Pain relief options for labour and birth

This article has been written to provide clear evidence based information about the various pain relief options available for labour and birth, so you can start to think about what you might prefer. There is a lot of information to take in, so we do advise that you also discuss these options with your midwife and doctor. They will be able to help you with any queries and provide any additional information that you might need, so you understand the benefits and disadvantages associated with each.

Introduction

Labour and birth are normal physiological processes, but tend to be uncomfortable and painful for the majority of women. Women’s experience of pain during labour varies considerably and the only person who will truly know how much pain you are experiencing and whether you are coping with it is you. The pain associated with labour and giving birth is often described as being a ‘positive’ pain that will come to an end, culminating in the birth of your newborn baby. In this respect, pain in childbirth is very different to the ‘pathological’ pain that is associated with disease or injury to our bodies. Unlike pain associated with illness, you can feel completely well between contractions as your body rests before the next contraction comes along. Labour contractions are strong, intense and can often feel completely overwhelming, but they have a job to do and that is to dilate your cervix (neck of the womb) and help your baby to move down the birth passage (vagina) and be born.

The pain associated with labour is rarely focused in just one area of the body and commonly affects several parts either simultaneously or intermittently. This pain can be felt in your back, down the tops of your legs and in your lower abdomen. Labour contractions can also affect your body’s functions causing nausea and vomiting, and difficulty passing urine or controlling your bowels. Women can experience a sudden urge to open their bowels, which isn’t dissimilar to the way that dysmenorrhoea (painful period pains) can affect some women.

Every labour is unique however, so some women will report that their labour contractions weren’t as bad as they’d anticipated, while for others, the experience was worse. This shows just how subjective and individualised the experience of labour pain can be.

Types of pain relief in labour

There is a wide range of pain relieving options available and you don’t necessarily have to rely on medication (drugs) to manage your labour pain. Studies have shown that pain relieving measures during labour that prevent ‘suffering’ as opposed to completely eliminating pain, build women’s confidence and help them to maintain a sense of control and wellbeing during their labour and baby’s birth.

Support in labour

The continuous presence of someone that you know and trust to support you during your labour and birth has been found to reduce the need for pain relief. See also our article, ‘Who can support me during labour?’ Having a supportive birth partner means that you can focus on your individual needs, relax more, and can basically just be yourself. Where women receive continuity of care – ie care from a midwife they already know or the same midwife throughout labour, this has been found to reduce the need for pain relieving drugs significantly. Research has also found that continuity of care is associated with a more positive overall birth experience; babies being born in better condition and not requiring assistance with their breathing (resuscitation at birth); a reduced incidence of episiotomy (a cut in the perineum that assists birth) and reduced incidence of post birth hospital admissions.

Where women receive continuous one-to-one support from a doula during childbirth, this has also been found to increase the likelihood of their achieving a normal vaginal birth with fewer complications for their newborn baby. Doulas can also provide comfort measures to help ease the pain from labour contractions including the use of massage and touch, relaxation techniques (eg breathing) and positive thinking. Studies that have looked at the impact of continuous doula support during labour have found that women are more likely to have a normal vaginal birth, as opposed to needing forceps, ventouse or a caesarean section. They are also significantly less likely to use any pain relief or report dissatisfaction with their overall birth experience. Where doula support continues into the postnatal period this has been found to support exclusive breastfeeding at four to six weeks post birth and encourage maternal/infant bonding and attachment – see also our article, ‘Bonding with your new baby’. Doula support has also been found to help women feel more confident in their transition to motherhood.

Comfort measures

This is an umbrella term that covers a range of approaches to easing pain and helping women to cope with their labour contractions. These measures include, assisting women to adopt different positions for their labour and the birth, the use of complementary therapies such as, aromatherapy and the application of heat or cold (hot compresses or ice packs).

The great thing about comfort measures is that they can be used in any birth setting, whether at home, in a Birth Centre/Midwife-led Unit (MLU) or Maternity hospital/unit. They can also be used in combination with other forms of pain relief and can provide interim comfort eg where a woman’s labour is rapid and the baby is born before pain relieving medication can be given, or where the labouring woman is waiting to have an epidural sited.

Aromatherapy

Aromatherapy refers to the age old practice of using essential oils to positively affect an individual’s emotional and/or physical health and wellbeing. These essential oils are frequently used in combination with other therapies such as massage, baths and inhalations (gas and air). Research studies that have looked at the effectiveness of aromatherapy to relieve pain during labour are limited. A large UK study found that the use of aromatherapy during labour was associated with relieving fear, anxiety and pain. Using aromatherapy during labour can also be calming, comforting and very reassuring. However, there is currently insufficient research evidence to say for certain whether aromatherapy is more effective than placebo (a medicine or procedure prescribed for psychological benefit rather than physiological) or other interventions for the management of pain in labour. Some midwives undertake additional training so they can offer aromatherapy to the women in their care. The use of essential oils can however, adversely affect some women and side-effects that have been associated with their use include, headache, nausea, rash and allergic reactions.

