Anesthesia during childbirth, etc. Anesthesia during childbirth: types of modern painkillers during childbirth, pros and cons
The wonderful nine months of waiting have passed; very soon there will be an addition to your family. But, the closer the day the baby is born, the more fears the expectant mother has. Many people want to undergo labor pain relief. But this is a natural process, every woman can cope without anesthetic drugs.
This article will focus on the issue of labor pain relief; its pros and cons will be described in detail. You will also find out what such intervention on the part of obstetricians poses to you and your unborn child. The types can be varied. Which ones exactly? Read more about this.
Pain relief for childbirth: obstetrics, new methods
During childbirth painful sensations appear due to muscle spasm, which intensifies due to the release of adrenaline. Often a woman experiences panic attack, aggravating physical suffering.
A woman who is psychologically prepared and has consciously approached planning the birth of a baby most often does not need pain relief during labor. But there are still cases when anesthesia is performed according to doctor’s indications.
Indications for pain relief
They give pain relief during childbirth if:
- premature birth;
- severe pain;
- long contractions;
- multiple births;
- C-section;
- slow labor;
- fetal hypoxia;
- the need for surgical intervention.
If none of the above is observed, then pain relief during labor is usually not required.
Types of anesthesia
Modern medicine can imagine the following types pain relief during childbirth: medicinal and non-medicinal. In this case, your doctor must prescribe a type of anesthesia that will not harm either you or your child. It should be noted that a woman in labor cannot prescribe pain relief for herself if there is no direct indication for it.
Non-drug methods of labor pain relief
This is the most safe group methods are especially popular among obstetricians. What does this include? Effective and simple exercises that can be started at any stage labor activity: breathing exercises, birth massage, aquatherapy and reflexology.
Despite the availability of more effective medicinal methods, many deliberately abandon them in favor of non-drug methods. Natural pain relief during childbirth includes:
- activity;
- correct breathing;
- massage;
- water birth;
- reflexology.
The birth of a baby is the most important event in your life. Non-drug methods of labor pain relief, which are completely harmless and useful for both you and your baby, will help you leave only positive impressions of this day.
Activity during labor
It is very important during contractions to choose an active position rather than a passive one. Help yourself and your baby to be born.
If you have an uncomplicated birth, then choose exercises for yourself, the main thing is to make it easier for you. However, sudden movements are strictly prohibited. Take note of the following:
- rolling from toe to heel;
- bending forward and to the side;
- rocking the pelvis, circular movements;
- arching and flexion of the spine;
- active walking;
- swinging on a fitball.
Breathing exercises
It is worth mastering breathing techniques even before childbirth, during pregnancy. The advantage of this method is the possibility of combination with other types of pain relief. You don’t need a doctor’s supervision; you can control the process yourself. You will feel relief immediately, and most importantly, you will pull yourself together. There are several techniques for breathing exercises. If someone close to you will be present with you at the birth, then he should be familiar with these exercises in order to help you during the birth process.
How it works? You need to distract yourself from the pain by concentrating on breathing. The deeper and smoother it is, the easier it is for you and your baby, because he receives more oxygen. And if this method is used together with it, the effect will be much better, your child will feel comfortable. There are several periods during which breathing should differ:
- first contractions;
- increased intensity of contractions;
- dilatation of the cervix;
- period of pushing.
During the first contractions
This type is different in that it is smooth and deep breathing, which saturates the blood of the baby and mother with oxygen. Focus on the count. Inhale through your nose for four counts and exhale through your mouth for six counts. The lips should be folded into a tube. You are distracted from pain, gymnastics gives a relaxing effect. It can even be used during times of panic or extreme stress to calm you down.
During intense contractions
During this period you need to calm down, now is the time to use the dog breathing technique. These are shallow, shallow inhalations and exhalations through the mouth, the tongue needs to stick out a little from the mouth. You shouldn’t think about how you look at the moment, the maternity hospital is a place where you only need to think about your well-being and about the child, especially, believe me, you are not the only one!
Moment of cervical dilatation
This is the peak, you won’t be in more pain than now! But you have to endure it, childbirth without pain relief by medication still preferable. Now it’s worth speeding up your breathing, taking shallow, quick inhalations and exhalations. Form your lips into a tube, inhale through your nose and exhale through your mouth. When the contraction releases, calm down a little, it is better to breathe deeply and evenly. This method allows you to slightly ease the acute pain.
Period of pushing
The worst is over, there are no more contractions. Your baby will be born very soon. If the birth is not complicated, then the baby will appear after 1-2 attempts. You need to push 2-3 times per push. Don't panic, because now is the final moment, almost painless. If you feel sorry for yourself and do not obey the orders of the obstetrician, you will have to use instruments, which will cause quite painful sensations. When pushing begins, you need to take a deep breath, exhale, deep breath and hold your breath for 10-15 seconds, while pushing. Don't push anus or straining your eyes, you can get hemorrhoids, stroke and other unpleasant and dangerous consequences.
Another important announcement: the period between contractions and pushing is needed in order to rest, relax and even out your breathing. You need to exercise every day during pregnancy so that you can pull yourself together during childbirth. Bring your breathing to automaticity, and you will control yourself and make labor easier.
Other options
Modern methods labor pain relief includes a large list of various procedures, but especially effective (non-drug) are massage, water birth and reflexology.
How to massage during contractions? There are points on the body that, by acting on them, can significantly reduce and soothe pain. In our case - the sacral zone. You can do this either yourself or ask the person who is nearby. This area can be stroked, pinched, massaged, or lightly tapped. To avoid redness and irritation in the massage area, periodically lubricate the area with cream or oil.
How does water help? In a warm bath, the pain of contractions is easier to bear; water also has a relaxing effect. The expectant mother can take a comfortable position and just relax, while you will avoid chills, elevated temperature and sweating, dry skin.
What is reflexology? Modern pain management childbirth also includes a method such as acupuncture. It helps improve labor and reduce the pain of contractions. As you can see, there are a lot of options, which one you choose is your personal decision.
Drug pain relief
In addition to the above-mentioned natural methods, there are also more effective, but, accordingly, more dangerous. Modern methods of medicinal labor pain relief include the following:
- epidural block;
- spinal block;
- spinal-epidural combination;
- drugs;
- local anesthesia;
- perineal blockade;
- tranquilizers.
Epidural block
Everyone has heard, but not everyone knows the intricacies of this procedure. Let's start with the fact that during childbirth it can be either partial or complete. If labor takes place naturally, then the drugs are administered on the basis that they are only enough for the first contraction (that is, contractions); during pushing, the effect of the drug ends. In this case, only pain signals in the area below the navel, motor ability remains, the person is conscious and can hear the first cries of his baby. If you wish or have special indications, the second stage of labor (pushing) can also be anesthetized, but this is dangerous, since you do not feel your body’s signals and labor can be significantly delayed or go completely wrong. If there is no such need, then do not anesthetize the pushing; during it, the pain is more tolerable.
Second option - In this case, a dose greater than in the previous option is administered, it is also blocked physical activity. The advantage of such anesthesia is the opportunity to immediately see and hear the baby.
Spinal block
This is also an injection that is given in the lower back, into the fluid around the spinal cord. This is a less expensive method compared to epidural anesthesia.
- you remain conscious;
- the effect lasts two hours;
- relieves pain throughout the body thoracic and below.
- may cause severe headaches;
- lowers blood pressure;
- may cause difficulty breathing.
Spinal-epidural combination
This is a relatively new technology that combines the two above methods. This anesthesia lasts much longer, while the mother remains conscious. For the first two hours, the epidural is effective.
Drugs
No matter how strange and contradictory it may sound, drugs are also used during childbirth, but extremely rarely, in special cases. What drugs are used? This:
- "Promedol";
- "Fortal";
- "Lexir";
- "Pethidine";
- "Nalbuphine";
- "Butorphanol".
