Posts Tagged ‘epidural’

Why isn’t the baby out yet?
assisting the birth
What is an assisted delivery?
An assisted delivery is one that uses either forceps or a ventouse, or suction cup (see p.204), to help extract the baby from the birth canal if the baby is not making good progress during labour or there are complications during the second stage of labour in a vaginal delivery You will still be helping to deliver your baby with your contractions, but the instrument used will be helping to guide the baby out of the birth canal.
How is an assisted delivery carried out?
Assisted deliveries are carried out using either forceps or ventouse (vacuum extraction) by a doctor (or specially trained midwife) Forceps are metal instruments specially shaped to fit around the baby’s head, whereas in the ventouse method, a vacuum is created by attaching a cup-like fitting to the head and using a mechanism to create suction to help draw your baby out.
How do they decide whether to use ventouse or forceps? Will it be my choice?
Both forceps- and ventouse-assisted births are relatively safe procedures and, although each has pros and cons, it’s best to be guided by the doctor, as the choice of instrument usually depends on the position of the baby and the doctor’s preference or experience, although your opinion will be taken into consideration. Although forceps used to be the most widely used instrument, ventouse has increased significantly in popularity. Many consider ventouse easier to use and less likely to cause damage and tearing to the mother. However, this method is also more likely to cause swelling to the baby’s head where the cup was placed
What is a “prolonged second stage” and does this mean that the delivery will be assisted?
It is difficult to define a ”prolonged second stage” as it depends on certain factors, for example if it is your first baby the position and size of the baby, if you have an epidural, if the contractions are effective and how often they are coming, how well you are pushing, and if the pelvis is an adequate size There is some evidence to suggest that if the baby has progressed further into the pelvis, and there is no sign of distress. then there is no need to put a time limit on labour. However, it does tend to be the case that hospitals have guidelines as to how long they will allow a woman to push for before deciding that intervention may be necessary Usually, after about one and a half hours, doctors may decide to assist the delivery to reduce the risk of fetal distress and of the mother becoming exhausted.
I had a forceps delivery as in the end I was too tired to push. Is this likely to happen again?
An assisted delivery is more common during a first birth than in subsequent ones. The first pregnancy and birth causes the pelvic ligaments to stretch, which can make subsequent births easier, and the uterus is often more efficient in contracting the second and subsequent times around, which also means that labour is usually shorter Often, even if the baby’s head is not in the best position for birth, for example if the baby is in a posterior position, where the back of the head is towards the mother’s spine and lower back, it may be delivered without assistance during a second delivery Therefore, it is likely, but by no means certain, that you will have a normal vaginal delivery next time.
Can I refuse to have forceps or vacuum extraction and what are the alternatives?
No-one can go against your wishes if you do not want to have a particular procedure. However, it’s usually best to have a flexible approach to labour. Although you may wish for certain things not to take place, the doctor or midwife is likely to have a good reason for wanting to carry out a procedure and has your and -your baby’s best interests at heart. If an assisted delivery is suggested, asking the midwife or doctor to explain and support this decision can help you to come to terms with it. Usually the only other alternative to an assisted delivery would be a Caesarean section: however, this may be difficult if the baby has gone too far into the pelvis
Will I have an anaesthetic before they use the forceps?
Suitable pain relief, such as a local anaesthetic injection, or an epidural, will be given before the procedure The doctor will then help to pull the baby out while the mother pushes. The forceps and ventouse cup are removed after the head has been delivered, and the body is delivered normally,
What can go wrong at an assisted birth?
Forceps and ventouse can cause bruising, swelling, and marks on the baby’s head or face, although these usually resolve without any problems within a few days In rare cases, cuts and severe bruising on
Assisted delivery
An assisted delivery, using forceps or a ventouse vacuum extraction, may be carried out for one or more of the following reasons:
* The mother is exhausted from a long labour and has insufficient energy to push.
* The baby is showing signs of distress during the second stage of labour.
* The baby’s head is in a slightly wrong position -if you are in the second stage of labour, forceps or ventouse can often be used to turn the head around and deliver the baby.
