Her Body: How to Manage Labor Pains

It's the part of pregnancy women least like to think about: delivering the baby. But in the last 15 years, a quiet revolution has been taking place. More women have decided that they'd rather not experience quite so much pain when they give birth. In the late 1980s, national surveys indicated that only about 20 percent of pregnant women got an epidural—a spinally-administered anesthetic that blocks pain in the lower half of the body—while in labor. That proportion has now climbed to two-thirds, recent surveys reveal.

Despite this increase in interest, many women still don't know a lot about their pain-relieving options, says Dr. William Camann, an associate professor of anesthesia at Harvard Medical School. Even if a mother-to-be attends childbirth class, chances are her instructor will stress either natural delivery (read: no drugs) or encourage epidurals. This can be a problem because the course of any one woman's labor and delivery is unpredictable. Women who plan on one route may find themselves detoured to the other.

That's why Camann has written a new book, Easy Labor (Ballantine Books, January, 2006) , to give pregnant women a comprehensive overview of all their options, not only for pain relief during delivery but for making labor more comfortable. Camann spoke to NEWSWEEK about what women need to know. Excerpts:

NEWSWEEK: What options do pregnant women have these days in terms of pain management?

Camann: There's the standard epidural, which involves hooking up a [spinal] catheter to a pump, and infusing the patient at a constant rate. Then there's the patient-controlled epidural. The infusion is hooked up to a button. When the woman pushes the button, she sets her own dose. She can tailor it to how much pain relief she needs. Research shows that when the patient has control of their pain medications, they actually tend to use less and they feel more satisfied. Not only do they get exactly what they need, but they also feel more in control. That's especially important during a woman's first birth when everything seems so foreign and scary and they don't know what's going on. Some women are afraid that they'll overdo it, but these systems are set up so that you can't overdose yourself. Then there's the combined spinal. It combines a spinal injection and an epidural injection, and both are done with the same needle. The advantage is that the woman experiences almost immediate pain relief, compared to the standard epidural that can take 10 to 20 minutes to work.

Do most women know in advance what they want out of labor, besides a healthy baby?

Most women think they know what they want. Some come in with very rigid goals: They don't want an epidural, no matter what. I have seen women come in with the most excruciating labors-you can hear them screaming in agony-but once they go through the delivery, they say it was the most wonderful experience, and they are very satisfied that they didn't use any medication. There are other women who don't want to feel any pain whatsoever, and want an epidural to start with the first contraction. But others find out that it hurts more than they expected or labor proceeds very differently than they expected, or some other complication comes up, like an infection, and they change their mind.

What are some of the hardest cases to call?

Some women plan to get an epidural, but by the time they get to the hospital, they're literally minutes away from delivering. Some nurses and midwives will tell these women to just push through it. But others would say that's the equivalent of saying to a man, "Is it okay if we put a clamp on your testicles for the next 10 minutes?' There's no man in the world who would say they wouldn't rather have pain relief in that situation, so I don't think it makes sense to say to a woman, it's only 10 minutes. If she planned on an epidural and wants an epidural, I think she should have it. If she doesn't want one, that's fine too. Women come in wanting a certain kind of experience and I think it's important not to downplay the importance of that.

Why do so many more women today opt for an epidural? Is it because they're hearing that they're better than they used to be or are they hearing that labor hurts?

Both. Word of mouth is a powerful thing, and women are hearing that epidurals a lot better than they used to be. When I first started training in the early '80s, you got what we called a "paralytic epidural'. The medicine was so strong that you couldn't move your legs and couldn't even move from side to side. You couldn't feel anything below the abdomen, so some women had a hard time pushing. Doctors often needed to use forceps to delivery the baby, and that made for some bad experiences. In addition, women's legs could remain numb for 12 to 24 hours after the delivery. Today, the cocktail of medicines we use allows women to feel the tightening of the contractions so they assist with the pushing. These medicines provide really good pain relief but give women the ability to move their legs and even get up and walk around. The block also wears off more quickly.

What kinds of risks are associated with epidurals?

When they hear the word "spinal', women are often afraid that they could end up paralyzed or experience spinal cord damage. The chance of that is so rare as to be nonexistent. During my 20 years of personal practice, I've done probably 10,000 deliveries and have never seen anyone paralyzed. What's more common is that your blood pressure can go down, but that's easily treated. Very frequently, women experience itching. This does not indicate an allergic reaction. Itching is just a side effect. Sometimes, women experience soreness in the lower part of their back, especially at the needle site. The issue of back ache has been studied extensively, and women experience the same incidence of it whether they have an epidural or not. It does not indicate back damage. Another risk, especially for first time moms, in a small percentage of cases, is a mild elevation in temperature that is not related to infection. It just seems to affect the way the body handles temperature regulation.

Is there a downside for the baby if the mother gets an epidural?

Anything that is injected into the mother will eventually get to the baby, but it's a very small amount, almost not measurable. There have been a number of well done studies on its effect on babies, in terms of their responses to breast feeding and bonding and other things, and the babies have been unaffected.

Are there any differences in their Apgar tests, the screen babies get right after they are born?

No. There have been many, many studies on that, and the answer is no.

Does a mother-to-be get to pick the type of epidural she gets?

The general answer is no. But I don't think it's unreasonable to ask about it. Some hospitals may not do combined or patient-controlled epidurals, but I think it would be fine to say you've read about these things and want to know if they offer them at your hospital.

You mention in your book that water treatments are among the most popular alternatives being offered by hospitals today. What's that about?

Water treatments are becoming extremely common and they are extremely efficacious. Most women are aware of the soothing effects of a warm bath or hot shower on a sore muscle. Your uterus is a muscle and it's getting a real workout during labor. A warm tub can offer significant pain relief and if nothing else, is a good distraction.

Is there any downside to this?

As long as it's done in a reasonable environment, the safety record is tremendous. Most women labor in water and then get out for delivery. It's less common, but some women give birth under water. The babies don't take their first breath until they come out of the water. That's becoming more common in birthing centers. It's much less common in hospitals.

What about acupuncture, hypnosis and massage?

All are becoming more common and some people do a combination of things. A technique we're seeing more of is hypno-birthing. You need to take classes in advance. Some women bring their instructors with them or hire a doula ( an ancient word for a birthing assistant) to do it with them. It can be extremely effective, and it's compatible with having an epidural. The same is true of acupuncture or massage, but I don't think acupuncture is all that effective during labor and massage is more of a distraction. Women use these techniques during early labor and get as much efficacy out of them as they can, and then, if they decide that they want to get an epidural later, they can. Some women also request that the lights be turned down and that music be playing. That can be very soothing and it creates a nice situation.

Are most hospitals open to these things?

Change comes very slowly in medicine. Many people in labor and delivery look at any alternative providers as a threat to their territory. But I am seeing attitudes changing and I think more hospitals are more willing to allow women to bring in a midwife or doula or alternative provider. The majority of these providers are wonderful and fit in beautifully and know their role.

Are there any alternative approaches that you feel uneasy about?

There are a variety of herbs and natural medications that some women use and we don't have good safety records on these things. Some may affect your blood's ability to clot or induce labor and some are dangerous. The same is true of some of the enemas women use as a natural way to induce labor. Another thing that is not a good idea is using sexual intercourse to induce labor. There are some reasons why it might work, but for some patients, this is not a good idea, especially if your membranes are ruptured or there's any sign of infection.