Wednesday, 2 March 2016

Pain and pain relief methods in labour

Pregnancy is a joyful experience and all hopes begin with the birth of a cute little baby. The birth of every little baby inspires the labour team to do more.

Labour is the process of giving birth to a baby, and is looked after by a team of doctors, nurses, midwives, support staff and led by the obstetrician. Before the advent of modern medicine in Bhutan, labour was a closed room process and the mother was taken care of by the experienced older women. When you listen to the stories of how your grandmother or mother gave birth, they don’t usually focus on the “pain” part of the story. This is because in many cultures, pain is not considered as a problem unless it affects your function. A pain in your foot is not a problem until it is severe enough to prevent you from walking. A woman in labour is anyway supposed to be bed bound, so it does not affect her ability to function.

Though we have many ways of describing different types of pain (a lot of descriptive expressions in Sharchokpa, Khengkha or other dialects), labour pain is not often described as it is embarrassing in our culture to talk about labour. However, with more educated women, many travel outside the country paying huge sums of money for obstetric care when there are available specialists, doctors, nurses and midwives in our country.

What is pain? And what is labour pain?
Our body senses many things through our senses – sight, smell, taste, touch. Pain is usually an unpleasant sensation but it has many important functions for the body. For example, when you accidentally touch a hot iron, you quickly withdraw your hand. In this, pain helps prevent further damage to your fingers. All body parts can experience pain, except the brain because any insult that can cause pain inside the brain is necessarily fatal (this is different than headache).

A pregnant woman undergoes many changes and her uterus enlarges to hold a baby of 2 – 3 kilograms at term. During labour, the baby is pushed out by force of contraction of the uterus. This contraction plus the stretching of the tissues and ligaments cause pain.

Science tries to measure everything in number. Pain can also be measured with various tools and quantified, but there is always a subjective component to pain. Labour pain nevertheless is one of the most severe pains known to mankind. However, with discoveries in science, there are many ways to help reduce pain on medical and humanitarian grounds.

Methods of pain relief in labour
Of the many methods to help relieve pain, this article is on pain relief in labour. There are many methods of pain relief in labour ranging from simple methods to ones requiring trained personnel depending on the place of delivery.

A simple and cost effective method of relieving labour pain is “psycho-prophylaxis” in which the pregnant woman is told about the stages of pregnancy and about labour pain in anticipation. These are done through antenatal (before birth of baby) pregnancy classes in major hospitals. This part of education can be done at all levels of obstetric care since 97.9%[1] of pregnant women have at least one encounter with a health personnel during her pregnancy.

Opioid analgesics
Analgesics are drugs that can relieve pain. The type of analgesic drug given to women in labour is from Step 2 or Step 3 of the severity of pain ladder (World Health Organisation pain ladder, Step 1 drug is paracetamol). The commonly used drug is pethidine, given as an injection in the shoulder. It is a good drug that relieves pain and sedates the mother (makes the mother sleepy), but there is risk of arrest in respiration in both the mother and the baby if given in excess and at wrong timing. To prevent this fatal respiratory arrest, the doctor needs training (an MBBS graduate can handle this).

Inhalation agents
There are gaseous drugs that can be inhaled as and when the woman gets labour pain. But these agents are slowly being phased out under the Montreal Protocol (for which Her Majesty the Gyaltsuen is the Ozone Ambassador) for its ozone depleting compounds such as nitrous oxide. In addition, it is cumbersome for the mother and not a popular method.

Regional anaesthesia
This method of pain relief can ensure a painless delivery. There are several methods of regional anaesthesia, one of which is the epidural analgesia. In this method, the anaesthetic agent (pain relief drug), usually bupivacaine or lignocaine, is delivered through an injection into the spine of the mother. This blocks nerve impulses from the lower half of the mother’s body and the mother is fully awake, hence it’s called “regional” analgesia (compared to general anaesthesia when a patient is fully unconscious).

In epidural analgesia, a special needle is used to inject the drugs at a particular point in the lower part of the mother’s back (just outside the dural covering of the spinal cord, to be exact). The anatomy in this part of the body consists of several layers of tissue and the needle must reach the correct depth of tissue plane before delivering the drug. For this, the doctors need special training. Usually, it is delivered by a medical officer in anaesthesia under the guidance of a specialist anaesthetist or by a registrar or a specialist in anaesthesia. This limits its availability only in tertiary care hospitals.

Apart from anaphylactic reaction to pain relief drug (which can be treated with drugs, if not fatal), it can cause other complications to the mother. For this, nurses must be trained on how to detect these complications at an early stage.

In addition, to provide an epidural analgesia, a surgical epidural set is needed which will be taken care of by the already existing facilities at major hospitals.

There are other forms and concepts of pain relief in labour which are too expensive to be afforded by the government and they are not necessarily good methods.

Who decides what type of pain relief the woman gets?
In an ideal setting, the woman has all the right to make an “informed” decision on the type of pain relief. The doctor must offer options with the pros and cons of each method and the woman makes an “informed decision”.

However, in resource poor settings like ours, and in hospitals where necessary expertise are available, the obstetrician (the doctor who looks after pregnant women) makes the decision to provide epidural analgesia when there are certain situations (“indications”) in the mother. On the other hand, the obstetrician can decide not to provide epidural analgesia in conditions (“contra-indications”) such as very low blood pressure, bleeding tendencies or skin infection in the epidural site. Since it is the anaesthetist who actually delivers the epidural, the anaesthetist can decide not to provide it in cases of bleeding tendencies, spinal deformity or chronic low back pain. These are all specialist opinions.

In hospitals manned by only MBBS doctors (and not specialists), opioid analgesics can be given. And in all hospitals and institutions capable in delivering a baby, must always comfort and simply talk to the mother. It is noted that every intervention in medicine is like pulling a chord from a network of strings, so every intervention must be taken with a good knowledge, thoughtful decision and the simplest and the safest interventions chosen first. It must also be noted that a pregnant women is not a patient though she visits hospital unless she visits due a medical illness, and she is not yet a mother until she delivers a baby, she is a normal person.

What does the country gain from the re-introduction of epidural analgesia?
The re-introduction of epidural analgesia with the birth of His Highness the Gyalsey is a good omen in obstetrics and anaesthesiology in Bhutan under the kind and wise initiative of Her Majesty the Gyaltsuen.

It is a big milestone in the course of modern health in Bhutan. The women of our country now have an opportunity for painless labour and make pregnancy even more joyful. The health system and health personnel get an opportunity to upgrade their skills and is a general indication that our health system can offer much and many more to our people under the wise, strong and continued leadership of Their Majesties.

Dr Thinley Dorji MBBS (Col)
Published in Kuensel, page 10, 6 February 2016

[1] National Health Survey Bhutan 2012

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