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Effective Pain Relief Interventions During Labor

Brooklynn Kirkpatrick, Madison McGowan, Gianna Myers and Natalie Sisler

Department of Nursing, Youngstown State University

Nursing Research

Dr. Danielle Class

April 5, 2023
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Effective Pain Relief Interventions During Labor

Childbirth occurs when a pregnancy is complete and a baby is brought from inside its

mother’s womb to the world. It is how every living being enters this world. Whether a baby is

born through a cesarean section, or a vaginal delivery, a woman’s labor process is the same.

There are four technical stages of labor and women experience some sort of pain in all four

stages. Based on a survey of 163 healthcare providers employed on obstetric floors, 79 percent

believe that women will feel moderate to severe pain during labor (McCauley et al, 2017). This

is a valuable survey as it statistically demonstrates that those who deliver babies and work with

pregnant women everyday expect women to experience intense pain during labor. This proves

that some sort of pain intervention is necessary during the birthing process and that it must be

effective to not only ensure that women have a positive labor and delivery experience, but also a

more positive postpartum experience. This is why it is so important that healthcare providers can

offer effective pain relief to all expecting mothers and supply them with a variety of different

options.

Healthcare providers and laboring mothers must understand this experience to provide

proper pain relief throughout the labor process. As mentioned before, labor has four specific

stages and there are different pain relief interventions that can be utilized in each of these stages.

The beginning of labor is marked by the start of contractions and cervical dilation, and it

concludes with bonding between the mom and the baby. The first stage of labor is usually the

longest. It lasts from the onset of regular contractions and early cervical dilation until the cervix

is completely dilated at 10 centimeters. Some important parts of labor that occur during this

phase include the rupturing of the membranes and the movement of the baby down the birth

canal. This stage contains two sub-stages known as the latent phase and the active phase. The
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latent phase is longer and is characterized by less intense contractions, while the active phase

manifests high intensity contractions that are very close together. These closer and more intense

contractions indicate that it might be time for some pain relief interventions. The close

contractions of the active phase combined with the complete dilation of the cervix to 10

centimeters, conclude the first stage of labor (Hutchison et al., 2022).

The second, third and fourth stages of labor are often much quicker than the first.

Together they complete the birthing process. The second stage begins when the cervix is

completely dilated and finishes when the baby is born. The fetus moves through this phase using

the seven cardinal movements: engagement, descent, flexion, internal rotation, extension,

external rotation, expulsion. This part of the experience can last for different amounts of time for

different women and pain relief strategies are necessary. The third stage of labor lasts from the

delivery of the baby to the delivery of the placenta. The placenta is usually delivered within 30

minutes post birth. Once the placenta is completely delivered, the labor will progress toward the

final stage. This stage is all about bonding between the mom and the baby for the first two hours

after the placenta is delivered (Hutchison et al., 2022).

Overall, labor can be long and can most definitely be painful for mothers. That is why it

is important to prove that there are effective pain relief strategies available for them. In order to

find out exactly how effective certain non-pharmacological interventions can be, this review asks

the question: For women, during labor, how do non-pharmacological pain relief strategies such

as hydrotherapy, breathing techniques, massage therapy and use of the birthing ball compare to

the traditional pharmacological pain relieving methods such as the epidural?

There are two main categories of pain relief used during labor and delivery throughout

the world which include pharmacological and nonpharmacological strategies. Although this
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review focuses specifically on the non pharmacological interventions, it is still important to

acknowledge that there are also effective pharmacological interventions that can be used.

Pharmacological methods used for women during labor include opioid or epidural analgesics.

These are medications administered throughout different parts of the labor process for pain relief.

Medications that are administered during the labor process have specific uses during the

different stages of labor. Opioid analgesics such as Nubain and Stadol are used during active

labor to diminish the intense pain of contractions (Baczek et al., 2022). However, these

medications have restrictions as to when they can safely be administered. Opioids cannot be used

close to the transition phase of labor because of the risk of respiratory depression in the newborn

(Czech et al., 2018). Whereas another method like epidural analgesia can be used more freely

during the first stage of labor (Baczek et al., 2022).

Epidural analgesia can be used at almost any time during labor as long as an

anesthesiologist is available to place the catheter and the woman is in active labor. Czech et al.

(2018) explained how a blockade is formed by an epidural or spinal injection and found that this

is the standard of pain relief that women seek during labor. Epidural analgesia is injected by an

anesthesiologist directly into the epidural space located in the lower back. This injection provides

pain relief and is often described as numbing women from the abdomen and throughout the legs.

Since the catheter stays in the epidural space after the needle is removed this allows for a

continuous flow of medications for pain control until the birthing process is complete. A

statistical analysis performed by Baczek, et al. (2022) concluded that epidural analgesia is

performed more often in young women, primigravida pregnancies, and more advanced or

high-risk pregnancies.
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A study was performed that documented the labor experience, pain control methods, and

the effectiveness of those methods for 258 women. Epidural analgesia was used by 42 women

and was documented to significantly relieve pain during the first, second, and third stages of

labor. Although this method proved to significantly reduce pain during labor, it was not found to

be of the highest satisfaction out of all methods used (Czech et al, 2018).

As with all medications, there are side effects and risk factors that must be

acknowledged. There are side effects with opioid analgesics that include respiratory depression,

bradycardia, and hypotension in the mother, and if given too close to birth opioids will have this

same effect on the newborn (Baczek et al., 2022). The epidural also has its own set of risks.

Aside from the respiratory and other body system side effects, Baczek et al. (2022) provided a

study that shows that the risk for episiotomy increases by five times, the risk for perineal

laceration increases by two times, and there is an increased risk for operative delivery in women

who receive epidural analgesia.

Every woman has the right to choose her pain management strategy during her labor.

