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Pain Management During Labor: An interview with Dr. Nathaniel DeNicola

In the movie Knocked Up, Katherine Heigl’s character writhes in pain, mutters expletives, and begs for an epidural during a hospital birth scene. Anyone else remember Debra Messing’s long 10-second wail as she pushes her baby out in the film The Women? We’ve been exposed to concept of women’s pain during labor since we were kids.

There’s no doubt that birth, while beautiful and life-altering, can also be uncomfortable and painful. It’s normal for women, their partners, and loved ones to be fearful of this aspect of labor, especially given the heightened focus the media places on distress. However, like many things in Hollywood, these representations of birth don’t necessarily reflect reality. To learn more about discomfort during birth and pain management options from a trusted source, we sat down with Dr. Nathaniel DiNicola, a practicing OB-GYN with 10 years of experience and faculty member at George Washington University in Washington, D.C.

BINTO: One of the greatest fears of giving birth is the pain. What advice do you offer to patients who are particularly anxious about this aspect of labor?

Dr. DiNicola: Patients think a lot about this. There’s a great fear of the unknown. Honestly, you can’t really tell a woman not to worry about this. It’s not fair to say, “Don’t think about the pain.”

I advise patients to remember that labor is a natural process that women have been going through since the beginning of time. A woman’s body instinctively knows what to do and how to give birth. However, part of this process is worrying about pain. There are a number of non-medical and medical ways to minimize it. There are also some medical ways to take the pain away completely.

BINTO: What exactly is happening in the body during labor that causes pain?

Dr. DiNicola: The first and most constant pain felt during birth are the contractions. The uterus is flexing when women experience both menstrual cramps and labor contractions. It can be helpful for women to remember that they have felt this sensation before. It’s just much more enhanced during labor. Women feel pain from contractions because when the uterus muscle contracts, this causes inflammation. In turn, a woman’s pain fibers and nerves react.

At the stage of pushing, on average, a 6.5 to 7 pound baby is emerging through the vaginal canal. Inevitably, this causes a lot of tension. A woman’s vaginal and perineal tissue stretch to where they’ve never been stretched before. Despite the pain, a woman’s body naturally works to accommodate it. Estrogen levels increase which helps the pelvis open and the ligaments and tissue to become more flexible.

It’s also important to address pain experienced after labor. Especially for the first delivery, there’s often some kind of vaginal tear during delivery. It can be painful, like any cut on your body, and the repair usually involves some stitches. This part of labor isn’t discussed often, but it’s important to be aware of when considering pain management options.

BINTO: Women have options, including medications and natural methods, to manage labor pain. How should women approach making the decision as to whether or not they want to use medical options like drugs?

Dr. DiNicola: There's always the option to keep going up in terms of intensity of treatment. It's a fine option to start with a low intervention, non-medical route and see how it works. If it's not enough to address a woman’s pain needs, they can move higher up the treatment scale. Options are rarely closed, even when delivery is imminent. It’s common to see multiple methods, both natural and medical, used throughout the course of one labor. It’s not like one excludes the other.

Ultimately, it comes down to personal preference. All women and labors are different. There are a few occasions where for medical or safety reasons, a provider might recommend a certain level of pain control or quick access to anesthesia for a cesarean section (c-section). But for the most part, pain management options can be individualized--except in cases where there is a medical reason or emergency.

BINTO: Walk us through natural pain management options.

Dr. DiNicola: Relaxation techniques like meditation and deep breathing are shown to help control pain, increase one’s ability to focus, and ease stress and anxiety. Keeping the body active and moving by walking or sitting or rolling on labor balls can relieve pain for some.

In fact, there’s a dance that an OB-GYN came up with specifically for labor. Though it was created to help induce labor, anecdotally it’s been shown to control pain during labor, too. Massage is also useful. This is one way partners can support the birthing mother. Many women also like hydrotherapy, which involves getting into the tub or shower during labor.

BINTO: What about medical options?

Dr. DiNicola: Non-medical options can work well for some people, but not so well for others. Narcotics and opiates, like morphine, provide very good pain relief. They don’t numb a woman, like an epidural, but rather take the edge off of the pain. This also means they don’t impact her ability to push.

However, they can make patients groggy, which some women may not want during birth. It’s important to take these medications such that they won’t impact the baby after delivery. This means patients can’t use narcotics or opiates during the pushing phase, when the pain is worse. They must be delivered in the earlier stages of labor.

Epidurals are one of the few things that medicine has nearly perfected--there are very few downsides. They don’t impact the baby, increase the chance of c-section, or change the course of labor. They also don’t affect the mother in terms of mental alertness.

Usually, epidurals are given as a drip slowly infused into the system as opposed to a one-time shot. Epidurals can be used throughout the entire course of labor and even turned off at any point. Patients can’t walk once they are given an epidural, but they can be administered late in labor. This means mothers can be up and walking for as long as they wish. Patients often elect to wait on an epidural early in labor so they can maintain the ability to walk around and sit on an exercise ball or try medication. Later on, when pain is greater with more active labor, they may request an epidural.

Beyond epidurals, a small amount of local anesthesia, delivered via a shot to the area where delivery occurred, can be used after birth to help with pain during tear repair.

BINTO: There can be stigma and judgment around deciding to use medical options like these. What are your thoughts on this?

Dr. DiNicola: There should be no stigmas around any of the choices. It doesn’t matter, as long as the labor is moving towards a healthy mom and healthy baby. It’s also important to keep in mind that everyone has a different version of the word “natural.” So, it’s hard to hold anyone to a certification of natural since everyone is using a different definition.

At the end of the day, labor is a natural process regardless of your personal choices. There are different pathways to arriving at the same final chapter: healthy mom and healthy baby.

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