Download Pain Relief During Labour and Anesthesia for Cesarean Section

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Pain Relief During
Labour
and
Anesthesia for
Cesarean Section
Table of Contents
Labour........................................................................................................1
Distraction Techniques ..............................................................................2
TENS ........................................................................................................2
Nitrous Oxide ............................................................................................3
Narcotics....................................................................................................4
Epidural Anesthesia ..................................................................................6
Combined Spinal Epidural Analgesia......................................................11
Commonly Asked Questions ..................................................................12
Anesthesia for Cesarean Section ............................................................13
The purpose of this booklet is to provide information to help you
understand the options that are available before you experience the
pain of labour. This booklet reviews the techniques commonly available
in the Calgary Health Region for the relief of pain during labour. Also,
anesthesia for cesarean section is discussed. We encourage you, especially
if this is your first baby, to enroll in Childbirth Education classes. It is
important to think about the kinds of pain relief that you might want to
use in labour before you are in labour. If you are aware of your options
and the risks and benefits of each one, you will be able to make the
best choice for you when the time comes.
Labour
What will labour be like?
Labour hurts. It is not simply "uncomfortable". Labour is the most painful
experience most women will likely ever know. While most pregnant
women prefer not to take medications unless needed, most women ask
for pain relief during labour. A number of methods are available to
relieve the pain of labour. All labours are different. First labours are
usually the longest, but this is not always true.
What types of pain relief are available during labour?
There are a number of pain relief options that make it easier to deal
with the pain of labour. Many options are easy to use at home as well
as at the hospital. These include breathing and positioning techniques,
showers, hot water bottles, massage, music, imagery and TENS
(transcutaneous electrical nerve stimulation). Other options, including
laughing gas (nitrous oxide), narcotics (for example Fentanyl®,
Demerol® and morphine) and epidural pain relief are only available at
the hospital. The epidural method provides the most reliable pain relief
of all the techniques.
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How do I make a choice?
The type of pain relief you use during labour is a personal choice. Speak
with your doctor or midwife before you go into labour. When you are in
the hospital, the decision to use pain relief and the kind to use will be
made by you, your nurse and your doctor(s). The better informed you
are, the more likely you will be happy with whatever you choose.
Distraction Techniques
The distraction techniques do not use medications or needles. They work
best when used in early labour, but can be used throughout labour. These
methods include breathing and relaxation techniques, water therapy (warm
shower or bath), hot water bottles, massage and music. By focusing on
something other than the pain of labour, it is easier to cope. These
techniques work best if you learn about them before labour starts. The
advantages of the distraction techniques are that they are easy to use, do
not harm the mother or baby, and can easily be started and stopped. If
they do not work for you, you can try something else. The disadvantage
is that they do not provide much pain relief–they are ways to help you
cope.
What is TENS?
TENS stands for transcutaneous electrical nerve stimulation. A TENS
machine is a small electrical device with controls that you adjust. There
are wires going from the machine to electrodes (like bandages) on your
middle and lower back. During contractions, you adjust the controls on
the unit to produce a small electrical current over the skin where the
electrodes are placed. You can adjust the current from a tingling to a
pulsing sensation (like a shower massage). The machine usually attaches
to your belt or over your shoulder.
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TENS seems to be most helpful in early labour, especially for "back"
labour. Some women find TENS helpful throughout labour, perhaps
combined with a narcotic or nitrous oxide as labour progresses.
However, many women who start with TENS want to try something else
(for example, a narcotic or epidural) by the time they are 4-6 cm dilated.
If you want more information on TENS, speak with your doctor or a
physiotherapist. TENS may be useful at home in early labour or the
pre-labour period. A maternity TENS unit can be rented from many
home medical supply stores.
Nitrous Oxide
Nitrous oxide, also known as "laughing gas", is a weak anesthetic
agent commonly available in labour and delivery for pain relief. It is a
combination of two gases, nitrous oxide and oxygen. It is also know by
the names Entonox® or Nitronox®.
