For many pregnant women, concerns about labor pain are second only to concerns about their baby's welfare. Decisions you make about pain relief measures can have a profound effect on:

• Your experience and memories of labor
• Procedures, medications, or restrictions that may become necessary for you or your baby
• Your and your baby's well being after the birth

It is for these reasons that it is important to research all different types of pain management. This discussion guide will be restricted to medical management of pain, and the different pharmacological methods available. We will define and discuss the risks and benefits of each type.

It is important to note that pain is subjective. There are many factors that can influence ones perception of pain. For example, fear will intensify pain. Cultural beliefs, support, previous experiences, and the labor environment-these can all impact a woman's ability to cope with labor pain.

How is labor pain different than other pain?

• Labor pain is not a symptom of injury or illness. We are used to feeling pain when something is wrong, when we are hurt or sick. This can trigger an anxiety response that makes the sensation of pain stronger.
• Labor pain is self-limiting. Labor rarely takes more that 24 hours
• Labor pain is rhythmic. The pain is not continuous. Each contraction takes a minute or so with several pain-free minutes in between.
• Labor pain intensifies over time. Contractions start out mild and gradually build. This allows the bodies endorphins, natural pain relievers, to be released therefore decreasing sensation of pain.

Analgesics and narcotics (Demerol, Nubain, Phenergan, Stadol, Vistaril, Seconal, Morphine)

Most medications are given IV (intravenously) or IM (intramuscularly). Certain meds will be given IV via a PCA or patient controlled analgesia pump. This is common after a cesarean and the medication is administered in small doses when the patient presses a button. There is a limit on how often and how much medication the patient can receive.

Generalized Pros and Cons to narcotics
Pros

• Decreases perception of pain
• Promotes rest
• Does not cause muscle weakness
• Decreases anxiety
• Some decrease nausea

Cons

• Causes drowsiness, hallucinations, sedation
• Can cause nausea/vomiting
• Can cause respiratory depression in mom and baby
• May suppress memory of labor
• Delayed breastfeeding due to sleepy baby
• Possible allergic reaction

The timing of these medications must be appropriate. If given too early, they can slow the progress of labor. If given too late, the baby can have difficulty breathing requiring resuscitation and a medication called Narcan to reverse the effects of the narcotic. This would mean a separation of mother and baby after the birth, and depending on the extent of observation needed may delay breastfeeding and the initial bonding of mother and baby.

Epidural Anesthesia
Epidural anesthesia is a mixture of an anesthetic drug such as lidocaine, chloroprocaine or another "-caine" drug and a narcotic such as fentanyl, Demerol, morphine or nubain. The mother is asked to sit curled over so that her back is rounded. Her back will be cleansed and covered with a sterile drape. Local anesthetic will be given to numb the area. A needle is used to identify the epidural space between the vertebrae. Then a catheter is threaded through and left in place as the needle is removed. The external portion of the catheter is taped to the mothers back and stabilized. Once insertion is complete, usually about 20 min., the anesthetic can be administered. A test dose is done, to make sure the catheter is in the right place and then the medication may be given. It may be given in intermittent boluses, continuously by pump or by a patient controlled epidural pump.

Pros and Cons (thanks to Varneys Midwifery 4th ed.)
Pros

• Most women report complete relief of pain
• This is the most effective pharmacological method of pain relief
• Women are able to stay awake and alert
• Ability to "labor down" so this may reduce the amount of time pushing
• If a cesarean is necessary, epidural can be dosed so that woman may stay awake during birth

• May provide uneven pain relief
• There are many side effects resulting in increased medical interventions
  1. Hypotension (low blood pressure) is reported in 50% of women receiving epidurals. This is caused by muscle relaxation. The treatment is IV fluids, and because of this risk, the mother will have her blood pressure taken every 15 min. This means an automatic cuff left on for the duration of labor. Significant complications are uncommon, however this drop in blood pressure means a decrease in blood flow to the uterus, which can affect the baby, and blood flow is also decreased to the mothers vital organs. Due to this, the baby must be monitored for the duration of labor. If the low blood pressure is prolonged and unresponsive to IV fluids, a medication must be used to increase the pressure.
  2. Bladder distention is a common side effect due to a loss of sensation, relaxation of overall bladder tone and loss of control of the urinary sphincter. This is significant because an empty bladder is necessary for progression of labor, and a distended bladder can cause problems such as postpartum hemorrhage and infection. If the woman is unable to urinate on her own she will have intermittent catherizations or an indwelling catheter will be placed.
  3. Maternal fever is also a common side effect. This is likely due to a "thermoregulatory alteration." (Something in the brain that causes the body temperature to increase.) This increase in temperature is not related to an increase in infection. However, during labor it is impossible to tell if the fever is from the epidural or from an infection. Because of this many women receive IV antibiotics, and more women have cesareans or instrument assisted vaginal births because of possible infection. Babies of mothers with fevers are more likely to have a sepsis workup.
  4. Difficulty breathing, called "total spinal anesthesia" occurs when the level of medication climbs too high, resulting in paralysis of the respiratory muscles. This occurs about 0.03% of the time. The treatment is assisted ventilation until the medication wears off.
  5. Systemic local anesthetic toxicity can occur from an IV injection of the medication. The incidence of this is 0.01%, and this can cause seizures, cardiac arrest, or death to mother and/or baby.
  6. Permanent injury to the spinal cord is very rare, 1/500,000 to 1/1,000,000. This is usually caused by an epidural hemorrhage due to low platelets or by a spinal abscess secondary to infection.
  7. A spinal headache, or "postdural puncture headache" occurs in 1% of epidurals. This is caused when the needle punctures the dura and cerebrospinal fluid leaks into the epidural space. This causes a low pressure in the spinal canal. When the woman sits upright, the brain pulls on sensitive structures causing a severe headache. The treatment is to lay flat for a few days and take Ibuprofen (unpractical while trying to care for a new baby), or a "blood patch" is used in severe prolonged cases. This results in relief in 80% of cases.
• May slow the first stage of labor
• Studies have shown that babies born to a woman with an epidural take longer to initiate breastfeeding
• Use of epidurals in early labor relaxes the pelvic floor and may contribute to fetal malpositions, which increases the use of pitocin and forceps/vacuum deliveries
• The second stage (pushing) is lengthened resulting in increased use of forceps/vacuums for birth. (Forceps and vacuum assisted deliveries have a much greater incidence of perineal lacerations and injury to babies)
• The woman is (usually) confined to bed. "The aura of normalcy of the labor and birth process, strength and health of the woman and the sense of a woman being in control of her body and its functioning are shifted to a 'sick role' requiring specific (and frequent) medical attention." (Varneys pg. 772)
• Possible allergic reaction

Of course there are many non-pharmaceutical methods of pain management, but that is another day. Refer to the Posterior Birth discussion guide for more information.

And as always, note that continuous labor support has been proven to decrease the need for medications in labor!!!