Labour and delivery is a joyful process sans pain.

Is painless delivery possible?
You can have an amazing experience during labour and delivery without having to experience the pain thanks to the advancements in medicine.

29 year old pregnant mother was induced labour after her waters broke around 1pm as she had no spontaneous uterine contraction a phenomenon associated with delivery. After induction, she started getting contractions around 8pm. Her contractions that are helping her deliver baby were strong. As obstetrician I’m happy with the progress but patient had other troubles. The contractions were very painful that she started requesting caesarean section just because of the pain. Labor analgesia(pain relief) played a role here. After a discussion about labour analgesia, which she was aware in the antenatal period, she opted for Epidural analgesia. epidural analgesia was placed at 9pm and she progressed and delivered vaginally at 5am. Her total labour time was 9 hours of which she had good and adequate pain relief for 8hours.

As obstetrician, during routine antenatal visits I discuss about well being of mother and baby to the expectant mothers. So do we speak about painless delivery options at around 36 weeks of pregnancy. Mothers, while they listen to the options, they don’t give much thought about it. It is time for them to be happy with the anticipation of new arrival to their family as well as anxiety about health of the mother and baby. Delivery process takes a back seat and painless delivery options flashes in their mind only when the labour pain starts hurting them. The article is to highlight how delivery can be a double delight with available painless delivery options.

How and when it started?
Initial steps of painless delivery:
Many scientific advances have met with resistance in its nascent stages. Painless delivery is no exception. Religious taboos proved to be hurdle for anaesthesia or any pain reducing measures to delivering mother in mid 1800. Simpson JY administered first obstetric anaesthesia amidst public and peer resistance. John Snow’s (of course, not from Game of Thrones) willingness to provide analgesia for Queen victoria’s delivery paved way for future. Anaesthesia and, obstetric anaesthesia in particular took a huge leap from there. Nowadays analgesia during delivery is a common practise in many western countries.

The initial uterine contractions are mild in intensity and are infrequent. As labour advances, both the strength as well as frequency of contractions increases. So does the associated pain.

What are the options for painless delivery?
There are non pharmacological and pharmacological methods of pain relief.

Nonpharmacological measures:
Breathing, relaxation and massage

The evidence suggests that breathing and relaxation techniques can reduce measured pain. Massage may alleviate the symptoms of pain through relaxation and reduction of anxiety.

Hypnosis and acupuncture have no proven clinical benefit, although they may assist the mother psychologically and potentially reduce the need for further analgesia.

The psychological impact of continuous support by partner during labour has been associated with a reduced requirement for analgesia.

These therapies need no additional drugs but needs training during antenatal period and cooperation of mother during intrapartum period. The degree of pain relief provided is only very limited and rarely can be sole analgesic modality on their own.

Pharmacological methods
Gas and Air (Entonox)
Gas and air is a mixture of Nitrous oxide gas and oxygen. It reduces the pain but won’t remove completely. Mother has to breathe in the gas and air through a mask or mouthpiece just as contraction begins. It takes about 15-20 seconds to work and works best if mother takes slow, deep breaths. However, for many parturient women Entonox alone does not provide sufficient analgesia for all of labour. It may not be easy for mothers to coordinate contraction with inhalation of entonox. Most mothers may not be able to continue to inhale Entonox in later stages of labor as intensity of pain increases. In short this modality needs the mother who experiencing pain to make effort to provide their own analgesics.

Pethidine injections in labour
Injection of the drug pethidine into the thigh or buttock to ,help the mother to relax. It takes about 20 minutes to work after the injection. The effects last 2-4 hours. The pain relief is better than the previously described methods but do not match the duration of labour. Mothers needed to be given repeated injections. The repeat dose wouldn’t be recommended if She is close to the pushing (second) stage of labour as these drugs can enter baby through placenta. This can affect baby’s breathing when they are born. Pethidine or similar group of drugs in mother can cause dizziness, slowing of breathing of mother, nausea and vomiting. Some of these effects can be reversed by another group of drug but may also reverse the pain relief.

Epidural Anagesia
This is considered the best available method to provide pain relief during the labour. An epidural is a special type of local anaesthetic technique that can be used during entire labour duration. It numbs the nerves that are involved in carrying the pain impulses from the birth canal to the brain. For most women, an epidural gives complete pain relief. It is helpful for women who are having a long or particularly painful labour.

This technique has been enormously analysed in medical literature and has a proven track record with good quality pain relief with few side effects. Epidural is not totally free of side effect but those are few and nothing has any short or long term maternal or fetal effects. During a antenatal visits closer to due date mothers can have a visit to anaesthetist for any clarification regarding labour epidural.

Labour and childbirth exists since humans evolved. It’s time we incorporate medicine to our advantage and utilise the comfort it provides. Making a timely decision about painless delivery is prudent. Happy birthing.

Dr Indumathy (OBG)

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