Labour and Delivery - Pain relief during

 Pain Relief during Labour and Delivery  

Table of contents
1. Introduction
2. Drugs administered for pain relief: morphine-like drugs
Advantages of pethidine / Disadvantages of pethidine / An overview of the advantages and disadvantages of pethidine
3. Regional anaesthesia
What is epidural pain relief? / What does the procedure involve? / What is the effect of epidural pain relief? / How does the delivery proceed with an epidural? / An overview of the advantages and disadvantages of epidural anaesthesia
4. Spinal anaesthesia
What is spinal anaesthesia? / Side-effects and possible complications of spinal anaesthesia / Can spinal anaesthesia always be given? / An overview of the advantages and disadvantages of spinal anaesthesia

1. Introduction
Giving birth hurts – any woman who has had a baby can vouch for that. Women know that pain is a normal part of giving birth and expect it. For the baby to be born, the cervix (neck of the womb) has to dilate. For the cervix to dilate, the muscle layer of the uterus (womb) has to contract, and these labour contractions are very painful. The length and severity of the contractions depend on the stage of labour, but often the pain increases as the cervix becomes more dilated. The pain is mainly in the lower abdomen but can also be experienced as severe backache. The labour contractions are followed by the actual delivery, that is, pushing to get the baby out. The amount of pain women experience during this stage varies too. While some women are glad to give in to the urge to push, others find it the most painful part of the process.

Breathing and relaxation exercises can help alleviate labour pain. Such exercises stimulate the production of endorphins, compounds produced by the body which act as natural pain-relievers. These endorphins make the pain bearable. However, many women still find the pain overwhelming, and physical exhaustion, anxiety or stress can make it even worse. Taking a hot shower or bath, having a massage or changing positions often helps, but sometimes the pain is so severe that some form of pain relief is needed.

This brochure describes the types of pain relief most commonly used in the Netherlands. The two primary methods are: 1) the administration of drugs that have a morphine-like effect, such as pethidine, and 2) regional anaesthesia, either epidural or spinal anaesthesia.

2. Drugs administered for pain relief: morphine-like drugs
Pethidine is the most widely used drug for pain relief in labour. Sometimes a different drug with the same effect is used. Because these kinds of medicines have side-effects, they are only administered when you have been admitted to the hospital. Pethidine is given via an injection into the muscle in the buttock or upper leg. It usually takes around 15 minutes to start working. It reduces the worst pain, which allows you to relax between contractions. Some women even doze off or fall asleep. The effect lasts two to four hours. It is sometimes combined with a sedative, such as phenergan or normison.

Advantages of pethidine
Pethidine is an effective pain-reliever. It makes you more relaxed and helps you cope with the pain. Because it can also act as a muscle relaxant, in some cases the cervix dilates faster.  

Disadvantages of pethidine
For the mother
An injection of pethidine is effective for two to four hours. If the effects wear off too fast, you can have another injection. Potential side-effects are nausea, headache and dizzyness. After the injection, you may not walk around. Pethidine can make you feel drowsy and alter your perception of events around you. As a result, you can feel less alert and not actively experience the entire birth; some women later report having little memory of the birth. Although most women can have pethidine, it is not advised for women with severe asthma or in combination with certain other drugs.

For the baby
Because pethidine crosses the placenta, it also enters the baby’s bloodstream and can make the baby drowsy and cause reduced foetal movement. If the midwife or doctor has any concerns about the baby’s condition, pethidine should not be administered. Pethidine can also cause breathing difficulties after birth. This can be remedied by giving the baby an antidote, such as naloxon.

An overview of the advantages and disadvantages of pethidine

• Easy method of pain relief.
• Has a calming effect.
• You may not walk around after the injection.
• Potential side-effects and possible adverse effects in combination with other medicines.
• After birth the baby can be drowsy and experience breathing difficulties. A special drug can be given to reduce this effect. 

3. Regional anaesthesia
There are two kinds of regional anaesthesia: the epidural and the spinal block. Epidural pain relief, also called peridural anaesthesia, is administered for normal deliveries, while spinal anaesthesia or a combined spinal/epidural is mainly used for caesarean sections. This will be dealt with later.

What is epidural pain relief?
The anaesthetist injects an anaesthetic (pain medicine) via a thin flexible tube (catheter) into a space, called the epidural space, between the vertebrae in your lower back. The nerves that transmit pain signals from the uterus and birth canal pass across this space. When these nerves are numbed, your contractions become less intense and painful. Because the nerves that feed the muscles in your legs are also found in this space, you will temporarily have less sensation and muscle control in your legs and lower body.

