bladder catheter.
You may also want to have a conversation with your care provider or hospital to better understand what epidural they will likely use should you choose to have one.
If you want to learn more about epidurals, here is a podcast I did that goes even deeper into the conversation of epidurals:
Know Your Options: Pain Meds During Labor with Rachel Salem CRNA
Know Your Options: Pain Meds During Labor with Rachel Salem CRNA
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