Week 38: Pain Management

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This is your Pea in the Podcast for week 38 of your pregnancy. I'm Bonnie Petrie joined by Dr. Laurie Swaim, an obstetrician with Houston Women's Care Associates in Houston, Texas.

This week you may be starting to lose your mucus plug. What is that? "Well the cervix is made of cells that produce mucus, they're called epithelial cells. There is this big, fat, disgusting mucus plug, that's all it is, that's in the center of the cervix and when the cervix actually softens and loosens, the plug comes out and it's gross, it looks like snot." Now the mucus plug can be a thick glob of stringy mucus, like snot, which is thicker than what you would see with normal vaginal secretions, there may also be pink, brown or red blood mixed in with secretions. That's called the 'bloody show'. Now many people think losing your mucus plug or the bloody show means that labor is imminent, Dr. Swaim says that it really has no clinical significance at all. You may lose your mucus plug this week and still carry your baby for another month. Believe it or not, losing your mucus plug this late in pregnancy is not a reason to call your doctor. By the way some women never lose their mucus plug at all, but as you reach the final countdown to birthday you're probably thinking about how much this is going to hurt and wondering about how you're going to manage your pain. Dr. Swaim says there are several things to consider, "I usually tell my patients there's like three major categories, and I preface this by pointing out a few things that I sort of feel very strongly about and I think I would hope that most obstetricians feel this way. First of all, the ultimate decision of what the patient uses for pain management is hers. It's not anyone else's. It's not the nurse, it's not her mom, it's not her friends, it's not her husband and I know a lot of husbands want to be involved in this decision but, let's face it, the women are the one who are in labor, not the men. The pain medications that we use are not harmful to their baby and their fetus and so we sort of point that out to them. The second thing that we point out to them is that they don't have to decide now; they decide when they're in labor. If this is their first baby, they've never done this before, they have no idea what to expect and we don't make them, we tell them, we don't make them sign up for stuff, we don't run out of stuff, but keeping an open mind is probably the best option. And the third thing is, most of the time we don't have medical reasons where we would ask someone to use one thing over the other so they don't really have to worry about that too often."

So what are the three options for pain management? "The first is nothing; some women don't want to be given anything to help manage the pain of labor, that's fine. The advantages are they can feel everything. The disadvantages are that labor hurts and it can last a long time. For women who want to do this we even more strongly suggest child birth education classes than those who don't, the more information they have the easier it may be for them to help manage their pain.

The next major category is an IV narcotic like Demerol, Nubain, Stadol, all sorts of similar action. The advantage to this is it affords the woman some pain relief without having a procedure; it helps because it goes in her IV, helps her relax when she's in contractions, helps take the edge off the pain. The disadvantages are the same �.actually makes her loopy, takes the edge off the pain but it's not going to take away the pain. No one can really promise a woman pain free labor for her entire labor but we've got better stuff. The narcotic does cross the placenta, it can get to the baby and it generally really doesn't have any adverse affects and if it does it's just the baby just doesn't want to take a deep breath when its born, it's breathing but it doesn't want to put much effort into it; for which there's an antidote in every labor and delivery in the country so it's not that big of a deal. If a woman receives an IV narcotics she's not going to be up walking around.

