What you need to know about painless delivery

Monday January 28 2019


By Joan Salmon

Jean had a baby boy by vaginal delivery in December last year. “He is my fourth child and came to us after an eight-year hiatus. I had been fortunate to have had the first three children by vaginal delivery but I did not explore any labour pain management options because of lack of knowledge that any existed,” she shares. However, this time round, her gynaecologist suggested that she explore the option of an epidural, “I welcomed this information happily as I was not sure whether I still had the energy and resilience to deliver vaginally eight years on,” she says. During the labour process, the doctor who administered the epidural gave her all the information needed regarding the actual procedure, benefits, side effects and what to expect at each stage of its administration.

“Everything went as planned and the epidural gave me the much needed pain relief, leaving me only to deal with the pressure on the pelvis that comes with each contraction. The epidural also accelerated the contractions and within two and a half hours of receiving the epidural, I was delivered of our baby at International Hospital Kampala,” she adds.
For about two days after delivery, the spot in the spine at which the epidural had been administered was sore. However, that pain has faded progressively and my body is back to normal. “All in all, the experience was great and I would recommend the epidural to all,” she says.

Dr Aggrey Lubikire, an obstetric anaesthesiologist and intensivist ( a board-certified physician who provides special care for critically ill patients), at Jinja Regional Referral Hospital, says there are various places on the body an epidural can be administered.

“The injection is given in the thoracic area for chest operations, lumbar area for all operations below the naval and caudal epidural given between the buttocks (natal cleft) for operations in the pelvic region and abdomen, especially for paediatric patients,” he says.

Looking at the essence of an epidural, Dr Lubikire says, every person has a certain level of pain they can endure. Whilst all mothers in labour would need an epidural, there is a certain section of mothers who due to their medical conditions would benefit more such as those with sickle cell disease, heart conditions, high blood pressure and those undergoing labour induction.

While some prior research indicated that epidural increases the risk for C-section, Dr Andrew Kintu, a lecturer and obstetric anaesthesiologist at Makerere University College of Health Sciences, department of anaesthesiology, says it does not obstruct progress of labour. However, for first time mothers, labour might be prolonged for about 30 minutes to an hour owing to lack of experience on how much effort to use when asked to push, hence the need for occasional instrumental delivery such as vacuum delivery.

Dr Lubikire adds that many times, mothers will not have the urge to push ‘Ferguson reflex’ while under epidural labour analgesia. However, they will report the need to go to the toilet hence the need for an obstetrician or midwife to examine her.
However, owing to the information gap, many are unaware of such. Therefore, trained gynaecologists, midwives and anaesthesiologists make a great team when an epidural is being used. Doulas (birth companions) are also a great addition to the team as they offer great techniques through the delivery process, Dr Lubikire adds.

Before the procedure
Before an epidural is given, contact is made with the mother so that an informed decision is made. Issues discussed include risks and complications associated with the procedure, advantages and disadvantages and mother’s position when administering the medicine.
A physical and medical examination is also done for issues such as previous back injuries, general health conditions, although these can be got from prior medical examinations, as well as general back anatomy to assess whether an ultrasound is needed when administering the epidural.

For example, obese or morbidly obese mothers as well as those that have suffered from a bone deforming disease such as scoliosis would need an ultrasound to ease the insertion of an epidural. We also need to know if this is a first time mother or if they are using the procedure for the first time. The issue with first time mothers as previously discussed is that they are naïve regarding the process of pushing. Dr Lubikire shares some risks accruing from an epidural although very rare.

There are two basic epidurals in use today.

There are two basic epidurals in use today. Hospitals and anesthesiologists will differ on the dosages and combinations of medication. You should ask your care providers at the hospital about their practices in this regard.

Post dural puncture headache
This is a headache that is commonly described as a band around the head and neck pain that gets worse on sitting or standing up. This is from inadvertent puncture of the dural (contains cerebral spinal fluids). However, with a calm mother, wet taps are highly avoided as the occurrence of these is heightened when the mother is not steadily seated, moves continually during administration and if the epiduralist is not ever so gentle at performing the task at hand.

Prevention is key. It should be done in a sterile environment, on a scrubbed back, with scrubbed and gloved hands, and masked face. Some mothers may get allergies, which may occur but the medical team is equipped to resuscitate the mother.

Nerve injury
Though rare, it is a big complication. Epidurals should be done with a well-trained team and it is very crucial that the mother gets informed prior to the procedure.

Failed epidurals
Despite having well placed epidurals and good intentions for labour analgesia, at times the epidural system may not work well due to differences in maternal vertebral anatomy hence other adjuncts for labour analgesia may be used to during the labour.

Previously healthy labouring mothers under epidural tend to run a high temperature and feel chills due to increased vessel vasodilation following the administration of the drugs coupled with the heat from the repeated uterine contractions. If this happens, it can be managed.

Blood pressure drops
When the vessels dilate, the blood pressure might drop. Medication is given to stabilise the pressure to mitigate maternal dizziness. In cases where there is need for C-section post epidural insertion, like in case of failed or poor labour progress, the same epidural is used.

When performing an epidural, Dr Kintu says, the positions used are either sitting or lying down. However, sitting is the most ideal position. It will take 10-15 minutes for the anaesthesiologist to perform the procedure. The patient will need a cannula for intravenous fluids.

The baseline foetal heart beat rate, blood pressure and progress of labour would have to be taken and recorded before the start. Then in either the sitting or lying position, the mother is asked to bend forward as though looking at the naval. This opens up the space between the bones where they will apply the epidural. While the epidural needle is being inserted, the patient needs to keep still and steady and in case of any oncoming contraction inform the anaesthesiologist so that he can let her breath through it.

After locating the space, a plastic catheter (tiny tube) will be left in place through which epidural medicine is injected intermittently or by continuous infusion. It takes about 10-15 minutes before full pain relief is achieved. For the remaining period of labour, the drug could be administered using a continuous infusion pump or replenished every 30-45 minutes, intermittently.
The midwife will be required to continuously check the blood pressure, contractions and the foetal heartbeat.

Cost and facilities
The procedure will cost between Shs500,000 and Shs2m depending on the health facility that the mother goes to. The cost is independent of the labour charges by the hospital.
Dr Andrew Kintu, a lecturer and obstetric anaesthesiologist at Makerere University College of Health Sciences, says any hospital with an anaesthesiologist can carry out this procedure and some of these include International Hospital Kampala, Paragon Hospital, Nakasero Hospital, Mbarara Regional Referral Hospital, Masaka Regional Referral Hospital, Mbale Regional Referral Hospital, Jinja Regional Referral Hospital, Lacor Regional Referral Hospital, TMR Hospital, CASE Hospital, Mulago Referral Hospital, Kampala Hospital, and Nsambya, Mengo and Rubaga hospitals.