Pregnancy, Childbirth, and the Newborn: The Complete Guide, 4th Ed.

CHAPTER 10 Labor Pain and Options for Pain Relief

When new mothers were asked to describe the sensations of childbirth, some used words that depicted a positive experience, such as exhilarating, empowering, and even orgasmic; others used words that portrayed a negative experience, such as painful, exhausting, and traumatic. For still other women, childbirth wasn’t a particularly transformative event, and they used words such as tedious, uncomfortable,and manageable to describe the experience.

The preparations you make during pregnancy can influence the kind of birth experience you’ll have. You’re more likely to have a positive birth experience if you learn about your pain relief options practice a variety of coping techniques,* and arrange for continuous labor support from people who respect your preferences for pain relief. This chapter describes labor pain and provides an overview of your options for coping with it so you can have the best possible birth experience.

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In this chapter, you’ll learn about:

• Why labor is painful, and the difference between pain and suffering in labor

• Factors that increase labor pain and those that decrease it

• How birth experiences differ when pain medications are used and when they aren’t

• Options for labor pain medications, such as intravenous (IV) narcotics and epidural analgesia, as well as their benefits and risks

• How to define and communicate your preferences for pain management

• The importance of being flexible with your pain-relief preferences if labor proceeds differently than expected

Why Labor Is Painful

In almost all pregnancies, labor begins with mild contractions that come and go. As labor progresses, the contractions occur more frequently and their intensity increases. Although a few women have reported experiencing little to no pain during labor, the process is painful for most women. The following physical changes contribute to labor pain:

• Reduced oxygen supply to the uterine muscle during contractions, which creates a buildup of waste products, such as lactic acid, that in turn causes pain (The pain disappears as soon as the contraction stops.)

• Stretching of the cervix as it dilates

• Pressure of the baby on nerves in and near the cervix and vagina

• Tension and stretching of the ligaments of the uterus and pelvic joints during contractions and the baby’s descent

• Pressure of the baby on the urethra, bladder, and rectum

• Stretching of the pelvic floor muscles and vaginal tissues during the birth

Although these changes can hurt, the pain isn’t a sign of harm. Instead, it’s an expected side effect of the normal labor process that lets women efficiently and effectively push their babies out into the world. For this reason, labor pain is often called “pain with a purpose.”1

Your Perception of Pain

Simply understanding the physical reasons for labor pain helps many women cope with it. They’re able to acknowledge that labor pain is normal and temporary, which allows them to work with their bodies and prevent the pain from overwhelming them. By changing the way they think about the pain, these women alter their perception of it and reduce its severity. The following sections describe two theories about other factors that influence pain perception.

THE GATE CONTROL THEORY OF PAIN

The Gate Control Theory of Pain helps explain why people feel more pain in some cases and less pain in others, and why some people feel more or less pain than others do. You’ve probably had some of the following experiences with pain:

• A headache that goes away when you’re watching an exciting movie, but returns when the movie ends

• A stubbed toe that hurts less when you dance around

• A bruise, acquired while playing a sport, that goes unnoticed until the game is over

• The pain of physical exertion that’s eased when you focus on silently creating a rhythm (counting, chanting, or singing a song in your head)

• The pain from dental work that’s eased when listening to music through headphones

Although the pain stimulus never goes away in any of these examples, your awareness of it decreases when your brain receives other stimuli that are non-painful or pleasant (pain modifiers). This theory states that the balance between painful and non-painful stimuli that reach your consciousness determines your perception of pain and its severity. This explains why distractions help relieve pain. Your brain is so busy processing the non-painful stimuli that it can’t pay as much attention to painful sensations.

You can make pain more manageable during labor by increasing pleasant stimuli (such as massage, music, cold packs, a heating pad, or other distractions) and focusing on them.

THE NEUROMATRIX THEORY OF PAIN

The Neuromatrix Theory of Pain is an expansion of the Gate Control Theory of Pain and takes into account all possible factors that can influence how pain is felt and interpreted.2 It has been applied to help explain why women differ in their reactions to labor pain, and why some women find comfort measures more helpful to relieve pain than other women do. The theory acknowledges that the painful and non-painful stimuli a woman receives in labor aren’t the only factors that affect her perception of the pain. Past experiences of pain or trauma are also factors, as are preexisting factors such as chronic pain or painful medical conditions, anxiety, personality or temperament, physiological factors such as the central nervous system’s and endocrine system’s reactions to stress, and cultural or familial attitudes toward pain. Some of these factors are genetically determined; others are formed earlier in life.

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Factors That Increase Labor Pain

Physical factors

• Hunger or thirst

• Fatigue

• Muscle tension

• Full bladder

• Discomfort from staying in the same position for too long

Emotional or mental factors

• Fear, anxiety, loneliness, or feeling watched or judged (All of these emotions can cause the release of excessive stress hormones and make labor longer or more painful than usual.)

• Lack of confidence and preparation

• Ignorance or misinformation about labor and birth

• Unsupportive staff or relatives

• Feeling powerless to make decisions, or feeling that your decisions aren’t being respected

Variations during labor

• Frequent long contractions, or coupling contractions (occur in pairs with little break between the first and second contractions)

• Baby that’s malpositioned (See page 285.)

• Prolonged, tiring labor; exhaustion

• Rapid intense labor, with little break between contractions

• Expectations for labor and birth that don’t match the actual experience

• Hospital policies, procedures, or interventions that limit mobility or ability to use coping techniques

Different Views on Labor Pain

When asked to describe the pain experienced in labor, new mothers had many different responses. Here are a few examples:

I’d first feel cramping in my back, then it’d move around to my front and my whole belly would tighten. Later in labor, I could feel the cramping even in my thighs.

The pain is hard to explain. The contractions were just really intense. My body demanded my complete attention, like it does when I sneeze, orgasm, or vomit. The contractions were all my body would let me think about right then.

The best way to describe labor pain is that it’s like the kind of aching pain you get when you do something that requires a lot of effort such as doing a chin-up or holding an advanced yoga pose for a long time. Your muscles burn as they get tired. That’s what my uterus felt like.

Measures That Make Labor Pain More Manageable

To minimize the factors that increase labor pain, be aware of them in advance, make plans to manage them, and ensure that your support people are aware of them and work to minimize their impact on you. The following are examples of ways to counteract the pain-increasing factors listed on page 179:

• Eat and drink enough to stave off hunger and thirst.

• Dim the lights and arrange for minimal interruptions to increase your sense of privacy.

• If past trauma has made you fearful, get counseling before the birth to help you learn skills to manage the fear. Visit our web site, http://www.PCNGuide.com, to download a work sheet to help with this process.

Throughout your life, you’ve learned ways to make pain and anxiety more manageable. To help you prepare for coping with labor pain, ask yourself these questions and brainstorm as many answers as you can.

• What comforts you when you’re sick?

• When you were a child, what did your parents do when you were sick that made you feel better? (Or what do you wish they had done?)

• What do you do during heavy physical exertion to help you keep going?

• What soothes the pain of a headache or sore muscles?

• What helps you feel safe in an unfamiliar situation?

• What calms you when you’re stressed or scared?

• What kind of support from others best helps you? Do you want a shoulder to cry on? Someone to cheer you on? Empathy and gentle guidance? Reassurance and a calm, quiet presence? Distracting chatter and entertaining activities? Your answers to these questions will give you clues about what you’ll find most helpful in labor. Visit our web site to download a work sheet to help track your observations.

A number of other comfort measures are also particularly helpful in labor, such as massage, relaxation techniques, breathing techniques, positions and movement, and pain medications. See Chapter 11 for more information on non-medicated comfort measures.

PAIN VERSUS SUFFERING IN LABOR

While pain is a natural part of the labor process, suffering certainly isn’t. Pain is a mildly to severely unpleasant physical sensation that might or might not be associated with physical damage. Suffering is a debilitating emotional state that might be associated with pain or with another cause such as grief, humiliation, or defeat.

You can have pain without suffering. For example, during a strenuous workout, you may experience the pain that accompanies exertion. You know why your body hurts, but you also associate the pain with improved physical conditioning, which makes the pain manageable. In the same way, you may experience intense pain during labor but not feel as though you’re suffering, because you associate the pain with normal labor progress.

