Pain management during childbirth

Pain management during childbirth is the treatment or prevention of pain that a woman may experience during labor and delivery. The amount of pain a woman feels during labor depends partly on the size and position of her baby, the size of her pelvis, her emotions, the strength of the contractions, and her outlook.[1] Tension increases pain during labor.[2] Virtually all women worry about how they will cope with the pain of labor and delivery. Childbirth is different for each woman and predicting the amount of pain experienced during birth and delivery can not be certain.[1]

Pain management during childbirth
Mother in labor appears to be in pain
Specialtyobstetrician

Some women do fine with "natural methods" of pain relief alone. Many women blend "natural methods" with medications and medical interventions that relieve pain. Building a positive outlook on childbirth and managing fear may also help some women cope with the pain. Labor pain is not like pain due to illness or injury. Instead, it is caused by contractions of the uterus that are pushing the baby down and out of the birth canal. In other words, labor pain has a purpose.[1]

Preparation

Preparation for childbirth can affect the amount of pain experienced during childbirth. It is possible to take a childbirth class, consult with those managing the pregnancy, and writing down questions can assist in getting the information that a woman needs to help manage pain. Simple interaction with friends and family can alleviate concerns.[1]

Non-pharmacological
Moche – female figure in birthing position

Many methods help women to relax and make pain more manageable. A review of the effectiveness of non-medical approaches to pain relief found that water immersion, relaxation methods, and acupuncture relieved pain.[3] These and other non-pharmacologic pain management options are further discussed below.

  • Breathing and relaxation techniques[1][3]
    • Relaxation methods may be helpful in reducing the risk of assisted vaginal births.[3]
  • Warm showers or baths[1]
  • Massage[1][2]
    • Many types of massage can be used during various stages of labor.  Literature suggests light touch or stroke massage techniques may aid in the release of oxytocin, which may help stimulate contractions and facilitate cervical dilatation.  Various types of massage may also help soothe and distract from the pain of labor.[4]
  • Warm or cold compresses, such as heat on lower back or cold washcloth on forehead[1]
    • Applying warm compresses, especially to the lower back area, while the cervix is dilating may help reduce pain during the first stage of labor and may even help to decrease the length of labor itself, however, the evidence supporting this is limited.[4]
  • Changing positions while in labor (stand, crouch, sit, walk, etc.)[1]
  • Use of a labor ball[1]
    • Using a labor ball during childbirth first began in the 1980s.  It is best used during the first stage of labor.  Evidence suggests using a birthing ball can facilitate pain relief by supporting the perineum and providing gentle stimulation to the area during cervical dilatation.  It may also aid in fetal descent through various positioning exercises and with gravity.  [5]
  • Listening to music[1]
    • Although little evidence supports music as an effective method in decreasing pain, it may provide a distraction or assist in creating a more positive birth experience which may ultimately decrease the chance of negative postpartum outcomes.[4]
  • Acupuncture[3]
  • Continuous supportive care of a loved one, hospital staff member, or doula[1]
    • The presence of a doula or support attendant may decrease the need for pharmacological pain control and increase the likelihood of spontaneous vaginal births as opposed to cesarean section.[6] A positive support person may also assist in creating an environment leading to a more positive birth experience.[7]
  • Other methods include hypnosis, biofeedback, sterile water injection, aromatherapy, and TENS, however there are limited studies that demonstrate the effectiveness of in reducing pain during labor and delivery by using these methods.[3]

Water and childbirth
Main article: Water birth

According to the American Office of Women's Health, laboring in a tub of warm water, also called hydrotherapy, helps women feel physically supported, and keeps them warm and relaxed. It may also be easier for laboring women to move and find comfortable positions in the water.[1]

Water immersion during the first stage of labor may help decrease the need for analgesia and possibly shorten the duration of labor, however, there is limited data to suggest that water immersion during the second and third stages of labor significantly reduce the use of pharmacologic interventions.[8][9]

In waterbirthing, a woman remains in the water for delivery. The American Academy of Pediatrics has expressed concerns about delivering in water because of a lack of studies showing its safety and because of the rare but reported chance of complications.[1]

Medical and pharmaceutical methods of pain control

Physicians, nurse practitioners, physician assistants, nurses and midwives will typically ask the woman in labor if there is a need of pain relief. Many pain relief options work well when given by a trained and experienced clinician. Clinicians also can use different methods for pain relief at different stages of labor. Still, not all options are available at every hospital and birthing center. Depending on the health history of the mother, the presence of allergies or other concerns, some choices will work better than others.[1]

