OB/GYN Explains Epidurals and Other Pain Control Options for Labor

Hello everyone and welcome back to our channel. This week we're going to talk about all the pros and cons of getting an epidural while in labor and some of the other options you have for pain control. So if this is your first time meeting us I'm Kurt, I'm Sarah, and we are the Doctors Bjorkman. Welcome back. As most of you know I'm an OBGYN and I am nearing the end of the third trimester of pregnancy with baby number one. And I'm a pediatrician and we've been going week by week through this pregnancy as we've been giving medical advice to pregnant moms and new parents for years and we're finally putting that medical expertise into practice and living through pregnancy ourselves. Yes so something I think about a lot as an OBGYN and even more now as this labor and delivery is fast approaching is pain control and epidurals and options for that pain control during your labor. Yeah because labor is a tough and painful process but it's a very rewarding process because at the end of it you get to hold that sweet baby and all those sweet baby snuggles. Yes but as you said it is can be an intensely painful process and it makes a lot of mamas very nervous myself included and so moms and patients want good information about what the pain control options are and what kind of pain levels to expect. And as an OBGYN managing your pain in labor is a major goal of your care during labor and delivery. And so our goal of this episode this week is to give you the information so that you can be prepared for what to go to and so that your partner knows how they can help you best. So studies have shown that when looking at the degree of pain women are going to feel in labor that they often actually underestimate how bad that pain is going to be. Which is pretty amazing because I feel like everyone recognizes that labor is a pretty painful process. But also these same studies show that women want to have some agency some control and play a part in that decision-making process about how their pain is going to be controlled. And unfortunately oftentimes after the fact they feel like they didn't get as much control over that process as they wanted. Additionally studies have reported that a woman's ability to cope with pain during labor really depends on two things. And the first thing is if they have continuous kind of individualized labor support. And the second thing is if they kind of have this acceptance that there is a need for to experience some pain during childbirth. So that labor support person is really important because it makes women feel supported. They have less fear and less loneliness less anxiety and that helps them better cope with labor and labor pain. And so that support person is really critically important. Let's talk about the different types of pain. So kind of two types of pain that we talk about in medicine. And the first is somatic pain. So this is like easily to localize pain. Like oh I cut my finger my finger hurts. And the second kind is visceral pain. This is very like diffused. I have a belly ache. Organ pain. And this classically is early labor. This diffused generalized your whole abdomen is tightening pressure that you can also feel then radiating to your lower back maybe your butt and your thighs. Right. And so as those contractions really start to push that baby down further into your pelvis in the late first stage and then that pushing stage, those contractions cause the baby's head to be putting pressure on your pelvic floor, on your vagina, on your perineum. And that really intense pain is called somatic pain. It's transmitted to your brain via nerves in your pelvis and it's very localized very sharp somatic. You know right where that pain is. So all that pain sounds pretty miserable to me but there's lots of good options for managing this pain right? Yes there are a wide variety of options that range from non-medication options like massage or being in the shower or the tub during the first stage of labor or acupuncture or hypnotherapy that are really directed at helping patients or moms just cope with the labor pain versus really taking that pain away. It's just trying to cope and prevent suffering while experiencing that pain. So in addition to those non-pharmacological options there's medication options like IV, epidural, laughing gas too right? Yes totally. And those medication options are really directed at decreasing or eliminating the physical sensation of labor pains altogether. Before we get to all the medication options, I know there's a lot of women and couples out there who want kind of to have less medical intervention in their birth. So if someone's interested in that kind of where do they go or what kind of things do they think about? Yeah so things like directed breathing, reciting a mantra, some hypnotherapy, all these different positions you can be in or certain massages can be really helpful and comforting to patients who are in labor. And I would really recommend if this is some this medication free birth experience is something you're really interested in that you try to find maybe a birth class or a birth doula who specializes in that kind of thing because they just have a lot of techniques and tips that they can show you and they can show your partner how to massage your sacrum and all these different positions that you know just feel good and it makes sense that they feel good and that might help lower mom's stress level. So if that's something you're interested in I would definitely do some homework to prepare so you are better prepared to do that. As the person who's not going to feel any pain other than maybe her squeezing my hand, you know the American College of Obstetrics and Gynecology