Ways of managing your labour

Many things can affect how a woman experiences the sensations of labour: the kind of surroundings and support she has, whether she is being encouraged and assisted to move about and use helpful positions, whether her labour starts and progresses unaided or whether it is being artificially induced or speeded up, her own state of mind, and whether there are any complicating factors.

If you are well supported, feel confident in your ability to give birth, and positive about using the sensations to guide you, you may find that you are able to manage your contractions using self-help and comfort methods alone. Alternatively, if your labour is not straightforward, or lasts for a very long time, artificial pain relief may help to make it a more positive experience. Also, many women find that induced labour is more painful than spontaneous labour, which can mean that they need additional support.

It’s important to be aware that whatever method or methods you choose there may be unwanted consequences as well as benefits; and there is a tendency for stronger forms of pain relief to have more significant side effects. You may find it helpful to consider how you feel about each of the following options, and in what circumstances (if any) you might want to use them, then make sure that your partner and/or other birth supporters as well as your midwife are aware of your preferences. It’s also important to know that there is no right or wrong decision. Go with what is right for you, remembering that you can always change your mind about declining or accepting pain relief.

What methods are effective?

Unfortunately, the research evidence for many of the methods is limited, however a large-scale analysis of all the available research1 concluded that:

  • There is good evidence that Epidural analgesia and inhaled drugs like Entonox (“Gas & Air”) are effective in the relief of pain but that they may give rise to unwanted side-effects.

  • There is some evidence to suggest that being in water, using relaxation techniques, massage and acupuncture/acupressure are helpful, and these methods have few, if any, negative side-effects.

  • There is not enough evidence to say whether hypnosis, sterile water injection, aromatherapy, TENS, or injected opioids (like Pethidine and Meptid) are effective or not. It is very important to note that this only means that not enough clinical research has been done to show how these methods compare with others. However, there is no doubt that a very large number of women do find them useful.

There is also good evidence that having continuous support during labour both improves a mother’s chances of a straightforward birth and reduces her need for artificial pain relief.2 The greatest benefit is with a trained and experienced person (such as a Doula) who is there purely to provide support.

Self-help and comfort methods

This includes things that you can do yourself or with the help of your partner/birth supporter(s), which help you to feel relaxed and encourage the labour hormone oxytocin to flow. (Oxytocin, which produces effective contractions, also creates a sense of well-being).

  • Labouring in comfortable surroundings where you feel safe and private, so that you can let go and work with your body.

  • Focusing on relaxed breathing and any other method of relaxing that works for you.3

  • Massage – which means any kind of soothing touch from your partner/birth supporter(s) - can reduce tension, and there is some evidence4 that women who use it find labour less painful.

  • Cuddles with someone you love can also be very effective – oxytocin is “the love hormone” and its production is stimulated by loving words and physical contact.

  • Finding comfortable, upright positions. Sometimes it’s helpful to move around or even go for a gentle walk if you want to encourage your labour to progress, but make sure you rest (preferably in an upright position) when you need to.

  • Supporter(s) giving you lots of encouragement as well as caring for your practical comfort (providing food and drink, hot or cold packs, helping you to change position, controlling the temperature, running you a bath etc.)

Benefits

  • Many women find these methods very effective. Some women find they can cope with labour without any other form of pain relief.

  • They can help both you and your partner/supporter(s) to feel calm and in control, which in turn can help your labour to progress.

  • They are available anywhere and little or no special equipment is needed (though a birth-ball, bean-bags, massage rollers etc may be useful.)

  • There are no side-effects for you or your baby.

Possible downsides

  • You may not find them effective for the whole of your labour, especially if it is long or there are complicating factors.

Complementary therapies

Most of these techniques have been in use for many years, if not centuries, and women often find them useful. However, with one or two exceptions noted below, there has been little or no clinical research into either their effectiveness or their safety. Again, this does not mean that they are not effective, just that there have not been scientific studies to look at whether they are or not.

Some midwives have expertise in complementary therapies, and some hospitals are starting to offer options such as aromatherapy and acupuncture.

  • Acupuncture uses fine needles or electrodes to stimulate specific points on the skin, and acupressure involves applying pressure to the same points. There is some evidence5 that acupuncture or acupressure can make contractions feel less painful and reduce a mother’s need for pain-killing drugs.

  • Hypnosis (Natal hypnotherapy/Hypnobirthing®) creates a state of mental relaxation, in which you are open to suggestion, so the theory is that you can use it to help you feel more relaxed, positive and in control during labour. It is possible to “teach yourself” by listening to CDs, or you can attend classes. As mentioned above, the research evidence1 is limited, but many women say it helped them to cope better with their labours, and one trial6 showed that women felt less anxious than they had expected.

