Transcript episode #28:your options for managing pain in labor
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00:00 In this episode, I'm going to talk about the various options for managing pain in labor, including non-medication techniques, medications that aren't an epidural, such as IV pain medication and nitrous oxide, and also epidurals.
00:15 Welcome to the All About Pregnancy and Birth podcast. I'm your host, Dr. Nicole Calloway Rankins, a board certified Ob Gyn physician, certified integrative health coach and creator of The Birth Preparation Course, an online childbirth education class that will leave you feeling knowledgeable, prepared, confident, and empowered going into your birth. Quick note, this podcast is for educational purposes only and it's not a substitute for medical advice. See the full disclaimer at www.ncrcoaching.com/disclaimer.
00:53 Hello and welcome to episode number 28 of the podcast. Thank you for being here today. I'm talking about your options for managing pain during labor, and what I'm going to do is give a broad overview of what the options are. I'm going to talk about non-medication options. I'll talk about medications that aren't epidural, so IV pain medications, opioid medications, as well as nitrous oxide. And I'll talk about epidurals, and what I'll do is I'll go through the risks, the benefits, the pros and the cons of each of those methods so you can make an informed decision about how you want to manage pain during your labor. Now to help you out, I created a downloadable pdf that goes with this episode and it just includes all the information that I'm going to discuss, including some additional questions that you may want to ask your doctor or midwife.
01:49 You can grab that pdf at www.ncrcoaching.com/pain. That's www.ncrcoaching.com/pain and the link of course will be in the show notes. Now, before we get into the episode, a couple of quick things. Let me mention that this episode is sponsored by my online childbirth education class, The Birth Preparation Course. The Birth Preparation Course will leave you knowledgeable, prepared, competent and empowered going into your birth. It has over eight hours of content that covers everything from getting in the right mindset for your birth to who should support you to the details of labor, to possible things that could happen like labor induction or c-section to the postpartum period. Everything is online so you can go through it on your own time and at your own pace. You can go through it with your partner, and there's a private Facebook group with a community manager who's a Doula. I'm in the group as well doing live Q and A sessions and you get lifetime access to the course, so definitely check it out for childbirth education. That's www.ncrcoaching.com/enroll and you can learn more about it there.
02:57 And let me give a quick listener shot out. This is to Sydney Kasner. Sydney left me a review in iTunes that says this... Doctor Rankins provides a unique pregnancy and birth podcast that will keep mama's feeling uplifted and supported. She does an excellent job keeping bias out of this podcast so you can make your own opinions or decisions based on the information provided. This podcast is not just for mamas, I'm a devoted listener and don't anticipate pregnancy anytime soon. I just love health education and feel better prepared for when my time comes. Thank you, Dr. Rankins. Well, thank you so much Sydney for that lovely review. You hit on so many of the things that I'm trying to do to be of service in this podcast. Keeping bias out, provide excellent information, uplift women, support women. So thank you. Thank you. Thank you for those kind words.
03:58 Okay, so without further ado, let's go ahead and hop into your pain management options during labor. Now before we start, let me just kind of give you a background about labor pain. Now people call contractions or labor pain, different things. Some call it surges, some call it waves in order to help mentally kinda wrap ourselves around it a bit better. You can call it however you feel. I am going to refer to it as pain just because I feel like the simple, that's how I refer to it. Now. Although women experience labor differently, most will interpret the contractions in the intensity is pain and how to deal with this.
04:43 Labor pain is often the thing that can concern women the most about giving birth. There's a lot of fear surrounding labor pain. Some of that comes from what you see on TV and depictions of labor. Some of that comes from perhaps your personal experiences where you've had a friend or family member go through labor and you saw how intense that process is. All of that fear is completely and totally normal and also very common. Now it can be helpful and actually not just helpful, but it's really crucial in order to help deal with that pain that you have a good mindset toward it that will help you work with your body to manage the pain instead of fearing that pain. See, pain is normally something in our bodies that we interpret as a problem. It means that something's wrong. You know, if you fall, you hurt yourself, then you have pain, something's going on there. Or if you break a bone or you know, if something is going on inside your body, if you have pain, that means something's wrong.
