Labor involves hard work, and pain is part of the process. The good news is that you have many options to manage pain, as long as you know what those options are. This episode covers a wide range of medical pain relief options, including epidurals, nitrous oxide, IV medications, nerve blocks, and local anesthetics. Hear about the research on the risks, benefits, and effectiveness of each method so you can make informed decisions about which strategies are right for you and your baby.

Listen Now

This episode is made possible with support from our sponsors. I appreciate your support for the brands that help power this podcast.

Article and Resources

Overview of Medical Pain Relief Options

While some expecting mothers may opt for an unmedicated birth, you do have access to many pain relief options. According to the American College of Obstetricians and Gynecologists, there is no other circumstance in which it is considered acceptable for an individual to experience untreated severe pain that is amenable to safe intervention while the individual is under a physician’s care.

Epidural Anesthesia

In the United States, 77% of expectant mothers utilize an epidural, making it the most common method of pain relief during labor.

Technically, three different methods are widely referred to as an epidural: epidurals, spinals, and the combined spinal epidural. An epidural involves inserting a tiny catheter into the epidural space in your lower spine to deliver medications that block the nerve impulses from the lower half of the body. Once it is in place, it takes around 15 minutes or less to be effective, and more medication can be delivered through the catheter if needed. A spinal block is a one-time injection directly into your spinal fluid. This takes effect within about five minutes and lasts about one to two hours. A spinal is frequently used with an epidural to make a combined spinal-epidural. This takes effect quickly and then works to deliver continuous medication. While they differ, both provide continuous medicines, and the information here applies to both.

An epidural is an ideal pain medication for labor and birth because it affects the area from your belly button to your upper legs. While it numbs pain, you can still feel pressure, which is helpful during the second (pushing) labor stage. This is an intervention available in all hospitals, but it is not an option if you opt for a home birth or a birth center.

Epidural Medications

Epidurals typically combine more than one drug, with the type, dose, and duration depending on several factors. Generally, the medication you will receive is a combination of a local anesthetic and an opioid. A local anesthetic blocks feeling, while an opioid reduces the anesthetic dose needed, prolongs effects, and helps stabilize blood pressure.

Walking and Patient-Controlled Options

A “walking” epidural is a lower dose of medication from an epidural that allows you to maintain more feeling. Despite the name, you may not be able to walk. The lower dose preserves more sensation, which can help you feel contractions and know when to push. You may also have the option of patient-controlled epidural analgesia. Patient-controlled means the epidural has a pump with a button to press if you would like more medication. You don’t need to worry about overdosing because the pump limits how much medicine can be delivered within specific time frames.

When to Get an Epidural

In the past, doctors often waited until you were in active labor to start an epidural because of concerns that it might slow contractions. Today, most providers will support starting an epidural whenever you request it. An anesthesiologist performs this procedure, and it usually takes about 30–45 minutes from the time you request it until it is in place and working. You can request an epidural anytime up until your baby’s head is crowning. Some parents choose to get one as soon as they arrive at the hospital, while others may wait. Another option is to have the catheter placed early and delay starting the medication until labor is more active.

Benefits of Epidurals

The main benefit of an epidural is its ability to block or significantly reduce pain. It can also give you a chance to rest, which may be especially valuable if your labor is long and exhausting. Some mothers are even able to sleep during early labor with an epidural. Unlike general anesthesia, an epidural keeps you awake and alert so you can actively participate in your birth. Another benefit is that your doctor can adjust the type and amount of medication as your needs change.

Effectiveness of Epidurals

According to one study, 98.8% of participants reported adequate labor anesthesia with an epidural. In this study, initially, 12% of epidurals failed, but most could be corrected with adjustments. Some scenarios in which an epidural may be ineffective are if the baby is in an especially uncomfortable position. Occasionally, an epidural only works on one side if the catheter is out of place, becomes dislodged, or you stay in one position too long. Your anesthesiologist can quickly correct most of these issues. In some cases, if your epidural is inadequate, you may require a higher dose of medications. Please speak up and advocate for yourself if you get an epidural and you do not feel like it is effective.

