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Nonpharmacologic approaches to management of labor pain

Penny Simkin, PT
Michael C Klein, MD, CCFP, FAAP, FCFP, ABFP
Section Editor
Charles J Lockwood, MD, MHCM
Deputy Editor
Kristen Eckler, MD, FACOG


The 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 the physical sensation of labor pain, whereas nonpharmacologic approaches are largely directed at prevention of suffering. 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; fear of death of the mother or baby [1]. Although pain and suffering often occur together, one may suffer without pain or have pain without suffering.

Most women use nonpharmacologic approaches for managing labor pain, with or without pharmacologic approaches [2]. 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 prevent suffering by enhancing the psycho-emotional and spiritual components of care. In this approach, pain is perceived as a normal accompaniment of most labors. The woman is educated and assisted by her caregivers, childbirth educators, and support people to take an active role in decision-making and in using self-comforting techniques and nonpharmacologic methods to relieve pain. Her caregivers and support people also help her by providing reassurance, guidance, encouragement, and unconditional acceptance of her coping style. By taking an active role in decision-making and receiving appropriate support, women are more likely to be able to transcend their pain and experience a sense of mastery, control, and well-being, factors associated with their ability to cope with labor [1].

A systematic review of studies on women's expectations and experiences of pain and pain relief during labor and their involvement in the decision-making process found a gap between their expectations and their actual experiences [3]. They were inadequately prepared for the reality of labor pain and were unable to make informed choices about pain relief. In order to close this gap, women need information prenatally about the risks and benefits of both pharmacologic and nonpharmacologic methods of pain management, and opportunities to practice in nonpharmacologic pain relief methods.

This topic will explore the variety of nonpharmacologic methods of management of pain during labor and the evidence of their efficacy. Most birthing facilities offer at least some of these techniques; however, some procedures, such as acupuncture, usually require credentialing and may not be available in all birth settings. An overview of systematic reviews of pain management in labor concluded that there was some evidence of efficacy for water immersion, relaxation, acupuncture, and massage, but it was unclear whether the following techniques are effective: hypnosis, biofeedback, sterile water injection, aromatherapy, and transcutaneous electrical nerve stimulation (TENS) [4].

Pharmacologic methods of pain relief are reviewed separately. (See "Pharmacologic management of pain during labor and delivery".)


