What about Labour pain?
By Anne Marie van Hengel, MD – InterMed Women’s Health
Understandably, one of the most common concerns women have during their pregnancy is how they will handle the pain of labour.
I tend to view labour like a “Black Box.” No one knows what their labour is going to be like until they are in it, but knowledge can make that black box smaller and thus less scary, so…. Knowledge is Power!
Generally when people experience pain it is because something is wrong, which causes fear and a tendency to “fight it/tense up.” But labor is one of the very few times when this is not the case. Nothing is wrong — it is normal. So you don’t have to like it, but you do not need to be afraid of it! Which hopefully means you ride the pain rather than fight it. Obviously to do this it is helpful to have tools to aid you in this.
The first thing I recommend is to educate yourself. Be as knowledgeable as you can be as to what expect in labour:
- If possible, sign up for Child Birth Education classes in person, rather than doing it on-line or watching a video. The personal connection allows more opportunity to ask questions and to interact with your instructor. In addition, there is great value in developing relationships with other couples — they can provide excellent support postpartum.
- Envision your labour: Are you hoping to avoid medications, or are you sure you will want an Epidural? There is no right answer, just your answer, and realize that labor is unpredictable, so plans can change. Nothing is set in stone.
- Live the moment – Do not worry about what is going to happen, just concentrate on what is How am I doing right now? As things change, we can adapt.
- Good labour support – Consider whether a Doula is something that may work for you and your partner. There is excellent data that show that a dedicated trained labor support person decreases epidural rates and satisfaction of the birth experience.
So what are the options out there?
Non-medical pain relief options for childbirth
Research suggests that good preparation can help decrease or modify your pain and anxiety.
- Consider prenatal yoga classes
- Stay active in labor (up and about in room, different positions using ball, birthing stool)
- Hydrotherapy tub or shower
- Visualization and mindfulness techniques
- Breathing techniques
- Massage/pressure point
- Hot packs/cold packs
- Music/calm environment
- Constant one-on-one labor support from partner /doula
Medical pain relief options
The three main medical pain-relieving options for labour include:
- Nitrous oxide
- Epidural anesthesia
In many ways Nitrous is the new kid on the block. Although it has been safely used in Europe for 60+ years and in several major medical institutions in the U.S. for almost a decade, it has only recently become more widely available. Commonly known as laughing gas, nitrous oxide is frequently used in dentist offices, but at a higher concentration.
For labor it is categorized as an analgesic (as opposed to an anesthetic) and does not require the same level of surveillance. It is administered by mask and is completely controlled by you — you take as many or as few breathes as you like, and since it is very rapidly cleared from your system, if you don’t like how you feel on it, it is out of your system within a few breathes, unlike the effects of a narcotic, which lasts a few hours.
Nitrous oxide doesn’t interfere with contractions and does not affect your blood pressure or the baby’s heart rate. It doesn’t linger in either the woman’s or the baby’s body.
Possible side effects include:
- Nausea and vomiting
- Confusion and disorientation
- Claustrophobic sensations from the face mask
- Lack of pain relief – in approximately one-third of women, nitrous oxide offers no pain relief
|Adverse Effects of Nitrous Oxide|
Nitrous Oxide FAQsClick to Show
Nitrous is the same gas used by dentists, but at a lower dose, so that it acts as an analgesic (pain relief) rather than anesthesia. Ninety-nine percent of the gas you breathe in is immediately exhaled with your expiration. Only 1 percent gets into your system.
It tends to lessen pain and worry during labor and childbirth. While it can help you feel more in control, it won’t take away all your pain. Some people say that you still feel the pain, but you just don’t care as much.
How do I use it during labor?
You take it yourself when you need it. Nobody else may give it to you. To use the gas, hold the mask to your face and start breathing in. Your nurse will help you figure out how to use the mask.
Since nitrous takes a few seconds to work, you will start using the gas about 30 seconds before a contraction. This helps the gas to reach its peak effect as the contraction is reaching its peak. The effect only lasts a few minutes after you remove the mask, as the gas starts clearing from your body as soon as you stop breathing it in. It can take a few contractions to figure out the best technique for you.
Will nitrous oxide affect my labor or my baby?