Side Effects of Epidurals

As with any medication, there are possible side effects. A few of these symptoms include shivering, ringing in the ears, backache, or soreness at the insertion site. The narcotics delivered through an epidural can cause itchiness, particularly in your face, or nausea.

According to the American College of Obstetricians and Gynecologists, approximately 30% of mothers with an epidural will experience a fever. About 10% of women receiving an epidural will experience a sudden drop in blood pressure. One concern with this side effect is that it also affects blood flow to your baby. This is often treated with IV fluids, medications, and oxygen. Less than 0.7% of women will experience a severe headache caused by spinal fluid leakage. This can be treated with a “blood patch,” in which a small amount of your blood is injected into the epidural space.

In rare instances, an epidural could affect your breathing and very rarely could cause permanent nerve damage or result in an infection. This is an overview of the side effects, and this list is not specific to any particular medication. Please discuss any possible side effects of the medicines you will be given with your doctor.

Limitations of Epidurals During Labor

An epidural can affect the natural flow of hormones that happens during birth. The use of an epidural decreases your oxytocin levels. Oxytocin is the hormone that drives your contractions. For an in-depth analysis of how an epidural may affect hormones during labor, see this article. A Cochrane review that examined studies comparing epidurals to other pain medications and non-medicated births found that Pitocin (synthetic oxytocin) was slightly higher in the participants receiving an epidural.

The medicines in an epidural decrease your sensation in the lower half of your body. This is beneficial for relieving pain, but it may bring additional challenges. Depending on how numb you are with an epidural, you may have difficulty telling when you are having a contraction, making pushing difficult to control. You may also be restricted to a hospital bed if you cannot stand safely. Thankfully, nurses and hospital staff are very helpful in assisting you with positions within your limitations.

Additional interventions that accompany an epidural may limit your mobility. This includes being hooked to an IV, having a catheter, and continuous electronic fetal monitoring. There is evidence that some labor positions are more effective than others. Upright and squatting positions tend to be more effective and may even reduce your time in labor. It may be challenging to utilize these positions with limited mobility.

Epidural Effects on Your Baby

It is tough to assess exactly what the impact of an epidural on your baby is. There is limited research isolating this intervention alone. Any medication you use during labor enters your baby’s bloodstream through the umbilical cord. Many of the effects on your baby directly result from the possible side effects the epidural can have on you, like running a fever or having a drop in your blood pressure.

There are some conflicting studies on the effects of an epidural on breastfeeding. Research is about split in half between those that showed a negative association between epidurals and breastfeeding, and about half showing no effect. Take advantage of being in a hospital and ask to see a lactation consultant to ensure you get off on the right foot with breastfeeding.

Nitrous Oxide (N₂O) for Pain Relief

Nitrous oxide is a nonflammable, tasteless, odorless gas commonly known as laughing gas. This is an anxiolytic and decreases anxiety to help you be more relaxed. The nitrous oxide used during labor is a blend of 50% nitrous oxide and 50% oxygen. This differs from the nitrous oxide commonly used in dentists’ offices, which allows for a higher concentration (up to 70%) of nitrous oxide. In a dental setting, you have a mask strapped to your face to breathe nitrous oxide continuously. During labor, the use of nitrous oxide is intermittent.

Over 50% of births in Finland, Norway, England, Australia, and New Zealand, 60% in the United Kingdom, and 70% in Sweden involve nitrous oxide. In the United States, the use of nitrous oxide has decreased with the rise in epidural use since the 1970s. Although it has not been widely available, access to nitrous oxide during labor is expanding in hospitals and birth centers. The American College of Nurse-Midwives has an official position statement noting that women “should have access to a variety of options, both pharmacologic and nonpharmacologic, to assist them in coping with labor. Among these should be nitrous oxide (N2O) analgesia, which is commonly used in maternity care worldwide.”

How Nitrous Oxide Works

Nitrous oxide works by increasing endorphins, dopamine, and other natural opioids in the brain while decreasing cortisol release. Inhaling this gas induces feelings of euphoria, and in labor, it can create a disassociation with the discomfort of contractions. Rather than blocking or numbing sensation, nitrous oxide changes your perception of the pain from contractions.

