 Good afternoon everyone, today's topic is on painless delivery, something which we all know about, but we feel that we really don't know much about that in today's times. Well, painless delivery is really a reality. So often it has been said that, you know, it's the pain of labor that is really not remembered. It is the baby that is remembered, the baby who's born. But in today's time, giving a painless delivery is really a challenge and it is something a woman can really look forward to. So what is painless delivery? A painless delivery refers to the use of an epidural injection which is given by a trained anesthesiologist for pain relief during labor. It is injected in the lower back and a plastic tube is placed through which drugs are released around the spinal cord. These drugs are very safe for the baby. So you may feel the contraction, but they will not be painful. Giving birth can and it should be a beautiful experience, but the prospect of delivery may sometimes give women anxiety. I've seen women who have been with me for nine months, they've been absolutely fine and as the due date comes closer, they start becoming extremely anxious because of the anticipated pain and discomfort. It is at this point of time that we can give them an option of an epidural analgesia which can help them in taking the pains of labor relatively easily with less of anxiety. What I would like to stress is an epidural takes just about 10 minutes to place and another 10 minutes to 15 minutes to work. What would be the benefits? Well, it's very effective and we have a patient who has pregnancy induced hypertension. While you still feel the contraction, the pain has decreased significantly. So in a scale of 1 to 10, if 70% goes away, you can still manage with the 30% comfortably. Since it takes away the pain being gypy and of course it is also known to lead to a faster delivery. That means there is a smooth muscle relaxation and the cervix dilates, that is the mouth of the uterus dilates and the baby can easily come down with the increasing contractions. In today's time, we see a lot of women are opting for what is called as a CDMR, that is a serine delivery on maternal requests. One of the main reasons for it is the fear of labor and pain. So when we counsel them and we tell them that you see if you are afraid of labor and afraid of taking the pain, why don't you try a painless labor? So they then they come around it and are willing to try to have a normal vaginal delivery. So an undesirable serine section can be avoided, especially when it is a CDMR. Of course, if it needs to be done, that is if it has to be done for the sake of the baby or if there is a problem with the labor. Then the same epidural or the same painless labor method that is employed can be used to provide anesthesia and a serine can also be done. Epidurals allow you to rest, relax, get focused, give the strength to move forward and to listen to the gynecologist as she tells you when to push and how to deplete. So you get focused on the labor and ultimately it becomes a positive birthing experience. They can also help with the exhaustion, the irritability and fatigue and a woman is in a better and a very happy state of mind. The amount of epidural can be increased or decreased as and when required. This is the other advantage which Dr. Sunil who is here with us will explain in detail. As every method, even a neighbouring is concerned has some disadvantages, all of which can be taken care of. There may be some backache, some soreness. Sometimes there is a headache, what we call a post-noodle puncture headache. There may be dizziness, there may be shivering, all of which can be controlled. There may be a dip in the mother's blood pressure immediately after an epidural and there could be a decrease in the heart rate of the baby. Usually this is temporary and it is picked up. At times it may lead to an emergency system in section. There may be numbness in the lower part or a loss of sensation in the lower part after delivery. Most of the time it's only reassurance that is required because it eventually goes away. So we keep the patient under supervision. At times there may be a prolonged second stage with a reduced urge to bear down. That's when cooperation with the gynecologist is very important. We inform them how to bear down and we have to guide them through the second stage. At times even a vacuum delivery may be required. There have been instances where a woman may need help for walking. Though most of the time a woman with the epidural can have no difficulty in walking. The event of modern medicine and the availability of techniques with skilled practitioners. It is now considered inhuman not to relieve the pain of labor. In fact, most of the time I find that it is the older generation who finds it extremely difficult to believe that labor can be painless. Because this was really not something which was there in the last century. Nobody had even heard of it. Even now the acceptability is not as much as we would have it in India. And now I would say that in the 21st century it is really inhuman if we do not help the woman relieve the pain of labor. Just like a surgery is never done without anesthesia. So also techniques are available to ensure painless delivery and they should be resorted to. Of course you must remember that receiving pain relief in labor is not a prerequisite. It is entirely dependent on your tolerance level and the choices you want to make. This is just one of the choices that are there in front of you. And the idea is to put it across so that those who would wish to take it can offer it. So thank