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Your Guide to Pain Management

Labor analgesia

Aaron Barry

on 26 October 2017

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Transcript of Your Guide to Pain Management

Your Guide to Pain Management During Labor and Delivery
So, you're about to have a baby.
To ensure a safe delivery, your anesthesiologist will:

Obtain a comprehensive medical history
Perform a brief, directed physical examination
One of the roles of the anesthesiologist is to assist you with pain management during labor and delivery.

However, our primary concern is to provide a
environment for both you and your baby.
Your anesthesiologist will work closely with you and your obstetric team to coordinate goals for your labor and delivery.
You and your anesthesiologist will discuss:
Your safety
Any medical problems you may have (asthma, diabetes, bleeding disorders, past surgeries, etc.)
Your medications
How you prefer to address pain management
Your religious and cultural beliefs
This guide was developed by anesthesiologists as an introduction to the many options available to you for your pain management during labor and delivery.

This includes medicinal options, as well as non-medicinal alternatives.

As most patients do not have the opportunity to speak to an anesthesiologist before admission for labor and delivery, it’s best to learn about these options well ahead of time.
What is the purpose of this guide?
There are several methods for managing pain that do not require medication or intervention from a healthcare provider.
Non-Medicinal options
These options involve very little risk and have varying degrees of effectiveness.
Each person will have different levels of satisfaction with these methods, and many patients use them in combination.

We will discuss the effectiveness of each of these options in detail when we cover the results of the Listening to Mothers Survey.
These pain management options are prescribed and administered by a healthcare professional.
Pharmacologic options
Depending on hospital policies, pharmacologic options will require varying levels of monitoring and intervention.
Let's discuss each option separately...
Narcotic pain medication can come in the form of intramuscular injections (delivered directly into a muscle), pills, or intravenous injections (delivered directly into the veins).

During labor and delivery, the preferred method of delivering narcotic pain medication is through the IV. This allows for better pain control.
Narcotic Pain Medication
Easily administered
Safe in prescribed doses
May be sedating (too sleepy)
Less effective as labor progresses
Doses later in the course of labor must be restricted to make delivery safe for the baby. (However, studies have shown no difference in Apgar scores, cord gases, respiratory effort, and initiation of breast-feeding of the baby when mothers are treated with narcotic pain medication)
Note: Apgar scores and cord gases are clinical measures of the overall health of the baby at the time of delivery.
Nitrous oxide (laughing gas) is another method of pain relief used during labor.

A 50/50 mix of oxygen and nitrous oxide is delivered through a well-fitted face mask that is under the patient's control.
Nitrous Oxide
You've likely heard of an epidural. It’s the pain management solution most commonly chosen by pregnant women during labor and delivery.
This was a nation-wide survey of pregnant and post-partum patients to examine a wide range of topics.
Listening to Mothers Survey
As labor progresses, the baby's head will begin to flatten and stretch the cervix.

Once the cervix is flat (effaced) and fully open (complete), the baby will begin to move down the birth canal.

No two deliveries are alike, and the position of the baby's head and body while in the birth canal will have an effect on which nerves will carry pain signals to your brain.

A perfectly good pain control regimen may become less effective as the position of the baby starts to change. For example, if the head of the baby is pressing against the bones of the lower spine (sacrum), an epidural may not function as well. This may require additional medication, as discussed earlier.

Because labor pain is constantly changing, many patients will try several pain management options to optimize their pain control. The anesthesiologist will also make adjustments to an epidural. On rare occasions, it may need to be replaced as labor progresses.
It's Time!
Works quickly to relieve pain (about 5 breaths)
30% of patients report that this treatment is very helpful
Since it clears the bloodstream so quickly, it can be used right up to delivery
Although nitrous oxide circulates through the bloodstream to the baby, studies have shown no difference in Apgar scores, cord gases, respiratory effort, and initiation of breast-feeding of the baby when mothers are treated with this medication.
Note: Apgar scores and cord gases are clinical measures of the overall health of the baby at the time of delivery.
46% of patients report that this treatment is little to no help
May cause a sense of restlessness, uneasiness, or dizziness in some patients
The woman typically sits up with her legs hanging over the edge of the bed and with her back to the anesthesiologist. (Some anesthesiologists will prefer to have you lay on your side)

Curling your body forward will open spaces between the bones of the spine, allowing for easier placement of the epidural. It often works well to curl around a pillow and to have a support person stand in front of the laboring patient for balance.

