Pain Medication for Labor

This content is also available in audio form as episode 6 of my Transition to Parenthood podcast, which you can find at that link, or on any major podcasting service.

painmed chart

Overview of the Options

I will start with a super top level overview just to get you oriented, then we’ll go into more detail. So,  for each of the options: how is it administered? What is the benefit – how does it help you to cope with labor pain? What are some common side effects?

  • Nitrous oxide is a gas that is breathed in. It reduces anxiety and helps someone to relax. There are few side effects and the effects of the medicine wear off very quickly.
  • IV opioids are given through an IV catheter – a tube inserted in a hand or arm. They don’t reduce pain sensation, but they do help someone to care less about the pain they’re experiencing. They can reduce blood pressure, cause itching and nausea, or make someone feel disoriented.
  • Epidural analgesia is the most common pain medication for labor. Medication is given through a tube inserted in the back. It reduces pain sensation, and also reduces how much you care about the pain you can feel. Most people report high levels of satisfaction with the pain relief. The trade-offs are that labor is more medicalized with more equipment and monitoring. The most common side effects are slower labor and delivery, lower blood pressure or fever.
  • General anesthesia – where the patient is unconscious – is rarely used for labor and birth – typically only in case of an emergency cesarean where there’s not time to place a spinal anesthetic.

Now, let’s look at most of those options in more detail, starting with nitrous oxide.

Nitrous Oxide

Nitrous has been used in the UK, Canada and elsewhere for decades, but is just recently becoming available at American hospitals, so check with your care provider to see whether it will be an option for you.

How administered: Nitrous oxide, also called ‘laughing gas’, is an inhaled medication. About 30 seconds before a contraction begins, the person in labor holds a mask over her nose and mouth and breathes it in. When she’s had enough, she relaxes and her hand drops away from her face, stopping the flow of the medicine.

Benefits: It stimulates the brain to release endorphins and dopamine, hormones that help reduce the intensity of the pain. Don’t expect it to take away all the pain – it only reduces it. Half of people still report severe pain while using it. But 92% said they had less pain with nitrous than without it.

Nitrous also reduces anxiety, helps the patient relax, and may cause a pleasurable or euphoric sensation. This can reduce the unpleasantness of the pain. 98% of users were satisfied with its use. It can also be helpful during anxiety provoking procedures.

It takes effect very quickly. The patient can decide when to use it and when not to use it which increases their sense of control. It is very inexpensive, and there are no side effects for the baby.

Side effects: There are few trade-offs – the equipment may slightly reduce your mobility – ask your caregiver about this. Side effects are minimal – could be mild nausea, dizziness, drowsiness or feeling silly. But any time you want to stop using it, the effects wear off in minutes.

Takeaway: If you want significant pain relief, then an epidural is the best option. But, if you want a “coping boost” that helps relax you a bit with few side effects, nitrous may be worth trying. Patients report a similar level of pain relief to IV opioids, and there are far fewer side effects than with opioids.

Learn more about nitrous oxide here, and here,  and read about research on nitrous oxide in labor.

IV Opioids

The next option is Injectable Opioids – which may also be called IV narcotics. The medication could be morphine, fentanyl, or remifentanil.

How administered: These medications can be given through an intramuscular injection – a shot. But they’re typically given intravenously. A needle is inserted into the patient’s hand or arm, then a tube (an IV catheter) is placed. IV fluids are given, which include the medication. It may be continuous flow, or sometimes ‘patient-controlled analgesia’ where the person receiving medication presses a button for a dose. IV opioids may be used for an hour or two during labor. After opioids wear off, most people choose an epidural. It’s harder to return to an un-medicated labor after opiates, as they reduce your body’s production of endorphins.

Benefits: Like nitrous, narcotics don’t take away the pain – they just help you not care about it so much. 2/3 still reported moderate to severe pain. But 75% describe opioids as at least somewhat helpful.

They are less expensive than epidurals, and are available at all hospitals, unlike nitrous and epidural which are not always available.

Side effects: The trade-offs are that you’ll have an IV, and narcotics tend to make you feel sort of fuzzy-headed – that sensation doesn’t trouble some people but others really hate that sense of being mildly disoriented. Common side effects are itching, nausea and vomiting, and reduced blood pressure.

Opioids do cross the placenta and affect the fetus. Also, if the baby is born less than an hour or two after the parent received narcotics, the baby could have short-term side effects on their breathing and on breastfeeding right after the birth.

