Patient perspective: Managing pain during labor and delivery

INTRODUCTION — This topic was written by an individual patient. It is intended to offer clinicians insight into the experience of a single individual from that individual's point of view. This description of a particular patient's experience is not intended to be comprehensive or to provide recommendations regarding diagnosis, treatment, and/or medication information. It is not intended to be medical advice or to be a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances.

For related clinical topics, please see:

●(See "Preparation for childbirth".)

●(See "Nonpharmacologic approaches to management of labor pain".)

●(See "Pharmacologic management of pain during labor and delivery".)

●(See "Neuraxial analgesia for labor and delivery (including instrumental delivery)".)

●(See "Continuous labor support by a doula".)

UpToDate also offers patient education materials. "The Basics" topics are short overviews written in plain language, at the 5^th to 6^th grade reading level, that answer the main questions a patient is likely to have about their condition. You can share this content directly with your patients:

●(See "Patient education: Managing pain during labor and childbirth (The Basics)".)

●(See "Patient education: Labor and childbirth (The Basics)".)

MY PREGNANCY — This was my first time being pregnant. I was 29 years old when I gave birth. I didn't have any problems becoming pregnant or any complications during my pregnancy. My doctor never had concerns about me or my baby.

LABOR

At home — My labor started at 40 weeks and 1 day of gestation, when my bag of water broke at midnight while I was asleep. I didn't feel any contractions and slept soundly until 7 AM. At that point, I called my doctor to let her know my water had broken but my contractions were minimal. I spoke with my doula as well, and we all decided that I should try to labor at home as long as I could. Though I wanted to give birth in the hospital, I also wanted to minimize interventions.

I went for a walk and then bounced on my ball, at which point I had a gush of vaginal fluid with a small amount of meconium in the fluid. I called my doctor and told her I was coming in.

Admission to the labor and delivery unit — I was admitted to the labor and delivery unit around 10 AM, accompanied by my husband and doula. I had been 3 cm dilated at my last office visit and was 5 cm dilated on admission to the labor and delivery unit. My contractions were very easy to deal with so I thought I was just excellent at handling labor; however, both my doula and my doctor assured me that my labor hadn't quite kicked in. My doctor wanted to give me oxytocin to get the labor going since my membranes were ruptured and meconium was in the fluid. I agreed. Once the oxytocin kicked in, labor became intense.

Experiencing the pain of labor — My husband and doula helped me manage my contractions with various exercises and movements. I was able to move around and bounce on a birthing ball. I felt that I was handling my contractions.

After a few hours, my doctor wanted to check my cervix because she thought I may be entering the second stage. Although my contractions were painful, the cervical check was even more painful: 10 out of 10, I could barely be still, and I felt like my insides were being scraped open. I was also only 8 cm dilated and stayed at 8 cm for the next hour and a half. The idea of having to experience more cervical checks before I had to push threw me over the edge. I was also terrified that the pain of pushing would be even worse. Though I went into my birth knowing that I wanted to minimize interventions, I was also open to getting an epidural, and I knew I wanted it at this time. I said "umbrella" to my doula, which was the "safe word" that I chose before labor to indicate to her during labor that I had changed my mind about not having an epidural.

Getting the epidural — We called my doctor in, and she told me it was unlikely I would be able to get an epidural because the anesthesiologist on duty was very busy. I was nervous, but I knew I had my doula and my husband to support me. Luckily, the anesthesiologist came into the room not long after. I was able to sit still while he gave me my epidural. I went from feeling exhausted and in pain from every contraction to having no contraction pain, which gave me an immense sense of relief. Within 30 minutes of getting the epidural, I was 10 cm dilated and ready to push.

Pushing and giving birth — I pushed exclusively on my back with my legs in the air because I thought I had to do this with the epidural in place. At the time of birth, I didn't weigh my options and assumed that birthing on my back was the only option. In retrospect, I wonder if other positions should have been discussed with me, such as birthing on my side, sitting upright, or squatting. The option to birth in a different position was never offered.

The nurses and my husband held my legs at various points. While the epidural had provided tremendous relief, I could feel pressure from pushing. I pushed for about two hours. When my baby was crowning, I did feel a tremendous burning sensation. I gave birth at 7:30 PM that night. She was large (9 pounds, 2 ounces) and perfectly healthy.

I had a second-degree tear. My doctor delivered the afterbirth and stitched me up while I had skin-to-skin contact with my baby. Between meeting my healthy baby, the hormones, and my epidural, I felt only happiness and intense relief.

MY THINKING ABOUT PAIN MANAGEMENT — I came into my prenatal care knowing that I wanted to try for an unmedicated birth. I was fortunate to work with a doctor who was in favor of minimal interventions during my birth and who understood my goals and desires. She was the person who recommended my doula. My doula gave birth to two of her own babies with this doctor and had done so naturally with no epidural.