In this position, your back will be shaped like the letter 'C'
Positioning for Epidural Placement
Most complete pain relief
Dose adjustable
Patient controlled
Continuous use throughout labor and delivery
Can be administered AT ANY POINT during labor (Old teaching of waiting for cervical dilation of 4 cm is no longer valid)
Can be used for C-section, if necessary (Although they do NOT increase the likelihood of a C-section)
Minimal drug exposure to the baby
Invasive procedure requiring an IV and a small epidural catheter in your back
Bed confinement to prevent falls
Must have a clear liquid diet
A bladder catheter may need to be placed if you have trouble urinating
You will need occasional blood pressure monitoring and continuous fetal heart rate monitoring.
May increase the length of labor (on average, this is less than 20 minutes, but could be as many as 60 minutes)
10% increase in assisted vaginal delivery (requiring a vacuum or forceps to deliver the infant), but no increase in C-section rate
The main medication is local anesthetic - the same type of drug that the dentist uses to numb your mouth.

The anesthesiologist will control the rate of the epidural (controls how much of your body is numb) and the concentration of the medication (controls how 'dense' the pain relief is).

Many anesthesiologists will also place additional medications into the local anesthetic solution to enhance the potency of the block.

Most anesthesiologists will add narcotic pain medication to the epidural solution, although the doses are much lower than those needed to have an effect when given through an IV.
What goes into an epidural?
Failure of epidural (2-3%) - Repeat attempts at placing the epidural are usually successful.
Sometimes pain relief is in patches - which can usually be fixed by adjusting the epidural medications. Occasionally the epidural will need to be replaced to fix a patchy block.
May decrease blood pressure
Headache (1/200)
Infection (very rare)
Bleeding (extremely rare)
Nerve damage (1/100,000)
Misplacement of the catheter into a blood vessel or the cerebrospinal fluid (rare with a test dose)
Decreased sensation may increase the risk of nerve stretch injuries from positioning during delivery
Risks of Epidural
1) Get into position
2) The anesthesiologist will prep your back with antiseptic
3) A small injection of lidocaine (local anesthetic) will be placed to numb the skin.
4) The anesthesiologist will find the epidural space using a needle and syringe
5) A small tube (catheter) will be placed into the epidural space and secured to your back with tape. The catheter is about the size and shape of a piece of spaghetti. It is soft and flexible and you can lay on it.
6) The anesthesiologist will administer a small 'test' dose to ensure that the catheter is in the epidural space. He or she will monitor your vital signs closely during this test.
7) Finally, the catheter will be connected to a pump that will deliver medication throughout labor. You will also have some control over the rate of medication delivery through the epidural.
Placement of Epidural
Labor is different for every mother, but there are a multitude of options to choose from for pain management.

The effectiveness of these options varies for each individual, and some treatments may have more side effects or require more monitoring and intervention. You can try various pain management options, and how much or how little medication you receive can be adjusted to your individual needs.
Remember This:
We sincerely hope that this teaching module will help you make the best decision for yourself and your baby when it comes to the many pain management options you have available to you.
A CSE is very similar to an epidural, with the added step of placing a dose of medication into the spinal (intrathecal) space using a very small needle prior to placing the epidural catheter.
Combined Spinal-Epidural (CSE)
Combined-Spinal Epidural (CSE)
Adapted from Listening to Mothers I and II Telephone surveys (2002, 2006)
The goal of an epidural or a combined spinal-epidural is to reduce and control painful sensations from labor, but not to remove all sensation or strength for pushing.

This means that it is unlikely that labor will be completely pain free. Many women still have some discomfort, even with an epidural.

However, it is important to have enough sensation to know when the baby is moving down the birth canal and when to push.

