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health information 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. 1 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. 2 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. 3 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. 4 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. 5 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 6 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. 7 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. 8 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. 9 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. 10 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. 11 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. 12 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. 13 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 14 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. 15 Notes 605281 © (2005/11)