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Database No.: 56b Sterling Way London N18 1QX User Information Leaflet Pain Management in Labour Introduction This leaflet has been produced to help you understand how you can prepare for the experience of labour and explains briefly the types of pain relief that are available in North Middlesex University Hospital Maternity Unit. It is important to understand that labour is painful and that only you can know how much pain you are experiencing in labour. Aims of the leaflet To inform you of the choices of pain relief available to you when you are in labour To assist you in making the choice that is right for you To enable you to make a birth plan to discuss with your midwife To ensure that you are happy with your choice of pain relief To ensure that you know that you may change your mind at any time during the pregnancy or when in labour Pain relief in labour There are several methods of pain relief available and as you will not know how long or painful your labour may be, it is important to think about the methods of pain relief that you might wish to use. It is also a good idea to ensure that you have someone available to help you in labour, whether it is your partner, your mother or a friend. Having a familiar person to support you can reduce the need for pain relief in labour. Talk to your midwife and to your birth companion about the support that you would like to receive during labour. Consider practicing self-help strategies and relaxation techniques at antenatal preparation, such as breathing, the use of music, thinking positively and the use of meditation or prayer. Keep active during labour – you can choose to walk or move around, to sit or to stand. You can also choose to lie down but you are more likely to feel the pain more intensely in this position. Having your back massaged can be very helpful. You might want to spend some of the time when you are in early labour relaxing in a warm bath. Water The effect of soaking in warm water to aid relaxation and help relieve the pain of contractions in labour is renowned. The water must be quite warm (35-370C) and provides, for some, a comfortable feeling of weightlessness. Some women may go on to deliver in the pool. Please discuss this choice carefully with your midwife to plan your delivery. Advantages Soaking in the pool during your labour can offer good analgesic effect and has been know to speed the progress of labour. You can go on to delivery your baby in the pool, so long as this has been discussed with your midwife and you meet the safe criteria for a waterbirth (your midwife will discuss this with you). You can have a waterbirth at home. For more information, we have a leaflet about waterbirth (026b). Disadvantages There are certain criteria for entering the pool– your midwife will discuss these issues with you. If there is any concern regarding you or your baby‟s condition, you will be advised not to enter the pool. If your condition or that of the baby changes (eg: meconium-stained liquor, abnormal fetal heart rate or raised blood pressure), you will be asked to leave the pool. You will not be able to have injection analgesia in the pool and you need to remove your TENS machine prior to entering the pool. S.Siriwardhana Consultant Anaesthetist, B.Subba Consultant Obstetrician, M.Oldfield Supervisor of Midwives th Date approved: Joint Forum January 2004 / 19 March 2007 Review: April 2009 Database No.: 56b Entonox (gas and air) This is a mixture of gases: oxygen and nitrous oxide. You breathe it through a mask or mouthpiece that you hold for yourself. It will not remove all the pain, but it can help by reducing it and making it easier to bear. It is easy to use and you control it yourself. The gas takes 15 to 20 seconds to work, so you breathe it just as a contraction begins and stop as the contraction goes. Your midwife will advise you on how to use this method effectively. Advantages You decide when to use it, so you feel more in control. It works in a short period of time but with no lasting effects. It has not been shown to have any unpleasant side effects on your baby. It does not stop you wanting to push and you can use it right up to the moment you give birth. You can use this with other forms of pain relief. Disadvantages You may need a bit of practice with the mask/mouthpiece and timing with your contractions, before you feel the full effects. It can make you feel sick, dizzy or light-headed and may limit how much you can walk about. If you try Entonox and find that it does not give you enough pain relief, you can ask for another type of pain relief. Inform your midwife if you have asthma as it may mean that this form of pain relief is contraindicated in your labour. TENS Transcutaneous Electrical Nerve Stimulation (TENS) works by affecting the pain messages from your body through your spine to your brain, so that the intensity is reduced. TENS also works by stimulating the release of endorphins – your body‟s natural pain relieving hormones. TENS pain relief is given via four electrode pads. The electrodes are positioned either side of the spine where the nerves from the uterus and the cervix and birth canal join the spinal cord. This is where the pain is centered during childbirth. There are no known side effects on either you or the baby and you can move around while using it. The electrodes are taped on to your back and connected by wires to a small battery powered stimulator known as a pulsar. You hold the pulsar and can give yourself small, safe amounts of current. TENS should not be used Where a cardiac pacemaker is fitted When the user has a heart disease Also, it may interfere with electronic fetal heart monitoring. Advantages Any effect is immediate and you are in control of managing your own pain relief as and when you need it and to the level you need. Disadvantages You will have to hire a TENS machine from “Babycare TENS” or from other sources, such as Boots the Chemists. You will need to practice using the electrode pads and control box before you go into labour. You will need someone to put it one for you. TENS needs to be removed if you choose to go into a bath or birthing pool. Injections Pethidine is a drug used for pain relief in labour, but has some unfortunate side effects for both mother and baby. For this reason, the midwives at the North Middlesex University Hospital offer Meptid. This has similar pain relieving effects to the Pethidine, but fewer side effects. It takes about 20 minutes to work and the effect lasts between two and four hours. Advantages It helps many women to relax and does lessen the pain, although it does not take it away altogether. Disadvantages The drug can make some women feel sick and/or drowsy. Unfortunately, there