The anesthesiologist will adjust the epidural to find a balance between pain control and maintaining some pressure sensation so that you know when it is time to push the baby out.
1) When is the right time to receive an epidural?
The timing of the epidural placement is ultimately up to you, based on your preferences for pain control. As long as you are in labor, and before the baby is just about to come out, you can have an epidural.
2) Can I breastfeed my baby after receiving an epidural?
Yes. The epidural will not put enough medication into your breast milk to cause a problem. Most women are also able to breastfeed after receiving narcotic pain medications, although some of this medication will be in the breast milk. It is very unlikely that this will cause a problem for the baby.
3) Can I have an epidural if I'm on a blood thinner, or if I have a bleeding disorder?
The short answer is maybe. Blood thinners and bleeding disorders can increase the risk of serious bleeding - possibly leading to nerve damage, and even paralysis, as a result of the epidural. You will have to discuss with your doctors the risks and benefits of stopping blood thinners and how much risk is involved if you have a bleeding disorder. Certain herbal remedies and over-the-counter medications can also increase bleeding risk, and you should discuss these medications with your doctors.
4) Can I have an epidural if I have a back tattoo?
Yes. This will not affect your tattoo, either.
Epidural FAQs
Here's what we'll discuss in this course:

1. The role of your anesthesiologist
2. Non-medicinal options
3. Medicinal (Pharmacologic) options
Narcotic medications
Nitrous Oxide (laughing gas)
Regional anesthesia (Epidural)
4. Results of the Listening to Mothers Survey in 2006
Safety and comfort
for you and your baby
Your anesthesiologist will also answer questions and address other concerns you may have.
Working together towards a common goal
Types of Non-Medicinal Options
Music therapy
Breathing exercises
Positioning changes
Birthing ball
Relaxation techniques
Doula or Labor coach
Ice/hot packs
What to expect
Narcotic Pain Medications
What is it?
Epidural literally means ‘above the dura,’ and refers to the location where the medication is delivered. The ‘dura’ is the tissue that surrounds the spinal cord, which is bathed in a solution called Cerebrospinal Fluid (CSF). 'Epidural' is not a type of medication, but rather a method of medication delivery.
How does it work?
The epidural space lies very close to the nerves that carry pain signals during labor, so it is an ideal place to deliver medication. When those nerves are exposed to medications you will have decreased sensation from the belly button down to your feet.

This method is useful because medication is directed to specific regions of the body instead of circulating throughout. Therefore, we can use very low doses of medication to achieve potent effects. Since we use very low doses, and they don't circulate throughout the body, very little, if any, medication gets to the baby. Exposure is very limited.
While this is likely to be a very busy and exciting time for you, it's normal to also feel some anxiety about the labor and delivery process, especially if this is your first child.

We’re here to help you learn about your pain management options, and give you the tools you’ll need to make informed decisions for yourself and your baby.
What does this mean?
Nitrous Oxide
Communication is key
This survey offered a lot of useful information about how well each pain management option works, but every patient is different and every labor and delivery is different. Many women will try several different methods for managing pain before they find a combination of things that works best for them.

Here are the results of the survey regarding pain management. The table is arranged from most effective to least effective treatments.
What to Expect During Labor

These options include:
Narcotic pain medication
Nitrous oxide (laughing gas)
Regional anesthesia (Epidural)

This may include:
IV access to give medication and fluids
Continuous fetal heart rate monitoring
Pulse oximetry (a finger probe that measures blood oxygen content)
Blood pressure cuff
Supplemental oxygen
Bed rest
A restricted diet (typically clear liquids)
Placement of a bladder catheter
What is it?
As labor progresses, the anesthesiologist will assess your epidural to ensure that it is working well. Occasionally, it may be necessary to adjust the medications in the epidural solution or to provide extra doses - called "top offs" to optimize pain control from the epidural
Finding the balance that's right for you
This medication is injected into the cerebrospinal fluid (CSF) and directly bathes the spinal cord.

The spinal dose is
and relieves pain within a few minutes. Dosing of the epidural will typically take about 15 minutes to have an effect. The main benefit to this technique is the speed of the pain relief.

Utilization of this technique varies widely between medical centers and individual practitioners.
While your anesthesiologist and obstetrician or midwife will provide guidance and ensure your safety, the way you manage your pain during labor and delivery is ultimately up to you.
5) Can I have an epidural if I've had back surgery?
Usually Yes. However, abnormal curvature of the spine, like scoliosis and certain hardware from surgery can make placement of the epidural more challenging. The risk of epidural failure or misplacement is increased slightly in this setting, but it does not mean that you cannot have an epidural. Please bring any x-rays or other imaging with you to your appointments so that the anesthesiologist can review them and give you specific recommendations.
6) Why do I have to stay in bed when I have an epidural?
Even though you may have good strength in your legs, your sensation will be affected with an epidural. As a result, it will be difficult to keep your balance, and nobody wants you to fall.
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Prepared by Aaron Barry, MD
Full transcript