05:51 But labor pain is a different type of pain. It's actually a pain that is caused by something that's good. It's caused by birth. And I'm talking about full term, you know, regular, normal pregnancy of course. So the pain of labor is different in that, it's definitely going to come to an end. It comes and goes at mostly predictable intervals. And at the end of it, you have this beautiful thing, your baby is here. So if you can think about labor pain in that way, that it's different than other types of pain, then that can help make it easier to manage. Now, as far as how to manage pain, there is absolutely no right set choice for how you manage pain in labor.
06:49 This is very much so a personal decision and one that you have to make for yourself. Your friends can't make it for you, your mom, your sister, your family members can't make it for you. You have to make it for yourself and please know that whatever choice you make is the right decision for you. Be confident that you've made the right choice for yourself. It's a choice that only you can make. Okay, so let's get into the options for pain medication first.
07:24 I want to talk about options that are not medication. So all women, yes, all women really should be familiar with techniques to manage labor pain without medication. That's even if you plan to use some sort of medication. Even if you plan to get an epidural as soon as you hit the door, there will be a period of time, most likely that you will experience labor pain before you can get any medication or before you can get an epidural. So you need to know how to manage the pain in that period of time. In addition, sometimes things can go pretty quickly, you know, faster than you anticipated and delays can happen where you can't get an epidural right away. So you want to have these in your back pocket, ways that you can manage pain. Again, both because there's going to be a period of time when you don't have the epidural or things may go so quickly that you may not have time to get that epidural. If you do plan from the jump that you are going to go without medication for the duration of your labor. That's cool. A lot of women are making that choice. More and more women are making that choice to do a medicated birth.
08:47 Now if you do this, then I think you need to be a bit more prepared, more prepared and in depth preparation than what I'm going to talk about in the podcast episode. You really need to have a plan in place to cope with the pain. Some women come in, they just kind of go with the flow and do it, but I find that if you have a plan in place, then the pain is not so overwhelming and you find it easier to manage, especially in the hospital setting where options for medications are so easy to get to. If you have a plan in place in the beginning, then again, it's much easier to go the duration without paying medication in the hospital. Actually have a a whole separate bonus lesson in my childbirth education class. The birth preparation course for women who want to do an unmedicated birth in the hospital. So if you enroll in the course, you'll definitely need to check that out for sure. And if you want to do an a medicated birth, one of the things that's important is that you have good support.
09:48 You need to have a partner there, you know, a friend, family member, you know, whoever you want, they need to be prepared to assist you with moving around with some of the techniques that I'm going to talk about. They also need to be prepared to advocate for you and your wishes when you can't, when you're in the throes of labor. It's not necessarily easy to have like a detailed conversation about something. So you need to have someone there who can advocate for you on your behalf and who knows your wishes. Well, the other thing, and this is something that I see people miss sometimes, is that whoever is with you, your partner needs to feel comfortable with seeing you experience pain. It can be very hard for a partner or your mother or sister or friend to see you in pain. That can be hard to physically watch. So they need to be prepared ahead of time to understand that this pain again is something different. It doesn't mean something's wrong and that they need to be comfortable and able to deal with that.
10:55 In addition to your partner a Doula is a great support for an unmedicated birth. A well-trained Doula can offer you lots of techniques and not just techniques for you, but techniques for your partner as well to help you manage pain without medication. And as far as some of the techniques that are commonly used, massage is one that's commonly used in a couple of specific places. There's low back massage that may help, hip squeeze, double hip squeeze may help. Focused breathing is a common technique, pattern breathing. The classic one is the, the mas like ha ha. But of course there are lots of other techniques, but just kind of focusing on breathing can help a lot.
11:44 When you're focused on breathing, it just takes your attention away from the pain or you're not quite as fixated on it, so to speak. Position changes can help whether you lay down or on your side or squat or lean against a wall or leaning against the partner or the bed. All of those things can help walking. It can be a big help to cope with pain when you're doing it without medication. Hypnosis, hypnobirthing is a common thing that women often use to help manage pain without medication. Hydro therapy, and that's just getting in the shower or the bathtub. Water can be outstanding. A lot of women really, really like that as an option to help cope with pain when you're going without medication. And then finally the birthing ball, the birthing ball, you just sit, you sit on an exercise ball, and you move around on it and it helps too, it just helps you to kind of relieve that pain and pressure.
