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Pain Relief in Labour

In early labour
Labour pain can often be managed with simple comfort measures, but sometimes you need more pain relief. We offer a number of different options to help you manage your pain. 


Have a dedicated support person to provide practical and emotional support. This person can be a partner, family member or friend. They can give you a back massage, prepare a bath, walk with you, or just provide company. 
A doula is good option if you do not have a support person or you would like the support of a trained caregiver. Doulas are not covered by the BC Medical Services Plan. Some extended healthcare plans may cover the cost, or you may have to pay privately. 

For more information on doulas visit: Doula Services Association of BC.

Moving and changing your position frequently during labour may increase your comfort level. Try walking, rocking in a chair, swaying, kneeling over a birthing ball, squatting and other positions. Use the position you find most comfortable. Upright positions may be useful if your labour progress has slowed or if you have back pain. See Example Labour Positions. 

Exercise balls are excellent tools to use during labour. BC Women’s has exercise balls you can borrow to use in labour. Ask your provider for more information. 

Benefits of movement
  • May help you manage pain caused by contractions
  • Labouring in an upright position uses gravity to help your baby move down through your pelvis, speeding up your labour
Limitations
Trying to stay in an upright position can be tiring ‎‎

‎Placing a warm gel pack, blanket, heated rice pack, or hot moist towel on your lower abdomen, groin, low back or shoulders may provide temporary pain relief. Placing a cold pack (ice bag, frozen gel pack, cold cloth) to painful areas may also provide comfort.


Benefits of heat therapy

  • Temporary pain relief if you are cold, sore or tense
  • May also help reduce swelling

Benefits of cold therapy

  • May reduce pain in your lower back
  • May provide relief to your sweating brow, face, chest or back of your neck

Risks

  • May cause skin damage (redness, blisters) if the temperature is too hot or cold. Use carefully if you have an epidural as your sensitivity to hot and cold will be reduced. 
Touch can be soothing. Someone holding your hand, stroking your arm, massaging your back, feet or shoulders may help you relax and ease some of the pain in early and active labour. 

Benefits of touch 
  • Relief from feelings of depression and anxiety
  • Reduced leg and back pain
  • Shortened labour and reduced need for pain medication
Note to support people: Some people do not like massage or touch during labour. Ask first before touching anyone in labour.‎‎
Taking a warm shower or bath may relieve pain. The stimulation of a shower or bath may also relieve tension and anxiety by reducing your awareness of your labour pain.

Take precautions
  • Make sure you have a support person to help you in and out of the shower or bath to avoid slipping on wet floors.
  • Keep track of the water temperature to avoid burns
  • Drink plenty of water to avoid dehydration‎
 

‎A Transcutaneous Electrical Nerve Stimulation (TENS) machine is a small box with wires and pads attached to the skin sending small electric impulses to areas where you need pain relief. Electrical stimulation blocks some of the pain messages from reaching the brain. The brain registers the tingling sensations from the TENS instead of the pain.


Benefits of a TENS machine
  • Can be used in early to active labour and in combination with other pain relief methods
  • Has no harmful effect on you or your baby
  • Does not restrict your ability to move about in labour
Limitations
  • Not covered by the BC Medical Services Plan; some extended health care plans may cover the cost or you may have to pay privately
  • Machine must be rented or purchased beforehand, pads must be purchased
  • Cannot be used in the bath or shower 
 
Morphine and Gravol are used together to provide pain relief and help you rest during early labour. Morphine is a strong opioid medication given by injection to reduce pain by blocking the pain messages to your brain. Gravol reduces nausea (upset stomach) caused by the morphine or by labour and can help you to sleep. Morphine and Gravol are good pain relief options if you are having difficulty managing early labour. After receiving Morphine and Gravol in hospital, you can return home to rest and continue your labour.

Morphine and Gravol do not increase your risk of needing an assisted delivery (e.g., forceps) or a cesarean delivery. They will not cause addiction or overdose when administered by your health care provider during labour.

Morphine is not given in active labour because it stays in your body for several hours after it is given which can have a prolonged effect on the baby. Morphine is also less effective for pain in active labour when compared with fentanyl.

Benefits of Morphine
  • Reduces pain but does not take it away completely
  • Works within 20-30 minutes and pain relief lasts up to 4 hours
Side effects
  • Morphine may cause nausea, vomiting, dizziness, and sleepiness
  • Gravol may cause sleepiness
  • If given near the time of birth, Gravol may cause drowsiness and impaired breathing in the baby. This is short-term and is treatable with another medication if needed. 
 


