What are the Drug options (during labour)

What are the Drug options?

Yes you can go through labour quite successfully without any pain medications. However life doesn’t always turn out how you plan. Having someone explain to you the pros and cons of different medications in between contractions is not really the most ideal of situations. There are non-medicated options such as breathing, meditation and other coping strategies. Today the focus is on the medicated ones.

Hospital Policy on pain relief

The hospitals I have worked with have a policy that they will not offering you pain relief – you need to ask. This is done for many reasons and this is something that should be your choice. In addition, a labouring woman is vulnerable and suggesting that she might want pain relief, may suggest that medical staff don’t think she is coping. We also don’t want to unduly influence someone. Different hospitals may have different policies, just ask during that antenatal period what your hospital policy is.

Nitrous Oxide

This is also known as laughing gas. Dentists sometimes use it too. It is a mixture of nitrogen and oxygen. It has a short term effect and can be quite useful for managing the pain of contractions. It doesn’t influence baby and is safe. However some women find that it makes them feel nauseous.

It works by taking deep breathes of the Nitrous Oxide mixed with normal air. You start the breaths when the contractions are building and continue throughout the contraction. It is often mobile; so whether you are standing, pacing, sitting, or lying down it is useable.

It works for some people and not for others, if people ask for pain relief, this is the first medicated step people will suggest. Many women report that they feel nauseous when they use it – we do have bags – but it isn’t for everyone. There are of course, non-medicated coping strategies and I will write about them in a future post.

Sterile Water Injections

This is a non-medicated version where simultaneous injections of sterile water and injected either side (not into) the spine. They can hurt quite a bit at first – like a nasty ant bite – but this does settle. If you are having a lot of back pain, they can provide one to two hours of magical pain relief for many women. Whether you have back pain or not is often determined by where baby is sitting (for example if baby is posterior – baby spine contracting against your spine). Again, these have the advantage of not being chemical and have no influence on baby - after all it is just water.

Because this is a focus on back pain, if you aren’t having back pain then they won’t help. In addition, it does hurt initially.

Morphine

Morphine is an opiate and a strong pain relief option. It is normally injected into the muscle (often the upper arm). There are pros and cons for this drug too. It can help manage the pain throughout labour and also allow you to rest in between contractions. This is especially useful for those poor women who go into labour during the evening, after being awake all day. In this case, the ability to rest between contractions helps you save your strength for birth. It is also important to remember that people have different pain thresholds and anything that helps you keep your state of mind focused and strong can help.

Before you can consent to a drug, it is important to know both sides of the equation. Morphine does suppress the respiratory system (slows you breathing). This is fine for an adult (and helps you rest). However as morphine does cross the placenta, there is an effect on baby. Before birth this isn’t as important – let’s face it, baby isn’t breathing in there. If there is still morphine in the babies system at birth, you may notice a paediatrician and people taking special care of the neonatal equipment in case we have to support baby’s breathing.

As a general rule, we don’t like to give a dose of morphine within two hours of birth. The difficulty with that is that we don’t know exactly how long it will take until you birth. On top of that, the effect (on you and baby) will vary with dose, body size and metabolism. This is something you need to discuss with your medical professional about your unique situation.

Epidurals

Oh Hollywood, what have you done! This seems to be the first thing so many women ask for – yet they don’t really know what there is or the alternatives. This is our last resort pain relief. An anaesthetist injects a fluid into the area surrounding your spinal cord. Spinal Epidurals can be patient controlled (allows you a button to top up dose once every ten minutes), automatic (machine controlled) or commonly they have a mixture of both.

They work by blocking the pain receptors and they will get a piece of ice and test at which point on your body you can (or can’t) feel temperature changes. You may still feel some pressure, but the pain shouldn’t be there.

The potential list of side effects or things that can go wrong is quite extensive. While potential permanent paralysis is a rare occurrence, it is one you need to be aware of. They may also not work or not work properly. I’m not going to focus on all of the nasty things that can go wrong – your anaesthetist will go through those with you. I am going to focus on how they can influence your labour.

Recently I worked with a woman who had an epidural work only on one side of her body. An epidural will also mean that a urinary catheter needs to be insert, you will have decreased maternal ability to assist in pushing. You will also be unable to move from the bed. I believe statistically there isn’t a higher increase in caesareans with epidural pain relief however for first time mothers this may not be the case (I have the studies saved to my hard drive but I can find the links for people if you’re interested – just message me or comment below). In my (limited) experience, I’ve witnessed one incident of an epidural that did not ultimately result in caesarean. In that case the baby was birthed with assistance from forceps.

