INTRODUCTION — Pain is a common labor symptom and may be located in the abdomen, back, pelvic floor, perineum, or other locations. Physiologic drivers of labor pain include factors such as uterine contractions, cervical dilation, and pressure from the fetus. Labor pain can be increased by abnormal fetal position, intrauterine infections such as chorioamnionitis, and other pathologic factors such as placental abruption. The perception of pain is also impacted by cognitive, environmental, and social factors.
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.
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" . Pain is further influenced by cognitive, environmental, and social factors . 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 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 . Although pain and suffering often occur together, one may suffer without pain or have pain without suffering .
●Physiology of labor pain – 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 . 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 . (See "Pharmacologic management of pain during labor and delivery", section on 'Pain pathways'.)
●Types of labor pain – 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 . 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 .
●Patient preferences – Many women have strong preferences about using pharmacologic versus nonpharmacologic pain relief to cope with pain during labor, but even among those who prefer pharmacologic care, most will also use some nonpharmacologic approaches for managing labor pain prior to, during, or after use of pharmacologic methods . For example, an Australian study found that 90 percent of pregnant women had a strong preference for continual support during labor, regardless of their desire to use pharmacology to manage labor pain . Therefore, understanding of and confident delivery of nonpharmacologic care to address labor pain must be priorities in all maternity care settings and for all birthing people, regardless of intent to also receive pharmacologic pain relief
●Goals of nonpharmacologic treatment – Nonpharmacologic approaches to labor pain management are not intended or expected to 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. The nonpharmacologic framework is focused on increasing coping with the sensations of labor. As childbirth can be an intensely painful event, many women desire information about pain levels and options for relief . Lack of relevant information has been associated with increased anxiety . 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 .
•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 . Constant support established a sense of safety and reduced feelings of loneliness and fear, which enhanced their coping ability. However, the review also reported a gap in many clinical settings between women's need for continuous support and its availability.
●Role of antenatal education – 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. Women will also benefit from opportunities to rehearse and master nonpharmacologic pain relief techniques prior to labor. Lastly, their caregivers and teachers must know how and when to utilize nonpharmacologic methods of pain management .
EVALUATING TREATMENT EFFICACY — In evaluating treatment efficacy, one must consider the study outcomes 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 analog 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 [15,16]. 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 . For this scale, the patient is asked "On a scale of 1 to 10, how well are you coping with labor right now?" .
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 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 . 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 .
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) [21,22]. (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 of 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 makes efficacy difficult to measure. One small trial (n = 80) reported improved outcomes (eg, lower pain scores, shorter time in labor) among nulliparous women randomly assigned to receive a series of three nonpharmacologic interventions (eg, birth ball exercises, massage, and water immersion) versus normal care .
BASELINE INTERVENTIONS — Among other basic elements, all women should have:
●The right to participate in informed shared decision-making about their care [24,25]. Childbirth 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.
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. Patients should make their preferences known to the staff and their own team (eg, caregivers, childbirth educator, doula, and support people) so that they can assist as the patient prefers. Patient caregivers and support people also help by providing physical comfort, reassurance, guidance, encouragement, and unconditional acceptance of coping style. With such support, along with taking an active role in decision-making, patients who wish to minimize their use of pain medications are more likely to do so . Intangible benefits can include reduced feelings of helplessness and an increased sense of mastery, control, and well-being . Of course, parents must also know that birth is unpredictable, and circumstances may require the use of less preferred interventions in order to ensure safe passage of mother and infant.
●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 evaluate, and attempts to do so have reported inconsistent results. 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 [22,24,26], at least one meta-analysis reported decreased anxiety or fear of childbirth for women who received childbirth education . Despite these studies, large numbers of expectant parents attend CBE classes, and caregivers continue to recommend them [17,28]. 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 [21,26]. 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 . Additional supporting data come from a Canadian study of attitudes and beliefs of obstetric providers and the women they serve [29-31]. 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 [30,31]. 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 . 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) . The alternative birth setting was also associated with significantly lower rates of obstetric 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 .
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 [35,36]. 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 .
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 obstetric outcomes . A 2019 qualitative review of 51 studies concluded that labor companionship helped patients have positive birth experiences . 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 . 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" . 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 . This topic is discussed in detail separately. (See "Continuous labor support by a doula".)
OUR 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 psychoemotional and spiritual components of care and thus reduce suffering. In this approach, pain is perceived as a normal component 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 patient is educated about the choices for pain relief methods available (preferably as part of antenatal care) and then weighs the risks, benefits, and alternatives for each method. The patient considers any fears of pain, exertion, fatigue, or 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, the patient plans an approach that best suits their 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 their approach to pain management during the actual labor should be respected. Patients intending to labor and birth using only nonpharmacologic methods for coping may proceed through delivery and recovery without medication but should not be denied medication if they request it.