12:47 Now as far as what's required, hydrotherapy and the birthing ball really don't require any special training at all. You just kind of hop in the shower, hop in the bathtub. Both of those things are things that you can have at home so you can hop in the shower at home if you're in early labor or in the bathtub at home if you're in early labor. Also if you have a birthing ball at home, you can squat on that or sit on that when you're in the early part of labor. So those are great tips, techniques to use when you're at home. The hospital probably has a birthing ball. They may or may not have showers or bathtubs. You have to ask your specific hospital if they have that available to you.
13:25 And other techniques like massaging, breathing or hypnosis, those things require a little bit more knowledge and preparation and that's where I suggest you either get a Doula or do some additional training to become more familiar with those techniques in more detail. As far as some additional places you can reach out to get more training, some common books that I think women find helpful. I know Guide to Childbirth is a popular one that a lot of women use if they want to do an unmedicated birth. I liked the book Birthing From Within a lot. I thought that was a really helpful book. When I read it, there's some parts of it, they're a little bit artsy and I was like, okay, maybe not for me, but I think overall it's a great book and then there's books for the Bradley method. There's a hypno birthing book, so you can check all those out.
14:14 You can also take classes whether online or in person that are specifically geared towards unmedicated birth, hypnobirthing classes, Bradley method has a class, Birthing From Within has a class, Momma Natural. You can check all those out and those are linked in the pdf that you can download with the episode too. All right. Now, some of the pros of the medication free options are that there's no exposure to medication for you or your baby. So that can be a bonus for a lot of people. Most women will feel very empowered after an unmedicated birth. Occasionally I see circumstances where women feel overwhelmed by it because they weren't expecting to do it and things went so fast. But for the most part, women feel very empowered after they have an unmedicated birth. And then in my experience, women recover faster from an unmedicated birth fairly quickly. You're up and you're walking around. You don't have to wait to get you feeling back. You just feel like more like yourself after the unmedicated birth. That's a common thing I hear when I encounter women who've had both options, epidural and no epidural.
15:23 The con, and I don't know if this is a con necessarily, but it can be tempting or easy to get an epidural in the hospital if it's readily available. So again, that's where that planning really comes into play, that this is what you want to do, that you're prepared ahead of time to deal with it. In my free Webinar on how to make your birth plan, I talk about some questions you need to ask when you're making your birth plan if you're thinking about an unmedicated birth, so check that webinar out. It's www.ncrcoaching.com/birth-plan.
15:57 Okay, let's move on to medications, but that are not an epidural, so these can be divided into two categories. One is opioid medications and the other is nitrous oxide. That's an inhaled medication and these medicines work by reducing your awareness of pain. Now, opioids we're familiar with opioids from the opioid epidemic. It's the same opioids, just given in a different way. These are a very powerful class of medications that help relieve pain. Now in the context of labor, they can be given into a muscle or they can be given intravenously through an IV, and that's how they're most often given is through an IV. Sometimes we give a big dose in the muscle if someone's in a long, early labor and they need to get some rest, but most of the time it's given through the IV. The common ones that are used in labor are morphine, fentanyl, nubain, which is actually a brand name stadol, also actually a brand name and what's used is really provider and hospital dependent.
17:07 When I was in training and in residency at Duke, we use stadol all a lot. At the last two hospitals I've been at, we use nubain a lot. It really just depends. Now, just so you know, all opioid medications will cross the placenta and they will get to your baby. However, your baby clears the medication out of its system the same way that you do. But in that period of time, as the baby's clearing out the medication, there may be some changes in the baby's heart rate because you know how opioids, if you've ever been exposed to opioids, will make you kind of sleepy. It'll do the same thing for your baby, so your baby's heart rate won't bounce up and down as much. That's something called a loss of variability.
