YOU’RE having a baby. This period has no doubt brought with it a myriad emotions which may include excitement, anxiety and nervousness about many things, including the labour process.

Labour analgesia or anaesthesia has been associated with myths and controversies since its inception. Modern obstetric anaesthesia as a medical endeavour began a mere three months (January 19, 1847) after the successful administration of surgical anaesthesia by a professor of midwifery, James Young Simpson, who administered ether to a patient in labour.

The sub-speciality of obstetric anaesthesia has, however, continued to experience growth, and as such the quality of labour analgesia has seen improvement.

Now, obstetrical anaesthesia is different from any other type of anaesthesia and is one which is associated with higher risks, as there are two patients involved — you and your baby.

The pregnancy carries with it quite a few changes (physical, physiological [functioning], endocrinal [hormonal], etc), and a thorough knowledge and understanding of these changes as well as the possible effects of anaesthetics on the baby and the benefits or risks associated with various techniques is key to the delivery of a safe anaesthetic.

Physician anaesthetists work on the labour ward or maternity unit to administer anaesthesia/analgesia where desired or necessary, so as to, alongside the obstetricians and pediatricians, ensure a safe course for both mother and baby, which is the prime objective.

LABOUR EXPERIENCE

Each woman’s labour experience is unique and women differ in their ability to tolerate pain. Most women, in my experience, tend to fall into one of three categories:

1. Those who would prefer to attempt the birthing process without any form of pain relief;

2. Those who are absolutely sure they will require pain relief; and

3. Those who are somewhat unsure as to their need for pain relief and the options available.

Regardless of the category into which you may fall, it is important to be educated as to how anaesthesia and analgesia are used in the labour and delivery process, and thus the options available.

USE OF ANAESTHESIA AND ANALGESIA IN LABOUR MANAGEMENT

The first and probably most important step is a thorough pre-anaesthetic visit, no matter how far along in your pregnancy you are, (but oftentimes the second or third trimester). An anaesthetist meets with you and enquires as to your current state of health, how the pregnancy has been progressing, if you have any chronic illnesses (or those that may have developed as a result of the pregnancy), bleeding tendencies, family history of illnesses, lower back problems, previous surgeries, previous anaesthesia, drug allergies etc, just to name a few. We will also look at any investigations (blood studies, heart tests, as necessary) you may have had done.

Please do understand that this forms part of our normal routine and does not necessarily suggest there is a problem. It is with this information that the best labour management option can be considered.

The term anaesthesia means ‘without sensation’ or loss of feeling, and this can be achieved either by way of being placed in a state of ‘controlled unconsciousness’, termed loosely as ‘being put to sleep’ (general anaesthesia), or by numbing a specific area or region of the body (regional anaesthesia). Analgesia speaks to ‘relief of pain’.

Pain experienced during labour and delivery is as a result of the uterus contracting, dilatation of the cervix and stretching of the perineum, which is the area between the anus and bottom of the vaginal opening. The choice of the analgesic technique resides primarily with the woman. However, your medical condition, the stage of labour at which you are, the condition of your baby, and the availability of qualified personnel are also factors.

So, what are your options?

There are several different options available which may be used independently or in conjunction with one another. Some of the most common include:

SEDATION

For this, medication is administered as an injection in the muscle (intramuscularly) or in the vein (intravenously), which can help reduce the pain of labour but will not eliminate the pain entirely. They are also used to ease the anxiety that sometimes accompanies the delivery process.

REGIONAL ANAESTHESIA

Regional anaesthesia has been largely found to be safer for both mother and baby. It enables the parturient to remain awake during the surgical intervention or fully participant in the birthing process as during vaginal delivery. This allows early bonding of mother and baby, as there is often a flood of emotions at hearing baby’s first cry and thereafter holding baby.

PUDENDAL BLOCK

Administered as injections of local anaesthetics to numb your vaginal area in preparation for delivery. Usually performed by the obstetricians.

