Maternity

Pain Relief Options for Labour and Delivery

Introduction

Having a baby can be the most wonderful experience in a woman’s life, but for some women the pain of childbirth is one of the most difficult things they ever have to bear. Obstetric anaesthetists provide pain relief in labour that can allow almost pain-free labour for most women. In most large city hospitals about a quarter of all women in labour will choose an epidural for pain relief in labour and another quarter will develop complications in their labour that require their obstetricians to recommend a Caesarian Section or assisted vaginal delivery (ventouse or forceps). About 1 in 10 women will have their baby through an elective Caesarian Section because of previous complications of pregnancy or labour. This means more than half of most women having a baby in a large city hospital will have some interaction with an anaesthetist.

When You Choose Pain Relief

In New Zealand the Lead Maternity Carer (LMC) is usually a midwife who provides women with care in pregnancy, in labour and after delivery. Your LMC, who knows you well, is the best guide for you to talk to before labour about your pain-control options.. Because things can change rapidly in labour, having discussed a range of options is a good idea.

Most women will have done antenatal classes where they and their partner will have learned different pain relief strategies, including breathing exercises, postural changes, and massage. Some LMCs recommend a variety of approaches to pain relief that may include warm baths, homeopathic remedies, aromatherapy, acupuncture or hypnotherapy. For some women these options will be insufficient. A small dose of pethidine is often administered by the LMC to assist in painful labours. The LMC may recommend nitrous oxide (laughing gas) to be used for periods of up to several hours to ease the pain of contractions. Occasionally some patients benefit from a TENS machine, but this option needs to be discussed with your LMC weeks before your delivery in order to organise the unit and learn how to use it effectively in labour.

The most effective pain relief in labour is an epidural. Initially used in the 1960s to shorten prolonged labour, the use of epidurals has become widespread throughout the western world. They have a very impressive safety record in obstetrics. Your anaesthetist is the best person to decide if one is safe for you.

Epidural and Combined Epidural Spinal (CSE)

Epidurals provide the most effective form of drug-based pain relief available for labour. Epidurals are used in 30% of all deliveries in New Zealand and are very safe, but are also the most complex form of pain relief and may have some unwanted effects.

An epidural involves the putting of a fine plastic tube (known as a catheter) into the “epidural space” which is an area that circles the spinal cord in your back bone. This is done by carefully placing a needle in your lower back in just the right spot and depth after numbing the skin. Local anaesthetic, like a dentist uses, is put down the tube where it “numbs” the nerves as they leave the spinal cord. This means that the nerves that carry the messages of pain from your contractions to your brain are temporarily “blocked”. You will feel little of the pain of your contractions, but are usually aware that you are having them.

In some situations you may be given a a combined spinal epidural (CSE). This is a very similar procedure but involves a “spinal block” where the local anaesthetic is injected in to the fluid that surrounds your spinal cord. An epidural catheter is still put into the epidural space just as described but this technique gives a faster onset and sometimes a lighter “block”. It still only involves the one injection in the back as it is performed via the same needle. In many places this is only used if you are have a caesarian section.

An epidural or CSE requires an anaesthetist (a medical specialist) to place the catheter. The anaesthetist will discuss the procedure with you and prepare the equipment beforehand. It takes about 15 minutes to put in and then takes around 15-30 minutes before it is fully effective.

Advantages

Epidurals are generally very safe if performed by experts and cared for within safety guidelines. Only 1 in 100,000 women will be permanently harmed by an epidural (about 1 every 7 years in New Zealand)
It is extremely effective; 90% of women who have an epidural get virtually complete pain relief.
Epidurals are very safe for babies. In fact, because women do not hyperventilate during contractions with an epidural it may be safer for the baby than natural labour.
If you need stitches, forceps or a caesarian section the epidural can be adjusted to provide you with the right amount of drug so that you can be pain free and still enjoy the birth of your baby.

Disadvantages

There is some minor discomfort when the epidural is inserted. Sometimes it may be difficult to find the right spot, or it only works on one side, or not at all. In this case, it may need repeating.
Some women cannot have epidurals because of spinal problems, infection, or blood clotting problems. These problems can develop in labour, but usually are pre-existing. In either case, they must use other forms of pain relief.
Epidurals cause your blood pressure to fall a bit. Your LMC or anaesthetist will place a drip in before the epidural starts as a precaution.
An epidural may slow your labour; while this is not normally a big issue you may need a drug called oxytocin to help your labour continue. It is a bit more likely that you may need forceps or a “Ventouse” to help deliver your baby as the epidural reduces the powerful urge to push in the final bit of labour.
An epidural may give you the shivers or shakes, and may give you a fever. The reason for this is not known, but it usually isn’t much of a problem.
Your legs usually become a bit weak; this makes it difficult to walk around safely. In addition, you may need a tube in your bladder to help you pass urine.
Headache due to spinal fluid leakage occurs in 1%. This usually gets better by itself, but some women need a ‘blood patch’ in their back to deal with the symptoms. Permanent injury to nerves or the spinal cord is extremely rare (about 1 in 100,000).

While an epidural may sound a bit scary, it is a very effective type of pain relief. Not everyone will need an epidural, and there are other types of pain relief that are outlined in this booklet that you may prefer to try first.

You are free to change your mind about self-managing your pain before or during your labour at any stage and decide to have an epidural. If, however, you have progressed far into labour and your baby is ready to be born it may be wise to avoid an epidural with any potential complications. Your LMC and your anaesthetist are there to support your decision, whatever you decide.

Additional Sources of Information

Here are some useful website links if you want more information from Australia and England. The first one, which is British, gives a detailed description of pain relief in obstetrics and is available in different languages. The other two are from the Australian Society of Anaesthetists website and give information on epidurals, including use in Caesarian Section, and pain relief in labour.

The NZSA recognises that small differences in practice may exist in different countries so that minor details may be different from New Zealand.

http://www.oaa-anaes.ac.uk/content.asp?ContentID=115

http://www.asa.org.au/for_patients/patient_information

http://www.asa.org.au/for_patients/epidural_anaesthesia

NZSA - A Voice for Anaesthesia