you very much. I'm Dr. Sunil Malik and a scientist and I've been trained in painless deliveries in Republic of Ireland. So thank you Dr. Leena for taking this topic forward. So I'll be discussing more about pain relief from the anesthetic point of view. So as in most of the situations in life like there are two sides of the coin and in pregnancy also like people say like nine months of pain. But I'll say like think positive. So take it as a lifetime of game. Some says nine months of sickness. But I'll say like take it as a lifetime of happiness. So nine months of pregnancy is the beginning of your legacy. So be happy and we'll take care of your pain part. So I will talk about how painful it is to understand to you know so that you can make your choice to opt for a painless delivery or any pain relieving methods or not. And why and where it hurts during the birth so that you understand the process and you understand like what we are doing to tackle that thing. And what as we can do as an anesthetist to relieve your pain. So labor pain is defined as the most intense pain a woman can experience in a lifetime and it is typically worse than a pain associated with a deep cut. And 60% of primary virus that is first pregnancy woman they describe it as unbearable intolerable and extremely severe physiological responses to pain. If I tell you like everybody has a different perception of pain. Maybe a pain which is severe for you maybe a mile for me or a vice versa. So apart from just a perception of the pain it has a physiological responses in the body as well. Like the responses on your changes in your heart or lung that in heart it causes an increase in heart rate and increase in blood pressure that causes a increased burden on your heart. And similarly in lungs also it can causes an increase in breathing causing an increase in oxygen consumption so that less of the oxygen will goes to the baby. So a negative effect on baby if you have a troubling pain so epidural will help in life. So just briefly about the stages of labor because where the pain hurts and what we do. So this is stage one you can see in the picture on the top that service is dilated at the bottom. So you feel a stretching in the bottom part and so there the pain relief is required and in the second stage the contraction is happening in the upper part of the uterus and pushing the baby down. So upper part of the tummy the pain will be there and that requires a pain relief. So a third is not that much of important for the pain relief. Then this is just to have an understanding like a pain pathway like wherever in the body the pain is initiated like in this figure. You can see your needle prick is there that now signal goes to a spinal cord and from spinal cord here is a spinal cord and from here it goes to the brain and you will perceive the signal as a pain. So what we do we interfere in this spinal cord area with epidural so that the pain signal comes to the spinal cord but it will not goes to the brain. So even if the pain is there you will not perceive it. So this is where it is important to understand the pain pathway as I say like the bottom part of yours like near a cervix and all where the nerve endings are there and the upper part of the uterus. So from here the nerve signals goes to the spinal cord area and where we with the epidural we interfere and stops the signal going up. So how severe it is like as I say like a pain perception varies from a person to person and it is very difficult to explain how severe it is. But with the studies and data we came up with the pain rating scale. So if you take a zero on the scale as no pain and 50 is a maximum what a live person can can have. So if you categorize into a 0 to 10 and then further tense with a different color. Most of the very common pains which are easily variable lies in 0 to 10 and 10 to 20 are your like pains like sprain small fracture to take for which you take a smaller energy six some pain killers. Milder ones and that is manageable. 20 to 30 is a more of a chronic back pain terminal cancer pain which are more troubling. And 30 to 40 is where a child but pain lies which can be similar to even an imputation of the dope. So in studies it has been shown that it is a very severe pain. And what we do as a other status with the epidural it normally lies in the 30 to 40 as you can see in this game. So with epidural it usually gets down below 20 and even below 10 also. So the unbearable uncomfortable pain becomes a variable now. So instead of saying like it is a total pain less delivery which might be there but we cannot guarantee that. But most of the cases you'll have a pain in the scale of 0 to 10 or maybe around 15 so that it is easily tolerable. This is just a lab labor epidural demo. I just have this video to show that what we do in a labor room to demonstrable like this one which was not visible in that part. So this is like your position will be and then a set is doing in the epidural from the back and this is the magnified view at the bottom of the epidural space. The yellow part is a spinal cord. You can see the epidural space is a very small. It's actually a millimeter kind of a space and the catheter is inserted just outside the spinal cord. So it's a very delicate thing. It's a blind thing. We don't know exactly it is just by the experience. So it needs a lot of expertise and a patience from your side as well to undergo this process. What are the benefits actually. So while you're talking a lot about labor epidural pain less deliveries. So definitely there are more of a benefits than the disadvantages. That's why we as a doctor recommend