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Pain Relief Options During Labor

Osher Ben-Or, Certified Midwife
13 June 2024

The pain experienced during labor is distinct from other types of pain; however, as opposed to other types of pain, labor pain is viewed positively as it contributes to the progression of the childbirth process.

While there are numerous reasons for pain, most include uterine muscle contractions, cervix dilation, and the pressure of the embryo on the perineum.

Managing Pain: What Can Be Done?

Despite the intended role of pain during labor, every woman undergoing childbirth will need techniques to manage the pain, whether through medical interventions or natural approaches.

The midwife will offer you various choices, both medical and natural, that are available within the medical facility you have selected for childbirth. You can then opt for one of these alternatives.

Arriving well-prepared and familiarizing yourself beforehand with all the available options is recommended. This includes understanding the advantages and disadvantages, the application process, and the potential effects each choice might have on you. Occasionally, a combination of several options, for instance, medical with natural solutions, may be the best and most suitable option for you.

Pain relief options include:
  • laughing gas.
  • Epidural.
  • Pethidine.
Natural pain relief options include:
  • Touch, breathing.
  • Complementary medicine and guided imagery.
  • TENS device.
  • Water.
  • Heating.

The pain experienced during labor is distinct from any other pain you may have encountered in every respect: its nature, intensity, frequency, location, and the role it has during labor, with an emphasis on the progression of the childbirth process.

The nature of pain during labor

Labor pains come in waves. Between contractions, you will experience no pain at all. However, towards the end of the active stage (the second stage of labor), many women report a pressing pain between contractions. This is attributed to the position of the embryo’s head, which puts pressure on the perineum.

The intensity of pain and individual reactions will vary among women. The considerable variation in both pain response and intensity is not only apparent among different women but also within labors of the same woman.

When you make a hospital labor tour, it is important to inquire about the strategies for managing labor pain, including both medicinal choices (if desired) and the natural alternatives available within the medical facility you have selected for childbirth. It is advisable to remember that cognitive flexibility holds significance during labor just as much as any pain relief method.

Recognizing that childbirth is a complex process capable of changing and evolving can greatly aid in coping with every decision, even if it was not initially part of your birth plan. If you have chosen a natural birth and then decided that the pain is too intense and prolonged, trust yourself and act on your gut instinct; you know best what is right for you at any stage.

The reasons for pain during labor

Initially, at the latent stage, most of the pain is due to uterine muscle contractions and cervix dilation. Women describe it as mild menstrual pain with intermittent back, lower abdomen, and thigh contractions. During the first stage, the pain builds up in intensity and frequency, and the duration of each contraction extends.

Towards the end of the active stage (the pushing stage), a sensation of pressure is added in the perineum. The more the embryo's head continues to push and progress through the birth canal, the more the sensation of pressure will increase. The sensation of pressure is essential to the second stage, the pushing stage.

The indication of pain is your sign that it is time to give birth, and the evolving nature of the pain allows the labor room staff and the patient the ability to estimate the stage you are in.

Factors influencing the experience of pain

Various factors influence the experience of pain and the way it is perceived (including psychological, cultural, and more). However, what they all have in common is that, as opposed to any other pain you may have encountered that in every other medical field may be perceived negatively as a pain to be cured, labor pain is considered positive as it advances the process of labor.

However, despite the intended purpose of labor pain, every woman experiences labor uniquely and will require strategies to cope with the pain, either natural or medicinal. Occasionally, a combination of both can prove to be the best and most effective solution. Throughout the process, it is crucial to recognize that you know your body best, even though you may not be able to predict how you will feel or respond to the pain. Therefore, it is advisable to proactively inquire about the available pain relief options.

Medicinal strategies for labor pain relief

The epidural injection stands as the prevalent and most effective method for relieving labor pain, and in Israel, the majority of labors are carried out utilizing it. Epidural analgesia is a regional anesthetic. It is typically called epidural analgesia because the injected medicine is administered through a tube inserted into the epidural space of the spine. The anesthetic injection is only administered by an anesthetist.

