OBSTETRIC PAIN MANAGEMENT
Epidurals for labour pain
Management of labour pain is an important part of your birthing plan. Your obstetrician and midwife will have discussed many forms of pain relief during your antenatal care.
Even though your birth plan may not include epidural pain relief, it is important to know about epidurals before labour, as you may not manage with other forms of pain relief and therefore may consider having an epidural once you are in labour.
As an anaesthetist, I am asked by your midwife and /or obstetrician to perform the epidural for your pain relief. This is my gold standard technique for management of labour pain. Additionally, epidurals are also used in the management of specific obstetric problems such as high blood pressure and instrumental (Ventouse/vacuum-assisted or forceps) delivery. For more detailed information on the procedure, please see the patient information section on Epidurals.
Patient Controlled Epidural Analgesia (PCEA)
Most hospitals that I service utilise PCEA for the ongoing management of labour pain following placement of the epidural. This machine is connected to your epidural catheter. It delivers a regular amount of medication (prescribed by me) through into your epidural every hour to maintain your pain relief. Additional medication is also injected when you push a button (which is connected to the machine). Thus, you can control your pain management instead of ringing for your midwife.
How often should I press the button? When your contractions begin to become uncomfortable. Administration at this time is much more effective than pushing the button when the pain becomes ‘unbearable’.
Can I overdose? No. I ensure safety by programming a lockout time between each successful delivery of pain relief. This ensures that the medication has time to work before a further dose is given.
Who can push the button? As you are the only person who can feels the pain, only you can push the button. It is dangerous for your family members to push the button for you.
How long will I have the PCA? Your epidural will continue until you are fully dilated and ready to deliver your baby. At this point, your midwife may ‘turn down’ your epidural medication to allow you to coordinate your pushing with your contractions.
Types of anaesthesia for Caesarean Section (C-section)
In general, I provide four types of anaesthesia for Caesarean section:
- Spinal Anaesthesia: I provide a single dose of local anaesthetic into a space just deep to the epidural space (called the subarachnoid space). This allows delivery of a smaller amount of drug to achieve surgical anaesthesia for the C- section. No catheter is placed in the back. Please see the patient information section on Spinals.
- Epidural Anaesthesia: this is used in women who I have already have an effective epidural catheter inserted for labour pain. I provide a ‘top-up’ dose of a stronger medication to achieve surgical anaesthesia for the Caesarean section. Please see the patient information section on Epidurals.
- Combined Spinal/Epidural Anaesthesia: I provide a single injection into the spinal space (spinal anaesthetic), before immediately placing an epidural catheter into the epidural space.
- I perform this in situations where there is risk of the spinal anaesthetic ‘wearing off’ prior to your Caesarean section being completed (high-risk operations, multiple births etc). This option is rare, and performed in consultation with your obstetrician.
- General Anaesthesia (GA): I very rarely perform a general anaesthetic for a C-section. This is only performed in a very time-critical emergency, where the placement of a spinal is not possible.
Standard obstetric practice has a strong preference for spinal/epidural techniques over general anaesthesia, for the following reasons:
- In most patients, these regional techniques are considered safer. They avoid inherent general anaesthetic risks to the mother (e.g. aspiration of gastric contents into the lungs), and the baby does not receive any anaesthetic medication and is therefore more alert on delivery.
- The mother is awake to enjoy the special occasion.
- Her partner can join her in the operating room for the delivery.
Ensuring block effectiveness
A common anxiety is whether you will feel pain during the C-section with a spinal/epidural block. I always test the block before allowing your surgeon/obstetrician to commence. I may do this in several ways:
- Asking you to raise your legs off the bed. Your legs should feel very heavy, your movement significantly weaker than normal, or even non-existent.
- Asking you to detect the coldness of ice on your skin. The area of surgery (abdomen) up to your breasts is usually numb to the cold feeling of the ice. Temperature nerve fibres also transmit pain, so loss of this sensation is indicative of successful anaesthesia for surgery.
‘Feeling’ during surgery
Both spinal and epidural anaesthesia numb the lower half of your body to pain. However, the nerve supplying the sensations of pressure and stretching are often not blocked. Your uterus is also indirectly connected by abdominal connective tissue to the upper-half of your body. Therefore, you will experience a sensation of pressure and/or pulling by the surgeon as the delivery of your baby nears. This is expected, normal and not an indication of ineffective anaesthesia.
That being said, I will be next to you the whole time to listen to any concerns voiced, and manage any discomfort felt.