Pain Relief - Overview

Labour and childbirth is usually a painful experience and women vary in their response to it. Some women wish to avoid drugs or other medical interventions, while others are happy to consider all available options. It is a good idea to be aware of all your alternatives and the different methods of pain relief in order to make an informed decision.

It is also helpful for whoever is going to be with you during your labour to know about the different options, as well as how they can support you. Ask your midwife or doctor to explain what's available so that you can decide what's best for you during childbirth.

Record your wishes in your birth plan, but remember that you should keep an open mind. You may find that you want more pain relief than you'd planned, or your doctor or midwife may suggest more effective pain relief to help the delivery. Even if you planned for a drug-free birth and find yourself struggling to cope with the pain of contractions, it's okay to change your mind.

Different ways of relieving pain are below:

1. Self –help
2. Hydrotherapy
3. Epidural anaesthesia
4. Entonox / Nitrous oxide
5. Pethidine
6. TENS
7. Alternative methods

Self-help pain relief options for childbirth

Research suggests that adequate preparation may assist in reducing pain, or at least modify the perception of pain and reduce anxiety, which can help you to better cope with the pain of labour.

• Being in good physical condition is important. Exercise gently and regularly throughout your pregnancy, avoid cigarettes and alcohol, and eat a healthy, balanced diet.
• Learn about labour. Knowing what to expect during the various stages of labour can help reduce anxiety making you feel more in control and less frightened about what’s going to happen. Read up on labour, talk to your doctor or midwife, and attending antenatal classes is strongly recommended.
• Breathing techniques may help you to ‘ride the waves’ of each contraction.
• Constant, close support from your partner (or a trusted friend or loved one) for the duration of labour can reduce anxiety.
• Using distractions like music can help to take your mind off the pain.
• Hot or cold packs, massage, a warm shower or immersion in a warm bath, may all be helpful.

Hydrotherapy pain relief options for childbirth

Hydrotherapy uses water as a form of pain relief during labour, and is also a delivery option during childbirth. The water in birth pools is typically kept comfortably warm at about 37 degrees C, however this can vary. Hydrotherapy can be used on it’s own (however is not as effective as other pain relief options), or in conjunction with other methods of pain relief, allowing for a level of comfort that few other methods can provide. As such, many midwives describe the use of a large warm bath as their 'natural epidural', and use it to help calm, relax and soothe the woman in labour, before opting for pain relieving medications.

Hydrotherapy can be the answer to assisting a woman struggling with a long and difficult labour, helping her to progress without resorting to an oxytocin drip, and can help women achieve comfortable positions in the bath. Pregnant women with limb or hip disabilities have used the bath to achieve a natural active birth.

Some women believe so deeply in the power of hydrotherapy that they choose to spend much of their labour immersed in water, and some even deliver their babies there. While hydrotherapy is fine for almost any pregnant woman, delivering underwater may not be. If you wish to have a water birth speak to your practitioner to ensure there are no medical objections. If you get the green light, do some research on how and where to take your delivery dip. While there are still some concerns about the safety of water births, they are regularly practiced throughout the world and are approved of by a number of different health authorities.

What is an epidural?

An epidural is a type of regional anaesthetic which effects a large area of your body. Painkilling drugs are passed into the small of your back, via a fine tube, to the nerves in your body that carry pain signals during labour. This results in a numbness in the body from the waist down, providing very effective pain relief for vaginal delivery, or allowing you to stay awake and alert during birth by caesarean section.

How is an epidural administered?

Your anaesthetist will inject local anaesthetic into the lining of the spinal cord through your lower back. Guiding a hollow needle between the small bones in your spine, the needle enters the space between the layers of tissue in your spinal column (the epidural space). A fine tube, or catheter, is then passed through the needle. Once the tube is in place, the needle is removed. The tube is taped up your back and over your shoulder.

Keep very still while your anaesthetist sets up the epidural. You will either be on your side or sitting on the edge of the bed. You will be instructed to curl forward to open up the spaces between the bones of your spine. Concentrate on your breathing to help you to keep still; breathing in deeply through the nose and out slowly through the mouth. It may help to hold hands with your birth partner and keep eye contact with them.

Epidural painkillers are administered in several ways:

1) Injection with top-ups:

Your anaesthetist injects a mixture of painkillers into the tube to numb the lower part of your stomach. If the epidural is working well, you should no longer be able to feel your contractions. As the epidural begins to wear off, you can have top-ups which last between one and two hours.

2) Continuous infusion:

Your anaesthetist will set up an epidural catheter. The other end of the tube is attached to a pump, which feeds the pain-relieving epidural solution into your back continuously. You can have stronger top-up doses of local anaesthetic as well, if you need them. Sometimes the pump is under your control. This is called patient-controlled epidural analgesia or PCEA, but is usually only available in larger teaching hospitals.