* Forceps are sometimes used to protect the delicate head of a premature baby during birth
* Forceps are sometimes used to deliver the head of a breech baby
* If the baby is particularly large - this can be the case when the mother has had gestational diabetes .
the baby can occur. The paediatrician, a doctor who specializes in babies and children, may prescribe a paracetamol-based medicine to ease any discomfort that the baby may feel There is also an increased
risk of the baby developing jaundice, where the baby looks yellow due to the presence of the waste product bilirubin (see p.164), particularly in cases of severe bruising The levels of bilirubin in the baby will be checked if the doctor is concerned and the condition can be treated, if necessary
For the mother, the two main concerns are that there is an increased risk of tearing or being cut during the procedure - and hence an increased risk of more bleeding (which can be dealt with straight away) - and, rarely, damage may occur to the tubes that lead from the bladder.
If the situation warrants an assisted delivery, the benefits of delivering babies by these methods far outweigh the risks. If the procedure is not successful, an emergency Caesarean may be necessary.

Helping your baby’s birth

A delivery may be assisted using either vacuum extraction (or ventouse), which involves a small suction cap (metal or plastic) being placed on the back of your baby’s head and very gently pulled, or forceps, metal tongs that guide the baby out.
Why might this be necessary? There are several reasons why the obstetrician, and in some units the midwife, will advise this type of birth.  Generally an assisted delivery is carried out because the mother is too tired to carry on pushing after a prolonged second stage of labour, and the ventouse suction cap or forceps can help accelerate the baby’s progress through the birth canal. An assisted delivery may also be necessary if your blood pressure has risen suddenly or if there are signs of fetal distress You will be given either an epidural or local anaesthetic before the procedure is carried out
Is it safe? This is a safe way for your baby to be born, although there is a very small chance that your baby may bleed under his scalp and may need to go to the neonatal unit to be cared for and monitored after the birth, After vacuum extraction, most babies will have a little bump (a ”chignon”) where the soft cup has been attached to the head, and the baby s head may look slightly elongated Babies delivered by forceps may have marks on the sides of the head where the tongs were. However, any swelling or marks should disappear within a few days
Will I need an episiotomy? An episiotomy - a cut made between your vagina and back passage to make more space for your baby to be born in order to prevent tearing - is sometimes carried out if you have an assisted delivery, and is more likely with a forceps delivery.

Episiotomy
An episiotomy is an incision, or cut, made with scissors into the area called the perineum, which is the piece of tissue between the vagina and the anus. This area stretches and thins during the birth to allow for the baby’s head to be born with ease An episiotomy is performed only in an emergency situation An example of this is if the baby needs to be born quickly, or sometimes during an assisted delivery for example with forceps (see opposite), to prevent uncontrolled tearing Before the procedure is performed, a local anaesthetic is gently injected into the muscle to reduce the discomfort or pain during the procedure. An episiotomy will need stitching afterwards, and this is usually done by the midwife who has been involved in your delivery or by the obstetrician involved in the birth. Although episiotomies used to be routine around 10 to 15 years ago, they are now performed only when really necessary You should be informed why one is being recommended and give your verbal consent before the procedure is carried out.

MEDIO-LATERAL CUT:
What is an episiotomy and why might this be done?
An episiotomy is a cut along the muscle between the vagina and anus, known as the perineum, to widen the area where the baby will be delivered (see above) This is done only when absolutely necessary and will not be performed without your consent. There are several reasons why an episiotomy may be recommended including if the baby is in distress, to speed up the delivery of the head; in cases of forceps or ventouse deliveries! if the baby’s head is too large to pass through the vagina; if the perineum has not stretched sufficiently by the end of the second stage of labour to allow the smooth passage of the baby’s head through the vagina; if there is a complication in the vaginal delviery of a breech baby: or if the mother is finding it difficult to control her pushing while the baby’s head is crowning (see p. 186), which means she is more likely to tear significantly during the delivery
Usually, local anaesthetic is injected into the muscular area first and the procedure is performed at the strongest part of the contraction, as this distracts you from what is being done and assists with a quick delivery
The thought of having a cut down there is terrifying. What can I do to prevent this?
