Pain:
The pain of labor has been with us since the Garden of Eden.
Some women seem to be able to control their pain with breathing, focusing, or relaxing techniques. Others want to be 'knocked out'. The challenge for the anesthetist is to stop or minimize the pain but not the labor, and do so in a manner 'SAFE' to both the baby and mother.

Available options:



Choosing Epidural Anesthesia
Advantages and Benefits
Pain relief is adjustable from complete to partial.
Relieves pain while still allowing some movement (varies with dosage and type of epidural).
Mother is awake, even for a cesarean section.
May enhance labor progress if mother is exhausted or very anxious.
May enable a gratifying birth experience if natural coping mechanisms fail.
Just knowing it's available reduces the fear of birth.
Presumed safe for mother and baby.
Preferred by some care providers and nurses.

WHAT CAUSES PAIN IN LABOUR ?

Labour begins when your uterus (womb) begins to contract. In the days before labour starts, you may experience tightening of the uterus which cause discomfort rather than pain. Labour is said to start when you get regular contractions. Contractions increase in frequency and intensity throughout labour and can become painful in a similar way as you may experience pain in other muscles in your body when you do vigorous exercise.

At the same time the opening into the uterus (the cervix) is stretching to eventually allow your baby to pass through into your birth canal. When the opening to the cervix is fully open (dilated) you begin what is known as the second stage of labour, when your baby is born. The baby passes through your birth canal and is born by a combination of the continuing contractions of your uterus and your conscious effort to push your baby out by using the muscles of your lower abdomen

COPING IN LABOUR

You can do a lot to help. Preparing for childbirth during your pregnancy can improve these natural changes. Relaxation and breathing exercises to help you manage your labour pains. Sometimes this is all that you may need. Care with your diet, and stopping smoking are other ways you can help yourself by improving your fitness and training your body for the task that lies ahead.

Obstetricians are doctors specializing in the medicine of childbirth. As part of this they may have knowledge and administer some forms of pain relief including some local anesthetic techniques involved in childbirth. Anesthetists are specialist doctors having knowledge and experience in providing all types of pain relief and can apply more sophisticated forms of pain relief to you in labor, as well as giving anesthetics should they be necessary.

EPIDURAL ANALGESIA

The nerves from the uterus (womb) and birth canal go to the brain through part of your lower back. It is possible to bathe these nerves with local anaesthetic using an injection. A fine tube is placed in the region of the nerves so that painkiller can be injected. This can be repeated or 'topped up' when needed during your labour. Positioning of this tube is done by an anaesthetist. Once the tube is in position you will be almost unaware of it's presence. For the second stage of labour the 'top up' is usually injected with you sitting up. This stops the pain from the lower nerves. This top up will also allow a doctor or midwife to deliver your baby painlessly if assistance is required. Any stitching can be done while the epidural is still working. An epidural will leave you pain free, but you may still have some sensation of pressure, particularly as your baby is born.

Epidural placement:



How an Epidural Block is Given

The following is a general description of the step-by-step procedure:

1. The care provider orders the epidural and the anesthesiologist is called. A nurse remains throughout the procedure and afterward until optimal anesthesia has been achieved and all vital signs are stable. She remains close by thereafter.

2. A bolus (1 liter) of intravenous fluids is quickly administered to the mother to increase her blood volume and reduce the likelihood of a dangerous drop in her blood pressure.

3. The anesthesiologist obtains informed consent from the laboring woman after explaining the risks and benefits of the procedure

4. An electronic fetal monitor is used to help document fetal and uterine response to the epidural.

5. The mother's blood pressure, respiration, and pulse are observed to provide a baseline for assessing effects of the epidural; these will be checked frequently.

6. The mother is asked to sit up, rounding her back, or to curl up on her left side, close to the edge of the bed, and remain very still.

7. :The anesthesiologist

A. Locates the desired vertebral space in the low back.

B. Scrubs the area with antiseptic

C. Injects a local anesthetic to numb the skin

D. Inserts the epidural needle slowly and carefully to locate the epidural   space; Giving the epidural:

Needle placement:



Anatomy:



Anatomy:



E. Draws back on the syringe, to check for blood or cerebrospinal fluid; if either is found, the anesthesiologist relocates the needle or starts over again.

