Pain relief in labour Maternity Patient Information Leaflet
Introduction This leaflet aims to give you information about the forms of pain relief available to you which can help you cope with pain when you are in labour. Late in pregnancy you may experience Braxton Hicks contractions which are usually painless tightenings of your uterus (womb) that happen every so often but are not regular. When labour starts these tightenings (contractions) become regular and much stronger, and may cause waves of pain that at first feel like period pain, but which build up in strength and frequency as labour progresses. The amount of pain women experience in labour can vary considerably depending on the position of the baby, the length of the labour and whether it has started naturally or artificially, for example, stimulated by a hormone drip. Many women find they need some sort of pain relief. There are several ways of helping you cope with pain and it is difficult for you to know beforehand what sort of pain relief you think you might want. You do not always need to have drugs to help you cope, especially in early labour. Remember that labour pain is a positive pain and the stronger and more frequently you experience contractions, the nearer you are likely to be to the birth of your baby. The different types of pain relief are described in the sections which follow. Self help methods Whether you are giving birth at home or in the hospital maternity unit there are several methods that can be used to help relax you and refocus your mind away from the pain from contractions. This 2
includes ways in which your birthing partners can help support you during each stage of labour. These methods will be discussed with you at meetings with your community midwife and at antenatal classes. For more information please read our leaflets called Am I in labour? and Complementary therapies during pregnancy. Water Using water in labour has several benefits. The combination of warmth and support provided by the water allows you to become more relaxed whilst remaining upright and mobile. This in turn helps to reduce your body's own production of stress-related hormones and increase your body's own natural pain-relieving hormones. The use of water is only available for women under midwife-led care not those whose care is being lead by a consultant. Gas and air (Entonox) This is a mixture of oxygen and nitrous oxide that you inhale through a mouthpiece. You hold the mouthpiece and can control when you use it. It works best if you begin to breathe in the gas and air as soon as a contraction starts and stop as soon as the contraction starts to fade. You do not need to use it between contractions. Advantages of Entonox It is quick to act and the chemicals used quickly go out of your body It works as a pain-reliever by taking the edge off' contractions It does not harm your baby and gives you extra oxygen which may be beneficial for you and your baby 3
It can be used at any time during labour and you can use other forms of pain relief at the same time It can be used whilst using the birthing pool Disadvantages of Entonox It will not take the pain away completely It sometimes makes you feel light-headed, have a dry mouth, a pins and needles sensation or feel a little sick for a short time Transcutaneous electrical nerve stimulation (TENS) machine This is a small battery-powered stimulator which sends gentle electrical pulses through electrodes (flat pads) that are taped to your back. You can hold the stimulator and control the strength and frequency of the pulses yourself. It is most effective when it is started early in labour. It helps to block some of the pain signals sent by the nerves surrounding your spinal cord to your brain, and stimulate your body to release its own natural painkillers called endorphins. It should not be used while you are in the bath, birthing pool or shower. Advantages of TENS It will take the edge off' the contractions and may help with backache Is very effective when used in early labour You can remain mobile during its use It has no known harmful effects on your baby You can use some other forms of pain relief at the same time (except an epidural and water) It can be used at home 4
Disadvantages of TENS If you wish to use a TENS machine you will need to either buy or hire one before you give birth Pethidine This is a drug is usually given by injection into your leg. The painrelieving effect builds up over about 20 minutes and can be given in small doses at regular intervals Your midwife will discuss this and the benefits and disadvantages of Pethidine with you. Benefits of Pethidine Pethidine can help you relax and relieve some of the pain of contractions You can use Entonox and TENS at the same time as Pethidine Risks and disadvantages of Pethidine It may make you feel sick but an anti-sickness drug will help this and is given at the same time as the Pethidine injection It will delay the emptying of your stomach which can be a problem if you later need a general anaesthetic It may make you drowsy and you will be advised to relax on the bed and not move around until the drowsiness wears off Pethidine does cross the placenta and can affect the baby. It can make your baby sleepy and slower to start breathing when it is born. This will depend on your baby and what stage of labour the pethidine was given to you If your baby is drowsy from the effects of the drug it may take longer to establish breastfeeding You will not be able to have your labour in water if you have had Pethidine until the effects of the drug have worn off 5