has a statement that says there is no instance in medicine where a patient under a physician's care should be going through severe pain that is amenable to pain relief that's safe. And so it's so funny to me that like this is an area in medicine where we have the ability to almost always like adequately control pain to make it a manageable comfortable experience or comfortable is maybe the wrong word but so like that always seems funny to me but I understand if this having a natural birth is something that's really important to you like more power to you absolutely. One other thing just like being there often as a pediatrician at the end of the pushing like labor is really long and gosh I can't imagine being in pain for hours like that and so sometimes you know just from my anecdotal experience as the not OB in the room a handful of times like sometimes like just the fatigue of being in pain for all of those hours and so if you have good pain control throughout kind of that labor process of just dilation and contraction every couple minutes for hours like it just I imagine that would give you more energy to push at the end again this is and and and you say that at the end also like labor is really painful pushing that baby out is really painful often there is a repair of a vaginal tear or something that needs to be repaired at the end and it just feels like your vagina is on fire and so when you have to do that repair it's also nice to have an epidural so that your doctor or physician or midwife or whoever is doing that repair can get good exposure can put things do your stitches and get things back together and you're comfortable for that so that's something that is also really nice. What about some of the medication options what about like IV medications? So sometimes IV pain medications are an option and these are pain medications you've heard of like morphine, fentanyl, or stadol they can be given through the IV or even in your muscle and they kind of help take the edge off the pain. Gotcha and so but one thing that's really important to know is that all opioids these are like classic pain medications like morphine etc that you get if you break your arm when not pregnant they do cross the placenta and so some of those can get to baby and can cause some things like decreasing the variability of baby's heart rate or maybe decreasing the baseline heart rate for baby or they can also if they last a while in the baby's system which it does take a little bit longer for baby to get rid of these medications can cause decreased respiratory drive or maybe some neuro neurobehavioral changes right after birth and so this is why these medications are usually not given kind of late in labor. Exactly they they do wear off and once the drugs wear off babies tend to bounce back to their baseline but generally these medications are given in early labor when mom's not quite sure if she's ready for an epidural but really needs some relief and some rest and just again you kind of want to take the edge off so a kind of a common combination that I've seen is giving some stadol and some benadryl through the IV to again you know help you get some sleep and help a little bit with that pain. So earlier you mentioned something like laughing gas for this labor pains too. Yes so nitrous or nitrous oxide is an inhaled anesthetic that has been used in general anesthesia for decades and it's been used for labor and delivery and kind of postpartum laceration repairs for a long time in the UK it's becoming more popular and more widely used here in the United States but basically it's administered via kind of a face mask that mom has to hold for herself and she holds this mask her face and she breathes in this nitrous and it's really neat because again it's self-administered to mom and she's still you're still able to be up and walking around when you're not using it it wears off really quickly and it again is one of those things that can kind of take the edge off if you're not sure if you're ready for an epidural you can you know maybe try the nitrous and see if that gets you through. Again it may make you a little drowsy or a little dizzy but the thing is is once you are inhaling it if you get a little sleepy you know your hand's gonna fall down it wears off really quickly so as soon as you take that mask away from your face you are going to breathe in some fresh air and it wears off and so it's just great to hold to your face and breathe through during those contractions and again you can't really overdose on it because you are the only one who can hold it nobody can hold the mask for you nobody else in the room can try the nitrous it mom only so it's really kind of a neat option for pain control if your hospital has it not all hospitals have nitrous as an option so this brings us to that really well-known pain control for labor called an epidural yes so epidurals are very popular very effective and are what we call neuraxial anesthesia meaning that the goal is to take away pain from a region of your body and for labor and birth that region is going to be from the waist taking the pain away as much as possible from the waist down and so a survey in the u.s in 2016 of providers show that about 70 percent of women who give birth will use an epidural or neuraxial anesthesia and it's really important we have to do a little bit of myth-busting here before we go any further there's no evidence that getting an epidural will increase your risk of a c-section correct so when we are talking about neuraxial anesthesia or regional anesthesia it's kind of divided into two things epidurals and spinals there's also combined but that it's named that way because of where the pain medication is delivered so either in the epidural space