Despite the fact that pain in labor doesn’t necessarily lead to suffering, some women nonetheless do suffer. Suffering includes any of the following experiences:

• A perceived threat to your body or psyche

• Helplessness and loss of control; distress

• The inability to cope with a distressing situation

• Fear of dying or the death of the baby3

The Neuromatrix Theory of Pain (see page 179) helps explains why some women suffer in labor while others don’t, even though all experience pain. If you don’t receive enough stimuli that help reduce your perception of pain (such as massage, movement, baths, and encouraging words) or if you have too many factors that increase your perception of pain (such as fear, loneliness, ignorance of what’s happening, immobility, unkind or insensitive treatment, and anxiety or depression), you’re more likely to be overwhelmed by the pain and feel as though you’re suffering.

Rating Your Intensity of Pain and Your Ability to Cope

In many hospitals, the staff use a very helpful tool called a pain intensity scale to assess how much pain a patient is experiencing during a medical procedure or postoperative recovery. By rating the intensity of pain, the patient can alert staff of potential problems that are then treated with pain medications. During labor, however, pain is a normal and expected part of the process, and women have a range of preferences for how they want to manage the pain, which don’t always include pain medications.

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Another way to assess labor pain is by using a pain coping scale. This scale focuses not on how much pain a patient is experiencing, but rather on how well she’s coping with the pain. If you’re asked to rate your pain on the pain intensity scale, do so, but then also rate how well you’re coping. Let the staff know whether you find the pain manageable or overwhelming.

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Pain does not equal suffering. Suffering equals inability to cope with pain.

CONTROL IN LABOR

For many pregnant women, the possibility of losing control of themselves during labor is the most upsetting part of childbirth. They worry that the pain will be so intense, they’ll do or say things they’ll regret later. They’ve seen movies or heard stories in which a laboring woman panics, screams, or says hurtful things to those around her. To avoid becoming “that woman,” some expectant mothers plan to dull labor pain with anesthesia to prevent themselves from behaving in a way that’s socially unacceptable.

Normal behavior in labor, however, isn’t the same as normal behavior in everyday life. Childbirth is an emotionally transformative and physically demanding experience that compels your body to work hard and requires your complete attention to seeking comfort, maintaining the Three Rs (see page 206), and expressing yourself freely. As long as you’re coping well in labor, the idea of whether your behavior is socially acceptable shouldn’t be a concern to you or to those attending to you.

Releasing Control versus Losing Control

Although you can’t consciously control your contractions any more than you can control digestion, you can control how you respond to them. For example, during pregnancy you may prepare for labor by practicing a certain breathing technique and making sure you’ll have access to a bathtub. When labor begins, however, you may find yourself breathing in a different, unplanned rhythm and needing to walk rather than soak in the tub.

Instead of forcing yourself to follow your plans, you choose to give them up—that is, you release control and allow yourself to discover new ways of coping that help you work in harmony with the labor process. Releasing control is a matter of responding to your labor in the moment, as it unfolds.

Conversely, losing control in labor comes from feeling overwhelmed and helpless when labor doesn’t go as expected, or from feeling that you’re being excluded from the decision-making process. To help avoid feeling discounted, passive, or powerless in your care, learn about your options for childbirth well before labor begins (see Chapter 2), ask your caregiver the key questions on page 10 for any interventions you’re considering, and make sure your decisions are reflected in your birth plan (see Chapter 8).

Options for Pain Relief

While some women want a drug-free birth, others can’t imagine giving birth without pain medications. Most women’s opinions fall in between these two extremes: They want to minimize the amount of strong pain medications they receive during labor, yet they don’t want the pain to overwhelm them. The information in this section will help you form your own opinions on pain-relief options.

To effectively manage labor pain, it’s essential to have a “toolbox” of coping options. During pregnancy, you can read books on childbirth and take childbirth preparation classes to help you stock your toolbox with options such as the following:

• Coping skills you’ve used throughout your life to comfort yourself when you’re sick, tired, worried, in pain, or physically exerting yourself (See page 180.)

• Self-help skills that you can practice during pregnancy to lessen labor pain or help you cope with it, such as breathing techniques, relaxation techniques, and visualization and attention-focusing (see Chapter 11) as well as positions that enhance comfort and labor progress (See pages 221–223.)

• Comfort items that you can use at the birthplace, such as your own pillow or clothes, snacks and beverages, heating pads and cold packs, birth ball, and shower or bathtub (See page 212.)

• Hands-on support from your partner or doula, such as massage, gentle stroking, and acupressure (See pages 213 and 214.)

• Changes to the environment to make it more comfortable, such as dimming the lights, playing music, using pleasing scents or aromatherapy, and asking for minimal disruptions

• Pain medications, including intravenous (IV) narcotics (see page 194) and epidural or spinal analgesia (see page 196).

Before labor, you may think you know which coping techniques will work best for you. During labor, however, you may discover that those options don’t work as well as expected. This is why it’s important to learn a variety of coping techniques: The technique you never imagined you’d use may be the one that helps you the most!

AVAILABILITY OF PAIN-RELIEF OPTIONS

Your options for pain relief depend on where you plan to give birth. If you’ll give birth at home or in a freestanding (unaffiliated with a hospital) birth center, you can use most non-drug coping techniques, but you won’t have access to pain medications such as epidural analgesia. If you’ll give birth in a hospital, medications will be available. Hospital policies, care practices, and available equipment might or might not support various comfort techniques such as eating in labor, mobility, baths and showers, birth balls, acupuncture, and aromatherapy.

To learn what pain-relief options are available at your birthplace, ask the questions on page 10 during your prenatal care appointments, hospital tour, and childbirth preparation classes. If you’re considering using pain medications, ask your caregiver which ones are typically available, which can be given by your caregiver or nurse, and which require an anesthesiologist. Also ask about the availability of the anesthesiologist. Some hospitals have anesthesiologists on call at all times; others don’t. Lastly, make sure to discuss the risks and benefits of pain medications with your caregiver (see page 193) so you can better make an informed decision about using them.

EFFECTIVENESS OF VARIOUS PAIN-RELIEF OPTIONS4

The following table summarizes the effectiveness of various pain-relief options. The ratings are based on reports given by women who were surveyed in the first year after giving birth.

 

Percent Who Used the Option

Percent Who Said the Option Was Very Helpful

Percent Who Said the Option Was Somewhat Helpful

Epidural or spinal analgesia

76%

81%

10%

Immersion in bathtub or pool

6%

48%

43%

Hands-on techniques (such as massage)

20%

40%

51%

IV narcotics

22%

40%

35%

Birth ball

7%

34%

33%

Shower

4%

33%

45%

Application of heat or cold

6%

31%

50%

Mental strategies (such as relaxation)

25%

28%

49%

Position changes

42%

23%

54%

Changes to environment (such as dimming lights)

4%

21%

57%

Breathing techniques

49%

21%

56%

This table shows that the majority of women received epidural or spinal analgesia to help cope with labor pain, and most found the medications to be very helpful. However, this option wasn’t the only one that effectively relieved or reduced labor pain. Of the other options included in the survey, all proved somewhat to very helpful for most of the women who used them. For example, the total percentage of women who found pain relief from immersion in a bathtub or from hands-on techniques (such as massage) equaled the total percentage of women who found pain relief from epidural or spinal analgesia (91 percent).

If non-drug measures were found to help relieve pain, why didn’t more women use them? For example, less than 10 percent tried making changes to their environment or used the tub, shower, birth ball, or applications of heat and cold. The overall effectiveness of these pain relief options was rated between 67 to 91 percent. The reason these measures weren’t used as often is probably because most of the women surveyed either didn’t know about them or hadn’t learned how to use them—which is unfortunate, given their safety and effectiveness for pain relief.

Although pain medications—especially epidural analgesia—can effectively minimize or eliminate labor pain, they’re also expensive and carry risks and disadvantages that may complicate labor and birth. See pages 193–197 to learn about the potential tradeoffs, side effects, and risks of pain medications.

Conversely, non-drug methods for pain relief are free (or inexpensive) and easy to use, have few side effects, can be easily discontinued or replaced by other measures, and allow you to work with your body and take an active role in childbirth. See the chart below for a more complete comparison between a non-medicated labor and a medicated one.

