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The birth of a child can be a wonderful experience for both mother and father. Unfortunately, for some people, the pain associated with labor and childbirth can significantly detract from the joy of the moment. For some people, the ordeal of childbirth is all part of the experience. For these people, the pain of contractions is a natural process that should be dealt with in a "natural" way. While this "natural" technique works well for some people, others prefer to use techniques or therapies that may reduce or eliminate the pain of labor. With the help of her Obstetrician, each expectant mother can choose the best method to ensure a pleasant birthing experience. Below you will find several different methods of to deal with pain during childbirth. The different methods of pain control may be used individually or in combination with other treatments to help a person weather her trial of labor. You should discuss these options with your Obstetrician before you actually go into active labor. |
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One of the most important ingredients of a pleasant childbirth experience may well be knowledge of what to expect. Many new and strange things occur to a woman as she progresses through pregnancy and the process of childbirth. Many of these new experiences can be wonderful, such as the first feelings of movement of the child. Some changes during pregnancy are bothersome, but easily tolerated. Unfortunately, for the inexperience new mother, many of her body changes or experiences can be surprising or even frightening. These experiences can be particularly intense and discomforting as the woman goes through the normal changes that occur during the labor and delivery process. If the new mother knows what to expect, however, these changes become milestones to look forward to. Sudden, frightening changes in her body may become manageable and even pleasant. Many hospitals offer childbirth education courses for the expecting parents. These courses usually provide the important information that will help these new parents through the process of bringing a new baby into the world. Not only do these courses teach breathing and relaxation techniques, but they also review the changes and events the mother can expect to encounter. The spouse of the expectant mother can benefit greatly from these courses as well. If childbirth education courses are not available, or you are unable to attend your hospital or Obstetrician's office may have literature available which may provide this information. Ask your Obstetrician about the childbirth education opportunities in your area. Relaxation and breathing techniques are important tools to control the anxiety and pains of labor. These techniques are frequently taught in Childbirth Education Classes. Used either by themselves or in conjunction with other pain control methods, these techniques can be extremely helpful to the laboring patient. The relaxation techniques attempt to divert the patient's attention from the pain by focussing on something else. This allows the patient to cope with the contraction pains throughout labor or deal with the pains temporarily until other methods of pain control can be started. Certain breathing exercises may be used in conjunction with these relaxation techniques to help the patient to deal with the contractions. These breathing techniques are also useful at the end of labor when the patient needs to begin pushing. Narcotics can be given to the laboring patient to decrease the pains of contractions. Commonly used narcotics may include Morphine, Demerol, Nubain, or Stadol. The advantage of using systemic narcotics include: |
| 1. | Ease of administration as they can be given by intramuscular injection or by injection through the intravenous line (IV). |
| 2. | Relatively rapid onset. (They usually begin to work in a few minutes.) |
| 3. | Reversibility. If the patient or baby become too sleepy, a drug called Narcan can be given to reverse the effects. |
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Narcotics are often used on women that are early in labor or women who are tolerating labor fairly well, but may need a little help to control the pain of the contractions. While intravenous or intramuscular narcotics can be safe and quite helpful, they do have certain disadvantages. These disadvantages may include some of the following: |
| 1. | Pain control: The narcotics do not eliminate all of the pain of the contraction, but may only dull the pain. Therefore, after receiving narcotics, some patients may be extremely sleepy between contractions, but still have significant pain during contractions. |
| 2. | Drowsiness: With narcotics some patients may become very sleepy. This is not always a problem, however. Some patients may get some well-deserved rest. Unfortunately, some mothers may have trouble remembering the birth of her child if the narcotics make her too drowsy. This oversedation was common fifteen to twenty years ago when a narcotic was combined with a drug called scopolamine or inapsine. Though less common today, some patients may have significant drowsiness with these narcotics. |
| 3. | Infant sedation: Because these narcotics have a systemic effect (throughout the body), the newborn child may also be sedated with the mother. Usually, this is not a problem. On rare occasions, however, the infant's sedation may affect his rate of breathing. On these occasions, a drug, such as Narcan, may be given to the infant to reverse the effects of the narcotics. |
