Planning Your Childbirth
Labor and Delivery
Besides choosing a baby name and nursery color, expectant mothers also need to decide how they wish to have their pain managed during childbirth. Staying comfortable is an important part of a positive birth experience, and women should feel free to discuss all their options with their obstetrician and anesthesiologist.
The information in this section contains important information about safety and pain control during childbirth. The TSA encourages expectant mothers to read these resources carefully so they can make an informed decision.
Misconceptions About Pain Management in Labor and Delivery
When planning for the arrival of a new baby, there is much to prepare for. Parents are often focused on equipping the nursery, attending birthing classes and maintaining mom’s health. What many expectant moms may not realize is that they should also be preparing to make important decisions regarding their pain management options during labor and delivery. In order to help expectant mothers prepare for childbirth, the American Society of Anesthesiologists (ASA) wants to set the record straight regarding common misconceptions about obstetric pain management.
Misconception 1: Epidurals slow down the labor process.
There is no credible evidence to show that epidurals (or other pain management procedures) slow labor. Since epidurals are more frequently used in “difficult” labors versus relatively easy labors, some have tried to infer that epidurals, therefore, cause difficult labors. This is not an accurate interpretation of the data. Conversely, there is some evidence that epidurals can actually speed labor for some women, by allowing them to relax.
The best information we have is that pain management procedures have no significant impact on the labor process.
Misconception 2: Epidurals cause C-sections.
Again, there is no definitive evidence that concludes an epidural will cause a C-section. Women who receive epidural anesthesia report higher pain levels earlier in labor than those who do not. Such pain itself may be a marker for an unusual labor, which may be longer or more likely to end in a C-section. Women requesting epidurals also tend to be dilating at a slower pace than those who do not; they deliver larger babies; they are more likely to be receiving medication to augment labor, and they are more frequently having their first baby.
Misconception 3: You can’t get an epidural until a certain level of dilation has occurred.
Women do not have to wait until they are dilated to a certain level before they can ask for, or receive, an epidural. According to the ASA’s current guidelines, “patients in early labor should be offered the option of receiving neuraxial analgesia (spinal or epidural) when the service is available, and it should not be withheld to meet arbitrary standards for cervical dilation.” If a woman is in active, established labor, and is uncomfortable, epidural analgesia is the most effective method of pain relief. There is no medical reason to wait for a specific dilation target.
Misconception 4: Women with lower back tattoos can’t get an epidural.
There is no evidence that lower back tattoos cause harm in this situation. Initiating an epidural through the ink of a lower back tattoo will not cause ink to enter the blood stream or the spinal canal, or cause further complications for the mother or baby.
Misconception 5: Having an epidural is extremely painful.
For most patients, the only painful part of the epidural procedure is the numbing of the lower back before the epidural is placed, which does cause a momentary stinging or burning sensation. The insertion of the epidural itself is usually felt as just pressure. In the hours and days following delivery, some women experience discomfort in the lower back where the needle was placed, but this is rarely a significant problem.
Misconception 6: Epidurals can cause permanent medical problems for the mother and/or the newborn.
Serious complications from an epidural procedure are extremely rare. The biggest risk that faces most patients is that the epidural will not work as effectively as desired. The anesthesiologists can administer more medication or make other adjustments in such cases.
Misconception 7: Epidurals make labor less "fulfilling" for the mother.
What makes a labor meaningful and fulfilling is subjective, but it is important to most women that they remain alert, aware of contractions and participate in the process of childbirth. An epidural does not prohibit any of this from occurring. Eliminating the distraction of labor pain can make the birth process more enjoyable for many women.
Misconception 8: Epidurals depress babies so they can't breast-feed.
Some women worry that the medication they receive via the epidural may somehow reach their baby and make him or her less able to breast-feed. While learning to breast-feed is not always easy, most delivery centers have “lactation specialists” to help new mothers and infants master the skill. Epidural analgesia actually exposes the baby to less medication than many other methods of pain relief.
Misconception 9: The window for receiving an epidural can close.
The primary requirement for receiving an epidural is that the patient can hold still and the baby isn't already in the process of being delivered. Beyond that, there isn’t an arbitrary time when it becomes “too late” to perform the procedure.
Misconception 10: Epidurals are guaranteed to provide optimal relief.
Like all medical procedures, with epidural analgesia, each individual responds differently to medication and sometimes not enough medication is delivered to the right spot. These instances are rare and even when they do occur, an anesthesiologist can make adjustments.
Types of Pain Relief in Labor and Delivery
Each woman’s labor is unique, and the amount of pain she feels during labor depends on many factors. Her discomfort can be affected by the size and position of the baby and the strength of contractions. Some women take classes to learn breathing and relaxation techniques to help cope with pain during childbirth.
Others may find it helpful to use these techniques along with pain medications outlined below:
Analgesics vs. Anesthetics
There are two types of pain-relieving drugs — analgesics and anesthetics. Analgesia is the relief of pain without total loss of feeling or muscle movement. Analgesics do not always stop pain completely, but they do lessen it.
Anesthesia is blockage of all feeling, including pain. Some forms of anesthesia, such as general anesthesia, cause you to lose consciousness. Other forms, such as regional anesthesia, remove all feeling of pain from parts of the body while you stay conscious. In most cases, analgesia is offered to women in labor or after surgery or delivery, whereas anesthesia is used during a surgical procedure such as cesarean delivery.
