تسكين آلام الولادة بالتخدير الموضعى للحوض

[الشافعى الصغير]

تسكين آلام الولادة بالتخدير الموضعى للحوض " ابرة الظهر " Epidural (بالصور) ..
التخدير الموضعى للحوض Epidural أثناء الولادة



يتضمن تسكين الألم أثناء الولادة العديد من الطرق مثل ابرة البثيدين، أو المورفين المخففة للألم وكذلك قناع الاكسجين مع غاز ثاني اكسيد النيتروجين (انتونكس) وابرة الظهر المعروفة بالابيديورال (Epidural).واصبحت الاخيره من التقنية الشائعة ومن حسناتها انها تخدر القسم السفلى من الجسم ولا تفقد الحامل وعيها ووفقا لكمية المخدر المعطاة يمكن ان تشعر المرأة بعض الشىء بالعمل الجارى او لا تشعر به مطلقا

تخضع الحامل للتخدير الموضعى حين يتمدد عنق الرحم جيدا ليصل الى 3سم تقريبا وهى تؤثر على الأعصاب المتمركزة فى النخاع الشوكى وليست كل دور توليد مجهزة بالفريق الكفوء لاجراء التخدير الموضعى اذ يتطلب هذا الامر وجود طبيب بنج بشكل متواصل لذلك مهم جدا قبل ان تطلبى استعمال هذة التقنيه ان تسألى وتستفسرى من طبيبك وتجرى مقابلة مع طبيب التخدير المتمرس... كما لكى الحق ان ترفضى عملية التخدير بهذة الطريقة اذ كنتى تريدى ان تكون ولادتك طبيعية او لو كنتى غير مطمئنه لأخذها

ابرة الظهر نوعين

1-SPINAL ANALGESIA


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وهي عن طريق حقن ابرة رفيعة جدا وجرعة واحدة في السائل او الSUBARACHNOID SPACE اي في السائل المحيط بالحبل الشوكي وهي تحتاج الى نسبة بسيطة جدا من جرعة التخدير لانها تؤدي الى التخدير الجزء السفلي من الجسم وهى اقوى من ابر الظهر الاخرى المستخدمة للولادة الطبيعية حيث تستخدم هذه الابرة لغرض الولادة القيصرية ...ويمكن استخدامها بالمشاركة مع ابرة الظهر المسمى بالEPIDURAL ANALEGSIAولكن بعدها تتم ازالةالابرة من مكان الحقن ووضع مضخة في الظهر في الDURA SPACE اي الاغشية السحائية الخارجية ....في حالات الولادة الطويلة والمتعسرة .

2- EPIDURAL ANALEGESIA

فهي حقنة الظهر التي تستخدم اكثر لتخفيف آلام الولادة في بعض الولادة التي يصحبها ضغط واجهاد ووقت طويل وساذكر لاحقا استخداماتها الاكثر

هذة الابرة المستخدمه

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طريقة الحقــن

يبدأ الطبيب اولا باعطاء المريضة محلول في الوريد لتجنب هبوط الضغط على شكل preload of 500-1000ml of crystalloid ونبدا بالتقنية عن طريق تعقيم المنطقة اولا لمنع انتشار او دخول اي بكتيريا عبر هذه الفتحة الى الدماغ والحبل الشوكي ثم عن طريق حقن ابرة تجريبية لتاكد من وضعها الصحيح ..مابين الفقرة L2-3اوL3-4اكثر شيوعا واكثر امانا ...وتقوم الابرة اولا بشفط الهواء للخارج للتاكد من عدم خروج دم او السائل الشوكي وعند التاكد من المكان الصحيح يقوم الطبيب بحقن المادة المخدرة بجرعة تجريبية لتاكد من مفعولها ومكانها اثر TESTING DOSE عن طريق حقن 2ml OF 0.5 percent buivacaine حيث ان هذا الدواء وبهذه الجرعة له تاثير بطيء جدا اذا كان في منطقة الاغشية السحائية الخارجية بينما اذا كان قريب جدا او داخل السائل الشوكي يكون تاثيره جدا سريعا ويؤدي الى خدر سريع وضعف في الساقين وهبوط في الدم


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صورة توضح مكان دخول الابرة بين فقرات الظهر في الغضروف بعيدا عن الاعصاب

والطبيب بهذا الحقن يري ان تكون في الاغشية الخارجية فقط الduraاذا لم تظهر اعراض الاغشية الداخلية subarachanoid spaceو عند التأكد من المكان خلال 5دقائق من الملاحظة يبدأ الطبيب باعطاء الجرعة التمهيدية loading dose

