Anaesthesia and pain management in Nepean Blue Mountains

[Patient – Jennifer Wilson]

Well, it was quite early after I had discussions with the doctor that delivered my first son.

And he had told me that my pelvis was quite small and, my son was almost 10 pounds, so he said there was no way he was coming out, so yeah, I just decided to go elected this time.

"Hi."

[Nurse]

"Hi, how can I help you?"

[Patient – Jennifer Wilson]

"I just have an appointment today."

I'm anticipating this one to be a lot better and a lot smoother, and nice to be awake and actually see my child being born.

[Midwife Educator – Sandra Lyness]

When we bring the ladies in, we usually like to check on their well-being, how they've been going over the last couple of weeks since we've last seen them.

"Hi Jennifer, we're just going to do your visit so if you don't mind having a seat in the corner."

"I'll just have a seat."

"So how have we been going?"

[Patient – Jennifer Wilson]

"Good."

[Midwife Educator – Sandra Lyness]

"Yeah, yeah?"

"Is the baby moving?"

[Patient – Jennifer Wilson]

"Yeah."

[Midwife Educator – Sandra Lyness]

We also like to check that the baby's been moving that's really up at the top list because we know if the baby's been moving well, that the baby's nice and well and healthy.

And then we also listen to the fetal heart with a doppler to make sure the heart rate us within normal limit.

We also then do a measurement of the baby, the lady's tummy and it should match up to about how many weeks pregnant they are, so then we're checking that the baby is growing.

We then like to check that the mother's blood pressure and within normal limits, so we're concerned about her health as well.

"Blood pressures good, okay, which is good sitting on 120 on 60."

But then we just ask about what they're going to do over the next couple of weeks do some education around some breastfeeding and expressing or even sometimes contraception or any other tests that they may just go through the pregnancy. We check that they've all been updated, like blood tests.

"Okay Jennifer it was a pleasure we'll see you next week okay. We'll pop you in with the doctor. I find the doctor where she’s hiding."

They discussed their mode of delivery with the obstetrician and if they've had a previous caesarean they should see the anaesthetists if they're going to have another one and it depends on the one happened the first time around as to how that goes whether they have a normal vaginal birth after caesarean or whether they choose to have another caesarean section, and that's where they come on with her doctors.

[Obstetrician – Dr. Sarah Pixton]

"Midwife's already done your routine visit for the morning, hasn't she? But I think we're here to talk about the plan for delivery?"

[Patient – Jennifer Wilson]

"Yes."

[Obstetrician – Dr. Sarah Pixton]

"Very important we get a complete workup pre-op. We want to make sure we've got the health of you and your baby at the best condition possible. This is the cesarean paper that we have to do together. Also, there are some brochures on having your baby by elective caeser. One of the things we do when we send it to the anaesthetist is give you this brochure on anaesthetic for c-section, so I'll put those with those other brochures you've got there, and the other thing we need to do today to get it all done is go through the consent form together and being an elective c-section, it is a slightly different environment compared to the chaos and rush in anxiety that can happen with an emergency c-section. You'll have a full team on board there'll be the theatre nursing staff team, the theatre anesthetic team and the obstetric team which is the obstetrician and this assistant as well as the midwife."

So today after consulting with Jennifer, we've decided to definitely go ahead with her caesarean section next week and I feel her questions have been answered and that seems the appropriate decision.

[Patient – Jennifer Wilson]

Consultation with the obstetrician went really well, and I feel that because we both communicated all the history of everything that went along that it made her more aware of where I was and where I'm going to and it's going to be a lot better, an experience and I think that's what she wants me to have a nicer experience than the last time.

[Clinical Lead – Dr Manoj Mallikahewa]

In this pre-admission clinic what we do is we try to get their story, assess, listen to them.

"So, I've got this referral from Sarah, and how many weeks are you now?"

[Patient – Jennifer Wilson]

"37."

[Clinical Lead – Dr Manoj Mallikahewa]

"This Wolff-Parkinson-White, how much does it trouble you? Is that only you? "

[Patient – Jennifer Wilson]

"So my grandfather and both of my sisters have it."

[Clinical Lead – Dr Manoj Mallikahewa]

"So, what sort of symptoms do you have? Do you have any problems with your heart?"

[Patient – Jennifer Wilson]

"So, I've just have, had the racing heart. Sometimes it would be 180 beats a minute."

[Clinical Lead – Dr Manoj Mallikahewa]

"For your previous cesar, what sort of anesthetic did you have?"

[Patient – Jennifer Wilson]

"General anaesthetic."