Narcotic substances can be administered either intramuscularly or intravenously (via a catheter); the second option is the most successful, since the dosage of the drug can be adjusted. This method is good because the pain is blocked for about six hours and the woman in labor can rest. The effect occurs within a couple of minutes. Of course there is also negative sides: Breathing may slow down for both you and your baby.
Local anesthesia
It is not used to relieve pain during contractions, but it is very effective when making an incision in the vagina or stitching after a tear. The injection is made directly into the vaginal area, the effect occurs almost instantly, pain in the injection area is temporarily blocked. Neither you nor your child will experience any bad side effects.
Perineal blockade
The injection is made directly into the vaginal wall, blocking pain on only one side. This injection is given immediately before the baby is born. The effect of the drug lasts no more than an hour and has no side effects. This type of anesthesia is not suitable for the period of labor.
Tranquilizers
Tranquilizers are used for relaxation; injections are given at the first stage, when contractions are rare and not so sensitive. Such drug pain relief during labor dulls awareness and has a hypnotic effect, reducing the child’s activity, but does not completely relieve pain. Tranquilizers can be in the form of tablets or administered intravenously or intramuscularly. When administered intravenously, the effect is immediate.
Postpartum period
Pain relief is also provided after childbirth. For what? So that a woman can relax and gain strength. What may concern:
- spasms caused by contractions of the uterus;
- places of ruptures and cuts;
- difficulty going to the toilet;
- chest pain;
- cracking of the nipples (due to improper feeding).
If the pain is caused by tears and incisions, then painkillers or ointments are suggested, but if the birth was carried out correctly and you pay attention to personal hygiene, then there should be no pain, or it should be minimal. During suturing, the doctor is obliged to numb the pain, and how this will happen should be discussed with you in advance.
There are several ways to minimize pain:
- frequent and short-term water procedures;
- special cooling pad (will help avoid swelling);
- store the pads in the refrigerator (they will dull the pain);
- get ready for a speedy recovery;
- Disturb the site of cuts and tears less (avoid infection, do not make sudden movements, this will contribute to a quick recovery);
- sitting on a special cushion (exerts minimal pressure on the problem area).
Pain associated with uterine contractions goes away on its own a week after the baby is born. To reduce them:
- perform special exercises;
- lie on your stomach;
- get a massage.
The following exercise will help with back pain: lie on a hard surface, bend your right leg at the knee and hold your knee with your right hand. With your left hand, guide the heel of your right foot toward your groin. Stay in this position for a few seconds, rest and repeat the exercise. If your back hurts on the left side, then do the same with your left leg.
Update: October 2018
Almost all women are afraid of the upcoming birth, and this fear is largely due to the expectation of pain during the birth process. According to statistics, pain during childbirth, which is so severe that it requires anesthesia, is experienced by only a quarter of women in labor, and 10% of women (second and subsequent births) characterize labor pain as quite tolerable and bearable. Modern anesthesia during childbirth can alleviate and even stop labor pain, but is it necessary for everyone?
Why does pain occur during childbirth?
Labor pain is a subjective sensation that is caused by irritation of nerve receptors in the process (that is, its stretching), significant contractions of the uterus itself (contractions), stretching of blood vessels and tension of the uterosacral folds, as well as ischemia (deterioration of blood supply) of muscle fibers.
- Pain during labor occurs in the cervix and uterus. As the uterine os stretches and opens and the lower uterine segment stretches, the pain increases.
- Pain impulses, which are formed when the nerve receptors of the described anatomical structures are irritated, enter the roots of the spinal cord, and from there to the brain, where pain sensations are formed.
- A response comes back from the brain, which is expressed in the form of vegetative and motor reactions (increased heart rate and breathing, rise blood pressure, nausea and emotional agitation).
During the period of pushing, when the opening of the uterine pharynx is complete, pain is caused by the movement of the fetus along the birth canal and the pressure of its presenting part on the tissue birth canal. Compression of the rectum causes an irresistible desire to “go big” (this is pushing). In the third period, the uterus is already free of the fetus, and the pain subsides, but does not disappear completely, since it still contains the placenta. Moderate uterine contractions (the pain is not as severe as during contractions) allow the placenta to separate from the uterine wall and be released.
Labor pain is directly related to:
- fruit size
- pelvic size, constitutional features
- number of births in history.
In addition to unconditioned reactions (irritation of nerve receptors), the mechanism of formation of labor pain also involves conditioned reflex moments (negative attitude towards childbirth, fear of childbirth, worry about oneself and the child), as a result of which adrenaline is released, which further narrows the blood vessels and increases ischemia myometrium, which leads to a decrease in the pain threshold.
In total, the physiological side of labor pain accounts for only 50% of pain sensations, while the remaining half is due to psychological factors. Pain during childbirth can be false or true:
- They talk about false pain when discomfort provoked by fear of childbirth and the inability to control one’s reactions and emotions.
- True pain occurs when there is any disruption in the birth process, which actually requires anesthesia.
It becomes clear that most women in labor are able to survive childbirth without pain relief.
The need for pain relief during labor
Labor anesthesia must be carried out in case of pathological course and/or existing chronic extragenital diseases in the woman in labor. Relieving pain during childbirth (analgesia) not only alleviates suffering and relieves emotional stress in the woman in labor, but also interrupts the connection between the uterus - spinal cord - brain, which prevents the body from forming a response from the brain to painful stimuli in the form of vegetative reactions.
All this leads to stability of cardio-vascular system(normalization of blood pressure and heart rate) and improvement of uteroplacental blood flow. In addition, effective pain relief during labor reduces energy costs, reduces oxygen consumption, normalizes the functioning of the respiratory system (prevents hyperventilation, hypocapnia) and prevents narrowing of the uteroplacental vessels.
But the factors described above do not mean that drug pain relief for labor is required for all women in labor without exception. Natural pain relief during childbirth activates the antinociceptive system, which is responsible for the production of opiates - endorphins or happiness hormones that suppress pain.
Methods and types of pain relief for childbirth
All types of pain relief for labor pain are divided into 2 large groups:
- physiological (non-drug)
- pharmacological or drug pain relief.
Physiological methods of pain relief include
Psychoprophylactic preparation
This preparation for childbirth begins in antenatal clinic and ends one to two weeks before the expected due date. Training at the “school of mothers” is conducted by a gynecologist who talks about the course of childbirth, possible complications and teaches women the rules of behavior during childbirth and self-help. It is important for a pregnant woman to receive a positive charge for childbirth, cast aside her fears and prepare for childbirth not as a difficult ordeal, but as a joyful event.
Massage
Self-massage will help relieve pain during contractions. You can stroke the sides of the abdomen in a circular motion, collar area, lumbar region, or press with fists on points located parallel to the spine in the lumbar region during contractions.
Correct breathing
Pain-relieving poses
There are several body positions, which, when taken, reduce the pressure on the muscles and perineum and relieve the pain somewhat:
- squatting with knees wide apart;
- standing on your knees, having previously separated them;
- standing on all fours, raising the pelvis (on the floor, but not on the bed);
- lean on something, tilting your body forward (on the back of the bed, on the wall) or jump while sitting on a gymnastic ball.
Acupuncture
Water procedures
Taking a warm (not hot!) shower or bath has a relaxing effect on the muscles of the uterus and skeletal muscles(back, lower back). Unfortunately, not all maternity hospitals are equipped with special baths or pools, so this method of pain relief cannot be used by all women in labor. If contractions start at home, then until the ambulance arrives, you can stand in the shower, lean against the wall, or take a warm bath (provided that your water has not broken).
Transcutaneous electrical nerve stimulation (TENS)
2 pairs of electrodes are applied to the patient’s back in the lumbar and sacral region, through which a low-frequency electric current is supplied. Electrical impulses block the transmission of pain stimuli in the roots of the spinal cord, and also improve blood supply in the myometrium (prevention of intrauterine hypoxia).