  • Aromatherapy is the use of concentrated plant oils which are thought to aid relaxation. You can use them diluted in oil and massaged into your skin, add them to a bath, or inhale the vapour. Although “natural”, the oils are powerful, and some can be harmful in pregnancy, so consult a properly trained aromatherapist before using any of them. What little research there has been did not find clear evidence of benefit1, but many women say they find aromatherapy soothing.

  • Homeopathic remedies are said to stimulate the body’s own systems and consist of very low doses of substances that would produce the symptoms that the remedy aims to cure. A homeopath can prescribe for you specifically or you can buy “Labour Packs” from some health shops from which you or your supporters select remedies depending on how you are feeling and how your labour is going. There hasn’t been any clinical research on the effectiveness of homeopathy for managing labour.

  • Reflexology involves the gentle manipulation of areas of the foot. Stimulation of certain areas is said to help to relieve labour pain, but there haven’t been any clinical studies on this.

Benefits

  • Using these methods may help you to feel more relaxed and in control of your labour, which is likely to help it to progress more efficiently as well as helping you to cope with your contractions.

  • Apart from the need to be careful about aromatherapy, there are no known risks to you or your baby.

Possible downsides

  • In most cases you will need training or guidance from a qualified practitioner, who can explain how to use the techniques during labour. You may also need to buy some materials.

  • If you want to have a therapist with you in hospital, it’s wise to check that the hospital is happy with this.

Water

  • Immersion in water, ideally in a large and deep custom-made Birth Pool.

  • Birth Pools are increasingly available in hospital maternity units. Birth centres will usually have them in all rooms, and if you are planning a homebirth you can hire, borrow or buy your own.

  • An ordinary bath or a shower can also be effective.

Benefits

  • Being in water has been shown to significantly reduce women’s need for epidural analgesia and make their labours a little shorter.7

  • Most women find being in water very relaxing

  • Many women find that getting into the pool significantly reduces their pain levels but if a woman finds that it’s not right for her, she can just get out.

  • In a birth pool, you can readily move between positions that maximise your comfort and the efficiency of your labour.

  • There are no known side-effects for you or your baby 7, provided the water is not too hot and you bring your baby to the surface straight after birth.

Possible downsides

  • Birth Pools are not always available in hospitals although they are becoming more common, and some hospitals are now providing inflatable pools to make them available to more women when the fixed pools (if they have them) are in use.

  • Hospitals sometimes have strict guidelines on the use of birth-pools and may try to restrict use by women who are classed as “high risk” for any reason. These guidelines have little if any evidence to support them, and it may still be possible for the mother to negotiate to use a birth pool. Many hospitals now have telemetry available which allows for continuous monitoring of the baby’s heart-rate whilst the mother is in the pool.

TENS (Transcutaneous Electronic Nerve Stimulation)

  • A TENS machine is a small, battery-powered device that delivers mild electric pulses through pads stuck onto your back. You control the timing and strength of the pulses with a hand-held device.

  • It’s believed to work by blocking pain signals from reaching the brain, but there is little clinical evidence to say whether TENS is effective1 although many women have reported that it has helped them. No research has been done for women using it at home in early labour.

  • They are often available in hospitals and birth centres but you may want to hire one so that you can use it from the early stages at home (which is often when women find it most useful).

Benefits

  • It can give you a sense of control, and may act as a distraction from your contractions.

  • Many mothers say it gave good pain relief.

  • There are no known side-effects for mother or baby.

  • If you don’t like it or find it unhelpful you can simply take it off.

Possible downsides

  • Some women say they found it ineffective, or only useful in early stages of labour.

  • You can’t use it in a birth pool, bath or shower.

  • If your baby’s heart rate is being monitored electronically, TENS might interfere with this, but it is not usually a problem.

Entonox (“Gas and Air”)

  • This is a half-and-half mixture of nitrous oxide (“laughing gas”) and oxygen that you can breathe through a mask or mouthpiece.

  • It is not a pain-killer as such, but alters your sense of the pain, making it easier to manage.

  • It’s available in hospital labour rooms and Birth Centres, and for a planned home-birth the midwife can bring it in a cylinder.

Benefits

  • There is good evidence that it provides very effective pain relief1.

  • The drug is very quick acting (within seconds of breathing it in) and also wears off very quickly. This means that if you decide you don’t like it you can simply stop breathing it.

  • There are few known risks to you or your baby (see below)

  • It provides extra oxygen, which may help your muscles to work effectively and help your baby’s well-being through labour.

Possible downsides

  • It makes some women feel drowsy or nauseous.