وبعدها يجب ان تسلتقي المراة على احد جوانبها ويفضل ان يكون الجانب الايسر حتى يميل الرحم ناحية اليسار ويخف الضغط على الوريد التجويفي الذاهب الى القلب.... مع وضعية ميلان السرير حسب درجة الهبوط في الضغط لديها وملاحظة الضغط كل خمس دقائق لمدة نصف ساعة

و يأخذ مفعول الابرة الاولية من3- 5دقائق حتى يخدر الرحم وخلال عشرة دقائق تحس المراة بخدر عام في الجزء السفلي


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لذلك تحس المراة براحة اكثر اثناء الدفع اما في الحالات التي لا يكون الدفع فيها جيد او مؤثر توقف الجرعة عن طريق المضخة التي تكون ملتصقة في ظهر الحامل طبعا من دون الابرة عبر سلك من البلاستيك يضخ كمية المخدر في الظهر ...للتاكد من الدفع الجيد ثم يعاود الطبيب ضخ المخدر مرة اخرى حتى يتأكد من سيطرة المراة على الوضع والدفع اكثر

وضعية الحامل اثناء اخذ الابرة


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وتتم ملاحظة تقلصات الام ونبضات قلب الجنين عن طريق الCTGلتاكد من وضع الجنين لانه هذا النوع من التخدير يسبب احيانا تباطؤ ضربات قلب الجنين و في حالة تعب الجنين وطول الولادة قد يلجا الطبيب لايقاف التخدير واحيانا الى الولادة القيصرية ...قد لاتكون هذه الطريقة ذات تاثير قوي في بعض الحوامل الاتي يكون وضع الجنين عندهم ضاغط على الخلف والظهر اكثر مما يسبب الم في الظهر

صورة لتوضيح المنطقة المخدرة بهذه الطريقة من التخدير


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فوائـد استخدامها

1-الولادة الطويلة ...كالبكرية وغيرها
2-الحمل المتعدد كالتوائم
3-بعض الحالات المرضية التي تكون مصاحبة للام اثناء الحمل وتحتاج الى هذا النوع من التخدير كالمصابات بداء السكرى او بداء فى القلب او اللواتى كان ينبغى ان يخضعن لعملية ولادة قيصرية ..
4-عندما يكون هناك حاجة لتدخل جراحي من قبل الطبيب اثناء الولادة ككبر حجم الجنين والحاجة الى استخدام شفط او ملقط جراحي لتسهيل خروج الجنين على الام
5-فى حال عدم اتساع الرحم فهذة التقنية تجعله أكثر ليونة وتسرع عملية الاتساع بسبب اثرها المضاد للتشنج

اما في حالات الام التي لديها ولادة سابقة فلاتنصح بها لان مدة توسع عنق الرحم للاستعداد للولادة تكون قصيرة احيانا تاخذمن30-60دقيقة ...وستكون ولدت خلال مدة قصيرة اذا لم تكون هناك مشاكل لتاخر الولادة وبالتالي ستكون عرضه للاصابه بالآثار الجانبيه اكثر من الاستفاده منها

موانع استخدامها

1-اذا كان هناك مشاكل في الدورة الدموية من تخثر اوسيولة
2-التهاب موضع او عام في الجسم حتى لايصل الى الدماغ عبر هذه الفتحة
3-هبوط في الدورة الدموية HYPOVOLOEAMIA
4-عدم وجود فريق متمرس من الاطباء لهذا النوع من التخدير
5-في حالات حدوث مشاكل ونزيف كالمصاحب للمشيمة النازلة او حالة تسمم الحمل الشديد او تعب الجنين FETALDISTRESS

الاعراض والآثار بعد الولادة

1-حدوث خدر وقشعريرة مثل البرد في جانب واحد من الجسم فقط كرد فعل للتخلص من الالم

2- صداع مابعد الولادة ويمكن التخلص منه خلال 4-6 ساعات وعن طريق اخذ مسكنات بشرط ان لاتؤثر على الضغط والاستلقاء بطريقة افقية في الفراش

3- قد تشتكي بعض النساء من صعوبة في التبول نتيجة التاثير على عضلات الجزء السفلي لكن العارض يزول خلال 4-6 ساعات

اما عن حالات الشلل التام فهي نادرة جدا هذه الايام لزيادة خبرة الاطباء في هذا المجال

