By Dr Mohamed Mubarack
The delivery of the infant into the arms of a conscious and pain-free mother is one of the most exciting and rewarding moments in medicine. Pain relief in labour has always been surrounded with myths and controversies. Hence, providing effective and safe pain relief during labour has remained an ongoing challenge. Modern regional anaesthesia for labour pain relief reflects a shift in obstetrical anaesthesia, thinking away from a simple focus on pain relief towards a focus on the overall quality of pain relief. It is the most versatile method of labour pain relief and the gold standard technique for pain control in obstetrics that is currently available.
The use of regional anaesthesia has increased dramatically in the last 20 years, especially in the west. It is unlikely that this will change soon as compared with other techniques. The satisfaction of birth experience is greater with regional anaesthesia. Epidural pain relief refers to local anaesthetics and adjuvants injected into the epidural space. Women request an epidural by name more than any other method of pain relief. More than 50% of women giving birth at hospitals use epidural anaesthesia.
As you prepare yourself for “labour day,” try to learn as much as possible about pain relief options so that you will be better prepared to make decisions during the labour and birth process. Understanding the epidurals, how they are administered, and their benefits and risks will help you in your decision-making during the course of labour and delivery.
What is epidural anaesthesia?
Epidural anaesthesia is a regional anaesthesia that blocks pain in a particular region of the body. Epidurals block the nerve impulses from the lower spinal segments. This results in decreased sensation in the lower half of the body. A Labour epidural delivers continuous pain relief to the lower part of your body while allowing you to remain fully conscious. It decreases sensation but doesn’t result in a total lack of feeling. Medication is delivered through a catheter – a very thin, flexible, hollow tube – that’s inserted into the epidural space just outside the membrane that surrounds your spinal cord and spinal fluid. The medication delivered by the epidural is usually a combination of a local anaesthetic and a narcotic. Local anaesthetics block sensations of pain, touch, movement, and temperature, and narcotics blunt pain without affecting your ability to move your legs. Used together, they provide good pain relief with less loss of sensation in your legs and at a lower total dose than you’d need with just one or the other. You may also have the option of patient-controlled pain relief, which means that you can control when you get more medication via a pump that’s connected to the catheter. (The amount of medication you can give yourself is limited, so there’s little chance of overdose.) After you deliver your baby, the catheter will be removed. (If you’ve had a c-section, sometimes the catheter is left in to administer postoperative pain medication.) Having the catheter removed doesn’t hurt at all beyond the sting of having the tape pulled off.
When is the best time to get an epidural?
In the past, many practitioners wanted a woman to be in active labour before starting an epidural due to a concern that it might slow down her contractions. These days, most caregivers will allow you to start an epidural whenever you ask for it. Typically epidurals are placed when the cervix is dilated to 4-5 centimetres and you are in true active labour.
What are the benefits to having an epidural for pain relief during labour?
An epidural provides a route for very effective pain relief that can be used throughout your labour.
The anaesthesiologist or nurse anaesthetist can control the effects by adjusting the type, amount, and strength of the medication. This is important because as your labour progresses and your baby moves further down into your birth canal, the dose you’ve been getting might no longer cover the pain, or you might suddenly have pain in a different area.
Since the effect of the medication is localised, you’ll be awake and alert during labour and birth. And, because you’re pain-free, you can rest if you want (or even sleep!) as your cervix dilates. As a result, you may have more energy when it comes time to push.
Once the epidural’s in place, it can be used to provide anaesthesia if you need a c-section or if you’re having your tubes tied after delivery. When other types of coping mechanisms are no longer helping, an epidural can help you deal with exhaustion, irritability, and fatigue. An epidural can allow you to rest, relax, get focused, and give you the strength to move forward as an active participant in your birth experience.
The use of epidural anaesthesia during childbirth is continually being refined, and much of its success depends on the skill with which it is administered
What are the disadvantages?
You have to stay in an uncomfortable position for five to ten minutes while the epidural is put in, and then wait another five to 20 minutes before the medication takes full effect. This may seem like a minor inconvenience, though.
Depending on the type and amount of medication you’re getting, you may lose some sensation in your legs and be unable to stand. Sometimes, particularly in early labour, so little anaesthetic is needed to make you comfortable that you have normal strength and sensation in your legs and can move around without difficulty. (This is called a “walking epidural.”) Still, many practitioners and hospitals won’t allow you to get out of bed once you’ve had an epidural, whether you think you can walk or not.
An epidural requires that you have an IV, frequent blood pressure monitoring, and continuous fetal monitoring.
An epidural often makes the pushing stage of labour longer. The loss of sensation in your lower body weakens your bearing-down reflex, which can make it harder for you to push your baby out.
Will an epidural affect the new-born?
The most recent studies suggest that an epidural does not have a negative effect on a new-born (as measured by his Apgar score, an evaluation routinely done immediately following birth). In fact, some studies show that babies whose moms had epidurals had better Apgar scores than babies whose moms had prolonged labours without the relief of an epidural.
Can anyone have an epidural?
Not all women are good candidates for this kind of pain relief. You won’t be able to have an epidural if you have abnormally low blood pressure (because of bleeding or other problems), a bleeding disorder, a blood infection, a skin infection on the lower back where the needle would enter, or if you’ve had a previous allergic reaction to local anaesthetics. Women taking specific blood-thinning medications can’t have this kind of pain relief, either.
In short epidural pain relief is commonly performed to relieve labour pain. Compared with other techniques, it is the most effective form of pain relief. Recent innovations in drug combinations and delivery systems have resulted in a flexible technique that meets the needs of most parturients in a safe and effective manner. The use of low concentrations of local anaesthetics, combined with lipid-soluble opioids does not impede the progress of labour or depress the new-born. The addition of patient-controlled epidural pain relief and innovations using new technologies enhance patient satisfaction.
* Dr Mohamed Mubarack, MBBS, MD (Anaesthesiology), is a Specialist at Aster Hospital, Doha
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