Various methods are used for labor pain relief, including psychoprophylaxis, transcutaneous electroneurostimulation, systemic medication, inhalation methods and neuroaxial blockade. In addition, caudal and paracervical blockades are sometimes used.

Psychoprophylaxis

The concept of “natural childbirth” came from the phrase “minted” by Grantley Dick-Reed in 1933. He was convinced that childbearing is a painless process and does not require medical intervention if the woman is adequately prepared. The Pavlovian birth management methods used in Russia were adapted for Europe by the French obstetrician Fernan Lamaz in the late 1950s. and popularized among women in labor. The method was based on the development of a conditioned reflex in a woman in labor to overcome pain and fear of childbirth. The method used the moral support of the woman in labor in childbirth by a close person, as well as training programs:

proper breathing technique during labor;

arbitrary muscle relaxation technique;

high degree of concentration to overcome pain.

Of course, even the presence of another woman for the moral support of the parturient in childbirth had a positive effect on the outcome, including even the length of labor.

TENS during pregnancy

It was believed that TENS reduces pain by suppressing nociception at the presynaptic level in the lateral horns, reducing the central transmission. Electrical stimulation mainly activates myelinated nerve endings with a low excitation threshold. Afferent inhibitory effects prevent the spread of nociception along non-myelinated small nerve B-fibers, blocking the passage of impulses to conducting cells in the substance of gelatinosis of the lateral horns. It was believed that TENS enhances the release of endorphins and dinorphins. The imposition of electrodes on the waist in the region of the segments T10 - T1 can provide some analgesia to the woman in the initial period of labor. However, Tsen et al. It was not possible to prove the effectiveness of this method either for anesthesia of childbirth or as an addition to epidural analgesia.

Systemic Medication Anesthesia

Opioids are a class of drugs most commonly used for systemic medical anesthesia of labor. All opioids have varying degrees of side effects, including:

respiratory depression;

• mental disorders, starting with euphoria and ending with deep sedation.

All opioids freely penetrate the uteroplacental barrier due to their physicochemical characteristics and can cause respiratory depression in the newborn. However, when used properly, systemic opioids can reduce maternal pain for a short time. Other tools used for labor pain relief are sedatives, tranquilizers, and ketamine.

Mepredin.

Mepredin is the opioid that is most often used parenterally for pain relief of labor. A recent survey on parenteral opioid use in childbirth, conducted in the United States, showed that they are used in 39-56% of patients. In clinics with more than 1500 births per year, opioids are given parenterally in 39% of patients, whereas in clinics with up to 500 births and from 500 to 1500 per year in 56% and 50% of patients, respectively.

The intramuscular dose of meredidine is from 50 to 100 mg with a peak of action from 40 to 50 minutes. The intravenous dose is 25-50 mg with the onset of action at 5-10 minutes. The analgesic effect lasts 3-4 hours. The peak of the concentration of opioids in the fetal blood is noted 2-3 hours after the administration of the drug to the mother. It is believed that meredidin is the least depressing respiration of the newborn, and therefore is used most often. However, it can reduce fetal heart rate variability.

Meta-analysis did not reveal the advantages of other opioids over meperidine in labor anesthesia. However, some authors prefer to use fentanyl and remifentanil.

Fentanyl.

In patients with contraindications to neuroaxial methods, fentanyl is an alternative for pain relief of labor. The short half-life makes it possible to use it continuously during labor, either intravenously or as an analgesic for patient-controlled anesthesia. It provides the necessary level of analgesia with minimal fetal depression.

Despite the fact that fentanyl is a powerful opioid, its use in childbirth is limited to its side effects and short duration of action. Fentanyl penetrates the uteroplacental barrier. In one study of intravenous administration of fentanyl in childbirth, it was shown that 4 out of 11 newborns whose mothers received fentanyl for analgesia during childbirth needed naloxone as an antidote. The usual dose of fentanyl for labor pain relief is 25-50 µg intravenously.

The maximum effect occurs in 3-5 minutes and lasts from 30 to 60 minutes. Despite the rapid transplacental transition of fentanyl, studies have shown that using a dose of 1 µg / kg, there were no changes in the pH of the umbilical cord blood, nor a decrease in the estimates of newborns on the Apgar scale. Studies have shown the use of fentanyl in childbirth, in doses of 50-100 mcg moderate maternal sedation occurred. In addition, there has been a decrease in fetal heart rate variability. Despite these phenomena, some authors consider the use of fentanyl in childbirth more preferable than meredidin. Fentanyl has the advantage that it can be used non-parenterally, including subcutaneous, orally and as a patch to the skin. However, these uses of fentanyl in childbirth are poorly understood.

Butorphanol and nalbuphine.

Butorphanol and nalbuphine are opioids of the “agonist-antagonist” class, which are structurally related to oxymorphone and naloxone. Their potential advantage is that they cause less nausea and vomiting than other opioids. Butorphanol is a k-agonist and p-antagonist with minimal affinity for st receptors. It is used in a dosage of 1-2 mg intramuscularly or intravenously, its duration of action is up to 4 hours. Nalbuphine is a partial k-agonist and a potential p-antagonist with minimal C-receptor activity. Its dose of 10 mg, administered intramuscularly or intravenously, is equivalent to 10 mg of morphine, while the effect occurs on the 2-3rd minute when administered intravenously and 10-15 minutes after intramuscular injection. The duration of the analgesic effect of nalbuphine is up to 6 h.

One of the advantages of these drugs over p-agonists is that they have the effect of saturation, and therefore increasing the dose does not lead to further depression of respiration. Unfortunately, the use of these drugs in clinical practice is limited because they quickly penetrate the uteroplacental barrier and cause severe sinus arrhythmia in the fetus. As it turns out, these episodes of arrhythmia are “false positive” and insignificantly threaten the life and well-being of the fetus, as is usually seen in such cases. Despite this, obstetricians reluctantly allow the use of the drug, which can cause such potentially dangerous changes in the fetal heart rhythm. The use of antagonists or antagonist agonists may cause acute withdrawal in the mother and newborn among opioid-dependent patients. This syndrome has been described both after parenteral administration and after neuroaxial blockades.

Remifentanil.

Remifentanil is a potent short-acting β-opioid receptor agonist that has been approved for clinical use in the United States since 1996. The drug is a piperidine derivative with a normal opioid configuration, but contains an ester bond that allows it to be metabolized by nonspecific esterases in the blood and muscles. This feature of metabolism creates remifentanil a unique pharmacological profile compared with other opioids. Therefore, remifentanil has an extremely fast plasma clearance and speed of onset of action; its half-life is 8-40 minutes, and prolonged use does not cause accumulation. Thus, the effect of the drug on the fetus is minimal due to its rapid metabolism or redistribution, or both. These properties make it a very attractive alternative to systemic analgesic in pregnant women who are contraindicated for regional anesthesia. The results of studies of the drug, including randomized, described in the literature, are consistently positive when using remifentanil in obstetric anesthesia. During the study of doses of intravenously administered remifentanil during patient-controlled analgesia, it was found that the average effective bolus dose of 0.25 µg / kg with an interval of 1 minute and a constant infusion of remifentanil at a dose of 0.5-1 mg / kg / min a bolus of 25 mcg and an interval of 5 min provide satisfactory analgesia for labor. Also described prolonged use for 34 hours in patients with aggravated history, which regional anesthesia was contraindicated. No adverse effects were noted. The results of studies of remifentanil in obstetric practice, carried out so far, have not answered the question whether remifentanil is the best systemic opioid analgesic for anesthesia of labor in pregnant women. Although preliminary results were very promising, it would be premature to recommend the extensive use of remifentanil before extended studies evaluate its safety, dosage, and optimal uses completely.

Sedatics and tranquilizers.

Sedatives and tranquilizers, including barbiturates, phenothiazines, hydroxyzines, and benzodiazepines, are used for sedation, anxiolysis, or both in the initial stage of labor and before a cesarean section. Although barbiturates such as secobarbital were once popular, they are not currently used because of their antianalgetic effects on the mother and prolonged depression in the newborn. Even with the use of small doses of barbiturates that do not lower the Apgar score, the reflexes of the newborn can be reduced by more than 4 days.

Promethazine is phenothiazine, most commonly used in obstetrics. When used together with meredine, it can be administered in doses of 25-50 mg for the prevention of nausea. Its ability to potentiate the analgesic effect of opioids is in doubt. Promethazine is detected in the fetal blood at the 1-2nd minute after intravenous administration to the mother and reaches an equal concentration with the mother after 15 minutes.

Ketamine is an antagonist of N-methyl D-aspartate receptors, causes dissociative anesthesia and is used in pregnant women. Ketamine is a derivative of phenylcyclidine; therefore, its mechanism of action may be based on interaction with phenylcyclidine receptors located in the limbic and corticotalamic zones of the brain. The data of some studies nevertheless indicate that antagonism of NMDA receptors is the main mechanism of action of ketamine. Ketamine is used to relieve childbirth in subanesthetic doses. In addition to use in childbirth, ketamine at a dose of 25-50 μg can be used as a supplement to incomplete neuroaxial blockade at caesarean section. Its main disadvantages are the ability to cause hypertension and various reactions.

High doses can provoke psychomotor agitation and increase the tone of the uterus, which can lower Apgar scores and cause an increase in muscle tone in the newborn.

Benzodiazepines, such as diazepam, lorazepam and midazolam, can be used as sedatives and anxiolytics during labor. These drugs freely cross the placenta and are half eliminated in 48 hours for diazepam and up to 120 hours for their main metabolite, N-desmethyldiazepam. There is an opinion that the appointment of benzodiazepine in early pregnancy can cause fetal malformations, such as cleft lip. Detailed studies on the use of benzodiazepine in the first trimester of pregnancy showed that most of the newborns were normal and subsequently developed normally. The use of these drugs in childbirth, of course, will not cause fetal malformations, but may be associated with such problems in the newborn as:

• hypotension;

• impaired metabolic response to stress.

In addition, since these drugs are powerful amnestic agents, a woman in labor may not be able to remember the process of childbirth. Many side effects of these drugs can be eliminated by prescribing flumazenil, which is a competitive antagonist of benzodiazepine receptors.

