Obstetrical Anesthesia
Planning
Your Childbirth
One
of the most thrilling and gratifying experiences in your life
will be
the birth of your child. This significant event should be made
as safe and pleasant as possible for both you and your baby. Your
obstetrician,
anesthesiologist and nurses want to help you and your partner
reach this goal.
Each
woman's labor is unique to her. The amount of labor pain you feel
will differ from that felt by other women in labor. It depends
on factors such as your level of pain tolerance, the size and
position of the baby, strength of uterine contractions and prior
birth experiences. Medical
decisions regarding control of your labor pain must be made for
you specifically.
Some
women achieve adequate pain control with the breathing and relaxation
techniques learned at childbirth classes. Others may find them
inadequate. Many mothers are reconsidering the idea that childbirth
is "natural" only without medication, and they are choosing
to have pain relief during labor and delivery to help them experience
a more comfortable childbirth.
ANALGESICS
AND ANESTHETICS
Analgesia
is the full or partial relief of painful sensations. Anesthesia
is usually considered to be a more intense blockage of all sensations,
including muscle movement. Your wishes and your medical condition
are important in selecting the type of pain relief administered
to you. Be assured that your physicians will prescribe or administer
medications only in the amounts and during those stages of labor
that are best for the safety and well-being of your baby. There
are several choices for pain relief:
Intravenous
"I.V." Medication - Pain-relieving medications that
are injected into a vein or muscle will help dull your pain but
may not eliminate it completely. These I.V. medications are usually
prescribed by your obstetrician. Because they sometimes make both
you and your baby sleepy, they are used mainly during early labor.
Local
Anesthesia - Other pain-relieving medications may be injected
in the vaginal and rectal areas by your obstetrician at the time
of delivery. These medications are local anesthetics. They provide
a numbness or loss of sensation in a small area. Local anesthesia
is often used to ease the pain of delivery or when an episiotomy
incision is done to assist the delivery. It does not, however,
lessen the pain of contractions.
Regional
Blocks - Regional blocks can reduce the discomfort of labor
and provide either analgesia or anesthesia. Regional blocks refer
to epidural and spinal blocks. They are administered in the lower
back, usually by a specialist physician called an anesthesiologist.
Local anesthetics and other drugs are used for these procedures
to reduce or "block" pain and other sensations over
a wider region of the body. Epidural analgesia may be used for
labor and vaginal delivery. An epidural block may be used to provide
anesthesia for a cesarean section. A spinal block may be used
to provide labor analgesia or anesthesia for a cesarean delivery.
A combined spinal/epidural block also may be used for labor analgesia
and/or anesthesia in certain cases.
REGIONAL
BLOCKS FOR LABOR
Regional
blocks for labor and delivery have become very popular because
of the comfort they provide. The epidural block decreases sensation
in the lower areas of your body, yet you remain conscious. The
right time to administer the epidural block will vary from patient
to patient. If you request an epidural block, your obstetrician
and anesthesiologist will evaluate you and your baby, taking into
account your state of health and past anesthetic experiences,
the progress of labor and your baby's responses.
How
is the epidural block performed?
An epidural block is given in the lower
back. You will either be sitting up or lying on your side. The
block is administered below the level of the spinal cord. This
is called a lumbar epidural block. The block also may be given
in the tailbone area. This is called a caudal block. Before the
block is performed, your skin will be cleansed with an antiseptic
solution. The anesthesiologist will use local anesthesia to numb
an area of your lower back or near the tailbone. A special needle
is placed
in the epidural space just outside the spinal sac. A tiny flexible
tube called an epidural catheter is inserted through this needle.
Occasionally, the catheter will touch a nerve, causing a brief
tingling sensation down one leg.
Once
the catheter is positioned properly, the needle is removed and
the catheter is taped in place. Additional medications are given
as needed without another needle being inserted. The medication
bathes the nerves and blocks out the pain. This produces epidural
analgesia.
How
soon will the epidural block take effect?
Because the medication needs to be absorbed
into several nerves, the onset is gradual, not immediate. Pain
relief will begin to occur within 10 to 20 minutes after the medication
has been injected.
What
will I feel after the block takes effect?
Although significant pain relief will occur,
you still may be aware of pressure or sensations with contractions.
You may feel your obstetrician's examinations as labor progresses.
Depending on your circumstances and your baby's condition, your
anesthesiologist adjusts the degree of numbness for your comfort
and to assist labor and delivery. You might notice some degree
of temporary numbness, heaviness or weakness in your legs.
What
is a combined spinal/epidural block?
A combined spinal/epidural block uses both
techniques and can provide pain relief much faster. An injection
of medication is made into the spinal sac followed by the placement
of the epidural catheter. There may be less numbness with this
technique. Some women may be able to walk around after the block
is in place. A variation of this technique is sometimes referred
to as a "walking epidural."
How
long will the block last?
The duration of epidural analgesia can be
extended usually for as long as you need it. After the epidural
catheter is placed, additional medication can be administered
through it as needed. Throughout your labor, your comfort and
progress will be monitored frequently and medications adjusted
accordingly. A nurse may assist your anesthesiologist with this
monitoring. After delivery, the epidural catheter will be removed
and, within a few hours, sensations will return to normal.
Will
the epidural block affect my baby?
Considerable research has shown that epidural
analgesia and anesthesia can be safe for both mother and baby,
with little or no effect on the infant. However, medical judgment,
special skills, precautions and treatments are required. That
is why a qualified anesthesiologist should perform this procedure.
Will
it slow down my labor?
