Pain Management in Labour & Delivery

There are many different types of pain relief that can be given during labour. Your choices for pain relief will depend on what stage of labour you are in, what types of pain management you prefer, your health, and condition of your unborn baby.

Non-medical ways of relieving pain

One of the best “tranquilizers” during labour is proper psychological preparation of the pregnant mother. If you are afraid of labour, and fearful of the unknown, you are likely to need pain medication. If you are free of fear, and confident in yourself and your health care providers, you may need less or no medication.

Childbirth is a natural life event, and there are a number of ways to deal with the pain of childbirth without the use of medication. There are various programs you can tap into, such as Lamaze or the Bradley method of natural childbirth. Your health care provider can give you additional tips and provide support. Here are a few ways to cope with the pain:

  • Try to relax.
  • Use breathing patterns to help relaxation.
  • Make releasing noises like chants, hums, and moans when you feel the need to.
  • Take advantage of gravity to help push the baby along: try standing and leaning against your partner, sitting and leaning over a chair, kneeling on all fours, walking slowly, or relaxing in the shower.
  • Try to walk in between contractions.
  • Sway, rock, and dance to keep your pelvis mobile.
  • Consider water therapy: soak in the jacuzzi, bathtub, or shower.
  • Have your partner or a friend give you a massage.
  • Urinate frequently.
  • Distract yourself with music, television, or meditation.

Your partner and loved ones can also help you to deal with the pain by doing the following:

  • reassuring you with loving words and slow, steady movements
  • offering praise, not criticism
  • trying to distract you
  • helping you to take one contraction at a time
  • letting you stand and lean against him (or her), in an effort to have gravity push the baby along
  • mopping your forehead with a wet cloth
  • bringing you ice chips to chew on, and drinks and food if permitted by your health care provider
  • giving you a massage if you want it
  • encouraging you to rest between contractions if you are able to
  • encouraging you to resist pushing until your health care provider says that you should

Even if you have your heart set on a natural childbirth, try not to close the door to other pain relief options. Childbirth is not a test of strength or bravery. The pain of childbirth is considered to be the most intense of the human experience. There is nothing wrong with admitting that you need pain relief, and getting that relief through medication. There is a variety of different pain medications available for labour and delivery. These include analgesics, tranquilizers, inhalants, local anaesthesia, regional nerve blocks such as epidurals and spinal blocks, and sometimes in the case of caesarean section, general anaesthesia.

Analgesics

Analgesics are commonly used pain relievers. These drugs, often narcotics, are given when labour is well established. A number of different analgesics are available for use in childbirth. These drugs are commonly given intravenously or as an injection into the muscle. The intravenous administration provides pain relief faster than the intramuscular injection. If a narcotic is provided as an injection, it is better to have frequent injections of small doses, rather than one injection with a large dose. Large doses of a narcotic, or doses that are given too close to the time of delivery, can make the baby too sleepy to suck after he is born, and can also lead to breathing problems especially during the first few hours of life. Side effects for the mother vary depending on how sensitive she is to the drug, and may include nausea, vomiting, depression, and low blood pressure. Narcotics do not appear to prolong labour.

Inhalants

Nitrous oxide is a gas that is sometimes used to provide pain relief during labour and delivery. More commonly, nitrous oxide is provided in combination with other medications when general anaesthesia needs to be given. Nitrous oxide is administered through the use of a gas mask. All inhaled gases cross the placenta and may affect the unborn baby.

Local anaesthesia

Local anaesthesia is an injection of anaesthetic into a particular region of the body. In childbirth, local anaesthesia is most commonly used during or after delivery when an episiotomy needs to be performed. Sometimes local anaesthesia is used to supplement a regional block. In some extremely rare cases, local anaesthesia might be used for caesarean section if no other anaesthesia support is available

Regional nerve blocks

Regional nerve blocks are injected to cut off sensation in a particular part of the body. Regional blocks allow the mother to remain awake and alert during the birth and after the baby is born. Regional blocks can stop the woman’s urge to urinate, so a catheter is sometimes needed to drain urine. The most common types of regional anaesthesia are pudendal blocks, epidural blocks, and spinal blocks.

Pudendal blocks

Pudendal blocks are a safe and simple type of pain relief in childbirth. In a pudendal block, a long needle is inserted into the vaginal wall, where there is a nerve called the pudendal nerve. Anaesthetic is injected through this needle. Pudendal blocks reduce pain but do not eliminate it entirely.