this. So the important thing is it allows you to rest. Otherwise with the labor pain you are total in a panic a lot of anxiety. So it allows you to rest and understand what is going on. So overall I'll say like it gives you a positive birthing experience which is very important. As we know that you are not coming to the hospital with some disease. So it's a delivering a baby should be a good or a happy moment. So why do you have a troubling pain around. So this will give you a positive birthing experience in most of the patients and you'll be able to alert. You'll be more alert and you'll be actively participant in the process. So you'll be able to understand more of by your obstetric doctor and your anesthetist that what you need to do and what you need to require to undergo a normal delivery. So in my experience I'll say like these all things makes a normal delivery more feasible because you will be a active participant. Otherwise you'll be jumping in the pain and you will not be able to cooperate and understand what we want from your side. Physologically it is good in various medical conditions as we discussed. So it is very important in these COVID times also because you all know that COVID causes impairment in your lung like pneumonia kind of features. So it causes less burden on your heart and lungs. So that it always give you a benefit and your baby also gets a benefit of this. So if cesarean is required the same epidural catheter can be used by giving a top up and you can have a cesarean section even with the same labor epidural in place. Everything has a side effects also like will not say that this is a full proof positive technique. It can have a side effect which are mostly tolerable, readable and even avoidable in some of the circumstances. So legs can be numb and heavy. That is the most common thing you will experience and almost every patient experiences this. But as soon as the epidural is stopped within 2 to 3 hours your legs will be back to normal. And this is due to a medicine what we give for your pain less delivery. So that is a additional or a side effect of that medicine which causes a numbness. So that's why you are not allowed to walk or stand without any assistance. So that is why we recommend if you have a labor epidural always remember your legs can be numb. Teaching is another side effect which can be due to a medicines we use for a pain relief. These are also treatable, manageable. Mostly mild doesn't require any treatment but if required it is treatable and it subsides when the epidural is stopped. No blood pressure while doing an epidural and immediately for a couple of minutes after an epidural is quite possible. But it is always manageable. We are trained for that thing and as a anesthetist we are always there to manage these things. So unless you are totally stable the anesthetist will not go away leaving you in these unstable conditions. Partial or no effect. As I say like epidural is a very delicate procedure. It is a very millimeter kind of a space and blind procedure. So the failure rates can also be there and it's not a very definitive space. So it can have a partial effect or there will not be any effect in very less number of cases. In that case a catheter manipulation will help most of the time and even sometimes rarely it requires putting an epidural again if it is really required. Hedic as Dr. Lina was also saying like PDPH you called it as post-dural puncture headache. That happens in less than 1% of the cases but there are n number of reasons for this headache. I'll say like a lot of mood changes and anxiety and a lot of other factors which can cause you a headache in these scenarios. But if you ever come across headache after an epidural you should always discuss with your doctor and report it to an anesthetist because we want to rule out epidural as a cause of headache. Because if it is known earlier in the early phase it is very easily treatable and manageable without any complications. Nerve damage some people say like they still feel tingling or some nerve damage can be there because you are doing it around the spinal cord. I'll say like a temporary nerve damage it is reported internationally in 1000 but temporary means it subsides in couple of hours or minutes or days. And sometimes takes around 6 weeks, 6 to 8 weeks in most of the cases it subsides but it is just a kind of a numbing patch somewhere in your leg which subsides automatically in couple of days. So myths are very important everybody says like permanent backache I have after an epidural I'll say like permanent backache doesn't exist it has been proven in the 30s. So just a mile or a backache for a while for a couple of hours like if you have an injection anywhere in your body you can have a backache or you can have a pain around that injection. So same with the epidural also you have an injection so it can cause you a bit soreness or pain for couple of hours or days but not a permanent. Increased chance of caesarean that is not there it this is also proved now earlier in the past the medicine a kind of medicine in doses which are used causes more relaxation of the pelvic muscles and causes more chances of caesarean. So what is we are using a very low dose of epidural regime so it retains your muscle capacities. So people used to say you cannot have an epidural until some centimeter tall at a like usually four as the doctor says but you can have an epidural anytime in your leg pain the earlier the better I'll give you. Some say like you won't know when to push I say like you'll be more active you'll be more alert you'll be able to know when to push you'll be