17:50 And we have to be careful about giving too much opioids close to delivery because if the baby has those medicines in their system when they're born, then the baby may have difficulty breathing, they may have trouble suckling. These things are possible. I've not seen them happen, but you do have to be careful again about giving those opioids close to delivery. Now, opioids work pretty quickly. They take effect in between 5 to 10 minutes. So it doesn't take long and they can last anywhere from 30 minutes or even up to six hours in some cases. It just depends on how your body metabolizes the medication. It generally takes babies longer to clear the medication from their system. So the effects on the baby may last a bit longer. So again, that's why we have to be careful about the timing of it.
18:44 Now remifentanil is a very short acting opioid. So we avoid some of those issues where it can change the heart rate with the babies if the baby's born that the baby has trouble breathing, that kind of thing because it gets out of the system very quickly. It's administered through an IV and you do it as something called a PCA, which is patient controlled analgesia and that just means you push the button yourself to give yourself doses of the medication. You do have to be closely monitored while using remifentanil because it can cause your breathing to slow down to a really low level. So, again it requires some extra special monitoring. Now nitrous oxide is the other non epidural medication that you can use and it's known as laughing gas. It's an inhaled gas. It's actually been used for decades to provide pain relief in labor.
19:45 It is much more commonly used in Europe and other countries than it is in the United States. But it's popularity and availability is increasing in the US. And the way that you do nitrous oxide is that you give yourself the medication through a mouthpiece or a face mask and it contains a combination of the nitrous oxide gas and oxygen, usually at a 50/50 ratio. There are some things that have to be in place. You have to have the right equipment in place so that you only get the medicine when you inhale and other people in the room aren't exposed to it. But this medicine is cleared very quickly from your system, and very quickly from your baby's system, so it really doesn't have any risks for the baby. It can be used up until the end of birth.
20:34 Okay. Now as far as some of the side effects or risks of these things for IV medications, those opioid medications, some women are allergic to them, so you have to be careful with that. Some women can have itching as a result of the medication that's just separate from an allergy. It just causes this really intense itching. Some women can have nausea or vomiting with opioid medications and then for some women you can feel just sort of drowsy and kind of out of it. Similarly for nitrous oxide, it can cause dizziness, nausea, vomiting or a drowsy or silly feeling, which again is why we call it that laughing gas. Now for the pros and cons, those longer acting IV opioid medications, these can be fantastic at helping you get through a rough patch of your labor. So if you're having like a long part of labor, opioid medications can be great to help you get some rest and regroup and get back in the game for the remainder of your labor.
21:46 Now for those short acting IV medications, that remifentanil that I talked about, the good thing about that is that you can have control over the medication and like I said, it's short acting. Now for the nitrous oxide benefits, those include you can still be mobile, you can move around, you have control over it, it's short acting. It does not require continuous monitoring, so you don't need to be on the monitor all the time. Whereas actually you do with the opioid medications and again, it's cleared from your baby's system very quickly. Now as far as the cons, the biggest con, and I don't know if this is a con, but something to be aware of, is that these medications are not as effective as an epidural. Do not think that these can be a substitute for the type of pain relief that you get with an epidural. They just, they just aren't.
22:40 And some of the cons for those longer acting, IV medications like we talked about, they can make your baby drowsy, make you drowsy, make your baby have trouble breathing if they receive the medication close to birth. As far as the cons of the short acting IV medication that remifentanil and the nitrous oxide, they're not available in most hospitals or a lot of hospitals. So you need to ask ahead of time if they have those things available.
23:07 All right, so let's talk about an epidural. An epidural works by decreasing most sensation, including pain. So it's not just that your pain level will be decreased. You won't feel a lot of anything with an epidural. It decreases all sensation. Now the way an epidural works is that a catheter is placed in what is the outer most part of the spinal canal that is called the epidural space, and putting that catheter there allows for repeated or administration of pain medicine. So what that means is you can keep getting doses or you can get a continuous infusion of medication through a pump. So once you get an epidural, that pain relief is going to last for the duration of your labor, no matter how long your labor is, whether it's a few hours or a couple days, the epidural lasts the entire time.
