The “walking epidural,” officially known as the Combined Spinal-Epidural (CSE) technique, is a modern approach to pain relief during labor. It aims to balance effective pain management with the preservation of motor function. This technique is gaining popularity because it allows for a more active labor experience compared to conventional methods, primarily due to lower medication dosages that permit the person to retain more sensation and strength in their legs.
Defining the Low-Dose Combined Spinal Epidural
The low-dose combined spinal epidural is a two-part procedure designed for rapid, yet sustained, pain relief while minimizing motor block. The procedure begins with the spinal component: a single, small injection of medication into the cerebrospinal fluid. This injection, typically a low dose of an opioid (like fentanyl) and a local anesthetic (such as bupivacaine), provides immediate pain relief within minutes.
Following this, an epidural catheter is placed into the epidural space, located just outside the spinal cord’s protective membrane. The catheter delivers a continuous, low-concentration infusion of similar medication. Using low concentrations of local anesthetic preserves muscle strength, allowing for retained leg movement. This dual approach ensures quick relief from the spinal dose, followed by prolonged pain management via the epidural infusion.
Mobility and Practical Application During Labor
Despite the name “walking epidural,” the ability to walk unassisted is often limited and should not be the primary expectation. The term accurately refers to retaining motor function and the ability to change positions, which is a major benefit over traditional epidurals. With this low-dose technique, individuals can typically move their legs, shift positions in bed, stand at the bedside, or shuffle short distances with assistance.
Retained motor strength allows the laboring person to utilize gravity and different upright positions, which can help with the progression of labor. The ability to actively push during the second stage is also often improved because the lower concentration of anesthetic affects the pushing muscles less. Active participation in labor, such as squatting or kneeling, contributes to a more positive birthing experience. Safety is paramount, and most institutions require constant monitoring and staff assistance when any movement is attempted to prevent falls.
Comparing Low-Dose and Traditional Epidural Characteristics
The low-dose CSE technique differs from a traditional epidural in its speed of onset, pain relief level, and common side effects. Since the CSE includes a direct spinal injection, pain relief is significantly faster, often taking effect within five minutes. A traditional epidural requires 15 to 20 minutes to fully establish through the catheter and uses a higher dose of local anesthetic. This higher dose results in more complete pain blockage but causes a near-complete loss of sensation and motor function in the lower body.
The trade-off for retained mobility with the low-dose CSE is that pain relief may be slightly less complete or “patchy” than the dense block of a traditional epidural, though patient satisfaction remains high. The inclusion of an opioid in the initial spinal dose provides rapid relief but can increase the incidence of side effects like maternal itching (pruritus). The low-dose CSE is associated with a lower risk of severe hypotension and less leg weakness than the traditional technique.
Eligibility Criteria and Contraindications
Eligibility for a combined spinal-epidural is determined by a thorough assessment conducted by the anesthesiologist and the obstetric team. A patient must be stable and medically fit to undergo this neuraxial procedure.
Medical Contraindications
One significant contraindication is a pre-existing condition affecting blood clotting, such as a low platelet count or being on anticoagulant medications. Infections, including sepsis or a local skin infection at the insertion site, are also reasons to postpone or cancel the procedure due to the risk of spreading infection to the spinal canal.
Procedural Limitations
Rapid progression of labor may make the CSE impractical, as the time needed for safe placement can be a limiting factor. Furthermore, specific anatomical or neurological conditions, such as certain spinal abnormalities or pre-existing neurological diseases, may be considered relative contraindications.