As you think about pain relief for your labor, consider trying various non-drug methods first, to see if they can help you manage the pain effectively. See Chapter 11 for information on comfort techniques. Remember that you can increase overall effectiveness of these methods by using several at any one time and shifting to others whenever you desire. If you find that these methods aren’t helping you cope as labor progresses, you can always request pain medications at that time.

Even if you’re planning to receive an epidural or use pain medications in labor, it’s still wise to learn the comfort techniques in Chapter 11, because you’ll need ways to cope with contractions before heading to the hospital or while waiting to receive an epidural or pain medications at the hospital, or if the drugs turn out to be ineffective for you. Some comfort techniques—such as relaxation, breathing patterns, massage, and some movements—are more effective if you practice and adapt them well before labor begins.

Non-medicated Labor versus Medicated Labor

The following chart compares a labor that’s managed by using non-drug coping techniques with one that’s managed with medications. This comparison helps you see how your labor may differ based on the choices you make.

Non-medicated Labor

Pain-relief Option Used

• How it affects your experience of pain

• Feedback from women who used it

• How it affects your mental state

• How it affects your mobility

• What you’ll need from your support people

• Equipment and precautions required

• Impact on labor progress

• Timing

• Availability

• Possible risks to you

• Possible risks to your baby

• Cost

• Best option for you if...

Non-drug Coping Techniques*

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• Increases pain-relieving endorphins, enhances oxytocin production, decreases muscle tension, eases anxiety or fear distracts your attention from the pain, and enhances your mood.

• “It was really challenging to handle the contractions. I finally discovered that if I got on my hands and knees and rocked and roared, I could do it. It was as though I’d found my inner tiger!”

• You’re fully focused on coping with the contractions and are less aware of surroundings.

• You’re fully mobile to find comfort: You can walk rock sway, sit, and so on. You may need to keep moving in order to cope with pain.

• You’ll need their continuous presence; active, hands-on assistance with massage, movement, and positions; encouraging words; and more.

• None (However, you may choose to use the bathtub, shower, birth ball, rocking chair, cold packs, or heating pads. In addition, you’ll have periodic monitoring of your baby, contractions, blood pressure, and vital signs.)

• Usually promotes labor progress.

• Can be used at any time during labor and birth.

• Anytime, anyplace

• None (But you’ll still have labor pain.)

• None

• Free or Inexpensive

• You’re committed to a non-medicated labor or want to delay use of medication, have a supportive staff, have made necessary preparations, and have recruited a support team.

Medicated Labor

IV Narcotics

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• Blocks pain receptors in the brain so pain messages aren’t recognized or interpreted as pain. Pain intensity at the peak of the contraction might not be reduced by narcotics and might be hard to manage.

• “I felt really fuzzy-headed and slept between contractions. During a contraction, I’d wake up, cry out, and rock back and forth while my husband rubbed my back. Then I’d crash again.”

• You’re relaxed, drowsy, foggy, or disoriented. You may hallucinate.

• Mobility may be limited by policy, by equipment, or if you’re unsafe standing because you’re dizzy or groggy.

• You’ll need some assistance with movement and mental reorientation (if you’re foggy) and help coping at the peak of contractions.

• Intravenous (IV) fluids, electronic fetal monitors (EFM) to continuously check your baby’s heart rate; equipment to frequently monitor your blood pressure, respiration, and vital signs; oxygen supply and mask.

• May slow normal labor.**

• Best used in active labor. Effects last 45 to 90 minutes. Can be repeated. Not used if birth is expected to occur within 2 hours.

• All hospitals, anytime

• Some (See page 195.)

• Some (See page 195.)

• Moderate

• You want only an hour or two of moderate pain relief, or feel that you’re coping well at the peak of contractions but want to feel as though you have a longer rest between contractions.

Epidural Analgesia

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• Blocks nerve endings so they don’t send pain messages to the brain. Light doses eliminate contraction pain (but not the pain of pushing) and dull other sensations. Heavy doses also cause numbness and inability to move your legs.

• “After I got the epidural, it was great. No more pain! But then it seemed as though labor took forever, and we were sitting around watching TV—it wasn’t quite what I thought birth would be.”

• You return to your normal, everyday mental state. You may be chatty or may sleep through much of labor, if tired.

• You’re rarely allowed out of bed. Movement in bed is limited by equipment and lack of sensation. You may need assistance to move at all.

• You’ll need companionship to help pass the time, manage anxieties, identify contractions, and guide pushing.

• Epidural catheter and pump; IV fluids; EFM to continuously monitor your baby’s heart rate; equipment to frequently monitor your blood pressure, respiration, and vital signs; oxygen supply and mask pulse oximeter; bladder catheter.

• Likely to slow normal labor progress (may require Pitocin).**

• Can be used at any time except if birth is anticipated within 30 to 60 minutes. Once started, the medications usually stay in effect until after your baby is born.

• Some hospitals, anytime; other hospitals, limited hours and an anesthesiologist must be called in at night. Not available in 3 percent of U.S. hospitals.5

• Some (See page 197.)

• Some (See page 197.)

• Expensive

• You want to experience the least amount of pain, and are willing to have more medical interventions to minimize the adverse side effects of the epidural and to maintain labor progress; or you require painful interventions for safety or progress.

* It’s assumed that you’ll use a variety of techniques from among those listed on pages 182–183 and described in Chapter 11.

** Deep-seated fear, stress, and pain-related anxiety can slow labor. If you experience a prolonged labor due to these causes, pain medications may speed up progress by lowering stress hormones.

Two Views on Managing Labor Pain

I wanted to be able to use pain medications. But Ben was worried about the side effects. We talked with our caregiver about how to minimize the possible side effects and risks, and created a plan that we were both comfortable with.

—Ann

Ashley really wanted to have a “natural” labor. But I knew it’d be hard for me to see her in pain. I worried that I’d talk her into getting drugs. Luckily, we have a friend who had given birth without pain medications. She came with us to the hospital and helped us both cope with natural labor.

—Nick

Determining Your Preferences for Pain Relief

The following are factors that help determine whether you’ll use or avoid pain medications in labor.

Your preference for pain medications

Do you prefer to give birth without drugs, or do you prefer to use medications? How strongly do you feel about this preference? Your views may be influenced by past experiences with pain, your expectations about how challenging labor will be, your confidence in your ability to cope with pain, and whether you want to rely on your own resources or prefer to turn over management of your labor to others. (See the Pain Medication Preference Scale on page 187to help clarify your preferences.)

Preparation

You’re better able to cope with labor pain if you have complete information on all available options for pain relief, and have had opportunities to learn, practice, and adapt non-medicated comfort measures. Without such preparation, you’re likely to need pain medications.

Support

You’re more likely to avoid, postpone, or minimize your use of pain medications if you have the following:

• A partner or doula (see page 190) who encourages you and helps with self-help comfort measures

• Support staff who are skilled in comfort measures

• A caregiver who’s patient and encouraging

Luck

The nature of labor affects the use of medications. The more uncomplicated your labor is, the better your chances are for a non-medicated birth. If your labor is prolonged, complicated, or includes the use of potentially painful interventions (such as Pitocin, forceps delivery, vacuum extraction, or cesarean section), you’re likely to need medications.

DEFINING YOUR PREFERENCES WITH THE PAIN MEDICATION PREFERENCE SCALE (PMPS)

Even though it’s impossible to know how painful labor will be for you, the PMPS lets you determine how strongly you feel about medications and under what circumstances you’ll use them. Whatever your preferences, address them in your birth plan (see Chapter 8) and remind your caregiver and hospital staff of them during labor.

Using the PMPS with Your Labor Support Partner

During pregnancy, review the PMPS with your partner to help discover whether you have different preferences for pain medications. First, read the statements under “Your Preference” and find the one that best describes how you feel. Keep your selection to yourself. Next, have your partner read these statements and mentally choose the one that’s closest to what he or she wishes you’d choose. Then, reveal your selections to each other and discuss them to clarify how you’ll work together to achieve your goal. Also discuss the tips in the third column to plan how your partner can help you cope with labor and support your preferences for pain relief. If your partner is uncertain about his or her ability to support you, consider having an additional support person at your labor.

Pain Medication Preference Scale (PMPS)

Rating

• +10

• +9

• +7

• +5

• +3

• 0

• -3

• -5

• -7

• -9

• -10

Your Preference

• I don’t want to feel any pain. I prefer to be numb and to get anesthesia before labor even begins (typically not possible).

