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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
The pain that women experience during labour is affected by multiple physiological and psychosocial factors and its intensity can vary greatly. Most women in labour require pain relief. Most women do not require pain relief during early labour, but seek it once the active phase of first-stage labour begins.
Non-drug 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, particularly if support is provided from early in labour.
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.
- The National Institute for Health and Care Excellence (NICE) advises that it should NOT be offered to women in established labour.
- 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 Midwives (RCM) 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.
- Inhaled analgesia appears to be effective in reducing pain intensity and in giving pain relief in labour.
Parenteral opioids provide some relief from pain in labour but are associated with adverse effects - eg, maternal nausea, vomiting and drowsiness. Pethidine 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.
This is given as patient-controlled analgesia (PCA). A 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. Studies have shown that epidural analgesia is superior to remifentanil in terms of pain intensity score but that there is no difference in satisfaction with pain relief between both treatments.
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% of 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.
November 2017 - Dr Hayley Willacy recently read a paper looking at whether adopting a lying down or an upright position increased the rate of spontaneous vaginal birth in nulliparous mothers who had chosen to have a low-dose epidural. Among the 3,093 women from 41 UK hospital labour wards between October 2010 and January 2014 (1,556 in the upright group and 1,537 in the lying down group), there were fewer spontaneous births in women in the upright group (35.2%), compared with women in the lying down group (41.1%). This represents a 5.9% absolute increase in the chance of spontaneous vaginal birth in the lying down group. No disadvantages were apparent in relation to short- or longer-term outcomes for mother or baby.
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.
This is 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 and paracervical block are the most commonly performed local anaesthetic nerve blocks.
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 three lines.
- Test before the procedure.
Further reading and references
Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour; Royal College of Obstetricians and Gynaecologists (2007)
Jones L, Othman M, Dowswell T, et al; Pain management for women in labour: an overview of systematic reviews. Cochrane Database Syst Rev. 2012 Mar 143:CD009234. doi: 10.1002/14651858.CD009234.pub2.
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.
Intrapartum care: care of healthy women and their babies during childbirth; NICE Clinical Guideline (Dec 2014)
Smith CA, Collins CT, Crowther CA, et al; Acupuncture or acupressure for pain management in labour. Cochrane Database Syst Rev. 2011 Jul 6(7):CD009232. doi: 10.1002/14651858.CD009232.
Smith CA, Levett KM, Collins CT, et al; Relaxation techniques for pain management in labour. Cochrane Database Syst Rev. 2011 Dec 7(12):CD009514. doi: 10.1002/14651858.CD009514.
Smith CA, Levett KM, Collins CT, et al; Massage, reflexology and other manual methods for pain management in labour. Cochrane Database Syst Rev. 2012 Feb 152:CD009290. doi: 10.1002/14651858.CD009290.pub2.
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.
Smith CA, Collins CT, Crowther CA; Aromatherapy for pain management in labour. Cochrane Database Syst Rev. 2011 Jul 6(7):CD009215. doi: 10.1002/14651858.CD009215.
Evidence based Guidelines for Midwifery-Led Care in Labour: Immersion in Water for Labour and Birth; Royal College of Midwives (2012 - being updated)
Cluett ER, Burns E; Immersion in water in labour and birth. Cochrane Database Syst Rev. 2009 Apr 15(2):CD000111.
Klomp T, van Poppel M, Jones L, et al; Inhaled analgesia for pain management in labour. Cochrane Database Syst Rev. 2012 Sep 129:CD009351. doi: 10.1002/14651858.CD009351.pub2.
Ullman R, Smith LA, Burns E, et al; Parenteral opioids for maternal pain relief in labour. Cochrane Database Syst Rev. 2010 Sep 8(9):CD007396. doi: 10.1002/14651858.CD007396.pub2.
Evron S, Glezerman M, Sadan O, et al; Remifentanil: a novel systemic analgesic for labor pain. Anesth Analg. 2005 Jan100(1):233-8.
Freeman LM, Bloemenkamp KW, Franssen MT, et al; Remifentanil patient controlled analgesia versus epidural analgesia in labour. A multicentre randomized controlled trial. BMC Pregnancy Childbirth. 2012 Jul 212:63. doi: 10.1186/1471-2393-12-63.
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 Feb82(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 Dec97(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 Dec44(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 Mar21(2):94-7.
Novikova N, Cluver C; Local anaesthetic nerve block for pain management in labour. Cochrane Database Syst Rev. 2012 Apr 184:CD009200. doi: 10.1002/14651858.CD009200.pub2.