Not all hospitals are able to offer all types of pain relief medications. However, at most hospitals, an anesthesiologist will work with your health care team to pick the best method for you.
Systemic analgesics often are given as injections into a muscle or vein. They lessen pain but will not cause you to lose consciousness. They act on the whole nervous system rather than a specific area. Sometimes other drugs are given with analgesics to relieve the tension or nausea that may be caused by these types of pain relief.
Like other types of drugs, this pain medicine can have side effects. Most are minor, such as nausea, feeling drowsy or having trouble concentrating. Systemic analgesics are not given right before delivery because they may slow the baby’s reflexes and breathing at birth.
Local anesthesia provides numbness or loss of sensation in a small area. It does not, however, lessen the pain of contractions.
A procedure called an episiotomy may be done by your doctor before delivery. Local anesthesia is helpful when an episiotomy needs to be done or when any vaginal tears that happened during birth are repaired.
Local anesthesia rarely affects the baby. There usually are no side effects after the local anesthetic has worn off.
Regional analgesia tends to be the most effective method of pain relief during labor and causes few side effects. Epidural analgesia, spinal blocks and combined spinal–epidural blocks are all types of regional analgesia that are used to decrease labor pain.
Epidural Analgesia — Epidural analgesia, sometimes called an epidural block, causes some loss of feeling in the lower areas of your body, yet you remain awake and alert. An epidural block may be given soon after your contractions start, or later as your labor progresses. An epidural block with more or stronger medications (anesthetics, not analgesics) can be used for a cesarean delivery or if vaginal birth requires the help of forceps or vacuum extraction. Your doctors will work with you to determine the proper time to give the epidural.
An epidural block is given in the lower back into a small area (the epidural space) below the spinal cord. You will be asked to sit or lie on your side with your back curved outward and to stay this way until the procedure is completed. You can move when it’s done, but you probably will not be allowed to walk around.
Spinal Block — A spinal block—like an epidural block—is an injection in the lower back. While you sit or lie on your side in bed, a small amount of medication is injected into the spinal fluid to numb the lower half of the body. It brings good relief from pain and starts working fast, but it lasts only an hour or two.
A spinal block can be given using a much thinner needle in the same place on the back where an epidural block is placed. The spinal block uses a much smaller dose of the drug, and it is injected into the sac of spinal fluid below the level of the spinal cord. Once this drug is injected, pain relief occurs right away.
A spinal block usually is given only once during labor, so it is best suited for pain relief during delivery. A spinal block with a much stronger medication (anesthetic, not analgesic) is often used for a cesarean delivery. It also can be used in a vaginal birth if the baby needs to be helped out of the birth canal with forceps or by vacuum extraction. Spinal block can cause the same side effects as epidural block, and these side effects are treated in the same way.
Combined Spinal–Epidural Block — A combined spinal–epidural block has the benefits of both types of pain relief. The spinal part helps provide pain relief right away. Drugs given through the epidural provide pain relief throughout labor. This type of pain relief is injected into the spinal fluid and into the space below the spinal cord. Some women may be able to walk around after the block is in place. For this reason this method sometimes is called the “walking epidural.”
General anesthetics are medications that make you lose consciousness. If you have general anesthesia, you are not awake and you feel no pain. General anesthesia often is used when a regional block anesthetic is not possible or is not the best choice for medical or other reasons. It can be started quickly and causes a rapid loss of consciousness. Therefore, it is often used when an urgent cesarean delivery is needed.
Anesthesia for Cesarean Births
Whether you have general, spinal or epidural anesthesia for a cesarean birth will depend on your health and that of your baby. It also depends on why the cesarean delivery is being done. In emergencies or when bleeding occurs, general anesthesia may be needed. If you already have an epidural catheter in place and then need a cesarean delivery, most of the time your anesthesiologist will be able to inject a much stronger drug through the same catheter to increase your pain relief. This will numb the entire abdomen for the surgery. Although there is no pain, there may be a feeling of pressure.
Nitrous Oxide During Labor
Nitrous oxide, commonly known as laughing gas, is used very infrequently (in less than 1 percent of women) as a form of labor analgesia in the U.S. There are only a few centers in the country where this type of inhaled gas is routinely available to patients. It tends to be used more frequently in the United Kingdom and some other countries.
Studies that have been published about the use of nitrous oxide for labor analgesia indicate that pain relief is very minimal, similar to that of injected narcotic pain relievers. Although some studies show no pain relief at all when mothers use it during labor, a few women did report relief of some sort. However, nitrous oxide does not improve the rates of maternal nausea or vomiting during labor.
There has been little research on the effects of nitrous oxide on the baby during labor. Anesthesiologists do not know the long-term effects the gas might have on the brain and neurologic development of infants, or if certain infants may be at higher risk for problems. Nitrous oxide also can depress breathing in some mothers, as well as cause drowsiness. However, modern monitoring technology typically helps to manage these issues.Another concern about the use of nitrous oxide during labor is that environmental pollution occurs when it is inhaled by mothers and then exhaled into the atmosphere. Air in labor rooms could contain significant concentrations of the gas and expose it to other individuals in the room, such as nurses, labor coaches and family members. Since nitrous oxide is a “greenhouse gas,” it has the same negative effects in the atmosphere as carbon dioxide.
© 2014 American Society of Anesthesiologists.
All rights reserved. Reprinted with permission.