Pain relief during labour

There are several pain relief options available to you during labour. The type of pain relief needed can depend upon the type of birth you will have and your preferred option. Pain relief is often a personal choice. Some women plan to deliver their baby in a certain way and select the pain relief option that fits their planned delivery, for example acupressure during a home water birth. Other women may need to be induced or have a caesarean which requires a stronger form of pain relief. In all instances, if a woman feels in control of her pain experience, she has a more satisfying labour. Let's now look at the different types of pain relief available to you during labour.

On this page

Natural Pain Relief
Emotional support
Massage
Music
Staying active
Acupressure
Breathing
Herbal supplements
Pharmacological Pain Relief
Systemic opioid analgesia
Anaesthesia
Combined spinal-epidural
General anaesthesia
Caesarean Section
Emergency caesareans
Elective caesareans
Natural caesareans
Recovering from a caesarean section
Future pregnancies

Natural Pain Relief

Emotional support

Emotional support during labour is important and can minimise the need for pain relief drugs during delivery. Mothers who have a birthing partner throughout are less likely to need analgesia, are more likely to have a vaginal delivery without the need for ventouse or forceps and are more satisfied with their labour. Being in a calm and joyous state can reduce pain levels. The birthing partner can be anyone who you are comfortable with, for example your partner, mother, sister, doula, midwife, etc.

Massage

Having a massage is well known to induce feelings of relaxation. Research has shown that having repeated pregnancy massages before going into labour can help reduce stress and pain levels, allowing for a better labour experience. I would recommend only having a pregnancy massage from a qualified and accredited massage therapist.

Music

Music can be an important tool during labour as it helps to induce feelings of calm and relaxation, which in turn helps to maintain a steady flow of the labour hormone oxytocin to the uterus. Soft, gentle music is often preferred. Find some music that works for you and have it downloaded on to your device, just in case you lose your Internet connection.

Staying active

Staying active and being able to walk around and find a comfortable position is important in managing pain. Pain is often made worse when lying flat on your back unable to move. Positions such as squatting, being on all fours, or sitting on a birthing ball or chair can reduce pain levels and the need for pain relief medication. Birthing balls are often available in hospitals, which means that you may not have to bring your own unless you want to.

Most women in the UK and US give birth lying on their backs with their hips flexed in what is known as the lithotomy position or a semi-sitting position. These positions are weight bearing through the sacrum and coccyx (tailbone) and can restrict movement of joints during labour. Additionally, they do not allow for gravity to assist in the descent of your baby through the birth canal.

Birthing pools (warm baths)

The use of birthing pools or warm baths has been shown to reduce pain, shorten labour and the need for regional analgesics such as epidurals. However, they should not be used within two hours of taking opioid analgesics as they can cause drowsiness.

A warm pool or bath can help muscles and ligaments to relax and aid in feelings of relaxation, which help the labour hormone oxytocin to flow. The temperature of the bath water should be set at an ideal temperature for the baby, which is 36.5-37.5-C (97.7-99.5-F). If it is hotter than this (38.5-C/101.3-F), it can increase the baby's heart rate and cause them distress.

Most maternity wards in the UK will have several birthing pools that mothers can use, while in other countries such as the USA most hospitals do not. Within hospitals, the birthing pools are usually on a first come, first served basis and cannot be reserved as no one can predict when labour will actually start. You can also use a birthing pool at home. Most water births in the USA occur at home. New guidelines issued by the American College of Obstetricians and Gynaecologists recommend using birthing pools during the first stage of labour but not in the second stage due to increased risk of infection from poorly cleaned pools. They also state the lack of evidence from having a water birth in stage two of labour, so if you have decided that this is what you want and you live in the US, you may be met with opposition. However, if you feel your labour would be easier and more comfortable, then you should go with it. New research now advices the use of home water births. If you have been diagnosed with COVID- 19, you cannot give birth in a birthing pool as there is a risk that you may transmit the virus to the baby.

Acupressure

Acupressure can help with labour pain. Certain acupuncture points can be stimulated by a birthing partner to help give pain relief, such as Hegu (LI 4) - see page 205. Acupressure is useful when you are in a relaxed state and are going with the pace of delivery. In other instances, when the pain is greater and the mother is in distress, acupressure may not be strong enough to provide adequate pain relief. It is then necessary to use pharmacological drugs instead.

