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whitewriter Pain relief options in labour:
Non pharmacological:
1. Hot shower and hot bath.
Textbook says using these in early labour may stop labour... but senior midwives just say "the woman can get in the bath whenever she wants to".
Not recommended if your water breaks early or if you suspect your waters are broken -- you should attend hospital to get checked re: if its broken or not (because the clock starts once the waters are broken for the kid to come out-- this is due to infection).
Some hospitals have lovely big bath tubs (SSH for example).
2. Heat packs and massage
Best time to involve dad in supporting mum on both her worst and best day.
3. Acupuncture (except this is usually used to increase the strength of the contractions. Remember, no pain, no baby). The point here is that if the contractions can be good and strong, the labour can be shorter - so less time spent in pain.
4. Aromatherapy
Usually it's clary sage thats utilised in labour and this is similarly to number 3: to actually increase the strength of the contractions, to then make the labour shorter. Rather than relieve pain.
That being said, if there's a favourite scent you like, it might help you out (probably mostly to distract you with a wonderful smell).
5. Music
Make your playlist! Anything to distract you, is what we're looking for here.
6. Intradermal water injections for back pain
Pros: super effective
Cons: very painful for about 30 sec, but then it works miraculously for about ... 2 hours?
Won't work if the pain is not in your back
7. TENs machine
I've been advised that the one at costco is very good.
It's a small portable machine worn on your body, it gives small electrical pulses to the skin.
Some women say it helps (mostly in early labour-- as labour progresses, it becomes less effective).
Pharmacological methods:
1. Nitrous oxide gas
pros: you suck on a tube, the gas enters your body. When you stop breathing the gas, the gas leaves your body and so too does the pain relief. You only suck it when your in pain. The benefit is, the drug is only inside you for so long as you are breathing it in/out.
Because of the ease with which the gas leaves the body; it has the least amount of risk. You can reverse any of its negative effects by ceasing use.
Cons: it can make some people feel nauseated, it can make people feel dizzy or drowsy. These should subside when you stop breathing in the gas.
2. Morphine needle.
Pros: It lasts about 4-ish hours.
It's better than nothing. Buys time, and can help a woman just get over the worst of it.
Cons: It probably takes about 50% of the pain away. But for some women, this is enough.
Can effect the baby after birth - in the sense they might be sleepy coming out, therefore have breathing difficulty - but this is usually easily solved with stimulation, and if needed, some CPAP (supportive breaths via a machine with air).
You typically can only have it once or twice, because after that it gets close to birth - the midwives usually don't like to give it for fear that the baby will be flat when it comes out.
3. Oral medications:
paracetamol, endone
Similar to the morphine needle but less effective and less predictable when they would start helping.
Usually we give these in adjunct to the needle, hoping that all together as a combination, they'll all help out each other to reduce pain.
4. Epidural
Pros: Effective pain relief is achieved in 80% of cases.
In the other 20% it didn't work -- the anesthetist doctor will come back and re put the catheter in.
More insertions does increase the chance of problems but increases the chance that the 2nd epidural catheter, may do the trick and the epidural works. Sometimes they need to re-do it 3 times. Typically by the 3rd time the anesthetist will say that it just won't work for you and apologise.
The catheter stays inside your back for duration of the labour. You can move about the bed with it in. (like roll to your left or right, and even be on all fours possibly).
Cons:
Once the epidural is in, you won't be able to leave the bed (unless it's a walking one, which I don't think is commonly used in Australia).
You will not be able to walk to the toilet, also the epidural reduces your ability feel your bladder, so the midwife will put in a thin tube into your bladder. Your pee will come out this tube.
You will be on the bed, so this reduces positions that you can use in labour. Standing and squatting are out, but you can do all fours -- which is a highly recommended position -- if you can move your legs. Some women have a dense epidural meaning, they can't move their legs much. Everyone's a little different so even at low doses, the effects differ per woman.
You might feel the contractions or you might not.
The epidural typically takes away contraction pain, but not the pain of pressure on your vagina, or the head coming through. This is because we want you to feel when you need to push.
Some women still can't feel the contractions or pressure, resorting to the midwife to feel her abdomen, and tell her when to push. This goes against nature informing you of what to do when, leaving it to the midwife who probably never met you until this day, to feel your pain externally (by putting our hand on your abdomen). I find this practice extremely abnormal and uncomfortable as a midwife myself. Imagine your constipated on the toilet and your trying to do a poo. Now. Imagine that for some reason, you know your constipated, but you can't figure out coordinating when to strain to push it out, because of the anesthetic numbing your butt.