Aromatherapy and audiotherapy
Inhaling aromatic oils allows you to relax and relieves labor pain somewhat. The same can be said about listening to pleasant, quiet music during contractions.
Pharmacological methods of pain relief include
Non-inhalation anesthesia
For this purpose, narcotic and non-narcotic drugs are administered intravenously or intramuscularly to the woman in labor. From narcotic drugs Promedol and fentanyl are used, which help normalize discoordinated uterine contractions, have a sedative effect and reduce the secretion of adrenaline, which increases the threshold of pain sensitivity. In combination with antispasmodics (, baralgin), they accelerate the opening of the uterine pharynx, which shortens the first stage of labor. But narcotic drugs cause central nervous system depression in the fetus and newborn, so it is not advisable to administer them at the end of labor.
Of the non-narcotic drugs for pain relief during labor, tranquilizers (Relanium, Elenium) are used, which not so much relieve pain as relieve negative emotions and suppress fear; non-narcotic anesthetics (ketamine, sombrevin) cause confusion and insensitivity to pain, but do not impair respiratory function, do not relax skeletal muscles and even increase the tone of the uterus.
Inhalational anesthetics
This method of pain relief during childbirth involves inhalation through a mask by the mother in labor. inhalational anesthetics. At the moment, this method of anesthesia is used in few places, although not so long ago cylinders with nitrous oxide were available in every maternity hospital. Inhalational anesthetics include nitrous oxide, fluorotane, and trilene. Due to the high consumption of medical gases and the contamination of the delivery room with them, the method has lost popularity. 3 methods are used inhalation anesthesia:
- inhalation of a mixture of gas and oxygen continuously with breaks after 30 0 40 minutes;
- inhalation only at the beginning of the contraction and stopping inhalation at the end of the contraction:
- inhalation of medical gas only in between contractions.
Positive aspects of this method: rapid restoration of consciousness (after 1 - 2 minutes), antispasmodic effect and coordination of labor (prevention of the development of abnormalities in labor), prevention of fetal hypoxia.
Side effects of inhalational anesthesia: breathing problems, heart rhythm disturbances, confusion, nausea and vomiting.
Regional anesthesia
Regional anesthesia involves blocking specific nerves, spinal cord roots, or nerve ganglia (nodes). The following types of regional anesthesia are used during childbirth:
- Pudendal nerve block or pudendal anesthesia
Blockade of the pudendal nerve involves the introduction of a local anesthetic (usually a 10% lidocaine solution) through the perineum (transperineal technique) or through the vagina (transvaginal method) to the points where the pudendal nerve is localized (the middle of the distance between the ischial tuberosity and the edges of the rectal sphincter). Typically used to relieve pain during labor when other methods of anesthesia cannot be used. Indications for a pudendal block are usually the need to use obstetric forceps or a vacuum extractor. Among the disadvantages of the method, the following are noted: pain relief is observed only in half of women in labor, the possibility of the anesthetic entering the uterine arteries, which, due to its cardiotoxicity, can lead to death, only the perineum is anesthetized, while spasms in the uterus and lower back persist.
- Paracervical anesthesia
Paracervical anesthesia is permissible only for pain relief in the first stage of labor and consists of injecting a local anesthetic into the lateral vaults of the vagina (around the cervix), thereby achieving blockade of the paracervical nodes. It is used when the uterine pharynx is opened by 4–6 cm, and when almost complete dilation is achieved (8 cm), paracervical anesthesia is not performed due to high risk injection of medication into the fetal head. Currently, this type of pain relief during childbirth is practically not used due to the high percentage of development of bradycardia (slow heartbeat) in the fetus (approximately 50–60% of cases).
- Spinal: epidural or peridural anesthesia and spinal anesthesia
Other methods of regional (spinal) anesthesia include epidural anesthesia (injection of anesthetics into the epidural space located between the dura mater (outer) of the spinal cord and the vertebrae) and spinal anesthesia (introduction of anesthetic under the dura mater, arachnoid (middle) membrane without reaching the pia mater meninges - subarachnoid space).
Pain relief from EDA occurs after some time (20–30 minutes), during which the anesthetic penetrates the subarachnoid space and blocks the nerve roots of the spinal cord. Anesthesia for SMA occurs immediately, since the drug is injected precisely into the subarachnoid space. The positive aspects of this type of pain relief include:
- high percentage of efficiency:
- does not cause loss or confusion;
- if necessary, you can extend the analgesic effect (by installing an epidural catheter and administering additional doses of drugs);
- normalizes discoordinated labor;
- does not reduce the strength of uterine contractions (that is, there is no risk of developing weakness of labor forces);
- lowers blood pressure (which is especially important for arterial hypertension or gestosis);
- does not affect respiratory center in the fetus (there is no risk of developing intrauterine hypoxia) and in the woman;
- if abdominal delivery is necessary, the regional block can be strengthened.
Who is indicated for pain relief during labor?
Despite the many advantages various methods pain relief during childbirth, relief of labor pain is carried out only if there are medical indications:
- gestosis;
- C-section;
- young age of the woman in labor;
- labor began prematurely (in order to prevent birth trauma to the newborn, the perineum is not protected, which increases the risk of rupture of the birth canal);
- estimated fetal weight of 4 kg or more (high risk of obstetric and birth injuries);
- labor lasts 12 hours or more (protracted, including with a preceding pathological preliminary period);
- drug labor stimulation (when oxytocin or prostaglandins are added intravenously, contractions become painful);
- severe extragenital diseases of the woman in labor (pathology of the cardiovascular system, diabetes);
- the need to “turn off” the pushing period (high myopia, preeclampsia, eclampsia);
- discoordination of generic forces;
- birth of two or more fetuses;
- dystocia (spasm) of the cervix;
- increasing fetal hypoxia during childbirth;
- instrumental interventions in the pushing and afterbirth periods;
- suturing incisions and tears, manual examination of the uterine cavity;
- rise in blood pressure during childbirth;
- hypertension (indication for EDA);
- incorrect position and presentation of the fetus.
Question answer
What pain relief methods are used after childbirth?
After separation of the placenta, the doctor examines the birth canal to ensure its integrity. If ruptures of the cervix or perineum are detected, and an episiotomy has been performed, then there is a need to suturing them under anesthesia. As a rule, infiltration anesthesia of the soft tissues of the perineum with novocaine or lidocaine (in case of ruptures/incisions) and, less commonly, pudendal blockade are used. If EDA was performed in the 1st or 2nd period and an epidural catheter was inserted, then an additional dose of anesthetic is injected into it.
What kind of anesthesia is performed if instrumental management of the second and third stages of labor is necessary (fertility surgery, manual separation of placenta, application of obstetric forceps, etc.)?
In such cases, it is advisable to perform spinal anesthesia, in which the woman is conscious, but there is no sensation in the abdomen and legs. But this issue is decided by the anesthesiologist together with the obstetrician and largely depends on the anesthesiologist’s knowledge of pain management techniques, his experience and the clinical situation (the presence of bleeding, the need for quick anesthesia, for example, with the development of eclampsia on the birth table, etc.). The method of intravenous anesthesia (ketamine) has proven itself well. The drug begins to act 30 - 40 seconds after administration, and its duration is 5 - 10 minutes (if necessary, the dose is increased).
Can I pre-order EDA during labor?
You can discuss pain relief during labor using the EDA method with your obstetrician and anesthesiologist in advance. But every woman must remember that epidural anesthesia during childbirth is not a mandatory condition for providing medical care to a woman in labor, and the mere desire of the expectant mother to prevent labor pain does not justify the risk of possible complications of any “ordered” type of anesthesia. In addition, whether EDA will be performed or not depends on the level of the medical institution, the presence of specialists in it who know this technique, the consent of the obstetrician leading the birth, and, of course, payment for this type of service (since many medical services, which are performed at the request of the patient, are additional and, accordingly, paid).
If EDA was performed during childbirth without the patient’s request for pain relief, will you still have to pay for the service?