F. May place a pulse meter on the mother's finger or earlobe.

G. May administer a test dose of local anesthetic with or without epinephrine to detect any adverse effects of the medication and to act as a safeguard against injecting into a blood vessel.

H. Threads a thin Teflon catheter through the needle into the epidural space. The mother may feel pressure and occasionally a shooting pain or shock sensation down one leg.

I. Tapes the catheter to the mother's back, extending it to her shoulder. The catheter is either topped up every one to three hours or attached to an infusion pump that drips concentrations of medication for more consistent pain relief

J. Observes fetal heart rate, maternal blood pressure and pulse, and if necessary, gives oxygen to the mother, changes her position, or administers intravenous medications to raise her blood pressure.

K. Tests the area for loss of sensation or pain relief with a series of touches with a cold swab, pinpricks, or pinches over her trunk

L. Returns periodically to add medication or to check the infusion pump and the mother's comfort

M. Can increase the level and depth of anesthesia for a cesarean delivery, if necessary, and monitor maternal well-being during the surgery.

8. Pain relief begins within 5 to 10 minutes. The area affected may range from a band around the mother's trunk or a larger area from nipples to toes, depending on the concentration of the drug and the number of spinal segments in contact with the medication.

9. A bladder catheter may be placed one the epidural has taken effect, since the sensations of a full bladder and the ability to urinate are reduced.

10. The nurse continues to check vital signs and the contraction pattern, and takes appropriate action if problems arise.

11. The mother usually has marked reduction in pain and some loss of control of the muscles in her trunk and legs, without any mental effects.

Different Types of Epidurals

Traditional, CSE, and Intrathecal

Traditional, All-Anesthetic Epidural :

The practice of using only anesthetic is currently out of fashion and it's unlikely that you'll an all-anesthetic epidural.

Epidural catheter may be left in place for continuous or patient controlled pain relief. Provides the best pain relief over a long period of time.

Intrathecal:  This is considered spinal anesthesia, and not an epidural. This technique involves placing a small dose of narcotic in the intrathecal space (the fluid-filled space surrounding the spinal cord). Provides almost immediate pain relief and the patient is able to move, and push without any muscle weakness.

Combined Spinal Epidural: This is a new technique that combines the first two techniques from above. The anesthesiologist will use both an anesthetic in the epidural space to provide long-lasting pain control, as well as a narcotic in the intrathecal space. The addition of the narcotic allows the anesthesiologist to use very little anesthetic and still provide good pain relief.

EPIDURAL RISKS AND SIDE EFFECTS

Maternal Risks

Hypotension (Drop in blood pressure).

Urinary Retention and Postpartum Bladder Dysfunction.

Uncontrollable Shivering.

Itching of the face, neck and throat Nausea and Vomiting.

Postpartum Backache.

Maternal Risks

Maternal Fever.

Spinal Headache.

Uneven, incomplete or nonexistent pain relief.

Feelings of Emotional detachment.

Postpartum feelings of regret or loss of autonomy.

Inability to move about freely on your own Loss of perineal sensation and sexual function Maternal Risks.

Very Serious and rare risks.

Convulsions.

Respiratory paralysis.

Cardiac arrest.

Allergic shock.

Nerve injury.

Labor Side Effects.

Prolonged First Stage of Labor.

Increase of malpresentation of baby's head.

Increased need for Pitocin augmentation.

Prolonged Second Stage of Labor.

Decrease in the ability to push effectively.

Increased liklihood of forceps or vacuum extraction delivery.

Increased likelihood of needing an episiotomy.

Increase in cesarean section.

Baby Side Effects.

Fetal distress.

Abnormal fetal heart rate.

Drowsiness at birth.

Poor sucking reflex.

Poor muscle strength and tone in the first hours.

Contraindications for having an Epidural Bleeding disorder or on anticoagulants

Infection in area of Epidural Injection, Thrombocytopenia, Patient refusal