able to understand your doctor instructions so you'll be more cooperative and pushing will be much better. Some say like if you wait too long you can't have an epidural. Some say like earlier the better because as they later in part of your labor pains your labor pains will be more continuous less interval will be there so that you'll be able to sit and the procedure can be done in a nicer way. So the failure rate of epidural insertion or effect will be more because you will not be able to sit in a better way to have an epidural so earlier the better. So epidurals are scarier than childbirth says like I don't think that is a question at all. Otherwise we won't be sitting here and talking all about this epidural. When you cannot have an epidural I'll say the broad message is like any bleeding tendency. Or you are on any blood thinners like aspirin and all or no plate that comes like Dengu conditions. So then the epidural is avoided because bleeding in this area is should be avoidable and around the spinal cord we don't want bleeding or any infection. If you have to insert the needle through the insect infection site that is not at all recommended. So apart from labor epidural just to have your awareness on these things like even if you don't have an epidural and you have emergency cesarean or any kind of cesarean because of any indication. You can have these options of peripheral outlaw which gives you a bit of pain relief after your cesarean as well. So even the same epidural can be extended for your cesarean and a pain after a cesarean also the same epidural can be extended. In covid this is the last summarizing slide because it's a covid time but it's not complete without talking about the concerns about covid. So benefits of epidural in covid the pain relief will reduce burden on heart and lung we have discussed it many times. Comfortable breathing the oxygen consumption is reduced that is very advantageous. So epidural anesthesia is the best for cesarean in covid. General anesthesia if possible to be avoided especially in covid time. Emergency cesarean a same epidural can be used so it can avoid general anesthesia in many cases if the epidural is already in place. Enjoy printing. Thank you. See you know the proof of the pudding is in the eating. When you said about the epidurals being scarier than you know. The child birth one should really have a question and take a feedback from those ladies who have had epidurals and to understand what it means to be alert and cooperate when you are asked to push down. I think it's an excellent method and like you know everything you know even childbirth has side effects there can be some complications that take place even in absolutely normal childbirth. So what we should send a message across is that if you can take the pain that's fine if you can't we have a viable option for you. Which you should try to take as early as possible given the times that we are in right now. Which will of course will not alter the success of having a normal delivery or a cesarean section you know what I mean to say it's not going to alter your outcomes. Like if the baby is doing well the passages are fine the labour pains are good you will have a normal delivery. So what I would want you to do is to give one message to women all over or to families that try to encourage the patients to also consult with their citizens clarify their doubts in the activated period. You know in the nine months of pregnancy like you keep coming to be to us as gynecologists you come and you know visit us we check your baby simultaneously after the sixth seventh month they should have at least one consultation. So that you know those doubts are clear because you know what I have seen Dr. Suneep a patient is telling us that okay can we decide about pain relief at the time. Although Suneep tells us that okay if you feel you can't bear it we will give a treatment. That's the most common scenario I believe like and that is why you know like many times it is inadequate because things were not planned in the treatment. So I will definitely like to convey this message that it is always good to talk to your obstetrics doctor about the painless delivery options in your hospital. And if possible talk to your one of the anesthetists also through her that if you have any queries or what is the best plan for you if you come for a season or normal delivery. There is one question which is the best fees. I guess she wants to say which is the best time. Yeah, yeah, I can read it a few times in the slides that earlier the better that's a message to be taken up. Even the people have done like have made a protocol like before even starting a labor pain you put an evidence but I say like whenever you start in labor you are in labor pain and you are admitted for that. Now it is decided that you have to undergo a delivery now in the next couple of hours. So anytime the earlier the better to decide for a epidural because the later it will be you know you will be jumping with the pain. So it will be difficult to do a delicate process to give you a good success. That is why earlier the better otherwise you can have an epidural anytime. Yeah, so our textbooks of you know obstetrics always mention that you know at least the patient should be in labor with at least 3 centimeter dilatation of the service but like is now decided if you can decide when you want to take it. It's not that too early. Once it is decided you are going for a delivery now in the hospital you can take it so you can take it. The next question is are you tense during my menses as I have a lot of pain is it true that my labor phase