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?

Believe it or not I do still have a hankering for a fourth, . Most of the time it seems like a bad idea but you only need to think it's a good idea for five minutes (or less) for it to become a reality

Mears - the thing about the intact membranes is really interesting. I had my waters broken with ds1 at 4cm because I had been 4cm for dear knows how long (I went in with some bleeding; no contractions; they said I was too dilated to go home; slept all night and so they decided to get things going in the morning). With ds2 I was at 10cm before my waters broke spontaneously and I didn't understand until after why they hadn't broken them for me - having them intact does explain why it wasn't as horrifically painful as the first time (it took 2 hours from waters being broken to ds1 being born). They were trying to explain that I could in fact deliver ds2 with my waters intact which was too bizarre a concept to get my labouring head around! It was also not so bad because I had morphine. Having checked with dr dh it was morphine and it was given with no reference to a doctor - the midwife prescribed it (I think). It was fantastic - didn't stop the pain but made it bearable and allowed me to really rest between contractions. Mw warned that it may slow things down but given that the whole labour was 4 hours with the second stage officially recorded as 2 mins that kind of slow I can deal with!

Mears - like Harrysmum I was really interested to read about the waters being intact. I have always felt this to make sense and yet have never read any proffessional actually saying so. Reading you words has meant a great deal to me.

Against my wishes (and the previous mw caring for me?s advice to the next one at the cross over), a change of shift resulting in a different mw examining me and breaking my waters with a throw away comment like "there you go, we will get a faster move on now" I was horrified as suddenly my whole birth experience changed from being calm and in control to being unable to cope with massive increase of pain (not prepared so was also very frightened) and agreeing to pain relief that in other circumstances I would never have taken (pethidine). The pethidine made me feel even less in control (couldn?t speak but could hear all going on around me) and to cut a long story shorter, baby became distressed, hb dropped, ventouse done - again with no discussion - (pethidine wasn?t working in terms of good pain relief and so ventouse proved very painful - was badly bruised). She arrived "safely" but was very sluggish, slow to latch on etc. etc. All in all, left feeling as if I had been violated (examined frequently with no prior warning or sensitivity to my contractions), my labour hijacked by an impatient mw and possibly my babies health put at a slight risk. Judging by the huge number of staff who ended up in my room at the end, they were clearly worried that something was going wrong - never offered much of an explanation or decent "debriefing" - depsite several requests at the time. I was so shell shocked that we just wanted to get out of there and go home to recover.

So, personally, I would never take pethidine again. I never like feeling drunk and hated feeling unable to coordinate my words and express my feelings despite being able to see and hear everything. The pain relief seemed minimal and didn?t notice any real reduction. The medical staff seemed to take my "enforced compliance" to mean that they could just get on with it and tell me what they were doing rather than ask - eg. "I am examining you now" - despite being mid contraction and me desperately wanting to ask them to wait or ask if it were necessary - seemed to have one every ten minutes, I believe a student midwife was "practising" at the time.... I even remember one member of staff leaning right over me and telling my husband "don?t worry about her now, she is totally out of it". Those words still haunt me - it was so frustrating not to be able to shout back at her "no I am not, I am in pain, and very frightened. Stop ignoring me and start treating me like a real person again." Interestingly, a close friedn?s sister who was a mw for several years (now on maternity leave herself) said that pethidine was often given to women by some mws she worked with just to "shut them up a bit and let the staff get on with their job"...not sure how much truth is in this but she is a lovely girl and seemed genuine when saying this.

Sorry to go and on - this post has uncovered a lot of deep seated feelings that I thought I had worked out of my system but obviously not! I am going for a home birth this time and hope to avoid all medical intervention as much as is possible.

yes very interesting about the waters, in both my (normal) deliveries the waters did not break by themselves, but were broken for me and I delivered less than 20 mins later. I had always thought that it was necessary for the waters to break and that somehow my body "failed" me by it not happening naturally. Now I realise that my body was doing the best thing. Thanks Mears.

I think the waters thing is interesting too.

My waters broke naturally whilst i was in an upright position (semi squatting, I think, definitely leaning against a sink). My daughter was posterior (I had an anterior placenta i.e. on the front of the uterus which prob didn't help) and she ended up in an unusual position with her head presenting sideways, chin and ear first.

In some ways I wish my waters had waited a little longer before going or I had been in a position where there was less room in my pelvis (not at all squatting) as my DD's head might have got into a better position and not got stuck! Perhaps if I had been in a position to do handstands, that might have helped.