Within this overall approach to coping with labor pain, care should be further tailored by two factors: the laboring patient's intentions for nonpharmacologic versus pharmacologic care and how well the intended approach (nonpharmacologic versus pharmacologic) is helping the patient cope with labor pain. The basic approaches to pain management are briefly reviewed relevant to these two considerations.
●Nonpharmacologic approach – For women intending nonpharmacologic approaches during labor and birth, the basic approach to pain management for these individuals includes:
•Use the nonpharmacologic approach selected by the laboring patients.
•Switch to different or additional nonpharmacologic approaches when the laboring patient communicates that they need more help coping with labor sensations.
•Attend to the laboring patient's verbal and nonverbal communication regarding preferences to continue with nonpharmacologic approaches.
-With communication that nonpharmacologic approaches are satisfactory, continue these approaches.
-With communication that nonpharmacologic approaches are not satisfactory, even after changing or adding nonpharmacologic techniques, inquire if the patient would like to initiate pharmaceutical options.
●Combined approach – For patients intending both non- and pharmacologic approaches during labor and delivery, the basic approach to nonpharmacologic pain management for these individuals includes:
•Use of the nonpharmacologic approach selected by the laboring patients.
-If the original nonpharmacologic approach selected by the patient is not sufficient for coping during the time they prefer to avoid pain medication, switch to different or additional nonpharmacologic approaches until the patient indicates that they are ready for pharmacologic care.
•Initiate pharmacologic pain relief when the patient requests.
-Nonpharmacologic care may continue as before, or new types of nonpharmacologic care may be initiated once pharmacologic care is established.
-Periodically, pharmaceutical approaches do not provide sufficient labor pain relief. When a patient intended only pharmacologic intervention during labor but is experiencing labor pain that cannot be controlled with medication, they are at high risk for suffering. Clinical experience suggests that these patients will benefit from especially attentive and compassionate care during labor and birth. Continuous labor support is highly recommended. Offering trials of other nonpharmacologic approaches can also be helpful.
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".)
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.)
●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, can communicate support, and may help lower stress levels in the mother, indirectly modifying their 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 [41,42]. Pelvic dimensions vary with differences in maternal positions; thus, these changes may help to ameliorate labor pain . 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 . 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 monitoring or because of institutional culture or provider preferences . (See "Labor and delivery: Management of the normal first stage", section on 'Physical activity'.)
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 were not associated with increased intervention or negative effects . 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 :
•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 . 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. Patients also stand or kneel and lean their upper bodies over the ball, which can provide comfortable support of the torso or back. Birth balls are easy to use and can be used along with other interventions for patient comfort (eg, analgesics, hot shower, massage).
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 analog 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) . 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. The peanut-shaped ball is unlikely to be used for pain relief; however, given the wide variety in preferences and responses to nonpharmacologic pain management approaches, some laboring patients may find the peanut-shaped ball helpful in itself. Most peanut-shaped birth ball literature addresses the use of this ball with epidural analgesia. One randomized trial reported that placing the ball beneath the upper leg of the side-lying parturient using epidural analgesia shortened their labor (by 29 minutes in nulliparas and 11 minutes in multiparas) . Another trial reported a shorter first stage of labor among nulliparas using epidural analgesia and the ball. The ball might be placed between a patient's legs, or they might be in a Semi-Fowler's (semi-prone) position with their upper leg resting on the ball and lower leg resting on the bed .
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 [49,50]. Additionally, touch was sometimes reported as annoying or painful, particularly when the abdomen or pelvic area was being touched in conjunction with an assessment. This illustrates the need to understand the context when assessing touch and also to carefully attend to laboring patient's verbal and nonverbal communication regarding touch.
Establishing a touch relationship during labor requires sensitivity and awareness from the person offering touch. There is great variation in people's experience of and history related to touch. Additionally, clinical settings and cultures can introduce complex power dynamics between a patient and the health care team; some patients may struggle to indicate when a birth attendant's touch is unhelpful.
●Our approach – Our clinical experience informs our approach to offering touch during labor and birth:
If the patient indicates interest in trying this nonpharmacologic approach, we start with touching the feet or a foot massage. This approach initiates supportive touch and/or massage in an area of the body that may feel less intimate for many patients. While contact/holding of the feet may continue during contractions, we recommend particular focus on touch/massage of the feet to encourage relaxation between contractions. This step is often accompanied by praise and helping the patient understanding how to maximize relaxation between contractions.
•It is critical to provide the laboring patient with both permission to decline touch and specific verbal and nonverbal examples of how to indicate that they do not want to be touched.
•If the clinician believes that touch is helping the patient, we also recommend confirming this after approximately 15 minutes of touch. We suggest the clinician phrases the inquiry in such a way that the laboring patient can respond with either a gesture or a simple yes/no response.