No. If epidural anesthesia or any other labor anesthesia was carried out without a request from the woman in labor to relieve pain, therefore, there were medical indications for easing contractions, which was established by the obstetrician and pain relief in this case acted as part of the treatment (for example, normalization of labor in case of discoordination of labor forces ).
How much does EDA cost during childbirth?
The cost of epidural anesthesia depends on the region in which the woman in labor is located, the level of the maternity hospital and whether this medical institution private or public. Today, the price of EDA ranges (approximately) from $50 to $800.
Can everyone have spinal (EDA and SMA) anesthesia during childbirth?
No, there are a number of contraindications for which spinal anesthesia cannot be performed:
Absolute:
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Relative ones include:
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What kind of pain relief is given during a caesarean section?
Method of pain relief during caesarean section is chosen by the obstetrician together with the anesthesiologist and agreed upon with the woman in labor. In many ways, the choice of anesthesia depends on how the operation will be performed: for planned or emergency reasons and on the obstetric situation. In most cases, in the absence absolute contraindications In addition to spinal anesthesia, the woman in labor is offered and given EDA or SMA (both for planned caesarean section and emergency). But in some cases, endotracheal anesthesia (EDA) is the method of choice for pain relief for abdominal delivery. During EDA, the woman in labor is unconscious, unable to breathe on her own, and a plastic tube is inserted into the trachea, through which oxygen is supplied. In this case, anesthetic drugs are administered intravenously.
What other methods of non-drug pain relief can be used during childbirth?
In addition to the above methods of physiological pain relief during childbirth, you can do auto-training to ease contractions. During painful uterine contractions, talk to the child, express the joy of a future meeting with him, tune yourself to successful outcome childbirth If auto-training does not help, try to distract yourself from the pain during a contraction: sing songs (quietly), read poetry or repeat the multiplication table out loud.
Case study: I gave birth to a young woman with a very long braid. It was her first birth, the contractions seemed very painful to her, and she constantly asked for a caesarean section to stop this “torture.” It was impossible to distract her from the pain until one thought occurred to me. I told her to undo the braid, otherwise it was too disheveled, to comb it and braid it again. The woman was so carried away by this process that she almost missed the attempts.
Anesthesia in obstetric practice is carried out during the application of obstetric forceps, manual and instrumental examination of the uterine cavity, suturing ruptures of the vagina and perineum, and fetal destruction operations. Anesthesiologists are also involved in the work of administering medicinal sleep and rest during childbirth.
When applying obstetric forceps preference is given to total intravenous anesthesia with sodium thiopental 4-6 mg/kg in combination with analgesic doses of calypsol 0.5 mg/kg against the background of inhalation N2O:O2 1:1. The choice is based on the need for relaxation of the perineal muscles and the minimal impact of this type of anesthesia on the fetus. Premedication includes anticholinergics and antihistamines in standard doses. If the method of prolonged epidural anesthesia was used to relieve labor pain, IV anesthesia with sodium thiopental 4 mg/kg is combined with epidural injection of 10-12 ml of 2% lidocaine into the lower catheter. The purpose of administering thiopental in this case is to exclude the presence of a woman during the manipulation.
During manual and instrumental examination of the uterine cavity and suturing ruptures of the vagina and perineum preference is given to total intravenous anesthesia with calypsol. When suturing ruptures, the introductory dose of calypsol is 2 mg/kg; anesthesia is maintained by repeated administration of calypsol at a dose of 1 mg/kg according to indications. If prolonged epidural anesthesia was used during childbirth, it is enough to inject 10 ml of 2% lidocaine into the lower catheter. During manual examination of the uterine cavity, the introductory dose of Calypsol is 1.5 mg/kg, since exceeding it causes contraction of the myometrium and complicates the procedure. During these procedures, premedication is supplemented with ataractics (Relanium 10-20 mg).
Medication-induced sleep-rest provided to a woman in labor in case of incoordination of labor. Includes narcotic analgesics (usually promedol 20-40 mg), antihistamines (diphenhydramine 10-20 mg), neuroleptics (droperidol 5-7.5 mg) and sodium hydroxybutyrate at a dose of 50-70 mg/kg.
During fruit-destroying operations General anesthesia is considered the method of choice. In those cases. when the operation is limited to perforation of the head and excerebration with subsequent suspension of the load, one can limit oneself to total intravenous anesthesia with calypsol or sodium thiopental after premedication with anticholinergics, antihistamines, narcotic analgesics and ataractics. If, following perforation of the head, it is planned to perform cranioclasia and simultaneous extraction of the fetus, then preference is given to multicomponent endotracheal anesthesia.
Pain relief for childbirth.
For labor pain relief, preference is given to prolonged, controlled epidural anesthesia. It reduces metabolic acidosis and hyperventilation, the release of catecholamines and stress hormones. As a result, uteroplacental blood flow improves and, as a result, the condition of the fetus improves. Indications for the use of this type of anesthesia are considered to be ERN-preeclampsia grades I-III, incoordination of labor, chronic feto-placental insufficiency, the patient’s desire. Contraindications are the same as for perioperative epidural anesthesia, as well as the presence of a uterine scar.
An ideal local anesthetic should have the following properties: safety for the mother and fetus, sufficient analgesia with minimal motor block to ensure normal flexion and internal rotation of the fetal head, and no effect on the force of pushing. Based on pharmacological properties, the most commonly used local anesthetic in obstetrics is bupivacaine. There is wide variation in the literature regarding recommendations for the use of its doses and concentrations. In English-speaking countries, bupivacaine is used in 0.25-0.5% concentration. However, these concentrations cause high degree motor block, which leads to a 5-fold increase in the frequency of forceps application and a 3-fold increase in the frequency of posterior-occipital presentation. Low concentrations of bupivacaine have been shown to be safe and at the same time provide effective selective analgesia without significant muscle relaxation in the second stage of labor and, therefore, does not increase the indication for forceps. Currently, 0.125% bupivacaine is considered the drug of choice for labor analgesia because it does not have a negative impact on the normal dynamics of labor. All of the above is also true for 2% and 1% lidocaine. The technique of using a large volume and low concentration of anesthetic is the safest. The disadvantage of this technique is incomplete analgesia due to insufficient “density” of the block. The combination of a local anesthetic with epinephrine and opioids improves the quality of analgesia, reduces the dose and reduces the number of side effects of the anesthetic. Adrenaline is added at a concentration of 1:800,000. Among opioids, preference is given to fast-acting lipophilic drugs such as fentanyl and sufentanil due to their transplacental metabolism. These drugs, administered at a dose of fentanyl 75 mcg and sufentanil 10 mcg, do not cause respiratory depression and neurobehavioral disorders in the fetus and do not affect its Apgar score.
Another drug used as an “additive” to the local anesthetic is the alpha-2 agonist clonidine. When administered alone epidurally, it provides good analgesia and exhibits synergism with opioids and local anesthetics. The use of epidural clonidine does not cause proprioceptive and motor block, is not complicated by nausea and vomiting, and does not cause respiratory depression, although changes in ventilation parameters may be observed due to sedation. Clonidine can provide analgesia in several ways. It causes a central effect, i.e. blockade of descending pathways involved in nociceptive transmission. When administered epidurally in its pure form, analgesia develops as a result of stimulation of alpha-2 receptors in the dorsal horn (spinal mechanism). It is assumed that clonidine also acts at the supraspinal level, where a high concentration of alpha-2 receptors is found. As a result of adsorption from the epidural space, clonidine causes sedation. The peak of its concentration in plasma is observed after 15 minutes. after introduction. There have been no reports of significant sedation in neonates following the administration of clonidine. Clonidine is used in a dose of 100 mcg.
Methods of performing epidural anesthesia during childbirth.