Can't help but smile at the thought of 42 week pregnant woman weighing 92kgs doing a handstand in a delivery room! Maybe tying me by my ankles and dangling me from the ceiling may have helped!

Both my labours waterrs went of their own accord at the end of the first stage.
I have been a doula to a mum who delivered baby in water with its sac intact! Very interesting... it burst when she came out !

A small vote for pethidine here (sorry haven't had diamorphine Mears). I had a home birth and after 8 hours through the night of contractions 3-4 mins apart (dd was very low apparently) and still at only 3cm dilated I was deperate for some rest. Pethidine enabled me to doze between contractions for the next 5 hours through to 10cm and 2nd stage was only 15 mins. No problems for baby or me. My waters were broken at 10cm - I must admit I too assumed they had to be broken some time!

JUST READ SOME OF THIS THREAD AND MEARS DIDN'T REALISE YOU WERE MW EITHER!
MY WATERS BROKE OVER 3 DAYS BEFORE I HAD MY DD AND AFTER BEING SENT HOME IN AGONY LOADS OF TIMES BEING TOLD I WASN'T IN ACTIVE LABOUR THEY FINALLY LET ME STAY AND GAVE ME PETH WHICH I DIDN'T WANT BUT WAS SO TIRED HAD AND SLEPT FOR NEXT 6 HOURS! WOKE WITH BAD CONTRACTIONS AGAIN ONLY 7CM SO HAD EPIDURAL AND THEN WENT ANOTHER 12 HOURS BEFORE ACTUALLY GETTING DD OUT!
NO-ONE EVER TOLD ME WATERS BREAKING MADE IT MORE PAINFUL! KNOWING THIS MAKES ME FEEL A BIT MORE HAPPY FOR WHEN I TRY FOR ANOTHER, HOPE FOR SHORTER LABOUR AND CAN HANG ON TO MY WATERS!
IS IT ANY MORE LIKELY THAT THEY WILL BREAK EARLY AGAIN?

Hi SueW - midwives can no longer administer Pethidine. Hospital midwives actually should not have been doing it in the first place but fairly new legislation regarding the administration of drugs makes it unlawul. Opiates should only be prescribed by doctors and pethidine is included in that. There are drugs that midwives and nurses are authorised to administer without a prescription and these come under Patient Group Directions. Community midwives may be able to give pethidine. There needs to be an ammendment to the legal situation but in the mean time, Diamorphine is prescribed in our unit for all women since the doctor needs to write it up anyway (midwives used to write up the pethidine).
The law needs to be ammended for community midwifery units where a doctor isn't present. It annoys us that we have to get the doctor to write the prescription for our midwifery cases. You know how long the legal wheels to turn.

We have just conducted a large two centre randomised blinded controlled trial of 484 women comparing 7.5mg diamorphine with 150mg pethidine for labour pain. Diamorphine gave better pain relief for the first 1.5 to 3hrs compared to pethidine but at the expense of longer labours by about 1.5hrs. We looked at all the confounding factors that may prolong labour and eliminated them and we still found that mothers who had diamorphine delivered about 50mins to 1.5hrs longer. This is not widely known by women who choose diamorphine. There were no significant differences in the outcomes of the babies from mothers who had either diamorphine or pethidine and we looked at a number of outcomes during labour and up to 2hrs post-delivery including sedation and breastfeeding. We hope to publish our findings soon in a high impact medical journal. So the simple message is - if you want diamorphine, be prepared for a longer labour but you will get better pain relief for about 3hrs after the drug. More women seemed to be more satisfied with diamorphine compared to pethidine but 85% of women in our trial in BOTH the diamorphine and pethidine said they would choose the same analgesia again for their next pregnancy.

I was told diamorphine was a " cleaner"drug and didnt pass placenta as much as pethadine? and was also more effective?

I had pethadine, there wasnt much else to choose from, the g&A wasnt cutting it - although still had it - and i wasnt allowed an epidural with the old - too far gone, not far gone enough routine....

with nothing else to try - i had pethaine and it certianly relaxed me whilst still feeling the pain.

it was definalty a postive - but its not like there were many other options....

YES mw should be able to adminsiter it - why add another thing for busy over stretched docs to try and do !!!

For what it's worth I had a great experience with pethadine!!
I think I had what is referred to as failure to progress.

My contractions started on the Thursday night 22.00 ,
Coming every 4 minutes but lasting a max of 25 seconds....
The where strong enough and regular enough that I couldn't sleep.
This continued right the way through till Friday tea time 6.30 when my contractions (which I hadn't had a break from) began to last 1 minute. They where still coming regularly every 4 minutes...

