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Pain relief in labour


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If you plan to give birth at home or you are in the early stages of labour being calm and relaxed can be most helpful. Its a good idea to learn and practice some breathing techniques during pregnancy, however if you havent done so then calm, deep breathing is always useful. Some women find it helpful to be distracted by music or TV or carrying on as normal while others want to be calm, relaxed and focussed. Every woman has a different experience so its a good plan to follow your natural instincts.

 

Warm water may help to relax you and helps to release endorphins, your body’s natural painkillers.

Massage may provide relief from back ache and reminds you to remain relaxed.

Changing positions and being mobile can help the baby get into a good position in the pelvis and also enable your muscles to work more effectively.

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Entonox

This is a mixture of nitrous oxide and oxygen (Gas and Air)  that you breathe in through a mouthpiece during contractions. To get the best effect start breathing as soon as you feel a contraction starting to relieve intense pain over the height of the contraction.

Benefits

Entonox gives some pain relief. It will not take the pain away completely, but it may help. Entonox is quick to act, and quick to wear off. It can be combined with other forms of pain relief such as the birth pool or diamorphine.

Risks

Entonox sometimes makes you feel light-headed or a little sick for a short time. It can affect Vitamin B12 metabolism so strict Vegans and others at risk of Vitamin B12 deficiency should not use Entonox, however, this rarely leads to any problems.

Diamorphine and Pethidine

These are a group of morphine-like painkillers, including Codeine, Diamorphine and Pethidine . All these morphine-like  painkillers act in a similar way, by mimicking natural painkillers

(endorphins) produced by the body during labour. Codeine is taken as a tablet, and is usually only offered in early labour. Diamorphine and Pethidine are given as an injection into your arm or leg.

Benefits

These are powerful drugs, but they do not take the pain away completely. The effect starts after about 15 minutes and may last a few hours. Although pain relief is often limited, some women say it makes them feel relaxed and less worried about the pain. Other women are disappointed with the effect of opioids on their pain and say they feel less in control.

Risks

These injections may make you feel sleepy or sick. You are usually given an anti-sickness medication at the same time to prevent this. The pain killing injections  may also make your baby slow to take a first breath or be drowsy after delivery, so this needs to be taken into account when making your choices.

Epidural

Just under a third of mothers at the RVI choose to have epidural analgesia.  This is often because the mother wishes to have one for pain relief or can also be for a medical reason, such as high blood pressure.

An epidural consists of a small plastic tube, which is placed between two of the backbones at the base of the spine by a specially trained doctor (anaesthetist). Placing the tube needs to be done in a particular way, to ensure that the tube is clean. You need to sit or lie in a curled up ‘bad posture’ position, and to be still while the epidural tube is being put in.

Local anaesthetic to numb the skin is used before the tube is inserted. The local anaesthetic stings a bit, but otherwise it does not really hurt to get an epidural put in place. It may take 40 minutes to get pain relief (allowing time for putting in the epidural tube,giving medicine down it and waiting for them to work). Once the tube is inserted, it is stuck down with a large patch of adhesive tape. You can then move about on the bed. No needle is left in your body.

Pain relief is produced by putting a mixture of two medications down the tube – we use a standard mixture of local anaesthetic (levobupivacaine) and an opioid (fentanyl) at the RVI.

Benefits

90 in every 100 epidurals give complete pain relief (which is better than any other option). An epidural can be topped up rapidly to provide anaesthesia for a forceps delivery or Caesarean section, so it can reduce the need for other types of anaesthesia.

Risks

Ten in every 100 epidurals do not work well. One side of the body is often more numb than the other, or you may still have a strong feeling of pressure in the bottom. There are usually steps which can be taken to improve an epidural, but it is sometimes necessary to re-do the epidural. Epidurals are more likely to fail if labour is advanced (if your cervix has dilated more than 7cm), and if you have  been taking morphine or similar medication regularly before labour.

One in every 100 epidurals result in a fall in blood pressure. Your midwife will carefully monitor your blood pressure and a drip in your hand is positioned to help promptly treat low blood pressure with fluids or medication.

One in every 100 epidurals can lead to a headache called a post-dural puncture headache. The headache can be severe and needs specialist treatment. To minimize the risk of this problem it is important that you keep still while the tube is being put in.