Some studies have shown that massaging the perineum regularly in pregnancy, using an unscented vegetable oil, can reduce the risk of tearing (see p.111) as this helps to make the area more flexible and may consequently help to stretch the area as the head is being born Wash your hands thoroughly before massaging the perineum. Although an episiotomy may be a worrying prospect, if you are advised to have one, this may prevent uncontrolled tearing.
Why might they do an emergency Caesarean section?
Emergency Caesareans are carried out for several reasons. The baby may be showing signs of being very tired, picked up by the fetal heart monitor or a blood test carried out during labour, and this could lead to the baby being distressed, known as fetal distress, in which case a Caesarean may be recommended Rarely, the umbilical cord comes down before the baby, a condition known as cord prolapse, and this is an emergency that requires immediate delivery by Caesarean.

LABOUR AND BIRTH
It’s all your fault, stop the pain!
choices for pain relief
What is the best form of pain relief in labour?
As each woman and labour is very different, it is difficult to say which is the ”best” form of pain relief. This will also depend on an individual’s coping mechanisms and pain threshold. There are many different types of pain relief (see p 174) including alternative therapies such as aromatherapy acupuncture, homeopathic kits, reflexology and hynobirthing (using self-hypnosis to reach a state of deep relaxation); natural methods, such as water, massage, TENS, and the positions you adopt; and drugs, such as gas and air and pethidine, and epidural. Your midwife will talk to you about the different choices available and the advantages and disadvantages of each one.
Last time I made a real idiot of myself. I don’t want to lose control again - what do you advise?
The best advice is to know your options, have an open mind, and be guided by labour and how you are feeling. Being positive and having appropriate support can not only result in a good experience, but can reduce your preception of the pain, and feeling empowered helps you to stay in control
Are relaxation and childbirth classes helpful?
Relaxation and breathing techniques taught in antenatal chidbirth classes are extremely useful when used together and at the correct times in labour (see p.176). This, combined with working with your partner and the midwife, can help to make the pain more bearable and thus the birth experience more pleasurable. It is worth pointing out that people have different pain thresholds and relaxation and breathing techniques alone may not be enough to help you cope with the pain of labour, especially as
labour advances. Practising breathing and relaxation techniques before labour begins increases the benefit so classes are helpful.
Can moving around during labour help with the pain?
Providing the labour is straightforward, it does
seem to be the case that being as active as possible can help the progress of labour. Not only does this help with the pain, but it can also encourage more effective contractions so that labour is faster As the labour advances, it may be difficult to get into a position that is comfortable, and often women move around to try to find the best one. Favoured positions are standing, kneeling, or squatting, and rocking the pelvis, either on a birthing ball with your legs astride or leaning onto the bed or into the wall
Being prepared
practical and mental preparation for labour
Inevitably, labour will involve a degree of pain. Although this can be a frightening prospect, accepting this and thinking in advance about how you might deal with the pain may help you to cope better when the time comes. * Be as informed as possible about pain-relief options to help you make choices you are happy with in labour, Find out if you need to do anything in advance, such as inform staff if you want a water birth. * Try to think about the final outcome of labour and view the pain as part of the process that brings you closer to your baby.
How can a birthing ball help during labour?
Using a birthing ball during labour has the advantage of opening up the pelvis to allow the baby to move down more easily You can take your own birthing ball into hospital, and this may be advisable as supplies may be limited.
What is a TENS machine and how do they work?
TENS (transcutaneous electrical nerve stimulation) works by stimulating the production of endorphins, the body’s natural painkillers, and also by blocking some of the pain pathways Electrodes placed on
your back or abdomen are attached to a unit that fires electrical impulses when a button is pressed, blocking pain pathways The strength and frequency of the current can be altered according to your needs. This is a natural form of pain relief that requires no drugs and is a good way to involve your partner, who can position electrodes.
The machines will produce a tingly sensation,
but this does not hurt. Some people do not like the sensation, while for others it works very well, so it’s a good idea to hire a machine before labour to see if this form of pain relief suits you.
The advantages of TENS are that you are in control of your pain relief and are free to move around while you are using it. Check in advance whether the unit supplies TENS, or whether you need to hire one before going to hospital
Will I be able to use my TENS machine at the same time as other types of pain relief?
TENS can be used with pethidine or diamorphine and gas and air, but not with water (because it is electrical) or with an epidural (because of the position of the electrodes on your back).