The medication (which blocks the pain signals to the brain) is administered throughout labor through a catheter that is inserted into the epidural space with the aid of an automated pump that is controlled by the anesthetist.

Timing of initiating epidural analgesia

If and when you decide to opt for epidural analgesia, it's important to discuss the timing with the midwife, as the timing of administering the epidural holds significance. It is recommended to administer it when you are at the active stage; however, occasionally the pace of the labor process is rapid, and it is recommended to perform it earlier.

There are additional factors that influence the midwife’s decision, including whether it is a first or subsequent childbirth.

Steps in administering epidural analgesia

Preparation:

  • When you tell the medical staff you are interested in receiving analgesia, the midwife will explain how the process is conducted and guide you regarding the required preparation.
  • You will get fluids intravenously to increase blood volume and reduce the risk of decreased blood pressure after the procedure. Afterwards, the midwife will summon an anesthetist.
  • The anesthetist will make sure that there are no contraindications for preforming the procedure, including running a platelet count. After receiving an explanation on the process, you will sign a consent form.

Preforming the procedure

  • The anesthetist will get ready for the procedure, wearing a white coat and sterile gloves. You'll be instructed to either sit on your side in a fetal position (head toward your chest and legs folded upward) or, alternatively, assume a sitting position with your back curved (as determined by the anesthetist). During the procedure, you will be asked to keep this position and not move. If you experience a painful contraction, tell the doctor in the room (or the midwife), and they will be able to guide you.
  • The midwives assist the anesthetists in preparing the sterile equipment.
  • First, the anesthetist will wash your back with an antiseptic substance and cover it with a sterile drape before injecting local anesthesia at the location of the epidural catheter and inserting the catheter itself. Consequently, the doctors will verify the catheter's proper placement and request the midwives' assistance in securing the catheter along your back.

After the procedure

  • Once the injection and catheter insertion procedures are finished, you will be instructed to lie on your back to ensure a balanced and uniform distribution of the epidural medication. The midwife will continuously monitor your blood pressure. The doctor will then prepare the epidural medication and initiate its administration through an automated pump, ensuring a consistent flow of the anesthetic throughout labor. If required, an extra dose can be administered. After approximately 20 minutes, you will be permitted to shift to lying on your side.
  • The anesthetist will stay in the room for several minutes to make sure the blood pressure is normal and that the necessary analgesic impact has been made.
  • The initial frequency of blood pressure measurements, originally frequent, will gradually decrease if everything remains normal
  • You will continue to be monitored through continuous cardiotocography until the completion of labor.
  • The impact of epidural analgesia is gradual; the pain diminishes until it becomes imperceptible. In the majority of cases, the pain becomes faintly perceptible; nevertheless, a few women mention feeling the contractions without the accompanying pain. It is also feasible that one side might be more anesthetized than the other or that you experience discomfort. Communicate your sensations to the anesthetist or midwife so that they can provide assistance. In some cases, an extra dosage of medication might be necessary. Sometimes, pain signals the advancement of labor, and there's a possibility that the process of epidural catheter insertion will need to be repeated.

Side effects of epidural analgesia

  • Difficulty urinating spontaneously; usually a catheter will be required to empty the bladder.
  • Itching and an uncontrollable tremor.
  • Elevated body temperature during labor.
  • Nausea and vomiting due to a temporary drop in blood pressure (resolving quickly).

Complications of epidural analgesia

Epidural analgesia comes with infrequent yet noteworthy complications. It's important to be aware of these potential issues when deciding whether to opt for this technique.

  • Failure to perform epidural anesthesia.
  • Blood pressure drop that may cause a slowing of the embryo’s pulse. Occasionally, medications that raise blood pressure will be required.
  • Spinal fluid leakage into the epidural space, resulting from dura membrane puncture, can lead to severe headaches and might necessitate supportive treatment. This leakage is managed with fluids and typically resolves within a few days. In some cases, treatment involves injecting the patient's blood into the epidural anesthesia area to seal the leak.
  • Infection at the injection site.
  • Neurological damage.

