If you are pregnant right now and worrying about pain during labour, you’re definitely not alone, it’s a common concern when thinking about birth.
This blog discusses what labour pain is and the difference between physiological and non-physiological labour pain. Along with your non-pharmaceutical and pharmaceutical pain relief options. You have many.
It is up to you do the research and make an informed decision about what feels best for you and your baby. You can use the BRAIN (Benefits, Risks, Alternatives, Instinct, Nothing) acronym to help you make these choices and decide what is best for your birth.
What is labour pain?
It can be helpful to think about what labour pain actually is. The pain or sensations you might experience during birth are the action of your powerful uterus (womb) muscles working to firstly, shorten and open the cervix, pulling the cervix up over your baby's head. This power is slowly transformed from the bottom of the uterus, to the top of the uterus (the fundus), so the fundus can push your baby out into the world. There's a lot going on.
“Labour pain is different from pathological pain experiences, such as having a tooth extracted. It is functional, purposeful and productive pain that brings a woman closer to meeting her baby” (Whitburn et al. 2019)
Reframing labour pain as productive and having an acceptance for birth pain, working with it using nonmedical comfort measures that reduce pain and assist with relaxation can, according to research, reduce pain perception. (Reed R, 2021, p 101)
Is labour and birth always 'painful'?
Everyone experiences labour 'pain' and sensations differently. Some women and birthing people report not feeling any 'pain' during birth, some describe experiencing birth in an orgasmic way.
"I could feel incredible intensity and powerful sensations throughout my entire being, which I fully embraced, but experienced no 'pain' at all" Marie Molloy (Hill, M. 2022 p 73)
At the end of the day you are an individual, how you experience birth will be as unique as you are.
Is all birth pain the same?
There's a difference between physiological birth pain from a spontaneous labour (one that starts naturally on its own) and pain from a non-physiological birth, such as an induced labour. Contractions or surges from an induced labour are not physiological and more likely to require pain medication. (Reed R, 2021, p 102)
What are my pain relief options?
You have MANY options for comfort measures in labour and birth. Some of the options below will only be available in a hospital setting and need to be administered by an anaesthetist or midwife, but many can be used in all birth settings.
What are my non-pharmaceutical options?
2. Water
4. Breathing
6. Aromatherapy
10. TENS Machine
11. Comb
What are my pharmaceutical options?
4. Epidural
Beta-Endorphins: Your body’s built in pain relief system:
It’s helpful to understand that physiological birth (e.g. not induced) is a complex hormonal cocktail. (see this blog post about birth hormones to understand more) If labour is progressing physiologically this hormonal cocktail has built in pain killers. Pretty cool huh! Beta-endorphins are the body’s natural pain killers and are many times more powerful than morphine. They work in synergy with oxytocin, (the hormone that works your womb muscles to squeeze baby out), to make the sensations manageable. Beta-endorphins build with your labour contractions/surges to help you manage the more intense sensations later on in labour. Quite simply the more natural oxytocin you have the more beta-endorphins you have. Beta-endorphins can make you feel sleepy or in an altered state of conscious, helping you to rest between surges.
Water:
Warm water immersion during labour can be very helpful in managing pain and labour sensations. A 2009 Cochrane review concluded that those who used water immersion during labour were less likely to need epidurals or spinal pain relief. They also concluded water may also reduce the duration of the first stage of labour as well as increasing women and birthing peoples the level of satisfaction with their birth experience. (Cluett ER, Burns E. 2009)
You could use a birth pool – also great for supporting birth hormones due to the natural privacy it provides. If a pool is unavailable to you, you could try a hot water bottle on your lower back or use a shower or bath. Again, being in the bathroom is a great private environment which helps to boost your oxytocin (it’s a shy hormone and thrives in privacy) and beta-endorphins (see above).
Hypnobirthing:
It is a misconception that hypnobirthing works as ‘pain relief’ during birth. In actual fact hypnobirthing teaches you to build a tool kit of coping strategies that you can utilise during labour and birth as you wish. These include using self-hypnosis, deep relaxation, visualisations, massage, positive anchors and breathing techniques practiced before birth to positively impact the mind and therefore your body. These techniques encourage you to remain within your para-sympathetic nervous system – the nervous system needed to optimise physiological birth. A 2022 study concluded the skills taught in hypnobirthing antenatal classes had a benefit on pain perception and birth experience (Leutenegger, V., Grylka-Baeschlin, S., Wieber, F. et al. 2022) Hypnobirthing techniques can be utilised in all birth scenarios so if your birth evolves away from plan A into something else, you still have tools you can use to help you remain calm.