Inhalation analgesia

Inhalation analgesia is the administration of subanesthetic doses of inhalation anesthetics for pain relief during labor. These methods of anesthesia should not be confused with inhalation anesthesia associated with loss of consciousness and suppression of protective laryngeal reflexes. Despite the fact that inhalation methods provide some level of analgesia, it is not enough to adequately relieve childbirth in most mothers. But these methods can be used as a supplement for failed neuraxial blockades, or for contraindications to the latter. Inhalation analgesia can be performed intermittently and permanently. Inhalation methods can be used for autoanesthesia, but under the supervision of an anesthesiologist to control the level of consciousness and the correct use of equipment. Although inhalation analgesia during labor is still used in some European and most developing countries, it is rarely used in labor in the USA. In addition, the collection and purification of exhaled gases is still a problem.

Antonox is used for many years both as a mono-anesthetic and as an adjuvant for regional methods of labor anesthesia. Associated side effects include dizziness, nausea, apathy, and decreased contact. The maximum analgesic effect occurs within 45-60 seconds after the start of inhalation. Therefore, it is very important for the woman in labor to start inhalation at the first precursors of the contraction and end it after the peak of uterine contraction. The absence of gas collectors for exhaled gases in the prenatal wards theoretically puts the medical staff at risk of prolonged exposure to excessive concentrations of exhaled anesthetics. As it turned out, inhalation of a mixture of nitrous oxide with oxygen in the ratio of 50:50 does not affect the function of the liver, kidneys, cardiovascular and respiratory systems. The latest meta-analysis, performed by Kronberg and Thomson, found that inhalation of nitrous oxide provides a significant but far from sufficient level of analgesia during childbirth for the majority of pregnant women. The analgesic effect of nitrous oxide is dose-dependent, which provides some efficacy in labor pain relief.

Desflurane, enflurane and isoflurane are also used for pain relief of labor, but their effectiveness is comparable to that of nitrous oxide. More recent studies have shown the effectiveness of sevoflurane for pain relief of labor. The inhaled concentration was acceptable for effective analgesia during labor. Sevoflurane, in comparison with entonox, provided a higher level of analgesia, but against the background of more pronounced sedation. He did not show any side effects and was convenient for women in labor. The use of these vapor-forming analgesics in labor is limited by depression of consciousness, unpleasant smell and high cost. The main danger when using vapor-forming analgesics is in an accidental overdose with loss of consciousness and loss of reflexes that protect the respiratory tract.

Regional anesthesia during pregnancy

In the obstetric clinic, various methods of regional anesthesia / analgesia are used, the aim of which is to achieve optimal anesthesia with minimal undesirable effects on the mother and fetus. These methods are most effective for pain relief childbirth. Regional methods of labor anesthesia are more manageable, effective and safe compared to medication and inhalation. Regional methods do not have medication depression on the mother and fetus. Most often used:

epidural;

spinal;

combined spinal-epidural techniques.

Sometimes obstetricians themselves produce paracervical, pudendal and infiltration perineal analgesia. Each technique has its own advantages and disadvantages and can be used for anesthesia in obstetrics.

Preoperative examination of the patient and preparation

Before initiating regional methods, it is very important to find out the general and obstetric history of the woman in labor, conduct a general clinical examination and assess the condition of the woman's respiratory tract in case of possible tracheal intubation. Herbal therapy is gaining popularity among adults, and obstetric patients are no exception. There is evidence that a certain percentage of pregnant women used herbal medicines after the 20th week of pregnancy. Preparations of garlic, ginkgo, ginseng, ginger and feverfew can be important for pain relief.

In the process of preoperative preparation, it is necessary to clarify the plan for the upcoming labor and the condition of the fetus. It is necessary to obtain the informed consent of the patient, and the anesthesiologist must explain to the woman in labor the essence of the method of pain relief and its possible complications. A retrospective analysis of the satisfaction of the parturient women with the quality of anesthesia during labor and their attitude to informing about the upcoming procedure showed that stress during labor does not prevent the woman in labor from perceiving information related to agreement on the upcoming epidural analgesia. Moreover, women in labor considered that the information received from the anesthesiologist before the epidural puncture, as well as information from neonatologists, was the most valuable. Patients want to know the most formidable, even fatal, complications of the epidural technique before agreeing to it. It is necessary to check the performance of all anesthesia and respiratory equipment and the availability of medicines for emergency care. Prior to the procedure, it is necessary to provide venous access and start infusion, as well as provide the necessary monitoring of the mother and fetus.

Epidural analgesia

Lumbar epidural analgesia is a safe and effective method of labor pain relief. It is universal and can be used during prolongation for the instrumental or operational completion of labor. Low doses of local anesthetics, sometimes in combination with opioids, are used to achieve a prolonged sensory block at the level of the T10-L1 segments in the first stage of labor. In the future, the maintenance of the block may be necessary to anesthetize the end of the first and the entire second period of labor with the help of the sacral block. The advantages of epidural analgesia are effective anesthesia without an undesirable motor block, a decrease in the level of catecholamines in the mother, and the possibility of quickly obtaining a surgical depth of anesthesia.

Despite numerous relative contraindications, there are few absolute contraindications to neuroaxial analgesia. Absolute contraindications include:

mother's failure;

maternal coagulopathy;

skin infection in the area of ​​puncture;

hemodynamic instability of the woman in labor.

Other risk factors, such as a cardiac output limit, should be considered with an assessment of the risk / benefit ratio for each parturient woman individually.

When performing regional blockades in obstetrics, and for epidural puncture including, ultrasound navigation is increasingly used. The use of an ultrasound image of the lumbar spine helps identify the necessary anatomical landmarks and determine the depth of the epidural catheter in a woman in labor. This may be especially useful in women with morbid obesity and in patients with a history of unsuccessful epidural punctures.

Epidural Test Dose

The question of whether a test dose is needed when performing epidural analgesia remains controversial. Due to the use of solutions with small concentrations of local anesthetics and the production of a diagnostic aspiration test, some authors consider the administration of a test dose to be optional. Other authors support the need to introduce a test dose to exclude the intrathecal or intravascular position of the catheter, since the aspiration test from the catheter is not always indicative.

The use of epinephrine for testing the position of the catheter also remains controversial. In volunteers and surgical patients, it was shown that epinephrine causes a marked increase in heart rate in the intravascular position of the epidural catheter.

However, the variability of the woman's heart rate during labor, associated with pain from uterine activity, can lead to incorrect interpretation of the results, and intravenous administration of epinephrine can have a negative effect on uteroplacental blood flow. Measures to improve the reliability of the test with epinephrine include the introduction of the dose in the interval between contractions with the re-introduction of the test dose and getting the same answer.

In any case, the low specificity and sensitivity of the test dose raises questions about the appropriateness of its use as a diagnostic tool. Leighton et al. described another way to exclude the intravascular position of the catheter. They propose to inject 1-2 ml of air into the lumen of an epidural catheter and scan the area of ​​the right atrium using a mother Doppler monitor to detect air bubbles. If a highly diluted solution of a local anesthetic is infused into the epidural catheter and the patient does not test the motor block, we can confidently say that the catheter is in the correct position. If after a few hours the patient has inadequate analgesia, then the catheter is likely to have moved. In the event that the catheter has moved intrathecally, the patient may have a motor block.

In any case, the use of solutions of ultra-low concentrations of local anesthetics does not pose a serious threat. But this does not apply to the use of concentrated solutions of anesthetics used for the anesthesia of operative delivery. Some authors argue that the use of a test dose is mandatory when carrying out any epidural anesthesia. Regardless of the method of anesthesia, the rules for the safe conduct of epidural analgesia during childbirth dictate the first aspiration catheter test, then bolus anesthetic with mandatory monitoring of the onset of symptoms of systemic toxicity of anesthetics.

Spinal analgesia

A single subarachnoid injection of a local anesthetic or opioid provides a quick and effective onset of analgesia during labor. This is especially convenient in the initial stage of labor and in emotionally labile mothers to create more comfortable conditions for both the mother and the anesthesiologist when performing epidural puncture. A one-time subarachnoid injection of a local anesthetic can also be performed when instrumental completion of labor is required in women who have had no pre-set epidural catheter. Although this technique is used in a number of institutions as a routine, it does not provide such controllability as anesthesia that a permanent catheter provides.

Prolonged spinal analgesia with a “macrocatheter” can be used in case of an unintentional penetration of the catheter into the subdural space or in extremely high-risk patients. It provides excellent analgesia and relative control with a spinal catheter. Such a technique can reduce the frequency of post-puncture headache after an unintentional puncture of the dura mater with an epidural needle. When a catheter is left in the subarachnoid space, it is necessary to notify the entire medical staff involved in assisting the woman in labor and the puerperal, in order to avoid accidental overdose of local anesthetics.

"Small-bore" spinal catheters were introduced into clinical practice in the late 1980s. and quickly gained popularity due to convenience, rapid onset of effect, and potentially lower frequency of PGGB. However, publications about cases of horse tail syndrome with this anesthesia method for cesarean section forced the US Food and Drug Administration to prohibit the use of these catheters in clinical practice. Explanations of the possible causes of the cauda equina syndrome included insufficient mixing of anesthetic solutions with cerebrospinal fluid in the subarachnoid space and the use of too highly concentrated solutions of potentially neurotoxic anesthetics, which led to neuronal damage. Currently, research continues on the use of microcatheters for pain relief of labor, and, perhaps, their results will confirm the necessary level of safety of this technique, which will allow it to be revived in clinical practice.

Combined Spinal Epidural Analgesia

Combined spinal-epidural analgesia is widely used in obstetric practice for pain relief of labor. It provides effective, fast-onset analgesia with minimal toxic risk and a missing motor block. In addition, this technique allows to prolong the analgesia as much as necessary, using an established epidural catheter. Moreover, if it is necessary to switch to operative delivery, the same catheter can be used to anesthetize the operation. The onset of spinal analgesia occurs instantly, and its duration varies from 2 to 3 hours, depending on the injected anesthetic or its combination with adjuvants.

