Meljons
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- Jun 25, 2012
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Niliiskia hii habari mwaka huu kwamba unaweza kujifungua bila uchungu tena ukiwa unaangalia TV au hata ukisoma gazeti kwa hii process ya epidural.
Ila pia nasikia ni gharama sana kwa wale wenye nazo ndo watapata hii bahati.
Pia naskia hapa bongo ipo Mikocheni hospital.
Swali langu ni kwamba hii kitu inayoondoa maumivu ya kujifungua ambayoni makali kuliko kawaida ni njia salama kweli?
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Ila pia nasikia ni gharama sana kwa wale wenye nazo ndo watapata hii bahati.
Pia naskia hapa bongo ipo Mikocheni hospital.
Swali langu ni kwamba hii kitu inayoondoa maumivu ya kujifungua ambayoni makali kuliko kawaida ni njia salama kweli?
Epidural anesthesia is the most popular method of pain relief during labor. More women request an epidural by name than any other method of pain relief.
More than 50% of women giving birth at hospitals use epidural anesthesia.
As you prepare yourself for "labor day", try to learn as much as possible about pain relief options so that you will be better prepared to make decisions during the labor and birth process.
Understanding the different types of epidurals, how they are administered and their benefits and risks, will help you in your decision-making during the course of labor and delivery.
What is epidural anesthesia?
Epidural anesthesia is regional anesthesia that blocks pain in a particular region of the body.
The goal of an epidural is to provide analgesia, or pain relief, rather than anesthesia which leads to total lack of feeling. Epidurals block the nerve impulses from the lower spinal segments. This results in decreased sensation in the lower half of the body.
Epidural medications fall into a class of drugs called local anesthetics, such as bupivacaine, chloroprocaine, or lidocaine. They are often delivered in combination with opioids or narcotics such as fentanyl and sufentanil in order to decrease the required dose of local anesthetic.
This produces pain relief with minimal effects. These medications may be used in combination with epinephrine, fentanyl, morphine, or clonidine to prolong the epidural's effect or to stabilize the mother's blood pressure.
How is an epidural given?
Intravenous (IV) fluids will be started before active labor begins and prior to the procedure of placing the epidural. You can expect to receive 1-2 liters of IV fluids throughout labor and delivery.
An anesthesiologist (specialist in administering anesthesia), an obstetrician, or nurse-anesthetist will administer your epidural. You will be asked to arch your back and remain still while lying on your left side or sitting up.
This position is vital for preventing problems and increasing the epidural effectiveness.
An antiseptic solution will be used to wipe the waistline area of your mid back to minimize the chance of infection.
A small area on your back will be injected with a local anesthetic to numb it. A needle is then inserted into the numbed area surrounding the spinal cord in the lower back.
After that, a small tube or catheter is threaded through the needle into the epidural space. The needle is then carefully removed, leaving the catheter in place to provide medication either through periodic injections or by continuous infusion.The catheter is taped to the back to prevent it from slipping out.
What are the types of epidurals?
There are 2 basic epidurals in use today. Hospitals and anesthesiologists will differ on the dosages and combinations of medication.
You should ask your care providers at the hospital about their practices in this regard.
• Regular Epidural: After the catheter is in place, a combination of narcotic and anesthesia is administered either by a pump or by periodic injections into the epidural space.
A narcotic such as fentanyl or morphine is given to replace some of the higher doses of anesthetic such as bupivacaine, chloroprocaine, or lidocaine. This helps reduce some of the adverse effects of the anesthesia. You will want to ask about your hospital's policies about staying in bed and eating.
• Combined Spinal-Epidural (CSE) or "Walking Epidural": An initial dose of narcotic, anesthetic or a combination of the two, is injected beneath the outermost membrane covering the spinal cord, and inward of the epidural space.
This is the intrathecal area. The anesthesiologist will pull the needle back into the epidural space, threading a catheter through the needle, then withdrawing the needle and leaving the catheter in place.
This allows more freedom to move while in the bed and greater ability to change positions with assistance.
With the catheter in place you can request an epidural at any time if the initial intrathecal injection is inadequate.
You should ask about your hospital's policy on moving around and eating/drinking after the epidural has been placed. With the use of these drugs, muscle strength, balance and reaction are reduced.
CSE should provide pain relief for 4-8 hours.
What are the benefits of epidural anesthesia?
Allows you to rest if your labor is prolonged.
By reducing the discomfort of childbirth, some woman have a more positive birth experience.
