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Labor and birth : Pain Relief Options (part 5) - Drugs for Pain Relief - Managing the epidural

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Natural pain relief

Whether you’re still at home and it’s too early in labor to get pain medication, or you’re trying to wait it out at the hospital to see if you really need drugs, you can try any or all of the following techniques that may help to relieve pain without medication:

  • Taking a warm bath or shower

  • Changing your position

  • Meditation

  • Hypnosis

  • Getting a back massage from your partner

  • Walking around

  • Meditation

Aspirin: not for labor pain

When you start to experience the pain of labor contractions at home, no matter how tempting it may be, do not reach for an aspirin to relieve your pain. Aspirin can be extremely dangerous during pregnancy, particularly in the third trimester and leading up to labor and delivery. The drug interferes with your blood-clotting ability, which means that your risk of a hemorrhage during delivery increases if you take aspirin in the weeks leading up to your baby’s birth. Taking too much aspirin in the last trimester may actually prolong labor. Bleeding problems may even develop in your newborn. Taking aspirin regularly toward the end of your pregnancy can also affect your baby’s heart or blood flow, so it’s best to avoid aspirin, unless your doctor recommends you take it. Your best bet for dealing with labor pain at home is to keep active until it’s time to head to the hospital. While you wait, do something to distract yourself from the pain, whether it’s counting the length of time between contractions, packing your bag for the hospital or anything else that feels right. Ask your partner for a massage or try a warm shower. No matter what you do, refrain from drug use. This way, if you need pain relief when you get to the hospital—many women do—you won’t have any medication in your system.

Opioids

Advantages

  • Opioids help you to relax during labor, which can help you to conserve your energy between contractions.

  • Opioids can produce a feeling of well-being, which many women find beneficial during labor.

Disadvantages

  • Many women report feeling nauseous with opioids, which can be an unexpected and unpleasant side effect on top of your pain and contractions.

  • Opioids can cause dizziness, and this can be can be disorientating during labor.

  • Some women have reported feeling out of control with some opioid medications and therefore out of touch with how their labor is progressing.

  • Opioids cross the placenta easily and pass into the baby’s bloodstream. This can have the affect of sedating the baby and can affect the baby’s breathing after the delivery. The administration of opioid medications therefore needs to be carefully timed during labor so that they are not given too close to the time of the delivery of the baby.

  • Opioids can depress the mother’s breathing during labor. However, this side effect is more common when the mother has a preexisting respiratory illness, such as asthma or emphysema.

  • Opioids cause a delay in emptying the bowels and therefore increase the overall risk to the mother should general anesthesia be needed later on (see General anesthesia).

Opioids (pethidine and diamorphine)

Advantages

  • Opioids help you to relax during labor, which can help you to conserve your energy between contractions.

  • Opioids can be administered by a doctor or a midwife. A doctor can give an advance prescription at around 36 weeks so that an opioid can be given by a midwife at a home birth.

  • Diamorphine produces a feeling of wellbeing, which many women find beneficial during labor.

Disadvantages

  • Many women report feeling nauseous with opioids. Pethidine in particular has side effects of nausea and vomiting.

  • Opioids can cause dizziness, which can be disorientating during labor.

  • Some women report feeling out of control with pethidine and therefore out of touch with how their labor is progressing.

  • Opioids cross the placenta easily and pass into the baby’s bloodstream. This can have the effect of sedating the baby and can affect the baby’s breathing after the delivery. The administration of these drugs therefore needs to be carefully timed during labor so that they are not given too near the time of the delivery of the baby.

  • Opioids can depress the mother’s breathing during labor. However, this side effect is more common when the mother has a pre-existing respiratory illness, such as asthma or emphysema.

  • Opioids cause a delay in emptying the bowels; if general anesthesia is needed later, this increases the small risk of stomach contents being inhaled into the lungs under anesthesia.

Considering an epidural

Pros

  • An epidural provides absolute pain relief in 90 percent of cases; 10 percent of women have some degree of residual pain, but still have a marked improvement in their overall discomfort.

  • Epidurals do not pose any risk to your baby.

  • The presence of an effective epidural means that if intervention is needed at any time, the epidural can be topped off with anesthetic for either an assisted delivery with forceps or vacuum, or a cesarean delivery. This also reduces the likelihood that a general anesthetic will be needed.

Cons

  • Around 1 in 10 women do not experience absolute pain relief with an epidural.

  • Some women develop a headache that persists after an epidural (see An Epidural “headache”).

  • A rare complication is patches of heaviness in the legs or feet.

There are a few very rare risks with an epidural

  • In common with all invasive procedures, inserting an epidural can result in infection. Meningitis occurs in around 1 in 100,000 women and an epidural abscess occurs in about 1 in 50,000 women.

  • There is a 1 in 170,000 risk of developing a blood clot in the epidural space (epidural hematoma).

  • There is a 1 in 100,000 risk of the epidural tube moving into the fluid around the spine and resulting in unconsciousness, and there is a 1 in 250,000 chance of the epidural causing some form of paralysis.

How an epidural is done

If you opt for an epidural, the doctor should explain the procedure to you, and you should have the opportunity to ask the anesthesiologist any questions.