واخيرا اذا ارادت المراة اخذ هذا النوع من التخدير يجب ان تكون متاكدة من دخولها مرحلة الولادة النشطة وان لايكون حدث توسع لعنق الرحم اكثر عن 3-4سم لانه بعد هذه المرحلة يكون تاثير الابره ليس بالقوي اذا قررت المراة استخدامها فجاة اثناء الولادة

[الشافعى الصغير]

Epidural Anesthesia for Labor and Birth
Medications for Labor



Making the Decision to Have an Epidural

The decision to have an epidural in your labor is best made once labor is well established. Before labor it is best to keep an open mind about all of your options, including an epidural. This means that a good childbirth class will help you learn about what an epidural is and what it isn't, so that there are few surprises once labor starts
If you are at the hospital and you would like to have an epidural, you will probably have a consultation with the anesthesiologist or nurse anesthetist before getting an epidural. This is a chance for them to get a complete medical history from you, including drug allergies, previous reactions to anesthesia and your family history. This is also the time for them to explain the procedure and what to expect

You will also have an opportunity to ask questions about the procedure, what you will feel, what you won't feel and potential risks for you, your baby and labor

This is called informed consent and should happen with every medical decision that is made. Remember to use your BRAIN.

Get the benefits, risks, alternatives, intuition, not now, later
Once all of this is done, you will usually be given some time to make the decision alone with your support people

Preparing for the Epidural

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IV in Labor

Once the decision has been made to have an epidural and the anesthesia team has cleared you medically, there are a few things that have to happen before it would be safe to get an epidural
You will have your blood drawn, if it has not been drawn previously at this hospital visit. You will also be given an IV in your arm. This is to give the medical team access to your veins in case emergency medications are required. It is also used to help keep you hydrated since you will not be allowed to eat or drink with an epidural in place

One of the procedures before an epidural is also to ensure that you are well hydrated. You will be given fluids, usually at least 1 liter, prior to the placement of the epidural. This is to expand your blood volume to prevent your blood pressure from dropping dangerously low and harming you or causing fetal distress when the epidural medications are started. You will get continuous IV fluids for the duration of your labor and birth

You will be attached to electronic fetal monitoring (EFM) prior to the epidural to check your baby's baseline heart rate. You will most likely have continuous electronic fetal monitoring to ensure that your baby is responding well to the medications of the epidural

The Epidural Procedure

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Once you have been prepared for the epidural procedure the anesthesia team will come in. This may be just your labor and delivery nurse and the anesthesiologist or nurse anesthetist. Typically everyone else will be asked to leave while your epidural is placed. In some hospitals, doulas are allowed to stay for the procedure, but not your husband or other family and friends

You will be asked to assume a position that will help the anesthetist find the landmarks on your body needed to place the needle correctly. This maybe sitting up on the edge of the bed leaning over and pushing your back outward or it may be laying on your side curled up in a ball, also pushing your back out. The position is uncomfortable because of the belly in the way. Most moms worry a lot about having to stay still during contractions. Be sure to talk to those with you about this fear. They will tell you what you need to do to ensure that they know when you're having a contraction, so it is well timed

Your back will be washed and a shot of a numbing agent will be given before the epidural. Then the epidural needle is placed into the epidural space around the spinal cord. A test dose is given to ensure that the epidural is in the correct place. Once this test is done the medications are set to a continuous drip. A small catheter is left in place to deliver the medications continuously throughout labor. This catheter is taped up your back so that it is difficult to remove without trying

You may be asked to lay in certain positions for awhile as the medication works with gravity. You will also have your blood pressure monitoring every few minutes, continuous fetal monitoring and other monitoring to ensure you react well with the anesthesia

Once you are numb, a urinary catheter will be placed because you can't go to the bathroom

What You Will Feel with an Epidural

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The medications used in the epidural vary widely. The amounts and mixtures, often called epidural cocktails, will largely determine what you feel. Some epidurals, like those used for surgeries, like a cesarean section, leave you feeling very little or completely numb. Some epidurals are designed so that they just barely take the edge off the pain, even allowing some women to be able to have enough control that they could walk, hence the name walking epidural. Most epidurals are some where in between

The hard part, the art part of an epidural, is getting exactly what you want with the epidural. You might order completely numb and still feel contractions. Or vice verse. About 80% of women say that their epidurals worked adequately. Some women find that they had very little pain relief, either completely or partially, known as a ******** A window is where you have one small area that you are not numb at all. This can be simply an anatomy issue with your body. The anesthetist may be able to help you, or you may need to rely on other comfort measures or IV medications to assist you

Many women are able to sleep or at least rest with an epidural. Some women feel when they are having contractions, but don't feel pain with the epidural

