All About Medications

There are many options when it comes to the use of pain medications for labor and birth. Some of these options may not be available at your particular place of birth, so, if you plan on using medication during labor and birth, it is a good idea to consult with the anesthesiologist at your birth place. This will also enable you to talk to the about your concerns and to ask any questions that you  might have about the procedures involved.

As with any/every intervention, the use of pain medication during labor and birth inadvertently always carries risk. Weighing the benefits with the risks will allow for families to make the best choice for their birthing needs and desires.Best odds, interventions should be reserved for emergencies; interventions should never be routine.

When accepting an intervention, such as pain medication, always ask yourself:

• What are the risks?
• What are the benefits?
•  Do I accept the possible risks in order to receive the benefits?

Some doulas, like myself, use an epidural agreement with mothers. This epidural agreement is useful in all situations involving the choice of medications. Herein, we will be talking about the benefits and risks of medications that might be available to you, so that you can make an educated decision regarding them during your birthing time.

Medicated Pain Management - Analgesics:

Pudendal Block: An injection of narcotic medication (usually  bupivacaine) is given through the vaginal wall and into the pudendal nerve in the pelvis, numbing the perineum. This is not a readily available option and most doctors don't offer this anymore. The few women I have worked with who have had this (in past births) said that the administration was quite painful and one said the numbing was 'confusing'.

• Pros: given shortly before delivery so less medication reaches baby, quick acting and short term (2-4 hours), alleviates pain associated with the second stage of labor 
• Cons: does not relieve the discomfort of contractions, short window of time that it can be administered, may cause residual to permanent nerve damage, increases swelling of perineum, decreases elasticity of perineum (which increases risk of tearing), can puncture fetus, can puncture uterus or arteries of mother.

Paracervical block: An injection of narcotic medication into the tissues around the cervix. A form of
local anesthesia. This is not a readily available option and most doctors don't offer this anymore. The few women I have worked with who have had this (in past births) said that the administration was very painful.

• Pros: decreases contraction and dilation discomfort, short term (1 to 2 hours)
• Cons: can puncture uterus causing infection, can puncture placenta causing hemorrhage, can puncture baby, can cause swelling in cervix, can cause damage to cervical tissue.

Stadol: an analgesic (works on whole nervous system instead of one area) which is administered via IV. It is an opiate derivative (narcotic) with an additive to combate the dysphoriate reaction to narcotics.

• Pros: near instant relief, takes the ‘edge off’ of hard labors, moderate (2-4 hours) spanning. Oftentimes sleepiness occurs, contractions feel shorter in duration.
• Cons: loopy or high feeling, hallucinations, nausea, depressed respiration in mother and baby, decreased cardiac output, decreased oxygen in blood in mother and baby, fetal heart rate deceleration, and/or epidura hematoma (bleeding on the brain) can occur. Roughly 20% of women have a sensitivity or allergy to the narcotic Stadol. Does not remove pain, simply makes one not care about the process or the pain, or too sleepy to resist the contractions.

Demerol: a narcotic analgesic which is administered via IV sometime in the early-late phase of first
stage. This medication is very closely related to Stadol.

• Pros: near instant relief, makes one relaxed enough to not care about pains of labor, moderate (2-4 hours) spanning. Oftentimes sleepiness occurs, contractions feel shorter in duration.
• Cons: loopy or high feeling, nausea, irreconcilable fatigue, depressed respiration in mother and baby, decreased cardiac output, decreased oxygen in blood in mother and baby, fetal heart rate deceleration, and/or epidura hematoma (bleeding on the brain) can occur. Does not remove pain, simply makes one not care about the process or the pain, or too sleepy to resist the contractions.

Nubain: another narcotic analgesic, administered via IV throughout the first stage of labor.

