Making the Decision
Deciding on how to handle the pain of labor is an important personal decision. Nothing gets women more passionate about labor than talking about their beliefs concerning pain management techniques. However, keep in mind that the choice should be yours to make, in conjunction with your partner and with guidance from your care providers. Throughout your pregnancy, you will undoubtedly get unsolicited advice from a lot of sources regarding whether or not to use pain medication during labor. Take what they have to say with a grain of salt because your experience will differ from their experience(s).
Labor is such a diverse experience for each and every woman that you can never really go into it with a solid idea about what labor will be like for you. Some women go in expecting to use medication and end up making it through labor without it, while others go in not wanting medication but end up changing their minds during labor. The best thing you can do to prepare in advance is to gather as much information about pain management techniques beforehand and make an educated decision about what you would and would not like to try. Feel free to incorporate these preferences into your birth plan if you are creating one. Also, share your preferences with your primary care provider (doctor, OB/GYN, or midwife), your partner or birth coach, and your care team at the hospital (labor and delivery nurses, specifically).
Keep in mind that labor can be an unpredictable process, so if you go in with an open mind and flexible expectations, you can avoid some unwelcome surprises. If complications arise, like the need for an emergency C-section, you may not have a choice in terms of medications used. This doesn't always mean that you will be forced to make decisions that you did not want. So, be as true to your own preferences as the situation allows, but trust those you have chosen to provide your care if they offer alternative suggestions. Feel free to ask as many questions as you want, whenever you want, if you are being encouraged to make a decision that you wanted to avoid, then make your decision. If you are in a vulnerable state or in no state to talk at all, encourage your partner or birth coach to ask questions for you (prep them for this beforehand so they know how to be a good advocate for you).
Non-medicated Labor
There are a variety of different methods that are currently in use in terms of dealing with pain during labor without the use of medication such as Lamaze, the Bradley Method, and Hypnobirthing. Click on these links or see our previous post on Childbirth Classes in order to learn more about these specific methods. The main focus during an unmedicated labor is to listen to your body and provide it with what it needs. You can choose to follow the guidelines of a certain method during labor, or you can use a combination of any of the following techniques to facilitate pain management during an unmedicated birth. Additionally, should you choose a medicated birth, you can still employ any of these methods to keep yourself calm and focused during labor.
- Deep breathing exercises: Most childbirth classes that you take will offer at least basic training in breathing techniques. Yes, we've all been breathing long before we have the opportunity to take a class on it, but a class will teach specific techniques that increase your awareness and focus your attention on your breathing. Breathing techniques include taking a deep, cleansing breath before an after each contraction and patterned breathing that is rhythmic and comforting (such as the stereotypical hee-hee-hoo breathing).
- Massage/Counter-pressure: Ever heard of back labor? If not, you might be in for a surprise if your back hurts just as much as your front during labor. One of the best ways to manage back labor is to have your partner or birth coach massage your back or apply counter-pressure. Massage and touch can be a great way to manage pain, especially if delivered from your partner since it can provide both physical relief and emotional connection during labor. Have your partner massage whatever part of your body that feels good, whether it be your back, your arms, or your feet. Some women, however, find that they don't want to be touched at all during certain points in labor, and that's perfectly okay. Be flexible and communicate with your partner (in the kindest way that your contractions will allow, haha).
- Warm or cold compresses: If you get overheated during labor, ask for a cold compress to put on your forehead. Likewise, you can have your partner or birth coach apply cold or warm compresses to your lower back to manage back labor. Just see whether cold or hot feels better at the time, or alternate between the two if you like.
- Movement/Changing positions: Some women find that getting up to walk, moving around on a birthing ball, or simply changing positions can offer some measure of relief. For the most part, hospitals have women in a semi-reclined position to give birth, but if other positions (squatting or on all fours, for example) feel better to you, go ahead and shift. If you choose to get up and walk around, you may find it helpful to stop and lean against something or someone during the hardest part of your contractions.
- Visualization: You can picture yourself in a calming place, imagine yourself as a female warrior, or visualize yourself holding your baby. Whatever you choose to do, visualization can often help to distract you from the pain or hold out through each individual contraction by focusing on a specific goal or image.
- Self-hypnosis: This method often involves getting some sort of training from a professional before you employ it. It is often used to create a deep sense of relaxation to manage pain, fear, or anxiety during labor.
