From all-natural to epidural, moms can customize pain relief during childbirth.

As your baby’s due date approaches, there is one question that you have likely thought a lot about: What about the pain?

Dr. Daniel Forest, an OB-GYN anesthesiologist at Novant Health Forsyth Medical Center in Winston- Salem, said that laboring moms have plenty of pain-relieving practices, medications and holistic therapies from which they can choose. Here he explains the different tiers of pain relief that are available during childbirth.

Tier 1 pain relief: positioning and support

For every woman who delivers at Forsyth Medical Center, the first level of pain management is the same, Forest said.

“Where we start off first is by having an environment of nurses, midwives, a very well-rounded group of physicians and staff that understand the process of labor and understand the fact that patients are in pain,” he said.

An experienced team of healthcare providers is key, Forest explained, because they can identify different causes of pain. Posterior positioning, for example, when the baby is facing upright and pressed up against mom’s back, can cause back labor and severe discomfort. When the healthcare team recognizes this issue, they position mom to help prevent back pain and pressure.

“Having a very knowledgeable staff that's trained to be able to provide that information to patients really helps patients cope with their pain and their labor,” Forest said.

The labor and delivery team may also suggest using a “peanut ball,” a large, inflated ball that is pinched in the middle, to ideally position and support the legs and hips during labor. Studies have shown that using a peanut ball may reduce labor time and likelihood of needing a C-section.

“This is something that allows patients’ legs to be positioned in a certain way to help with facilitating cervical dilation and that can also aid in patient comfort,” Forest said.

Novant Health Forsyth Medical Center is among just 17 North Carolina hospitals to receive the coveted U.S. News and World Report High-Performing Hospitals designation for maternity care.

Tier 2 pain relief: breathing techniques

Breathing techniques are one of the main pillars of labor pain management for many reasons. Breathing helps to soothe the mind, relax the pelvic floor muscles and promote blood flow to the abdomen. Forest said the care team assists laboring moms with breathing. Other support individuals, like doulas and family members, commonly help as well.

“Breathing through contractions can actually help a lot toward managing something that's very challenging,” Forest said.

A recent study concluded that breathing is even a beneficial preventive intervention in shortening the duration of the second stage of labor, the stage that includes pushing and ends in the birth of your baby.

Tier 3 pain relief: aromatherapy, massage and TENS

Aromatherapy, the practice of using plant compounds and/or essential oils for therapeutic benefits, is shown to help promote pain relief and reduce anxiety during labor. These plant compounds may be added to a foot bath, applied on the forehead in a compress, inhaled using a diffuser or used in massage. An essential oil commonly used in aromatherapy is lavender, known for its relaxing properties.

The certified nurse midwives at Forsyth Medical Center frequently use aromatherapy as part of holistic birthing practices, and Forest said he always notices when they do.

“I love being in the room when there's a midwife because those are the rooms that smell the best,” he said.

Aromatherapy may be combined with massage, or using touch and pressure on the body’s soft tissues. Because massage relies on human contact, it can provide an additional layer of comfort from a support person present in the labor room. Massage is a highly individualized preference and you may find that anything from deep pressure on the lower back to very light strokes over the belly to be comforting.

An additional holistic pain-management technique that laboring moms may use is called a transcutaneous electric nerve stimulation unit, or TENS unit. This is a small, battery-operated machine that treats pain by delivering low electrical currents to the nerves underneath the skin by way of electrodes. During labor, the electrodes are placed on your upper and lower back area. Forest said that a TENS unit may be used with the assistance of a support person, like a doula, and may play a role in early labor.

Tier 4 pain relief: hydrotherapy

Hydrotherapy involves immersion in warm water to promote circulation, relieve pain and relax the muscles. At Forsyth, there are six rooms available with hydrotherapy tubs for laboring moms to soak in. The water is kept at a temperature of no more than 100 degrees Fahrenheit, making it safe for both mother and baby.

During hydrotherapy, Forsyth’s labor and delivery team follows the American College of Obstetrics and Gynecology’s recommendations, which is for the second stage of labor to take place outside of water. This means moms can stay in the tub as long as they like during the first stage of labor, but when it’s time to push, it’s time to go back to dry land.