EPIDURAL

An epidural involves the administration of medication (local anaesthetic) delivered through a thin plastic tube called a catheter, which is placed in the small of the back, into a space that lies just outside the covering of the spinal cord.

Once it is placed correctly, it will be taped to your back such that the medications can be administered when needed for continued pain relief.

Epidural anaesthesia is versatile in that it can be given for labour and vaginal delivery, or if stronger medication is required, the same administration point can be used to facilitate a caesarean section. The medicine given blocks pain impulses originating from the uterus and cervix. You will still be able to move your legs, albeit they may feel a little heavy. You may be able to feel touch and appreciate some pressure. An advantage of the epidural is that it allows most women to fully participate in the birth experience while relieving most, if not all, of the pains of labour. In most cases, the anaesthetist will start the epidural when cervical dilation is four to five centimetres. Under certain circumstances, it may be possible to place the epidural earlier.

SPINAL

This anaesthetic is done in a similar way to an epidural. However, a catheter is not used and instead the medication is administered via a special needle (around the lower back) into the spinal canal below the level of the spinal cord, and thus avoiding any risk of spinal cord injury. Its effects are therefore felt much faster than with an epidural.

Most often patients experience a tingling feeling to the legs reported sometimes as ‘pins and needles’. This is only experienced, however, for a short period before the lower body becomes numb and the absence of (if any) painful contractions. Sensation and movement will return to the lower body usually within two to three hours. Spinal anaesthetics are oftentimes used for delivery by cesarean section.

COMBINED SPINAL EPIDURAL

This procedure has the dual advantage of a spinal as well as an epidural. It will not only produce a rapid anaesthetic but, additionally, pain after operation is oftentimes minimal as top-up doses can be administered via the epidural.

The utility of this option is useful especially in our high-risk pregnant patients, for example patients with heart disease.

The medication used for both an epidural/spinal are generally safe for your baby. There are, however, some instances when either an epidural or a spinal cannot be administered to a patient (for example patients who are more likely to bleed). The reason for same is varied and will be discussed with the patient if this is so.

GENERAL ANAESTHESIA

Previously, general anaesthesia was being used frequently for caesarean sections. However, it is being used less and oftentimes only employed when regional anaesthesia is not possible. It is achieved through the administration of anaesthetic drugs via the vein and thereafter having the patient breathe anaesthetic gases, while receiving other medication, as needed, during the operation.

After delivery of your baby, your anaesthetist will give you pain medication such that on awakening you will have less discomfort. General anaesthetics can be administered quickly and is therefore most times used in the setting of an emergency.

Prior to receiving any form of anaesthesia, standard precautionary and emergency measures are put in place. An intravenous line will be placed and your vitals checked. Frequent checks of both you and the baby are continued during this period.

COMPLEMENTARY METHODS

Some women may, on occasion, require no anaesthesia/analgesia to facilitate the labour process and some may opt to forego any type of pain-relieving medication. These options include the use of breathing techniques, massages, or the use of heat packs. However, should there be a change of one’s mind, your anaesthetist is right there to help.

All of these procedures like everything else are associated with risks. Some include failure of the epidural/spinal, nausea, vomiting, and headaches. This list is by no means exhaustive and again will be discussed in detail with you at the pre-anaesthetic visit.

CONCLUSION

Paul Poppers wrote: “The quality of obstetric care can be considered a criterion for the level of civilization that a particular society has attained.”

A part of this care is trying to ensure that you have the most positive labour and delivery process possible. There is no ideal anaesthetic and the plan, as mentioned above, can change. It is, however, important that you be informed as to your options along with the concomitant benefits/risks. The more prepared you are before, the more rewarding the entire experience will be.

Dr Deborah Douglas MBBS, DM (Anaesthesia and Intensive Care) is an Anaesthetist and Chief Resident at the University Hospital of the West Indies, Section of Anaesthesia and Intensive Care. Feedback : douglas.deborahr@gmail.com