The impact of epidural on the process of childbirth

If contractions weaken following epidural analgesia, they can be intensified based on the stage of labor by administering Pitocin. This substance mimics the effects of endogenous oxytocin on uterine contractions.

Occasionally, labor can be progressed by artificial rupture of the membranes, which contain contracting substances. The rupture of membranes contributes to the direct pressure of the embryo’s head on the cervix.

Moreover, epidural analgesia typically prolongs the second stage of labor (from full dilation until the baby is delivered) by an average of one hour. This is, essentially, the reason why an epidural is typically recommended only when there are regular, frequent contractions and progressive cervical dilation.

Advantages of epidural analgesia

When the analgesia takes effect, you will feel complete or significant pain relief. When childbirth is prolonged, you can rest and even sleep. This will help you conserve your energy for the pushing stage when you will need to be strong to help deliver your baby. You will feel the pushing contractions, but at a reduced intensity, which will enable you to cooperate and push.

The effects of analgesia can be maintained for as long as needed by administering additional doses of medication through the tube. This could be necessary if the perineum needs to be stitched after birth, if the placenta needs to be removed manually, or if the uterus needs to be examined for retained placenta.

Epidural analgesia has minimal to no effect on the embryo, except for helping to maintain normal maternal blood pressure.

Disadvantages of epidural analgesia

Alongside potential side effects, you might encounter an inability to rise from bed and occasional limitations in shifting within the bed due to a sensation of heaviness in the lower limbs.

When is it not permitted to perform epidural analgesia – contraindications

If you answer yes to any of the following questions, please come to the labor room early and inform the staff of your condition. Some hospitals provide senior anesthetist consultations on epidural analgesia prior to delivery. It is imperative that you bring all the relevant medical information for the consultation (for instance, if you have a structural problem in your spine, bring an up-to-date orthopedist’s estimation, including an x-ray, CT, etc.).

  • Updated blood count: Low platelet count.
  • Infection at the injection site (pustular sores or other skin infection.
  • Blood clotting disorders.
  • Use of blood thinners, such as Clexane. If you are taking Clexane, consult your doctor to determine the duration for which you should continue injecting the medication. Write in your maternity file which medication you have taken, the dosage, and the date and time of the last injection.
  • Structural problems in the spine that interfere with needle insertion into the epidural space.
  • The presence of a large tattoo at the injection site.

Walking epidural

A walking epidural is a type of epidural analgesia available in a few medical centers in Israel. When used it is possible to walk and no movement limitation is required.

It selectively affects the thin nerve fibers that transmit pain without causing sensory or motor paralysis. This enables the patient to walk around, urinate spontaneously, and assume various labor positions. The patient has greater mobility and control with this technique. A skilled and experienced anesthesiologist is required to perform this analgesia technique.

Who is it suitable for

  • Women who prefer not to have invasive procedures.
  • At the first stages of labor.
  • When the patient desires pain relief but there is insufficient time for epidural analgesia due to the active and rapid progression of labor.

The impact of laughing gas

Laughing gas causes a feeling of euphoria, or lightness, and it disconnects the sensation of pain, so despite the fact that it does not eliminate pain, it can make it more bearable.

Advantages of laughing gas

  • Laughing gas is easy to use, non-invasive, safe for the woman and the embryo, and its impact is quick and commences after approximately 50 seconds.
  • In this technique, the patient breathes through a mask to receive the laughing gas. The effects of the gas wear off within 2 minutes of the patient taking the mask off.
  • The gas does not affect the strength or frequency of uterine contractions during labor.

How to use laughing gas

The patient breathes in the gas (which flows from the wall through a tube and is connected to a regulator) through a mask she needs to hold in her hands and attach to her face while taking a slow and deep breath. The mask should be held tightly to the face to prevent gas from leaking from the sides of the mask. The gas is safe to use as long as the patient is the only one holding the mask.

As labor progresses, the patient can synchronize between inhaling the gas and the pain of the contractions, usually with an inhalation half a minute before the beginning of the contraction so that the peak of the gas influence will come simultaneously with the peak of the contraction.

