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.
Psycho-prophylaxis
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.
Others
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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