My midwife says that I can have my baby at home, but what pain relief will I be able to have?
There are a variety of, mainly natural forms of pain relief that you can use in your own home. Alternative therapies, such as aromatherapy, homeopathic kits,reflexology. and acupuncture can all be used, as long as an appropriately trained person is providing them. Many women having home births opt for warm water. either in the bath or in a hired pool, as this is an effective form of pain relief. The midwife can also offer gas and air and pethidine as alternatives, if natural forms of pain relief are not working.
However, you may find that just by having your baby at home, you are less likely to need much pain relief. This is because evidence suggests that women who stay at home for as long as possible during tabour, or for the whole of their labour, have a more positive experience, which includes needing less pain relief. By adopting the correct positions, using massage, and breathing and relaxation techniques, you may find that you limit the amount of medical pain relief you need.
How an epidural works
An epidural is an injection into your back that numbs your body so that you are unable to feel the contractions. For about 90 per cent of women it completely blocks the pain. Epidurals work by blocking pain nerves as they enter the spinal cord Setting up an epidural is a medical procedure that can only be done by an anaesthetist. A local anaesthetic is injected to numb the area of the lower back before the procedure is carried out. A special needle is then carefully inserted into the space near to where the nerves enter the spinal cord. A fine tube is pushed carefully through the needle and left in place so that drugs can be run through it The procedure usually takes around 20-30 minutes, and it takes approximately 15-20 minutes for the epidural to start working effectively.
HOW THE EPIDURAL IS INSERTED:
Will I be able to cope through all the stages of labour using breathing techniques alone?
Relaxation and breathing techniques are extremely useful when used together and used at the correct times. It is common for women to breathe short, rapid breaths at the strongest part of the contraction. Studies show that this can cause a panic-type response in your body that can increase tension and heighten the pain. Learning to “sigh out slowly’ (SOS) and keeping your shoulders down can help you in labour, if you have practised during pregnancy, At the end of tabour, when it is necessary to control the head as it delivers, the midwife will ask you to pant or blow. This is two short breaths out followed by a longer breath out. Combining breathing techniques with working with your partner and the
midwife can help to make the pain more bearable and thus the birth experience more pleasurable. It is worth pointing out that people have different pain thresholds, and breathing alone may not be enough, especially as labour advances.
Can a water birth help with pain?
It is well documented that water can help with labour pains (see p 156). The heat of the water reduces muscle spasms, and the buoyancy of the water relieves pressure on the pelvis, which lessens the overall pain experienced The water is kept around body temperature by topping up with warm water and needs to be covering your ”bump” to be effective. Studies have shown that it can reduce the length of labours and the risk of tearing. Babies can be born completely under water so that they do not gasp until they hit the cold air. Most hospitals allow you to use gas and air in a pool as an additional form of pain relief.
I want to remember everything about the birth - how can I achieve this?
Probably the most effective way to remember as much as you can about your labour and the birth of your baby is to try to remain as healthy and rested as possible prior to the start of your labour, which will give you the best chance of staying strong and clearheaded during labour Feeling strong and having plenty of energy may also help you to remain upright and active during the course of your labour, reducing the need for opioids, such as pethidine, which can create a mild state of amnesia, meaning that you may have some difficulty remembering the finer details of the birth It’s also helpful to have a partner or close friend with you throughout your labour so that they too can help fill in any blanks later, and photographs and videos are good prompts If you do find after the birth that there are parts you can’t remember, you could ask your midwife to let you see your birth notes Or you could try to keep a birth journal between contractions!
I want an epidural but I’m afraid about having one -should I be worried?
Epidurals work by blocking pain nerves as they enter the spinal cord (see opposite). The doctor performing the procedure will be very experienced as it is a very small area they need to aim for. You need to sit very still in the position demonstrated to avoid any problems. There is a slight chance that if the needle goes in too far, it can cause a leak of fluid causing a aural tap”, which can result in a severe headache Other fears include future backache, which may be prevented by changing your position frequently in labour There is a very small risk (although this is highly unlikely) that damage is caused to the nerves.
I’m scared to death about going into labour - will I get an epidural?