So someone else --- is sitting next to you, and feeing your abdomen with their hand, and is telling you when and how to do that poop.
Sounds weird? That's because it is weird.
But that's basically how it goes when it's time for the baby to come out and an epidural is in.
The midwife may also put their finger inside your vagina and tell you to "push against my hand". This is also to help you to understand where we want you to push. This is usually only a thing we do when an epidural is in. Because if you didn't have one... we wouldn't have to explain it, your body would just know and do it.
Epidurals have multiple risks, mostly they're pretty small.
main ones are:
1. drops your blood pressure (so we will make sure you have a cannula in your hand and we give you extra fluids for it)
- note that dropping your blood pressure can also drop baby's blood pressure too --
Therefore
2. You must be on CTG monitoring, of baby's heart rate post the epidural going in --
so you will have monitors strapped to your belly.
Furthermore, an epidural typically tends to reduce the force of your contractions, and so after the epidural goes in we usually recommend augmenting your labour meaning we give some hormone medications to increase the force of the contractions. We will give this via the cannula in your hand.
As you already have a cannula in for fluids, we would just use the same one.
Since you already have a good epidural in, this is usually not a problem, (to increase the force of the contractions, and effectively increase the "pain") as your not going to feel it.
So if your not feeling the labour, how will we know when your fully dilated (in normal labour, we can tell by your behaviours, you will get typically more angry or go more quiet. or something changes) --
so for that, we just do 4th hourly vaginal exams, and check the CTG very closely for any signs of baby's distress.
Distress can be seen in the heart rate pattern and it can be due to:
1. your blood pressure dropped due to the epidural
2. your position in the bed needs changing (in natural labour, you can more easily be moving about, but with an epidural you wouldn't so we would be telling you to move if we saw signs that you should on the CTG)
3. the baby has descended, and or hopefully your fully
4. your baby does not like the hormone drip and is feeling stressed by it .
Reason 1: check your blood pressure and then give fluids
Reason 2: change your position and the heart rate recovers, all is well.
Reason 3. do a vaginal exam
Reason 4: do a vaginal exam
If the vaginal exam doesn't show decent or opening of your cervix ... then we can give fluids to hope that it helps out in the interim but likely you will be going for a c-section because we're now worried the baby is not coping.
If the vaginal exam shows your fully, and ready to go, then we usually do about 1 hour of wait and watch and hope for some passive decent of the baby into the vagina so that you have less to push when it comes to it (this is if the CTG shows the baby is ok). It's harder to push when you don't feel everything --
therefore epidural will increase the possibility of a forceps or vacuum delivery (that's another topic for another post).
Other less significant side effects of epidurals:
1. Itchiness -- very common, but harmless. Happens a lot. As soon as the epidural is in, about an hour later, the woman is feeling very itchy on the legs.
This will persist throughout. Medications to reduce the itchy are unlikely to be effective unless they stop the epidural from working (you wouldn't want that...)
2. Shivering
The epidural may interfere with your body's ability to detect hot and cold (theory, not proven). Women get really worried by this side effect, but what we do is check your temperature, and if your not having a fever (febrile) we chalk it up to the epidural causing it.
If you are febrile, there could be two reasons: the epidural itself interfering with your thermoregulation or you have an infection. As we can't rule out one or the other that quickly, we may take blood samples and give you antibiotics (regardless of what the blood test shows. We will just give them incase as we can't tell and infection at this stage, may effect the baby. Mostly your rise in temperature does stress out the baby, causing their heart rate to rise.
Sometimes it's the rise in the baby's heart rate that prompts us to check the woman's temperature- as that's a common cause (as is dehydration - for which more fluids are given).
Do epidurals increase the chance of going for a cesarean section?
If it's your first baby, there is a higher chance of this compared to a second time mother.
How much more of an increase is this?
Marginal.
One study suggests that compared to women who didn't have one :
those without - 8 in 100 had a c-section
those with - 12 in 100 had a c-section.
(increase of 4/100)
What about the effects on the baby (of the epidural)
Typically, the baby is fine. But many midwives do think that having an epidural in labour effects the baby's ability to coordinate suck and swallow at the breast.
To have the best supply, it is recommended that women breastfeed within 1 hour post birth.
