Most women do not require pain relief during early labour, but seek it once the active phase of first-stage labour begins.
Nondrug techniques can be learnt as part of antenatal care, including relaxation techniques. However, as pain increases with advancing labour, the woman should be aware that drugs are available and should not be made to feel that she has failed if she uses them.
Women who receive continuous support during labour are more likely to give birth unaided and are less likely to use analgesia. This is more effective when it is started early in labour, by women who are not part of the hospital staff. There is research to support the use of doulas, but equally effective is support from a trusted member of the family or a friend.
Transcutaneous electrical nerve stimulation
Transcutaneous electrical nerve stimulation (TENS) applies controlled mild electrical stimulation to the skin by means of electrodes. Stimulating peripheral nerve endings in this way seems to inhibit the transmission of painful impulses at the dorsal horn of the spinal column, and/or activate some of the descending pain-inhibitory systems above the spine. TENS may also stimulate the body to produce natural endorphins.
- Randomised controlled trials provide no compelling evidence for TENS having any analgesic effect during labour.
- However, papers show a high degree of patient satisfaction with this method. During TENS application, pain (p) scores are significantly lower (p <0.0001), but there is no statistically significant difference in incidence of epidural analgesia in TENS users.
The National Institute for Health and Clinical Excellence (NICE) advises that it should NOT be offered to women in established labour.
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- The trials of acupuncture showed a decreased need for pain relief.
- Women taught self-hypnosis had decreased requirements for pharmacological analgesia, including epidural analgesia, and were more satisfied with their pain management in labour compared with controls.
- No differences were seen for women receiving aromatherapy.
- Acupuncture and hypnosis may be beneficial for the management of pain during labour; however, the number of women studied has been small.
Few other complementary therapies have been subjected to proper scientific study.
Immersion in water during labour is claimed to increase maternal relaxation and reduce analgesic requirements. It is supported by the Royal College of Obstetricians and Gynaecologists for healthy women with uncomplicated pregnancies. Concerns have been raised, however, that there may be greater harm to women and/or their babies, eg a perceived risk associated with neonatal inhalation of water and maternal/neonatal infection.
- A Cochrane review found that water immersion during the first stage of labour reduces the use of analgesia and reported maternal pain, without adverse effects on labour duration, operative delivery or neonatal outcome.
Nitrous oxide and oxygen (Entonox®)
This is a 50:50 mixture inhaled during painful contractions during the first and second stages of labour. It is often used as a supplement to pethidine.
- The main advantages are that it is under the patient's control, it takes effect within seconds and wears off quickly with no side-effects.
- Half of women obtain satisfactory relief.
- It is generally considered safe, but there has been a case report of severe hypoxaemic episodes associated with its use in labour, in an otherwise healthy woman.
This is widely used. It is effective within 15 minutes and lasts for 2-3 hours. There has been wide debate over the efficacy of pethidine.
- One study found that systemic pethidine was more effective at relieving labour pain than placebo, but its analgesic effect was modest.
- A recent Swedish study showed that opioids did not relieve labour pain, but did reduce anxiety and discomfort.
- Other intramuscular opiates include diamorphine, meptazinol and pentazocine, however there is little evidence to show superiority of one over another.
This is given as patient-controlled analgesia (PCA). A recent double-blind, randomised, controlled clinical trial showed that an intermittent, incremental regime with repeated small-dose PCA boluses of remifentanil, provided effective and reliable analgesia during labour and delivery. There is the potential for adverse effects on the fetus who may be floppy at birth and with respiratory depression. This effect is temporary and responds to gentle stimulation.
Epidural analgesia is a central nerve block technique achieved by injection of a local anaesthetic close to the nerves that transmit pain. It is widely used as a form of pain relief in labour.
It is the most effective way of relieving pain in labour - providing complete relief in 95% of cases. It also has the benefit of avoiding need for greater analgesia/general anaesthetic if forceps, vacuum extraction or Caesarean section are required. It is not associated with increase in symptoms related to perineal trauma and pelvic floor muscle weakness.
- Dizziness or shivering may occur.
- It increases the length of the second stage.
- There is an increased rate of operative vaginal delivery. Many delivery units discontinue epidural to reduce operative delivery rate. However, there is insufficient evidence to support this practice. There is evidence that it increases the rate of inadequate pain relief in the second stage of labour.
- Transient hypotension occurs in 20% women.
- Increased numbers of non-reassuring fetal heart tracing on setting up and topping up the epidural - this may be linked to the previous point. This necessitates greater levels of monitoring of mother and child.
- Dural tap occurs in 1% women and this causes severe headache in 50%.
Epidurals are not available in the community and may steer the woman towards a more interventionalist environment than she wants.
