Pain Relief in Labour

There are lots of options for pain relief in labour, including natural pain management techniques, medication and medical procedures. If you read about and consider how you feel about these before the moment arrives, this will both help you write your birth plan and help you make decisions in labour if things don't go exactly as you expected.

If this is your first pregnancy, you won't know quite how labour pain will feel, so you might consider writing more than one option into your plan, giving you alternative choices in the event that your first choice for pain management isn't right for you. Even if you have already had several labours and are quite sure that you know what pain relief you want, it's useful to know what the other options are and how they work, in case things don't go quite as you expect.

Not all types of pain relief are available wherever you deliver your baby - for instance, you can't have an epidural at home, and birthing pools are not always available in every hospital.

What choices are there for pain relief in labour?

The possible options include:

• Natural methods of pain management:
• The support of a partner or birth supporter.
• Breathing and relaxation techniques - self-hypnosis, aromatherapy, massage, meditation.
• Mindfulness.
• Immersion or flotation in water.
• Patient-controlled pain relief:
• TENS machine.
• Gas and air (Entonox®).
• Injected painkillers:
• Opiate injection - for example, pethidine.
• Local anaesthetic blocks:
• Pudendal block.
• Perineal local anaesthetic.
• Regional anaesthetic blocks:
• Epidural anaesthetic.
• Mobile epidural.
• Spinal block.
• General anaesthetic.

Who should be my birth supporter?

Women who have continuous support during labour, from someone experienced in providing that support, are less likely to need pain relief. Your partner or close friend may do this for you, although some women also choose to bring a doula, a woman whose role is to provide one-to-one support for parents from late pregnancy, through labour and birth and into the first hours and weeks with their new baby.

What natural pain control can I use in labour?

Most women find labour manageable at first, and will move around, breathe, bathe and try to relax and get some rest as they get to grips with the rhythm of what's happening and start to get a gauge on how their bodies are behaving and how the pain will feel.

In the early stages of labour, before it's fully established, your contractions may be short and some time apart, although they can still be quite intense, and most women agree that they are definitely painful rather than just uncomfortable. However, you will have recovery time in between them. This is your opportunity to practise natural methods of pain management and to try to get an idea of what is going to work for you. If these things work very well for you, they may be enough for you throughout your labour.

Knowledge

Understanding what is going to happen (perhaps by attending antenatal classes) can make the pain of labour more manageable.

Acceptance

In normal labour the pain you are experiencing is that of a normal, healthy body having a baby. If you can think of this as exciting, rather than frightening, it will help the way you deal with the pain. Fear makes pain worse, and excitement makes it more manageable, even though fear and excitement involve the same hormones and feelings. It's how we think of them that changes what they are. Think of each contraction as another step towards the birth of your baby, and try to conserve energy between them but be pleased you are progressing when they start.

Movement and breathing

Moving about helps labour to progress. Many women cope with the pain better by rocking and leaning forwards, or by wriggling their hips. Breathing control can help and many antenatal classes will teach you techniques for breathing through contractions. Keep your breathing calm and rhythmic, and try not to gasp. Making a noise may help.

Massage

Massage, pressure or heat on the lower part of your back just above the top of your bottom can help, although some women suddenly find they don't want to be touched.

Relaxation and stress-reducing techniques

We know that fear and lack of knowledge both make labour pain worse. It's not unusual to be afraid of childbirth - 1 in 4 women say that they are. Research shows that it's possible to change both fear and lack of knowledge, and as a result to change the experience of childbirth.

There are many different techniques for focusing away from, managing, or accepting the pain of contractions. Most need to be learned and practised during your pregnancy. They include self-hypnosis, aromatherapy, massage, mindfulness techniques and acupuncture. They give effective enough pain control for some women to use them for the whole of labour. Research has shown that hypnosis and acupuncture both reduce women's need to use other pain control methods.

A set of complementary therapies developed in Australia called the She Births® programme includes acupressure, visualisation and relaxation, breathing, massage, yoga techniques, and facilitated partner support. This has been shown to reduce the need for epidural and for and caesarean section, and may lead to shorter labours, particularly the second stage.

