Pain Relief

By Midwife Rosie Harris

Having a baby for the majority of women is a time of not only excitement and pleasure but a time of apprehension and anxiety about the labour and coping with the demands that this can make on not only the woman but the partner as well.

The concept of pain is an individual one and every woman will experience it differently and how she reacts to it will depend on many factors. Pain experienced in labour is related to the womb contracting to dilate (open) and efface (thin out) the cervix or neck of the womb. The womb is a large muscular organ that has housed the baby for forty weeks or more and when labour commences it starts to contract, usually mildly and irregularly at first but as labour progresses, becomes more painful and powerful. This is entirely normal and has a working function which enables the neck of the womb to open fully to allow the baby to descend further into the pelvis and birth canal, culminating in the actual birth of the baby and placenta.

Before labour has started, most women will have given some thought about pain relief and some of the options that are available in the place where she has chosen to give birth. Information is available from; parent craft classes led by midwives, books, leaflets and the internet.

Here at Warwick Hospital on the delivery suite there is a wide range of options available. On arrival in the delivery suite, you will be met by a midwife; hopefully it will be someone you know from the Lavender Team. Here you will be shown to a room and the midwife will discuss with you your birth plan if you have one. If not, then pain relief options will be discussed depending on the stage of labour that you are in at the time.

WATER

The use of warm water in the bath has been used for centuries for relieving backache and the cramps of early labour. It is very relaxing and soothing to lie in a warm bath for the early stages of labour. At Warwick there is a birthing pool which can be used for pain relief and to give birth in if desired.

*See our Water Birth page *

MOBILITY AND USE OF DIFFERENT POSITIONS

Being upright and mobile in the early stages can help labour to progress more quickly. The use of the birthing ball to sit on also aids the process of labour as it helps the baby descend into the pelvis and into an optimum position for birth.

RELAXATION TECHNIQUES

If you have been to a class to be taught these techniques, then the midwife will encourage and support you with these. If you have not, then the midwife caring for you will aim to give you simple instructions in breathing techniques to help you cope with the contractions.

TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION or TENS

This non-invasive form of pain relief has a rapidly growing reputation as one of the safest and most effective forms of pain relief for women. It is a drug-free form of pain control and there are no documented side effects for the baby or woman. TENS relief is achieved by stimulating your own body’s natural defences against pain. Four self adhesive pads are placed on your back which will be demonstrated either by the instructions with the TENS machine or the midwife will help you apply them. The pulsed signal causes a release of endorphins, the body’s natural morphine like pain killers, which relax you and relive pain. The pulsed signal also stimulates fibres within your nervous system to create a “closed gate” which prevents pain messages from reaching your brain.

TENS equipment can either be hired from various stores or from the hospital. Your midwife will advise you on how to obtain from the hospital. They can also be purchased and we have a small number on the delivery suite for you to try and use if you so desire.

INHALATION ANALGESIA (ENTONOX) or GAS AND AIR

Entonox is the trade name used to describe an equal mixture of oxygen and nitrous oxide. Nitrous oxide in higher concentrations is used in general anaesthesia. Entonox is piped to the delivery suite and is on constant supply to the area, so there is never danger of it ‘running out’. It is also available in canisters so if you are lying in a bath and need to use the Entonox it is freely available to you. It is usually breathed through a mouthpiece or a mask, which ever you prefer. Again, the midwife will advise you and help you use the Entonox. Ideally, it is not used for long periods of time as it can be quite dehydrating and sometimes with a first labour it does not provide adequate pain relief if used on its own but combined with perhaps the TENS or Pethidine (which will be discussed next) it can be very effective. As Entonox is excreted quickly from the lungs it is not thought to have any residual effects on the baby or woman.

PETHIDINE

Pethidine has been used as analgesic for women in labour since the 1940s. Other narcotic drugs have been tried from time to time but none have shown any distinct advantage over Pethidine. Pethidine is an opiate derivative and is given in the form of an intra-muscular injection. It is usually given with an anti-emetic. This is a drug to prevent vomiting or the feeling of nausea which is often present during labour and not directly attributed to the drug itself. Pethidine is reported by some women as making them feeling drowsy and sleepy but still experiencing the pain. Some women report that the drug helps them relax which in turn helps the labour along especially if it still in the early stages. It is a very individual choice and again it is one that the midwife will help you make at the time.