When can I use nitrous oxide?
Nitrous oxide can be used at any time during labour. However, most
women find nitrous oxide best for short-term use (1-2 hours).
How do I use nitrous oxide?
Nitrous oxide is a gas. You put a mask over your nose and mouth and
take deep breaths at the start of a contraction to fill your lungs with the
gas. You keep breathing the gas through your contraction, and, at the end
of the contraction, you take the mask off your face and breathe room air.
How long can I use nitrous oxide?
Nitrous oxide is often used to "bridge" the time before you deliver your
baby or receive other methods of pain relief. If you are near the end of
labour and want something to help you through, nitrous oxide might
work well for you. You can also try nitrous oxide when you are in early
labour. If you find it helpful and want to use it for hours it is safe.
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What are the side effects of nitrous oxide?
Most women who use nitrous oxide feel dizzy or light-headed. If you do
not like the feeling you get from nitrous oxide, stop using it. You will
feel like your normal self in just a few minutes. Some women may feel
nauseated (sick to their stomachs) when using nitrous oxide
If nitrous oxide does not work, what do I do?
Using nitrous oxide does not limit any future choices for pain relief. If
you try it and it does not work, you can choose another form of pain
relief.
Narcotics
Narcotics are commonly given to women in labour and provide fair to
good pain relief for many of them.
What narcotics are used?
There are many narcotics available. Your doctor will decide what the
best medication for you is. Possible medications include (but are not
limited to) Fentanyl®, Demerol® and morphine.
How are narcotics given?
Narcotics can be given as an injection into a muscle or vein. Mothers
may have the chance to control how much narcotics they receive by
using Patient Controlled Analgesia (PCA). PCA is available in most
centres and your doctor will decide if it is the best method for you.
How well do narcotics work?
The pain relief begins within 30 minutes if narcotics are injected into the
muscle, sooner if given by intravenous. The pain relief lasts about 2-4
hours and then gradually wears off. A second dose may be given. The
timing of future doses depends on the expected delivery time.
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Narcotics make it easier to cope with the pain of labour. They do not get
rid of the pain. They make it so the pain does not bother you as much.
Narcotics provide the best pain relief of the "coping" strategies.
What side effects do narcotics have?
Most women feel drowsy or sedated from narcotics. Sometimes some
women feel "spaced-out". Nausea and vomiting are also common. Some
women may have some itchiness or hallucinate (see or hear things that
are not there). If you do receive a narcotic, you usually must stay in your
room.
What effect may narcotics have on my baby?
Like their mothers, babies get sedated from narcotics. Sometimes a
baby's breathing may be affected. This occurs more often when narcotics
are given close to delivery. For this reason, we try not to give narcotics,
especially larger doses, if we think you will deliver in 1-2 hours. Doctors
and nurses in the labour and delivery area treat babies who are not
breathing well. If necessary, they will help the baby with breathing and
give the baby a medicine (naloxone) to stop the effects of the narcotic.
Drug effects last longer in babies than adults. If babies are sleepy,
breastfeeding might be more difficult on the first day. Keep trying!
What if labour still hurts?
If narcotics do not work as well as you would like, or you do not like the
side effects, you can use something else. The only option more effective
than a narcotic is an epidural.
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Epidural Analgesia
What is an epidural?
Getting an epidural involves placing a small, soft plastic tube (epidural
catheter) into the epidural space between the bones of the lower back.
Medicine is then given through the epidural catheter to relieve the pain
of labour. If you are interested in receiving an epidural, an anesthesiologist
will come and explain epidural analgesia to you.
How effective is epidural analgesia?
Epidural analgesia gives good to excellent pain relief for 90-100 percent
of women. It is the most effective and reliable form of pain relief
available for women in labour. In general, anesthesiologists try to take
away the pain of labour without making you any more numb than necessary. Often, epidural analgesia separates the sensations of pain and pressure. In other words, you will not feel the pain of labour, but you will
still sense your contractions as abdominal tightenings, or as rectal or
vaginal pressure.