When it comes to pushing, you should be able to have some feeling to feel to push. Many practitioners recommend the process of laboring down, or letting the baby come down on its own without a lot of pushing on your part. In this case you wouldn't start pushing until the baby had descended well into your pelvis

[الشافعى الصغير]

Labor with an Epidural

With an epidural you will continue to have contractions. Though many women will experience a slowing of their labor once the epidural is placed. Many doctors will use a medication known as Pitocin to help augment labor or speed it up. This medication is given in your IV. You may also have your water broken

If you have been in labor awhile, you may have an opportunity to sleep or rest before it is time to push your baby out

You will be able to move around in your hospital bed, with the help of others. In fact, continuing to move your body around can help prevent some of the risks of your baby getting in a bad position and staying there. Have your support team or doula remind you to move, even if it's simply from side to side, about every half an hour. Some anesthesiologists also recommend this for better medication coverage. If you are worried about moving with tubes and monitors, ask your labor nurse to help you

You can choose to use side lying positons, semi-sitting, etc. If you have more movement or feeling in your legs, you may be able to use even more positions. Feel free to use pillows to help hold your body at appropriate angles and to give you support so that you feel and look stable

What to do if the epidural doesn't work

Occasionally the epidural does not work, for whatever reason. You may have the option of undergoing another epidural procedure. For many women this works well, for others it is eitehr not an option or simply doesn't work. If you fall into this category, you will need a back up plan

Many women will try to use other medications, like IV pain medications to help them with the pain of labor

This may be a time where your doula and other support people can also help you with non-medicinal forms of pain relief, including positioning, massage, relaxation and more

Epidural Risks

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The complications that are most common with an epidural are things like a drop in mom's blood pressure (maternal hypotension) which can lead to fetal distress if not treated, is usually quickly treated by medications and position changes. Other complications can include

fetal distress
fetal malpositioning
increase in the cesarean rate
increase in the use of forceps and vacuum
maternal fever
These are relatively common with epidurals, but corrections require various procedures. Paralysis, numbness, nerve injury, accidental spinal and infection for mom are really rare but do occur

[الشافعى الصغير]

Seven Reasons You Can't Have an Epidural


Epidural anesthesia is the most popular form of medicinal pain medication for labor and birth. Many women decide on using an epidural prior to labor and don't even look at other forms of pain relief for labor and birth. This is not necessarily a wise choice for labor and birth because there are many reasons why an epidural may not be in your future. Here are a few of the reasons you might not be able to have an epidural


You are taking certain medications
Medications that you take can effect how likely you are to be able to get an epidural. The biggest culprit are blood thinners

Your blood work isn't just right
If you have a low platelet count or sometimes other problems with your blood work may make the placement of an epidural more risky

The doctor can't find the right space
Sometimes due to the normal growth of your back, your weight or back problems, including scoliosis, it may be impossible for the anesthesiologist to find the epidural space. Therefore you can't have the epidural placed in labor

You are bleeding heavily
If you are bleeding heavily or are suffering from shock, you will not be given an epidural for safety reasons. Since many women tend to have lower blood pressure with an epidural, this may be made even more dangerous with the lowered blood pressure of some of these problems

You have an infection of the back
It is not in your best interest to have your anesthesiologist place an epidural through an area that is infected. This can cause the infection to spread to the spine and other areas of your body and can potentially cause a great deal of damage

No anesthesiologist is available
Your hospital may only have an anesthetist available during certain hours of the day or days of the week. You may also have an anesthesia department that covers an entire hospital and not just the labor and delivery unit

Labor restrictions
Some hospitals will place restrictions on when you can have an epidural. It may be that you must be at a certain point in labor, like four (4) centimeters before an epidural can be given. Other hospitals may decide that epidural should not be given after a certain point of labor, for example when you've reached full dilation -10 centimeters


What to Do if the Doctor Says No

You might be able to find out beforehand that an epidural is not in your laboring future. If this happens you are able to prepare by looking at other methods of pain relief for labor. A good childbirth class that focuses on many different types of pain relief from medications to natural forms of relief of pain may be the best option for filling your birth bag with many tools to cope with labor, particularly for the surprise revelation that you can't have an epidural

Enlist support for getting through labor. Labor is hard work, with or without pain medications. Consider hiring a doula, even if you prefer an epidural. A professional labor assistant can help you and your partner through different pain relief options including natural pain relief like relaxation, positioning, massage, etc. She will also be trained in letting you know what your other options are for pain relief like TENS, IV medications, etc

