Nonpharmacologic approaches to management of labor pain

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Nonpharmacologic approaches to management of labor

pain
Author: Aaron B Caughey, MD, PhD
Section Editor: Charles J Lockwood, MD, MHCM
Deputy Editor: Kristen Eckler, MD, FACOG

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Sep 2020. | This topic last updated: Feb 05, 2019.

INTRODUCTION

Management of labor pain is a major goal of intrapartum care. There are two general
approaches: pharmacologic and nonpharmacologic. Pharmacologic approaches are directed at
eliminating or decreasing the physical sensation of labor pain. In contrast, nonpharmacologic
approaches are largely directed at increasing comfort, enabling the laboring woman to cope with
the pain, and preventing suffering.

This topic will explore a variety of nonpharmacologic methods of pain management during labor
and the evidence of their efficacy. Related topics on the pharmacologic management of labor
pain and labor are presented separately.

● (See "Pharmacologic management of pain during labor and delivery".)

● (See "Neuraxial analgesia for labor and delivery (including instrumented delivery)".)
● (See "Management of normal labor and delivery".)

PAIN IN LABOR

The International Society for the Study of Pain describes pain as "an unpleasant sensory and
emotional experience associated with actual or potential tissue damage, or described in terms of
such damage" [1]. While pain is a sensory experience, it is also an emotional experience as it is
always unpleasant. Suffering may be defined in terms of any of the following psychological
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elements: a perceived threat to the body and/or psyche, helplessness and loss of control,
distress, insufficient resources for coping with the distressing situation, or fear of death of the
mother or baby [2]. Although pain and suffering often occur together, one may suffer without pain
or have pain without suffering.

Both uterine contractions and perineal pressure contribute to the pain experienced during labor.
Uterine pain is typically transmitted via nerve roots T10 to L1 and perineal sensation is
transmitted through nerve roots S2 to S4 [3]. In addition, there is anatomical support for the
hypothesis that at least some low back pain during labor is actually referred pain since the
nerves originating from the corpus uteri and cervix terminate in the dorsal horns of the spinal
segments T10 to L1 and reflect visceral pain, which is often referred to the lower back [4]. (See
"Pharmacologic management of pain during labor and delivery", section on 'Pain pathways'.)

From the patient's perspective, a questionnaire-based study reported that women described
three distinct types of labor pain: abdominal contraction pain, intermittent low back pain, and
continuous low back pain [5]. Women with intermittent low back pain superimposed on
continuous back pain reported the highest levels of pain. In an observational study of 93
Taiwanese women in labor, 75 percent reported back pain at some point during their labor [6].

Most women use some nonpharmacologic approaches for managing labor pain, with or without
pharmacologic approaches [7]. Nonpharmacologic approaches to labor pain management do not
make pain disappear; instead, these approaches help women better cope with the pain of labor
and maintain a sense of personal control over the birth process, thus reducing suffering. As
childbirth can be an intensely painful event, many women desire information about pain levels
and options for relief [8]. Lack of relevant information has been associated with increased
anxiety [9]. Two reviews report discrepancies between what women expect to be able to cope
with during labor pain and what they actually received for their pain in their clinical care.

● A systematic review of 32 studies (13 qualitative and 19 quantitative) reported that women
generally underestimated the pain they would experience, that many women wanted to
participate in the decision-making process, and that the degree that women were able to
take control in labor was less than anticipated [8].

● A review of 10 qualitative studies reported the two main influences on a woman's ability to
cope with labor pain were (1) continuous individualized support, and (2) acceptance of the
need for experiencing some pain to birth their infants [10]. Constant support established a
sense of safety and reduced feelings of loneliness and fear, which enhanced their coping
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ability. However, the review also reported a gap in many clinical settings between women's
need for continuous support and its availability.

In order to close these gaps and increase a woman's sense of control in the labor process,
women need information prenatally about the risks and benefits of both pharmacologic and
nonpharmacologic methods of pain management, and opportunities to rehearse and master
nonpharmacologic pain relief techniques. Lastly, their caregivers and teachers must know how
and when to utilize them [11].

EVALUATING TREATMENT EFFICACY

In evaluating treatment efficacy, one must consider the study outcome being used. While pain
scales or use of pharmacologic therapies have traditionally been evaluated, patient-important
outcomes, such as satisfaction with treatment or desire to use in future delivery, may be more
relevant for this group of therapies.

● Pain scales – Pain scales (eg, visual analogue pain scale [VAS]) are commonly used to
assess the impact of pain interventions (form 1). However, this outcome can be misleading
because a woman can rate her pain as severe and still be coping well without suffering or
feeling overwhelmed [12,13]. Conversely, medication may relieve pain but not anxiety or
suffering. To better address the complexities of the labor experience, a 10-point coping
scale has been suggested [14]. For this scale, the patient is asked "On a scale of 1 to 10,
how well are you coping with labor right now?" [15].

Most women who used nonpharmacologic methods of pain relief expressed satisfaction with
these methods and desired to use them to manage, though not eliminate, pain in
subsequent labors. This finding indicates that women may find value in these methods that
are not identified in studies that assess pain scores.

● Pharmacologic analgesia – The use of pharmacologic analgesia as an outcome that

indicates failure of nonpharmacologic approaches can also be misleading. Use of
pharmacologic analgesia may reflect the usual care practices of the hospital or the woman's
plan to use multiple types of pain relief strategies. Furthermore, the timing and duration of
pharmacologic analgesia is a valid outcome because some undesirable effects of neuraxial
analgesia may increase with time. Receiving medications later in labor may reduce duration
and dose-related side effects on mother, infant, and the labor, such as epidural-related
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hyperthermia in mother and baby (and related fetal tachycardia), persistent fetal
malposition, and increasing loss of mobility over time, making pushing less effective during
second stage.

When evaluating the efficacy of pharmacologic pain relief methods, especially neuraxial
analgesia, both early and late in labor, against nonpharmacologic methods, it is important to
realize that the available randomized controlled trials normally compare neuraxial analgesia
against narcotics. There are no studies comparing neuraxial analgesia against
nonpharmacologic methods or defined physiological approaches.

