Our Bodies, Ourselves (89 page)

When used systemically, opioids are given through an intravenous line (IV) or by an injection into your arm, leg, or buttock. They work by being absorbed into the bloodstream and going to the receptors in your body that diminish pain perception. In general, they make you feel relaxed, sleepy, and possibly a little dizzy, and you tend to feel your contractions less. They may make it easier for you to rest for longer periods of time between the contractions.

Each opioid works for only a limited length of time and can be safely given only at certain times during labor. After a peak of effectiveness, the medicine begins to wear off. The length of time varies from one medicine to another.
One to two hours is common, with the peak often being less than half an hour after the medicine is given.

One advantage of systemic medicines is that they are short-acting. They therefore can be used at a time in the labor when you just need some help to make it through a challenge. The use of morphine for women who are exhausted in early labor is one example. Another common example is a onetime dose of systemic medicine if you are in the middle of labor and feel exhausted or like giving up; it may be what you need to get through this short but tough time. Mothers who try this may get a second wind and do fine without further medication. Others may have an even harder time coping with labor because of the way the medication makes them feel (“high” or disoriented). Another advantage of using systemic medicine over regional medicine such as an epidural is that you can either avoid the possible adverse effects of the epidural altogether or delay getting the epidural until later in the labor, which may diminish the impact of some of the epidural's negative effects.

The main disadvantage of systemic opioids (narcotics) is that their use in labor has generally been found to have limited effect on controlling women's pain. When women rate the effectiveness of all the techniques used to minimize pain during labor, systemic opioids are less effective than immersion in water.
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They are also much less effective for pain relief than epidurals. They will not take the pain away completely. The medicine may “knock you out” between
contractions, or it may “take the edge off” by decreasing the intensity of the contraction at its strongest. Some women experience a welcome feeling of relaxation; others feel a bit out of control.

Other disadvantages of opioids are:

• The use of these medicines may decrease the production of your own endorphins (hormones that reduce your perception of pain).

• They are short-acting, and there is a time limit for when you can get another dose. So after you have been given one dose, there is usually a waiting period before you can have more if the first dose doesn't work as well as you want. Some women find this waiting period very difficult.

• Just as they circulate throughout your body, systemic medicines get into the baby's circulation. There, they have the same effect on the baby that they do on you. If a baby is born too soon after this type of drug is given to the mother, she or he may need help to breathe or may have to be given medication to wake up. For this reason, many care providers will not give systemic pain medication if birth is likely to occur soon.

• Babies of mothers who receive these medicines can also have trouble initiating breast-feeding successfully and may not be able to suck correctly during the first few hours or days of life.
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Epidurals and spinals cause numbness below the level of the back at which they are placed. In an epidural, medicine is infused just outside the outermost of the two membranes covering the spinal cord (the epidural space); in a spinal, the medicine is injected between the two membranes. Either epidurals or combined spinal-epidurals are offered for labor pain. These methods may involve the use of local anesthesia, which works by taking away sensation through a numbing effect on nerves. Or it may involve opioid medications only or a combination of local anesthesia and opioid medications.

To place an epidural or spinal, an anesthesiologist or nurse-anesthetist first numbs a small area of skin on your back. For an epidural, she or he uses a needle to place a catheter (a tiny, flexible plastic tube) into the epidural space. With the catheter in place, an anesthetic, or more usually a combination of anesthetic and opioid, can be infused through a pump that controls the dose and the rate throughout your labor. In patient-controlled epidural anesthesia, you have access to a button that activates the pump. (It has controls that won't allow you to overdose yourself.)

A spinal is a single injection usually used for short-term pain relief in situations when pain control is needed faster. A spinal uses local anesthetic and sometimes an opioid that is injected into the spinal fluid that surrounds the spinal cord. Loss of feeling below the site of injection occurs quite quickly. Spinals are often used for cesarean surgery and sometimes for forceps or vacuum extraction deliveries.

Some hospitals offer a combined spinal-epidural: a onetime dose of opioid or anesthetic is injected into the woman's spinal fluid, and then a catheter is left in place in the epidural space for use when the spinal medicine wears off. The advantage of the combined spinal-epidural is that the spinal component offers relief without numbing, and if relief wears off before the birth, the anesthesia staff can add anesthetics to the epidural catheter and avoid a second procedure.

An epidural or a spinal will be accompanied by continuous electronic fetal monitoring of the baby. In addition, women who have an epidural or spinal will have an IV and equipment to
monitor blood pressure. Most women will need a temporary urinary catheter to empty the bladder and will be confined to bed, because this type of medication also affects the nerves that control the hip and leg muscles.

The greatest advantage of epidurals (and spinals) is that they can take away the greater part of the pain in labor and while giving birth for most women who use them. An epidural can provide much-needed rest for an exhausted mother, especially when other approaches have failed. An epidural can be helpful in the case of a very long labor. Psychological issues or individual circumstances may make experiencing the physical sensations of labor too difficult for some mothers at some point. Finally, some women choose epidurals simply to eliminate all labor pain.