• I want as much medication as I can have. I fear labor pain and don’t want to experience any pain and stress.

• I want pain medications as early in labor as my caregiver will allow, and definitely before labor becomes painful.

• I want epidural analgesia in active labor (cervix dilated 4 to 5 centimeters). I’ll try to cope until then, perhaps with narcotic medications.

• I want to use some pain medications, but I also plan to use self-help comfort measures for as much of labor as I can.

• I have no opinion on pain medications or preference for or against them (a rare attitude among pregnant women, lthough not rare among partners).

• I’d like to avoid pain medications if I can. If I find labor too painful, I’d like to use as little medication as possible, but won’t feel guilty for taking it.

• I really don’t want to use pain medications so I can avoid their side effects on my baby, my labor, and myself. I’ll accept them only if labor is complicated or long.

• I strongly desire a non-medicated childbirth because of its benefits to my baby and my labor, and the gratification of meeting the personal challenge. I’ll be disappointed if I use drugs.

• I definitely don’t want pain medications. If I ask for them, I want my support team and the staff to refuse and insist I continue without drugs.

• I want no medication, even for a cesarean section (an impossible extreme).

How Your Partner, Doula, and Others Can Help You

• Discuss your wishes and fears with you.

• Explain that you’ll have some pain, even with anesthesia, and plan how you can cope.

• Promise to help you get medications as soon as possible.

• Same as for +10 rating, plus:

• Help you write a birth plan that expresses your fears and preferences.

• Review circumstances when an epidural may be delayed and how to cope while waiting.

• Ensure that someone will always be there to help you.

• Same as for +9 rating, plus:

• Help you learn the policies on timing of doses.

• Help you use relaxation techniques and comfort measures to cope in early labor, and while waiting for the anesthesiologist.

• Same as for +7 rating, plus:

• Help you with relaxation techniques and comfort measures in early labor.

• Suggest medications when you’re in active labor.

• Same as for +5 rating, plus:

• Help you with self-help measures.

• Help you get medications if you decide you want them.

• Help you become informed about labor pain, comfort measures, and medications.

• Emphasize coping techniques.

• Avoid suggesting pain medications.

• Avoid trying to talk you out of medications if you request them.

• Suggest half doses of narcotics or a light epidural.

• Same as for -3 rating, plus:

• Prepare to play a very active role in your labor support.

• Practice comfort measures with you.

• Avoid suggesting drugs, even if you appear to be having trouble coping. Suggest other non-drug options instead.

• Be aware of your code word (see page 189), which alerts your partner that you want him or her to stop suggesting other options.

• Help you accept pain medications if you’re exhausted, can’t keep a rhythm during contractions (see page 206), or if none of the comfort measures help.

• Same as for -5 rating, plus:

• Help you enlist the support of your caregiver and request a nurse who will help with natural birth.

• Plan and rehearse ways to get through discouraging times.

• Same as for -7 rating, plus:

• Explore with you the reasons for your feelings.

• Explain that if you change your mind, staff can’t deny your requests for medications.

• Reinforce that it’s your decision to use or avoid pain medications.

• Same as for -9 rating, plus:

• Help you gain a realistic understanding of the risks and benefits of pain medications.

• Explain that there are situations in which pain medications are required, and plan how you can cope if such a situation arises.

BEING FLEXIBLE WITH YOUR PLAN FOR PAIN RELIEF

While it’s helpful to plan for pain relief, it’s also important to be flexible with your plan in case labor doesn’t go as expected and your preferences are no longer possible or necessary. For example, if you planned to use medications, you may find that labor is easier than anticipated and you don’t need drugs. Or your labor may progress faster than expected, leaving no time for medications—or you may be one of the unlucky few for whom medications don’t provide adequate pain relief, in which case you’ll need to try non-drug comfort techniques instead. (This is why it’s important to learn and practice these techniques even when you’re planning for a medicated labor.) If you planned for a non-medicated birth, you may find labor to be more challenging than expected, or you may have unexpected interventions that make it difficult or impossible to give birth without pain medications.

Most women have particular times in labor when they doubt their ability to cope (see page 189). If you begin to doubt yourself, your partner can remind you of these predictable challenges to help you regain confidence. If your doubt turns into dismay and you ask for pain medications, your partner should remember your pain medication preferences and act accordingly. If you’d said you wanted pain medications, he or she should help you get them. If you’d planned to delay receiving medications, he or she should suggest trying another coping technique for four or five contractions before helping you get drugs if the technique is ineffective. If you’d planned to continue striving for a non-medicated birth, he or she should continue to encourage you to cope unless you say your code word (see page 189).

Preparing to Labor without Pain Medications

If having a drug-free labor is your goal, the following suggestions can help you avoid pain medications or minimize your need for them:

• During pregnancy, confirm that your partner agrees with your goal and feels capable of helping you achieve it. If he or she doesn’t, ask someone who does to accompany you both in labor to provide support.

• Choose a birthplace that supports non-medicated birth and has non-medical tools available to provide pain relief and comfort (such as birth balls and large bathtubs). Choose a caregiver with experience supporting women who labor without pain medications. Ask both the birthplace and the caregiver what percentage of their clients use pain medications. If most women do, the staff may have little skill or experience supporting women who don’t.

• Learn the comfort techniques in Chapter 11. Practice the relaxation and self-help comfort techniques with your partner or support person.

• Take childbirth preparation classes that focus on learning and practicing comfort techniques.

• Consider hiring a birth doula to guide and reassure you and your partner. (See page 190.) Studies show that a doula’s presence and guidance reduce a laboring woman’s need for pain medications.6

• State your wishes in your birth plan (see Chapter 8). Ask hospital staff to avoid offering you pain medications and instead provide you with encouragement, advice for labor progress, and ideas for comfort measures. (You will, of course, receive medications if you ask for them.)

• Avoid or minimize interventions that can increase labor pain (such as induction and augmentation) or that limit your mobility (such as continuous electronic fetal monitoring and IV fluids).

• Consider having a code word to communicate that you’ve changed your mind and you no longer want to labor without medications. Women with a strong desire for a non-medicated birth (rating a -5 to -7 on the Pain Medication Preference Scale—see page 187) often use a code word so they’re free to complain, vocalize, cry, or curse without others misunderstanding their actions as a plea for pain medications. For example, one woman told her support team that if she said, “I can’t” or “This is too hard,” she was really saying, “I need more support.” But if she said her code word uncle, her partner knew to help her get pain medications.

If you want to use a code word, make sure it isn’t one that’s commonly said in a childbirth setting or associated with pain or pain relief, such as drugs. That way, you’ll avoid having others mistakenly believe you want pain medications if you happen to say the word during labor. Instead, choose a word that’s unrelated to childbirth, such as pumpernickel. Let everyone attending to your labor know what your code word is as well as its purpose.

• Know the predictable challenges of labor and prepare for ways to manage them without medications:

* As you move from early labor to active labor (when your cervix dilates from about 3 to 5 centimeters), your contractions will become painful but you’ll realize you still have a long way to go before your baby is born. You may feel that labor is beyond your control. Try to adapt your breathing, movements, or activities in whatever way will help you cope. (See Chapter 11 for ideas.) You may find that if you can release control, you’ll spontaneously discover new ways of coping.

* When your cervix has dilated to 6 to 7 centimeters, your contractions may become very intense. Don’t expect to feel peaceful and relaxed during contractions. If you can relax between contractions and can maintain a rhythm in your breathing, movements, or activities during contractions, you’ll be coping well. Remember that as labor intensifies, progress speeds up. (See the graph on page 284.)

* As you move from active labor to transition, when your cervix dilates to 7 or 8 centimeters, you may need to rely heavily on your support team to help you keep your rhythm. Your partner can remind you that your contractions are about as painful as they’ll become (although they may occur closer together). If you can cope at this time, you can probably manage the rest of your labor without pain medications—as long as you want to do so and your labor continues to progress normally.

If you begin to struggle with the pain at any point in labor, you and your support team should have a contingency plan for coping. See page 191 for more information.

