Labour pains: What are your relief options?

Labour pains are different for every woman, but the important thing to know is you don’t have to suffer through them. Familiarize yourself with the many pain relief options available to you before you arrive in the delivery room.

During the first stage of labour, women are mainly faced with contraction pain from the uterus, explains Arun Anand, an anesthesiology resident at The Ottawa Hospital. These contractions are considered to be a period of moderate to severe pain, can occur every two to three minutes and can last anywhere from 30 seconds to over a minute, he adds. In the second stage of labour, the baby enters the birth canal, which causes stretching and pressure to the surrounding structures, resulting in minor trauma and pain. The length and intensity of labour vary from woman to woman, depending on pain tolerances, whether it is her first, second or third child, etc. During contractions, women can experience high blood pressure, hyperventilation and a lot of pain, so effective pain control can really help, says Anand. Fortunately, “having good pain control does not appear to impact any studied outcomes for your baby.”

Which methods of pain management will be most useful for you depend on your specific circumstances, such as whether you will be delivering vaginally or through a Caesarean section, explains Anand. Both non-pharmacologic and pharmacologic treatments are available, each with different benefits and risks. Non-pharmacologic treatments are potentially useful only for vaginal deliveries, says Anand.

Non-pharmacologic options:

• Psychoprophylaxis: Some women turn to relaxation and deep breathing exercises to get them through labour, but according to Anand, no benefits have been proven.
• Labour support: Having a family member or midwife to share the experience with and to support you through labour can be very helpful. Anand reports that having a labour support person has been linked to shorter labour, fewer operative deliveries, fewer analgesic interventions and an overall increase in patient satisfaction.
• Hydrotherapy: Water therapy can decrease pain for some women, but there is no change in the duration of labour.
• Transcutaneous electrostimulation (TENS): No benefits from this form of nerve stimulation have been proven, says Anand.
• Acupuncture: Anand suggests that the efficacy of acupuncture is subjective but says that patients have reported a reduction in pain scores.

Pharmacologic options:

• Opioids: Narcotic medications such as morphine and fentanyl are commonly used to help manage labour pain, says Anand. They can be administered either intravenously or through a spinal or epidural. Intravenous opioids are usually used when a labouring woman is waiting to get an epidural or if she chooses to not have an epidural. But these medications have side effects, such as an increased risk of nausea and/or vomiting, itchiness and urinary retention, and there’s a risk of being over-sedated, with a decreased drive to breathe, says Anand. In addition, these medications cross the placenta and expose the baby to side effects, such as the baby not being as awake as it normally would be due to the sedative effects. Anand points out that, although intravenous opioids are very effective for managing pain in other settings, it is unclear how effective they are for labouring women.
• Nitrous oxide: In conjunction with opioids, nitrous oxide can be breathed during contractions and delivery to manage pain, says Anand. Studies show conflicting results as to whether nitrous oxide provides a benefit to the labouring woman, but its use appears to be safe for the baby, he notes.
• Pudendal nerve block: This is a good technique to help with pain control after an episiotomy, says Anand. It is done transvaginally and blocks the nerve routes that supply the vaginal vault, perineum, rectum and parts of the bladder.
• Lumbar sympathetic blockade: This method is a reasonable alternative when there are contraindications to the more common procedures (such as a family history of a bleeding disorder, pre-eclampsia or HELLP syndrome during pregnancy, etc.), explains Anand.
• Epidural: This procedure, which involves injecting an anesthetic into the epidural space (outside the spinal canal) to block the nerve roots as they leave and enter the spinal cord, is the preferred technique for a woman in labour, says Anand. A catheter is left in the epidural space so additional drugs can be injected to control pain throughout labour.
• Spinal: This is the preferred technique for an elective (non-emergent) Caesarean section. A local anesthetic is injected into the spinal canal and mixes with the cerebrospinal fluid to freeze the nerves directly at the level of the spinal cord. “This is a one-time technique, and [the] drug is injected as a one-time dose,” explains Anand. The epidural and the spinal can be combined as a method of pain management.

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Regional anesthesia or “freezing” — which blocks the nerves from transmitting signals of pain to the brain — is the most common and most effective way to manage labour pain, explains Anand. There are many types of regional anesthesia techniques, as noted above, but by far the most common are spinals and epidurals, he notes.

Epidurals

“For labouring women who plan to deliver vaginally, an epidural is the preferred method of analgesia (pain relief),” affirms Anand. “Labour can take a long time, and it’s different for everyone in terms of the experience, the amount of pain and the length. In the latent phase of labour, a woman can have irregular contractions for a couple of weeks! Once a woman is in the active phase of labour (when her cervix becomes 3 to 4 centimetres dilated), and she is having regular contractions (every couple of minutes), depending on if this is her first pregnancy or not, she can be in this active phase for up to 10 to twelve hours. This is when we offer epidurals to help control contraction pain,” says Anand. You are likely to feel your contractions getting shorter and then go away altogether.

An additional advantage to having an epidural is that it is relatively painless. Some freezing is placed in your back with a small needle, and then you will simply feel a bit of pressure as the epidural is placed. The most important aspect of the procedure is to ensure you stay still in the event of a contraction, says Anand. In addition to being helpful for a regular delivery, epidurals can make things go more smoothly in the event of complications leading to an emergency C-section, because higher doses of drugs can be injected through the catheter already in place, explains Anand.

All that said, it is important to remember that, as with any procedure, there are risks. In about 10 to 15 per cent of cases, the epidural doesn’t work as expected, explains Anand. For example, one side of the body could become more numbed than the other. There is also the risk of a condition called the “post-dural puncture headache.” This is an excruciating headache that can leave the mother bedridden for at least a couple of days because standing up makes the pain worse. Post-dural puncture headache happens in about 1 to 2 per cent of cases. Treatments for this condition exist, and even with no treatment, 95 per cent of people get better after two weeks, says Anand. Rare but serious complications, such as bleeding, infection and temporary or permanent nerve damage, can also occur from an epidural. Fortunately the risk of incurring one of these serious complications ranges from one in tens of thousands to one in hundreds of thousands.

Spinals

Spinals are the preferred anesthetic for a booked or elective C-section, says Anand. The procedure freezes the mother from the chest down for a couple of hours while the surgical team performs the C-section. It is a one-time injection of a local anesthetic and sometimes the addition of narcotic medication to help control pain after surgery, explains Anand. The risk of complications with a spinal are lower than those associated with epidurals, he adds.

Which options are best suited to you can vary widely based on your medical needs and personal preferences. By considering all the possibilities, your wants and your doctor’s recommendations, you can get a sense of the right pain relief option(s) for you.

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