Pain relief in labour - Pethidine or Diamorphine?

[mears]

There is much debate about which injection is better in combatting pain in labour. They are both opioids but a lot of units have changed from Pethidine to Diamorphine. Herein lies a problem.
Midwives can legally administer pethidine in her own right, without a prescription from a doctor.
Some units only use Diamorphine which legally needs prescribed unless it is written up in advance ( technically not legal).
If practicing legally this could mean a delay for the woman in receiving pain relief when it has been asked for.
The question is - who has experience - good or bad - of either drug. Has anyone had pethidine with one labour and diamorphine with another?
I know it is preferable to have neither but for many women that is not an option ( and that is a different debate).
As a midwife I think women should be able to have a choice. If they are requesting pain relief they should be able to have Pethidine from me immediately or they can be prescribed Diamorphine by the doctor. That might mean a wait if he/she is not available just like the situation with epidurals.
The best solution would be that, if diamorphine is a better form of pain relief, the law be changed to allow midwives to give it in the same way that they can give pethidine.
What do experienced mumsnetters think?

[mears]

Where is everyone this morning?

[SoupDragon]

Well, I'm here but I had neither pethidine nor diamorphine so I can't help!

What's the advantage of Diamorphine over Pethidine? Is it a matter of cost or is one genuinely better for mother & baby than the other?

[mears]

I think it can safely be said neither is good! However some people think diamorphine is a better pain killer. Personally I think women are more sedated and just can't tell you that it's still sore.

[mears]

Thanks anyway soupdragon

[Demented]

OK, I wasn't going to answer as I have only had Diamorphine and thought that someone else could help better if they had experience of the two, but seen as it's you Mears!

During my first labour I was given Diamorphine, I felt more or less pushed into having it by the Midwife, all I can remember her repeating was 'we can give you little injection that will help'. I held off for a while saying that I wanted to wait until my DH arrived first. Through the blur I do remember that it was a Doctor who administered it, I had a half dose initially and it did feel good, I was giggling etc, only looking back when a Doctor came in to explain that I carried Strep B and would need an injection of Penicillin, all I could do was laugh at her and tell her that Penicillin gave me thrush on my tongue so I didn't want it (had the Penicillin in the end mind you).

Not long after I felt awful, sleepy and not in charge anymore, they gave me the second injection of it and I just felt worse, more sleepy, less in control. I wish I hadn't had it as it didn't take the pain away, just distanced myself from the pain, which was fine, but I also felt distanced from the birth experience as well.

Anyway although Diamorphine was not for me I think a Midwife should be able to administer it, afterall that surely would free the Doctor up to see to more urgent matters and although I got my injection right away I'm sure in many circumstances a woman would have to wait if there was no Doctor available.

Hope that helps and makes some sense, I haven't been getting my words out properly today.

[Tissy]

Again, have never had both pethidine and diamorph, but I was given the latter after my section when the spinal started to wear off. Diamorphine made me fell very peculiar! It did take the pain away, but I felt out of control and didn't want to hold dd in case I dropped her! I vote for voltarol suppositories- absolutely marvellous!(Though probably no good for labour!)

[Bumblelion]

I had pethidine for my first labour (only gas and air for subsequent two) on the advice of the midwife who was delivering me. She felt I was losing control and thought it would help me. It is not supposed to be administered within 4 hours of giving birth and my midwife thought I would not be giving birth until the following morning (this was about 11:20 pm). As it turned out, I gave birth at 11:35 pm and the paediatrician had to be called when they realised I was about to give birth and my daughter had to be given the anti-dote to the pethidine as it can make babies drowsy and late to respond.

[Demented]

Tissy you've just reminded me, after giving birth to DS1, having had diamorphine during labour I was sitting in the wheelchair going up to the ward and they put DS1 in my arms and I kept thinking 'I could just let go of him and he would roll off my knee and onto the floor', in my mind at the time this didn't feel like the wrong thing to do, just an option. IMO I don't think it helped with the bonding process being so spaced out. The midwives then left me lying in bed with DS1 latched on and I fell into the deepest sleep ever, surely this was not safe as I was still v much under the influence of the diamorphine.

[bundle]

mears, I'd heard that pethidine acted more as a sedative than a painkiller..and it's only effective in about 30% of women. haven't had it though...ended up with an epidural which was just as well as I needed an emergency c-section. I think the prescribing issue is very interesting..the midwife on my ante natal ward kept asking me/dh whether I wanted gas and air/pethidine even though it was in my birthplan - and we reminded her - that I wanted neither. she was very pushy and that was the last thing I needed when I was throwing up and having contractions.