- Aromatherapy: Some women like to use essential oils or something similar to help them relax and create a soothing environment. You can even combine aromatherapy with massage and have your partner or birth coach rub essential oils onto different parts of your body. Feel free to bring these kinds of things from home, but remember, no candles (no open flames!). If you are wondering what is okay and not okay to bring from home, call your hospital and double check with them.
- Listening to music: Just like with aromatherapy, listening to music can help foster a calming environment. Whether you choose to play it as ambient background noise in the room or you pop in/on your headphones, music can help you focus your attention elsewhere. Feel free to create a playlist of your favorite calming music (or rockin' music, if you prefer) in preparation for birth.
- Distraction: Most women will try this method during labor, whether they are aware of it or not. This doesn't require any special technique or anything like that. It can be as simple as joking with your husband or chatting with your L&D nurses. You can also play cards, watch TV/movies, update your blog, surf the internet, take a walk, or any other number of things. This method may be more effective during earlier stages of labor and more difficult to employ as contractions intensify, so be sure to have other methods in mind to manage pain.
- Taking a bath or shower: The impact of the water during a shower or the warmth of a bath can have very calming effects on a laboring woman, so much so that this method is often referred to as the "midwife's epidural." Jacuzzi tubs are a popular pain reliever because it offers some of the weightlessness and warmth of a tub in combination with the massage of the jets. You can take a warm bath or shower at any point during labor; some women even choose to give birth in a birthing tub.
- Having a focal point: This is simply choosing something in your environment to focus on during contractions. It can be a picture, a flower, a spot on the wall, or your partner's eyes. With this method, you focus your energy outside yourself and onto something else. This can be especially comforting if you are feeling panicked or anxious; you can lock eyes with your spouse or birth coach and throw your focus there. However, some women prefer to have an internal focus and close their eyes during contractions. Find whatever works best for you and go with it!
Medicated
There are several classes of medication that can be employed during the labor process, namely regional anesthesia, systemic medication, and general anesthesia. Following are brief descriptions of each class of medication, their general uses, names of common drugs or techniques in each class, and the differences between the three classes. Both advantages and disadvantages/risks are discussed for each class.
- Regional Anesthesia: These kinds of medication are used to numb or relieve pain in only a specific part of the body, which is why they are administered into the lower back during labor to target that area of the body. They cannot be administered by nurses, like other forms of medicated pain management may, but instead must be given by an anesthesiologist. The most commonly used regional analgesics are epidurals, spinal blocks, and the combined epidural and spinal block.
- Epidurals: A woman either lies on her side or sits up in a hunched position to expose the lower part of her back. The area is cleaned and then a small needle is used to numb the area where the epidural will be administered. A larger needle is then used to inject the medication into the epidural space (the fluid that surrounds your spine) and then a small tube—called a catheter—is inserted and left in the woman's back in order to allow for adjustments in the amount of medication or continued administration of the epidural throughout the labor process. Epidurals allow you to get pain relief in the lower part of your body without affecting your conscious state and can be given at any point during active labor (usually around 4 to 5 centimeters dilated--sooner than that, there may be a concern of slowing the labor process). Very little of the medication will reach your baby because it isn't introduced into your bloodstream. Some of the disadvantages of getting an epidural are being confined to your bed for the remainder of labor (you will get catheterized in that case to allow for emptying your bladder), being monitored more closely and frequently (both mom and baby), possibility of weakening the "bear down" response during the pushing stage which may extend how long it takes to push the baby out, risk of reducing your blood pressure and subsequently baby's heart rate, increased risk of itchiness and nausea, and small possibility of a bad headache that may last for several days.
- Spinal Blocks: A spinal block is similar to an epidural, but differs in two main ways. Instead of being delivered into the epidural space, the medication is delivered directly into the spinal fluid. Secondly, a spinal block is given in a one-time administration, usually right before the pushing stage, instead of being continuously administered through a catheter. A spinal block will usually last about 2- 2 1/2 hours, which is why it is usually give near the end of labor. The benefit of a spinal block over an epidural is that the pain relief is more fast-acting, but it won't last as long as the relief you may get from an epidural. Like with an epidural, only a small amount of the medication will reach your baby. You may benefit from a spinal if your labor is progressing really rapidly or if you ask for pain relief at a very late stage of labor. The disadvantages and risks of a spinal block are similar to an epidural.