for an epidural or the subarachnoid space for a spinal so when you have an epidural again they are going to use a needle to place a catheter into the epidural space in your spine and that allows for an infusion of medication kind of a numbing medicine and a pain medicine to be infused into that space to provide pain relief to numb you from the waist down and these are usually placed by the anesthesia team so either an another member of the anesthesiology team will come into your birthing room to help place this and then with that there's a couple different options if you have an epidural as sarah mentioned this is a continuous infusion of pain medication that can be given in extra little doses or boluses sometimes you can have a there's a patient controlled button to give additional analgesia as you're feeling more pain during that you can push and say oh i need a little bit bigger dose to that and that helps you get the minimum dose needed so that you can be comfortable without having you so immobilized by the lack of being in that you know a big part of being able to push is being able to have some ability to sense but also you want to have the pain control and so with that epidural and being able to sense if it's too dense you know you can't feel anything below the waist it's time to push can't move your legs anything they can kind of turn down the rate of your epidural so you feel a little bit more the same thing after delivery if you have a tear that needs to be repaired your epidural can often be turned up if you aren't getting enough pain relief same thing if you are in labor and you have an epidural and you end up needing a c-section most of the time the anesthesia team can just use that epidural that you already have in place and turn up the dose kind of so it's you know you feel absolutely nothing from the waist down and use that again for your c-section what about if someone says oh they was only working on one side what's that about it's called a window and it happens sometimes nothing is perfect and so sometimes you get better relief on one side of your body or another because that pain medication is being drifted it's a tiny little straw that's going into this epidural space in your back and so sometimes it can be fixed with positioning you know you're you have some pain on your left so you kind of lean more to your left side sometimes the anesthesiologist can come in and readjust some things to try to make that better okay and then how is that different from a spinal then so a spinal is a one-time dose of medication into the subarachnoid space and that provides more instant pain relief the thing with a spinal is it's that one-time injection so once the medication wears off it it's done whereas with the epidural you've got that kind of little catheter straw there that's constantly infusing so once the spinal wears off it wears off it usually lasts anywhere from one to two hours so frequently a spinal is the perfect kind of pain medication for a scheduled c-section because we know they're not going to take very long it's just a one time in and out and you're done whereas with labor finals always aren't always the best choice a one-time spinal because labor could take three hours it could be 10 hours we don't know when you're going to have your baby so you want more than that quick dose there and then the combination is where they give the spinal to give you kind of that immediate pain relief but then also have the benefit of the longer lasting titratable dose of epidural that can go up and down depending on how dense it is exactly so you might hear a cse a combined spinal epidural is kind of when they do both perfect so we did briefly mention earlier a little bit of myth busting you may have heard that getting an epidural might slow down your labor or you might have heard that getting an epidural is going to increase your risk of c-section yeah so they've actually looked at this taking what's called a meta-analysis so looking at lots of different randomized controlled studies and taking all of that information putting it together to get even more stronger data to show that on average an epidural will actually slow down the pushing stage or second stage of labor by an average of about seven and a half minutes but then the other question is does this increase your risk of c-section the answer is no there's not a statistically increased risk of c-section with an epidural regardless of when you got it whether you got it in early labor and a late labor or somewhere in between so the question that we've heard a couple of times is what is sarah gonna do i am absolutely going to get an epidural um you know i i guess i'll like see how it goes is the better answer um because i feel like you're pretty tough i feel like i'm pretty tough um but i tell you she's tougher than i am a lot of tough women labor and it does not look like a lot of fun um and i've also seen women who get an epidural they are super comfy they take a nap they play cards and listen to music with their family and it's just like a nice civilized time um and i've seen people have like non-medicated births who just like are total warriors breathe through it walk through it with their partners massaging and that's like also really beautiful i would rather take a nap and like watch a movie comfortably gotcha i think so i'm gonna see what happens and see how it all goes i've never had a contraction before that was painful so tbd um but i've seen women have some of these you know the spinal headache or baby going i've seen the complications having from a an epidural um and i think it's definitely worth the possible risk to to like be not dying in pain so gotcha we'll keep you posted i imagine for us like we're probably gonna like