Maternity FAQ - Pain relief

Pain in labour comes from the nerves around the bottom of your womb and women describe labour pain in many ways. They also feel the pain in different places – such as the lower back, lower tummy, legs or labia. At the point of giving birth, women often describe a very strong burning sensation.

Many things will affect the pain you experience, such as the position of your baby in the womb, how tired you may be, or whether you have someone with you for support. Other things going on in your life can affect how you cope with your labour pain, and if you are anxious, you could speak to your midwife, who will support you.

The pain relief options outlined in this leaflet are about reducing the pain that you feel or about helping you to cope with it, they are not about taking the pain away altogether.

At Worcestershire Royal delivery unit, we are able to offer women in labour several different types of pain relief throughout labour. This can help you to prepare for labour and you may want to include your preferences on your birth plan if you choose to have one.

The information below should be read in conjunction with the ‘Latent Phase of Labour’ leaflet and aims to explain the different types of pain relief available to you throughout your labour. This can help you to prepare for labour and you may want to include your preferences on your birth plan if you choose to have one.

Coping skills for labour

There is much you can do to help yourself during labour. For example, studies have shown that women find it important to have a birth partner throughout labour, and continuous one-to-one care can reduce the need for pain relief using drugs.

It is known that upright positions and walking often help labour to progress, so it may help to remain mobile, adopting different positions as you are able. Use chairs, cushions, and the bed to move between positions that make you feel most comfortable and relaxed.

Sitting on a birthing or exercise ball and rocking gently may help, and certainly you should avoid lying down on your back. Try relaxation methods and breathing techniques that you may have learned during childbirth preparation classes or yoga groups or using a CD or DVD.

Complementary Therapies

Complementary Therapies

- Reflexology

- Acupuncture

- Hypnotherapy (Hypnobirth)

Some women may use complementary therapies such as Acupuncture, Reflexology, and Hypnosis. However, whilst some midwives are trained in the use of Aromatherapy, if you wish to use another type of therapy, you will need to be trained in its use, and to bring a support therapist with you when in labour.

TENS

TENS

TENS stands for Transcutaneous Electrical Nerve Stimulation.

Four small pads are placed either side of the middle of your lower back. Small electrical impulses are then passed from the box through the pad and disturb the pain messages being sent from the womb to your brain. A specific “labour” TENS machine will have a Boost function enabling you to briefly increase the electrical stimulation during a contraction.

Advantages

• It has no known effects on your baby

• It does not restrict your movements

• You control the intensity

• Can be used at home in the latent phase of labour right up until your baby is born

Disadvantages

• Not everyone likes the tingling sensation from the electrodes

• It cannot be used in the bath or birthing pool

• It cannot be used if you have a heart pacemaker fitted or if you have heart disease

Water

Water

Using a birthing pool during labour can promote relaxation and has been shown to reduce the need for other forms of pain relief. You can discuss with your midwife about whether the pool is appropriate for you, but it can help with mobilising and finding a position that you find comfortable.

Your midwife will ensure that the water temperature remains within a comfortable range, particularly if you choose to give birth in the water. You will be encouraged to drink plenty of fluid when using the pool to avoid dehydration and to leave the pool at regular intervals to empty your bladder. You can also use Entonox (gas and air) whilst in the pool.

Advantages

• Provides a relaxing and peaceful environment

• You can use Entonox whilst in the water

• You do not need to exit the pool to give birth

Disadvantages

• Use of water during labour and birth is not suitable for everyone. Discuss with your midwife whether a birthing pool would be suitable for you.

• You will need to come out of the pool if you require any further pain relief other than Entonox

Oral Painkillers

In addition to the self-help techniques outlined above you may find that simple tablets can help you to cope with the early stages of labour. It is safe to take Paracetamol and up to 1 dose of Codeine, making sure you do not exceed the dose stated on the packaging. Ibuprofen is not recommended for use in pregnancy.

Entonox "Gas and Air"

To get most benefit from Entonox:

By starting to breathe the gas just as you feel a contraction starting means that when the contraction is at its most painful, you should be getting maximum effect from the drug. You should stop using it between contractions.

The advantages of Entonox are:

• It is simple to use, quick to act and wear off and you can use it at any time during labour

• You can control the amount you use

• It will cause your baby no harm and as you are breathing in extra oxygen, it may be of benefit to you both.

