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太迟的大宝产经,说说epidural的取舍问题
作者:home99
发表时间:2008-06-29
更新时间:2008-10-21
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大宝都四岁了,对于生两个宝的产经我一直没想过要仔细写,最多是轻描淡写地提一下,
一是总的来说还算顺利;二是delivery是相当顺利,好象没有多少可以写的;三是有
些细节实在不愿多想起,所以好象都忘了差不多了。


最近看了JMs好多关于讨论是否使用epidural的贴子,我觉得还是有必要写一写自己的
亲身经历。我想无论是否选择epidural都是个人的选择,而且每个人对于疼痛的忍受
程度可能不同,Labor的时间长短各人也不同,所以取与舍都要根据具体情况来定,
没有必要千篇一律。再说并不是每个人都可以用epidural,请JMs参看后面附的有关
资料。

epidural是药物,所以有些副作用是很正常的,例如大家可能担心epidural会影响
dilation的速度,但试想即便如此,也不过是宝宝晚出来几个小时,不至于要在宫缩阵
痛的煎熬中折腾数小时甚至十几个小时;再说每个人labor的时间长短本来就不一样,
delivery要十分钟还是几个小时谁也说不准。

dilation的速度快慢可能因人而异,并不一定是epidural的错。下面就来说说我的几近
惨痛的经历吧,说真的,这些年来我真不愿再多想当时的情景,这也是为什么我对生大
宝前后的很多事情淡忘了。生大宝时我是周四见红,周五早上感到明显宫缩,但当时不
懂,只是感到隔一定时间腿不由自主地抽筋,我问老公什么是contraction,是不是
contraction,老公回答不了,问同事朋友也没有经验。我只好告诉老公无论如何自己
没法开车去上班了。下午正好是39周的appointment,我打电话给医院时告诉见红时,
护士说血量多了再去,问我有无宫缩时我只好说不知道,护士便让我先去看OB,然后再
决定何时去医院。下午老公请假开车送我一起去医院,OB检查后告诉我,先回家吃完晚
饭后散完步再去医院。

我怕被医院打发回家,所以一直在家里坚持,后来老公看我说话都有些困难了才决定去
医院,去的路上雷电交加,到医院大概是晚上八九点钟。当时被安排在一个临时病床,
检查之后大概开了三指吧 (我不敢肯定是因为我好象没听见医生说什么,当时已经疼得
有些意识模糊,可以说有点儿半清醒状态,特别是后来),勉强可以住院。不久老公便
建议我用epidural,在此之前我还没听说过epidural,明白大概是什么之后还犹豫,想
坚持不用,也可能是认为药物不好,或者说因为妈妈她们没用,觉得自己也可以不用,
当然也顾虑是否要自己付钱。后来阵痛越来越频繁,越加剧,感到要窒息一样,我在老
公的一再劝说下,决定用epidural,此时却找不到麻醉师,麻醉师好象都是先去
emergency C。医生护士好象都忙得不可开交,后来才知当晚暴风雨,出生的宝宝特多,
后来听说那个晚上接生了11个。

因为我的羊水没破,所以没有什么危险,隔很久才有人来检查开了几指,问羊水破了没
有之类,可能因为dilation没多少进展,羊水又没破,所以医生护士很快就将我给忘了。
我当时可以说是疼得死去活来,后来老公告诉我当时他的双手都给我攥得生疼、攥得
麻木了,我当时也疲惫不堪,别说大叫,就是说话也有气无力了。老公去找护士好几次,
都是被告知没有房间available,总是告诉我快了,快了,要我再等等、再等等。而我
就这么“度秒如年”地在频繁而来的宫缩中熬了四五个小时,我已经精疲力竭,当时真
感到好无望,dilation并无实质性进展,总算好不容易有房间可以给我上epidural了。
后来才明白是因为上了epidural就不让乱跑了,所以一定要到产房才可以。

上epidural之前麻醉师和我说了什么,是否象生小宝时一样,给了一堆的东西还签字什
么的,一概记不起来了,上了epidural大概20分钟之后我从阵痛的煎熬中解脱出来,很
快沉沉睡去,大概第二天清晨隐约知道有OB来人工破水,其间可能也有检查开指情况,
后来快到中午时告诉OB快来了,护士不紧不慢将一切准备妥当之后便说教我练习如何
PUSH。OB不紧不慢地进来,还没完全进入状态呢,大宝就出来了。从学习PUSH到宝宝出
生花了不超过15分钟时间。当时的OB只是一个劲地说:You must come back! You must
come back!