● Self-efficacy – Higher levels of childbirth self-efficacy, a woman's belief that she can cope
with labor, are associated with reduced anxiety, pain, and obstetric intervention [16]. In a
trial of nearly 1800 Danish women comparing a structured antenatal program with
auditorium-based lectures, women in the structured program were nearly 50 percent less
likely to report low self-efficacy [17].

Alternate proposed measures for study include when in labor (eg, cervical dilation, hours before
delivery), the woman receives medication and patient satisfaction with birth experience. Use of
nonpharmacologic methods may make it possible to delay the use of pharmacologic analgesia
and avoid some undesirable duration-related side effects of medication (eg, fever with neuraxial
analgesia) [18,19]. (See "Intrapartum fever", section on 'Use of neuraxial anesthesia'.)

Additionally, there may be unique advantages to using nonpharmacologic pain relief methods,
aside from the degree to which they reduce or manage pain. For example, one can combine
many different nonpharmacologic techniques at the same time, which may increase pain relief.
Unfortunately, the use several techniques simultaneously does not lend itself to scientific
evaluation. Many of the trials have compared outcomes of use of a single technique with a
pharmacologic technique, although this is not typically how such techniques are used in real life.
Women also tend to use many techniques serially; when circumstances change or they
habituate to one technique, they shift to another. This is also makes efficacy difficult to measure.

BASELINE INTERVENTIONS

Among other basic elements, all women should have:

● The right to participate in informed decision-making about their care [20]. Childbirth

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education is an appropriate source of information for decision-making and should also

include mastery of activities (comfort and labor progress measures) to use if women prefer
to minimize medical interventions.

● Access to a safe and comfortable birth place, including freedom to move about, in, and out
of bed.

● Continuous emotional and physical comfort, provided by people of their choice.

Childbirth education — Childbirth education (CBE) (ie, prenatal or antenatal education) tends
to vary widely, but generally consists of individual or group classes designed to inform expecting
parents about some or all of the following: various maternity care choices; normal and
complicated labor and birth; common clinical care practices; nonpharmacologic pain
management (including self-help, partner-assisted, and other measures); pharmacologic pain
relief measures; and newborn care, early parenting, and infant feeding.

The outcomes of CBE are difficult to quantify. Although some meta-analyses of trials of childbirth
education have found little or no improvement in specific birth outcomes for those who attend
childbirth classes [19-21], at least one meta-analysis reported decreased anxiety or fear of
childbirth for women who received childbirth education [22], large numbers of expectant parents
attend them [23], and caregivers continue to recommend these classes [14]. Also, benefits may
extend beyond birth outcomes, such as the woman being more likely to present for care in active
labor, less likely to use an epidural, and more likely to have a vaginal birth [18,21]. It is possible
that better trial design and inclusion of other outcomes may detect some positive effect (such as
satisfaction from active participation, feeling closeness between parents and baby after working
hard together; a sense of achievement, mastery, or even avoidance of behaving shamefully or
feeling helpless; or other benefits). (See "Preparation for childbirth".)

Despite the lack of evidence of improved birth outcomes with CBE, it remains popular among
both the public and many maternity professionals. This is reason enough for us to advise that all
women have access to high-quality evidence-based childbirth education [21]. Additional
supporting data come from a Canadian study of attitudes and beliefs of obstetric providers and
the women they serve [24-26]. Results from two different questionnaire surveys included that at
least 20 percent of obstetricians have non-evidence-based beliefs about key issues in maternity
care, while, depending on the issue, 30 to 50 percent of women approaching their first birth are
inadequately informed, even at the end of their pregnancy, about issues such as episiotomy,
indications for cesarean section, role of doulas, induction, and postterm pregnancy [25,26].
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Properly constructed and evidence-based CBE offers one potential avenue for correcting these
deficiencies.

Birth environment — The ideal birth environment for labor pain management is comfortable,
private, quiet, and provides places to walk, bathe, and rest [27]. Locations that can meet these
needs include the home, birth centers, and conventional hospital-based labor and delivery units.
(See "Planned home birth" and "Birth centers".)

A systematic review of 10 randomized trials comparing hospital-based alternative birth settings

versus conventional hospital labor and delivery units found that home-like settings increased the
likelihood that the woman would not use intrapartum analgesia/anesthesia (relative risk [RR]
1.17, 95% CI 1.01-1.35; five trials, n = 7842) and reported small increases in the likelihood that
she would have a spontaneous vaginal birth (RR 1.04, 95% CI 1.02-1.06; eight trials, n =
10,218) or be breastfeeding at six to eight weeks postpartum (RR 1.04, 95% CI 1.02-1.06; one
trial, n = 1147). While these benefits are small, it is noteworthy that the mothers in the alternative
birth settings had a very positive view of their care: nearly double the numbers of mothers who
gave birth in conventional hospital settings (RR 1.96, 95% CI 1.78-2.15; two trials, n = 1207)
[28]. The alternative birth setting was also associated with significantly lower rates of obstetrical
interventions (epidural analgesia, oxytocin augmentation, episiotomy). There were no significant
effects on serious perinatal or maternal morbidity/mortality, other adverse neonatal outcomes, or
postpartum hemorrhage. A limitation of these findings is that women willing to participate in such
trials may not be representative of most laboring women.

An additional limitation in assessing the impact of birth environment is that each center has its
own rules regarding what types of supports are allowed and the types of interventions offered.
Some settings restrict the use of epidurals, electronic fetal monitoring, and augmentation of
labor; these settings will have higher transfer rates to the conventional setting. Other settings
allow all procedures, short of cesarean delivery. Thus what constitutes an alternative setting
varies greatly and has implications for outcomes [29].

Labor support — Support persons for a laboring woman can include her partner, family or
friends, professional support providers (eg, doula), and the medical team. The quality of
caregiver support can impact, positively or negatively, the woman's childbirth experience [30,31].
Active training of the laboring woman's partner in the use of pain control techniques that are
based on neurophysiological pain models has been reported to decrease both pain intensity and
unpleasantness for the woman [32].

