women

Drugs for Pain Relief

Various types of medication are available for pain relief during labor; many can be used alongside natural forms of pain relief.

For some, natural pain relief may not be sufficient to enable them to deal with the increasing intensity of contractions, and they may choose to use medication in combination with natural techniques. In some situations, for example if labor is induced  or augmented , contractions may start strongly rather than build up gradually and a stronger type of pain relief may be needed.

There are several types of medical pain relief available, which fall into two groups. Analgesic drugs dull the perception of pain, while anesthesia, which may be regional or general, numbs pain totally. In regional anesthesia, also known as a nerve block, local anesthetic drugs are injected around nerves that supply a particular area. There are several types of regional nerve block: epidurals and spinal blocks numb sensation in the abdomen and are used to reduce the pain of contractions; a pudendal block numbs sensation in the vagina and perineum and may be used in a forceps delivery. Occasionally, a general anesthetic is given during a cesarean.

Since all labors are different, it’s not possible to have a “one size fits all” approach to pain relief. Being flexible and informed will help you feel in control. Read any literature from your doctor, go to prenatal classes, and ask questions. Try to eliminate any worries by increasing your knowledge, for example by asking if it’s possible to attend a childbirth education class at the hospital that discusses the pros and cons of each type of pain relief. Keep in mind that some childbirth classes, like Lamaze and the Bradley method, can teach you breathing and relaxation techniques that may help reduce your need for pain medication during labor.

Pain relief plan

Having a birth plan ahead of time that outlines the circumstances during which you would resort to using medication for pain relief may be helpful for some women. For example, you may want to try to remain medication-free unless the pain is so intense, it interferes with your ability to hold a normal conversation, or it doubles you over in pain. Perhaps you’ll seek relief if your labor drags on hours longer than you expected and you need some respite to sleep for a while to regain your strength for the upcoming pushing that you’ll be doing. Whatever the case, you may feel more in control if you know ahead of time what your limits are and when you want to say yes to pain medication, rather than being overwhelmed by the situation, if you don’t give it much thought beforehand.

Opioids

These belong to a group of drugs called narcotics (which literally means sleep-inducing), which includes morphine. They attach themselves to receptors in the brain or nerves and block the transmission of pain.

Tranquilizers

These drugs don’t relieve pain, but they can help to relieve anxiety and help a women relax for several hours during early labor. Some women who are very anxious about the impending pain or of labor and childbirth may seek this sort of medication. Tranquilizers may be given orally, intravenously, or injected into a large muscle. Oral dosage takes the longest to take effect. Some women dislike what tranquilizers do to them, since they may feel drowsy and out of control. If the dose is very high, women may nod off between contractions. It may be hard for a woman to fully remember her labor experience if she’s taken tranquilizers. The drugs also effect the baby, decreasing his activity and muscle tone during and after birth. For these reasons, tranquilizers are not for everyone, but in certain circumstances, they can help a woman feel less anxious about labor.

Epidurals

An epidural is a regional anesthetic that can be given at any stage of labor to numb the abdomen and therefore block the pain of contractions, but it’s typically given when the woman is at least 4 cm dilated. In some cases, if a woman’s labor progresses very quickly and she doesn’t request one right away, she may not be able to get one before delivery. Epidurals are the most popular form of pain relief during labor in the US, with more than half of pregnant women delivering in hospitals choosing this treatment.

How epidurals work

A hollow needle is inserted between two vertebrae in the lower back. A tiny plastic tube is then passed through the needle and into the epidural space surrounding the spinal cord. A local anesthetic is injected into the needle and flows through the tube into the epidural space so that the nerve roots carrying the pain stimulus to the brain are coated with anesthetic and pain is reduced or completely blocked. This will affect sensation in your legs so that you need to remain in bed and your baby will be closely monitored. A stronger epidural also affects sensation in your bladder, so you will need to have a catheter. Used late in labor, a stronger epidural may mean that you need help to push the baby out, since the pelvic floor muscles will be heavy and ineffective. In this case, your doctor will put a hand on your abdomen to feel when a contraction starts and will tell you when to push. In some cases, an assisted delivery becomes necessary.

When are epidurals used?

Epidurals can be used throughout labor, but they’re typically given during active labor when a woman is 4–5 cm dilated. Since everyone has varying pain thresholds, the time when one is requested varies. There are factors to bear in mind should you opt for an epidural late in labor. To minimize the risks, you must remain completely still during the placement of the epidural tube. If your labor has progressed too far to enable you to do this, the anesthesiologist may refuse to proceed with an epidural for your own interest. Also, if you choose to have an epidural late in labor, it may be necessary to give a high dose so that it takes effect in time, which has disadvantages (see Considering an epidural).

If you’re considering using an epidural, inform your doctor early in labor so that she can consult the anesthesiologist. The anesthesiologist may then discuss this with you and take a brief medical history to ensure that it’s safe for you to have an epidural. She will discuss any risks, and answer any questions that you or your partner has, all of which can save time later on if you decide to go ahead.

There are occasions when an epidural is not advised. These include cases where a woman has had spinal surgery or is taking blood-thinning medication. Rarely, a woman may have an infection that could be exacerbated by an epidural.

Side effects

There are a number of minor side effects. The medication can cause blood pressure to fall, so this will be monitored (see How an epidural is done). If it does fall, you’ll be given fluids and medication, and subsequent doses may be reduced.