However, regional analgesia can change the course of labor in many adverse ways. The disadvantages of regional medications used for labor pain include:
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• Sometimes the insertion of the epidural is ineffective, and the process has to be repeated. Epidurals sometimes fail to work or fail to relieve pain in a small area of your abdomen or back (also known as an epidural window). Such areas sometimes can be anesthetized with higher doses of medication but some women never do get complete pain relief.

• You are more likely to have a short episode of low blood pressure right after the epidural or spinal is injected, which may be associated with a drop in the baby's heart rate. If this happens, your providers will increase fluids through the IV, help you change position, or administer medicine to raise your blood pressure. If the drop in the baby's heart rate lasts for more than a few minutes, your provider will likely give you oxygen and may place an internal monitor (which involves breaking your membranes, if they are not already broken) to better track the baby's response. These episodes of low blood pressure usually resolve quickly and do not cause any lasting effect on you or the baby.

• Spinal and epidural opioids can cause itching. This is generally mild but can be quite bothersome for some women.

• This type of medication can increase the amount of time that you are in labor, including a longer pushing phase.

• You may be more likely to receive Pitocin, a synthetic form of the hormone oxytocin, to make your contractions stronger. (See “Medical Approaches to Speeding
Up Labor.”
)

• The longer you have an epidural, the more likely you are to develop a fever during labor. Because your providers cannot know if a fever is from an infection or from the epidural, if you get a significant fever in labor, your providers will start antibiotics and your baby may be separated from you and subjected to more tests in the first hours after birth.

• You are more likely to have forceps or vacuum delivery. Instrumental vaginal deliveries are more likely to lead to tears into or through the anal sphincter muscle.

• Between one and two of every one hundred women who get an epidural, and fewer than one of every one hundred women who receive a labor spinal, get a severe headache called a spinal headache. The headache usually doesn't start until the next day; if it occurs, effective treatment is available.

Evidence is mixed on whether there is an association between epidurals and problems in establishing breastfeeding; such problems seem
more likely to be linked to epidurals that include high-dose opioids in the mixture.
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The active phase of labor is complete when your cervix is open wide enough to accommodate the baby's head (about 10 cm, or 4 inches) or there is full or complete dilation. Around this time, you will likely feel a strong urge to begin pushing your baby out the final few inches. Often, after transition and just before you feel like pushing or bearing down, your contractions may space out or even stop for a while, allowing you to rest.

The contractions were coming hard, [but] I could actually sleep between them. It was all very surreal and otherworldly. Immense pain and then total relaxation. I felt like I was in a scene from
The Red Tent
[a novel set in biblical times; the title refers to a tent in which women gave birth]. I pushed from somewhere buried inside me. Deep, guttural, almost animal-like noises came from within me. Loud noises. Noises I soon had no control over. My body was pushing out my baby, and I was merely providing the sound track
.

More rapid, intense contractions, a powerful opening-up feeling, and rectal pressure (a sense that you need to have a bowel movement) are signs that you are completely dilated and ready to push your baby down through your vagina and give birth. Pushing can be a great relief because it requires you to become an active participant, in contrast to the yielding and letting go necessary for active labor.

After a few pushes, I somehow realized that I had to change gears
. Pushing was up to me.
I wasn't supposed to lie there and cope with it, counting and breathing and moaning until it was over. It was time to be active, to decide when to push, when to breathe, when to rest
.

Pushing your baby out works best when you do just what your body wants, without external direction. Bear down when you feel the urge—an innate reflex stimulated when your body produces high levels of oxytocin in response to pressure from your baby's head low in your pelvis. In the past, women were taught to hold their breath and push during each contraction. Many providers may still tell you to hold your breath and push down as hard as you can for a count of ten. But breath holding and sustained, directed bearing down can be exhausting and frequently do more harm than good. Studies of women in labor have shown that holding your breath can increase the chance of worrisome fetal heart rate patterns because your baby does not get as much oxygen when you push this way.
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With gentle support and positive feedback, you can follow your own urges and find a rhythm that feels right and moves your baby down. You or your labor support companions may need to tell your care providers not to direct you how and when to push.

When I was pushing, really pushing, I felt powerful. When I realized that I was in charge of pushing, and when I felt my contractions as guides to how often and for how long I should push, I started to reel in my mounting panic and to harness my energy
.

Depending on the baby's position, pushing can sometimes be very painful and very hard work. Change positions to relieve pressure points and to find positions that are more comfortable for you. Sometimes pushing while sitting on the toilet can be effective, as we are psychologically conditioned to relax our pelvic muscles there. Being upright (leaning, squatting, hanging from something or someone) may
lessen pain and backache. Upright positions may also help align the baby in your pelvis better and open the pelvic bones a bit to give the baby more room, allowing her or him to navigate through the birth canal more easily.