Takeaway: IV opioids may provide some benefit for people who don’t want or can’t have an epidural.

Learn more about IV opioids during labor.

Epidural Analgesia

Let’s move on to epidurals, which are considered the “gold standard” for labor pain.

How an epidural is given: Epidural analgesia is given through an epidural catheter in her lower back, near the spinal nerves. The person in labor curls up and holds still. The anesthesiologist first gives a shot of a local anesthetic to numb sensation, then inserts the epidural needle and uses that to place a very thin tube. Then the needle is removed, the tube is taped down, and medication begins to flow. (To learn more about how it’s placed, read https://americanpregnancy.org/labor-and-birth/epidural/ or search on youtube for “epidural for labor.”)

An epidural takes about 10 minutes to place and 10 – 15 minutes to start working well. This waiting period can be extra challenging for women in labor, and labor support is critical. (Note: some hospitals offer combined spinal-epidural which takes effect more quickly. You can ask your care provider if this will be an option for you.) The epidural usually remains in place for the rest of labor.

There is also something called a spinal block, which is a shot. It’s similar to epidurals, except it’s a single dose, not a continuous infusion. It takes effect very quickly but only lasts for an hour or two, so is typically used only for cesareans.

When in labor can you get an epidural? Ask your care provider what they recommend and why. Many will say you can have an epidural at any point. Others recommend that the further you can progress in labor without an epidural, the better, because the less time you have an epidural in place, the less the chance for side effects. Some may recommend that you wait at least till you’re 5 centimeters dilated and have a good contraction pattern.

Most will say it’s never too late in labor to have an epidural, but practically, if it looks like the baby will be born in less than an hour, care providers may say it makes sense to just focus on getting the baby out rather than getting an epidural at that time.

Benefits: Epidural medication typically includes a combination of a narcotic like fentanyl – that reduces how much you care about the pain – and an anesthetic like bupivacaine, which significantly reduces how much pain sensation you actually experience. So an epidural reduces both the intensity and the unpleasantness of pain. You will still feel pressure in second stage, but that is actually a good thing as feeling that sensation helps you to push better.

Most people get very good pain relief with an epidural, better than with non-drug techniques, and better than opioids. In one study, on a scale of 0 to 100, one group rated their initial pain as 85 on average. With midwifery support, the average was 75. After an epidural, it was 27.  In a separate study, where pain was rated on a scale of 0 to 10, the pre-analgesia pain scores averaged 9 out of 10. After IV opioids, the average score was 4 in first stage labor and 5 in second stage. For those who received epidurals, the average score was 2 in first stage labor and 3 for pushing. (Source)

You remain fully awake and alert with an epidural. If you end up needing an instrumental delivery or a cesarean, the pain medication can be turned up to increase pain relief.

Epidurals can relieve pain well enough that many people can sleep after receiving one, which may be a relief after a long, difficult labor.

For those who use epidurals in labor, about 90% are very satisfied with their pain relief, around 5 – 7% are somewhat satisfied, and 2 or 3% do not get effective pain relief.

Tradeoffs: Epidurals are sort of a package deal. They come with continuous blood pressure monitoring, continuous fetal monitoring, extra IV fluids, a catheter to drain your bladder, an oxygen sensor on your finger and frequent temperature checks. You may have an oxygen mask. This can feel very medicalized as you feel like you have tubes and monitors everywhere. You will also have to remain in bed. People report feeling like passive patients after an epidural, vs. feeling like a more active participant in the labor before the epidural was placed.

Common Side Effects:

Your blood pressure may drop, and you may need interventions to correct this.

A fever can develop. That is more likely the longer the epidural is in place. If your baby is born with a fever, they may test for and possibly treat for possible infection, even though the fever is likely just a response to the epidural.

You will read in some places that epidurals slow labor, other say they do not – that other factors, such as the size or position of the baby may be the reason for a slower labor. Research does show that Pitocin augmentation is more likely. Research also shows that pushing may take longer. Before 2005, research showed that epidural made a forceps or vacuum delivery more likely, but that effect is not shown by more recent research on modern epidurals. Research shows no overall increased risk for cesarean.

There may also be some of the side effects you would see with IV opioids such as itching or nausea, but to a lesser degree, because epidurals contain a lower dose of opioid medication.

1% have a spinal headache after the birth.

A baby’s heart rate during labor may be affected by the epidural, so there will be continuous fetal monitoring, and there may be more discussion about the baby’s heart rate. These are just short-term issues and don’t appear to cause any long-term impacts for the baby.

