Obstetrical Anesthesia Safe Pain Relief for Childbirth
Introduction Pain relief (analgesia) for labor and delivery is now safer than ever. In the United States approximately two-thirds of all women receive pain relief for labor and delivery. At New York Hospital Queens more than 85% of all patients request and receive analgesia for labor and delivery. This is possible because of the dedicated and experienced work provided by our obstetrical anesthesiology attending staff who are in house 4 hours a day, 7 days a week. The degree of labor pain that one might experience is an individual matter. It depends on many factors, such as the individual s level of pain tolerance, size and position of the baby, strength of uterine contractions and prior birth experience. The American College of Obstetrics and Gynecology in their Committee Opinion #118, summarize pain relief for childbirth as follows: Labor results in severe pain for many women. There are no other circumstances where it is considered acceptable for a person to experience severe pain, amenable to safe intervention, while under a physician s care. Maternal request is a sufficient justification for pain relief during labor. 1
Pre-delivery Conference If you have any pre-existing medical conditions such as heart disease, hypertension, lung disease, neurological problems, scoliosis or you pregnancy is considered high risk by your obstetrician (i.e. placenta previae, multiple gestation, VBAC) you should be assessed by the obstetrical anesthesiologist during the seventh or eighth month of pregnancy, well before delivery is expected. This will allow the obstetrical anesthesiologist to become actively involved in the management of your care if necessary and therefore be prepared to provide the best management of pain relief at the time of delivery. If you have no preexisting condition but have any questions regarding labor pain management you would like to discuss, we encourage you to schedule a consultation with an OB anesthesiologist by calling (718) 670-1435 or leaving a message at (718) 670-1380. 7
What are My Pain Relief Options During Childbirth? There are several options available to help get you through labor. These options include 1) non-medicated childbirth relief, ) systemic/intravenous medications, 3) epidural analgesia or 4) combined spinalepidural analgesia (CSE). We will briefly describe these methods. 1. Non-medicated childbirth relief: If you are interested in attempting to deliver without pharmacological support, there are several psychopharmacologic techniques available. The Lamaze method is one method that consists of a repertoire of relaxation and breathing techniques that may be effective in blocking women s perception of pain of contractions. If you are interested in more information, the NYHQ Obstetrical Department offers regularly scheduled child birthing classes where you may learn more about these methods. Even if you decide on receiving analgesia (pain relief) during labor, childbirth classes are useful in preparing both the mother to be and the spouse for the labor experience. For more information, call (718)670-1156. 3. Systemic (intravenous/intramuscularly) medications: Pain relieving medications, mostly narcotics, may be injected into the blood stream to alleviate but not eliminate labor pain. Your obstetrician usually orders these medications. If the medications ordered by the
obstetrician are not enough to provide satisfactory pain relief, the anesthesiologist can arrange that the narcotics be given through an intravenous infusion pump. You are provided with a button that can be activated when you need pain relief. This method of administration is called intravenous patient controlled analgesia (IV PCA). Narcotics represent one of the most powerful classes of analgesic agents that we utilize. The side effects that they may cause therefore limit their usefulness. Respiratory depression, decreased ventilation as well as nausea, vomiting and constipation are some of the side effects that may be caused by these medications. In addition, if you plan to breast-feed, initial efforts may be difficult. Another side effect of the narcotics is that they cross the placenta and enter the baby s circulation. It is unlikely that the baby will be affected adversely as result of a small amount of the mother s medication. Increased doses however, are not recommended because of the potential of respiratory depression in the newborn. It is because of this side effect profile of intravenous narcotics that this method of pain relief can only serve to take the edge off the labor pain rather than provide superior analgesia throughout labor. 3&4. Epidural and Combined Spinal- Epidural (CSE) Analgesia: The ideal labor pain relief technique should dramatically reduce the pain of labor while allowing the mother to be to actively participate in the birthing experience. In addition, it should have minimal effect on the fetus or progress of labor. Modern labor epidurals come close to achieving these goals. The American College of Obstetrics and Gynecology/ (ACOG) Practice Bulletin #36, July 00 recommends regional analgesia (epidural, CSE) as the preferred 4 7