Normally, an epidural will allow you to remain alert and be an active participant in your birth.
If you deliver by cesarean, an epidural anesthesia will allow you to stay awake and also provide effective pain relief during recovery.
When other types of coping mechanisms are no longer helping, an epidural can help you deal with exhaustion, irritability, and fatigue.
An epidural can allow you to rest, relax, get focused and give you the strength to move forward as an active participant in your birth experience.
The use of epidural anesthesia during childbirth is continually being refined and much of its success depends on the skill with which it is administered.
What are the Disadvantages of epidural anesthesia?
Epidurals may cause your blood pressure to suddenly drop.
For this reason your blood pressure will be routinely checked to help ensure an adequate blood flow to your baby. If there is a sudden drop in blood pressure, you may need to be treated with IV fluids, medications, and oxygen.
You may experience a severe headache caused by leakage of spinal fluid.
Less than 1% of women experience this side effect. If symptoms persist, a procedure called a "blood patch", which is an injection of your blood into the epidural space, can be performed to relieve the headache.
After your epidural is placed, you will need to alternate sides while lying in bed and have continuous monitoring for changes in fetal heart rate. Lying in one position can sometimes cause labor to slow down or stop.
You might experience the following side effects: shivering, ringing of the ears, backache, soreness where the needle is inserted, nausea, or difficulty urinating.
You might find that your epidural makes pushing more difficult and additional interventions such as Pitocin, forceps, vacuum extraction or cesarean might become necessary For a few hours after the birth the lower half of your body may feel numb.
Numbness will require you to walk with assistance.
In rare instances, permanent nerve damage may result in the area where the catheter was inserted.
Though research is somewhat ambiguous, most studies suggest that some babies will have trouble "latching on" causing breastfeeding difficulties.
Other studies suggest that a baby might experience respiratory depression, fetal malpositioning, and an increase in fetal heart rate variability, thus increasing the need for forceps, vacuum, cesarean deliveries and episiotomies.
Common Questions About Epidurals:
Does the placement of epidural anesthesia hurt?
The answer depends on who you ask. Some women describe an epidural placement as creating a bit of discomfort in the area where the back was numbed and a feeling of pressure as the small tube or catheter was placed.
When will my epidural be placed?
Typically epidurals are placed when the cervix is dilated to 4-5 centimeters and you are in true active labor.
How can my epidural affect labor?
Your epidural can cause your labor to slow down and make your contractions weaker. If this happens you may be given the medicine Pitocin to help speed up labor.
How can an epidural affect my baby? As previously stated, research on the effects of epidurals on newborns is somewhat ambiguous, and many factors can affect the health of a newborn. How much of an effect these medications will have is difficult to predetermine and can vary based on dosage, the length of labor, and the characteristics of each individual baby. Since dosages and medications can vary, concrete information from research is currently unavailable.
One possible side effect of an epidural with some babies is a struggle with "latching on" in breastfeeding. Another is that while in-utero, a baby might also become lethargic and have trouble getting into position for delivery.
These medications have also been known to cause respiratory depression and decreased fetal heart rate in newborns.
Though the medication might not harm these babies, they might experience some subtle effects like those mentioned above.
How will I feel after the placement of epidural?
The nerves of the uterus should begin to numb within a few minutes after the initial dose.
You will probably feel the entire numbing effect after 10-20 minutes.
As the anesthetic dose begins to wear off, more doses will be given–usually every one to two hours.
Depending on the type of epidural and dosage administered, you can be confined to your bed and not allowed to get up and move around.
If labor continues for more than a few hours you will probably need urinary catheterization because your abdomen will be numb, making urinating difficult. After your baby is born, the catheter is removed and the effects of the anesthesia will usually disappear within one or two hours.
Some women report experiencing an uncomfortable burning sensation around the birth canal as the medication wears off.
Will I be able to push? You might not be able to tell that you are having a contraction because of your epidural anesthesia.
If you can not feel your contractions, then pushing may be difficult to control.
For this reason your baby might need additional help coming down the birth canal including the application of pressure on your abdomen at the top of your uterus and/or the use of forceps.
Does an epidural always work? For the most part, epidurals are effective in relieving pain during labor.
Some women complain of being able to feel pain and/or feeling that the drug worked better on one side of the body than the other.
Questions to ask your health care providers now and at the time of delivery in the hospital:
• What combination and dosage of drugs will be used?
• How could the medications affect my baby?