The duration of spinal analgesia, however, will be shorter in the parturient woman in active labor compared with the woman who received it at the beginning of labor. Patient satisfaction after spinal-epidural analgesia is usually higher in patients compared to traditional epidural, which is probably connected with a greater sense of self-control. In the original method of spinal analgesia of labor is the introduction of sufentanil or fentanyl, but adding isobaric bupivacaine to opioids allows you to get a more powerful sensory block with minimal manifestations of the motor block. The original description of the technique recommended intrathecal administration of 25 μg of fentanyl or 10 μg of sufentanil, but subsequent studies have established the feasibility of combining smaller doses of opioids with anesthetics. For example, many clinicians routinely practice intrathecal administration of as little as 5 μg of sufentanil or 15 μg of fentanyl intrathecal.

Some studies have shown that ropivacaine and levobupivacaine can be used instead of bupivacaine for spinal analgesia of labor. Combined spinal-epidural analgesia allowed women to move independently around the ward during the action of neuroaxial analgesia. Due to the absence of a motor block, this technique is called "walking epidural". This definition is actually not quite right, as many women in the process of neuroaxial anesthesia did not lose the ability to move, and at the same time many women with combined spinal-epidural analgesia never walked on their own.

In addition to the rapid onset of effect, combined spinal-epidural analgesia can reduce the incidence of some potential problems typical of the traditional epidural technique, including “mosaic anesthesia”, motor block and poor sacral spread. Preliminary research results suggest that another potential advantage of XECA is its ability to significantly shorten the duration of the first period of labor in primiparas.

For carrying out KSEA there are several methods:

Installing the epidural catheter first, then the spinal puncture in the underlying intervertebral space.

In one intervertebral space using a special epidural needle having a side channel for a spinal needle.

The most common method is “a needle through a needle”, which consists in identifying the epidural space and conducting a special long spinal needle of small diameter, “pencil type”, through the epidural needle before puncture of the dura mater. The free flow of cerebrospinal fluid is a confirmation of the correct position of the needle. Next, a bolus of opioid alone or its combination with a local anesthetic is performed. After that, the spinal needle is removed, and an epidural catheter is inserted through the epidural needle to a depth of 4-5 cm.

Side effects of intrathecal opioid administration include pruritus, nausea, vomiting and decreased diuresis. Respiratory depression as a result of the spread of opioids occurs rarely, but it is possible with the introduction of fat-soluble opioids. The use of low-concentration anesthetic solutions in combination with opioids provides sensory analgesia without causing a motor block, and allows many women in labor to move independently in the prenatal ward. But before that, it is necessary to monitor the woman for 30 minutes to exclude possible complications and assess the adequacy of the motor function of the woman.

Against the background of CSEA, there is an increase in the frequency of fetal heart rhythm disorders, most often in the form of bradycardia. The etiology of fetal bradycardia against the background of CEAS remains not fully elucidated, but it can be explained by a sharp decline in maternal catecholamines after the rapid onset of analgesia. In addition, it has been suggested that an imbalance between epinephrine / norepinephrine levels causes a unidirectional a-adrenoceptor effect on uterine tone and reduces uteroplacental blood flow. However, preliminary results of studies show that, possibly, impairment of uteroplacental blood flow does not occur.

Episodes of fetal bradycardia are usually short-lived and go off on their own in 5-8 minutes. A retrospective study of 1240 women in labor who received regional methods of anesthesia during childbirth, and 1140 women who gave birth medications or did not receive it at all, did not reveal a significant difference in the frequency of the transition to cesarean. In the same study, it was shown that there was no need to switch to a cesarean section due to the suffering of the fetus within 90 minutes after the intrathecal administration of opioids, if no additional obstetric indications occurred.

Permanent epidural infusion

Currently, most obstetric anesthetists prefer to use a constant infusion of low concentrations of anesthetics into an epidural catheter. Local anesthetics, such as bupivacaine, ropivocaine and left bupivacaine, are used either alone or in combination with opioids. Adding epinephrine can improve the quality of analgesia by reducing vascular absorption and systemic absorption of anesthetics, as well as by direct joint effects on a2 receptors.

For the patient, a constant infusion is preferable, because it creates a constant level of comfort without forcing him to expect periodic epidural injections of the analgesic.

Patient-controlled epidural analgesia

Patient-controlled epidural analgesia is an effective and safe technique. This method of introducing anesthetic provides equally effective analgesia of labor and good satisfaction of the woman in this process. It allows you to reduce the total amount of anesthetic consumed, and, therefore, reduces unwanted effects such as motor block and hypotension. It also reduces the burden on the medical staff in the birth unit and gives the woman in her work a sense of confidence. Usually, after an analgesia has been achieved with a spinal or epidural block, the catheter is connected to the patient-controlled anesthesia device, and after that the patient is able to independently administer an anesthetic bolus on demand. Some authors prefer continuous infusion with patient-controlled supplemental injections. At the same time, others adhere only to the bolus technique.

Paracervical and pudendal blockade

Paracervical blockade is an alternative method of pain relief for pregnant women who do not want to use neuroaxial methods or who cannot use such methods. This relatively simple blockade provides analgesia in the first stage of labor and does not adversely affect the progression of the labor. A local anesthetic is injected under the mucous membrane in the vaginal fornix laterally to the cervix in order to block the nervous transmission through the paracervical ganglion, which is located lateral and posterior to the connection of the cervix with the uterus. Since this block does not affect the somatosensory nerve endings of the perineum, it does not provide analgesia of the second stage of labor. However, this technique is still used by obstetricians for non-obstetric manipulations. Its widespread use in obstetrics is limited to severe fetal bradycardia, systemic toxicity of local anesthetics, postpartum neuropathy, and infection. The cause of fetal bradycardia in this case is a decrease in uteroplacental blood flow and a high level of local anesthetics in the fetal blood.

The controversial nerves depart from the lower sacral nerve bundle and provide sensory innervation in the lower part of the vagina, vulva and perineum, as well as the motor innervation of the perineal muscles. These nerves are easily anesthetized by transvaginal access, which is provided by the accumulation of a local anesthetic behind the sacral ligaments. This blockade provides satisfactory analgesia for both the second stage of labor and the output obstetric forceps. However, it is not effective for anesthesia of the first stage of labor. However, it is mostly inadequate for abdominal obstetric forceps, suturing of vaginal tears, as well as manual examination of the uterine cavity. Complications of this technique are rare, but include the systemic toxicity of local anesthetics in the mother, the formation of hematomas and infection.

Another type of blockade, which can be considered as an alternative to central neuroaxial blockade, is the paravertebral lumbar sympathetic blockade. This blockade can be used to reduce pain conductivity from the uterus in the first stage of labor. Despite the fact that technically it is a rather difficult blockade, it is associated with a significantly lower number of complications than paracervical.

Local anesthetics during pregnancy

Bupivacaine

Bupivacaine is an amide local anesthetic widely used for spinal anesthesia and analgesia in obstetric practice. Its long-lasting effect, the differentiation of sensory and motor blocks, and the relative absence of tachyphylaxis made it the drug of choice. The transplacental transition of bupivacaine, as well as in other amide local anesthetics, is regulated by two factors: the degree of ionization at physiological pH and the degree of binding to proteins. Bupivacaine has a pKa of 8.2 and 95% protein binding. Therefore, it is limited to cross the placenta compared with other local anesthetics. The UV / M ratio of the umbilical vein to the concentration of local anesthetic in the mother’s blood at the time of delivery has a range significantly less than that of lidocaine. In the late 1970s - early 1980s. began to pay special attention to safety issues after reports of several deaths associated with cardiovascular or cardiac toxicity of bupivacaine. Following these reports, the FDA banned the use of a 0.75% epidural solution in obstetric practice. Improving clinical practice has reduced the risk of inadequate intravascular injection of local anesthetics through the introduction of multiperforated catheters, as well as the use of stepwise dosing.

Bupivacaine consists of two stereoisomers, S- and R +, and is sold as a racemic mixture of these isomers. After the isolation of the R-isomer, it was established that it is he who gives bupivacaine undesirable toxicity. This finding allowed researchers to develop S-isomers for clinical practice, which led to the appearance of ropivacaine and levobupivacaine.

Lidocaine

Lidocaine has been used in obstetric practice for many years. He has a fast onset of action and its average duration. Despite the fact that lidocaine is very popular as a local anesthetic for epidural anesthesia during operative delivery, it is not used for pain relief in childbirth due to a pronounced motor block. Early studies have shown that lidocaine has an undesirable effect on neurobehavioral reactions in newborns, but numerous later studies have proven the illegitimacy of such an association. Contradictions have arisen over the use of 5% hyperbaric lidocaine for spinal anesthesia due to reports of transient neurological disorders. In 1994, the FDA issued a letter about 5% hyperbaric lidocaine, in which doctors were instructed to dilute lidocaine with saline or cerebrospinal fluid before administration. These warnings were subsequently included in the instructions attached to this drug. Later studies nevertheless showed that 5% and 2% solutions can cause transient radicular irritations. As a result, despite the experience of many years of clinical use without confirming neurotoxicity, many anesthesiologists have refused to use spinal 5% hyperbaric lidocaine.

2-Chloroprocaine

2-Chloroprocaine is an ethereal local anesthetic with a rapid onset of effect and a short duration of action. It is rapidly metabolized in the process of hydrolysis of the ester bond, which makes it safe in obstetric practice, since it practically does not penetrate the uteroplacental barrier. Due to its high rate of onset of effect, it is mainly used for the rapid transfer of epidural analgesia to anesthesia during emergency caesarean section during childbirth. In addition to the short duration of action, another disadvantage of chloroprocaine is its undesirable competition with epidurally administered opioids.

Competition with opioids may be due to its antagonism to the i- and k-opioid receptors. Moreover, it has been reported that chloroprocaine can compete with the later epidurally introduced bupivacaine. Previously released 2-chloroprocaine was considered neurotoxic due to reports of arachnoiditis after unintentional subarachnoid injection of the drug. In subsequent reports, there were negative reviews about the low pH of the drug and the substances used as its stabilizers.

The failure of metabisulfate and methylparaben reduced the risk of neurotoxicity. Nevertheless, precaution is necessary, since the preparation, which still contains the indicated components, is present on the market in parallel with the MPF form of the drug. Recently, even works have appeared on the spinal use of chloroprocaine.

Levobupivacaine

Based on the evidence that the cardiotoxicity of bupivacaine is more due to its R-entanomer, the S-entanomer was proposed for clinical use. Levobupivacaine is a long-acting local anesthetic with a clinical profile close to bupivacaine. Studies on volunteers and animals have shown that his safety profile is higher than that of bupivacaine.