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Literature review current through: Sep 2016. | This topic last updated: Oct 29, 2015.
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  1. Lowe NK. The nature of labor pain. Am J Obstet Gynecol 2002; 186:S16.
  2. Kozhimannil KB, Johnson PJ, Attanasio LB, et al. Use of nonmedical methods of labor induction and pain management among U.S. women. Birth 2013; 40:227.
  3. Lally JE, Murtagh MJ, Macphail S, Thomson R. More in hope than expectation: a systematic review of women's expectations and experience of pain relief in labour. BMC Med 2008; 6:7.
  4. Jones L, Othman M, Dowswell T, et al. Pain management for women in labour: an overview of systematic reviews. Cochrane Database Syst Rev 2012; :CD009234.
  5. Smith CA, Collins CT, Cyna AM, Crowther CA. Complementary and alternative therapies for pain management in labour. Cochrane Database Syst Rev 2006; :CD003521.
  6. Chaillet N, Belaid L, Crochetière C, et al. Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Birth 2014; 41:122.
  7. Maimburg RD, Vaeth M, Dürr J, et al. Randomised trial of structured antenatal training sessions to improve the birth process. BJOG 2010; 117:921.
  8. Escott D, Slade P, Spiby H. Preparation for pain management during childbirth: the psychological aspects of coping strategy development in antenatal education. Clin Psychol Rev 2009; 29:617.
  9. Humenick S, Shrock P, Libresco M. Relaxation. In: Childbirth Education: Practice, Research and Theory, Nichols F, Humenick S (Eds), WB Saunders Co, Philadelphia 2000.
  10. Nichols F. Paced breathing techniques. In: Practice, Research and Theory, Nichols F, Humenick S (Eds), WB Saunders Co, Philadelphia 2000.
  11. Cashion K. Pain Management. In: Adaptive Learning for Maternal Child Nursing Care, 5th, Perry SE, Hockenberry MJ, Lowderrmilk DL, Wilson D. (Eds), Elsevier, Maryland Heights, MO 2014.
  12. Smith CA, Levett KM, Collins CT, Jones L. Massage, reflexology and other manual methods for pain management in labour. Cochrane Database Syst Rev 2012; :CD009290.
  13. Declercq ER, Sakala C, Corry MP, Applebaum S. Listening to Mothers III: Pregnancy and Birth, Childbirth Connection, New York 2013.
  14. Simkin P, Whalley J, Keppler A, et al. Pregnancy, Childbirth and the Newborn: The Complete Guide, 4th ed, Meadowbrook Press, Minnetonka, MN 2010.
  15. Hodnett ED, Downe S, Walsh D. Alternative versus conventional institutional settings for birth. Cochrane Database Syst Rev 2012; :CD000012.
  16. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev 2013; 7:CD003766.
  17. Englemann, G. Labor Among Primitive Peoples, Chambers & Co, St. Louis 1882. (Republished AMS, New York 1977).
  18. Michel SC, Rake A, Treiber K, et al. MR obstetric pelvimetry: effect of birthing position on pelvic bony dimensions. AJR Am J Roentgenol 2002; 179:1063.
  19. Lawrence A, Lewis L, Hofmeyr GJ, Styles C. Maternal positions and mobility during first stage labour. Cochrane Database Syst Rev 2013; :CD003934.
  20. Makvandi S, Latifnejad Roudsari R, Sadeghi R, Karimi L. Effect of birth ball on labor pain relief: A systematic review and meta-analysis. J Obstet Gynaecol Res 2015; 41:1679.
  21. Gupta JK, Hofmeyr GJ, Shehmar M. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev 2012; :CD002006.
  22. Kemp E, Kingswood CJ, Kibuka M, Thornton JG. Position in the second stage of labour for women with epidural anaesthesia. Cochrane Database Syst Rev 2013; :CD008070.
  23. Cluett ER, Burns E. Immersion in water in labour and birth. Cochrane Database Syst Rev 2009; :CD000111.
  24. Simkin PP, O'hara M. Nonpharmacologic relief of pain during labor: systematic reviews of five methods. Am J Obstet Gynecol 2002; 186:S131.
  25. Odent M. Can water immersion stop labor? J Nurse Midwifery 1997; 42:414.
  26. Benfield RD, Hortobágyi T, Tanner CJ, et al. The effects of hydrotherapy on anxiety, pain, neuroendocrine responses, and contraction dynamics during labor. Biol Res Nurs 2010; 12:28.
  27. Gilbert RE, Tookey PA. Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. BMJ 1999; 319:483.
  28. Bowden K, Kessler D, Pinette M, Wilson E. Underwater birth: missing the evidence or missing the point? Pediatrics 2003; 112:972.
  29. Pinette MG, Wax J, Wilson E. The risks of underwater birth. Am J Obstet Gynecol 2004; 190:1211.
  30. Byard RW, Zuccollo JM. Forensic issues in cases of water birth fatalities. Am J Forensic Med Pathol 2010; 31:258.
  31. Eckert K, Turnbull D, MacLennan A. Immersion in water in the first stage of labor: a randomized controlled trial. Birth 2001; 28:84.
  32. Franzin L, Cabodi D, Scolfaro C, Gioannini P. Microbiological investigations on a nosocomial case of Legionella pneumophila pneumonia associated with water birth and review of neonatal cases. Infez Med 2004; 12:69.
  33. Gilbert R. Water birth--a near-drowning experience. Pediatrics 2002; 110:409.
  34. Kassim Z, Sellars M, Greenough A. Underwater birth and neonatal respiratory distress. BMJ 2005; 330:1071.
  35. Nguyen S, Kuschel C, Teele R, Spooner C. Water birth--a near-drowning experience. Pediatrics 2002; 110:411.
  36. Wise J. Legionnaires' disease in UK baby triggers warning over some home birth pools. BMJ 2014; 348:g4118.
  37. Committee on Obstetric Practice, American Academy of Pediatrics. ACOG Committee Opinion no. 594: Immersion in water during labor and delivery. Obstet Gynecol 2014; 123:912.
  38. The American College of Nurse-Midwives (2014) Position Statement. Hydrotherapy During Labor and Birth. American College of Nurse-Midwives, Silver Spring MD.
