Treating Pain During Labor
Some women choose to treat labor pain with medication. There are two choices to manage pain: intravenous medication and epidural. Epidural is for severe labor pain, or for pain which is not treated adequately with the intravenous medication. The decision to select IV pain meds or epidural is different for every woman, and may be different from one pregnancy to the next, in the same woman.
The intravenous medication (IV) used to treat pain is related to morphine or opium. It works in the brain, changing how the body reacts to the pain. Numorphan is used most frequently. A dose is usually given half and half, IV and subQ (in the skin). Each dose lasts about 1.5 to 2 hours. Multiple doses are safe if each dose works for about 90 minutes. If the dose wears off in less than one hour, the next dose usually does not help. This, and all, medications can reach the baby. The medicine can make moms loopy and it can make newborn babies loopy too, especially when the dose is given within 1-2 hours of delivery.
Epidural is stronger pain relief than the IV medication. The epidural works like Novocain, blocking the pain message by numbing nerves. Because it acts on the pain nerves, rather than on the brain, patients do Not get loopy. Because it also acts on the motor nerves, women can’t walk, and sometimes they can’t move their legs very well. Women must stay in bed with the epidural. Also, the numbness, usually from the belly button down, makes it so women can’t feel or empty their bladder, and need to have a catheter in place until after the baby is born. The epidural medicine is given as a constant infusion, like an IV, with a tube in place. This makes it possible to turn up the epidural, to become more numb, during labor, and turn down the epidural, less numb for pushing.
Pushing is no different with or without the IV medication. Pushing with an epidural can be a little tricky, especially for first time moms. We can turn down the dose so patients are less numb when it is time to push. Epidurals do not cause cesarean sections, but it can take longer to push out a baby with an epidural, compared to no epidural.
There are very few complications from epidural because we only give epidurals to patients in whom we expect a low chance of a problem. The most common problem is optimal dosing: some patients feel nothing, some patients still feel too much. We can adjust the dose to address these problems. There is no extra risk or danger for women with scoliosis or previous back surgery, but these patients may not get enough pain relief because of the changes in their spine anatomy. There is a special kind of headache that may come the next day, after the epidural catheter (tubing) is removed. This headache happens about 1/100. Women with high blood pressure complications of pregnancy need a platelet count, a blood test, to make sure epidural will be safe.
How Long to Wait
A woman can get her epidural at any time in labor. We used to think that waiting until 4 or 5 cm dilation was important for safe and proper use of epidural pain relief in labor. This was proven false in multiple research studies published around 2008. Early epidural does not slow down labor, and does not cause cesarean section. Early epidural just treats pain earlier.
Walking epidurals use medicines which block only pain nerves. The motor nerves, the nerves which control the muscles, are not affected. As a result, you can not feel anything, but you can walk.
A spinal anesthetic is Like an epidural. It’s awake nerve block anesthesia. The spinal is given as a single injection of medicine, and lasts about 2 hours. It’s best used to make patients numb for surgery such as a cesarean section. It’s not good for labor, because it wears off too soon and it is not safe to give a second spinal injection.