During active labour

Except for morphine, all the pain relief options used in early labour can also be used during active labour.  

Below are further measures for pain relief during active labour.

Sterile water injections may be used in active labour to provide pain relief; especially strong lower back pain. Your healthcare provider injects four doses of sterile water into your lower back just under your skin. The injections feel like a sharp bee sting at first, but the stinging and the back pain go away.

Benefits
  • Effective at relieving back pain in labour
  • Can be repeated as often as needed
  • Pain relief occurs within minutes of the injection and can last between 45-120 minutes
Risks 
  • There are no known side effects‎
 
Entonox is a mixture of nitrous oxide and oxygen, sometimes known as ‘laughing gas’. You breathe the gas in through a mouthpiece during contractions to ease the pain. 

Benefits 
  • Can help you cope with labour pains by providing fast-acting pain relief
  • Provides light relief and leaves the body quickly, with no risk to the baby
  • Can be used anytime in labour, and nearly anywhere in the room
  • You control how much and how often you want to use the gas
Risks
  • May make you feel light-headed and nauseated
  • May cause your mouth to feel dry for a short time‎

Fentanyl is a strong opioid medication given intravenously (through an IV). It offers a medium amount of pain relief. Fentanyl dulls your pain without the numbing effect of an epidural; it will not take all of your pain away.

Fentanyl is less effective for pain relief when your labour is long or difficult.  Fentanyl does not increase your risk of needing an assisted delivery (e.g., forceps) or a cesarean delivery. Fentanyl will not cause cause addiction or overdose when administered by your healthcare provider during labour. 

See Information about IV Fentanyl for more information.

Benefits of Fentanyl in active labour
  • Reduces labour pain but does not take it away completely
  • Works within minutes, but only lasts about 45-60 minutes, however, more doses can be given
Risks for you
  • You may become sleepy and relaxed
  • Your breathing may slow down; you may need to be given oxygen and be monitored
  • You may feel sick to your stomach
  • You may feel itchy
Risks for your baby
  • Fentanyl crosses the placenta and goes to your baby. 
  • Your baby may be sleepy and not breathe well at birth
  • Your baby may have a lower heart rate at birth
  • If you have a large dose of Fentanyl in labour, your baby’s breathing may need to be monitored for several hours after birth
  • Your baby may have trouble starting breastfeeding because they are sleepy; you may need help from your nurse or lactation consultant to get your baby to breastfeed‎

A local anesthetic (freezing) is administered by needle into your vagina. The anesthetic relieves pain along the pudendal nerve, which gives feeling to your perineum, vulva and vagina. A pudendal block can be used during the second stage of labour until just before your baby is born. It also relieves pain during a vacuum or forceps-assisted birth.


Benefits 

  • Provides some pain relief to the perineum, vulva and vagina
  • Works rapidly

Risks

  • Small risk of bleeding, infection
  • Injection into the blood vessels causing potentially toxic effects from the local anesthetic

Epidurals

Pain is a common part of labour and birth but there are many ways you can ease your pain.  You may want medication to relieve pain as your labour progresses. Your care provider may suggest an epidural or a combined spinal epidural (CSE) to help you manage pain throughout your labour. Talk to your care provider early in your pregancy about the pain relief options that are best for you. 

An epidural is a small tube placed in the lower part of your back to deliver pain relief medicine during labour.  An anesthesiologist (pain relief doctor)  will insert the tube with a small needle.  Pain relief begins within 5-10 minutes and lasts about 20-40 minutes. Epidurals are usually a safe and useful way to manage pain during labour and delivery.

An epidural does not completely block all pain or pressure, particularly if you are in the late stages of labour. Epidurals continue working throughout your labour and do not run out. Once admitted to a labour room you can get an epidural. It is never too late to ask for an epidural, but once you are fully dilated or if your labour progresses quickly, you may have your baby before the epidural starts to work.

Epidurals may not be appropriate for people with certain medical problems (for example:  spina bifida, previous back operations, and problems with blood clotting). 
Epidurals are the most effective form of pain control in labour. There are many benefits to using an epidural for pain relief:
  • Fast pain relief. Usually works within 10-40 mins
  • Can be inserted almost any time during labour
  • Allows you to walk around with support
  • Allows you to rest and relax during parts of your labour
  • Can provide anesthesia for surgery such as a cesarean delivery, or for a forceps-assisted delivery
 
An epidural usually has side effects.