另一个让我难忘的是,可能是因为宝宝头比较大,而宝宝出来太快,撕裂比较厉害,OB
缝合了很长时间,幸好有epidural的作用在,当时没感到痛,麻药过后是相当地痛,走
路都有些困难。加上我后来没有坐月子,身体恢复很慢不说,还落下了一身毛病,这在
别的贴子里已经提过,就不多说了。

我很感激老公一直伴在我左右,当时医生和护士根本顾不上我;我也很感激生宝宝时护
士指导有方(用了epidural感觉不到contraction,但可以根据监测显示的contraction
适时进行PUSH),使得delivery那么顺利。庆幸的是最终我选择了epidural,虽说晚了
点,倒是使我既体验了宫缩阵痛之痛,也体验到用了epidural之后的无痛与轻松,也就
是JMs所说的那种进入天堂的感觉。

有人说不上麻药,睡一觉就可以,可是那种阵痛情形下怎么可能睡得着(除非是没有频
繁的宫缩)?而我当时宫缩已经相当频繁,在上epidural之前这种状态就持续了恐怕至
少6个小时,我觉得呼吸都有些困难了,老公在一旁紧张得不行,以为我会休克。如果
不是后来上了epidural睡了几个小时,真难以想象后来我还有气力PUSH。所以我觉得如
果labor的时间短,dilation比较快,不用epidural也许还能忍受;但如果Labor的时间
长(第一个宝宝通常会比较长),还是建议用。千万不要因为用了epidural没有遭这份罪
而遗憾,因为实在没有什么可遗憾的!宝宝健康顺利出生是最重要的!如果实在感到遗
憾,生二宝时不是还有机会吗,到时可以试试不用epidural。


下面附上epidural有关的一些资料,供JMs参考。

Epidural Anesthesia

Epidural anesthesia is the most popular means for pain relief during labor. In fact, more women ask for an epidural by name than any other method of pain relief. Over 50% of women giving birth at hospitals use epidural anesthesia.

As you prepare yourself for “labor day”, learn as much as possible about pain relief options so you will be equipped and ready to make decisions throughout your birth experience. Understanding the different types of epidurals, how an epidural is administered, and the benefits and potential risks of an epidural will prepare you to make an informed decision for you and your baby as your birth unfolds.

* What is epidural anesthesia?

Epidural anesthesia is regional anesthesia that blocks pain in a particular region of the body. The goal of an epidural is to provide analgesia, or pain relief, rather than complete anesthesia, which is total lack of feeling. Epidurals block the nerve impulses from the lower spinal segments resulting in decreased sensation in the lower half of the body. Epidural medications fall into a class of drugs called local anesthetics, such as bupivacaine, chloroprocaine, or lidocaine. They are often delivered in combination with opioids or narcotics, such as fentanyl and sufentanil, to decrease the required dose of local anesthetic. This way pain relief is achieved with minimal effects. These medications may be used in combination with epinephrine, fentanyl, morphine, or clonidine to prolong the epidural’s effect or stabilize the mother’s blood pressure.

* How is an epidural given?

Intravenous (IV) fluids will be started before active labor begins and prior
to the procedure of placing the epidural. You can expect to receive 1-2
liters of IV fluids throughout labor and delivery. An anesthesiologist, a
physician who specializes in anesthesia, an obstetrician, or nurse-
anesthetist will administer your epidural. You will be asked to arch your
back and remain still while lying on your left side or sitting up. This
position is vital for preventing problems and increasing the epidural
effectiveness. An antiseptic solution will be used to wipe the waistline
area of your mid back to minimize the chance of infection. A small area on
your back will be injected with a local anesthetic to numb it. Then a needle
will be inserted into the numbed area that surrounds the spinal cord in the
lower back. A small tube or catheter is threaded through the needle into
the epidural space. The needle is carefully removed leaving the catheter in
place so medication can be given through periodic injections or by
continuous infusion. The catheter will be taped to your back to prevent it
from slipping out.