Who can have an epidural?
Most women who want an epidural can have one. Although epidurals are
usually done for pain relief, your obstetrician may recommend an
epidural to you for other reasons, for example if you are expecting twins.
Who cannot have an epidural?
Women with the following problems may or may not be able to receive
epidural analgesia:
bleeding problems
infection over the skin of the lower back
very severe infections
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surgery at the site where epidurals are placed
some rare medical conditions
tattoo at the site where epidural needle is inserted. Tattoo ink may
contain metals and/or organic material. Introducing these materials
close to nerves in the epidural space may be harmful. The effect of
these materials on nerves is not well-known or studied and may
appear many years after having an epidural. Large tattoos on the
lower back may mean that the anesthesiologist has to adjust the
epidural technique. Some anesthesiologists may choose to not
place an epidural at all.
Each case must be discussed with an anesthetist. Your delivering doctor
can arrange this before your labour or delivery.
How is an epidural catheter inserted?
1.
You will be positioned either sitting upright or lying on your side
for placement of the epidural catheter. Some anesthesiologists
allow you to choose the position; others prefer you in a specific
position. You will be asked to bring your knees up as high as
possible on your abdomen, put your chin on your chest and to push
the lower part of your back out (like a cat arching its back).
2.
Your lower back will be washed with antiseptic solution. Sterile
drapes may be placed to cover your back.
3.
Local anesthetic will be injected under the skin in the spot where the
epidural needle will go. The local anesthetic will cause a burning or
stinging sensation for a few seconds when it is injected.
4.
Once the skin is numb, an epidural needle will be inserted into the
epidural space. You may feel an uncomfortable pressure during this
procedure. You will be asked to stay still during insertion of the
epidural needle and catheter. The anesthetist usually stops working
during contractions.
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5.
Once the needle is in the epidural space the epidural catheter is
inserted through the needle into the space. You might feel a
sensation like an electrical shock in your bottom or leg when the
catheter is inserted (like hitting your "funny bone"). That feeling
quickly goes away.
6.
The needle is then taken out of your back and the plastic epidural
catheter is taped up your back to your shoulder. You will feel a
cool sensation on your back as medications are injecting through
the catheter. You can lie on your back and roll from side to side
without fear of injury or causing the catheter to fall out.
The procedure of inserting an epidural catheter normally takes 5-15
minutes. Medicine is then given to relieve the pain of labour. About 20
minutes are needed to get the full effect of any medication given, but an
epidural will often work faster.
How long does the pain relief last?
Pain relief usually lasts 1-2 hours after the epidural has been started.
Most hospitals use continuous infusion to maintain pain relief until after
delivery. However, at some hospitals you may be able to control the pain
medication with Patient Epidural Controlled Analgesia (PECA). You
push a button to give yourself a little extra medicine when you need it.
You are in control of how much medicine you receive. The pumps are
programmed to be very safe. You cannot give yourself too much medicine.
You can feel as much or as little of your contractions as you want,
depending on how often you push the button. Your anesthesiologist will
still check on you to make sure you are comfortable and can give you
extra medicine or adjust the pump as is needed.
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What are the common side effects of epidural analgesia?
Epidural analgesia is very safe. The effects of the procedure and
medications on the mother and baby are small, often less than narcotics
such as Demerol® or morphine. However, epidural analgesia has side
effects and complications.
Some common side effects of epidurals are:
Lower blood pressure: For this reason you must have an intravenous
infusion of fluids first. You will receive some intravenous fluid to
keep your blood pressure normal.
Shivering and shaking: Are common in labour and may be even
more common in women with epidurals.
Itchiness: Most patients can ignore the itch. If it is a problem there
is a safe, effective treatment.
