Most expectant mothers look forward to labor and delivery, the end of a long, 40-week process that results in the birth of a child. However, for most women, labor and delivery can be physically painful and emotionally draining. To help prepare for the delivery process, pregnant women should give thought as to how they want to treat pain during childbirth.
It is impossible to know beforehand how much pain a woman will experience during childbirth. The degree of pain varies from woman to woman and pregnancy to pregnancy. For these reasons, women should consider in advance their options for pain relief and inform their physician about the choice that feels right for them.
Some women prefer natural childbirth, in which the mother uses breathing techniques and other methods to deal with the pain of labor. In other cases, women may choose various types of drugs that can significantly reduce pain. In many cases, the way labor and delivery unfold will dictate the method of pain relief regardless of the patient’s desires.
Each woman’s perception of pain is unique and women have different tolerance levels. Women who initially choose to forgo medications should not feel ashamed if the pain of labor causes them to change their minds.
About pain relief during labor and delivery
Labor and delivery are the joyous culmination of 40 weeks of pregnancy that ends with the birth of a child. However, the reality is that labor and delivery are painful for most women. Therefore, expectant mothers should prepare in advance for this discomfort and plan strategies for addressing the pain when it arrives.
Uterine muscle contractions and pressure on the cervix are the chief causes of pain during labor. The baby’s position also can create pressure on the bladder, bowels, lower back and groin muscles. In addition, pain may result from stretching of the birth canal.
For some women, labor is among the most intense pains they will feel in their lifetime, but others may feel less intense sensations. Most women experience the pain of labor as cramping in the abdomen, groin and back. They may also experience a tired, achy feeling all over, and pain in their sides or thighs. The pain may resemble menstrual cramps, severe pressure or extremely strong waves that feel like diarrheal cramps. First-time mothers are likely to feel more intense pain than women who have previously given birth.
Intense pain experienced during labor often leads to hyperventilation, which is abnormally fast or deep respiration that causes loss of carbon dioxide from the blood. This in turn causes blood pressure to fall. The body’s response to stress and pain may also cause decreased blood flow to the placenta and decreased oxygen flow to the fetus. Finally, significant pain may cause deep emotional trauma for the mother that may contribute to postpartum depression. All of these symptoms can be minimized by controlling pain levels during labor and delivery.
Pregnant women should consider their options for pain relief in advance and inform their physician about the possible choices. It is recommended that women compose a birth plan that includes their preferences for pain relief during labor. They should provide their obstetrician (OB) with a copy of the plan, as well as the medical facility staff.
Some women prefer to have natural childbirth, in which breathing techniques and other pain-coping strategies are used to handle the pain of labor. Other women may be more comfortable choosing a form of medication that will bring them substantial relief from the pain of childbirth. There are several types of medications that are commonly used during labor and delivery. Some of these drugs reduce pain brought on by contractions, and some help during delivery. Certain medications do not relieve pain, but instead relieve anxiety and promote relaxation.
Some women who initially choose natural childbirth may find the pain so intense that they change their minds during delivery and decide to use medications. Many partners also experience difficulty observing the woman in pain and are more at ease once the mother is more comfortable. In other cases, the way in which labor and delivery unfold may create medical circumstances that dictate the method of pain relief regardless of the patient’s desires.
Types & differences of pain relief used in labor
There are a variety of techniques that women can use to reduce the level of pain they feel during labor. During pregnancy, women can continue to exercise and to perform special techniques such as Kegel exercises, in which the pelvic muscles are strengthened. This helps prepare a woman’s body for the stresses of labor and improves her level of endurance. However, women should not plan out or execute any exercise routine without first consulting their physician.
Pregnant women and their partners can also attend childbirth classes that teach techniques for handling pain. These include everything from visualization techniques to stretching exercises. Two of the most popular techniques taught in these classes are:
Lamaze technique. Also known as natural childbirth, it is among the most widely taught childbirth philosophies in the United States. Lamaze teaches women and their partners to use relaxation techniques, breathing exercises, distraction, massage and encouragement from a birthing “coach” as methods to decrease the perception of pain.
The Bradley method. Also known as husband-coached birth, it emphasizes a natural approach to childbirth without the use of medications unless absolutely necessary. The mother’s partner is actively involved in the process and acts as a birth coach. This philosophy emphasizes nutrition and exercise during pregnancy and instruction in relaxation and deep-breathing techniques.
Women use other techniques to lessen their perception of pain. These may include:
Some women choose to give birth while bathing in a pool of warm water, though not all hospitals offer this delivery option. Proponents say this method helps relax the mother and relieves the pain of labor. To date, studies have shown mixed results as to whether this technique significantly reduces labor pain.