Research does not show risks for babies at birth, in that Apgar scores at five minutes and admission to neonatal intensive care is not statistically different with an epidural. Nor do there appear to be long-term risks for babies.

Research about a possible effect of epidurals on breastfeeding is limited and challenging to interpret. People have wondered whether babies might be a little more tired after a longer pushing stage, or might have a little sucking ability in that first feeding due to the opioids. One study did show that the higher the medication dose received in labor, the more likely parents would report a fussy baby in the first few days and the less likely they were to still be breastfeeding at 6 weeks. It’s possible that any negative impacts of epidurals on breastfeeding could be fixed with a little more attention to the first feeding and a little more extra lactation support in those early days.

Takeaway: Epidurals do provide quite effective pain relief for most people with a high degree of satisfaction. However, 10% of people may not get adequate pain relief, so it’s essential that you also have a back-up plan of non-drug pain coping techniques. Check out other episodes of this podcast to learn more about comfort options. Birth with an epidural is more medicalized with lots of equipment and monitoring, and there are side effects that are fairly common, so it’s important to educate yourself about these.

Birth Plans and Pain Medication Preferences

Now that you know about your medication options, be sure to check out the podcast episode titled Labor Pain Toolbox. It talks about an important tool called the Pain Medication Preference Scale, which helps you clarify and describe your preference on a scale from absolutely want to absolutely don’t want. Knowing your preference, and the goals and priorities that shape it, are an incredibly helpful guide to those who will support you in labor.

For example, in your birth plan, if you’d marked a +3 on the scale, that says “I want to use some pain medications, but I also plan to use self-help comfort measures for as much of labor as I can.” It would also be helpful to describe what comfort measures you expect will be helpful to you and predict what factors would lead you to decide it was time for medications.

Learn more: If you’re planning an epidural, watch Penny Simkin’s video on Planning an Epidural. Tips for Avoiding Pain Medication, if that’s your preference: http://www.childbirthconnection.org/giving-birth/labor-pain/planning-ahead/

Labor Support with an Epidural

Early Labor

If someone is planning to use an epidural, then here are tips for getting labor off to a good start:

  • Moving around a lot in early labor, especially using positions that are upright, forward-leaning, and open up the pelvis, as I covered in the comfort techniques episode, will help the baby to descend and to rotate into the best possible position for birth. This is helpful for everyone in labor but may be especially important for those who are planning an epidural, as it is harder to change positions and move around once the epidural is in place.
  • Waiting to get an epidural till there’s a good solid pattern of contractions established, with contractions coming at fairly regular intervals, and getting longer, stronger, and closer together over time will help your labor to continue to progress well. Also, if you’re having a lot of back pain and irregular contractions, that may indicate the baby is not in the best position, so being upright and mobile a little longer may help correct that.
  • If someone is really counting on an epidural, then even the milder contractions of early labor may be very challenging for them, so they will need extra concentrated labor support to manage the pain till it is time to go to the hospital.

Active Labor

Upon arrival at the hospital, for someone with a pain med preference of +5 or higher, it can be helpful to talk to the nurse right away about the plan for an epidural. Sometimes they might be able to start an IV earlier so it’s already in place, or do some of the paperwork or anesthesiology consults earlier in labor so they’re out of the way and won’t be a barrier to getting the medication started when the time comes. Tip: It is helpful if labor support partners know answers to standard paperwork questions so the person in labor doesn’t have to recite her social security number, birth-date, allergies and so on.

Note: for someone who is planning an epidural, we may ask for that anesthesiology consult early. But if someone is hoping to labor as long as they can without pain medications (their pain med preference is from 0 to -10), then they might instead tell the nurse that this is their preference, and they would rather avoid or delay consulting with anesthesiology unless and until they decide to use pain medication.

In active labor at the hospital, use comfort techniques and labor support to reduce her pain for as long as she chooses to do so. (Be sure to listen to episode 1 – the Labor Pain Toolbox – and learn about the Pain Medication Preference Scale and the idea of a code word. Support people should talk with the pregnant person before labor to be certain they understand her preferences and how she will communicate that during labor.)

When the laboring person asks for medication, support people can help communicate this to the nursing staff, who will notify anesthesiology, and begin prepping for the epidural. Know that it can take a little while for anesthesiology to arrive. You can ask the nurse for a time estimate so you can plan. During this time, someone in labor needs lots of empathetic support. They had decided they were done coping with labor pain, and now need to do it for a little while longer, and these contractions can feel extra challenging!