Weak legs: You may have to stay in bed. If your legs are strong
enough, you may be allowed up in your room (for example, to go
to the bathroom, or to sit in a chair) or you may be allowed up in
the hallway. You may push the button on your pump to give more
medicine while you are up.
Unable to urinate (pass water): A tube will be inserted into your
bladder to drain the urine.
Minor back pain (bruised feeling): Common at the site of the
epidural, it usually goes away within a week. Generalized lower
back pain can continue for months after childbirth. This happens as
commonly in women who do not receive epidurals as in women
who do.
Depending on the strength of epidural medication, the second stage
of labour (the length of time from when the cervix is fully dilated
to delivery) may be longer. However, this is not usually a problem
for most women and babies.
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Rare complications:
The epidural needle is inserted into the spinal fluid (happens about
1 percent of the time). If this occurs, a "spinal headache" may
develop (usually one or two days after delivery of your baby).
Spinal headaches occur when you sit or stand and get better when
you lie down. If you get a spinal headache and it is severe, tell
your doctor or nurse. There is effective therapy available.
The medication used does not always work as well as we would
like: Sometimes it works better on one side of the body than the
other. Sometimes it seems to miss a spot. These problems can
usually be fixed. We may change your body position and give you
more medicine. However, sometimes we cannot make you as
comfortable as you would like to be. If this happens, the epidural
is usually redone.
A nerve gets injured and may lead to numbness of the thigh or
lower leg: Usually this is from the process of childbirth. The
epidural may allow you to tolerate a hip or leg position you
would have complained about without the epidural pain relief
(like stretching your leg more than you normally would). Less
commonly, it is a nerve injury from the epidural catheter. No
specific treatment is needed and the numbness reverses over the
next weeks to months.
Paralysis: Many patients fear that having a needle in their back
might make them paralyzed. Paralysis is possible after epidural
analgesia but is very rare.
Trouble with breathing or circulation: If epidural medications are
given accidentally into an epidural vein or into the spinal fluid, you
may have trouble with your breathing and circulation. This is also
very rare.
Allergic reactions: Are possible but very rare.
Infection: All procedures have a small risk of infection, including
epidural/spinal anesthesia.
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If you have an epidural, you will be attached to an electronic fetal
heart rate monitor when medications are given. The baby's heart rate is
monitored when medications are given. If the baby's heart rate tracing
shows there are no problems, you may be disconnected from the monitor.
The monitor will be placed around your abdomen again if there is concern
about the baby, if you receive oxytocin to stimulate your labour, or if you
receive extra doses of epidural medication. Most women who choose
epidural analgesia are "low risk" and continuous electronic fetal heart
rate monitoring is not needed.
Combined Spinal Epidural (CSE) Analgesia
Some patients receive a variation of epidural analgesia called a
Combined Spinal Epidural Analgesia (CSE). With this method, your
anesthetist uses both a spinal needle and an epidural needle to access
two spaces in your back, the spinal space and the epidural space. The
advantage of this method is that the pain relief is almost immediate,
while not making your legs too numb.
In general, complications from CSE are the same as with epidural
analgesia. However, itching is more common and more bothersome with
CSE. Your anesthesiologist will decide if CSE is suitable for you. Not all
anesthetists use this technique.
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Commonly Asked Questions
Who decides if and when I can have an epidural?
The decision to have an epidural is made by you, your nurse, your doctor
(family doctor or obstetrician) and your anesthesiologist. We suggest
you discuss pain relief with your doctor before you are in labour. Most
epidurals are placed when women are 3-6 cm dilated and having regular,
painful contractions. Sometimes epidurals are given earlier and sometimes
they are given later. Your situation will be looked at and the best decision
will be made for you.
Can I eat and drink if I have an epidural?
Women in active labour must not eat solid food. Clear liquids and ice
chips are often allowed.
How safe are the techniques described in this booklet?
All the techniques described in this booklet are very safe. Each has been
used for millions of women around the world.
How often are these techniques used?