- Combined: A relatively newer approach is the combined epidural/spinal which offers the fast-acting relief of the spinal with the longevity of the epidural. It is administered in much the same way as the epidural except that 2 needles are used instead of one (they put the smaller spinal needle inside the larger epidural needle so you only have to be stuck once). The spinal needle is then used to inject medication into your spinal fluid, then it is removed and the catheter is put in place so medication can be administered as needed. During earlier stages of labor, this is often referred to as a "walking epidural" because it tends to lead to less lower body weakness so you can continue to walk around for the first few hours, should you desire to do so. The disadvantages and risks are the same as those listed above.
- Systemic Medications: Systemic medications, such as narcotics (specifically morphine, Demerol, Fentanyl, Stadol, and Nubain for labor), are medications that are used to alter your perception of pain. Unlike regional anesthesia, which are used to specifically target the uterus and pelvic area, systemic medications are delivered directly into your bloodstream via an IV or into a muscle and will affect your entire body. These medications will dull or numb your pain, but they will not eliminate it altogether since a low dose is required to minimize the effects on your baby. They may make you feel sleepy, but unlike general anesthesia, it will not render you completely unconscious. In some cases, you may be given the option of patient-controlled pain relief where a small pump is hooked up to your IV and by pushing a button, you can increase the amount of medication that is being delivered to you; there are limits programmed into the pump so you don't have to worry about self-delivering too much medication. Systemic medications are a less invasive form of medication and don't require the services of an anesthesiologist. Additionally, women who use systemic medication instead of an epidural or spinal block are less likely to need pitocin or delivery assisted by forceps or a vacuum. The disadvantages of systemic medication are as follows: must be given in smaller doses so it may not offer as much pain relief as regional anesthesia, will cross the placenta and can affect the baby, unpleasant side effects such as nausea or dizziness, can slow labor if given too soon, can affect baby's heart rate, may make mom and baby less alert after birth so it can interfere with breastfeeding, and in rare cases it can affect mom's breathing and baby's breathing after birth.
- General Anesthesia: The most rarely used form of medication during labor is general anesthesia. This kind of medication is employed specifically to promote loss of both sensation and consciousness. The reason that it is used so rarely during labor is because the mother's participation during the process is key during most kinds of deliveries and the risks of general anesthesia usually far outweigh the benefits. The only time a general anesthetic would be used would be in the case of a Cesarean section, never in the case of a vaginal birth (doctors cannot facilitate a vaginal birth while the mother is unconscious). Some of the rare cases where this method is used are emergency C-section where very rapid loss of sensation is necessary, when an epidural or spinal block cannot be placed, and when a women cannot tolerate a regional anesthetic. When general anesthesia is used, the woman is given a muscle relaxant through an IV, which relaxes her and renders her semiconscious. She then inhales nitrous oxide which facilitates total loss of sensation and consciousness. A tube is inserted into the mother's trachea to maintain an open airway for breathing and to avoid inhaling vomited material should the mother throw up while unconscious. Research has shown that maternal and fetal death rates using this method are at least double those of regional anesthesia, therefore, the use of general anesthesia during birth has all but been eliminated in the U.S.
Questions to Ask Your Health Care Team Regarding Medications
- What's involved in the method? How will the medication be delivered into my system?
- How will it affect me?
- How will it affect my baby?
- What are the possible side effects?
- How quickly will it work?
- How long will the pain relief last?
- When is this method available to me during the labor process (at any time, after I have progressed to a certain point, only near the end of labor, etc.)?
- What happens if it doesn't work in the way it was intended or not at all?
- Will I be able to remember everything?
- Will I be able to breastfeed my baby right after birth with this medication in my system?
Sources: www.babycenter.com, www.mayoclinic.com, www.americanpregnancy.org. www.anesthesiologyinfo.com
Disclaimer: The "Pregnancy, Babies, and Birth" blog series is meant as a source of general information only. Its intended use is to encourage women to further consider and discuss reproductive and birthing decisions themselves, with their partners, and with their medical care providers. Information included in this series is not intended to be professional medical advice or a substitution for a relationship with a licensed physician or practitioner. Any serious questions or concerns about reproductive, prenatal, and/or perinatal health should be directed to your primary care physician or other licensed specialist. Women's Services and Resources does not promote any particular brand, medical provider, birthing location, or any other specific birthing decisions. We strongly encourage women to become as educated about their choices as possible so they are empowered to make educated decisions for themselves and their babies.
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