How does Yale Medicine manage pain during vaginal childbirth?
Most women who have a vaginal delivery choose to have some form of pain relief. Here are some options:
Epidural: Many women giving birth vaginally are given an epidural, according to Dr. Braveman. In this procedure, the anesthesiologist inserts a needle into the lower back, putting the tip into the epidural space, which is in the outermost part of the spinal canal. Next a catheter is threaded into the space through the needle, the needle is removed and the catheter is taped in place.
The doctor administers pain medication, usually a combination of an opiate and a local anesthetic, through the catheter for as long as it’s needed, even if labor lasts for many hours. The medication diffuses slowly into the spinal space to reach the relevant nerve receptors. The goal of the epidural is to take away the patient’s pain,but not her ability to move.
“The epidural is the best pain relief in terms of quality, but not all patients need that level of pain relief and not all patients want it,” Dr. Braveman says. She notes that women with certain medical problems such as blood clotting abnormalities cannot have an epidural.
Spinal (subarachnoid block): A spinal provides pain relief even faster because pain medication is injected directly into the spinal space; but it will wear off within two hours. During this procedure, the anesthesiologist inserts a needle through a patient’s lower back to deliver a combination of an opiate and a local anesthetic into the spinal fluid bathing the spinal cord. In rare cases, a catheter is placed in the spinal space.
The pain medication quickly reaches the nerve receptors transmitting the pain signals and provides relief. After the spinal wears off, another injection is required for additional pain relief. “We don’t typically use a single dose of spinal medicine for a vaginal delivery unless we have a good sense that the patient is going to deliver quickly,” Dr. Braveman says.
Spinal/epidural: A combination of the above pain relief methods, the anesthesiologist will insert the epidural needle into the patient’s back, then advance a spinal needle through it to deliver a small dose of medication into the spinal fluid, which provides immediate pain relief. Then, the doctor advances a catheter through the epidural needle, removes the needle and delivers a continuous infusion of pain medication into the epidural space.
Nitrous oxide: Also known as laughing gas, the analgesic commonly offered for dental procedures, nitrous oxide makes patients feel euphoric and more physically comfortable. “It’s a bridge for many patients in early labor who haven’t decided yet if they want an epidural,” Dr. Braveman says. Yale Medicine obstetricians order nitrous oxide which is then administered through a mask. Many women who start with nitrous oxide opt to go on to have an epidural.
Injected or intravenous medications: Yale Medicine obstetricians can give pain medication, typically an opiate, through an intramuscular injection or intravenously. This approach is best for women who can’t have, or don’t want, a spinal or epidural but would like some form of pain relief.
What should a patient getting an epidural or a spinal expect?
A patient getting an epidural or a spinal will be asked to sit scrunched over with her back in a c-shape, which speeds the anesthesiologist’s work. (Some patients might lie on their sides instead.) The doctor may inject local anesthetic in the skin and then poke the larger needle in. “There’s uncomfortable pressure, but not quite pain, just like if you get an I.V. started,” Dr. Braveman says. “A laboring patient is usually so focused on her contractions that it’s not a huge discomfort.”
It’s important that a patient remain still while being given an epidural or spinal. “We can’t put a patient at risk for being injured because they can’t hold still while we push a needle into their back,” Dr. Braveman says.
An epidural takes about 10 to 15 minutes from the time the prep solution is on the back to when the patient is able to lie back down. A spinal is even faster when no catheter is necessary.
How will the patient feel after the epidural or spinal has been given?
With an epidural, the anesthesiologist will administer a test dose to make sure that the catheter is in the right place. “The patient might feel a little tingling in her leg,” Dr. Braveman says.
Once that wears off, and the proper medication dose is established, she’ll feel “what I describe as mild to moderate menstrual cramps,” Dr. Braveman says. “So they’re going to feel pressure in their belly, they’re going to know when they’re having a contraction, but it’s not going to be painful.” A spinal has a similar effect.
What are the risks of pain management for vaginal childbirth?
When a woman in labor is made more comfortable through pain management, especially with an epidural or spinal, her blood pressure may drop slightly.
“My assumption is always that the blood pressure they start with is the blood pressure the baby is happiest at—unless they have hypertension to begin with,” Dr. Braveman says. The anesthesiologist will manage a patient’s blood pressure, along with the pain with a combination of intravenous fluids and medications.
Another common side effect of an epidural or spinal is a headache related to spinal fluid leaking into the spine’s epidural space. Though not serious, the headache can be annoying. “It can last up to 10 days after the birth, but we can treat it,” Dr. Braveman says. “Depending how bad it is, we’ll go for more aggressive therapy versus ibuprofen.”
Many patients report a backache after giving birth, although this also happens to women who don’t receive an epidural or spinal. And some women may have tenderness where the needle went in.
How is Yale Medicine’s approach unique for pain management for a vaginal birth?
Yale New Haven Hospital is the only hospital in Connecticut that has dedicated obstetrical anesthesiologists caring for patients 24/7. A minimum of three anesthesiologists are available at all times. “Our only responsibility is to take care of the patients on the labor floor,” Dr. Braveman says.
Also, Yale Medicine anesthesiologists consult with high-risk obstetrical patients who are from 26 to 36 weeks of gestation about pain management for their delivery. These have included women with high blood pressure, rods in their back—"something other than just being a healthy pregnant woman," Dr. Braveman says.
"If it’s going to impact their obstetrical anesthesia care, we will do an in-person consultation with the patient and talk with the obstetrician so that we have a plan.” For example, many other anesthesiologists would not attempt an epidural in a patient with rods in her back. “We absolutely will,” Dr. Braveman says.
All women planning to deliver at Yale Medicine can discuss their questions with an anesthesiologist in advance over the phone.
This consultation service is unique in the state and ahead of most other academic medical centers, Dr. Braveman says. “Everyone is moving in this direction,” she adds. “We’re just a little ahead of the curve.”