As found in most animal studies, the lethal dose of levobupivacaine was several times higher than that of racemic bupivacaine. This indicated a greater safety of levobupivacaine with occasional intravasal administration. Like racemic bupivacaine, levobupivacaine penetrates the placenta. In the study of parturients during elective caesarean section after epidural administration of 30 ml of solution. Levobupivacaine is more preferable for analgesia for cesarean section than bupivacaine.

Comparative evaluation of the bupivacaine sensory block with levobupivacaine showed no difference in the adequacy of the block or in the time of the onset of the surgical block stage. Also, several authors have recently published results showing that there are no differences between levobupivacaine and bupivacaine in the onset time and the duration of the sensory block during anesthesia for cesarean section. In addition, the onset and attenuation of the sensory and motor block, as well as the quality of anesthesia and muscle relaxation were comparable between the groups.

Levobupivacaine is also used for epidural analgesia during labor. During multicenter studies of the effectiveness of levobupivacaine and bupivacaine, it was found that both drugs have an equal analytical effect. It should also be noted that the intensity of the motor block was the same in both groups. Recent studies show that fentanyl significantly reduces the need for levobupivacaine, as in other anesthetics, during epidural analgesia during childbirth. Levobupivacaine is not currently sold in the United States, but is available in other countries.

Ropivacaine

Ropivacaine is a homolog of mepivacaine and bupivacaine. It was the first released S-isomer of a local anesthetic. Ropivacaine is less soluble than bupivacaine, and perhaps that is why it is less powerful. Despite the fact that clinical studies demonstrate the same analgesic power of these drugs, studies of the minimum concentration of local anesthetic found that the analgesic potential of ropivacaine in relation to bupivacaine is 3. It should be noted that ropivacaine is less toxic and causes a less pronounced motor block.

Childbirth invariably takes place as a thousand years ago, the approach to childbirth, puerperal, and children has changed. Childbirth is a long process so it was before, now childbirth in primiparous occur from 6 to 9 hours, in multiparous from 3 to 5 hours. Duration of labor depends on many factors, but your attitude is of great importance. There is a good saying, “He who gives birth well, thinks about childbirth a little”. So childbirth will be good and painless, if you think only about the good and about the imminent meeting with your child.

The onset of labor.

Most often, childbirth begins with contractions.The contractions are regular contractions of the uterus, accompanied by drawing pains in the lower abdomen and (or) in the lower back. At the beginning, contractions are weak, last a few seconds, and the gap between them is 10-12 minutes. Sometimes the contractions immediately begin every 5–6 minutes, but not very strong. Gradually, contractions become more frequent, strong, long, painful.

Typically, primiparous labor for 8 hours, for multipurpose 5 hours.

Sometimes fights are rare - after 20 - 30 minutes. These are not labor pains, but harbingers of childbirth. It is better to go to the maternity hospital when contractions are more often than once every 10 minutes.

Another variant of the onset of labor is the discharge of amniotic fluid or leakage in small portions. In this case, you no longer need to wait for the onset of contractions, but it is better to go to the maternity hospital right away. You urgently need to go to the maternity hospital if bleeding from the genital tract appears.

The first stage of labor

So, if you started having contractions or poured amniotic fluid, go to the hospital. In the emergency room you will be met by a midwife on duty who will draw up the necessary documents, measure blood pressure, body temperature, pelvic size, listen to the heartbeat of the fetus.

In the overwhelming number of maternity hospitals, sanitization is mandatory: shaving of pubic hair and a cleansing enema.

Usually, the doctor examines patients in the emergency department, conducts obstetric research and outlines a plan for management of labor. After that, you will be transferred to the maternity ward.

In the maternity ward, a midwife and a doctor will be watching you.

Observation is:

blood pressure measurement

listening to fetal heartbeat

control of contractions

In well-equipped maternity hospitals, there are monitors for this, which simultaneously monitor you and the fetus, beeping loudly if deviations appear. As the cervix opens, the doctor monitors.

At the beginning of labor contractions are not very painful, the gaps between them are quite long, so do not be afraid of contractions, they last a few seconds, after which you will have a few minutes to relax.

During the fight, breathe deeply enough. It is better to inhale through the nose and exhale through the mouth. Free movement in labor also eases birth pain. Try to stroke the lower abdomen or rub the sacrum during a contraction; this also reduces pain. If you give birth with your husband, he can be a great helper in this.

When the waters pour out

Sometimes this happens before the onset of contractions, which appear only a few hours later, and if they do not appear, they have to be called.

It is better if the waters pour out shortly before the birth of the child. Although the doctor who is giving birth, can open the bladder before, if there are any abnormalities during labor.

Amniotomy is an obstetric surgery - an artificial rupture of the membranes of the fetus and is carried out strictly according to the indications. Indications for amniotomy can occur during pregnancy and childbirth.

During pregnancy, amniotomy is performed to induce labor. The main reason for amniotomy is prolonged pregnancy. We are talking about repurposing, when after 41 weeks of pregnancy, labor does not occur on its own. Another important indication for amniotomy during pregnancy is severe preeclampsia, rhesus sensitization, or rhesus conflict. In childbirth, the most frequent reason for the opening of the fetal bladder is the weakness of the labor. At the same time, contractions do not increase with the passage of time, but weaken. Cervical dilatation is slowed down, and childbirth is delayed.

After an amniotomy, for some time it is necessary to conduct cardiomonitoring monitoring of the condition of the fetus in order to know how it reacted to the amniotic fluid. In most cases, the condition of the fetus does not change. When you are already well into childbirth (usually 4-6 hours after the start of regular contractions), pain relief can be done.

Pain relief childbirth

Childbirth is accompanied by pain sensations of varying severity. Each woman perceives this pain in different ways, depending on the psychological attitude to childbirth and the threshold of pain sensitivity.

It is very important from the very beginning of pregnancy to begin psychological preparation for childbirth, to tune in to a successful outcome. Great help in this can have a doctor who observes your pregnancy, of course, only if you have a full understanding between you. Ideally, when the same doctor leads and childbirth. During pregnancy, you become members of the same team, and during childbirth you will enjoy powerful psychological support.

Types of pain relief

The most commonly used:

promedol (narcotic substance that is administered intravenously or intramuscularly)

epidural anesthesia (a pain reliever is injected into the space in front of the dura mater surrounding the spinal cord)

Does anesthesia affect a child?

Promedol in the dose used for pain relief of childbirth does not adversely affect the fetus.

Epidural anesthesia is considered essential for careful management of labor, it makes labor less traumatic for the fetus, since the main obstacle that the head of the fetus encounters as it moves, the cervix softens and opens up faster.

Which is better: promedol or epidural anesthesia

Promedol can be administered only once, so it is better to inject it when strong contractions and the cervix is ​​well opened, since its action lasts 1-1.5 hours. Fully pain does not relieve promedol, but significantly reduces the severity of pain.

And during the epidural anesthesia, the pain is relieved completely, anesthesia can be added through a thin catheter as pain increases.

The second period of labor

After the cervix has fully opened, many women notice a reduction in pain, but contractions remain quite intense, repeated after 2-3 minutes, and attempts are joined to them.

The descending head of the fetus presses on the anus, the receptors of the rectum are irritated, and there is a feeling that I want to "by large". But truly it will be possible to push only when the fruit is well lowered. If you start to push too early, it will lead to unnecessary breaks and may cause birth trauma in the child. When you can push, the doctor will say.

How to push

It is necessary to push during a bout. At the same time, you need to get as much air in the chest as possible (as if you were going to dive under the water), hold your breath and pull (try to push the child out) without releasing the air. After that, make a smooth exhalation, inhale again and tighter.

In one fight, you should have time to tighter 3 times. It is necessary to do this, having collected all the forces, the harder you will be straining, the faster your baby will be born and the less he will suffer in childbirth.

It is necessary to listen to what you said the doctor or midwife.

The third stage of labor

After giving birth, the baby is usually placed on the mother’s belly and then the umbilical cord is cut. At childbirth should attend a pediatrician who examines the child immediately after birth.

After 5-15 minutes after the birth of the child, the child’s place is separated, and there is a desire to push. In order to give birth it is enough to strain the stomach once. So end childbirth.

Cesarean section

Caesarean section is a surgical operation in which the fetus is removed through an incision of the anterior abdominal wall and uterus ..

Caesarean section is carried out in cases where spontaneous birth is impossible or dangerous to the life of the mother or fetus. Caesarean section in a planned manner (before the onset of labor) is performed, for example, with high myopia with changes in the fundus, developmental defects of the uterus and vagina, abnormal fetal positions (transverse, oblique), previa of the placenta, the presence of two or more scars on the uterus after cesarean section and IVF.

Caesarean section in labor is most often performed with weakness of labor forces, which is not amenable to medical correction, as well as if during monitor monitoring there are signs of suffering (hypoxia) of the fetus.

When performing a caesarean section, the patient's consent to the operation is necessary.

With a favorable postoperative course, patients are discharged home for 4-5 days.

Anesthesia for caesarean section   may be:

general (endotracheal anesthesia)

regional (epidural or spinal anesthesia).

The level of modern surgical technology allows patients who have had a cesarean section to give birth spontaneously at the next birth, if there are no indications for a planned cesarean section.

Summing up the modern childbirth, this is birth in any maternity hospital in the city of Samara, joint birth with a husband or relatives, the choice of anesthesia, a joint stay of the mother and child in the ward, an extract for 3-4 days.

Anesthesia during labor is aimed at providing comfortable conditions for a woman in labor, avoids pain and stress, and also helps to prevent disruption of labor.

The perception of pain in a woman in labor depends on circumstances such as physical condition, anxious expectation, depression, features of education. In many ways, the pain in childbirth is aggravated by the fear of the unknown and the possible danger, as well as previous negative experiences. However, the pain will be reduced or better tolerated if the patient has confidence in the successful completion of labor, a correct understanding of the labor process. Unfortunately, so far, none of the currently existing methods of pain management during childbirth is absolutely perfect. To achieve the maximum effect, the choice of anesthesia method should be made individually. It is necessary to take into account the physiological and psychological state of the parturient woman, the state of the fetus and the obstetric situation. To increase the effectiveness of anesthesia, prenatal preparation is important, the purpose of which is to remove the fear of the uncertainty of the upcoming birth. In the process of such preparation, a pregnant woman should be informed about the essence of the processes accompanying pregnancy and childbirth. The patient is taught proper relaxation, exercises that strengthen the abdominal muscles and back, increase the overall tone, different ways of breathing during labor and at the time of birth of the fetal head.