TENS machines TENS stands for transcutaneous electrical nerve stimulation. It involves placing electro pads on to the painful area, which are connected by wires to a small battery-powered stimulator. You give yourself small amounts of an electric current through the electrodes to the pads. The pads will contract and stimulate nerves to produce endorphins and stimulate the acupuncture points they sit on. The amount of stimulation is controlled by you. You can still move around while using a TENS machine.

Some hospitals supply TENS machines in their delivery wards. If your hospital does not stock any TENS machines, you can buy your own or rent one. TENS is more effective during the early stages of labour, when many women experience lower back pain. It can also be used on the acupuncture point Sanyinjiao (SP 6) to help dilate the cervix (see page 205).

TENS may be useful if this is your second child and you plan to give birth at home. If you are interested in TENS, learn how to use it in the later months of your pregnancy during your acupuncture pre-birth treatments. Ask your acupuncturist to show you how the TENS machine works as most acupuncturists use it in their practice. You should not use a TENS machine if:

- you experience an allergic skin reaction to the electro pads - you have a pacemaker or another type of implanted electrical

device fitted - y ou have broken skin, varicose veins or recent scarring in the area

where you want to place the electrodes - you have epilepsy or a heart rhythm disorder (check with your obstetrician first) - you plan to use a birthing pool or warm bath

Breathing

Breathing is one of the most important pain relief methods used during labour. Because your mind has to focus on something and because you need to breathe, you can put the two together to relax your mind and aid contractions. By focusing on your breath you can relax your mind and perform controlled pushes. A simple breathing exercise I advise a lot of my patients to do is to take a breath in through the nose and say `I', and then breathe out through the mouth and say `surrender'. This allows you to let go of any tension and be present in the now, helping you to relax, which reduces pain levels. Alternatively, if you already know of a breathing meditation, you can use this instead. Remember that the mind creates stress, while the body gives birth. Breathing out your stress gets your mind out of the way of your body!

Herbal supplements

There are several natural herbs and oils that you can take to help encourage labour, which in turn should reduce the duration of delivery and pain levels (see Chapter Fifteen). Generally, a stalled labour causes more pain and discomfort. A stalled labour is termed stasis (stagnation) in Chinese medicine and stasis causes pain. These herbs can help to kick-start a stalled labour and reduce stasis in the uterus. I would recommend consulting with a qualified and accredited herbalist before taking any herbs during pregnancy.

- bethroot (trillium erectum) - black cohosh (rhizoma cimicifugae) - castor oil (ricinus communis) - clary sage (salvia sclarea) - cottonroot (gossypium thurberi) - motherwort (leonorus cardiaca) - raspberry leaf (rubus idaeus) - shepherd's purse (capsella bursa-pastoris) - valerian (valeriana officinalis L.) Sterile water injections (SWIs) SWIs or water blocks involves injecting sterile water intradermally into the lower back, usually in four spots (foramens) over the borders of the sacrum (coccyx - tailbone), to relieve pain in early labour. These injections are administered by midwives as they do not contain any drugs, just sterile water. There are generally two midwives with four syringes of sterile water.

Unknown to most midwives, these four spots in the tailbone are the acupuncture points Shangliao (UB 31) and Ciliao (UB 31). The injection of water causes the water to apply pressure to these acupuncture points, like acupressure or a massage. However, this procedure is very painful and only works for one to two hours.

I believe this is an out-of-date way of giving pain relief to a mother who is already stressed and in pain. A qualified acupuncturist or midwife who is qualified and accredited in acupuncture can painlessly insert four acupuncture needles into the four acupuncture points located on the tailbone, which will give better pain relief for longer without causing distress to the mother. Alternatively, a TENS machine can be placed on the tailbone instead.

Pharmacological Pain Relief

Pharmacological pain relief comes in several forms from the gas and air to stronger forms of pain control such as epidurals. Let's now look at the different types of pain relief that you may be offered and the pros and cons of each.

Inhaled analgesics (gas and air)

Gas and air are commonly used during labour and is sold under the brand name Entonox. It is a 50 per cent mix of oxygen and nitrous oxide and is considered safe, although it may cause nausea, vomiting, drowsiness and light-headedness in the mother and reduce the baby's breathing. It offers mild pain relief when compared to other anaesthetic gases such as isoflurane, desflurane and sevoflurane, which are less commonly used.

