06/07/2011

Yvonne Bohn, M.D., Allison Hill, M.D., and Alane Park, M.D.

Yvonne Bohn, M.D., Allison Hill, M.D., and Alane Park, M.D., all practice at Good Samaritan Hospital in Los Angeles. They call themselves The Mommy Docs, and offer tips on pain management during labor.

Although natural childbirth is a laudable goal, pain medications may be used during childbirth for many legitimate emotional and medical reasons. Patients with high-risk conditions may require labor induction or cesareans. In addition, many women simply do not want to feel the pain associated with labor. The bottom line is, there is no right or wrong way to deliver your baby. Your mission—and ours—comes down to this: a healthy baby and a healthy mom.

When our patients ask us how painful labor is, we reply that labor hurts but people perceive labor pain differently. Some women have almost no pain up to ten centimeters, but others are straining at only one centimeter. Labor pain can be controlled.

You know your temperament and tolerance for pain. Don’t let the pressure of family or friends persuade you. Do what you want to do. The experience of a drug-free birth is vitally important for some women but it’s not for everybody. Remember that no matter what you decide, your birth experience will be unforgettable.

These days, more than 50 percent of women in America give birth with an epidural or a spinal block. But nonpharmacologic pain­management alternatives do exist: relaxation, hypnosis, breathing, massage, acupuncture, labor coach, doula participation, walking, showering, bathtubs, and birthing balls. You do have other choices.

Following are several methods of pain management that you may have access to in your hospital.

Regional Anesthesia

The two types of regional anesthesia are epidurals and spinals. Epidurals are normally used to control labor pain for the duration of the labor. Spinals are primarily used for cesareans, take effect more quickly than epidurals, but wear off in a few hours. In an epidural, a small catheter or tubing is placed in the epidural space (in front of the spinal nerves). In a spinal, the anesthetic is placed directly into the compartment containing spinal fluid.

Epidural procedure

From the time you first make the request for an epidural to the time you’re pain free takes about thirty to forty-five minutes. So don’t wait to ask for an epidural until the pain is so severe that you’re at your wit’s end. Some doctors recommend waiting to get an epidural after you are at least four centimeters dilated; others allow epidural placement when you are having regular painful contractions, regardless of the dilation. You should talk to your doctor about his or her preferences.

The first step in getting regional pain management is to request it from your labor nurse, who will contact your doctor or midwife and then your anesthesiologist. Next, your nurse will start IV fluids to make sure you are well hydrated, to help prevent a drop in your blood pressure. When the anesthesiologist arrives, he or she will usually ask you to sit on the edge of the bed with your legs hanging off or lie on your side on the bed. You will curl over the baby in the shape of a C, like someone with really bad posture, to try to open up the space between each vertebrae. The anesthesiologist then injects numbing medicine into the skin where the spinal needle will be inserted. This injection feels like a pinch or it may burn.

The spinal needle is inserted into the epidural space, and a catheter (a very thin, long tube) is threaded through the needle into the space. The catheter is then taped to your back and connected to a pump containing the anesthetic medication. The catheter stays in place until the delivery. When the catheter is removed, it doesn’t hurt.

In some hospitals, you may have an epidural pump that you can control by pushing a button to give yourself more or less medication. Some women prefer to be completely pain free; others want to feel some of the contractions.

Pros and cons of epidurals

The most obvious advantage to having an epidural is pain relief. An epidural can be helpful precisely because it allows a tense patient to relax. It can be exactly what a mother needs to get her through her labor. Sometimes, just letting go of that pain-created tension allows the cervix to open up quickly.

On the other hand, epidurals have some potential disadvantages:

• Pushing can be more difficult if you have had an epidural because you do not have physical feedback telling you where and how hard to push. In these situations, we may lower the epidural dosage. Sensation returns in about thirty to sixty minutes. Sometimes, we use a mirror to help the mom coordinate her pushing effort so she can see what happens when she pushes. 
•  Hypotension, or a drop in blood pressure, is another potential side effect of an epidural. The medications used for the epidural relax the blood vessels, which can cause blood pressure to drop. In turn, this can lead to a decrease in the baby’s heart rate. To keep your blood pressure from falling too low, you will often be given a large amount of IV fluids just before the epidural placement. At other times, the anesthesiologist may give you a medication to increase your blood pressure.
•  Spinal headaches occur because some of your spinal fluid leaks out during the anesthesia placement. Spinal headaches hurt when you are sitting or standing but disappear when lying down. If you have a headache like this, notify your doctor. If the headache is mild, you will be asked to try some caffeine (coffee) and Tylenol or Motrin.
•  Labor duration may be affected by the use of epidurals. In some studies, epidurals have been associated with an increase in the duration of the first stage of labor by thirty to ninety minutes and the second stage of labor by fifteen to twenty minutes. However, most moms will gladly labor an extra hour if they can do it comfortably. Epidurals also increase the need for Pitocin and the use of the vacuum.
•  Fever may result if you have an epidural. The exact cause is uncertain. Whatever the reason, if you do develop a fever, your doctor will most likely recommend IV antibiotics.

 

IV Drugs

We can also deliver pain medications through an intravenous line directly into the bloodstream. These drugs are narcotics, from the morphine family. The medications take effect within a few minutes after they have been administered by the nurse. Although the feeling of pain is lessened, it does not totally disappear, allowing the mom to have the ability to push. However, IV medications affect mental clarity, causing the woman to feel drowsy. In addition, they cross the placenta to the baby, also leading to drowsiness in the newborn. If they are given too close to delivery of the baby, the newborn may be drowsy and have difficulty breathing. The pediatrician can give the baby a medication to reverse this effect. The pain medications do not have any long-term consequences for the baby.

General Anesthesia

As a rule, we try not to use general anesthesia during delivery because the medication crosses the placenta to the baby, making the baby very drowsy. In general anesthesia, a woman is completely asleep, on a breathing machine, and receiving anesthesia in the form of a gas. It is used only in emergency situations where the baby needs to be delivered quickly, and there is no time for the placement of an epidural or a spinal or the mother’s medical condition does not allow an epidural.

Local Anesthesia

Local anesthesia is medication that is injected directly into the vaginal tissue. It is most commonly used before an episiotomy or during repairs of any tears you may have developed during the birth. It is similar to medicine used for dental procedures.

Doula Support

A doula is a woman who is trained and experienced in childbirth and provides continuous physical, emotional, and informational support to a woman during labor, birth, and the immediate postpartum period. A doula is not a midwife and does not deliver babies, but she is well versed in relaxation, breathing, and other natural pain control techniques.

Studies have shown that having a doula during your labor and delivery decreased the need for pain medication, Pitocin, and vacuum or forceps-assisted deliveries, and shortened the time for labor and delivery.

Keep in mind, your unofficial doula may not be a credentialed, hired support person, but your partner, sister, or friend. We think of labor and delivery as a team effort. This team consists of the soon-to-be mom, her partner, her obstetrician (or midwife), her anesthesiologist, her L&D nurse, any other support person she desires, whether a sister, best friend, or licensed doula. Work with your obstetrician, family, and doula ahead of time to make sure everyone is on the same team for your delivery day.

 

Adapted from The Mommy Docs Ultimate Guide to Pregnancy and Birth by Drs. Yvonne Bohn, Allison Hill, and Alane Park, who practice at Good Samaritan Hospital in Los Angeles. Reprinted by permission of Da Capo Lifelong Books.