It can be very exciting to think about having a baby, but for some, especially if it’s their first time delivering, it can cause a lot of anxiety.
You might have a lot of questions surrounding the actual delivery of a baby such as, "Will it hurt?", "Can I get an epidural?", "When can I NOT get an epidural?", "What are pain management options if I don’t want an epidural?", and "Will pain management harm my baby?"
There are a lot of questions because there isn’t a singular answer or one-size fits all solution. Labor pain is dynamic, unpredictable, and individual to each person.
As Catherine Tsai, MD, Devon Smith, MD, and Mark Rollins, MD, PhD share in their YouTube video on labor pin management, “Factors of labor pain include the size and position of the baby, size and shape of the pelvic bones, strength and duration of uterine contractions, and a person’s individual pain tolerance and threshold to discomfort.” They go into detail about the stages of labor, non-pharmacologic pain control options, pharmacologic pain control options, narcotic pain control options, nitrous oxide, epidurals, and more!
It is normal to feel uncertain about the labor and delivery process, but I hope today’s information today gives you a better understanding of your options and what to expect. To discuss the topic of pain control during labor and delivery, I’m joined by Dr. John Patton, anesthesiologist and RAAPM fellow at Cedars Sinai in LA!
In this video, we discuss IV pain meds, epidurals, spinals and other hot topics regarding pain control during labor and delivery. We also discuss health disparities and racism in medicine and their impact on black and brown patients not getting the pain control they need.
One of the first things we discuss is the use of IV pain medications, also referred to parenteral opioids. This includes Fentanyl, Sufentanil, and Remifentanil. These drugs may be given intramuscularly or intravenously. Intravenous pain meds may be the recommended form of pain management when the birther has a medical condition that prevents them from getting an epidural or spinal (ex. low platelets, an infection, abnormal curvature of your spine or other anatomical reasons).
Unfortunately, IV pain medication can provide unreliable analgesia. Although there can be some pain relief during labor, effectiveness varies, and it can sometimes have adverse effects such as nausea and vomiting.
All opioids cross the placenta and may have adverse effects for the fetus or newborn. This may be reflected in loss of variability in the fetal heart rate (FHR), reduction in the FHR baseline, and neonatal respiratory depression at delivery. Drug elimination takes longer in newborns than in adults, so the effects may be prolonged, particularly if administered near the time of delivery. So if you are too close to delivery, these drugs may not be administered. Your physician does not want the baby to be too sleepy when it’s born.
If IV pain medications are being used, you may need a pediatrician and possibly NICU staff on standby in case the drugs have made the baby to sleepy at delivery. We want to make sure the baby is breathing well and all vitals are OK!
If you are someone who cannot have an epidural or spinal anesthesia, you can do an anesthesia consultation sometime before you deliver. This is largely underutilized and it is actually a great way to discuss your pain management options so you’re more prepared going into labor and delivery.
Next, we talk about neuraxial or regional pain management options. The neuraxial approaches are suitable for labor analgesia and operative anesthesia. Regional techniques (eg, epidural, spinal) provide pain relief during labor with minimal maternal and neonatal adverse effects.
There are 2 most common neuraxial techniques for labor and delivery anesthesia. These are the following:
If you are concerned that your decision for pain control will not be honored, consider this...as Dr. Patton says- “We are not there to force an epidural or spinal on you… we’re there to be your coaches. At the end of the day, whatever you want to do from a pain management standpoint, is up to you.”
Neuraxial analgesia does not appear to increase the Cesarean delivery rate and, therefore, should not be withheld for that concern. Consideration can be given to early placement of an epidural catheter that can be used later for women with certain special considerations like those undergoing a trial of labor after cesarean.
At minute 44:00, we discuss nitrous oxide, an anesthetic gas that is used frequently during general anesthesia. It has been used for labor and postpartum laceration repair analgesia for decades, although it has been used more extensively in the United Kingdom and other countries than in the United States for labor pain management.
At minute 33:35 in the discussion, we talk about health disparities and racism in medicine and their impact on patients of color not getting the pain control they need. From public health research, we know that black patients receive epidurals at a far lower rate than white patients. This stems from hundreds of years of systemic racism that continues to impact the treatment of patients of color, as well as the communication between them and their healthcare providers.
Women of color are also still dying at a higher rate than white women. As a physician, I want to impress upon other medical providers that we have to acknowledge the disparities, our own biases, and put into practice steps to improve the care for our patients of color.
Dr. Patton shares, “We have a lot of work to do. We have to check our personal biases. We have to be trained to be equitable in the way that we treat folks. We have to make sure we don’t assume…go into every situation with an open-mind.”
Information for Mothers from the Society for Obstetric Anesthesia and Perinatology (SOAP)
Labor Pain Management Video
Epidural Information from the American Society of Anesthesiologists
ACOG Bulletin on Obstetric Analgesia and Anesthesia
Shannon M. Clark, MD, MMS is a double board certified ObGyn and Maternal-Fetal Medicine Specialist, and founder of Babies After 35. In her roles as a clinician, educator and researcher at UTMB-Galveston, she focuses on the care of people with maternal and/or fetal complications of pregnancy. Dr. Clark has taken a special interest in pregnancy after the age of 35, which according to age alone, is considered a high-risk pregnancy.
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