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Preparing For Labor

Pain Management

Pain Management (med's, unmedicated and questions to ask.
 
This thread should tackle all your pain med questions. If it doesn't feel free and ask for clarification or extra resources.

This is a simple breakdown of the logistics, risks and benefits of common labor drugs. The specifics come from the book they gave at my hospital birth class called, "Prepared Childbirth: The Family Way" by Amis and Green. The commentary is from me based on what I have read in books as well as from moms on the boards and irl.

Analgesics/ Narcotics
Demerol, Stadol, Nubain
*Administered through injection or I.V. (though some are now being administered through the epidural catheter).
*The effects last about 3 hours.
*Given to "take the edge off"; takes away the perception of the pain but not the actual pain.
*Usually admistered prior to epidural though some women use these drugs independently of the epidural.

Side Effects/ Risks to Mom:
Drowsiness
Disorientation
More difficulty maintaining control over the contractions
Hypotension (drop in blood pressure)
Nausea/ vomitting
Dry mouth
Dizziness
Respiratory Depression

Many moms who use these drugs say that it made them feel "drunk." Not a pleasant feeling. Some report that these drugs allowed them to get a bit of rest. A majority of women don’t like the way these drugs make them feel.

Side Effects/ Risks to Baby:
Respiratory depression (baby not able to breath)
Decreased sucking ability
Same physical effects that mom experiences- groggy, sleepy
***These effects are most pronounced if given too close to delivery (less than 3 hours)

There are drugs available to help baby breath at birth. These drugs may interfere with your efforts to breastfeed as baby's sucking ability is not as good and baby may be sleepy.

Side Effects/ Risks to Labor:
Can slow down labor

Relaxation in labor is a good thing but these drugs may relax mom too much.
---------------------------------------------------------------------- ------------------------------------
Epidural
*Administered through a catheter that has been placed in the epidural space. The drug is injected intermittently throughout labor.
*Proceedure begins with a shot of Lydocaine at the site where the epidural is to be placed. This has been described as feeling like a bee sting. This drug should numb the mom for the duration of the proceedure.
* At least one pint of I.V. fluids should be administered before the epidural is received because mom's blood pressure may drop if this isn't done.
*The epidural may provide complete or partial relief.
*It takes about 15 minutes to be fully effective. It also takes about 30 minutes to administer.
*Numbs your legs and lower half of the body.
*A catheter may be used to help empty your bladder.

Some women describe the sensation of totally numb legs as unnerving. There are times when several attempts need to be made in order to get the medicine to work (sometimes it only takes on one side or doesn't provide adequate relief). Some epidurals take too much and cause numbness up to the neck. . A properly placed epidural should work as expected though.

An improperly timed epidural can also cause a few problems. Given too soon (before 4-5 cm) then it is more likely to slow down or stall out labor. This increases the need for further interventions (like pitocin). Some studies support the idea that an epidural given prior to 5 cm can triple the risk of a c-section. A newer study says that may not be the case BUT the study has faults and is for *lite* (walking) epidurals...big difference. Given too late and it may not be effective in time.

Side Effects/ Risks to Mom:
Hypotension
Incomplete coverage
Itching
Fever
Chills
Rare- spinal headache, pain at site of injection, difficulty breathing or seizures

Unlike the other drugs the epidural should allow mom to remain awake and alert.

Side Effects/ Risks to Baby:
Hypotension in mom can cause baby's heartrate to fall
Hypotonia (decreased muscle tone)
Subtle behavioral alterations

Some moms say that their baby was not alert after the birth when an epidural was involved. Some have more difficulty with breastfeeding.

Side Effects/ Risks to Labor:
Can slow down or stop labor; pitocin may be needed
Continuous monitoring is necessary (this method of monitoring has been shown to cause a higher false positive rate indicating fetal distress so some unnecessary c-sections may be performed)
Can diminish urge to push thus necessitating forceps or vacuum
Can impair normal descent and rotation of baby

Epidurals often come with other interventions. Some of them could negatively affect your birth and increase your risk of a c-section or assisted delivery. Pitocin can cause contractions that are too strong for baby and may increase their risk of distress. Laboring in bed makes it difficult for baby to descend into the pelvis correctly. Pushing is more difficult if mom has no sensation. This can lead to a prolonged pushing stage.


