Pain is a subjective feeling and is defined as ‘an unpleasant sensory or emotional experience, which may or may not be associated with tissue damage’. Hence, pain and the tolerance to pain vary greatly from person to person.
Labour pain is rated as severe by most women who do not receive pain relief. With advent of modern medicine and availability of techniques with skilled practioners, it is now considered ‘inhuman’ not to relieve the pain of labour. The American College of Obstetricians and Gynaecologists says “Labour results in severe pain for many women. There is no other circumstance where it is considered acceptable for a person to experience untreated severe pain, amenable to safe intervention, while under a physician’s care".
Just like surgery is never done without anaesthesia, so also techniques are available to ensure painless delivery. Receiving pain relief in labour is not a pre-requisite for delivery! It is dependent on your tolerance level and the choice you want to make.
Epidural is a small injection placed in your lower back, through which a fine tube (epidural catheter), the size of a thread, is passed into your back. Drugs can be injected through this tube to relieve the pain of labour. These drugs are local anaesthetics which cause numbing of the nerves and pain sensation without affecting the ability to move. These drugs are also very safe for the baby. With an epidural in place, you may feel the contractions, but they will not be painful.
Epidural is the best method of pain relief in labour, among all the options available.
• Epidural can allow you to rest, relax, get focused and give you the strength to move forward as an active participant in birthing. By reducing the discomfort of childbirth, most women have a more positive birth experience.
• If you deliver by caesarean section, the same epidural can be used to provide anaesthesia during the operation and effective pain relief during recovery.
• When other types of coping mechanisms are no longer helping, an epidural can help you deal with exhaustion, irritability and fatigue. And, it ensures that you have painless labour and delivery.
All women in labour who need pain relief can have an epidural, except those on blood thinning drugs or abnormal blood tests. Epidural is not always necessary for you to have normal delivery, but it can be beneficial in reducing the pain of labour.
In some patients epidural is recommended to optimize outcome.
• If you have a complicated or prolong labour. In such circumstances it will benefit you and your baby. So that, you can have a stress-fee and normal painless delivery.
• If you are trying for a VBAC (vaginal birth after cesarean section)
• If you have certain medical conditions such as certain heart conditions, hypertension & preeclampsia.
• Those with certain bleeding disorders
• Those taking medications that can affect blood clotting (clopidogrel, heparin, warfarin, etc.)
• If you have had a Lower back surgery (in certain cases)
• If you have certain neurological disorders
Your obstetrician and anesthetist will discuss this with you.
You will first need a drip, which is fluid running into a vein in your arm. You will be asked to curl up on your side or sit bending forwards. Your back will be cleaned and a little injection of local anaesthetic given into the skin, so putting in the epidural should hardly hurt. A small tube (the size of a twine) is put into your back near the nerves carrying pain from the uterus. It is important to keep still while the anaesthesiologist is putting in the epidural, but after the tube is in place you will be free to move. Through the tube pain relieving drugs can be given continuously by a pump. The anaesthesiologist and your nurse will check that the epidural is working well so that you have a normal painless delivery.
Monitoring will be done to note any changes in your blood pressure. This will be done every few minutes for about 15 mins and then at longer intervals. Your baby’s heart rate will be checked intermittently or continuously as per the Obstetrician’s advice. This will ensure that apart from having a normal delivery, you will also have a painless delivery.
Pain is the reason to have epidural and whenever your pain is significant you can request for an epidural. You only need to be in established labour, but there is no need to wait for a particular dilatation of the cervix. Also in those very anxious or keen to have an epidural, it can be placed at a convenient time before the labour pain is too bad, so that your cooperation is better.
Epidural analgesia causes significant reduction in pain. In fact, it is the most effective method for painless labour and delivery. Compared to when you did not have an epidural, there will be a significant reduction of pain and discomfort. All the same, you will feel some pressure symptoms and some tightness with contractions. Sometimes, especially towards the last part of labour, there will be discomfort related to the pressure effect of the baby’s head in the perineal area. These symptoms can also be removed if a “stronger dose’ of medicine is given, but there may be a risk of causing muscle block and inability to push to deliver the baby.
Occasionally, epidural may not work as well as we would like it to. If this happens while you are going through a normal delivery, the anaesthesiologist will help by giving extra doses or changing your position or the catheter position. If it still does not work, the procedure has to be repeated (by placing the epidural catheter again).
Side effects and complications
• Epidural can cause a drop in your blood pressure. To decrease this risk, you will be given fluids through an intravenous line.
• Some women may have itching which disappears when the epidural is stopped. Medication can be given to relieve the sensation.
• An epidural may prolong the second stage of labour and reduce the urge to bear down. Occasionally this may result in you having an instrumental delivery.
• One in 100 women may develop severe headache after an epidural. It is called post dural puncture headache and can be treated.
• About one in 2000 mothers gets a feeling of tingling or pins and needles down one leg after having a baby. Such problems are more likely to result from childbirth itself than from an epidural.
• A small number of women may experience numbness or heaviness in the legs. It usually wears off once the epidural is discontinued. The risk of any permanent damage is extremely low.
Backache is common during pregnancy and often continues afterwards when you are looking after your baby. There is now good evidence that epidurals do not cause long-term backache, though you may feel soreness at the site of the injection for a few days.
A large amount of research has been done on this topic and it is clear that epidural per se does not influence the rate of cesarean section. A proportion of women planning normal delivery will end up having a cesarean section. This proportion remains the same with or without an epidural.
Opioids are Morphine derivates and are very strong pain killers. They are effective for painless delivery, but have the following side effects:
• They cause drowsiness in the mother
• They can cross the placenta and go into baby’s circulation. If the baby is born before the drug is eliminated, baby may have breathing difficulty
For the above two reasons, opioid drugs are used sparingly and only in the early stages of labour
Entonox is a gas which is a mixture of Oxygen and Nitrous Oxide. When breathed deeply, it can cause pain relief during early labour. It is also associated with some light headedness in the mother as well as dry mouth due to constant breathing of the gas. It can also be used as a rescue effort in unsatisfactory epidurals.
We have a dedicated team of Anaesthesiologists to provide round the clock epidural service, and make sure that you have painless and normal delivery. All the doctors are trained in providing labour analgesia and dealing with any problems that may arise. From the time an epidural is asked, the procedure will be done within half an hour most often. It takes a further 15 to 20 minutes for the injected drug to produce pain relief.
If you have any queries, please contact the duty Anaesthesiologist .
Useful web sites for more information