In the position on the left side, according to the generally accepted technique, two catheters are installed in the epidural space: the first - at the levelTh12-L1, is carried out 4-5 cm cranially and is intended for pain relief in the first stage of labor, the second - at the levelL2-L3, is carried out 4-5 cm caudally and is intended for pain relief at the end of the first and beginning of the second stage of labor, as well as for pain relief for possible obstetric manipulations (episio- and perineotomy, suturing ruptures of the vagina and perineum). Pain relief begins after regular labor is established. 20 ml of 1% lidocaine is injected into the upper catheter, after which its continuous administration is established with an infusion pump at a rate of 20 ml/hour. From the moment the cervix is opened by 5-6 cm, 15 ml of 1% lidocaine is injected into the lower catheter, after which constant injection of anesthetic into both catheters continues at a rate of 25-30 ml/hour. To anesthetize episiotomy and episiorrhaphy, suturing ruptures of the vagina and perineum, 10 ml of 2% lidocaine is injected into the lower catheter.
If it is necessary to relieve labor pain and there are contraindications to prolonged controlled epidural anesthesia, it is possible to use opiates, inhalation of an N2O:O2 mixture, or a combination of these methods. Of the opiates, the drug of choice in our conditions is promedol at a dose of 20-40 mg due to the fact that it has the least effect on the fetus. It must be remembered that the administration of opiates less than 3 hours before the expected birth is undesirable.
Inhalation of a 1:1 N2O:O2 mixture is widely used for analgesia during labor. It provides moderate pain relief without loss of consciousness and depression of the mother and fetus. The N2O:O2 mixture can be given in the autoanalgesic mode if appropriate equipment is available. When using anesthesia equipment for this purpose general profile This is done by a midwife or nurse anesthetist. The mixture is given intermittently during contractions. To achieve optimal results, inhalation of the mixture should begin 10-15 seconds before the onset of painful contractions. This is not difficult because the woman in labor feels the onset of contractions before they become painful. Correct use of inhalational analgesia provides good pain relief in almost 60% of women and partial pain relief in more than 30%.
Pain relief for childbirth is becoming increasingly common with the advent of epidural anesthesia - a modern and fairly safe method for mother and child, which is also widely used thanks to high efficiency and convenience.
Epidural anesthesia (epidural anesthesia) is a method of regional anesthesia, the essence of which is the reversible loss of temperature, pain, tactile and motor sensitivity due to blockade of the spinal cord roots.
In this case, anesthetics will be injected into the epidural space - a rounded gap located throughout the entire spine, from the large foramen of the occipital bone to the coccyx. It is filled predominantly with fatty tissue, connective tissue, lymphatic and blood vessels. The width of the epidural space in the lumbar region is 5.0 – 6.0 mm. For comparison, the width of the epidural space in cervical spine is 1.0 – 1.5 mm, and in the mid-thoracic spine 2.5 – 4.0 mm. The spinal roots, which are directly affected during epidural anesthesia, are located in the adjacent space from the epidural - in the paravertebral space.
During the administration of a local anesthetic, the solution spreads through the epidural space not only up and down, but also penetrates the lateral openings, spreads through the tissue and freely penetrates into the paravertebral space, thereby providing an analgesic effect.
Note that the spinal cord is NOT located in the epidural space. It is enclosed in its own membranes and is located in another space (subdural).
The spinal cord ends at the level of the first lumbar vertebra (L1). Its continuation is the “cauda equina,” represented by numerous, thinner branches of the spinal cord to the level of the coccyx. That is why, when epidural anesthesia is performed during childbirth, the risk of damage to the spinal cord in the lumbar region is reduced to zero.
Indications for epidural anesthesia during childbirth
Expressed pain syndrome against the background of established, regular contractions.
- Ineffectiveness of other methods of pain relief.
- Preeclampsia and arterial hypertension (anaesthesia helps reduce blood pressure).
- Gestosis of pregnant women.
- Extragenital pathology.
- Discoordination of labor.
- Multiple pregnancy and breech presentation of the fetus.
- Delivery by applying actor's forceps.
- C-section.
Contraindications to epidural anesthesia during childbirth.
Absolute:
The patient's refusal to undergo anesthesia.
- Lack of voluntary informed consent for anesthesia.
- Lack of qualified personnel and equipment to carry out the manipulation.
- Allergic reactions to local anesthetics.
- Infected or tumor process at the site of the intended puncture.
- Bleeding before childbirth.
- Neurological disorders and processes associated with damage and loss of spinal cord functions.
- Volumetric processes inside the skull.
- Severe spinal abnormalities.
- Severe damage to the heart valves.
- Reduced number of platelets in the blood (less than 50x10*3 / ml).
- Pronounced violation hemostasis (blood coagulation system).
Taking small doses acetylsalicylic acid(aspirin) is not a contraindication to epidural anesthesia, nor is the prophylactic use of heparin. It is stopped within 6 hours, and low molecular weight heparin is discontinued within 12 hours, while blood coagulation parameters should be normal.
Relative:
Anatomical and technical difficulties when performing manipulation.
- Reduced circulating blood volume.
- Treatment with anticoagulants (blood thinning drugs).
- Chronic pain in back.
How is epidural anesthesia given during childbirth?
Preoperative preparation of the patient for epidural anesthesia takes place directly in the maternity ward, since it is not known in advance whether pain relief will be needed during childbirth.
Severe pain syndrome in a woman is observed against the background of established labor (regular contractions), when the cervix is opened by 2.0 - 4.0 cm. This is the optimal time for pain relief during labor.
At this time, an anesthesiologist-resuscitator is invited to visit the woman in labor. After collecting an anamnesis, assessing the possibility of performing epidural anesthesia, filling out medical documentation, in the case of a positive decision and receiving voluntary written informed consent from the woman in labor, the anesthesiologist-resuscitator proceeds with premedication.
Premedication is the prescription of sedatives in order to stabilize the psycho-emotional background of a woman in labor, relieve stress, tremor and fear. The drugs of choice are tranquilizers and anxiolytics.
How is epidural anesthesia performed?
The first manipulation is obtaining vascular (venous) access. This manipulation involves the percutaneous insertion of a sterile vascular catheter into a vein. Next, this catheter is fixed and a system for intravenous infusions with physiological sodium chloride solution is connected to it. The infusion load ranges from 500.0 to 1000.0 ml.
After infusion therapy, at the command of the anesthesiologist-resuscitator, with the help of medical personnel, the woman in labor is given the position in which anesthesia will be performed. There are two possible positions for epidural anesthesia - sitting and on your side.
Most often, epidural anesthesia is performed on the side, so it is easier for the mother to tolerate. Sometimes it is more convenient to sit the patient down, this is due to obesity.
If the woman in labor is in a sitting position, she needs to bend her head, relax and lower her shoulders, rest her hands on her knees and arch her back.
When the woman in labor is positioned on her side, she should bend her head, clasp her hands around her knees and arch her back.
The doctor will definitely help you at all stages and tell you what to do.
The woman in labor must strictly follow all instructions of the anesthesiologist-resuscitator. It’s standard, there aren’t many of them: lie quietly, don’t move, and immediately report any complaints that arise.
What does an anesthesiologist-reanimatologist do?
To perform epidural anesthesia, the anesthesiologist-resuscitator uses a special sterile kit.
After preparing the surgical field, the skin will be numbed, while the woman in labor will feel an injection, and immediately after that there will be cold and a slight feeling of fullness, which appears due to the spread of the anesthetic in the tissues. This may remind you dental procedure, where only the injection itself is painful, and after that you do not experience any pain.
Following local anesthesia of the skin, an epidural needle is inserted into the same area. The needle passes through the skin, subcutaneous fat, vertebral ligaments and encounters a dense, elastic formation on its way - the yellow ligament. Immediately behind it is the epidural space.
The anesthesiologist-resuscitator removes the mandrel (the needle that was in the needle cavity) from the needle and connects a syringe with a search solution.
The woman in labor feels only a feeling of pressure. There is no pain during this manipulation.