Acupuncture can be used as one of the methods of non-medical anesthesia of labor. Most often, when using this method, only partial anesthesia occurs, and most patients need additional methods of anesthesia. Another method of non-pharmacological anesthesia of childbirth is transcutaneous electroneurostimulation (TENS), which has been used for many years. During the process of delivery, two pairs of electrodes are placed on the back of the woman in labor. The degree of electrical stimulation varies according to the need of each individual woman and can be regulated by the patient herself. This form of analgesia is safe, non-invasive, and easily accessible by a nurse or midwife. The main drawback of the method is the difficulty in its application of electronic monitoring of the fetal state, despite the fact that percutaneous electroneurostimulation itself does not affect the fetal heart rate.

However, the use of appropriate medications is most important for pain relief in childbirth. Ways to relieve childbirth can be divided into three types: intravenous or intramuscular administration of drugs to relieve pain and anxiety; inhalation pain relief childbirth; local infiltration and regional blockades.

Narcotic analgesics are the most effective drugs used for labor pain relief. However, these drugs are used more to reduce than to completely stop the pain. With steady labor in the active phase of the first stage of labor, these drugs contribute to the correction of uncoordinated uterine contractions. The choice of drug is usually based on the severity of potential side effects and the desired duration of action. Intravenous administration of drugs is preferred compared to intramuscular, as the effective dose is reduced by 1 / 3-1 / 2, and the action begins much faster. Tranquilizers and sedatives are used in labor as components of medical anesthesia to relieve anxiety, as well as to reduce nausea and vomiting. In the active phase of labor, with the opening of the cervix more than 3–4 cm and the appearance of painful contractions, sedatives with narcotic analgesics in combination with antispasmodics are prescribed (No-IM intramuscularly). The use of narcotic analgesics should be stopped 2-3 hours before the expected moment of the expulsion of the fetus, in order to prevent its possible narcotic depression.

Inhalation pain relief childbirth

Inhalation pain relief of labor by inhalation of painkillers are also widely used in obstetric practice. Inhalation anesthetics are used in the active phase of labor when the cervix is ​​opened for at least 3–4 cm and in the presence of severe pain in contractions. The most common is the use of nitrous oxide (N2O) with oxygen, trichlorethylene (trilen) and methoxyflurane (pentran). Nitrous oxide is a colorless gas with a slight sweet smell, which is the most harmless inhalation anesthetic for the mother and fetus. The most common ratios of nitrous oxide with oxygen are: 1: 1, 2: 1 and 3: 1, allowing to achieve the most optimal and sustainable analgesia. In the process of inhalation anesthesia, control by the medical staff over the condition of the parturient woman is necessary. The effectiveness of anesthesia largely depends on the proper inhalation technique and rationally selected ratios of the components of the gas-narcotic mixture. Three options can be used to achieve the analgesic effect.

Variants of labor anesthesia using inhalation anesthetics

1. Inhalation of the gas-narcotic mixture occurs constantly with periodic interruptions in 30-40 minutes.
2. Inhalation is carried out with the onset of labor and ends with its termination.
3. Inhalation occurs only in the pauses between contractions, so that by the time they start, the necessary degree of anesthesia is achieved.

Autoanalgesia during labor with nitrous oxide can be performed throughout the active phase of the first period of labor until the cervix is ​​fully opened. Due to the fact that nitrous oxide is excreted from the body through the respiratory tract, this ensures greater controllability of the anesthesia process. When pain relief in childbirth after the cessation of inhalation of nitrous oxide within 1-2 minutes, consciousness and orientation in the environment is restored. Such an analgesia during labor also has an antispasmodic effect, providing coordinated generic activity, preventing anomalies of uterine contractile activity and fetal hypoxia. The use of the gas-narcotic mixture of nitrous oxide with oxygen is the most acceptable in obstetric practice for pain relief of childbirth. In addition to nitrous oxide, drugs such as trichlorethylene can also be used for inhalation anesthesia (it has a more pronounced analgesic effect in comparison with nitrous oxide); methoxyflurane (use is less controllable than nitrous oxide and trichlorethylene).

Epidural analgesia

Regional analgesia can also be used successfully to relieve childbirth. The cause of pain in the first stage of labor is the contraction of the muscles of the uterus, the stretching of the cervix and the tension of the ligaments of the uterus. In the second stage of labor, as a result of stretching and stretching of the pelvic structures, as the fetus advances, additional painful sensations occur, which are transmitted through the sacral and coccygeal nerves. Therefore, to achieve pain relief during labor, the transmission of pain impulses along the corresponding nerve bundles should be blocked. This can be achieved by blocking of the confining nerve, the caudal block, the spinal block, or the expanded epidural.

Epidural analgesia is one of the most popular methods of labor pain relief. The performance of epidural analgesia consists in blocking pain impulses from the uterus along the nerve pathways entering the spinal cord at a certain level by injecting local anesthetic into the epidural space. Indications for epidural analgesia are: severe pain of contractions in the absence of effect from other methods of anesthesia, discoordination of labor, arterial hypertension during childbirth, childbirth with and.

Contraindications for labor anesthesia with epidural analgesia

1. Bleeding during pregnancy and shortly before delivery.
2. The use of anticoagulants or reduced activity of the blood coagulation system.
3. The presence of the source of infection in the area of ​​the proposed puncture.
4. A tumor at the site of the intended puncture is also a contraindication to epidural analgesia.
5. Volumetric intracranial processes, accompanied by increased intracranial pressure.

Relative contraindications for epidural analgesia

1. Extensive back surgery performed previously.
2. Extreme obesity and anatomical features that make it impossible to identify topographical landmarks.
3. Transferred or existing diseases of the central nervous system (multiple sclerosis, epilepsy, muscular dystrophy and myasthenia).

Epidural analgesia is carried out with established regular labor and the opening of the cervix for at least 3-4 cm. Only anesthesiologist who has this technique is entitled to perform epidural anesthesia.

Pain relief in labor disorders

Deserve attention and violations of labor. Adequate timely treatment of discoordination of labor, as a rule, contributes to its normalization. The choice of appropriate therapy is carried out taking into account the age of women, obstetric and somatic anamnesis, the course of pregnancy, an objective assessment of the fetus. With this type of abnormal labor, the most reasonable method of treatment is to conduct long-term epidural analgesia. Frequent anomaly of labor is weakness, which is corrected by intravenous administration of agents that increase the contractile activity of the uterus. Before prescribing a generic drugs for patient fatigue, a woman should be given rest in the form of a pharmacological sleep. Proper and timely provision of rest leads to the restoration of impaired functions of the central nervous system. In these situations, rest helps to restore normal metabolism. For this purpose, a wide arsenal of medical drugs is used, which are prescribed by a doctor individually, depending on the prevailing obstetric situation and the condition of the woman in labor. In obstetric practice, the method of electroanalgesia is also used, the use of which allows to achieve stable vegetative equilibrium, to avoid allergic reactions that may occur when using pharmacological preparations (neuroleptics, parathyroids, analgesics). In contrast to pharmacological preparations, the use of pulsed current allows one to obtain the so-called “fixed” stage of therapeutic analgesia, which makes it possible to maintain consciousness during the birth act, verbal contact with the woman without signs of excitement and transition to the surgical stage of anesthesia.

Anesthesia for childbirth with diabetes

In diabetes mellitus at the beginning of the active phase of the first period of labor, it is advisable to avoid the use of narcotic analgesics and epidural analgesia is more preferable. This is due to the fact that the negative impact of systemic analgesics and sedatives is reduced, the stress response of the woman to the pain is less pronounced, pain is ensured by better control of the condition of the woman against the background of intact consciousness. In addition, epidural analgesia can prevent the development of fast and rapid delivery, allows for a painless, controlled completion of labor. If necessary, operative delivery is possible against the background of epidural analgesia, either through the natural birth canal (obstetric forceps, vacuum extraction), or by emergency caesarean (after a rapid strengthening of the block). If there are no opportunities and conditions for performing a regional block, it is possible to use inhalation analgesia by strengthening it with a block of the lenticular nerve.

Anesthesia for childbirth with heart disease

For rheumatic heart disease, anesthesia should be carried out until delivery and continue in the early postpartum period. These requirements are best met by the extended lumbar epidural block. This technique eliminates attempts in the second stage of labor, and provides the necessary conditions for applying obstetric forceps and the use of vacuum extraction. If a caesarean section is needed, the extended lumbar epidural block can be extended to the required level. This method of anesthesia helps prevent the development of acute heart failure with pulmonary edema and a decrease in venous return. In a patient with a prosthetic valve, and using heparin, for anesthesia of labor it is advisable to use tranquilizers and narcotic analgesics or inhalation analgesia without hyperventilation. In the second stage of labor should be supplemented with a block of the sham nerve.

Anesthesia and preterm labor

Discussion

But I gave birth with epidural analgesia. I didn’t have pain in the abdomen at all, but then the loin! And I was not afraid of childbirth, I knew how and what was happening, I breathed correctly, I did a light massage myself, but the delivery went more than a day, a baby was born 5 kg. Of course, it would be possible to get by, but I was tired, squeezed and dreamed of losing consciousness, just not to be present at this horror. Anesthesia helped further the opening of the uterus, and even after two hours, in one attempt, I gave birth to a healthy baby. Thanks to people who think how to alleviate the suffering of the mother!

