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Pain Management during Labour and Birth

We hope to clarify the mystery and fear of pain during childbirth with our articles about pain during labour and birth.

It is most probably the area of childbirth that most women fear. Can I do this? What if?



Understanding why it happens and how best it could be managed, will assist all mothers to have a more positive

birthing experience.



On this page:

  • Understanding pain during labour and birth

  • Natural Pain Relief Methods

  • Medicated Pain Relief Methods





Understanding Pain during Labour and Birth 
We are made to do this work and its not easy…I would say that pain is part of the glory, or the tremendous mystery of life. And that if anything, it’s a kind of privilege to stand so close to such an incredible miracle. Simone in Klasson 2001

 

Pain in General Explained

Pain is both a physical and emotional experience, much more than just the body’s nerve response to an injury or a change in a function of the body. Pain is a complex experience that is very personal (and sometimes isolated) for the individual person. It is invariably influenced by a person’s beliefs, culture, ideas, fears and feelings.

For the last 20 years or so, the concept of pain has been recognised as being what a person says it is, existing when they say it does and being as painful as they say they feel it. How an individual person views different types of pain will alter the way they react to that pain, and ultimately affect how they will feel about that pain after the experience.

Pain is transmitted to the brain by sensory nerve fibres. These nerves relay ‘sensation’ information (such as touch, heat, cold, sexual arousal, pressure and pain) from our bodies to our spinal cords and then on to our brains for interpretation.



The Gate Control Theory

The ‘Gate Control Theory’ remains one of the most respected understandings of one way our bodies can diminish the perception of pain.

The gate control theory is based on the fact that when the larger skin nerves (that sense touch, heat, cold and pressure) are stimulated, they are capable of overriding the smaller nerve fibres that sense the sharp, burning or aching pains. The larger nerve fibres carry the ‘sensory message’ to the spinal cord more rapidly and get priority, shutting ‘the gate’ as it were, to the pain messages being carried by the smaller fibres.

If the pain intensifies to a higher level the ‘gate’ can be pushed back open to a degree, making the pain sensation felt more intensely. This is the reasoning behind our natural instinct to ‘rub’ or massage our bodies when we hurt ourselves.

It is also the reason why natural therapies such as massage, cold or heat packs can alter the conscious pain sensation felt by a woman in labour, changing or modifying, the pain she experiences.

Other ways to stimulate the gate control is by changing position, walking, rocking, stomping and pelvic rocking. These movements activate receptors in the woman’s joints to help diminish pain. As the labour progresses and intensifies, methods using the ‘gate control’ can become less effective as the gate is ‘pushed back’ to a degree.

This is particularly so as the woman reaches the transitional phase of the 1st stage of labour, just before it is time to push. But remember those hormones! (See our post on Birthing Hormones)



Pain in Labour and Birth

The anticipation or the ‘expectation’ of pain can increase anxiety levels in a person and therefore increase the intensity of how they perceive the pain when it comes. For a woman who is fearful and anxious about labour, the need for pain relief can be higher.

It has also been suggested that women who feel they are in control of decisions about what is happening to them in labour, will perceive their pain as less intense and less threatening, as well feel more positive about the labour experience after the birth.



Labour pain differs from other kinds of pain in ways that make coping easier.

It is not a symptom of injury or illness: When pain signals that something is wrong, anxiety can increase painful sensations. Labour pain, however, is simply a sign that your body is working hard and well.

It is rhythmic: Contractions last no longer than a minute or so and come in a regular pattern with one to several (usually) pain-free minutes in between them. This means you can predict and prepare for each contraction and rest between them.

It intensifies gradually over time: Contractions almost always start off mild and gradually grow longer, stronger, and closer together, thus allowing you time to adapt.

It is self-limiting: Labour rarely takes more than 24 hours.

 

A woman’s body is already organized and finely tuned to do this work. But it is important that a woman and their caregivers understand how to work with – and avoid disrupting – her body’s inborn knowledge, drive, and direction for giving birth and caring for her baby.

The key is that you should be realistic about labour pain. For most women labour and giving birth is painful.



Things to remember are:

That a woman’s experience of pain involves many factors and complexities and while most will describe labour as ‘painful’, this does not necessarily mean it was an unpleasant experience.
The description of labour pain is widely variable; it may be that other women’s stories will leave you feeling no closer to fully understanding what your labour pain will be like. Your ‘benchmark’ will only truly be established once you have experienced labour yourself. It could also be a very empowering experience.
Unrealistic and inflexible expectations can place unnecessary pressure on you. For some women, when the labour and birth don’t meet their expectations, feelings of disappointment, depression or even anger can be felt in the days, weeks, or months after the birth.
Be realistic about your labour pain. Just as fears and concerns can encourage you to source out and embrace different strategies for support, so too will being realistic about what your labour could bring.
Allow your body to move with labour pain, do not fight it, as this can intensify your perception of the pain. It is something you need to accept and let it flow through your body, not something that you must fight.
And remember, labour pain is not constant; it comes and goes, allowing the labouring mother to rest in-between the contractions.

