I AM GOING TO HAVE A BABY
I AM WORRIED ABOUT THE PAIN OF LABOUR
Most women in labour develop significant pain with their contractions. There are many ways in which women can be helped to manage this pain.
Anaesthetists are usually only involved if you request an epidural for pain relief or your obstetrician needs to do some form of assisted delivery. The other techniques are usually organised by your midwife or obstetrician.
Your obstetrician may also request an epidural in certain circumstances where it may benefit your baby (eg twins, blood pressure, prematurity, breech presentation).
I WANT AN EPIDURAL WHEN I GO INTO LABOUR
An epidural is just one method of pain control in labour although it is generally the most effective form of pain relief currently available. The objective is to have you comfortable in labour. It will not take away ALL sensation. You will feel sensations of the contractions and the baby moving. You should not be distressed by what you feel.
There are a variety of factors that will determine the timing of the epidural. As a general rule, provided there are no contraindications for you to have an epidural, and upon consultation with the midwife and/or obstetrician, you can request the epidural at any stage during the labour.
There may be medical reasons for placement of an epidural; such as having high-blood pressure, pre-eclampsia, or the need for use of medications that augment and speed up labour due to poor/slow progress.
The other factor that needs to be kept in mind is that usually, but not always, the length of labour is shorter with each subsequent pregnancy. If this is not your first labour, the window of opportunity may be shorter for the epidural to be inserted and have its effect before delivering the baby. You should discuss the desire to have the epidural with your obstetrician or midwife looking after you at the time of labour. They will be able to advise you on the timing depending on the progress and status of your labour and medical condition at the time.
What is an epidural?
The epidural space is a layer between the bones of your spine and the spinal nerves as they leave your spine and travel out to the rest of your body. A local anaesthetic and/or opioid ("morphine-like”) drug can be injected into this space. The local anaesthetic can 'block' the passage of pain sensations back along these nerves to the brain and the opiate (usually a drug called fentanyl) alters the way the spinal cord interprets the pain signals.
Because labour may go on after the drugs have worn off, a small plastic tube (catheter) is inserted into the epidural space to allow continuous infusion of pain relieving drugs into the epidural space. This prevents the drugs from wearing off.
What happens when I have an epidural?
Your anaesthetist will introduce himself and ask some questions about your general health, pregnancy and labour thus far. S/he will then tell you about what is involved, what to expect and any possible risks. If you have any questions or concerns please ask, but we will understand if you are too distracted to pay much attention to all of this.
After inserting the intravenous line (‘drip’) you will be positioned either sitting up or lying on your side for the epidural.
Your back will be cleansed with an antiseptic solution and a local anaesthetic will be injected in to the skin, to make the epidural injection more comfortable. You will be encouraged at this stage to curl your back to open up the spaces between the bones of your spine, so that the epidural needle can be more easily inserted to reach the epidural space. Your partner will be able to sit close by you and the midwife will help support your body in the best position.
The epidural needle is then inserted in your lower back and an epidural catheter is inserted through the needle so that it’s tip lies in the epidural space. The needle is removed and the catheter is taped to your back. The pain relief medication is then infused through the catheter into the epidural space by an electronic pump.
For patients with normal anatomy, insertion usually only takes minutes, but if the patient has an abnormality of the spine or is significantly overweight, the procedure can become technically difficult and may take longer to complete.
What will I feel?
The initial injection of local anaesthetic into the skin may give a burning or stinging sensation for a few seconds, but most people do not experience significant discomfort during the insertion of the epidural needle itself. Rarely you may feel some pain down the legs if the needle touches one of the nerves.
Once the epidural has been successfully placed the initial dose of anaesthetic is administered and pain relief generally occurs within 10-15 minutes.
Pain control is maintained by a pump which delivers an intermittent dose of epidural mixture. You will also have a button to press to top-up the epidural yourself. Pain changes in location, intensity and nature during labour and although we attempt to have you comfortable, epidurals are not perfect. Occasionally, despite pressing the button, the pain control is insufficient and we will attempt to improve it.
How long will it work for?
The first injection given when the epidural is inserted will last from 2-3 hours but then a further dose can be administered down the catheter (a 'top-up'). More commonly, we will start an ‘infusion’; this is an electronic pump that can give the top-ups automatically and also allow you to give yourself extra top-ups if you need them.
When you are ready to deliver your baby, the epidural is sometimes turned off to allow you to have more strength to help push.
WHAT IS REMIFENTANIL PCA?
Remifentanil is a morphine-like drug, which has been shown to be useful in reducing the severity of pain during labour. Its pain-relieving effect comes on very rapidly, and also wears off very quickly afterwards. Although remifentanil cannot provide complete relief of pain during labour, many women find it helpful. A small dose of the remifentanil is given into a drip in your arm at your request by pushing a button on an electric pump.
