Pain Management During Labor

Pain Management During Labor

What is the cause of the pain?

During the early stages of labor pain typically results from uterine contractions. This pain is diffuse and can be hard to localize but lower abdominal pain is common. Many women also report low back pain or upper thigh pain. During the later stages of labor, the baby descends which puts pressure on the pelvic floor, vagina and perineum. This pain is easier to pinpoint and typically is described as pressure.

Types of pain relief

Analgesics are medications that decrease the level of pain. They do not interfere or alter your ability to move or feel touch. Examples include medications like morphine and Ibuprofen.

Anesthetics are medications that block pain by affecting the nerves. Because the nerves are affected, your ability to move or feel touch may also be affected. Examples include epidurals, nerve blocks, spinals.

Pharmacologic pain management options during labor

Epidural: 60% of American women in labor will use this method making it the most common method used in the United States.  An anesthesia provider will place a small flexible catheter in to what is known as the epidural space. The epidural space is a small sleeve that surrounds and cushions the spinal cord.  Analgesics and/or anesthetics can then be continuously or intermittently supplied through this catheter. Many hospitals have the option to set the medication up as a patient controlled pump where the patient has a button that when pressed delivers a dose of medication through the epidural catheter. If a cesarean section is necessary, a higher dose of medication can be delivered through the catheter to further numb the patient for surgery.

o An epidural can slow the first stage of labor (when the cervix is dilating) by 90 minutes and can slow the second stage (pushing) by 13 minutes but does not increase the risk of having a cesarean section

o 10% of patients will have low blood pressure following the first dose of the medication through an epidural.  However, this can be prevented and treated quickly with IV fluids.

o Itching is a common side effect but can be treated easily with medications like Benadryl

oThe risk serious nerve injury after an epidural is 1/36,000 people

o The risk of bleeding within the epidural space, epidural hematoma, is 1/250,000 and is related to the patient’s platelet level therefore epidurals are contraindicated with certain clotting disorders.

Spinal: In this technique an anesthesia provider will inject an analgesic and/or an anesthetic into the subarachnoid space. The subarachnoid space is the space around the spinal cord where cerebrospinal fluid is contained. Pain relief occurs quickly and lasts 1-2 hours which is more than enough time for a cesarean section which is what spinals are traditionally used for. However, because this is a single dose injection, the level of pain relief and numbness cannot be titrated up or down.

o The most common risk with a spinal is what is known as a spinal headache.  However, that risk is only approximately 1/1400 patients.

Pudendal nerve block: Here an obstetric provider will inject anesthetic through the posterior wall of the vagina to block the pudendal nerve. This nerve provides sensation to the vagina, vulva and perineum to help with stretching pain as the baby’s head crowns. This can also be used for pain control after delivery if there is a tear that needs to sutured.

IV medication: Analgesics such as fentanyl, morphine, or Nubain can be delivered through an IV or given as an injection. The effects last 2-5 hours depending on the medication and dose. All opioid medications will cross the placenta and can make the baby drowsy which shows up in their heart rate tracing.

o   Because of the effects on the baby, these medications should not be used if delivery is imminent.

o   Side effects of opioids include nausea, vomiting, itching, and drowsiness 

Nitrous Oxide: A mixture of 50% oxygen and 50% nitrous oxide gas is delivered through a mouthpiece or facemask. The patient is able to hold the mask to her face and breath in the gas when she needs it and remove the mask when she does not. The gas is an analgesic and also reduces anxiety however the patient retains mobility. The effects of the gas wear off within minutes. 

General anesthesia: An anesthesia provider administers IV medication that sedates and paralyzes the patient. The paralytic is used during surgery so the patient remains still.  However, because of paralysis, a breathing tube must be placed for the duration of the surgery. General anesthesia is used for cesarean sections when the spinal or epidural fails or in the case of an emergency and there is not time for a spinal. The IV medication crosses the placenta so the baby may need help breathing for a little while after delivery until the medication wears off.

o   General anesthesia carries a risk of aspiration meaning the contents of the patient’s stomach reflux up the esophagus and go into the lungs. This is why surgery is usually done after the patient has not eaten for several hours

o   Only 5% of cesarean sections are done under general anesthesia

Non-pharmacologic pain management options during labor

Breathing techniques: Being mindful of calmly breathing in and out during a painful contraction not only increases oxygen flow to the patient and the baby but also gives the patient something to focus on other than her pain.

Hypnosis: Practicing relaxation techniques prior to labor can help the patient be more physically and mentally prepared to deal with painful contractions. Some methods include calming music, visualizing progress through labor such as the cervix dilating and the baby descending, positive thinking or words to help keep the patient focused. This can be done alone, with audio tapes or a support person

What is the best pain management plan for labor?

Some people want the experience of natural or unmedicated labor and delivery while others want to have as little pain as possible; neither path is right or wrong.  Each patient is unique and the pain management plan must be adjustable to fit each woman. There is not certain stage or number you must reach prior to receiving medication as pain is subjective and not measurable.  Some women have pain when they reach 2cm and need medication while others have no pain until they are fully dilated. This certainly does not make any patient “stronger” than another. Pain management during labor and delivery is entirely at the patient’s discretion.  The best plan is to discuss the options with your health care provider prior to labor so you can come up with a strategy that best suits you. 

Author
Dr. Gottschalk Dr. Kathryn Gottschalk OBGYN

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