I do believe in providing a balance or pros and cons and so here they are for epidurals. They do take away most of the pain. This is really the main goal and it works quite effectively. If you are exhausted, pain doesn’t improve your frame of mind. In controlling the pain many women report they feel they are better able to cope with the trials of labour.

Overall

My experience is that the longer you can hold off on pain relief the better. My focus with women is always to keep the mind strong and focus on the positives. There is nothing wrong with pain relief but you do need to know what your options are. This whole birth and labour experience is supposed to be about you (not the midwives and doctors). Our role is to empower you throughout the process, not facilitate, control, dictate, judge or otherwise negatively impact you or your birth experience.

Most importantly I would like to stress that whatever pain relief you have, it won’t make your child any less wonderful. Just because the woman in the room next door gave birth to an 18 pound baby, no drugs, natural birth (that was the woman in the room next to me when I had my daughter), doesn’t mean that you shouldn’t have any drugs (she was 6”5’ and this was her fifth child).

I know my blog is still in its infancy stage but I always welcome feedback and comments! If there is a topic you’d like to know more about then let me know and I can try to prioritise it.

Modesty in Childbirth

So, those who know me know I am a student midwife (in addition to being a writer). As I am a student, answering these questions should be taken in the context of my learning as a student and not in place of contrary medical advice.

OMG.. but people are all going to be looking at my...

Well yes and no... That is kind of how babies come out. But there isn’t actually anyone taking notes or comparing your body with anyone else. Even though naked women giving birth is a daily phenomenon for medical staff, it isn’t for you. Answering the door in your pyjamas is something only some of us do – but even I am yet to answer it naked, while contracting, in pain and then invite people in.

Society has done a disservice to women, there is a shame about your body, a sea of constant flaw-finding and comparisons. Every bump, lump or freckle could be construed as an imperfection. Talking about sex is difficult and awkward for many people. Yet, when it comes to birth, people have an expectation that years of hushed whispering will magically evaporate now that there is a child involved.

It isn’t surprising that I have thus met a few women who have confided that they want a c-section due to modesty factors. So here is a little bit of a comparison from a modesty perspective caesarean versus vaginal birth.

Those words are a little off-putting aren't they? I remember secretly cringing when I was pregnant and people kept saying such words to me. After a couple of years of study, I can say such words as 'vagina' and 'penis' without giggling - most of the time! I can drop them into the dinner conversation; and have become oblivious to cringing looks my guests have while I discuss how much a placenta looks like the steak they are eating.

There are a lot of medical reasons to favour a vaginal birth. I'm not going to talk about those. I am going to talk about the emotional insecurities that tend to have us secretly favour the idea of anything that preserves modesty. Here is the harsh truth. You cannot really preserve your modesty through either method.

I'm sorry. This may be a reason for you to avoid getting pregnant, but if you are already growing a little life inside of you, mentally being prepared will serve you much better than false illusions.

Vaginal Birth

Say it out loud. It is just a word, don't be afraid of it. Vagina vagina vagina! See, the world hasn't stopped turning and the hell hasn't frozen over. Whether you had a conservative or more liberal upbringing, this is the time to become comfortable with you, your body and talking about it.

Many women come in to birth suite with a 'birth plan' and a lot of clothes on. As labour progresses, I often find that both of these are cast off and discarded in favour of anything that will make them more comfortable.

Points to remember:
No one should be in your birth suite without your consent. This includes partners, mothers, students or other staff. If you don't want someone there, then say so.

No one should touch or examine you without your consent. Consent doesn't need to be verbal, if I ask to take your blood pressure and you hold your arm out; that is called implied consent.

If someone says 'we have to do xxx'; that is not correct. You have a right to informed consent, if you don't consent it doesn't happen. Be informed and/or have someone that can help you discern the difference between medically necessary and scare tactics.

Awkward Moments:
So, you've come into birth suite, you seem to be contracting, they hurt, you've never done this before and people keep talking at you and not to you. Then someone says, "I'd like to examine you". "Right" you think, “they are going to put their hands on my belly and work out a few things". This is called palping. We do it to work out where baby is, is the head up or down, where is the spine and how far into the pelvis baby is. Pretty magical really. This is used to help us work out where to find the heartbeat and which way the baby will turn when it comes out. This is not the awkward part.

