Women in the United States have far less options for pain management than women in many other developed countries. Most hospitals in this country mainly offer Epidurals or IV opioids for pain relief during labor. These interventions tend to weigh riskier than some medical alternatives. If the hospital does offer other forms of pain management, they are not made known to the birthing woman and her family. Many countries have other pain management strategies such as hypnosis, acupuncture, and electrical stimulation all of which can be very helpful techniques. While in this blog we are primarily focusing on medical alternatives I do go in depth into alternative pain management techniques in my Preparing for Childbirth course. If you are interested in this course email me at maggie@marigoldmaternity.com

Why might one consider alternative pain medication?

It is well known and researched that an Epidural, in many cases, is the most safe and effective form of pain relief during labor. This relief, as well as all pharmacological pain relief options, however, do not come without risks. The epidural specifically can Increase the likelihood of additional medical interventions and ultimately increasing the likelihood of a C-section. In addition to the risks and side effects this form of pain medication in most cases reduces or eliminates completely the birthing mother's ability to be mobile during labor. Movement being one of the most helpful, if not the most helpful form of natural pain relief.  If your goal is to have a natural birth it is worth considering alternative pain management medications if you feel you need something during labor. I go more in depth about the epidural in this blog as well as why to think twice about an epidural in this blog.

Nitrous Oxide

Nitrous Oxide is a medical drug that is typically used in dental work as a systemic analgesic or whole-body pain relief. It has been used for pain management for over 100 years and is common for childbirth pain relief in many other countries despite its nuance in the United States. Statistically, it’s used in about 40% of births in British Columbia and Canada, 50% of all births in Finland, Norway, England, Australia, and New Zealand, 60% of births in other parts of the United Kingdom, and 70% of births in Sweden, and it’s even used in Hong Kong.  This form of pain relief is also becoming more common in the United States during childbirth due to its effectiveness for pain management and its minimal side effects. This drug is an inhalant which means it is breathed in as opposed to injected. It provides pain relief during contractions without total loss of feeling and limited mobility. 

What research shows us: 

One newer study published by Nodine et al in 2020, and it’s from a dataset called the I-NOW study looked at 463 people who had nitrous oxide during childbirth. This study showed us that 31% of women only used nitrous oxide while 69% eventually used another form of pain relief. Of that 69% about 91% decided to get an epidural while the remainder decided to use IV opioid or nerve blocks. When looking a those who used nitrous at any time during their labor the c-section rate was lower than the general average. Researchers think this lower c-section rate is due to the ability to remain mobile while using Nitrous as pain relief. While this study shows us that the majority of women decide to get another form of pain relief during labor, there was a study published in 2019 examining the effectiveness of nitrous oxide during childbirth. 

Published by Richardson et al in 2019, looking at 264 birthing women who had given birth vaginally, and only used nitrous oxide during childbirth. There were multiple key points recorded by healthcare providers regarding the quality of pain relief women received during labor. First many mentioned that the pain relief was temporary. Next was how the nitrous provided other effects other than just pain relief like reducing anxiety and helping them relax. They were also mostly pleased with how it allowed them to stick to their birth plan which in many cases was to avoid an epidural or other pain medication. Many reported how difficult the use of the machine was during labor. They also reported unpleasant side effects like nausea, vomiting, drowsiness, and dizziness. Overall, there were many compliments on the use of Nitrous oxide and how it helped them during their labor and births. 

Benefits of nitrous oxide: 

Regardless of the research above it is commonly reported that the use of Nitrous oxide is beneficial. Many who have used it previously report choosing it again as well as overall satisfaction with its use. When using Nitrous you still have the ability to use other forms of pain management. This drug also allows you to remain mobile and rely on more natural pain management as opposed to being bedridden when using an epidural. 

Nitrous Oxide can be used at any time during labor or even after labor while being sutured (if necessary) from a perineal tear. It can also very easily be stopped or switched to another form of pain management. It starts to work almost instantly upon inhalation whereas Epidurals or IV opioid injections can take 15-30 minutes to kick in. In addition to this Nitrous is less invasive than either of the aforementioned methods. 

