Pain Management Options in Labor

Introduction

For most women, having a baby is a painful process. In fact, an article published in 1996 reported that fewer than 1% of women experience no pain during childbirth. A study from Sweden found that over 41% of women report the pain of childbirth being the worst pain they had ever experienced. Each person’s pain experience is personalized, reflective of personal beliefs, emotional, social, and cultural circumstances. Knowing all your pain management options in labor can help you plan and prepare for your birthing experience. This knowledge helps reduce fears or anxiety you may feel in anticipation of this milestone.

How Does Labor Pain Affect Your Body?

You breathe harder and faster during contractions, which can lower oxygen levels for you and your baby.  Your blood pressure increases, which causes decreased blood flow to your placenta. Stress hormones are released into your circulation. Contraction patterns can be affected. Studies have found that psychological stress from the pain of labor can cause postpartum depression.

What is the Relationship Between Pain and Satisfaction with my Childbirth Experience?

You might guess that adequate pain relief during labor equals greater satisfaction. Still, research has shown that it is not that simple. The things that lead to greater satisfaction with a woman’s labor experience include:

• Having an experience that matched your expectations.
• Increased support from your doctor or midwife. The amount of support you receive from your obstetric provider leads to greater satisfaction, even when your labor partner stays with you throughout childbirth. Constant support provides a sense of safety and reduces anxiety. 
• The quality of your relationship with your obstetrician or midwife. Do you feel comfortable asking questions and making requests?
• The degree to which you feel involved in the decision-making process during labor. Are you encouraged to weigh in on decisions throughout labor?

Pain Management Strategies – Drugs or no Drugs

Pain management strategies are divided into two separate categories, pharmacological and non-pharmacological.

Nonpharmacologic Approaches:

• Do not involve the use of medications (drugs).
• Do not reduce pain
• Focuses on improving your ability to cope with the pain 

Pharmacologic (medication) Approaches:

• Involves the use of medications
• More effective in relieving pain

There are two types of medication approaches to pain relief in labor- analgesics and anesthetics. 

1. Analgesics reduce pain without inhibiting your ability to move. 
2. Anesthetics get rid of the pain while making you temporarily numb and unable to move. 

You may receive pain medicines in different ways, and you can receive medicine that affects a very small area of your body. These are called local anesthesia. Another method is a regional anesthesia, such as a spinal or epidural that numbs you from the waist down. Lastly, the medicine may affect your entire body, such as intravenous pain medicine or general anesthesia.

Analgesics That Affects Your Whole Body (Systemic Analgesics):

• medications are given through an IV or a pump
• makes you calmer and decreases your awareness of pain
• includes a class of drugs called opioids
• can cause itching, nausea, vomiting, and temporarily affect the baby’s heart rate   
• can cause respiratory depression (difficulty breathing) and sedation in both mother and baby
• crosses the placenta to the baby 

Opioids are not given close to the time of the baby’s birth to avoid affecting their breathing or causing sedation at a time when they need to be alert.

Opioid Analgesics

Opioids are a class of drugs that have been used for years for pain relief. They are given intravenously (IV) or as an injection in the muscle (intramuscular, I.M.) or less commonly, just under the skin (subcutaneous). All opioids cross the placenta and can temporarily affect your baby’s heart rate. The effects on your baby are similar to the effects on your body. It causes both you and your baby to be drowsy, and it reduces your alertness. As the medicine wears off, these effects diminish. Because your baby’s body is much smaller than yours, your body will metabolize the drug a lot faster than your baby’s. To avoid a dangerous build-up of the medication, repeat doses are not given until the medicine is metabolized by both you and your baby. It is not uncommon for you to request additional opioids because your medicine has worn off, and you are now feeling pain again, only to be told that you will need to wait because the medicine is still in your baby’s body. Giving the medicine too soon will cause a dangerous build-up and increase the risk of experiencing a side effect of the drug. Opioids are not given close to the time of delivery as it will diminish the baby’s alertness, causing difficulty in transitioning to life outside the womb.

Non-Opioid Analgesics

Non-opioid analgesics are less effective than opioids and, for this reason, are rarely used for pain relief in labor. Some of the non-opioid analgesics include anti-inflammatories, acetaminophen and anti-histamines. Studies show that none of these are as effective as opioids, though they are more effective than placebo. These medicines are rarely used in labor.