method of providing pain relief to the mother to be due to the superior level of pain relief during labor, when compared with the systemic medications and its minimal effects on the fetus. Epidural Analgesia: Epidural pain relief through a catheter technique is the most common method of providing pain relief for our labor patients because of its safety and efficacy. Our labor epidurals are delivered by a continuous infusion or epidural-patient controlled analgesia (PCEA). We use an ultra low dose local anesthetic/opioid mixture as our epidural medication. This method allows the patient to have continued pain control until they deliver. The infusion mixture will not affect lower extremity motor function and, therefore, one should be able to push effectively in second stage of labor. The mother to be may even be able to ambulate during labor if she so desires walking epidural. 5 Combined Spinal Epidural (CSE): The combination of epidural and spinal analgesia into one technique, termed combined spinal-epidural analgesia provides rapid onset pain relief with additional flexibility of continuous infusion using the epidural catheter technique. In this technique, a spinal needle is inserted through an epidural needle and a small dose of narcotic is injected into the spinal canal. The spinal needle is then removed and the epidural catheter is inserted through the indwelling epidural needle. The pain control is usually instant. There are specific patient categories who may benefit most from this technique. These include patients in early or late labor. The major advantage of CSE for patients in late labor is the almost immediate pain relief without motor block. CSE may also allow women to ambulate during labor. The mother to be s obstetrical anesthesiologist will discuss which technique may be most
appropriate at the time she is in labor. How is an Epidural performed? Epidurals are placed with the patient lying on her side or in the sitting position. Position of the patient is very important to the success of an epidural. The nurse will help the patient. An epidural is performed using sterile technique under local anesthesia at the injection site. Once the skin is numb an epidural needle is passed between the spines of the lumbar vertebra to reach the epidural space. This space is just outside the spinal canal. The spinal space contains cerebrospinal fluid and the spinal nerves. With the needle positioned in the epidural space, a small soft tube (epidural catheter) is placed into the epidural space through the needle. The needle is removed and the tube secured to the patient s back with sterile dressing and tape. Epidural pain relief medication is then infused through this catheter to keep the patient comfortable throughout labor. Most patients find that epidural placement is not as uncomfortable as they thought it would be. How is Combined Spinal Epidural (CSE) performed? The procedure involves identical steps as the epidural. Once the epidural space has been identified, a small spinal needle of greater length than the epidural is advanced through the epidural needle until cerebrospinal fluid is obtained. A syringe containing a small dose of narcotic/local anesthetic is attached to the spinal needle and the spinal medication is administered. The spinal needle is removed, and the epidural tube is then inserted through the epidural needle. Then, as above, the needle is removed and the epidural catheter is secured with sterile technique and tape. This technique also is not as uncomfortable as one would anticipate. 6 7
When can I have pain relief? The best time to administer labor epidural or CSE varies depending on you and your baby s response to labor. It has been suggested that the effect of epidural on labor outcome may be greater when such pain relief is administered before a certain degree of cervical dilatation (<4cm). Recent randomized controlled studies have found no difference in labor outcomes in women whose analgesia was initiated early and in those in whom it was initiated late. It is also well recognized that women with severe pain early in labor are more likely to choose epidurals. Painful labors themselves are more likely to be abnormally long and complicated. Therefore, the decision about when one can receive labor epidural should be coordinated among the obstetrician, anesthesiologist, and the patient. On the other hand, it is never too late to receive an epidural unless the head of the baby is visible (crowning). Certain techniques such as CSE are particularly beneficial in maximizing pain management in mothers to be with advanced labor (<8CM). 77