An epidural can cause you to develop a fever – this can happen over a long labour both with and without an epidural. All labouring women have their temperature checked regularly.

One in 10,000 epidurals can cause nerve damage that may be permanent. So this is very rare. In fact, nerve damage is more commonly due to other causes during labour such as pressure from the baby’s head on nerves in your pelvis.

What your epidural won’t do:

  • An epidural generally has little effect on your baby. The total amount of medicine given is small, and the local anaesthetic does not cross the placenta very well.
  • Occasionally the baby’s heart rate falls shortly after starting an epidural. We will monitor your baby’s heart rate continuously once you have an epidural. 
  • An epidural will not make you sick.
  • Epidurals do not cause long-term back problems. Many women have back problems after having a baby, but this is just as likely with or without an epidural.

Can everyone have an epidural if they would like one?

For some women it is not possible to put the epidural tube in safely, for example if you have some types of spina bifida or if your blood does not clot well.

If you have had back problems you can usually still have an epidural safely. Epidurals are often used to treat pain due to disc problems. We would encourage you to discuss this.

Patient-controlled analgesia (PCA)

With this option, you press a button to give small doses of morphine or a similar medicine to yourself through a drip (cannula) in your hand. You do not feel the dose being given and you are in control of the amount of pain relief but the dose is set so you cannot use too much.

This option is set up by an anaesthetist, and requires specialised equipment and a high level of care to ensure safety. It is not available to or appropriate for everyone. Your midwife or an anaesthetist will be able to tell you whether this option might be appropriate for you, and to give you further information.

Benefits

As with all morphine like drugs, pain relief is good but not complete. Most women use Entonox as well. Controlling the administration of the drug yourself, and the fact that each dose is small, allows you to balance the level of pain relief and side effects.

Risks

The total dose of medicine used tends to be much greater than with our usual way of giving opioids. The risks of feeling sleepy and sick are greater, and there is a greater risk of slowing your breathing. For this reason, your breathing will be monitored by your midwife. This is the reason why PCA can’t be offered to everyone.

Pain relief for caesarean sectionShow [+]Hide [-]

There are three options for anaesthesia. All of them are given by the anaesthetist and an anaesthetic nurse working as a team. A midwife will also be present, as will the obstetric operative team. There is a minimum of seven members of staff present in theatre during most obstetric operations.

Before we start

You will need a working ‘drip’ before the anaesthetic is started. We monitor your heart beat through sticky dots applied to your chest, use an automatic blood pressure cuff and a pulse oximeter to measure oxygen in the blood through a clip on your finger. We usually tilt the bed so your left side is downwards, to keep the weight of your baby off the middle of your back, until the baby is born. You will be offered a dose of antibiotics given through your drip before a Caesarean section. This may be delayed in extremely urgent cases but is usually given before the operation starts.

Spinal anaesthetic

A fine needle is used to place local anaesthetic (bupivacaine), usually mixed with pain killer (diamorphine) for pain relief after the operation, into the spinal fluid at the bottom of the spine. You need to sit up, with your back curled outwards. You are awake during the operation, which means that you and your birth partner can be present when your baby is born.

Cold antiseptic spray is used to clean your back first, then your lower back is covered with a plastic sheet. The needle is fine, and the procedure is not usually painful. The anaesthetic works quickly, usually within 15 minutes. You will be very numb from about the level of the armpit to the toes, and your legs will be heavy and difficult to move.

The anaesthetic is very effective, but does not always get rid of all feeling – you may be aware of movement during the operation. The numbness is checked carefully before we start the operation.

The anaesthetist and other team members, together with your birth partner, are with you throughout the operation, and we can explain things and offer other help if you need it during the operation. The numbness lasts for at least a couple of hours, then wears off gradually. It is common to feel pins and needles as it wears off.

Your legs should be able to take your weight after about six hours although this can vary. Please be careful and don’t try and get out of bed after the operation without someone else to help.

It is common for your blood pressure to fall as the spinal anaesthetic takes effect. To try and avoid this, we give medicine to raise the blood pressure through the drip. Sometimes, blood pressure falls a lot despite this medicine, and you can feel ill or sick until your blood pressure return to normal. Tell the anaesthetist straight away if you aren’t feeling well; he or she will be able to help.