Getting ready for an epidural

Before starting the epidural, a plastic tube will be placed in a vein in the back of your hand or in your arm, to which an IV containing fluid will be connected. You are given fluids during an epidural to stop your blood pressure from dropping. The doctor will then help you into the correct position to receive the epidural, which will either be sitting up with your legs over the side of the bed leaning forward, or curled up on your side on the edge of the bed. The position may depend on the preference of the anesthesiologist.

Your lower back will be cleaned with antiseptic and a drape placed over the rest of your back to reduce the risk of infection. Before the epidural needle is inserted, a local anesthetic will be given into the skin and surrounding tissues. This creates a numb patch to ensure that the insertion of the large epidural needle is not painful. When the local anesthetic is injected, you may feel a scratching sensation and experience a very short-lived sting in the area between the vertebrae bones

The procedure

Since it’s important for you to remain still during the procedure, the anesthesiologist will insert the epidural between your contractions. If this is difficult, you should try to concentrate on your breathing and remain as still as possible until the procedure is completed. You will feel a pushing sensation in your back while the anesthesiologist is trying to find the very small epidural space with the hollow needle. When the space is located, a tiny plastic tube will be fed into it through the needle. The epidural needle is then removed and the tube, which is secured onto your back with sticky tape, remains in the epidural space. The tube remains in place until your baby is delivered and, because it is very thin, soft, and pliable, it is perfectly safe to lie on the tube and to move around.

Managing the epidural

Once the epidural tube is successfully in place, the anesthesiologist will give the first dose of medication through it by means of a syringe. Once she is satisfied that the epidural is in the correct position and is working effectively, all subsequent doses, or “top ups,” can be given without another injection. Your blood pressure will be taken once the epidural is in place and will be monitored for the next half an hour or so, and then regularly thereafter, including after each top up. Each dose of medication takes around 10–20 minutes to take its full effect and can last between one and two hours. The epidural will be topped up as required, usually around every three to four hours, to keep you comfortable throughout your labor. An anesthesiologist should be available 24 hours a day to manage any concerns or problems that may arise with the epidural.

Before the epidural is given, your back will be covered with a sterile sheet and then a local anesthetic will be given to numb the area so that you don’t experience pain when the larger epidural needle is inserted.

The anesthetic is given through a tube that is inserted into the epidural space, avoiding the spinal cord and its covering.

An epidural “headache”

Some women report a headache after an epidural, which can develop more than 24 hours after the delivery and tends to be at the front of the head. It is made worse by sitting up and moving around and is much improved by lying down. This occurs in around 1 in 100 women and is caused by the epidural needle moving too far forward and cutting the dura sheath, the membrane maintaining the fluid around the spinal cord and brain. This small hole results in a loss of fluid from the sheath, which causes a headache. The risk is hugely reduced by remaining still during the placement of the epidural. In around 70 percent of women, the hole heals on its own. You will be advised to drink plenty of fluids and to take simple painkillers, such as acetaminophen and ibuprofen and you will be reviewed at regular intervals by an anesthesiologist.

If the headache persists, a procedure called a “blood patch” will be done. This is done in the sterile environment of an operating room by two anesthesiologists. One places an epidural needle in your back, while the other takes around 20 ml of blood from a vein in your arm. The blood is then passed down the needle into the epidural space. This forms a clot that seals the hole and prevents further leakage of fluid from around your spine, therefore relieving the headache.

Epidural pain relief

Alice was having her first baby. Her pregnancy had been uncomplicated and she had written a birth plan with her husband outlining her desire for a natural childbirth by keeping active and using TENS and then warm water to deal with contractions. Alice also stated that she wanted to avoid an epidural if possible.

Alice’s birth story:

My husband and I arrived at the delivery suite in early labor. I started to use a TENS machine for pain relief. However, as my labor progressed, I became very distressed since I hadn’t anticipated that the contractions would be so painful. When I was around 3 cm dilated, I decided to remove the TENS machine and get into the bath. My husband gave me a back massage and provided emotional support. However, I think he struggled to understand my discomfort and he needed support from the nurse. After 15 minutes, I decided to get out of the bath since it was providing little pain relief. I used a birth ball to stay active and my husband gave me more massage and acupressure. I coped well for the next hour, but then became increasingly exhausted and upset. When I was examined, I was only 5 cm dilated. We both felt despondent because we had hoped I was further along.

My nurse then suggested that I talked to the anesthesiologist about my options for further pain relief, and as a result of my conversation with the anesthesiologist, I decided to have an epidural. I told the anesthesiologist that I’d had an epidural a few years ago for knee surgery and how it had provided excellent pain relief, but that I had itched for hours afterward. The anesthesiologist surmised that the itch was caused by one of the painkilling medications (fentanyl) in the epidural top up and agreed that this medicine wouldn’t be used.

The anesthesiologist agreed to do a low dose combined spinal epidural that gave absolute pain relief within five minutes. My legs were a little heavy at first, but they felt fine within an hour. I felt that we were both able to take time out after the epidural and that I was able to refocus on my labor. I felt pleased that I’d managed a large part of my labor without pain relief, and was happy with the decision to have an epidural when I did. I had an unassisted delivery later that evening and gave birth to a beautiful baby girl.

The anesthesiologist comments:

Alice kept an open mind regarding pain relief and understood that different methods of pain relief could be used at different times during labor. After the epidural, she no longer felt that her labor was an endurance test and was able to focus again on her labor and on delivering a healthy baby.

A low dose “mobile” epidural means that you maintain some feeling in your legs and can remain active during labor.

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