Mindfulness-based Childbirth Education (MBCE) combines education and stress reduction techniques. Studies show it can help women keep a sense of control and decision-making in their labour, and that women who use it tend to feel more positive about their experience.

Water

In the early stages of labour, immersion in water can be relaxing and can ease contraction pains, although it can sometimes slow contractions down. Once you are in established labour, being in water can provide effective pain control, and allows you to change position much more freely.

Whilst being in your own bath can be helpful too, your bath isn't deep enough for you to feel the full effects of water, as it won't be deep enough for you to float and have your weight supported: for this you need a birthing pool. You can hire a birthing pool to use at home. They can take some time to fill, so most women fill the pool in the early part of their labour (although bear in mind that it will need a water change and cleaning after 24 hours). You should follow the instructions on your pool carefully, and it shouldn't be warmer than 37.5ºC.

Many delivery units have a birthing pool. This may be available only for pain relief in labour, or may also be available for delivery, depending on their policy and the availability of midwives trained in water birth. There is usually only one pool, so if it is already in use, you may not be able to use it.

When should I ask for extra help with labour pain?

This depends on how you feel and on how you are managing your labour pains. You may find that natural pain management techniques are enough for you throughout your labour.

For most women the intensity of labour increases as they move into active labour. Contractions will get closer together and will last for longer and become more intense. This means you will have an idea, at any one time, of what the next ten or twenty minutes will bring, which gives you time to think ahead and get a sense of whether you would like additional pain relief.

Using a TENS unit in labour

Some women find a transcutaneous electrical nerve stimulation (TENS) unit helpful before labour becomes established. A TENS unit consists of a set of pads placed over your lower back connected to a small device which you can control yourself. The pads transmit mild electrical impulses to your back, aiming to help block pain signals before they reach your brain, and to encourage your body to produce natural painkilling chemicals (called endorphins).

A TENS machine can be used throughout labour, unless you are in water or your baby has to be monitored electrically (when it can interfere with the monitor signal). It has no side-effects for you and your baby, and is completely in your control. Some women find a TENS machine very helpful, others less so. Studies suggest it is most effective in the early stage of labour, when lower back pain is common. If you want to use a TENS machine, you need to hire, borrow or buy one in late pregnancy.

Using gas and air in labour

Gas and air (Entonox^®) is available wherever you choose to give birth, including at home and in a birthing pool. About 8 out of every 10 women in labour use Entonox® as all or part of their pain relief.

Entonox® is a colourless gas made up of half nitrous oxide (sometimes called laughing gas) and half oxygen. It doesn't really smell of anything, although the breathing mask you need in order to use it may have a faint plastic smell. You use gas and air through a mouthpiece with a 'demand valve' which releases the gas as you breathe in, so that you completely control how much you take in, and when you do so.

Entonox® is best used at the start of a contraction, as soon as you feel it beginning. It takes about 20 seconds to work (and about two minutes to reach its peak). Using Entonox® as the contraction starts means that it reaches its peak effectiveness when you are in the most powerful part of your contraction.

Most women find Entonox® effective and some find it hugely effective. Many find that it lives up to its name of laughing gas by making them feel cheerful, relaxed and even euphoric. Some say that Entonox® does not take away the sensation of labour pain, but it stops them from finding it unpleasant or difficult to bear. Others say that it reduces the pain so that they feel able to manage it.

Entonox® is controlled by you and wears off very quickly once you stop inhaling it. It doesn't harm your baby and it can be used in most situations. However, some women don't like the slightly groggy sensation it can cause at first (although this often wears off) and it can make your lips and mouth a little dry so you should take plenty of sips of water to counter this.

Use of opiate painkillers during labour

The opiate painkillers which are used in labour include pethidine, diamorphine, fentanyl and meptazinol (Meptid®). All work in a similar way, to relax you and reduce the sensation of pain, although pethidine is the one you are most likely to be offered.