* How does an epidural work?

An epidural delivers continuous pain relief to the lower part of your body
while allowing you to remain fully conscious. Medication is delivered
through a catheter, a very thin, flexible, hollow tube that's inserted into
the epidural space just outside the membrane that surrounds your spine.

To allow the catheter to be inserted, you lie curled on your side or sit on
the edge of the bed while an anesthesiologist or nurse anesthetist cleans
your back, injects the area with numbing medicine, and carefully guides a
needle into your lower back. (This may sound painful, but for most women, it's
not.) She then passes a catheter through it, withdraws the needle, and
tapes the catheter in place so medication can be administered through it as
needed. You can lie down at this point without disturbing the catheter.

First you're given a small "test dose" of medicine to be sure the epidural
was placed correctly, followed by a full dose if there are no problems. Your
baby's heart rate is monitored continuously, and your blood pressure is
taken every five minutes or so for a while after the epidural is in to make
sure it isn't having any negative effects.

The medication delivered by the epidural is usually a combination of a local
anesthetic and a narcotic. Local anesthetics block sensations of pain,
touch, movement, and temperature, and narcotics blunt pain without affecting
your ability to move your legs. Used together, they provide good pain
relief with less loss of sensation in your legs and at a lower total dose
than you'd need with just one or the other.

* What are the types of epidurals?

There are 2 basic epidurals used today. However, hospitals and anesthesiologists vary on the dosages and the combinations of medication they use. You will want to ask your care providers at the hospital about their protocol.

◆ Regular Epidural: After the catheter is in place, a combination of narcotic and anesthesia is administered through either a pump or periodic injections into the epidural space. The narcotic, such as fentanyl or morphine, is given to replace some of the higher doses of anesthetic, such as bupivacaine, chloroprocaine, or lidocaine, which helps reduce some of the adverse effects of anesthesia. You will want to find out your hospitals policies about staying in bed and eating.

◆ Combined Spinal-Epidural (CSE) or “Walking Epidural”: An initial dose of narcotic, anesthetic or a combination of the two, is injected beneath the outermost membrane covering the spinal cord, and inward of the epidural space. This is the intrathecal area. The anesthesiologist will pull the needle back into the epidural space, threading a catheter through the needle, withdrawing the needle and leaving the catheter in place. This allows you to move more freely in the bed and change positions with assistance. With the catheter in place you may decide later to request an epidural if the initial intrathecal injection is not enough. You will want to find out your hospital’s policy on moving around and eating/drinking after the epidural has been placed. With the use of these drugs, muscle strength, balance and reaction is reduced. CSE should provide pain relief for 4-8 hours.

* What are the advantages to having an epidural for pain relief during
labor?

◆ Allows you to rest if your labor is prolonged

◆ Relieving the discomfort of childbirth can help some woman have a more
positive birth experience.

◆ Most of the time an epidural will allow you to remain alert and be an
active participant in your birth.

◆ If you deliver by cesarean, an epidural anesthesia will allow you to
stay awake and also provide effective pain relief during recovery.

◆ When other types of coping mechanisms are not helping any longer, an
epidural may be what you need to move through exhaustion, irritability, and
fatigue. An epidural may allow you to rest, relax, get focused and give you
the strength to move forward as an active participant in your birth
experience.

◆ The use of epidural anesthesia during childbirth is continually being
perfected and much of its success depends on the care in which it is
administered.

* What are the Disadvantages of epidural anesthesia?

◆ Epidurals may cause your blood pressure to suddenly drop. For this
reason your blood pressure will be routinely checked to make sure there is
adequate blood flow to your baby. If this happens you may need to be treated
with IV fluids, medications, and oxygen

◆ You may experience a severe headache caused by leakage of spinal fluid.
Less than 1% of women experience this side effect from epidural use. If
symptoms persist, a special procedure called a “blood patch”, an injection
of your blood into the epidural space, can be done to relieve the headache.