  • It can make a woman feel disorientated or detached from the birth experience if she has too much. However, the drug will clear from her body very quickly as soon as she stops using it.

  • If used for a long period of time, eg over 24 hours, which might happen in a long labour, it can deplete the body’s stores of vitamin B12, especially in women already prone to B12 problems.8

Injected Opiate drugs

  • Opiate drugs include Pethidine, Meptid and Diamorphine (medical grade heroin). they are usually given by injection into the muscle of the thigh.

  • They are not painkillers but mood-altering drugs that affects the sense of pain.

  • They usually start to take effect within 10-15 minutes of being given, and reach full strength in about an hour. The effect lasts for 2 – 4 hours but a repeat dose can be given.

Benefits

  • Some women find it very helpful.

  • The drugs can give a feeling of euphoria.

  • If labour is slow to get going they may help the mother to sleep, or at least to rest and save her energy for later. These drugs are not usually given outside of a hospital setting, but may be helpful when a mother is in hospital in the early stages of an induction.

  • By aiding relaxation, they may help labour to progress.

Possible downsides

  • There is evidence that injected opioids are less effective than epidural analgesia, and no clear evidence about how they compare with other methods.1

  • Many women find them of little or no use, and may actively dislike how it makes them feel, however once it has been given it will be some hours before it wears off.

  • Opiates can cause drowsiness, dizziness, disorientation and even amnesia, so that the mother does not remember giving birth. Because of these effects most hospitals do not want a mother to use a birth pool after having an opiate, and may ask her to remain lying down.

  • They may also cause nausea or vomiting, but a second drug can be given to reduce the risk of this.

  • These drugs cross the placenta and so can affect the baby. The impact of this depends on the timing of the dose in relation to the birth. If a baby is born before the drug has cleared from her or his bloodstream he or she may be slow to breathe or even need resuscitating (in which case an antidote is given). They may also be sleepy and unresponsive at first, and then fretful and unsettled for several days after the birth. The suckling reflex may be affected making it more difficult to establish breastfeeding.

  • Women who have had experiences of drug addiction should be aware of the specific risks to them of taking opiate drugs.

Patient Controlled Analgesia

  • A few hospitals offer “Patient Controlled Analgesia” (PCA) in which an opiate drug is given directly into the bloodstream by a small pump which the mother controls herself.9

  • This may be one of the opiate drugs listed above, or a different one called Remifentanil.

Benefits

  • The mother can decide when she wants another dose of the drug (with a control to make sure she doesn’t take too much.)

  • The drug takes effect more quickly than if it was injected into the muscles, and more quickly than an epidural.

  • Remifentanil is broken down by the body more quickly than other opiates, so is less likely to affect the baby.

Possible downsides

  • These are similar to the risks with injected opiates.

  • Remifentanil can affect the mother’s breathing.

  • PCA is not available in all hospitals.

Epidural Analgesia

  • This is a highly skilled procedure that must be carried out by an anaesthetist. It is therefore not available in a Birth Centre or at home, and even in hospital it may be necessary to wait some time for an anaesthetist to become available.

  • A fine needle is inserted into the space around the mother’s spinal cord and a tube is passed through this. The needle is taken out, and drugs are given through the tube to numb the pain nerves.

  • It takes about 10-15 minutes to set up and another 15 – 20 minutes to take effect.

  • Some medical conditions mean that a mother cannot have an epidural.

Benefits

  • There is evidence that epidurals provide more effective pain relief than injected opioid drugs do10, but there has been no research on how they compare with other methods of managing labour pain.

  • If the mother’s blood pressure is too high, an epidural can help to bring it down.

  • In the event of a ventouse, forceps or unplanned Caesarean birth the epidural can often be topped-up for this.

Possible downsides

  • In a small percentage of cases it is not effective, or works only in patches or on one side. If so, it may be possible for the anaesthetist to re-site it.

  • Having an epidural may make it harder for a mother to adopt upright positions or to move freely between positions, though it is usually possible for her at least to kneel over a pile of pillows, bean-bag or support bar on the bed. She may need to be prepared to ask for help to do this.

  • Depending on how the drugs affect her, a mother may find that she does not experience the “urge to push” which normally guides a woman to work with her body to birth her baby. This could mean that she needs to be coached to push, which can be upsetting for some women.

  • Epidural use has been shown to make the second stage of labour longer on average, and to increase the likelihood that forceps or ventouse are used to assist the birth9,10. It also increases the likelihood that the mother will have drugs to speed up her labour.