Pain Meds:
http://childbirth.org/articles/labor/painrelief.html
http://www.birthcenters.org/faqchildbearing/pain.shtml
http://www.americanpregnancy.org/labornbirth/narcotics.html

Walking Epidural
http://pregnancy.about.com/library/weekly/aa090897.htm
http://www.childbirth.org/articles/walkingepi.html

Intrathecal/ Spinal
http://www.parentspl.....38;arrival_freqCap=1&pba=adid=6529955


Epidurals- Risks and Benefits:
http://www.kimjames.net/epidural_risks_and_side_effects.htm
http://www.parentsplace.com/expert/midwife/articles/0,,239756_114928,00.html
http://www.parentspl.....fe/articles/0,10335,239756_114928,00.html
http://www.americanpregnancy.org/labornbirth/epidural.html


Walking epidurals are lighter versions of the traditional epidural. There is still a catheter in place so more meds can be added. It should leave you with more feeling and sensation. This is usually a positive thing because if you retain some control of your legs then you have the ability to labor and deliver in vastly better positions than if the lower half of your body is numb. It should take away the pain but you may still have pressure.

Odds are you won't be walking with it due to liability concerns. Epidurals can lower your blood pressure which can make you dizzy. That increases the chances of falling. You may not have enough feeling to walk unassisted. But, if you have good support, especially an attentive nurse, you should be able to take short walks to the bathroom or around the room. A walking epidural can minimize the odds of getting a urinary catheter because you should be able to feel when you need to pee. You may also be able to get to the bathroom when the urge comes. Urinary catheters shouldn't be painful at insertion if you are numb but they can be uncomfortable. Also, they increase the risk of an infection and can make urination more painful in the days after the birth.

I would go with a walking epidural if I were going for pain meds.
 
Questions to ask before you are in labor, or at least before you get pain meds.

-What kind of narcotics do you have standing orders for? Demerol? Stadol? Nubain? Fentanyl? What is the standard dose? Can I request a smaller dose or another drug? Why do you like this drug over the other ones?
**This is a great link that actually describes the differences between the different drugs. Some moms have more nausea, disorientation and dizziness with some vs others so it is important to educate yourself now:
http://www.americanpregnancy.org/labornbirth/narcotics.html

-At what point in labor can I have narcotics? (Usually you can get them earlier than an epidural). After a certain point will I be able to get a narcotic? (Some can affect baby's ability to breath so if you are close to delivery they may not be willing to administer one of the drugs).

-What other interventions come with an IV drug? Continuous monitoring? IV fluids? Restrictions on movement? Restrictions on eating and drinking? Is pitocin a likely intervention (if labor stalls or slows as a result of the meds this could be a possibility)?


-Can I request *not* to have narcotics and go straight for an epidural? (Some Dr.s like to see if they can help you without the epidural so they will always recommend the narcotics first. But because some moms really feel miserable and out of it from these drugs it might be best to actually skip to something that will take the pain away not just take away your perception of it).

-What is the "window" for an epidural? Do I have to wait till I am 4-5cm and in active labor? (Some studies have found that if given prior to active labor or before 4-5cm the risk of a c-section goes up dramatically as a result of possible other interventions and maternal fever). Is there a point where I won't be able to get an epidural? (every practice is different so don't assume anything from the birth of friends or family! Some moms get epidurals at 9-10cm while others are told "no" at 8cm).

-Will I have access to the newer anesthesia options like the CSE or "walking epidural"? (The walking epidural has quite a few benefits over the coventional epidural so it would be the way to go! It is a lighter dose of the standard epidural so it should be available).

-What interventions are common with an epidural? (see above for a list of possibilities)

-How might an epidural affect my ability to push? Will the meds be turned down or off so that I can push more effectively? Am I doomed to pushing on my back with legs in stirrups if I chose an epidural or will you help me push in more biogically sound positions that can help speed up this phase as well as minimize damage to my perieneum? Am I more likely to have forceps or vacuum extraction if I chose an epidural?