Opioids

There are many methods of pain relief during labor.  Opioids are a type of analgesia that is commonly used during childbirth to assist in pain relief.[10]  They can be injected directly into the muscle in the form of a shot or put into an IV. These medications may cause unwanted side effects like drowsiness, itching, nausea, or vomiting to the laboring mother.[10] Although they are short acting in the laboring mother, it takes longer for an infant to clear these medications. All opioids can cross the placenta and may poorly affect the baby by causing problems with heart rate, breathing, or brain function.  For this reason, opioids are not given close to delivery.[10] They can be beneficial in early labor, however, since they can help dull pain, but do not impair the mother’s ability to move or push.  Their use also does not seem to be linked to a higher chance of cesarean sections.[10] There are many things to consider when deciding to use opioids during a delivery and these options, as well as the risks and benefits, should be discussed early in the first stage of labor with a trained medical professional.  Asking questions about the procedures and medications which may affect the baby are valid questions.[11]

Epidural and spinal blocks
Further information: Epidural administration
Further information: Spinal anaesthesia
An anesthetic medication is injected into the spine.

An epidural is a procedure that involves placing a tube (catheter) into the lower back, into a small space below the spinal cord. Small doses of medicine can be given through the tube as needed throughout labor. With a spinal block, a small dose of medicine is given as a shot into the spinal fluid in the lower back. Spinal blocks usually are given only once during labor. Epidural and spinal blocks allow most women to be awake and alert with very little pain during labor and childbirth. With an epidural, pain relief starts 10 to 20 minutes after the medicine has been given. The degree of numbness felt can be adjusted. With spinal block, good pain relief starts right away, but it only lasts one to two hours.[1]

Although movement is possible, walking may not be if the medication affects motor function. An epidural can lower blood pressure, which can slow the baby's heartbeat. Fluids given through IV are given to lower this risk. Fluids can cause shivering. But women in labor often shiver with or without an epidural. If the covering of the spinal cord is punctured by the catheter, a bad headache may develop. Treatment can help the headache. An epidural can cause a backache that can occur for a few days after labor. An epidural can prolong the first and second stages of labor. If given late in labor or if too much medicine is used, it might be hard to push when the time comes. An epidural increases risk of assisted vaginal delivery.[1]

Pudendal block
Further information: Pudendal anesthesia

In this procedure a doctor injects numbing medicine into the vagina and the nearby pudendal nerve. This nerve carries sensation to the lower part of the vagina and vulva. This method of pain control is only used late in labor, usually right before the baby's head comes out. With a pudendal block, there is some pain relief but the laboring woman remains awake, alert, and able to push the baby out. The baby is not affected by this medicine and it has very few disadvantages.[1][12]

Inhaled analgesia
Further information: Inhalational anaesthetic

Another form of pharmacologic pain relief available for laboring mothers is inhaled nitrous oxide.  This is typically a 50/50 mixture of nitrous oxide with air that is an inhaled analgesic and anesthetic.  Nitrous oxide has been used for pain management in childbirth since the late 1800s. The use of inhaled analgesia is commonly used in the UK, Finland, Australia, Singapore and New Zealand, and is gaining in popularity in the United States.[13]

Although this method of pain control does not provide as much pain relief as an epidural, there are many benefits to this type of analgesia.  Nitrous oxide is inexpensive and can be used safely at any stage of labor.  It is useful for women wanting mild pain relief while maintaining mobility and have less monitoring than would be required with an epidural.[13]  It is also useful in early labor to assist with pain relief and used in conjunction with other non-pharmacologic pain methods such as birthing balls, position changes, and even possibly water birth.  The gas is self-administered so the laboring mom has full control of how much gas she wishes to inhale at any given time.[13]

Nitrous oxide has the added benefit of limited side effects.  Some mothers may experience some dizziness, nausea, vomiting, or drowsiness, however, since dosing is determined by the patient, once these symptoms begin she can limit her use.  The gas takes effect quickly, but also lasts a short period of time so she must hold the mask to her face in order to benefit from the effects of analgesia.[13] There is very little effect to the baby since it is quickly eliminated by the baby as soon as it begins breathing.[13] Evidence does not suggest any clinically significant risk factors in the use of nitrous oxide gas as opposed to other methods of pain management both non-pharmacologic and pharmacologic in terms of Apgar or cord blood gas.  There is also limited evidence to determine whether there are any increased occupational risks to the healthcare provider associated with the use of nitrous oxide.[13]

Pain management after childbirth

Perineal pain after childbirth has immediate and long-term negative effects for women and their babies. These effects can interfere with breastfeeding and the care of the infant.[14] The pain from injection sites and possible episiotomy is managed by the frequent assessment of the report of pain from the mother. Pain can come from possible lacerations, incisions, uterine contractions and sore nipples. Appropriate medications are usually administered.[15] Routine episiotomies have not been found to reduce the level of pain after the birth.[16]