Then the third category, the epidural, is also called conduction analgesia, it's a small little tube or catheter, it's place by the anesthesiologist, it goes in a woman's back, not in her spine (that's another one of those nasty myths). It stops at the station before the spine which is called the epidural space and the anesthesiologist places a combination of local anesthetic and narcotic that goes through this tube and essentially bathes the nerves on the way out to your butt and your stomach. So the advantages of an epidural is that if there is such a thing as 'pain free' labor then that's it, that's as close as you're going to get. The majority of women with epidurals are very comfortable, like comfortable enough to be sleeping. The disadvantages are it's a procedure so with procedures there are risks. You have to include bleeding and infection but that risk is far greater from having a baby then having a needle stick. There's a risk of it not functioning well in which case the anesthesiologist can fix it, sometimes it's unilateral or there's a window or something. There's something called the 'post dural puncture' or spinal headache that is pretty rare but it's more a nuisance than anything, it's a headache that usually occurs the following day when a woman stands or sits and it can be dealt with. The reports of women having back pain for life, this is bologny. Women don't have long term back pain from the epidural, it may be sore at the sight for a day or two but it's not going to hurt years from now. Paralysis actually has been reported and obviously I don't want to sound flippant about it because it's bad but it's been, to my knowledge, reported in patients mostly who couldn't clot their blood correctly and we know who they are now. These are sort of older events. The issue about whether epidurals are associated with increased risk for a cesarean delivery is sort of hotly debated; the older data, which were studies that were well done, suggested that epidurals placed early in labor could increase the risk for cesarean and operative vaginal delivery. The newer data suggests that's not true. It's sort of hard to determine, it's like an apples and oranges comparison. The stuff in epidural may be a little different than it was 15, or more, years ago and labor is managed a little bit more aggressively then they were in the studies. So those studies, well there was one in particular that said you had to be 5 centimeters dilated before you should get your epidural and that's pretty cruel and unusual punishment for some women. I know most of us, at least in our group, feel that it's best if you're in active labor. So this is when patients look at you and go 'well duh, why would I want an epidural if I wasn't in active labor'? That goes back to the pain tolerance thing, lots of women just can't tolerate even being one centimeter and some women are fine and don't want any pain medicine. Everyone is different. I point out to our patients that we have no intention of torturing them and if they end up with a cesarean after they had an epidural it's not their fault, they should never feel that way. Sometimes the epidural can have an effect on a fetus, it can lower blood pressure and kind of shun some blood away from the placenta for a few minutes so that that's easily dealt with also. There's some medicine that we give the mom that perks that right up and some fluid and it's not that common anymore anyway because the anesthesiologists are really good at managing those issues. So that's about it."

So what's happening with your little one this close to its grand entrance? Well your baby is growing an ounce a day and its intestines are filling up meconium for its first bowel movement. The circumference of its head and the circumference of its abdomen are about the same now. If you're having a girl, her labia is completely developed and if you're having a boy his testicles are now completely descended into his scrotum. Now speaking of boys, you may be wondering about circumcision. Your doctor may have talked to you about this. "If they know that it's a boy, I bring it up. I tell them the current recommendations, the risks and benefits. Also we talk about pediatricians, many of them will meet their pediatricians beforehand or already have one because they have another child and I encourage them to discuss it with their pediatrician too. The fact is although we're talking to them about circumcision, the pediatricians the one that takes care of kids for their whole life so they know better than we do." Now there is a lot of information about circumcision on the internet, almost none of it is unbiased either way so if you look there you're going to have to sort through what you find very carefully. Ultimately whether you circumcise your boy is between you and your partner and it is no one else's business. By the way the American Academy of Pediatrics does not recommend routine infant circumcision.

So how are you doing this week? Well aside from possibly seeing evidence of your mucus plug, you may begin to feel what can only be described as electrical buzzes down your legs and inside your vagina. That is your baby getting settled in your pelvis, hitting nerves along the way. Braxton Hicks contractions may be a regular part of your day. Most women agree that you'll be able to tell the difference between Braxton Hicks contractions and the real thing but not until the real thing happens. True labor pains will be progressive in strength and duration; they won't go away even when you change positions. You may also might be nesting now, madly preparing your home for the coming baby. That is normal but be careful not to get involved in any big projects you can't finish before the baby comes like painting the house or something. You're 38 weeks pregnant; you have two weeks to go until week 40.

That's your Pea in the Podcast for week 38 of your pregnancy. Dr. Swaim and I look forward to talking to you again next week. Enjoy this week. For a transcript of any of our Pea in the Podcasts go to our website peainthepodcast.com. For Pea in the Podcast, I'm Bonnie Petrie, thanks for listening.