-What percentage of your patients recieve some form of pain medication?

-What non drug options do you encourage your patients to try first or for the whole labor? Walking? Water? Position change? Minimizing medically unnecessary interventions (like breaking the water, non medically necessary inductions or augmentations, continuous monitoring...)? Do you support a mom who wants to have an unmedicated birth?

-What are the risks and benefits to pain meds?

-Are there any reasons why I would not be able to recieve either IV pain meds or an epidural? What are they?

*************************************************
Standard Questions to ask about all interventions and pain meds:
1) Is this an emergency or do we have time to talk?
2) What are the benefits of doing this?
3) What are the risks of doing this?
4) If we do this, what other procedures or treatments might we need as a result?
5) What else can we try first or instead?
6) What would happen if we waited before doing this?
7) What would happen if we didn’t do this at all?
I wrote up an epidural poll and an IV pain meds poll. This is their content as well as the links you can follow to hear what real moms have to say about their experiences with those pain meds.

Epidural Poll:
http://bbs.babycenter.com/board/pregnancy/childbirth/1818/thread/2484638

The actual epidural process and experience:

-What kind of eidural did you get- traditional, CSE, epi lite, (and not an epidural but used) a spinal/ intrathecal? (If you don't know then you probably got the traditional one)

-When did you recieve your epidural in labor?

-Did you have any other pain meds (stadol, nubain, fentanyl...)? When did you recieve those?

-Did you have an IV? Where did they put it and did it hurt? How many tries did it take?

-From when you requested the epidural till you had it in place and working- how long had passed? If you had to wait a while, why?

-What did the epidural process feel like? What did they do? How long did it take?

-Did the epidural hurt going in?

-How long did it take to work?

-Did it give you 100% coverage or were you one of the 15% that has "hot spots?"

-If you had hot spots, were they able tofix them?

-Did your epidural take too much- numb you too far?

-DId it take in time before you had to deliver?

-What was the worst part of the epidural process?

-What was the best part?

-Are you glad that you recieved an epidural?


Let's here about how it affected mom and, maybe, baby:

-Mom, did you have any of the following:
Chills
Drop in blood pressure
Itching
Nausea/ Vomitting
Fever
Pain at site
Spinal Headache
Any other complication

-Baby:
Malpresentation (come out at a difficult angle)
Fetal distress
Drowsiness at birth (note: if you had IV pain meds, they are a much more likely culprit)
Poor muscle strength and tone at birth


And since it is important to know the side effects of an epidural (mainly from other interventions), I want to know if you had any of the following:

-Continuous Fetal Monitoring (Internal or external)

-Continuous blood pressure monitoring

-Pitocin

-AROM (breaking the water)

-Lack of mobility

-Urinary Catheter (if so, when was it inserted in labor? before or after the epidural was complete? when did they take it out? did it hurt?)

-Assisted delivery with vacuum or forceps

-Episiotomy (if so, why? fetal distress, just to move things along, or some other reason)

-Pushing stage of 3+ hours

-C-section ********************************************
IV Pain med poll
http://bbs.babycenter.com/board/pregnancy/childbirth/1818/thread/2484642

Not all IV pain meds are created equal. Stadol, Nubain, Demerol, Fentanyl, Morphine...these are the most common drugs used in labor. Some will have more negative side effects than others. What was/ were your experience(s) with them?

Most moms I have discussed these meds with IRL or on the boards tend to describe this scenario...

They didn't really take the pain away. I could sleep between the contractions. I would wake up mid contraction then go back to sleep.

Some moms say that they were enough to take the edge off. Just perfect.

Others say they weren't worth it.

***Please read whole poll before replying***

Which experience did you have?

-Did they take the edge off with no negative side effects?

-Did they take the edge off with some negative side effects?

-Were the side effects not worth the relief that the meds offered?

I'm getting a bit ahead of myself.

-What drug did you recieve?

-Did they give you a full dose, a partial dose (like a half or quarter), or you don't know?

-When did you recieve it? How far along was your labor?

-Did you progress quickly after recieving it?

-Did you also recieve an epidural or spinal?