A NOTE TO FATHERS AND PARTNERS

It’s easy to neglect your own needs when caring for a woman in labor, especially one who’s laboring without pain medications. By taking care of yourself, you can help your partner meet the demands of labor. Stay hydrated and keep up your energy by eating nutritious snacks. Conserve your strength when physically supporting your partner (for example, sit or lean against something whenever possible, rather than standing), use good body mechanics (for example, lift with your legs, not your back), and work within your body’s limitations (visit our web site, http://www.PCNGuide.com, for more information). If others want to provide support, let them if you need the rest. Maintaining your stamina will help you provide the invaluable contribution that only you can make during the birth of your baby.7

The Invaluable Birth Doula

When considering options for pain relief, don’t overlook the important services that a birth doula can provide. Unlike the nursing staff, who must concentrate on completing clinical tasks while providing care, a doula can focus solely on you and your partner, making sure you’re both coping well.

This person (usually a woman) knows all the comfort measures and when to use them. From her meetings with you before the birth, she’ll know your birth plan (see Chapter 8), your pain medication preferences, your likes and dislikes, and your hopes for birth. She’ll know what to say and do to comfort and encourage you—and what not to say and do. For example, one woman told her doula, “Don’t tell me ‘you’re doing great’ when I’m clearly not. Please acknowledge what I’m feeling by saying, ‘I can see that it hurts, and I know it’s hard, but we can do this together.’”

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Women hire doulas for many reasons. One woman without a partner hired a doula to be her primary support person and to help her ask the caregiver or staff important questions. Another woman, whose mother had died, hired a doula because she wanted a mother figure with her during labor. One woman wanted the feminine energy of someone who had given birth and had supported many women through labor. Another wanted someone to help her and her partner with comfort measures so she was less likely to use pain medications.

Some couples hire a doula just as much for the partner as for the laboring woman, especially if the partner isn’t completely comfortable with the demands of labor support and needs a guide or helper, or wants someone else to take over the role of primary support person. If the partner has personal concerns, he or she may find that hiring a doula is a good idea. For example, a doula can provide backup support if the partner has a medical condition such as hypoglycemia (which necessitates getting regular food and rest), becomes queasy at the sight of blood, has physical limitations, or simply wants to avoid the pressure of having to learn and remember all the comfort measures.

A doula can also do necessary tasks for the partner, allowing him or her to focus on providing primary support. For example, the doula can run errands and fetch food, beverages, and comfort items such as ice packs. She can take photos of the labor and birth. She can report progress and developments to the couple’s friends and family. She can massage the woman’s back while her partner helps her maintain a rhythm. She can continue support so the partner can eat, get some air, or take a much-needed nap. For more information on doulas, see page 23.

Notes: Doulas might not be available in every area; see page 23 for information on finding a doula in your area. Furthermore, not all birthplaces welcome doulas; see page 13 for questions to ask potential birthplaces. If a doula isn’t available or allowed in your birthplace (or you don’t want one), trusted relatives or friends can do many of the things a doula can do, especially if they attend childbirth preparation classes with you and your partner.

CONTINGENCY PLAN

What if you plan to give birth without pain medications, but begin to have second thoughts during labor? If you truly don’t want to labor any longer without drugs, you can say your code word (see page 189) and your support people should help you ask for pain medications. However, if you’re struggling to cope but still don’t want to receive drugs, here are ideas to try:

• Change your environment. Take a walk or a shower, dim the lights, or put on some relaxing music.

• Change your ritual or your breathing techniques. (See pages 207 and 223.)

• Consider contacting another supportive friend or relative to be with you.

• Eat something or drink a sugary beverage. Sometimes all you need for pain relief is a quick energy boost.

• Find out how far your cervix has dilated. Labor may be difficult because you’re making rapid progress!

• Don’t base your decision to use pain medications on your experience with just one hard contraction. First try a new comfort technique (see Chapter 11 for ideas) for four or five contractions in a row. During this time, your endorphins may kick in and labor may feel manageable again. (See page 242 for more information on endorphins.)

If your labor is still too intense after trying all these suggestions, you may choose to receive pain medications. If you do, try not to feel disappointed in yourself or feel that you’ve failed in some way because you didn’t reach your goal. Take comfort in the fact that many women in this situation have reported feeling better about their decision because they’d first tried everything possible to manage without drugs, but were wise enough to change their minds when the pain led to suffering.

Preparing to Labor with Pain Medications

It’s wise to learn about pain medications during pregnancy, whether or not you plan to use them during labor. That way, if the need for medications arises in labor, you’ll already have some knowledge about them and can make an informed decision about their use.

Because both you and your baby are affected if you take pain medications, you and your caregiver should evaluate all possible risks and benefits of a drug. You should also be informed of extra precautions or interventions that may accompany pain medications to ensure their safety, as well as any acceptable alternatives to the drugs.

WEIGHING THE RISKS AND BENEFITS OF PAIN MEDICATIONS

The benefits of pain medications include an increased ability to relax and sleep, and the reduction or elimination of pain. If pain medications are used judiciously and with current methods, the side effects are often mild, manageable, and familiar to hospital staff.

However, as with all interventions, pain medications have potential risks. Examples include decreased blood pressure in the mother, prolonged labor, forceps delivery or vacuum extraction, fever in the mother and baby, and variations in the baby’s heart rate. While these risks are typically moderate, they may require additional interventions that have their own potential side effects. If you use pain medications in labor, your caregiver will be aware of all potential risks and take measures to either prevent or manage them.

Epidural Birth versus Natural Birth

Here’s one woman’s account of her birth experiences, one with an epidural and one without:

For my first birth, I’d planned to labor without drugs, but in transition I panicked and accepted an epidural. Soon we were cracking jokes and watching for my next contraction on the monitor. I didn’t feel any pain, but almost immediately after Hannah was born, I just wanted to sleep.

For my next birth, I again planned to cope naturally. When contractions got intense and I felt that I couldn’t possibly do it, my support people encouraged me that I could—and I did. I felt so alive afterward. Some friends still think I was crazy for not having an epidural. My only response is that I’ve given birth with drugs and without, and nothing compares to the euphoria I experienced with a drug-free birth.

As you consider the risks and benefits of laboring with pain medications, keep the following factors in mind:

• While medications can minimize pain or even eliminate it for some portion of your labor, they generally can’t prevent you from experiencing any pain throughout your entire labor.

• Any medication you receive affects your baby. Because his liver and kidneys are immature, the effects of some drugs last longer for him than for you. A medication’s effects depend on the drug, the amount received, how and when it’s given, and other factors. (Visit our web site, http://www.PCNGuide.com, for more information.)

• Pain medications affect your labor progress. They often slow contractions and may increase your need for other medical interventions. However, if labor progress is abnormally slow, drugs may speed up progress by letting you relax.

• Special precautions are required with most pain medications to prevent, minimize, or treat side effects that may interfere with labor progress or harm you or your baby. For example, the following interventions are necessary more often when pain medications are used than when they’re not: restriction to bed, restriction of eating and drinking, IV fluids, Pitocin augmentation, administration of oxygen, frequent monitoring of blood pressure and blood oxygen levels, bladder catheterization, continuous electronic fetal monitoring (EFM), vacuum extraction, and cesarean section.

• Several factors influence which medication is right for you, including the nature of your pain, stage of labor, allergies or medical conditions, other medications you use regularly, unusual anatomical conditions of your spine or lower back, and availability of anesthesia services at your birthplace. Tell your caregiver if you’ve ever had an allergy or adverse reaction to medication.

KEY VOCABULARY OF PAIN MEDICATIONS

Each drug has specific characteristics that make it safe and effective for pain relief in particular phases of labor. The following describe key terms for medications that can relieve labor pain:

Route of administration

How you receive a medication is its route of administration. Oral medication is a pill or liquid you swallow; inhalation medication is a gas you breathe. Intramuscular (IM) medication is a shot given into muscle, while intravenous (IV) medication is an injection into a vein, often through an IV catheter (see page 250). Lastly, neuraxial medications are drugs that are injected into the space surrounding the spinal cord (neuraxis), such as epidurals and spinal blocks. How quickly a medication takes effect depends on the route of administration.

Questions to Ask Your Caregiver about Pain Medications

During a prenatal visit, ask your caregiver the following questions about pain medications so you can make an informed decision about them before you’re in labor or in an emergency situation, when you’re in pain and clear thinking may be impossible.