If you are concerned about these issues be sure to talk to your doctor or midwife about your fears. It's also possible and highly recommended in some cases to actually visit the hospital and have a consultation with the anesthesiology department. They may do a physical exam of your spine, take a medical history, etc. This can help answer questions you may have about epidurals and labor. Being informed ahead of time is your best solution

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Epidural Facts


Epidural anesthesia is one of the most popular forms of medications for pain relief in labor and birth. It can be used for a normal vaginal birth, a vaginal birth with forceps or vacuum extraction, or even a surgical (cesarean) birth

Unlike medications previously used or currently used narcotics, the epidural can leave the mother wide awake and mentally aware of everything going on during the birth of her baby. Pain relief varies from mother to mother, some women experience a completely numb feeling from the level of their upper abdomen down to their toes, others feel only pressure during contractions or pushing. What you will experience will depend on the medication used, the placement of the epidural, and other

It is important to discuss with your anesthetist what type of feeling you would like to have after the medication is administered

However, as with any medication or procedure there are also risks. The major complication from epidural anesthesia is a drop in the mother's blood pressure. Most hospitals will try to prevent this by giving the mother IV fluids prior to the administration of the epidural. Sometimes an epidural can lead to fetal distress, fetal malposition, increased risk of forceps or vacuum extraction, episiotomy, and in some studies, and increased risk of cesarean section

When making the decision about pain medications it's important to keep all of your options open. Learning additional coping techniques can be very useful for the time period prior to receiving the epidural or if you fall into the 12-20% that have a partial rather than full block. A good childbirth class can teach you these skills and go more in depth about the epidural and it's uses in labor and birth

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Postpartum Pain Relief



In childbirth class or hospital classes you may learn a lot about epidural anesthesia. They will probably tell you all about the risks and the benefits. You will probably learn how and when it can be administered. You might even see the procedure or talk to an anesthesiologist about the procedure, but chances are the information you receive in class will end when the epidural is placed or shortly thereafter. Many moms have questions about the epidural procedure and its effects after the birth. Here are some of the answers to those questions

Q. When will the epidural catheter be removed

A. Typically the epidural catheter will be removed with an hour or two after the birth of your baby if you had a vaginal birth. This is typically not painful, but may feel strange as the epidural catheter is pulled from your back

Many moms report the removal of all the tape to be more painful than the removal of the epidural catheter
If you gave birth via cesarean surgery, occasionally the epidural catheter will stay in for a few more hours to help provide you with pain relief after the surgery. Your anesthesiologist can also place medications like Duramorph into the epidural catheter to help provide pain relief even after the epidural catheter is removed. This medication will not cause numbing like the typical epidural medications will cause

If you are having a tubal ligation, your tubes tied, after you give birth, the epidural will stay in place until after your surgery. Your epidural catheter may be removed by the anesthesiologist or nurse

Q. How long will I be numb from the epidural

A. Many moms report being able to wiggle their toes and a slow return to sensation within hours of having the epidural medications discontinued. Part of what you will need to factor into this answer will be what type of epidural you had - continuous or bolus. If you had the continuous flow epidural, once it is turned off you can usually have full sensation back with six hours of birth. A bolus type of epidural will depend on when the last dose of medication was given

Some women experience tingling, shaking, numbness and other sensations in their legs during this period or after. It can be perfectly normal, but you do need to report it to your nurse

Q. What about the bladder catheter

A. Your bladder catheter will be removed once you can actual weight bear on your legs. If you have problems urinating after birth you may have to have the catheter placed back into your bladder to help you until you can successfully urinate on your own consistently. It is important that your bladder remain empty. Some women have more trouble with this because of the epidural medications and numbing or because of damage done to the bladder with the bladder catheter. This is usually very temporary

Q. Anything else to expect

A. Of course! You can also expect to feel very sore once the medications wear off. I encourage you to begin taking medications that your doctor or midwife has prescribed as soon as you can, preferably before the epidural medications wear off. With an epidural you are more likely to have had an episiotomy, forceps, vacuum or a cesarean. These all intensify the normal pain felt after a birth. Start with the non-narcotics and see if they help your pain level, reserve the "big guns" for later

You may find that your lower body is stiff or sore. This is frequently because your muscles are stiff from remaining in the same position for a long time during your labor. This happens because you usually are unaware of the position you are in because your legs and lower body are numbed from the medication. Simple stretching and time will generally be all that is needed to help change this. You may also feel this because of extra expulsive efforts due to your inability to feel

Get up and walk as soon as you can to help you feel more in control of your body. This can really help change your physical and emotional feelings about your body. This also speeds recovery

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