• Will I be able to get up and walk around?
• What liquids and solids will I be able to consume?
When can an epidural NOT be used?
An epidural may not be an option to relieve pain during labor if any of the following apply:
You use blood thinners
Have low platelet counts
Are hemorrhaging or in shock
Have an infection in the back
Have a blood infection
If you are not at least 4 cm dilated
Epidural space can not be located by the physician
If labor is moving too fast and there is not enough time to administer the drug
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Overall Complications Rates for Epidural Anesthesia A general estimate of the overall complication rate of epidural anesthesia is 23%.
1. Effects of epidurals on cesarean rate:
When the dose is too large or when it sinks down into the sacral ("tailbone") region of the body, the perineum and the vagina are anesthetized. Anesthetic is intentionally injected into this area late in labor to deaden all sensation. When it "accidentally" happens earlier in labor, the muscles of the pelvic floor are prematurely relaxed, thereby interfering with the normal flexion and rotation of the baby's head as it passes through the birth canal. This interference can
lead to abnormal presentations which are more dangerous for the baby or to what is called "failure to descend," an indication for Cesarean birth.
2. Medication interactions:
A hidden danger of epidural anesthesia is its interaction with medications (prostaglandins) commonly used to soften the cervix and start labor. The use of prostaglandins is common at hospitals and creates a potentially dangerous situation in which the usual medications used to treat low blood pressure during labor will no longer work.
3. Significant Low Blood Pressure (Hypotension):
Significant low blood pressure is a complication of epidural anesthesia.
The ways that epiduralized patients must lie accentuate this. Their position is limited since they are essentially paralyzed people for the duration of the epidural.
Hypotension occurs among almost one-third of patients with serious hypotension occurring about 12% of the time.
Maternal hypotension is a major risk for the baby.
The epidural blocks the nerves which regulate blood pressure. It causes the blood in the body to pool, keeping it from being pumped around the body in the proper manner.
The arteries dilate and relax their usual, necessary level of tension, making it difficult for the heart to pump blood to the baby.
These changes lead to a decrease in the output of the mothers heart. Less blood per unit time can reach the placenta and therefore the baby.
The baby is completely dependent on the mothers heart to pump blood to the placenta to satisfy its needs.
All of its oxygen comes across from the placenta. All of the food for its brain and other organs comes across the placenta.
Brains cannot live without a relatively constant supply of oxygen and glucose. Without this they become damaged.
A good blood flow is needed to the uterus between contractions so it can get fresh oxygen.
During the contraction, blood flow to the uterus is cut off by the muscles contracting.
When the contraction stops, the uterus must quickly refill with fresh blood containing oxygen for the baby. If the amount of blood flowing to the uterus is reduced, the baby may not be able to get the oxygen it needs.
Then what is called fetal distress may occur. The baby's system does not get enough oxygen and goes into distress. Its blood retains excess acid, the oxygen levels go low and tissues and vital organs begin to fail from excess acid, lack of oxygen and lack of fuel.
4. Fetal Distress:
Fetal heart rate decelerations can occur following the use of epidurals.
1 Babies can develop fetal distress after epidural anesthesia.
11 This may be caused by the mothers blood pressure getting so low that blood cannot be adequately pumped into the uterus to deliver oxygen to the baby. As we mentioned above, epidurals make it difficult for the muscles in the arteries of the lower body to respond and to keep blood adequately flowing through the body.
The ability of the heart to respond to changing needs of the body is impaired.
One study suggested that induction of maternal analgesia may transiently alter the balance between factors encouraging and discouraging uterine contraction. A temporary increase in the uterotonic effects of endogenous or exogenous oxytocin may then produce a tetanic contraction with subsequent decrease fetal oxygen delivery and resultant fetal bradycardia.
Most babies of mothers receiving epidural anesthesia develop episodes of slow heart rate (bradycardia).
While this does not usually affect the healthy baby, it can be disastrous for the baby that is already compromised from some other problem (often unknown to the doctors).
Adverse effects on the baby indicative of insufficient oxygen reaching the baby (late decelerations) can occur.
These changes may also result from a toxic effect to the baby of the local anesthetic given in the epidural.
5. IV Cannulation:
Accidental injection of the anesthetic solution into the blood stream can occur and can cause the mother to twitch, have convulsions, or lose of consciousness. Seizures can occur from the toxic effects of the anesthetic agent entering the blood stream.
Local anesthetic toxicity occurred among 12 women in 1000 epidurals.