The availability of epidurals will depend on each hospital It is best to ask your midwife what the procedure is at the hospital you are booked at If you think in advance that you would like an epidural, or decide in labour that you would like one, let the midwife know as soon as possible so that she can contact the anaesthetist and arrange this.
Will having an epidural slow down my labour?
As epidurals numb your feelings, this can make it hard to know when to push As a result, it may slow the labour or increase the risk of a forceps
or ventouse delivery slightly However, if this occurs the midwife or doctor will gently lay a hand on -your abdomen and will be able to feel as soon as a new contraction begins in your uterus. This will be a
sign to them to encourage you to actively push, even though you do not feel the sensation of the actual contraction due to the epidural anaesthesia. Following the advice of the midwife in this way may reduce the need for an assisted delivery, as pushing with a contraction is safer and more effective in terms of easing your baby through the birth canal.
I’m very keen to stay active in labour - can I do this if I have an epidural?
One of the side effects of an epidural is that your legs may feel numb and unable to hold your weight, which can restrict your movements. Some maternity units do offer “mobile” epidurals. These work in the same way as a standard epidural, but you are given a lower dose of the analgesic drug. This means that you are unable to feel the pain of the contractions, but the nerves controlling your legs, abdomen, and bladder are relatively unaffected so you are still able to remain mobile. This leaves you free to move around and be upright during labour and can also mean that you do not need to have a catheter inserted to empty your bladder. A mobile epidural can also increase the likelihood of a vaginal delivery, as being able to move around will assist the progress of labour, and being less numb means that you will be able to push more instinctively during labour contractions You may want to check in advance with your midwife whether your local maternity unit provides this facility
I’ve heard that pethidine can make you feel sick, and the baby drowsy after birth. Is this true?
Pethidine is from the family of drugs called opiates and is the most commonly used drug during labour. It is usually given by injection and its side effects include nausea, vomiting, dizziness, or drowsiness; it can also delay the baby’s breathing.
To combat the nausea and vomiting, an anti-sickness drug is usually given with pethidine If the baby’s breathing is noticeably affected, an antidote injection is sometimes given to reverse the effects of the pethidine, although this is not usually necessary and would only be given if the baby didn’t respond well to other types of stimulus, such as gently rubbing the baby’s back with a warm towel, or gently stimulating and rubbing the feet of a baby, which can be enough to make him inhale. Your baby’s ability to breastfeed can be affected if he is drowsy, and midwives are now encouraged to
provide extra support to mothers choosing to breastfeed if they have had pethidine during labour in an attempt to overcome this side effect.
When is it best to start using gas and air?
Gas and air, or Entonox, is a combination of 50 per cent oxygen and 50 per cent nitrous oxide (laughing gas). It is widely available in maternity units and can be used in home births. This method of pain relief works by reducing the pain messages that the brain receives. It starts to take effect within 20 seconds, so it is advisable to time your intake of gas and air with your contractions, so that you start taking it just before or at the beginning of a contraction to get the maximum benefit, at around 45-50 seconds.
Gas and air can be used from the onset of your labour. However, some women report that they feel slightly drowsy and light-headed and therefore out of
Pethidine and diamorphine
Opiate drugs used for pain relief during labour
These drugs are useful in the early stages of labour, helping you to relax and deal with the pain, and pethidine in particular is widely used. They can only be administered in the form of an injection by a midwife or doctor, usually in the hospital or a maternity unit. As with much pain relief, these drugs have advantages and disadvantages.
* Pethidine has a sedative effect, relaxing the muscles of the uterus, and is especially useful if you are feeling anxious or experiencing a long labour as it helps you to rest.
* Both drugs can make you feel nauseous and they can enter the baby’s system. If given too close to the time of delivery, they can make the baby sleepy and can even cause problems with the baby’s breathing.
control while taking gas and air and therefore you may find that you want to stop taking it while you are pushing if it is distracting you too much and stopping you focusing on the contractions. Some women manage their entire labour on gas and air alone, while others find that they need another form of pain relief in the later stages of labour
How will I use the gas and air and is it likely to make me feel sick?
Gas and air is breathed in through a mouthpiece or mask that is connected to a cylinder or pipes in the wall that lead to larger cylinders elsewhere You administer it yourself, so are more in control of how much you take and when.