will also be painful. I will say it is not you know directly related to this. So don't think in your mind that it is somewhere you know you had a bad experience before and you will have a bad later on also. It is entirely independent. Yeah, yeah. So of course your tense your menstrual pains of PMS has got nothing to do with this so don't be anxious. I would like to reiterate is that you know a lot many women are very hesitant to go forward with the you know epidurals because there's sometimes feel that it is against the you know law of nature. So it's been ground into us that you know we have to take a lot of pains in childhood. It should be a very positive experience. I've had women who had normal delivery but they were they had such a bad time you know the pain was so bad that they sometimes tell us never again. Yeah. So it should not be that you know the pain of labor was so bad that it deters you from you know say even having another child. Yeah. Yeah. So immediately after delivery who had a labor pain mostly the women say that like in my experience also this is like this is our loss. Yeah. And whoever had a labor epidural I say like 90% says like we can think about the second one. Yeah. So that's a major difference. What are the doses of the drugs and when to top up this question. I would say on this one because this presentation was meant for a general public and this can take a you know a separate presentation. We will plan for detail with the drugs in top of doses will run a presentation soon. So all I could add is once you are having an undergoing an epidural you're being constantly monitored and you are giving a feedback. Okay. I'm feeling fine. I'm not feeling fine. So we can they are there to increase or decrease the data required. It will be titrated according to the aspect. Yes. And I think yeah for the general public. It is not no like visible to understand like. Okay. There is a question from a mother of a 10 year old. She said I had a C section and I have a constant backache. Is it due to the painless that I had taken? Or can I do something for it as I started getting headache also 10 years back. 10 years back you have an epidural and you still have a backache. But I don't not getting exactly you think you started getting a headache now or you had since that time on the beginning. Yeah. So if it is now, then totally it is not related with that. Then the 101% it is not related to that. But if you had a backache, which is constantly present. So it is being shown that I was talking in the myths like a word that it is mostly related to some other reason because like most of the people in these, you know, this era, when most of us are not moving around, we have a very sedentary lifestyle. So lower backache is very common and most of the people come across it. And when you had a delivery and a pregnancy, your lower back muscles also relaxed. You have a tendency to have a backache in your life. Otherwise also. So it's at the same time you had an epidural same side in your back and same side you have a backache, which is mostly due to other reasons you tend to correlate it with. So now the question is like what you can do is you can always get an assessment of this because there might be something else inside. So you can always consult a doctor for this backache. And this will be taken care of and headache. Yeah, if it is you started getting now, then it is not related to that. Okay, there was one statement put in that it is said we should take it at the ticket that is the epidural at four centimetre dialysis when I can answer that. There is no such thing as 345. It is entirely dependent on the pain threshold of the lady if she wants to take it in a latent phase which is you know between one to three centimetre sure enough ask for it and you will be given that there is no particular definitely I mean time that an epidural should be given to no particular time of dilation of the service. I think that is because I think in the past studies this statement was very you know like it was everywhere rampant and and this was because they say like if you have an epidural earlier because before this much of dilatation like four centimetre then your labour will not progress. So that is not totally obsolete and in the studies that have been shown that the epidural will not interfere with the progress of the labour. Yes, it can alter a little bit in duration in the first stage of labour but it will not prevent in progress. So what I would and I am sure gynecologist so many gynecologists if they are there on this you know in this meeting with us in this webinar would agree that actually the first stage of labour gets shortened because it takes away the anxiety of the patient and she relaxes and she is able to take those 8 to 10 hours quite easily. The only time when they could be a delay is in the second stage that's because you know the doctor you know non appreciation of bearing down where maternal effort counts. That's when you have to actually coach the patient and that's where you know if you do these antenatal classes before you know labour you actually coach them how to push how to deep breathe and how to push at the correct time. So that's very important whereas in your first stage is definitely there is no lengthening of that just because you took a net video. The next question is I'll do next week is there anything I can do for decreasing my labour hours. Can I use hot pack during labour? Yes, definitely you can use a hot pack during labour and as far as for decreasing your labour hours. See, labour by and large depends on three P's that is the power, the passenger