Nitrous oxide can be used at any stage of labor and can be started or stopped anytime. It is self-administered, and you hold a mask to your face and decide when and how much to inhale. Nitrous oxide takes effect 30-40 seconds after inhalation. The benefits dissipate quickly, within a few minutes of discontinuing inhalation. Ideally, you want to get into a rhythm of inhaling about 30 seconds before a contraction. This may take some practice through several contractions to get the timing and rhythm down.

Benefits of Nitrous Oxide

There are some benefits and advantages of nitrous oxide. You can start or stop at any time during any stage of labor. You could choose nitrous oxide, then decide you want an epidural later. In one study, 69% of participants converted to another analgesic method when they started with nitrous oxide during labor. Those who used labor induction, oxytocin augmentation, and labor after cesarean were more likely to convert to another method. Some women opt for nitrous oxide to help with anxiety or discomfort, while an anesthesiologist administers an epidural. 

Using nitrous oxide does not confine you to a bed, and you should be able to maintain your mobility. However, you will need to remain near the nitrous oxide to access it through your mask. Nitrous oxide does not affect oxytocin production, so it should not slow labor. 

Effectiveness of Nitrous Oxide

A study of 463 women who used nitrous oxide rated satisfaction on an 11-point scale from 0 to 10, with 10 being very satisfied, and the mean score was 7.4. 69% of participants converted to another type of pain relief during labor, most due to inadequate pain relief. The effectiveness of nitrous oxide or any intervention depends on your goal. An epidural may be a better option for someone who desires to feel no pain or discomfort during labor. If you want a less invasive alternative to take the edge off, nitrous oxide may be worth exploring.

Side Effects of Nitrous Oxide

Some women find the sensation of breathing into a mask during contractions to be unpleasant. In one study, the most commonly reported side effects were nausea (3.7%) and dizziness (1.7%). Fatigue may occur when used for prolonged periods, and this would apply if you use it throughout a long labor. 0.7% of participants reported drowsiness.

Nitrous Oxide and MTHFR Polymorphisms

Concerns have been raised about nitrous oxide if you have an MTHFR mutation. An MTHFR mutation is a genetic mutation that affects a large percentage of the population and impairs enzyme function, impacting your health. Dr. Ben Lynch, an expert on MTHFR, advises against the use of nitrous oxide, and you can read more about this on his website here.

One study found that patients with an MTHFR gene polymorphism had a higher risk of developing hyperhomocysteinemia after nitrous oxide anesthesia. This condition is when you have high levels of homocysteine, which can contribute to damage to your arteries or blood clots. This study used a concentration of 66% nitrous oxide over two hours, which differs from the levels of nitrous oxide used during labor and birth. If you have any questions about your MTHFR status or the use of nitrous oxide, please discuss them with your doctor or midwife.

How Nitrous Oxide Affects Your Baby

Nitrous oxide is often talked about in terms of not having effects on your baby. In one study, 97.8% of babies had an APGAR score of 7 or higher at five minutes. A review found that Apgar scores in newborns whose mothers used nitrous oxide did not differ significantly from those of newborns whose mothers used other labor pain management methods or no analgesia.

Systemic Analgesics (Intravenous Pain Medications)

Another pain relief option is systemic analgesics, which are intravenous pain medications. These use opioids that bind to opioid receptors in your brain, spinal cord, and gastrointestinal tract. They trigger dopamine and reduce pain messages to your brain. Opioids are a class of medications that include narcotics like fentanyl, oxycodone, morphine, and heroin. These are considered systemic analgesics and can be given intravenously or as a shot. These drugs have a calming effect and reduce awareness of pain, but do not eliminate it.

Systemic Analgesics Effectiveness

Medications vary in how quickly they go to work, their half-life, and how long they last. A review of 70 studiesdid not have sufficient evidence to assess which opioid drug provided the best pain relief with the least adverse effects. Please consult your doctor for more information on the specific medications used. According to ACOG, opioids have little impact on maternal pain scores, provide unreliable analgesia, and commonly have adverse effects such as nausea and vomiting. Typically, intravenous medications are not the method of choice when an epidural is an option.