There is also a lot more personal control you have over the use of this drug, being able to inhale when you need to for the duration needed as well as stopping when you are ready.  Without the lack of mobility there is no need for a bladder catheter or assistance in emptying your bladder. Since there is no limitation to ability you also are able to push in an instinctive position and allow your body to give you proper cues on when to push and how effective you are pushing. This allows for a more natural and physiological childbirth.

Risks of Nitrous Oxide: 

As with any form of medical interventions they do not come without risks. Some of these risks include having to hold the mask to inhale when pain relief is needed, sense of detachment, dizziness, drowsiness, nausea and vomiting. It is not recommended to combine Nitrous with IV opioids due to us sedative properties. In some cases, this can cause breathing difficulties and mild unconsciousness. Researchers have also found that nitrous oxide can disrupt cell function in both the mother and the baby for several days, called the inhibition of methionine synthase, this prevents enzymes from processing amino acids, which are the building blocks of proteins. The long-term impact of this is not yet known.  

A study in Norway found that exposure to nitrous oxide during childbirth may increase the risk of B12 deficiency in babies, and they suggest evaluating birthing people for B12 deficiency before recommending nitrous oxide. Nitrous oxide is also an NMDA antagonist. Which means it works by targeting the NMDA receptor, found on your neurons in your nervous system. Repeated multiple exposures to these types of anesthetics in young children have been associated with learning disabilities and attention deficit disorders, and researchers have found that exposure to nitrous in combination with other inhaled anesthetics can result in cellular death in rat or mice models, and non-human primate brain cells. Currently there are no reported or documented effects of exposure to intermittent 50% nitrous oxide, 50% oxygen during labor and childbirth causing neurological issues in children.

More on these narcotics

Pethidine also known as Demerol is commonly used in other parts of the world for pain relief during labor. However, in the United States it is rarely used due to its ability to cross the placenta and remain in the newborn for several weeks after birth. It also causes more drowsiness and sedation as compared to other injectable medications as well as the epidural. 

Fentanyl and Remifentanil have a short half-life meaning they do not last very long in the body because of this fact medication needs to be given more often. Typically for these medications a PCA pump or patient-controlled analgesia pump is installed so that the patient can press a little button to receive more mediation once it has worn off. These pumps are also equipped with a safety feature so that the patient does not receive too much medication. 

Nalbuphine, also known as Nubain, is another common opioid for use during labor, but some providers do not use it because it can slow down labor, even cause contractions to stall. Nubain does cross the placenta within five minutes of administration, and at 15 minutes, about 10 to 16% of the dose has entered the baby’s blood circulation. However,  Nubain is a mixed agonist antagonist which is a type of Opioid that is less likely to suppress your breathing or your baby’s breathing because of how the medication works.

Butorphanol, also known as Stadol, is another mixed agonist antagonist like Nubain. Because of this t’s also commonly offered during labor due to it being less likely to suppress your breathing or your baby’s breathing after birth. Now, Stadol does last a little bit longer in your body lasting from four to 10 hours until it is out of the patient's system.

The last option is Morphine, but it’s not used as much because it needs to be given in a pretty high dose in order to be effective, therefore there’s a higher risk of side effects. 

Risks of Injectable Opioids

Typically, these medications are only given in early labor and not in the pushing phase or closer to delivery to reduce the risk of them suppressing the baby's breathing and or heart rate after birth. Studies show that the use of injectable opioids do cross the placenta and can affect the baby. This can cause them to be sleeping for up to hours after birth, making initial bonding as well as breastfeeding challenging. Some medications do show risks of breathing problems for the mother as well. The pain relief from these medications may be unreliable when compared to the effectiveness of the epidural. In rare cases there are reports of maternal fetal arrest when using this method of pain relief. Side effects may include nausea, vomiting, drowsiness, dizziness, breathing problems, slowed reflexes, and confusion. 

