Pain Medication Options in the Hospital Setting From a Nurse’s Perspective
When you are admitted to a labor unit, your doctor or midwife initiates an Order Set. These are the same universal orders for each patient, with some choices that can be added on or removed. The option to have IV pain medication or an epidural if desired by patient is included in these orders. Your nurse, and occasionally your doctor, will work with you to discuss if and when these should be given.
IV Medication options during labor
First let’s talk about the IV medication options. There are two different IV medications that may be given for pain (please note medications may vary at different hospitals but these are pretty standard). One is called Stadol and one is called Fentanyl. They are small liquid doses that are administered through your IV site. There are usually half and full doses available, and you can usually repeat the dose again after a period of time. For example, Fentanyl may be ordered as 50mcg (micrograms) or 100mcg, every X hours, as needed for pain. And Stadol may be ordered as .5mg (milligrams) or 1mg, every X hours, as needed for pain. Both of them have a maximum amount that can be given. That means, if you’ve reached that amount, you can’t have anymore.
Benefits of IV medication
These IV pain meds can be helpful for taking the edge off. I tell patients they might knock the top off of the contraction mountain. The sensations are still there, but not as intense. Maybe mom will even get a short nap. She may be able to rest and regroup and get back in the game of coping with contractions. This is good for someone who is looking to avoid an epidural but is having a hard time. It’s nice to have something, and IV pain meds can be a useful tool in the “coping with labor” toolbox. The effect of these drugs in your system can last anywhere from 20 minutes to 60 minutes. On a side note, sometimes we see moms in triage having days of looooong early labor. We can give them these same IV pain meds, some IV hydration, some monitoring to watch baby during this, and usually they take a great nap. Often times they go home afterwards.
Potential Side Effects of IV Medication administered during labor
IV medications go into your bloodstream. Therefore they cause systemic effects, like mental changes. They’re narcotic drugs. They may make you feel loopy and out of it. You may not have a lot of experience feeling loopy and out of it or tipsy (especially since you’ve been pregnant for 10 months!). You may not like the way this makes you feel at all. The good news to that is that these are short acting drugs, so the effects (both good and bad) will be over quickly.
Will Baby Feel the Effects?
Since the drugs are in your IV and bloodstream, that means they are also in baby’s bloodstream. You will have to be continuously monitored with the belts around your abdomen during the time these drugs are in effect – the monitors are listening to and graphing baby’s heart rate as well as your contraction pattern. They sedate you, but they also sedate baby. Baby’s heart rate pattern will appear similar to what it looks like when they are sleeping. We would not be able to administer these drugs to you if baby had recently shown us any reason to be concerned about their wellbeing. Baby’s usually metabolize these drugs faster than you, and we see baby’s sedation wear off relatively quickly on the monitor.
How Long Can You Wait to Get IV Meds?
We also would not want to give you these drugs if delivery was imminent (meaning 8cm or more dilated for a first time mom, or a second + time mom who is dilating quickly). We would not want baby to be born with these drugs still active in their system, since they may make their responses to extrauterine life not as vigorous. We want a baby alert and crying (hello apgar scores!), not sedated. To be clear, these two IV narcotic pain medications and their doses are chosen for their use in pregnant women because they are safe to cross placenta to baby’s bloodstream. That’s why they aren’t very awesome and magical and pain relieving for you (those would be IV pain med drugs such as Dilaudid or Morphine), because that has to be balanced with safety for baby as well.
Alternatives to IV meds
Of course, all non pharmacological pain relief options are alternatives to IV pain meds. Additionally, if you don’t like the idea of your baby being exposed to short acting narcotic pain meds in utero, an epidural is a great option (more on that next!).
Reality & My Opinion as an L&D Nurse
I usually see IV pain meds administered as sort of a prelude to an eventual epidural. I usually don’t see IV pain meds alone. If you’re looking for that sort of relief/release, you will usually eventually have an epidural. Patients ask for some IV pain meds after either exhausting all of the non pharmacological coping strategies the doula or I have suggested (shower, walking, swaying, hip squeezes, distraction, birth balls, calm voices, encouragement…), or as a means of prolonging the time until they get an epidural (“I want to be 6cm before I get an epidural”). Probably an equal amount of times people are happy with the effects and take a spacy nap, vs feeling like ‘yuck, I hate feeling this out of it.’ And, for what it’s worth, I prefer to use Fentanyl for my patients because there seems to be less of the yuck.
Epidural Relief during Labor
On to our next pharmacological method of pain relief: the epidural. Epidural is not the name of the drug; rather it is the name of a space in your spinal column. That’s where the small flexible tube that will administer medications is placed. Think of it like your IV: we use a needle to get a small flexible plastic tube into a place, and then we remove the needle and tape the small tube in place. Medication drips continuously into this space and numbs the pain sensations of the nerves below it. The drug cocktail that makes up an epidural is a mix of Fentanyl and Bupivacaine.