See also

References
  1. "Pregnancy Labor and Birth". Office on Women’s Health, U.S. Department of Health and Human Services. 1 February 2017. Retrieved 15 July 2017. This article incorporates text from this source, which is in the public domain.
  2. Smith, Caroline A; Levett, Kate M; Collins, Carmel T; Jones, Leanne; Smith, Caroline A (2012). "Massage, reflexology and other manual methods for pain management in labour". Cochrane Database of Systematic Reviews (2): CD009290. doi:10.1002/14651858.CD009290.pub2. PMID 22336862.
  3. Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, Jordan S, Lavender T, Neilson JP (2012). "Pain management for women in labour: an overview of systematic reviews". Reviews. 3 (3): CD009234. doi:10.1002/14651858.CD009234.pub2. PMC 7132546. PMID 22419342. S2CID 7358365.
  4. Smith, Caroline A; Levett, Kate M; Collins, Carmel T; Armour, Mike; Dahlen, Hannah G; Suganuma, Machiko (2018-03-28). "Relaxation techniques for pain management in labour". Cochrane Database of Systematic Reviews. 3: CD009514. doi:10.1002/14651858.cd009514.pub2. ISSN 1465-1858. PMC 6494625. PMID 29589650.
  5. Makvandi, Somayeh; Latifnejad Roudsari, Robab; Sadeghi, Ramin; Karimi, Leila (2015-09-30). "Effect of birth ball on labor pain relief: A systematic review and meta-analysis". Journal of Obstetrics and Gynaecology Research. 41 (11): 1679–1686. doi:10.1111/jog.12802. ISSN 1341-8076. PMID 26419499. S2CID 476947.
  6. Hodnett, Ellen D.; Gates, Simon; Hofmeyr, G. Justus; Sakala, Carol (2012-10-17). Hodnett, Ellen D (ed.). "Continuous support for women during childbirth". The Cochrane Database of Systematic Reviews. 10: CD003766. doi:10.1002/14651858.CD003766.pub4. ISSN 1469-493X. PMC 4175537. PMID 23076901.
  7. Taheri, Mahshid; Takian, Amirhossien; Taghizadeh, Ziba; Jafari, Nahid; Sarafraz, Nasrin (2018-05-02). "Creating a positive perception of childbirth experience: systematic review and meta-analysis of prenatal and intrapartum interventions". Reproductive Health. 15 (1): 73. doi:10.1186/s12978-018-0511-x. ISSN 1742-4755. PMC 5932889. PMID 29720201.
  8. Cluett, Elizabeth R; Burns, Ethel; Cuthbert, Anna (2018-05-16). "Immersion in water during labour and birth". Cochrane Database of Systematic Reviews. 5: CD000111. doi:10.1002/14651858.cd000111.pub4. ISSN 1465-1858. PMC 6494420. PMID 29768662.
  9. "Immersion in Water During Labor and Delivery - ACOG". www.acog.org. Retrieved 2019-01-25.
  10. "ACOG Practice Bulletin No. 177: Obstetric Analgesia and Anesthesia". Obstetrics & Gynecology. 100 (1): 177–191. April 2017. doi:10.1097/00006250-200207000-00032. ISSN 0029-7844.
  11. "Pregnancy Labor and Birth". Office on Women’s Health, U.S. Department of Health and Human Services. 1 February 2017. Retrieved 15 July 2017. This article incorporates text from this source, which is in the public domain.
  12. Maclean, Allan; Reid, Wendy (2011). "40". In Shaw, Robert (ed.). Gynaecology. Edinburgh New York: Churchill Livingstone/Elsevier. pp. 599–612. ISBN 978-0-7020-3120-5.
  13. Likis, Frances E.; Andrews, Jeffrey C.; Collins, Michelle R.; Lewis, Rashonda M.; Seroogy, Jeffrey J.; Starr, Sarah A.; Walden, Rachel R.; Mcpheeters, Melissa L. (2014-01-01). "Nitrous Oxide for the Management of Labor Pain: A Systematic Review". Anesthesia & Analgesia. 118 (1): 153–167. doi:10.1213/ANE.0b013e3182a7f73c. ISSN 0003-2999. PMID 24356165. S2CID 6307442.
  14. Shepherd, Emily; Grivell, Rosalie M. (24 July 2020). "Aspirin (single dose) for perineal pain in the early postpartum period". The Cochrane Database of Systematic Reviews. 7: CD012129. doi:10.1002/14651858.CD012129.pub3. ISSN 1469-493X. PMC 7388929. PMID 32702783.
  15. Henry, p. 122.
  16. Jiang, H; Qian, X; Carroli, G; Garner, P (8 February 2017). "Selective versus routine use of episiotomy for vaginal birth". The Cochrane Database of Systematic Reviews. 2: CD000081. doi:10.1002/14651858.CD000081.pub3. PMC 5449575. PMID 28176333.
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