Dantea, it’s good to go into labor as relaxed, knowledgeable and comfortable as possible. [name]Reading[/name], studying, watching birth videos, taking childbirth classes and learning relaxation techniques are all valuable adjuncts to pain relief. Fear and anxiety will heighten the perception of pain.
However, you should not at all expect these sorts of methods to control the pain of labor and especially delivery. The pain is very intense and you should not feel like a weakling or an inferior mother or like you don’t earn a merit badge if you request pharmacological pain relief. I have delivered babies with and without pain relief (including in places like Haiti or [name]East[/name] [name]Africa[/name], where it was the mother’s 10th+ child) and can assure you that every woman, everywhere experiences intense pain with labor and delivery. You can obviously survive it and you can obviously give birth without pain relief, but it adds a needless element of suffering and tribulation to the birth experience.
In the US you have three options:
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narcotics. These are short-acting (either nubain or fentanyl) and are given via IV. They act systemically (meaning, they’re absorbed all over the body and work like any other narcotic, such as oxycodone or morphine). As such they [name]DO[/name] cross the placenta and they [name]DO[/name] get absorbed by the baby. Since they’re short-acting they last about 15 min, so no lasting effect is seen in the baby unless you get a shot immediately before pushing him out. Babies with narcotics on board are often a little stunned and have a decreased respiratory drive; however, these effects are very temporary. Lastly, narcotics “take the edge off,” making the pain bearable; they do not erase the pain. For these two reasons-- inadequacy of relief and systemic effects affecting the baby- narcotics are very rarely used as sole agents. Usually they are given while the anesthesiologist is being called for an epidural, or for women who desired a natural birth, declined an epidural when she was still able to receive one, and during pushing is finding the pain too much to bear.
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regional anesthesia: epidural or spinal anesthetic. Epidurals are far more common than spinals. An epidural is placed OUTSIDE of the sac surrounding your spinal cord (the dura). It cannot cause any neurological damage as the needle, and the anesthetic, are never in contact with the cord itself. The space around the cord remains pristine and sterile, so the risk of meningitis is also zero. Instead the local anesthetic (the same stuff you get when you’re numbed up for stitches, or dental work) diffuses around the spinal roots which innervate your body at specific levels. An epidural should provide a near-complete SENSORY block (meaning you’re numb from a certain level on down) but should not be so strong as to provide a MOTOR block (i.e. you should be able to move your legs, get into different pushing positions, etc). Most importantly-- the medication LITERALLY CANNOT be absorbed systemically. It is contained by the most fundamental laws of chemistry to stay in the epidural space. It cannot get out. It cannot enter your bloodstream. It is LITERALLY IMPOSSIBLE for it to affect your baby in any way whatsoever. I mean that-- there is not even a “theoretical risk” or a “one in a million chance.” It is just as possible to affect your baby as it is for you to throw a ball and see it go up, not down. The rate of the epidural can be adjusted by the anesthesiologist to provide near-perfect pain relief without clumsy motor problems.
A spinal anesthetic IS placed right next to the spinal cord itself. It does go through the dura. The risk of something like meningitis or neurological damage is very low (procedure is done sterilely, the needle is not large and is withdrawn immediately), but definitely possible. The main benefit is that it acts immediately-- complete and total pain relief within 1 minute. Sometimes facilities offer something called a CSE: Combined Spinal-Epidural. A shot of local anesthetic is delivered to the spine, so the mother experiences relief immediately. An epidural is actually left in place, not a spinal, so subsequent pain relief is that of an epidural.
- [name]General[/name] Anesthesia: this is only performed during absolute emergencies when there is no time for an epidural or other regional anesthesia. You are unconscious and paralyzed. The anesthetics are systemic and do pass on to the baby, so there is a careful ballet between obstetrician and anesthesiologist: as soon as the medication is administered into the vein, the OB makes the first cut. A good OB can have the baby out in under a minute, usually 30s in an emergency. The mother has perfect pain relief and the baby is out before the medication has time to cross the placenta.
- Laughing gas, or nitrous oxide, is not routinely offered in the US. If you’ve had it at the dentist, you know why. It’s an amnestic (makes you lose all memory of events), it alters the mother’s level of consciousness and behavior, and as such makes it impossible to coordinate pushing, changing positions, etc. The mother too will have a very distorted, altered memory of the birth itself, which is obviously not desirable.
[name]How[/name] an epidural is placed:
You are either seated or laying on one side (usually seated). You curl up your spine & hunch your back like a cat. The anesthesiologist is sterile and his/her equipment and medications are all sterile, so you cannot move, turn around, or touch anything. Everything is behind you so you will not see what’s happening, but they talk to you to let you know each step.
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a shot of skin-numbing local anesthetic is given, in a tiny wheal. This is similar to receiving stitches. That’s the last think you should feel.
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the larger, hollow, epidural needle is placed through the numbed skin into the tissue of your mid-back. The anesthesiologist will feel a ‘pop’ as the needle passes through the ligaments that support your spine and help with erect posture; that is their landmark. The needle does not pass through the dura [the sac surrounding the spinal cord] and never comes into contact with the spinal cord.
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the actual epidural catheter-- a thin, floppy piece of plastic that looks like your iPod headphones-- is threaded through the hollow needle.
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the needle is withdrawn. You now have just a floppy piece of plastic that is in no way sharp, cannot poke you or migrate anywhere, sitting in the space surrounding your spinal cord.
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Anesthetic is infused. You begin to feel the effects after about 5 minutes, and it’s complete in roughly 20. The catheter is taped in place sterilely and securely.
You can move around, lay on it, whatever you want. It can’t hurt you and you can’t do any damage with it.
Since there is so very little downside, you can see why it’s the preferred method of labor analgesia. You as the mother are fully awake and alert. You are able to move and to get into different pushing positions (though most places hold off on actually walking for fear of falling). The sensory block is near complete; from personal experience you can still feel your contractions just fine, but they’re more like [name]Braxton[/name]-Hicks tightening sensations than painful. You can relax and focus on the birth, and your experience thereof, without unncessary suffering. [name]Even[/name] the actual delivery is relatively painless, and the subsequent suturing/repair of lacerations is equally painless.
Timing
You can request epidural analgesia at any point in the first stage of labor, though most women don’t need it until their water has broken, the contractions are intensifying, and/or they’re experiencing transition once they reach 7-8cm. Once you start pushing most anesthesiologists are reluctant or refuse to place one, since it’s very hard to hold off on pushing and hold still once you’re getting going.
Placing one when you’re calm, still managing the pain well, and there are no looming concerns about your or your baby’s wellbeing is optimal. Again, for most women, that’s about 6-7cm dilated.
