Every hospital may have different options for pain relief, as well as have different policies for certain pain relief options. Such as, for epidural placement they do not always allow someone else in the room!
What are your most common options? And What questions should you ask to learn more about your options?
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Let’s continue with our article…
Epidural
This is the pain relief option of 70% of people in labor.
It is a regional anesthesia option that provides numbness from the belly button down. A needle is inserted into the lower part of the back into a space known as the epidural space where nerve endings are located, this is where the catheter is inserted, NOT into the spinal cord. The procedure can take anywhere from 5-30mins depending on your position, providers skill level, anatomy, and labor stage. It can take anywhere from 15-30mins for the epidural effects to reach maximum effect.
The goal of an epidural is to take away any sensation of pain, but not pressure! This helps with the ability to relax and rest during labor without the pain but still feel the pressure when baby is lower in the birthing canal. The still feeling pressure helps with pushing. If the pressure sensation is removed, this can make pushing harder.
For the procedure, you will get into a cat back position of pushing out your lower back to make the space the provider needs to get to more accessible. You will hold this position throughout the procedure. Prior to the procedure you will get a bag of fluid usually, in some hospitals it may be given concurrently as epidural placement. This is to offset the risk of low blood pressure after the epidural placement.
- They will numb the area with lidocaine, this is the most painful part of the procedure. They describe it as a bee-sting, and then when you count slowly to 10 it will get numb. From this point on you should only feel pressure!
- They will insert the epidural needle into the back to find the epidural space. Once they find it, it will feel like a lose of resistance to them, and this is when they will thread the catheter into the space.
- At this point they will do what is called a test dose. This is when the insert medication into the catheter to see if it is in the right place. We will see distinct symptoms if it is in the incorrect place. Such as a metallic taste in your mouth, ringing in your ears, or sudden numbness in the butt. Anesthesia will go over this with you before doing it.
- If the test dose is negative (no symptoms arise) They will then tape the catheter to your back using ALOT of tape. Then start the medication infusion.
- You will either lay reclined slightly or on your side, depending on hospital policy. This allows the epidural medication to full set in.
- They will monitor you closely for the next 20-30mins for any signs of your blood pressure dropping. Baby’s low heart rate may be the first sign of a lower blood pressure.
IV Pain Medication
These are IV narcotics that are administered through the IV that take the edge off of the contractions, but does NOT take it all away. Depending on the medication used, it has different lengths of relief. Some last 30-60mins and other can last a few hours.
With IV Pain medication, due to the fact that it crosses the placenta, it affects baby in the same way ti affects you. Just like if you were to get too much of the medication, it can cause respiratory depression. A baby is a lot smaller than we are, and if they are born soon after you receive IV pain medication, it could cause them to not have a respiratory effort at birth and need assistance.
I have seen this be a great option for those in an induction, in the earlier portion, who want to try to take a nap.
Nitrous Oxide "laughing gas"
Nitrous Oxide is also known as laughing gas, and is commonly used during dental procedures. It has been used as a pain relief option during labor for over 100 years, but recently started appearing in US hospitals as an option. It does not provide a sedation effect like in dental procedure.
This is similar to IV pain medication where it just takes the edge off, it does not take all the pain away. It is self-administered through a mask, you will apply the mask and start to take deep breaths at the beginning of the contractions. The peak of the nitrous oxide will peak at the same time as the contractions (usually) and this provides relief for the toughest part of the contraction. As soon as you take the mask off, the effects of the nitrous will leave your system in seconds. This is beneficial because of its short acting effect, it does not have long term effects on baby!
This is not available in all hospitals or free-standing birth centers, so a great thing to ask about prenatally!
Questions to ask the staff about pain relief options:
A great time to learn about all your options is during prenatal appointment with your provider or during hospital tours. Some hospitals will even offer classes/consults with Anesthesia to answer any questions you have.
Prenatal visits are the most common options to ask, and its very convenient.
Not all hospital are doing tours at this time, but one they start becoming more and more available, this can help with the planning of your birth. You can ask questions while on the tour to the educator giving the tour or even the nurses on the unit. If there isn’t a tour available you can always call your labor and delivery unit to ask these over the phone.
Asking if you can have an appointment or consult with Anesthesia if you are considering an epidural can be a great time to ask further questions at.