◆ After your epidural is placed, you will need to alternate from lying on
one side to the other in bed and have continuous monitoring for changes in
fetal heart rate. Lying in one position can sometimes cause labor to slow
down or stop.

◆ You may experience the following side effects: shivering, ringing of the
ears, backache, soreness where the needle is inserted, nausea, or
difficulty urinating

◆ You may find that your epidural makes pushing more difficult and
additional interventions such as Pitocin, forceps, vacuum extraction or
cesarean may become necessary.

◆ For a few hours after birth the lower half of your body may feel numb
which will require you to walk with assistance.

◆ In rare instances, permanent nerve damage may result in the area where
the catheter was inserted.

◆ Though research is somewhat ambiguous, most studies suggest some babies
will have trouble "latching on" which can lead to breastfeeding difficulties.
Other studies suggest that the baby may experience respiratory depression,
fetal malpositioning; and an increase in fetal heart rate variability,
which may increase the need for forceps, vacuum, cesarean deliveries and
episiotomies.

*  Common Questions About Epidurals:
Q: Does the placement of epidural anesthesia hurt?
A: This depends on who you ask. Some women describe an epidural placement
as feeling a bit of discomfort in the area where the back was numbed and
then feeling pressure as the small tube or catheter was placed.

Q: When will my epidural be placed?
A: Typically epidurals are placed when the cervix is dilated to 4-5
centimeters and you are in true active labor.

Q: How can my epidural affect labor?
A: Your epidural can cause your labor to slow down and also make your
contractions weaker. If this happens you may be given the medicine Pitocin
to help speed up labor.

Q: How can an epidural affect my baby?
A: As stated above, research on the effects of epidurals on newborn health
is somewhat ambiguous and many factors may be contributing to newborn
health at the time of birth. How much of an effect these medications will
have is difficult to judge and could vary based on dosage, how long labor
continues and individual babies. Dosages and medications vary, so concrete
information from research is lacking. Studies reveal that some babies may
initially have trouble "latching on" among other difficulties with
breastfeeding. While in-utero, they may become lethargic and have trouble
getting into position for delivery. These medications have been known to
cause respiratory depression, and decreased fetal heart rate in newborns.
Though the medication may not harm the baby, the baby may experience subtle
effects like those mentioned above.

Q: How will I feel after the placement of epidural?
A: The nerves of the uterus should begin to numb within a few minutes
after the initial dose. You will probably feel the entire numbing effect
after 10-20 minutes. As the anesthetic dose begins to wear off, more doses
will be given usually every one to two hours. Depending on the type and
dosage of epidural you receive, you may be confined to your bed and not
allowed to get up and move around. If labor continues for more than a few
hours you will probably need urinary catheterization because your abdomen
will be numb, making urinating difficult. After your baby is born, the
catheter is removed and the effects of the anesthesia will usually wear off
completely in one or two hours. Some women experience an uncomfortable
burning feeling around the birth canal as the medication wears off.

Q: Will I be able to push?
A: You may not feel that you are having a contraction because of your
epidural anesthesia. If you can not feel contractions then pushing may be
difficult to control. For this reason your baby may need additional help
coming down the birth canal. It may be necessary to apply pressure on your
abdomen at the top of your uterus and/or use forceps to pull the baby out.

Q: Does an epidural always work?
A: For the most part, epidurals are effective in relieving pain during
labor. There are some women who complain of being able to feel pain and/or
feeling that the drug worked better on one side of the body than the other.


**  Who can't have an epidural? **

Not all moms-to-be are good candidates for this kind of pain relief. You
won't be able to have an epidural if you have abnormally low blood pressure
( because of bleeding or other problems), a bleeding disorder, a blood
infection, or a skin infection on the lower back where the needle would
enter, or if you've had a previous allergic reaction to local anesthetics.
Women taking specific blood-thinning medications can't have this kind of
pain relief, either.

◆ You use blood thinners

◆ Have low platelet counts

◆ Are hemorrhaging or in shock

◆ Have an infection in the back

◆ Have a blood infection

◆ If you are not at least 4 cm dilated

◆ Epidural space can not be located by the physician

◆ No anesthesiologist is available

◆ If labor is moving too fast and there is not enough time to administer
the drug

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