If the baby has trouble feeding, we will express (squeeze out some colostrum) put it on a gloved finger, and finger feed the baby. If this is not achieved (some women don't have any colostrum) then we will likely recommend formula (oh the horrors). But if your baby won't suck your breast; and we can't squeeze anything out of it -- and the woman refuses formula (which is well within the woman's right to do so) -- then we will test the baby's sugar via a prick on the heel. If it's higher than 2.6 then we can wait and hope the baby sucks within the next hour after that.
Poor feeding in the 1st hour is associated with ongoing feeding difficulties and supply.
Not in everyone, but it is associated.
All the above being said.
No one else is feeling your pain, but you.
No one is going to give birth to this baby, but you.
If you say you need an epidural, then you need an epidural.
There's no reason why you can't have one at any stage.
Even fully dilated and ready to push. That being said --- If your fully we'll recommend you just push the damned thing out, because the epidural is not likely to cover that part of the pain anyway and in approx anywhere from 5 mins (multip) to 2 hours (1st timer) it'll all be over anyway.
That being said, we've had women outright refuse to push without an epidural in. That's their choice and wish -- then we will get the anesthetist. If there is too long a delay, then we will have to discuss this with the woman. An anesthetist is not always available - sometimes they're busy doing another woman (for example you may be 4th or 5th on the list) or they may be helping out in surgery with other patients and so forth.
But in general, if a woman wants an epidural, we endeavor for her to have one.
At what point do you say you want an epidural?
This is another good question.
If your in early labour, a midwife will always tell you to go home and come back when you can't handle it anymore (or if your water breaks).
This is because, the longer you stay out of the hospital and labour at home, the less chance there is of intervention (aka. higher chance of vaginal delivery without forceps/vacuum/c-section etc.
At the end of the day; you should get an epidural whenever you think you need one.
After the birth; once any stiches and etc. are done, the epidural is turned off and the catheter removed within about 1-2 hours (we let you breastfeed first), if you feel like you can walk at that time, we'll escort you to the toilet.
My recommendation for a first timer would be to try the showers and the bath first; heat packs and massage .... and then in hospital, use the gas. Then when those are failing you; if you want an epidural, have an epidural.
But once again, at the end of the day, it's your labour and your body and no one is feeling what you feel, but you!
The end!
More information:
https://www.thewomens.org.au/health-information/pregnancy-and-birth/labour-birth/managing-pain-in-labour
Non pharmacological:
1. Hot shower and hot bath.
Textbook says using these in early labour may stop labour... but senior midwives just say "the woman can get in the bath whenever she wants to".
Not recommended if your water breaks early or if you suspect your waters are broken -- you should attend hospital to get checked re: if its broken or not (because the clock starts once the waters are broken for the kid to come out-- this is due to infection).
Some hospitals have lovely big bath tubs (SSH for example).
2. Heat packs and massage
Best time to involve dad in supporting mum on both her worst and best day.
3. Acupuncture (except this is usually used to increase the strength of the contractions. Remember, no pain, no baby). The point here is that if the contractions can be good and strong, the labour can be shorter - so less time spent in pain.
4. Aromatherapy
Usually it's clary sage thats utilised in labour and this is similarly to number 3: to actually increase the strength of the contractions, to then make the labour shorter. Rather than relieve pain.
That being said, if there's a favourite scent you like, it might help you out (probably mostly to distract you with a wonderful smell).
5. Music
Make your playlist! Anything to distract you, is what we're looking for here.
6. Intradermal water injections for back pain
Pros: super effective
Cons: very painful for about 30 sec, but then it works miraculously for about ... 2 hours?
Won't work if the pain is not in your back
7. TENs machine
I've been advised that the one at costco is very good.
It's a small portable machine worn on your body, it gives small electrical pulses to the skin.
Some women say it helps (mostly in early labour-- as labour progresses, it becomes less effective).
Pharmacological methods:
1. Nitrous oxide gas
pros: you suck on a tube, the gas enters your body. When you stop breathing the gas, the gas leaves your body and so too does the pain relief. You only suck it when your in pain. The benefit is, the drug is only inside you for so long as you are breathing it in/out.
Because of the ease with which the gas leaves the body; it has the least amount of risk. You can reverse any of its negative effects by ceasing use.
Cons: it can make some people feel nauseated, it can make people feel dizzy or drowsy. These should subside when you stop breathing in the gas.
2. Morphine needle.
Pros: It lasts about 4-ish hours.
It's better than nothing. Buys time, and can help a woman just get over the worst of it.
Cons: It probably takes about 50% of the pain away. But for some women, this is enough.