• What medications are most commonly used for pain relief? How is each medication given?

• How does each medication relieve pain? How effective is it?

• What are the potential risks or undesirable side effects of the drug on me, my baby, or labor progress? What precautions do you take to prevent, control, or treat side effects?

• What are my alternatives to pain medications?

Be aware that the answers you receive may vary depending on whom you ask. For example, an anesthesiologist and a home birth midwife may give very different answers to these questions. An anesthesiologist, who is trained in the best pharmaceutical solutions to relieving pain, will likely believe that the side effects of recommended pain medications are manageable and their benefits outweigh any potential risks. A home birth midwife who’s familiar with non-drug coping techniques may recommend them first because they’re low-cost, low-risk, and can be done anywhere.

Keep any potential biases in mind when listening to your caregiver’s answers, and supplement the information you learn from him or her with the knowledge you’ve learned from research-based sources of information (such as this book and our web site, http://www.PCNGuide.com). This way, you can better make an informed decision about pain medications.

Area of effect

Medications may be systemic (affecting your entire body), regional (affecting a large area of your body), or local (affecting a specific, relatively small part of your body). In general, you need more medication to get the desired results with a systemic medication than with a regional or local medication.

Type of effect

Analgesia is any effect that reduces your perception of pain. In this chapter, this term refers specifically to medications that act on the brain so you don’t recognize pain stimuli or don’t interpret them as pain. Anesthesia indicates a loss of sensation, including pain sensation. Anesthetics block nerve endings from sending pain impulses to your brain.

Systemic Medications

Systemic medications come in many forms, including pills, injections, and gases. All are absorbed into your bloodstream and affect your entire body. The desired effect is to reduce your pain, but there may be side effects.

Because systemic medications are carried in your bloodstream, they may affect your baby as well, because the placenta can’t screen them out. The magnitude of effects depends on the type and amount of medication used and the time between the last dose and the birth. Other factors include your baby’s maturity, health, and response during labor. If a healthy, full-term baby and a premature, ill, or distressed baby were each exposed to the same amount of medication during labor, the healthy baby would show fewer side effects than the baby with problems.

Two Views on Narcotics

Initially, fentanyl made me feel as though I were drunk. I was a little dizzy, and I don’t think I was mentally all there. The contractions were still very painful, but more manageable, especially in the hot tub. About an hour later, my cervix was dilated to 6 centimeters, and I got another dose of fentanyl. The pain continued getting stronger, and I got a third dose, which unfortunately wasn’t effective at all.

—Sami

Within two hours of being admitted, I asked for drugs because the pain was making me very anxious. The Nubain helped me relax and focus on my breathing for the next wave of contractions. I completely lost track of time as I found myself instinctively using rhythm to cope. My cervix was checked ninety minutes later, and it had dilated to 7 centimeters. I was assured that an epidural was still an option, and the anesthesiologist was called.

—Jennifer

The medication or its byproducts might not disappear from your baby’s bloodstream for hours or days, and neurobehavioral changes may be present during the first few days after birth (visit our web site, http://www.PCNGuide.com, for details). These changes may be obvious, or they may be noticeable only to professionals who use highly sensitive tests to examine your baby.

General anesthesia is a systemic medication that causes a total loss of sensation and consciousness. It’s used for only a small percentage of cesarean births. (Visit our web site to learn more about this and other systemic medications such as sedatives, tranquilizers, and nitrous oxide.) Intravenous (IV) narcotics are the systemic medications used most commonly in labor, although intramuscular (IM) narcotics are sometimes given.

IV Narcotics or Narcotic-like Medications

Narcotics and narcotic-like drugs reduce the transmission of pain messages to the pain receptors in your brain.

Benefits

The analgesic effect is often described as “taking the edge off the pain.” It may take you longer to notice that a contraction has started, and it may seem to fade away sooner. The peak of a contraction, however, may still be intense enough that you feel the pain despite the narcotics.

Narcotics may work well for you if you’re handling the pain at the peak of a contraction but want to feel as if you have a longer break between contractions so you can rest. You may even be able to doze between contractions and wake up to manage the peak.

Note: Narcotics might not work well for you if you can’t handle the pain at the peak of a contraction, or if you can handle the pain only if you can feel the onset of the contraction and can begin using a coping ritual before the peak occurs. If you do use narcotics and doze between contractions, your partner or doula can help you prepare for the pain by noting the onset of the contraction (as indicated by a monitor or by your wincing or moaning), awakening or alerting you, and guiding you to use rhythmic breathing (see page 223) before the peak.

Tradeoffs

IV fluids, continuous electronic fetal monitoring (EFM), and restriction to bed may be necessary when narcotics are used. Narcotics may cause sleepiness or lethargy, and they may cause a hazy feeling, disorientation, or euphoria. Some women find the sensation relaxing or pleasant, while others feel out of control, which may make it difficult to use self-help techniques.

Possible side effects

Common side effects include itching, nausea, and vomiting. Narcotics may slow labor and cause variations in your baby’s heart rate. You can receive a drug called a narcotic antagonist to reduce these side effects, but it’ll reduce pain relief. After the birth, the narcotics in your baby’s bloodstream may cause her to breathe slowly and have poor muscle tone. She can receive a narcotic antagonist if needed. See page 448 for more information on possible side effects.

Timing

The effects of narcotics last for sixty to ninety minutes. Narcotics are used in early to active labor, when it’s believed that the birth is at least two hours away. This timing allows the narcotic effects on your baby to fade before the birth.

LOCAL AND REGIONAL ANESTHETICS

Local or regional anesthetics (often called “blocks”) cause reduced feeling or numbness in a particular area of your body. When an anesthetic drug is injected near specific nerves, it blocks the transmission of sensations along them. It also affects muscle control, blood flow, and temperature in the affected area to a degree. Lower doses of an anesthetic eliminate or dull pain while allowing some muscle control. Higher doses remove both sensation and the ability to use your muscles. Local and regional anesthetics don’t affect your mental state. Most anesthetic drug names end with the suffix “-caine,” such as lidocaine and bupivacaine.

Local Anesthetics (Perineal Block)

Local anesthetics block sensation in a small area near nerve endings. They’re injected into the skin, mucous membranes, or muscles. During labor, they’re typically injected in the perineum (perineal block). They can be injected in the cervix (paracervical block) or the vagina (pudendal block), but these blocks aren’t often used.

Benefits

Because a perineal block numbs the perineum, it’s necessary for the repair of an episiotomy or lacerations. It may also be used to numb the perineum before an episiotomy or a forceps delivery. (See pages 289–290 for information on these procedures.)

Tradeoff

The injections may be painful.

Possible side effects

If a perineal block is given during the repair of an episiotomy or lacerations, the side effects are minimal (barring an allergic reaction). If it’s given early in the second stage (which is rare), the medication may affect the baby’s heart rate during labor or his reflexes at birth. See page 449 for more information on possible side effects.

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Timing

Local anesthetics are given during the second stage if an episiotomy or forceps delivery is necessary. They’re given in the third stage for the repair of an episiotomy or lacerations.

Common Q & A

Q: Is it ever too late for an epidural?

A: You may have heard that it’s best to receive an epidural in early labor because you won’t be able to receive one in late labor. It’s true that if your labor is progressing quickly and birth is anticipated within thirty to sixty minutes, your caregiver may recommend against an epidural. However, if labor progress is slow, it’s possible to receive an epidural even during transition or the second stage.

If comfort techniques are helping you cope, don’t feel that you have to get an epidural in early labor because you fear it’ll be your only chance to get one. Keep using comfort techniques for as long as they help you manage contractions. If you decide later that you want an epidural, it’s very likely that you’ll be able to get one.

Regional (Neuraxial) Analgesia and Anesthesia: Epidural and Spinal Blocks

Neuraxial medications are injected in your lower back near nerve roots in the spinal column. The medications affect the region of your body to which these nerves and their branches go. The region can be as small as your abdomen and lower back, or as large as the area from your chest to your toes. The medications are often a combination of an anesthetic medication (see page 193) and a narcotic-like drug such as fentanyl, which enhances the overall numbing effect. A spinal block is an injection that takes effect quickly and lasts for an hour or two. An epidural catheter is a tube through which medication is given for as long as it’s needed.