●Specific to massage – Massage consists of purposeful and systematic manipulation of the soft tissues of the body for therapeutic purposes [51,52]. Through mechanisms such as offering counterpressure and/or decreasing muscle tension, massage might decrease physical labor pain while also helping with labor coping. There are no known harmful effects of massage. Maximally therapeutic labor massage will likely be performed by professionals or lay people who have received specific instruction, but there is no known harmful effect of labor massage delivered by those without training, and the potential benefits of this kind of touch are likely high.
•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) .
•The optimal massage technique is not known and further trials on efficacy are needed. However, 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) [54-58].
●A meta-analysis of 10 trials comparing acupressure during the first stage of labor (versus placebo and/or no intervention) found that acupressure predominantly using the L14 and SP6 acupoints was associated with significant reduction in labor pain during both the active phase of labor and during transition .
●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 .
●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) . 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.
●Patient preference – As with all nonpharmaceutical pain relief options, the patient'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.
●Skin protection – With both modalities, the caregiver should test the pack on their own skin and place one or two layers of cloth between the laboring patient's skin and the hot or cold pack to protect against the possibility of skin damage. Additionally, it is imperative that the patient has intact sensation if heat or cold is to be applied. Particular caution should be taken with individuals using epidural analgesia who also request hot packs as they may not become aware when there is potential for skin blistering.
●Heat – 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. In addition to being used for pain relief, heat is used to relieve chills or trembling, decrease joint stiffness, reduce muscle spasm, increase connective tissue extensibility, and to support relaxation between contractions.
•One technique for relief of contraction pain is to apply heat to the site of greatest pain (often lower abdomen or lower back) to coincide with the onset of a contraction.
•No studies have evaluated the optimal temperature or duration of heat therapy. Care should be taken to avoid burns. 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 [62-64].
●Cold – Cold packs may be applied to the lower back when a patient is experiencing back pain. While heat is more commonly preferred, some individuals receive relief by the application of cold to the site of most pain (often lower abdomen or lower back) to coincide with the onset of a contraction. 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) .
Despite minimal data, cold packs are frequently used to reduce postpartum perineal pain and swelling and can be used intermittently for days after birth. 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 and possibly in the active phase of labor . 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 . 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 . Available data suggest relaxation and breathing techniques may have a role in managing labor pain .
In a survey of women in the United States who gave birth in 2011 to 2012, 48 percent of the respondents reported using breathing techniques . 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 . 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 . 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  and reduce pain scores as measured by visual analog scale (VAS) . In addition, the women in the trial who received shower therapy reported higher satisfaction . 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 [66,72,73].
Before labor, the woman selects music (sometimes with the help of a music therapist) or 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 . 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 [75-77]. 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 .
●Data supporting effect:
•A trial of lavender inhalation during labor reported that, compared with a control group, a 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 .
•A meta-analysis including 17 trials found that aromatherapy significantly decreased labor pain between 8 and 10 cm of cervical dilation . Study limitations included wide heterogeneity in study setting, methods, variable definitions, and outcomes.
●No effect – 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) [75,76].
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 trustworthy sources for background information, safety issues, recommended websites, books, and practitioners [80,81].
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 [82,83]. Electro-acupuncture, which involves electrical stimulation via the strategically placed needles is also sometimes used, with effects similar to manual acupuncture on labor pain [84,85]. There are no known risks to acupuncture when practiced by adequately 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 . 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 .
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 of yoga appear to reduce maternal anxiety regarding childbirth . Two different reviews reported that women who practiced yoga during pregnancy reported fewer pregnancy discomforts, pain, and stress [89,90]. 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 [7,8]. 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 . 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 . 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 . The exact location of the injections does not appear to be critical to the success of the technique . 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 .
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 [92,96-98]. 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 . Hypnotic, or trance, states are described as making the participant more receptive to verbal and nonverbal communication, often called "suggestions" . It is estimated that hypnosis has been used for more than a century in pregnancy and childbirth, although supporting data are minimal . 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 .
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 .
Of note, hypnosis is contraindicated in persons with severe psychological disturbances or any history of psychosis . Any phobias or distressing situations need to be ascertained and avoided when suggesting a visualization intended to be relaxing. There are no other apparent risks or disadvantages to the indicated use of hypnosis for childbirth, except that it requires prenatal training, which may incur financial costs.
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 [106-108]. 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 . 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 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 . 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 . 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) . 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" .
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 . 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 . (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 fluid to be moved into the intravascular space, which leads to increased blood volume . 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 . 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 . However, their availability is limited in many regions of the world. Pharmacologic approaches 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
●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 'Our 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 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 potential side effects and require close attention to maintain safety. Given the constraints of these interventions, their availability may be limited in some environments. (See 'High resource' above.)
ACKNOWLEDGMENTS — The UpToDate editorial staff acknowledges Penny Simkin, PT, and Michael C Klein, MD, who contributed to an earlier version of this topic review.