Delivery

Three factors affecting delivery:

Power
Contractions lasting 45-60 seconds every 2-3 minutes enable the uterus muscle to move your baby down into your pelvis. Good strong contractions assist you in pushing your little one into the world.

Passage
The pelvic outlet has three changes in shape. First the baby’s head moves through the inlet which is 11x13cm into the mid cavity at 11cm round and finally to the outlet of the pelvic bones which are opposite shape to the inlet at 12.5x11cm. This is why the baby’s head normally rotates as it passes through the pelvis. Vaginal palpation is used to assess decent and is compared to the ischeal bones of the pelvis.

Passenger
The baby’s head position and lie varies. Most fetus are OA or Occipito-anterior (back of head against front of vagina). About 5% are OP (Occipito-posterior) – the other way round and occasionally the head can be transverse (OT Occipito-transvers). The neck of your baby can be at various stages of flexion which alters the diameter of the head passing through the birth canal.

 

Pain relief, Epidurals and local anaesthetic nerve blocks

During your antenatal classes you will be told about breathing exercises to help you through contractions and the pain that these can cause.

There are other safe forms of pain relief which can be used.

Gas and Air
Common forms of pain relief are the mixture of gas and air. This is nitrous oxide which is a gas you breath in through a tube mixed with a percentage of air. It should be used only during a contraction by breathing it in deeply so it gets to your lungs where it is able to access your circulation and actually get to where it is needed. By taking shallow breaths the gas and air doesn’t actually get very far and is much less effective.

Epidural
An epidural is a pain relief which helps to numb (not block) the nerves in a part of your back. It is a tube placed very carefully by an anaesthetist in a space (the epidural space) between the vertebrae in your lower back (usually between your 3rd and 4th lumbar vertebra). Through the epidural tube a small amount of local anaesthetic is injected and over 20 minutes you will begin to feel the effects as your contractions become less painful. The epidural can be linked to a slow drip which continues the pain relief.  You will still be able to walk about and move with this although you will have to take the epidural drip with you.

For an epidural to work effectively it is best to request one before the cervix is dilated too much as the medication takes time to work. When you are having the epidural inserted you must remain still and tell the midwife and doctor anaesthetist if a contraction is coming so they can stop and let it pass before they continue.

It is possible for the Epidural to be topped up with a different dose or volume of local anaesthetic to give enough nerve block for a caesarean section. It does take time to work and is only used for this if the epidural line is already in place and there is time for the medication to take effect before the delivery must occur. This is why we do not use the Epidural for routine caesarians or for more urgent deliveries as it takes too long to give a good anaesthetic block to the abdomen.

Spinal anaesthetic
A spinal anaesthetic block is very similar to an epidural. A spinal is a nerve block and is not used for pain relief. You cannot walk around after having one and it is the method of choice for planned caesarians. It is a single injection into a slightly different space still between the lumbar vertebra. Unlike the epidural no tube is left in situ and the injection works in a couple of minutes. The effects last for just over an hour and then start to wear off. This method means you have a much quicker onset of nerve block and the doctors can perform a caesarean section soon after the nerve block is given and you have a quicker recovery as the spinal wears off after delivery.

Spinal and Epidural anaesthetics for Caesarian sections are always tested. This is done by assessing your response to cold sensation. The nerves which carry pain run with those which detect the cold. By using a spray or piece of ice the anaesthetist with be able to tell how far the nerve block has spread. Where you feel the cold you have normal sensation where you don’t feel the cold the nerves are blocked.

Spinal or epidural?
There is often confusion about the words epidural and spinal, essentially they are very similar and both use local anaesthetic medicine to help with pain by injecting into a space between the vertebrae in the lower back. The epidural has a tub which is left in and provides pain relief and it can be topped up to give enough pain relief to perform surgery but it is slow to work taking 20 minutes or more. A spinal on the other hand is a one off injection into the same area of your back between the vertebrae which is a little deeper. It is therefore much quicker to work and provides immediate nerve block for the use in surgery. For these reasons your doctor will advise the epidural for alternative pain relief in labour but the use of a spinal if you are having a planned or urgent caesarean section. Sometimes a spinal is preferred rather then spending the time to top up the epidural, especially if you are not finding the epidural is helping very much.

© The Westover

 

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