Pain relief options for labour and birth

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, more commonly known as 'gas and air', is a mixture of 50% oxygen and 50% nitrous oxide gas.

It can help reduce pain during labour and make it more bearable. You breathe this gas in via a mouthpiece as soon as you feel a contraction coming so you have the full effect when the contraction is at its peak. You then breathe normal air between contractions. 

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. 

Epidural is usually the most effective method of pain relief during labour that we can offer. This can only be provided by an anaesthetist, who is a doctor that is specially trained to give anaesthetics and pain relief.

What is an epidural? 

An epidural is a small plastic tube that sits in the space surrounding your spinal cord. The plastic tube is fed through a needle placed in your back to make sure it is in the correct position and then the needle is removed, leaving only the plastic tube itself taped to your back. 

How does an epidural work? 

A local anaesthetic called Bupivacaine, and a very small dose of a morphine-like drug called Fentanyl are injected through the plastic tube and act by numbing the nerves which pass out from your spinal cord and travel to the areas causing pain such as your womb, cervix and vagina. 

At Worcestershire Royal Hospital we use a system called PCEA (patient controlled epidural analgesia). This means you have a button to press when you require pain relief, giving you more control over how much drug relief you receive and the ability to try and reduce side effects such as heavy leg. 

Who can have an epidural?

Generally, anyone can be offered an epidural once in labour. 

There may be certain circumstances when an epidural is unsafe or impossible to administer (for example problems with blood clotting and bleeding) and in the majority of cases we will have discussed these cases in the antenatal anaesthetic assessment clinic. 

If you would like any further information then you can discuss this with your midwife or obstetrician, who can then refer you to the anaesthetic clinic if appropriate. 

When can you have an epidural? 

Once your midwife or obstetrician has confirmed that you are in established labour you may request for an epidural to be sited. 

Epidurals are only given on Delivery suite as you will need additional monitoring.

An epidural can take up to 30 minutes to give you adequate pain relief in labour. There may come a point, late in your labour, when your midwife or obstetrician suggest that you may well deliver your baby before you get any benefit or pain relief from your epidural. 

This means the risks of having an epidural very late in your labour may outweigh any benefit you receive. 

Who will give you an epidural? 

A specialist doctor who has been specially trained to position epidurals for labouring women will do this for you (an anaesthetist).

We always have an anaesthetist available 24/7 on delivery suite, if they are busy, we can contact other anaesthetists to come and  site an epidural, there may be a short delay if this occurs, we will offer you additional pain relief in the meantime.

How is your epidural inserted?

The process of placing an epidural in your back for pain relief in labour should take approximately 15 to 20 minutes. It can take significantly longer than this if the procedure is difficult (for example increased weight or Body Mass Index (BMI) or if the epidural is being inserted late in your labour). 

You will need a cannula or drip in your hand if you don’t already have one. You will then be asked to either sit on the side of your bed or lie on your side.

Your anaesthetist will prepare your back with antiseptic and numb your skin with a local anaesthetic injection. This will sting for a few seconds but once the skin is numb you should not feel anything more than pressure or mild discomfort in your back.

It is possible that the plastic tube may brush against nerves in your back as it is inserted; you may feel this as tingling or an ‘electric shock’ in your hip or leg. It should only be a momentary sensation but you should still mention to your anaesthetist if it occurs.

Once your anaesthetist has confirmed the plastic tube is in the correct position, it will be stuck to your back with tape, and you will be asked to lie back in bed. The tube will be connected to a pump, and you will be given a button to press which you can use to control the amount of painkiller you receive through the tube. 

Your midwife will then monitor your blood pressure and the baby at regular intervals throughout your labour. 

What can you expect from an epidural? 

In most cases, you will begin to feel pain relief within approximately 30 minutes of insertion. Occasionally epidurals either do not work at all or work partially in an unpredictable way.

If this is the case your anaesthetist can attempt to get your epidural working by changing your position on the bed or by injecting extra doses of local anaesthetic through the epidural. Ultimately, it may be that your anaesthetist suggests removing it and putting another one in, but this will only be after discussion with you. 