Opiate painkillers are available in hospitals and birth centres, and pethidine is also used for some home births. (If you are planning a home birth you should ask your midwife in advance if they are happy to use pethidine during your home birth.) About 1 in 4 women use an injected opioid during labour. These painkillers are given by injection into your thigh, usually combined with an anti-sickness medicine, as they may otherwise make you feel sick.

Pethidine and other injected opiates
Pethidine is most useful in the earlier stages of labour, when it helps you relax and may enable you to get some rest. It can make you drowsy and make you lose track of time. It takes 20-30 minutes to work and each injection lasts for 2-4 hours. Your midwife may repeat the dose after one to three hours if it isn't having enough effect. Sometimes pethidine can be given by a pump that you control yourself by pressing a button on the pump.

Pethidine should not be given too close to the birth of your baby, as it can affect the baby's breathing and make them sleepy after birth. It may also make you too drowsy to push effectively. For this reason, you won't normally be offered pethidine if your midwife thinks that your first stage of labour is nearly over. There is an antidote, naloxone, which can be given to you and to your baby if the midwife needs the pethidine to wear off quickly.

Pethidine (and the other opiates) isn't for everyone - it doesn't cut out pain altogether and it can make you feel out of control. Some women find the side-effects unpleasant, and some women find it slows their breathing so that they need to use oxygen through a mask.

Pethidine (and the other opiates) can make your baby drowsy and affect their breathing after birth, which can make it more difficult to get breastfeeding started.

Patient-controlled intravenous anaesthesia (PCIA)
Sometimes an opiate medicine is offered not as a single injection but as an infusion, a tiny quantity at a time, via a pump into a vein. PCIA is set up by an anaesthetist, who will explain how to use it. PCIA allows you to control the amount of opioid medicine you have (safety devices prevent you from accidentally using too much). In a few maternity units, PCIA uses an opioid called remifentanil, a short-acting medicine which is less likely to affect your baby after birth, but which is more likely to slow your breathing.

What is an epidural like?

1 in every 3-4 women have an epidural or spinal injection during labour or after the birth. An epidural is a type of anaesthetic block which works by putting local anaesthetic and painkillers directly around the nerves that bring pain signals from your womb (uterus), the neck of your womb (cervix) and your perineum, close to where they join the spinal cord in your back. It is the most effective way of relieving pain.

What is the epidural space?

An epidural anaesthetic is injected into the epidural space. This is one of the outer protective layers around the spinal canal and is a cushioning space containing blood vessels and fat. Crucially, the roots of the nerves that join the spinal cord and carry pain sensation from your lower body pass through the epidural space. The epidural space is separated from the subarachnoid space (in which the spinal cord lies) by a tough membrane called the dura.

How is an epidural put in?

Siting an epidural is a specialised task performed by an anaesthetist. You'll need to have an intravenous drip sited first, so that you can be given fluids. The anaesthetist will usually put the epidural in place between contractions. You will normally need to lie on your side, curled up, and the anaesthetist will be behind you, feeling your spine. He or she will give you a local anaesthetic injection to numb the skin, then insert a fine needle into the lower part of your back between the bones. He or she uses this to place a thin, flexible medication-delivery tube into the epidural space, close to the nerves which carry pain messages from your womb and birth canal. The tube is taped in place so that it doesn't come out as you move around.

The tube is used to put the medications into the space, where they bathe the nerves. The epidural can then either be 'topped up' when the medications start to wear off, or may have painkillers pumping continuously into it. Both allow its effect to last for the whole of labour. The medications may consist of anaesthetic alone, or a mixture of a local anaesthetic and an opioid.

If you have an epidural then your midwife will need to monitor your baby's heartbeat and your blood pressure regularly. You won't be able to use a birthing pool.

How quickly does an epidural work?

An epidural usually takes 20-40 minutes to give pain relief, counting from the time the anaesthetist gets you to curl up. It has hardly any effect on your baby and it won't make you feel sick or sleepy.

When in labour is an epidural given?

You can have an epidural at any time in labour, as long as the anaesthetist is available. Women tend most often to want an epidural when their contractions are getting strong, and they are in active labour (which is usually when the cervix is 4 cm dilated or more), although if you wait too long and are about to push it may be a little late for the epidural to be given and to work before delivery.