Who should not receive laughing gas

Laughing gas in prohibited for women with respiratory problems, pulmonary arterial hypertension or intracranial pressure.

Disadvantages of laughing gas

While using the laughing gas, you will be confined to bed, and if you need to use the toilet or bath you will have to stop breathing in the gas for several minutes and the pain will resume. Furthermore, as long as you are wearing the mask, you must remain in bed, and if you wish to get out of bed, you must call for the midwife to assess your stability and help you out of bed.

Another disadvantage of using laughing gas is that it will require you to be constantly active, breathing in the gas and attaching the mask to your face; consequently, it will not allow you to rest between regular contractions because you have to hold the mask and breathe in the gas the whole time. This can be especially challenging if you are exhausted during a long labor and, therefore, may not enjoy substantial relief from the pain.

Potential side effects of laughing gas

  • Nausea, vomiting, and dizziness. Some women experience nausea and dizziness during the first breath; therefore, they throw the mask off their faces. This sensation usually passes in a short time.
  • Some women cry or experience anxiety and restlessness. It is important that while you are using the mask, the midwife is by your side until she makes sure that you are using it properly and feeling fine.

Pethidine is a narcotic pain reliever that may be administered only during early stages of labor, when it is established that the patient will not give birth within four hours after administering the medication. Pethidine can be given as an intravenous infusion or an intramuscular injection, depending on the stage of labor and the pace of its progress. The dosage is based on the patient’s weight.

The medication's effects last for 3 to 4 hours and include reduced pain sensation. Pethidine does not eliminate pain, but it can help reduce pain and relax the muscles. It can also enhance the effectiveness of uterine contractions and cause a feeling of release, dizziness, and relief. In some cases, pethidine can also cause anxiety and a feeling of loss of control.

Many women fall asleep under the influence of pethidine. The substance takes effect in 20 minutes and lasts for 4 hours.

The effects of pethidine on the embryo

Because pethidine passes through the placenta to the embryo, it may have an influence on them, as well, especially if it is administered close to the labor.

The effects of pethidine on the baby

If the baby is born shortly after the mother receives pethidine, the baby may have traces of the drug in their system, which can affect them for 3 to 6 days.

Side effects of pethidine

Pethidine has side effects that characterize opioid medicines, including nausea and vomiting (therefore it is always administered with anti-nausea drugs, such as Phenergan). Additionally, the patient may feel dizzy, have a decrease in blood pressure, experience a cold sweat, or have constipation. An overdose can cause hypoventilation, muscle limpness, and stupor.

Who should not be given pethidine – counterindications

  • Women who have a history of drug abuse and are currently in rehabilitation.
  • Women who currently use drugs.
  • Women who take antidepressants of a certain type.
  • Women who suffer from increased intracranial pressure.
  • Women who have an embryo who may be born premature.
  • Women who suffer from kidney or liver dysfunction.
  • When there is a concern for fetal distress.

Natural measures for reducing labor pain

You will benefit from a positive environment and taking actions that make you feel good in your daily life while you are experiencing labor pains at home during the latent stage (you can learn more about it here), as well as later in the labor room. You can select pleasant lighting, an object, or a photo you like and want beside you, music that you love (or white noise), a device that diffuses essential oils with your favorite scent, etc.

During pain, breathing can become irregular; nonetheless, between contractions, you can release and experience proper breathing. It is recommended to practice breathing exercises before labor to prepare your body and mind for the forthcoming challenges. During labor, when pain comes in waves, sometimes the tension towards the next contraction, the next wave of pain, may cause a sensation of tightness, leading to inefficient breathing and shallow and rapid breaths. Being aware of your breathing can help you relax and rest between contractions.

Furthermore, short, and shallow breathing does not allow for good oxidation of the body’s tissues. On the other hand, deep and slow breathing promotes proper oxygen supply, and the uterine muscle contracts efficiently and with minimum effort. Proper breathing enriches the body tissues with oxygen, enabling them to cope effectively with labor.