Inhalational Anesthetic

Nitrous oxide is an anesthetic gas that may be used for pain control in labor. Nitrous oxide is self-administered by way of a mask in bed. The medicine is only released when you inhale deeply, which allows the valve to open and release the drug. Studies suggest that the pain relief benefit is as good or better than the IV opioids. 

Nitrous oxide is not commonly used in the U.S. Its use is more common in the U.K. and the rest of the world. One advantage of nitrous oxide is that it allows you the autonomy of self-administration. You continue to have mobility, and the drug is metabolized rapidly in both you and your baby.

Local Anesthetic

Using a local anesthetic is reserved as a pain management in labor option for the repair of tears along the perineum. The perineum is the area on the outer portion of the vagina, between the vaginal opening and the anus. Suppose you experience a tear along your perineum and need suturing (stitches). In that case, your doctor may choose to use a local anesthetic, such as lidocaine, to numb the area. This may be used alone or in conjunction with previously administered regional anesthesia.

General Anesthesia

General anesthesia involves putting you to sleep and placing a tube down your throat to support your breathing. This is used if an emergency C-section is needed, and there is not enough time to wait for an epidural or spinal. This may also be used if your spinal or epidural is not working well enough for a non-emergent C-section. Because you are asleep with general anesthesia, you will not be awake to experience the birth of your baby. There is also the risk of aspiration, where your stomach contents can reflux into your throat and then go down into your lungs. This is a risk for anyone who has general anesthesia, but the risk increases in pregnancy. General anesthesia is only used in emergencies or if the regional anesthesia (spinal or epidural) does not work, and a C-section is needed.

Regional Anesthetics (affects a specific area or region below the waist) 

• Epidurals
• Spinals
• Nerve blocks
• Cesarean Delivery

What is Epidural Anesthesia?

An epidural is the most common type of pain relief used during childbirth in the United States and is one of the most effective. With an epidural, medication is given through a small tube placed in your lower back. The medication is continually infused for as long as it is needed. You will have some loss of sensation below the waist, but you remain awake and alert. Although an epidural will make you more comfortable, you may still be aware of your contractions and feel vaginal exams. The pain relief is much greater with the epidural than without it. You can move with an epidural, though you are not able to walk. Epidurals are effective in nine out of ten people. Epidurals have fewer risks for your baby than systemic opioids.

What is Spinal Anesthesia?

Spinal anesthetic, or simply spinal, as it is commonly called, is another type of regional anesthesia similar to an epidural. Spinals are primarily used for cesarean sections. With spinal analgesia, you receive a one-time administration of medication into the fluid around your spinal cord. This is different from an epidural, where the medicine is continually infused. After receiving a spinal analgesia, your pain relief is almost immediate. One drawback of a spinal is that the analgesic effect is temporary and will only last a few hours.

Combined Spinal Epidural

A Combined Spinal Epidural (CSE) is another form of regional anesthesia. It has the benefits of both a spinal and epidural. The spinal part acts quickly to relieve pain, while the epidural part provides longer, continuous pain relief. It has the same side effects and risks as an epidural.

Common Risks of Regional Anesthesia

(epidural, spinal, combined spinal-epidural)

• Itching
• Nausea
• Vomiting
• Decreased blood pressure – which can temporarily affect your baby’s heart rate.
• Fever
• Headache
• Lack of pain relief

Rare But Serious Risks of Regional Anesthesia

(epidural, spinal, combined spinal-epidural)

• Injury to your spinal cord or nerves
• Breathing problems if the anesthetic affects your breathing muscles
• Numbness, tingling, or a rapid heartbeat if the anesthetic is injected into a vein instead of a nerve

Who Should Not Get Regional Anesthesia?