At some stage someone may ask to do an internal examination. You may have had one of these in an antenatal visit as your maybe date approached, you probably said yes, didn't ask too many questions and stared at the ceiling trying not to make eye contact. This time, the stakes are higher. You're contracting, in pain and now people want to put another glove on and insert two fingers into your vagina. This examination tends to last a little longer than antenatal ones and you may be asked if they can stay in during your next contraction. This one tends to have more of an audience too; you may have your partner there, a midwife, a student, perhaps a doctor and of course, any of your friends/family who are present.

An initial examination when you first present is often a good idea as it creates a baseline so we can assess whether or not any changes have happened later on. For example, in one case, this early examination allowed me to determine that the head was de-flexed (baby didn't have its chin down) and subsequent examinations then showed that the baby was gradually extending its head (chin away from chest) which is not what you want during birth. My advice would be to look at the ceiling and try to relax. Many hospitals have a policy of repeating these examinations every four hours to check for progress. Progress isn’t just in the form of cervix dilatation, it also includes position, length and thinning of the cervix. It isn’t all about you either, these examinations can also tell us where baby is sitting, which part of the baby or their head is presenting, positioning, membranes etc. Of course, this is something that should happen with consent and it should be presented as such.

When it is getting closer to birth, the midwives and medical staff may have quick look (to see if head is visible during contractions). They may also ask to do an internal examination, but often at this point we are looking for signs of pushing – this often doesn’t require touching you and isn’t too invasive.

This whole viewing aspect may be paralysing to think about while you are pregnant, by this stage of labour you would sell tickets to the show if it meant that baby would arrive faster. The contractions will be intense and most women start to zone out during this phase and you won't notice or care when it comes to it. Accept this as a fear and that there are other things you will be focused on.

At the end of the day, your midwives and medical staff have seen enough babies being born that no one is thinking twice about the intimacy of your privates. While there may be medical reasons to avoid a vaginal birth, please don't let your personal worries be the reason to avoid it.

Birthing position
Hollywood has been disastrous for setting women up with expectations of births. Let’s face it, without the drama it just wouldn’t sell. It involves a lot of screaming, often for an epidural and you’ll almost always see a woman lying on a bed, possibly with her feet up in stirrups.

Dear Women of the world, please stop fighting Mother Nature. Babies do not come out through your spine, lying on your back is not helping to stop the pain or speed up the process. Gravity will. Birthing standing up, on your knees or squatting is far more natural. It does take a while to get your head around. Water births also have their advantages.

Watch a few births online, or ask your midwife for a video or three. Watch them until you can honestly say you aren’t squinting, looking away from embarrassment or terrified of the process. While I will touch on it in other posts, your mental state will play such a crucial role in the birth.

Caesarean Birth

In my limited experience, occasionally women feel like this might be less physically awkward that a vaginal birth. Again, I am not addressing medical reasons for having a caesarean. To have a caesarean, you will have needle injected into your spine which will hopefully block the feeling from the lower part of your ribcage down. If it doesn't, they will keep playing with doses until it does.
Then they will prepare you for surgery – if they haven't already. A nurse or midwife will shave your pubic region as necessary. You will have a catheter inserted into your urethra so that your urine gets stored in a bag resting between your legs. This will stay in place for up to a day after surgery – depending on when you regain movement or are likely to be able to be up and mobile.
Doctors will cut through the layers of your lower abdomen to get to baby. Hopefully you have a cold at this point so that the smell of burning flesh doesn't put you off. They use a metal scoop to try to get babies head out. The surgeon will end up with their hands inside of your uterus – sounding awkward yet?

Which is better?

At the end of the day, both will hopefully result in a beautiful baby in your arms. Medically there are arguments for both. However both require you recognise that the process of childbirth is the beginning of a selfless adventure where you are no longer the most important person in the room. It is a personal journey for you, your support people and the new little family you are creating. Decisions based on choice, knowledge and information will guide you favourably. Those made out of fear or ignorance may adversely affect your birth experience. The memories of birth will fade over time but you will always remember that first time you looked into your little ones eyes – regardless of how they come out!