To control the correct placement of the catheter in the epidural space, the anesthesiologist-resuscitator performs a “test dose”. It consists of injecting 3–5 ml into the catheter. 2% lidocaine solution. If the catheter is placed incorrectly, for example in the subdural space, in a short time (5-7 minutes), blood pressure will decrease and signs of spinal anesthesia will develop.
The final stage is to fix the epidural catheter at the puncture site with a sterile napkin or sticker and fix the catheter over the entire surface of the back, over the shoulder and out to the chest.
What will be introduced?
The main principle is to administer as little local anesthetic as possible, at a lower concentration, to maintain an adequate analgesic effect.
The drugs that the doctor will use are called local anesthetics. Solutions of lidocaine (0.5 - 1.0%), bupivacaine (0.125 - 0.25%) and ropivacaine (0.1 - 0.2%) can be used.
Epidural anesthesia is performed either as a bolus (i.e. the drug is administered simultaneously) or as a continuous infusion.
To assess pain relief and the development of the anesthetic block, the anesthesiologist-resuscitator pricks the woman in labor with the sharp and blunt end of a needle, and the woman in labor answers where she feels pain, where it is weak, and where it is completely absent. Then rub a gauze ball moistened with alcohol over the skin. When touching the skin, the mother will feel cold. When carried out at the site of the onset of the block, there should be no cold sensations.
Based on all the data obtained about the patient’s condition, scores are calculated and the effectiveness of the analgesic effect of the woman in labor is determined.
The speed of onset of the effect varies from person to person and averages from 10 to 30 minutes. The effect will persist throughout the first stage of labor, until the cervix is fully dilated and the fetal head is wedged. During anesthesia, the woman in labor forgets about contractions and pain. She can relax, sleep, and gain strength. The psychological mood of the mother is directly related to the fetus, so it is very important that the expectant mother gets enough sleep and tunes in for the upcoming birth.
The woman in labor will not feel the pain of contractions and discomfort, i.e. the analgesic component will predominate, while the motor reaction is most often preserved and the woman in labor can move her legs, raise her pelvis, and can even go to the toilet accompanied.
With the beginning of the second stage of natural childbirth, the administration of anesthetics stops. After the end of anesthesia, its effect may partially remain. Gradually the pain will return and the numbness will disappear.
Epidural anesthesia does not affect the management of natural childbirth. The woman in labor will be able to actively participate in the process of giving birth.
Complications of epidural anesthesia:
- Random puncture of the dura mater. This complication can lead to severe collapse due to the penetration of local anesthetic through the damaged membrane into the subdural space. The same complication, extremely rarely (2-5%), leads to the development of post-puncture headache.
- Epidural hematoma(less than 1 case in 150,000). The complication may be present in persons with a blood coagulation disorder or when taking anticoagulants.
- Nerve root injury(less than 1%), leads to neurological complications in the form of reversible loss of sensation in the limbs.
- Drop in blood pressure, can be observed in cases of accidental penetration of the needle lumen into the vein of the epidural space.
- Infection such as epiduritis or meningitis. A complication occurs in case of extreme violation of asepsis rules.
Side effects of epidural anesthesia for the mother:
Nausea and vomiting are rare and unnecessary accompanying epidural anesthesia.
Urinary retention after childbirth can develop regardless of epidural anesthesia.
Back pain, contrary to popular belief, is not a complication or side effect of anesthesia.
The pharmacological effect of epidural anesthesia on the fetus is minimal, so complications and consequences on its part are minimized.
After properly performed epidural anesthesia, no consequences, as a rule, develop.
Epidural anesthesia during childbirth is one of the most important stages of childbirth. Preparation and proper administration of epidural anesthesia, confidence, complete trust and mutual understanding with the anesthesiologist-resuscitator will ensure a comfortable and favorable entry into labor, give strength and, of course, give the expectant mother a great mood.
Anesthesiologist-resuscitator Starostin D.O.
Thank you
The site provides background information for informational purposes only. Diagnosis and treatment of diseases must be carried out under the supervision of a specialist. All drugs have contraindications. Consultation with a specialist is required!
Childbirth are a natural physiological process that completes the pregnancy of any woman. As a physiological process, childbirth has certain characteristics and is accompanied by a number of specific manifestations. One of the most well-known manifestations of labor is pain. It is the pain syndrome that accompanies every childbirth that is the subject of numerous discussions, both among pregnant women themselves and doctors, since this characteristic The birth act seems to be the most powerfully emotionally charged and deeply affecting the psyche.Any pain has a very specific effect on the human psyche, causing deep emotional experiences and creating a stable memory of the event or factor that was accompanied by the pain syndrome. Since pain accompanies almost the entire labor act, which normally can last from 8 to 18 hours, any woman remembers this process for the rest of her life. Pain during childbirth has a bright emotional coloring, which, depending on the individual psychological characteristics of the individual, as well as the specific circumstances that surround the birth act, can be tolerated easily or, on the contrary, very difficult.
Women for whom the pain of childbirth was tolerated relatively easily or, in the terminology of the mothers themselves, “was tolerable”, have absolutely no idea what other representatives of the fair sex experienced and felt, who, due to the will of circumstances, felt terrible, unbearable pain.
Based on their sensory experience, two radical positions arise in relation to pain relief during childbirth - some women believe that it is better to “be patient” for the sake of healthy baby, and the latter are ready for any drug, even one that is very “harmful” for the child, that will save them from hellish, unbearable torment. Of course, both positions are radical and therefore cannot be true. The truth lies somewhere in the area of the classical “golden mean”. Let's consider various aspects related to pain relief during labor, relying, first of all, on common sense and data from serious, reliable research.
Pain relief for childbirth - definition, essence and general characteristics of medical manipulation
Childbirth anesthesia is a medical manipulation that allows a woman giving birth to be provided with the most comfortable conditions possible, thereby minimizing stress, eliminating inevitable fear and without creating a negative image of the birth act for the future. Relieving pain and removing the strong, subconscious fear associated with it effectively prevents labor disturbances in many impressionable women who have a pronounced emotional perception of reality.Childbirth pain relief is based on the use of various medicinal and non-medicinal techniques that reduce the level of mental anxiety, relieve tension and stop the conduction of pain impulses. To relieve labor pain, you cannot use the entire range of currently available medications and non-drug methods, since many of them, along with analgesia (pain relief), cause complete loss of sensitivity and muscle relaxation. A woman during childbirth should remain sensitive, and the muscles should not relax, as this will lead to a stop in labor and the need to use stimulant drugs.
All currently used methods of labor pain relief are not ideal, since each method has pros and cons, and therefore, in a particular case, the method of relieving the pain of labor must be selected individually, taking into account the psychological and physical condition women, as well as the obstetric situation (position, fetal weight, pelvic width, repeat or first birth, etc.). The choice of the optimal method of labor anesthesia for each individual woman is carried out jointly by an obstetrician-gynecologist and an anesthesiologist. The effectiveness of various methods of labor anesthesia is not the same, therefore for best effect you can use combinations of them.
Pain relief during labor in the presence of severe chronic diseases for a woman, it is not just a desirable, but a necessary procedure, since it alleviates her suffering, relieves emotional stress and fear for her own health and the life of the child. Labor anesthesia not only relieves pain, but at the same time interrupts the functioning of adrenaline stimulation that occurs with any pain syndrome. Stopping the production of adrenaline allows you to reduce the load on the heart of a woman giving birth, dilate blood vessels and, thereby, ensure good placental blood flow, and therefore better nutrition and oxygen delivery for the child. Effective relief of pain during childbirth can reduce the energy expenditure of a woman’s body and the stress of her respiratory system, as well as reduce the amount of oxygen she needs and, thereby, prevent fetal hypoxia.
However, not all women need pain relief during labor, since they tolerate this physiological act normally. But you shouldn’t draw the opposite conclusion that everyone can “endure it.” In other words, labor pain relief is a medical procedure that should be performed and used if necessary. In each case, the doctor decides which method to use.