Can effect the baby after birth - in the sense they might be sleepy coming out, therefore have breathing difficulty - but this is usually easily solved with stimulation, and if needed, some CPAP (supportive breaths via a machine with air).
You typically can only have it once or twice, because after that it gets close to birth - the midwives usually don't like to give it for fear that the baby will be flat when it comes out.
3. Oral medications:
paracetamol, endone
Similar to the morphine needle but less effective and less predictable when they would start helping.
Usually we give these in adjunct to the needle, hoping that all together as a combination, they'll all help out each other to reduce pain.
4. Epidural
Pros: Effective pain relief is achieved in 80% of cases.
In the other 20% it didn't work -- the anesthetist doctor will come back and re put the catheter in.
More insertions does increase the chance of problems but increases the chance that the 2nd epidural catheter, may do the trick and the epidural works. Sometimes they need to re-do it 3 times. Typically by the 3rd time the anesthetist will say that it just won't work for you and apologise.
The catheter stays inside your back for duration of the labour. You can move about the bed with it in. (like roll to your left or right, and even be on all fours possibly).
Cons:
Once the epidural is in, you won't be able to leave the bed (unless it's a walking one, which I don't think is commonly used in Australia).
You will not be able to walk to the toilet, also the epidural reduces your ability feel your bladder, so the midwife will put in a thin tube into your bladder. Your pee will come out this tube.
You will be on the bed, so this reduces positions that you can use in labour. Standing and squatting are out, but you can do all fours -- which is a highly recommended position -- if you can move your legs. Some women have a dense epidural meaning, they can't move their legs much. Everyone's a little different so even at low doses, the effects differ per woman.
You might feel the contractions or you might not.
The epidural typically takes away contraction pain, but not the pain of pressure on your vagina, or the head coming through. This is because we want you to feel when you need to push.
Some women still can't feel the contractions or pressure, resorting to the midwife to feel her abdomen, and tell her when to push. This goes against nature informing you of what to do when, leaving it to the midwife who probably never met you until this day, to feel your pain externally (by putting our hand on your abdomen). I find this practice extremely abnormal and uncomfortable as a midwife myself. Imagine your constipated on the toilet and your trying to do a poo. Now. Imagine that for some reason, you know your constipated, but you can't figure out coordinating when to strain to push it out, because of the anesthetic numbing your butt.
So someone else --- is sitting next to you, and feeing your abdomen with their hand, and is telling you when and how to do that poop.
Sounds weird? That's because it is weird.
But that's basically how it goes when it's time for the baby to come out and an epidural is in.
The midwife may also put their finger inside your vagina and tell you to "push against my hand". This is also to help you to understand where we want you to push. This is usually only a thing we do when an epidural is in. Because if you didn't have one... we wouldn't have to explain it, your body would just know and do it.
Epidurals have multiple risks, mostly they're pretty small.
main ones are:
1. drops your blood pressure (so we will make sure you have a cannula in your hand and we give you extra fluids for it)
- note that dropping your blood pressure can also drop baby's blood pressure too --
Therefore
2. You must be on CTG monitoring, of baby's heart rate post the epidural going in --
so you will have monitors strapped to your belly.
Furthermore, an epidural typically tends to reduce the force of your contractions, and so after the epidural goes in we usually recommend augmenting your labour meaning we give some hormone medications to increase the force of the contractions. We will give this via the cannula in your hand.
As you already have a cannula in for fluids, we would just use the same one.
Since you already have a good epidural in, this is usually not a problem, (to increase the force of the contractions, and effectively increase the "pain") as your not going to feel it.
So if your not feeling the labour, how will we know when your fully dilated (in normal labour, we can tell by your behaviours, you will get typically more angry or go more quiet. or something changes) --
so for that, we just do 4th hourly vaginal exams, and check the CTG very closely for any signs of baby's distress.
Distress can be seen in the heart rate pattern and it can be due to:
1. your blood pressure dropped due to the epidural
2. your position in the bed needs changing (in natural labour, you can more easily be moving about, but with an epidural you wouldn't so we would be telling you to move if we saw signs that you should on the CTG)
3. the baby has descended, and or hopefully your fully
4. your baby does not like the hormone drip and is feeling stressed by it .
Reason 1: check your blood pressure and then give fluids
Reason 2: change your position and the heart rate recovers, all is well.
Reason 3. do a vaginal exam
Reason 4: do a vaginal exam
If the vaginal exam doesn't show decent or opening of your cervix ... then we can give fluids to hope that it helps out in the interim but likely you will be going for a c-section because we're now worried the baby is not coping.