Gas and air can make your lips and mouth feel tingly and dry, and in some cases women report feeling nauseous while taking it. Using a mouthpiece rather than a mask may help to reduce feelings of nausea brought on by the smell of the gas and the sensation of having a mask over your face, and taking sips of water may help. As the effect of gas and air is short-lived, you only need to use it during contractions; taking gas and air between contractions will not help with the pain of the next contraction and is likely to increase the sensation of nausea.
I want to have a great birth but you hear such awful stories -how can I stay positive?
For every awful birth story there is an equally positive one — it does tend to be the case that you are less likely to hear about the positive birth stories as these aren’t such good topics of discussion! However your labour and birth proceeds, the birth of your baby will be amazing because you will finally meet the little person who has dominated your life for the past nine months.
It is sensible to remain open minded about labour and birth, because it’s impossible to foresee exactly how things will go on the day. However, there is a lot that you and your partner can do to help prepare yourselves for labour and birth so that you
Gas and air
A form of self-controlled pain relief in labour
A mixture of oxygen and nitrous oxide that is self-administered in labour.
Gas and air, also known as Entonox, is taken through a mask or a mouthpiece during labour. This dulls the pain centres in the brain and produce a sense of euphoria. This needs to be timed with your contractions as the effects are short-lasting, with the gas being breathed in just prior to and during a contraction You will feel normal once you stop using it
Gas and air tends to be the preferred choice for managing pain in women who want to labour as naturally as possible. The reason for this is that gas and air has several advantages, including the fact that you can remain mobile and active while using it; it can be used during a water birth; it doesn’t affect the baby in any way, and it doesn’t make you feel drowsy during labour, which allows you to feel more in control throughout and to remain as focused as possible on your contractions However, although it is a widely available and a popular choice of pain relief in the UK, it doesn’t tend to be used in the United States.
have the best chance of having a positive overall birth experience For example, you can both learn as much as possible about the process of labour and birth so that you can make informed decisions in labour. You can chat with your midwife, read books, find information on the internet, and attend antenatal classes. Also, knowing how labour progresses helps to demystify the experience and therefore removes some of the fear that accompanies labour and birth. Learning basic relaxation and breathing exercises also helps (see p 173), as being able to relax as much as possible during labour helps you to feel less anxious, which in turn can help the labour to proceed as quickly and smoothly as possible

Breathing techniques
Using relaxation and breathing techniques can help you to relax and cope with the contractions throughout your labour. Try practising techniques with your partner before labour. Learning to control your breathing has many benefits, including helping you to increase your energy reserves and let go of tension and anxiety so that you can breathe with the rhythm of the contraction. In the earlier stages of labour, you may want to practise longer, deeper breaths between contractions to help keep you calm and focused You can also try breathing in slowly at the start of a contraction and then exhaling slowly and continuing this pattern until the contraction has passed. Later in labour as contractions become stronger, you may find taking shorter, lighter breaths helps you to ride over the contraction.

How to manage the pain

There are a range of pain relief options available It’s wise to think about which method you would prefer before going into labour.
Relaxation, breathing, keeping mobile,
and massage: You remain in control and avoid intervention. Being upright can help the position of the baby and there are no side effects. This may not be sufficient pain relief for strong contractions
Water: Using a birthing pool in labour and possibly for delivery can hale you to labour quicker and less painfully, with no side effects.
TENS (transcutaneous electrical nerve
stimulation): Sticky pads placed on your back send small electrical impulses to trigger the release of endorphins. You control the current
with a hand-held device. This may not provide sufficient relief for very strong contractions.
Gas and air: 50 per cent oxygen and 50 per cent nitrous oxygen. This is easy to use and drugs don’t accumulate in your body, Some women feel sick or sleepy and find this isn’t strong enough.
Pethidine or diamorphine: These can lessen
the pain, but can cause sickness and affect the baby’s breathing if given too close to delivery.
Epidural anaesthesia: A local injection near the spine, this is the most effective form of pain relief and doesn’t enter the baby’s system. It increases the chance of forceps, ventouse, and Caesarean, as you may not be able to feel when to push. You will be less mobile and will need monitoring