Pain Management
Our philosophy of care supports effective pain management. Our patients are interested in a variety of pain management strategies and our goal for each mother is to ensure that she is comfortable and that she is empowered to use strategies that bests suites her. We support the use of water therapy, the use of mobility and the use of positioning to manage labour pain. We encourage the use of breathing techniques and the use of techniques learned in Hypnobirthing classes for those of our patients who take this class during their pregnancies.
We welcome and will work alongside your chosen support system, your doulas, your friends and family. Please consider your options, discuss them with your care provider and indicate in your birthplan those pain management strategies you intend to use in labour. Communicating with us will help us to partner with you in achieving your birth goals in the fullest possible manner.
Medication Options for Pain Management in Labour
Many women experience significant pain during labour and choose to use pain medication. The decision to have pain medication is a personal one. Your nurse, obstetrician, family doctor, midwife/or anesthesiologists are available to help you with this decision. Occasionally, your doctor will recommend regional anesthesia (epidural or spinal) for medical reasons such as high blood pressure, breech birth or multiple births.
The goal of the entire health care team is to make your labour and birth as comfortable and safe as possible for you and your baby.
Information about comfort measures and pain management is provided in our prenatal classes. You can also sign up for a “Meet the Anesthesiologist” session through the prenatal education registration site.
Intramuscular/Intravenous/Inhaled Pain Relievers
Narcotics are sometimes offered in early labour. Morphine is the most common narcotic for this purpose and may be given intravenously or intramuscularly. If given intramuscularly, pain relief takes effect within 20 to 30 minutes and lasts from two to four hours. Gravol is usually given with together with Morphine to prevent nausea. Sleepiness can be a side-effect for both you and possibly the baby. For this reason, narcotics are usually used in early labour only. The narcotic that is ordered for you is at the discretion of the attending doctor.
Intravenous PCA is often offered to labouring women who are unable or unwilling to receive regional anesthesia. Fentanyl and remifentanil, are the two medications offered at Mount Sinai Hospital. In either case, the patient is offered a pump and self administers the medication according to her needs. Your health-care provider can arrange a consult with the anesthesia department to develop a pain management plan such as PCA, in case you contemplate this alternative form of pain relief.
Nitrous Oxide: A combination of nitrous oxide (laughing gas) and oxygen is self administered by the patient to provide pain relief during labour and delivery. Nitrous oxide assists in reducing pain but it does not eliminate pain. Nitrous oxide is safe and does not make your baby sleepy. Some women may feel slightly dizzy and disoriented. Nitrous oxide is mostly used in the transitional stage of labour, but can also be used while waiting for an epidural if there is a long wait-time.
Regional Anesthesia
Epidurals are the most effective and widely accepted method of pain relief for labour and birth. At Mount Sinai Hospital we administer over 5,000 epidurals each year. A combination of local anesthetic and narcotic is injected into the epidural space to reduce or eliminate pain in the lower body. You will not experience drowsiness as you do with most other methods of pain relief. The epidural allows for ongoing pain relief through labour and birth, and is safe for the baby.
You will be asked to sit up or lie on your side with your knees and head tucked to your chin; this opens the spaces between the bones of the spines (vertebrae) to allow the anesthesiologist to insert the catheter more easily. Your lower back is washed with an antiseptic solution. The anesthesiologist injects a small amount of freezing into the skin over the lower back. This freezing stings for a second or two. Some women will experience a feeling of pressure while the anesthesiologist carefully advances the needle and identifies the epidural space. The nurse will remind you to stay very still at this time. Tell her if you feel a contraction starting. A tiny plastic catheter is inserted through the epidural needle. Once in place, the needle is removed and the catheter is taped to your back. You may feel a sudden tingling down one leg if the catheter brushes against a nerve. This feeling is very brief and does not cause any harm. After the catheter is taped in place, medication used for pain relief is injected through the catheter. The nurse will stay with you for approximately the next half-hour to monitor your blood pressure, the baby’s heart beat and to monitor your pain relief.
Epidural medication is delivered through a continuous infusion which involves the epidural catheter being connected to a pump that delivers the medication continuously at a set rate. You will be given a button to push when you feel pain, but if this pain continues you should inform your nurse. The pump rate may be adjusted or additional medication given.