My first caesarean was very hectic I went in, and they put the Prostin gel on me and then I straightaway had an allergic reaction to it, and then they gave me another medication to counteract that and that made me, made me faint. So within ten minutes, I was in the theatre and under general anaesthetic, three hours later I woke up and had a baby.

[Clinical Lead – Dr Manoj Mallikahewa]

You see a lot of patients just like Jennifer, who had previous caesars, sometimes under general anesthetic and emergency, or even the spinal anesthetic as an emergency Cesar. We have seen that patients don't remember much what happened to them at that time it was a kind of a, sort of a blurred dream that that just passed away I can't remember exactly what happened.

"So, this time it is a bit different. So you are going to be awake and we will do it on the regional anaesthetic what we call a spinal anaesthetic. This is the one that we liked you to concentrate on actually is this pamphlet is something that we have written here in this hospital. When you come into the theatre, first will do a little cannula in your hand and then we get all the fluid set up, after a group check-in we go into the theater room, your partner or husband will have to, you know take a seat in the anaesthetic bay when we go in. So we will get you to sit on the operating table sideways, my anesthetic nurse will put all the monitors on getting one blood pressure get things ready and the anaesthetist on the day will be scrubbed masks down to make sure that everything is nice and sterile. So the first thing that happens is they will clean your back with a very cold solution. After we do that, we start preparing our trolley. Why we do that is because we need to let that solution dry into your skin to make sure that it is properly sterile and then what we do is we'll put a sterile drape on your back then at that time we will get you to get into that real position with your chin on your chest holding on to the pillow and just slump your shoulders and stay still for some time until we get things done. The anaesthetics will fill your hips at the top of your hip levels just to get to make sure that there's a level we'll come to the midline and feel for your spinal spaces in the midline. Then we put some local anaesthetic, to numb your skin in there. Local anaesthetic when it goes in of course the needle you feel and then the expansion, the pressure we will feel in there and then literally in about three seconds, it gets numb in there. And through that numb area, we put that little spinal needle that I taught you about when I say literally it's thin but long needle, we put it in until it gets into the spinal fluid. And then we will give the medication. As soon as the medication is given, you'll start feeling your bottom going warm and pins and needles running down your both legs. And then the let's test going heavy so immediately we will get you to lie down on one of your shoulders and get you to turn on your back, we will be you know measuring your blood pressure every one minute until, your baby comes out most of the time because first 10 to 15 minutes the blood pressure can drop. We will check your anaesthetic level with some ice, and ice in a glove. We use the ice as a sort of a clinical marker to get a sensory level. The reason to use ice in a glove is because you lose your hot and cold sensation. When you and the anaesthetist both agree that the midline and on the sides that your level is around the mid-chest, and also your legs are heavy, we let the obstetrician start working on you."

The whole idea is to give the patient good understanding, what to expect on the day. I feel that well informed, when they come under on the day, and when the anaesthetist on the day start talking to them of getting into a position, they know exactly what they need to do.

[Patient – Jennifer Wilson]

I feel like everybody is aware and everybody is on the same page so everything should be smooth.

[Midwife Educator – Sandra Lyness]

It is a team effort, we work as a team. We work together, like the obstetrician, the midwife, the mnaesthetist. We all work together in a team.

[Clinical Lead – Dr Manoj Mallikahewa]

What we're trying to make sure that the patient's journey you know satisfaction is a lot better and she understands, and I'm sure she will enjoy the baby the moment that the baby is born a lot better.

[Midwife Educator – Sandra Lyness]

We've got, multiple people that play an important role in making sure that everything goes smoothly and safely for mum and baby, and that this is an experience that is super special for them, but it's also approved leading a joy for the staff involved to be able to witness and support that family through those really momentous occasions.

[Faye Mathews]

That's what we want our patients to feel. We want them to feel supported, at all times no matter what procedure they have been done, and to do this we you know I've introduced new information, and better information.

[Patient – Jennifer Wilson]

I'm anticipating this one to be a lot better and a lot smoother and nice to be awake and actually, see my child being born. So yeah.

I’m expecting everything to go pretty straightforward and just be, nice and relaxed because the last one was so rushed, I'm actually looking forward to having a normal procedure. I don't feel any anxiety at all about it.

[Recovery – Georgia Stellios]

When mum comes out we keep her here for about half an hour just to monitor her and make sure she's okay, after she's had major abdominal surgery. If mum pre-empts that she'd like a caseload midwife she's entitled to have the baby down here where she can provide skin-on-skin and breastfeed.

[Patient – Jennifer Wilson]

It felt really good because he latched straight away, and he was breastfeeding perfectly straight away, and I didn't get that with my other son.