Benefits

Avoids the risks of general anaesthesia. Compared with a general anaesthetic caesarean section you usually have less pain afterwards.

Risks

Two or three in every 1000 women develop a particular type of headache following a spinal anaesthetic, related to a continuing leak of spinal fluid. This can be severe and require treatment with an epidural injection.

Three in every 1,000 women are unable to have a spinal anaesthetic because it cannot be placed easily or it is not effective enough for the operation to be started. You may need a general anaesthetic if that happens. Rarely (about 1 in every 10,000 cases) the anaesthetic has much more effect than intended. If this happens you will need a general anaesthetic until the effects wear off.

Very rarely (about 1 in every 100,000 cases) nerves are damaged during a spinal injection or as a result of complications such as an infection or blood clot in the spine. The effects vary, but are potentially serious.

Epidural top up

If you already have a working epidural, this can be rapidly topped up in about 10 minutes.

Benefits

Rapid anaesthesia without needing any extra procedures. For pain relief after the operation, longer acting pain killer can be given down the epidural tube.

Risks

Epidurals do not always provide enough numbness for an operation; if your epidural has not worked well for labour, we will not top it up for a Caesarean. We recommend a spinal anaesthetic (or a general anaesthetic) instead.

General Anaesthetic

We ask everybody to read about this option before labour, because one of the commonest reasons for choosing this type of anaesthesia is that the situation is such an emergency that there is no time for any of the other options. In an emergency, there may not be much time to explain what is happening, and it is very helpful if you have already read about it.

Unfortunately birth partners cannot accompany you to theatre during general anaesthesia. This is for safety reasons as the team cannot attend to a partner if they have questions or are unwell during critical phases of the anaesthetic or operation, especially in an emergency.

About 1 in every 100 women having a planned caesarean section and 10 in every 100 women having an emergency caesarean section at the RVI has a general anaesthetic. The anaesthetic is given into a drip in your hand or arm, following which you rapidly lose consciousness and ‘go to sleep’ – though it is deeper than sleep.

You will be given a small dose of antacid medicine (sodium citrate) to drink . The anaesthetist needs to check your mouth and neck, looking for loose, capped or crowned front teeth and to plan breathing assistance for you during the anaesthetic.

First you will be asked to breathe oxygen through a clear plastic face mask. It is extremely important for your safety and that of your baby that you do this. The mask needs to fit closely over your nose and mouth, so that you are not breathing air from the room at all. The purpose is to exchange the air in your lungs for oxygen, this usually takes one or two minutes.

The anaesthetic

As soon as the oxygen breathed out of your lungs reaches the correct level, the anaesthetist will give you some anaesthetic medication through the vein. As this is given, the anaesthetic assistant will start pressing on the front of your neck. This is necessary to prevent vomit going down the wrong way as you are going to sleep.

Waking up

You will wake up shortly after the end of the operation. You may be aware of a tube in your mouth which is taken out as soon as you are awake. You may not remember much for a short time after your anaesthetic.

Benefits

General anaesthesia can be given very quickly. General anaesthesia is the only option in circumstances where a spinal or epidural top up are not possible.

Risks

Your blood pressure can rise at the start of a general anaesthetic. If you have high blood pressure then you will be given extra medication to prevent this. A sore throat is common after a general anaesthetic.

Two or three in every 1,000 women who have a caesarean section under general anaesthetic are not as unconscious as intended during the operation, and can recall people talking or feel that they have been dreaming.

Four in every 1,000 general anaesthetics for caesarean section are complicated by unexpected difficulty in helping the mother with her breathing at the start of the anaesthetic. This is usually managed by following an emergency drill without the mother being aware of the difficulty, but on rare occasions can result in waking the mother up without doing the operation.

Very rarely, serious complications occur, and can lead to serious brain damage or death of the mother. The anaesthetic drugs cross the placenta and can make the baby sleepy or slow to take a first breath. It is unusual for the baby to be sleepy for longer than a few minutes. A paediatrician will come to help look after your baby immediately after birth if you have a general anaesthetic.

During your time in theatre and afterwards in the recovery area we ask that only one birth partner accompany you.

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