Modern pain relief for childbirth. Requirements for obstetric drugs
Lecture No. 16 (04/15/14)
Pain relief for childbirth: modern principles and methods.
Pain relief for childbirth – a set of measures aimed at the prevention and treatment of disorders of uterine contractility, correction of a threatening condition intrauterine fetus and elimination of severe discomfort in women in labor.
Excessive labor pain can disrupt the normal course of labor, contribute to fatigue during labor, and the development of weakness and incoordination. labor activity. At the same time, complete analgesia is achieved and labor weakens or stops. Therefore, it is acceptable for a woman to maintain moderate levels of physical overstrain. Such an interpretation of the significance of labor pain is consistent with its modern understanding as a negative biological need that forms a functional system that ensures the process of childbirth.
Pain response levels:
Level 1 – fabric
Level 2 – segmental
Level 3 – NS, subbuttal area
Level 4 – CNS, cerebral cortex
A painful birth is more likely in the following cases:
Dysmenorrhea, painful menstruation before giving birth
At the birth of a large baby
First birth
Long lasting labor
Premature birth
Use of oxytocin during childbirth
After expiration amniotic fluid
In case of insufficiency of ………………………… of a woman in labor
The main causes of pain during childbirth are:
Opening of the cervix, rich in nerve receptors of the highly sensitive peritoneum.
Uterine sprain
Excitation of vascular receptor fields
Myometrial contraction
Labor pain relief should be started under the following conditions:
Established labor activity
Development of regular contractions
Opening of the cervix by 3-4 cm
Expressed painful sensations and restless behavior of the mother in labor
No obstetric contraindications
Requirements for obstetric drugs:
Pain relief must be long-term
Should be carried out in the first and second stages of labor
It should be easily interrupted - it is impossible for light obstetric anesthesia to turn into deep anesthesia, when the muscles relax, gas exchange between the mother and the fetus worsens
During the operation, a deeper anesthesia is given, but also taking into account the interests of both the mother and the fetus, so as not to cause drug-induced depression.
Group of pain relief methods:
Drugs that have an effect on the cortex, hence the subcortex: magnesium sulfate, morphine and its derivatives, scopolamine, hydrochloride, chloroform, nitrous oxide, GHB, Viadrin, hypnosis, CiPPOR, electroanalgesia.
Agents acting on the subcortex: veronal, pyramidon, medinal, periakton, amitaoiatria.
Spinal block: lumbar, sacral, pervertebral, epidural, caudal - is widely performed abroad, but the percentage of surgical interventions increases, since it is paid.
Local anesthesia (infiltration, conduction).
When conducting analgesia during labor, it should be remembered that the placenta does not interfere with the passage of analgesics. The fetal respiratory center is sensitive to sedatives and analgesics, so the use of these drugs leads to respiratory depression in newborns.
General anesthesia:
In obstetrics they are used only in emergency cases, as anesthetics penetrate the placenta and depress the central nervous system of the fetus.
Inhalation anesthesia:
Nitrous oxide– used in the 1st and 2nd stages of labor. It does not prolong labor time or suppress contractions. A mixture of nitrous oxide and oxygen in equal proportions provides sufficient analgesia, the patient breathes this mixture between pushes during the second stage of labor.
Cyclopropane– used only shortly before resolution – depresses the fetal central nervous system.
Halothane– used to achieve maximum relaxation of the uterine muscles (internal rotation, bringing down the fetus by the leg, reversing the inversion of the uterus).
Atonic bleeding may develop, so the administration of the anesthetic should be short-term.
Analgesia and sedation during labor:
Meneredine and Promethazine– the joint of a narcotic analgesic tranquilizer effectively relieves pain during childbirth. Menedine 50-100 mg with Promethazine 25 mg can be administered every 3-4 hours. The effect occurs after 45 minutes.
Butorphanol and Narbuphine– synthetic narcotic analgesics are used intravenously. The fetal respiratory center is less depressed.
Morphine– a strong narcotic analgesic, and is rarely used during the active phase of labor. Usually prescribed IM 10-15 mg to patients with frequent, painful, ineffective contractions during discoordinated labor.
Naloxone– an antagonist of narcotic analgesics, normalizes the breathing of a newborn.
Barbiturates (Sodium Thiopental, Hexenal, drugs for non-inhalation anesthesia) - after intravenous administration of 65-70% of the dose, barbiturates bind to plasma proteins, the remaining free fraction has a narcotic effect. The narcotic effect of barbiturates is based on inhibition of the cerebral cortex and blockade, and the degree of fetal depression is directly proportional to the concentration of the mother’s blood.
Ataralgesia:
This is a combination of analgesics with diazepam, seduxen and other benzodiazepam derivatives. Benzodiazepine derivatives are among the safest tranquilizers; their combination with analgesics is especially indicated for severe fear, anxiety and mental stress. The combination of roperidol with seduxen has a beneficial effect on the course of labor, shortening the total duration of the period of cervical dilatation. However, there is an effect on the condition of the newborn, in the form of lethargy, low scores on the Aprgar scale, and low neuroreflex activity.
Conduction anesthesia:
* Nerve pathways– complete pain relief is achieved by blocking fibers of the 9th and 12th thoracic nerves, parasympathetic and sensory fibers, and sacral nerves.
* Paracervical blockade– effective for pain relief during contractions, including the second stage of labor. 5-10 ml of a 1% lidocaine solution is injected into the paracervical area at 3 and 9 o'clock or into the uterosacral area at 4 and 8 o'clock on both sides of the cervix. The effect occurs within 1-2 hours.
* Pudendal nerve block- Pudendal anesthesia.
* Spinal anesthesia– contraindications: bleeding, severe hypertension, disorders of the blood coagulation system.
* Epidural anesthesia.
Physiological methods of SIPPOR:
Systematic monitoring of a pregnant woman for timely detection of pathology and taking appropriate measures.
It is correct to formulate the dominant attitude towards the act of childbirth as a physiological process in order to relieve a woman of the feeling of fear that childbirth is painful.
Familiarization with the process of the birth act in order to eliminate surprises, alarming orientations.
Teaching a pregnant woman correct, reasonable behavior, performing pain relief techniques - which are a technique for toning the cortex.