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While narcotics given intravenously or intramuscularly may help dull the pain of contractions, they may not always give complete pain relief. They are often used in combination with other techniques of pain control for labor. If you have other questions about the use of intravenous or intramuscular narcotics during labor, please discuss them with your physician. |
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Your Obstetrician can sometimes use regional anesthesia techniques (an injection of local anesthetic) to decrease the painful sensations or numb a specific area during delivery. As with other techniques, these can be used alone or in combination with other pain control methods. The following techniques may be used during labor or delivery. |
| 1. | Local Anesthesia: The Obstetrician may inject a local anesthetic (such as Lidocaine) directly into an area such as the perineum (the area around the vagina and rectum). That area would then become numb so the physician could cut an episiotomy or repair a laceration of the vagina, which might occur during delivery. |
| 2. | Paracervical or Pudendal Block: The Obstetrician may inject local anesthetic into an area of the vagina around the cervix (Paracervical) or close to a group of nerves (Pudendal). These blocks will decrease the pain caused by the dilation of the cervix. Unfortunately, these blocks may only lasts for one or two hours. If the patient has prolonged labor, the Obstetrician may need to repeat the injections. Paracervical or Pudendal blocks work well to supplement intravenous/intramuscular narcotics or subarachnoid narcotics. |
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Saddle blocks, Spinal anesthetics, and Subarachnoid blocks are different names for the same procedure. This procedure involves injecting medication into the fluid of the spinal canal. The nerves from the spinal cord are surrounded by membrane called the Dura. In the lower part of the back, this Dura forms a sac filled with a clear fluid (cerebrospinal fluid) and the spinal nerves. The Anesthesiologist may inject small amounts of medications into this sac of fluid to control the pain of labor. The type of medication will determine whether the patient has analgesia (relief of pain), anesthesia (lack of feeling), or both. The following paragraphs will attempt to explain the different types of Subarachnoid Blocks. |
| 1. | Saddle Block: Fifteen to twenty years ago, Obstetricians or Anesthesiologists would perform a Saddle Block on a laboring patient immediately prior to delivery of the infant. The patient would be placed in the sitting position. She would then receive an injection into her lower back. Through this injection, a small amount of local anesthetic would be placed into the subarachnoid space (the sac containing the spinal nerves and cerebrospinal fluid). The patient would remain sitting for a minute or two to allow the medication to settle in the lower part of the subarachnoid space. The most common effect was the loss of sensation around the vagina and rectum. (You can imagine the loss of feeling of that area which contacts the saddle when you are sitting on a horse, thereby the name "Saddle Block".) This was very effective in eliminating the pain of the last stage of labor as the baby is delivered. Unfortunately, the Saddle Block did not help with the earlier stages of labor, which may last several hours. In addition, the spinal anesthetic that followed may have decreased the woman's ability to push at the final stages of labor, resulting in a forceps delivery. Some of the side affects from the spinal block included a low blood pressure and/or a spinal headache. Although the Saddle Block is seldom used for vaginal delivery today, other techniques which involve injections into the subarachnoid space are very popular, safe, and effective techniques for controlling labor pain. |
| 2. | Subarachnoid Narcotics/ Spinal Narcotics: A Subarachnoid or Spinal Narcotic injection (also known as Intrathecal Narcotic Injection) has become a popular technique for control of labor pain. This technique is similar to a Saddle Block as it involves injection of a medication into the subarachnoid space (the sac containing the spinal nerves and cerebrospinal fluid). The local anesthetic injected with a Saddle Block causes loss of feeling of the perineum (the area around the vagina and anus). The Subarachnoid Narcotic technique simply replaces the local anesthetic with a small dose of narcotic injected into the subarachnoid space. The narcotics do not cause anesthesia (loss of feeling), but give excellent analgesia (loss of pain) for contractions. After the injection, the patient may feel the pressure of the contractions, but the pain is either greatly diminished or completely relieved. Depending on the narcotic used, the analgesia may last up to four hours, sometimes longer. A Paracervical or Pudendal Block may be added at the final stage of labor to make the perineum numb for the delivery and episiotomy, if necessary. This technique is excellent for patients with a history of very short labor or someone who is rapidly progressing to the final stages of labor. |