Application of heat or cold

The application of heat and cold has been used to aid relaxation of tense muscles and provide soothing relief for centuries. This might include, applying a warm compress to ease lower backache; often associated with a baby lying in the occipito-posterior (OP) position (ie where the baby’s back is lying against the mothers), or the application of icepacks to the perineum or anus during the second stage of labour – ‘pushing’ phase, to relieve the burning sensation caused by the perineum stretching. There are however, some situations where the application of heat or cold is contraindicated. This includes where women have sensory nerve impairment or an epidural for pain relief. This is because the anaesthetised (numbed) parts of her body are at increased risk of burns or frost injury.

Cognitive strategies (positive thinking)

This approach focuses on positive thinking and the labouring woman’s awareness, beliefs and feelings, and how these impact on her ability to cope with her labour pain and childbirth. An example might be, encouraging the woman to visualise her cervix (the neck of the womb) as a rose bud that is gradually opening with each contraction. There is limited research on the application of cognitive therapies to labour and birth; however, it is widely recognised that such approaches have been used effectively for hundreds of years. The main advantages are that they encourage relaxation with women often reporting a sense of control and wellbeing; there is no adverse effect on women’s state of consciousness or interference with normal labour progress; there is zero potential for harm; they can be used in any birth setting; and they don’t adversely impact on women pushing during the second stage of labour.  However, some techniques do require that women receive pre-labour instruction and practice to ensure that they feel confident using them for pain relief once their labour has started.

Examples of cognitive strategies include:

• Breathing  techniques
• Conscious relaxation of tense body muscles
• Relaxing music and environmental sounds
• The use of prayer
• Meditation and visualisation
• Repeating a mantra and vocalising eg “My body can birth my baby”.

Positions for labour and birth

Labouring women are often observed to instinctively adopt a range of positions that provide relief from the pain of their uterine contractions. These positions include kneeling on all fours, standing, sitting-down, lying on their side (lateral) as well as, positions that are supported by their birth partner or with cushions, foam wedges and birth balls eg squatting.

It is unlikely that you will have any clear idea of what position will work best for you until your labour has begun. However, many women report an overwhelming urge to stay upright and remain mobile. Studies have shown that where women stay upright during labour, this is associated with a shorter labour and increased maternal comfort. Similarly, where labouring women have a baby lying in the OP position (back-to-back), kneeling on all fours has been found to reduce the backache often experienced, as well as, a reduced need for sutures (stitches). Where women remain upright or are in lateral for the second stage of labour; this is associated with fewer reports of severe pain and a shorter second stage. Similarly, squatting and leaning forward while kneeling are known to widen the pelvic outlet which gives the baby more space to be born. Research indicates that women should be encouraged to adopt the position(s) they find most comfortable during labour and for their baby’s birth. Where the baby’s heartbeat needs to be continuously monitored, the midwives will do their best to ensure that women are able to adopt those positions that offer them the most comfort. The exception to this however, is where women have an epidural for pain relief, which means they are unable to walk around. For more detailed information see our article, ‘Positions in labour and for your baby’s birth’.

Immersion in water

A soak in a warm bath can do wonders for aches and pains, so it is no surprise that immersion in water during labour and birth can help women to relax and cope better with their contractions. Studies have shown that for women with uncomplicated pregnancies and labours, immersion in water is a safe and effective form of pain relief. Where women have used water for their labour and/or birth, they report an overall more positive birth experience including feeling more in control. Studies also show that women who use immersion in water during labour have a reduced need for pain-relieving drugs. However, not all maternity units have waterbirth facilities, which require specialised bath tubs/pools. Where this is the case, you may wish to consider hiring a pool at home or simply enjoying a soak in your own bath during the early stages of labour. Your midwife and doctor will be able to advise you about the facilities that are available locally and can provide any additional information that you might need.

Where you use immersion in water as pain relief during labour, your midwife will need to check your temperature and listen to your baby’s heart rate regularly. They will also need to monitor the temperature of the bath water. This is because where you become too hot, your baby will become even hotter (they are one degree warmer while inside your uterus) and this can cause their heart to beat too rapidly. There are a couple of points that you should also be aware of if you are considering immersion in water for pain relief. Your midwife will advise you against entering the water too soon. If you are not in established labour and/or you remain in the water for longer than a couple of hours, this can slow down your labour progress.