SIPPOR has two links:
Women's consultation
Hospital (maternity hospital)
The effects of medications on the fetus:
Oxytocin overdose– increased uterine tone, persistent disruption of uteroplacental perfusion – development of hypoxia.
Beta blockers and sedatives – decreased heart rate variability.
Epidural anesthesia– decreased maternal blood pressure, decreased maternal blood flow – fetal hypoxia.
Sedatives– decreased fetal activity and CTG reactivity.
Alternative methods of labor pain relief include:
Changing body position:
Standing or walking
Squatting
Squatting with support
Hanging on your partner
The presence of a loved one can help:
Reducing the duration of labor
Reduce the need for painkillers
Reducing the number of surgical interventions
Reducing the number of newborns with low body weight on the Apgar scale
Reducing negative perceptions of the birth process
Update: October 2018
Almost all women are afraid upcoming birth and to a greater extent this fear is due to the expectation of pain during birth process. According to statistics, pain during childbirth, which is so severe that it requires anesthesia, is experienced by only a quarter of women in labor, and 10% of women (second and subsequent births) are characterized by labor pain as completely tolerable and tolerable. Modern pain management during childbirth it allows you to relieve and even stop labor pain, but is it necessary for everyone?
Why does pain occur during childbirth?
Labor pain is a subjective sensation that is caused by irritation of nerve receptors in the process (that is, its stretching), significant contractions of the uterus itself (contractions), stretching of blood vessels and tension of the uterosacral folds, as well as ischemia (deterioration of blood supply) of muscle fibers.
- Pain during labor occurs in the cervix and uterus. As the uterine os stretches and opens and the lower uterine segment stretches, the pain increases.
- Pain impulses, which are formed when the nerve receptors of the described anatomical structures are irritated, enter the roots of the spinal cord, and from there to the brain, where pain sensations are formed.
- A response comes back from the brain, which is expressed in the form of vegetative and motor reactions (increased heart rate and breathing, rise blood pressure, nausea and emotional agitation).
During the period of pushing, when the opening of the uterine pharynx is complete, pain is caused by the movement of the fetus along the birth canal and the pressure of its presenting part on the tissue birth canal. Compression of the rectum causes an irresistible desire to “go big” (this is pushing). In the third period, the uterus is already free of the fetus, and the pain subsides, but does not disappear completely, since it still contains the placenta. Moderate uterine contractions (the pain is not as severe as during contractions) allow the placenta to separate from the uterine wall and be released.
Labor pain is directly related to:
- fruit size
- pelvic size, constitutional features
- number of births in history.
In addition to unconditioned reactions (irritation of nerve receptors), the mechanism of formation of labor pain also involves conditioned reflex moments (negative attitude towards childbirth, fear of childbirth, worry about oneself and the child), as a result of which there is a release of adrenaline, which further narrows blood vessels and increases myometrial ischemia, which leads to a decrease pain threshold.
In total, the physiological side of labor pain accounts for only 50% of pain, while the remaining half is due to psychological factors. Pain during childbirth can be false or true:
- They talk about false pain when unpleasant sensations are provoked by the fear of childbirth and the inability to control one’s reactions and emotions.
- True pain occurs when there is any disruption in the birth process, which actually requires anesthesia.
It becomes clear that most women in labor are able to survive childbirth without pain relief.
The need for pain relief during labor
Labor anesthesia must be carried out in case of pathological course and/or existing chronic extragenital diseases in the woman in labor. Relieving pain during childbirth (analgesia) not only eases suffering and relieves emotional stress in a woman in labor, but interrupts the connection between the uterus - spinal cord - brain, which prevents the body from forming a brain response to painful stimuli in the form of vegetative reactions.
All this leads to stability of cardio-vascular system(normalization of blood pressure and heart rate) and improvement of uteroplacental blood flow. Besides, effective pain relief childbirth reduces energy costs, reduces oxygen consumption, normalizes work respiratory system(prevents hyperventilation, hypocapnia) and prevents narrowing of the uteroplacental vessels.
But the factors described above do not mean that drug pain relief for labor is required for all women in labor without exception. Natural pain relief during childbirth, it activates the antinociceptive system, which is responsible for the production of opiates - endorphins or happiness hormones that suppress pain.
Methods and types of pain relief for childbirth
All types of pain relief for labor pain are divided into 2 large groups:
- physiological (non-drug)
- pharmacological or drug pain relief.
Physiological methods of pain relief include
Psychoprophylactic preparation
This preparation for childbirth begins at the antenatal clinic and ends one to two weeks before the expected due date. Training at the “school of mothers” is conducted by a gynecologist who talks about the course of childbirth, possible complications and teaches women the rules of behavior during childbirth and self-help. It is important for a pregnant woman to receive a positive charge for childbirth, cast aside her fears and prepare for childbirth not as a difficult ordeal, but as a joyful event.
Massage
Self-massage will help relieve pain during contractions. Can be stroked side surfaces abdomen in a circular motion, collar area, lumbar region or press with your fists on points located parallel to the spine in lumbar region during contractions.
Correct breathing
Pain-relieving poses
There are several body positions, which, when taken, reduce the pressure on the muscles and perineum and relieve the pain somewhat:
- squatting with knees wide apart;
- standing on your knees, having previously separated them;
- standing on all fours, raising the pelvis (on the floor, but not on the bed);
- lean on something, tilting your body forward (on the back of the bed, on the wall) or jump while sitting on a gymnastic ball.
Acupuncture
Water treatments
Taking a warm (not hot!) shower or bath has a relaxing effect on the muscles of the uterus and skeletal muscles (back, lower back). Unfortunately, not all maternity hospitals are equipped with special baths or pools, so this method of pain relief cannot be used by all women in labor. If contractions start at home, then until the ambulance arrives, you can stand in the shower, lean against the wall, or take a warm bath (provided that your water has not broken).
Transcutaneous electrical nerve stimulation (TENS)
On the patient's back in the lumbar and sacral region 2 pairs of electrodes are applied through which a low-frequency electric current is supplied. Electrical impulses block the transmission of pain stimuli in the roots of the spinal cord, and also improve blood supply in the myometrium (prevention of intrauterine hypoxia).
Aromatherapy and audiotherapy
Inhalation aromatic oils allows you to relax and relieves labor pain somewhat. The same can be said about listening to pleasant, quiet music during contractions.
