On Monday, we posted a survey on our Facebook page asking how women approached their pain during labor. The responses have been fairly evenly distributed, highlighting the fact that there isn’t a single answer that’s right for everyone.
There are a few things in life that you can never really understand from an emotional perspective without experiencing it. The pain associated with labor is one of those things. This is probably why it can be such a source of anxiety for most women. Most people understand that it is an intense and unique pain, but there is often some fear about just how bad it will be.
This article is intended to help you understand pain control in labor from a medical perspective, with the hope that it will help with the emotional process you go through as you prepare for labor.
Why is labor so painful?
The uterus is a powerful muscle, and, when it contracts, two processes cause intense cramping pain: stretching and pulling of muscle fibers and lack of oxygen (called ischemia). The uterus has a tremendous blood supply. When a contraction occurs, it temporarily closes down the blood vessels carrying this oxygenated blood. This lower level of oxygen causes pain, just like when you get a side ache from running. The pain is transmitted by “visceral nerves,” which are a special kind of nerve fibers that send a crampy pain signal from the uterus to the brain.
As labor progresses and the baby descends, other tissues become involved. The stretching of the tissues in the pelvis (vagina, pelvic floor muscles, pelvic ligaments and perineum) send a different kind of pain signal to the brain. These signals are sent by “somatic nerves,” which send a more specific signal of burning, poking or searing pain.
What are the options for pain control during labor?
There are a range of options, and there really isn’t one that is better or worse than the other. It is a highly individualized choice. The options include no medical intervention (with or without preparation for how to deal with the pain), intravenous pain medicine, regional anesthesia (epidural or spinal anesthesia) or a nerve block.
No medical intervention (“natural” childbirth)
Medical intervention for pain control is not a necessity. If this is what you really want, you shouldn’t feel any pressure to receive any. After all, women have been successfully laboring for thousands of years without it. Of course, that doesn’t mean it will be easy. There are some specific methods that have developed over the last century to help deal with the pain naturally. The Lamaze, Bradley and hypnobirthing methods are several examples. Each involves a lot of physical, mental and emotional preparation for labor. A quick internet search can help you find information on these methods and classes in your area. Give them a call and see if they are right for you.
Intravenous pain medicine
The main intravenous medicine used in hospitals for labor pain is fentanyl. This is a narcotic medicine similar to morphine, but it has a more rapid effect and doesn’t last as long. It can make mothers a little sleepy, which can be annoying to some women (or helpful to others). A small amount of the medication does cross the placenta, but it is safe for the baby in both the short and long term. It is an effective medicine, but it usually doesn’t completely get rid of the pain. I have heard patients describe it as “taking the edge off.”
Regional (epidural or spinal) anesthesia
There are two types of regional anesthesia: epidural and spinal. An epidural anesthetic is when an anesthesiologist or nurse anesthetist passes a small tube through a needle right next to the “dura” or membrane that surrounds the spinal cord and spinal fluid. Medication is dripped through this tube and numbs the nerves coming from the uterus just before they enter the spinal cord. Often the patient is given a button to push for more medicine, so they can control the amount of pain they are feeling. This is called “Patient Controlled Epidural Anesthesia.” A spinal anesthetic is when a very narrow needle is placed through the dura into the spinal fluid, and a single dose of medication is delivered. This medication lasts for 1-2 hours. Since the length of labor is unpredictable (and usually much longer than two hours), epidurals are much more commonly used than spinals for labor pain.
Regional anesthetics are safe for mothers and babies, and they have become quite popular. Epidurals typically allow women to feel their contractions without experiencing the associated pain. The delivery of the medicine right near the spinal nerves allows the total medication dose to be much lower than with intravenous medication. This reduces side effects, including sleepiness. The medication that reduces the pain also causes weakness in the legs. Women who choose epidurals typically stay in the labor bed after given the anesthetic or only get out of bed with assistance.
A decade ago, it was common for providers to withhold regional anesthesia until women reached a certain cervical dilation (often four centimeters). This is not recommended anymore because studies have shown earlier epidurals provide safe pain control without increasing the rate of c-sections or other delivery problems. Now women in labor can have regional anesthesia whenever they want it. The indications are that they are in labor, having pain and request it.
Without medication, the very end of labor is marked by an extremely intense burning pain associated with the stretching (and usually tearing) of the perineum as the baby’s head is delivered. This pain signal is sent to the brain through the pudendal nerve, which can be accessed safely by a numbing injection called a pudendal block. Placing a pudendal block just before delivery inhibits sensation in the vulva, preventing this pain from occurring.
This can be an effective and useful option for women who want to experience the contraction pain of labor but not the perineal pain from delivery. It can also be quite useful after delivery for women who have not had an epidural. Most lacerations caused by delivery need to be repaired with stitches. A pudendal block can numb the entire area and allow the provider to repair the laceration without causing more pain for the mother. She can then focus on her new baby.
Do doctors, midwives or nurses get a vote in your choice about pain control?
Not really. Your choice is a very personal one, and our role is to advise and explain. We know, however, that natural labor involves pain more intense and different than any other pain. Indeed, pain this intense is considered unacceptable in any other medical field. Therefore, there are two very important things that we want you to know as part of childbirth education:
- Even if you have decided that you definitely don’t want any medical intervention for pain, you can change your mind. It is rarely too late to have an epidural.
- If your plan was originally to have no pain intervention, and you change your mind during labor, you shouldn’t view this as a failure in any way.
There are more details to pain control in labor. If you have questions about these, don’t hesitate to ask your obstetric provider at one of your prenatal care visits. They can help you better understand your pain control in labor, and this will help you prepare.
Join the conversation: visit our Facebook page and vote in the labor pain management survey or leave a comment.
Dr. Greg Eilers is a board-certified OB/GYN physician and surgeon who sees patients at the Eastbank and Tabor offices of Women’s Healthcare Associates, LLC in Portland, Oregon. A native Oregonian, he has lived in Portland for most of his life. He received his undergraduate degree from Stanford University, returning to Oregon to pursue his medical education and specialty training at Oregon Health & Science University. His professional interests include general obstetrics and gynecology and minimally invasive surgery.