Benefits

The American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) have stated that among all options for medicated pain relief, the epidural is the most effective for reducing pain, while allowing the woman to stay alert and actively participate in her labor.8 Among women who receive epidural pain medications, almost all (98.8 percent) have significant pain relief for at least some of their labor. (See page 202for information about the possibility that an epidural may fail to provide effective pain relief for a woman during her entire labor.) Once the epidural takes effect, the medications typically continue to provide relief for the rest of labor.

Because of the locations of the injection sites, much smaller amounts of neuraxial medications can be used than are needed for either local anesthesia or systemic analgesia. With neuraxial medications, women typically have fewer mental and respiratory side effects, and have a higher level of satisfaction than with other pain medication options. At birth, their babies are more alert, breathe better, and have better muscle tone than babies born with higher doses of systemic narcotic-like medications.9

Tradeoffs

To minimize the side effects of neuraxial medications, various additional precautions and interventions must be used to maintain safety. For example, an epidural is accompanied by IV fluids, a bladder catheter, and continuous monitoring of blood pressure, contractions, and your baby’s heart rate. Eating and drinking are restricted and you’re confined to bed. Along with the effects of the medications, the accompanying medical equipment significantly reduces mobility (you might not be able to move your legs or change positions in bed without assistance) and contributes to the feeling that the birth has become a medical event.

Possible side effects

The most common side effects include decreased blood pressure, a longer labor, a longer pushing stage, and fever. These effects may lead to further interventions (such as Pitocin augmentation, vacuum extraction, or forceps delivery) and secondary side effects on both you and your baby (such as uterine hyperstimulation or variations in your baby’s heart rate). The narcotics in the epidural can also cause itching and nausea. Some women worry that an injection near the spinal cord may carry the risk of paralysis or even death; however, these outcomes are so rare, they’re nearly nonexistent. See pages 450–451 for more information on the possible side effects of neuraxial medications.

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Current methods of epidural analgesia focus on finding a balance between maximizing pain relief and minimizing side effects. Caregivers and nurses are trained to recognize and treat side effects when they occur. With an “ideal” epidural, your pain is significantly reduced, you and your baby experience few side effects, you have at least a slight urge to push, and you can move your legs and change positions with assistance.

Whether you’ll have few or many side effects can’t be predicted or controlled, and your experience won’t depend solely on the skills of the anesthesiologist who administers the epidural. Many other factors will influence your experience, including your and your baby’s physical state and well-being as well as how your body reacts to medications.

A postpartum side effect of epidural analgesia may be a shortened duration of breastfeeding. Compared to a woman who had a non-medicated birth, a woman who had an epidural is more likely to stop breastfeeding sooner, partly because she might have taken longer after the birth to begin holding and nursing her baby, and partly because of a mistaken perception that she might not make enough milk.10These problems can be overcome by early and frequent skin-to-skin contact between the mother and baby, and by starting breastfeeding within the first hour after the birth. The earlier a woman initiates breastfeeding and the more often she nurses, the more milk she makes and the more likely she is to have breastfeeding success. (See Chapter 18 for more information on breastfeeding.)

Timing

Some caregivers recommend (or require) that a woman be in active labor (4 to 5 centimeters cervical dilation and strong, regular contractions) before receiving an epidural. This recommendation is based on past research that indicated epidurals given in early labor were likely to slow or stall labor. Other caregivers allow a woman to receive an epidural at any point in labor, a practice based on conflicting research that doesn’t show early epidurals prolong labor. Still other caregivers use a combined spinal-epidural (CSE): that is, spinal narcotics early in labor and an epidural later on.

Procedure for Epidural and Spinal Blocks

If you decide to receive an epidural or a spinal block, here’s the procedure you can expect:

1. As you wait for the anesthesiologist, who might or might not be immediately available, you cope with contractions that may be especially intense and require you to rely on extra support to manage them.

2. You may receive IV fluids to help reduce the risk of a drop in blood pressure and to allow for administration of additional medications, if needed. This procedure can take ten to twenty minutes. If you have an IV in already, your nurse can increase the flow to give you 1/4 to 1 liter of fluid quickly.

3. When the anesthesiologist arrives, you’re asked to either lie curled on your side or sit up and lean forward to curve your back. The anesthesiologist then cleans your lower back with an antiseptic and numbs your skin with a shot of local anesthetic. This preparation, along with the delicate placement of the epidural catheter or spinal needle, can take ten minutes or longer. You may need extra support to help you sit or lie still during contractions. If you can’t stay still during the peak of a contraction, the anesthesiologist can pause until the pain subsides.

4. Where and how the anesthesiologist places the needle or catheter in your back depends on the type of block.

Spinal block

A single injection of an anesthetic or narcotic is given with a needle that’s inserted through the dura (the tough membrane that surrounds your spinal cord) into the intrathecal space, which is filled with cerebrospinal fluid. (See the illustration at right.) Drugs given in this location and in this way are called intrathecal medications. A spinal block takes effect within minutes and lasts a few hours.

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Epidural catheter

A needle is inserted into the epidural space, just outside the dura. A thin plastic tube (catheter) is threaded through the needle, the needle is removed, the catheter is taped to your back, and a test dose of medications is given through the catheter to ensure you don’t react poorly to the drugs. The catheter is attached to a pump device that steadily releases small amounts of anesthetic or analgesic.

Within a few minutes, tingling and numbness are noticeable; within fifteen minutes, you’re likely to be completely numb from the top of your uterus to your pelvis or even from your chest to your toes. (The effects sometimes take longer to be felt, and the catheter may need to be repositioned to yield the best effects.) The catheter remains in place and pain relief continues throughout the rest of your labor. You may receive medications by continuous drip, from a series of doses (a method that’s becoming uncommon), or from doses that you administer when you need them (patient-controlled epidural analgesia, or PCEA—see page 200 for more information).

Combined spinal-epidural (CSE)

The epidural needle is inserted, then the smaller spinal needle is inserted through it and into the intrathecal space for the administration of a spinal narcotic. The spinal needle is then removed and the epidural catheter is inserted. No medication is added to the epidural at this time. The effects of the spinal narcotic last a few hours or until your cervix has dilated to 4 to 6 centimeters and the intensifying contractions cause you to feel pain. When you need more relief, the epidural medication is given through the catheter.

5. Your temperature, blood pressure, pulse, and blood oxygen levels are checked frequently, and your contractions and your baby’s heart rate are closely monitored. You may also have an electrocardiogram (EKG) to monitor your heart function.

6. Many women receive excellent pain relief with epidural analgesia and don’t experience any side effects beyond the tradeoffs described on page 196. However, if monitoring indicates that you or your baby are reacting poorly to neuraxial medications, then more interventions may be necessary.

For example, if your blood pressure drops signifcantly, your baby’s heart rate will also decrease. To improve your oxygen levels and increase your baby’s heart rate, your nurse or caregiver will turn you onto your side, place an oxygen mask on your face, and ask you to breathe deeply. While the oxygen mask may concern you and your partner, it almost always corrects the problem quickly. If not, you may also be given medications or additional IV fluids to raise your blood pressure.

Managing side effects often causes a “cascade of interventions,” in which the use of one intervention leads to additional side effects that necessitate even more interventions. For example, if epidural medications cause your contractions to slow down, you may receive Pitocin to stimulate them—which may overstimulate your uterus, which can lead to variations in your baby’s heart rate, which may increase your need of a cesarean section. To be able to make an informed decision about any pain relief option, you need to acknowledge the possibility of this type of outcome.

Any side effects you experience can also have an impact on your baby. For example, your chances of fever increase when you have epidural anesthesia, because the medications alter your ability to regulate your temperature. The longer the epidural is in place, the higher your risk of fever is. When you have a fever, your baby’s heart rate may increase to a worrisome level, a problem that may require an intervention such as a cesarean section to resolve. In addition, although an epidural won’t cause an infection in your baby, it may increase the chance she’ll need to be treated for one. The reason is because if you have a fever during labor, your baby may have one at birth. If she does, her fever can’t be assumed to be a result of the epidural, because fever is also associated with infection. Your baby will be checked for infection with blood tests and possibly a spinal tap. She may be kept in the special care nursery and given antibiotics for two days, until her test results are known. Although the testing and preventive treatment will separate you from your baby and can be worrisome, test results will likely show that your baby is fine.