-If you did recieve an epidural or spinal, how does the IV drug compare? In hindsight would you have preferred just skipping to the epidural or spinal? Or did you recieve both at the right point in your labor?

-Did you recieve more than one dose of the IV med? Was it the same drug both times?


There are negative side effects, risks, to the IV pain meds. Answer yes or no to the following for mom and baby:

Mom, did you have any of the following:
-Drowsiness
-Disorientation
-More difficulty maintaining control over the contractions
-Hypotension (drop in blood pressure)
-Nausea/ vomitting
-Dry mouth
-Dizziness
-Respiratory Depression
-Hallucinating

Baby:
-Respiratory depression (baby not able to breath, especially if given close to delivery))
-Decreased sucking ability or impaired breastfeeding
-Same physical effects that mom experiences- groggy, sleepy (These effects are most pronounced if given too close to delivery (less than 3 hours)
-Difficulty maintaing body temperature
-Alteretd neurological behavior

Overall, how do you feel about IV pain meds for labor? Will you use them again for future births?

Any other thougts, comments...please share.

So, if you have experience with these, please add your experiences to my polls!!
 
It never hurts to have some tricks up your sleeve just in case. At the very least these coping strategies can help you through early labor since most car providers won't administer epidurals till you have made at least some progress (some do it at 4-5cm, others earlier so you should ask). IV drugs can be given in early labor but they don't usually take the pain away.

There are some times when you plan for an epidural or pain meds but it doesn't end up working out. Here are some possible scenarios:
1. You progress too quickly. If you are 7+cm they may decide that they aren't going to do an epidural. One, it might not be effective before the baby is born. Two, it could impair your pushing ability which would up the odds of an assisted delivery or a long pushing phase. Three, the staff may decide that other moms should have the anesthesiologist's services more. Though most care providers set a certain cut off point it isn't a hard and fast rule. There are some moms who have demanded an epidural at 9+cm and gotten one. You have to weigh out the risks and benefits as well as the pros and cons for yourself. Pushing usually isn't at all like labor.

2. I mentioned before that you could progress too slowly. It depends on your careprovider's philosophy as to when you can get an epidural. There have been some studies that show that given before active labor (4-5cm) the rate of c-sections triples. This is usually because epidurals can trigger a series of other interventions that can cause problems. These include laboring in bed (you lack the aid of gravity and the weight of your uterus could cut down baby's O2 supply), pitocin to speed up a slow or stalled labor which can happen with the epidural, and continuous monitoring (the American College of OB/Gyns [the major OB policy making body in the US] admits that continuous monitoring can give false results and prompt a potentially unnecessary c-section.

3. There could be a health reason why you can't have an epidural. One reason would be if your platelet count was low. Blood infection, use of blood thinners, hemmoraging, low blood pressure are some potential medical reasons why they might say "no."

4. Sometimes the epidural doesn't provide full relief. Some moms experience "hot spots" (happens about 15% of the time); where they still have full sensation. Other times it can be patchy in coverage. Often these can be fixed but sometimes they can't.


You never know what will happen when the time comes so I urge you to have a back up plan. It can't hurt and you can use some of the coping strategies in early labor no matter what.

-Be sure that you are on the same page as your careprovider with your hopes and plans. They can make or break the experience.

-Learn about the routine policies where you are giving birth. If you don't agree with them (like I didn't agree with a routine IV), talk to your careprovider. They can make standing orders that support your hopes.

-Write a birth plan and make sure that you, your partner and your care providers are all on the same page. Have contingency plans too. Think about how you would want an induction to go if one became necessary. Same thing for a c-section. Newborn care is an important thing that you shouldn't ignore. I'll give you some links to info on birth plans and tools to help you write one.

-Try the “20 Minute Rule.” Once you decide that you want pain medication, try something new for 20 minutes first and then reasses how you are doing. Walk, try a new position, use water, a birthing ball, a heating pad anything that you haven’t tried yet or recently. You might find that after 20 minutes you have progressed more and/or you feel up to continuing just a bit more. Remember that for most moms they don’t get the feeling thatthey can’t do it anymore till they are almost about to start pushing.