3) Combined spinal epidural (CSE):

You'll be injected with a mini spinal: a low dose of pain-relieving drugs, which works quicker than an epidural alone. At the same time, the anaesthetist inserts a catheter without passing any drugs down the tube. When the effect of the mini-spinal injection starts to wear off, your anaesthetist will pass the epidural solution through the tube to give you ongoing pain relief.

How does it work?

An epidural works the same way as a local anaesthetic, to numb the nerves that are carrying pain signals from your uterus (womb) and cervix to your brain.

In Australia, most hospitals use low-dose epidurals. These contain a mixture of painkilling drugs, usually a local anaesthetic, bupivacaine, and an opioid, fentanyl. The advantage of a low-dose epidural is that you may have some sensation in your legs and feet, which is why some people call it a mobile epidural. However, the low-dose epidurals which most hospitals offer are not the same as an ambulatory or walking epidural, which can only be provided if there are ample staff to provide the extra monitoring you'll need.

When should I have it?

An epidural can be administered at any point in labour, however most women choose to have an epidural when their contractions are getting quite intense, which is often when their cervix has dilated by about 5cm or 6cm.

You'll also be offered an epidural if your labour is being sped up with a Syntocinon drip. This is a synthetic version of the hormone oxytocin, which makes your cervix dilate and contractions intensify. You may need extra pain relief, because this can make your contractions difficult to cope with.

Once your epidural is in place, it should stay in until after your baby is born and your placenta delivered. It can also provide pain relief after your baby is born if you need stitches.

What are the advantages of having an epidural?

• It usually provides excellent pain relief during labour.
• It works fairly quickly, taking about 20 minutes to insert and set up and another 20 minutes once the anaesthetic has been injected before starting to work.
• Top-ups can be given by an experienced midwife , so you don't usually need to wait for an anaesthetist once the epidural is in place.
• Your mind remains clear. You may still be aware of your contractions, but feel no pain.
• If you have high blood pressure, it has a useful side-effect of lowering blood pressure.
• It can be topped up with stronger local anaesthetic if you need a caesarean section.

What are the disadvantages of having an epidural?

• It may not work properly at first, and you may find that you are numb in only parts of your tummy. If you're not pain-free within half an hour of the epidural starting the procedure may need to be repeated.
• Immediately after the epidural has been inserted, some women experience a drop in blood pressure that can cause nausea and dizziness.
• Some women experience pain at the injection site.
• Because of muscle weakness in the legs, women with an epidural anaesthetic may be confined to bed until the drug wears off.
• In most cases, due to the lack of sensation in the lower body, a urinary catheter must be inserted.
• Having an epidural may make the second stage of labour, the pushing stage, last longer. If you don't feel an urge to push and there is no sign of your baby's head yet, you should be encouraged to wait for at least an hour or until you feel the urge to push.
• You're more likely to need your labour speeded up with a Syntocinon drip. However, hospital staff should give you the chance to have a longer, slower labour, before using drugs to speed it up.
• There's more chance of your baby needing to be born with the aid of forceps or ventouse and this may be because epidurals can make it difficult for your baby to move into the best position to be born. By the time you’re ready to give birth your baby is more likely to end up in a posterior position, with the back of its head towards your spine, even if baby wasn't in that position when labour started.
• There is a small risk of you having a severe headache (around 1%). This can happen if the epidural needle punctures the bag of fluid which surrounds the spinal cord, causing a leak of fluid . It's usually treated by taking a small amount of blood from your arm, and injecting it into your back to seal the hole made by the needle. This is done after your baby is born, and may need to be done more than once to achieve a seal.
• Around one in 550 women experience ongoing patches of numbness near the injection site.
• There's a very small risk of nerve damage, leaving you with a numb patch on your leg or foot, or a weak leg. This rarely happens. The risk is about one in 1,000 for temporary nerve damage and one in 13,000 for permanent damage.
• It may make you feel shivery.
• You may develop itching or a fever.
• You may need a catheter to empty your bladder.
• You will need more monitoring. Your baby's heartbeat will be monitored continuously for at least 30 minutes when you're first given an epidural, and after each top-up. Your blood pressure is taken every five minutes when the epidural is started, for about 30 minutes, and after each top-up.

What are the possible effects of an epidural on my baby?

• An epidural make cause your blood pressure to drop, which can affect the flow of oxygen to your baby. You'll need to have a small tube, called an intravenous cannula, inserted into your hand or arm in case your blood pressure drops suddenly. Low blood pressure can be treated by fluids fed through the cannula to increase your blood volume.
• Epidural solutions contain the opioid, fentanyl, or a similar drug, which can cross the placenta. In larger doses (more than 100 micrograms), these drugs may affect baby's breathing, or cause drowsiness.