Woman should not be given this gas for long periods as it can cause anaemia (by affecting levels of vitamin B12, which affects iron absorption) and affects white blood cell production thereby weakening the immune system. Vegetarians and vegans are at greater risk of developing anaemia. Most women will notice the bad taste the gas has, which can make them feel nauseous. This is normal. Carrying on will lessen the taste. However, if it makes you want to vomit, stop using it.

Systemic opioid analgesia

Systemic opioid analgesics are morphine-like medicines injected

into the bloodstream that affect the whole body. These medications have a limited effect on pain relief and can make you feel slightly disconnected from reality. Known as diamorphine or pethidine, they are derived from the poppy plant but will not make you an addict as they are only used during labour. However, they do pass the placenta and can affect the baby.

These medications can be given as an injection in the thigh (every four hours) or intravenously so you can decide when you need it, which is termed patient-controlled analgesia (PCA). Side effects of diamorphine and pethidine include nausea, vomiting, dry mouth, low heart rate, an irregular heart rate, palpitations, swelling, hypotension, hallucinations, vertigo, unease, mood swings, disturbed sleep, headaches, visual disturbances, sweating, rashes and itching. Antiemetics (drugs to stop nausea and vomiting) are often given together with opioid analgesics, but unfortunately have their own side effects, which include reduced appetite, physical weakness, upset tummy, constipation and headaches. Other side effects to be aware of when given diamorphine or pethidine include:

- B abies whose mothers had pethidine in labour may feed less frequently in the first 48 hours as it can make them drowsy for several days.

- If the medication has not worn off towards the end of labour it can make it difficult to push. You might prefer to ask for half a dose initially to see how it works for you.

- If pethidine or diamorphine are given too close to the time of delivery, they may affect the baby's breathing.

- It can make some women feel woozy, sick and forgetful. - Pethidine can cross over the placenta to the baby. - Y ou cannot use a birthing pool or warm bath for around four

hours after being given pethidine until the effects have worn off fully.

Anaesthesia

There are several types of anaesthesia that can be used during labour. These types of pain relief techniques offer a strong form of pain relief should you need it. The different types are:

1. local block

2. epidural block

3. spinal anaesthesia

4. combined spinal-epidural

5. general anaesthesia

Local block (pudenal analgesia) A local block is the numbing of the pudendal nerve that serves the external vagina area below to the anus where pain might be felt during delivery. A local anaesthetic such as lidocaine or chloroprocaine is injected at the end of the tailbone to numb the area. It takes about twenty minutes to work after the injection and lasts between two and four hours.

The side effects of these drugs include anxiety, paraesthesia (pins and needles), dizziness, blurred vision, tinnitus, headaches, nausea, vomiting, muscle twitches, tremors, convulsions, depression, drowsiness, respiratory failure, unconsciousness, coma, hypotension, slow heart rate and heart failure. Heart failure can be caused by hypotension (low blood pressure). If you have low blood pressure, take adequate levels of iron during pregnancy (see page 148). Nerve damage occurs in fewer than 3 out of every 100 local nerve blocks.

Epidural block and spinal anaesthesia (regional analgesia) A regional analgesic involves injecting an analgesic drug (bupivacaine hydrochloride, ropivacaine hydrochloride, lignocaine/lidocaine hydrochloride) into either the spinal canal or epidural space. Often opioid medications are combined with the analgesic drug. In general, spinal canal injections are used for caesarean deliveries while epidural injections are used for vaginal deliveries. This form of pain relief has an increased risk of forceps delivery as mothers cannot feel when they are having contractions and when to push.

