Pain Management During Childbirth
The Miracle of Childbirth—every woman dreads it and every man thanks his lucky stars that he’ll never have to face it. While some women forgo painkillers in order to embrace “natural” childbirth options, many others elect to minimize the pain. There are many ways this can be accomplished, and your doctor will help you decide which one is right for you in light of the particular circumstances of your pregnancy.
Epidural and Spinal Blocks
An epidural involves the injection of drugs through a catheter directly into the epidural space in the spinal canal, just outside the fluid-filled sac that surrounds your spinal cord. The pain relief provided by the epidural procedure is generally rapid—sometimes taking effect within as little as ten minutes—and can last for many hours.
A spinal block is similar in some ways to an epidural, but the injection goes deeper, past the epidural space and into the subarachnoid cavity where the spinal fluid is found. Because the drug goes directly into the spinal fluid, the dosage administered with a spinal block is also much smaller, in some cases no more than one tenth what the patient would get with an epidural.
A spinal block is a one-time injection, whereas with an epidural, a catheter may be left in place for additional injections later on and for continuous delivery of medication through the catheter. A spinal block works much more quickly than an epidural, and the effect tends to be stronger, although it does not last as long.
The most commonly used drug for a spinal block is bupivacaine (Marcaine), although tetracaine, lidocaine, procaine (Novocaine) and others may also be used. These drugs are all local anesthetics. Marcaine is also commonly used for epidurals.
There is also a type of procedure known as a combined spinal–epidural block (CSE), which is sometimes used in emergency situations (such as an unplanned C-section delivery) in which the speed of a spinal block and the duration of an epidural are both required.
Epidural and spinal block are associated with fewer side effects and faster recovery than general anesthesia, but potential side effects of epidural may include headaches, nausea, and fever. An epidural or a spinal block may leave you with a sore back for a few days.
A pudendal block involves the injection of chloroprocaine or lidocaine (lidocaine is used more often because it lasts longer) into the pudendal canal in order to block signals from the pudendal nerve, which is responsible for sensation in the genitals and in the skin around the vagina, vulva, anus, and perineum. Only a qualified obstetrician should perform a pudendal block. Generally these have fallen out of favor due to the high percentage of deliveries that take place with an epidural.
If a pudendal block is called for, it will usually be done during the second stage of labor (the pushing phase), just before the baby comes. A pudendal block lasts about an hour, and the procedure is often used during episiotomies. The primary risk associated with a pudendal block is that the medication may get into the bloodstream, cross the placenta, and be absorbed by the baby. A more common scenario is that it does not always work all that well.
After a vaginal delivery, there may be a laceration or episiotomy that needs repair. Even with an epidural in place, there may still be sensation in the perineal area, and so a local anesthetic, usually 1% lidocaine, is often given to numb up the area prior to suturing.
Analgesics vs. Anesthetics
There are two basic types of pain medication: analgesics and anesthetics. Analgesics act to reduce pain but do not cause a total loss of sensation, nor do they interfere with muscle control and movement. Anesthetics, on the other hand, block all sensation. Some analgesics are regional, acting only on the part of the body where the doctor applies them, and others are systemic, affecting the nervous system throughout the entire body. Spinal, epidural and local anesthesia procedures use anesthetic drugs. Other drugs used during labor can provide analgesia.
Opiate drugs are analgesic painkillers that are usually administered in small doses. Unlike epidurals and spinal blocks, opiates do not completely numb the pelvic region, and so they do not interfere with a woman’s ability to “push” as she needs to do during labor. With any opiate, there is a risk of respiratory problems for the baby.
Some commonly used opiate painkillers:
- Demerol: One of the most commonly used painkillers during pregnancy, Demerol affects the patient’s perception of pain by acting on pain receptors in the central nervous system. It acts quickly, often within less than five minutes. Many hospitals no longer use Demerol due to a rare complication of seizures.
- Morphine: This drug is not used in childbirth as often as it once was because it has been found to have the potential to cause respiratory distress in the baby.
- Stadol is a fast-acting painkiller that is sometimes used during the first stage of labor. One important advantage of Stadol is that, when used properly, it has minimal effects on the baby.
- Fentanyl, like Stadol, is fast acting with minimal fetal effects, but its effects only last for about 45 minutes. This is a very powerful agent, and dosages used are quite small, as low as 50 to 100 micrograms.
General anesthesia—in layman’s terms, putting the patient to sleep—is only resorted to in childbirth under the most extreme circumstances, such as when surgery is necessary in cases of amniotic fluid embolism, uterine rupture, or other such emergency. If this turns out to be necessary in your case, a trained anesthesiologist will handle it, but there is an increased risk for the baby, who may require breathing assistance
If you opt to give birth in a natural setting, with the assistance of a midwife rather than a doctor, you will not have access to pain medications or other types of drugs. Midwives and other professionals who attend these kinds of births are experienced with holistic pain management techniques, including meditation, hypnosis, yoga, biofeedback, and others. Some mothers-to-be elect to have water births, and some take Lamaze classes while they are pregnant. In some cases, “alternative” pain control methods such as acupuncture may be used, although there is no hard evidence that such methods work.
Some women choose to take this route because they feel it will provide a more visceral experience that will enable them to forge a particular bond with their child, or because they do not want to “miss” anything due to their perceptions being clouded by narcotics. Make no mistake, however—this kind of childbirth is difficult, and it is not for everyone. Consult your physician before deciding on natural childbirth, and ask any prospective midwife what pain management techniques she has experience with.
Talking to Your Doctor
Here are some questions you can ask your doctor about pain management during childbirth:
- I’m considering having a medication-free natural childbirth; do my physical condition and the circumstances of my pregnancy allow for such a thing? What are the dangers?
- Do you think I will need general anesthesia during labor?
- How painful is childbirth? What will we do if I feel that I cannot handle the pain?
- If we use narcotic painkillers, how soon will I be able to breastfeed?