Tips for epidurals:

• Not everyone can have an epidural. Talk to your doctor if you think you have a medical condition that might affect whether you can have one.
• Epidurals are only available in obstetrician-led maternity units, not in birth centres, midwife-led units or for home births.
• Depending on what your local unit offers and when you go into labour, be prepared for the possibility that you may not be able to have one. Even maternity units equipped to give epidurals may not offer a 24-hour service.

What is Entonox / Nitrous oxide?

Referred to as Entonox, Nitrous oxide, Gas and Air, or Laughing Gas, Entonox is a colourless and odourless gas made up of half oxygen and half nitrous oxide. It is administered to the mother through a facemask or a tube held in the mouth and has a calming effect and takes the edge off labour pain, rather than blocking it out completely.

Entonox should be available wherever you choose to give birth in most hospitals, including in birth centres. Most hospitals pump entonox to the labour wards from a central supply, or if you're in a smaller hospital or a birth centre your midwife may bring you entonox in portable cylinders. Check with your homebirth midwife whether she carries gas and air.

When and how should I use it?

You can have entonox whenever you want in labour. It is administered through a mask or mouthpiece:

1. Simply bring the mask up to your face or put the mouthpiece between your lips or teeth.
2. Keep it there as you breathe deeply and evenly. The mask or mouthpiece has a two-way valve that releases the gas and air for you to breathe in and takes away the carbon dioxide you breathe out.
3. Continue to breathe deeply until you start to feel a little light-headed. Take the mask or mouthpiece away from your face.
4. Within a few seconds, you will feel perfectly normal again.

It takes only approximately 30 seconds for the gas to build up in your bloodstream and for you to feel the benefits. It is important to breathe from the mask as soon as you feel a contraction beginning. You may need a bit of practice to get the timing right. If you wait until the contraction really hurts, and then start breathing, it will take effect between contractions.

What are the advantages of entonox?

• Nitrous oxide does not interfere with contractions, nor does it linger in your body or your baby’s.
• While it doesn’t stop the pain completely, it can take the edge off the pain.
• You are in direct control of it, even while feeling its effects.
• It is flexible and quick-acting.
• It is easy to use.
• It doesn't stay in your system. As soon as you stop breathing it in, the gas and air in your system is cleared by your lungs and any side effects will stop too.
• It's safe for your baby.
• Your baby does not require any extra monitoring.
• It can be used while in the water if you give labour in a birth pool or in the bath.

What are the disadvantages of entonox?

• It is only a mild painkiller - for around one-third of women, nitrous oxide offers no pain relief at all.
• It may take a while to get the timing right so that it's effective at the peak of your contractions.
• You may feel light-headed or sick and experience nausea and vomiting.
• It may cause confusion and disorientation
• It dries out your mouth if used for long periods.
• Keeping hold of the mask or mouthpiece may stop you from moving around and getting into a comfortable position.
• For those prone to claustrophobia, you may feel claustrophobic sensations from the facemask
• If used with painkilling drug pethidine, it may make you feel even more drowsy.

Useful tips for entonox:

• Confirm with your health carer before you go into labour whether the mouthpiece or mask and breathing tube are new, or if it will be properly cleaned beforehand.
• If you're having a home birth, ask your midwife if she carries gas and air during your antenatal visits. When she arrives ask her to check that the mouthpiece, valve section and breathing tube are all in working order and that she has enough canisters for your labour.
• You control the gas delivery so ask your midwife for a demonstration on how to use it for maximum effectiveness. The midwife can increase or decrease the amount of gas as you desire.
• Sips water in between contractions to keep your mouth moist.
• You may find it easier to concentrate in the second stage of labour without using entonox. Alternatively, you could have a little gas and air at the beginning of each contraction, but then put the mouthpiece to one side.
• Entonox may not be enough to help you cope with contractions. If this is the case using gas and air can be used in conjunction with other pain relief drugs.

What is pethidine?

• Pethidine is a strong painkilling drug with anti-spasmodic properties to promote relaxation. It's an opiate drug (derived from the opium or poppy plant) and is a synthetic version of morphine.
• Because pethidine can make you feel sick, anti-nausea medications are usually administered at the same time.
• Pethidine during labour is usually administered by intramuscular injection into the buttock. It may also be administered intravenously (directly into a vein).
• While it pays to remember that the effects of any drug will vary from person to person, generally, the effect of pethidine lasts around two to four hours.

When should I have pethidine?

Pethidine is administered during the first stage of labour before you start pushing, when your cervix is opening up to 10cm dilated. You shouldn't have pethidine if your midwife thinks you're close to giving birth because it may not be good for your baby.

What are the advantages of pethidine?

