Medications in Labor

3 Main Uses

1. Sleep: if a woman has early labor that goes for days, sometimes she will be given a sedative to help her sleep, a barbiturate such as Nembutal or Phenobarbital. These can relieve anxiety and induce sleep only in the absence of pain. If the woman is experiencing pain, sedatives without analgesics increase anxiety, may make her hyperactive and disoriented. Sometimes morphine is used for sleep; one study of morphine use found that after sleeping for several hours, 2/3 of the women woke up in active labor, but 1/3 woke up to find their labor had stopped.

2. High anxiety; mom experiencing excessive fear and apprehension which may complicate early labor. May be given sedatives or tranquilizers, such as Thorazine. (See side effects chart at the bottom of this page.)

3. Most common use: Pain relief.

 

Communicating with your partner about pain medications

Some time in late pregnancy you and your partner should sit down and really talk about what your preferences are regarding pain medication so that when you’re in labor, your partner will know what your preference is. (See Simkin, Whalley, and Kepler for the Pain Medication Preference Scale, a good starting point for this discussion.)

Also, agree on how you will communicate that the time has come for pain medication. I had a client who really wanted to have a birth without pain medication, but knew there would be times in labor she would feel discouraged, and was likely to say things like “I can’t do this anymore, it’s too painful.” We agreed ahead of time that if she said things like that, it was a call for more active emotional support and reassurance, and some suggestions about positions and comfort techniques to try, and that we should not discuss pain medications. However, she wanted to know that she could choose pain medications if necessary, so we agreed that if she said “I’m done”, we would know to begin discussing medication with her.

Narcotic Analgesia (e.g. Morphine, Fentanyl)

 

Epidural Anesthesia

 

What is an epidural? 

 

Benefits of Epidurals: why would you ask for one in the first place?

                                     

How is an epidural administered, what equipment is involved, and what are the side effects? 

 

Time for the Birth

- Can you feel the urge to push? Generally not. Medical staff will check cervix to tell you when to start pushing; and will watch monitor to tell you when a contraction comes so that you can push with the contraction.

- Can you push as effectively with an epidural? No. Abdominal muscles are weakened: normal pressures exerted during second stage are 120-135 mm Hg, with an epidural, they barely reach 100 mm Hg. Also, you can’t use your voluntary muscles as well to aid in the pushing, and you can’t move into the most effective positions (i.e. squatting)

- Does the baby rotate as well into the correct position if mom has had an epidural? No. Amongst non-epidural mothers, only 4% had a posterior baby persisting into second stage; after epidural, 19% failed to rotate.

As a result of these factors, there’s an increased risk of: forceps, vacuum extractor, and c-section. Of 24 studies reviewed, 22 studies showed a significant association between epidural and instrumental delivery; other 2 suggested an association, but it was not statistically significant. With narcotics, instrumental delivery: 3-7% With epidural: 15-53%

Thorp referred to some studies where the epidural medication was stopped once the mother reached 8 cm dilation, so that sensation would return for second stage labor. You may wish to consult with your caregiver about whether this practice is currently recommended.

Increased Risk of Cesarean

In a review of 15 available studies, 12 suggested a significant association between epidural and c-section. Risk of c-section generally found to be 2-3 times more likely with epidural.

An influence on this is what point in labor the epidural was administered. One study found that cesarean rates were 11% if epidural was given at 5 or more cm dilation, 16% at 4 cm, and 28% at 3 cm. Another study was even more striking, finding that cesarean rates increased to 26% when epidural was given at 4 cm, dilation, 33% at 3 cm, and 50% when the epidural was given at 2 cm dilation. So, the longer you can wait to have an epidural, the better.

Possible Effects After the Birth.

Backache. 10% of new moms develop a backache for the first time that lasts at least 6 weeks. Among women who’d had epidurals, the number jumps to 18%. This may be due to poor positioning during birth: women with epidurals may not be able to sense discomfort when they are in a position which is straining muscles, so support people need to pay attention to keeping mom in a comfortable, healthy position.

Medications cross the placenta and may have subtle side effects on the baby, including more difficulty in self-soothing, subtle changes in reflexes.

Decrease in maternal oxytocin during labor may interfere with oxytocin release after birth. Bonding and milk letdown reflexes may be decreased.