When a patient says “I want an epidural now,” it takes about 45 minutes from that statement until you start to feel relief. Let’s suppose you already have an IV. I start giving you a whole bag (one liter) of IV fluid really fast. I let the anesthesiologist know that you want an epidural. Where I work, there is always an anesthesiologist or a nurse anesthetist in the building. I get all the materials anesthesia needs to perform the procedure at your bedside. I help you cope with the contractions that keep coming, because usually these last ones feel really intense. Mentally you have decided on the epidural, so you are ready for these contractions to be over. They may not actually be stronger, but they feel stronger because your coping has lagged.
Procedure for administering an epidural
When anesthesia arrives at the bedside, we sit you up on the side of the bed with your legs dangling. We sit your support person down on a stool right in front of you to help squeeze your hands and talk to you and distract you and just generally be up close in awe of how tough you are. We discuss what’s going to happen. It’s all about positioning, so we coach you into the right position. Think of the cat pose in yoga, or pushing your lower back out in slouchy posture. Maybe a pillow helps you round over your belly, chin to chest, shoulders relaxed. Anesthesia cleans your back, places a sterile drape over your back, touches your bony spine to determine the spot they are going to place the epidural. They numb your skin with lidocaine – which burns! That’s usually the worst part. But everything burning and tingling is getting numb. After that you just feel touch.
Positioning for Getting an Epidural
We help you get in the ideal position with rounded back. Having a rounded back makes the spaces between the bones of your spine bigger. They use a needle (that large, long needle everyone talks about, but your eyes will never see it) between two of your lower vertebrae almost like a dart. Then they thread a long, soft, flexible skinny straw into the space, and pull the needle away. It takes just moments. The needle does not stay in your back. We test and make sure the tube is in the right place by giving a tiny bit of medication first. We would know instantly if it was in a wrong place such as a blood vessel. Your heart would race, you would have a metallic taste in your mouth and a ringing in your ears if this happened. I’ve seen it happen twice. The amount of the drug is so small those side effects are over almost immediately, and anesthesia fixes the placement of the catheter.
Do Epidural Meds go to Baby?
It’s important for us to determine that the tubing is in the right place because we only want the epidural to be in the epidural space of your spinal column. That’s where the medication stays. The medication does not go in your blood stream, and does not go to your baby. I’m anticipating some comments here about studies and evidence to the contrary, but the point I’m making is that compared to IV pain meds, epidurals do not “drug” your baby at all. Your baby does not know you have an epidural, and your uterus doesn’t know you have an epidural.
Dosage of Epidurals
Then we tape the tube to your back really well and connect it to the pump that gives you medication constantly. Epidurals don’t run out—we continue the medication until it’s no longer needed. You are usually quite comfortable initially because you get a loading dose, and then afterwards you have a remote button that you can press and give yourself a little more. I tell my patients if they are ever making the wincing ouch face again, it’s time to press the button. The button is totally optional.
We lay you down flat to let the medicine settle evenly across your whole pelvis. The contractions fade away like a sunset, rather than a light switch. The first couple feel shorter (even though they’re not) and then eventually you don’t realize that you’re talking to me through a contraction without noticing. We monitor your blood pressure closely. We place a catheter in your bladder to drain urine since you can’t walk to the bathroom anymore. This does not usually hurt.
Moving Around After an Epidural?
Once you have an epidural you can no longer bear weight on your legs, and it’s not safe to stand up. I don’t know what people are talking about when they request “walking epidurals.” You are bed bound. You’re not totally numb in a panicky “I can’t feel my legs” way. You are able to help us change your position every hour or so from side to side. You don’t generally lay on your back for the same reasons we tell you not to do that when pregnant – bad for blood flow to uterus. I like to keep a peanut ball or a folded pillow in between your knees to keep your hips open. It’s important to remind your care team to do that if it’s not being done. Epidurals take away pain, not pressure, so you may still have awareness of your belly getting hard with contractions, and ideally you still feel vaginal and rectal pressure with contractions when it’s time to push. If you’re getting close to the time to push and you are really really numb, I’ll suggest not pressing the button for awhile.
Benefits of an epidural
You’re able to sleep. Many of the epidurals I am apart of are for therapeutic rest, and not for an inability to tolerate painful contractions. You’ve been awake for days or even just all night (especially with the long early labors that are notorious in so many first time moms), and the epidural is a valuable tool to allow rest, relaxation and regrouping for pushing and early parenting.
Maybe mentally you’re in your own way. Fear, anxiety, and interpreting pain as suffering send your body “fight or flight” messages. Adrenaline overpowers oxytocin, and can stall labor. You need to feel safe as an animal to give birth. Your body needs to relax in order to release, surrender, and dilate. Sometimes the relaxation of an epidural is exactly what that body needs to dilate.
You remain numb throughout the rest of dilating to 10cm and throughout the one, two or three hours it may take to push baby out (if you’re a first time mom) or the maybe 20 minutes of pushing if you’re a repeat mom. We turn off the epidural pump after the placenta is delivered and any possible repair to your perineum (aka stitches) is completed. We take the tube itself out an hour or so later when we get you up to try walking to the bathroom. You might complain about the tape coming off your back and won’t notice the sensation of me pulling out the tiny tube.