• Pros: Near instant effectiveness, moderately spanning, similar reactions as marijuana. Oftentimes sleepiness occurs, contractions feel shorter in duration.
• Cons: abdominal cramps, nausea and vomiting, rhinorrhea, lacrimation, restlessness, anxiety, elevated temperature, respiratory depression in the neonate, and death. Does not remove pain, simply relaxes mom so that she forgets or does not concern herself with the process of labor. Roughly 20% of women have a sensitivity or allergy to the narcotic Nubain.

More information on the medications listed above:
http://www.drugs.com/cdi/nubain.html
http://www.drugs.com/cdi/stadol-solution.html

Medicated Pain Management - Anesthesia:

Spinal (saddle block, intrathecal) Block: an injection of opiates between the vertebrae of the low-mid back, through the epidura, and just beyond the dura – before the spinal cord. This injection is directly into the spinal fluid.

• Pros: near instantaneous relief, less medication than epidural, less chance of infection as there is no running line, should completely numb the uterine area. Should still be able to feel the tightening of the contractions. Feelings of pressure but no pain with contractions.
• Cons: can be ineffective (either completely or in ‘windows’), re-administration means another needle. Can cause fever, maternal drop in bp, fetal respiratory depression, arresting of labor, inability to push, urinary incontinence, decreased cardiac output of either mother or neonate, increase risk of jaundice, fetal bradycardia (decreasing heart rate with or without contractions), improper engagement (head or presenting part not moving through the pelvis correctly), breastfeeding problems, fetal death, maternal death, or cardiac arrest. Long term consequences can include chronic lower back pain, spinal headache, ruptured discs, or permanent nerve damage.

Epidural: a cocktail of various opiates and narcotic anesthetics placed into a catheter (thin tubing). The catheter is fed between the vertebrae of the low-mid back and into the epidura space before the
dura/spinal cord; hence the term ‘epidural’.

• Pros: can be given in varying doses, works quickly (within 5-10 minutes), easy to re-administer if it runs out, easy to increase the dose if necessary for a c-section, should completely numb from the uterus to the toes. Ideally, will retain mobility of legs and feet. Feelings of pressure but no pain with contractions.
• Cons: can be ineffective (either completely or in ‘windows’), cause fever, maternal drop in bp, fetal respiratory depression, breastfeeding problems, increase risk of jaundice, fetal bradycardia (decreasing heart rate with or without contractions), improper engagement (head or presenting part not moving through the pelvis correctly), arresting of labor, inability to push, urinary incontinence, fetal death, maternal death, or cardiac arrest. Long term consequences can include chronic lower back pain and ruptured disc.

Walking Epidural (Combined Spinal Epidural, CSE): a combination of the epidural and the spinal. An initial injection into the spinal fluid, then a catheter line running continuous low-dose narcotics and opiates to the epidural space of the spinal column.

• Pros: quick acting, again can be given in varying doses. easy to re-administer if it runs out, easy to increase the dose if necessary for a c-section, should completely numb in the uterine area while still allowing movement of the legs.
• Cons: all of both the epidural and the spinal. In addition, though it is called a walking epidural, a mother does not have full use of her legs and will still be, most likely, confined to bed or sitting in a chair.

More information on the medications used in the spinally administered medications,  bupivacaine and
Fentanyl:
http://www.drugs.com/cdi/fentanyl.html
http://www.drugs.com/mtm/bupivacaine.html

Nitrous Oxide:  this option is becoming more readily available in the United States. Nitrous Oxide is an odorless and tasteless gas that is inhaled during contractions. It is self administered through a hand-held face mask and takes effect within a minute.

• Pros: Alters pain perception, can  be used intermittently or continuously and can be stopped at any time. Short term relief. Has very little effect on baby as nitrous oxide dissipates from the neonates blood stream upon first breaths. Can be administered in any birth setting.
• Cons: Doesn't eliminate pain, dizziness, drowsiness, nausea, and restlessness can occur. Can cause problems with mild maternal hypoxemia.  

In closing, consider printing out and going through the PMPS here. This worksheet can  help you to establish just what types of pain management you are comfortable with and just want support your birth team might be able to provide for you during your birthing time.