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The phrase "continuous labor support" refers to the inclusion of a trained companion (such as a
doula) to provide nonmedical care in the form of guidance, reassurance, comforting touch, and
assistance with positions and movements to the laboring woman continuously throughout labor
and birth. A nurturing, supportive companion during labor, who is neither a family member/close
friend of the laboring woman nor a member of the hospital staff, has been shown to help the
woman cope with pain and anxiety and improve obstetrical outcomes [33]. In one survey study
of United States women who gave birth in 2005, doula support was associated with a threefold
increased odds of using nonmedical methods of labor induction and a fivefold increased odds of
using nonmedical labor pain management [7]. The American College of Obstetricians and
Gynecologists has stated that "one of the most effective tools to improve labor and delivery
outcomes is the continuous presence of support personnel, such as a doula" [34]. Of note, in a
subgroup analysis of nine trials, the largest effect on successful vaginal delivery (favoring
continuous support) was noted in the women whose support provider was not a hospital
employee [33]. This topic is discussed in detail separately. (See "Continuous labor support by a
doula".)

APPROACH

The nonpharmacologic approach to pain management includes a wide variety of techniques that
address not only the physical sensations of pain, but also attempt to enhance the psycho-
emotional and spiritual components of care and thus reduce suffering. In this approach, pain is
perceived as a normal accompaniment of most labors. The goal, rather than to eliminate pain, is
to keep the pain within manageable limits; thus the emphasis is on coping effectively with the
pain. The woman is educated about the choices for pain relief methods available to her
(preferably as part of her antenatal care) and then weighs the risks, benefits, and alternatives for
each method. She considers any fears she may have of pain, exertion, fatigue, or of invasive
procedures or concerns about the side effects of the pain-relief method (eg, relative immobility,
potential effects on labor progress, the fetus/newborn, lack of mental clarity). With this
information, she plans an approach that best suits her needs. Of note, while such plans may be
made in advance of labor, patient preference in the moment is extremely important and any
changes the patient desires to make in her approach to pain management during the actual
labor should be respected.

The basic approaches to pain management include:

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● Use of nonpharmacologic approaches for as long as possible during labor and delivery.
Such women may proceed through delivery and recovery without medication, but should not
be denied such if they request it.

● Use nonpharmacologic approaches through early labor until active labor is established, and
then add pain medication.

● Use of medication from onset of early labor through delivery.

The options for medication in labor, with a discussion of benefits and risks of each, is presented
elsewhere. (See "Pharmacologic management of pain during labor and delivery".)

The antenatal choice of pain management plan will dictate many other decisions, such as the
kind of childbirth preparation, labor environment, and care providers the woman will seek. She
should make her preferences known to the staff and her own team (caregivers, childbirth
educator, doula, and support people) so that they can assist her as she prefers. Her caregivers
and support people also help her by providing physical comfort, reassurance, guidance,
encouragement, and unconditional acceptance of her coping style. With such support, along with
taking an active role in decision-making, those women who wish to minimize their use of pain
medications, are more likely to do so [7]. Intangible benefits can include reduced feelings of
helplessness and an increased sense of mastery, control, and well-being [2]. Of course, parents
must also know that birth is unpredictable and that circumstances may require the use of less
preferred interventions in order to ensure safe passage of mother and infant.

CLASSIFICATION OF NONPHARMACOLOGIC APPROACHES

We divide nonpharmacologic techniques into three categories based on the level of required
resources:

● Low-resource interventions are simple, readily available, inexpensive, and low-risk

techniques including distraction, self-help, and comforting strategies or tools. These may be
used individually or in combination with others. (See 'Low resource' below.)

● Moderate-resource interventions require patient motivation, specialized training,

professional assistance, specific equipment, financial resources, or a combination thereof.
(See 'Moderate resource' below.)

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● High-resource interventions require professional training and monitoring, have greater risk
of adverse effects on mother, fetus, or labor, require increasingly complex equipment and
training by staff and/or patient, and incur significant cost. They are highly effective in
reducing labor pain, and include neuraxial analgesia and anesthesia and inhaled
anesthesia. (See 'High resource' below.)

LOW RESOURCE

Low-resource interventions include distracting, self-soothing activities (eg, slow breathing with or
without moaning, counting breaths, or reciting a mantra in rhythm with breathing; tension release
at end of contraction) and acts of kindness such as support from a companion or doula (eg,
encouragement, soothing touch, hand-holding, complimentary words, a cool washcloth to brow).
Though these have not been studied for effects on birth outcomes, they should be mentioned,
because they constitute humane care and may help lower stress levels in the mother, indirectly
modifying her perception of pain. Additional low-resource techniques for pain management
include the following:

Movement — Laboring women have always walked, moved, and changed positions to make
themselves more comfortable [35,36]. Pelvic dimensions vary with differences in maternal
positions; thus, these changes may help to ameliorate labor pain [37]. Besides these self-
initiated comfort-seeking movements, caregivers often suggest specific positions to accelerate
labor progress or correct a fetal or maternal problem (eg, fetal heart rate decelerations or
malposition, maternal hypotension). There is little evidence that one position is best, and thus,
no one position is advised [14]. Maternal mobility can be limited, however, when women are
connected to equipment, unable to support themselves due to pain medication, or asked to limit
movement because of the need for continuous maternal or fetal monitoring [23]. (See
"Management of normal labor and delivery", section on 'Maternal activity and position'.)

Allowing the mother to move during childbirth and labor in the position that is most comfortable
for her makes intuitive sense, and reviews assessing the impact on birth outcomes of movement
and positioning during first or second stages have reported some benefit for women who did not
have an epidural at entrance into the trial, as discussed below:

● In a 2013 systematic review of controlled trials of maternal position and mobility in the first
stage of labor, walking and upright positions in the first stage of labor appeared to reduce
the duration of labor, the risk of cesarean birth, and the need for epidural anesthesia, and
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were not associated with increased intervention or negative effects [36]. However,
heterogeneity and bias limited the quality of these data.