Potential Side Effects of an Epidural
We need to monitor baby and contractions continuously, so you’ve got those belts on from now on. We also need to monitor your vitals pretty regularly (aka the annoying blood pressure cuff stays on, sorry). The most common side effect of an epidural is a blood pressure problem. It can drop low. We try to prevent this by giving you all that IV fluid first. If it drops it can make you feel sweaty, nauseous, light headed, and gross. That’s what low pressure feels like. But baby doesn’t like it because they’re used to the glub-glub-glub of your blood pressure chugging along nicely. If we see this we will intervene quickly to raise your blood pressure back up and correct baby’s response to it.
Let’s talk about the Cascade of Interventions. Yes, if your contractions space out from every 2-3 minutes to every 5-7 minutes, and your cervix pauses in its dilation progress, your doctor will recommend augmenting with some pitocin. That means giving you an IV version of the drug pitocin, which is modeled after your own hormone oxytocin, which causes uterine contractions. We would also suggest this to you if these same conditions were present in labor without an epidural, by the way. Yes, if you get an epidural in early labor, you will have an epidural for a long time (first time moms take about 1 hour to dilate 1cm…and we’re going to 10cm = 10 hours at least, usually 16-24 hours), and interventions will likely be offered to you.
Reality & My Opinion as an L&D Nurse
We don’t have “rules” about getting epidurals only after 4cm and only before 8cm, but ask your nurse or doula to help you cope with contractions until you’re in active labor. And once you have an epidural make sure you are turning from side to side every 1-2 hours, and keeping knees and hips open with peanut balls or pillows. If you have an epidural you will not be able to take advantage of gravity efficient birthing positions such as squatting, so it may take you some time to learn how to push, and you may push for one, two or three hours. My advice: use the mirror!
The same rules apply to interventions whether you have an epidural or not: always be an empowered and informed healthcare consumer. If an intervention is offered and discussed it is totally ok to ask:
- What are the benefits?
- What are the risks?
- What are the alternatives?
- What if we wait an hour?
- What if we do nothing?
Other side effects to note in an effort at full disclosure: maybe it takes several tries to get it in the right spot, maybe it works better on one side of the body than the other, maybe there is a hot spot on your belly where you still feel discomfort, maybe you weren’t as numb as you wanted to be, maybe you’re too numb when it’s time to start pushing. Your nurse and anesthesia provider will work to troubleshoot these problems. Before they start placing an epidural you will need to sign a consent form whereupon are all other possible known risk factors and serious side effects of having an epidural. The only serious side effect I’ve seen in my career is when there is an error in placement and a couple days later (usually when you are still hospitalized on the postpartum unit), you end up suffering from a terrible postural headache. That means you are fine when laying down, but feel awful when sitting up. It has to do with the levels of fluid in your spinal column and gravity. It is treatable.
Reality & My Opinion as an L&D Nurse
I feel like patients with epidurals are divided between women who know they want an epidural eventually and it’s just a matter of when (my job is to help steer them towards being in active labor first); women who maybe want an epidural but are afraid and anxious about getting one (my job is education and emotional support); and women who are getting epidurals for therapeutic rest after fighting long hard battles with natural labor (my job is emotional support).
The ebb and flow of popularity for different trends in obstetrics is interesting over time. We are currently in a natural parenting surge, which is great. I sat down to write this article after breastfeeding my 3.5 year old. I get it. I just want people to remember that access to an epidural was once a women’s rights cause, and women marched in the streets demanding access to them. I completely reject the guilt, shame, and “mommy wars” hostilities that women place on each other for their childbirth and parenting choices, especially the choice to have an epidural or not. You do you! I did not have an epidural with either of my deliveries, but oh I was talking about it. I had put in some good hard time (naked, moaning, out of body experience), and if my midwife would have said “You’re 5cm” I would have said “Epidural.” Done. But it just so happened that she said “You’re 8cm” (and with second baby, “You’re 10cm”). The thought of being close to the end was reward enough to keep going, and soon after those babies were here. I may be biased, but I think most pregnant L&D nurses and obstetricians (at least all the ones I know) operate on a pretty similar and effective “Birth Plan” for their own deliveries: use whatever you need if you need it. No shame, no guilt!
This guest post was written by Maureen Hodges, BSN, RNC-OB, LCCE. Maureen has over ten years of Women & Children’s nursing experience. For the past seven years she has been a Labor & Delivery nurse at a very busy hospital in the Austin area. She teaches private, hospital, and online childbirth classes. She has two children, aged 1 and 3, and a husband who knows all her L&D pep talks verbatim from listening to her answer every pregnant woman’s questions at dinner parties, on airplanes, and on the phone in the middle of the night. She has attended the deliveries of everyone in her book club. She could not pick any of their vaginas out in a line up. You can find her on instagram at @empoweredbirthatx or on facebook at Empowered Birth Austin.