Pain Relief in Labor

Only in some very rare individuals is labor not associated with considerable pain. The pain that most women experience during childbirth has been written and talked about for centuries. It makes quite an impression on almost all women. Most women remember their labor and birth experiences with exquisite detail. This is not to say that the experience is beyond the internal resources of every woman. On the contrary, the very continuance of the species is evidence of the fortitude of women. Since the beginning, most women have endured the pain of childbirth without any significant pain relief.

How does a woman deal with the pain of childbirth? Many methods of pain relief have been tried. Initially, there is usually some anxiety about the pending event. This anxiety may continue into labor, and add to a woman’s pain level. In fact, much of modern childbirth education exists in an effort to decrease a woman’s anxietiy about childbirth. Through a combination of education and relaxation techniques, a woman can enhance her own internal resources and meet pain with self-assurance and pure determination to survive the experience. This is the basis of “natural childbirth”……a trust in one’s self and in the natural process…….often associated with some mistrust of the medical profession’s ability to help without complicating the natural process.

If you are inclined to attempt natural childbirth, there are plenty of resources available to get you started. However, ultimately, it is your internal resources which will see you through the experience…….and your motivation must be high, your resolution steadfast, but with an understanding of the fact that you cannot predict what might happen in your labor. Thus, a certain degree of flexibility in your plan may be wise in order to meet some of the potential realities which you might not have counted on. That is to say, that although the course of the average labor may be well planned for, Mother Nature frequently has her own ideas……in those situations, you are really not in control.

If you are resolved to the course of natural childbirth, you are already most of the way there. You need nothing but yourself. To increase the chances that your goals are met, make certain you have someone you love and trust next to your side. This should be someone who supports your goals, feeds your soul, and will stick with you through a potentially long and trying day. This may be your husband, your lover, your mother, your sister or anyone else who “feels right”. It is important that the people who surround you in labor “feel right” to you. If you have second thoughts about someone, they should NOT be there.

There are professional labor support persons. They are called doulas. Most often the role of a doula is served by a friend or family member, a midwife, or a nurse. But there is a growing number of professional support people. Doulas are special people. They usually feel “a calling” to be a doula. Most are blessed with an enviable strength and a reassuring presence. If you feel the people close to you may not fit the bill as far as labor support goes, consider hiring a doula.

One of the complications of natural childbirth has little to do with the physical outcome of the labor and birth. That is the feelings of failure that some women experience when they do not achieve their goal. It is important for you to realize how little control you might have in some of the situations which can arise during labor. One must realize that through mishap of the forces of nature, bad things can happen to good people. The plans that one makes for a beautiful childbearing experience can be extinguished by the very real (and fortunately, rare) complications which may force one to adjust their expectations.

Water
If a laboring woman could choose only one external factor to employ for dealing with the discomforts of labor, she could do far worse than choosing to labor suspended in water. With or without labor, the full-term, pregnant body can be a force in itself to reckon with. The effects of gravity exert force on the skeleton, the pregnant abdomen and breasts. In water, the body becomes near-weightless. Movement is effortless. Comfort surrounds and supports. Many of the discomforts associated with labor are weight-, position-, and support-dependent.

Unfortunately, there is still a dearth of scientific information on the benefits of water immersion. There is an active movement proclaiming the effects of water immersion (and even water birth!), but the science on the effects and possible complications is still quite embryonic. Common sense would support some of the obvious benefits, and early studies show a very low risk of complication (for example, infection or water aspiration). Tubs are appearing in most newer hospital units, and birthing centers have used tubs for years. By and large Ob/Gyn physicians in the U.S. have yet to embrace the tub as a significant tool for use in labor, and seem much more comfortable with the idea of narcotics and epidurals. There is also a heavy dependence on the use of the electronic fetal monitor throughout labor which many seem to think precludes the use of tubs. However, some of the new fetal monitor transducers are waterproof……and there is actually no need for a low-risk mother to be electronically monitored at all.

If you have the use of a tub, the water temperature should be below 100-degrees-Fahrenheit. Current available studies support the use of tubs even if your bag of water is broken……there is virtually no chance of significant amounts of tub water ascending the vagina. If the tub is filled just prior to use there is no need to chlorinate/brominate the water.

Narcotics
Narcotics are substances originally derived from the poppy plant. Opium, heroin, morphine, and meperidine (Demerol) are all examples of narcotics. There are other drugs not derived from the poppy that have narcotic properties. The narcotics are effective pain relief substances. They also induce narcosis, a physiologic state in which the central nervous system activites are depressed. A person in the state of narcosis feels sleepy, restful and pleasantly intoxicated.