24:08 The epidurals can be given at any point in labor, even at 10 centimeters. And I've seen the full gamut as I've seen women who are being induced and they don't want to feel really much of any pain. So they get an epidural fairly early in the process. I've seen women get an epidural at 10 centimeters when they are completely dilated. It's not as common, but it can certainly be done. So epidurals can be given at any point in the labor process. They do take some time to set up. So be mindful that it doesn't just happen right away. Usually it takes about 20-25 minutes for the pain relief to kick in.
24:45 There are also some circumstances where women cannot get an epidural. If you have issues with your platelets, which are what help your blood clot, if they're too low, you can't get an epidural. If there's something different about your anatomy, so your scoliosis may be one where you can't get an epidural, or if you've had surgery on your back and you have hardware in your back, you may not be able to get an epidural. Your doctor should alert you if you fall into this category so you can plan accordingly. You can often see an anesthesiologist during your pregnancy to decide if you can or can't get an epidural, if that's a concern for you.
25:24 Now, contrary to popular belief, the research shows that epidurals do not increase your risk for c-section. So when you look at all the research studies, it's just not the case. Now epidurals do, however, increase your risk of having an assisted vaginal delivery with either use of a vacuum or forceps. And I think that's related to the fact that if you're not feeling as much, then it's harder for you to push and you end up pushing longer. And then we get into the vacuum or forceps situation, but it's only a slightly increased risk and epidurals will also slow down labor a bit. That is true, but only by short amounts. Studies show that maybe 30 minutes that an epidural will slow down labor. So it's not a significant amount of time.
26:13 Now, one thing you may have heard about is walking epidurals where you're able to get up and move around with an epidural. This is really a misnomer. Most women do not have enough sensation in their legs to walk with an epidural in place. However, we can, or I should say the anesthesiologists can, decrease the dose of the medication so that you're not dead numb. We can kind of tailor it a bit. So you're feeling some but not everything and you're not like where you can't feel anything. And the reason that that's important is because if you're completely numb, when it comes time to push, then it's very difficult to push. You need to feel some sensation so you know the right place to focus on where you push. So if you find that you're very numb when you get an epidural, then ask the nurse to decrease the epidural dose when it's time to push. Because again, you want to feel something.
27:16 I definitely don't think you should go into this with an epidural thinking you're not going to feel anything at all. You'll never feel a single contraction or a single bit of pain. You don't want to go into it with that mindset. You want to go into it with able decrease this insatiable of pain, but you want to feel something so that you're able to push most effectively when the time comes. Now there are some side effects to epidurals. The most common side effects are itching. It can cause pretty intense itching. It can cause nausea and vomiting. A really sort of odd one I guess that we don't completely understand why it happens is shivering, like very, very intense shivering. Even though you're not cold. Epidurals can also cause a drop in your blood pressure and when your blood pressure drops, then the blood flow to your uterus can drop and that can affect the baby's heart rate and typically that's going to happen right after the epidural is placed. If it drops your blood pressure and your baby's heart rate drops, then we have to give medications to fix your blood pressure, which then fix the heart rate.
28:30 Another side effect is that epidurals may need to be replaced. Occasionally they do not last the duration, they move or something happens, the catheter gets bent and it may need to be replaced during the course of your labor. They can also be one sided where you get more relief on one side than the other. Another thing that may happen is headaches. Some people get a pretty intense headache actually from epidurals, and then finally it can reduce your ability or your effectiveness, of breastfeeding. That's short term and gets better pretty quickly with time. I don't want to like scare you off from epidurals, but it's the biggest intervention, and with a bigger intervention, it comes with more potential side effects. Those things do not happen very commonly. I don't see that it needs to be replaced commonly, I don't see the headaches or blood pressure issues commonly, but these things do happen.
29:33 Now. Some of the pros of having an epidural. Number one is that it is excellent pain relief. There is no getting around that. When you have a great epidural, you will have excellent pain relief during labor. The other pro is that it's going to last up until delivery whenever you get it, that catheter that's there allows for that continuous administration of medicine so it'll last the duration. Epidurals can also be used towards c-section if needed. If it comes to it, you just get a big dose of medicine through that catheter and it will work during a c-section. And then finally we believe that very little medicine from the epidural reaches the baby. The medicine almost exclusively stays in that epidural space around your spine so it doesn't reach the baby. Whereas opioid medications will.