and the passage. What your bony pelvis is that is the passage. What are the power, power is the labour pains and the passengers of course the baby. So everything has to be in sync you know if the baby is too big obviously the baby will take longer to get into the bony pelvis. And there are various maneuvers where it gets into the pelvis and makes its descent in the pathways. Power is dependent on the kind of labour pains you have. Your labour pains are sluggish then sometimes it takes longer and then it has to be accelerated. Yes, hot packs during labour do help they make the pains less but other than that they do not accelerate labour. The labour will depend on those three P's that I mentioned just now. The next question is is Lamas helpful during labour and will give me strength to not take any adjuvant medicines. My yoga trainer suggested yes alternative methods are there and Lamas does help you as does you know labour exercises which are done during labour. Let me tell you all these are there for you. I mean if that helps you that helps you take the labour pains well. You could manage with just this like I said this is not something which is imperative. It depends upon your pain tolerance of the labour. All these methods do help and they are being used in addition to an epidural if required. Next is again an obstetric question that I have a breech baby that is upside down and 34 weeks. Can I still have normal delivery and taken epidural? Let me tell you that at 34 weeks this is not the final position. Your baby can still flip can still become kephalic that is the which is the normal position which is head down. So just wait a while longer and wait till you both because you are said you are 34 weeks. I suggest you take the same question once you reach 37 or even 38 weeks so wait a while and as far as normal delivery. Yes, breech babies can be delivered or can have a vaginal delivery. I wouldn't call it a normal delivery. We call it a vaginal delivery. It has its own risks if there is a breech baby and they have to be tackled by you know expert obstetricians at expert centers. And why not epidural can definitely be given in such cases also. There is no difference. I mean it's not that if it's a breach you can't take a epidural. I think the next question is for you. Can I take intermittent epidural during my labour? See if you're talking about intermittent the term is not about doing a procedure like procedure will be done at the beginning and that is once the job is done it is done. So then the continuous or intermittent delivery of a medicine. So that is entirely depending on you know the local protocols in that hospital and you can always discuss with the concerned NSR test there because how they are managing these things. Intermittent and continuous drug dosing can be done. But once you have an epidural in place this can be done. I would wonder why you want to take an intermittent epidural when you're getting painless and pain free and there's absolutely none. It doesn't it's not that your risks are less or your list are more if you are taking a continuous epidural just that the dose can be made absolutely you could say very very minimum dose you know. So that you get to feel because I've had a lot of patients who also say no we do want to feel the pains but at the same time we don't want to be overwhelmed by the pains. So you can train or you can sort of tailor make it according to your likes and dislikes. You can say OK doctor this is this much I can take but I can't take beyond that. So you can convey it to your doctor and that's where you know an obstetric setup which has a good in-house you know facility for giving you labor energy is here. That's where these things really matter and they will really help you because then you can ask and you can get what you require and which for you may be different and for another person or another lady it may be different. So we tailor make it according to the patient. Once you have taken a decision I think leave it to your doctor what is safe for you. They will definitely take care of that and they'll decide you know what kind of doses and how much. So once the procedure is done nothing is interpreted only the doses that the doctors will take care. OK. So how is peagles relevant for labor. My organic is advised me to do every day. I can't feel anything while doing it. Peagles for labor. Well. Peagles is basically an exercise for strengthening your pelvic floor. It's basically for tightening the pelvic floor muscles. As far as labor is concerned it doesn't it actually is more beneficial after your delivery. You know because in labor there is a lot of relaxation of the pelvic floor. There's a lot of stretching which happens. There and so there is a lot of you know looseness of the muscles post delivery and six weeks later lady may who hasn't gone in for kegels after a normal delivery may feel that she's a you know in it. In quality she's passing urine and she's not able to control the bladder or the you know the inner splinter. So in such cases you know these things are relevant. But as far as labor is concerned it would not you know really help her in so far as you know the getting prepared for upcoming labor. So right now it is not very relevant but you're probably being taught peagles right now. So that post delivery you can do it easily. Oh that's so nice. I mean we are getting a thank you for our advice. Thank you. Yes. Do we have any more questions? Okay. So thank you very much for listening in and for giving your comments that made us connect with you in a very positive way. Yeah. Yeah. Thank you very much. Thank you.