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Labour & Delivery - Your Pain Relief Options Explained

Giving birth is one of the most natural and beautiful things a woman can do. It’s something we’ve been doing successfully since the beginning of time! However, it is also one of the most painful experiences women will have and sometimes we need a little assistance – whether that is for pain relief during normal labour, or anaesthesia for a caesarean section.  I’d like to take some time to discuss the options and medications that can be used, to hopefully make them a little less daunting and to empower you to make an informed choice if and when the time comes for you or a loved one.  Because this is such a large topic (and one I want to cover thoroughly) I will be covering it across two posts.

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To start off with, I’d like to touch on the variety of pain relief approaches available – both drug-free, and pharmacological.  The power of self-help methods is amazing and undeniable during labour. Calm breathing can help to reduce pain by both increasing the oxygen supplied to your muscles, and as a distraction technique. Relaxation techniques can also be very useful in helping alleviate labour pains, and having a massage can often be comforting and reassuring.  Labouring in a birthing pool has been shown to reduce pain, and whilst there aren’t many studies on the safety of water births, studies have shown you are less likely to need an epidural if you birth in water.  Some women also find relief from acupuncture, reflexology, aromatherapy and hypnosis.  It is important to discuss each of these modalities with someone trained in that therapy to ensure they are used in the safest way possible for you and your baby. Transcutaneous Electrical Nerve Stimulations (TENS) is also available in some centres in Australia and New Zealand. A light electrical current passes through flat pads stuck to your back, causing a tingling sensation.  Some women find it can provide some light pain relief.  You are able to control the strength of the current yourself.  It has no known harmful effects on your baby.

One of the most commonly used analgesic options used during labour is Entonox – 50% oxygen and 50% nitrous oxide (more commonly known as ‘the gas’). It is breathed through a mask or mouthpiece, and has a rapid onset and short duration of action.   There are no known side effects for your baby, and Entonox can provide some women with good pain relief, although it will not provide absolute analgesia. The most effective method of analgesia in labour and delivery is Epidural and Spinal anaesthesia. It is also the most common method of anaesthesia for a caesarean section.  Regional anaesthesias of this kind are referred to as ‘blocks’ and are always performed by an Anaesthetist. There are three approaches that can be used: Spinal, Epidural or a combination of both – a so-called Combined Spinal Epidural (CSE).  Performing any of these techniques involves passing a single needle between the bones of your spine in your back and into either the epidural space (a tiny space that lies inside the spinal canal but outside the dura mater), or further in to the subarachnoid space (for a spinal).  The main differences between the two are: An Epidural is more difficult to perform (the epidural space is much smaller than the subarachnoid space), takes longer for onset (20-30 minutes versus 5 minutes), and allows the insertion of a small plastic catheter that enables ongoing top ups of analgesia (whereas a Spinal wears off in a few hours).  A common approach for a Caeserean section is a CSE – which allows the rapid onset of a Spinal for the procedure, and the ongoing pain relief of an Epidural post-operatively.

The insertion of all three options is the same.  You will be positioned either sitting on the bed with your feet firmly on the ground (or a chair) and asked to slump your shoulders forward and push your lower back out, or on your side with your knees drawn up towards your chest.  These positions allow optimal opening of your spine, making it easier to pass the needle between the bones and into the spaces it needs to access.  Some local anaesthetic is then placed into your skin – which can sting a little – and from there the procedure should be pain free.  The Anaesthetist will ask you to let them know if you feel any pain or altered sensation from here on.  Because of the small size of the spaces being accessed it is especially important that you remain as still as possible.  During labour your anaesthetist will work with you to ensure insertion is done at a time between contractions when you are as comfortable as possible. Once the medications (and/or catheter) are in the correct spot the needle is removed and the catheter taped in position on your back.  Once the epidural is working your legs will feel weak, and your bottom can start to feel warm. In a caesarean the level of block is always assessed prior to proceeding.  Because pain and temperature travel together in the same pathway, we can assess your sense of temperature to assess the level of block. Pressure sensation travels in a separate pathway that doesn’t respond as well to anaesthetic, meaning that throughout the caesarean you will be able to feel a little pushing, especially at certain moments of the procedure. This is completely normal.

The medications used in a spinal/epidural are local anaesthetics and opioids.  Opioids such as Morphine can be added to the spinal to help with post-operative pain relief. A common standard mix for Epidurals includes another opioid called Fentanyl.  Opioids are excellent pain relievers. They can also be used Intra-venously or Intra-muscularly during labour although this approach is being used less commonly.  Depending on the route of administration, the risk of side effects varies. Epidural or Spinal opioids have much lower side effects than other routes of administration.  Opioids may make you sleepy or nauseated (this can be treated with anti-nausea medications). If you are given opioids just prior to giving birth, there is a minimal effect on your baby. Intra-venous opioids administered prior to birth can sometimes make your baby drowsier, which may make breast feeding a little more difficult.

It is always important to consider the risks and benefits of any decision we make, and this is never truer than in labour. In my next post I’ll talk more about anaesthesia for caesarean section as well as more on the risks and benefits of the analgesic and anaesthetic options available for labour.  Please feel free to ask me any questions you have on this broad, exciting (and a little confusing) topic!

Looking forward to our next talk about health soon, xx Morgan

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