1. What IV pain relief do you offer? How close to delivery can it be given?
Fentanyl is short-acting so can be given close to delivery, sometimes even when someone is 9cm. Nubain/Stadol are longer-acting so preferably not given close to delivery for the safety of the baby. Understanding the type of IV pain relief available can help you gauge what may be available to you based on where you are in your labor.
Remember that IV pain meds do not take the pain away completely, more dull it. The first dose of IV pain meds tends to be the most effective at pain relief, and subsequent doses tend to be less helpful. This timing can be really helpful.
2. Is Nitrous Oxide available?
Some facilities may have restrictions on nitrous oxide use due to COVID, and others are using it again. Nitrous is not readily available in all hospitals or birth centers.
3. How will my care look if I choose to use it? Will I have to stay in the bed or will I have freedom of movement?
Understanding the restrictions, and how long those restrictions may be after receiving nitrous or IV pain meds, can help you decide on whether or not the potential pain relief is worth it for you. Some hospitals will require you to stay in bed after IV pain relief, nitrous, or epidural. Some will allow you free range even with any of the pain relief options.
4. Can nitrous (or what else) be used during epidural placement? What about during laceration repair if unmedicated?
One of the benefits of nitrous is that it can be used as an anti-anxiety medication if you are nervous for epidural placement OR it can help you cope with the contractions during placement. Not all hospital will allow it to be used at the same time though.
If you have an unmedicated birth and need a laceration repair. If the lidocaine is not covering the pain of the repair, asking if you can used nitrous during the repair to help with the discomfort of it. Especially if it will be a longer repair than a few minutes.
6. How fast can I get an epidural if I chose that? Is Anesthesia on the unit only or do they cover the whole hospital? Is there only one or multiple that can place the epidural?
How fast you can get the epidural is dependent on a few different factors:
- Depending on where in the hospital anesthesia is located can determine how fast they can get to you. If they are always on Labor and Delivery, they can get to you quicker than if they are the Anesthesiologist for the entire hospital, or if they are at home until you need them.
- Depending on what is happening on the unit. If someone else is getting an epidural at that time, or they are back for a c-section, you will have to wait till they are available to get yours. Sometimes this is quick, other times it may take a few hours.
- IV placement and Labs resulting. If you get to the hospital and instantly want your epidural, they will need to place an IV catheter and may have to wait till your lab results come back for the platelets number until it can be placed. IV placement can take some time depending on how easy your veins are to find and the lab can take 30-60mins depending on how busy lab is.
7. Will I need a foley that is placed till pushing or do you do intermittent straight catheterizations for bladder drainage?
In the case of keeping the bladder empty, once you have an epidural, you no longer have the ability to control when you urinate. This can cause your bladder to fill up, which can cause issues for your labor and birth. So they will empty the bladder using a foley catheter. There are two ways of doing this, one is placing a foley that stays there until pushing starts OR they can do intermittent catheterization where they will empty your bladder every few hours. Both have their risks and benefits. Discussing which one to expect can be helpful for expectation management!
8. In the case of an emergency c-section, how close is the anesthesiologist? Are they in the hospital or will they need to be called in?
This fact is helpful for both epidural placement AND in the cases of emergency. Is the anesthesiologist in house (in the hospital) or do they stay at home and are “on call”
This could affect how fast they can respond in the case of emergency.
The risk of having an emergency c-section is already low, but for some any risk is too much and may prefer to deliver at a hospital that has anesthesia in house.
9. Where is the OR located? Is it on the same floor or is it on another floor? What could I expect if I had to have a c-section?
This is important to know where you are going if a c-section needs to occur. Not every labor and delivery has an OR on their unit, and you will need to take an elevator down to the OR. Similar with the risk with the question above, for some this may be too big a risk and others not important to them .
10. What anesthesia will they use if i need an unplanned c-section?
For an unplanned c-section they will do a few options depending on if you have an epidural or not.
If you have an epidural: They will dose the epidural with different medication to provide a stronger block for the surgery. They can also use the epidural to provide postpartum pain relief.
If you do not have an epidural: They can either place a spinal if time permits. Which is similar to an epidural but there is no catheter and the medication is injected into the spinal fluid. The effects are instant and last for 2-3 hours.
If time does not permit, this is when general anesthesia is use. Commonly referred to as “being put to sleep”
Conclusion
Whatever pain relief option you choose to utilize or not utilize during your labor is completely up to you!
Knowing what options are available to you during your birth along with the risks and benefits of each can make it easier to help decide. So ask those questions to your provider! You should not ever leave a prenatal appointment or your birth experience with questions about anything!!