If you have certain medical conditions, your doctor may advise that you do not receive an epidural. These conditions include:

• Bleeding Disorder- whether this disorder is something you are born with or has developed due to your pregnancy complication the recommendation remains the same. 
• Low Platelet Levels- your platelets help to control bleeding. It is measured through a blood test. Your platelets can become low in pregnancy. 
• Severe Infection- especially infection that has entered your bloodstream, which can make it difficult for your body to maintain control of your blood pressure. Regional analgesia can cause an even more significant drop in your blood pressure, which can be dangerous. 
• Some types of severe pre-eclampsia
• Brain Tumor

FAQs Surrounding Regional Anesthesia

Q: Will an epidural cause me to labor longer? 
A: The answer is mainly no. One study showed that women who received an epidural shortened their first stage of labor by as much as ninety minutes. Another study shows that the second stage of labor is increased by 7 minutes in women with an epidural. So overall, the time is reduced. The first stage of labor involves getting you to 10 cm dilated. The second stage involves pushing to delivery. 

Q: Will an epidural increase my risks of having a C-section?
A: No, getting an epidural does not increase your risks of a C-section.

Q: Will an epidural affect my ability to breastfeed? 
A: Most studies show no effect of epidural on breastfeeding. 

Q: Will an epidural cause me to be paralyzed? 
A: The risks of serious neurological injuries from receiving an epidural or spinal anesthesia is 1 in 36,000.

What Are Some of the Non-pharmacologic Strategies for Pain Management During Labor?

Acupuncture and Acupressure

Acupuncture is a form of treatment that involves the insertion of very thin needles through your skin at specific points on the body and to various depths. Acupressure is based on the same theory as acupuncture, but instead of using needles, acupressure is delivered using fingers, thumbs, knuckles, or other tools to place firm pressure on different areas of the body.  Sometimes, firm pressure is only needed in a few areas to induce a sense of relaxation or pain relief.

Acupressure can be performed by anyone, such as a midwife or a labor partner, but a licensed provider must deliver acupuncture. Researchers aren’t exactly sure how acupuncture and acupressure work to relieve pain, but it is thought that it acts by stimulating the nervous system or helping the body release natural, pain-relieving hormones. At this time, research on the use of these methods for pain management in labor is limited. However, there is the hope that it could be used as a complement to the existing methods.

Aromatherapy

Aromatherapy is a type of alternative medicine that uses natural plant oils that give off strong, pleasant scents to promote relaxation and a sense of well-being.

 In one large study, more than 50% of mothers rated aromatherapy as helpful to cope with labor. Peppermint has been noted as being extremely helpful at decreasing nausea and vomiting, and orange, rose, geranium, and lavender seem to lower rates of pain and anxiety.  While there are no research studies showing any harm occurring to mothers and infants who used aromatherapy during labor, it does have the potential to cause allergic reactions and skin irritation.

Music Therapy

Studies on using music for pain relief during labor are limited, and results are mixed. Most findings suggest a benefit. 

Evidence from two randomized trials shows that music helps relieve pain during early labor. Another trial that found music helped during the transition phase of labor.

Since music is stimulating to your central nervous system and affects your memories and emotions, it is reasonable that listening to music you find relaxing may provide positive benefits during labor.

Self-Hypnosis

Hypnosis in labor is a form of self-hypnosis designed to increase a sense of control and reduce fear and anxiety in childbirth. 

Hypnosis involves focusing your attention inward and allowing yourself to be open to suggestions from others. 

The focus on feeling relaxed and comfortable make labor sensations more positive and less painful. 

Referring to contractions as waves or surges mitigates the mental anxiety surrounding them. The brain is powerful, and your mind can significantly impact your perception of your experience.  While research is limited, studies so far suggest that the use of hypnosis is associated with an overall reduction in the use of medication in labor. Self-hypnosis may be used in combination with other methods of pain relief.

Water Immersion

Water immersion and water births are two different things. In water immersion, a laboring mother gets into a tub or pool of warm water, either alone or with her partner, before the baby is born. You then come out of the water before the baby is delivered. The baby is not born in the water. There is controversy regarding your risks for infection with water immersion if your water bag is broken or in a late labor stage. Research has shown that immersion in water during the first stage of labor may be associated with shorter labors and decreased use of spinal and epidural analgesia. It has not shown any increased risks for the mother or baby.

Waterbirth

In a water birth, you remain in the water during the actual birth of the baby, and the baby is brought to the surface of the water right after birth. Waterbirths are associated with serious risks. 