Any women in labour can request to use remifentanil PCA. We would advise women with an allergy to morphine, pethidine or other related drugs or if you have severe heart or lung disease, not to use remifentanil. Remifentanil may be useful also in certain situations where for one reason or another, women cannot have an epidural. If you try remifentanil and then decide to change to another method of pain relief in labour (e.g. pethidine, epidural), all the other options for pain relief are open to you. Having tried remifentanil does not limit your choice.
I NEED A CAESAREAN SECTION
About 1 in 10 women will require a Caesarean delivery for the birth of their baby. This may be 'elective' in that this is planned early in the pregnancy—usually because you have had a previous Caesarean or the baby is lying in an unusual position—or it may be an 'emergency'. An emergency Caesarean is usually done because your obstetrician feels that there is too much risk to the mother or baby if the birth is allowed to proceed along natural lines.
An emergency Caesarean can be very disappointing to the parents as most people want a natural childbirth and you will have very little time to come to terms with the change in your plans. It often seems that everything becomes very rushed and that you are no longer in control.
Most Caesareans are now done under a spinal anaesthetic. This is because most parents want to be present and awake when their child is born. Also, the risks of an anaesthetic are slightly higher when you are pregnant and a spinal anaesthetic can reduce some of these risks. However, some mothers find the prospect of being awake during surgery too terrifying; please discuss this with your anaesthetist as a general anaesthetic is quite acceptable. See below for comparisons of general and spinal anaesthetics.
The third option is for an epidural anaesthetic which is very similar to a spinal anaesthetic. Epidurals for Caesareans are now uncommon as spinals are judged to be easier and more effective unless it is an emergency Caesarean and you have already had an epidural inserted during your labour. For the surgery, the epidural can be 'topped up' with a stronger type of local anaesthetic that will numb your lower body completely.
Before a caesarean section
Your anaesthetist will visit you before your operation, to introduce themselves, assess your general level of health and discuss options and risks of the anaesthetic. If you have any questions please ask.
What happens with a Spinal Anaesthetic
On arriving in the theatre suite, you and your partner will be taken to the anaesthetic room where there may be several people; your Anaesthetist, your midwife, a theatre technician and an anaesthetic nurse. An intravenous line (‘drip’) is inserted to give some fluids and prevent a drop in blood pressure.
You will then be placed in to the correct position for the spinal. Usually this means sitting with your legs over the side of the bed. Less commonly you will be asked to lie on your left side and curl up in to a ball. Your back will be washed with some antiseptic solution and a plastic sheet placed on your back. The Anaesthetist will feel the bones in your spine and then inject a small amount of local anaesthetic in to the skin so the longer spinal needle doesn't worry you as much. A very fine spinal needle will then be inserted and the anaesthetic given.
How soon will the spinal anaesthesia work?
The first feeling is usually a warmth in your legs rapidly followed by tingling, numbness and heaviness. In about 5-10 minutes you should feel numb from the ribcage down, and the surgery can begin.
What are the advantages of having a spinal anaesthetic for caesarean section?
· Disadvantages of a spinal anaesthetic
Pain relief after the spinal anaesthetic
The numbness of the spinal anaesthetic usually wears off in two to four hours, however your anaesthetist will usually add a dose of morphine to the spinal mixture. This helps with pain relief for the rest of the day. In addition, simple oral analgesia (usually Paracetamol, Diclofenac and Oxycodone) are given regularly.
If no morphine is used in the spinal mixture, mothers may be offered a device called a Patient Controlled Analgesia (PCA) system. If you have pain, then pushing on a button will give you a small dose of painkiller, as often as required. The system is designed so that only small doses are given at safe intervals. It is uncommon to overdose yourself, however all opioids may cause sedation, nausea, vomiting and itch. These side effects can be treated.
You may request or be advised to have a general anaesthetic for your Caesarean delivery. In this case you will not be able to have your partner present at the birth.
The procedure will be like any normal general anaesthetic, the only slight difference is that because of the pregnancy we need to take steps to reduce the risk of any stomach acid spilling in to the lungs while you are anaesthetised. This may include an antacid medication as a premed. Also, as you are drifting off to sleep, the anaesthetic nurse will place some firm pressure over your neck.
You will wake up in the recovery room after the procedure and your baby will have been transported to the nursery to be kept warm. Pain relief will be administered in the form of a morphine drip (PCA) but you may experience some discomfort until adequate levels of this are achieved.
What are the advantages of a general anaesthetic?
What are the disadvantages of a general anaesthetic?
Making a choice
For many people this is an easy choice, but you shouldn't be pushed in to something you don't want. Sometimes it will be much safer to choose one technique or the other because of your medical condition and your anaesthetist or obstetrician will inform you of this. Normally though, the choice is yours. If you have questions or concerns please discuss them with your Anaesthetist before the operation.