Pharmacological methods of pain relief include
Non-inhalation anesthesia
For this purpose, narcotic and non-narcotic drugs are administered intravenously or intramuscularly to the woman in labor. From narcotic drugs promedol and fentanyl are used, which help normalize discoordinated uterine contractions and have sedative effect and reduce the secretion of adrenaline, which increases the threshold pain sensitivity. In combination with antispasmodics (, baralgin), they accelerate the opening of the uterine pharynx, which shortens the first stage of labor. But narcotic drugs cause central nervous system depression in the fetus and newborn, so it is not advisable to administer them at the end of labor.
Of the non-narcotic drugs for pain relief during labor, tranquilizers (Relanium, Elenium) are used, which not so much relieve pain as relieve negative emotions and suppress fear; non-narcotic anesthetics (ketamine, sombrevin) cause confusion and insensitivity to pain, but do not impair respiratory function, do not relax skeletal muscles and even increase the tone of the uterus.
Inhalational anesthetics
This method of pain relief during childbirth involves the mother inhaling inhalational anesthetics through a mask. At the moment, this method of anesthesia is used in few places, although not so long ago cylinders with nitrous oxide were available in every maternity hospital. Inhalational anesthetics include nitrous oxide, fluorotane, and trilene. Due to the high consumption of medical gases and the contamination of the delivery room with them, the method has lost popularity. 3 methods are used inhalation anesthesia:
- inhalation of a mixture of gas and oxygen continuously with breaks after 30 0 40 minutes;
- inhalation only at the beginning of the contraction and stopping inhalation at the end of the contraction:
- inhalation of medical gas only in between contractions.
Positive sides this method: fast recovery consciousness (after 1 - 2 minutes), antispasmodic effect and coordination of labor (prevention of the development of anomalies of labor forces), prevention of fetal hypoxia.
Side effects of inhalational anesthesia: breathing problems, heart rhythm disturbances, confusion, nausea and vomiting.
Regional anesthesia
Regional anesthesia involves blocking specific nerves, spinal cord roots, or nerve ganglia (nodes). Used during childbirth the following types regional anesthesia:
- Pudendal nerve block or pudendal anesthesia
Pudendal nerve block involves inserting local anesthetic(a 10% lidocaine solution is more often used) through the perineum (transperineal method) or through the vagina (transvaginal method) to the points where the pudendal nerve is localized (the middle of the distance between the ischial tuberosity and the edges of the rectal sphincter). Typically used to relieve pain during labor when other methods of anesthesia cannot be used. Indications for a pudendal block are usually the need to apply obstetric forceps or vacuum extractor. Among the disadvantages of the method, the following are noted: pain relief is observed only in half of women in labor, the possibility of the anesthetic entering the uterine arteries, which, due to its cardiotoxicity, can lead to fatal outcome, only the perineum is anesthetized, while spasms in the uterus and lower back persist.
- Paracervical anesthesia
Paracervical anesthesia is permissible only for pain relief in the first stage of labor and consists of injecting a local anesthetic into the lateral vaults of the vagina (around the cervix), thereby achieving blockade of the paracervical nodes. It is used when the uterine os opens by 4–6 cm, and when it reaches almost full disclosure(8 cm) paracervical anesthesia is not performed due to high risk injection of medication into the fetal head. Currently, this type of pain relief during childbirth is practically not used due to the high percentage of development of bradycardia (slow heartbeat) in the fetus (approximately 50–60% of cases).
- Spinal: epidural or peridural anesthesia and spinal anesthesia
Other methods of regional (spinal) anesthesia include epidural anesthesia (injection of anesthetics into the epidural space located between the dura mater (outer) of the spinal cord and the vertebrae) and spinal anesthesia (introduction of anesthetic under the dura mater, arachnoid (middle) membrane without reaching the pia mater meninges– subarachnoid space).
Pain relief with EDA occurs after some time (20 - 30 minutes), during which the anesthetic will penetrate into the subarachnoid space and block nerve roots spinal cord. Anesthesia for SMA occurs immediately, since the drug is injected precisely into the subarachnoid space. TO positive aspects This type of pain relief includes:
- high percentage of efficiency:
- does not cause loss or confusion;
- if necessary, you can extend the analgesic effect (by installing an epidural catheter and administering additional doses of drugs);
- normalizes discoordinated labor;
- does not reduce the strength of uterine contractions (that is, there is no risk of developing weakness of labor forces);
- lowers blood pressure (which is especially important for arterial hypertension or gestosis);
- does not affect the respiratory center in the fetus (there is no risk of developing intrauterine hypoxia) and in the woman;
- if abdominal delivery is necessary, the regional block can be strengthened.
Who is indicated for pain relief during labor?
Despite the many advantages various methods pain relief during childbirth, relief of labor pain is carried out only if there are medical indications:
- gestosis;
- C-section;
- young age of the woman in labor;
- labor began prematurely (to prevent birth trauma the newborn is not protected from the perineum, which increases the risk of rupture of the birth canal);
- estimated fetal weight of 4 kg or more (high risk of obstetric and birth injuries);
- labor lasts 12 hours or more (protracted, including with a preceding pathological preliminary period);
- drug labor stimulation (when oxytocin or prostaglandins are added intravenously, contractions become painful);
- severe extragenital diseases of the woman in labor (pathology of the cardiovascular system, diabetes mellitus);
- the need to “turn off” the pushing period (high myopia, preeclampsia, eclampsia);
- discoordination of generic forces;
- birth of two or more fetuses;
- dystocia (spasm) of the cervix;
- increasing fetal hypoxia during childbirth;
- instrumental interventions in the pushing and afterbirth periods;
- suturing incisions and tears, manual examination of the uterine cavity;
- rise in blood pressure during childbirth;
- hypertension (indication for EDA);
- incorrect position and presentation of the fetus.
Question answer
What pain relief methods are used after childbirth?
After separation of the placenta, the doctor examines the birth canal to ensure its integrity. If ruptures of the cervix or perineum are detected, and an episiotomy has been performed, then there is a need to suturing them under anesthesia. As a rule, infiltration anesthesia of the soft tissues of the perineum with novocaine or lidocaine (in case of ruptures/incisions) and, less commonly, pudendal blockade are used. If EDA was performed in the 1st or 2nd period and an epidural catheter was inserted, then an additional dose of anesthetic is injected into it.