03/11/2007 01:08:05, Tina

I am a pediatrician, invalid 2-gr on the musculoskeletal system. I gave birth to my two children myself, and I can say with confidence that the best anesthesia is preparation for childbirth during pregnancy (swimming, bath, baths, self-education, physical exercises), the presence of the husband, his care, psychological support, awareness of the physiology of childbirth and how to behave in the movement (movement, postures during labor, etc.), warm water with sea salt, lack of fear, etc. In this case, the delivery goes on endorphins.
If a woman is systematically intimidated in the antenatal clinic during pregnancy, stuffed with vitamins, calcium, does not tell her anything about how to prepare for childbirth physically (and not materially), then very often it ends with birth trauma or cesarean. In our maternity hospitals, you can give birth normally, if you are knowledgeable, and you don’t go on about intimidation, you are physically prepared, and if you agree with the doctor so that he doesn’t interfere in the process of childbirth.
It really does not hurt to give birth when you know that this so-called. "pain" every minute, second brings you closer to meeting with the desired creature, which will be born. Fear binds, is transmitted to the child, causes pain in childbirth and discoordination of clan activity. And Rodostimulyatsiya ?! This is one, not ending fight, it is very painful, especially if the woman is lying on her back, it is not physiological, it is harmful for the child (vena cava syndrome), THIS IS AGAINST ALL THE RULES!
Give birth without fear - and there will be no pain. WARRANTY! Nature - it also provides for everything, it is better to follow it, and not artificial methods of delivery.
By the way, my great-grandmother was a midwife, and I had no special education. She just KNEW how to help a woman in labor - DO NOT interrupt! She herself gave birth to eight, and almost all the children in the village helped to be born, even took my mother. If she was alive, I would never have gone to give birth to the hospital.
Good luck everyone!
Natasha
13.03.2006

03/14/2006 04:39:44, Natasha

The most important thing in this article is written in the first paragraphs, and for that, thanks a lot to the doctor, perhaps unknowingly, he spoke in support of natural childbirth and such an unknown concept in our country as the protection of the psychological well-being of the mother. Her peace of mind, confidence in the positive outcome childbirth, the opportunity to receive support from loved ones - this is the main anesthesia of childbirth, absolutely harmless. Thanks to Dr. Makarov for reminding us that there is no perfect medical anesthesia, it is possible that someone will stop using drugs during childbirth and will give his child a chance to be born without them. But if I hadn’t given birth to three children by the time of reading the article, by the way, absolutely without medical anesthesia, I’d probably be scared. For me, the best anesthesia was the support of my husband, water, and a caring midwife. To give birth is not so painful!

02.27.2006 21:36:39, Svetlana

Comment on the article "Pain relief of childbirth"

Here in my head the whole scheme was outlined, but, remembering giving birth on oxytocin without anesthesia, I lost heart and could not say that no, no one oxytocin pricked me. In addition, my uterus was very painfully reduced.

Discussion

My uterus is most painful after the second birth has been reduced. And after the third - it is normal, although I was waiting for tin. But did not happen :)

Pricked 3 days oxytocin, an antibiotic and anesthesia. (I do not know which one). I have PKS and the first birth, very sick, especially after oxytocin. I was worried that I didn’t know what contractions and childbirth were in general, PKS: in the morning I got up and went for an operation. And after oxytocin it became clear how it would be ...
Nosh-poo allowed, you could ask for a candle, and a hot-water bottle with ice.

I did not anesthetize the childbirth, but I was tolerant, if the pain is unbearable - I need to anesthetize, IMHO. As for anesthesia, when it is necessary to alleviate the suffering of the dying - is it generally necessary, the meaning of enduring something?

Discussion

I do not think anesthesia is a whim. I did not anesthetize the childbirth, but I was tolerant, if the pain is unbearable - I need to anesthetize, IMHO. As for anesthesia, when it is necessary to alleviate the suffering of the dying - is it generally necessary, the meaning of enduring something?

06/03/2016 22:01:52, NuANS

well, specifically on the topic - in general, anesthesia is not evil, I do not think. but personally in my examples: during childbirth, now, would know not to anesthetize, in case of cancer, instead of anesthesia, euthanasia. clean imho

Currently, the best way to manage the delivery of infected women is not fully defined. To make a decision, a doctor needs to know the results of a comprehensive virological research. Natural childbirth includes a whole range of measures aimed at adequate anesthesia prevention of fetal hypoxia and early discharge of amniotic fluid to reduce injuries to the birth canal of the mother and the baby’s skin. Only with the observance of all preventive measures occurs ...

Discussion

Totally agree. Unfortunately, at the moment there is no consensus on the safest management of labor for hepatitis C. According to statistics, the probability of a child being infected with hepatitis is somewhat lower with a planned cesarean section than with natural births. However, none of these methods can guarantee the safety of the child in terms of infection with hepatitis. Therefore, the choice of the method of obstetric care is based more on obstetric history than on knowledge of the presence of this infection.

At lunch I already said that anesthesia is not necessary. Nothing hurted, neither the head, nor a back, not legs. 2 cc with spinal. The first cc after 6 hours of childbirth, after anesthesia, she felt in paradise, and after 15 minutes she was given a baby.

Discussion

Do not be afraid. I also had some reasons for this, but in the end I gave birth in a natural way :) Too good.

With the first daughter was no problem. one spike, everything was cut off from chest to toe. I tried to consider the process in the reflection of the llamas and in the tile, but the medical staff spoke their teeth and did not let them look, which is a pity. I'm glad I heard my daughter's first screams. They gave me a kiss on the heel :) very touching. I gave birth to the second one in the same way, only exhausted all the nerves (I gave birth for free) - in the operating room it was shaking either from the cold or from the nerves; the result: anesthesia did not work - they gave a common one. I did not hear the first shouts, it was difficult to leave.

1 ... when you visit your grandmother, put on your cap just before you ring the door of her apartment. After all, she does not like that if you go in the winter without a hat! 2 ... you don't always have perfect order in your apartment. But what is there, his reign is so short-term that often goes unnoticed. 6 ... you are convinced that tears make you irresistible. And you do not believe the mirrors that are trying to convince you otherwise, this is unfortunate lighting, but in reality everything is not ...

Since ancient times, pain in childbirth people perceived as evil, attributed to the punishment emanating from supernatural forces. To coax these forces, amulets were used or special rituals were performed. Already in the Middle Ages, they tried to apply decoctions of herbs, poppy heads, or alcohol for the anesthesia of childbirth.

However, the use of these drinks brought only slight relief, accompanied by serious adverse events, especially drowsiness. In 1847, English professor Simpson first used ether anesthesia for pain relief of childbirth.

Physiological basis of pain during childbirth.   Usually contractions are accompanied by painful sensations of varying severity. Many factors affect pain in childbirth, their intensity, really painless childbirth are rare. Pain during contractions due to:

1. Opening the cervix.

2. Contraction of the uterus and tension of the uterine ligaments

3. Irritation of the peritoneum, the inner surface of the sacrum due to mechanical compression of this area during the passage of the fetus.

4. Pelvic floor muscle resistance.

5. The accumulation of tissue metabolism products formed during a prolonged contraction of the uterus and a temporary disturbance in the blood supply of the uterus.

The strength of the painful sensation depends on the individual characteristics of the pain sensitivity threshold, the emotional state of the woman and her attitude to the appearance of the child. It is important not to be afraid of childbirth and labor pain. Nature has taken care to provide the woman with the necessary pain relievers for the childbirth. Among the hormones produced during childbirth, a woman's body releases a large amount of hormones of joy and pleasure - endorphins. These hormones help a woman to relax, relieve pain, give a feeling of emotional lift. However, the mechanism of production of these hormones is very fragile. If a woman experiences fear during labor, then reflexive suppression of endorphin production and release of significant amounts of adrenaline (stress hormone produced in the adrenal glands) into the blood occurs. In response to the release of adrenaline, convulsive muscle tension (as an adaptive form of response to fear) occurs, which leads to squeezing of muscle vessels and disruption of the blood supply to the muscles. Disruption of blood supply and muscle tension irritates the receptors of the uterus, which we feel as pain.

The effect of pain on childbirth.   In the uterus there is a complex system of receptors. There is a relationship between painful stimulation of uterine receptors and the accumulation of a labor hormone (oxytocin) in the pituitary gland. The facts of the reflex effects of various pain stimuli on the motor function of the uterus are established.

Feelings during childbirth largely depend on the mental state of the woman. If all the attention of the mother is concentrated only on pain, a violation of homeostatic mechanisms, a violation of normal labor, can occur. Pain, fear and excitement during labor stimulate that part of the nerve fibers that irritate the circular fibers of the uterus muscles, thereby resisting the pushing efforts of the longitudinal fibers of the uterus and violate the opening of the cervix. Two powerful muscles begin to resist each other, this leads to the musculature of the uterus in great tension. The stress is average and perceived as pain. Overstress causes a malfunction in the baby through the placenta. If this phenomenon is short-lived, then the fetus does not suffer, as much less oxygen saturation is necessary for its life support than for an adult. But if this situation persists for a long time, then due to the lack of oxygen, irreversible damage to the tissues and organs of the fetus, primarily its brain, as the organ most dependent on oxygen, can occur.

The main task of labor pain relief is an attempt to break this vicious circle and not bring the muscles of the uterus to overstretch. Many women prepared for childbirth can cope with this task on their own, without resorting to medication due to psychological stability and various psychotherapeutic techniques (relaxation, breathing, massage, water procedures). Other women just need to provide appropriate medical care, easing the feeling of pain or dulling the reaction of the nervous system to pain. If this is not done on time, then overstressing the uterine muscles can lead to negative consequences for the mother and fetus.

Drugs used for pain relief childbirth should meet the following requirements:

1. Have a sufficiently strong and rapid analgesic effect.

2. Suppress negative emotions, a feeling of fear, while not disturbing the mother-child’s consciousness for a long period.

3. Do not have a negative impact on the mother and fetus, slightly penetrate through the placenta and into the brain of the fetus.

4. Not to have a negative impact on labor, the woman’s ability to participate in childbirth and the course of the postpartum period.

5. Do not cause drug addiction with the required course of taking the drug.

6. To be available for use in any obstetric institution.

The following groups of medical preparations are used for labor pain relief:

1. Antispasmodics   - medicinal substances that reduce the tone and contractile activity of smooth muscles and blood vessels. As early as 1923, Academician A.P. Nikolaev suggested using an antispasmodic agent for pain relief in labor. The following drugs are commonly used: DROTAVERIN (NO-SHPA), PAPAVERIN, BUSKOPAN. The purpose of antispasmodics is shown:

Women in labor who did not undergo sufficient psychoprophylactic training, who show the features of weakness, nervous system imbalance, are too young and older women. In such cases, antispasmodics are used at the beginning of the active phase of the first stage of labor (at 2–3 cm cervical dilatation) in order to prevent birth pain and only partly to eliminate it. It is important to wait for regular stable contractions, otherwise this process of childbirth may stop.

