Planning in advance about the types of pain relief you want during labour can make the experience a less painful one.

LABOUR is a painful experience. The pain is felt especially in the active phase of the first and second stages. Pain depends on various factors like the strength of contractions, the size and position of the foetus, and the individual’s pain threshold, which can vary markedly.

There are several ways in which you can deal with labour pains. A discussion with the doctor or midwife at the antenatal clinic and on admission to the labour ward, on the methods of pain relief available, would be useful.

A relaxed person copes with labour pains better. Try learning about what happens during labour, and how to relax from the doctor, midwife and/or from antenatal classes. – Reuters

It would also be helpful to plan for your pain relief. However, you should always keep an open mind about pain relief, however high your pain threshold is. The mother-to-be may find that more pain relief is required than anticipated, or more effective pain relief may be advised by the attending doctor or midwife (accoucheur) to facilitate the labour and delivery.

Self-help

A relaxed person copes with labour pains better. There are a number of ways of self-help. They include learning about what happens during labour from the doctor, midwife and/or from antenatal classes, learning to relax, and taking deep breaths.

When in labour, it would be helpful to find a comfortable position by walking, lying on the side, rocking back and forth, or kneeling. It would also be helpful if someone, whether it be spouse, relative or friend, is around during the labour to provide support.

However, there is no need to worry if there is no one, as the attending midwife will provide support.

Systemic analgesia

Analgesia is the provision of pain relief without a loss of feeling or the ability to move about. The pain does not disappear, but its intensity is lessened.

Systemic analgesia is the injection of medicines, usually narcotics like pethidine or morphine, into the muscle of the thigh or buttock, or into a vein. The injection acts on the whole body, and not on a specific part. The injections help in relaxation, thereby decreasing the intensity of pain.

In an epidural, a tiny plastic tube is inserted into the epidural space just outside the spinal canal, and a mixture of local anaesthetic and narcotic is injected into this tube to numb the nerves involved in conveying pain signals from the uterus.

When an intramuscular injection is given, it takes about a quarter of an hour or so to act, and it is effective for about two to four hours. If given intravenously, its action is within minutes.

The side effects include drowsiness, difficulty concentrating, and nausea. If the medicine has not worn off by the second stage, it can affect the mother’s ability to push.

If given too near the second stage, it may slow the baby’s reflexes and the initiation of breathing.

However, there are medicines that are given to counteract this effect on the baby’s breathing.

Local analgesia

Local analgesia provides pain relief for a specific area of the body. It has no effect on uterine contractions.

Local analgesia is used if a cut is made in the area between the vulva and anus (episiotomy) prior to the delivery of the baby, or to repair a perineal tear after the delivery.

The local analgesia does not affect the foetus, and there are usually no side effects for the mother after it wears off.

Gas and air

This mixture of 50% oxygen and 50% nitrous oxide, called Entonox or “laughing gas”, does not remove the pain, but it makes it more bearable. It is easy to use and the patient is in control. It is useful in the active phase of labour, when the contractions are stronger, longer and more frequent.

It involves breathing in the Entonox through a mask which is held by the labouring mother-to-be. As the Entonox takes about 20 seconds to act, slow, deep breaths should be made at the start of the contractions.

There are no harmful side effects for the foetus. However, some women feel dizzy, sleepy, have difficulty concentrating or experience nausea. These will cease when the use of Entonox is stopped.

If the Entonox is insufficient for pain relief, systemic analgesia can be given.

Transcutaneous electrical nerve stimulation

Transcutaneous electrical nerve stimulation (TENS) involves taping electrodes, which are connected by wires to a battery-powered stimulator, to the back. The emission of small amounts of current by the stimulator is controlled by pressing on a button.

TENS acts by stimulating the body’s production of its own painkillers (endorphins), and by reducing the transmission of pain signals to the brain by the spinal cord.

TENS is effective during early labour when there is low back pain. It has not been shown to be effective in the active phase of labour.

If there is interest in using TENS, it would be advisable to learn how to use it in late pregnancy. Some hospitals have TENS devices. If they do not have, then one should ask how to rent the device.

There are no known side effects.

Regional analgesia

Regional analgesia involves pain relief for a part of the body. In the case of labour, the nerves that transmit pain in the uterus and birth canal to the brain are numbed by analgesic medicines. Regional analgesia provides effective pain relief in labour with few side effects.

The types are epidural, spinal, or a combination of epidural and spinal analgesia. As they are provided by an anaesthetist, it is important to check if such a service is available at the place of birth.

An epidural involves inserting a drip into an arm vein, after which the mother-to-be is asked to lie on the side or sit up in a curled position. The anaesthetist will clean the back with an antiseptic solution and inject local anaesthetic to a small area.

A tiny plastic tube is then inserted into the epidural space just outside the spinal canal and a mixture of local anaesthetic and narcotic is injected into this tube to numb the nerves involved in conveying pain signals from the uterus.

It takes about 20 minutes to do an epidural, and an additional 15 minutes for it to work. Some adjustments may be necessary if the epidural does not work perfectly. When the medicines wear off, a top-up is done by the midwife.

Continuous foetal heart monitoring is done by attaching a belt and an ultrasound transducer (CTG) to the abdomen. Alternatively, an electrode may be attached to the foetal scalp instead of the abdominal transducer.

A spinal block involves an injection into the sac of spinal fluid below the level of the spinal cord. Pain relief is almost instant and lasts an hour or two. It is best for pain relief in the second stage.

A combination of epidural and spinal block has the benefits of both.

Although uncommon, the side effects and risks of regional analgesia occur occasionally. Fluids are run in through the drip in the arm to prevent a drop in the mother’s blood pressure, which occurs sometimes. The legs may feel heavy.

As the second stage may be prolonged, it is important to act on the midwife’s instructions to push, to avoid instrumental delivery by forceps or vacuum extraction.

The injection of less anaesthetic towards the end of the first stage may help in the pushing out of the baby naturally.

Some mothers may experience difficulty in urination, requiring the insertion of a catheter into the bladder.

About less than one in 100 mothers may get a headache, which usually goes away after a few days. If the headache does not go away or it becomes severe, it can be treated.

There may be some backache for a day or two after regional analgesia.

Occasionally, the medicines may inadvertently be injected into the veins in the epidural space, which are swollen during pregnancy. This causes rapid heartbeat, dizziness, and a funny taste or numbness around the mouth, at the time of insertion. If such symptoms occur, the anaesthetist should be informed immediately.

Regional analgesia does not cause drowsiness or vomiting.

Hydrotherapy

Warm water helps one to relax. The Royal College of Obstetricians and Gynaecologists (RCOG), and the Royal College of Midwives (RCM) of the United Kingdom, support labouring in water for healthy women with uncomplicated pregnancies.

However, the jury is still out as to whether hydrotherapy provides pain relief.

With regard to birth in water, the joint RCOG and RCM statement in 2006 stated: “Informed choice on the benefits and risks of birth in water is clouded by the lack of good quality safety data. Although there is no evidence of higher perinatal mortality or admission to special care baby units (SCBUs) for birth in water, caution is advised because of small numbers, possible under-reporting of SCBU admissions, and exclusion of women who were in labour in water, but gave birth conventionally after complications.”

> Source: Dr Milton Lum