Most women in labour use some kind of pain relief option. Overall, in
the Calgary Health Region, epidural pain relief is used by 3500-7000
women per year. Up to two-thirds of women having their first baby will
choose epidural analgesia at some point during labour.
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Anesthesia for Cesarean Section
About 20-25 percent of children born in Calgary are delivered by cesarean
section (c-section). For women who go into labour on their own and
everything starts off well, about 10 percent will end up needing a
c-section. For these reasons, keep in mind that you may need a cesarean
delivery.
C-sections are done under epidural, spinal or general anesthesia. For
women who receive epidural pain relief during labour, epidural anesthesia
is used. For women without epidurals, spinal anesthesia is often preferred.
If it is not possible to use a spinal or epidural anesthetic, general anesthesia
is used. Most anesthesiologists believe that epidural and spinal anesthesia
are safer than general anesthesia for women needing c-sections.
Most women prefer to be awake during a c-section. They can hear and
see their baby right after birth and can hold their baby within minutes of
the birth. Recovery is faster than with general anesthesia. Mothers can
easily nurse their baby in the recovery room (as they do not feel sleepy,
as they would with general anesthesia). For women who are awake, they
are usually welcome to have someone with them during surgery (partner,
coach, mother, sister or friend).
If you have an epidural in place and need a c-section, you will be given
enough medicine to make you numb for surgery. Generally, you are
numb from your breasts down. It takes 15-20 minutes to make most
women numb enough for surgery. You feel some sensations during surgery
(touch, pressure) but not pain. Your anesthesiologist is with you during
surgery to deal with any problems.
Spinal anesthesia is similar to epidural anesthesia. However, with a
spinal anesthetic, the needle is placed past the epidural space into the
spinal fluid and not to the spinal cord itself. Medication is injected and
the needle removed. There is no needle or catheter left in your back.
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Spinal anesthesia makes you numb in minutes (faster then epidural
anesthesia). Again, you are numb from your breasts down. Like epidural
anesthesia, women under spinal anesthesia feel sensations during surgery
(touch, pressure). In general, women with spinal anesthesia feel less than
women receiving epidural anesthesia.
With either spinal or epidural anesthesia, a small dose of morphine is
usually given (in the spinal fluid or epidural space). This small dose
keeps most women fairly comfortable until the next day. You may be
given pain medication by tablet (e.g. acetaminophen with codeine, such
as Tylenol®#3, or ibuprofen, such as Advil® or Motrin®) until discharge.
Your obstetrician will then give you a prescription for pain medication.
Side effects of morphine include itchiness and nausea/vomiting. These
can be treated, just let your nurse know.
General anesthesia is usually done for emergencies when the obstetrician
wants the baby delivered right away. Also, if women cannot receive
spinal or epidural anesthesia they will have general anesthesia. A small
number of women prefer general anesthesia. You should discuss this
with the anesthesiologist in your hospital ahead of time. Should you
need a c-section your anesthesiologist will discuss your options with
you. More information is available on the subjects discussed in this
booklet. Public "Pain Relief Options Workshops" are currently help
within the Calgary Health Region at the Foothills Medical Centre four
times a year, usually the first Monday of March, June, September and
December (these dates can be found on the Calgary Health Region website). An anesthesiologist is present to answer your questions. The presentations are intended for women delivering at all hospitals. These
classes are organized through Childbirth Education (prenatal classes).
Please plan to attend if you want more information. If you have specific
questions, your family doctor or obstetrician can arrange for you to meet
with an anesthesiologist before your labour or c-section. If you come into
the hospital and have questions, your nurse can have the anesthesiologist
come and answer them for you. There is an anesthesiologist affiliated
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with the labour and delivery units at each of the three delivering hospitals in Calgary. If you are delivering your baby at a hospital outside of
Calgary, please ask your local hospital if an epidural is available.
The birth of a baby is an exciting fulfilling time for everyone. We
welcome the opportunity to assist in your care if you wish. Good luck
with your labour and delivery.
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Notes
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