  • It can cause a sudden drop in the mother’s blood pressure, which may affect the baby’s well-being. Although epidurals have not been shown to increase the rate of Caesarean births overall, there seems to be an increase in Caesareans that are carried out due to concern over the baby’s well-being

  • It’s common to experience itching or a slight fever, and around 1% of mothers suffer a severe headache that can last for several days, weeks or even years and need special treatment which is not always successful. Other, more serious complications are possible but rare9

Patient controlled epidural analgesia

  • A patient-controlled epidural (PCEA, sometimes misleadingly called a “walking” or “mobile” epidural) is designed to provide some, but not complete, pain relief while leaving the mother with some ability to move around and adopt upright positions.

  • As with PCA, the mother can control the timing of top-up doses herself with a hand-held device.

  • The theory is that by enabling more mothers to be upright and to have some sensation of when to push, the need for ventouse or forceps to assist the birth will be reduced compared to a traditional epidural; however as yet there is no evidence to support this.

Benefits

  • Some women find it works very well, giving them good mobility and sufficient pain relief.

  • It can help a mother to feel more in control.

Possible downsides

  • Most of the risks associated with a traditional epidural will still apply. It is not yet known whether it has less impact on the length of labour, need for drugs to speed up the labour, forceps or ventouse than a traditional epidural.

  • As people react differently to drugs some mothers find they have good pain relief but limited or no mobility, and some will have good mobility but insufficient pain relief.

  • Often the effect of the drug builds up, so that if it’s used for a long time the mother becomes unable to stand.

  • It is not available in all hospitals.

Sterile Water Injection

This is a method of pain relief which is intended specifically to relieve the continuous low back-ache which some women experience during labour. This is different to the pain of labour contractions, which tends to come and go.

Very small amounts of sterile water are injected at four points just under the skin of the lower back. This is thought to block pain signals in a similar way to TENS.

The method has been widely used in Scandinavia for many years, and is gaining in popularity in the UK. Several small studies have reported a reduction in the amount of back pain experienced by mothers using this method, however the clinical evidence of benefit remains inconclusive.11

Benefits

  • Many midwives and mothers have said that this method can bring very rapid relief from low back pain in labour, which lasts for up to 2 hours.​12

  • The injections can be repeated as needed, and used alongside any other form of pain relief.

  • It is a drug-free method and there are no known risks for mother or baby.

Possible downsides

  • The initial injections produce an intense stinging sensation similar to a bee sting, but this usually wears off very quickly.

  • It does not affect the pain of labour contractions, so some other form of pain relief is likely to be needed in addition.

  • It is not available in all areas yet.

Author: Nadia Higson

Reviewed by: Emma Ashworth

Published date: March 2018

Review date: March 2020

References

  1. Cochrane Review “Pain management for women in labour – an overview”, 14th March 2012 http://www.cochrane.org/CD009234/PREG_pain-management-for-women-in-labour---an-overview

  2. Cochrane Review “Continuous support for women during childbirth”, 15th July 2013 http://www.cochrane.org/CD003766/PREG_continuous-support-for-women-during-childbirth

  3. Cochrane Review “Relaxation techniques for pain management in labour”, 7th December 2011 http://www.cochrane.org/CD009514/PREG_relaxation-techniques-for-pain-management-in-labour

  4. Cochrane Review “Massage, reflexology and other manual methods for pain management in labour”, 15th February 2012 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009290.pub2/abstract

  5. Cochrane Review “Acupuncture and acupressure for relieving pain in labour”, 6th July 2011 http://www.cochrane.org/CD009232/PREG_acupunture-or-acupressure-for-relieving-pain-in-labour

  6. British Journal of Obstetrics and Gynaecology 122 (9) p1226-1234 August 2015 “Self-hypnosis for intrapartum pain management in pregnant nulliparous women: a randomised controlled trial of clinical effectiveness” Downe S. et al https://www.ncbi.nlm.nih.gov/pubmed/25958769

  7. Cochrane Review “Immersion in Water in labour and birth” 15th April 2009, http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000111.pub3/abstract

  8. BOC website http://www.bochealthcare.co.uk/en/products-and-services/products-and-services-by-category/medical-gases/entonox/entonox.html

  9. Obstetric Anaesthetists Association “Pain Relief in Labour”, July 2013 http://www.labourpains.com/UI/Content/Content.aspx?ID=46

  10. Cochrane Review “Epidurals for pain relief in labour”, 7th December 2011 http://www.cochrane.org/CD000331/PREG_epidurals-for-pain-relief-in-labour

  11. Cochrane Review “Sterile water injections for the relief of pain in labour”, January 2012 http://www.cochrane.org/CD009107/PREG_sterile-water-injections-for-the-relief-of-pain-in-labour

  12. Online discussion Association of Radical Midwives April 2001 https://www.midwifery.org.uk/articles/sterile-water-injections-to-relieve-back-pain/

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