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?

I know someone who's baby also nearly died at birth due to pethidine; the MWs told the mother she was ages from delivery; she had the pethidine jab & 20 minutes later baby was born, not breathing.

Her 2nd labour went similar, and she was sorely tempted towards the pethidine, but resisted because of the first experience. Sure enough, less than 1/2 hour after she nearly opted for pethidine her 2nd child was born.

I had pethidine with ds1 but it was probably about 8 hours before birth but he was fine and had an apgar of 10 straigh away. I didn;t like it though - lost control a bit and felt realy weird so didn't have anything for ds2

Haven't read the whole thread (just the recent bits) but I just thought I'd ask if having pethedine could increase the risk of baby being in distress during labour?

Both of my children had meconium in the water but only dd was in distress to the point that her heart beat was dangerously low and things got a bit frantic. No one ever said that it was due to the pethedine, I didn't get any explanation just accepted that that was the way it goes some times.

Mears - I had diamorphine with my ds. I was extremely thankful at the time, but in hindsight it still hurt like hell and my gas and air was a distraction for me.

The diamorphine made me drowsy, unaware fully of what was going on and I kept drifting off inbetween contractions which meant I would wake up midcontraction..... too late to take a nice big inhale of gas & air.

I also didn't like the fact that I felt totally spaced out and when ds was born I still felt drunk. I have had to rely on my dp to tell me all the details of the labour. Plus my ds was a bit groggy too and wouldn't latch on to the breast for a good 24 hours.

I really would rather do it without diamorphine next time so I can remember clearly what it was like to see their wee face for the first time.

I had two lots of pethadine (a 36+ hour labour) with my ds, then a epidural. When ds was born he wasn't reactive and to my view was dead (although this was never confirmed). He was eventually bought round in SCBU (so I don't know how they did it) and went on to suffer serveral convulsions.
The morning following his birth I was asked whether I had taken any drugs during my preganancy (like heroin or cocain), which I certainly hadn't - I really think it was due to the amount of drugs they had given me during a very painful labour (they had also given me 20mg antidepresant that can help you sleep, can't remember what its called). They only discovered he was back to back with me after about 15 hours of labour, so the care we got there was crap. Bummer is I am having 2nd baby next march and thats the hospital I have to go to

dinosaur - I have never come across your experience being attributed to Pethidine - what an awful experience for you. It is extremely unusual for a baby to need that level of resuscitation so I am not sure that there will be evidence around to support the belief that it would be due to the pethidine. However, since there was no other sign of distress prior to delivery I can see why the connection has been made.
Pethidine/Diamorphine in labour can have an effect on the baby. Babies most affected are usually born around 2-3 hours after the injection. It used to be that paediatricians were called to the delivery if it occurred within 2 hours of the admimistration of pain relief, but the effects of the drug are not usually at it's height then. It can affect the establishment of breathing in the baby and floppiness. An antedote called Narcan can be given in extreme cases.
Epidurals can also affect babies because the drugs used in them can also cross over to the baby. One of the drugs used often is Fentanyl (Sublimaze) and it can also cause the same effects in the baby.
Alternative forms of pain relief such as TENS, Massage and water (pool) can be really effective without the side effects of drugs. The support of midwives is also crucial.
Dinosaur - second labours are often much more straight forward and there is less need for drugs. The chances of the same thing happening to you are remote I would think. Best wishes for a good experience next time

Hello Mears, I realise this is an old thread, but are you still interested? I have had both pethidine and diamorphine and am happy to write about it if it would be useful, but one was in a "normal" delivery and the other a C section, so it's not a very scientific comparison.

I am always interested in womens' experiences

Ahh, that's nice! Well, it's all highly unscientific, but my first labour was all fairly hideous, culminating in a ventouse and baby with very badly damaged scalp. I was given pethidine, I would guess about 3 or 4 hours before he was born, and I absolutely hated it. It made me sleepy and spaced out, so I was completely unprepared for the contractions when they came, I was just woken up to a wall of pain, it felt like. I really find it hard to believe that it dulled the pain; I can't be sure, obviously, but it just felt as though it was just as intense but I was less able to deal with it.

The second time my dd was breech, and it turned out I have a very narrow pelvis, so I had a C section. I had diamorphine on a pump I controlled, and it felt so much better than the pethidine -I'd been dreading it as I assumed it would be the same, but although it made me a bit drowsy I didn't feel out of control, and it helped the pain enormously. Obviously I was post-operative and not in labour, so you see what I mean about it not being a very valid comparison!

Thanks for listening

Mears I too had not realised you were a midwife. Oh can I ask you some questions about my labour with ds then please? I know that you must get this all the time but there are a couple of things that are still bothering me 17 months on and getting in touch with someone at the hospital to talk to is like.... well the words needle and haystack spring to mind.

If I can help Jenie, I am happy to.

I was sent to hospital to be induced as I was 10 days over due and fed up, dp was going away with work the following week and I was desperate for him to see ds prior to leaving.