Will pain relief affect my baby? Direct effects of the medications used to provide epidural pain relief are negligible and considerable research has demonstrated that this technique, when conducted properly is safe for your baby. An indirect side effect that may occur following activation of the epidural or CSE for labor is transient drop of maternal blood pressure. This is not a major concern as blood pressure is measured frequently and corrective measures with hydration and blood pressure medications are undertaken if necessary. At NYHQ, our epidural medications are ultra dilute and therefore we infrequently face significant blood pressure changes in our patient population. How soon does Epidural/CSE take effect and how long does it last? Epidural analgesia starts working within 10-0 minutes after injection of medication. Pain relief lasts as long as labor since the medication is delivered by continuous infusion. An important point to mention is that even though the continuous infusion may be maintained throughout the mother to be s second stage of labor (while she is pushing) there should be no reason why her motor strength to push should be impaired. If the mother to be s efforts to push are optimal and she is making progress the epidural infusion will not be turned off. Combined Spinal Epidural analgesia works almost immediately and lasts about 90 minutes. Once the spinal medication begins to wear off the epidural will be activated and a continuous infusion delivery system will also assure continuous pain relief until delivery. How numb will Epidural/CSE make me? Although the mother to be will experience significant pain relief in first stage of labor, she may still be aware 8 7
of mild pressure from your contractions. We deliberately utilize an ultra low dose epidural medication so that the mother s motor function and perineal sensation will be intact allowing her to push with maximal efficiency during second stag of labor. Are there any side effects of Epidural/CSE? The mother s anesthesiologist takes special precautions to prevent complications. Although side effects are frequent we would like to mention the more common as well as rare side effects seen. Common benign side effects: shivering, itching, and tingling in the legs. These effects may be seen with all epidurals/cse and do not indicate any problems as result of the procedure. Most patients tolerate these minor effects well. Occasionally, itching may be treated with a medication. 9 Decreased blood pressure: The mother will receive intravenous fluid and her blood pressure will be carefully monitored and treated to prevent significant drops in blood pressure. At our institution, the incidence of low blood pressure as result of epidural requiring treatment is less than % (national average is 9%). Transient low blood pressure as long as it is treated does not harm the baby. Unequal or patchy epidural block: Sometimes the anesthetic does not reach an area leaving a side or patch which is still painful. The epidural catheter position is not always in our control and catheter migration is known to occur. If the mother s epidural is behaving in this fashion, her anesthesiologist may offer to repeat insertion of the epidural rather than to continue injecting more medication. The incidence of patchy epidurals at our institution is less than 5% (comparable to national standards). Dural puncture headaches: Most headaches seen after labor and delivery are unrelated to epidural
anesthesia. However in less than 0.5% of all cases, a headache may develop following the epidural or CSE procedure. This occurs as result of a needle hole in the spinal canal wall during the epidural procedure. Leakage of spinal fluid out of the canal and into the epidural space creates a low intracranial pressure system with traction on the brain contents and pain sensitive nerves leading to a postural headache. Usually the headaches occur within 36 hours and lasts, if untreated, about a week. Conservative treatments for this headache include: hydration, rest, caffeine containing fluids and medications. The definitive treatment is to perform an epidural blood patch. This is extremely effective. A blood patch is done by performing an epidural near or at the site of the previous puncture and injecting blood obtained from the same patient into the epidural space. These, as well as other treatment options, will be discussed with the mother in more detail if she should have a dural puncture at the time you receive an epidural. Rare but potentially serious complications include: intravascular injection, high block, epidural/spinal space infection, epidural hematoma and neurological injury. These complications are extremely rare and if diagnosed early enough can be successfully treated without development and permanent neurological sequelae. Are there side effects unique to Combined Spinal Epidural Analgesia? CSE has been reported to be as safe as conventional epidural techniques. Side effects occur infrequently and include: uterine hyperstimulation/fetal bradycardia and maternal respiratory depression. Since the mother and her baby will be continuously monitored in our Labor/Delivery/and Recovery Rooms early detection and treatment when necessary help assure a safe outcome. 10 7