-Ask for an internal exam before accepting pain meds. You might find that you are already 7+cm and that you can get through just a bit more. Transition is often the most intense part of labor but usually the shortest too. Some moms have transitions that last 20 minutes or less!

-Hire a doula! A doula can be an absolutely tremendous asset to the birth. While my dh and I were very well prepred (lots of classes and reading), it was still great to have someone in the room who was a professional labor support person. She was full of good tips and ideas to help me stay comfortable. She also helped dh help me feel better by giving him more ideas. She was there exclusively for our physical and emotional needs. Money well spent, imo.

-Know about interventions and use them wisely. Know what strings come attached to the various interventions. For example, if you consent to having your water broken do you also inadvertently consent to laboring in bed with a continuous monitor (whether it be internal or external)? Just know what chain of events can get set into motion by your choices. In general, unnecessary interventions can make your birth harder. Use them sparingly and wisely.

-Stay out of bed- unless you are able to master the Bradley Method of full relaxation. Change positions frequently to help the baby come down in the best possible position. Walking, position change, water, using a birthing ball, rocking in a chair, "slow dancing" with your partner...these are all great ideas to help you stay comfortable and manage the contractions.

-It might sound silly but vocalizing (aka, moaning) feels great! Saying, "oww, oww, oww!!" just makes you tense up all over. Moaning forces you to relax your shoulders, face, and chest.

-Deep breathing makes more sense than patterned breathing for most moms. It helps you to relax rather than try and distract yourself. Tension can really hinder labor progress and make the contractions harder to manage.

-Bring a heating pad with you. It can really help if you have back labor.

-Consider making up flash cards of all of the pain relief tricks you learn so that you can refer to them when you are in labor. It can be hard to remember all of them and there might just be one that perfectly suits your needs.

-Labor at home as long as possible, or as long as you feel comfortable. You avoid feeling like a watched pot waiting to boil. You can also probably relax better at home.

-Consider returning home if you go in to be checked and are less than 4-5cm.

-Read some good birth books by authors like Dr. Sears, Henci Goer and Ina May Gaskin. Consider picking up a copy of "Natural Childbirth the Bradley Way" by Susan McCutcheon. I found it to be a very empowering read (very biased on interventions but lots of great info on the emotionns of labor).

-Sit down with your partner before you go into labor and individually do these to assessments. Sit down and compare your answers. Birth Beliefs’ Questionare:
http://transitiontoparenthood.com/ttp/foreducators/handouts/beliefs.pdf

Pain Medication Preference Scale:
http://dolphin.upenn.edu/~doulas/documents/PMPS.pdf


This is a good article about alternative pain management techniques AND info on the actual pain medications:
http://askdrsears.com/html/1/T010800.asp#T012000

To find a doula near you, here is a link:
http://dona.org/FindingADoula.html

Birth Plan Maker
http://www.birthnaturally.org/HospitalPlan.htm
http://www.babycenter.com/calculators/birthplan/

Pros and cons of birth plans
http://pregnancytoday.com/reference/articles/birthplanarticle.htm

More reasons to write up a birth plan:
http://birthplan.com/plan-why.htm

Common interventions and risks/ benefits:
http://www.lamaze.com/birth/choices/articles/0,,167805_240720-2,00.html#npo

Tips to have an easier first birth [or second, third…]..:
http://sheknows.com/about/look/609.htm

15 tips to have an empowering birth:
http://sheknows.com/about/look/102.htm

Accept that contractions aren't your enemy. Keep this acronym in mind.
PAIN
P- Contractions are Purposeful. Every contraction works to help you efface, dilate, move the baby down into the pelvis or change your cervix from posterior to anterior.

A- Labor contractions are Anticipated. You learn in labor the rhythym of your contractions so you can gear up for the next one. You also can practice coping strategies before the baby comes.

I- It is Intermittent. You will ot spend all of labor having contractions. There will be a break between them. Use that break to the best of your advantage.

N- Labor pain is Normal. It is there because your body is working really hard to deliver the baby.

(I got this from the workbook they gave us in our hospital sponsored birth class. the book is calles "Prepared Childbirth the Family Way" by Amis and Green)


Someone recently posted their birth story and said something very true:
"Labor isn't actually about the pain. It's about really hard work."

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