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Pregnancy and birth: Epidurals and painkillers for labor pain relief

Last Update: July 19, 2012; Next update: 2017.

During pregnancy many women give some thought to how they will be able to cope with labor pain during the birth. Some women would rather avoid medication. Others feel reassured knowing that there are effective ways of relieving the pain. Many decide to have an epidural.

Knowing that their partner, friend or another person close to them will offer consolation and support during the birthing process can often already help women cope with labor pain. Non-drug approaches such as walking, breathing exercises, heat packs or relaxation techniques can also help make it a little easier to bear the pain.

Hospitals also offer medication for pain relief. They effectively relieve pain, but still make it possible for the woman to be awake to witness the birth. Mothers-to-be usually have several options to choose from, and they can decide based on their own preferences. The most effective is a local anesthetic, commonly called an epidural. The epidural is the most popular form of drug-based pain relief in childbirth.

What is an epidural?

An epidural is a way to deliver an anesthetic by injecting it into the epidural space of the spine. This stops pain signals from reaching the brain. Epidurals cannot be used in women who are allergic to anesthetics or have blood clotting problems.

When a woman has an epidural, a small amount of anesthetic is injected into the epidural space. The epidural space is filled with fluid and surrounds the spinal cord. Nerves that carry pain signals from the body to the brain (spinal nerves) connect to the spinal cord in certain places. The anesthetic numbs the spinal nerves, blocking the pain signals. For a birth, the medication is injected into the lumbar area, which is the lower part of the spine. If it works properly, you will no longer feel pain in the lower part of your body. But with a low dose you are still able to move your legs, or even get up and walk around with a bit of help and support. An epidural can also be used for partial anesthesia if the woman needs to have a Cesarean section.

Because a single injection is often not enough to last throughout the entire birth, a catheter is usually put in and then attached to the woman’s back. This thin plastic tube is pushed forward into the epidural space using a special needle. It can be used to inject more anesthetic or painkiller as needed. Doctors often do this by hand, or the catheter may be attached to a small pump that continuously supplies small amounts. Sometimes there is a patient-controlled pump. This means that you can give yourself more medication if you need it.

When epidurals are used, a small tube (cannula) is usually put into the woman’s arm as well, so that a drip can be attached to it. This is a safety precaution, for instance because blood pressure can drop rapidly during an epidural. The cannula can then be used to very quickly supply the right drug to help increase blood pressure.

It sometimes takes a while for anesthetists to get the injection in exactly the right place in the back, or they may not manage to do so at all. The dose is usually increased gradually to avoid injecting too much at once. Pain relief is typically felt about 10 to 20 minutes later.

How effective are epidurals and what side effects do they have?

Epidurals are very effective and can almost always relieve pain better than other medications. Most women who have an epidural feel little or no pain. About 1 out of 100 women need additional painkillers if they have an epidural. By comparison, about 28 out of 100 women need additional painkillers during labor if other pain relief options were used first.

An epidural can be used to deliver different types of local anesthetic, which also differ in the side effects that they cause. Some drugs may cause itching. If that happens, changing the drug could solve the problem. The anesthetist will explain things in detail beforehand.

Common side effects of epidurals include a drop in blood pressure and fever. In about 14 out of 100 women the epidural causes blood pressure to drop, which can lead to dizziness or nausea. In about 23 out of 100 women the epidural causes fever. By comparison, this is only the case in about 7 out of 100 women who use another type of pain management.

An epidural can cause numbness or tingling in the legs. It can make it hard to urinate too. You might need a urinary catheter to help you urinate during the epidural. Roughly 15 out of 100 women have problems urinating because of the epidural.

If the injection goes too deep, it might make a hole in the protective layers (dura) around the spinal cord, and spinal fluid might leak out. If too much fluid is lost, it can cause severe headaches that may last up to several days. This happens in about 1 out of 100 women who have an epidural. Women who had an epidural were not generally more likely to have headaches than women who used other forms of pain relief during labor.

Some women are worried that epidurals might cause long-lasting back pain. However, according to current knowledge, back pain is not more common in women who had an epidural during labor than in women who used other painkillers.

How does the epidural affect the baby? Does it change the course of the birth?

Any medication that a woman uses during labor enters the child’s bloodstream as well via the umbilical cord. This includes pain-relieving drugs and anesthetics delivered through epidurals. But anesthetics do not have a stronger effect on the baby than other painkillers that might be considered for use during childbirth. Epidurals have no known long-term disadvantages. One difference, though, is that births take a bit longer on average in women who have epidurals. Epidurals might make it more difficult for some babies to get into the best position for birth.

