Pain relief - What are the options?

Dr Anil Sharma explains the various options available when it comes to pain relief in labour.

Whenever labour is depicted on television or in the movies, it almost always involves the image of a sweaty, loud woman in pain (usually having her personal space invaded by her panic-stricken, hapless partner). While I am conscious of the fact that I will never experience the event itself, labour does not have to be like this. It never ceases to amaze me how women cope so well with what must be one of the most imminently foreboding experiences for our species. Careful preparation and a thorough knowledge of options to deal with the pain, as well as a go-with-the-flow approach, are arguably the best tools against the fear of the unknown.

When it comes to labour and the topic of pain relief, there are very different firmly held views from women, women’s groups, midwives, doctors and just about everyone else.

A measure of pain
Labour involves a number of changes, including muscle contractions and stretching of tissues, and it is not surprising that pain receptors in your body will let your brain know that the process is causing pain. First labours are probably more painful than subsequent ones, and induced labours often hurt more than natural-onset ones. The other thing to remember is that everyone's perception of pain is different, and what is just uncomfortable for one person can be extremely painful for another. Pain is a complex topic with many external factors as well. These include culture, upbringing and life experiences. Attitudes to medications, both natural and other, also play a part. I think it's safe to say that no two labours are alike, not even for the same woman.

It is also fair to say that the more physically fit you are, the higher the chances you will cope better (in general) with the pain of labour. Therefore, care with your diet, stopping smoking, and regular, appropriate exercise are all useful.

Support is key
Your midwife will spend a lot of time with you in labour, and this support itself has been shown to significantly help with the perception of pain in labour. Labour support includes continuous presence (around 80% of the time or more), emotional support, and physical comforting. In a review of many trials involving a total of nearly 13,000 women, there was a lower likelihood of needing or using opiate drugs for pain relief or epidurals if the woman received continuous labour support. There was an even greater benefit if the support person was not a member of the hospital staff and if their only task was to provide the labouring woman with support.

In position
There have been a number of trials looking at how a woman's position can help with the pain of labour. The problems, of course, centre on how to set up protocols for each position and do adequate comparisons. However, in summary, these trials in both the first and second stages of labour suggested that, in general, sitting more upright most of the time with occasional other positions decreases pain and may possibly shorten labour. Also, it must be remembered that whatever position is most comfortable for you in labour is the best one.

Music
Audio analgesia is the use of auditory stimulation, such as music or environmental sounds, to try and reduce pain. While the studies do not provide firm evidence for it being helpful, there are no known drawbacks to using music in labour.

Water
A bath or shower can be useful in labour as it is soothing, can make you feel lighter, and can be a nice distraction. The results of studies on baths in labour indicate that with attention to water temperature, duration of the bath, and other guidelines for safety, they are effective in reducing pain. A discussion about the pros and cons of birthing in water is beyond the remit of this article although your LMC will have more information if you ask for it.

Heat and cold
Heat is typically applied to your back or tummy and less often to the outside of the birth canal. This can be with a hot water bottle, wheat pack, or even a warm cloth compress.

Cold is usually applied on your back, chest or face during labour. Forms of cold include a bag filled with ice, or a cloth soaked in cold water. It is important to protect the skin where the application is taking place to avoid direct skin damage. These thermal applications should not be used (on the anaesthetised areas) if you have an epidural, as it could damage your skin.

Acupuncture and acupressure
Acupuncture originated from traditional Chinese medicine and involves the passage of very fine needles into the skin at combinations of specific points along specified areas (called meridians). Acupressure is when pressure with fingers or small beads is applied on acupuncture points. There is no published evidence that it can work in relieving labour pain. Acupuncture, on the other hand, has been shown to significantly reduce the reports of pain. Maternal satisfaction was high and there are no known risks to women who use acupuncture, when practiced by trained practitioners using disposable needles. Acupuncture provides an effective alternative to drug-based pain relief; however, larger studies are needed to properly evaluate acupuncture for widespread use in labour.