• It can be used with other forms of pain relief

The potential disadvantages are:

• Entonox will not take away your contraction pain completely

• It can make some people feel sick or light headed or make your mouth dry

Pethidine

This is a morphine-like drug (opioid) traditionally used to treat moderate to severe pain. It has been used for many years to treat labour pain and for some people it can be effective in helping you to cope with pain in labour. It is given usually as an injection into a large muscle in your bottom or leg; it can make you feel sick and so an anti-sickness medication is often given to you at the same time.

Advantages of Pethidine:

• It should be readily available to anyone because midwives are able to give pethidine without prescription from a Doctor.

• Pain relief may be limited but some women say that the drowsiness it causes makes them feel less concerned about the pain

Disadvantages of Pethidine:

• It can take 20-30 minutes to work and the pain relief may only last 2-3 hours. It has less effect on pain than Entonox

• Some women complain about being disappointed with the pain relief as well as feeling less in control of their labour.

• It may make you feel: sleepy, sick, or slow your breathing down enough to need oxygen through a mask.

• It may make your baby drowsy and slow to take its first breath and this may affect how well it can breast feed. (This is true of all morphine-like drugs such as morphine, diamorphine, fentanyl, or Remifentanil but especially Pethidine and if given more than one dose. This is because it takes your baby much longer to remove the drug from its body than an adult does).

Epidural

Epidural

An epidural is a small plastic tube or catheter which is placed in the lower part of your back through a needle. This is done by a specially trained doctor called an Anaesthetist.

A combination of local anaesthetic drug (Bupivacaine) and a morphine-like drug (Fentanyl) are then injected through the tube to produce numbness and pain relief to your tummy and back.

They will also produce numbness and heaviness in your legs which may be undesirable.

In Worcester we use a Patient Controlled Epidural Analgesia (PCEA) system. This means that you have a button to press which enables a special pump to give you a dose of painkiller. It means that you can give yourself as much painkiller as you need but also the opportunity to use it less often to reduce side effects such as heavy legs and reduced ability to move around.

The advantages of Epidural pain relief in labour can include:

• The most effective pain relief we can offer that will continue to work throughout your labour

• There is less acid in your new-born baby’s blood compared to using other pain relief such as Pethidine.

• The ability to use an epidural as an anaesthetic if needed for a Caesarean section or use of forceps to assist vaginal delivery.

• Avoiding all the negative side effects of and problems with the morphine-like drugs to mother and baby including: drowsiness, sickness, itching, difficulty emptying you bladder and less need to use medication to help you baby breathe when it is born.

The Disadvantages of Epidural pain relief in labour include:

• Your legs may feel weak and heavy reducing your ability to move around the bed or assume a wider variety of birthing positions

• The chance of needing an assisted delivery (use of Venteuse cap or forceps) increases if the epidural has made you very numb

• An epidural can prolong the second stage of your labour after you are fully dilated and pushing the baby out. You are also more likely to need medication through a drip to make your contractions stronger (Oxytocin).

• You will find it difficult to pass water and may need a tube to be passed into your bladder to drain the urine – this is usually removed straight away

• You may feel itchy or develop a fever which can distress your baby

There is more comprehensive and detailed information about Epidurals here

Other options for pain relief in Labour

These drugs all work in a similar way to Pethidine but are administered through a vein, usually as part of a Patient Controlled Analgesia (PCA) system (you controlling the amount of painkiller you receive through a drip by using a button which enables a pump to give you a dose when you need it). By using this system, giving strong painkillers through a vein can be much safer.

Remifentanil is a drug like morphine but much stronger. It acts very quickly and wears off within a few minutes as gas and air does. This means any effects of the drug you or your baby may feel will wear off a few minutes after stopping it, unlike the effects of other strong painkillers like Diamorphine and especially Pethidine.

Remifentanil is available at WRH, but its use has usually been discussed and agreed with an Anaesthetist before labour. It can have dangerous side effects and can slow your breathing and heart rate down considerably. This means your heart rate and oxygen levels will be monitored continuously and your midwife will be with you at all times whilst using the drug.

Research tells us that although the pain relief provided is not as good as with epidural, mothers are generally satisfied when they use it for pain relief in labour.

This link will help you compare the risks and benefits of the different types of labour pain relief: http://www.labourpains.com/assets/_managed/cms/files/InfoforMothers/Pain%20Relief%20Comparison%20Card/pain%20relief%20comparison%20card%20september%202014.pdf

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