Pain relief during childbirth - pros and cons (should I have pain relief during childbirth?)
Unfortunately, at present, the issue of pain relief in childbirth is dividing society into two radically opposed camps. Adherents of natural childbirth believe that pain relief is unacceptable, and even if the pain is unbearable, you need to, figuratively speaking, grit your teeth and endure, sacrificing yourself to the unborn baby. Women with the described position are representatives of one, radical part of the population. They are very vehemently opposed by representatives of another part of women who adhere to the exact opposite, but equally radical position, which can be conventionally designated as an “adherent” of pain relief during childbirth. Adherents of pain relief believe that this medical procedure is necessary for all women, regardless of the risks, the condition of the child, the obstetric situation and other objective indicators of a particular situation. Both radical camps argue fiercely with each other, trying to prove their absolute rightness, justifying possible complications pain and pain relief with the most incredible arguments. However, no radical position is correct, since neither the consequences of severe pain nor the possible side effects of various pain management methods can be ignored. It should be recognized that labor anesthesia is an effective medical procedure that can reduce pain, relieve associated stress and prevent fetal hypoxia. Thus, the benefits of pain relief are obvious. But, like any other medical procedure, labor anesthesia can provoke a number of side effects on the part of the mother and child. Data side effects, as a rule, are transient, that is, temporary, but their presence has a very unpleasant effect on the woman’s psyche. That is, pain relief is an effective procedure that has possible side effects, so you cannot use it as you would like. Childbirth should be anesthetized only when a specific situation requires it, and not according to instructions or some standard averaged for everyone.
Therefore, the solution to the question “Should I perform labor anesthesia?” must be taken separately for each specific situation, based on the condition of the woman and fetus, the presence of concomitant pathology and the course of labor. That is, pain relief must be performed if the woman does not tolerate labor pains well, or the child suffers from hypoxia, since in such a situation there is no benefit medical manipulation far exceeds possible risks side effects. If labor proceeds normally, the woman tolerates contractions calmly, and the child does not suffer from hypoxia, then you can do without anesthesia, since additional risks in the form of possible side effects from the manipulation are not justified. In other words, to make a decision on labor pain relief, you need to take into account the possible risks from not using this manipulation and from its use. The risks are then compared, and an option is selected in which the likelihood of cumulative adverse consequences (psychological, physical, emotional, etc.) for the fetus and woman will be minimal.
Thus, the issue of pain relief in childbirth cannot be approached from a position of faith, trying to classify this manipulation as, figuratively speaking, unconditionally “positive” or “negative”. Indeed, in one situation, pain relief will be a positive and correct decision, but in another it will not, since there are no indications for this. Therefore, whether to give pain relief must be decided when labor begins, and the doctor will be able to assess the specific situation and the woman in labor, and make a balanced, sensible, meaningful, and not an emotional decision. And an attempt to decide in advance, before the onset of childbirth, how to relate to pain relief - positively or negatively - is a reflection of the emotional perception of reality and youthful maximalism, when the world is presented in black and white, and all events and actions are either unconditionally good or such definitely bad. In reality, this does not happen, so labor pain relief can be both a blessing and a disaster, like any other medicine. If the medicine is used as directed, it is beneficial, but if it is used without indication, it can cause serious harm to health. The same can be fully applied to pain relief during childbirth.
Therefore, we can draw a simple conclusion that pain relief during childbirth is necessary when there are indications for this on the part of the woman or child. If there are no such indications, then there is no need to anesthetize labor. In other words, the position on pain relief in each specific case should be rational, based on taking into account the risks and condition of the mother and child, and not on an emotional attitude to this manipulation.
Indications for the use of labor anesthesia
Currently, labor pain relief is indicated in the following cases: - Hypertension in a woman in labor;
- Increased blood pressure in a woman during childbirth;
- Childbirth due to gestosis or preeclampsia;
- Severe diseases of the cardiovascular and respiratory systems;
- Severe somatic diseases in women, for example, diabetes, etc.;
- Cervical dystocia;
- Discoordination of labor;
- Severe pain during childbirth, felt by the woman as unbearable (individual pain intolerance);
- Severe fear, emotional and mental stress in a woman;
- Delivery of a large fetus;
- Breech presentation of the fetus;
- Young age of the woman in labor.
Methods (methods) for pain relief during labor
The entire set of methods for pain relief during labor is divided into three large groups:1. Non-drug methods;
2. Medication methods;
3. Regional analgesia (epidural anesthesia).
Non-drug methods of pain relief include various psychological techniques, physiotherapeutic procedures, proper deep breathing and other methods based on distraction from pain.
Medicinal methods of labor pain relief, as the name implies, are based on the use of various medications that have the ability to reduce or stop pain.
Regional anesthesia, in principle, can be classified as a medical method, since it is produced using modern powerful painkillers that are administered into the space between the third and fourth lumbar vertebrae. Regional anesthesia is the most effective method of pain relief during labor, and therefore is currently used very widely.
Methods of pain relief during childbirth: medicinal and non-medicinal - video
Non-drug (natural) labor pain relief
The most secure, but also the least in effective ways labor pain relief are non-drug, which include a combination of various methods based on distraction from pain, the ability to relax, creating a pleasant atmosphere, etc. Currently, the following non-drug methods of labor pain relief are used: - Psychoprophylaxis before childbirth (attending special courses where a woman gets acquainted with the process of childbirth, learns to breathe correctly, relax, push, etc.);
- Massage of the lumbar and sacral spine;
- Proper deep breathing;
- Hypnosis;
- Acupuncture (acupuncture). Needles are placed on the following points - on the stomach (VC4 - guan-yuan), hand (C14 - hegu) and lower leg (E36 - tzu-san-li and R6 - san-yin-jiao), in the lower third of the lower leg;
- Transcutaneous electrical nerve stimulation;
- Electroanalgesia;
- Warm baths.
Most common ways non-pharmacological pain relief childbirth are massage of the lower back and sacrum, being in the water during contractions, proper breathing and the ability to relax. All these methods can be used by a woman in labor independently, without the help of a doctor or midwife.
Pain-relieving massage and birth positions - video
Drug pain relief for childbirth
Drug methods of labor pain relief are highly effective, but their use is limited by the woman’s condition and possible consequences for the fetus. All currently used analgesics are capable of penetrating the placenta, and therefore for pain relief during labor they can be used in limited quantities (dosages) and in strictly defined phases of labor. The entire set medicinal methods labor pain relief, depending on the method of drug use, can be divided into the following types: - Intravenous or intramuscular injection drugs that relieve pain and eliminate anxiety (for example, Promedol, Fentanyl, Tramadol, Butorphanol, Nalbuphine, Ketamine, Trioxazine, Elenium, Seduxen, etc.);
- Inhalation administration of drugs (for example, nitrous oxide, Trilene, Methoxyflurane);
- Introduction of local anesthetics into the area of the pudendal nerve (pudendal blockade) or into the tissue of the birth canal (for example, Novocaine, Lidocaine, etc.).
In recent years, there has been a tendency to replace narcotic analgesics with non-narcotic ones, such as Tramadol, Butorphanol, Nalbuphine, Ketamine, etc. Non-narcotic opioids, synthesized in recent years, have a good analgesic effect and at the same time cause less pronounced biological reactions.
Inhalational anesthetics have a number of advantages over other drugs, since they do not affect the contractile activity of the uterus, do not penetrate the placenta, do not impair sensitivity, allow the woman to fully participate in the birth act and independently resort to the next dose of laughing gas when she deems it necessary. Currently, nitrous oxide (N 2 O, “laughing gas”) is most often used for inhalational anesthesia during childbirth. The effect occurs a few minutes after inhaling the gas, and after stopping the supply of the drug, its complete elimination occurs within 3 to 5 minutes. The midwife can teach the woman to inhale nitrous oxide on her own as needed. For example, breathe during contractions, and do not use gas in between. The undoubted advantage of nitrous oxide is its ability to be used for pain relief during the period of expulsion of the fetus, that is, the actual birth of the child. Let us remind you that narcotic and non-narcotic analgesics cannot be used during the period of expulsion of the fetus, as this may negatively affect its condition.