Hypnosis
Hypnosis is a state of deep physical relaxation that allows the subconscious mind to be more readily accessed. In this state, the individual is more open to be influenced or have increased 'suggestibility'. Hypnosis for childbirth is almost always self-hypnosis. The hypnotherapist teaches you to induce the hypnotic state in yourself during labour. Various techniques are taught, including 'glove anaesthesia', in which you imagine that your hand is numb and can spread that numbness to other painful areas by touching them.

TENS
TENS is a way of passing a low-voltage electric current across some pads on your back. This stimulates your body to produce it's own natural pain relieving substances called endorphins. It can take around 30 minutes before any effect is felt and the results do vary across individuals. It is a safe and often effective method of pain relief (especially in early labour) and the machines can be hired from some pharmacies in New Zealand.

Massage
Massage can provide good analgesic (pain-relieving) qualities and be a great relaxant. Ask your partner for plenty of practice massages using suitable oil in the months leading up to labour. Massage of the lower back seems particularly helpful for many women in labour. However caution is advised, as many women cannot bear to be touched or crowded when in pain.

Breathing techniques
While a slightly controversial topic, there is no doubt that good breathing techniques, like those taught in yoga, invoke a feeling of wellness and calm. Oxygen delivery to both mum and baby is better with regular, relaxed deep breathing, and concentrating on breathing also provides distraction therapy to the pain.

Antenatal classes
While there is no research trial evidence, it is likely that these would be useful to prepare couples in their first pregnancy. In my opinion, given the unpredictability of pregnancy and labour, it is best to go to a 'balanced' class that will discuss all possibilities and not just focus on one type of birth or outcome.

Entonox (gas and air)
This is a mixture of 50% nitrous oxide (laughing gas) and 50% oxygen, which is inhaled by a mouthpiece. It is good for taking the edge off the pain during a contraction and can be safely used with other types of pain relief.

Pethidine
This opiate narcotic drug is used widely for pain relief in labour, being given by injection, usually into the muscle of the leg, or occasionally directly into an upper limb vein. It works by altering your perception of the pain. While usually very effective, it can cause nausea and drowsiness. Nausea can be managed with other drugs while drowsiness might allow you to get some much needed rest.

If given in a large dose too close to the birth, it can reduce your baby's breathing rate. This is relatively uncommon and a side effect that can be quickly reversed by giving the baby a drug called naloxone. Pethidine is very useful, as it doesn't negatively affect the process of labour. However, it will not take the pain away completely. Rather, it helps you cope, especially in early labour when a few hours of feeling relaxed, and possibly sleeping, would be welcomed.

Epidurals
The spinal cord is an extension of the brain that comes down in the backbone (which protects it). There are many nerves that carry commands away from it to muscles, and others that bring in signals (including pain signals). Epidural analgesia involves injecting medicines (local anaesthetic and opiate analgesic) into the epidural space (around the spinal cord), in order to block the impulses of the spinal nerves and to relieve pain.

An anaesthetist must set up and administer an epidural, so only medical maternity units with anaesthetists on call can offer this service. The main reason to have an epidural is for the relief of pain in active labour and while there is some disquiet and controversy about the so-called epidural epidemic, it remains a widely accepted form of pain relief in labour. The anaesthetist will discuss the procedure of setting up an epidural with you and a consent form will be signed by both parties. After inserting some local anaesthetic into the lower back via a needle and syringe, a thin tube is then inserted into the epidural space around the spinal cord. After a test dose, the medical agents are attached and very quickly (usually within 10-15 minutes) the contractions will be significantly less painful.

The main disadvantage is that epidurals also block the nerves that supply our muscles and bladder, thereby stopping other functions like movement of the lower half of the body and passing urine. The loss of some or most of the awareness of where to push in the second stage of labour can also be a problem for some women. Because of the blockade of other nerves that help us keep our blood pressure up, this can fall and therefore your blood pressure and your baby's heart rate are monitored once an epidural is sited. It remains a very popular choice for many mothers-to-be.

Dr Anil Sharma, MB ChB DGM Dip Legal Med FRANZCOG FRCOG, is a specialist gynaecologist working in Auckland. Dr Sharma was OHbaby!’s resident expert in obstetrics and gynaecology from 2008 to 2011. For more information on his practice visit dranilsharma.co.nz.