Months before giving birth, I was asked whether I wanted to have an epidural during my delivery. I answered no, but I was not opposed to an epidural if I felt like I needed one. My reasoning was twofold: I wanted to see if I could give birth naturally, but I was also concerned about the potential complications of getting an epidural. I'd heard that epidurals could decrease the efficacy of my pushing, increase my time in labor, and could potentially increase the chance of having a cesarean birth. I discussed my concerns with my doctor prior to going to the hospital. My doula also helped me plan for a natural birth with the understanding that I could potentially opt for an epidural.

I was aware of the use of both inhaled and intravenous medications for labor pain. Inhaled medication was not offered for pain relief at my hospital. If it had been offered, I likely would have tried it before opting for an epidural. I was not well counseled on intravenous medication, and it didn't occur to me as an option during my labor.

COMMUNICATION

What went well

●My obstetrician definitely incorporated the core concepts of patient- and family-centered care. She respected and honored my choices, shared information with me during appointments (when I asked for it), and encouraged my participation and collaboration in my care. She also encouraged my outside research about my options for managing pain during my birth.

●I feel that my choice to get an epidural during my birth impacted me positively. While I was fortunate to have had a comparatively easy labor, I think that choosing to get the epidural when I did saved me from the pain of cervical checks and the more intense pain of active labor. I was also able to rest before I started pushing, which I believe made an enormous difference for my stamina.

What could have been done better

●I never received any literature or information from my provider or my practice about receiving an epidural, despite the fact that they asked me about this decision fairly early in my prenatal care. I think that pamphlets or other literature, as well as some education about epidurals from medical professionals, should be standard in educating patients about their choices. The only reason I had the information that I did was because I took a birth class, did my own independent research, and consulted with a family member experienced with labor and delivery both as a certified nurse midwife and a mother.

●I was aware of some potential complications of epidurals. The main side effects that concerned me were headaches, itchy skin, and insufficient pain relief. I was also worried that having an epidural might prevent me from pushing well, which could lead to a cesarean birth. At the time of my decision to have the epidural, the potential side effects seemed acceptable if I could get relief before I needed to push. I was concerned that I would become too exhausted to push effectively without the epidural.

Fortunately, I did not experience any of the side effects that concerned me. Unfortunately, everything I knew about the side effects of an epidural was from my own independent research. Without the birth class I took or the information I got from medical providers in my own family, I might have thought epidurals did not have side effects. My providers did not discuss any side effects of epidurals during my pregnancy or before I received one in the hospital.

●I didn't have much time in the hospital to decide about getting an epidural, and I think my provider assumed I was informed on my decision. Immediately prior to getting my epidural, I was neither encouraged nor discouraged from seeking a second opinion or consulting with family members, but I don't think either of these things would have changed my decision.

●I wish I understood the costs of receiving an epidural (which ended up being expensive). This was not covered by the deposit that I put down to have my doctor perform my delivery. I was billed by the anesthesiologist's practice separately. No one ever counseled me about the potential cost of getting an epidural.

●I had limited contact with the anesthesiologist who performed my epidural. He made inappropriate jokes before the procedure, did not provide me with information, and did not seem to encourage participation or collaboration among me, my husband, my doula, and himself. I never saw him again after the procedure or received any follow-up contact.

●I wish I had known how long the numbness from my epidural could potentially last and wish that I had more support from the nursing staff after giving birth regarding the ongoing effects of the epidural. I was unable to move well because of this, though I didn't fully understand how numb I was until I tried to go to the bathroom. One leg was still numb 14 hours after my baby was born. It took another two hours for the numbness to completely wear off.

●I wish that my providers would have impressed upon me that going to the bathroom (because of birth, but more so because of the numbness) would be extremely difficult. After giving birth, the hospital seemed short-staffed. I felt that I wasn't given as much support for self-care, breastfeeding, and baby care as I would have liked. I almost fell when I tried to get out of bed, even with assistance, because I didn't realize the extent to which the epidural affected my mobility.

FINAL THOUGHTS — I would not encourage or discourage someone else to choose an epidural; I realize that my experience is different from those of other people, and I think this choice is very personal. While I was glad that I received an epidural, I don't think this is the best decision for everyone. I know some people do not want to experience the pain of childbirth. I would advise those people that getting an epidural is likely a good decision for them. I would encourage any pregnant person to learn more about epidurals and their potential side effects before making the decision whether or not to have one.

If I had experienced some of the side effects of epidurals, such as headaches, itching, or complications leading to a cesarean birth, I would not have felt that this was a positive choice. I will always wonder how I would have fared without an epidural, and I still wouldn't choose to have one for future births without first seeing how my body responded to labor. I learned that I could trust my body and my pain cues to make the right decision for my care.

RESOURCES — One resource that I consulted frequently was Evidence Based Birth (https://evidencebasedbirth.com). I used this website frequently to make decisions about my birth plan, including whether or not to get an epidural. I think everyone should have access to birth classes, whether online or in person.