In the not-too-distant past, pregnant women going into labor had few options to manage the pain of delivery. In fact, they had two options.
“Traditionally it’s been you get an epidural or you get nothing, which one do you want?” says Dr. Kristen Wolfe of Boulder Medical Center. “But, really, the more appropriate thing might be something in the middle.”
In just the last few years, Boulder County hospitals have embraced new pain management tools — everything from nitrous oxide to virtual reality — and have made a conscious decision to phase out opioid use. The change has been supported by Boulder County mothers, who choose to use epidurals at relatively low rates (less than 50 percent at some hospitals), and who are eager to try these new and innovative ways to manage labor pain.
Nationally, the rate of women who choose to use epidurals is around 70 percent, though many of the doctors, nurses and midwives we spoke to for this story say hospitals they’ve worked at previously had a rate closer to 80 percent. There are plenty of reasons why the epidural rate is lower in Boulder County — a strong commitment to naturopathic and holistic medicine, a desire among local women to be more active during labor, and skepticism and wariness of medical intervention, particularly one that requires an anesthesiologist and a large needle in the back.
“Definitely there’s a thought out there that one intervention begets another intervention and it’s a spiral and you end up with a C-Section,” says Wolfe, who delivers at Longmont United Hospital.
Longmont United recently added nitrous oxide to its list of pain management techniques. At low concentrations, nitrous oxide is a pain and anxiety reliever with few side effects for the mother and child. At both Longmont United and the labor and delivery unit at Boulder Community Health’s Foothills Hospital, which has been using nitrous oxide for almost three years, women can self-administer the gas through a mask.
“The nitrous oxide can play a role for somebody who doesn’t quite feel like they need an epidural but wants something to control their pain during labor,” Wolfe says.
Nitrous oxide also allows women to get up, walk around, and use other pain management techniques that an epidural wouldn’t allow them to use.
“The thing about nitrous is it’s in and out of the body really, really fast,” says Lisa Allen, the Family Birth Center director at BCH Foothills. “You inhale [nitrous oxide] and a couple inhalations [of oxygen], and it’s gone from the system. It takes the edge off. It seems to work better for lighter contractions, but we can also use it after delivery, if there’s any issue with delivering the placenta.”
Still, the nitrous oxide is not a perfect replacement for the epidural, Wolfe says.
“It’s dramatically less effective than an epidural … but it can be comforting and distracting,” Wolfe says. “It can help somebody get through a tough period in a labor. But for somebody looking for something that’s excellent pain relief for contractions, the nitrous is not going to fit into that box.”
That’s where other techniques can fit into a pain management plan. Allen says women delivering at BCH are encouraged to share a comprehensive birth plan with the labor and delivery team and investigate all the tools and techniques available.
Many of the unique pain management options women can choose in delivery involve distraction. At BCH, women can utilize the TENS machine, which sends a low-voltage electrical current to pads strapped on a woman’s back.
“It tricks the mind into focusing on something else so you’re not focusing on the pain,” says Charlotte Wilkes, a certified nurse midwife at BCH Foothills. “So you can turn it up or down depending on how much stimulus you want. Some people, just a little of it is enough to get the brain thinking something else, and sometimes they need a lot of it.”
On a trial basis, Allen says BCH brought in virtual reality equipment to help women manage their pain in labor. Women wore headsets plugged into a virtual reality program on their phones. The programs showed either serene scenes, like a beach with crashing waves, or mind-consuming games, like one in which patients shoot floating objects by staring at them. It wasn’t worth all the fuss it turns out, Allen says.
“Both moms and nurses felt like it was really cumbersome,” Allen says. “One of the moms felt detached from what was happening with her. … The goggles are big and kind of heavy, and then if your phone falls out, it’s too much fiddling around.”
Virtual reality, nitrous oxide and the TENS machine have all been around for decades in various forms and for various uses, but it’s only in the last few years that they’ve been used during labor and delivery. In fact, it’s the repurposing of old techniques that marks the biggest innovation in labor and delivery. A concerted effort to reduce opioid use in hospitals around the country has contributed to doctors administering drugs like fentanyl less often. But in terms of finding a new wonder drug, Allen says she’s eager to bring in new techniques and ideas, but rhetorically points out, “labor has been around for how long?”
“I’m not sure if there’s anything else out there that’s going to be new and great in the labor and delivery world in terms of pain management,” Wolfe agrees, adding that epidurals are so effective and so relatively low-risk that there isn’t much incentive for innovation from the pharmaceutical industry.
What is changing though, and is getting a case study in Boulder County due to its low epidural rate, is a commitment to trying multiple “alternative” pain management techniques. Every woman’s pain tolerance is different, so what works for one woman might be useless for another.
“We are all hard-wired differently,” Wolfe says. “I have seen people come in with strong labor contractions, and they’re seven centimeters dilated and they’re like, ‘I’m fine.’ I think they’re truly having a different experience than someone who’s four centimeters dilated and is in miserable pain. We all experience pain differently in our brains.”
That’s why having a suite of options is beneficial. BCH is installing ladders on some delivery room walls, so women can climb, hang and take the weight off their backs. Balls of various shapes, both stored in-house and brought in by pregnant women, help reduce pain. Different breathing and meditative exercises have arisen in recent years, and both Wolfe and Allen have no preference over which a woman chooses, as long as it’s effective for her. A technique called spinning allows physicians to move the baby, while still in the womb, into a position that alleviates pain and makes delivery easier. Doulas (trained birth coaches) help guide women through pain and can help communicate to medical professionals what technique or tool might be most effective. All are now offered to women as the myth that epidural use is the only or best pain management tool is getting busted.
These techniques are also good alternatives to have on hand in case of an emergency. Because of the low rate of epidural use, anesthesiologists aren’t always on-site at local hospitals, which means women who choose an epidural may have to wait 15-20 minutes for the physician to arrive and set up. It is, however, a myth that there’s a window in which women can receive an epidural, and if that window passes, they can longer receive one.
“We can do an epidural at almost any time,” Wilkes says. “Unless [the baby’s] head’s crowning, that’s not a good time not to get an epidural. … But it’s a myth not just with patients and clients, it’s a myth with [some] providers and anesthesiologists as well.”
Still, there are reasons why an epidural might be the most effective option. Wilkes says if a woman’s delivery is not progressing, an epidural can help hasten the process. And though Allen says there is absolutely nothing wrong with women choosing an epidural, the range of pain management tools available to Boulder County women should encourage them to at least take a second a look.
“Epidural rates are high [nationally] because people think that’s what you do,” she says. “But it shouldn’t be the default.”