[Midwife – Tiarni Bright]

The normal role in the postnatal period that we do as a midwife is normal observation checks, so checking blood pressure temps pulse making sure that everything's normal.

"Hello. I just need to do a blood pressure on you. Are you okay with that?"

[Patient – Jennifer Wilson]

"Yup."

[Midwife – Tiarni Bright]

"Beautiful!"

We'd also do like a head-to-toe check so obviously those physical sides to having babies, so we ask how they're feeling and what their pains are like. After a caesarean section, one of the main checks we do is obviously checking the wound where the baby came out making sure that that's all good. And also obviously they usually have medication that makes them not move so that they don't feel anything so we also make sure that they're getting up and mobilising and that their legs are okay.

[Consultant Anaesthetist – Jacquie McPhee]

"Do you have the notes for Jennifer?"

The first thing we check is to make sure that she's comfortable.

"Hi good morning! How are you feeling this morning?"

[Patient – Jennifer Wilson]

"Good."

[Consultant Anaesthetist – Jacquie McPhee]

We want to make sure that she's getting enough painkiller. That she's used the painkillers that are on offer and that she's using them in the right way. Sometimes people are afraid to use painkillers.

"Uncross your legs for me. Just push up against my hand. That's good."

And then we check to make sure that you've recovered the sensation in your legs and the movement in your legs.

"Push up. Push your toes up against my hand. That's it."

And we also check to make sure that you're back where the needle went into your back is nice and clean and dry and there are no signs of infection or any problems there.

We make sure that they're comfortable before they go so they're not you know struggling with pain at home when they've got a new baby.

[Patient – Jennifer Wilson]

That felt really relaxed just because I knew what was coming ahead and I knew all the team that we’re gonna be in there and I met everyone and it was just very relaxed, knowing what was to come.

I felt them pushing it just, when they pushed, I felt him move from the top down, and then that, then I felt him when he came out, I just felt everything just settled in my belly like it yes just felt very different.

[Patient – Shilshila Shrestha]

I chose to have elective c-section because of the previous c section. I was just worried about the anaesthesia. It's really helpful, he demonstrated how to make my body posture during the procedure. During the procedure when the nurses asked me to maintain that posture I still remember his voice. It's really helpful about this, it got all the information. It helped us to prepare mentally. It helps to reduce our fear and anxiety.

[Consultant Anaesthetist – Jacquie McPhee]

The introduction of an Anaesthetist clinic is where the woman gets much more information much more counselling, about anaesthetics and theatre and what's going to happen to them when they reach the theatre.

[Patient – Sandra Grey]

When I was in Poland. I arrived at the emergency, it turned up that I needed to undergo an emergency c-section and the experience was actually quite horrific. I wasn't told what's going to happen to me. I wasn't asked if I'm okay. They just put me on a table. If I had to compare it with Nepean hospital, the nurses and the surgical team was there to calm me down and talk to me and actually explain the process to me, the whole procedure, the whole process. I'll probably not even allow them to touch me, I was shaking and trembling. I actually cried I was I cried not because I just gave birth to my baby but I cried because this procedure was not a traumatic experience.

[Patient – Jennifer Wilson]

Everything went really smoothly, and it was really good getting to know all the staff before because I'd already met all the staff at Katoomba, and I knew he was going to be delivering my baby but, yeah everything went to plan that's all, the only thing I was worried about at Nepean was yeah not knowing everybody and then everything just happened really quickly and it all went really well, so yeah, I was very relaxed.

[Birth Unit - Kerry Tosswil]

Here at Birth Unit, we have about 4,000 births per year.

We cater for very low-risk to quite high-risk complex cases.

We work as a team the midwives and doctors work closely together so we can provide the best and most appropriate care for every patient as an individual.

Every day in birth unit the team of doctors, midwives and anaesthetists, meet and discuss all the patients that are presently in the unit and any expected patients. This way we were able to develop individualised care plans discuss any complex needs and specific individualised needs.

We have quite a range of analgesia options for women, we can provide nonpharmacological, such as a heat packs water immersion, acupressure points mobilisation, all these things that you can either do at home and we can help you do once you get to Birth Unit, and then we can move up to medications such as nitrous gas, morphine injection or epidurals.

We also have options of perineal compressors which we can use when the baby's crowning to help relieve the pain as the baby's birthing, there's sterile water injections for some women they can have quite severe back pain, and the sterile water injection into the back is very effective in relieving this.