During Epidural Placement

When anesthesiology arrives to place the epidural, in some hospitals they may ask the labor supporter to leave the room. Ask your care provider whether this would happen at your hospital and whether it is possible to stay. If not, then support partners can plan to use this time as a break for self care.

Assuming you can stay in the room, labor support during the placement of the epidural is vital. Helping her to remain still and calm, and breathe her way through the contraction will help get the epidural placed more quickly.

Labor Support after the Epidural Takes Effect

Once the epidural has taken effect, and she is experiencing much less pain, it may feel like labor support is no longer needed. But it is still very important to help her feel cared for. The oxytocin flow from feeling loved and supported will help labor to progress.

Supporters can help to keep her company, get answers to any questions she has, offer ice chips or hard candies to suck on, offer a cool washcloth for her forehead or neck, or a warm blanket if she’s chilled. Help her connect to the labor and to the baby by using her hand to feel her belly for contractions and listen to the baby’s heart rate on the monitor.

If she wants to sleep, then supporters can sleep but make sure she knows she can wake someone if she needs anything, even just company and reassurance. Place the things she may need in easy reach for her. An eye mask or earplugs may help her sleep. Supporters can silence phones and ask the nurse to minimize disruptions.

Changing positions in labor can help with labor progress. It is more challenging with an epidural in place, but can still be done with support. Partners can help with the “epidural rollover”, moving through these six positions: lying on her left side, then lying semi-prone (halfway between on her side and on her belly), then up on her hands and knees or kneeling over the ball, then semi-prone on her right side, side-lying on her right side, then semi-sitting. Change positions every 20 minutes.

She could also use a peanut ball ball – this is a peanut shaped exercise ball that she can place under one knee while semi-sitting, or while side-lying. Ask whether one is available at your hospital or you can purchase one for home birth use, or use pillows to achieve the same effect. This positioning helps the baby rotate into the best position for birth. (Learn more about peanut balls in labor, and research studies on their benefits.)

If she does not have enough pain relief from the epidural, support people can help her advocate for more. If she experiences side effects, they can offer support: for itching, offer a cold compress. If nauseous or vomiting, support with that. She may shiver or tremble – reassure her that is normal. (Her body is still experiencing a lot of stress, even if she can’t feel the pain.) Sometimes a high block causes someone to feel like they can’t breathe – reassure her that she is breathing fine.

Learn more about: Labor Support with an Epidural, or watch Penny Simkin’s video on Care of a Woman with an Epidural.

Second Stage with an Epidural

When she has reached 10 cm dilation, and her contraction pattern indicates that second stage has begun, they may have her do a few “practice pushes”. If they’re not effective, then the care providers may recommend “laboring down” which just means resting until baby is crowning at the vaginal opening, then beginning the pushing effort.

During pushing, the care provider will make recommendations about pushing positions and pushing technique. The support partner may be asked to help hold her leg or support her in a certain position. If so, be sure to be aware of her typical range of motion, and don’t hold her leg in a position that would strain it if she could feel it.

Learn lots more about Support with Second Stage after an Epidural.

After the Birth

After the birth, support partners can insure that there is immediate skin-to-skin contact between the baby and the birthing parent. People who have labored without pain medications tend to have a huge rush of hormones that encourage them to demand contact with their baby – the epidural can disrupt this a bit, but support people can help to correct for that by prioritizing skin-to-skin contact, undisturbed time for the first breastfeeding session and rooming in with the baby. Research is unclear on whether epidurals can have any negative impact on breastfeeding but you can always request extra lactation support with getting nursing off to a great start. If the birthing parent had a lot of IV fluids during labor, that can cause the baby to have extra fluids at birth, and thus there might be more weight loss right after birth as they pee all that fluid off. Ask for a weight check for the baby at 24 hours as a baseline to compare to later.

Takeaways from this episode:

Even if someone is planning to use pain medication, it is helpful to learn pain coping techniques to get to the point in labor where they can have an epidural, or in case the epidural is not effective for them. After an epidural, labor support is still important and can include assistance with positioning, increasing comfort, and providing support to decrease fear about the birth.

More Details about Epidurals

The links given at the end of each section above are the best consumer-friendly sources on each topic. Here are some more advanced resources for those who really want all the details on epidural.

For more information about birth and labor support, read Pregnancy, Childbirth, and the Newborn: The Complete Guide. Or read the articles (or listen to the podcasts) on this site.