Pain Relief During Labour

“Giving birth should be your greatest achievement, not your greatest fear” –Jane Wiedeman

The birth of a child is one of the most memorable events in a couples life. Labour(childbirth) is an emotional experience and involves both physiological and psychological factors. Childbirth in each woman is unique and experiences labour discomfort differently. Many factors influence how one experiences childbirth. The size and position of the baby, how well the labor progresses and the level of pain tolerance. Although some women cope with labour using only breathing and relaxation techniques learned in childbirth classes, many choose to combine these techniques with pain medications or epidural analgesia. Effective management of labour pain plays an important role in how a woman experiences childbirth.

What Is Labour (childbirth)?

Labour is the active process of delivering a baby and is characterised by regular, painful uterine contractions which increase in frequency and intensity.

Labour pain has two components: Visceral pain which occurs during the first stage of labour( when the cervix or mouth of the womb dilates slowly and steadily) and somatic pain which occurs during the late first stage and the second stage of labour (delivery of the baby).

The visceral pain is felt in the lower abdomen, back and upper thighs and is dull in character. Somatic pain occurs closer to delivery, is sharp in character and localised to the vagina, rectum and perineum.

Psychology of Labour Pain

Labour pain is an emotional experience and presents a psychological challenge for many women in labour. Recent studies about the factors that influence childbirth have concluded that women who had continuous support during labour were less likely to have pain relief medications or report unpleasant experiences. Also, it has been suggested that anxiety and fear about labour can both result in a higher dose of pain medications and prolong the labour.

Why Is Antenatal Education Important?

Attending childbirth classes builds woman confidence and ability to give birth. It helps overcome the fear of childbirth. It empowers the woman to make informed choices about birthing. It educates women about the healthy lifestyle to keep pregnancy comfortable and make a smoother postnatal recovery. Antenatal childbirth preparation has a role in increasing maternal satisfaction and may reduce pain perception.

Management of Pain During Labour 

The aim of pain relief is to have a woman in labour relatively pain-free while she still is able to participate in the birthing experience. Ideally, there should be no associated side effects or risks to both mother and baby. 

Complementary and alternative therapies for labour pain Pharmacological analgesia for labour pain
1)Psychological e.g. hypnosis 1)Inhalational analgesia e.g. Entonox (reduce pain perception)
2)Physical e.g. transcutaneous electrical nerve stimulation (TENS), acupuncture 2)Parenteral opioids e.g. pethidine, morphine.
3)Others e.g. aromatherapy, water immersion 3)Regional analgesia e.g. epidural,(reduce pain transmission)

 

Complementary and alternative therapies for pain management in labour 

1. Use of a birthing ball, patterned breathing techniques, movement and positional changes, application of hot compresses to lower back and perineum, massages to the shoulders, neck and back, aromatherapy, music, focus and distraction are some of the natural birthing techniques which help decreases the perception to pain thereby alleviating pain. 

2.TENS (Transcutaneous nerve stimulation) It is effective during the early stages when many women experience lower back pain.

3.Waterbirth –It means part of the labour, delivery or both happen while in a pool filled with warm water. It may be associated with shorter labours and a decreased need for medications to hasten the labour. The associated feeling of weightlessness also adds to comfort and allows for easy change of position during labour. Warm water induces muscle relaxation and reduces anxiety. However, there is no clear evidence on the benefits of waterbirth. Critics argue that safety of water birth has not been scientifically proven and there have been some adverse outcomes like an increased mother and newborn infections and the possibility of newborn drowning.  

How do TENS  work?

Electrodes are taped on to the back and connected by wires to a small battery-powered stimulator. Holding this, one can give oneself small, safe amounts of current through the electrodes and still can stay mobile. TENS is believed to work by stimulating the body to produce more of its own natural painkillers, called endorphins. It also reduces the number of pain signals sent to the brain by the spinal cord. However, TENS provide pain relief which is incomplete, unpredictable and can be inconsistent. 

Pharmacological methods for labour pain

1.Entonox: This is a 50:50 mixture of oxygen and nitrous oxide gas. It won't remove all the pain, but it can help reduce it and make it more bearable. Many women like it because it's easy to use and they can control it themselves. There are no harmful side effects for the mother or the baby. In a few women, it can make one feel light-headed.

2.Pethidine: This is an opioid injection that is given to the buttocks to relieve pain. It is more of a sedative(induces sleep and promotes calmness) than an analgesic. The effects last between 2 and 4 hours and are generally given in the early stage of labour. There are some side effects to be aware of: it can make some women feel drowsy and sick. If pethidine is given too close to the time of delivery, they may affect the baby's breathing.

 3.Epidural: Epidural analgesia is thought to be the most effective method of providing pain relief in labour and involves injecting local anaesthetic close to the nerves of the back that transmit pain. It can be helpful for women who are having long or particularly painful labour. It also helps in case the labouring mother requires forceps delivery or caesarean section. An anaesthetist is a person who can give an epidural. An epidural can provide very good pain relief, but it's not always 100% effective in labour. The Obstetric Anaesthetists Association estimates that 1 in 8 women who have an epidural during labour need to use other methods of pain relief. 

How does an epidural work?

To have an epidural: an intravenous drip is started into a vein of an arm of the patient. While the patient lies on her side or sit up in a curled position, an anaesthetist will clean the back with antiseptic, numb a small area with some local anaesthetic, and then introduce a needle into the back. A very thin tube will be passed through the needle into the back near the nerves that carry pain impulses from the uterus. Drugs (usually a mixture of local anaesthetic and opioid) are administered through this tube. It takes about 10 minutes to set up the epidural, and another 10-15 minutes for it to work. It doesn't always work perfectly at first and may need adjusting. The epidural can be topped up by a trained nurse, or continuous infusion can be given. Mothers uterine contractions and the baby's heart rate will need to be continuously monitored. 

 Side effects of epidurals in labour

  1. An epidural may make the legs feel heavy.

  1. Blood pressure can drop (hypotension), but this is rare because the fluid given through the drip in your arm helps to maintain good blood pressure.

3) Epidurals can prolong the second stage of labour. As one can no longer feel the contractions, the nurse will have to tell when to push. This means that forceps or a ventouse may be needed to help deliver the baby's head at times. Sometimes less anaesthetic is given towards the end, so the effect wears off and the patient can feel to push the baby out naturally. About 1 in 100 women get a headache after an epidural. If this happens, it can be treated. Epidurals don't cause long-term backache. About 1 in 2,000 women feel tingles or pins and needles down one leg after having a baby. This is more likely to be the result of childbirth itself rather than the epidural.

Shivering, nausea and vomiting can occur during labour which can be treated if troublesome. Life-threatening or serious complications (such as unusual drug reactions or nerve damage due to bleeding or infection near the spinal cord) are extremely rare.

Conclusion

The woman should be better informed about the different options of pain relief in labour available to them in the antenatal period itself, so that they can make informed choices based on their values, expectations and preferences rather than taking a hurried and passive decision during an unpredictable event as labour. 


 

Dr Vidyashri Kamath C

Consultant Obs & Gyn

KMC Hospital Dr B R Ambedkar Circle Mangalore

 

 

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