6. Trauma to Blood Vessels:
Trauma to blood vessels can occur as a result of epidural anesthesia. In one study, bleeding in the spinal column and unintentional placement of the catheter into an artery or vein occurred 0.67% of the time (67 women of every 1000 epidurals).
The catheter actually escapes outside of where it is supposed to go 1 to 6% of the time.
Hemorrhages can occur around the spinal cord and even within the skull following epidural anesthesia.
These were associated with persistent backaches or headaches.
Failure to treat these problems usually results in permanent paralysis.
Surgery must be performed within 8 hours of the onset of paralysis or the prognosis is poor.
Chronic subdural hematoma has resulted from epidural anesthesia and has even presented as post-partum psychosis.
7. Punctured Dura:
The actual dura may be punctured as a result of epidural anesthesia. Because of the large size of the needle used, severe headache may also result. Dural punctures have been found to occur about 1.8% of the time.
Unintentional dural puncture occurred in 61 of 1000 epidurals in a University hospital (resulting in spinal anesthesia).
8. Infection:
An infection can develop at the site of injection. Bacterial meningitis can occur from contamination during placement of the epidural.
An abscess can also form at the site where the epidural catheter is placed.
9. Backache:
Backache after an epidural is a common complication. Back pain commonly occurs after epidural anesthesia (18.9% of the time ).
Upper back pain can happen at some distance from the site where the epidural is injected.
The back pain can last very long-term.
Nineteen percent of women had long-term backache after epidural anesthesia.
It probably results from a combination of its effects on the nerves and from extreme postures and stretching that occurs after the epidural during labor.
Low back pain after epidural anesthesia for childbirth is also frequently mentioned.
10. Broken catheters:
Occasionally the catheter has broken and a small piece is left in place. It usually causes no ill effects.
11. Abnormal Uterine Contractions:
Uterine contractions can become weaker and less frequent.
An oxytocin infusion is then necessary to improve labor and produce good strength contractions Mothers having epidurals have longer labors and have a higher incidence of the use of oxytocin than mothers having non-medicated deliveries.
12. Second Stage Labor Effects:
With large doses the patient loses the desire and the ability to bear down and push. This results in an increased use of forceps and vacuum extractions over women having unmedicated deliveries.
13. Other Neurological Disabilties:
Other neurological disabilities (including a condition called Horners syndrome) can develop along with hoarseness (from even just one dose of epidural anesthetic).
One study reported an incidence of Horner's syndrome during epidural anesthesia for elective Caesarean section of 4%.
The incidence of Horner's syndrome with epidural anesthesia for vaginal delivery was 1.33%.
They found it impossible to predict which patients would develop a Horner's syndrome.
Even the nerves to the face can be blocked, sometimes temporarily, sometimes permanently.
Tremors and shakes can occur.
Paresthesias (persistent tingling from sensory nerves) occurred in 0.16% of patients in one study (1.6 per 1000) with an incidence of persistent neuropathy of 0.04% (4 per 10,000). Four of these patients had a neuropathy which eventually resolved.
In another study 3.0% of patients had tingling of the hands or fingers, while 26 of almost 5000 women had persistent tingling or numbness in the lower
back, buttocks or legs.
Dizziness and fainting can become a problem after epidurals.
One study found these symptoms persisting in 2.1% of women.
14. Interactions Occur with Other Illnesses:
As an example, women who have migraines can have more visual disturbances after epidurals.
15. Accidental Spinal Anesthesia:
When an epidural accidentally turns into a spinal anesthetic, many complications can occur:
-Postspinal headaches.
-Dysfunction of the bladder is frequent
-Occasionally numbness and tingling (paresthesias) of the
lower limbs and abdomen develop, and sometimes there is a temporary loss or diminution of sensation in these areas.
-Unilateral footdrop (paralysis of the muscle that lifts the foot) has occurred.
-Permanent nerve damage (conditions called chronic, progressive adhesive arachnoiditis or transverse myelitis) can occur.
These lead to paralysis of the lower parts of the body.
-Deaths have been reported.
-Difficult breathing
- Increased incidence of forceps deliveries.
N.B: What must be remembered for any technical procedure, is that it is studied in major academic
centers where highly skilled professors supervise residents and all outcomes are monitored closely.
The actual practice, however, takes place in smaller institutions by less qualified individuals so that the actual complication rates of any procedure (obstetric, cardiac, pulmonary) are always higher than what are found in studies.