Rain, after all is only rain; it is not bad weather. So also, pain is only pain; unless we resist it, then it becomes torment.   I Ching​





Natural Pain Relief Methods during Labour and Birth 

A wide variety of natural pain management techniques may be used to ensure a smoother birthing. It is quite common to use different methods throughout the different stages of birth. There is no magic answer here. The best method is to listen to your body – your preferences will change throughout your birthing – be open to new ideas. It is advised to ensure that your caregivers know about these different techniques, so that they can suggest these to you throughout your labour. A doula present during your birthing will assist greatly in this regard.



An important factor is not to starve your body during labour and birth. Eat when you are hungry and ensure that you drink fluids during this time.

Birth is a normal, healthy part of a woman’s life. Many alternative methods of pain relief are available that are safe and inexpensive. Whether a woman is actively seeking a natural, drug-free childbirth experience, or simply wishes to minimise the amount of medical interventions and their possible negative impact on her labour, she may want to try these methods during some or all of her labour. These skills, ideally, should be explore and learned before labour begins.



Breathing and Relaxation

These are perhaps the most familiar forms of alternative pain coping methods. Commonly referred

to as “Lamaze Breathing”, which uses learned breathing patterns to aid the woman’s relaxation efforts, as she consciously releases any tension in her body, allowing her uterus to do its work without any added effort or waste of energy. The ability to quickly relax under stressful conditions such as labour is an acquired skill that improves with practice.



Hydrotherapy

Showers or baths in labour use water to provide comfort to a labouring woman. Numerous studies have shown that hydrotherapy, when used correctly during labour, is safe, reduces pain, enhances progress, and reduces the likelihood of tearing. A shower is beneficial almost anytime during labour. A bath (immersion in a deep birth pool or tub of clean, warm water) may speed labour along if it is used in active labour . This is also referred to as water birth, when the water is used extensively during labour and the birth.

Not all hospitals in South Africa will allow you to use hydrotherapy, whether it is the use of a shower or a bath. Please discuss this with your caregiver and find out what the policies are of the hospital are regarding the use of water.



TENS

Transcutaneous Electronic Nerve Stimulation uses electrical current to numb areas of the body. These soothing pulses, which travel across the surface of the skin and along nerve fibres, prevent pain signals from reaching the brain. They also stimulate your body to produce higher levels of endorphins. This method is not usually used in hospitals in South Africa, as hospital staff are not familiar with this method.



Acupressure, Massage, Reflexology and Counter pressure

These are specific touch techniques that help relieve pressure or pain and enhance relaxation and endorphin release. Stimulating certain acupressure points in the body of a labouring woman may help speed labour progress. Try hand and/or foot massage, effleurage (light, circular stroking of the abdomen), the double-hip squeeze, or the knee press. Childbirth educators, midwives, nurses, and doulas may be familiar with these specialized techniques.



Hot and/or Cold Compresses

Applied to the lower back, these help relieve back labour. A ‘hot rice sock’ (a tube sock filled with uncooked rice and heated in a microwave for 2 minutes) placed under your belly, on your back, or over your shoulder feels wonderful! It can be reheated as often as necessary.



The Birth Ball

A physical therapy ball that labouring women use in a variety of positions. Sitting on the ball and rocking back and forth is comfortable and helps labour progress using gravity, while increasing endorphin release because the elasticity and the curvature of the ball stimulate receptor sites on the pelvic floor which are primarily responsible for endorphin release. The ball should be soft and under-inflated, and large enough in diameter so that the woman’s knees are flexed at a 90-degree angle. Hold on to a chair or bed as you sit down on the ball safety.



Aromatherapy

The use of aromatic substances that stimulate chemoreceptor sites in the nasopharanyx that trigger other chemical responses in the body.  This can be used in various ways; using a burner, spraying fragrance in room, burn fragrance candles ……



Music

Auditory, acoustic, and vibratory stimulation actually decrease our perception of pain and enhance relaxation. Different types of music are useful at different stages of labour. Couples should bring their own musical selections with them to hospital or birth centre. Music masks the distracting sounds often experienced in the hospital environment while helping to create a more personal, spiritual atmosphere in which to labour. If you are planning a hospital birth, find out if you will be allowed to bring music along.



