RELIEF OF PAIN IN LABOUR: Information for the Pregnant Woman

Introduction
The experience of labour for individual mothers is unique and varies from one birth to another.  The pain of labour accordingly is different at each delivery and because of this there are many approaches to its management.  It is important to adopt a realistic approach to individual tolerance of pain.  With good childbirth preparation the expectant mother can adopt a more flexible approach to pain relief in labour, based on in informed choices.  This page reviews the current methods of pain relief in labour which will make your delivery a safe and enjoyable experience.  It is not intended that this should be a comprehensive document and it focuses on the commonly available methods.  If you do not already know what are the available methods of pain relief in the unit where you plan to have your baby, ask your obstetrician early in your pregnancy.  For example, some units may not be able to offer an Epidural service.  If there is something which you do not understand or  require more information, let your Obstetrician know and arrangements will be made for you to discuss it with an Anaesthetist.

Antenatal Classes
An understanding of what happens when you start in labour is an important part of reducing the pain which you experience.  It is therefore an advantage to attend a course of ante-natal classes which are held in your hospital or privately.  As well as providing you with an explanation of the process of labour and delivery, a technique of positive conditioning known as psychoprophylaxis will be taught.  Breathing exercises coupled with defocusing techniques form the basis of the programme.  The effect of this training is to distract from or inhibit the pain of uterine contractions.  It is also an advantage if your support person is available to attend some classes as he/she will understand your needs better.  While psychoprophylaxis can be a help, you should not be disappointed if you should need to use other available methods of pain relief.

Use of “Entonox”
Nitrous Oxide or “laughing gas” is a very useful anaesthetic agent.  When it is mixed with oxygen in equal parts the mixture is called “Entonox”.  Entonox is available in the delivery ward and some mothers find it provides satisfactory pain relief.  If you need to use entonox you will be handed a mask to place over your nose and mouth at the beginning of a contraction.  As you breath in you will inhale entonox which has a slightly sweet smell.  There is no danger that you might take too much.  It is important to commence breathing entonox at the start of a contraction so that it has time to work before the peak of the contraction.  If you time your contractions you will have some idea when the next one is due so you can begin to use the mask at the right time.  This technique does not work for every patient as the interval between contractions may be too short.  Breathing “Entonox” can make you a bit light headed and you may suffer a slight headache after delivery.

Pethidine Injection
Patients who require a stronger pain relieving drug are usually given Pethidine by injection.  This drug is considered to be the safest and is the drug of choice which satisfies the mother’s need for pain relief without causing the baby to become too sleepy.  Because of the ability of Pethidine to make the baby sleepy, it is usual to limit the amount which can be given.

Epidural Analgesia
Epidural Analgesia in one of the most effective methods of pain relief available at present.  While it is correct to say that it can be administered to most patients who require it, there are a number of situations in which Epidural analgesia is not advised.  The doctor who will be involved in your Epidural is a specialist in anaesthesia and will give you an explanation if it is felt you should not have one.  There are many questions and misconceptions about Epidurals.  I have listed some of the commonest questions mothers ask and, I hope, provided some answers.

Q.  What is an Epidural ?
A.  An Epidural is one method of injecting local anaesthetic and pain relieving drugs close to the nerve which carry the pain messages to the brain, it usually involves locating the area with a special needle.  A very fine tube is then passed through the needle which allows the drugs to be given.  The needle is then taken out and the tube is strapped in place. There is no needle left in the back !

Q.  When can I have the Epidural ?
A.  An Epidural is usually given when you are in established labour and the cervix is dilating.  There may be occasional circumstances when it is given earlier.

Q.  Which way do I lie when it is being set up ?
A.  The position usually adopted is lying on your left side (occasionally the Right side or sitting)  with you back along the edge of the delivery couch.  Your knees are brought up and your head, resting on one pillow, is bent down towards you chest.  This allows the Epidural to be placed more easily.

Q.  Will it hurt ?
A.  Some minor discomfort may be felt when the local anaesthetic is injected into the skin before inserting the special needle. Otherwise a feeling of pressure may be experienced.

Q.  Will it hurt the baby ?
A. No adverse effects have been shown in babies born to mothers who are given an Epidural for pain relief.

Q.  Do I need a drip ?
A.  You to need extra fluids when you have an Epidural for pain relief.  To do this a drip is set up.  The fluid contains only salts.  No drugs are contained in this drip.  If you do need drugs they are put into another container.

Q.  Will I be paralysed ?
A.  This is a very common question and is the cause of much anxiety in mothers who are thinking of having an Epidural.  In most Epidural procedures it is likely that some of the local anaesthetic given to relieve pain will spread to involve other nerves.  For example, there may be some spread to the nerves supplying the skin and muscles of the thigh which may become heavy and weak. This weakness usually lasts for a couple of hours after the drug has been stopped.  Occasionally both legs may become involved particularly if the baby has to be delivery by Caesarean section.  When Patients ask the question “will I be paralysed”, what is usually meant is “will I be permanently paralysed” or “will I be able to walk again” ?.  If the risk of permanent nerve damage resulting from an Epidural were real it is certain the procedure would not be performed.

