Monday March 14 2016

Pain free birth is possible

Anaesthesia is injected into the back to block

Anaesthesia is injected into the back to block pain signals, and thus making giving birth pain free.  

By Janet Birungi

When I first heard of painless childbirth, I thought to myself, ‘it is impossible’. The Bible in Genesis 3:16 explicitly states ‘in sorrow you shall bring forth children’. However, anaethesists have done their best to eliminate pain.
According to a study by Dr Mary Nabukenya, an anaesthesiologist, I am among the majority of women who do not know that one can have a painless delivery. The study found out that only seven per cent, 91 women, of the more than 1,000 women interviewed knew about the procedure.

“Of 1,293 participants interviewed, only seven per cent had knowledge of labour analgesia despite 87.9 per cent of them having more than one child delivered ‘normally’. Of these, 79.2 per cent had delivered in a national referral hospital,” the study reads in part. Almost 67 per cent of the women interviewed described the pain of child birth as severe and if given the chance to, 87.8 per cent felt that labour should be pain-free.

So what is painless delivery or labour analgesia?
Dr Aggrey Lubikire, an obstetric anaesthesiologist says a woman can literally feel no pain during child birth if she chooses to. He identifies two types of painless delivery.

A woman can have an epidural under normal delivery or under the cesarean section. Under normal delivery, she pushes the baby but feels no pain whatsoever. Dr Lubikire says a catheter attached to an injection is given in the spinal cord of the expectant woman, the catheter is left at the back and epidural medicine is continuously given through it.

Dr Andrew Kintu, a lecturer at Makerere University department of anesthesiology and an obstetric anesthesiologist adds that a cannula can be inserted in the hand where medication such as high blood pressure medicine can be administered when need arises.
Before the drugs are administered though, the woman’s passage must be 4cm wide, the baby’s position should have been confirmed and must be well aligned (feet or head first). A cardio-tocograph machine used to monitor the baby’s heart rate, contractions and oxygen circulation among others, is also attached to the expecting mother.

“Drugs are administered through the catheter during the birth process. A skilled midwife is always at hand to determine or predict pain. At this point, he or she should be ready to give the drugs to prevent the patient from feeling any kind of pain,” Dr Lubikire explains.
He adds; “A weak or small concentration of the drugs is given first. Since pain intensity increases with the progress of the baby, a midwife must be at hand to examine and get feedback from the mother so that if she starts feeling the pain, a higher dose of the drug is given.”

How it works
Dr Kintu adds that instead of feeling pain, the mother feels pressure in the womb to signify contractions. He says the drugs, which are given until the baby is delivered, do not stop the contractions which means the normal birthing process continues until after delivery when the catheter is removed.
If no complications arise during delivery such as cutting the vagina to allow room for the baby to pass, the catheter is immediately removed. But in case the woman has been cut, Dr Lubikire says the catheter can be left for more medication to be given till the pain starts receding which usually happens after 24 hours.
Under the C-section, he says the baby is removed without pain but the added advantage is that the catheter can remain until the pain starts reducing which happens after 48 hours.
“After undergoing the knife, a woman experiences the most pain in 48 hours. With the epidural, this pain will not be felt and after it (pain) subsides, it can be removed,” he adds.

Single shot spinal or spinal block
Dr Lubikire explains that a single shot spinal numbs the pelvic muscles which participate in the birthing process but unlike the epidural; this procedure involves one injection filled with pain relief drugs into the spinal cord which lasts between three to eight hours allowing enough time for the mother to give birth.

“This procedure can be an option for a failed epidural. The midwife estimates the birthing process and administers the drug when the woman is about to give birth. The numbing can last up to eight hours depending on the dose given allowing enough time to give birth and rest without feeling the pain,” he continues. However, this procedure is not 100 per cent pain blockade.
Under C-section, the spinal block is the most common type of painless delivery. During delivery, the mother is numbed from the belly button to the legs; which means when the surgeon is removing the baby, the mother is aware of every procedure but cannot walk.

General anaesthesia
This is applicable only under the C-section. Anesthesia drugs are given through the veins but if not administered rightly, the baby can be affected. Dr Lubikire says the midwife waits until the surgeon is ready or at hand to remove the baby to administer the drug.
“The surgeon should be in the room ready to remove the baby within three to five minutes by the time the drug is administered. If the drug is given longer than five minutes before the baby is removed, then the drugs will seep through to the baby and affect him or her,” Dr Lubikire explains.
He mentions slowing down of breathing and heart rate of the mother when the drug is administered which can as well affect the baby if it lasts long in the mother’s body.

Risk factors
Dr Lubikire says that if not well administered, the epidural could be given in the wrong area and fails to be effective. He says if this happens, then a single shot spinal can be used to have the desired effect on the woman.
“Trained health personnel should administer an epidural but in case a mistake is made and it is not given in the right area, there is a solution and it (the epidural) should not be repeated,” Dr Lubikire explains. He continues to say that in case the midwife administers epidural drugs in the veins, an antibiotic called intralipid should be at hand to reverse its effects in the mother and baby.
The mother can as well experience soft tissue injury which can improve within 12 weeks and experience pressure going down which can be improved with drinking water. After the procedure, the mother can have post epidural headache, trauma, hypotension and vomiting, among others.

However, the risks are not as far reaching as the advantages. Dr Kintu says many women; especially young women, are increasingly adopting cesarean section because they do not want to undergo pain during delivery. He says the pain experienced during contractions is severe and can have far reaching consequences on both mother and child.
He says it can help avoid complications like eclampsia by controlling the mother’s blood pressure from increasing. It also allows for improved healing of the wound especially if the mother has undergone the C-section. He says the mother is able to resume her work routine which increases her chances of healing.

Dr Lubikire adds that pregnant women have a higher chance of getting blood clots and once they resume their work routine, it reduces their chances of getting them. Overall, Dr Kintu says there is maternal comfort because there is no pain.
However, to secure a painless delivery, a person needs on average of Shs850,000 to cater for the anesthesiologist who has to keep on monitoring the patient until the time of delivery no matter how long it takes. This is on top of the hospital bills for using the facilities. However, Dr Kintu says delivery is no surprise so parents can plan ahead of time.

Medical expertise to carry out the procedure is also lacking. Dr Lubikire says the midwife-to-patient ratio at its best is lacking in Uganda yet to undergo an epidural for example; a midwife has to be at hand all the time to keep monitoring the baby’s progress.
Despite all this however, the study by Dr Nabukenya revealed that of the women interviewed, 87.7 per cent wanted to have labour analgesia for their next delivery.

On the other hand, 10 per cent said labour pain is natural and should be experienced; of these, 45 per cent said they wanted to experience natural childbirth, eight per cent said it was against the will of God not to feel pain, eight per cent thought it would harm the baby, five per cent said they would love their baby more if they feel the pain and one per cent said the pain was a form of birth control.