As well as giving you pain relief, epidurals will make your legs feel heavy. This heaviness will often prevent you getting out of bed and may stop you moving around the bed. By using your button less frequently you may be able to reduce the heaviness in your legs and so increase your mobility.

All epidurals can be 'Mobile' epidurals and if you wish, and it is safe to do so, then an epidural does not have to restrict you to bed. You can discuss this with your midwife or anaesthetist at the time. 

Epidurals are available to you as means of pain relief during labour. The purpose of an epidural is not necessarily to remove all pain and sensation therefore reducing your ability to participate actively in delivering your baby, but to assist you in getting through your labour and delivering a healthy child. 

The loss in sensation you feel will disappear very quickly after the epidural has been stopped. 

What are the benefits of an epidural? 

Although not 100% reliable, epidurals are the most effective form of pain relief we have to offer you. 

If required, an epidural can be used to make you completely numb if you need either a caesarean or forceps assisted delivery. 

They can have even greater benefits for people with heart and lung disease or if your blood pressure has been difficult to control (eg. Pre-eclampsia). These can be discussed with your anaesthetist. 

Patients are generally more satisfied with their pain relief in labour from an epidural compared to other methods such as pethidine or gas and air (Entonox). 

What are the side effects of an epidural? 

These are mostly predictable and will affect different individuals to a variable extent. They include: 

• Dizziness and nausea caused by a fall in blood pressure (this often only lasts for a few minutes after the initial dose or a larger drug dose is given through the epidural) 

• Itching (can last for several hours after stopping the epidural) 

• Heavy, tingling legs (disappears soon after epidural stopped) 

• Inability to feel a full bladder and pass urine whilst epidural is working (may mean you need a catheter tube passed into your bladder whilst the epidural is working. This is removed as soon a sensation returns) 

• Are there any complications? 

Some complications are less serious but may happen more frequently and include: 

• Failure to give you adequate pain relief in labour. Your epidural may need to be removed and replaced before it works adequately. 

• Failure to work well enough if a caesarean section is required so that you need a general anaesthetic 

• (Approximately 1 in every 20 women having an epidural) 

• Headache (Post Dural Puncture Headache) 

• (Approximately 1 in every 100 women having an epidural) 

An area of numbness that lasts longer than expected (eg. Days to weeks) (There is no convincing research to tell us how often these mild and short lived complications occur but they are probably in the region of 1 in every 1000 to 4000 women having an epidural). Effects that last longer than 6 months are much less common at approximately 1 in every 24,000 women who have an epidural. 

It is possible that you will be more likely to require an assisted delivery (Forceps or a Ventouse/suction cap)(link to assisted delivery page) if stronger drugs need to be used due to the epidural not working well enough. Very weak painkiller is used in our epidurals so that a good balance between pain relief and side effects can be reached. 

Other side effects are VERY rare but CAN be serious such as: 

• The local anaesthetic affecting your breathing and making you so drowsy that you need a general anaesthetic (Total Spinal)

There is no evidence to suggest how often this occurs but is very rare in the order of 1 in every 5000 women having an epidural)

• Infection around the spinal cord (Epidural abscess)

(Approximately 1 in every 50,000 women having an epidural)

• Meningitis (infection around the spinal cord and brain)

(Approximately 1 in every 100,000 women having an epidural)

• Blood clot within the epidural space (Epidural haematoma)

(Approximately 1 in every 170,000 women having an epidural)

• Damage to spinal cord resulting in permanent disability

(Approximately 1 in every 250,000 women having an epidural)

These figures are based on the best evidence we have available at the moment and will be reviewed at regular intervals.

Before you have an epidural your anaesthetist will go through any advantages, common side effects and serious potential complications. For further information see the resources below.

Epidural analgesia - Labour Pains

Epidural - NHS

Myths about Epidurals

There's a lot of myths about the reality of an epidural. For example: 

• Epidurals do not increase the risk of you having a caesarean section. An epidural will sometimes be requested then because your labour is more complicated or the doctors and midwives looking after you feel that there is a very high risk of needing an assisted delivery or caesarean section. This means that epidurals may be used or in place in mothers who end up having caesareans, but research has shown that epidurals are not the cause of needing the operation. 