Hypnobirthing also teaches you about how your body works during birth, which can be helpful to reducing birth fear. As well as important decision making and advocating skills to help you and your birth partner ensure your wishes are respected and your voice heard.
Breathing:
Taking deep breaths in through your nose with a longer breath out your mouth reduces tension in your body, oxygenates your muscles and helps you remain in your para-sympathetic nervous system. A 2022 review of 10 separate studies concluded “skilled breathing and relaxation techniques may positively influence self-efficacy (self-belief), the need for pharmacological support, specifically the use of epidural anaesthesia, and the memory of labour pain.” (Leutenegger, V., Grylka-Baeschlin, S., Wieber, F. et al. 2022) You can utilise this breath during labour and birth or any time you feel stressed e.g. waiting for a job interview. You can practice this calm breathing when you get up in the morning or before you go to sleep.
Active Birth:
Remaining active and moving instinctively during labour is a great way to manage labour sensations and also assist baby to descend through your pelvis, hello gravity! You can use anything to help you stay active, birth ball, lean over the bed, using your partner for support, birth pool to support your body weight…anything. You might develop rhythmic movements, as your labour progresses, like a dance, swaying or squatting. Bottom line, you don’t need to over think it, trust your instincts, if you are free to move you will likely adapt positions that feel most comfortable to you. Being active doesn’t mean you have to move non-stop, remember to rest between surges, if that feels right for you.
Aromatherapy:
Essential oils can help with reducing labour pain and anxiety, according to a 2020 systemic review. Most commonly lavender, which when inhaled has been shown to significantly decrease pain intensity during labour (Tabatabaeichehr M, Mortazavi H. 2020)
Other aromatherapy oils also proved beneficial, such as Jasmine, Geranuim and Chamomile.
You could use a diffuser or place the oil on a handkerchief. You could also combine aromatherapy with other comfort measures such as massage, acupressure and water.
Acupuncture & Acupressure:
Acupuncture and acupressure come from Traditional Chinese Medicine, and some women and birthing people may use these methods to help manage pain and sensations during labour.
A Cochrane review showed acupuncture “may increase satisfaction with pain relief…and probably reduces the use of pharmacological analgesia”. (Smith, CA et al, 2020) Another 2020 study stated “Acupressure is an effective method of pain reduction during first stage of labour.” (Haj Najafi Raana, Xiao-Nong Fan. 2020)
With the Cochrane review also saying that acupressure “probably reduces the caesarean section rate” (Smith, CA et al, 2020)
In both cases the authors said more randomised control trials were needed, however, with no know side effects to the baby. This might be something you’d like to look into.
Continuous Support:
Having the continuous support from the same person; someone you trust and you know has completely got your back, is proven to be beneficial in labour and birth. A Cochrane review (Bohren MA, 2017) into 26 trials looking at over 15,000 women found that having continuous support from the same person lead to less need for pain relief, fewer interventions and better outcomes for mothers and babies. Continuous support might not be possible from your health care team, so this is where a really kick ass birth partner is needed. Or you could look into hiring a Doula, who is a professional birth supporter.
Nipple & Clitoral stimulation:
There are really good hormonal reasons why ‘self-help’ such as masturbation or nipple and clitoral stimulation can help labour progress – hello oxytocin and endorphins! Self-stimulation, or ‘assistance’ from your birth partner, might feel like the last thing you’d think to do during birth, but if labour is slowing down, maybe get yourself some privacy and try some ‘self-help’ what do you have to lose? It might feel good. Some women have described their birth as feeling orgasmic. Maybe that could be you?
