Anaesthetics - Pain Relief in Labour

What will labour feel like?

• While you are pregnant, you may feel your uterus (womb) tightening from time to time. These are called Braxton Hicks contractions. When you go into labour, these tightenings become regular and much stronger
• The tightening may cause pain that feels like period pain, and usually becomes more painful the further you get into labour. Different women experience labour pains in different ways
• Usually, your first labour will be the longest
• If medication is used to start off (induce) labour or speed up your labour, your contractions may be more painful

Key points:

• It is difficult to know in advance which form of pain relief you will require during your birth
• It is helpful to learn about the different types of pain relief before you go into labour
• Simple techniques, including ‘gas and air’, are enough for many women, but many require more pain relief
• Labour can be unpredictable, most women use a range of ways to cope with labour pain so it helps if you are flexible with your birth plan

Preparation for labour

• Antenatal parenting classes help you prepare for the birth. These classes will help you understand what will happen in labour and may help you to feel less anxious
• If you cannot go to antenatal classes, you should still ask your midwife about what is available to reduce the pain. You can then discuss this with the midwife who cares for you while you are in labour
• Where you choose to give birth can affect how painful it is. If you feel at ease in the place you give birth, you may be more relaxed and less anxious about labour. For some women this means giving birth at home, but other women feel reassured by the support offered at a hospital or birth centre
• Having a friend or birth partner with you while you are in labour can be helpful for you. It is important to talk to your birth partner about your concerns and what you want, and they can help you to focus during your labour

Self-help: What you can do for yourself

• Relaxation is important. It can be difficult to relax when you are in pain, which is why it can be helpful to practise before you actually go into labour. There are a number of different ways you can learn to relax. Music and massage might help
• Birth classes can teach ways of breathing that may help you cope with the pain of contractions. Calm breathing may increase the oxygen supplied to your muscles, and so make the pain less intense. Also, because you are focusing on your breathing, you are less distracted by the pain
• Your position can make a difference and some mothers find that keeping mobile is helpful
• Paracetamol is helpful in early labour
• A warm bath may help you relax in early labour

Water birth

There are not many studies that have looked at the benefits and risks of using a birthing pool. However it has been shown that if you have your labour in water you may find it less painful.

There are some concerns that if the water is too warm your baby may show signs of distress during labour, but studies have shown that there is no more risk to you or your baby if you have your labour in water than if you have it out of water. The midwife will continue to monitor your progress and your baby’s wellbeing.

For uncomplicated pregnancies, it is safe for both mother and baby. If you want to use water during your labour, it is a good idea to find out more about it. Ask for the information leaflet. If you plan to have your baby at home you may also want to talk to your midwife about the possibility of having a water birth.

Pain Relief in Labour

Gas and air: Entonox

Entonox is a gas made up of 50% nitrous oxide and 50% oxygen.

• You breathe it through a mouthpiece or facemask which you hold yourself
• It is simple and quick to act
• It wears off in a couple of minutes, after you stop taking it
• It will not remove all pain but many mothers find it helpful
• It can be used at any time during labour
• It is available in the community
• It does not harm the baby
• It may make you feel light headed or sick for a short time. This will wear off within a few of minutes of stopping using the gas and air

Many mothers like it because they can control it themselves.

Timing is very important if gas and air is to work well. It takes 15-20 seconds for Entonox to start to work. You should start
breathing the gas as soon as you feel a contraction starting. That way, the pain of the contraction and the relief from the gas and air peak together.

Breathe room air between contractions. If you breathe gas and air all the time, it can make you dizzy and a little spaced out. For this reason, please don’t ask your partner to hold the mask/ mouthpiece on your face for you.

TENS (Transcutaneous electrical nerve stimulation)

• It works by stimulating the body to produce its own painkillers
• A gentle electric current is passed through four flat pads stuck onto your back. This causes a tingling feeling in your back. You control the strength of the current yourself
• There are no known side effects to you or your baby
• You can move around while using it
• You may hire a TENS machine from a number of shops. Ask your midwife about this. You can start using it as soon as you go into labour

Diamorphine or Pethidine (opioids)

• Given by injection into the leg or arm muscles by the midwives
• It takes about twenty minutes to work and lasts two to four hours
• Opioids are less effective at easing pain in labour than Entonox
• Although pain relief may be limited, some women say it makes them feel more relaxed and less worried about the pain
• It can make you drowsy and sometimes makes you forgetful
• It may make you feel sick. If this happens you can have an anti- sickness injection to stop this feeling
• It may slow down your breathing. If this happens, you may be given oxygen from a face-mask and have your oxygen levels monitored
• They may make your baby slow to take its first breath or be drowsy, but an injection can be given to your baby to stop this
• If the baby is very sleepy it may cause a short delay in establishing breast feeding

Epidurals

• Epidural is the most effective method of pain relief
• The painkillers may be a local anaesthetic to numb your nerves, small doses of opioids, or a mixture of both
• An epidural usually does not make you feel drowsy or sick
• Having an epidural increases the chance that your obstetrician will need to use a ventouse (a suction cap on your baby’s head) or forceps to deliver your baby
• An epidural can be topped up to provide pain relief if you need a ventouse, forceps or a Caesarean section if it is working well
• An epidural takes about twenty minutes to set up and a further twenty minutes to become fully effective. Because of this they are less useful if birth is imminent
• As they are set up by anaesthetists there may be a delay in setting up the epidural if the anaesthetist is busy with another patient
• They have very little effect on the baby

What does the epidural involve?