● In a systematic review of 30 studies (n = 9015 women) comparing various labor positions

with supine position on birth outcomes for women in the second stage of labor without an
epidural, any non-supine birth position was associated with [38]:

• Fewer assisted vaginal deliveries (RR 0.75, 95% CI 0.66-0.86; 21 trials; 6481 women)
• Fewer episiotomies (average RR 0.75, 95% CI 0.61-0.92; 17 trials; 6148 women)
• A mean reduction in the second stage of labor of six minutes (MD -6.16 minutes, 95%
CI -9.74 to -2.59 minutes; 19 trials; 5811women)
• No clear difference in the rate of cesarean delivery (RR 1.22, 95% CI 0.81-1.81; 16
trials; 5439 women)
• Fewer abnormal fetal heart rate tracings (RR 0.46, 95% CI 0.22-0.93; 2 trials; 617
women), but no clear difference in number of admissions to the neonatal intensive care
unit (RR 0.79, 95% CI 0.51-1.21; 4 trials; 2565 infants)
• A possible increase in second degree perineal tears (RR 1.20, 95% CI 1.00-1.44; 18
trials; 6715 women) with no clear difference in the rate of third or fourth degree
lacerations (RR 0.72, 95% CI 0.32-1.65; 6 trials; 1840 women)
• Increased estimated blood loss greater than 500 mL (RR 1.48, 95% CI 1.10-1.98; 15
trials; 5615 women)

● In a systematic review of five trials (n = 879 women with an epidural) comparing recumbent
with upright positions in the second stage of labor, there were no differences between the
groups in risk of operative birth (cesarean or instrumented vaginal), duration of second
stage of labor, maternal birth trauma, abnormal fetal heart rate tracing, low cord pH, or
admission to the neonatal intensive care unit [39]. Thus, the potential benefits of maternal
position do not appear to carry over to women with an epidural.

Birth ball — Use of a birth ball (an exercise ball or physical therapy ball) during labor
encourages relaxation of the trunk and pelvic floor, and also provides some pain relief while
allowing women freedom of movement and personal control of the intervention. When used in
the sitting position, the ball applies a nonpainful pressure to the perineum, which may block part
of the nociceptive message at the level of the spinal cord and thereby reduce the sensation of
pain. Women also stand or kneel and lean their upper bodies over the ball, which provides
comfortable support. Birth balls are easy to use and can be used along with other interventions

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for patient comfort (eg, analgesics, hot shower).

In a meta-analysis of three trials including 205 women, women using a birth ball reported an
approximately one point reduction in pain, as assessed by a 10 cm visual analogue scale,
compared with women not using a ball (pooled standardized differences of means of labor pain
-0.9, 95% CI -1.3 to -0.6) [40]. Limitations of the analyzed trials included small numbers of
patients, potential differences for women who began using the ball during pregnancy versus
those first receiving instruction during labor, and the lack of ability to blind patients or care
providers. Nonetheless, the birth ball provided a modest reduction in pain with minimal cost and
risk.

A variation of the birth ball (a peanut-shaped ball) is an aid to positioning, particularly when a
woman has an epidural. Though unlikely to be used for pain relief (since it is used primarily with
women who have epidurals), one randomized trial reported that placing the ball beneath the
upper leg of the side-lying parturient, shortened their labor (by 29 minutes in nulliparas and 11
minutes in multiparas) [41]. Another trial reported a shorter first stage of labor in nulliparas with
the use of the ball. The ball might be placed between her legs, or she might be in a Semi-
Fowler's (semi-prone) position with her upper leg resting on the ball and her lower leg resting on
the bed [42].

Touch and massage — The impact of touch in labor (hand-holding, patting, stroking) to convey
caring, reassurance, or a message to release tension has not been assessed in placebo-
controlled randomly-assigned trials. However, some older descriptive studies reported pain
reduction when touch was applied by laboring women's midwives, nurses, or partners [43,44].
Additionally, touch was sometimes reported as annoying or painful, particularly when the
abdomen or pelvic area was being touched in conjunction with an assessment, which illustrates
the need to understand the context when assessing touch.

Massage consists of purposeful and systematic manipulation of the soft tissues of the body for
therapeutic purposes [45,46]. In a meta-analysis of four trials comparing manual massage with
usual care in laboring women, women in the massage group reported less pain during the first
stage of labor (standardized mean difference -0.82, 95% CI -1.17 to -0.47, four trials, 225
women) [47]. Although massage may improve coping, pain still tends to increase as labor
progresses. There are no known harmful effects of the use of therapeutic massage in labor, but
it should be performed by professionals or lay people who have received specific instruction.
The optimal massage technique is not known and further trials on efficacy are needed. However,

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massage remains a simple, low-cost, and safe option to provide relief to laboring women.

Acupressure — Acupressure, or Shiatsu, is pressure with fingers or small beads at

acupuncture points. Limited data suggest a benefit to pressure on points Spleen 6 (located
roughly on the medial surface of the low tibia) and Large Intestine 4 (located roughly on the
fleshy tissue back of the hand between the base of the thumb and the base of the index finger)
[48-52].

● A meta-analysis of four randomized trials of acupressure for pain management in labor

found that pain intensity was significantly reduced in the acupressure group compared with
a placebo control (light touch) or compared with a combined control (light touch or no
treatment); however, there was no significant difference between intervention and control
groups in use of pharmacologic analgesia [53].

● A different meta-analysis of thirteen trials compared acupressure during childbirth with

placebo (usual care) on duration of labor and mode of delivery. Acupressure reduced the
length of the active phase by 1.31 hours (95% CI -1.738 to -0.882; p = 0.001). The chance
of vaginal delivery also increased (odds ratio 2.329, 95% CI 1.348-4.024, p = 0.002) [54].
Though pain reduction was not measured, the shorter labors and fewer cesareans mean
less exposure to painful contractions or painful surgery.

