Pain-Free Labor and Delivery

Many pregnant women near their delivery date have preconceived notions about the management of their labor and delivery. Some plan a “natural” delivery, some want only intravenous opioids for pain relief, and others want an epidural anesthetic as soon as possible. For women who have never undergone surgery, the pain of labor can be the worst they have ever experienced. Roughly half of the pregnant women who plan a “natural” delivery change their minds during the course of the first stage of labor and then rely on an epidural anesthetic as their only tolerable choice. Nearly all women in labor who have had an epidural anesthetic for labor and delivery in the past are happy to receive another epidural anesthetic, and they do not wait until they have severe pain to ask for epidural anesthesia.

Opioids are lipid-soluble chemical compounds that can bind to specific receptors in the brain, spinal cord, and GI tract. Intravenous opioids produce pain relief primarily through their action in the brain, which tends to blunt the higher level, complex, comparative thinking processes. In effect, intravenous opioids makes one care less about pain, but doesn’t attenuate or eliminate it. Even with freely self-administered patient-controlled intravenous opioid therapy, the average reported pain score is 3 on a scale of 1 to 10. Since all opioids can cross the placenta, they also have the potential to enter the fetal circulation where it can lead to slowing of the fetal heart rate (a potentially ominous sign from the obstetrician’s point of view) and to slowing the fetal respiratory effort at birth (a potentially ominous sign to the neonatologist who may need to intervene with neonatal respiratory support measures).

A vaginal delivery without an epidural anesthetic is as natural as a vaginal delivery with an epidural anesthetic. The safety of the mother and baby are the most important outcomes. An epidural anesthetic can be administered in a pain-free manner in just a couple of minutes, and it can eliminate the pain of uterine contractions while having no detrimental effect on fetal well-being. By administering a continuous infusion of dilute local anesthetic with a tiny dose of an opioid into the epidural space, women can remain pain-free throughout their labor and delivery. The average reported pain score of women in labor with an epidural anesthetic is between zero and 1 on a scale of 1 to 10. Should the need arise to proceed to a cesarean delivery, the anesthesiologist can administer a concentrated local anesthetic via the epidural catheter to insure a pain-free surgical experience. After delivery, one small dose of epidural morphine (4 milligrams) will provide profound pain relief for 20-24 hours after surgery.

The most recent anesthesia literature supports a modification to routine epidural anesthesia: combined spinal-epidural anesthesia (CSEA) for labor and delivery. Using this technique, the obstetric anesthesiologist identifies the epidural space in the same manner, then inserts a 27-gauge spinal needle through the epidural needle and into the cerebrospinal fluid of the pregnant patient. Sterile injection of a 2.0 ml solution containing bupivacaine 2.5 mg and fentanyl 4 mcg into the spinal fluid produces profound pain relief (pain score of zero) in less than one minute. No other method or technique can compare. The 2.0 ml solution is not difficult to obtain: it is the exact same as taking 2 ml from an epidural infusion bag that contains 0.125% bupivacaine with fentanyl 2 mcg/ml – a standard epidural infusion cocktail. By using a 27 gauge spinal needle, the risk of spinal headache is zero. After the spinal injection, an epidural catheter is inserted and used for routine epidural anesthesia for labor and delivery. Finally, although we don’t know the scientific basis for this result, it has been discovered that the first stage of labor among women who receive CSEA is shortened, compared to the duration of the first stage of labor among women who receive routine epidural anesthesia. CSEA produces rapid, profound pain relief and shortens labor. There isn’t a laboring patient, OB nurse, or obstetrician that doesn’t appreciate that.

Most hospitals have obstetric anesthesiologist on duty 24/7. Take the time to discuss the options for epidural anesthesia with the obstetric anesthesiologist on duty. You may be talking to your new best friend!