Pain Relief-continued

For some women, neither natural childbirth breathing techniques nor short-acting narcotics provide enough relief. They prefer to feel no pain while remaining awake and aware. In the last 30 years, this preference became possible, with the advent of epidural anesthesia. Epidural anesthesia and its close relative spinal anesthesia are techniques in which the nerve roots of the spine are numbed with a local anesthetic. The effect is similar (and the drugs are similar) to numbing your mouth with novocaine in preparation for dental work. However, the numbing effect takes place over a much larger area, leaving you without sensation below the waist. Your labor continues, but you don't feel it.

Epidural anesthesia is administered through a tiny catheter (tube) placed in your back, overlying your spine. The catheter provides a continuous flow of anesthetic that bathes the nerve roots of your lower body as they leave the spinal cord. Usually, you receive continuous and complete pain relief. Sometimes, however, not every nerve root is reached by the catheter. In that case, you may have a "window," which is a small area that is not anesthetized. This can be very disconcerting, but it can usually be fixed by readjusting the catheter.

The advantages of an epidural are obvious: You can experience a pain-free labor while remaining awake and fully aware. There are disadvantages, though, and these are not trivial. Epidural anesthesia, if given too early in labor (before 4 cm. dilation) can slow the progress of labor significantly, often so much so that an intervention that will strengthen the contractions, such as Pitocin, is required. Epidural anesthesia can also anesthetize the nerves that control the diameter of blood vessels and thereby regulate blood pressure. After an epidural is administered, you may experience a temporary drop in blood pressure, which may decrease blood flow to the baby. This condition can be corrected with extra intravenous fluid or medication, if necessary.

Finally, an epidural can also anesthetize the nerves that control muscles, which may hamper your ability to push when the time comes. If the baby is small and your pelvis is large, this will be of no consequence; you will be able to push the baby out anyway. But if the fit is tight, this diminution of your strength may make it very difficult to push the baby out.

The rate of forceps and vacuum-assisted deliveries is much higher in women who have received epidural anesthesia, due to the temporary loss of muscular strength. Because the amount of anesthetic flowing through the catheter can be regulated, if the amount is lowered, you will regain some or all of your muscle strength. Of course, you will also regain some pain. The trade-off, then, is increased pain for increased muscle power. If you are anxious to avoid forceps or vacuum, this may be the right trade-off for you.

Spinal anesthesia operates on the same principle as epidural anesthesia and was often used in labor before epidurals became available. Because of its distinct characteristics, spinal anesthesia is now considered more appropriate for C-sections and forceps deliveries than for labor. Spinal anesthesia requires the injection of anesthetic directly into the space surrounding the spinal cord. It is administered in the same way as an epidural, but no catheter is left in place. Because only a one-time dose can be given, the amount of anesthetic injected in relatively large. This results in quick (5 minutes versus 15 for epidural) action and dense (strong) anesthesia. The anesthetic almost always affects motor nerves, and therefore muscle power, significantly. Most women lose control over their legs and cannot push effectively after a spinal anesthetic has been given. These qualities present severe disadvantages in labor, but make spinals especially useful during C-sections. They provide quick anesthesia, strong enough to allow major abdominal surgery with no pain at all. Best of all, the mother is awake and aware throughout the surgery.

Today, there are a wide variety of options available for pain relief in labor. Consider them all, and try to determine your preference, but wait until you actually experience labor before making the decision that is right for you. Above all, do not be frightened or disappointed if you find that labor is more painful than you anticipated, and that you need pain medication you thought you would avoid. Experience is still, after all, the best teacher.