Ease the pain
Just how bad is it going to hurt, and how am I going to
cope? These are questions that run through the mind of many a
pregnant woman. 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.
Oh, the pain!
Labour involves a number of changes, including muscle contractions
and stretching of tissues, and it is not surprising that pain
receptors in a woman's body parts will let her brain know that the
process is causing pain. First labours are probably more painful
than subsequent ones, and induced labours are too (compared with
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 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.
Continuous support in labour
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 whose only task was to provide continuous
support.
Labour positions
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 the woman
in labour is the best one.
Antenatal classes
While there is no evidence from research trials, it would seem
likely that these would be useful to prepare couples in their first
pregnancy. In my opinion, given the number of unpredictable events
that may occur in your 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.
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 women 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
and is controversial, although here is information available from
your LMC. It is always important in labour not to forget the other
benefits of water, including remaining well hydrated.
Heat and cold
Heat is typically applied to the woman's 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 the woman's back, chest or face during labour.
Forms of cold include a bag or surgical glove filled with ice, but
is commonly 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 the woman has an epidural, as it
could damage her skin.
Aromatherapy
This is the use of essential oils and plant-based extracts to
reduce fear and anxiety, and therefore pain. The evidence of one
large study found that the majority of users found it helpful, and
given the relative lack of any known harmful effects, there would
seem to be no reason to discourage use.
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 the woman to induce the
hypnotic state in herself during labour. Various techniques are
taught, including "glove anaesthesia," in which the woman imagines
that her hand is numb and can spread that numbness to other painful
areas by touching them. The evidence for widespread availability in
hospitals is lacking, but the techniques are thought to be safe
enough.
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.
TENS
TENS is a way of passing a low-voltage electric current across some
pads on one's 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.
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
the woman's perception of the pain. While usually very effective,
it can cause nausea and drowsiness - the former is often managed
with other drugs given at the same time and the latter is used to
get some sleep! If given in a large dose too close to the birth, it
can reduce the 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 the woman and get a consent form 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 the woman's blood pressure and the baby's heart rate is
monitored once an epidural is sited. It remains a very popular
choice for many mothers-to-be.
Dr Anil Sharma is a specialist doctor in
gynaecology and maternity. He is very involved in lectures and
updates for family doctors, and frequently takes part in debate
regarding women's health and maternity for print media and radio.
He believes that anxiety and fear can be conquered by knowledge.
Anil immigrated to New Zealand from the UK in 2001 with his wife,
Rachel, and he tries hard to be a hands-on and fun father (putting
golf and cars on hold for the time being) to their three daughters,
who were all born here. Visit
www.dranilsharma.co.nzto find out more about
Anil and his practice.
As seen in OHbaby!
magazine Issue 10: 2010
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