Massage and touch

Massage has been used for hundreds of years to promote relaxation and ease pain and discomfort. Touch can also convey emotional support and instil feelings of wellbeing. Labouring women will often find massage very effective in helping them to relax between their labour contractions. Back massage can also be very effective in soothing the lower back ache that labouring women often experience. There is however, limited research on how massage affects women’s experiences of labour and childbirth. The available research has shown that where women use massage for pain relief in labour, they report less anxiety and severe pain. Studies have also found that massage throughout labour is associated with a shorter labour and more positive overall birth experiences.

Acupuncture

Acupuncture involves the insertion of very fine needles into the skin at a combination of specific points along the meridians in the body. Meridians are channels of energy, called ‘Qi’ (pronounced ‘chee’). Once inserted, these needles may be rotated, heated or have electrical stimulation applied – this is called electro-acupuncture. There are 12 meridians and 365 acupuncture points along the meridians. Where acupuncture is used for pain relief in labour, the exact placement of the needles will be determined by a number of factors which include; (i) the location of the pain being felt (ii) its severity (iii) the stage of labour; (iv)the level of the woman’s anxiety, tension and fatigue.

Studies that have examined the use of acupuncture in labour have found that women were significantly less likely to require Pethidine or an epidural. Acupuncture has been found to also increase relaxation and decrease the need to use drugs (Oxytocin) to speed up labour contractions – this is called augmentation of labour. Its use is also associated with fewer assisted vaginal births and caesarean sections. Acupuncture reduces women’s experience of labour pain without adversely affecting their state of consciousness. Although it is one of the more invasive methods of pain relief and not to everyone’s taste, women do report high levels of satisfaction with its use. However, the insertion of the needles during treatment can interfere with the woman’s mobility and her adopting different positions. It also requires access to a trained/registered acupuncturist or a practitioner who has undertaken additional training to be able to provide this therapy in labour. Where women have used acupuncture in pregnancy they will sometimes go on to use it for their labour and birth. Where this is the case, a woman’s acupuncturist may also act as her birth companion.

Acupressure (Shiatsu)

This is similar to acupuncture but instead of inserting needles into various acupuncture points; pressure is applied using fingers or small beads. Acupressure has been used to alleviate minor ailments and discomfort in pregnancy and has also been found to be effective in relieving labour pain.  While there is limited research on the use of acupressure in managing labour pain, those studies available have shown that women found it to be an effective method of pain relief. They also suggest that it may be effective in shortening the duration of the first stage of labour. Unlike acupuncture, acupressure is a non-invasive therapy that requires only minimal training and therefore, can be provided by the labouring woman’s birth partner/companion or by those providing her care. Some midwives have undertaken additional training to be able to offer acupressure to labouring women in their care.

Hypnosis (Hypno-birthing)

When you start thinking about hypnosis your first thought might be those television programmes where audience members are placed into a state of hypnosis before being prompted to act out of character. This is not the hypnosis that we are considering here. Hypnosis is in fact, ‘a state of deep physical relaxation with an alert mind [where] critical faculties are suspended and the subconscious mind can be more readily accessed’. Where this level of deep relaxation is achieved it is thought to inhibit the stress response in labour, so that women view their uterine contractions very positively. Hypnosis can be used in two ways; (i) to control women’s perception of their labour pain, women place themselves in a trance during labour – this is termed self-hypnosis and (ii) post-hypnotic suggestions that replace fear with confidence.

Studies that have looked at the use of hypnosis for pain relief in labour have found that women required less pain relieving drugs; were less likely to need oxytocin to augment their labour; and were more likely to achieve a normal vaginal birth and report a more satisfying birth experience. Studies also suggest that hypnosis may reduce the likelihood of women having a forceps, ventouse or caesarean birth. Its use may also enable women to postpone, limit or avoid the need for pain-relieving medication. However, there is currently insufficient research evidence to say for certain whether hypnosis is more effective than placebo or other interventions for pain management in labour.

If you are considering hypnosis for your labour and birth there are a few considerations that you will need to be aware of. Firstly, hypnosis is contraindicated where individuals have a history of the mental health disorder called psychosis. If you want to use hypnosis for childbirth, you will need to receive training and preparation from a qualified hypnotherapist. The extent of the pain relief achieved is likely to depend on your hypnotic susceptibility – the higher a person’s susceptibility, the greater the reduction in pain experienced. However, this should not put you off exploring this option, because there remain significant benefits conferred by the deep state of physical relaxation that hypnosis can offer.

