Labour may be the most painful experience many women would encounter and proper pain relief has now become a component of standard care in the delivery room. The experience of labour pain is different for each woman, just like there are different options available for controlling it. The factors that may influence a woman’s experience include whether she is delivering for the first time or not, her psychological state, level of mental preparation, availability of emotional support, and cultural influences. An individualised approach is therefore necessary for the management of pain in labour. There are many hospitals in the urban centres of Nigeria which offer a number of options for managing the pain of labour.
Available options
The techniques for managing labour pain are grouped into those that do not involve the use of medications (non-pharmacological) and those in which medications are used (pharmacological). The non-pharmacological group includes breathing techniques, water immersion, aromatherapy, acupuncture and acupressure, massage techniques and transcutaneous nerve stimulation (TENS).
Pharmacological techniques include gas inhalation, injectable medications and epidural block. The effectiveness of the non-pharmacological techniques in reducing labour pain is limited which prevents them being offered in major hospitals. The pharmacological techniques are more effective and more commonly offered in hospitals. The gas technique is popular in the United Kingdom and involves the labouring woman breathing a gas mixture called Entonox (oxygen and nitrous oxide) through a special face mask or mouthpiece. It is self-administered, can be used on demand, continuously or intermittently, and is simple to master following initial supervision. Entonox is not as effective as other pharmacological techniques and may cause side effects like nausea and vomiting, dizziness and drowsiness.
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The injectable medication technique involves the use of powerful pain-relieving medications called opioids. Pethidine is the opioid drug that is commonly used for labour pain. It is usually injected directly into muscle by midwives and is moderately effective in relieving labour pain. Other opioid medications like fentanyl and remifentanil may be injected through a vein using a special technique called patient-controlled-analgesia (PCA) where the woman is given control in activating the injections when required. Opioid medications may cause drowsiness, nausea and vomiting in the mother and it may depress the baby upon delivery. Epidural block is the most effective technique for relieving pain in labour and is regarded as the gold standard.
Epidural block
Labour epidural provides effective relief from the pain of labour and delivery. It is popular around the world with epidural rates ranging from as low as 40% in the UK to as high as 80% in France. In Nigeria, studies have shown that the awareness of pain relief in labour was low but has been increasing in recent years especially among women with a tertiary-level education. Epidural is usually provided on demand in maternity units but may be recommended to pregnant women who have specific conditions like hypertensive disease because of its benefits. However, there are individuals for whom epidural is not recommended like those with blood clotting abnormalities, those who have suffered significant bleeding at the time of delivery, those who have an infection on the skin of the lower back or a severe infection affecting the whole body, and women who are allergic to local anaesthetics, which are the main medications used to perform epidural blocks.
Epidurals are administered by specialist doctors known as anaesthesiologists and the procedure involves passing a special needle into the lower back after the skin is numbed. The needle tip stops at a place called the epidural space which is located within the spine. A tiny flexible plastic tube called an epidural catheter is then passed into the epidural space through the needle which is taken out once the catheter is in place. Medications are injected through the catheter into the epidural space where they come into contact with, and temporarily block the nerves that transmit the pain of labour and delivery to the brain. Epidurals usually provide complete relief from the pain of labour contractions and significant relief from the pain of the actual birth. The woman is monitored continuously and the epidural catheter is removed after delivery. Like every intervention in medicine, epidurals have their side effects and complications. Fortunately, the common problems (nausea, low blood pressure, itchy skin and shivering) are harmless and the harmful ones (headache, nerve damage, infection) are rare in experienced hands.
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An epidural block could lead to a slight prolongation of labour and could make it more likely that instruments (forceps or vacuum) will be used to assist in delivering the baby. However, it won’t increase the likelihood of delivery by Caesarean section and it doesn’t cause long-term low back pain.
Dr. Raji Bello is Consultant Anaesthesiologist,