Each mother may respond differently to the
various epidural medications. Some may have a brief period of
decreased uterine contractions. Many, however, are pleasantly
surprised to learn that after the epidural medications have made
them more comfortable and relaxed, their labor may actually progress
faster.
Can
I "push" when needed?
Regional analgesia allows you to rest during
the longest part of labor, which occurs during cervical dilation.
Then, when your cervix is completely dilated and it is time to
push, you will have energy in reserve. The regional block can
reduce your pain while allowing you to push when needed. Even
if you do not have the urge to push, you should be able to do
so with instruction.
If
the baby's head needs to be guided through the birth canal with
forceps or a vacuum instrument, the block can be intensified to
provide anesthesia and muscle relaxation.
What
are the risks of a regional block?
Although not common, complications or side
effects can occur, even though you are monitored carefully and
your anesthesiologist takes special precautions to avoid them.
To help prevent a decrease in blood pressure, fluids will be administered
intravenously (into one of your veins). In addition, during your
labor, you will be positioned usually on your side. After delivery,
you should remain in bed until the block wears off. Shivering
may occur and is a common reaction. Sometimes it happens during
labor and delivery, even if you did not receive any anesthetic
medications. Keeping you warm often helps it subside.
Although
uncommon, a headache may develop following the block procedure.
By holding as still as possible while the needle is placed, you
help to decrease the likelihood of a headache. The discomfort,
sometimes lasting a few days, often can be reduced or eliminated
by simple measures such as lying flat, drinking fluids and taking
pain tablets. Occasionally, a patient may need additional treatment
if the headache persists. On rare occasion, the anesthetic medication
may affect the chest muscles and make it seem harder to breathe.
Oxygen can be given to relieve this feeling and help the breathing.
The
veins located in the epidural space become swollen during pregnancy.
There is the risk that the anesthetic medication could be injected
into one of them. To help avoid unusual reactions stemming from
this, your anesthesiologist will first administer a test dose
of medication and you may be asked if you notice any dizziness,
a funny taste, rapid heart beat or numbness.
Your
anesthesiologist carefully evaluates your condition, makes medical
judgments, takes safety precautions and provides special treatment
throughout the procedure. You should feel free to talk with your
anesthesiologist about your options for pain relief and their
possible side effects.
ANESTHESIA
FOR CESAREAN BIRTHS
Epidural,
spinal or general anesthesia may be given safely for cesarean-section
deliveries. Choices depend on several factors, including the medical
conditions of you and your baby and, when possible, your preferences.
How
is the epidural block given for a cesarean delivery?
If you already have a labor epidural catheter
in place and then need a cesarean delivery, it is usually possible
for your anesthesiologist to inject additional anesthetic medication
through the same catheter to enhance pain relief safely. This
stronger concentration of medication converts the analgesia to
anesthesia. Anesthesia is necessary to numb the entire abdomen
completely for the surgical incision. If you prefer to have an
epidural block during your cesarean childbirth and you did not
have labor epidural analgesia, there usually is enough time to
provide epidural anesthesia.
What
is spinal anesthesia?
Spinal anesthesia is given using a much
thinner needle in the same location of the back where an epidural
block is placed. The main differences are that a much smaller
dose of anesthetic medication is needed for a spinal block, and
it is injected into the sac of spinal fluid below the level of
the spinal cord. Once the spinal anesthetic medication is injected,
the onset of numbness is quite rapid.
When
is general anesthesia used?
General anesthesia is used when a regional
block is not possible or is not the best choice for medical or
other reasons. It can be started quickly and causes a rapid loss
of consciousness. It is used when an urgent vaginal or cesarean
delivery is required, as in rare instances of problems with the
baby or vaginal bleeding. In these circumstances, general anesthesia
is quite safe for the baby.
One
of the most significant concerns during general anesthesia is
whether there is food or liquids in the mother's stomach. During
unconsciousness, "aspiration" could occur, meaning that
some stomach contents could come up and then go into the lungs.
Here they could possibly cause pneumonia. Your anesthesiologist,
therefore, takes extra precautions to protect your lungs, such
as placing a breathing tube into your mouth and windpipe after
you are anesthetized. Before your cesarean delivery, you also
may be given an antacid to neutralize stomach acid.
It
is best to remember, though, that YOU SHOULD NOT EAT OR DRINK
ANYTHING AFTER YOUR LABOR PAINS BEGIN, regardless of your plans
for delivery or pain control. Sometimes during labor, small sips
of water, clear liquids or ice chips are permissible with your
physician's consent.
Will
I receive a separate bill from the anesthesiologist?
Your anesthesiologist is a physician specialist
like your obstetrician or pediatrician whose medical services
have been requested. You likely will receive a bill for your anesthesiologist's
professional service as you would from your other physicians.
If you have any financial concerns, your anesthesiologist or an
office staff member will answer your questions. You
will note that your hospital charges separately for medications
and equipment used.
Modern
anesthesiology offers today's mothers a variety of choices for
a more comfortable childbirth. It is the goal of your anesthesiologist
to answer your questions, ease your fears and make your labor
and delivery as safe as possible for you and your baby.
Please
discuss your anesthesia-related questions or concerns with your
obstetrician. A consultation with an anesthesiologist usually
can be arranged before your anticipated delivery. The more prepared
you are -- in other words, the more you "plan your childbirth"
-- the more comfortable and memorable the birth of your baby will
be.
"Anesthesia
& You ... Planning Your Childbirth" has been prepared
by the American Society of Anesthesiologists through the cooperative
efforts of the Society's Committee on Communications and the Committee
on Obstetrical Anesthesia.