Childbirth philosophies such as Lamaze encourage women to forsake use of medications during labor. Though some women successfully deliver their child using natural childbirth, it should be noted that these techniques cannot eliminate the pain a woman feels during labor and delivery. In some cases, women who planned to forgo use of medications may find the pain of labor to be much worse than anticipated. It is not unusual for women to change their minds and ask for medications during labor. This is common, and women should not feel ashamed of the request.
Medications have been used for labor and delivery pain relief since the mid-19th century. Today, there are several drugs available to help mothers endure the pain of childbirth. Most can be classified as analgesics or anesthetics. Analgesics relieve but do not completely stop pain. They work without causing a loss of sensation. The patient who receives the drugs usually remains conscious.
Anesthetics substantially or completely block feelings of pain, but usually cause a loss of sensation. Treatments that use local or regional anesthesia (such as epidural and spinal blocks) will not cause women to lose consciousness. However, women given general anesthesia – which is usually reserved for emergency Caesarean delivery (C-section) or other emergencies – will lose consciousness.
Medications can be extremely effective in lessening the pain of labor. In addition to making contractions less painful, medications also may allow the patient to rest more effectively between contractions. This rest period may accelerate the opening (dilation) of the cervix allowing for delivery of the baby.
Any medication a woman takes can affect her baby. For this reason, the type of medication, dosage level and time of administration relative to delivery are planned for optimal benefit to the mother while ensuring minimal impact on the child.
Types of medications used during labor and delivery include:
Epidural block. This medication blocks pain below the belly button and alters the perception of pain for several hours. It is a mixture of an anesthetic such as chloroprocaine or lidocaineand a narcotic such as fentanyl, meperidine, morphine or nalbuphine. The drug is injected into the lower back just outside the tough sac (dura) surrounding the spinal cord. This is where the nerves that receive sensations from the lower body meet the spinal cord.
An epidural block can be used during both active labor and C-section. The patient is asked to sit or lie on her side with her back curved outward. As the needle is inserted into the lower back, a small tube may be inserted through it. Medication can be given continuously through this tube if it is connected to a mechanical pump or small doses can be given through the tube at a later time without need for further injections. The initial dose of the medication takes about 20 minutes to administer, with numbness setting in about 20 minutes later. Epidurals may not be allowed if a woman has reached a certain point in her labor.
Women who have an epidural block remain awake and alert, and the epidural does not significantly slow labor. Women who desire to continue walking during labor can have a walking epidural, which leaves the woman with enough muscle strength to move. A CSE (combined spinal-epidural block) or “walking epidural” requires a special technique and may not be available at all birthing centers or hospitals. The advantage of this procedure that has recently become more popular is that because it only numbs a woman’s abdominal nerves, it allows her to move around without discomfort for an extended period prior to delivery. Due to the combined technique in CSE there is rapid pain relief provided by the spinal part in addition to long-lasting, continuous relief through the epidural portion. However, a woman should assume that if she is going to get an epidural, she will not be able to ambulate until after the delivery, when the epidural is discontinued.
Disadvantages of epidurals include that fact that they sometimes affect one side of the body more than the other, resulting in uneven pain relief. These medications may also make pushing more difficult for the mother due to the reduced sensation in the area. Epidurals increase the likelihood that forceps or vacuum extraction might be needed to help remove the baby. They may also decrease the mother’s blood pressure. Usually, preventive steps are taken to keep blood pressure problems from developing, including administration of intravenous (I.V.) fluids and positioning the patient on her side to aid blood circulation. In rare cases, women report the sensation of breathing difficulties. This is a result of the medication’s effect on the chest muscles, and although it produces no real danger, it can provoke anxiety. Most women who get an epidural will lose the sensation that their bladder is full. Therefore, most women who receive an epidural will also need a urinary catheter during labor to keep their bladder empty. Finally, some women report severe headaches due to the leakage of spinal fluid, and others may experience allergic reactions.
In an epidural, some medication reaches the baby. However, the amount is far less than what the baby would get intravenously or under general anesthesia. Nonetheless, use of epidurals sometimes slows the baby’s heart rate as the mother’s blood pressure drops. In addition, a recent large-scale study indicates that use of epidurals during labor and delivery may affect breastfeeding. Results from the study showed that women who were administered epidurals during labor were more likely to experience nursing problems in the first week after delivery, and to give up breastfeeding before the baby was six months of age.
Spinal block. A treatment similar to an epidural, it uses the same drug mixture of an anesthetic and a narcotic. However, it is injected deeper than an epidural, through the dura into the fluid surrounding the spinal cord. This allows the medication to take effect in seconds. Spinal blocks can be used in active labor or prior to a C-section to provide pain relief from the chest down for up to two hours. The mother remains alert and awake after receiving the medication.
