Common forms of pain relief using drugs

There are several choices to make regarding medical forms of pain relief, and each has its advantages and disadvantages. Talk through your options with your midwife. The right choice will depend in part on how far into labour you are, and how quickly labour is progressing. Your midwife will do an internal examination to see how dilated your cervix is, to help you decide which form of pain relief is most appropriate.

• Pethidine and Meptazinol (Meptid)
• Gas and air
• Epidurals - traditional and mobile

Pethidine and Meptazinol (Meptid)

Both Pethidine and Meptid are similar to morphine and given by injection. They can be given at home, if you are planning a home delivery and take effect in about 20 minutes.

Timing

You can have Pethidine or Meptid (opiates) during the first stage of labour. The first stage of labour is when contractions gradually open up the cervix or neck of the womb to 10cms to allow your baby to pass down into the vagina. If your midwife thinks that you are likely to give birth within a couple of hours, she will discourage you from having Pethidine or Meptid. This is because Pethidine and Meptid crosses the placenta to the baby and its effect on the baby will be at its maximum if given shortly before he is born.

How it is administered

It is given by injection into your thigh or bottom. If you are a small woman or you know that taking even a mild drug such as aspirin tends to affect you strongly, it might be wise to talk to your midwife about having a smaller dose than is usually given.

Side effects

Opiates do have sedative effects and make women drowsy and their breathing shallow. Many women feel very sick, so it is given with another drug to prevent sickness. Some women become very weepy after they have had pethidine.

Opiates given during labour crosses the placenta with the result that some babies are slow to start breathing after they are born. Every delivery room carries a supply of a drug that can reverse the effects of pethidine (Naloxone)and this can be quickly injected into the baby if he is drowsy. However, the opiates will linger in the baby’s system for up to a week and may make the baby unresponsive and difficult to feed in the early days of his life.

Women's views

There is a huge range of reactions to pethidine. Some women will tell you that it is marvellous because it enables you to have a rest during labour and to awake feeling refreshed and able to cope again. Others say that they felt out of control after they had the drug, uncertain as to where they were.

Some women find that pethidine gives excellent pain relief and others that it doesn’t help at all. So much depends on your individual response to the drug, and also on how important it is to you to feel in control during labour.

If you talk to other women about their labours, many will say that they had some gas and air to help them cope with contractions. Gas and air, otherwise known as Entonox, is composed of 50 per cent oxygen and 50 per cent nitrous oxide.

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If you have decided to have your baby at home, your midwife will bring a supply of gas and air in a cylinder when she comes to you in labour. If you are having your baby at a hospital, gas and air will probably be piped to your delivery room from a central source.

Timing

Gas and air is useful whenever you need some extra help during your labour, but is most often used towards the end of the first stage when contractions often come thick and fast. In the second stage of labour (when you are actually pushing your baby out) your midwife may suggest that you have a little gas and air at the beginning of each contraction and then concentrate on pushing.

How it is used

You use a mouthpiece or mask with a two-way valve so that you can breathe in and out through it. As soon as you feel a contraction starting, you hold the mask to your mouth and breathe deeply and evenly through the mouthpiece. The gas builds up in your blood stream over a period of seconds so that by the time the contraction is at its peak, you’ve had enough gas to give you some pain relief. When the gas starts to make you feel a little light-headed, your muscles relax and your hand automatically drops away from your face so you stop breathing the gas. By the end of the contraction, you are no longer affected by it.

Side effects

The oxygen content of Entonox is probably good for your baby. If you use gas and air over a long period of time, your mouth and throat will become very dry. It’s vital, therefore, to have sips of water in between contractions, or try sucking some slivers of ice.

Women’s views

Some women find that gas and air isn’t enough to tide them over the most difficult parts of labour and that they need to choose stronger pain-relieving drugs to help them. Some women don’t like the light-headed feeling that gas and air produces. But by and large, it is well tolerated by most people and you will often hear women say that they couldn’t get enough of it in labour!

Epidurals - traditional and mobile

There is no denying that labour is a painful process but with the modern techniques now available, the birthing experience can be as wonderful as you want it to be. One of the most effective forms of pain relief is the epidural, a procedure which can provide complete freedom from pain throughout labour. Currently, about one in four women choose to have an epidural in labour. You may have already decided whether or not you want an epidural but it is not unusual for a woman to change her mind during labour. Read on to find out all you need to know to help you decide if this is the right sort of pain relief for you.

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• What is an epidural?
• When can it be given?
• How is it given?
• Traditional epidurals
• Mobile epidurals
• Advantages and disadvantages
• Some simple facts

What is an epidural?

