pain relief in labor

Pain Relief in Labor – Epidural vs Natural Childbirth

However delighted a mother is, childbirth is always tiring and to some extent uncomfortable. Many women require some form of pain relief in labor.  Epidural vs Natural Childbirth is a hot subject and now with more and more women discovering the Lamaze and Bradley natural childbirth techniques, the argument is far from settled.  It is important to accept this and to be prepared to use whatever methods are appropriate.

DRUGS

Many pain-relieving drugs have been used in labor, but the most commonly used nowadays are pethidine (known as demerol in some countries) and morphia in various preparations of which Omnopon is, perhaps, the most common. Both these drugs, when given in adequate dosage, are effective in relieving pain.

They do, however, pass across the placenta and, having entered the fetus’s circulation, tend to depress the fetus’s breathing. This can delay the onset of normal breathing when the baby is born. For this reason, pethidine and morphia are not usually given in late labor, say two hours before the birth. Given earlier in labor, they are perfectly safe for both mother and baby.

inject pethidine


Pethidine is often combined with a mild sedative in order to encourage sleep and this also increases the pain-relieving effect. Both pethidine and morphia are given by injection and start to work after Fifteen to twenty minutes. The mother-to-be will then be less aware of the contractions and will usually feel rather drowsy. The effects wear off after three or four hours when a repeat injection can be given if necessary and if the birth is not imminent.


pain relief in laborGAS AND OXYGEN

A mixture of fifty per cent nitrous oxide (laughing gas) and fifty per cent oxygen has replaced the earlier gas and air mixture. It is administered through a special face mask which the mother-to-be holds herself. The breathing of this gas mixture slightly anaesthetizes the mother-to-be so that pain is relieved without her becoming completely unconscious. (It is very important for proper instructions to be given in how to use the machine – otherwise it will be ineffective.)

As soon as the contraction starts the mother-to-be should place the face mask firmly against her face, covering both mouth and nose, and should then breathe deeply, drawing as much gas into the lungs as quickly as possible. The gas should be breathed throughout the contraction, but not between contractions or else she will become too drowsy.

Gas and oxygen is most often used for the find of the first stage and during the second stage of labor. When the woman is in the second stage she should take only two or three quick deep breaths of gas before holding her breath and starting to push. Gas and oxygen causes the woman to feel slightly ‘drunk’ at the time she is using it, but it is completely safe and does not cause any harmful effects to the fetus. It is most unlikely to stop the baby breathing normally at birth.

LOCAL ANAESTHESIA

A local anaesthetic can be injected into the perineal tissues to make them numb and so relieve the perineal pain of the second stage of labor. Such an injection should always be given before carrying out an episiotomy or when stitches are inserted to repair a perineal tear.

Pudendal Block

The pudendal block is an injection of local anaesthetic on each side of the lower vagina wall. This will anaesthetize the pudendal nerve which supplies the perineum and the lower vagina. It is most often used when a simple forceps delivery or vacuum extraction is required.

Epidural Block

Epidural block is method of relieving pain during the first and second stages of labor. It consists of an injection of a long-acting local anaesthetic and is given through a needle introduced into the lower part of the back. The tip of the needle is usually inserted into the spinal canal close to the nerves that carry painful sensations from the uterus to the spinal cord above.

Because the injection is given low down there is no risk of damaging the spinal cord itself. In addition to anaesthetizing the uterine and vaginal nerves, the perineum and leg nerves are also affected.

This means that as well as relieving pain from uterine contractions, the epidural makes the legs and perineum numb and may temporarily stop the woman being able to move her legs properly. In the modern form of epidural, once the needle has been placed in position a fine soft plastic catheter (tube) is passed down through it and the needle is then withdrawn leaving the catheter in place. This remains in place throughout labor, so that, when the effect of the first injection wears off, subsequent injections can be given without difficulty. This enables the pain relief to be continued throughout labor.

There is no doubt in my mind that at the present time the epidural block is the most effective method of pain relief in labor. The pain is abolished completely without any loss of consciousness on the part of the mother or drug effect on the baby. Failure of the method is rare in the experienced hands of an anaesthetist and nerve damage is almost unknown.