What does the procedure involve?
Preparation and monitoring
To prevent your blood pressure from dropping, you will first be given extra fluids via an IV in your arm. In most cases, you will be hooked up to monitors to keep an eye on your pulse and blood pressure. The baby’s heart tones will also be monitored by means of a CTG (cardiotocogram).

Who performs the procedure?
Epidural pain relief is administered by an anaesthetist. During the night the procedure is performed in the delivery room, and during the day, in the recovery room of the operating theatres.

The needle insertion
The anaesthetist performs the injection with you lying on your side or sitting up in a flexed position. Your back must be as rounded as possible and you must remain very still. This makes it easier to access the space in your back. The skin of the injection area is disinfected and local anaesthetic is administered with a small needle. The doctor then inserts the epidural needle and passes a fine catheter through the needle into the epidural space. The needle is then withdrawn and anaesthetic is injected via the catheter, temporarily numbing the nerves.

What you will feel
You will hardly feel any pain when the epidural needle is inserted. This is because you first receive a local anaesthetic to numb the skin and because the actual insertion occurs so rapidly. Introduction of the catheter, however, can sometimes create the sensation of short electric shocks. Because the catheter will be left in place for as long as pain relief is required, it is secured with a dressing.

After the procedure
Once the catheter has been secured in place, you may move freely again. However, as the medication starts to take effect, your legs will become weak and you will have to stay in bed. It generally takes about 15 minutes to feel the effects of the medication. The catheter is connected to a pump to provide a constant flow of small amounts of anaesthetic.

Continuous monitoring
Throughout the entire process of labour and delivery, your blood pressure, heart rate, urine production and sometimes the oxygen level in your blood will be monitored regularly. You will also be asked if the degree of pain relief is adequate. The baby’s condition will also be monitored.

What is the effect of epidural pain relief?
The purpose of epidural pain relief is to alleviate pain during labour and delivery. Your legs will usually feel weak and you may experience numbness and tingling in the skin of your abdomen and legs. This will disappear once the medication has been stopped.

Epidural pain relief is inadequate in about 5% of women. In such cases, the doctor needs to check whether the catheter is properly positioned and/or if the dosage of anaesthetic is high enough. Sometimes the needle has to be re-inserted. The anaesthetist always strives to find the perfect dosage: high enough to keep the pain bearable and low enough to minimise adverse effects. Therefore, at the peak of a contraction you may still feel a bit of pressure or pain. But the epidural will give you the chance to rest and regain your strength, and by reducing the level of pain and anxiety, the cervix often dilates faster.

How does the delivery proceed with an epidural?
Once the cervix is fully dilated, the amount of anaesthetic is sometimes reduced. This allows you to feel the contractions and actively participate in pushing the baby out. Sometimes it takes awhile before you feel the urge to push, which can make the actual delivery take a bit longer. As with all births, some form of assistance may be required, such as the use of forceps or the ventouse (vacuum extractor) (for more information, see the brochure ‘Assisted Vaginal Delivery’). In other cases a caesarean section may be indicated. If so, the anaesthetist will increase the amount of medication through the epidural catheter or choose to give another type of pain relief, namely, spinal anaesthesia or general anaesthesia.

Can an epidural always be given?
Epidural pain relief is contra-indicated in the presence of blood clotting disorders, infection, certain neurological diseases and some types of spinal deformities or previous spinal surgery. In the absence of contra-indications, epidural pain relief can be administered at Bronovo Hospital at any time of day or night.

Side-effects and possible complications of epidural anaesthesia
Decreased blood pressure
One effect of epidural anaesthesia is that the blood vessels in the lower body dilate, causing your blood pressure to drop. To prevent this, you will receive intravenous fluids before the epidural catheter is inserted. If your blood pressure decreases too much, you may feel unwell or dizzy; this can be remedied by lying on your side. A decrease in your blood pressure can also affect the baby’s heart rate; this is shown by CTG monitoring.

Bladder control
When your lower body has been numbed by the epidural, it’s hard to feel if your bladder is full. Going to the toilet can be difficult too. Labour room staff will closely monitor your urine output to ensure that your bladder doesn’t get too full. In some cases, a urinary catheter will be placed, particularly if you can’t empty your bladder on your own.

Itching
Mild itching is a fairly common side-effect of pain medicine but rarely needs to be treated.

Shivering
Shivering may occur even though you don’t feel cold. It usually doesn’t last very long and is a common reaction.

Headache
In about 1% of patients, the epidural needle pricks a hole in the sac surrounding the spinal cord causing leakage of spinal fluid into the epidural space. This results in headache, usually about 24 hours after the epidural block. This will cause discomfort but is not a dangerous complication. In most cases, headache can be reduced by simple measures such as lying down and drinking plenty of fluids. If headache persists, the anaesthetist will evaluate the problem and find another remedy.