• It can be administered by a midwife, there's no need to wait for a doctor.
• It takes effect quickly.
• It can help you to relax.
• It won't slow down your labour, if you're already in established labour.
• It may help you to postpone or avoid having an epidural if you're finding your contractions hard to cope with.
• You can still use a birthing pool or bath during labour, but not within two hours of a dose of pethidine, or if you feel drowsy.

What are the disadvantages of pethidine?

• It provides only limited relief from labour pain, and in some cases no relief
• You may experience respiratory depression, whereby your breathing may be reduced.
• One in three people find opiate drugs such as pethidine unpleasant.
• It may make you feel drowsy.
• It can make you feel sick or vomit, even if you have an anti-sickness drug.
• Pethidine may make you feel dizzy or you may possibly feel elated, or depressed.

What are the possible effects of pethidine on my baby?

• Pethidine may affect your baby's breathing and making them drowsy for several days, particularly if your birth progresses more quickly than expected and baby is born within two hours of the drug being administered.
• It may be more difficult to get breastfeeding started because the drug may affect your baby's rooting and sucking reflexes.
• Because your unborn baby is exposed to the drug via the umbilical cord, it may experience respiratory depression at birth, particularly if several doses are given or the baby delivers soon after a pethidine injection. This effect can be reversed by an injection given to the baby.

Useful tips for pethidine:

• Prior to having pethidine, remember to ask for a vaginal examination to see how far your cervix has dilated. If you are further on than you thought, you might decide you don't need it after all.
• Pethidine can be administered in either in 50mg or 100mg doses with repeat doses between one and three hours if it isn't having an effect. If you are easily affected by medications ask for a small dose to begin with.
• It will take 20 minutes to feel the effects, so use your breathing techniques to help until the drug kicks in.
• Pethidine is not recommended if you have taken certain antidepressants in the few weeks prior to labour.
• After the birth, be patient with your baby, and yourself. Pethidine takes a couple of days to completely leave baby’s system, and with time baby will get the hang of breastfeeding.

What is TENS?

Transcutaneous electrical nerve stimulation (TENS) is little pulses of electrical energy which are administered to you via a machine. The machine consists of a small box with a clip that attaches to your clothing, and four wires connecting to sticky pads. TENS machines assist in having a natural birth, and can be hired for use at home for the beginning of labour, through to birth.

Your birth partner can place the pads on your back for you, two on either side of your spine at about bra-strap level, and the other two lower down, at about the level of the dimples in your bottom. The pads are covered in a gel to help the electrical pulses pass through your skin more easily.

The frequency and strength of the pulses can be controlled via a dial on the machine, along with a boost button for you to hold in your hand and press for maximum output to help you with a difficult contraction.

When and how should I use TENS?

TENS is most effective when used from the very beginning of your labour, so hire a TENS machine and use it at home before you go into hospital, if you're having a hospital birth.

It takes about an hour for your body to respond to the electrical impulses by releasing endorphins, so begin using the machine when you're getting regular contractions or backache. You may find it is more effective at relieving your backache than abdominal pain.

Begin with the controls at their lowest settings and turn them up gradually as your contractions or back pain becomes more intense. Use the boost button at the peak of contractions for maximum output and relief.

Very few hospitals provide TENS units. This is partly because most women are only admitted to labour wards once they are in established labour, by which time TENS does not work as well. You may bring your machine with you if you wish to continue using it in established labour.

What are the advantages of TENS?

• It's portable and non-invasive.
• It's under your control.
• TENS is easy to use.
• You can keep moving while using it.
• You can use it for as long as you want and then take it off.
• There are no lasting side-effects.
• It's safe for your baby.
• It doesn't need an anaesthetist, doctor or midwife to administer, so you can start using it as soon as you want to.
• It can be used for a home birth.

What are the disadvantages of TENS?

• You will need assistance putting the pads on.
• It may only help in the early stages of labour.
• Hiring a TENS machine costs between $60 and $80 plus postage for a month to six weeks.
• It may have to be removed if your baby's heart has to be monitored electronically.
• Having a TENS machine connected can make it more difficult for your birth partner to massage your back, which can be an effective form of pain relief.
• TENS can not be used whilst in the water during a birthing pool or bath pregnancy.

Useful tips for using TENS:

• Persevere, and don’t give up immediately if you think your TENS is not working. It takes at least an hour for your body to build up endorphins in response to the stimulation.
• Take the pads off every three hours and smear them again with gel before reapplying them to ensure maximum contact.
• Keep mobile. Moving around during labour helps women feel more in control and should therefore enhance the effect of TENS.

Alternative methods of pain relief

Some women prefer to avoid the types of pain relief listed above, and choose alternative treatments such as acupuncture, aromatherapy, homeopathy, hypnosis, massage and reflexology.

If you'd like to use any of these methods, it’s important to discuss them with your midwife or doctor and let the hospital know beforehand. Most hospitals don't offer them for pain relief during labour.