• Epidurals do not cause back pain. If you have pain in your back after going through pregnancy, labour and then delivering a baby, it is easy to blame a needle in your back if the pain is close to where the needle was inserted. There has been a lot of medical research into this and the conclusion is that epidurals do not produce new back pain or make existing back pain worse. 

• You can have an epidural at any time from when your midwife confirms you are in established labour and your anaesthetist has established it is safe for you to have one. If you ask for an epidural at the end of your labour then your anaesthetist and midwife may advise you that you will probably deliver your baby before an epidural can be sited and give you any pain relief. This means you run all the risks of and epidural but probably deliver before getting any benefit from pain relief. 

• You will not be paralyzed by an Epidural or spinal. Permanent, severe damage to nerves which results in paralysis of your legs is profoundly rare in pregnant women. This can occur by introducing infection or a very damaging drug through the epidural onto the nerves or the needle makes direct, painful and prolonged contact with the nerves. 

Anaesthetists receive a high level of training to enable them to position and inject epidurals cleanly and safely is intensive and thorough and there are tight controls over the drugs which are injected into epidurals. A specific project looked at all the epidurals sited in the UK over a year and found that with more than 320,000 epidurals and spinals performed on labouring women, none died or were paralyzed by a needle in their back. 

The number of times this problem occurs is SO rare that it is impossible to collect enough information to give accurate estimates of how often they occur. The rough estimate of 1 case of paralysis in every 250,000 epidurals hopefully gives the correct impression that this problem is VERY rare and we would hope that this would not put women off having epidurals for pain relief in labour. 

Useful Information  

Epidural analgesia - Labour Pains 

Epidural - NHS 

Remifentanil is available on delivery suite and is a strong painkiller similar to Pethidine (opioid).

How is Remifentanil given during labour? 

The pain-relieving effect of Remifentanil comes on very quickly and wears off very quickly. Therefore, it must be given in repeated short bursts targeting the same pattern of your labour contractions. It is given through an intravenous cannula (a drip in your vein) which will be attached to a Patient Controlled Analgesia (PCA) device.

This means you will be given a handheld button to press on when you feel the pain. When pressed, a measured dose of Remifentanil will go into your bloodstream, which will act instantly. After a few attempts, you will quickly learn when to press the button to get the peak effect of the drug to coincide with the peak of your contraction pain.  

What additional monitoring do I need while using Remifentanil PCA? 

Because Remifentanil is a very strong opioid, it can affect the breathing and level of oxygen. Therefore, additional monitoring and precautions are required. The midwife will have to stay with you at all times.

Your oxygen levels will be continuously monitored with a probe on your finger. You may need supplementary oxygen whilst using the PCA button. Your midwife will also monitor your blood pressure and heart rate. You will be allowed sips of water but will not be allowed to eat. 

What are the side effects of Remifentanil? 

Possible side effects include drowsiness, dizziness, nausea, itching and a drop in oxygen level as it might affect your breathing. There has been a small number of reported cases who have stopped breathing, but they all responded quickly to treatment; that is why the midwife will monitor you continuously. It may also slow your heart rate or drop your blood pressure.

You can stay mobile while using a remifentanil PCA however you may be restricted as you will be attached to a drip. Some studies have shown that labouring mothers are quite happy with Remifentanil pain relief for the first part of their labour, but as the contractions intensify, they become less satisfied.

You can use Entonox or your TENS machine along with the Remifentanil in this case. Remifentanil has been shown to be safe for babies. 

Who can use a Remifentanil PCA? 

Apart from a few contraindications, such as allergies, other medication you may be taking that could interact with remifentanil, or health issues such as severe heart or lung disease most patients can have a Remifentanil PCA as an alternative to an epidural.

The epidural is still considered the best pain relief we can offer in labour, so we tend to recommend Remifentanil to those who cannot have an epidural or when the epidural is not effective; however, the choice is yours as long as there are no risk factors.

For further information about pain relief options in labour and to compare the risks and benefits of each method pyou can visit: Pain relief and anaesthesia choices during labour - Labour Pains.