When women have an epidural, their baby is more likely to need to be delivered with the help of instruments that use vacuum suction (a “ventouse” delivery) or forceps. This is known as an assisted or instrumental delivery.

  • About 10 out of 100 women who do not have an epidural need an instrumental delivery, compared to
  • about 14 out of 100 women who have an epidural.

Before a child can be delivered using suction or forceps, an episiotomy (cut made in the back of the vagina) is usually necessary, which then needs to be stitched.

Some women still feel the desire to push despite having an epidural. But because the epidural means they cannot feel when it is time to push, doctors and midwives need to let them know when they should start pushing.

Sometimes epidurals are stopped towards the end of labor because it is thought that this will make it easier for the woman to push her baby out. But comparisons between the two approaches show that his does not help: Stopping the epidural will mean the woman has more pain, but it does not make the birth easier.

The epidural can be set at a dose that is low enough for the woman to get up and walk around during the first phase of labor. In this early part of labor the cervix (opening of the womb) thins out and opens fully. This is called full dilation. Walking around is supposed to help make the birth easier. But studies that compared women who walked around with women who remained lying down during an epidural found that this made no difference to the birth. During the last phase of labor, when the baby is pushed out, women are sometimes advised to sit up a bit more, for instance by adjusting the head of the bed or leaning on their partner. It is not known whether this really affects the course of the birth, so it is best for the woman to choose the position that feels most comfortable.

Do epidurals make Cesarean sections more likely?

Having an epidural does not increase the likelihood of needing a Cesarean section. However, if a woman does end up needing a Cesarean section, a higher-dose epidural can be used instead of a general anesthetic. This means that she can be awake to witness the birth of her child. A curtain is placed in front of the women’s belly during a Cesarean section so that neither she nor her partner, who is sitting next to her, can see the procedure. The woman can remain awake enough to be able to take the baby in her arms immediately after the operation.

Spinal and pudendal blocks

Spinal anesthesia works in a similar way to epidurals, but the anesthetic is injected even closer to the spinal cord: into the area called the subarachnoid space. This causes the entire lower half of the body to feel numb. Spinal anesthesia, also known as a spinal block, has a faster effect than an epidural. For this reason it is used if a Cesarean section needs to be done but it is too late to start an epidural.

It is also possible to combine a spinal block and an epidural. But it is not clear if this has major advantages or disadvantages compared with just an epidural. The combination means that the pain-relieving effect starts faster, but it is also more likely to cause itching.

Something known as a pudendal block can be performed during the last phase of labor, when the baby is pushed out. This involves injecting an anesthetic into the vaginal and perineal tissue (the tissue between the vagina and the anus). But this is usually not done unless the birth is not progressing properly, and the child needs to be delivered with the help of a suction cup or forceps.

How effective are painkillers?

Painkillers can also be injected directly into the bloodstream or inhaled (breathed in). These affect the woman’s whole body, not just her abdomen. One advantage over local anesthetics is that a catheter is not needed. But painkillers are not as reliable as epidurals, and some also have more side effects.

Opioids

Opioids can also be used for pain relief. They can be injected into muscle tissue or “dripped” into the bloodstream using an infusion (a drip). Although opioids do not offer as much pain relief as epidurals when they are given this way, they can help some women. But studies show that as many as two thirds of women who are given opioids still have moderate to severe pain one or two hours later. Possible side effects include a drop in blood pressure, nausea, vomiting and drowsiness. The higher the dose, the more likely it is that the woman will experience side effects.

Opioids can sometimes affect the baby’s breathing. Then the baby may be given a drug called an opioid antagonist to counteract this effect. The mother may be given this drug too. But opioid antagonists not only reduce the side effects of the opioid; they also reduce the pain-relieving effects.

Laughing gas ("gas and air")

Inhaling painkillers through a mask used to be a common and popular way to relieve labor pain in Germany. Laughing gas (nitrous oxide) was generally used for this purpose. It is given together with oxygen – a combination known as “gas and air.” Although this approach is still common in some other countries, it is very rarely used in Germany nowadays because it is not as reliable as other pain-relieving drugs. One advantage, though, is that women can regulate how much they inhale. Laughing gas has a rapid effect, but it also wears off quickly. It may cause nausea, vomiting, drowsiness or dizziness.

Other options

Other medications like acetaminophen (paracetamol), non-steroidal anti-inflammatory drugs (NSAIDs) or sedatives are rarely used to treat labor pain. Compared with the other available options, they are not very effective.

Sources

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