On average it takes approximately 10 to 15 minutes to perform an epidural. However, this may vary among patients. You usually feel two or three more contractions before the pain begins to ease. It takes about 15 to 20 minutes for the epidural to become fully effective. If you are not comfortable by this time, more medication will be given. On rare occasions, the epidural procedure may need to be repeated if the pain relief is not sufficient.
Significant pain relief should occur once the epidural is in full effect. You may still experience tightening or pressure sensation as you reach full dilation. Your legs often feel warm and tingly and may be numb or weak, particularly if additional doses of local anesthetic have been given.
An epidural can last as long as it is needed. The initial dose gives pain relief for about two hours. A continuous infusion of local anesthetic and narcotic is started after the initial epidural dose is administered. Your comfort and progress in labour are assessed frequently and medication is adjusted accordingly. Once the baby is born, the infusion pump is stopped and the epidural catheter will be removed before being transported to the Mother & Baby Unit.
The epidural or spinal medications that are administered to you in labour or during a caesarean section, typically a combination of local anesthetic and narcotics, are safe for you and your baby.
It is advised to wait until labour is well established and contractions are regular and uncomfortable. There is no set time or degree of cervical dilation that must be reached before you can have an epidural. You may request the epidural when you feel the need for pain relief. Your nurse, obstetrician, family doctor, midwife and/or anesthesiologist can help you with this decision.
Epidurals have not been shown to significantly affect the rate of progress of labour.
Although many women are fearful of backaches, studies do not show any increase in long term back pain or back problems after an epidural. There may be some soreness or bruising at the needle site for several days after birth. Pregnancy and childbirth may cause backache due to the stretching of pelvic ligaments and changes in posture, whether or not an epidural was given.
The most common complications are minor and easily treated. A drop in blood pressure may occur. Your nurse will check your blood pressure frequently after you first receive the medication. Direct pressure from the uterus on the blood vessels can also drop your blood pressure. It is very important to lie on your side and not flat on your back. If necessary, the anesthesiologist has medication to reverse the effect on blood pressure.
Shivering is a very common reaction during labour and birth, even if you did not receive an epidural. Itching may also occur. Difficulty in emptying your bladder may occur. If you are unable to urinate, a catheter may have to be inserted intermittently to empty the bladder. Having a labour epidural does not mandate a continuous bladder catheter.
An accidental spinal tap can result in a spinal headache one to two days later. This is caused by a leakage of spinal fluid. This occurs once in one to two hundred epidurals. Treatment includes rest, fluids and pain medications. This headache may last one to two weeks. If the headache is disabling, there is a special treatment called a blood patch your anesthesiologist will discuss with you.
A test dose is given to check for correct placement of the catheter. Rarely, accidental injection of medication into a vein can occur. This can cause temporary effects such as ringing in the ears, dizziness, metallic taste or blurring of vision. Seizures occur very rarely and only with larger doses.
Many patients are concerned about the risks of nerve damage or paralysis. These are extremely rare and usually a result of an infection or bleeding in the spine. If you are at risk, your anesthesiologist will not do the procedure.
A patchy block or a high block is also very rare. A patchy block will provide inadequate pain relief and a high block may cause numbness in the arms and heaviness in the chest with breathing difficulties. This can be treated quickly and effectively by the anesthesiologist. Heavy numbness in the legs may prevent you from pushing effectively and your doctor or nurse may have to assist you.
Mount Sinai Hospital has a remarkable obstetrical anesthesia patient safety record. There has never been a serious complication such as major nerve damage or paralysis resulting from the administration of a regional anesthetic for labour.
The CSE is a variation of the epidural where a low-dose spinal is done through the epidural needle. It combines the best features of both the epidural and the spinal techniques. It has the advantage of providing very effective and fast pain relief. It is most commonly indicated in patients in advanced labour or in whom there is an indication for fast onset of pain-relief. Sometimes, this is referred to as a “walking epidural”. It is usually up to the anesthesiologist to decide if you are a candidate for this type of epidural. It is common after a CSE for the baby’s heart rate to slow down temporarily. Your health-care provider will monitor you and your baby closely.
The anesthesiologist will top-up an existing epidural for caesarean births. If you do not have an epidural in place then a spinal anesthetic will be administered in the operating room. The spinal anesthetic is a single injection of medication into the spinal space. It is a combination of local anesthetic and pain medications. The risks and benefits are the same as epidural anesthesia. In some rare cases, a general anesthetic may be administered.