Common Side Effects
  • Feeling lightheaded (low blood pressure)
  • Shivering
  • Itching
  • Fever
  • Small bruise at site of epidural
  • 5-10% of epidurals  leave areas of your belly 'unfrozen', which may be corrected by additional or different medications
  • It may be hard to urinate (pee) and a catheter may be inserted to help you empty the bladder
  • Epidurals have been shown to slightly increase the duration of the earlier stages of labour

For most people, the benefits of pain relief outweigh the risks of having an epidural. Epidurals do NOT make you more likely to need a cesarean (c-section) delivery.


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Table: Epidural risks for you

 

(Click on image to enlarge)


A Combined Spinal Epidural (CSE) may be useful if you are in a later stage of labour or in significant pain. A CSE technique combines a more rapid onset of analgesia with the benefit of the epidural tube for additional medicine. Having a CSE will NOT make you more likely to need a cesarean delivery. The choice to place a CSE may depend on your anesthesiologist.

Benefits of Combined Spinal Epidural (CSE)

  • Faster acting than an epidural, pain relief in about 5 minutes. 
  • You may still be mobile with a CSE, though you may not necessarily be able to walk in the first 60 minutes

Risks and side effects of Combined Spinal Epidural (CSE)

  • Risks and side effects are the same as for an epidural (see above) except for an increased risk of meningitis (infection around your brain). While meningitis is more common with CSE, it is still rare (1:40,000). 
  • An increased chance your baby’s heart rate will decrease in the first 10 minutes after a CSE is placed; your nurse will monitor your baby's heart rate closely after your CSE is placed. 
  • You will either sit on the side of the bed or lay on your side.
  • The anesthesiologist may scan your back with an ultrasound machine to check spaces between your bones.
  • Your back is cleaned with a disinfectant liquid.
  • Local anesthetic (‘freezing’) medicine is injected into the skin where the epidural will be placed, this causes a few seconds of discomfort.
  • A hollow epidural needle is inserted between the bones in your lower back to find the ‘epidural space’; you may feel an ache or pressure as this is done but it does not usually hurt.
  • A thin plastic epidural tube is put through the hollow needle into the epidural space.
  • The epidural needle is removed and the epidural tube is taped to your back.
  • Pain medicine is injected through the epidural tube.
If you are overweight or it is hard to feel the bones in your back, an epidural may be more difficult and take longer to put in place.
 
  • You will either sit on the side of the bed or lay on your side.
  • The anesthesiologist may scan your back with an ultrasound machine to check spaces between your bones.
  • Your back is cleaned with a disinfectant liquid.
  • Local anesthetic (‘freezing’) medicine is injected into the skin where the epidural will be placed, this causes a few seconds of discomfort.
  • A hollow epidural needle is inserted between the bones in your lower back to find the ‘epidural space’; you may feel an ache or pressure as this is done but it does not usually hurt.
  • An anesthesiologist inserts a smaller needle through the epidural needle and puts a tiny amount of medication directly into your spinal fluid. An epidural tube is left in place so more medication can be given when you need it. 
  • A thin plastic epidural tube is put through the hollow needle into the epidural space.
  • The epidural tube is connected to a “patient-controlled epidural pump” which allows you to give yourself extra medication when you feel you need it.
 
  • The area between your groin and belly button becomes numb
  • Your legs may feel warm, tingly and sometimes a bit heavy
  • Your contractions should feel less intense and less painful, but you may still feel pressure
 
The medications used in an epidural/ CSE allow you to move even though your legs may feel numb. You need to remain in bed for the first 30 minutes after the epidural/CSE starts. Your healthcare provider will measure your blood pressure, leg strength and test the feeling in your feet to make sure it is safe for you to stand and/or walk. Once your healthcare provider deems it is safe, you should be able to move easily in the following ways: 

  • Labour in different positions
  • Use the bathroom
  • Sit in a chair
  • Walk in your labour room
  • Walk around the hospital unit
You must have a support person with you at all times when you are walking. Your support person can help you. 

You may not be allowed to walk if:
  • You have significant pain and need more medication
  • Your healthcare provider does not feel it is safe
 
For more information
Pain relief in labour options.  

Ask your healthcare provider if you can speak with an anesthesiologist. 


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