During the expulsion period, especially during childbirth with a large fetus, you can use anesthesia with local anesthetics (Novocaine, Lidocaine, Bupivacaine, etc.), which are injected into the area of the pudendal nerve, perineum and vaginal tissue located next to the cervix.
Drug methods of pain relief are currently widely used in obstetric practice in most maternity hospitals in the CIS countries and are quite effective.
General application scheme medications for labor pain relief can be described as follows:
1.
At the very beginning of labor, it is useful to administer tranquilizers (for example, Elenium, Seduxen, Diazepam, etc.), which relieve fear and reduce the pronounced emotional coloring of pain;
2.
When the cervix is dilated by 3–4 cm and painful contractions appear, narcotic (Promedol, Fentanyl, etc.) and non-narcotic (Tramadol, Butorphanol, Nalbufin, Ketamine, etc.) opioid painkillers can be administered in combination with antispasmodics (No-shpa, Papaverine, etc.). It is during this period that non-drug methods of labor pain relief can be very effective;
3.
When the cervix is dilated by 3–4 cm, instead of administering painkillers and antispasmodics, you can use nitrous oxide, teaching the woman in labor to independently inhale the gas as needed;
4.
Two hours before the expected expulsion of the fetus, the administration of narcotic and non-narcotic painkillers should be stopped. To relieve pain in the second stage of labor, either nitrous oxide or local anesthetics can be injected into the area of the pudendal nerve (pudendal block).
Epidural pain relief during childbirth (epidural anesthesia)
Regional analgesia (epidural anesthesia) has become increasingly widespread in recent years due to its high efficiency, accessibility and harmlessness to the fetus. These methods make it possible to provide maximum comfort to a woman with minimal impact on the fetus and the course of labor. The essence of regional methods of labor pain relief is the introduction of local anesthetics (Bupivacaine, Ropivacaine, Lidocaine) into the area between two adjacent vertebrae (third and fourth) lumbar region(epidural space). As a result, the transmission of the pain impulse along the nerve branches is stopped, and the woman does not feel pain. The drugs are injected into the part of the spinal column where the spinal cord is absent, so there is no need to fear damage to it. Epidural anesthesia has the following effects on the course of labor:
- Does not increase the need for delivery by emergency caesarean section;
- Increases the frequency of applying a vacuum extractor or obstetric forceps due to the incorrect behavior of the woman in labor, who does not feel well when and how to push;
- The period of fetal expulsion with epidural anesthesia is slightly longer than without labor anesthesia;
- It can cause acute fetal hypoxia due to a sharp decrease in the mother's blood pressure, which is relieved by sublingual use of nitroglycerin spray. Hypoxia can last a maximum of 10 minutes.
Currently, the following indications are available for epidural anesthesia during childbirth:
- Preeclampsia;
- Premature birth;
- Young age of the woman in labor;
- Severe somatic pathology (for example, diabetes mellitus, arterial hypertension, etc.);
- Low pain threshold of women.
Painkillers for epidural anesthesia (as well as narcotic analgesics) can begin to be administered no earlier than the dilatation of the cervix by 3–4 cm. However, the catheter is inserted into the epidural space in advance, when the woman’s contractions are still rare and less painful, and the woman can lie in the fetal position 20 – 30 minutes without moving.
Labor pain relief medications can be given as a continuous infusion (like an IV) or in fractions (boluses). With continuous infusion, a certain number of drops of the drug enter the epidural space over an hour, which provides effective pain relief. With fractional administration, drugs are injected in a certain amount at clearly defined intervals.
The following local anesthetics are used for epidural anesthesia:
- Bupivacaine - 5 - 10 ml of 0.125 - 0.375% solution is administered fractionally after 90 - 120 minutes, and infusion - 0.0625 - 0.25% solution at 8 - 12 ml/h;
- Lidocaine - 5 - 10 ml of 0.75 - 1.5% solution is administered fractionally after 60 - 90 minutes, and infusion - 0.5 - 1.0% solution at 8 - 15 ml/h;
- Ropivacaine - 5 - 10 ml of 0.2% solution is administered fractionally after 90 minutes, and infusion - 0.2% solution at 10 - 12 ml/hour.
If for some reason local anesthetics cannot be used for epidural anesthesia (for example, a woman is allergic to drugs of this group, or she suffers from heart defects, etc.), then they are replaced with narcotic analgesics - Morphine or Trimeperedine. These narcotic analgesics are also fractionally or infused into the epidural space and effectively relieve pain. Unfortunately, narcotic analgesics can provoke unpleasant side effects, such as nausea, itching of the skin and vomiting, which, however, can be easily controlled by the administration of special drugs.
Currently, it is common practice to use a mixture of a narcotic analgesic and a local anesthetic to produce epidural anesthesia during childbirth. This combination allows you to significantly reduce the dosage of each drug and relieve pain with the greatest possible efficiency. A low dose of narcotic analgesic and local anesthetic reduces the risk of lowering blood pressure and developing toxic side effects.
If an emergency caesarean section is necessary, epidural anesthesia can be enhanced by introducing a larger dose of anesthetic, which is very convenient both for the doctor and for the woman in labor, who will remain conscious and will see her baby immediately after removal from the uterus.
Today, epidural anesthesia is considered a standard procedure in many maternity hospitals. obstetric benefits, accessible and not contraindicated for most women.
Means (drugs) for pain relief during childbirth
Currently used for pain relief during labor medications from the following pharmacological groups: 1. Narcotic analgesics (Promedol, Fentanyl, etc.);
2. Non-narcotic analgesics (Tramadol, Butorphanol, Nalbuphine, Ketamine, Pentazocine, etc.);
3. Nitrous oxide (laughing gas);
4. Local anesthetics(Ropivacaine, Bupivacaine, Lidocaine) - used for epidural anesthesia or injection into the pudendal nerve area;
5. Tranquilizers (Diazepam, Relanium, Seduxen, etc.) - are used to relieve anxiety, fear and reduce the emotional coloring of pain. Introduced at the very beginning of labor;
6. Antispasmodics (No-shpa, Papaverine, etc.) – are used to accelerate the dilatation of the cervix. They are inserted after the uterine os is dilated by 3–4 cm.
The best analgesic effect is achieved with epidural anesthesia and intravenous administration of narcotic analgesics in combination with antispasmodics or tranquilizers.
Promedol for pain relief during childbirth
Promedol is a narcotic analgesic, which is currently widely used for pain relief in childbirth in most specialized institutions in the CIS countries. As a rule, Promedol is administered in combination with antispasmodics, has a pronounced analgesic effect and significantly shortens the duration of cervical dilatation. This drug is affordable and very effective.Promedol is administered intramuscularly and begins to act within 10 to 15 minutes. Moreover, the duration of the analgesic effect of one dose of Promedol is from 2 to 4 hours, depending on the individual sensitivity of the woman. However, the drug penetrates perfectly through the placenta to the fetus, so when using Promedol, you should definitely monitor the child’s condition using CTG. But Promedol is relatively safe for the fetus, since it does not cause any irreversible disorders or damage to it. Under the influence of the drug, the child may be born lethargic and drowsy, will have difficulty latching on the breast and will not immediately be out of breath. However, all these short-term disturbances are functional, and therefore will pass quickly, after which the child’s condition is completely normalized.
If epidural analgesia is unavailable, Promedol is practically the only available and effective analgesic that relieves pain during childbirth. In addition, during induced labor, which accounts for up to 80% of the total number in the CIS countries, Promedol is literally a “saving” drug for a woman, since in such cases contractions are extremely painful.