Application of heat or cold — Superficial applications of heat and/or cold, in various forms, are
popular with laboring women, although there are minimal supportive data. However, they are
easy to use, inexpensive, require no prior practice, and have minimal negative side effects when
used properly.

Women's personal choices are key factors in the use of heat or cold. Cultural proscriptions
against exposure to cold during the childbearing time exist in many cultures and should be
respected; in such cases, heat is the treatment of choice. With both modalities, the caregiver
should test the pack on his or her own skin and place one or two layers of cloth between the
woman's skin and the hot or cold pack to protect against the possibility of skin damage.
Additionally, it is imperative that the woman has intact sensation if heat or cold is to be applied.

Heat is typically applied to the woman's back, lower abdomen, groin, and/or perineum. Possible
heat sources include a warm water bottle, heated rice-filled sock, warm compress (towels
soaked in warm water and wrung out), electric heating pad, or warm blanket. No studies have
evaluated the optimal temperature or duration of heat therapy. Care should be taken to avoid
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burns. In addition to being used for pain relief, heat is used to relieve chills or trembling,
decrease joint stiffness, reduce muscle spasm, and increase connective tissue extensibility.
While results from small trials are encouraging, data from large trials are needed to assess
efficacy and determine optimal time of application and ideal temperatures [55-57].

Cold packs may be applied to the low back when a woman is experiencing back pain. Women
who already feel cold generally need to feel warm before they can comfortably tolerate using a
cold pack. Forms of cold include a bag or surgical glove filled with ice, frozen gel pack, camper's
ice, a hollow plastic rolling pin or bottle filled with ice, soda cans chilled in ice, or a frozen bag of
vegetables. Instant cold packs, often available in hospitals, usually are not cold enough to be
effective for the pain of labor. Chilled soda cans and rolling pins filled with ice give the added
benefit of mechanical pressure when rolled on the lower back. In addition to pain relief, cold has
the additional effects of relieving muscle spasm and reducing inflammation and edema. Though
the application of cold may make the woman feel better, supporting data are sparse. In a 2012
systematic review including 10 trials (n = 1825 women) of various localized cooling treatments
for relieving pain from perineal trauma during childbirth compared with no treatment, other forms
of cooling treatments and non-cooling treatments, there was only limited evidence to support the
effectiveness of local cooling treatments (ie, packs, cold gel pads, cold/iced baths) [58].

Despite minimal data, cold packs are frequently used to reduce postpartum perineal pain and
swelling and can be used intermittently for days after birth. Women who already feel cold
generally need to feel warm before they can comfortably tolerate using a cold pack. Forms of
cold are the same as those used in labor above.

Breathing techniques with relaxation — Relaxation training, which can take many forms, has
been associated with reduced pain in the latent phase of labor [59]. Most childbirth education
classes and most books on childbirth present relaxation techniques, including a variety of
rhythmic breathing patterns intended to complement and promote relaxation or to provide
distraction from labor pain. These techniques are also used to enhance a woman's sense of
control [60]. The thoroughness of the teaching along with the amount of time devoted to
rehearsing these techniques vary widely, from a quick mention or demonstration, to repeated
practice and adaptation to the individuals' preferences, designed with the goals of enhancing
mastery and confidence [61]. Available data suggest relaxation and breathing techniques may
have a role in managing labor pain [47].

In a survey of women in the United States who gave birth in 2011 to 2012, 48 percent of the

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respondents reported using breathing techniques [23]. Most women who use breathing
techniques report them to be "very helpful," "somewhat helpful," "good," or "very good."
However, a trial that randomly assigned 140 women to breathing patterns during the active
phase of labor or routine care reported no differences in anxiety, pain, fatigue, and maternal
satisfaction between the two groups [62]. These disparate outcomes could result from selection
bias in the survey-based study or limitations of the trial, including lack of effectiveness of the
specific breathing training, use only in the active phase of labor, or too small a sample size. In
addition, relaxation breathing may be very helpful in ways other than relieving pain. Rhythmic
breathing may contribute more to a woman's ability to cope with labor pain than to actually
reducing that pain. Incorporating relaxation with rhythmic breathing helps avoid tension and its
pain-augmenting effects [23]. Larger trials are needed to elucidate the impact of breathing
techniques on the management of labor pain.

There are no known drawbacks to the use of properly performed relaxation and breathing
techniques, except that women sometimes expect more pain relief from them than they actually
receive during labor, and then express disappointment. Proper performance includes rhythmic
breathing during contractions, while releasing tension on the exhalations. Being able to do this
without hyperventilating, at both a slow pace (6 to 12 breaths per minute) and at a moderately
fast pace (30 to 60 breaths per minute), allows the woman to adapt her breathing pattern to the
intensity of the contractions.

Showers — Laboring in a warm shower for an unspecified length of time has been used as a
form of water therapy to reduce pain with labor. Showers for laboring women are readily
available in many resource-rich countries. Although data are limited, showering while in labor
appears to increase coping and relaxation [63] and reduce pain scores as measured by visual
analogue scale (VAS) [64]. In addition, the women in the trial who received shower therapy
reported higher satisfaction [64]. There were no adverse effects. Showers are relatively
inexpensive in water-rich settings, and are convenient.

Music and audioanalgesia — Audioanalgesia is the use of auditory stimulation, such as music,
white noise, or environmental sounds, for a pleasant distraction or a rhythmic guide, to decrease
pain perception. It is popular for the relief of pain during dental work, after surgery, and for other
painful situations. However, there is no high-quality evidence of efficacy in treating labor pain,
although small trials have reported some reduction in pain and anxiety [59,65,66].

Before labor, the woman selects music (sometimes with the help of a music therapist) or

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environmental sounds that have a positive effect on her. She may use these to rehearse
relaxation or self-hypnosis, and to take her into a relaxed or hypnotic state during labor. During
labor, she chooses selections to help her relax and lift her spirits [67]. Her selections personalize
the birth event and may give her a greater sense of control. Some women prefer to use
headphones to listen to music, because this provides more compelling distraction and the
woman is in constant control of the volume. There are no known adverse effects of audio
analgesia and it appears to be a simple and popular option for laboring women.