try to work through things be up walking around as we try to get labor to progress and then eventually there will come a time where my back rubs cease to be helpful and sarah says hey it's time tapping out now um and and and please remember if you want to do non-medicated wonderful if you want to do medicated with an epidural wonderful you don't get a medal for doing either you're taking home a baby at the end that is all that matters so good luck so with all this why would someone maybe not want an epidural or what are some risks with that sure i think everybody has different goals and thoughts and opinions when it comes to labor um with an epidural once you have it it's you're kind of confined to the bed which is definitely a turnoff for some people your legs are really heavy you don't feel much from the waist down so you're not reliable on your feet so your nurse is not going to let you get up and get out of bed and a lot of women want to be up bouncing on a ball in a shower walking around doing different things so sometimes that is a reason that people aren't interested um there also are some risks as there are with any procedure um there is a risk when you first get that epidural that it causes your blood pressure to drop quite a bit um they usually try to combat this by giving you a fluid bolus beforehand to kind of tank up a liter of fluid exactly to try to help because sometimes when your blood pressure drops that can distress the baby because the placenta isn't perfusing as well so the baby can be distressed usually recovers but it happens is that common it's not common but it happens it's something that we said as your blood pressure dropped the baby got mad we're going to change your position we're going to make sure your fluids are going and do some different things okay um there also is a chance when you get this epidural that the medication in it just causes you to be really really itchy all over in your abdomen your back and your legs um and that's not fun there is less than a one in a hundred chance that you get a very very terrible headache um a spinal headache a spinal headache it's very a very rare complication but it can happen it is treatable um and there is also a very very six in a million chance that you end up with an epidural hematoma so that's like a blood clot in your in that space in that space um which can be very dangerous it's extraordinarily rare we usually see that in people who have some kind of bleeding disorder or on anticoagulation but it's one of those big deal complications again super rare but those are some of the risks when your anesthesiologist comes in to do your epidural they're going to go over a consent form and talk about all these risks with you and have you sign a consent form and say hey i understand these things could happen i really want the pain relief and so risk benefit there it is so another thing that i've heard happen sometimes or that i've seen kind of being a pediatrician in the room is that you know a mom will come in and have a very fast labor and maybe even uh doesn't get the epidural in time can you talk about that it does happen uh it can be kind of traumatic for people who really wanted an epidural the good news is it sounds like it happens quickly um there are some options for local pain medication just like you know if you cut your finger and need stitches they inject some local lidocaine like the dentist for yes and just to get you numb there's something called a pudendal block and not a lot of providers do this anywhere but some do where they inject they use a really long needle to inject local anesthetic near your pudendal nerve it's up in your vagina near the ischial spine they inject some local anesthetic and it really numbs your perineum pretty well um they some providers will do this if you have some bad tearing um that needs to be repaired some will do a pudendal block most of the time for a repair after delivery your doc's just going to use an injection of some lidocaine in your vagina around the muscles and the tissue that needs to be put back together so you don't feel a thing if you are find yourself in the delivery room and you are having your tear repaired and you feel like you're really uncomfortable just say hey hey i'm really feeling that is there anything you can do and they can give you some local anesthetic to try to make that so so it's really important to note that everyone experiences pain differently right this is based on biology based on life experiences etc and so one thing that we wanted you guys to get out of today's episode is that regardless of what happens with your birth experience there's multiple options and things that you can do whether it's breathing exercises mindfulness or medications IV epidural spinal etc things that we can work to help your labor and birth process be as manageable as possible yes it's not always perfect right but often if you say hey i am really uncomfortable what can we do about this there's often an option and your provider wants to work with you to help that process and be as manageable as possible exactly whatever that threshold is for you there's probably something out there and it is your provider's goal to help manage your pain and labor so hopefully this gives you a good overview and so that's going to be it for us this week guys we've got some more stuff coming up next week as we're getting ready for the birth of our very own baby we're excited to meet our little girl please let us know if you have questions comments concerns and click subscribe we're doctors but not your doctors anything we've said in this video is for education or entertainment purposes only it is not medical advice any specific medical questions you have should be directed to your provider