Movement, Positioning, and Position Changes

Your baby’s position contributes directly to the pain of labour as well as the length of labour. Labour progress in enhanced when woman is allowed to follow her body’s messages and move and change positions frequently. Walking, swaying, slow dancing, stair climbing, squatting, lunging, hands-and-knees positioning with pelvic rocking, rocking on a birth ball or on a rocking chair are all examples of helpful movement and position changes for labour.

Changing your environment by walking outside in the garden instead of being indoors could also assist you greatly.

Our private hospitals in South Africa prefer the labouring mother to be bed  or room bound, and you will have to discuss this with them prior to the birth to find out how they will feel about you being mobile  in and outside your room during your labour and birth.



Companionship and Support

Labour support provided by a professional Doula or birth companion, has been shown to improve birth outcomes, reduce the numbers of Caesarean sections, epidurals and other medical interventions, while promoting bonding and successful breastfeeding. Doulas are usually hired by a couple before labour and provide continuous, personal emotional and physical support to both of them throughout the entire process.

If you are planning a hospital birth, find out what the hospitals policy is of making use of a Doula.



Hypnotherapy

Hypnosis creates a state of deep relaxation that eliminates fear and anxiety from the birthing experience. This is done by changing your mind’s perception of pain, so that what you experience is interpreted by your mind as pressure rather than pain.

During labour and childbirth you will use hypnosis to move into a deeply relaxed state. This will help you to breathe deeply and rhythmically, increasing the flow of oxygen in your blood system. This oxygen helps to keep your baby calm and stable, and stimulates the production of Oxytocin – the hormone responsible for contractions. As well as keeping you relaxed, the use of hypnosis techniques





Medicated Pain Relief Methods

​

The most important thing to remember when choosing to use pain medication during labour and birth is that you will become a patient, and not just a mother giving birth.
We encourage every mother to take this decision to use pain medication seriously and evaluate for yourselves the benefits and downsides to both natural birth and medicated birth before you jump to any hasty conclusions. Granted, pain medication does have its place in labour and birth, but don’t make your decision out of fear of the unknown.


Pain medication, such as epidurals, carry with them hefty sacrifices and interventions. With epidurals being such a popular choice of pain intervention, we have written extensively on this subject, so that you can be informed before making your choice.



We discuss the most common used methods:



Entonox (Gas and Air)

Entenox is basically 50% Nitrous Oxide (laughing gas) and 50% air (oxygen, nitrogen, carbon dioxide etc)
The benefits of gas and air are that although it does cross the placental barrier to the baby the effects are very short lived and therefore there are not known to be any serious side effects with its use for the baby.
However with gas and air there is about a one-minute time lag between starting breathing it and the gas having any effect. This means that if you start breathing it when the contraction starts you will not actually get the benefit of the gas for that contraction as they only generally last a minute or so.
Nitrous Oxide is also a sedative so it can make you feel very woozy and dizzy. It can also make you feel very nauseous and given that women often feel sick during labour anyway you may feel that you would want to use another method other than gas and air. The nice thing about gas and air is that you control it so you can simply choose not to use it anymore if you do find it unhelpful. This method can be used both with home and hospital births.



Opiate based painkillers (Pethidine)

Opiate based pain killers are related to morphine. They are falling out of favour in the west because they cross the placental barrier to the baby. They are effective as painkillers but they do have some unwanted side effects. They affect the breathing of the mother and the baby and are sedative, so both mum and baby will often appear very sleepy. Because this is not really conducive to a healthy birth (a sedate mum won’t feel like getting actively involved in the birth), forceps interventions for vaginal delivery may well be employed. This is far from the natural birthing experience that most women hope for and these methods of assisted delivery can lead to increased perineal trauma.
Babies born after the mum has had Pethidine are often very sedate for several days after the birth and a big disadvantage is that they do not readily breast feed which can be distressing for the mother and partner.
Although all mothers and babies do not experience these side effects you may wish to consider the risk/ benefit ratio before allowing Pethidine to be administered. Many mothers report that Pethidine does not alleviate the pain to the extend they wished for, but you end up so sleepy that you don’t seem to care!
The amazing thing about the human body is that it already creates a naturally occurring opiate type painkiller, which will work well when it is allowed to. It is incredibly potent (200 time stronger than morphine) and the are called endorphins.



Epidural analgesia

Different variations: To begin with, what is popularly known as an epidural is correctly termed epidural analgesia. The term epidural properly refers to the space into which the anaesthetist delivers the medication rather than an agent or technique.