What kind of anesthesia is performed if instrumental management of the second and third stages of labor is necessary (fertility surgery, manual separation of placenta, application of obstetric forceps, etc.)?
In such cases, it is advisable to perform spinal anesthesia, in which the woman is conscious, but there is no sensation in the abdomen and legs. But this issue is decided by the anesthesiologist together with the obstetrician and largely depends on the anesthesiologist’s knowledge of pain management techniques, his experience and the clinical situation (presence of bleeding, need rapid anesthesia, for example, with the development of eclampsia on the birth table, etc.). The method of intravenous anesthesia (ketamine) has proven itself well. The drug begins to act 30 - 40 seconds after administration, and its duration is 5 - 10 minutes (if necessary, the dose is increased).
Can I pre-order EDA during labor?
You can discuss pain relief during childbirth using the EDA method with your obstetrician and anesthesiologist in advance. But every woman should remember that epidural anesthesia during childbirth is not prerequisite providing medical care to a woman in labor, and the mere desire of the expectant mother to prevent labor pain does not justify the risk possible complications any “ordered” type of anesthesia. In addition, whether EDA will be performed or not depends on the level of the medical institution, the presence of specialists in it who know this technique, the consent of the obstetrician leading the birth, and, of course, payment for this type of service (since many medical services, which are performed at the request of the patient, are additional and, accordingly, paid).
If EDA was performed during childbirth without the patient’s request for pain relief, will you still have to pay for the service?
No. If epidural anesthesia or any other labor anesthesia was carried out without a request from the mother in labor for pain relief, therefore, there were medical indications to ease contractions, which was established by the obstetrician, and pain relief in this case acted as part of the treatment (for example, normalization of labor in case of discoordination of labor forces).
How much does EDA cost during childbirth?
The cost of epidural anesthesia depends on the region in which the woman in labor is located, the level of the maternity hospital, and whether the hospital is private or public. Today, the price of EDA ranges (approximately) from $50 to $800.
Can everyone have spinal (EDA and SMA) anesthesia during childbirth?
No, there are a number of contraindications for which spinal anesthesia cannot be performed:
Absolute:
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Relative ones include:
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What kind of pain relief is given during a caesarean section?
The method of pain relief during a cesarean section is chosen by the obstetrician together with the anesthesiologist and agreed upon with the woman in labor. In many ways, the choice of anesthesia depends on how the operation will be performed: planned or emergency indications and on the obstetric situation. In most cases, in the absence of absolute contraindications to spinal anesthesia, the woman in labor is offered and performed EDA or SMA (as with planned caesarean section, and in case of emergency). But in some cases, endotracheal anesthesia (EDA) is the method of choice for pain relief for abdominal delivery. During EDA, the woman in labor is unconscious, unable to breathe on her own, and a plastic tube is inserted into the trachea, through which oxygen is supplied. In this case, anesthetic drugs are administered intravenously.
What other methods of non-drug pain relief can be used during childbirth?
In addition to the above methods of physiological pain relief during childbirth, you can do auto-training to ease contractions. During painful uterine contractions, talk to the child, express the joy of a future meeting with him, and set yourself up for a successful outcome of childbirth. If auto-training does not help, try to distract yourself from the pain during a contraction: sing songs (quietly), read poetry or repeat the multiplication table out loud.
Case study: I gave birth to a young woman with a very long braid. It was her first birth, the contractions seemed very painful to her, and she constantly asked for a caesarean section to stop this “torture.” It was impossible to distract her from the pain until one thought occurred to me. I told her to undo the braid, otherwise it was too disheveled, to comb it and braid it again. The woman was so carried away by this process that she almost missed the attempts.
The process of childbirth is a very exciting and painful process that is difficult to endure not only morally, but also physically. Probably every woman who gave birth during labor was visited by the thought of pain relief. Some say that this is an excellent way to endure childbirth normally, while others believe that pain relief can negatively affect the baby’s health and the process of labor.
Methods of pain relief during childbirth
When contractions begin and later, the woman experiences severe pain, which can sometimes provoke a malfunction of the heart, breathing and blood pressure. For certain indications, pain relief may be recommended to protect the life of the expectant mother and fetus.
Medical anesthesia
1. Mask anesthesia. With the help of nitrous oxide, a woman is put into a state of anesthesia and thus helped to painlessly endure the period of labor, when the cervix dilates. The medicine is administered by inhalation by inhalation.
2. Endotracheal general anesthesia. The medicine is injected into the lungs through the trachea and provides long-term pain relief. Also used in combination with this type of anesthesia is artificial ventilation lungs. The anesthetic consists of several drugs; its use is possible only as prescribed by an obstetrician and anesthesiologist. This type of pain relief is used during a caesarean section.
3. Intravenous anesthesia. Anesthesia is injected into a vein, causing the woman in labor to fall asleep for a short time.
4. Local anesthesia. To reduce sensitivity individual areas body during labor, a woman can be given an intramuscular injection, which will numb a specific part of the body.
5. Epidural anesthesia. A new and very popular method of pain relief during childbirth. When administering this type of anesthesia, the anesthesiologist inserts a small thin needle between the vertebrae of the woman in labor and injects an anesthetic through it. hard shell spinal cord. This way you can temporarily deprive of sensitivity those parts of the body that are located below the injection site. The good thing about this method is that it allows the woman to be conscious and feel pretty good.
The disadvantage of this method is that without experiencing pain during contractions, it is difficult for a woman to maintain labor and facilitate the birth of a child.
6. Drug pain relief. When choosing an anesthesia method, you should ask what medications are used to relieve pain. Previously, narcotic drugs were widely used, which included tincture of opium, morphine, nitrous oxide and others. It is known that they negatively affect the child’s health to one degree or another. In modern medicine it is used relatively safe analogue of these drugs - promedol.
Except standard types anesthesia, there are non-drug methods of pain relief during childbirth.
Non-drug pain relief
1. Psycho-emotional preparation. One of the most important factors in the fight against pain during childbirth. The fact is that women who know what awaits them and understand how childbirth takes place endure contractions easier and less painfully and have better control over themselves.
2. Massage. By stretching, for example, the muscles of the neck, collar area, lower back and back, you can distract a woman from pain in the abdomen and pelvis and relax tense muscles.