[Catt]

Diamorphine is actually the medical name for heroin. It must therefore be mainly a sedative rather than a painkiller and I suppose pethidine is in the same class? I had neither of these (had an epidural that contained a mixture of lignocaine & fentanyl). I know fentanyl is a strong painkiller so I reckon it's a better bet if you're after pain relief rather than feeling woozy.

Mears - I can't see why midwives can't be allowed to administer diamorphine just as they administer pethidine. I mean, it's not as if you're going to turn people into junkies is it? Isn't pethidine a controlled drug, just like diamorphine?

[bundle]

I had diamorphine post-caesarean and it's certainly a very effective pain reliever - you can really feel it when it's wearing off!

[SueW]

I had pethidine.

I do remember it made me quite paranoid, or maybe it was the situation. I had been having contractions for about 6 hours (was induced) and after I'd had the jab, I lay on my left side, laughing and joking with mum and DH.

A midwife came in carrying a kidney dish with a syringe and needle in it. For some reason (cos I was spaced out I suppose!) I was convinced she was going to give me another injection. I said I wanted to see E, the midwife who had been looking after me. She said E was on a break and she was looking after me now.

I just about lost it - I looked at DH and my mum wildly, trying to work out if this was a conspiracy and they were in on it - another injection. In the end, I blurted out 'I don't want another injection' and then the midwife explained it wasn't for me, she'd just popped in on her way to someone else cos she thought I should be more relaxed. She tried to calm me down by rocking me back and forth and making soothing noises but I wasn't really up for relaxation! I calmed down when she'd left.

I haven't experienced diamorphine personally but saw MIL take morphine in a syrup when she had cancer (self-administered orally by syringe). She was told to take one, wait a couple of mins to see if the pain went, then take another if necessary. It seemed a very effective form of pain relief.

DD had diamorphine following her op. It was via one of those syringe machines. It made her nose itch and she was out of it for the first 16 hours post-op but since it was night-time that didn't really matter. The biggest problem was it made her nose itch which meant she kept knocking her oxygen mask off. I also saw it's painkilling effects on the girl in the bed opposite who had suspected appendicitis and to whom it was administered during the night. 20 mins of agony then a shot from the doc helped no end.

I think if midwives are able to dispense one drug they should be able to dispense both but my concern would be that the possible side effects of both weren't explained to women and they weren't offered a proper choice. In the heat of the moment, it's very easy to say 'Whatever you think best' - I know, I've done it!

[mears]

Thanks for your responses. Catt - they are both controlled drugs. The act that allowed midwives to administer pethidine was passed in 1971. Things have obviously changed over the years. Diamorphine has become the drug of choice in a lot of units. It certainly is the medical name for heroin. Lots of midwives and doctors feel it is more effective. Only a couple of small studies have been done providing evidence that women feel the same. How do you do a valid trial - no 2 women's labours are the same. Second labours tend to be less painful than 1st ones so so couldn't compare 2 different drugs on the same woman. Very difficult issue isn't it?

[pupuce]

Mears - This was in the Independent today... there is more on pain relief as well (including pethidine)
It is a review of Nikki Bradford's latest book :

"So, were she to compile a list of the top five painkillers, which would occupy the number-one spot? Uncontroversially, Bradford opts for spinal injections such as epidurals. "They're the Rolls-Royce of pain relief," she says. "They knock about a third to two thirds off the pain, although one in 20 don't work properly and they can lead to backache." Her choice for second place, though, is more surprising: "That would be a trained birthing partner, or doula," she says. "Someone to stay with you and say, 'I'll rub your back, talk to the doctors ? I'll do whatever you want'. Studies have shown that a doula's presence makes labour on average a third faster and reduces the need for pain-relieving drugs by five sixths."

The whole article is here :

www.independent.co.uk/story.jsp?story=340802

[sb34]

Message withdrawn

[SofiaAmes]

Mears, I had a 40 hour labor followed by a c-section first time around. I was given a shot of pethidine somewhere around 20 hours. I didn't find that it offered much in the way of pain relief though it did take the edge off the contractions. I am surprised about what you are saying about a mid-wife being able to administer it without a doctor's permission as this was not my experience. I had to wait several hours for a doctor to give a midwife the ok to give me the injection. I did all my dialating in the 12 hours after being given the injection (don't know if this was coincidental or not). I was then told I needed to be induced, so I asked for an epidural, but during the 5 hours it took them to come up with the epidural, I used gas and air which I found barely helpful. The epidural took away all pain, but I could still move my legs. I was given what I think was Diamorphine after the c-section and that seriously dulled the pain, but didn't make me out of control as others have described. I would say it was far more effective than the pethidine. However, it was a pretty big shock (I got the shakes really badly) when the effects wore off.
Why is gas and air considered a "natural" pain killer? For example it was the only "drug" pain killer offered on the natural "birth centre" floor where I had my second baby.

