Many women wish to avoid intervention in labour, including the use of pharmacological methods of analgesia. The use of psychoprophylaxis (‘childbirth without fear’) dates from the 1950s, and since then a variety of relaxation techniques have been introduced. Relaxation techniques, self-hypnosis, acupuncture, aromatherapy, reflexology, water labour/birth and transcutaneous electrical nerve stimulation (TENS) are now widespread.
Problems and special considerations
Fear of the unknown is a major factor in the experience of pain. Provision of antenatal education about the process of labour and the common complications that occur is an essential first step in the provision of analgesia for labour. Translations of information leaflets and availability of interpreters must be considered, especially in units delivering a significant number of women for whom English is not their first language. It is desirable to have an independent interpreter rather than a family member whenever possible. Videos about pain relief in labour are readily available and provide information in a format that is familiar and accessible to the majority of the population. Attendance at parentcraft classes should be encouraged.
Relaxation techniques
These range from simple breathing exercises to formal yoga techniques. There is a vast range of literature in the lay press about such techniques. The association between tension, anxiety and pain is well recognised, and the use of relaxation techniques should be encouraged for all pregnant women.
Self-hypnosis
Practitioners of hypnosis differentiate between a hypnotic state and deep relaxation. Hypnosis has been successfully used not only for pain relief in labour but also to provide anaesthesia for caesarean section. Hypnosis is time-consuming, requires considerable antenatal preparation, and is not freely available to the majority of women. Not all women are susceptible to its effects. While current evidence suggests that women taught self-hypnosis have reduced requirements for pharmacological analgesia overall, there is no decrease in the use of epidurals nor an increase in the rate of normal vaginal delivery.
Acupuncture, aromatherapy and reflexology
Acupuncture has much evidence to support its use in certain areas of medicine, but properly conducted studies in obstetric practice are few. What evidence there is from the few studies published mostly concerns manual acupuncture and suggests there may be a beneficial effect on pain and analgesic requirements in labour, including a reduced need for epidural analgesia.
Practitioners of aromatherapy and reflexology are becoming more numerous, and include an increasing number of midwives. The use of such analgesic techniques is dependent on the availability of a practitioner. The available evidence does not suggest a reduction in pain or analgesic requirements with aromatherapy. The National Institute for Health and Care Excellence (NICE) recommends that these techniques should not be provided in labour, but their use should be supported if women wish to use them.
Water
For decades, mothers have been advised to have warm baths to help them relax in early labour, and use of the pool for labour analgesia is an extension of this advice. Women who have had a lot of back pain during pregnancy often find the birthing pool particularly helpful. Benefit is thought to derive from inhibition of pain transmission and support of the gravid uterus by the warm water. Enthusiasts for the pool claim reduced rates of virtually all forms of medical intervention in labour, whereas some obstetricians view the pool as an unnecessary additional hazard for the labouring mother. The evidence regarding the first stage of labour suggests a reduction in labour pain and analgesic requirements with no effect on outcome of labour or neonatal status, and NICE recommends that water immersion should be an available option for women in labour.
Continuous fetal monitoring using telemetry that is suitable for use in water is available in some units, but if not, the mother with an at-risk fetus should be advised against using the pool. Similarly, the use of the pool is inadvisable in mothers needing intravenous infusions or any form of continuous maternal monitoring. Mothers requesting pharmacological analgesia should be asked to leave the birthing pool, though Entonox is usually allowed. In an emergency situation the mother should be helped out of the pool; an evacuation net may be required, and staff should be trained in its use.
TENS
The mechanism of action of TENS is through interference with transmission of efferent pain signals by electrical stimulation, according to the gate theory of pain. Particular benefit for TENS is claimed for women in early labour, those with backache associated with a posterior position, and women with a prolonged latent phase of labour.
The advantages of TENS are the absence of any effect on the fetus and the lack of any significant side effects for the mother. Meta-analysis of randomised controlled trials of TENS in labour suggests only limited evidence of its efficacy, and TENS is not supported by NICE for women in established labour, but it remains popular with mothers and midwives.
Water blocks
This technique involves the injection of small volumes of sterile water (0.1 ml) subcutaneously, or more commonly intracutaneously, over four spots lateral to the lumbosacral spine. It is thought that the mechanism of action is similar to that of TENS. Although it can be intensely painful for up to 30 seconds after injection, meta-analysis suggests a reduction in pain scores lasting up to 2 hours. Water blocks are common in certain countries but rarely used in the UK, and are not recommended by NICE.
Doulas
It is recognised that the constant presence of a supportive and encouraging second person reduces the pain scores of women in labour and may result in a reduced intervention. Some cultures ban the father from the labour room and provide a female partner for the labouring woman. There has been a resurgence of interest in use of birth partners, or doulas, in both the USA and the UK. The constant presence of the midwife during labour is also thought to reduce demand for analgesia and other interventions.
Management options
Anaesthetists should be aware of the benefits and limitations of non-pharmacological analgesia and be able to advise mothers when use of these methods of pain relief is or is not appropriate. It is important that anaesthetists realise that maternal satisfaction with pain relief in labour is not necessarily related to the degree of analgesia obtained. Many women benefit from the sense of control they gain from employing non-pharmacological methods of analgesia.
Non-pharmacological methods of pain relief have the major advantage of minimal or absent fetal and maternal adverse effects, and as such their use by mothers in normal, uncomplicated labour should be encouraged. However, prolonged use of these methods of pain relief by mothers with pregnancy or labour complications may increase the risk of ultimate recourse to general anaesthesia for delivery. For this group of women a change from non-pharmacological to regional analgesia is advisable.
Key points
• There is evidence for efficacy of several non-pharmacological methods of analgesia, and many women request them.
• Those techniques for which evidence of efficacy is limited or lacking still have minimal, if any, adverse effects, and women should not be denied them if that is their wish.
• Antenatal education should include all methods of analgesia available in a particular unit.
Further reading
Bohren MA, Hofmeyr GJ, Sakala C, Fukuzawa RK, Cuthbert A. Continuous support for women during childbirth. Cochrane Database Syst Rev 2017; (7): CD003766.
Cluett ER, Burns E, Cuthbert A. Immersion in water during labour and birth. Cochrane Database Syst Rev 2018; (5): CD000111.
Dowswell T, Bedwell C, Lavender T, Neilson JP. Transcutaneous electrical nerve stimulation (TENS) for pain relief in labour. Cochrane Database Syst Rev 2009; (2): CD007214.
Madden K, Middleton P, Cyna AM, Matthewson M, Jones L. Hypnosis for pain management during labour and childbirth. Cochrane Database Syst Rev 2016; (5): CD009356.
National Institute for Health and Care Excellence. Intrapartum Care for Healthy Women and Babies.
Clinical Guideline 190. London: NICE, 2014 (updated 2017). www.nice.org.uk/guidance/cg190 (accessed December 2018).