Probably the biggest thing looming in the minds of most pregnant women when they think about their upcoming labor is pain. This can be a touchy subject. Some people feel very strongly that using pharmaceutical pain relief in labor and birth is unnecessary and unwise. Others liken the refusal of medication to insisting on getting a root canal without pain relief -- i.e. why torture yourself? This is NOT going to be a discussion of which view is "right" or "wrong." Every woman and every birth is different, and there are many factors that go into the decision about whether or not to use pharmaceutical pain relief. What I want to do here is outline the different options you may have for responding to the sensations of labor and birth, and provide information about the risks and benefits of each option. This is such a big topic, so I'm going to break it up into two blog posts.
The first, sometimes only, thing that comes to mind for most people when it comes to pain relief in labor is the epidural. It seems that many think their choice is either to get an epidural or to do nothing and just "tough it out." In fact, there are several options for responding to the pain of labor. All of these options may not be available at your place of birth, but I will highlight some common ones. Please note that I am not intending to give medical advice or to sway readers in one direction or another. I just want to provide a detailed list of the risks and benefits of each option.
Pain relief options fall into two major categories: pharmaceutical and non-pharmaceutical. In this post we will talk about the pharmaceutical options.
- Epidurals: The most famous of all labor pain relief options, an epidural is a local anesthetic (meaning it only affects part of the body, not the entire body). It is inserted into the epidural space near the spine, and it works by blocking the the transmission of nerve impulses. The injection is usually made up of local anesthetics such as bupivacaine, chloroprocaine, or marcaine. These drugs may be combined with narcotics like fentanyl or sufentanil so that the anesthesiologist can reduce the amount of local anesthetic being used so that the side effects of the epidural will be lessened. Sometimes the local anesthetics are combined with morphine, epinephrine, or clonidine to allow the epidural to last for longer or to stabilize your blood pressure.
Benefits: The epidural often gives complete relief of pain, although sometimes it will only numb one side of the body, meaning you could have areas where you feel the full effect of contractions. If you have high blood pressure, an epidural could be helpful because one of the side effects is that is lowers blood pressure. If you are having a hard time relaxing or are feeling very tense, an epidural might give you the relief you need to relax enough for your cervix to begin to dilate. If you are exhausted from a long labor, getting an epidural might allow you to sleep for a little while so that you have enough energy to face the rest of your labor. If you are giving birth via a cesarean, having an epidural is safer than going under general anesthesia (being unconscious), and it allows you to hold your baby immediately after birth in most cases.
Risks: There are several common, short-term risks and some risks that are more rare associated with epidurals. We'll start with the more common risks. Epidurals often lower the blood pressure. They can cause a fever, nausea, vomiting, and/or uncontrollable shivering. Having an epidural can cause your labor to last longer. Epidurals can cause generalized skin itching, and sometimes cause a ringing in the ears. Some mothers report feelings of emotional detachment, and sometimes they just don't work all the way or at all. There are some more severe risks, which are far more rare. These include respiratory difficulties, convulsions, toxic drug reactions, slight to severe headache, septic meningitis, allergic shock, and cardiac arrest. There are also a few risks to the baby including sleepiness at birth, which can make the baby less eager to breastfeed. If you get a fever after getting the epidural, there is no way of knowing for sure if the fever was from the medication or the result of an infection. Because of this, your baby may be given antibiotics and be subjected to testing to make sure he or she does not also have an infection. The medication in the epidural can cause poor muscle tone in the baby in the first few hours, and difficulty with breastfeeding because of poor sucking reflex. It can also increase the chances of jaundice in the baby. An epidural also increases the possibility of an assisted delivery using forceps or a vacuum because it reduces the tone of the pelvic floor muscles.
- Spinal and Caudal Blocks: Spinal and caudal blocks are very similar to epidurals. The main difference between spinal and caudal blocks and epidurals is the area of the spinal column that the needle is inserted into. A spinal block is placed into the subarachnoid space, beneath the epidural space. A caudal block is injected into the caudal canal at the base of the spine, close to the sacrum. The risks and benefits are similar to those of an epidural.
- Narcotics: Narcotics commonly used for labor include stadol or demerol, diamorphine, nubain, and meptid. All of these work similarly to morphine. They are given through an IV or as an intramuscular injection and they block opioid receptors in the body, preventing the transmission of pain messages to the brain. They affect the entire body.
Benefits: The use of narcotics can give you a chance to rest if your labor has been exceptionally long, and you are exhausted. If you're having a hard time letting go of tension, this could relax you and allow labor to speed up later.
Risks: Narcotics cause your stomach to empty more slowly. This may increase the risk of aspiration of the contents of the stomach if you go on to go under general anesthesia. It might make you feel nauseated, out of control, and unable to communicate. For some mothers, the medication does not actually relieve the pain, or it causes them to sleep for the first part of a contraction, and then woken up aware of the pain at the peak of each contraction. It could slow your breathing, resulting in less oxygen in your blood. Also, if you decide you don't like the way the drugs make you feel, the effects cannot be turned off; you just have to wait until it wears off. Your baby could be sleepy after birth and have a hard time breastfeeding and/or be especially fussy in the first few days. Narcotics cross the placenta and take awhile for the baby to metabolize. The can cause the baby to be born with breathing troubles. There is an antidote called Narcan that can be given to the baby to help with respiratory problems, but this does not stay in the baby's system as long as the narcotic does, so when it wears off, the baby may start having trouble breathing again. There is also a higher risk of jaundice in babies whose mothers have had narcotics in labor.
- Pudendal Block: A pudendal block is a local anesthetic that is injected into the pudendal nerve, which is in the vagina. It numbs the vagina and perineum, but does not affect the pain of contractions. They are most often administered right before the pushing stage. There are no significant risks or benefits.
- Entonox: Entonox is a combination of nitrous oxide and oxygen. You can administer it yourself by breathing in through a facemask or small plastic tube. It begins working right away and gives a feeling of separation from the pain. This effect wears off a few seconds after you stop inhaling the medication. It does cross the placenta, but it metabolizes very quickly, and there are no known risks to the baby.
Benefits: You, the mother, can be in complete control of when and how often you inhale the medication. It can lessen the intensity of the pain, but not leave you with a feeling of being out of control.
Risks: Some women experience nausea and vomiting as a result of entonox.
Whew! I know that was a lot of information, but I hope that at least some of it will be helpful as you make decisions regarding how you will respond to be sensations of labor and birth. Next, we will take a detailed look at non-pharmaceutical methods of pain management.