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Pain relief during labor is a huge question that weighs on any expectant mother’s mind. No one likes pain and the mere anticipation of labor pain is a scary thought for most. I make it a point to review all pain relief options with all of my pregnant patients prior to delivery. One of the most common questions that I get is whether to get an epidural or not, and what are the risks and alternatives?
What pain relief options are available?
There are two main options available for patients who are in labor. The first is intravenous (IV) pain medications. The second is regional anesthesia usually in the form of an epidural, which is a catheter placed in your back in which medication is infused around the spinal nerves to make your belly and pelvic region numb.
Which method is the best?
Epidurals, by far, relieve labor pain most effectively. The epidural medications cause you to lose feeling in your belly and pelvic area by blocking nerve signals from the lower spinal nerves. Epidurals are very targeted and block pain directly from nerves that supply the uterus and vagina. IV pain medications, on the other hand, simply cause a decreased perception of pain and don’t necessarily target any specific organs. Their effects often wear off quicker as well.
How is an epidural placed?
An epidural block is performed by an anesthesiologist. A small area in your lower back is cleaned and made sterile. A needle is inserted into your back and a catheter is threaded over it into the epidural space (space just outside the spinal cord). Medication is then infused via the catheter, which blocks the targeted nerves. This infusion of medication is set at a constant rate but can be altered using a small pump. Since you will not be able to fully feel your bladder sensations after the epidural is placed, you will have a catheter to drain your bladder.
What are the “side effects” of an epidural?
There aren’t many major side effects of an epidural although some do exist. One possible side effect is low blood pressure. If you experience a drop in blood pressure, there is medication used to raise it to ensure good blood flow to your baby. Epidurals can also cause post-delivery headaches if spinal fluid leaks out. Rarely, a spinal hematoma, which is a blood collection around the spinal cord, can develop however the incidence of this is very rare at less than 1 in 250,000. Other minor side effects include fever, shivering, nausea, or vomiting. One last important side effect is a prolonged second stage of labor (“pushing” stage). This is due to an inability to feel the anything in the vaginal region which then makes pushing less effective. While you may push a little longer, the vast majority of women still deliver vaginally.
Will an epidural increase my chances of a C-section?
No. Studies have shown that epidurals do not increase your risk for C-section.
Is there any reason why I can’t get an epidural?
There are a few rare conditions that preclude a patient from getting an epidural. These include a low platelet count, a coagulopathy (clotting disorder), a space occupying brain lesion, or an allergy to the medications in the epidural.
What if I don’t want an epidural or pain meds? Are there any other options?
During labor, the main pain relief options are IV medications or an epidural. The only other options would be a pudendal nerve block or local anesthesia. A pudendal block is a numbing medication that is directly injected around the pudendal nerve through the vagina. This is typically performed as a mother is pushing as its effects are relatively short-lived. Local anesthesia is given as a direct injection of numbing medication into the vaginal tissue to temporarily numb the area. This is typically done after the delivery however, and only used when a vaginal tear has to be repaired.
A lot of my time in the office is spent on educating patients about their bodies and the changes that occur during pregnancy. As women get closer to their due date, many questions come up about pelvic pressure, belly pain, and contractions. Pregnancy is a time of great physical stress on a woman’s body and changes do occur that are foreign to most women. These physical changes can be unusual and even scary for some patients. There is a lot of confusion surrounding the following questions: “When exactly does my labor begin? When will my baby be born? When should I go to the hospital? What can I do about labor pain?” We doctors are responsible for educating all patients early and often on these topics so that they feel prepared and comfortable with the labor process.
“My doctor gave me a due date. Is that when my baby is going to be born?”