Side effects from bupivacaine hydrochloride and ropivacaine

hydrochloride include arrhythmias (fast heart rate), back pain, chills, dizziness, hypotension, hypertension, nausea, paraesthesia (pins and needles), urinary retention and vomiting. Side effects from lignocaine/lidocaine hydrochloride are more severe and include anxiety, arrhythmias (fast heart rate), heart failure, confusion, dizziness, drowsiness,headaches,loss of consciousness,methemoglobinemia (lack of oxygen to the blood), muscle twitching, nausea, neurological effects, pain, psychosis, respiratory disorders, seizures, altered temperature, tinnitus, tremors, blurred vision and vomiting. Epidurals can also prolong labour. Caesarean deliveries will use this form of pain relief. A research study found that mothers who had epidurals were less positive about them five years later. Having acupuncture during labour reduces the need for epidurals. Areas that can be numbed by an epidural include:

- abdomen - chest - legs - pelvic area

The procedure involves lying on your side or sitting up in a curled position while an anaesthetist cleans your back with an antiseptic.They will then numb a small area with a local anaesthetic and introduce a needle into your back. A very thin tube will be passed through the needle into your back near the nerves that carry pain impulses from the uterus. The drugs listed above are usually mixed together with opioid medications and are administered through this tube. It takes about 10 minutes to set up the epidural and another 10-15 minutes for it to start working. It does not always work perfectly at first and may need adjusting. For example, you may feel more of a feeling in one leg than another. After it has been set up, the tube is left in your back and you can lie down.

Your midwife can top up the epidural, or you may be able to top it up yourself through a machine, usually every two hours. Your contractions and the baby's heart rate will need to be continuously monitored. This means having a belt around your abdomen and not being able to move. When it is time to deliver the baby, you will be told when you are having contractions by the midwife and when to push as you will no longer feel the contractions yourself.

Epidurals have been routinely used for many years and are widely accepted as an effective method of pain relief during labour. However, as with all medical procedures, there are some associated risks that, although small, you should be aware of before deciding whether to have one. Possible risks include:

- n erve damage - occurs between 1 in 1,000 (spinal) and 1 in 100,000 (epidural)

- p uncture of the dura headache (PDPH) - occurs in 1 in 100 women

Combined spinal-epidural

A combined spinal-epidural involves the combination of the above two techniques: spinal anaesthesia and epidural block.

General anaesthesia

General anaesthesia is not commonly used during labour, as it is difficult to manage in pregnant women. It is used during a caesarean delivery in special cases.

Caesarean Section

A caesarean section is known as a C-section or caesarean delivery. It involves the use of surgery to deliver the baby. It is the most frequent type of major surgery performed in the US. In the UK, one in four women has a caesarean birth. Caesarean deliveries are only recommended by your obstetrician if there is a medical need for it, for example:

- absolute cephalopelvic - older mums disproportion (CPD) - placenta complications - previous caesarean delivery - breech baby - twins or more - extreme maternal anxiety - uterine complications - failure to progress in labour - infant complications

A caesarean delivery is generally not performed before week 39 unless the baby's lungs are mature or it is an emergency. Most caesareans are carried out using spinal or epidural anaesthetic. During the procedure, you will be awake, but the lower part of your body is numbed and you will not feel anything. The procedure will be carried out behind a screen so you cannot see. A cut about 10-20cm (4-8in) long will be made across your lower abdomen, just below your bikini line, then through eight layers of muscle (your core muscles) and into your womb (uterus), hence why this procedure is classified as major surgery. You may feel some tugging and pulling during the procedure, which is normal. The scar is usually hidden in your pubic hair. After the baby is delivered, it takes around 5 minutes to stitch each layer of muscle, therefore 40 minutes in total.

There are emerging side effects that are being noticed as more women select to have a caesarean birth. They include:

- A reduction in breast milk levels due to irregular hormone levels. - A uterus with a scar is less able to contract properly, possibly

leading to another caesarean section in a future pregnancy. - B abies born from caesareans are more likely to develop respiratory

problems, such as asthma. This is most likely caused by the baby's lungs not being fully mature before the caesarean birth. - Increased risk of infection or bleeding. - Sluggish bowel movements. New research has shown that acupuncture can speed up bowels movements thereby reducing constipation. - T he scar that is left on the uterus wall can cause problems for future pregnancies as the placenta may attach on or close to it, thereby increasing the risk of a miscarriage or a retained placenta, which will require emergency surgery.

Emergency caesareans

Emergency caesareans are needed when complications develop during pregnancy or labour and the baby needs to be delivered quickly. If your midwife or obstetrician is concerned about the safety of you or your baby, they will suggest that you have a caesarean straightaway. For instance, this could be if your cervix does not dilate fully during labour and birth is not progressing properly or if you bleed heavily during labour or the baby is in distress.