[pupuce]

Gas and Air is not a pain killer free labour... it is laughing gas and interestingly enough only the UK and Australia use it... To my knwoledge it isn't used anywhere else !
It can make women quite "funny", laugh or cry and they can loose the plot if they seriously inhale too much !

[mears]

Gas and air- which is actually a 50% mix of nitrous oxide (laughing gas) and oxygen has a very short half life. That means that there are virtuallty no side effects except in very prolonged use. When it is breathed in it must be started at the beginning of the contraction so that it is working before the height of the contraction. Once the contraction is gone the effects of the gas quickly leave the system. The baby has no lasting effects after birth, unlike diamorphine/pethidine which cause the baby to be sleepy and possible feeding problems in the first few days.
Although the mum feels 'drunk' breathing the gas, the effects go when she stops breathing it. That means she is in control of when to start and stop. Once an injection is in the effects are there for hours, sometimes lasting post birth which can cloud the experience.

[Eulalia]

Wasn't offered Pethidine at our hospital. Had Diamorphine both labours. Gas and air doesn't do anything for me, just makes me feel nauseous.
The midwife didn't need permission to give me the injection. In fact the first time I only saw one person throughout the whole labour except to give me the morphine and that was only because I was being given an injection so another midwife came in. Certainly no doctors were present. I didn't know that about not giving it 4 hours before the birth as with my 2nd labour I had the baby about 45 mins after the injection.

The morphine did make me very woozy first time but also extremely relaxed. It certainly calmed me down and helped me get through the next few hours. I felt able to 'wake' myself up OK to push and the birth was no problem. I did feel a bit spaced out afterwards but I don't think it interfered with bonding. Ideally I'd not like to have had it as I am sure it didn't help with feeding problems but the problems were going to be there anyway. Also I did feel jumpy afterwards for a few days.

2nd time I don't think the morphine had time to take effect as the birth was so fast. If I'd known then I probably wouldn't have bothered having pain relief. I think the adrenalin of giving birth wiped out most of the effects and I had no after effects this time. Perhaps also because I'd had it before. I only had one shot each time and I this was enough.

For me it worked postively - I think it affects people differently (makes some sick) and also depends on your mental status, ie how tired you are already and if the labour is going well and how in control of the situation you are.

[ionesmum]

I had pethidine and diamorphine. And gas and air. And an epidural. And a general anaesthetic.

[hmb]

ionesmum,

And me, except the GA! And I had a Tens machine. And they were all wonderful, a various times. The diamorphine was better for me because it didn't make me feel sick, the petadine did.

[mears]

The reason I posted this question was because there has been a recent change in the law (2001) about patient group directions. Up until then the hospital had a standing order which named the drugs midwives could give without getting the doctor to physically prescibe. Since this change midwives cannot give pethidine/diamorphine without physically getting the doctor first. This means a delay for women when the unit is busy. There issue of pethidine could be argued because, in law, midwives did not need a prescirtion technically. However, most hospitals have now changed to diamorphine as it is thought to be more effective for labour pain, with less vomiting associated with it. I have been getting information from all quarters and it would seem that it is not worth preserving the right of midwives to give pethidine as diamorphine is better. The law needs to be ammended to allow midwives to administer it legally when the woman wants it. How long do you think that will take?

[Catt]

Mears - it's interesting that, as a midwife, you turn to those who have been in labour for their views. In my experience, that's what midwives do. They work with us to achieve the best possible labour experience we can have. But as for the hospital or health service as a whole, let's face it they will amend the law late in the day, long after midwives have been pushing for a change (excuse the pun!)and definitely without bothering to find out what actual women in labour think.

Call me cynical, but I wouldn't hold your breath for a quick change in the law to bring practice up to date.

[Willow2]

I didn't have pethidine or diamorphine during labour - but have had the former numerous times after operations, and I would just like to say that I love it and would strongly recommend it to anyone recovering from an operation! It makes you go all woozy and lovely and warm - frankly, if they could bottle it and sell it in Oddbins they would be on to a winner. Having said that it also makes you talk absolute xxxxxxxx - I once asked the nurse to stop my dog from knocking over the flowers - so it might not be a good thing during labour if you are keen to make informed choices!