Finding out a “due date” is very exciting for mothers and fathers to be. Once a due date is given, patients often mark it down on their iPhone calendar or due date app or immediately text it to family members and close friends. However, I always caution them about this and tell them that a “due date” is NOT THE EXACT DATE when the baby will be born. It’s actually a calculated date that tells us when you are exactly 40 weeks and is based on your last menstrual period and first ultrasound of your pregnancy. Your baby could come a little earlier or a little later than that date depending on when your body is ready for labor. Labor is defined as when a woman experiences regular contractions with progressive cervical dilation (opening). Dilation from 0 to 4 centimeters takes days to weeks, however dilation from 4 or 5 centimeters to 10 centimeters (when a woman is ready to push) only takes hours! For this reason, you are not considered “in labor” and not required to stay in the hospital until you have reached 4 or 5 centimeters. Consequently, you may be allowed to go home if your cervical dilation is less than 4 cm although you may be feeling contractions.
“How do I know if I am in labor?”
The natural follow up questions that patients have are “How do I know when I am 4 centimeters? Can I tell by my contractions? How do I know when to go to the hospital?” Great questions. The answer is there is no way to know for sure unless you get checked by your doctor or at the hospital. My recommendation is to time your contractions. Look at the clock to see how often your contractions are coming and for how long they have been lasting. If they are irregular, on and off, or coming every 15 to 30 minutes apart, just wait. These are Braxton-Hicks contractions (false labor). They are not associated with labor but can be uncomfortable. Once your contractions start coming every 3-5 minutes for more than 30-45 minutes then you should go to the hospital.
“Should I go to the hospital for anything else other than contractions?”
Yes. You should go to the hospital if you are experiencing leakage of fluid or vaginal bleeding. The “bag of water” is the amniotic sac. It holds the amniotic fluid that bathes the baby. The bag of water can rupture on its own at any point during labor or even prior to labor. Once the bag has ruptured there is no longer a protective layer around the baby, and infection can potentially set in. For this reason, you should go to the hospital immediately when your water “breaks”, and if you are found to be less than 4 centimeters, your labor will be induced. Regarding bleeding, it is never normal to have bleeding, however bleeding isn’t always an ominous sign. Sometimes, bleeding can occur after a cervical check in the office or just from cervical dilation during labor. However, bleeding can also be a sign of fetal distress so my recommendation is that vaginal bleeding should always be evaluated by your doctor at the hospital.
“What things can I do to relieve labor pain from contractions?”
Labor is appropriately named because having a baby is very hard work! Whether false labor, early labor, or real labor, pain from contractions can be very uncomfortable and at times, downright intense. Contractions can affect your ability to sleep, your appetite, can make you feel nauseated, or your ability to move around like normal. The first thing to remember is that contractions are a normal part of late pregnancy as you approach your due date. Don’t be scared. Being of sound mind and not panicking is key when contractions start. There are also several things that you can do to help relieve some of the pain from your contractions. First, you can perform breathing exercises in order to relax your body. Controlling your breathing and establishing a regular breathing pattern will help alleviate some of the pain and the anxiety that comes along with labor. Next, taking a warm bath can help relieve pain as immersing your belly in water will have a soothing effect. Just ensure that the water is warm and not too hot. Massages are another helpful option. Involve your significant other with this. Gentle rubbing of the lower back, shoulders, or sides can provide a lot of relief. Other things that can relieve the pain from contractions are applying warm or cool compresses to your belly, putting yourself in a low stress/quiet environment, and continuous movement to get to a comfortable position (on your right or left side, on your back, leaning against pillows to optimize back/front support).
“What about an epidural?”
Labor pain is intense, and I always feel bad for patients who are experiencing a great deal of pain. Standing at the bedside and watching an expecting mother go through labor pain is not an easy sight to see. Luckily, we now have epidurals and medications that weren’t around in the past to help us alleviate the pain you feel from contractions. An epidural is a small catheter that is placed in your back, whereby medications can be administered that will numb the areas from the top of your belly to the vaginal area to decrease the pain sensation from contractions. Epidurals are safe for the baby and are the most effective way of relieving pain from contractions. Epidurals are only given to women who are in labor (4 centimeters or more) or who have already ruptured their bag of water (regardless of cervical dilation). With an epidural, you will be much more relaxed, your baby will tolerate labor better, and you can enjoy the childbirth experience much more. As always, I leave the decision up to the patient as to if and when she wants an epidural, but I believe that epidurals are a great way to take your mind off labor pain so that you can better focus your attention to what’s really important, which is having your baby.
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