3. Reflexology. Acupuncture is considered quite effective method pain relief during childbirth.
4. Hydrotherapy. Staying in a warm bath or shower at a comfortable temperature can temporarily relieve pain and ease contractions.
Only a doctor can decide to prescribe pain relief during childbirth. There are certain indications for this. But if an obstetrician during the birth process sees that severe and prolonged pain weakens the woman in labor, threatens her health, or that she has a low pain threshold, he must administer anesthesia so that the birth process ends safely and the lives of the mother and fetus are safe.
Pain relief during childbirth is aimed at ensuring comfortable conditions for a woman giving birth, it avoids pain and stress, and also helps prevent labor disorders.
The perception of pain by a woman in labor depends on such circumstances as physical state, anxious anticipation, depression, peculiarities of upbringing. In many ways, pain during childbirth is intensified by fear of the unknown and possible danger, as well as previous negative experiences. However, the pain will be reduced or better tolerated if the patient has confidence in the successful completion of labor and a correct understanding of the labor process. Unfortunately, so far, none of the currently existing methods of pain relief during childbirth is absolutely ideal. To achieve maximum effect, the choice of pain relief method should be individualized. In this case, it is necessary to take into account the physiological and psychological condition women in labor, fetal condition and obstetric situation. To increase the effectiveness of pain relief important has prenatal preparation, the purpose of which is to remove the fear of the unknown of the upcoming birth. In the process of such preparation, the pregnant woman must be informed about the essence of the processes accompanying pregnancy and childbirth. The patient is taught proper relaxation, exercises that strengthen the abdominal and back muscles, increasing general tone, in different ways breathing during contractions and at the moment of birth of the fetal head.
As one of the methods Not drug pain relief acupuncture may be used during childbirth. Most often, when using this method, only partial pain relief occurs, and most patients need to use additional methods pain relief. Another method of non-drug labor pain relief is transcutaneous electrical nerve stimulation (TENS), which has been used for many years. During labor, two pairs of electrodes are placed on the mother's back. The degree of electrical stimulation varies according to the needs of each individual woman and can be adjusted by the patient herself. This form of analgesia is safe, non-invasive, and can be easily administered by a nurse or midwife. The main disadvantage of the method is the difficulty in its use of electronic monitoring of the fetal condition, despite the fact that transcutaneous electrical neurostimulation itself does not affect heartbeat fetus
However, the most important thing for pain relief during labor is the use of appropriate medications. Methods of pain relief during labor can be divided into three types: intravenous or intramuscular injection medicines to relieve pain and anxiety; inhalation pain relief for labor; local infiltration application and regional blockades.
Narcotic analgesics are the most effective drugs used for pain relief during childbirth. However, these drugs are used to reduce pain rather than completely stop it. With established labor in the active phase of the first stage of labor, these drugs help correct uncoordinated uterine contractions. The choice of drug is usually based on the severity of potential side effects and the desired duration of action. Intravenous administration of drugs is preferable compared to intramuscular administration, since the effective dose is reduced by 1/3-1/2, and the effect begins much faster. Tranquilizers and sedatives are used during childbirth as components of drug pain relief to relieve agitation, as well as to reduce nausea and vomiting. In the active phase of labor, when the cervix is dilated more than 3-4 cm and painful contractions occur, sedatives with narcotic analgesics in combination with antispasmodics (No-spa intramuscularly) are prescribed. The use of narcotic analgesics should be stopped 2-3 hours before the expected moment of expulsion of the fetus, to prevent possible narcotic depression.
Inhalation pain relief for labor
Inhalation pain relief for labor by inhaling painkillers is also widely used in obstetric practice. Inhalational anesthetics are used during the active phase of labor when the cervix is dilated by at least 3-4 cm and in the presence of severe painful contractions. The most common are nitrous oxide (N2O) with oxygen, trichlorethylene (trilene) and methoxyflurane (pentrane). Nitrous oxide is a colorless gas with a slight sweetish odor that is the most harmless inhalational anesthetic for mother and fetus. The most common ratios of nitrous oxide to oxygen are: 1:1, 2:1 and 3:1, allowing for the most optimal and sustained analgesia. During the process of inhalation anesthesia, supervision is required from medical personnel for the condition of the woman in labor. The effectiveness of pain relief largely depends on correct technique inhalation and rationally selected ratios of the components of the gas-narcotic mixture. Three options can be used to achieve an analgesic effect.
Options for labor pain relief using inhalational anesthetics
- Inhalation of the gas-narcotic mixture occurs continuously with periodic breaks after 30-40 minutes.
- Inhalation is carried out with the beginning of the contraction and ends with its end.
- Inhalation occurs only in pauses between contractions, so that by the time they begin, the required degree pain relief.
Autoanalgesia during labor with nitrous oxide can be performed throughout active phase first stage of labor until full opening cervix. Due to the fact that nitrous oxide is eliminated from the body through the respiratory tract, this provides greater control over the pain relief process. During pain relief during childbirth, after stopping inhalation of nitrous oxide, consciousness and orientation in the environment are restored within 1-2 minutes. Such analgesia during labor also has an antispasmodic effect, ensuring coordinated labor, preventing abnormalities in uterine contractility and fetal hypoxia. The use of a gas-narcotic mixture of nitrous oxide and oxygen is the most acceptable in obstetric practice for pain relief during labor. In addition to nitrous oxide, drugs such as trichlorethylene (which has a more pronounced effect) can also be used for inhalation anesthesia. analgesic effect compared to nitrous oxide); methoxyflurane (use is less controlled than nitrous oxide and trichlorethylene).
Epidural analgesia
Regional analgesia can also be successfully used to relieve labor pain. The cause of pain in the first stage of labor is contraction of the uterine muscles, stretching of the cervix and tension ligamentous apparatus uterus. In the second stage of labor, due to stretching and elongation of the pelvic structures during the advancement of the fetus, additional pain sensations arise, which are transmitted along the sacral and coccygeal nerves. Therefore, to achieve pain relief during childbirth, the transmission of pain impulses along the corresponding nerve bundles should be blocked. This can be achieved by a pudendal nerve block, a caudal block, a spinal block, or an extended epidural block.