Transcutaneous electrical nerve stimulation (TENS)

This is a small hand-held battery operated unit which transmits electrical impulses to the lower back in order to reduce the labouring woman’s awareness of her uterine contractions. To use TENS for pain relief during labour, four adhesive surface electrodes (pads) are placed against the skin on the lower back – these pads are attached to the TENS unit by wires. The unit allows women to adjust the intensity of the electrical impulses so that they can set them to the level which provides the most comfort. Although studies indicate the use of TENS has little effect on reducing the pain of labour, or women’s use of other forms of pain relief; most women view it favourably and say they would use it again for subsequent labours. TENS appears to be particularly helpful in easing back ache and seems to be more effective when started early in labour. It doesn’t limit women walking around, may help them to delay or avoid having an epidural sited; and has no known adverse effects. Because women are able to self-administer TENS, it can also help to increase their sense of control over their labour and birth experience. However, there is currently insufficient research evidence to say for certain whether TENS is more effective than placebo or other forms of pain relief in labour. The only contraindication is where women choose immersion in water – we all know that water and electricity don’t mix!

Nitrous oxide inhalation (Entonox)

Entonox is also commonly referred to as ‘gas and air’. It is actually a mixture of nitrous oxide and oxygen which you inhale (breathe in) through a mouth piece. Although Entonox may not eliminate labour pain; it can be very useful in helping women to control their breathing pattern during contractions. The side effects commonly associated with its use include; dizziness, feeling sleepy and/or light-headed and feeling nauseous. This means that women who use Entonox in labour are advised against walking around. It can also cause ‘pins and needles’ sensations in the hands or feelings of numbness, and can also interfere with women’s recollection of the events around their labour and birth.

Entonox takes around 30-40 seconds to take effect, but dissipates very rapidly with no lasting effects. This can make timing its use quite tricky – if women only start inhaling the Entonox once they feel the pain of the contraction, they won’t derive much pain relief. However, as women begin to recognise the onset of a contraction and gain confidence using the mouthpiece, they will soon begin to maximise its full effects. Because it is self-administered, women are able to control its use and this prevents them from inhaling too much and losing consciousness. Women can use Entonox throughout labour although the midwife is likely to advise other methods of pain relief in early labour; also that Entonox is used less often during the pushing phase. Entonox does not interfere with labour contractions or progress; it can also be effective in delaying or avoiding the need for an epidural. It can make the lips and mouth feel very dry, so regular sips of water and using a lip balm can be helpful!

Pethidine

Pethidine is given by midwives worldwide to provide pain relief during labour. It is given by injection into the muscle of the buttock (bottom) or the top of the leg (thigh). Once injected, Pethidine takes around 20 minutes to take effect and lasts for at least a couple of hours. It doesn’t remove the pain of labour, although it takes the ‘edge’ off and enables women to relax and doze between contractions. Providing women are in established labour having Pethidine does not slow down contractions or labour progress. Its use can also help to delay or avoid the need for an epidural.  As with other drugs, Pethidine is associated with a number of side-effects. These include; feeling dizzy, sleepy, and nauseous – an anti-emetic (anti-sickness) drug is usually given at the same time as the Pethidine to relieve nausea or vomiting.  Some women experience hallucinations, while others demonstrate euphoria (feeling excited; happy) or dysphoria (being in a state of unease; unhappy). Pethidine can adversely impact on women’s ability to understand what is happening and cope. Because it causes drowsiness, immersion in water is contraindicated within two hours of its administration. It also means that it is too unsafe to walk around; however, women can still remain upright in a chair supported with pillows, or lie down on their side.

Pethidine will make the baby sleepy too. This reduces the variability of the baby’s heartbeat, so the midwife and doctor will monitor the baby’s heart rate pattern closely. For more information see our article, ‘Monitoring your baby’s heart rate in labour’. Some babies may be sleepy following birth where Pethidine is given close to the time of birth; however, this rarely causes a problem.

Diamorphine

Intramuscular Pethidine is used for managing labour pain worldwide; however, the use of intramuscular Diamorphine has increased in the UK over the past 15 years. Research that has compared the effectiveness of each drug has found that Diamorphine is a little more effective in providing pain relief during labour, compared with Pethidine. However, women using Diamorphine have been found to experience significantly longer labours.

Epidural

Epidural (also called ‘regional anaesthesia’) is a method of pain relief that blocks the pain from uterine contractions to specific nerve endings. This enables the labouring woman to feel her uterus contracting without feeling any pain. An epidural is the most effective technique for pain relief in labour; however, it is also one of the most invasive methods and is only offered in maternity units with anaesthetic services.