The midwife (who i had been in contact with all day) came to my house at around 7.30 where she checked and said I'd dilated 1cm....

She left and came back at 11.30 and I was still only 1.5cm...
So she referred me to the hospital (I had been due for a home birth)

Once at the hospital the midwife there gave me pethadine to help me sleep. :-)
2 hours later I woke "needing a pooh" as I thought she checked me and I was fully dilated,
Contractions still only every 3 minutes lasting slightly longer than 1 minute.
I had no further pain relief, didn't feel I needed any.
60 minutes later baby was born, only complication was he had done a pooh in the amniotic fluid, so was monitored straight afterwards,
But he was fine.

I have already told my MW that if the same happens I want pethadine.

Pethidine with ds1. Felt really drugged up and although I could still feel the numbed contractions iyswim, I couldn't talk or move much.

But it did dull the pain.

Ds2 I had diamorphine and I loved it!! Only the first shot though.... Was exhausted an needed a rest.

Had 2 further shots which I feel prolonged labour but again was exhausted and had not wry supportive mw's

In hospital for over 24 hours before ds2 was born via emergency spinal block and ventrouse. Was going to have a caesarean if ventrouse didn't work.

Ds3 due in 12 days and I'm shitting myself

Don't want pethidine or diamorphine but worried how I'll cope with the pain if its another long labour and I'm exhausted.

Hello Mears - I know I'm very late in joining this convo but wanted to add my 2p worth! I only had Diamorphine (I asked for it plus had it on my birth plan) - don't remember Pethidine being talked about much but for me Diamorphine was a big mistake as it didn't relieve my pain and just sent me off the rails - didn't listen to any midwife instructions from then (apparently!) and tore badly which I believe was from not listening and going a bit la-la. My DS was so knocked out when he was born he wouldn't feed properly for 2 days and I have always wondered if it had a long term affect on his brain - do you know if there is any evidence to show this could be possible? You may have long gone from these conversations but have always wondered..... Happy 2013!!

WeeObsAnaesthetist - has a report been published? Would be interested to learn more of findings from Diamorphine as my son wouldn't feed properly for 2 days after birth as he was so knocked out and I wonder if there are any findings of long term affects on the baby? (Son is age 9 now!). thank you.

Weeobs interested in this "More women seemed to be more satisfied with diamorphine compared to pethidine but 85% of women in our trial in BOTH the diamorphine and pethidine said they would choose the same analgesia again for their next pregnancy."

What were they comparing with - especially if it was a first child?

Having had both pethidine and an epidural, I had wooziness, slight nausea, hardly any pain relief and difficulty in communicating with the former. I refused pethidine for a subsequent birth so that I could argue forcibly for an epidural which I got (after a battle) and which gave 100% pain relief with no side effects whatsoever.

I had Diamorphine. I was begging the midwives for it, for about 2 hours before they let me have it. I was in a huge amount of pain.

When they injected me, I screamed 'it's just water!!'. But it worked. BUT...it did result in a very very very sleepy baby who didn't feed for ages, total actual birth amnesia for me, which I think led to my PND and psychosis (was convinced baby belonged to someone else, as I couldn't remember giving birth, just being in labour). I pretty much gave birth, threw up, had a shower, and fell asleep (only had short labour, so wasn't like I'd been awake for hours like some women). Didn't want to hold the baby until we got home, which was 4 hours after birth. And even then I didn't really pick up except to feed/when the midwife came. Felt totally disconnected from him.

Also, I got the injection about 20 minutes before I gave birth, had been using the pool and G&A up till that point. I was in so much pain I would have shot myself (or anyone else including my partner!) if it would've stopped the pain.

My really big issue with pethidine is that many women are not making an informed choice in opting for it, because many midwives don't set out the facts on how ineffectual it can be as an analgesic in advance.

Women need to be told that perhaps half of those who take it will still be in severe pain an hour later.

My understanding is that midwives routinely rate pethidine as more effective as pain relief than mothers themselves do. Perhaps because it makes women nice and quiet and easy to look after.

Haven't read the whole thread, but my experience of diamorphine was awful. I was still in agony, but couldn't express it. I was hallucinating, and it took about three days to feel normal. Just awful.

This thread is older than my children!

I had pethidine for first birth, diamorphine for second. The latter was better, a 'cleaner' pain reliever. It worked well for a few hours until I had to have a synto drip.