MODERATE RESOURCE

Moderate-resource interventions require high patient motivation, specialized training, specific

equipment, or a combination thereof.

Aromatherapy — Use of aromatherapy during labor is increasing, although some experts warn
that essential oils are potent, potentially harmful, and open to misuse or abuse [68-70].
Aromatherapy is a complementary medical approach used by trained professionals that involves
application of concentrated essential oils or essences that are distilled from plants with the
purpose of benefiting from their therapeutic properties. Plants can be prepared in numerous
ways: to be inhaled, massaged into the skin, swallowed as teas or tinctures, or as lozenges [71].
Two different meta-analyses that assessed the efficacy of aromatherapy for labor pain reported
no effect of treatment on pain intensity, surgical delivery, or the use of pharmacologic pain relief
(epidural), but the results were limited by small numbers of included trials (two and four) and
patients (535 and 715) [68,69]. A subsequent trial of lavender inhalation during labor reported
that, compared with a control group, significant reduction in pain severity occurred after
inhalation of the lavender at 4 to 5, 6 to 7, and 8 to 9 cm dilation, when compared with inhalation
of an odorless placebo by a control group [70].

Although the limited data on aromatherapy efficacy conflict, many hospitals around the world
offer it as an amenity for laboring women. Professional aromatherapists or specially trained
midwives oversee these services. Pregnant women should be cautioned against mixing their
own essential oils, as they can cause harm when managed by untrained individuals. On the
other hand, they may purchase pre-mixed massage oils or lotions from reputable dealers, as
long as all precautions are heeded and the hospital staff is informed of their use, to protect
against an allergic reaction in those sensitive to some essential oils. Because of the lack of
regulation of aromatherapy products, pregnant women and others are advised to consult

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trustworthy sources for background information, safety issues, recommended websites, books,
and practitioners [72,73].

Acupuncture — Acupuncture involves placement of needles at specific points on the body

(termed acupuncture points). (See "Acupuncture".)

For labor pain, placement of needles and type of stimulation depends on the degree and
location of pain, stage of labor, level of maternal fatigue, tension, anxiety, and a variety of other
factors [74,75]. Electro-acupuncture, which involves electrical stimulation via the strategically
placed needles is also sometimes used, with effects similar to manual acupuncture on labor pain
[76,77]. There are no known risks to acupuncture when practiced by trained practitioners using
disposable needles. While the limited findings on acupuncture in labor are supportive,
conclusions are limited by a lack of large trials as well as significant heterogeneity in the
available studies. Great variability in skill, techniques, and experience among acupuncture
practitioners will add to the uncertainty of benefit from this modality. Systematic reviews that
separate acupressure from acupuncture are largely unavailable. As examples:

● A systematic review of nine randomized trials involving approximately 1550 women

concluded that acupuncture and acupressure may help relieve labor pain [78]. When
compared with placebo or no intervention, acupuncture was associated with superior pain
relief (standard mean difference -1, 95% CI -1.33 to -0.67; in one trial, 163 women),
increased satisfaction with pain relief (RR 2.38, 95% CI 1.78-3.19; one trial, 150 women),
and reduced use of pharmacologic analgesia (RR 0.72, 95% CI 0.58-0.88; one trial, 136
women). Compared with standard care, acupuncture reduced use of pharmacologic
analgesia (RR 0.68, 95% CI 0.56-0.83; three trials, 704 women) and instrumental deliveries
(RR 0.67, 95% CI 0.46-0.98; three trials, 704 women).

● A different review examined the evidence and findings of various systematic reviews of
acupuncture and acupressure to relieve labor pain. The authors concluded that the
disparate results were in part a result of including randomized trials that differed from one
another in study design, research questions, treatment protocols, and outcome measures
[79].

Additional studies are required, and patient-centered outcomes may be more appropriate for
evaluating treatment efficacy.

Yoga — At least one study has reported that the relaxation, breathing, and posture techniques
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of yoga appear to reduce maternal anxiety regarding childbirth [80]. Two different reviews
reported that women who practiced yoga during pregnancy reported fewer pregnancy
discomforts, pain, and stress [59,81]. It is not known if one particular component of yoga (eg,
specific breathing pattern, position, or type of yoga) is more effective than another.

Sterile water injection — Intracutaneous or subcutaneous sterile water injections (also called
water blocks) are used intrapartum primarily to decrease pain in the lower back, which has been
reported in up to 25 percent of laboring women [5,6]. A systematic review of seven trials
(including 766 women) comparing injections of sterile water with placebo noted that all studies
reported greater reduction in pain scores with the sterile water. Meta-analysis was not possible
because of the heterogeneity of the study designs, so the magnitude of the differences could not
be reported [82]. Four trials used intracutaneous injections, two used subcutaneous injections,
and one used both. Beyond the reduction of back pain, there was no difference between water
injection and placebo in rates of use of additional analgesia, cesarean delivery, instrumented
vaginal delivery, timing of delivery, or Apgar scores.

While the mechanism of action is not known, it is hypothesized that the firing of A-delta fibers
overwhelms the visceral pain input from C fibers such that the visceral pain is not noticeable; this
hypothesis is based upon the gate control theory of pain, and is sometimes referred to as
counterirritation. Alternatively, release of local endorphins may be responsible for any analgesic
effect [83]. This technique is useful in situations where there is little access to pain medication or
if the woman desires to use alternate approaches.