Side Effects and How Systemic Analgesics Affect Your Baby

Side effects of systemic analgesics for a mother in labor include nausea, vomiting, and drowsiness. All opioids cross the placenta. Your doctor will monitor your baby’s heart rate because changes in variability, decelerations, and slowing of the fetal heart rate are common with opioids. Additional risks to your baby include lower Apgar scores, respiratory depression, decreased muscle tone, and difficulty suckling. Many of the side effects in your baby can negatively impact breastfeeding and bonding after birth. The half-life of opioids in newborns is much longer than in adults, and as a result, systemic analgesics are usually limited to the first stage of labor.

Pudendal Nerve Block in the Second Stage of Labor

A pain relief option available in the second stage of labor is a pudendal nerve block. Your pudendal nerve has two branches, one on each side of your body, and carries sensations from your labia, clitoris, and perineum. A pudendal nerve block is an injection of an anesthetic that works to block the pudendal nerve. This shot is administered transvaginally (through your vagina) in the second stage of labor, just before your baby is born. Your doctor may use a pudendal block to repair a tear or episiotomy, although a local anesthetic is more commonly used for these procedures. Keep in mind, this will not block any discomfort from contractions. If you are concerned about pain during the second stage in your vagina or perineum, it will help.

Benefits of Pudendal Nerve Blocks

The benefit of a pudendal nerve block is pain relief in the second stage of labor. It is also possible to use this method with other pain medications. A double-blind study that paired a pudendal nerve block or a placebo with an epidural found that a pudendal nerve block decreased drug use in an epidural and shortened the second stage of labor. The participants who received the nerve block were more satisfied with their pain relief than the participants in the placebo or control group.

Side Effects and Risks of Pudendal Nerve Blocks

The most common side effect of a pudendal nerve block is discomfort at the injection site. There is a small risk of bleeding or infection. Rare side effects can include damage to the pudendal nerve or damage to organs nearby, like the bladder. There is also the rare possibility of puncturing the pudendal artery, which could be fatal. This is a procedure that is considered safe by a trained medical professional. In the research reviewed for this article, I found no evidence that a pudendal nerve block affected babies.

General Anesthesia in Labor

General anesthesia is a pain relief option usually reserved for emergency cesareans, where an epidural is not an option. Under general anesthesia, you are not awake and cannot see, feel, or hear anything during the birth. Just over 5% of cesarean births use general anesthesia. General anesthesia typically uses a sedative such as propofol or ketamine and a muscle relaxant. During this procedure, you are intubated with a tube inserted into your airway and placed on a ventilator. Your birth partner cannot be present for the surgery, but can be with your baby after they are born until you are awake.

Local Anesthetic Injection for Perineal Repair

In addition to pain relief options for labor, you may require pain relief for perineal repair after you have your baby. A local anesthetic injection is a shot of pain-relieving medication to a specific area. This is routine before performing an episiotomy or repairing a tear in your perineum or vagina. The most commonly used pain medication for a local anesthetic is lidocaine. A local anesthetic is available in all birth settings, including by a midwife in a home birth. A local anesthetic works by binding to the sodium channel in cells and blocking nerve signals to your brain. You may still feel pressure, but you should not feel pain in the area where the anesthetic is injected.

Benefits, Effectiveness, and Side Effects of Local Anesthetics

If you require an episiotomy or need a tear repaired with stitches, there is no reason you should feel pain during these procedures. Even if you plan an unmedicated birth, you would incorporate this if needed. Local anesthetics are commonly used in all medical settings and generally have no side effects. In rare cases, you could have an allergic reaction, nerve, or heart problems if the dose is too high. Since this is a standard procedure, you should trust that your care provider is skilled in performing local anesthesia. There should be no adverse effects on your baby.

Choosing Your Pain Management Strategy

Your experience matters, and you deserve to know your options so you can decide what works best for you. There is no one-size-fits-all, and this is not an all-or-nothing scenario. Some of these options can be combined. Please advocate for yourself if there is a method you want to incorporate into your birth experience. If you have any questions about the pain relief options available to you, please consult your doctor or midwife.

Thank you to the brands that help power this podcast.