Epidural analgesia is one of the popular methods of labor pain relief. Epidural analgesia involves blocking pain impulses from the uterus through nerve pathways, entering the spinal cord at a certain level by injecting a local anesthetic into the epidural space. Indications for epidural analgesia are: severe painful contractions in the absence of effect from other methods of pain relief, incoordination of labor, arterial hypertension during childbirth, childbirth during and.
Contraindications to labor pain relief with epidural analgesia
- Bleeding during pregnancy and shortly before childbirth.
- Use of anticoagulants or decreased activity blood coagulation system.
- The presence of a focus of infection in the area of the proposed puncture.
- A tumor at the site of the intended puncture is also a contraindication to epidural analgesia.
- Volumetric intracranial processes accompanied by increased intracranial pressure.
Relative contraindications to epidural analgesia
- Extensive surgical interventions on the back, which were performed previously.
- Extreme obesity and anatomical features, making it impossible to identify topographical landmarks.
- Previous or existing diseases of the central nervous system (multiple sclerosis, epilepsy, muscular dystrophy and myasthenia).
Epidural analgesia is carried out when regular labor is established and the cervix is dilated by at least 3-4 cm. Only an anesthesiologist who knows this technique has the right to perform epidural anesthesia.
Pain relief for labor disorders
Disorders of labor also deserve attention. Adequate timely treatment Discoordination of labor activity, as a rule, contributes to its normalization. The choice of appropriate therapy is carried out taking into account the age of the women, obstetric and somatic history, the course of pregnancy, and an objective assessment of the condition of the fetus. With this type of abnormal labor, the most reasonable method of treatment is long-term epidural analgesia. Frequent anomaly labor activity is a weakness that can be corrected by intravenous administration means that enhance contractile activity uterus. Before prescribing birth-stimulating drugs if the patient is tired, it is necessary to provide the woman with rest in the form of pharmacological sleep. Proper and timely provision of rest leads to the restoration of impaired functions of the central nervous system. In these situations, rest helps restore normal metabolism. For this purpose, a wide arsenal is used medications, which are prescribed by a doctor on an individual basis depending on the current obstetric situation and the condition of the woman in labor. In obstetric practice, the method of electroanalgesia is also used, the use of which makes it possible to achieve stable vegetative balance and avoid allergic reactions problems that may arise when using pharmacological drugs(neuroleptics, ataractics, analgesics). Unlike pharmacological drugs, the use pulse current allows you to obtain the so-called “fixed” stage of therapeutic analgesia, which makes it possible to maintain consciousness during the birth act, verbal contact with the woman in labor without signs of her excitement and transition to the surgical stage of anesthesia.
Pain relief for childbirth with diabetes
At diabetes mellitus at the beginning of the active phase of the first stage of labor, it is advisable to avoid the use of narcotic analgesics and the use of epidural analgesia is more preferable. This is due to the fact that the negative impact of systemic analgesics and sedatives, the mother's stress reaction to pain is less pronounced, and better control over the mother's condition is provided against the background of preserved consciousness. In addition, epidural analgesia helps prevent the development of rapid and rapid labor, allows for painless, controlled completion of labor. If necessary, against the background of epidural analgesia, surgical delivery is possible both through the natural birth canal (obstetric forceps, vacuum extraction) and by emergency cesarean section (after quickly strengthening the block). If there is no possibility and conditions for performing a regional block, it is possible to use inhalation analgesia, enhancing it with a block of the pudendal nerve.
Pain relief for childbirth with heart disease
At rheumatic diseases heart pain relief should be carried out until delivery and continue in early postpartum period. These requirements the best way An extended lumbar epidural block responds. This technique allows you to eliminate pushing in the second stage of labor, and provides the necessary conditions for the application of obstetric forceps and the use of vacuum extraction. If a caesarean section becomes necessary, an extended lumbar epidural block can be extended to the required level. This method of pain relief helps prevent the development of acute heart failure with pulmonary edema and decreased venous return. In a patient with a prosthetic valve and using heparin, it is advisable to use tranquilizers and narcotic analgesics or inhalational analgesia without hyperventilation. In the second stage of labor it should be supplemented with a pudendal nerve block.
Anesthesia and premature birth
Discussion
But I gave birth with epidural analgesia. I didn’t have any pain in my abdomen at all, but I did have pain in my lower back! Moreover, I was not afraid of childbirth, I knew how and what was happening, I breathed correctly, I did it myself light massage, but the birth lasted more than a day, the baby was born 5 kg. Of course, it would have been possible to get by, but I was tired, pinched and dreamed of losing consciousness, just not to be present at this horror. Anesthesia helped further dilate the uterus and within two hours, with one push, I gave birth healthy baby. Thanks to the people who think about how to alleviate the suffering of a mother!
03/11/2007 01:08:05, TinaI am a pediatrician, 2nd grade disabled musculoskeletal system. I gave birth to my two children myself, and I can say with confidence that the most best pain relief is preparation for childbirth during pregnancy (swimming, sauna, baths, self-education, physical exercise), the presence of the husband, his thoughtfulness, psychological support, a woman’s awareness of the physiology of childbirth and how to behave during childbirth (movement, postures during contractions, etc.), warm water With sea salt, lack of fear, etc. In this case, childbirth is fueled by endorphins.
If a woman is methodically intimidated in the antenatal clinic throughout pregnancy, stuffed with vitamins and calcium, and not told anything about how to prepare for childbirth physically (and not financially), then very often the matter ends in birth trauma or cesarean. In our maternity hospitals, you can give birth normally if you are information-savvy and don’t give in to intimidation, are physically prepared, and if you agree with the doctor so that he does not interfere too much with the birth process.
It really doesn't hurt to give birth when you know that this so-called... “pain” with every minute, second brings you closer to meeting the desired creature that will be born. Fear constrains, is passed on to the child, causes pain during childbirth and discoordination of labor. What about labor stimulation?! This is one, continuous contraction, it is very painful, especially if the woman is lying on her back, this is not physiological, it is harmful for the child (vena cava syndrome), THIS IS AGAINST ALL THE RULES!
Give birth without fear - and there will be no pain. GUARANTEE! Nature - she provides everything, it is better to follow it, and not artificial methods of childbirth.
By the way, my great-grandmother was a midwife, and no special education Did not have. She simply KNEW how to help a woman in labor - DON’T INTERFERE! She herself gave birth to eight children, and helped almost all the children in the village to be born, even accepted my mother. If she had been alive, I would never have gone to the maternity hospital to give birth.