Water injections usually consist of four intracutaneous or subcutaneous injections of 0.05 to 0.1
mL sterile water (using four 1 mL or two 2 mL syringes with 25-gauge needles) to form four small
blebs or papules (similar to a tuberculin skin test). The use of "unphysiological" sterile water is
required. Although physiological saline does not burn, it also does not work. The injection sites
are most commonly located over the two posterior superior iliac spines and 3 cm below and 1
cm medial to these two sites. Alternatively, some clinicians ask the woman to point to the area
where she hurts most and they place the four injections in that area. Onset of back pain relief is
within 1 to 2 minutes, and lasts 1 to 2 hours. The water blocks can be repeated as desired [84].
The exact location of the injections does not appear to be critical to the success of the technique
[85]. A trial that compared four injection sites with one injection site reported greater pain relief
with the four site method, but also noted increased injection pain with four rather than one
injection [86].

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Because intracutaneous injections are typically very painful for up to one or two minutes, some
providers offset the discomfort of administration by giving injections during a contraction and
have two providers give the injections simultaneously to speed the process. Women need to be
forewarned of the burning sensations they will experience during the injection. Several studies
have reported that injection pain can be reduced by giving the injection subcutaneously, rather
than intracutaneously. Pain relief appears to be equivalent [83,87-89]. Since some women may
find the burning sensation from intracutaneous injection too painful, it is desirable to place the
first two injections of the four on opposite sides. Many women will receive substantial pain relief
from only two of the four injections.

Hypnosis — Hypnosis, or hypnotherapy, appears to result in altered states of consciousness

that prevent normally perceived experiences, such as pain, from reaching the conscious mind
[90]. Hypnotic, or trance, states are described as making the participant more receptive to verbal
and nonverbal communication, often called "suggestions" [91]. It is estimated that hypnosis has
been used for more than a century in pregnancy and childbirth, although supporting data are
minimal [92]. In a meta-analysis of nine trials including nearly 3000 women comparing hypnosis
with other pain relief methods or placebo, women receiving hypnotherapy (antenatal or in labor)
were less likely to use pharmacologic pain relief (not including epidural) (average risk ratio 0.73,
95% CI 0.57-0.94, eight studies, 2916 women), but there were no differences between the
groups in sense of coping with labor (mean difference 0.22, 95% CI -0.14 to 0.58, one study, 420
women), spontaneous vaginal birth (average risk ratio 1.12, 95% CI 0.96-1.32, six studies, 2361
women), or satisfaction with pain relief compared with other pain treatments [93].

Hypnosis used for childbirth is almost always self-hypnosis: The hypnotherapist teaches the
woman to induce the hypnotic state in herself during labor. Sometimes her partner is taught to
signal her into the hypnotic state. Common hypnotic pain relief techniques are "glove
anesthesia," in which the woman imagines that her hand is numb and that it can spread
numbness to other areas by placing her hand on painful areas; "time distortion," which enables
the woman to perceive the time between painful contractions as longer and the painful period as
shorter than it really is; and "imaginative transformation," in which the pain is interpreted as
benign and acceptable, and contractions are seen as surges of energy that cause only a light
pressure sensation [94].

Of note, hypnosis is contraindicated in persons with severe psychological disturbances or any

history of psychosis [95]. Any phobias or distressing situations need to be ascertained and
avoided when suggesting a visualization intended to be relaxing. There are no other apparent
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risks or disadvantages to the indicated use of hypnosis for childbirth, except that it requires
prenatal training, which may incur financial costs.

Biofeedback — Biofeedback is a therapeutic technique where individuals receive training to

gain control over physiological responses with the aid of electronic instruments. It helps the
individual to consciously regulate both psychological and physical processes, such as pain, that
are not usually under conscious control. However, it does not appear to be effective in reducing
labor pain. A systematic review of biofeedback for pain management in labor included four trials
(186 women) [96]. Most trials assessed the effects of electromyographic biofeedback in women
who were pregnant for the first time. There was no difference between biofeedback and control
groups in terms of use of pharmacologic pain relief, augmentation of labor, assisted vaginal
delivery, or cesarean delivery. Although electromyographic biofeedback appeared to have some
positive effects early in labor, there was a need for additional pharmacologic analgesia as labor
progressed. Conclusions were further limited by the diversity of interventions and measured
outcomes and lack of data describing the sources of bias that were assessed.

Transcutaneous electrical nerve stimulation — Transcutaneous electrical nerve stimulation

(TENS) is the transmission of low-voltage electrical impulses from a hand-held battery-powered
generator to the skin via surface electrodes. Some TENS units are specifically designed for use
by laboring women, and are available for rent without a doctor's or midwife's order in drugstores
and medical equipment companies in many countries. Most TENS units allow the wearer to
adjust frequency, intensity, and wave form.

While there is some evidence of efficacy for TENS in reducing acute pain, supporting data for
TENS use to reduce pain in labor are lacking [97-99]. As examples:

● A 2009 systematic review (17 trials including over 1400 women) comparing TENS for
management of labor pain with routine care, other nonpharmacologic pain treatments, or
placebo device concluded there was no difference in pain ratings between TENS recipients
and control women [100]. Of note, the subgroup of women receiving TENS to acupuncture
points were less likely to report severe pain (RR 0.41, 95% CI 0.32-0.55). There was no
benefit in using TENS as an adjunct to epidural analgesia and no consistent evidence that
TENS had any impact on labor interventions and outcomes. No adverse events were
reported. The majority of women using TENS, however, were satisfied and would use it
again in a future labor.

● A subsequent trial that randomly assigned 46 low-risk laboring women to either TENS or
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usual care reported an 11 point reduction, or 10 percent, in pain levels (100 point scale,
standard deviation 18 mm) after treatment and a five hour longer mean time until initiation of
medication in the TENS group [98]. There were no differences in patient satisfaction or
maternal or neonatal outcomes between the groups.

To perform TENS, one pair of electrodes is usually placed paravertebrally at the level of T10-L1,
and another at the level of S2 to S4. The woman controls the intensity of the current by turning a
dial, and can vary the stimulation pattern with a thumb switch on her TENS unit. She uses a
continuous stimulation during contractions and a pulsing pattern between contractions. TENS
causes a buzzing or prickling sensation that may reduce her awareness of contraction pain.