Research on waterbirth has reported serious consequences for the baby, including potentially fatal infections, drownings, and rupture of the umbilical cord. Until there is more research, the American College of Obstetricians and Gynecologists (ACOG) take the position that water immersion during labor may be safely offered to healthy women with uncomplicated pregnancies at term, but that water birth is strongly discouraged.

Massage

Massage is rubbing the soft tissues of the body to promote relaxation. Some people enjoy an intense massage, while others may prefer light strokes, called effleurage.

Researchers believe that non-painful massage floods the body with pleasant sensations. While the brain is concentrating on those pleasant sensations, more painful messages are blocked from getting through.

It is theorized that the pain from intense, deep massages cause your body to release endorphins. The endorphins mitigate your perception of painful contractions. 

Massages may also decrease the release of “stress” hormones and increase the release of “mood calming” hormones like serotonin. There is not a lot of quality research regarding massage in labor. Still, because it doesn’t have any risks and can potentially decrease pain and anxiety, it can be helpful for some women.

Doula Support

A birth doula is a companion who provides continuous support during labor and birth. They provide physical support through massage and by encouraging movement and changing positions during labor.

Doulas provide emotional support by creating a calm environment, giving you praise and encouragement, and helping you maintain “mindful acceptance” of the labor process.

A doula can help you and your partner prepare for childbirth through education, information, developing coping skills, and counseling. They help you talk through your fears and suggest mitigation techniques such as breathing, relaxation, movement, and changing positions.

Doulas help facilitate communication between you and your provider and encourage you to voice your desires.

Studies have shown that being provided with continuous support from a doula during your labor decreases your risk of a cesarean section by 39%, decreases the use of pain medication by 10%, increases your chance of having a spontaneous vaginal birth by 15%, and makes you 31% more likely to be satisfied with your birth experience.

Sterile Water Injections

Sterile water injections are similar to the method used in a T.B. skin test. A tiny needle is inserted just under the skin, and sterile fluid (water) is injected. A little bubble forms just under your skin. These injections are placed in your lower back by your obstetrician or midwife.

The onset of pain relief is within two minutes and can last as long as two hours. Sterile water injections can be given any time during labor; in one research study, they found that some people received injections up to 30 times during their labor. Researchers believe it works in the same way as painful massage; the pain from the injection stimulates the brain to release natural pain-relieving hormones called endorphins, which help you perceive less pain from contractions.

The American College of Obstetricians and Gynecologists (ACOG) report that sterile water injections have demonstrated statistically significant reductions in pain in many studies and may help manage labor pain. The use of sterile water injections to relieve pain in labor is more prevalent in Scandinavian countries and is not well known globally.

Movement

Research has shown that remaining upright and moving around during the first stage of labor shortens it, decreases requests for epidurals, and makes a cesarean section less likely. 

Several other studies have shown that using a birthing ball can significantly reduce labor pain.

Reboza

A reboza comes from Mexican birthing culture and refers to a long, woven fabric placed on the laboring mother’s hips.

Using controlled motions, the reboza is used to gently move the hips from side to side in a rocking motion. Most commonly, the mother is on hands-and-knees, lying down or standing, while their support person uses the reboza to guide their movements.

Many providers who use the reboza feel that the swaying motion helps bring the baby into a better position for delivery.

The reboza should not be used when there is concern about the fetal heart rate, when there is any vaginal bleeding, or when a cesarean section is planned.

Summary:

Every labor is different, and so are the ways that people experience pain. What works for some women may not work at all for others, and what worked in one pregnancy may not in another. Even within the same labor experience, you may find that one method of pain relief may be sufficient in the first stage of labor yet be inadequate as your labor progresses. Expectations vary among different women, and with the same woman at different stages of labor and of life. You may have desired a pain-free experience with one pregnancy while being open to alternative experiences in another. Between these two extremes, however, lies a great continuum of attainable comfort levels in labor.

Going into labor with your mind open to trying a variety of approaches while not wholly rejecting anything beforehand leaves you open to all that is available to support you and make your experience the best it can be.

Copyright: myObMD Media, LLC | Written by: Lisa Shephard, MD October 10, 2020 | Edited by Dayna Smith MD