Epidural An epidural is a fine plastic tube (catheter) which is inserted into your back. Once the catheter is in place local anaesthetic can be injected down it. This numbs the nerves carrying pain from your uterus to your brain. Most people can have an epidural but it cannot be given to people who have bleeding disorders and some complications of pregnancy. The final decision as to whether you will be able to have it will be with the anaesthetist (doctor with specialist skills in pain management). How is an epidural set up? A cannula (drip) is inserted into a vein in your hand to allow fluids and medications to be given if needed. To insert the epidural you will be asked to curl up on your side or sit bending forwards. Your back will be cleaned with an antiseptic solution and a small amount of local anaesthetic injected under the skin which may sting. This numbs the area but you may still feel pressure sensations or discomfort while the catheter is being inserted. The epidural should be inserted in between contractions so you will need to tell the anaesthetist when a contraction starts. The epidural catheter is inserted through a needle and this needle is removed once the catheter is in place and the catheter is taped to your back. How long does it take to work? Epidurals usually take about twenty minutes to work. Once the epidural is inserted you will be given a button to press which will allow you to give yourself further doses when you are in pain. The system is designed so that it locks when a dose has been given so that you cannot give yourself too much of the drug no matter how often the button is pressed. 6
In certain cases a technique called a combined spinal epidural (CSE) is used at first. This combines both a spinal and epidural anaesthetic and works quicker than just one or the other. When this initial dose of CSE begins to wear off, an epidural will be used in the same way as described before. What if I can t have an epidural? If an epidural cannot be inserted for any reason then a PCA (patient controlled analgesia) can be tried. This works by allowing you to control a pump connected to a drip in one of the veins in your arm. The pump contains a painkiller medication called Remifentanil which is similar to Pethidine. Benefits of an epidural An epidural provides the most effective form of pain relief in labour as it numbs the nerves rather than masking pain It is still most likely that you will give birth to your baby vaginally as an epidural is not known to increase the risk of a Caesarean section If labour does result in a forceps/vacuum delivery or a Caesarean section, this can usually be performed under epidural anaesthesia rather than an emergency general anaesthetic Risks and disadvantages of an epidural An epidural can make your labour longer and reduce your urge to push You may be more likely to need a forceps/vacuum delivery Your may not be able to move around as the baby s heartbeat will need to be continuously monitored It requires regular top ups You will only be able to drink clear fluids (water) You will have to wear a theatre gown, and anti embolic stockings (to prevent blood clots developing in your veins) 7
The epidural may cause your blood pressure to drop and you may feel sick and dizzy if this happens. This is the reason for having a drip, as it allows fluids and medications to be given to bring your blood pressure back up again if needed. However, whenever a drip is inserted there is a risk of infection You may experience some shivering but this usually goes quite quickly Some people experience an itching sensation due to one of the pain-relieving drugs used in an epidural Occasionally the epidural does not work well at first. It may also miss a nerve in one particular area or down one side. This may mean that the catheter may need to be re-sited or adjusted by the anaesthetist You may lose the sensation of wanting to empty your bladder and may need a urinary catheter to be placed into your bladder to help you to do this. The use of a urinary catheter increases the risk of an infection One in 100 women experience severe headaches as a result of an epidural. This can occur up to a few days after insertion and can be treated About one in 2,000 mothers get a feeling of pins and needles down one leg after having a baby. If this has happens you will need to tell your midwife who will ask an anaesthetist to check you. However this is more likely to be caused by childbirth than the epidural. Patches of numbness after an epidural are rare and if they happen they tend to get better within three months Permanent nerve damage can happen but is extremely rare (one in 13,000) 8
Backache is common in pregnancy and after giving birth but there is no evidence that an epidural can give you long-term backache There will be some local bruising for two to three days around the insertion site but this disappears quickly If you are overweight it may be more difficult to insert both the drip and also the epidural catheter. This may mean that the procedure takes longer than usual and it is more likely that it will not be successful References Midwives Information and Resource Service (2005) Informed choice for women. Bristol: MIDIRS. Obstetric Anaesthetists' Association (2003) Pain Relief in Labour. London: OAA. If you have any questions or if there is anything you do not understand about this leaflet please contact: Community midwives/midwifery-led unit triage 01384 456111 Ext 3358 Maternity triage 01384 456111 Ext 3053. 9
Originator: Date originated: May 2014 Date for review: May 2017 Version: 1 DGH ref: DGH/PIL/00951 Leanne Cruickshanks, Clinical Governance Midwife, Karen Brighton, Midwife Catherine Brennan Consultant anaesthetist 10