Disadvantages of spinal blocks include their tendency to decrease blood pressure and slow the baby’s heart rate. There is also a higher risk of spinal headache than with epidurals, and some women experience loss of bladder control, resulting in the need for a urinary catheter. Rarely, women may experience lightheadedness or nausea. Spinal blocks cannot be used with an indwelling catheter, so additional medication cannot be given without additional injections. Therefore, they are used when the anesthetic is needed for a defined period of time, such as in a C-section or a rapid vaginal delivery.
Analgesics and narcotics. These medications decrease pain perception and promote rest without causing muscle weakness. They can include drugs such as butorphanol, fentanyl, meperidine and nalbuphine. Analgesics and narcotics are injected into a muscle in the thigh or buttocks or are provided through an I.V. catheter. In some cases, the patient may be allowed to control her own dosage through the I.V. by pressing a button that increases medication level. Analgesics and narcotics can be used in labor, and their painkilling effect lasts two to six hours. In some cases, additional drugs are given with analgesics and narcotics to relieve tension or nausea.
However, analgesics and narcotics sometimes cause sleepiness and lower the mother’s attention and strength to push. The drugs can also decrease a woman’s memory of her birth experience. In addition, they may temporarily depress respiration in the mother and baby. The effect of these drugs on the baby depends on how much of the drug is administered and how close to delivery the drug is given to the mother. Some babies show signs of sleepiness – including slowed breathing and reflexes – immediately after birth. For this reason, analgesics and narcotics are usually avoided just before delivery.
Local anesthetic. An anesthetic such as chloroprocaine or lidocaine is sometimes injected into tissue at the vaginal opening to numb the tissue shortly before or after delivery. This is usually done prior to cutting the tissue to enlarge the vaginal opening (episiotomy) to facilitate delivery. In addition, this tissue may be numbed before a tear is repaired. Local infiltration anesthetics provide localized pain relief with a high margin of safety.
However, this technique does not provide pain relief from contractions. In addition, local infiltration anesthetics may provoke an allergic reaction in some women. In rare cases, they also may cause blood pressure to fall when the medication is injected into a vein.
Pudendal block. These drugs block pain between the vagina and anus (perineum) in cases when delivery of the baby needs to be assisted by vacuum extraction or use of a forceps. In this treatment, an anesthetic medication such as chloroprocaine or lidocaine is injected into the pudendal nerve, through the vaginal wall shortly before delivery. Pudendal blocks can be used to relieve pain experienced after an episiotomy or a tear during delivery. Pain relief is localized and usually lasts for several minutes up to an hour.
Pudendal blocks do not provide pain relief from contractions and they may slightly decrease a woman’s urge to push. In addition, some women experience allergic reactions to the medication. In rare cases, women may experience a fall in blood pressure or may faint if medication is injected into a vein.
General anesthetic. General anesthesia is not used to relieve the pain of labor. It can be used during C-section or during emergencies. The patient will not be conscious once general anesthesia has been used. The drug is given either through a face mask or intravenously, and is usually administered just prior to delivery.
Patients who undergo general anesthesia are subject to various side effects. If a woman’s stomach is not empty, she may vomit with a risk of the food entering her trachea and lungs (aspiration). This can cause choking or pneumonia. For this reason, women are asked not to eat prior to delivery if general anesthesia may be used. Once general anesthesia wears off, patients often feel woozy and tired for several hours after waking up. Patients may also feel sick to their stomach with nausea and vomiting. These symptoms usually subside within a day once the drugs are out of the patient’s system.
Tranquilizers and barbiturates. In rare cases, these drugs may be used to relieve a patient’s anxiety and promote rest during early labor. Tranquilizers include diazepam promethazine and propiomazine. Barbiturates include amobarbital, pentobarbital or secobarbital. They are given by mouth, injection into a muscle in the thigh or buttocks, or intravenously. The effect of these drugs usually lasts four to eight hours. These drugs are sometimes given in conjunction with analgesics or narcotics.
Tranquilizers and barbiturates do not provide pain relief and may cause drowsiness and reduced awareness of the labor by the mother. In addition, they can decrease the baby’s muscle tone and activity at birth.
Questions for your doctor on pain relief in labor
Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor or healthcare professional the following questions regarding pain relief in labor and delivery:
What can I expect in terms of pain during labor and delivery?
What is natural childbirth?
Who should get a copy of my birth plan with my preferences?
Who will be responsible for monitoring my pain during labor and delivery?
What type of pain relief will be tried first during my labor?
What type of medications might be used during my labor?
What are the benefits and risks of these medications?
How will these drugs affect my baby?
What is the difference between an epidural and a spinal block?
Is there a restriction on when I can receive an epidural or spinal block?
Will I be able to receive a “walking epidural”?
What will I receive for anesthesia if I need a C-section?
Will I automatically receive local anesthesia for an episiotomy?
Does the medical facility offer alternative birthing practices, such as under water?
Where can I go for childbirth classes that can provide Lamaze training?
