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Labor-Pain Control: Weighing Your Options

If you're like most pregnant women, you're wondering how painful your labor will be. In anatomical terms, your relatively nonstretchy cervical opening is enlarging from the size of a pin to the size of a grapefruit; plus there's the pressure to your kidneys, bladder, colon, stomach, and spine as your baby passes through. First labors tend to cause greater pain, as do big babies, a small pelvis, and certain positions of the baby.

But there's no way to predict how you'll react to the pain, which is why you should at least know what pain-relief choices are available, and what the advantages and disadvantages are for each.

And what about the baby? Thanks to low doses and new drug combinations, the effects on newborns are minimal, say experts. (The exception: See "IV Narcotics.")

The best time to start talking to your doctor or midwife about pain relief is during your last trimester. Although not every hospital has the same range of choices available, your options are likely to include the following:

Epidural

What happens: An anesthesiologist injects a needle with a catheter threaded through it into your spinal column. The catheter stays in, delivering medication continuously into the covering around the spinal cord, called the dura. You can ask for an epidural at any stage of labor.

What's good about it: Most women lose sensation from the waist down within five minutes (sometimes it takes slightly longer), depending on the strength of the dosage. Epidurals block the pain of contractions without inhibiting your ability to move around. You're also able to rest, possibly even sleep, before the pushing stage.

What to be aware of: The most common side effect is a headache, which occurs about 1 in 200 times -- a result of the needle nicking the dura and releasing fluid into the spinal canal. Other possible side effects include nausea, vomiting, itching, and shaking, which usually go away after the drugs wear off. (Contact your doctor if your symptoms don't subside. For ways to alleviate some of them, see "3 Sure Bets.")

An epidural may also decrease your ability to use the muscles of the pelvic floor, which could mean a longer second stage of labor. You should expect to push for about three hours -- about an hour longer than a woman who hasn't had one, says Joy Hawkins, M.D., director of obstetrical anesthesiology at the University of Colorado in Denver. There's also a slightly greater chance that you may need forceps.

Nationwide, epidurals are the most popular form of pain relief. And doctors have worked on reducing dosages and combining drugs to minimize side effects and increase the expectant mom's mobility. In fact, say experts, many of the epidurals given today are known as "walking" ones -- which means you can literally get up and stroll if you feel like it. One innovation is the patient-controlled epidural, in which you regulate the amount of medication delivered by pushing a button.

Spinal Block

What happens: As with an epidural, a spinal is administered by an injection in the lower back. The needle goes through the dura directly into the spinal canal. Most women feel numb from the waist down, which can affect their ability to push. Spinals are usually given as close to delivery as possible, because they usually wear off after a couple of hours.

What's good about it: Spinal analgesics offer nearly immediate pain relief (within a minute or two) with a lower dosage of drugs than an epidural.

What to be aware of: Doctors are reluctant to put more than one hole in your spine because of the risk of headache, so they will only administer a spinal once. And since predicting delivery time is never exact, the drug may wear off before the baby is born. Side effects can include itching, nausea, vomiting, and shaking.

Combined Epidural-Spinal

What happens: Also called the "double-needle technique," an anesthesiologist administers a spinal and inserts a micro-catheter in the needle. This allows for more pain relief with an epidural if the spinal loses its effectiveness before the baby is delivered.

What's good about it: It's the best of both worlds: the immediate pain relief of a spinal, plus the continuous medication of an epidural if you need it. You also don't lose the ability to move.

What to be aware of: It can bring on the same side effects associated with a spinal and an epidural.

IV Narcotics

What happens: The drugs are either injected or, more commonly, administered through an IV. The best time for narcotics is early in your labor to minimize the side effects -- including low blood pressure -- and give your baby a chance to metabolize the drugs.

As epidurals have become more widely available, narcotics such as Demerol and Nubain are now given as primary labor-pain relief only if there's a risk of infection or you're extremely squeamish about needles going into your back.

What's good about them: These drugs won't cause numbness or difficulty pushing.

What to be aware of: Two extremes: Those on IV narcotics are either wide awake and complaining of pain, or conked out, says David Birnbach, M.D., director of obstetric anesthesiology at St. Luke's-Roosevelt Hospital Center in New York City. The patient-controlled pump allows you to increase the medication as needed and moderate these extremes.

More important, though, the narcotic enters your bloodstream directly, so more of it reaches the baby, whose short-term side effects may include drowsiness and difficulty breathing.

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