The baby also goes through a complex and exhausting process, receiving oxygen through the placenta, assisting him in coping better with the birthing process.

How do I breathe correctly during labor

Inhale deeply and fill your lungs with air. Hold your breath for a few seconds, then exhale slowly and steadily through pursed lips, as if you are blowing through a straw.

Numerous studies have been conducted on the issue of guided imagery and the power of thinking, demonstrating their noteworthy influence on physiological functions. Through this method, one can envision how each contraction advances the process of cervix dilation, thereby drawing the baby closer to the mother. Guided imagery adjusted to the patient can instill a sense of calmness, leading to relaxation and diminished pain levels.

Water can be very effective in relieving labor pain. Sitting in a bath or having warm water run over your back can help relax your muscles and reduce pain. It is important to use lukewarm water, not hot water, as hot water can cause a drop in blood pressure and fainting.

Many women report that localized heating of the painful area provided relief during labor. At the beginning, on the lower back, above the tailbone, and afterwards, a heating measure on the perineum, for instance, a heated towel, to ease the strain associated with the pushing stage.

Applying heat dilates blood vessels, improves blood circulation, and increases oxygen delivery to muscles, thus easing pain.
For lower back pain, use a hot water bottle.

To address a "burning" sensation in the perineum, you can dampen cloth nappies with lukewarm water or warm a soft, comfortable towel and apply it to the area, particularly during the pushing phase.

Engaging in movement during labor can greatly aid in pain management. Additionally, movement plays a role in advancing labor and facilitating the engagement of the baby's head in the pelvis.
Pelvic movements, in combination with gravity and specifically adopting vertical postures where the body stands upright, help the baby engage better in the pelvis. These movements also help the baby's gradual descent further down into the birth canal by enlarging the pelvic bone space.

Another important advantage of moving during labor is that it can help you feel more in control and involved in the process. When you are actively moving, you are also taking an active role in your labor and contributing to its progression.

It is advised to plan ahead: there are various positions and pelvic movements that you can try during contractions. Getting to know them and practicing them during pregnancy can help you find the ones that work best for you during labor.

Examples of pelvic movements

  • Pelvic rotation movements while sitting on a physio ball or when the body is leaning on a physio ball that is placed high up, such as on a bed.
  • Pelvic rotation movements while standing up and leaning on the wall.
  • You can combine asymmetric movements, such as lifting one leg to a low chair and moving the pelvis back and forth in circular movements or to the sides.

Touch therapy during labor can be helpful in alleviating contraction pains and promoting relaxation within the body. Adequate preparation and mastering touch techniques can significantly contribute to easing the pain experienced during labor. In addition, when a spouse is present during labor, it presents a valuable opportunity for them to provide active support, further strengthening the partnership between the two individuals.

Identifying specific touch points that alleviate contraction pains is crucial, and it is recommended to be attentive to your body's signals to communicate what is beneficial and what is not.

Possible touch points

  • Massaging the lower back.
  • Pushing the lower back area above the tailbone.
  • Massaging the feet.

It is crucial to remember that each woman is unique, and so are her reactions. Therefore, some women may have a reverse reaction to touch — a reaction of repellence. If the touch is unpleasant, do not be ashamed to say so.

The TENS device is a small device that delivers electrical stimulation to the brain through electrodes attached to the skin in the back area. The stimulation "tricks" the brain into not reading the contractions pain signals, thereby alleviating pain. The device is positioned on the body so that it does not limit movement, and it is activated by the patient.

You can select the program and intensity that you prefer, and you can stop the device at any time. It is safe and easy to use, but it is important to note that it should not be used in the shower.

Although many women report that TENS can relieve pain, even at the early stages, it does not work for everyone.

The device can be rented in Yad Sara with a new set of stickers for a deposit and a nominal fee (for the stickers).

In some labor rooms in Israel, alternative medicine services such as Shiatsu therapy for labor pain, acupuncture, and reflexology are available. These therapies are provided by therapists who have been specifically trained to work in delivery rooms.