Good luck everyone!
Natasha
13.03.2006
All the most important things in this article are written in the first paragraphs and for this I thank the doctor very much, maybe without knowing it he came out in support natural birth and such a concept, still unknown in our country, as protecting the psychological well-being of a woman in labor. Her calmness, confidence in the positive outcome of childbirth, the opportunity to receive support from loved ones - this is the main pain relief for childbirth, absolutely harmless. Thanks to Dr. Makarov for the reminder that there is no perfect drug pain relief, perhaps someone can refrain from using drugs during childbirth and give their child a chance to be born without them. But if by the time I read the article I had not given birth to three children, by the way, completely without drug pain relief, I would probably have been scared. For me, the best pain relief was the support of my husband, water and a caring midwife. Giving birth isn't that painful!
02/27/2006 21:36:39, SvetlanaComment on the article "Pain relief for childbirth"
Then the whole scheme was outlined in my head, but, remembering the birth on oxytocin without pain relief, I became faint-hearted and could not say that no, no one injected me with oxytocin. In addition, my uterus was contracting very painfully.
Discussion
My uterus contracted the most painfully after the second birth. And after the third - it’s normal, although I expected it to be tough. But it didn't happen :)
I was injected with oxytocin, antibiotic and painkiller for 3 days. (I don’t know which one). I had ACL and my first birth, it hurt a lot, especially after oxytocin. I kept worrying that I didn’t know what contractions and childbirth were in general, but ACL: I got up in the morning and went to the operation. And after oxytocin it became clear how it would be...
Nosh-pu was allowed, you could ask for a candle and a hot water bottle with ice.
I didn’t give birth pain relief, but it was tolerable for me; if the pain is unbearable, you need to give birth pain relief, IMHO. And as for pain relief, when it is necessary to alleviate the suffering of a dying person - is this generally necessary, is there any point in enduring?
Discussion
I don't think anesthesia is a whim. I didn’t give birth pain relief, but it was tolerable for me; if the pain is unbearable, you need to give birth pain relief, IMHO. And as for pain relief, when it is necessary to alleviate the suffering of a dying person - is this generally necessary, is there any point in enduring?
06/03/2016 22:01:52, NuANSWell, specifically on the topic - in general, I don’t consider anesthesia an evil. but personally, based on my examples: during childbirth _now_, _knowing_, I would prefer not to undergo pain relief, during cancer - instead of anesthesia, euthanasia. pure IMHO
Currently the best way management of labor in infected women has not been fully determined. To make a decision, the doctor needs to know the results of a comprehensive virological research. Natural childbirth includes a whole range of measures aimed at adequate pain relief, prevention of fetal hypoxia and early rupture of amniotic fluid, reducing injuries to the birth canal of the mother and the baby’s skin. Only if all preventive measures are followed does...
Discussion
I completely agree. Unfortunately, on this moment there is no consensus on the safest management of childbirth with hepatitis C. According to statistics, the likelihood of a child becoming infected with hepatitis is somewhat lower during a planned caesarean section than during a natural birth. However, none of these methods can guarantee the safety of a child from hepatitis infection. Therefore, the choice of method of obstetric care is based more on obstetric history than on knowledge of the presence of this infection.
At lunchtime I already said that pain relief was not needed. Nothing hurt, not my head, not my back, not my legs. 2 ks with spinal. The first CS after 6 hours of labor, after anesthesia I felt like in heaven, and after 15 minutes the baby was delivered.
Discussion
There is no need to be afraid. I also had some reasons for this, but in the end I gave birth naturally:) Also good.
I went with my first daughter without any problems. one prick, everything was cut off from chest to toe. I tried to look at the process in the reflection of the llamas and in the tiles, but the medical staff spoke their teeth and did not let me look, which is a pity. I'm glad I heard my daughter's first cries. They let me kiss my heel:) very touching. I gave birth to my second in the same way, only all my nerves were exhausted (I gave birth for free) - in the operating room I was shaking either from the cold or from nerves - the result: the anesthesia did not work - they gave me general anesthesia. I didn’t hear the first screams, it was difficult to escape.
1 ... when you visit your grandmother, you put on a hat just before you ring the doorbell of her apartment. After all, she doesn’t like it so much if you walk around in winter without a hat! 2 ... your apartment is not always peaceful perfect order. What’s more, his reign is so short-lived that it often goes unnoticed. 6 ... you are convinced that tears make you irresistible. And you don’t believe the mirrors that are trying to convince you otherwise - this is bad lighting, but in reality it’s not...
Despite the constant development of medicine, anesthesia during childbirth is still not a mandatory procedure. Much depends on the characteristics of the pain threshold of the woman in labor: if she can endure a natural birth without the use of painkillers, they are not used unless there is an indication for this. Much less often during childbirth, general anesthesia is used with drugs that immerse the person in deep dream, but they are unsafe for the child, so it is most often recommended to resort to spinal or epidural anesthesia.
During pregnancy, many women are interested in issues of pain relief during childbirth, since it is no secret that the process is always associated with pain, which can be long-lasting and unbearable. They ask the doctor questions: is it possible to give birth without using pain relief methods and what is better - epidural anesthesia or general anesthesia? Modern methods of anesthesia are considered relatively safe for both the mother and her child, and make childbirth more comfortable for the woman.
Types of pain relief during natural childbirth
There are non-drug (natural) and medicinal methods pain relief. Natural Methods completely safe and effective. These include: breathing techniques, massage, acupuncture, aromatherapy, relaxation, etc. If their use does not bring results, they resort to drug pain relief.
Methods of drug anesthesia include:
- epidural anesthesia;
- spinal anesthesia;
- local anesthesia;
- inhalation anesthesia;
- general anesthesia.
In natural childbirth, epidural and spinal anesthesia are used.
Epidural anesthesia
Epidural anesthesia qualitatively eliminates sensitivity in the lower part of the mother's body, but it does not affect her consciousness in any way. The stage of labor at which the doctor uses epidural pain relief varies from patient to patient depending on their pain threshold.
During epidural anesthesia, the anesthesiologist and obstetrician evaluate the condition of the mother and the unborn child, and also refer to the history of anesthesia in the past and the course of previous births, if any.