  39. Labrecque M, Nouwen A, Bergeron M, Rancourt JF. A randomized controlled trial of nonpharmacologic approaches for relief of low back pain during labor. J Fam Pract 1999; 48:259.
  40. Mårtensson L, Wallin G. Labour pain treated with cutaneous injections of sterile water: a randomised controlled trial. Br J Obstet Gynaecol 1999; 106:633.
  41. Reynolds JL. Practice tips. Intracutaneous sterile water injections for low back pain during labour. Can Fam Physician 1998; 44:2391.
  42. Mårtensson L, Nyberg K, Wallin G. Subcutaneous versus intracutaneous injections of sterile water for labour analgesia: a comparison of perceived pain during administration. BJOG 2000; 107:1248.
  43. Bahasadri S, Ahmadi-Abhari S, Dehghani-Nik M, Habibi GR. Subcutaneous sterile water injection for labour pain: a randomised controlled trial. Aust N Z J Obstet Gynaecol 2006; 46:102.
  44. Wiruchpongsanon P. Relief of low back labor pain by using intracutaneous injections of sterile water: a randomized clinical trial. J Med Assoc Thai 2006; 89:571.
  45. Mårtensson L, Stener-Victorin E, Wallin G. Acupuncture versus subcutaneous injections of sterile water as treatment for labour pain. Acta Obstet Gynecol Scand 2008; 87:171.
  46. Hutton EK, Kasperink M, Rutten M, et al. Sterile water injection for labour pain: a systematic review and meta-analysis of randomised controlled trials. BJOG 2009; 116:1158.
  47. Mårtensson L, Wallin G. Sterile water injections as treatment for low-back pain during labour: a review. Aust N Z J Obstet Gynaecol 2008; 48:369.
  48. Derry S, Straube S, Moore RA, et al. Intracutaneous or subcutaneous sterile water injection compared with blinded controls for pain management in labour. Cochrane Database Syst Rev 2012; 1:CD009107.
  49. Osborne C. Pre-and Perinatal Massage Therapy: A Comprehensive Guide to Prenatal, Labor, and Postpartum Practice, Wolters Kluwer, Baltimore 2011.
  50. Stillerman E. Prenatal Massage: A Textbook of Pregnancy, Labor, and Postpartum Massage, Mosby Elsevier, Philadelphia 2008.
  51. Nesheim BI, Kinge R, Berg B, et al. Acupuncture during labor can reduce the use of meperidine: a controlled clinical study. Clin J Pain 2003; 19:187.
  52. Cho SH, Lee H, Ernst E. Acupuncture for pain relief in labour: a systematic review and meta-analysis. BJOG 2010; 117:907.
  53. Smith CA, Collins CT, Crowther CA, Levett KM. Acupuncture or acupressure for pain management in labour. Cochrane Database Syst Rev 2011; :CD009232.
  54. Mackenzie IZ, Xu J, Cusick C, et al. Acupuncture for pain relief during induced labour in nulliparae: a randomised controlled study. BJOG 2011; 118:440.
  55. Kaptchuk TJ, Stason WB, Davis RB, et al. Sham device v inert pill: randomised controlled trial of two placebo treatments. BMJ 2006; 332:391.
  56. Lee MK, Chang SB, Kang DH. Effects of SP6 acupressure on labor pain and length of delivery time in women during labor. J Altern Complement Med 2004; 10:959.
  57. Hjelmstedt A, Shenoy ST, Stener-Victorin E, et al. Acupressure to reduce labor pain: a randomized controlled trial. Acta Obstet Gynecol Scand 2010; 89:1453.
  58. Kashanian M, Shahali S. Effects of acupressure at the Sanyinjiao point (SP6) on the process of active phase of labor in nulliparas women. J Matern Fetal Neonatal Med 2009; :1.
  59. Cyna AM, McAuliffe GL, Andrew MI. Hypnosis for pain relief in labour and childbirth: a systematic review. Br J Anaesth 2004; 93:505.
  60. Ketterhagen D, VandeVusse L, Berner MA. Self-hypnosis: alternative anesthesia for childbirth. MCN Am J Matern Child Nurs 2002; 27:335.
  61. Madden K, Middleton P, Cyna AM, et al. Hypnosis for pain management during labour and childbirth. Cochrane Database Syst Rev 2012; 11:CD009356.
  62. Landolt AS, Milling LS. The efficacy of hypnosis as an intervention for labor and delivery pain: a comprehensive methodological review. Clin Psychol Rev 2011; 31:1022.
  63. Mongan M. HypnoBirthing: The Mongan Method: A Natural Approach to a Safe, Easier, More Comfortable Birthing, 3rd ed, Health Communications, Inc, Deerfield Park, FL 2005.
  64. Cyna AM, Crowther CA, Robinson JS, et al. Hypnosis antenatal training for childbirth: a randomised controlled trial. BJOG 2013; 120:1248.
  65. Kroger WS. Clinical and Experimental Hypnosis in Medicine, Dentistry, and Psychology, 2nd ed, Lippincott, Williams & Wilkins, Philadelphia 1963.
  66. Dowswell T, Bedwell C, Lavender T, Neilson JP. Transcutaneous electrical nerve stimulation (TENS) for pain relief in labour. Cochrane Database Syst Rev 2009; :CD007214.
  67. Thomas IL, Tyle V, Webster J, Neilson A. An evaluation of transcutaneous electrical nerve stimulation for pain relief in labour. Aust N Z J Obstet Gynaecol 1988; 28:182.
  68. Bundsen P, Peterson LE, Selstam U. Pain relief in labor by transcutaneous electrical nerve stimulation. A prospective matched study. Acta Obstet Gynecol Scand 1981; 60:459.
  69. East CE, Begg L, Henshall NE, et al. Local cooling for relieving pain from perineal trauma sustained during childbirth. Cochrane Database Syst Rev 2012; :CD006304.
  70. Browning CA. Using music during childbirth. Birth 2000; 27:272.
  71. Smith CA, Levett KM, Collins CT, Crowther CA. Relaxation techniques for pain management in labour. Cochrane Database Syst Rev 2011; :CD009514.
  72. Tiran D. Massage and aromatherapy. In: Complementary Therapies for Pregnancy and Childbirth, 2nd ed, Tiran D, Mack S (Eds), Balliere Tindall, New York 2000.
  73. Smith CA, Collins CT, Crowther CA. Aromatherapy for pain management in labour. Cochrane Database Syst Rev 2011; :CD009215.
  74. Barragán Loayza IM, Solà I, Juandó Prats C. Biofeedback for pain management during labour. Cochrane Database Syst Rev 2011; :CD006168.