The nerves from your uterus and surrounding muscles go through the lower part of your spine to reach the brain. Most of the pain felt during labour comes from these nerves. An epidural is a local anaesthetic, sometimes given with pain relieving drugs, which is injected into this part of your spine to numb the nerves so you don't feel the pain of contractions during labour.

When can it be given?

An epidural can be given from early on in labour right up until the end of the second stage when the cervix has fully dilated. Dr Geraldine O'Sullivan, an obstetric anaesthetist, says, "I would say it's never too late. A woman having her first baby may be 9cm dilated but still have two or three hours to go." However, she suggests that a third or fourth-time mother with only half an hour to go before delivery might be a different story as the pushing stage of labour is more effective if you can feel the contractions clearly.

How is it given?

Midirs, the Midwives Information and resource Service, says, "Although epidurals are the most effective way of ensuring a pain-free labour, they require specialist services to be set up to care for you." Because of this, epidurals are started by anaesthetists, although once they are in place and working, your midwife will take over. You will be asked to lie on your side or sit up and bend over a pillow. This opens the spaces in your spine to make the procedure simpler. Your skin will be made numb with a little local anaesthetic and then a small hollow needle is inserted into your back. A very fine plastic tube called a catheter is then threaded through the needle and secured into place with tape once the needle has been removed. The anaesthetic and, depending on the type of epidural, pain relieving drugs are then administered through the catheter. It takes about 10-20 minutes for the epidural to become effective.

Traditional epidurals

Epidurals have been used during childbirth for over twenty years. Traditionally, epidurals use a very strong anaesthetic which numbs the lower half of the body, leaving mothers with little or no sensation or muscle control. Because of this, labour can be longer and more medical intervention may be required, such as forceps or ventouse deliveries. However, in the mid-nineties the mobile epidural was brought into practice and its use has increased over the last decade.

Mobile epidurals

The mobile epidural works in the same way as the traditional epidural but the main difference is the drugs which are administered. Mobile epidurals use a much lower dose of analgesia, such as bupivicaine, given in combination with a pain killing medication similar to morphine, such as fentanyl. These are known as mobile epidurals because nerves to the bladder, abdominal and leg muscles are not totally blocked, and you can move about, sit up, empty your bladder without a urinary catheter and deliver your baby vaginally.

The effect of a mobile epidural lasts for about 2 hours, after which time your midwife can give you a top up dose of analgesia and painkillers. Alternatively, you may be able to control how much you get by using a special pump called patient controlled analgesia (PCA). This works by pressing a small button which then tops up the epidural. There may be some tingling in your legs during a mobile epidural and you will probably need some help to get around but the main difference is that you will have the maximum pain relief with the minimum numbness, allowing you to push during the final stages of labour and thus reducing the risk of medical intervention.

Advantages and disadvantages

As with all procedures, there are both advantages and disadvantages to having an epidural.

The advantages include:

• You will receive very effective pain relief without sedation or mental confusion
• You will be awake for the birth of your baby
• With mobile epidurals you can feel and use your contractions
• It can reverse or reduce your body's stress-related responses to labour pain, making the experience of birth better for both you and baby.

Disadvantages are:

• It has been estimated to add an hour onto the time that you are in labour
• They may cause low blood pressure so a drip will be set up during labour so you can be given more fluids if your blood pressure does drop
• An epidural may make medical intervention more likely as muscle tone is less and the pushing second stage of labour may be longer causing distress to your baby and leading to the use of forceps or ventouse.
• Very occasionally, the epidural may not take, or it may only partly work, on one side for example. In this case, it may need to be repositioned.
• Very rarely, a leak of spinal fluid may occur causing a bad headache which will mean you need to lie flat for a couple of days.
• The epidural drugs can make your skin itch.
• You may find your temperature rises and you and your baby need antibiotics in case the rise in temperature is due to an infection.

It used to be believed that epidurals caused backache but the most recent research has demonstrated that you are no more likely to get backache if you labour with an epidural than if you have your baby without an epidural.

Some simple facts

• Studies in the UK and Australia say that over 90 per cent of women who have had epidurals are moderately to extremely satisfied with their pain relief.
• Most women who have an epidural say they will opt for the same pain relief in future pregnancies.
• Not all hospitals offer mobile epidurals so it's best to check with your antenatal clinic or midwife.

Where to next?

• Find out about natural forms of pain relief
• Find out about complementary therapies for labour (reflexology, hypnotherapy,acupuncture, aromatherapy)