With epidural anesthesia, the drug is injected into the space of the spine in which the nerve roots are located. That is, the procedure is based on nerve blockade. This type of pain relief is usually used during natural childbirth to ease the process of contractions.
Technique:
- the woman takes the “fetal” position, arching her back as much as possible;
- the injection area is treated with an antiseptic;
- an injection with an anesthetic drug is made into the spine area;
- after the medicine begins to act, a thick needle is punctured into the epidural space until the anesthesiologist feels the dura;
- after this, a catheter is inserted through which anesthetics will enter the woman’s body;
- the needle is removed, the catheter is secured with adhesive tape on the back and a trial administration of the drug is carried out along it, during which the doctor carefully monitors the woman’s condition;
- The woman should remain in a lying position for some time to avoid complications. The catheter remains in the back until the end of labor, and a new dose of medication will be injected through it periodically.
The catheterization procedure itself takes no more than 10 minutes, and the woman must remain as still as possible. The drug begins to act approximately 20 minutes after administration. For epidural pain relief, medications are used that do not penetrate the placental barrier and cannot harm the child: Lidocaine, Bupivacaine and Novocaine.
Indications for epidural anesthesia:
- kidney disease;
- myopia;
- young age of the expectant mother;
- low pain threshold;
- premature labor;
- incorrect presentation of the fetus;
- severe somatic diseases, for example: diabetes.
Contraindications:
- heart and vascular diseases;
- poor blood clotting;
- spinal injuries and deformities;
- high risk of uterine bleeding;
- inflammation in the puncture area;
- increased intracranial pressure;
- reduced arterial pressure.
Positive sides:
- a woman can move relatively freely during childbirth;
- the state of the cardiovascular system is more stable in contrast to general anesthesia;
- pain relief has virtually no effect on the fetus;
- the catheter is inserted once for an indefinite period, so if necessary, medications can be administered through it desired period time;
- a woman will see and hear her child immediately after birth.
Negative sides:
- the likelihood of an inadequate result of pain relief (in 5% of women the effect of the anesthetic is not achieved);
- complex catheterization procedure;
- the risk of intravascular administration of the drug, which is fraught with the development convulsive syndrome, which, although rare, can cause the death of a woman in labor;
- the drug begins to act only after 20 minutes, so with rapid and emergency childbirth the use of epidural anesthesia is not possible;
- If the drug is injected through the arachnoid membrane, a spinal block develops and the woman requires emergency resuscitation.
Spinal anesthesia
Spinal anesthesia, like epidural anesthesia, is performed in almost the same way, but using a thinner needle. The difference between spinal and epidural anesthesia is as follows: the amount of anesthetic for a spinal block is significantly less, and it is injected below the border of the spinal cord into the space where the cerebrospinal fluid is localized. The feeling of pain relief after injection of the drug occurs almost immediately.
The anesthetic is injected once into the spinal cord canal using a thin needle. Pain impulses are blocked and do not enter the brain centers. The proper result of pain relief begins within 5 minutes after the injection and lasts for 2-4 hours, depending on the chosen medication.
During spinal anesthesia, the woman in labor also remains conscious. She sees her baby immediately after birth and can put him to her breast. The spinal anesthesia procedure requires mandatory venous catheterization. A saline solution will flow into the woman's blood through the catheter.
Indications for spinal anesthesia:
- gestosis;
- kidney disease;
- diseases of the bronchopulmonary system;
- heart defects;
- high degree of myopia due to partial retinal detachment;
- incorrect presentation of the fetus.
Contraindications:
- inflammatory process in the area of intended puncture;
- sepsis;
- hemorrhagic shock, hypovolemia;
- coagulopathy;
- late toxicosis, eclampsia;
- acute pathologies of the central nervous system of non-infectious and infectious origin;
- allergy to local anesthesia.
Positive sides:
- 100% guarantee of pain relief;
- the difference between spinal anesthesia and epidural implies the use of a thinner needle, so the manipulation of drug administration is not accompanied by severe pain;
- medications do not affect the condition of the fetus;
- the muscular system of the woman in labor relaxes, which helps the work of specialists;
- the woman is fully conscious, so she sees her child immediately after birth;
- no probability systemic influence anesthetic;
- spinal anesthesia is cheaper than epidural;
- the technique of administering the anesthetic is more simplified compared to epidural anesthesia;
- quickly obtaining the effect of anesthesia: 5 minutes after administration of the drug.
Negative sides:
- It is not advisable to prolong the effect of anesthesia for longer than 2-4 hours;
- after pain relief, the woman should remain in a supine position for at least 24 hours;
- headaches often occur after a puncture;
- Several months after the puncture you may experience back pain;
- the rapid effect of anesthesia is reflected in blood pressure, provoking the development of severe hypotension.
Consequences
The use of anesthesia during childbirth can cause short-term effects in the newborn, for example: drowsiness, weakness, depression respiratory function, reluctance to take the breast. But these consequences pass rather quickly, since the drug used for pain relief gradually leaves the child’s body. Thus, the consequences of drug anesthesia of labor are due to the penetration of anesthesia drugs through the placenta to the fetus.
You need to understand that anesthesia blocks pain, but this effect does not come without unpleasant consequences. For a woman in labor, the introduction of anesthetics into the body affects the activity of the uterus, that is, the process of natural dilation of the cervix becomes slower. This means that the duration of labor may increase.
Decreased activity of the uterus means that contractions are suppressed and may stop altogether. In this case, specialists will be forced to introduce into the mother’s body medications to stimulate the birth process, in some cases, use obstetric forceps or perform a caesarean section.
Also, after using anesthesia during childbirth, side effects such as headache, dizziness, heaviness in the limbs. With epidural and spinal anesthesia, blood pressure decreases. In general, the analgesic effect is achieved successfully with all types of anesthesia, but a feeling of pressure in the lower abdomen may persist.
In developed countries, more than 70% of women resort to pain relief during childbirth. Increasingly, women insist on pain relief during labor to minimize the pain of contractions, despite the fact that childbirth is a natural process that can occur without outside intervention. During natural childbirth, the body produces a significant amount of endorphins - hormones that provide physiological anesthesia, promote emotional uplift, and reduce feelings of pain and fear.
Useful video about epidural anesthesia during childbirth
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