30:27 Now some of the cons of having an epidural. Now this is going to connect you or tether you for lack of a better word, to a lot of stuff. So you will have an IV, you have to have an IV in place. When you have an epidural, you have to get a lot of IV fluids ahead of time to help prevent your blood pressure from dropping. You have to keep getting IV fluids. You can not feel the sensation to use the bathroom with an epidural. Remember I said it doesn't just decrease pain, it decreases all sensation and if you can't feel the sensation to use the bathroom, then there's a risk of your bladder over filling and you don't want that to happen. If your bladder overfills it gets too distended, then sometimes it forgets how to empty itself. So in order to keep your bladder from overfilling, you have to either get a catheter in place and leave it in place or every two to three hours or so your nurse will empty your bladder with a catheter. Because you can't feel that sensation to go.
31:33 For the most part, you are confined to the bed. Remember I said that walking epidurals are pretty much a misnomer. I've never seen anybody or any anesthesia. I've never seen any anesthesiologists do what people think of maybe walking epidurals where you can get up and walk around with it. That's just not very common that that happens. It does require you to have continuous fetal monitoring. The baby needs to be on the monitor all the time while you have an epidural. Whereas with the nitrous oxide or unmedicated, you can have intermittent fetal monitoring. Epidurals take time and preparation. They take anywhere from 20 to 30 minutes to get everything set up to get the fluids you need ahead of time to get the anesthesiologist there. The thing is that the anesthesiologist may not be in the hospital 24/7 to place an epidural. Not all hospitals have an anesthesiologist available 24/7so that may be a question that you want to ask for your hospital too, if you're super interested in getting an epidural. And final, you may push a bit longer than if you didn't have an epidural, and that just goes back to that sensation piece.
32:43 Okay, so to recap your choices for pain medicine in labor, you have medication free techniques which include massage focused or pattern breathing, position changes, walking, hypnosis, hydrotherapy, and the birthing ball. You have medication techniques that are not an epidural. Those would be opioid medication, either long acting opioid medications that go through your IV or in a muscle, or short acting opioid medications that go through that PCA. That short acting version is not available in most hospitals. Also nitrous oxide or laughing gas as the other medication that's available that's not an epidural. Again, that may have limited availability in the hospital. So you need to ask ahead of time. And then finally, of course we have epidurals.
33:46 Now remember I had that pdf that you can download that has all of this information there so you can print it out, look at it, take it to your doctor's office, talk about your options, make a decision about what pain management option works best for you. Again, this is a personal choice for how you manage pain in labor and with every choice, you decide what is the right choice for you. Now I would love to know how you plan to manage pain in labor. Let me know in the All About Pregnancy and Birth Podcast community on Facebook. If you are not a member, you can click the link in the show notes to join or search for it, the All About Pregnancy and Birth podcast community on Facebook and answer the couple of quick questions and we'll get you right into the group.
34:36 And don't forget about my online childbirth education class, The Birth Preparation Course. I go into even more detail how to manage pain in labor in the course. And also there's that bonus lesson specifically for women who went to do an unmedicated birth in the hospice, so check that out as you look for childbirth education. Also be sure to subscribe to the podcast in iTunes or wherever you listen to podcasts. That way you never miss a show and if you feel so inclined I'd appreciate you leaving an honest review in iTunes, it helps other women find my show and I will give you a shout out on a future episode. Now, next week on the podcast is a birth story. We have Debbie coming on. Debbie is going to talk about how she started off with the physician. She then switched to a midwife for her care and she also had a Doula for her birth, so come on back to the podcast next week. And until then I wish you a healthy and happy pregnancy and birth.
35:34 Today's episode is brought to you by Women's Wellness Coaching by Doctor Nicole Calloway Rankins. Head to www.ncrcoaching.com to check out my free one hour mini course on how to make your birth plan as well as my comprehensive online childbirth education class, The Birth Preparation Course, with over eight hours of content and a private course community. The Birth Preparation Course will leave you knowledgeable, prepared, confident, and empowered going into your birth. Head to www.ncrcoaching.com to learn more.