An epidural can be particularly helpful if your labour is speeded up with an oxytocin or syntocinon drip, which makes your contractions stronger.

What are the pros and cons of an epidural?

The advantages of epidurals are considerable, which is why they have become one of the most popular choices for women in labour:

• Epidurals are the most effective form of pain relief during labour. Women are usually completely pain-free.
• Your midwife can usually top up the epidural, so this is quick and easy and does not need the anaesthetist.
• You won't feel drowsy or groggy and you may be aware of your contractions.
• Your midwife will try to keep the epidural 'light' so that you still feel the urge to push and can push your baby out as normal.
• An epidural can be topped up with stronger local anaesthetic if you need an assisted delivery or an emergency caesarean.
• An epidural has virtually no effect on your baby.

The disadvantages and risks of having an epidural are:

• You have to wait for an anaesthetist to come to site the epidural, so from deciding you want one to it working fully can be 40 minutes or more.
• For about 1 woman in 8, the epidural works partially and extra pain relief will be needed as well.
• You may feel shivery, hot or itchy.
• Your legs will feel weak or heavy, so you probably won't be able to walk around. A few hospitals do offer true 'mobile' epidurals (see below).
• It can affect your ability to pass urine, so you may need a catheter to empty your bladder just after your baby is born.
• An epidural can slow the first stage of labour slightly and so it slightly increases your chance of needing an oxytocin drip.
• An epidural can slow the second stage of labour slightly, reducing the urge to push and slightly increasing the chance you'll need an assisted delivery.
• There is a 1 in 100 risk of you getting a headache. This can happen if the epidural needle punctures the bag of fluid that surrounds the spinal cord. It's usually treated by taking a sample of blood from a vein in your arm and injecting it into your back to seal the hole made by the needle (this is called epidural blood patch) after your baby is born.
• There's a 1 in 2,000 risk of temporary damage to your leg nerves, leaving you with a numb patch on your leg or foot, pins and needles, or a weak muscle. There is a 1 in 24,000 risk of this being long-lasting.

Some women worry that epidurals can cause backache. In fact backache is very common after pregnancy and labour and is not more common in women who have had epidurals than in women who have not. The site of the epidural can occasionally be tender to touch for some days after your delivery.

What is a walking epidural?

Some hospitals have a 'walking epidural' (mobile epidural) service (although most women will not be able to walk, even when they have a walking epidural). A walking epidural is a type of low-dose epidural. It aims to allow you to retain enough sensation in your legs and feet to move around, by varying the medications you are given and keeping them to a minimum.

With a mobile epidural you may be able to move around and possibly even walk about, although your balance and strength are both likely to be greatly reduced, so somebody will need to be with you and supporting you. Because the medication dose is low you may feel more of the sensations of labour, but otherwise a mobile epidural is very like a normal epidural, except that you have more power and sensation in your legs.

Mobile epidurals need specialist equipment that can monitor your baby's heart rate without you being connected to the device by a cable. Not all hospitals have these.

Is an epidural for a caesarean section different to an epidural for labour?

An epidural for a caesarean section is sited in exactly the same way as an epidural for labour. If you need a caesarean section then the doses of medications in your epidural will be higher, to ensure you have absolutely no sensation in your tummy during the caesarean operation.

If you have an epidural in labour, it can be converted to an epidural for a caesarean section by topping up the medications in it. However, in about 1 in 20 women the epidural is not quite effective enough for this, in which case you might additionally need a spinal anaesthetic or a general anaesthetic (see below) for a caesarean section.

What is a spinal injection like?

A spinal injection is a single, one-off injection. It is put into your back in a very similar manner to an epidural, by an anaesthetist, but into a slightly different place:

• For a spinal injection, the painkilling and numbing medications are injected into the protective fluid (cerebrospinal fluid, or CSF) which surrounds the spinal cord itself. The place where the medications are put is called the subarachnoid space. (This is further 'in' than the epidural space, which is an outer, cushioning space, separated from the subarachnoid space by a tough membrane called the dura.)
• A spinal injection is usually injected slightly lower down in your back than an epidural.
• A spinal injection is less selective - it will bathe the lower part of the spinal cord and the nerves to the lower body with painkilling medications so that all the nerves to your lower body are affected. You won't feel your tummy, hips, bottom or legs at all. You won't be able to move your legs.
• A spinal injection can't be topped up as no tube is left in place. It typically lasts 1-2 hours, which is easily enough for most caesarean sections and assisted deliveries, although it can last longer, depending on the medications that are used.