Gate Control Theory (GCT)
This is the idea that there is a gate mechanism in the brain and spinal cord nerves (the central nervous system). When the gate is open, pain messages get through to the brain and you feel pain. When the gate is closed, these pain messages are blocked and the pain is not felt. Your brain can only focus on one intense sensation at a time, so with GCT, you are exchanging one sensation for another. There are multiple ways to do this…
TENS machine:
This is a battery-operated hand-held device that you control. You attach pads to your back and electrical impulses generated by the TENS machine interfere with and block pain messages sent to the brain. TENS machines are thought to stimulate certain non-pain-carrying nerves and close the gate. In effect, the brain is busy dealing with the messages it receives quickly from the TENS machine, rather than the slower (more painful) pain signals that the body is receiving from elsewhere. TENS machine also stimulates the body to produce natural pain killing beta-endorphins, which I’ve mentioned before are more powerful than morphine.If you don’t like it you can stop using it with no side effects to you or baby. You wouldn’t be able to use it with water as, well obviously, water and electricity don’t mix so well.
Comb:
Squeezing a comb during contractions so the ‘teeth’ gently press into your palm is said to work on the acupressure point Lao Gong, releasing endorphins and acting as a distraction for your brain from one sensation (the contraction) and diverting it to another (your hand). The portable nature of the comb means you can use it anywhere, and it’s completely within your control. The only risk could be holding it too hard and hurting your hand, so maybe swap hands from time to time.
Sterile water injections (SWI):
Injections of sterile water are inserted into the lower back at 2 or 4 injection points. The water forms small blisters under the skin to relieve pain in labour and ‘shut the gate’ and prevent back pain or labour signals from reaching the brain. A study found women reported a significant reduction in low-back pain during labour following SWI. (Fouly H et al. 2018)
Injections are painful, and the injection pain lasts about 30-60 seconds but SWI can help reduce surge pain for 2-3 hours.
Midwives can administer these, if they have been trained to do so. They might not be widely available so check with your maternity team if this option is available to you.
Gas and Air:
Entonox, or ‘gas and air’ is a mixture of nitrous oxide (laughing gas) and oxygen inhaled through a mouthpiece. Usually available at home births and in hospital settings, it can be used during water birth. Gas and air doesn’t remove pain but can ‘take the edge off’. It takes about 15 – 20 seconds to work so it’s best to start inhaling at the beginning of a surge/contraction. Gas and air enters the body quickly and leaves the body quickly, you are in control of when you use it and there are no harmful side effects to you or your baby. It can make you feel lightheaded, sick, sleepy or unable to concentrate, but if this happens you can stop using it.
Drugs:Paracetamol:
Taking paracetamol is often recommended to manage sensations in early labour. However, it’s worth giving it a bit of thought, as paracetamol it is known to inhibit prostaglandin synthesis, which is important for dilating the cervix and establishing labour. Some midwives have suggested this is something that requires further research.
Opioid Drugs:
Opioids don’t remove pain altogether, they alter your state of couscous making you feel ‘out of it’ and changing your experience of the pain. Opioids used in labour such as pethidine, meptid and diamorphine are derived and synthetized from the resin of the opium poppy. These can be administered in hospital by injection into the thigh. These drugs take 20 to 30 minutes to work and last for two to four hours.
Remifentanil, is a very strong, short acting pain killer and can be administered by an anaesthetist who inserts a via a drip which you control using a machine.
If you are planning a home birth you can request a prescription, such as Dihydrocodeine from your GP to have with you, just in case.
Opioid pain relief can alter your mood during labour and help you rest and sleep if you need to during a long labour. (Lowth M, 2017)
Timing is key to taking these drugs. Pethidine is best taken earlier in labour as it can affect your baby’s breathing and make them sleepy after birth and make you too drowsy to push effectively, it can also make breastfeeding harder to establish. (Lowth M, 2017)
Epidural:
Epidural is a very common and effective form of pain relief in labour. Epidural is a local anaesthetic that is administered by an anaesthetist using a needle to insert a fine plastic tube called an epidural catheter into your back (spine) near the nerves that carry pain messages to your brain. The needle is then removed, leaving just the catheter in your spine. Pain relief medicines are then given through the catheter. You can ask for a ‘mobile’ or ‘low dose’ epidural if you would like more mobility, or a ‘full epidural’, where you won’t feel anything. You would need to discuss these options with your health care team. It takes about 25 minutes for the epidural to be set up until it is working. Not including the time waiting for the anaesthetist to be available to administer it.