There has been a great deal of coverage given to the fact that Pethidine may be detrimental to the baby in that it suppresses the baby’s respiratory centre making the baby less responsive and less likely to feed. Recent research has shown that this maybe the case if Pethidine is given in large doses or just before delivery. The baby is less likely to be affected if Pethidine is not given between 2 and 4 hours before delivery. On the delivery suite here at Warwick, Pethidine is prescribed carefully and only 2 doses are administered during a labour thus reducing the risk of side effects.

The advantages of Pethidine are that if given in the early stages of labour it can help the woman relax and enable the body to labour more effectively as some research has shown that fear and anxiety can inhibit the production of natural hormones that enable a woman to labour. Pethidine is given after discussion and informed consent from the woman.

For more information see MIDIRS Informed Choice Leaflet - Non-epidural Pain Relief

EPIDURAL

This form of pain relief is administered by an anaesthetist and is a medical procedure. Here at Warwick, the unit is able to offer a 24 hour service for this but sometimes the anaesthetist is not able to come straight away to the delivery suite if he or she is involved in major cases in other parts of the hospital such as Intensive Care, Theatre or Accident or Emergency. This does not occur frequently but we are obliged to bring this to your attention.

The anaesthetist will prepare you for this technique by discussing all the side effects and possible complications from the epidural. These are well researched and will be discussed with you. If you give your consent to the procedure, then you will be positioned on the bed and your back cleaned and prepared for insertion of the epidural catheter which is a very thin tube which is attached to a continuous infusion of dilute concentrate of drugs used in Epidural analgesia. Prior to this, an intravenous cannula will be inserted into your hand or arm to administer fluids as sometimes your blood pressure can drop in response to the epidural drugs. This will rectify this.

Prior to the siting of the epidural, your skin will be numbed using a dose of local anaesthetic similar to the drug used by dentists to numb your mouth for treatment. When the epidural is in place and working, the midwives will monitor your blood pressure every 5 minutes initially for 30 minutes and then every 30 minutes along with the baby’s heartbeat to ensure all is progressing well. Your legs will be a little numb in response to the effects of the epidural, so you will have to remain on the delivery bed and be monitored continuously to ensure that labour is progressing and that the baby is coping with the labour as well. Also, at some point, because you will be unaware of when you need to empty your bladder, then a urinary catheter will be inserted into your bladder, thus protecting the bladder from overfilling and causing problems in the labour. This usually remains in place for 6 hours after delivery or until feeling is back in your legs and you are able to walk to the toilet or use a bedpan.

The advantages of an epidural are usually more apparent when there are medical or obstetric complications. If the baby is occipito-posterior or back to back to you, when labour is usually longer and more exhausting then this is an ideal form of pain relief. If you are expecting twins, then epidural is usually advised in case there is the possibility of a manipulative delivery for one of the twins. If your blood pressure is raised then it may be recommended as pain may exacerbate the blood pressure and make it higher. The other indication for epidural is usually when all other methods of pain relief have been tried and nothing is working effectively resulting in a slow progress in labour.

Some of the disadvantages are well cited such as the block not working effectively and only working on one side of the body. A drop in blood pressure as discussed previously and the numb legs and loss of sensation resulting in the use of an indwelling urinary catheter to empty the bladder. Sometimes, labour slows down as a result of the effects of the epidural which then necessitates the use of a hormone drip such as Syntocinon (artificial form of the hormone oxytocin) to help labour continue. Even if the epidural is well managed, the feelings of numbness can result in the woman being unable to feel the pressure to push the baby out which results in an instrumental delivery (forceps or ventouse) in the pushing stage of labour.

*For more information see the MIDIRS Informed Choice Leaflets on Epidurals

All of the methods of pain relief described will be discussed with you when you are in labour. Nothing is given to you without your consent and all options are weighed against the pros and cons bearing in mind that if you are relaxed and relatively pain free then hopefully your labour will not be too long and difficult. As midwives, we aim to promote and support the normal physiological response to a woman and her needs whilst in labour. We also endeavour to provide a safe environment for you to give birth in and we will support you in what ever choice you make for pain relief.

Written by Rosie Harris - Midwife January 2004