How to Keep Normal Labor Normal – Part 6 – Pain Control

This blog series is designed to help women who are developing a birth plan join together with like-minded birthing professionals so as to have a shorter and safer labor and birth. Although written primarily for professional birth attendants, I hope information will be helpful to lay women planning their birth. Today we’ll look at the fourth “P” of my 10 “P’s” of keeping labor shorter and birth safer — pain control.

“Controlling the pain of labor without harm to (the) … labor process remains a major focus for maternity care.”(61) This focus has resulted in the escalation of epidural use, despite the fact that epidurals continue to be controversial.

Even so, meta-analysis and critical reviews are available.

“Epidural, when properly administered, provides excellent analgesia, although it is associated with prolonged labor, results in higher rates of instrument-assisted delivery, increased use of oxytocin, and possibly increased cesarean -section rate…as up to 47% of fetal heart rate tracings may be abnormal after epidural blockade.”(5)

One meta-analysis says that “recent study contains well documented data showing an approximate increase of two hours in the length of the 1st stage of labour.”(62)  A population based study says that “epidural use increases the average length of second stage of labor by 38 minutes in primiparas and 23 minutes for multiparas.”(63)

Another tact of the attack on epidurals says that “women who receive an epidural were 4.3 times more likely to have a cesarean than those who did not (17% vs 4%) … when all factors were controlled for, epidural anesthesia was associated with a 3.7 fold increase for cesarean section, and a 6.5 fold increase for failure to progress. They also had slower rates of dilation (0.5 vs 1.2 cm/hr).”(64)

However, meta-analysis data seem to confirm this criticism:  “There is a significant increase in the cesarean section rate in the three largest studies which were of sufficient size to report an incidence of cesarean section. The major reason for this seems to be an increase in the cesarean section rate for fetal distress.” (62)

“The only two trials in which relevant data were reported confirm that epidurals predispose to a two fold increase in the incidence of malrotation of the presenting part, and a four fold increase in the use of instrumental delivery.”(62)

One meta-analysis summed it up this way, “…Given such strong evidence of the effects of epidural analgesia on the dynamics of labour, a mother receiving epidural analgesia can no longer be considered to be having a ‘normal’ labour.”(62)

If this is true, then it follows that avoiding epidural, by definition, will help keep normal labor normal, at least until further study shows that different techniques dispel these criticisms.

Although whirlpool baths in labor (called by some “the midwives’ epidural”(65)) seem to have “…positive effects on analgesia requirements, instrumentation rates, condition of the perineum and personal satisfaction…”(65), all of which help keep normal labor normal; however, they may significantly lengthen labor.(65,66)

Overlooked by many maternity caregivers is the literature that says, “…Many simple, effective, low-cost methods to relieve labor pain can be initiated by nurses, midwives, or physicians with the potential benefits of improved labor progress, reduction in the use of riskier medications, (improved) patient satisfaction, and lower costs … Unfortunately, training and practice in the use of these measures are not included in the education of most maternity caregivers … This lack of knowledge is at least partially responsible for today’s reliance on drug management of labor pain.  Employing a broad range of effective and simple techniques can promote the laboring woman’s physical comfort … and labor progress.”(61)

Here’s the entire series:

  1. Philosophy,
  2. Partners,
  3. Professionals,
  4. Pain control,
  5. Procedures,
  6. Patience,
  7. Preparation,
  8. Positions,
  9. Payment, and
  10. Prayer.

Citations:

(5) Smith MA, Acheson LS, Byrd JA, et. al. A critical review of labor and birth care.   J Fam Pract 1991;33:281-292.
(61) Simpkin P.  Reducing pain and enhancing progress in labor: a guide to nonpharmcologic methods for maternity caregivers.  Birth 1995;22:161-71.
(62) Howell CJ.  Epidural vs non-epidural analgesia in labour.  In:  Pregnancy and childbirth module (eds. Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP), ‘Cochrane Database of Systematic Reviews’: Review No. 03399, 6 May 1994.  Oxford: Update Software, 1994, Disk Issue 1.
(63) Johnson S, Rosenfeld JA.  The effect of epidural anesthesia on the length of labor.  J Fam Pract 1995;40:244-247.
(64) Stephenson J.  Epidural during first stage of labor quadruples risk of C-section.  Fam Pract News 1995, March 15:29.
(65) Rush J, Burlock S, Lambert K, Loosley M, Hutchison B, et. al.  The effect of whirlpool baths in labor: a randomized, controlled trial.  Birth 1996;23:136-43.
(66) Bastide A.  A randomized, controlled trial of a whirlpool bath on labour, birth and postpartum.  In: Chalmers I, ed.  Oxford Database of Perinatal Trials, version 1.2, disk issue 8, record 5789.  Oxford: Oxford University Press. 1992.

6 thoughts on “How to Keep Normal Labor Normal – Part 6 – Pain Control

  1. amanda

    While I agree with the principle of this blog post, I find it disappointing that none of your referenced citations were published in the last decade!

  2. Dr. Walt Post author

    This is a reprint of an article I wrote in the past. Thus, the age of the citations. However, truth is truth irrespective of the age of citations, eh?

  3. Heather

    Thank you for this, Dr. Larimore. With the birth of my first child, I had wished to go drug-free, but after being induced and experiencing horrible back-labor, this no longer was a goal I could attain. I had 2 reasons for not wanting an epidural: the possibility of spinal headache and lack of desire to nurse in the newborn. Unfortunately, both came true for me. I am now pregnant with our 2nd child, so as soon as I finished reading this blog, I hopped on the internet and found a Bradley Birthing Method class to attend with my husband in the hopes that I will be drug-free the second time around!
    Thanks again!

  4. Amanda Geidl

    Dr. Larimore, I love reading that research is confirming what God has known to be true for a long time–women’s bodies were made for giving birth. While it is painful, it is manageable. I loved reading Dr. Bradley’s book, _Husband-Coached Childbirth_, as well as Ina May Gaskin’s book, _Ina May’s Guide to Childbirth_. Both books inspired me and gave me the confidence I needed to have a medication-free delivery (which was by far my shortest and smoothest delivery!). It was also my favorite birth b/c Dave was much more involved than when I had epidurals. It also helps to not give in to fear of pain. Fear is from the enemy, and if you work with your body, you can manage your pain. Even though it hurt, I embraced it, and I would do it all over again, no changes. I also enjoyed having an FP instead of an OB/GYN. Adam Myers is by far the most supportive doctor I’ve ever worked with in labor.

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