Pain relief

Your body usually reacts naturally to the pains of delivery by making painkillers (endorphins). Fear or tension hinders the production of endorphins. This is why it is important to be as relaxed and comfortable as possible during your delivery.

If you want to use painkillers, you can choose between methods that include medication and ones without medication.

Morphine-like medication

Pethidine is a medicine that can be given in every hospital at every moment. Sometimes another medicine with a similar effect is used: Nubain. Usage of this medication can cause side effects, therefore you always need to be taken in. The one who helps you with your delivery – us/ your own midwife or someone from the hospital – differs per hospital.

Pethidine is administered via an injection in the buttocks or upper leg. You will start to feel the effects within 15 minutes: the worst pain will decrease, allowing you to relax in between contractions. Some women doze off or even fall asleep. The medicine works for 2 to 4 hours. Pethidine is only given during the dilation phase. Sometimes it is combined with a sleeping pill such as Phenergan or Normison.

Advantages of Pethidine

Pethidine has a strong pain-killing effect. You will be able to rest and control the pain better. This speeds up the dilation process.

Disadvantages of Pethidine

For the mother

An injection of pethidine works for 2 to 4 hours. Sometimes this is too short and you may get a new injection. Sometimes you may experience nausea, headaches or dizziness. Pethidine makes you sleepy and distant; this means that some women are not very conscious about the delivery. Consequently, they may feel like they have ‘lost’ parts of the process.

Pethidine is only administered in the hospital. Once you’ve had your injection you’re not allowed to walk around freely anymore. Almost all pregnant women can get Pethidine, however sometimes it isn’t wise when you’re asthmatic or if you are on certain types of medication.

For the child

Pethidine penetrates the placenta and therefore also reaches the child. This causes him or her to become sleepier and more calm in the uterus. This can be seen on a heart sound recording (cardiotocograph or CTG): the heartbeats will become less variable. If the midwife or doctor has any doubts about the child’s condition then it can be a reason to decide not to administer Pethidine. Pethidine can also halt the child’s breathing causing him or her to have trouble breathing or to be sleepy after delivery. To prevent this, you may receive an injection of the antidote (naloxon) before the birth. This can also be administered to the baby after delivery.

The advantages and disadvantages

•   Easy method as a painkiller that can be administered at each moment at every hospital, causing the pain to become bearable.

•   A soothing effect.

•   Short period of effect.

•   Walking around is no longer possible and you have to stay in bed.

•   Sometimes side effects occur, the combination with other medication may be unfavourable.

•   The child’s heartbeat can become less variable, making the CTG harder to evaluate.

•   Sometimes your child may be sleepy and drowsy after the delivery or they may experience trouble breathing. Another medicine can minimalise this effect.

An epidural

There are two kinds of epidurals: a painkiller and a sedative. Usually you are given the painkiller during delivery. During a C-section you’re usually given a sedative.

What is an epidural as a painkiller?

An anesthetic is administered by an anesthesiologist through a catheter in the space between the vertebrae: the epidural space. This is where the nerves are located that transfer pain stimuli from the uterus and pelvis. If these nerves are shut down, then you won’t feel the pain from the contractions anymore.

Aside from pain nerves, this space also contains nerves that control the muscles in the lower body. It may therefore be possible that the muscle power in your legs can decrease temporarily after an epidural. Furthermore you’ll have less feeling in your legs and abdomen.

How is it administered?

You’re given extra liquids through an infusion. This is because your blood pressure should not become too low. Your puls and blood pressure are checked regularly, sometimes with the help of automatic safeguarding machines. The baby’s heartbeat is checked via an CTG (cardiotocograph).

Who gives the epidural?

An epidural is given by an anesthesiologist. In some hospitals this is done in the delivery room, in others it is administered in the operating room.

The anesthesiologist administers the epidural while you’re lying on your side or leaning forward. You have to round your back as much as possible while keeping very still; this makes it easier to find the space between vertebrae. The skin is cleaned and anesthetized with a thin needle. Then the doctor places a catheter through another needle in between the vertebrae and into the epidural space. This causes a temporary shut-down of the nerves. This is a short process and doesn’t hurt due to the anesthetic.

After the epidural: You can move again once the catheter is in place. Often the catheter is attached to a pump, thereby providing a regular dosis of anesthetic. It takes about 5 to 15 minutes on average until you start to feel the effect.