Water immersion — Immersion in warm water deep enough to cover the woman's abdomen is
thought to enhance relaxation and reduce labor pain [101]. In a 2018 meta-analysis of
randomized trials that evaluated the safety and efficacy of water immersion during the first stage
of labor, use of epidural, spinal, and paracervical analgesia/anesthesia was slightly lower for
immersion groups compared with controls (risk ratio 0.91, 95% CI 0.83-0.99; five trials) [102].
There were no significant differences in narcotic use or overall analgesia outcome, total labor
duration, operative delivery rates, perineal trauma, or neonatal outcomes. In response to this
review and other data, the American College of Obstetricians and Gynecologists (ACOG)
concluded that water immersion during the first stage of labor "may be offered to healthy women
with uncomplicated pregnancies between 37+0 and 41+6 weeks of gestation" [103].

Women can remain in the bath for a few minutes to a few hours during the first stage of labor. In
a retrospective cohort study of 327 laboring women, 82 percent initiated hydrotherapy and the
mean duration of tub use was 156 minutes [104]. Nearly 30 percent of women had to be
removed from the tub because they developed medical exclusion criteria, which included
maternal fever or suspected infection, abnormal fetal heart rate tracing, nonprogressing labor,
excessive vaginal bleeding, and any condition requiring continuous electronic fetal monitoring.
To avoid elevating the woman's core temperature and potentially increasing fetal risk, the water
should be at or slightly above body temperature [105]. (See "Intrapartum fever", section on
'Consequences'.)

The optimal time to initiate water immersion in the course of labor is not known. Prolonged
immersion (more than two hours) has been reported to prolong labor and slow uterine
contractions by suppressing oxytocin production. It is hypothesized that during immersion in
deep water, the hydrostatic pressure of the water on the mother's edematous tissue causes the

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fluid to be moved into the intravascular space, which leads to increased blood volume [106]. This
results in increased production of atrial natriuretic factor (ANF), which eventually suppresses the
production of vasopressin (a fluid-regulating hormone) by the pituitary gland; an accompanying
effect is the suppression of production of oxytocin. This phenomenon was supported in a study
of water immersion during labor in 11 women [107]. At 15 minutes and at 45 minutes after
immersion in the water, there were decreases in vasopressin and oxytocin levels (p <0.05)
compared with pre-immersion levels.

HIGH RESOURCE

Pharmacologic therapies (injection, intravenous, inhaled, and epidural) are considered high-
resource interventions because they require professional training and monitoring, have greater
risk of adverse effect, and incur significant cost. That said, trials support that epidural, combined
spinal epidural (CSE), and inhaled analgesia effectively reduce labor pain [108]. However, their
availability is limited in many regions of the world. Pharmacologic approached to managing labor
pain are presented separately. (See "Pharmacologic management of pain during labor and
delivery".)

RESOURCES FOR PATIENTS AND CLINICIANS

● Childbirth Connection – A nonprofit organization that promotes evidence-based maternity

care through policy and quality changes and works "to improve and transform the nation's
maternity care system so that childbearing women and babies consistently receive high-
quality, woman- and family-centered care." Includes sections for maternity professionals and
the public.

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Labor".)

SUMMARY AND RECOMMENDATIONS

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Nonpharmacologic approaches to management of labor pain
● Uterine contractions, back pain, and perineal pressure contribute to the pain experienced
during labor. Most women use some nonpharmacologic approaches for managing labor
pain, with or without pharmacologic approaches. Nonpharmacologic approaches to labor
pain management do not make pain disappear; instead, these approaches help women
better cope with the pain of labor and maintain a sense of personal control over the birth
process, thus reducing suffering. (See 'Pain in labor' above.)

● While pain scales or use of pharmacologic therapies have traditionally been evaluated,
patient-important outcomes, such as a sense of mastery and ability to manage the pain with
self-help and partner-assisted techniques rather than pain medications for all or part of
labor, may be more satisfying and feel safer for some women. (See 'Evaluating treatment
efficacy' above.)

● Although the supporting data are limited, we believe that all women should have access to
quality childbirth education, a physical space conducive to labor and delivery, and emotional
support. Women who have continuous labor support from a trained nonmedical provider
(such as a doula) are more likely to arrive in active labor, deliver vaginally, use less
medication, and report high satisfaction with their birth experience. (See 'Baseline
interventions' above.)

● The nonpharmacologic approach to pain management includes a wide variety of techniques

that attempt to enhance the psycho-emotional and spiritual components of care and thus
reduce suffering. However, many of the available nonpharmacologic methods lack data
demonstrating efficacy on pain reduction, but this may reflect the absence of patient-
important outcomes in assessing efficacy. A woman can use one or a combination of
treatments, and the choice is largely driven by her preferences and the availability of the
therapies. (See 'Approach' above.)

• Low-resource interventions include movement, touch or massage, application of heat or

cold, breathing techniques, showers, and audioanalgesia. Benefits include the ability to
use multiple modalities (in series or parallel), ease of use, and low cost. While the
supporting data range from mixed to minimal, these interventions are generally low risk.
(See 'Low resource' above.)

• Moderate-resource interventions with some supporting data include acupuncture, water

immersion, sterile water injections for back pain, transcutaneous electrical nerve
stimulation (TENS), and yoga. The body of evidence is minimal or unsupportive for
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aromatherapy, hypnosis, and biofeedback. Although the risks to the mother and fetus
are likely low, there are risks of hyperthermia (water therapy) and toxicity
(aromatherapy). (See 'Moderate resource' above.)

• High-resource therapies include all pharmacologic therapies (injection, intravenous,

inhalation, or epidural). While these interventions require professional training,
materials, and funding, the body of evidence demonstrates that epidural, combined
spinal epidural (CSE), and inhaled analgesia effectively reduce labor pain, though they
also have significant side effects and require close attention to maintain safety. Given
the constraints of these interventions, their availability is limited. (See 'High resource'
above.)

ACKNOWLEDGMENTS

The editorial staff at UpToDate would like to acknowledge Penny Simkin, PT, and Michael C
Klein, MD, who contributed to an earlier version of this topic review.

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