[Consultant Anaesthetists – Dr. Tim Suharto]

I'm Dr. Tim Suharto. I'm an anaesthetist here at Nepean Hospital and I'm gonna be talking to you today about the different options in labor. We have some pain injections such as morphine that you can have during your time in the delivery suite while you're labouring. However, we have some very strict criteria with regard to how often and how much you can have.

Now I'm going to talk to you about another form of pain relief in labor and that is probably the most well-known form which is gas. So, what I have behind me is the gas machine that we have here at Nepean. It is actually a combination of two gases we have nitrous oxide and oxygen. The way that our machines work it's through this tubing where, we can suck in through here, the gas is delivered and then it's expelled through another mechanism. Now the way that our gas works is that we can actually vary the concentration of the nitrous oxide, that increases the amount of pain relief that you get, over a certain range. In some women some of the side effects unfortunately you know caused a little bit of annoyance in some people they don't tolerate it, so these side effects include things that are annoying like tingling around the mouth, but it can make some people feel quite nauseated and the other effect that some women feel uncomfortable with is, that feeling of haziness or cloudiness.

Now the last thing I'm going to talk to you about is the epidural. This is really where we as an anaesthetist get called in and we'll talk to you about, how the epidural is placed, what are the benefits and the potential risks of the epidural and what to expect after you have the epidural placed. The epidural is a targeted approach to your pain relief it essentially intercepts the messages coming from the areas of the contraction going up to the brain and we stop the messages at the spinal level where the epidural is being inserted, as a result it can give you the most effective pain relief compared to other things like medications that are ingested or injected, and it has, in general, the least effects on your baby. Other benefits include an increase in the blood flow to the placenta and therefore oxygen is delivered to the baby, so there are multiple benefits for both, you and your baby.

[Consultant Anaesthetists – Swapna Sharma]

It's very important for the women to be positioned in a certain way, especially sitting position helps us with opening the spaces in the back and it makes the positioning for anaesthetist very easy, positioning the epidural.

It's very important to communicate with the patient clearly at all times that just to know that you're not hitting the nerves and cause any sort of nerve damage.

[Consultant Anaesthetists – Dr. Tim Suharto]

It's a safe approach to providing pain relief. In some women it may not be possible to insert an epidural. These include women that have problems with bleeding or are on medications to thin their blood. They may have problems with their back that affect their nerves or the potential for infection either at the site or systemically. In general, nine out of ten epidural has worked very well, in some epidurals we need to change the medication and increase the concentration of the medication or manipulate the epidural in order to make it work better. There are a number of other things that you need to know that sometimes it can decrease your blood pressure and therefore the midwife will be there once the epidural is inserted for the first half hour taking a blood pressure every five minutes. Other issues include increasing the risk of nausea particularly if your blood pressure as well, and also shivering, which is usually as a side effect of the local anaesthetic, the more significant but rare risks include a headache related to your epidural, infection around the site, bleeding around the site or trauma to one of the nerves. Having an epidural does not increase your risk of having a caesarean section, okay. But it does potentially increase the second stage of labor, that's when the baby presents, and there's potentially an increased risk of having a suction or some sort of manipulated delivery. What we do know is that for most women one of the concerns that women have is about back pain related to epidural, and what we do know is if we look at women who have had epidurals and women who have not had epidurals, the the risk of back pain is no different but your anaesthetist will talk to you about your specific risk on the day. What I have here which is an epidural pump, it is programmable, it is attached to the pain button once the epidural is inserted. It is attached to this pump, and then we as anaesthetist will program the pump so that it is able to deliver doses of epidural medication to allow you to have good pain relief. The way that we program it will be a combination where the epidural pump will be giving you epidural doses at prescribed times and then within those times within a certain time frame you'll be also be able to press the button and give yourself some pain relief.

[Patient – Kirsty]

I'm Kirsty, I'm a midwife and a mum of two. With my first baby, I went in quite open-minded, I prepared with calm birth classes, my first baby was an induction that after I use massage movement, nitrous which was gas and then from there after six hours of sentosa and induction, I hadn't really progressed so I decided at that time it would be beneficial for me to have an epidural to help with the progressive labor. Once having in the epidural, I was able to continue in with my induction process and approximately nine hours later then I had to have an instrumental delivery to fetal distress so having the epidural was quite beneficial as we were able to act promptly and deliver the baby through an instrumental delivery with me being as comfortable as possible, and then I had my second child a few years later I was an induction again with my daughter, at a certain point in my labour I decided that I would have an epidural because I found it beneficial the first time around, so I opted for the epidural and I found it good relief with the induction process and then had, a few hours later, had my beautiful baby girl.