Other complications
The chance that significant amounts of pain medicine accidentally enter the bloodstream or cerebrospinal fluid is extremely small. On rare occasions, you may have trouble breathing; this can be readily treated. You will be closely monitored during and after the entire procedure, so that any complications can be quickly identified and treated as required.

Back pain
Some 5-30% of women complain of back problems during pregnancy and as they approach childbirth. Back pain after giving birth with epidural pain relief is not usually due to the epidural but rather from the physical stresses of childbirth and pressure on nerves and ligaments in the pelvis and spine. However, the epidural catheter can cause some localised pain where the needle was inserted.

An overview of the advantages and disadvantages of epidural anaesthesia

• It is the most effective type of pain relief during labour and delivery and can basically be given throughout the entire process - during labour contractions and the actual delivery. Sometimes the dosage of pain medicine is reduced or stopped so the woman can actively participate in pushing the baby out. You may feel some pain during this stage.
• Both you and the baby will be closely monitored. You will be given an IV in your arm, a blood pressure cuff, a catheter in your back connected to an infusion pump, CTG monitoring, sometimes an intrauterine pressure catheter to monitor contractions and a urinary catheter.
• The risk of serious complications is extremely small. Side-effects occasionally occur but are not serious; these include decreased blood pressure, headache, weakness in the legs, itching and reduced bladder control. These reactions are temporary and can easily be treated.
• In most cases, you will not be allowed to walk around and will be confined to bed during labour.
• Epidural pain relief is not available to the same degree in every hospital.
• In some 5% of women the level of pain relief achieved is inadequate.

4. Spinal anaesthesia
If a caesarean section has to be performed, either epidural or spinal anaesthesia can be administered. A combined spinal-epidural is a technique often used in planned C-sections. In emergency C-sections, spinal anaesthesia is usually administered because numbness occurs quite rapidly.

What is spinal anaesthesia?
The anaesthetist inserts a thin spinal needle between the vertebrae in your lower back and injects a small amount of anaesthetic into the sac of spinal fluid below the level of the spinal cord. In general, insertion of the needle is not painful and does not take very long. Sometimes a local anaesthetic is first injected to numb the skin.
Occasionally you may feel a shooting pain in your legs when the spinal needle is inserted. Your lower body from just above the navel will quickly go numb, starting with a warm tingling sensation in your legs.

Once the anaesthetic has taken effect, you will not be able to move your legs at all or only slightly, but you will be fully conscious. The incision site will be completely numb so you won’t feel any pain during the operation, but you may feel some pressure as the doctor performs the procedure, such as when the abdominal muscles are spread apart. If circumstances permit, you will be able to see your baby right after the birth. More information about the operation is available in the brochure 'Caesarean Section'.

Side-effects and possible complications of spinal anaesthesia
Decreased blood pressure
See section above as described for epidural anaesthesia.

Chest tightness and breathing problems
On very rare occasions the anaesthetic medication travels upward of the injection site and affects the chest muscles, making it harder to breathe. If this occurs there is no need for alarm as the anaesthetist will be monitoring your breathing very closely and will intervene as needed, such as by providing oxygen.

Headache
The spinal needle pricks a small hole in the sac surrounding the spinal cord. This hole almost always closes off automatically but occasionally it allows some leakage of spinal fluid. This results in headache. The risk of this happening is 1 to 3%. The headache will cause discomfort but is not a dangerous complication and can easily be treated.

Total spinal block
In a total spinal block the upper body also becomes numb. Even breathing becomes difficult and you may have to be intubated and put on a ventilator. You will be able to breathe again unaided as soon as the anaesthetic medication wears off. This is a very rare complication.

Can spinal anaesthesia always be given?
Spinal anaesthesia can be administered for a caesarean section at any time of day or night, even if you are already having contractions. Very occasionally, however, the gynaecologist or anaesthetist will advise against it, such as if you have a blood clotting disorder or infection or if an emergency C-section has to be performed. Another form of anaesthesia may also be recommended in the presence of certain neurological diseases and some types of spinal deformities or previous spinal surgery. On rare occasions an attempt to administer spinal anaesthesia is unsuccessful and the surgery has to be conducted under general anaesthesia.

An overview of the advantages and disadvantages of spinal anaesthesia

• An effective method of anaesthesia for caesarean sections.
• You are awake and can fully experience the birth of your baby.
• The risk of side-effects or serious complications is small.

Questions?
If you have any questions after reading this brochure, please do not hesitate to contact your gynaecologist, midwife or family doctor. They are available to answer your questions and alleviate any concerns you may have.