Elective caesareans

A caesarean is elective if it is planned in advance. This usually happens when your obstetrician or midwife believes that labour will be dangerous for you or your baby. For example, if your baby is in the breech position or your pelvic canal is not wide enough (CPD - normally measured by your foot size, see page 196), or if the placenta is obstructing the womb exit.

If you ask for a caesarean when there are no medical reasons, your obstetrician or midwife will explain the risks of having a caesarean delivery compared to a vaginal birth. Most hospitals in the UK do not support elective caesareans unless there is a medical reason for it. Being anxious or worried about childbirth or that it is your first birth will often not persuade them to allow you to have an elective caesarean. If they refuse and you still want an elective caesarean then you can either try another hospital or opt to have a caesarean performed privately.

Natural caesareans

A `natural' caesarean is where obstetricians make an incision through your abdomen and into your uterus around where the baby's head is located. The obstetrician then pulls the baby's head through and leaves the baby, allowing it to wriggle its way out by itself. It is supposed to create a `calmer and slower' entry into the world, thereby causing less distress to the baby. It also allows the mother and child to bond better as the baby is allowed to lie on the mother's chest as the umbilical cord is cut.

Recovering from a caesarean section

In most cases, it takes longer to recover from a caesarean section than from a vaginal delivery. You should be able to get out of bed around 24 hours after having a caesarean and your wound dressing may be removed. Women generally stay in hospital for around three days after having a caesarean section. However, if you and your baby are well and want to go home earlier, you should be able to leave after 24 hours and have your follow-up care at home.

In the first few weeks after giving birth, try to rest as much as possible. Avoid walking up and down stairs too often, as your tummy may be sore. However, you should take gentle daily walks to reduce the risk of blood clots. You will be given pain medication, i.e. paracetamol (acetaminophen, Tylenol), ibuprofen (non-steroidal anti- inflammatory drugs (NSAIDs) such as Brufen, along with Advil, Motrin, and Nurofen) or codeine (co-codamol). Your midwife will advise you on how to look after your wound to prevent infection, such as wearing loose, comfortable clothing and cotton underwear, and gently cleaning and drying the wound daily.

In general, it will take about six weeks for all your tissues to heal completely. Before this time, basic activities, such as caring for your new baby and looking after yourself, should be possible, but may be difficult. For example, lifting up your baby becomes harder without the use of your abdominal (core) muscles, which are still healing.

You may not be able to do some activities straightaway, such as driving a car, exercising, carrying heavy things and having sex. Only start to do these activities when you feel able to do so. Ask your midwife for advice if you are unsure.

If you drive, check your insurance cover for any restrictions about driving after having a caesarean as it is classified as a major operation. Some companies require your obstetrician or doctor to certify that you are fit to drive. Most women do not feel fit to drive for a few weeks after a caesarean and many wait until after their six-week postnatal check.

Future pregnancies

If you had a delivery by caesarean section, it does not necessarily mean that you will need to have another caesarean again in the future. It depends on the next pregnancy, where the placenta attaches to in the uterus, etc. You can discuss future pregnancy options with your midwife, obstetrician or doctor in the hospital, who will take account of:

- the overall risks and benefits of a caesarean section - the reason for your first caesarean - the risk of tearing the wall of your womb (uterine rupture) along

the scar from your previous caesarean section - the risk to your own and your baby's health at the time of birth - your preferences and priorities If the caesarean was carried out for a health reason that will not change in your next pregnancy, for instance, if you have a very narrow birth canal, it is likely that a caesarean section will be necessary for each subsequent delivery.

My Pregnancy Guide

My Pregnancy Guide by Dr (TCM) Attilio D’Alberto is a comprehensive week-by-week guide to a healthy pregnancy and labour, based on over 750 peer-reviewed research studies and 20 years of clinical experience. It blends the latest evidence-based science with the proven theories of traditional Chinese medicine to give you everything you need for a confident, well-supported pregnancy and a positive birth experience.

The book covers pregnancy week by week, an optimal pregnancy diet and supplements, how to reduce your baby’s risk of developing autism, managing complications including gestational diabetes and pre-eclampsia, preparing for labour, pain relief options, acupuncture for labour induction, natural herbs to support birth, and postnatal recovery. Available in paperback, Kindle and ebook from Amazon, Waterstones and all major bookshops.