Epidurals are inserted and set up by anaesthetists. They are doctors who are specially trained to provide pain relief and give drugs that make you go to sleep.

• You will need a drip put into your arm, if there is not one in already
• You will be asked to sit, bending forwards, or curl up on your side
• Your back will be cleaned with antiseptic and numbed with a local anaesthetic injection
• Then your anaesthetist inserts a needle into the lower part of your back and uses it to place an epidural catheter (a very thin tube) near the nerves in your spine. The epidural catheter is left in place when the needle is taken out
• If you have a contraction tell the anaesthetist and they will wait until it has passed. It is very important to keep still while the needle is being inserted in to your back
• The tube is taped to your back and the pain relief can then be given into the epidural

While the epidural is starting to work, your midwife will take your blood pressure regularly. Your anaesthetist will usually check that the epidural painkillers are working on the right nerves by putting cold spray on your tummy and legs and asking you how cold it feels.

Sometimes, the epidural doesn’t work well at first and your anaesthetist needs to adjust it, or even take the epidural catheter out and put it in again.
 
During labour, you can have extra doses of painkillers through the epidural catheter. After each epidural top up, the midwife will take your blood pressure regularly in the same way as when the epidural was started. You will also be able to give yourself extra doses of painkiller using a button attached to the epidural pump if you need to. Your midwife and anaesthetist will explain this.

The aim of the epidural is to take away the pain of contractions. Usually, the epidural also reduces the pain when your baby is delivered. Some women prefer to have some feeling during the delivery so they have a better idea of how to push the baby out.

The epidural cannot be adjusted exactly, so if you want to have more feeling when your baby is delivered, there is more chance that you may have an uncomfortable sensation during labour as well.

Who can and cannot have an epidural?

Most people can have an epidural, but certain medical problems (such as spina bifida, a previous operation on your back or problems with blood clotting/infection) may mean that it is not suitable for you. The best time to find out about this is before you are in labour.  It is likely you will be offered an appointment to see an anaesthetist in clinic while you are pregnant if this is the case.

If you have a complicated or long labour, your midwife or obstetrician may suggest that you have an epidural as it may help you or your baby. If you are overweight, an epidural may be more difficult and take longer to put in place. However, once it is in you will have all the benefits.

Advantages

• If working well, it should remove the pain of labour. It reduces the pain of labour better than any other method
• It should not make you feel drowsy or sick
• It has no long term effects on the baby
• It has no effects on breastfeeding
• If you need an operation it is often possible to ‘top up’ the epidural with local anaesthetic for the surgery. This means that you would not need a general anaesthetic or another injection in your back before the surgery could proceed

Things an epidural does not make a difference to

• With an epidural, you do not have a higher chance of needing a Caesarean section
• There is no greater chance of long-term backache. Backache is common during pregnancy and often continues afterwards. You may have a tender spot in your back after an epidural which, rarely, may last for months

Disadvantages

• With an epidural, the chance of the obstetrician having to use a ventouse or forceps to deliver your baby is 14%. Without an epidural it is 7%
• With an epidural, the second stage of labour (when your cervix is fully dilated) is longer and you are more likely to need medication (oxytocin) to make your contractions stronger
• It may reduce the urge to push or bear down
• Sometimes epidurals are ineffective or only work on one side. The anaesthetist may be able to remedy this
• Occasionally they cause a drop in blood pressure. The drip will help to prevent this. Your blood pressure will be checked regularly whilst the epidural is working
• Your legs may feel heavy and numb
• Your baby’s heartbeat will need to be monitored continuously
• Your skin may itch
• There is about a 1 in 100 chance of getting a headache afterwards. There are various treatments available if this occurs
• Your back may feel a little tender at the site of the epidural for a couple of days afterwards. Epidurals do not cause or worsen long term backache
• Some mothers have small numb patches on their legs which stay numb after birth. These are much more likely to be due to the process of childbirth than the epidural. Such patches do get better on their own but it may take some months. Serious or permanent nerve damage is very rare
• Some epidural solutions include painkillers as well as local anaesthetics. Rarely these may make the baby a little drowsy

This leaflet is partly based on the Obstetric Anaesthetists Association © Pain relief and anaesthesia choices during labour information. The OAA is not responsible for the contents of the local leaflet. Further information and references are available at www.labourpains.org