See the chart on pages 450–451 for more information about the effects and side effects of regional medications.

Different Views on Epidurals

When asked about epidurals, new mothers had many different responses. Here are a few examples:

For me, taking fentanyl and getting in the hot tub weren’t much help, so I just rested on my side in bed for a while and did my breathing exercises. Some time later the epidural came—relief at last! I even slept. I think the epidural slowed things down, but the pain relief was very helpful.

I had twenty hours of labor with a great support team and without drugs. I was coping with the pain okay, but I was exhausted. So I got an epidural and slept. My son was born by vacuum extraction ten hours later, after four hours of pushing. I was glad to get the epidural, but the birth was definitely a much more medical experience than I’d expected.

I’d hoped the epidural would take away all my pain, but it didn’t. I was pretty numb overall, but this one spot on my belly hurt a LOT. It was almost harder to cope with that window of pain than it’d been to cope with regular contractions. Luckily, James remembered all the comfort techniques we learned, and helped coach me through the contractions.

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Options for Epidurals

The types of epidurals offered vary among hospitals. Ask your caregiver about the availability of the following options, and whether he or she recommends them. Side effects of the medications may be reduced for some options; however, because side effects can still occur, all precautions and safety procedures that accompany an epidural must still be used (see page 196).

Patient-controlled epidural analgesia (PCEA)

PCEA allows you to press a button attached to your epidural pump to give yourself more medication when you need it. When women are allowed to control their dosage, they tend to use less medication and are more satisfied with the epidural experience than when the dosage is controlled for them. Although you have some control over the flow of medication with PCEA, the device has a timer that limits the number of doses, which are carefully measured so you can’t overdose. (Note: Patient-controlled analgesia, or PCA, may also be available for IV narcotics.)

Combined spinal-epidural (CSE)

CSE uses a spinal narcotic in early labor (which may allow for more mobility), then an epidural later in labor, when you need more pain relief.

Light or late epidural

You can reduce some side effects by delaying an epidural until you’re in active labor (late epidural) and requesting a low concentration of the medications (light epidural).

Policies for managing labor with an epidural also vary among hospitals. Ask your caregiver about the following measures:

Movement

Ask whether you’ll be able to move with an epidural and whether movement in bed is encouraged.

Food and drink

Many hospitals allow women with epidurals to consume only ice chips; however, the American Society of Anesthesiologists recommends allowing women to drink clear fluids. Ask what you’ll be allowed to consume.

Delayed pushing (also called passive descent or laboring down)

Rather than pushing as soon as your cervix is fully dilated, you may wait to push until your baby’s head is visible at the vaginal outlet. Delayed pushing has been proven to reduce vaginal tears, forceps delivery, vacuum extraction, and the need for a cesarean section. It also won’t harm your baby. Ask whether delayed pushing is common practice.

Lowering the dosage or discontinuing the epidural

By slowing or stopping the flow of epidural medications at the beginning of the second stage of labor, you may be able to bear down more effectively. (However, labor pain may be intolerable when it returns.)

A Note to Fathers and Partners

When your laboring partner has an epidural, the shift from intense effort and pain to complete physical relaxation may be sudden. At that point, you may think that she no longer needs your constant support. You may begin thinking about taking a nap, going for a walk, or turning on the TV; however, your job isn’t done. Even though your partner may be more comfortable physically, she still needs your emotional support. If you shift your attention away from her once the epidural has taken effect, she may feel as though you’re abandoning her.

To reassure your partner that you’ll continue to provide support, stay with her and relax together. Do things that soothe her such as holding her hand or brushing her hair. An epidural may leave your partner feeling disconnected from her body and the birth experience; talk with her about the labor and your baby to help her reconnect with events. (Resist the temptation to turn on the TV, post status updates online, or text everyone you know!) If she’s worried or anxious, listen to her fears, acknowledge them, and reassure her. Help her change positions as much as possible; if she has a light epidural, she may even be able to get on her hands and knees with assistance and if you remain by her side to help keep her steady. If she falls asleep, she’ll probably be restless. She’ll be reassured by your staying awake or at least staying in the room so she can wake you if she needs anything.

There are occasional challenges with epidurals. Your partner might not initially receive sufficient pain relief, she might experience “windows” of pain, or the pain might return after initial relief. (See page 202for more information.) Be sure to alert the staff if any of these situations occur. They may be able to fix it by adjusting the epidural or by having her change positions. If your partner is among the few women for whom an epidural doesn’t provide effective pain relief, even after multiple attempts to correct the problem, she’ll need your support to help cope with the pain and to deal with the disappointment that the epidural failed her.

Your partner may also experience discomforts that are caused by the medications, such as itching, nausea, and feeling overheated or chilled. Make her more comfortable by giving her a massage, helping her change positions, covering her with a warm blanket, placing a cool cloth on her forehead, or giving her ice chips or sips of water (if allowed). Do not, however, place heating pads or ice packs on any part of her body that’s affected by the epidural. The medications will affect her sense of temperature, and she might not be able to tell if a heating pad or cold pack is damaging her skin.

Be aware that some side effects of epidurals may lead to other interventions or may require a decision from your partner on how to manage the problem. Try to stay calm and supportive so you can help her make decisions that are best for her.

Even with pain relief, your partner may experience intense pressure or burning during the pushing stage. Reassure her that these sensations are normal and signal that your baby will be born soon. If you’re holding up one of her legs as she pushes, be careful not to pull it back too far. Think about her hips’ normal range of motion, and don’t force her leg beyond that point so you avoid straining her hips, thighs, or lower back. (Your partner will be unable to tell you when her muscles are straining because the medications will have numbed all sensation.)

After the birth, help your partner get lots of early skin-to-skin contact with your baby so breastfeeding can begin in the first hour.

THE IMPORTANCE OF LEARNING COMFORT TECHNIQUES WHEN PLANNING FOR AN EPIDURAL

If your Pain Medication Preference Scale rating is +5 or higher (see page 187) and you’re planning for an early epidural, you may think you don’t need to learn self-help techniques to relieve pain. Keep in mind, however, that it’s likely you’ll have at least a few painful contractions before the epidural takes effect. It’s also possible that even if your epidural is effective, you’ll still feel strong, painful sensations deep in your pelvis when pushing. For these reasons, it’s wise to know how you’ll cope with the pain.

Failed Epidurals

Although epidurals are very effective for most women who use them, they can pose challenges for some women. Twelve percent of epidurals don’t provide complete pain relief when first inserted, while 7 percent may provide good pain relief initially but fade over time. Some epidurals provide only minimal pain relief; others allow for “windows” of pain, in which most of the area is numbed but one spot still has sensation and the woman can fully feel the pain in that area.11

If you have a problem with your epidural, the staff may be able to fix it by changing your position, increasing the medication, or repositioning the epidural catheter. These measures have resulted in good pain relief for nearly all women with epidurals (98.8 percent). However, while the staff works to correct the problem, comfort measures can help you cope.

When you’re unprepared to manage labor pain, your inability to cope can make you feel that you’re suffering, which in turn can create a very unhappy memory of what should be one of the best days of your life. Learn self-help techniques in Chapter 11 so you can manage these challenges and have a more satisfying birth. As a bonus, these techniques can help you deal with other challenging or painful situations at other times in your life.

Key Points to Remember

• Labor pain is a physical sensation that many women can manage by using coping techniques and receiving continued respectful support. Suffering is an emotional response that includes feelings of helplessness, fear, and panic. No one should suffer in labor.

• Well before the birth, learn about your pain relief options and discuss your preferences with your caregiver to help you and your support team plan how to meet your needs in labor.

• Many non-drug techniques can reduce labor pain. Learn and practice them during pregnancy so they’re effective in labor.

• The goal of using medications is to relieve pain without compromising the well-being of your baby or labor progress. The side effects to you or your baby are influenced by the medications used, total amount received, route of administration, your response to the drugs, and your baby’s condition during labor. To learn more information about pain medications, see pages 193-200 and visit our web site, http://www.PCNGuide.com.

• Be flexible with your plans for pain relief. Have a contingency plan in place, in case your labor proceeds differently than you expected.

* See Chapter 11 to learn specific skills you can practice in pregnancy and use in labor.