Dr.Vijayalakshmi.G.Pillai. DGO,MRCOG. VIJAYALAKSHMI MEDICAL CENTRE, CHAKKARAPARAMBU,VENNALA ERNAKULAM
"The delivery of the infant into the arms of a conscious and pain-free mother is one of the most exciting and rewarding moments in medicine" said Donald Moir, founder President of the Obstetric Anesthetist's Association. He had worked hand in hand with Sir Ian Donald. They were together instrumental in shaping present day attitudesof care towards a pregnant and parturient mother. I feel strongly for this.
I feel, Obstetrics is to be practiced with the conviction and courage of a well disciplined Army. Routine work requires just periodic drills. But Emergencies have to be handled and led with the fitness and courage of a winning Armys General.
It is a myth that Cesarean Section mitigates most vows of untoward complications to the mother or the fetus. FIGO, WHO and various Governments have tried to stipulate certain acceptable percentage of complications and hence CS rate. Kerala Gov. has introduced a GO in the form of guidelines to reduce Cesarean rate. If followed well, definitely it stands testimony to the acceptable good practice Obstetric judgmentsof all developed countries.
G.O for Caesarean section rate - Arogyakeralam.gov.in
At around 16 weeks onwards we encourage patients to visit our Antenatal Physiotherapy sessions, at least twice in pregnancy. We make sure that they practice these things. Many buy theraband and exercise ball and bring even to labour room to practice while in labour. A short video taken at our physiotherapy premises.
Play an important role. All are well trained and disciplined to have good presence of mind. They have kept their check-lists in the form of documents which hang in each Labour room. From patient comfort, to positioning during labour, dose adjustments of drugs as per schedule are done by them.
Emergency admission is the usual norm to all low risk patients. Elective labour Induction is opted only for Obstetric indications. We have private Labour-delivery-postpartum rooms for every patient. A birth attendant, preferably husband is expected to be with the patient throughout her stay in the labour room. Baby resuscitation room is adjacent.
Not all patients have active managementof labour, including must do amniotomyat or above 4cm. Social convenience of the doctors, priorities for other cases, patient fixation etc. modify our actions. Patients who do not want to modifytheir natural labour are left to their wishes,except that they are asked to undergo intermittentCTG monitoring. Patients even refuse PV at first stage of labour after the initial assessment at admission, and may get on to the Labour cot only at second stage, without further PV assessment and , having refused all pharmacological agents. Labour help classes galore in a society like Kochi,and they advocatenatural child birth.
The Bishop score system to assess methods of Induction of Labour. PGE2 gel (Dinoprostone)intracervically is the favoured method of choice in the low score patients, where a cervical ripeningis what is intended. All women who are induced,stay under continuous CTG in the labour room. For the ones having cervical ripening,monitoringis for 1-2 hrs in the labour room. In a patient with score =/> 7, Amniotomyfollowedby Oxytocin Infusion of the low dose protocol is followed. All infusions are given by Infusion pump in well titrated doses.
GDM on Insulin in well controlledmothers with average size babies have IOL at 39/+ weeks. Post datism is waiting up to 41 weeks for spontaneous onset of labour. PROM at term with clear liquor and no clinical evidence of chorioamnonitis,waits up to 24 hrs before an IOL is planned. PGE2 gel is not denied if the Bishop score is poor for PROM. Twice weekly BPP scoring is done for every woman at or near 40 weeks. For a 40+ weeker woman,the vigilance is further strict with daily NST as well.
A case is called failed Induction after a liberal trial, especially in a primigravida. For cervical ripening, intracervical Dinoprostone gel, 0.5mg every 6 hrs to a maximum of 3 doses each day, starting at 6.00 am and lasting a maximum of 9 doses, spread over 3 to 7 days. A patient has the right to stop further trials of IOL, if she finds it mentally not acceptable. Most women consent to maximum try. Routine sweeping/stripping of membranes is attempted to almost all low risk women around 38 weeks unless they decline.
All though we have a recordedPartogram, it is hardly followed. A dated, timed sequence of events in the IP record sheets with explicit orders make up for the cramped Partogram. All patients are monitored by a multipara monitor (usually only SPO2 & NIBP). ECG leads are connected only in cases of : all Epidurals, unexplained maternal tachycardia, known Cardiac conditions, severe PIH on Labetalol Infusion and MgSulf infusion etc. All fetuses are continuously monitored by external CTG, unless specifically told to be ambulant. Preload of crystalloids given to all mothers who opt for epidurals. Patients in active labour are restricted from eating solid food and only clear fluid is recommended, except citric juices, caffeine containing drinks etc.
Many first timers are apprehensive about Epidural analgesia. Many would like to opt out of this choice,imagining that the pain would be bearable. Many, who later choose Epidural analgesia in labour,are the ones who had thought of opting out in the initial stages. N2O2 and O2 inhalation anesthesia (CSDS) is also offered in our hospital and patient is not asked to give special consent . CSDS (Conscious Sedation Delivery System) is found to be very useful and convenient to the ones who think Epidurals may cause long term complications. It has liberal takers.
In many countries today, the availability of regional analgesia for labour is considered a reflection of standard obstetric care. According to the 2001 survey, the epidural acceptance is up to 60% in the major maternity centers of the US. The NHS Maternity Statistics of 2005-2006 in the UK reported that one-third of the parturient chose epidural analgesia. In our country,the awareness is still lacking.
The concentration of local anesthetic used to maintain labour epidural analgesia is (0.0625- 0.125%). The use of a low concentration of local anesthetic has reduced the total dose of local anesthetic used as well as the side-effects,such as motor blockade. Continuous dilute low-dose mixtures has major advantage over intermittent bolus dose. The dosage recommended for labour analgesia is 0.0625% bupivacaine with 2 mcg/ml of fentanyl, infusing at 10-12 ml/h.
It is an apparatus which is used to deliver a mixture of N2O2 and O2 through a nasal mask (gas & mask). The one in our Labour room is designed to draw each of these gases from the central gas pipeline valve, do the mixing at the ratio of N2O2 and O2 as per our settings and to a volume determined by us. For margin of safety,O2 can be given up to the maximum 100% and N2O2 cannot go beyond 70% A maximum ratio is of 70:30 of N2O2 to O2 and the minimum is 0:100 of N2O2 to O2.
The usual pre-set volume of the mixed gas flow rate is 6 to 8 litres per minute. The usual settings will be of the ratio 50:50 of both gases. The ratio is adjusted according to patient pain and need for Oxygen. It is self administered and has high level of safety at the settings mentioned above. The system has an on-demand valve in the mask, which opens to let in gas only if the woman inhales deeply. The gas is odorless. The patient is conscious throughout the inhalation and obeys to command.
The time spent in laboring and the sense of pain seems to be detached from her memory. Labour progresses very fast because of absence of anxiety. Many patients do not recall the labour experience the next day. It is a good agent in a well conditioned mind. It is cheap and effective and much superior to IV Opioids. There is no Fetal respiratory depression as it is flushed from our systems in less than 30 seconds.
Each per-vaginal examination is done with utmost aseptic precautions. For each PV, a separate sterile bowl,gauze/cotton and gloves are used (PV set) after proper aseptic hand washing. After documenting in the Indoor case file, a check book of records kept by the nurses is initialed,to ensure limited numbers of PV exams as well as to clearly note the name and time of the person who has done that. This cross check has clearly reduced the rate of Infections,and we have a minimum antibiotic use