No. One of the advantages of nitrous is that it has no bad effects on labor or the baby. It does not affect the body’s natural release of oxytocin, so that it will not space out your contractions.
It will not cause your blood pressure to drop, will not affect your baby’s heart rate, and does not increase the need for neonatal resuscitation.
You can keep moving around in the room or be in the tub if you like, as long as someone is with you. No additional monitoring is required.
You can use the gas right up until you have your baby and it will not affect your ability to breast feed and it does not affect APGAR scores or Need for resuscitation/NICU admissions.
Does nitrous oxide have side effects?
Ten percent of women may suffer from nausea/vomiting, and approximately 20 percent experience dizziness or lightheadedness.
The good news is that we do have medications that could help with those side effects. If those do not work, or prefer not to use them, just stop using the nitrous.
Since it is cleared VERY rapidly from your system (within a few breathes), any unpleasant symptoms resolve very quickly. Remember, you have total control over the medication. As soon as you stop taking a breath of gas it will be on its way out of your system
Are there any reasons I can’t use nitrous oxide?
You can’t use nitrous oxide:
- If you can’t hold your own face mask.
- If you took an opioid or other medicines in the past 2 hours that might make you sleepy.
- If you have pernicious anemia or lack vitamin B-12 (people who have had Gastric bypass are at high risk for B12 deficiency).
- If you have one of a few other rare health problems (if you do, your provider will talk with you about it).
- If you’ve had recent intra ocular or middle ear surgery.
- If you share the nitrous oxide with others (you have to agree in writing not to share the gas).
Do I have to choose between nitrous oxide or an epidural or other IV pain medicine?
No. You can use nitrous oxide before you have an epidural or an opiate, although you cannot use them together.
It’s perfectly fine to start with nitrous and then switch to an epidural or other IV pain medicines. At any time after using nitrous you can switch to an opiate or an Epidural but you cannot use them together. If you use a narcotic first, you must wait at least 2 hours before trying nitrous.
What if I have more questions?
Talk with your Provider. We’re here for you.
Women who either don’t want an epidural or who can’t have one may opt for opioids like Nubain, which can be delivered through your IV or an injection under the skin.
These will tend to take the edge off the pain and allow you to relax/rest between your contractions. Unlike an epidural, IV pain medicine can make you drowsy and nauseated, and it does enter the baby’s bloodstream, making the baby a little sleepy, so if we think the delivery will happen within an hour, we try not to use them.
Side effects may include:
- Drowsiness or drunk feeling
- Confusion and disorientation
- May cause contractions to space
The most common and most effective method of pain relief used during childbirth in the U.S. involves injecting medication into a space around your spinal cord which numbs you from the waist down, while allowing you to remain alert (or allowing you to sleep if you are exhausted from your labour).
It can lower your blood pressure, which can lead to a decrease in your baby’s heart rate, although this generally resolves quickly without any ill effects for your baby. It can also affect your ability to empty your bladder, so you may need a catheter.
Since your legs will be numb, it may limit the positions you can push in and generally the second stage of labour (from full dilation to delivery of your baby) will take a little longer.
Although some people say that it increases your risk of C section, many studies have shown this not to be true. Some people worry that they will miss their opportunity to get an epidural, and choose to get an epidural a little earlier than they feel that they really need it, however it is only ever too late if you are really are about to have the baby.
Side effects may include:
- Blood pressure drop
- In rare cases, a bad headache in the days after you give birth
- Persistent tenderness at epidural placement site
Note: There are some circumstance in which women cannot get an epidural, such as certain bleeding disorders, severe scoliosis, or previous back surgeries.
|Nitrous Oxide||IV/IM Narcotics||Epidural|
|Pain Relief||Variable||Variable||Dense, often complete|
|Anxiety||No effect||No effect|
|Side Effects||Mile, transient||Uncommon/rare serious side effects||Mild|
|APGARs?||No effect||May affect||No effect|
You will have choices. Talk it over with your provider so that you will be comfortable that you know and really understand all your options.
I always recommend that you do as much complex processing BEFORE labor. Once you are in active labor you do not want to be grappling with new information. Keep in mind that your choices may change when your labor starts — it might be a complicated birth or different than you and your doctor expected. It’s great to have a plan, but it’s also OK to change it if you need to.