This is a low-dose epidural that relieves pain, but allows women to walk about during labour. Staying mobile in the first stage of labour for women with epidural analgesia has not been shown to produce any benefit to delivery outcomes or satisfaction with analgesia, but there are no obvious harms either.
The combined spinal-epidural (CSE) technique has been introduced in an attempt to reduce the adverse effects noted with epidural.
- It has been shown to provide a faster onset of effective pain relief from the time of injection, and to increase the incidence of maternal satisfaction.
- However, CSE women experience more itch.
- There is no difference between CSE and epidural techniques in the incidence of forceps delivery, Caesarean section rates or admission of babies to the neonatal unit.
Used for women who have not had an epidural but require forceps or vacuum extraction delivery. It is also used for repair of episiotomy or perineal tear.
Pudendal nerve block
- This uses 10 ml of 0.5% lidocaine injected behind each ischial spine of the pelvis via the vagina.
- Use 10 ml for perineal infiltration.
Perineal nerve infiltration
- Inject, in a fan-like pattern, 20 ml of 0.5-1.0% lidocaine from the posterior fourchette at the midline in 3 lines.
- Test before the procedure.
Further reading & references
- Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour, Royal College of Obstetricians and Gynaecologists (2007)
- Choices for labour. A consultant midwife explains the choices available to women during labour, including pain relief, relaxation and birthing positions. Short video from NHS Choices. (July 2008)
- Carroll D, Tramer M, McQuay H, et al; Transcutaneous electrical nerve stimulation in labour pain: a systematic review. Br J Obstet Gynaecol. 1997 Feb;104(2):169-75.
- Dowswell T, Bedwell C, Lavender T, et al; Transcutaneous electrical nerve stimulation (TENS) for pain relief in labour. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD007214.
- van der Spank JT, Cambier DC, De Paepe HM, et al; Pain relief in labour by transcutaneous electrical nerve stimulation (TENS). Arch Gynecol Obstet. 2000 Nov;264(3):131-6.
- Intrapartum care, NICE Clinical Guideline (2007)
- Smith CA, Collins CT, Cyna AM, et al; Complementary and alternative therapies for pain management in labour. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD003521.
- Immersion in Water During Labour and Birth, Royal College of Midwives and Royal College of Obstetricians and Gynaecologists (2006)
- Cluett ER, Burns E; Immersion in water in labour and birth. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD000111.
- Lucas DN, Siemaszko O, Yentis SM; Maternal hypoxaemia associated with the use of Entonox in labour. Int J Obstet Anesth. 2000 Oct;9(4):270-2.
- Tsui MH, Ngan Kee WD, Ng FF, et al; A double blinded randomised placebo-controlled study of intramuscular pethidine for pain relief in the first stage of labour.; BJOG. 2004 Jul;111(7):648-55.
- Olofsson C, Ekblom A, Ekman-Ordeberg G, et al; Lack of analgesic effect of systemically administered morphine or pethidine on labour pain. Br J Obstet Gynaecol. 1996 Oct;103(10):968-72.
- Elbourne D, Wiseman RA; Types of intra-muscular opioids for maternal pain relief in labour. Cochrane Database Syst Rev. 2000;(2):CD001237.
- Evron S, Glezerman M, Sadan O, et al; Remifentanil: a novel systemic analgesic for labor pain. Anesth Analg. 2005 Jan;100(1):233-8.
- Sartore A, Pregazzi R, Bortoli P, et al; Effects of epidural analgesia during labor on pelvic floor function after vaginal delivery. Acta Obstet Gynecol Scand. 2003 Feb;82(2):143-6.
- Anim-Somuah M, Smyth R, Howell C; Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD000331.
- Torvaldsen S, Roberts CL, Bell JC, et al; Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD004457.
- Wilson MJ, Cooper G, MacArthur C, et al; Randomized controlled trial comparing traditional with two "mobile" epidural techniques: anesthetic and analgesic efficacy. Anesthesiology. 2002 Dec;97(6):1567-75.
- Roberts CL, Algert CS, Olive E; Impact of first-stage ambulation on mode of delivery among women with epidural analgesia. Aust N Z J Obstet Gynaecol. 2004 Dec;44(6):489-94.
- Hughes D, Simmons SW, Brown J, et al; Combined spinal-epidural versus epidural analgesia in labour. Cochrane Database Syst Rev. 2003;(4):CD003401.
- Aneiros F, Vazquez M, Valino C, et al; Does epidural versus combined spinal-epidural analgesia prolong labor and J Clin Anesth. 2009 Mar;21(2):94-7.
|Original Author: Dr Hayley Willacy||Current Version: Dr Hayley Willacy|
|Last Checked: 21/06/2010||Document ID: 507 Version: 3||© EMIS|
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