To women in labor, as an independent painkiller for already developed pains, or in combination with other means, when opening the cervix by 4 cm or more.

With the development of labor activity, antispasmodics do not affect the strength and frequency of contractions, they do not violate the consciousness of the parturient woman and her ability to act. Antispasmodics help to cope well with cervical dilatation, relieve smooth muscle spasm, reduce the duration of the first stage of labor. Negative effects on the fetus do not have. From side effects there is a drop in blood pressure, nausea, dizziness, weakness. However, the analgesic effect of these drugs is not pronounced.

2.​ Non-narcotic analgesics:   ANALGIN, TRAMAL, TRAMADOL. The use of drugs in this group, in spite of a good anesthetic effect, has some limitations in labor.

In particular, analgin when prescribed at the very beginning of labor can weaken the contraction of the uterus and lead to the development of weak labor. This is due to the fact that analgin suppresses the production of prostaglandins, which accumulate in the uterine wall in order to ensure the correct functioning of the uterus muscles during labor. At the same time, when labor activity is expressed, analginum does not affect the contractility of the uterus. In addition, analgin affects blood clotting, which can increase blood loss in childbirth. And the use of a combination of analgesics with antispasmodics shortens the duration of the first stage of labor. Contraindications for the use of analgin in childbirth are renal or liver dysfunction, blood diseases, bronchial asthma.

In addition to pain medication, tramadol has a sedative effect, which is useful for the pronounced emotional component of labor pain. However, the sedative effect of tramadol allows it to be attributed to an intermediate position between analgesics and drugs. Respiratory depression in the parturient in the application of tramadol, as a rule, does not occur, rarely causes transient dizziness, blurred vision, impaired perception, nausea, vomiting and itching. It is forbidden to use these drugs in late toxicosis of pregnancy (pre-eclampsia). However, the use of these drugs is limited, as with repeated injections they affect the nervous system of the fetus, slow down the breathing of the newborn, and violate its heart rhythm. Premature newborns are especially sensitive to these drugs.

3. Sedatives -   sedatives, relieving irritability, nervousness, stress. These include DIAZEPAM, HEXENAL, TIOPENTAL, DROPERIDOL Hexenal and thiopental are used in labor as components of medical anesthesia to relieve arousal, as well as to reduce nausea and vomiting. Side effects of these drugs include hypotension, respiratory depression. They quickly penetrate the placental barrier, but at low doses do not have a pronounced depression in mature full-term newborns. During labor, these drugs are rarely prescribed. The main indication for their use is to obtain a rapid sedative and anticonvulsant effect in pregnant women with severe forms of preeclampsia.

Diazepam does not have an analgesic effect, so it is prescribed in combination with narcotic or non-narcotic analgesics. Diazepam is able to accelerate the opening of the cervix, helps to relieve anxiety in a number of pregnant women. However, it easily penetrates the fetal blood, therefore it causes respiratory disorders, a decrease in blood pressure and body temperature, and sometimes signs of neurological oppression in newborns.

Droperidol causes a state of neurolepsy (calm, indifference and alienation), has a strong antiemetic effect. In obstetric practice has received considerable distribution. However, you should be aware of the side effects of droperidol: it causes poor coordination and weakness in the mother, respiratory depression and pressure drop in the newborn. With high blood pressure in the woman, droperidol is combined with analgesics.

4.​ Narcotic analgesics:   PROMODOL, FENTANIL, OMNOPON, GHB

The mechanism of action of these drugs is based on interaction with opiate receptors. It is believed that they are safe for mother and child. They act soothingly, relaxes, keeping the mind. They have an analgesic, antispasmodic effect, promotes cervical dilatation, contribute to the correction of uncoordinated uterine contractions.

However, all narcotic drugs have a number of disadvantages, the main of which is that in high doses they depress respiration and cause drug dependence, a state of stupor, nausea, vomiting, constipation, depression, and lower blood pressure. Drugs easily penetrate the placenta, and, the more time passes from the moment of introduction of the drug, the higher its concentration in the blood of the newborn. The maximum concentration of promedol in the blood plasma of a newborn is noted 2-3 hours after its administration to the mother. If the birth occurs at this time, then the drug causes a temporary depression of the child’s breath.

Sodium oxybutyrate (GHB) is used when it is necessary to provide a rest to the mother. As a rule, with the introduction of the drug sleep occurs after 10-15 minutes and lasts 2-5 hours

5.​ Inhalation pain relief childbirth   NITRIC OXIDE, TRILENE, PENTRANE

These methods of pain relief have been used for a very long time. Ether for anesthesia of childbirth is currently not used, as it significantly weakens the labor activity, can increase blood pressure, adversely affect the fetus.

Inhalation pain relief of labor by inhalation of painkillers are still widely used in obstetric practice. Inhalation anesthetics are used in the active phase of labor when the cervix is ​​opened for at least 3–4 cm and in the presence of severe pain in contractions.

Nitrous oxide is the main inhalation agent used for the anesthesia of obstetric operations, and for the anesthesia of childbirth. The advantage of nitrous oxide is safety for the mother and fetus, the rapid onset of action and its rapid termination, as well as the absence of a negative effect on the contractile activity, and a strong odor. Nitrous oxide is given through a special apparatus using a mask. A woman in labor is introduced to the technique of using a mask and she herself applies the mask and inhales nitrous oxide with oxygen as needed. Inhaling his woman feels dizzy or nauseated. The effect of gas manifests itself in half a minute, so at the beginning of the fight you need to take several deep breaths.

Trilene is a clear liquid with a pungent odor. It has an analgesic effect even in small concentrations and with preservation of consciousness. Does not suppress labor activity. This is a well-controlled, fast-acting agent - after stopping inhalation, it quickly ceases to have an effect on the body. The downside is an unpleasant smell.

6.​ Epidural anesthesia during childbirth and caesarean section

The performance of epidural analgesia consists in blocking pain impulses from the uterus along the nerve pathways entering the spinal cord at a certain level by injecting local anesthetic into the space around the spinal cord envelope.

Performed by an experienced anesthesiologist. The time for the onset of epidural analgesia is determined by the obstetrician and anesthesiologist, depending on the needs of the woman and the child during childbirth. Usually it is carried out with established regular labor and the opening of the cervix for at least 3-4 cm.

Epidural lumbar anesthesia is performed in the lower back while the woman is sitting or lying on her side. After treating the skin in the lumbar spine, the anesthetist puncture between the vertebrae and enters the epidural space of the spine. First, a test dose of anesthetic is injected, then, if there are no side effects, a catheter is installed and the required dose is administered. Sometimes the catheter can touch the nerve, causing a shooting sensation in the leg. The catheter is attached to the back; if it is necessary to increase the dose, subsequent injections will no longer require repeated puncture, but will be made through the catheter.

Anesthesia usually develops 10–20 minutes after epidural administration and can be continued until the end of labor, as a rule, it is very effective. Epidural anesthesia is safe for mother and child. Side effects include a decrease in blood pressure, back pain, weakness in the legs, and headaches. More severe complications - toxic reaction to local anesthetics, respiratory arrest, neurological disorders. They are extremely rare.

Sometimes the use of epidural anesthesia leads to a weakening of labor activity. At the same time, a woman cannot effectively squeeze, and thus the percentage of surgical interventions (obstetric forceps) increases.

Contraindications to the use of epidural anesthesia are: impaired blood coagulation, infected wounds, scars and tumors at the site of puncture, bleeding, diseases of the nervous system and spine.

With a sufficient degree of safety, epidural anesthesia can be used for caesarean section. If an epidural catheter is already installed in labor and there is a need to perform a cesarean section, it is usually sufficient to insert an additional dose of anesthetic through the same catheter. A higher concentration of the drug allows you to cause a feeling of "numbness" in the abdominal cavity, sufficient for surgery

7. General anesthesia.   The indications for the use of general anesthesia during childbirth are emergency situations, such as a sharp deterioration of the child’s condition and maternal bleeding. This anesthesia can be started immediately and causes a rapid loss of consciousness, which allows immediate cesarean section surgery. In these cases, general anesthesia is relatively safe for the child.

The use of any painkillers during childbirth is carried out only by obstetricians-gynecologists and anesthesiologists-resuscitators. Nurses, anesthetists and midwives carry out the appointment of doctors, monitor the status of the woman and note possible side effects that require changes in treatment.

Currently, the need for anesthesia of childbirth, especially in cases of their pathological course and the presence of concomitant extragenital pathology in the woman in childbirth, is obvious. The advantages of analgesia during childbirth are not only to alleviate the suffering and reduce the emotional stress of the woman, but also to interrupt the sympathoadrenal response to pain, ensure the stability of the cardiovascular system, improve uteroplacental blood flow. Effective labor anesthesia helps to reduce energy consumption, the work of the respiratory system, reduces oxygen consumption, prevents hyperventilation, hypocapnia and respiratory alkalosis, and also prevents the development of vasoconstriction and reduction of uteroplacental blood flow.

The choice of anesthesia method is carried out by the anaesthesiologist and reanimatologist, together with the leading childbirth obstetrician, taking into account the severity of the pain syndrome, the obstetric situation, the expected time of birth, the presence and severity of concomitant extragenital pathology, as well as contraindications to various methods of anesthesia.

However, this does not mean that all parturients need medical anesthesia. The effectiveness of various non-pharmacological methods is based on the natural activation of a woman’s own antinociceptive system in the prenatal period.

NON-MEDICAL IMPACT

Various methods of physiopsychological prophylactic preparation of pregnant women for childbirth as well as hypnosis and suggestion, acupuncture and electroacupuncture, electroanalgesia and transcutaneous electroneurostimulation are referred to non-pharmacological methods. In various studies using these methods, the principal possibility of achieving analgesia, the absence of a negative effect on the mother and fetus, and a favorable effect on the course of labor are shown. Nevertheless, at present, the use of these methods of analgesia in obstetrics is limited due to lack of motivation, a high probability of partial anesthesia, and the lack of necessary experience from doctors.