Epidural blocks

Epidural blocks numb the area from the waist down, and can be used in both vaginal and caesarean deliveries. In an epidural, a fine tube is inserted into the woman’s back, specifically into a space between the spinal cord and its outer membrane. This is done when the woman is lying on her side or sitting up and leaning against something. Once the tube is in place, anaesthesia medication is delivered through the tube into the space in the woman’s back. Sometimes the epidural medication may be reduced or stopped when the woman needs to push, to make that stage of labour more effective.

Epidural
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A small needle is inserted between two vertebrae in the lower spine. The tube delivers anesthesia medication into the epidural space. This epidural space is between the vertebrae and the dura mater, a tough outer covering of the spinal cord . The tube stays in place during labour. The medication slowly takes effect, but it is long acting and it can be given continuously or as needed.
Although epidurals are relatively simple and safe in most circumstances, they have been known to slow labour and increase the need for forceps delivery and caesarean section. There are a number of potential complications to be aware of when considering an epidural:

  • Low blood pressure: Epidurals can cause the mother’s blood pressure to drop suddenly, posing a risk to mother and baby. Because of this, the mother’s blood pressure will be monitored during the time that the epidural is in place. If the mother develops low blood pressure, intravenous fluids and medication may be given to counteract the problem.
  • High spinal blockade: If the epidural is not inserted properly, it can result in a total block of the spinal nerves. This can cause low blood pressure and breathing problems in the mother. Rarely the mother’s respiratory system can become paralyzed. In this case, a ventilator will be required to help her to breathe.
  • Ineffective pain relief: Pain relief from an epidural takes time to kick in, but most women eventually experience complete numbing. However, some only feel partial relief, and 3% experience no pain relief at all. In rare situations, an epidural might not provide enough pain relief during a caesarean section, in which case nitrous oxide, local anaesthesia, or general anaesthesia may also be needed.

Spinal blocks

A spinal block can be given right before an assisted vaginal delivery or caesarean section. In an assisted vaginal delivery, forceps or vacuum extraction is needed to ease the baby out of the birth canal. A low spinal block can be used to completely block sensation under the waist, when the cervix is fully dilated and the baby is ready to be delivered. For caesarean section, the dose of anaesthetic given in a spinal block is higher than that for an assisted vaginal delivery.

The spinal block is injected in one single dose into a part of the spinal column. The mother lies on her side with her back arched and her neck and knees flexed in order to receive the injection. The pain relieving effects of a spinal block are almost instant, and they last for about an hour to an hour and a half after the injection. Spinal block anaesthesia is very effective at completely blocking pain.

Spinal Block
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A small needle is inserted between two vertebrae in the lower spine. This is below the point where the spinal cord ends. The tube delivers anesthesia medication into the fluid that is around the spinal cord. The medication quickly takes effect.
Like epidurals, spinal blocks can lead to low blood pressure and high spinal block. Other possible complications include headache, bladder problems after delivery, and high blood pressure.

General anaesthesia

General anaesthesia, which puts the woman to sleep, is used occasionally for emergency caesarean sections and for other surgeries as required. General anaesthesia works rapidly, and therefore is used when there is no time to wait for a regional block to take effect. Intravenous general anaesthetic drugs are easy to administer, work extremely fast, can be controlled, and allow for a prompt recovery.

There are two major risks to using general anaesthesia, however. One is that, because the mother is sedated, the baby may also become sedated. All general anaesthetics can cross the placenta and depress the baby’s central nervous system. This can be avoided by putting the mother under general anaesthesia as close to the time of delivery as possible. This reduces the amount of drug that the baby receives.

The other major risk of general anaesthesia is the possibility that the mother might vomit and aspirate, or inhale, the vomited material. This can cause the mother to develop breathing difficulties and other serious health problems. Sometimes women are asked to refrain from eating and drinking during labour, just in case they need to have surgery under general anaesthesia. However, fasting does not necessarily reduce the risk to the mother because the stomach juices themselves are very acidic and can cause problems if inhaled. If you do need to have a general anaesthetic, a tube will be inserted through your mouth into your throat to reduce the chance of aspiration.

Nicolette Caccia, MEd, MD, FRCSC

Rory Windrim, MB, MSc, FRCSC

9/11/2009


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