Some call it pain….some call them labour surges. Call them what you will, contractions are not a naturally easy thing to deal with. Your cervix has done its job and kept your baby enclosed in it a safe environment for the duration of your pregnancy. When you start your labour, your cervix needs to relax, to soften and to open. This is something that happens when the action of your hormones, your baby, your pelvis and the rhythmic contraction of the uterine muscle are in the right balance. Let’s face it – opening up and letting out a new person is never going to be easy or comfortable.
The uterus is a muscle. Whenever muscles work, they fatigue and produce by-products (such as lactic acid) that build up and cause us pain or discomfort (if you have ever been to the gym imagine holding a 60-second squat then standing up and shaking it out, only to back it up with another 60-second squat). There are several ways to manage your labour. Some of these are natural methods, others rely on medicine and medications. Whatever you choose please make sure you are aware of your options and as always, ask whatever questions you need to ensure you are making an informed decision about your choices.
Natural Pain Management
The body has a built-in pain management system. Endorphins act as neurotransmitters and hormones and are produced by the brain during exercise, excitement, pain, love and orgasm. They operate in a similar way to opiates in their ability to produce analgesia and a feeling of wellbeing. In this way, they work on the central and peripheral nervous systems to reduce pain. Labour will usually start slowly, enabling the body to release endorphins according to perceived pain levels.
In unmedicated labours, endorphins continue to rise steadily and steeply through to birth. High endorphin levels during labour and birth can produce an altered state of consciousness. This state helps the mother to go with the flow even if their labour is long and challenging. For your endorphins to work as they should, you need to be in a safe and comfortable environment and to minimise stress. Adrenalin (a stress hormone) can block the action of endorphins (50).
Staying mobile is an excellent way of managing your labour. Babies play an active role in the birthing process and usually have some work to do to get in the right position. They need to wriggle and rotate and move their hands out of the way and flex their head; staying in one position sometimes means that baby does not have the room to turn the way they need to. In this way, mothers and babies need to work together for the baby to be born.
Not only this, but the nasty byproducts that our muscles make during a contraction are easier to eliminate if we move. These products return to the blood system where they transfer to the lungs and are breathed out. This physiology is the reason you will be encouraged to breathe through your contractions. It ensures that the baby is getting maximum oxygen while disposing of the waste products from the system. This elimination helps to relieve some pain. Listen to your body. Walking and moving as your body needs to is also a distraction from the pain, passes the contraction time a bit faster and gives your baby the opportunity to move if they need to.
Breathing and relaxation
Both of these methods can be very effective, especially if they are a part of your usual health regime before labour, or before pregnancy. Hypnobirth® and Calmbirth® are two approaches which use these techniques to great effect in some women.
If these aren’t for you, then many antenatal classes teach relaxation and breathing awareness as a way of coping with contractions. Relaxation doesn’t take away the pain, but it can prevent pain from becoming more intense as stress and anxiety during your labour and increase tension in surrounding muscles. This tension results in your uterus having to work harder as it fights against the surrounding muscles. Relaxation will help your endorphins work better too.
Water in labour
Heading into a warm bath or shower when we are feeling discomfort or pain, tired or fatigued helps us relax, and relieve our discomforts. Water simply makes us feel better. Getting in the bath or shower during labour has been shown to enhance our endorphins, increase our relaxation levels and reduce our perceptions of pain (47, 48).
Water immersion is also associated with fewer interventions during labour, including the caesarean section (47, 48).
For more information on water immersion and waterbirth, please click here.
Some other methods of natural pain relief include:
- TENS (Transcutaneous Electrical Nerve Stimulation) machines
- Acupuncture or acupressure.
Please speak to your midwife about these and other pain relief options available to you. You may need to see a specialised practitioner if you are interested in these methods.
Medicine and Pain Medications
Sterile water injections
Sterile water injections (SWIs) are a medical pain management strategy. While it is a drug-free option, it is invasive (injecting a small amount of sterile water under the skin in your lower back). It must be performed by a practitioner trained in this procedure.
By all accounts, SWIs are incredibly useful for back pain in labour; however, medical research is yet to confirm this scientifically with clinical trials (51). It works on the pain-gate theory.
The injections are performed by two midwives who inject the water in four different points in your back simultaneously (2×2) during a contraction. These injections are extremely painful for about a minute (more than the contraction), but when they settle they alleviate back pain for up to a couple of hours (sometimes longer). For women with an OP baby (see which way’s up?), SWIs can be the difference between getting through your labour without an epidural. SWIs can be repeated whenever you need them as they do not involve drugs. However, they are not as effective if you rub the area, use a heat pack or get in the birthing pool.