Tier 5 pain relief: intravenous medications

Pain relief medications can be administered intravenously, meaning through a small plastic tube, an IV, that will connect to a vein in your arm or hand. IV medications do not entirely block pain, but help to relieve it. One medication that Forest said he commonly administers is called butorphanol (brand name Stadol), a mild opioid. Other pain relievers that may be used are fentanyl or morphine.

Any time an IV pain reliever is administered, the medication enters the mom’s bloodstream and creates a chance that the baby could receive some of it. Because of this, Forest said, a mom’s labor and delivery team will measure her cervical dilation, and IV pain medications are only given up to a certain point to decrease crossover of the medication to the baby. If mom progresses faster than expected, additional support staff from the neonatal intensive care unit (NICU) may be asked to attend the delivery to ensure the highest level of safety.

Tier 6 pain relief: nitrous oxide

Nitrous oxide, sometimes known as “laughing gas,” is an inhaled anesthetic gas. It is typically used in combination with one or more of the other pain-management techniques listed. It provides some analgesia and is effective at reducing anxiety while making users less attuned to pain. Because nitrous oxide is broken down in the lungs, it can be used during any stage of labor without risk of it reaching the baby.

For those who may be familiar with the “loopy” sensation they get from laughing gas at the dentist, nitrous oxide during childbirth is a different experience because the dosage is lessened. The tank contains a specialized blend of nitrous oxide gas and oxygen, and the healthcare team provides education on how to correctly use the mask, Forest said.

“It's set to a point where it's already a safe blend,” he explained. “The ratio is appropriate, so there's no adjusting. Right at the bedside, women can go ahead and take a breath of nitrous oxide during their labor.”

Tier 7 pain relief: epidural, CSE or PCA

An epidural or combined spinal epidural (CSE) are types of “neuraxial blocks,” meaning they work by placing local anesthesia around the nerves of the central nervous system.

“At Forsyth, most moms in labor receive a CSE wherein the epidural is preceded by a spinal injection of a numbing medicine. This ensures that patients get pain relief quicker and more effectively,” Forest said.

During an epidural, an anesthesiologist inserts a needle and a tiny tube, called a catheter, in the lower part of your back. Once the catheter is tested, it is connected to an infusion pump and delivers continuous medication that creates a band of numbness from just above your bellybutton to your upper legs.

Patients are also given a button where they can safely give themselves additional medication on demand without the concern for overdose as the pump is set by an anesthesiologist. It typically takes about 15 minutes for the numbing medication to work, and because the catheter is left in place, it can be administered for as long as required.

Epidurals or CSEs are the most common form of pain relief used at Forsyth, with approximately 85% of laboring moms there choosing one. Epidurals and CSEs are administered at Forsyth only by highly experienced board-certified/board eligible anesthesiologists, Forest said. This level of experience increases the overall success and comfort rate with epidurals while decreasing the chance of side effects, such as headaches, paresthesia (a pins-and-needles nerve sensation) or misplacement of the epidural needle.

“In addition to delivering excellent pain control, epidurals also add a safety component for laboring moms as the medication going through the catheter can quickly be changed to provide surgical anesthesia if a C-section is required” Forest said.

In the event a C-section is required during labor at Forsyth, both an anesthesiologist and a certified nurse anesthetist skilled in obstetric anesthesia work together to ensure the mother and baby have the best possible experience and outcome.

Women who want a pain block but are unable to receive an epidural because of a preexisting medical condition — such as a low platelet count — may receive a patient-controlled analgesia (PCA). This delivers a narcotic infusion through an IV with the press of a button.

“Mothers are in control and they only give themselves a dose when they want one,” Forest said.

Forest emphasizes that regardless of which pain-management method a woman chooses, she can change her mind in the moment. Versatile pain-management methods are accessible through a team of in-house anesthesiologists who are part of the core obstetric team and available 24/7.

“Everyone deserves the right to have an open conversation with a very caring and understanding care team made up with a multidisciplinary approach,” Forest said. “What are your goals? We're going to try to achieve those goals for you.”