Having an epidural involves an anaesthetic and/or pain-relieving drug, being inserted into the space around the spinal cord – the epidural space. An epidural is sited by an anaesthetist and the woman is asked to sit upright or lie on her side to have this done. An intravenous infusion (drip) is started before the epidural is sited (if the woman doesn’t already have one in place); this is because the drugs used in an epidural can cause the blood pressure to drop. If this happens fluid is given via the drip to help rectify this. Where the blood pressure falls, women often feel sick and/or dizzy and the midwives and doctors will advise labouring women to tell them if they start to experience any of these symptoms. They will also check the woman’s blood pressure and pulse at regular intervals. A small number of women will have a more severe drop in blood pressure and where this is the case, they can be given a special drug via the intravenous infusion to bring their blood pressure back up.

Having an epidural requires the woman to have a hollow needle inserted into the skin of her lower back; a small injection of local anaesthetic is given beforehand to numb the area (this feels rather like a bee-sting). A very fine catheter (tube) is then inserted through the hollow needle. The needle is then removed leaving a small length of the catheter inside the back. The remaining catheter tubing is long enough to lie against the surface of the woman’s skin for the entire length of her back, right up to her shoulders. The catheter is then carefully secured in place with adhesive tape to prevent it from moving. The anaesthetic/pain-killing drugs are injected through the catheter which numbs the nerve endings and stops women feeling the pain of their contractions and any backache.

Epidurals can be given in different ways: (i) as a bolus (single) dose of the drugs (ii) via an intravenous infusion (drip) or (iii) as a hand-held device (called a PCA – patient-controlled analgesia); this enables women to control their own pain relief by topping up the dose when they begin to feel pain. The epidural takes effect within 10-20 minutes of being sited and will affect how much a woman is able to move her legs, stand upright or walk. It is also very common to lose the sensation of needing to pass urine and the midwives will ensure that the woman empties her bladder regularly during labour. Women are more likely to need a urinary catheter to help with this, as a full bladder can impede labour progress.

Studies have found that epidurals appear to be very effective in reducing pain during labour. However, women who choose this form of pain relief tend to have a longer labour and are at an increased risk of having an assisted birth using forceps or ventouse. Epidurals are not associated with an increased risk of caesarean births, long term backache, or babies requiring resuscitation (assistance with breathing) at birth. Epidurals can however, interfere with successful breastfeeding because the drugs used can make babies ‘sleepy’ and not interested in feeding. The drugs injected into epidurals can also cause pruritis (itchy skin); however, specific drugs can be given to relieve this. Epidural and spinal anaesthesia causes motor block (numb or heavy legs) and where this is the case, women are advised to remain on the bed as it would be unsafe for them to walk around. Very rarely, numb patches on the legs continue post birth and can sometimes continue for a few months postnatal; however, this should resolve on its own.  Occasionally, women can develop a persistent headache post birth – where the headache worsens upon standing and improves when lying down; this can be linked to the epidural. It can be treated very effectively though, so it is important that women tell their midwife or doctor if they are experiencing these symptoms.

Women can develop a high epidural block which sometimes affects their breathing; however, this is an extremely rare occurrence and the anaesthetists, midwives and obstetric doctors are trained to manage these situations swiftly and effectively.

Spinal anaesthesia

Spinal anaesthesia is commonly used for performing caesarean sections; they are also used for assisted births using forceps; particularly, where the doctor has concerns that they may not be able to deliver the baby vaginally and might need to proceed to a caesarean section. More complex vaginal tears may also be repaired (stitched) in theatre under spinal anaesthesia.  In these circumstances, a needle is inserted into the spinal fluid in the back and anaesthetic/pain-relieving drugs are injected which provide the spinal anaesthesia. The body is numbed completely from the waist down and the woman will have no leg movement or sensation for up to four hours. Sometimes a ‘spinal’ may be given prior to inserting an epidural, because it acts very quickly to make a woman pain- free. In these circumstances a much smaller dose of anaesthetic/pain-killing drugs are given. The spinal needle is then removed and an epidural catheter inserted (as explained previously). Where a small dose of anaesthetic is used during an epidural, women may be able to walk with assistance/close supervision – this is referred to as a ‘mobile epidural’; however, these are not available in all units.

NB. There can be circumstances where an epidural may not be immediately available eg if the anaesthetist is already inserting an epidural for another woman, or if they are attending a caesarean section. Your midwife will explain any delay to you and in these circumstances it can be helpful to know about the other forms of pain relief that are available in the interim.

We recommend that you discuss any concerns that you might have about labour pain with your midwife or doctor during your pregnancy. They will be able to answer any questions you might have to ensure you understand the benefits and disadvantages associated with the different methods of pain relief available.