PHARMACOLOGICAL ANESTHETIC METHODS

Drugs used for pharmacological anesthesia should ideally meet the following requirements: provide controlled analgesia, be available, have a strictly selective analgesic effect (without a pronounced sedative and narcotic effect), should not inhibit the birth activity and have a negative effect on the fetus and newborn. An increase in the duration of the analgesic effect can be achieved by the combined use of pharmacological agents capable of potentiation. However, it is known that almost all drugs used for pain relief of childbirth penetrate the placenta and can have an adverse effect on the fetus.

MORPHINOMYMETICS (OPIOID ANALGETICS)

Morphinomimetics are widely used in obstetric hospitals for labor pain relief, their use should be considered as a variant of replacement therapy in case of insufficiency of the woman’s own antinociceptive system. The most effective systemic opioids are narcotic analgesics: trimeperidine (promedol © 10–20 mg IV and 20–40 mg IM / a), fentanyl (50–100 µg IV). In recent years, non-narcotic opioid analgesics (tramadol, butorphanol, nalbuphine) - partial agonistants of antagonists with respect to different types of opioid receptors, are widely used; they cause less pronounced biological reactions compared to full agonists.

Preparations of this group may weaken the contraction of the uterus when administered during the latent or early part of the active phase of labor. At the same time, when the development of labor has stabilized, they can correct discoordinated uterine contractions due to a decrease in the basal tone of the uterus and the level of adrenaline secretion in response to anesthesia. A certain sedative effect appears to be useful in case of a pronounced emotional component of generic pain. The use of a combination of analgesics with antispasmodic agents shortens the duration of the first stage of labor. Intravenous administration of morphinomimetics compared with intramuscular allows reducing the effective dose by 35–40%, more likely to achieve adequate analgesia (5–10 min and 30–40 min, respectively), rarely causes short-term dizziness, even less often nausea, vomiting and itching.

Depression of respiration in the mother, as a rule, does not occur. Repeated administration of opioid analgesics is undesirable due to the possible depressive effect on the central nervous system of the fetus and newborn (lack of fetal heart rate variability, respiratory depression and neurobehavioral disorders in the newborn). Premature newborns are especially sensitive to these drugs.

INHALATION ANESTHETICS

Currently, of the products in this group, only nitrous oxide C (N2O) is used in a concentration of up to 50%, to avoid hypoxia, it is used in a mixture with oxygen. For pregnant women who received parenteral analgesics, concentrations of nitrous oxide C and oxygen in the ratio of 30 and 70% can be recommended. Sometimes neuroaxial methods of analgesia, despite their high efficiency, also require central potentiation of their effect with nitrous oxide © in the second stage of labor. N2O allows you to achieve pain relief in most women in labor and, as a rule, does not turn off the mind. The method is highly manageable: analgesia occurs within a few minutes, and after stopping the supply of anesthetic, its complete elimination quickly takes place (after 3-5 min). Perhaps training mothers autoanalgesia. N2O has virtually no effect on uterine contractility.

Thus, the short-term use of nitrous oxide © in the absence of signs of fetal hypoxia is fully justified. In the period of exile, inhalation analgesia of N2O is advisable to combine with the pudendal unit.

Of the side effects, confusion, nausea and vomiting may occur, therefore, N2O analgesia is recommended in women with empty stomach. Unfortunately, the method requires the use of special anesthetic equipment, which makes it possible to dispense the concentration of N2O and automatically stop the supply of the latter in the event of an interruption in oxygen supply. Inhalation of N2O for a long time leads to pollution of the atmosphere of the delivery room, as well as to the high consumption of medical gases, which makes the method costly.

NON-INNALING ANESTHETICS, TRANSCILIZERS

For vaginal delivery or small obstetric manipulations, in addition to local anesthesia, ketamine is used in a dose of 0.2–0.4 mg / kg IV, but not more than 100 mg in 30 minutes. Ketamine has a good analgesic effect, does not affect the hemodynamics of the woman, the contractility of the uterus and the condition of the fetus. The use of benzodiazepines (diazepam, midazolam) in labor is undesirable because of their ability to cause prolonged depression of the fetus, amnesia for the period of labor in the mother.

REGIONAL METHODS OF ANALGEZY

Undoubtedly, the most effective - methods of regional analgesia. They are widely used because of the high quality and controllability of pain relief during labor, comfort for the parturient woman, and a small number of side effects. The methods of regional analgesia include periodic fractional (bolus) or continuous administration of local anesthetics, opioids, and their combinations in the epidural and (or) subarachnoid spaces. Modern advances in anaesthesiology have contributed to introducing into the practice of labor pain relief such variants of prolonged epidural analgesia as patient-controlled analgesia and combined spinal-epidural anesthesia.

Indications for regional analgesia in labor

· Anomalies of labor (discoordinated labor, dystocia of the cervix, excessive labor).
· Gestosis of moderate and severe.
· Preterm labor.
· Primiparous young age.
· Severe extragenital pathology (diabetes, asthma, hypertension, etc.).
· Individual intolerance to pain (low pain threshold).

Absolute and relative contraindications for regional analgesia were discussed in the anesthetic maintenance section of obstetric operations.

High efficacy and safety for the mother and fetus of regional methods of analgesia are possible only under certain conditions. These include:

· Consent of the woman in labor;
· Appropriate qualifications of the birth team (obstetrician, anesthesiologist, neonatologist), and the possibility of the permanent presence of the anesthesia team in the delivery room;
· Availability of equipment and equipment for emergency care in case of complications;
· The ability to monitor the status of the woman and the fetus (cardiac monitoring, pulse oximetry, CTG and hysterography);
· Compliance with measures aimed at the prevention of aortocaval compression syndrome and arterial hypotension in the mother.

Despite the fact that epidural anesthesia is recommended for the development of regular labor and the opening of the uterine throat by 3-4 cm, it is advisable to perform catheterization of the epidural space in advance when the woman is able to take the position necessary for puncture, and does not experience pronounced discomfort (natural delivery after a previous CS, with a high probability of operative delivery, with severe preeclampsia, possible “difficult intubation”, etc. ).

Prolonged epidural analgesia is achieved by periodic fractional (bolus) or continuous administration of low concentration local anesthetics. The most commonly used in obstetrics are low concentrated bupivacaine (0.0625% –0.25%), ropivacaine (0.2%), lidocaine (0.5–0.75%) solutions, which provide a good sensory block with a minimum motor block. Peak action with the introduction of bupivacaine is reached after 20 minutes, analgesia lasts about 1.5 hours. Analgesia with the use of lidocaine begins within 10 minutes after administration and lasts 45–60 minutes. Ropivacaine is slightly weaker than bupivacaine, but it is less cardiotoxic (with an unintended intravascular injection) and causes a weaker motor block. Infusion of anesthetic data at a rate of 8–12 ml / h allows adequate blockade at TX – SIV level (Table 13-1).

Table 13-1. Use of local anesthetics for epidural anesthesia during labor

If it is impossible to use local anesthetics (allergic reactions, hypovolemia, heart defects, pulmonary hypertension, etc.), the method of choice for pain relief during labor is epidural or subdural analgesia using narcotic analgesics: morphine, trimeperidine. The latter do not cause sympathetic blockade and do not inhibit motor activity. The introduction of epidurally 2.5–5 mg of morphine provides prolonged analgesia for up to 12–24 hours, however, it may be accompanied by side effects (nausea, vomiting, pruritus).

The ability of hydrophilic opioids to rapidly spread to the higher parts of the central nervous system and easily penetrate the placental barrier leads to inhibition of the mechanisms of reflex regulation of respiratory function in the mother and newborn. Fentanyl, which is widely used abroad (10–20 µg intrathecally and 50–75 µg epidurally), is currently not applicable to Russian practice due to the lack of permission to use it in regional anesthesia methods.

The combination of local anesthetic and opioid can reduce the dose, improves the quality of the epidural block during childbirth, as it allows you to effectively influence both the somatic and visceral component of pain, reduces the risk of arterial hypotension and toxic side effects.

There are the following ideas about the effect of epidural analgesia on the course of labor:

· Epidural analgesia does not change the frequency of operative delivery, but increases the frequency of instrumental benefits during labor;
· The change in the duration of the opening period of uterine pharynx during regional analgesia depends on the method and the drugs used, with epidural analgesia the expulsion period is prolonged;
· When adding epinephrine to a solution of a local anesthetic, the activity of the uterus is inhibited, the intensity of contractions decreases. At the same time, the development of an effective epidural block helps to reduce the concentration of catecholamines in the patient's plasma, increase the tone of the uterus (parasympathetic influence), reduce the frequency of oxytocin use to stimulate labor;
· In 5-17% of cases, hypertonicity of the uterus is accompanied by the development of fetal bradycardia (manifestation of acute hypoxia). In this situation, it is necessary to exclude arterial hypotension in the parturient due to sympathetic block and aortocaval compression syndrome, apply sublingual spray of nitroglycerin in a dose of 100 μg or intravenous dosage of infusion with dose titration from 50 to 500 μg. Tocolytic effect lasts up to 10 minutes.

Maternity-controlled epidural analgesia is a modification of long-term epidural labor anesthesia by the method of prolonged infusion. A woman in labor by pressing the trigger, if necessary, can introduce a single dose of a local anesthetic with or without opioids, triggering the plunger of a syringe connected to an epidural catheter. The baseline infusion rate, the volume of boluses and the minimum blocking intervals between administration are determined by the anesthesiologist.

In some cases, it is advisable to use a combined spinal-epidural anesthesia and analgesia during childbirth. A local anesthetic (sometimes with the addition of opioids) is administered subarachnoid, achieving rapid anesthesia, which is supported by the additional introduction of anesthetic through the catheter. The advantage of the method over the epidural introduction of anesthetic is the immediate onset of anesthesia, the possibility of active participation of the mother in the process of childbirth. Reduced motor block, reduced frequency of instrumental deliveries due to the introduction of lower doses of local anesthetics.

Thus, the growth of knowledge in the field of physiology and pharmacology of pain, as well as the development of obstetric anesthesiology as a separate area of ​​the specialty, have improved the quality and effectiveness of analgesia during childbirth and made it accessible to all pregnant women. Regional analgesia today in many hospitals is considered as part of the standard obstetric benefits.