A fall in blood pressure, which causes the mother to feel faint and sick, may occur after the injection has been given. This, however, is quickly corrected by turning the mother on her side and giving intravenous fluid. This means that an intravenous drip must always be set up when the epidural catheter is being put into place.

One disadvantage of the method is its very effectiveness. Because all the painful sensations are abolished the mother may not be aware of contractions during the second stage of labor and will need to be told when to push. This lack of sensation may lead to an increased chance of needing a simple low forceps’ delivery, but with the epidural block this is easily done without risk to either mother or baby.

Some mothers feel cheated if they do not experience the pain and sensations of childbirth and for them the epidural is an anathema. For women who desire pain relief without being drugged, however, I regard the epidural block as a very satisfactory solution to the problem of labor pains.

The Caudal Block

The caudal block is very similar to the epidural except that the injection is made lower down. It is less popular than the epidural, but equally good results can be obtained.

Spinal Anaesthesia

Epidural and spinal anaesthesia are often confused. A spinal anaesthetic is given through a needle inserted in the same place as for an epidural, but the tip of the needle is advanced further so that the injection of local anaesthetic is given into the cerebro-spinal fluid.

Pain relief is complete, as with epidural, but lasts for only two or three hours and cannot then be repeated. Muscle paralysis is much more profound and the anaesthetic sometimes causes a headache. It is a very safe and useful anaesthetic but it has no advantage over epidural.

NATURAL CHILDBIRTH

Since childbirth is a natural process many people, including doctors and midwives, have suggested that it should be kept as natural as possible and that medical intervention should be reduced to a minimum.

This is sound in theory and every midwife or doctor who looks after a mother-to-be who does not need pain relief, and who delivers her baby naturally with the minimum of assistance, is delighted.

lamaze classHowever, in practice, such mothers are comparatively uncommon. For most women, nature is given some assistance, both in the easing of pain and the ensuring of the mother’s and baby’s safety. Without such assistance I believe that most modern women would find labor a painful and unpleasant experience.

The late Dr Grantly Dick Read pioneered the concept of natural childbirth, based on the observation that fear produced tension and that tension caused labor to be much more painful than it need be. He advocated a series of relaxation exercises, based on controlled breathing, which helped the patient to relax and thereby relieve pain.

Dr Lamaze, in Paris, and in Russia, Dr Nicolaiev developed a similar system, called psychoprophylaxis, which also consists of relaxation exercises. Psychoprophylaxis is widely used, especially in Europe and in Russia.

All these methods involve educating the mother-to-be in the process of labor, and also in the idea that uterine contractions are not painful if the correct relaxation exercises are followed. In Britain, at the present time, the National Childbirth Trust teaches relaxation as well as giving instruction on all other aspects of pregnancy and labor.

There are a number of techniques for controlling and overcoming discomfort and pain in labour taught and used very successfully. All of these are dependent on a full understanding of the physical process and the use of controlled breathing.

The intention of the various techniques of natural childbirth is to enable the mother to cope with the increasing intensity of her uterine contractions by identifying her own particular needs and progressing through several stages or levels of controlled breathing. Most hospitals run such clinics, but these tend to lay greater stress on mother-craft, ie., caring for the baby after the birth. Most women find instructional classes helpful and are, as a result, able to some extent to relieve the pain in labor by relaxation.

For some, this method is all that is needed to cope with labor and delivery, and for them the sense of achievement is considerable. It is, however, important that those who are unable to use the method without additional assistance should not feel that they have failed in some way. labor and the birth of a healthy baby is always a success, no matter how or with what help it is achieved.

In recent years Dr Leboyer, in France, has written and spoken extensively on the need for peace and calm at the time of birth and the effect that such conditions, or a lack of them, will have on the birth and subsequent development of the child. That a tranquil birth produces a tranquil person is a most attractive theory, but, in my view, the necessary proof is lacking at present and much more research is needed before further conclusions can be drawn as to what is the best method for pain relief in labor.