Some uncontrolled studies have been done, which aren’t conclusive due to lack of controls, but interesting nonetheless: unmedicated mothers reported that their babies were more sociable, more rewarding, and easier to care for. Unmedicated moms were more responsive to their babies’ cries. Women who had epidurals smiled less at their infants.

 

 

 

More Details on Side Effects of Specific Drugs

 

Type

Drug Names

Advantages/Purposes

Disadvantages/Risks

Sedatives / Hypnotics

Barbituates:

Pentobarbital (Nembutal)

Secobarbital (Seconal)

Amobarbital (Amytal)

Phenobarbital (Luminal)

Given in smaller doses, as sedatives, these medications reduce anxiety, irritability, and excitement. Lower perception of stimuli. In higher doses, as hypnotics, induce rest, relaxation, or sleep.

Usually administered very early in labor.

To the mother: May cause dizziness and disorientation, especially if the mother is experiencing painful contractions and sedatives are given without analgesics. Can prolong labor by impairing uterine activity.

To the baby: May cause respiratory depression, decreased responsiveness, and impaired sucking ability in newborn. Effects may last for 24-48 hours after birth.

Tranquilizers

Phenothiazines Thorazine, Phenergan, Sparine, etc.

 

Benzodiazepines. Valium, Xanax, etc.

 

 

Given to reduce tension, apprehension, and anxiety. May be used to reduce nausea and vomiting. Sometimes combined with narcotics to increase the effects of the narcotic.

Used in first stage of labor.

 

Benzodiazepines generally only given after birth because of side effects for baby.

To the mother: May cause drowsiness, dizziness, blurred vision, confusion, dry mouth, and changes in heart rate or blood pressure. When given with sedatives or narcotics, tranquilizers my increase sedative or depressant effects.

To the baby: Phenothiazines can inhibit newborn reflexes and cause jaundice. Benzodiazepines in labor can cause fetal heart alterations, and cause drop in body temperature, poor muscle tone, sleepiness, and sucking difficulties in newborn. Effects last 24-48 hours.

Narcotic Analgesics

Meperidine (Demerol), morphine, fentanyl (Sublimaze), codeine.

Reduce pain, promote relaxation between contractions.

Some narcotics may relax cervix, and may speed labor that is slowed by tension or stress.

Sometimes in the case of a prolonged prelabor, large doses are given to stop contractions and give mother a chance to rest.

Given after cervix is 3-4 cm dilated.

To the mother: May cause drowsiness, hallucinations, dizziness, euphoria, respiratory depression, nausea, and vomiting. May lower blood pressure. May slow labor progress, especially if given before active labor.

To the baby: May make fetal heart less reactive to stimuli, depress respiration, and alter infant’s behavioral responses for several days or weeks.

Combination Narcotic / Antagonist

Stadol, Nubain, Talwin

A narcotic plus narcotic antagonist; provides pain relief without causing respiratory depression in mother or baby.

Narcotics and combinations are fast-acting, taking effect within a few minutes with IV injection, and lasting for a few hours.

Narcotic Antagonist

Naloxone (Narcan)

Reduce or reverse the effects of narcotics. Given to mother if there is narcotic toxicity, or to the newborn when respiratory depression is caused by narcotics.

Abrupt reversal of narcotic depression can cause increased blood pressure, nausea, vomiting, sweating, trembling.

 

 

Sources: Most statistics cited are from “Epidural Anesthesia in Labor: An Evaluation of the Risks and Benefits” by Thorp and Breedlove, Birth, June 1996. This was a literature review article, which summarized the results of numerous studies involving thousands of births. Other information from: Pregnancy, Childbirth, and the Newborn by Simkin, Whalley, and Keppler (2001 edition). Maternity & Women’s Health Care by Lowdermilk, Perry, and Bobak (6th Edition, 1997). Family-Centered Maternity and Newborn Care by Celeste R. Phillips (Fourth edition, 1996). “Epidural Epidemic” by Dozer and Baruth, Mothering, July-August 1999. “What no one tells you about Epidurals” by Penny Simkin; “The Cascade of Interventions” by Pam England; and Epidural’s Effects on Babies” by Beverley Lawrence Beech, in Mothering, March-April 2000.  “Epidural Express” by Nancy Griffin, Mothering, Spring 1997.

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