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How is the procedure done? Position: Before the procedure, your Anesthesiologist will speak with you and review your medical history. You may be given an additional amount of IV fluid just prior to the procedure to reduce the chance of low blood pressure. You will then be asked to either sit on the side of the bed or lie on your side. In either position, you will be asked to curve your back outward (like a mad cat arching his back). Although this may not be the easiest position to assume while you are pregnant and in labor, the arched back makes the approach to the subarachnoid and epidural space much easier. Injection: The anesthesia provider will then wash your back with an iodine or another anti-bacterial solution. He/she will then inject a small amount of local anesthetic into the skin and the tissues just below the skin at a spot on your lower back. This injection may burn briefly. The spinal needle is then inserted through the area that has been numbed. Although this may sound painful, the patient usually only feels a pressure sensation as the needle is inserted through the numbed skin. When the needle is in the proper position, the medication is injected (painless). Then the needle is removed. After the injection: You will then be asked to lie on your back. A pillow or another object may be placed under your right hip at that time so that you are lying at a slight tilt. The nursing staff will check your blood pressure frequently over the next fifteen minutes to ensure that you do not have any sudden changes in your blood pressure. You should have significant pain relief within a few minutes. The effects of the injection should last for 3 to 4 hours. Occasionally you may experience some mild itching after the injection. If the itching becomes uncomfortable, you have nausea, or any other bothersome symptoms develop, notify your physician or nurse so the appropriate treatment may be given. If you have any questions about Subarachnoid Narcotic Injections, please ask your Obstetrician or Anesthesiologist. |
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In most hospital labor suites today, the most common form of pain control for the woman in labor is Continuous Lumbar Epidural Analgesia also known as a Labor Epidural. This technique involves placing a small plastic tube, or catheter, into the Epidural Space in your lower back. The epidural space is a small space that surrounds the Dura (a membrane which covers the spinal nerves and spinal fluid). The epidural space runs from your tailbone to your head. The plastic tube, or catheter, is inserted into the epidural space in your lower back, close to the spinal nerves that transmit the painful sensations during labor. After the catheter is inserted, medications can be injected through the catheter that block the sensations that pass through these spinal nerves. The catheter can remain in place as long as necessary. Therefore, medications can be given through this catheter to reduce the pains of labor throughout most of the labor process, whether that should last 20 minutes or 20 hours. The medications used may include a low dose local anesthetic and/or a narcotic. Because these medications are injected into the epidural space, they work at the spinal cord level to relieve pain and have very little effect systemically (throughout the rest of the body). The patient can be comfortable with little or no drowsiness. Very little, if any, of the medication is passed to the infant. Use of an epidural catheter has the added benefit of the ability to titrate the medications. The anesthesiologist may give small doses to remove the pain, but still allow the mother to feel some of the contractions, or give bigger doses to take away all of the feeling of labor. The dose can be further increased to provide anesthesia for a Cesarean Section if necessary. When is an epidural started? Obstetricians have different opinions as to what point in your labor is optimal to begin your epidural analgesia. Some will allow you to have your epidural as soon as you are having pain from your contractions. Some Obstetricians prefer to wait until you have established a consistent contraction pattern demonstrating that you are well into labor. Still other Obstetricians prefer to wait until you are more than 5 centimeters dilated before allowing placement of the epidural. If you are considering an epidural for control of pain during labor, speak with your Obstetrician about labor analgesia. Your hospital's anesthesia department may offer a full labor epidural service or may have limited types of labor analgesia available. Some anesthesia groups require a consultation with the patient before she goes into labor. Your Obstetrician can answer your questions about labor analgesia or put you in contact with the anesthesia group that will provide that service for you. How is the procedure done? (Different anesthesiologists may have different routines for placement of a labor epidural. The following describes one such routine. Your experience should be quite similar.) At the time in your labor that you and your Obstetrician feel it is appropriate to begin epidural labor analgesia, the Anesthesia Department will be notified. When the Anesthesiologist arrives, he/she will review your history and physical exam as necessary. When preparations are complete, you can usually expect the following: |
| 1) | You will then be helped into the appropriate position for placement of the epidural catheter. You will be asked to either sit on the side of the bed or lie on your side (usually left side down). Your back should be bowed out, like a mad cat that is arching his back. |
| 2) | The anesthesiologist may palpate, or feel, your back to determine the best place to insert the catheter. He/she will then wash that area of your back with an antiseptic solution. The solution is usually Betadine, an iodine type solution. It will feel cold and wet on your back. |