Another injectable medication: Paracetamol

Another medication option called paracetamol also known as acetaminophen is often suggested by doctors to women who are in the early phase of labor or less than 4cm dilated.  It can be purchased over the counter or offered as an injectable medication in the hospital. Anecdotal evidence shows us that the use of this medication in excess may prolong the early or latent phase of labor due to its impact on prostaglandin production (prostaglandins being a crucial hormone in the progression of labor especially in the early stages.) However, another study shows that intravenous paracetamol as labor pain relief is effective, safe, cost effective, with no maternal or fetal side effects when compared to pethidine (a commonly used opioid for pain relief during labor.)

Risks of paracetamol

One study reported; “The relationships between prenatal APAP (paracetamol) exposure and adverse neurodevelopmental outcomes have been investigated in 29 observational studies in 14 cohorts including over 220,000 mother–child pairs from different parts of the world. Of these studies, 26 identified positive associations with APAP exposure during pregnancy and a range of clinically assessed and parent-reported neurodevelopmental outcomes, primarily attention deficit hyperactivity disorder (ADHD) and related behavioral abnormalities, but also autism spectrum disorder (ASD), language delays, decreased IQ, cerebral palsy, oppositional–defiant disorder, decreased executive function, and conduct disorders.." Consistent use of this drug during pregnancy has been shown to cause preterm birth and or low birth weight. There is an increased risk of cryptorchidism as well as other reproductive and urogenital disorders. 

Risks of the Spinal Block

It may decrease maternal blood pressure and in rare cases it has negatively impacted the fetal heart rate. Because of the total numbness this may cause difficulty pushing in the second stage of labor. A few side effects that have been observed are dizziness, itching, back soreness and in rare cases a bad headache and/or convulsions.

Local Anesthetic/ Pudendal Block

A pudendal block is a local anesthetic injection that might be used shortly before delivery to block pain in the perineum or between the vagina and anus. It is injected directly into the pudendal nerve which is located prior to injection by your provider in most cases either via internal vaginal exam or ultrasound. It can also be used to relieve pain during the repair of a tear after delivery. The local anesthetic is injected into the vaginal wall near the pudendal nerve and takes effect in 10 to 20 minutes. This form of pain management provides localized relief to the perineum, vagina and vulva which are the areas being stretched during labor and more specifically during the later stages. While this form of pain relief is known to be highly effective it does not eliminate the pain or discomfort from uterine contractions. Because of the localized numbing this block creates you are able to remain more mobile unlike the epidural. 

Risks of Pudendal block

The most common side effect of this method is discomfort or pain near the injection site. Less common is the risk of bleeding and or infection at the injection site. The location of this nerve is close to your sciatica nerve and in some cases this procedure can cause temporary leg numbness or unsteadiness. A few rare but more serious risks include pudendal nerve damage, injury to organs near this nerve like bladder or rectum and in some cases pudendal artery puncture leading to local anesthetic toxicity which is potentially fatal. 

Conclusion

Unfortunately, there is no perfect pharmacological pain relief for use during labor that is 100% effective and comes with zero risk. Being an advocate of informed consent, I believe that women and their husbands should know what all of their options are, and the risks + benefits associated with each, so they are able to truly make an informed decision. When it comes to these different methods of pain management it is a process of weighing the pros and cons and ultimately making the choice that feels best for you and your family.

This blog is a resource for information on many of the pharmacological pain management methods that can be using during labor and childbirth. I recommend consulting with your healthcare provider weather that be a midwife or OB on these different choices to see what is available and preferred in their practice.  It is important to remember that your doctors work for you and it is their job to answer any questions or concerns you have. 

Thankfully we do have many alternative pain management techniques that can be taught and learned with surprisingly high effectiveness rates. If you are interested in learning more about these more natural pain management techniques check out this blog. If you're pregnant and looking to learn these skills firsthand to help you have the natural birth you desire email me maggie@marigoldmaternity.com about my Preparing for Childbirth course.