Utilising calm breathing techniques can be hugely beneficial during the insertion of an epidural as it’s important you stay very still.
Epidural alters the tension of your pelvic muscles, which can interfere with the rotation of baby through the pelvis and increase chance of instrumental birth. (Reed R, 2021, p 103)
You can use pillows or a peanut ball to be supported by your birth partner and health care team to not lie flat on your back. This allows your sacrum (back of your pelvis) and coccyx (tail bone) to still be able to move, as it is designed to, during birth. Alternatively, you may birth flat on your back with coached pushing, which may increase the chance of severe perineal tearing or episiotomy.
The website www.evidencebasedbirth.com gives detailed benefits and risks of epidural use in labour.
I hope you have found this helpful in knowing more about the options available to you. As I said at the beginning, it is up to you do the research and make an informed decision about what feels best for you and your baby.
If you'd like to talk about how a Positive Birth Leeds hyopnobirhting course can help you and your birth partner feel get prepared and feel confident for your birth get in touch.
I'm always happy to chat.
Charlotte x
Check out the latest group course dates here Or get in touch to ask about Private 1:1 Course availability. Disclaimer: The information contained in this blog does not constitute medical advice in any way. If you have any specific concerns, talk to your Midwife or maternity team.
References:
Whitburn LY, Jones LE, Davey MA, McDonald S. The nature of labour pain: An updated review of the literature. Women Birth. 2019 Feb;32(1):28-38. doi: 10.1016/j.wombi.2018.03.004. Epub 2018 Apr 22. PMID: 29685345. https://pubmed.ncbi.nlm.nih.gov/29685345/
Dr R Reed, Reclaiming Childbirth as a Rite of Passage, 2021, p101
Cluett ER, Burns E. Immersion in water in labour and birth. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD000111. DOI: 10.1002/14651858.CD000111.pub3. Accessed 22 March 2023. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000111.pub3/full
Leutenegger, V., Grylka-Baeschlin, S., Wieber, F. et al. The effectiveness of skilled breathing and relaxation techniques during antenatal education on maternal and neonatal outcomes: a systematic review. BMC Pregnancy Childbirth 22, 856 (2022). https://doi.org/10.1186/s12884-022-05178-whttps://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-022-05178-w
Tabatabaeichehr M, Mortazavi H. The Effectiveness of Aromatherapy in the Management of Labor Pain and Anxiety: A Systematic Review. Ethiop J Health Sci. 2020 May;30(3):449-458. doi: 10.4314/ejhs.v30i3.16. PMID: 32874088; PMCID: PMC7445940. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7445940/
Smith CA, Collins CT, Levett KM, Armour M, Dahlen HG, Tan AL, Mesgarpour B. Acupuncture or acupressure for pain management during labour. Cochrane Database of Systematic Reviews 2020, Issue 2. Art. No.: CD009232. DOI: 10.1002/14651858.CD009232.pub2. Accessed 22 March 2023. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009232.pub2/full
Haj Najafi Raana, Xiao-Nong Fan, The effect of acupressure on pain reduction during first stage of labour: A systematic review and meta-analysis, Complementary Therapies in Clinical Practice, Volume 39, 2020, 101126, ISSN 1744-3881, https://doi.org/10.1016/j.ctcp.2020.101126.
Bohren MA, Hofmeyr G, Sakala C, Fukuzawa RK, Cuthbert A. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2017, Issue 7. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub6 https://www.cochrane.org/CD003766/PREG_continuous-support-women-during-childbirth
Fouly H, Herdan R, Habib D, Yeh C. Effectiveness of injecting lower dose subcutaneous sterile water versus saline to relief labor back pain: Randomized controlled trial. European Journal of Midwifery. 2018;2(March). doi:10.18332/ejm/85793. http://www.europeanjournalofmidwifery.eu/Effectiveness-of-injecting-lower-dose-subcutaneous-sterile-nwater-versus-saline-to,85793,0,2.html
Lowth, M, 2017. https://patient.info/pregnancy/labour-childbirth/pain-relief-in-labour
Dekker R, 2018. https://evidencebasedbirth.com/epidural-during-labor-pain-management/