| 3) | A paper or plastic drape is placed on your back. A hole in the middle of the drape allows access to the area through which the catheter is inserted. |
| 4) | The anesthesiologist may palpate your back again to determine proper position. Using a very small needle, a local anesthetic (usually Lidocaine) is injected into the skin. This injection may burn or sting, but only briefly. That area will then be anesthetized, or numb. Through the anesthetized area, the anesthesiologist will then insert the epidural needle. Because this area is numb, the patient usually only feels a pressure sensation or nothing at all. When the needle is in the right place, the anesthesiologist will thread a tiny plastic tube (the epidural catheter) through the needle and into the epidural space. Most people do not feel the catheter as it is placed. [Occasionally, however, you may feel a very brief tingling sensation or electric shock like feeling down one of your legs. If you have this sensation, simply tell your anesthesiologist.] It is very important to remain in the proper position with your back arched throughout the procedure. If you move during the procedure, it may be more difficult for the anesthesiologist to place the epidural catheter. This may prolong the procedure and thereby delay your pain relief. Once the catheter is in the proper position, the anesthesiologist will remove the epidural needle, leaving the epidural catheter in place. The anesthesiologist will then tape the catheter to your back to hold it in place. After the catheter is taped into position, you should be able to lie on your back without problem. Most people feel only the tape on their back. |
| 5) | When you lie down after the procedure, a wedge (such as a pillow or a blanket) will be positioned under your right side. This wedge will give you a slight tilt to the left. This position will displace the pregnant uterus off the major blood vessels that return blood to your heart. This will help to maintain your blood pressure and help to ensure good blood flow to the placenta, and therefore to the baby. |
| 6) | After the catheter is in position, the anesthesiologist will inject the medication through the catheter. When the medication is injected, you may feel a cold sensation run down your back as the medicine passes through the catheter. Otherwise, most people do not feel the medication go in at all. About ten to fifteen minutes after the medication is injected, you may feel your legs begin to feel warm and/or a tingle sensation. Usually within five to fifteen minutes after injection, the pain of the contractions should begin to subside. |
| 7) | The initial bolus of medication will usually provide about 1 to 11/2 hour of good pain relief. Many anesthesiologists will begin a continuous infusion of medication through your epidural using a small pump. This medication should maintain your pain relief throughout labor. If the contraction pains begin to return, simply tell your nurse. She can then contact the anesthesiologist. Occasionally, the anesthesiologist may have to boost your maintenance dose by injecting an additional bolus of medication through your catheter. |
| 8) | Most epidurals work extremely well and provide complete pain relief. Some epidurals provide good analgesia (pain relief) but the patient can still feel the pressure of the contractions. Unfortunately, not all epidurals are perfect. Some patients may experience incomplete analgesia. This may result in excellent anesthesia except for one small area that may still be painful during contractions. Rarely, the patient may experience complete pain relief on one side of the body, but no pain relief on the other side. This incomplete analgesia does not occur frequently, but when it does, the anesthesiologist can usually overcome it by giving additional medication. On the rare occasion that the epidural does not provide adequate relief, the anesthesiologist may need to remove the epidural catheter and replace it in a slightly different location. |
| 9) | In most patients the medication infusion will be continued until after the delivery. When everything has settled down after the delivery, the epidural catheter will be removed. Removal of the epidural catheter is a painless procedure, except for the few little hairs pulled out as the tape is removed from the patient's back. The numbness from the epidural may last for one or two hours after the epidural drip is stopped. |
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Unfortunately, no discussion about childbirth analgesia would be complete without some discussion about a surgical delivery of the baby, commonly known as a Cesarean Section. The reasons for proceeding with surgical delivery of the infant are varied. Certainly, the safety of the mother and child is the overriding concern in your obstetrician's decision to perform a Cesarean Section. (Speak with your Obstetrician about the possible reasons for Cesarean Section.) The type of anesthesia used in a surgical delivery will be determined by the urgency of the situation, the medical history of the mother and infant, and other factors. If you require a Cesarean Section, your anesthesiologist will review your history and present situation to determine the best type of anesthesia for you. Below you will find a review of the most common forms of anesthesia used for Cesarean Section (C-Section). Regional Anesthesia: Epidural Anesthesia: In recent years, the most common type of anesthesia used for C-Sections is regional anesthesia. Regional anesthesia for C-Section is usually either Epidural Anesthesia or Spinal Anesthesia. If the patient has a well functioning epidural catheter in place for labor analgesia, the anesthesiologist may simply inject a higher dose into the catheter to make a stronger block. As the local anesthetic takes effect, the patient will feel numb from about the nipple line down. The patient will be taken to the operating room and moved to the operating table or bed. [See "The Surgical Experience" below] Spinal Anesthesia: Another very common form of anesthesia for C-Sections is Spinal Anesthesia. If an epidural catheter is not already in place, many anesthesiologists prefer to perform a spinal anesthetic for Cesarean Section. A spinal anesthetic involves a shot in the lower back. A local anesthetic and sometimes a narcotic are injected into the sac of fluid around the spinal nerves. This injection will make the patient numb from the chest down to the toes. In experienced hands, a spinal anesthetic can usually be performed quickly, safely and produce an excellent anesthetic block. When a spinal anesthetic will be used for a C-Section, the patient is moved into the operating room. In the Operating Room the anesthesia team will place monitors on you and then place you in the sitting or lateral (on your side) position. The anesthesia provider will wash the patient's back with a sterile solution. After local anesthetic is injected into the skin, a spinal needle is inserted into the patient's lower back and into the sac of fluid that surrounds the spinal nerves. You may or may not feel pressure in your lower back as the needle is inserted. The medication is injected, the needle is removed, and the patient is allowed to lie back down. Although this may sound like a painful procedure, most patients feel only the small sting from the local anesthetic. After only a few minutes, the patient will feel numb from about mid-chest down to her toes. The Surgical Experience: [The following example attempts to represent a typical experience for a patient undergoing Cesarean Section. Your experience may be different but should be fairly similar.] Once the Regional block has taken effect, the surgical team will proceed with the C-Section. If a foley catheter (a tube inserted into the bladder to drain your urine) has not been placed, one will be inserted. As the patient is usually numb from chest down, the placement of the foley catheter is usually a painless procedure. The patient's abdomen will then be washed with an antiseptic solution (usually betadine, an iodine solution). Sterile drapes will be positioned around the abdomen. These drapes help to maintain a sterile field and prevent the patient from seeing the surgery. After the surgeon has checked to ensure the patient is numb, the surgery will begin. During the surgery, the patient may feel some tugging or pulling where the surgeon is working, but should not feel pain. Medication for sedation of the patient is usually not given until after the baby is born. The anesthesia provider will be with the patient throughout the entire procedure. Should the patient have questions or become uncomfortable during the procedure, she can simply speak with the anesthesia provider who is caring for her. If necessary, the anesthesia provider can give additional medication through the patient's IV for sedation or analgesia, after the baby is born. When the surgery is over the patient will be taken to the Recovery Room or Post Anesthesia Care Unit for 30 minutes to one hour as needed to appropriately recover from the anesthesia and surgery. If you have questions about Cesarean Section or surgical delivery of the baby, please speak with your Obstetrician. General Anesthesia: Most of the authorities on Obstetrical Anesthesia feel that Regional Anesthesia is the preferred type of anesthesia for Cesarean Section. Unfortunately, in certain circumstances, a Regional Anesthetic is either not possible or undesirable for surgical delivery of the baby. General Anesthesia is a safe and effective anesthetic for these patients. When the anesthesiologist decides to use general anesthesia for a C-Section, the patient will be taken to the Operating Room. The appropriate monitors will be applied. The patient's abdomen will then be washed with an antiseptic solution. A sterile drape will be placed over the abdomen, up to the patient's upper chest. The anesthesia provider will ask the patient to breath oxygen through an oxygen mask. Most patients are then "put to sleep" by a medication injected into the intravenous line. Usually, the next thing the patient remembers is awakening after the surgery is over. Immediately after the patient is under general anesthesia, a breathing tube is inserted into the patient's airway to control the breathing. This tube is removed as the patient awakens. Because the messages to the brain are blocked under general anesthesia, the patient does not remember the breathing tube or the surgery itself. After the surgery, the patient will be taken to the Recovery Room for care until she is ready to return to her room. For more information on General Anesthesia, follow the link to the discussion on General Anesthesia for surgery, or speak with your Anesthesiologist or Obstetrician. The following are some links with more information about analgesia for childbirth: Pain Relief Options During Childbirth Planning Your Childbirth Planning Your Childbirth (Spanish version) |