Epidural: The anaesthetist inserts a needle into the epidural space, which lies between the tough, outer membrane that covers the spinal cord and the next deeper membrane. A tiny tube or catheter is threaded through the needle. The needle is removed and the anaesthetist injects an anaesthetic similar to those used in dentistry or, in most hospitals today, a mixture of anaesthetic and narcotic (narcotic epidural) into the catheter.

Continuous infusion: The catheter is attached to a syringe driven by a pump that gradually delivers a continuous dose. This technique is the standard because it provides steady labour pain relief.

What is involved in having an epidural?
You will be asked to curl up on your side or sit up with your back arched outward. Your back will be washed with antiseptic and covered with a sterile drape. The anaesthetist will numb the skin before inserting the needle. You must remain absolutely still while the needle is in your back. One or more tests (such as pulling back on the syringe to see if blood flows in) will be performed to make sure the needle is in the right place. A catheter will be threaded through the needle and taped to your back to keep it from moving.


Other interventions are common with epidurals to monitor, prevent, or treat possible side effects. As part of epidural management, you will definitely have:

  • An IV (intravenous drip): you will be given about a quart of IV fluid before the epidural is administered

  • Continuous electronic foetal monitoring (EFM)

  • Frequent monitoring of blood pressure, usually with an automatic blood pressure cuff that periodically self-inflates and records the results.

  • You are more likely to require:

  • IV Syntocynon, a drug to make contractions stronger

  • Drugs to combat a drop in blood pressure

  • A urinary catheter for inability to pass urine

  • A vacuum or a forceps delivery.

  • Controversy exists over whether you are also more likely to have a Caesarean section.

What are the advantages of an epidural?

An epidural is the only labour pain relief technique that can completely eliminate pain
A plain epidural, without narcotics doesn’t affect consciousness.


What are the drawbacks of an epidural?
An epidural:

  • Requires the presence of an anaesthetist: this means an epidural may not be readily available when you want it

  • Involves delay in obtaining relief: even when the anaesthetist is in the hospital and not busy elsewhere, it can take an hour from your request to the time when the procedure is done and the medication takes effect

  • Changes the experience of labour: it converts labour and birth from a normal life experience in which you are an active agent to one in which the equipment (IV, Syntocynon pump, epidural pump, electronic foetal monitor, blood pressure cuff, etc.) is the centre of attention

  • May interfere with your ability to move about: it numbs much, if not all, sensation in the belly, genitals, and legs, and you may feel groggy if it contains narcotics; these effects can prevent you from activities that may help labour progress

  • Requires or increases the need for other procedures: Augmentation of labour, continuous foetal monitoring and blood pressure monitoring as just some of the procedures that could be introduced

  • Can cause episodes of low blood pressure: this is a problem because it reduces your baby’s oxygen supply

  • Can cause itching: this is a common, but generally mild, side effect if narcotics are given

  • May interfere with the pushing phase of labour: you may have difficulty pushing your baby out, and this phase may be lengthened and need interventions like a forceps of vacuum assisted birth

  • Can lead to the cutting (episiotomy) of the perineum: this is the cutting of the tissue between your vaginal and anal openings

  • Can cause life-threatening complications (dangerously low blood pressure, respiratory or cardiac arrest, severe allergic reaction, convulsion): the odds may be as high as 1 in 4,000 to 1 in 3,000 cases.

  • Can cause maternal fever: the longer you have the epidural, the more likely you are to run a fever, which can have its own consequences:  Developing a fever appears to increase your likelihood of birth by caesarean section, vacuum extraction, or forceps. Fever in the mother may be associated with more babies being born in poor condition and an increase in newborn seizures.  Because fever raises the possibility of infection, babies of mothers with fever are more likely to be evaluated for infection; this involves drawing blood, and may involve precautionary antibiotics through an IV (intravenous) line; mothers and babies may be separated during these procedures.

  • First-time mothers tend to have more difficulties with epidural side effects than women who have previously given birth.

Question: I haven’t heard anything about drawbacks to an epidural; in fact, the hospital, my doctor, and even my childbirth educator have nothing but good things to say. Why might this be?
In medicine, the desired effects of a drug or procedure often receive more attention than undesired effects. The unmatched effectiveness of epidurals at relieving labour pain has impressed both caregivers and women. Many caregivers also believe that new techniques and medications have minimized side effects. For these reasons, the disadvantages and potential complications are often under-recognized or seen as unimportant because they can be managed. They may also be considered an acceptable trade-off given the benefits of superior labour pain relief. Every woman needs to understand these trade-offs and make informed decisions according to her values, preferences, and options.