The narcotics also depress respiration, and given in large doses to a woman in labor close to delivery are capable of depressing the respiratory efforts of the newborn. There is also evidence that medium dosages will depress the suck reflex of a newborn. Given in small doses, and avoided close to the time of delivery, the narcotics (usually given through an IV line) have been used successfully for decades.

Narcotics in labor will not take away all of the pain of contractions. The response is variable depending upon a woman’s tolerance for pain. The narcotics will help a woman relax, and will decrease the pain somewhat. Depending on which narcotic is used, the effects last anywhere from 45-90 minutes. Often, repeated doses are needed.

If it is important to you to be fully conscious and alert during the labor or for the birth, narcotics may not be a good choice for you. The term, narcosis, means “sleep”. Narcotics make one sleepy and fog one’s perception. One feels “drugged”, depending on the dosage and the amount of time since the last dose.

Epidurals
The spinal cord delivers and sends message between the brain and the parts of the body. Some of these messages make the body move (motor messages) and some of these messages are responsible for sensation (sensory messages). The spinal cord runs through the vertebrae of the “backbone”. Surrounding the spinal cord is a sheath called the dura. Inside the dura and circulating around the spinal cord and brain is the spinal fluid. If a local anesthetic, similar to the novocaine which dentists use, is injected near the spinal cord, it can produce profound anesthesia usually in the nerves which are below the point of injection. The level of anesthesia depends on the dose and strength of the local anesthetic used (there are many).

To anesthetize the lower abdomen two techniques are commonly used. For short term anesthesia, the dura can be punctured and the local anesthetic placed directly on the spinal cord. This is called a “spinal”. It is also possible to place a small plastic catheter between two layers of the dura and infuse local anesthetic (or narcotics) in the “epidural” space. This is the classic “epidural”. With the use of the catheter, repeated doses (or a continuous infusion) may be given.

The epidural is common in hospitals in the U.S. for the pain of childbirth. Although some obstetricians are trained in the use of epidural and spinal anesthesia, an anesthesiologist or nurse-anesthetist is usually called in to place and manage these forms of spinal anesthesia. Often a hospital has an anesthesiologist or anesthetist “on call” for the obstetrical unit.

Fifteen years ago, epidurals had earned a deservedly poor reputation in obstetrical units in the U.S. When large doses of concentrated local anesthetics are used, the complication rate is unacceptably high. If the “block” that an epidural produces is too strong the blood pressure can drop dramatically, labor can slow down or stop, and without sensation some women will not push effectively. With these “heavy” epidurals the rates of c-section and forceps use increase significantly.

The modern obstetrical epidural is as close to perfect pain relief as one can get. But, nothing is perfect. When significant pain relief is warranted or desired, a good epidural can produce profound pain relief with an acceptable risk of complications. What are the potential complications?

  • The blood pressure can still drop, but is easily managed with IV fluids and some common drugs.
  • There is also about a 2% chance of puncturing the dura and allowing spinal fluid to leak out. This can cause the infamous “spinal headache”.
  • Given too early and with too much anesthetic, labor can still be slowed down or stopped.
  • Epidurals can also diminish the urge to push, a reflex which is sometimes necessary to bring about completion of the second stage of labor (the birth!).
  • Also, some women experience a pain at the epidural site for months after delivery (probably due to damage of the ligaments around the spinal vertebrae from the needle used to insert the catheter).

Two characteristics of the modern epidural separate it from the older version. The concentration of the local anesthetics used has decreased by as much as a fourfold difference (1/16% as opposed to 1/2%). The second characteristic is the use of narcotics in the epidural space. A mixture of a light anesthetic and a small amount of narcotic is a formula for the near-perfect epidural for active phase labor.

It is also possible to use only a narcotic in the epidural. Narcotics affect only the pain receptors on certain nerves, whereas local anesthetic affects both sensory (“pain”) and motor (“movement”) nerves. With a heavy local block, a person may be prevented from even moving that part of the body which is anesthetized. With a labor epidural, that means that the legs cannot be moved. If a narcotic is used alone in the epidural, pain is blocked but one is still able to move the muscles. The narcotic-only epidural has been called a “walking epidural” because of this. A side effect of narcotics placed in the epidural space is itchiness.

If a woman is certain that she wants an epidural for labor, it is possible to place the epidural catheter as soon as it is certain that she is in labor (not always an easy thing to determine!). When contractions become significantly painful, a small amount of narcotic can be injected. Later, when labor is well-established and the contractions are at their strongest, a mixture of local anesthetic and narcotic can be infused continuously with the use of a pump. For the woman set on an epidural, this type of pain management plan may help keep her mobile longer, and reduce the complication risks associated with large, concentrated single-dose epidurals.

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