Labor Pain-Relief Primer

From epidurals to spinals, what you must know about your medication options during childbirth.
Lucy Schaeffer

Understanding Drug Options

Whether you're determined to have a drug-free delivery or want an epidural the moment you feel a twinge, you should understand your drug choices before heading to the hospital. "After all, you can't tell ahead of time how you'll tolerate labor pain," says Frank Witter, M.D., director of labor and delivery at Johns Hopkins Hospital, in Baltimore.

There are two main categories of pain relief -- regional blocks and opioid analgesics. Regional blocks, such as epidurals, spinals, or combined spinal-epidurals (CSE), are injected into your lower back to deliver pain relief right where you need it: your uterus and vagina. They work by stopping pain impulses from traveling up your spinal cord. Opioid analgesics, such as Demerol, are narcotics that are injected into a muscle or run through an IV into a vein. They dull your senses and decrease your brain's ability to perceive pain throughout your body.

According to the American College of Obstetricians and Gynecologists, regional blocks are preferable because they allow the mother to remain more alert and participate in the labor. (Opioid analgesics can cause sleepiness.) However, some obstetricians and midwives choose opioids because they are easier to administer and do not require the services of an anesthesiologist.

The kind of pain relief you're offered may depend on the hospital and region where you are delivering. Doctors at large teaching hospitals tend to keep abreast of the latest pain-relief options, while doctors in small hospitals may use older techniques. Similarly, in big urban hospitals, teams of anesthesiologists are available 24 hours a day, while in rural facilities, laboring women may have to wait for the on-call anesthesiologist to be summoned from home. In the latter case, "a woman may be given an opioid analgesic to tide her over until the anesthesiologist arrives at the hospital," explains David Birnbach, M.D., chair of the American Society of Anesthesiologists' committee on obstetrical anesthesia. "Once it wears off, he can safely administer a regional block." Use our chart to educate yourself; then discuss your options with your doctor. Once labor starts, however, be ready for anything -- and don't judge your delivery on whether or not you took medication. "The real success," Dr. Witter says, "is delivering a beautiful child."

Natalia gave birth two weeks early to her second baby, Maya, after her water broke unexpectedly. Watch her discuss her positive delivery experience with an epidural.


How It's Given

A catheter is inserted into the space between the sheath surrounding the spinal cord and the vertebrae of the spine, and a continuous infusion of drugs is delivered, numbing the lower body.

What It Does

Relief begins after about 15 minutes. Alleviates pain in the pelvic area to a varying degree, depending on the concentration of anesthetic.

Things to Consider

  • Many hospitals still use more traditional epidurals (those with 0.25 percent or more bupivacaine), which can make it difficult to get out of bed and may prolong labor. Newer, more dilute combinations (known as walking epidurals) are less likely to hamper mobility but increase your risk of breakthrough pain. Ask what is available at your hospital.
  • Small risk of infection at the injection site.

Spinal Analgesia (also called "intrathecal analgesia")

How It's Given

Drugs are delivered directly into the spinal fluid through a needle that's much smaller than those used to insert an epidural catheter.

What It Does

Pain relief to the pelvic area begins immediately. However, the injection lasts only one to two hours and may have to be repeated if labor is prolonged.

Things to Consider

  • Patient is usually able to walk around.
  • A woman may develop an intense itching on her body (most often the face, chest, and arms) for 10 to 20 minutes; it generally goes away on its own.
  • If spinal fluid leaks from the puncture point, you may suffer a severe headache within 24 hours after delivery. This occurs in 1 percent of cases.

Combined Spinal Epidural (CSE)

How It's Given

Drugs are both injected into the spinal fluid and delivered by catheter to the space between the sheath surrounding the spinal cord and the vertebrae.

What It Does

The spinal immediately blocks pain and lasts for an hour or two, while the epidural kicks in after an hour and can provide relief throughout labor.

Things to Consider

  • CSEs are growing in popularity, but because they're still relatively new, they're generally available only in teaching hospitals and state-of-the-art institutions.
  • In almost all cases, a woman can get out of bed and walk around.
  • In almost all cases, a woman can get out of bed and walk around.
  • As with a spinal, a woman may develop intense itching for 10 to 20 minutes.

Opioid Analgesics

How It's Given

A drug is injected into a muscle or run through an IV into a vein. Injected shots must be repeated every hour or so.

What It Does

Takes the edge off pain but does not alleviate it as well as a regional block would. (Still, some women find this method less frightening than a needle in the back).

Things to Consider

  • Can make the mother groggy, sleepy, or nauseated.
  • Because the drugs cross the placenta, they can make the baby groggy, depress her breathing, and delay her ability to latch on after birth.
  • The mother may experience breakthrough pain during contractions.

Copyright © 2002 Alice Lesch Kelly. Reprinted with permission from the September 2002 issue of Parents magazine; 9/02

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