Further check-ups: Your blood pressure, pulse and urine production are checked during the rest of the delivery. Sometimes the check-ups also include the oxygen levels in your blood and check if the painkillers are sufficient. The condition of your child is also closely watched.

What is the effect of an epidural? It is possible that you don’t feel any pain at all during the dilation or pushing phase. Sometimes your legs can become flaccid or you get a tingly feeling in your stomach and/ or legs. These effects disappear once the medicine has stopped working.

Approximately 5% of women experience insufficient results from the epidural. Then the catheter must be checked for proper placement and if the anesthetic is strong enough. Sometimes it is necessary to do another injection.

The anesthesiologist always looks for a balance in the dosis: the pain must be bearable while the effects are minimalised. Therefore you may still experience some pain or pressure during the climax of the contraction. The epidural gives you rest and allows you to gather your strengths; the dilation process can go faster by decreasing the pain and fear.

What happens during the rest of the labour process with an epidural?

The dosis of medicine given is decreased by the time you’re fully dilated. This is done so that you can feel the contractions that are necessary to push. Sometimes it take a while until the natural need to push comes back. Help may be needed in the form of a vacuum, tongs or C-section. It is possible to use the epidural catheter should a C-section be necessary. However the anesthesiologist may choose another painkiller: spinal anesthetic or a full anesthetic.

Can an epidural always be given?

The possibilities for an epidural depend on the hospital. It depends on the size and equipment in the center and on local agreements with the anesthesiologist. Ask your gynaecologist or midwife about the possibilities.

An epidural may be undesirable in certain situations, such as disturbances in blood clots, during infections, during some neurological diseases and with disorders or previous operations on the spinal chord.

Side effects and possible complications of an epidural

Decrease in blood pressure: The anesthetic causes the veins in the lower body to widen, thereby lowering the blood pressure. To prevent this from happening you are given additional liquids via a drip before the catheter is administered. A low blood pressure can cause you to feel unwell or dizzy; by laying down on your side you can minimalise this and prevent further decrease in blood pressure.

The lower blood pressure can also affect the baby’s heartbeat. This becomes evident on the heart monitor (CTG).

Bladder function: It is difficult to feel whether your bladder is full due to the anesthetic in the lower body. Urinating may be difficult as well. The people who will help you during your labour therefore constantly check if your bladder is not too full. Usually you are given a bladder catheter just to be sure.

You can have a slight itch as a reaction to the anesthetic. This rarely causes for treatment.

Shaking: You may start shaking while you’re not feeling cold after the epidural is administered. This is harmless and usually lasts for a very short moment. The shaking is caused by changes in your feeling of temperature.

Complications

Headache: In 1% of women with an epidural, the space around the spinal chord can be touched by accident. The result is a headache which only surfaces the next day. It is an annoying yet harmless complication. Usually it is helped by simple measures such as rest, medication and lots of water. The anesthesiologist will look for another solution should the headache remain.

Other complications: The chance that large amounts of anesthetics will find their way into the bloodstream or brain are extremely slim. Should this happen, breathing becomes more difficult; you can be treated for this. This is why you’re thoroughly examined during and after the epidural is administered.

Back pains: 5-30% of women experience back pains during the pregnancy. Back pains after a delivery with an epidural are not directly caused by the epidural catheter, but are more likely due to the unusual posture during the delivery and pulling forces on the nerves, pelvis and spine. The catheter can however give a bruise on the spot where it was administered.

The advantages and disadvantages of an epidural

– The most effective painkiller during a delivery. In general it can be administered continuously, during dilation as well as pushing. Sometimes the dosis is decreased or stopped during pushing to enhance your active pushing motions. Therefore it is possible that you may experience some pain during pushing.

– Both you and your child must be well guarded. You are put on a drip, given a blood pressure band, a catheter in the back which is also usually attached to a drip, CTG scanning via an electrode on your child’s head, a pressure catheter in the uterus to monitor the contractions and sometimes a bladder catheter.

– The chances of severe complications are very slim. Sometimes harmless side effects can show: lower blood pressure, headache, limp feeling in your legs, itchiness and a decreased bladder function. These complaints are temporary easily treated.

– You are not able to walk around before the delivery and you must stay in bed.

– 5% of women experience the anesthetic as an insufficient method to decrease the pain.