It’s common to experience itching with epidurals, caused by the release of histamine from the opioid component of a mobile epidural. Histamine is a substance released by the body during an allergic reaction that can cause itching. The itch can be treated, but in most cases it gets better on its own. If you develop an itch, a greater concentration of local anesthetic alone will be used.

It’s not unusual to shiver with an epidural, although this is a more common side effect if a concentrated local anesthetic is used, as is the case for a cesarean delivery.

Epidural pain relief can cause a rise in temperature. If this occurs, you’ll have a blood test to eliminate an infection since this can also cause your temperature to rise. You will be given preventative antibiotics while waiting for the blood test results, and acetaminophen to bring your temperature back to normal.

Problems with epidurals

In addition to side effects, there can occasionally be problems with the effectiveness of an epidural. The anesthetic may not spread evenly in the epidural space, which may be caused by the epidural tube sitting on one side of the epidural space. This can mean that pain relief only occurs on one side of the body. If this occurs, the anesthesiologist will try to reposition the tube and give another dose of anesthetic. If this doesn’t work, the only other solution is to redo the entire epidural.

Sometimes, one spot can remain painful, usually in the groin area or low down in the front of the abdomen, which is referred to as a “missed segment.” This results from a single nerve root not being coated with the local anesthetic. Again, the anesthesiologist may reposition the tube. Sometimes, a stronger local anesthetic or an opioid is used to numb the area. If a persistent missed segment is too uncomfortable, the anesthesiologist may do a combined spinal epidural block, known as a CSE.

It’s thought that epidural pain relief may prolong the second stage of labor. It also increases your chances of having an assisted delivery, especially if a high dose of anesthetic is given toward the end of labor, which affects your ability to push. However, an epidural doesn’t increase the chance of a cesarean and doesn’t, despite common misconceptions, cause long-term backache after the birth.

Spinal block

This is similar to an epidural in that a needle is put in your back and pain relief is achieved by blocking nerve fibers that supply the pelvic organs. However, in a spinal block, the needle is passed through the epidural space to pierce the membrane covering the spinal cord (the dura) so that anesthetic can be injected into the fluid around the spinal cord; no tubes are left in place. The needle used for a spinal block is smaller than that used for an epidural, which means it’s less painful to insert. There is still a risk of a headache as with an epidural (see An Epidural “headache”) and the side effects should be treated the same way.

A smaller dose of anesthetic is needed and it works very quickly: pain relief is almost immediate, whereas an epidural takes 10–20 minutes. However, the use of a spinal block is limited because only a single dose of medication can be administered. As a result, spinal blocks are usually reserved for use during a cesarean, or for an assisted delivery when an epidural isn’t in place.

Combined spinal epidural (CSE) or “walking epidural”

This involves both a spinal injection and putting an epidural in place. It’s sometimes done when problems are encountered with an epidural (see Epidurals) and is also used for a cesarean. A CSE gives pain relief throughout labor. However, it’s a specialized technique and isn’t offered in all units.

Pudendal blocks

This type of regional anesthesia involves injecting a local anesthetic into the vagina where the pudendal nerves are located to reduce pain in the vagina and perineum. The pudendal needle is quite long and thick, so before the injection is given, a cold anesthetic spray is applied to the area. The anesthetic has no effect on the baby and can be used with other medications. It takes effect very quickly and is sometimes used just before birth to aid an assisted forceps delivery.

General anesthesia

Most cesareans are conducted using regional anesthesia. However, in some cases general anesthesia, where the mother is put to sleep, is necessary. This may be because of a failure of regional anesthesia, blood-clotting problems in the mother, an infection in the mother’s bloodstream, or persistent fetal distress.

The procedure

Precautions are taken to minimize the risks to you and your baby. You’ll be given an antacid to reduce stomach acid. Often a catheter is inserted into the bladder and antiseptic is applied to the abdomen before you’re put to sleep to minimize the baby’s exposure to the anesthetic.

As the mother is put to sleep, a face mask is held tightly over her nose and mouth. Because a major risk during general anesthesia is undigested food or liquids in the stomach re-entering the mouth and going into the lungs (which can cause damage) you’ll likely be told not to eat or drink anything once labor begins (because labor usually slows digestion), in case you need general anesthesia. You may be able to have ice chips, though. Once asleep, an anesthesiologist inserts a tube through your mouth and down your throat so that oxygen can easily reach your lungs. You may therefore have a sore throat when you wake up.

During the surgery the anesthesiologist cares for the mother, giving painkillers and anti-nausea medicine when needed. The baby is cared for by the doctor. Depending on hospital procedure, your partner may or may not be present for the birth. However, no hospitals allow the partner to be present while the mother is being put to sleep.

After the surgery

The procedure takes about an hour. The mother is woken 5–10 minutes after the surgery. The baby is kept with the mother at all times unless he needs extra care.

Since general anesthesia doesn’t give localized pain relief, it’s normal to need pain relief afterward. Oral medicine will be given regularly and morphine-based medication may be given for a day or two.

Up until 150 years ago, there were few options for pain relief during childbirth.

The history of modern obstetric pain relief began in the mid-19th century with the discovery of chloroform. Nitrous oxide and opioids followed and at the start of the 20th century, enthusiasm for pain-relieving drugs was so great that they were overused, with women in labor in a state of near-unconsciousness. The natural childbirth movement in the 1960s and 1970s was a reaction to such overuse of drugs. In the 1970s another revolution was at hand as epidurals became available.

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