Q.  Will I have to stay in bed ?
A.  Yes, is the answer at this time. You may have read in the press about mothers walking around with an Epidural in place.  At this time this technique in not routinely available but may occasionally be used in some centres. (see Ambulatory Epidurals below).
                                                                                                             
Q.  How long does it take to work ?
A.  In most patients it is fully effective at 10 - 15 minutes

Q.  Will it last until I am delivered ?
A.  Yes.  In some units drugs are given intermittently as needed.  In other centres it is usually to have a continuous infusion of a low concentration of drug from an infusion pump.  This tends to reduce the spread of drug to other nerves so allowing the mother to have some movement of the legs.  It may also allow some sensation to remain when the time comes to push the baby out.  This reduces the chance of having a forceps delivery.  Even with the infusion technique top-ups may occasionally be required.

Q.  If an Epidural did not work before will the same thing happen again ?
A.  It is sometimes difficult to know why an Epidural failed to work.  Perhaps it was given too late to be fully effective.  In the majority of cases it can be made to work satisfactorily,  provided sufficient time is available to make adjustments.

Q.  Why did it work only on one side the last time ?
A.  When the fine tube is passed through the Epidural needle it can end up more towards one side than the centre.  This situation is more likely to result in the Epidural working on one side only.

Q.  Does it slow down the progress of labour ?
A.  No.

Q.  Does the Epidural cause backache ?
A.  There have been a number of reports in the press that the use of Epidural analgesia is associated with an increase in back problems after delivery.  One mother in 10 who does not have an Epidural and who has a normal delivery may have new backache afterwards.  With an Epidural in place it is nearer to 2 in 10 mothers.  If an Epidural is used for an elective Caesarean section there is no problem with backache.  In the majority of patients this pain is of short duration and may be helped with physiotherapy. 

Q.  Can an Epidural be given following previous surgery for Backpain ?
A.  All mothers who have previously had surgery to relieve backpain should be seen during the pregnancy by a specialist in Anaesthesia who, following detailed examination,  will discuss the problem with them.

Q.  Are there any other side effects ?
A.  Some minor side effects may be noticed such as shivering or itching of the skin.  After delivery you might experience some difficult in passing urine the first time.
                                                                                                       
Q.  Am I likely to suffer with a headache ?   
A.  There occasionally may be technical difficulties in setting up the Epidural which may cause you to have a headache after delivery.  This occurs in about two or three mothers out of every  100  who have an Epidural.  This headache tends to be more severe than one which you might normally experience. 

Q.  Will I need a forceps delivery?
A.  You may need a forceps delivery for a number of reasons not necessarily because you have an Epidural in place.  The indications for forceps delivery vary from patient to patient and unit to unit.  The majority of reports indicate a higher chance of having a forceps delivery with an Epidural.  However some units have reported low forceps rates in patients receiving Epidural analgesia.

Q.  If I need to have a Caesarean Section can it be done under an Epidural ?
A.  There are many reasons why it is preferable to have a Caesarean section done under Epidural anaesthetic or spinal anaesthetic.  If there is enough time to top-up the Epidural or insert a spinal anaesthetic, without risk to you or your baby, it will be done.    

Q.  Can the same Epidural be used for the Caesarean Section ?
A.  Yes!  The same equipment can be used, but because a Caesarean section is a surgical procedure it is necessary to alter the Epidural analgesia or “pain relief” to an Epidural anaesthetic.  This requires some time to do to ensure that your surgery is satisfactory.  Operating conditions have to be right for you and your Obstetrician.

Q.  Can my support person be present at Caesarean Section?                                                                                                       
A.  In general the answer is  ‘yes’  if it is done under Epidural or spinal anaesthetic and he/she so wishes.  However there may be occasions when your Obstetrician or Anaesthetist may prefer that your support person is not present.  If you should require or prefer to have a general anaesthetic for your Caesarean section then your support person will not be allowed to be present.

Ambulatory Epidurals

It is a very attractive idea that a mother could be in labour be pain free and be able to walk around.  As Epidurals are at present the most effective way of providing pain relief in labour, ongoing research suggests that if the concentration of drug used is reduced to very low levels that the mother could be pain free and walk around.  A number of mothers given this technique cannot walk around because there may be some loss of power in the legs or her blood pressure may fall too low.  As labour progresses a standard Epidural will be needed and the mother will have to remain in bed.  Ambulatory Epidurals are not generally available at the present time.
                                                                                                                    

Uncommon methods of pain relief

Acupuncture
In traditional Chinese medicine, acupuncture is used to provide anaesthesia for surgical procedures.  The technique involves the insertion of fine needles at precise points in the body and then manipulating the needles either by twirling or connecting them to an electrical current.  There are a number of suggested ways acupuncture might work to relieve pain.  There are a number of reports where acupuncture was used to provide pain relief for labour and delivery. The success rate was not very encouraging.

T.E.N.S.
Transcutaneous Electrical Nerve Stimulation.  This non-invasive technique has been found to be completely safe for mother and baby but its effect in pain relief is variable.  It consists of putting two pairs of electrodes each side of the spine and passing an electrical current through the skin.  It works best in early labour and as an adjunct to more common methods of pain relief.  It has been suggested it may be of use where there is a lot of back-pain with contractions.  As labour progresses any pain relief obtained tends to fade and other methods may be required.  It probably works best in the well motivated patient who would prefer to avoid more invasive methods. T.E.N.S. equipment is not usually available in labour wards but can be hired through various outlets.