Does Epidural or CSE analgesia cause long-term back pain? Since this is the most common question asked by our patients concerning long-term side effects of epidurals, it deserves a detailed answer. While transient soreness at the needle puncture site is possible, long-term back pain is NOT caused by epidural or CSE administration. Three recently published studies have provided clear evidence that epidural blocks in labor DO NOT increase incidence of longterm back pain. The results of these studies should allay any fears a mother might have about long term effects on her back. Unfortunately pregnancy itself predisposes some patients to develop long term low back pain. Anesthesia for Cesarean Births Epidural, spinal or general anesthesia may be given safely for cesarean-section deliveries. Choices depend on several factors, including the medical condition of you and your baby. The mother s personal preferences will also be taken into consideration whenever possible. How is the epidural block given for a cesarean delivery? 11 If the mother already has a labor epidural catheter in place and then needs a cesarean delivery, it is usually possible for the anesthesiologist to inject additional anesthetic medication through the same catheter to
enhance pain relief safely. This stronger concentration of medication converts the analgesia to anesthesia. Anesthesia is necessary to numb the entire abdomen completely for the surgical incision. If mother prefers to have an epidural block during her cesarean childbirth and she did not have labor epidural analgesia, there usually is enough time to provide epidural anesthesia. What is Spinal Anesthesia? Spinal Anesthesia is given using a much thinner needle in the same location of the back where an epidural block is placed. The main differences are that a much smaller dose of anesthetic medication is needed for a spinal block, and it is injected into the sac of the spinal fluid below the level of the spinal cord. Once the spinal anesthetic medication is injected, the onset of the numbness if quite rapid. When is General Anesthesia used? General anesthesia is used when a regional block is not possible or is not the best choice for medical or other reasons. It can be started quickly and causes a rapid loss of consciousness. It is used when an urgent vaginal or cesarean delivery is required, as in rare instances of problems with the baby or vaginal bleeding. In these circumstances, general anesthesia is quite safe for the baby. One of the most significant concerns during general anesthesia is whether there is food or liquids in the mother s stomach. During unconsciousness, aspiration could occur, meaning that some stomach contents could come up and then go into the lungs, where they could possibly cause pneumonia. The mother s anesthesiologist, therefore, takes extra precautions to protect her lungs, such as placing a breathing tube into her mouth and windpipe after she 1 7
is anesthetized. Before her cesarean delivery, she may also be given medication to neutralize stomach acid. It is best to remember, though, that YOU SHOULD NOT EAT OR DRINK ANYTING AFTER YOUR LABOR PAINS BEGIN, regardless of your plans for delivery or pain control. Sometimes during labor, small sips of water, clear liquids or ice chips are permissible with your physician s consent. Postoperative Pain Relief Is there pain after the operation if I have a cesarean delivery? 13 7 Pain from surgical incision on the abdomen can blunt your ability to get out of bed and bond with your newborn. Early ambulation is also very important to help decrease the incidence of deep vein thrombosis and to allow for early bowel function return after surgery. At NYQH, the OB Anesthesia Department offers the latest most advanced method of pain control for all post-cesarean delivery patients. These methods include: epidural morphine, epidural PCA and intravenous PCA morphine. The method of pain relief used is dependent on the anesthetic you received for the cesarean delivery. Most patients at NYHQ prefer to be awake during the cesarean delivery and therefore received regional anesthesia (epidural spinal). This allows for the administration of a long-acting morphine medication through the epidural catheter. The pain control usually lasts 4 hours. A second dose is offered once the patient begins to have pain and
then the epidural catheter is removed. If you had a general anesthetic for your cesarean delivery, pain would be controlled with intravenous narcotics using a PCA device. Your anesthesiologist will discuss these options with you in more detail if you require a cesarean delivery. Are there side effects? The pain medication and the delivery system used will have no effect on your baby if you plan on nursing. Minor side effects such as itching, nausea, constipation and numbness are easily treated should they arise. Major side effects such as respiratory depression is exceedingly rare and treatable as well. To prevent any side effects our postpartum nurses have been thoroughly trained to identify signs and symptoms, and our 4-hour in-house physicians are readily available to treat any complications should they arise. Conclusion After reading this brochure on anesthesia and childbirth, we are confident that your concerns about safety have been addressed. On behalf of the entire obstetrician stuff we look forward to taking an active part in your childbirth experience at NYHQ. 14 7