If the vaginal exam shows your fully, and ready to go, then we usually do about 1 hour of wait and watch and hope for some passive decent of the baby into the vagina so that you have less to push when it comes to it (this is if the CTG shows the baby is ok). It's harder to push when you don't feel everything --
therefore epidural will increase the possibility of a forceps or vacuum delivery (that's another topic for another post).
Other less significant side effects of epidurals:
1. Itchiness -- very common, but harmless. Happens a lot. As soon as the epidural is in, about an hour later, the woman is feeling very itchy on the legs.
This will persist throughout. Medications to reduce the itchy are unlikely to be effective unless they stop the epidural from working (you wouldn't want that...)
2. Shivering
The epidural may interfere with your body's ability to detect hot and cold (theory, not proven). Women get really worried by this side effect, but what we do is check your temperature, and if your not having a fever (febrile) we chalk it up to the epidural causing it.
If you are febrile, there could be two reasons: the epidural itself interfering with your thermoregulation or you have an infection. As we can't rule out one or the other that quickly, we may take blood samples and give you antibiotics (regardless of what the blood test shows. We will just give them incase as we can't tell and infection at this stage, may effect the baby. Mostly your rise in temperature does stress out the baby, causing their heart rate to rise.
Sometimes it's the rise in the baby's heart rate that prompts us to check the woman's temperature- as that's a common cause (as is dehydration - for which more fluids are given).
Do epidurals increase the chance of going for a cesarean section?
If it's your first baby, there is a higher chance of this compared to a second time mother.
How much more of an increase is this?
Marginal.
One study suggests that compared to women who didn't have one :
those without - 8 in 100 had a c-section
those with - 12 in 100 had a c-section.
(increase of 4/100)
What about the effects on the baby (of the epidural)
Typically, the baby is fine. But many midwives do think that having an epidural in labour effects the baby's ability to coordinate suck and swallow at the breast.
To have the best supply, it is recommended that women breastfeed within 1 hour post birth.
If the baby has trouble feeding, we will express (squeeze out some colostrum) put it on a gloved finger, and finger feed the baby. If this is not achieved (some women don't have any colostrum) then we will likely recommend formula (oh the horrors). But if your baby won't suck your breast; and we can't squeeze anything out of it -- and the woman refuses formula (which is well within the woman's right to do so) -- then we will test the baby's sugar via a prick on the heel. If it's higher than 2.6 then we can wait and hope the baby sucks within the next hour after that.
Poor feeding in the 1st hour is associated with ongoing feeding difficulties and supply.
Not in everyone, but it is associated.
All the above being said.
No one else is feeling your pain, but you.
No one is going to give birth to this baby, but you.
If you say you need an epidural, then you need an epidural.
There's no reason why you can't have one at any stage.
Even fully dilated and ready to push. That being said --- If your fully we'll recommend you just push the damned thing out, because the epidural is not likely to cover that part of the pain anyway and in approx anywhere from 5 mins (multip) to 2 hours (1st timer) it'll all be over anyway.
That being said, we've had women outright refuse to push without an epidural in. That's their choice and wish -- then we will get the anesthetist. If there is too long a delay, then we will have to discuss this with the woman. An anesthetist is not always available - sometimes they're busy doing another woman (for example you may be 4th or 5th on the list) or they may be helping out in surgery with other patients and so forth.
But in general, if a woman wants an epidural, we endeavor for her to have one.
At what point do you say you want an epidural?
This is another good question.
If your in early labour, a midwife will always tell you to go home and come back when you can't handle it anymore (or if your water breaks).
This is because, the longer you stay out of the hospital and labour at home, the less chance there is of intervention (aka. higher chance of vaginal delivery without forceps/vacuum/c-section etc.
At the end of the day; you should get an epidural whenever you think you need one.
After the birth; once any stiches and etc. are done, the epidural is turned off and the catheter removed within about 1-2 hours (we let you breastfeed first), if you feel like you can walk at that time, we'll escort you to the toilet.
My recommendation for a first timer would be to try the showers and the bath first; heat packs and massage .... and then in hospital, use the gas. Then when those are failing you; if you want an epidural, have an epidural.
But once again, at the end of the day, it's your labour and your body and no one is feeling what you feel, but you!
The end!
More information:
https://www.thewomens.org.au/health-information/pregnancy-and-birth/labour-birth/managing-pain-in-labour