Well after labour was started using that cream thing, I was in full throws give or take 1hr and in the delivery suite in heaps on pain. Well my waters didn't break for a long time (about 20 mins prior to his delivery). When they did there was meconium (sp) in the water the midwife said something about it being there for over 24 hrs (how did she know this) and got the pead down for clearing airways etc.

Well when he was deliverd he had the cord wrapped around his neck and it had a knot in it (how does it get knotted?).

Something was then mentioned about if I hadn't been induced that night that he may well have died due to this...... would that be right? I had to beg and plead and plain old refuse to leave until I'd been induced due to staff shortages.

I'd been in and out just befor due date as I kept having contractions that were painful but nothing was happening other than that, everytime I was given an internal ds head would "bob away". Should this have indicated that there was alot of water surrounding him and that maybe they should have been scanned for this.

Any way if you could answere these questions I'd appreciate.

Hi Jenie,

I'll answer your questions in a different order if you don't mind so that you can see a chain of events if you like.

When you mentioned that the head would "bob away", that is a sign that the baby's head has not engaged as yet. It is quite common for women to come to hospital thinking they are in labour because of painful contraction but often these contractions are 'pre labour' ones which, although they are painful, are the body's way of preparing for labour. I would say that your previous admissions were prelabour pains and that the head was not engaged. There is no need for a scan at this stage unless the baby was facing the wrong way or the head was no where near the pelvis.

The prostin gel you were given obviously put you into good going labour so you were probably close to going into labour on your own anyway.

It is not uncommon for baby's bowels to move in the womb (meconium stained liquor) when you go past your dates. Sometimes it can be a sign of distress if the heartbeat shows decelerations on the monitor tracing. Often there is meconium but no distress of the baby at all. If there is a lot of meconium seen in the waters prior to delivery, a paediatricain is called so that the baby's airways can be cleared at birth before the baby has a chance to 'breathe in ' the meconium (meconium aspiration). However, babies actually sort of breathe in the womb anyway and the meconium can already be in the lungs prior to birth. Usually the paediatrician looks down the baby's throat with a light to see the vocal cords. If no meconium is seen then it hasn't gone into the lungs. If a baby comes out screaming there really is no need to look down because they would not be able to cry like that if there was a problem with the meconium. You can tell by the shade of the meconium whether it is fresh or old. I presume yours looked like old meconium hence the midwife saying it looked like over 24 hours old.

It is better for the baby actually the longer the waters go without being broken (intact membranes), even if there is meconium. Intact membranes cushion the baby during contractions and it is les painful for the mother.

I think it is ridiculous that someone said the baby might have died had you not been delivered that night. It is not uncommon for a baby to have the cord wrapped round the neck (all 4 of mine did). Some babies have really long cords and they are wrapped round the body and limbs as well.
I have seen true knots a few times. The knot occurs because of movements of the baby in earlier weeks. The baby may have moved to breech and back again and the knot has been made as the baby has swum through a loop. The cord has blood vessels with thick jelly round them to protect them. Knots can be present that cause no problem for the baby. Sometimes though, the knot can be tight and the baby's heart rate slows down a lot during contractions. If the tracing of the heartbeat shows a significant problem then the baby might need to be delivered by caesarean.

Being induced is actually very stressful for a baby. You laboured very well but had they tried to induce you say a week earlier, the gel might not have worked and you might have needed to have your waters broken as well and be put on a drip. When the waters are broken the baby is not so well cushioned and because of the cord round the neck and the knot in the cord, your baby would have been much more stressed. It is a good thing that your waters were not broken which some hospitals automatically do when you are getting induced. How was your baby at delivery? Any problems?

Hope I have answered your questions. Let me know if you think of anything else

Thank you so much it does help to know, I wasn't in there for long afterwards, had a bath and toast then left with ds.

My labour only lasted 3hrs from having the cream to delivery so there wasn't time for too much monitering but he had a good heartbeat up to the point of my waters breaking and by then I'd done the rest so it would have surely been quicker for me to carry on. Glad I did tbh.

Ds was fine after delivery, he had a floppy larinx that I don't think is connected and so had very noisy breathing for about 8 months (still does to some degree now) but they removed the cord and cut it befor he was fully delivered. Lots of facial bruising (normal as it was the same with dd).

That's about it.

Ever thought of answering mothers labour questions for a living? Everyone I know has atleast one question. You could charge £10 per question - blimey I'd owe you atleast £30......

Blimey Mears.... if only more MW felt the way you do!

It is very rare that you hear this :
"Epidurals can also affect babies because the drugs used in them can also cross over to the baby."
Or
"It is better for the baby actually the longer the waters go without being broken (intact membranes), even if there is meconium. Intact membranes cushion the baby during contractions and it is les painful for the mother." - way too many women get their waters broken !

or

" It is not uncommon for a baby to have the cord wrapped round the neck" - so many people are told that they are lucky their baby is alive.... they are led to believe that the Dr saved their baby (and this justifies the intervention)...grrrr.....

Sorry had to rant!

for all the help mears has been to me I will need to get a bank loan....

Thanks you lot I adore being a midwife and am happy to help when I can. Any sign of anymore babies Jasper - only time I get hands on to myself is when friends have babies