ANALGESIA OF THE BIRTH

WHAT'S THIS

It is a set of techniques capable of reducing, to varying degrees, the pain of childbirth.

Among the different techniques the most practiced, for its effectiveness and safety, is

• The Epidural

It consists in positioning, by means of a needle, a catheter in the epidural space through which local anesthetics and analgesics are administered which selectively act on the sensitive nerve fibers and little or nothing on the motor fibers.

The epidural is:

• effective             because it makes uterine contractions painful but not perceptible
• safety                 for mother and child: thanks to the very low doses of anesthetic
• flexible               for the possibility of modulating analgesia according to the stage of labor and the intensity of pain
• advantageous    because it increases maternal satisfaction and reduces fetal acidosis
• respectful           physiological dynamics of labor: allows you to feel contractions, walk, push

In some cases, for particular clinical reasons, analgesia can be obtained by:

• Subarachnoid puncture

• it also consists of a puncture in the lumbar region
• it can only be used in the very advanced stages of labor

• Intravenous administration of sedatives

• it has less efficacy than the epidural
• may affect the fetus

In cases where there are contraindications to the epidural or when the positioning of the epidural catheter has failed, in the sole judgment of the anesthesiologist, analgesia can be administered by:

• Breathing of nitrous oxide

• it has less efficacy than the epidural
• can cause nausea and sedation

HOW YOU DO IT

To perform the positioning of the epidural catheter you will have to sit down, bend your head forward, relax your shoulders and arch your back exposing it to the anesthesiologist who will be behind you. The anesthesiologist, after disinfecting, anesthetizes the skin with a very fine needle to make the area numb. Then introduce a larger needle until it reaches the epidural space. Then the doctor introduces the catheter into the needle, then removes the needle leaving the catheter in the epidural space. Finally fix the catheter to the skin and inject the drugs that produce analgesia; it occurs in about 15 minutes. The whole procedure is no more painful than an intramuscular puncture.

WHEN YOU DO

When you enter the delivery room you will be assigned an obstetrician who will follow you through all the labor until the birth of the baby. If you have decided to give birth with analgesia and you have followed the entire path described below, you will have to communicate it to your midwife, who will notify the anesthesiologist at the right time. If labor is ongoing, analgesia can be started at any time you request it, regardless of the degree of cervical dilatation. However, the anesthesiologist will decide whether and when to proceed with analgesia, also taking into account the possible, contemporary urgencies that he must face in the delivery room and the opinion of the gynecologist and obstetrician. When entering the delivery room, your choice must be clear: if at the beginning of the labor you opted not to do the analgesia, a subsequent rethinking could be late and for the reasons listed below, you may not be able to receive analgesia.

WHEN NOT DONE

There are some cases, fortunately very rare, where you will not be able to receive analgesia:

• For the timing of your labor:

• If the anesthesiologist is called upon to deal with several patients at the same time, he must give priority to the most critical situations, when the health of mother and child is at risk. In these cases your analgesia may be delayed or not started. You will not be able to perform analgesia if you arrive in the delivery room with labor so advanced that you think that the birth of your baby is imminent. In this case the beginning of the analgesia would coincide with the coming to light of the newborn and therefore the analgesia would be late and useless.

• For obstetric contraindications:

• When the gynecologist considers the analgesia contraindicated to the good progress of your labor, it will not have started or, in extreme cases, it can be interrupted. Our priority is the well-being of your child.

• For anesthesiological contraindications:

• Coagulation abnormalities (which is why some blood tests are required).
• Some septic syndromes with fever.
• Some serious neurological pathologies.
• Presence of skin pathologies or tattoos in the area of skin where the catheter should be positioned.

• For an unfavorable conformation of your back:

• which could create difficulty in positioning the needle and catheter by preventing analgesia.

All these situations are certainly exceptional, but know that it could happen, so do not consider analgesia a certainty, but a splendid opportunity!

PROBLEMS, UNDESIRABLE REACTIONS, COMPLICATIONS

As in all medical acts, unwanted reactions, inconveniences and complications can also occur in birth analgesia.

• Drawbacks and unwanted reactions can consist of:

• paresthesias, that is, shocks and tingling, in the sacrum and lower limbs
• dizziness and chills
• realization of a unilateral or non-uniform analgesia

These events may sometimes require repetition of the puncture and in extreme cases abandonment of the technique. In any case, in 2% of cases, analgesia can be ineffective.

• Epidural complications are rare, their percentage is very low, but they must be mentioned for a conscious choice:

• MINOR COMPLICATIONS

• Headache

• it is a complication that can follow the accidental puncture of the dura mater
• has an incidence of 0.2 - 4% of cases
• it can occur 24 hours after the puncture and lasts about 1 week
• increases in an upright position and disappears in a supine position
• it can be associated with nausea, vomiting and visual or auditory disturbances
• treatment requires bed rest, hydration and administration of anti-inflammatory drugs

• Back or sciatic pain

• They can appear in 20 and 40% of women who have given birth, regardless of whether they have performed an epidural
• They are related to the stress to which the spine and nerves of the pelvic region are subjected during childbirth
• Only rarely are they caused by the needle following repeated attempts to find the epidural space, in which case they resolve in 3-4 days

• MAJOR COMPLICATIONS

• Nerve and spinal cord damage can result from:

• direct trauma from the needle or catheter
• compression from epidural hematoma
• infections
• chemical injuries by the drugs used
• ischemic suffering from severe hypotension

These complications are very rare and have an exceptional character.

The reports of major neurological accidents in women who have given birth to the epidural have an incidence of:

• 1 in 6,700 cases for transient damage
• 1 in 240,000 cases of permanent damage (1)

CHANGES IN THE NATURAL PERFORMANCE OF THE BIRTH INDUCED BY ANALGESIA

• initial, transient changes in fetal heart rate, which have no consequences for the baby
• reduction of the duration of the dilating period and increase of the duration of the expulsion period
• increased use of Kristeller's maneuver (compressions exercised by the midwife on the woman's abdomen), use of the suction cup and administration of oxytocin
• the use of cesarean section remains unchanged