We often recommend simple analgesia (such as panadol) for women in early labour. These are mild forms of pain relief, and to date, no evidence that suggests their use harms you or your baby when used as recommended. For a few women, this is all the pain relief that they require – for others, it doesn’t seem to scratch the surface. It is difficult to gauge how much of an effect something has had on pain during labour. This difficulty is due to the nature of contractions – the intensity escalates as labour continues. The pain relief may have had an effect which has now been cancelled out by the contractions being stronger.
Gas (gas and air, Entonox® and Equanox®) is an inhalation method of pain relief similar to the laughing gas you may have had at the dentist. The gas comes with a tube and a mask or mouthpiece so you can breathe in and out. It generally takes two good breaths to get into your system. If you start to breathe it in when you feel your contraction coming it has had time to work when the contraction reaches its peak. It then takes a few good breaths to get out of your system, and as such does not linger or potentially cause harm to you or your baby. Babies do not appear to be affected as very little gas reaches them.
You can use gas in conjunction with other forms of pain relief, and it is usually safe to use in the shower or bath. You can remain mobile within the radius of the tube you have to breathe on. Some women don’t like how the gas makes them feel (some say light headed, some nauseous) and others won’t let it go and continue to breathe on it between contractions. It is, however, a controlled drug and so partners and friends do not get a go.
Opioids (or opiates) are drugs that are related to morphine. We administer them by injection and calculate the dose on your body weight.
Most opiates take around 15 minutes to work and last for two to four hours. Some women feel sick with these drugs; however, we usually give anti-sickness medicine at the same time. The drug may make you tired or sleepy. You may feel lightheaded or slightly ‘high’. They don’t take the pain away but make it easier to manage. You may not feel the start or the end of the contraction, and the middle won’t be as distressing. This result may be because you are relaxed but also as a result of the pain-relieving action of the drug.
All opiates can affect the baby’s breathing when they are born. The baby may be sleepier and less interested in feeding for two or three days, depending on which drug we used. If we give an opiate within the two hours before the baby’s birth, it may not have had a chance to wear off. This effect increases the risk of a delay in the baby’s breathing. A baby doctor (paediatrician) may be present at your birth in case baby needs any help to get going. If your midwife feels that your birth is imminent, they may recommend that you not use opiates for this reason.
An epidural refers to a pain management technique where local anaesthetic is injected into the epidural space around your spine.
You will be asked to sit up and curl yourself over a pillow while the anaesthetist inserts the epidural. If you are having difficulty with this you may also be able to curl up on your side. While the epidural is being inserted it is important to keep still. You should let the anaesthetists know if you are having a contraction and they will wait for it to pass. It usually takes about 20 minutes to get it in and a further 20 minutes to work. Some epidurals do not work and need to be adjusted or replaced. Some work on one side better than the other. If this is the case there are things that can be done to get it working better for you.
A fine plastic tube will remain in your back so that more anaesthetic can be given as needed. Your pain relief can then be given by a ‘continuous infusion’ or by top-ups. An ideal epidural will be one which is dense enough that you do not feel pain but still lets you move the lower half of your body. You should still be able to tell when your contractions come, but they should no longer be painful. If you have a walking epidural you can continue to mobilise and just have top-ups when you need them.
Keeping you safe
In either case, you will also need a drip in your hand. This way, we can give you fluids and intravenous medicines if required. Low blood pressure can be a side-effect of epidurals and may affect your baby’s heart rate. We recommend that if you are not mobile, you permit insertion of a catheter into your bladder via your urethra. As you are not mobile, you will not be able to visit the toilet. The ability to feel when your bladder needs emptying is one of the first things that gets numbed when we site an epidural. We also recommend compression stockings reduce the risk of blood clots. Your baby’s heartbeat will need continuous monitoring. Other than potentially restricting your movement (and thereby baby’s movement), epidurals generally do not affect your baby.
Epidurals aim to relieve the pain of labour, not take away your ability to move. The epidural may make it more challenging to push and may also slow down the second stage of labour slightly. You are more likely to need help with the delivery with forceps or ventouse (52).
We will stop the epidural shortly after your baby is born. However, heavy legs and numbness can last for a few more hours.
A spinal anaesthetic is administered in a similar way to an epidural, with all the monitors and associated interventions. However, a spinal will make you utterly numb below the waist. If you aren’t completely numb, then its probably not working correctly. Most caesarean sections are performed with this anaesthesia alone. Due to their effectiveness, they are not usually given for labour, but for procedures in the operating theatre.
The other difference is that when a spinal is given, it is a once-off shot of anaesthesia, after which the needle is removed. Nothing is left in your back as it would be with an epidural.
Dr Janelle McAlpine (PhD), Clinical Midwife
Photo by Tyler Olson, used under license from Shutterstock.com