is no way of knowing what the effects will be on you until you have tried it. Meptid is given with a drug that helps to prevent/ counteract the sickness. However, Meptid may make the baby a little „sleepy‟ S.Siriwardhana Consultant Anaesthetist, B.Subba Consultant Obstetrician, M.Oldfield Supervisor of Midwives th Date approved: Joint Forum January 2004 / 19 March 2007 Review: April 2009 Database No.: 56b and possibly require assistance with breathing but it is uncommon and an antidote injection can be given to the baby to reverse the effects of Meptid. Epidural Anaesthesia This is the only method of pain relief that can make labour pain free. An epidural is an injection of local anaesthetic or pain relieving drugs (or both) into the lower back to block the nerves that come from the uterus and the surrounding structures and organs. These are the source of pain felt during contractions in labour. An epidural takes about 10 to 20 minutes to work after you have had the injection. As it numbs the nerves, which carry the feelings of pain, for most women an epidural gives complete pain relief. An epidural can be very helpful for women who are having a long or particularly painful labour or who are becoming very distressed. Before an epidural is positioned, it is usual for you to have an intravenous fluid “drip” started, if you do not already have one. We will place this in the back of your hand or your lower arm. To start the epidural an anaesthetist will come and see you to explain what is involved. The epidural is inserted with you either in a sitting position or lying curled up on your side. Under local anaesthetic, the anaesthetist inserts a needle between the bones of your spine to reach the space surrounding the dura. The dura is the covering, which surrounds the spinal cord and nerves. A thin plastic tube called a catheter is inserted through the needle, into the epidural space and the needle is then removed. Local anaesthetic is injected through the catheter. This anaesthetises the nerves, which transmit pain from the lower part of the body to the spinal cord. It may also partially anaesthetise the nerves going from the spinal cord to the muscles of the legs. This may result in temporary weakness in your legs. However, the local anaesthetic has no effect on your baby. Once the anaesthetist is satisfied with how the epidural is working, the local anaesthetic and pain-relieving drugs are then injected through the catheter via a continuous epidural infusion. A continuous epidural infusion is a pump that ensures that you are given a measured amount of the drugs all the time. Advantages For most women epidural gives complete pain relief. As far as we know epidurals have no long- term effects on the baby. Disadvantages You need an Anaesthetist available to give you the epidural and a midwife, who has no other commitments, to be available to care for you. You will need continuous electronic fetal heart monitoring. Your mobility will be restricted and you will have to stay on the bed. The drugs used on the epidural can make your blood pressure drop and your midwife will check your blood pressure regularly. If your blood pressure drops, you may feel sick or dizzy and you should tell your midwife if this is the case. A few women will need to be given a specific drug to bring their blood pressure up again. You will need a “drip” so that fluids can be given directly into your blood. As the epidural makes you feel numb, it may be difficult to pass urine. And you are more likely to need a small tube (catheter) put into the bladder to help with this problem. The epidural drugs can in some cases make your skin itch . Sometimes the epidural only works properly on one side, so you may feel the pain or discomfort from contractions on the other side (the Anaesthetist will try and correct this). A small number of women get a bad headache as a result of the epidural and over half of these women have a very severe headache (Dural Tap). Some women still have small patches of numbness on their legs after they have given birth. This is quite rare and the problem usually gets better on its own although it can last up to 3 months. Permanent damage, such as paralysis, is extremely rare. Very rarely a woman has a life-threatening problem because of an epidural. The anaesthetists, midwives and doctors on Labour Ward are trained to deal with this. S.Siriwardhana Consultant Anaesthetist, B.Subba Consultant Obstetrician, M.Oldfield Supervisor of Midwives th Date approved: Joint Forum January 2004 / 19 March 2007 Review: April 2009 Database No.: 56b Alternative methods of pain relief Some women want to avoid these methods of pain relief and choose acupuncture, aromatherapy, homeopathy, massage and reflexology. If you would like to use any of these methods, it is important to let the hospital know beforehand. Please discuss the matter with the antenatal clinic midwives. Also, make sure that the practitioner you use is properly trained and experienced. For advice, contact the Institute of Complementary Medicine, PO Box 194, London SE16 1QZ. Pain relief following labour/delivery The majority of women, who give birth, even if it is a spontaneous vaginal delivery, need some pain relief afterwards. Please ask the midwife for regular tablets to help relieve your pain. Following a Caesarean birth you might be given a combination of methods to help relieve your pain, regular oral tablets, suppositories and injections. If you are breast-feeding you cannot use aspirin based tablets but you can use other tablets, your midwife will advise you accordingly. Your questions and comments If you have a problem when in hospital that the midwives or doctors are unable to resolve you can contact the Patient Advice and Liaison Service (PALS) who will be happy to help you. PALS offers assistance, advice and support for patients and their families. The service can help if you have worries or concerns about treatment or care. PALS may also be able to provide further information about tests and procedures. Useful telephone numbers Switchboard (020) 8887 2000 Labour Ward (020) 8887 2500/2510 Antenatal Clinic (020) 8887 2502 Community Office (020) 8887 2581 / (020) 8807 7097 Useful Websites North Middlesex University Hospital NHS Trust www.northmid.nhs.uk NHS Direct www.nhsdirect.nhs.uk NICE (National Institute for Clinical Excellence) www.nice.org.uk The Midwives Information Service (MIDIRS) also produces leaflets that may be useful to you in your pregnancy. www.infochoice.org Produced with thanks to the Mayday Hospital S.Siriwardhana Consultant Anaesthetist, B.Subba Consultant Obstetrician, M.Oldfield Supervisor of Midwives th Date approved: Joint Forum January 2004 / 19 March 2007 Review: April 2009
"Pain Management in Labour Leaflet"