The advantage of a spinal injection is that it is effective very quickly - taking about five minutes to work. This is much faster than an epidural, and this can make it a better option late in labour. There is also a much lower risk of complications such as headache than with an epidural.

The combined spinal-epidural

A combined spinal-epidural anaesthetic (CSA) is not offered in all hospitals. It consists of a combination of a spinal and an epidural anaesthetic, so that you get the fast and complete painkilling effect of the spinal injection, combined with the ability to top up the epidural if the spinal injection wears off. Sometimes two separate needles are used - the spinal first. Sometimes both the spinal and the epidural are given via one injection.

The intention of this combination method is to give less total medication dose (a spinal injection uses an extremely small medication dose compared to an epidural) whilst keeping the ability to give you added pain control in the postoperative period (when the spinal injection wears off).

What is a general anaesthetic like?

A general anaesthetic may be needed for an emergency caesarean section if you don't already have an effective epidural and there isn't time for a spinal injection to work.

• You will have an intravenous cannula in your hand or arm. You may be given an antacid medicine to drink.
• You'll be taken into an anaesthetic room and a mask will usually be placed over your face to give you extra oxygen.
• You may be asked to count, and the general anaesthetic will be given into your drip. You may be slightly aware that someone is supporting your neck, but you won't remember anything after this. The medication works extremely quickly.
• You will wake up in the recovery room and can see your baby as soon as you are awake.
• Your throat may feel sore and you may a bit muddled. You may feel sick, but will be given medication to settle this if it happens.
• Your partner won't be able to come into theatre with you if you have a general anaesthetic, as his or her role is to support you (rather than to watch the operation), and you will be asleep.

The risks of a general anaesthetic are higher for you and your baby than a regional anaesthetic like an epidural. However, a general anaesthetic is usually used for a caesarean only if the risks for you have changed, so that overall, general anaesthetic has become the safest option.

The common complications include a sore throat, feeling sick, muscle pains and shivering. Rare complications include acid getting into your lungs, serious allergic reactions and being awake during the procedure.

How do I decide what pain relief to choose?

No single method of pain relief is the best choice for everyone, as women vary in their experience of pain and of labour. You may try several different things before you find what works for you. Your choice will be affected by what you think about the various methods, by the experience you would like to have and by how labour goes for you.

Writing your birth plan will help you think about what you would like to happen. If you have questions, your midwife will be able to give you advice. Once you are in labour it will help you to keep an open mind. Labour is an unpredictable experience, even if you have done it before, and the best and safest option for you and your baby may change as things progress.

The task of your delivery team is to keep you and your baby healthy, to deliver your baby safely and in the way that is safest and best for both of you, and to do everything with your involvement agreement, whilst keeping you fully informed. Very occasionally, things change too quickly for you to have as much time as you would like to make decisions - and if this happens it is very important that people talk things through with you afterwards, so that you are able to understand what happened and, hopefully, feel that choices made on your behalf were the right ones.

Feeling proud of yourself

Women give birth every day, in a world in which we often set ourselves very high standards. It is easy to look around and find stories of women who gave birth without pain relief, calmly and serenely, at home or in birthing pools where they delivered babies that didn't cry. Faced with this it's possible to feel that, if you don't do the same, you have been less brave or stoical or brilliant than you should have been, and that by taking advantage of modern pain management options you have in some way let the side down.

Try to remember, if you feel this way, that giving birth isn't a competition; it's an heroic and extraordinary thing to do. Labour is different for every single woman, and most women need some help with pain management. Don't set yourself impossible standards - you should feel proud of yourself for facing and experiencing this huge challenge, whatever pain control and whatever type of delivery you have.