There is no correct way for women to handle pain during their labor, as pain is subjective, and

the labor process is different for everyone. All possible interventions should be spoken about

throughout the birthing process, along with the risks and benefits of each. Poorly managed labor

can lead to both maternal and fetal complications, a prolonged laboring process, and physical

injury to the mom or the baby (Czech et al, 2018). Although using a medicated approach is often

thought of when going through labor, a wide variety of effective strategies that do not use pain

relief medications are being performed in hospitals, including hydrotherapy, breathing

techniques, the use of a birthing ball, and incorporating massage therapy into the birthing

process.
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One of the most effective and practiced nonpharmacological methods used for laboring

mothers is hydrotherapy. The therapeutics of water therapy used as a method of healing dates

back to the Greek, Roman, and Egyptian era. One study assessed the effects on the labor process

and parenting behavior of hydrotherapy applied during the active phase of labor. This study was

conducted to compare the effect of hydrotherapy during the laboring process. As explained in the

article, many studies have proven that hydrotherapy lowers the vasopressin level, enhances

uterine perfusion, and leads to less painful contractions for women in labor (Tuncay et al., 2017).

This further supports hydrotherapy used as a laboring method and proves that using this

intervention reduces anxiety, shortens labor by accelerating cervical dilation, facilitates

adaptation to labor, and improves labor satisfaction. This study covered the use of hydrotherapy

in the first stage of labor, showing there was a decrease in the use of epidural, spinal, or

paracervical analgesia among laboring mothers. The importance behind this data is that the

mother and fetus forgo all risks of pharmacological interventions.

Another benefit of water therapy would be the lack of weight felt by the mother due to

decreased gravity in water. This not only allows for easier position changes but also takes the

pressure and weight from the back and abdominal area during the labor process (Odent, 2018).

Labor pains come in two forms, visceral and somatic pain, an example of the visceral form of

pain was shown in a study done by Odent’s hydrotherapy observation. He tested the connection

between the psychological aspect of immersing the body in water and the dilation of the cervix,

finding that the dilation time significantly progressed while using hydrotherapy. Another

significant discovery researchers have found was the link between the occurrence of perineal

lacerations and the use of water therapy. This literature review found that being immersed in

water decreased the occurrence of severe perineal lacerations and reduced the risk of a
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postpartum hemorrhage (Nutter et al., 2014). Being that it is so common for the perineum to tear,

it makes it critical to take all measures to avoid this maternal complication and the pain that

comes along with it.

Finally, a study was performed using the Visual Analog Pain Scale (VAS) to show how

effective hydrotherapy truly is during the active phase of labor. The VAS scale measures the

intensity of pain during labor out of ten. Those participants in the study who received the

hydrotherapy had an average VAS score of 5.03 ± 1.10 while the participants who did not had a

much higher average of 8.30 ± 0.52. This is a large difference and this study proved

hydrotherapy to be very effective (Tunkay & Kaplan, 2017).

The next pain relief intervention studied in this review is the use of breathing techniques.

Breathing techniques have been part of labor before any pharmacologic intervention was

discovered. This non-pharmacological method is a simple, non-invasive technique approach

proven to improve newborn outcomes and shorten labor duration. Multiple studies have observed

that non-pharmacological approaches such as breathing therapy have several positive effects on

the relief of pain and anxiety for laboring mothers (Balijon et al., 2020). One type of breathing

used is called “Lamaze Breathing". The science behind this type of breathing therapy is related

to the central nervous system in the body triggering the fight-or-flight response. Chao defines the

Lamaze breathing technique as focused breathing, mainly involving muscle relaxation, structured

breathing, and focus shifting. This helps laboring women distract themselves from negative

emotions and more on breathing movements, which contributes to these mothers staying calm

and increasing their confidence while giving birth (Chao et al., 2021).

Scientists have found that deep abdominal breathing stimulates the parasympathetic

nervous system and results in the release of endorphins. These endorphins will decrease the heart
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rate and increase the feeling of calm in the mother, while also counteracting the sympathetic

nervous system. This leads to a decrease in the release of stress hormones such as cortisol. A

study conducted on primigravida of 37 to 41 weeks of gestation with no history of chronic

disease or pregnancy-related disease, compared baseline results of pain from uterine contractions

and the release of maternal stress hormones in mothers who used breathing therapy and mothers

who did not. Furthermore, these stress hormones can slow the production of oxytocin in the

body, resulting in longer and more painful labor. Breathing therapy allows for the release of

natural oxytocin helping the mother to transition into motherhood with a positive experience

(Chew, 2020) . This simple therapy technique shows immense support for laboring mothers and

should be available to all laboring mothers through their birth experiences.

Another study using the VAS scoring system was done, but this time it was used to prove

the effectiveness of these breathing techniques. This study was found in the National Library of

medicine and it tested the effectiveness of breathing exercises relieving pain in the second stage

of labor. The VAS scores were as follows: The experimental group practicing the breathing

techniques had a VAS score average of 8.82 ± 0.63 while the group that did not practice these

exercises had an average score of 9.05 ± 0.7 (Yuksel et al., 2017). Although there was not a

massive difference between these scores, this study still proved that breathing exercises provide

some relief to laboring mothers and these techniques should definitely be taught to all women.

The next non-pharmacological pain relief method used during labor is the birthing ball.

The birthing ball is a round, rubber exercise ball used during the labor process to help ease the

pain from contractions. Throughout the process of labor, many nurses, midwives, and doctors

suggest the use of a birthing ball.“Birthing balls during labor have various benefits and uses from

opening the pelvic outlet, helping with the progression of labor without an epidural, and helping
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reduce the pain of contractions”(Grenvik et al., 2021). Sitting on a birthing ball and moving in

rhythm with contractions helps to decrease pain and helps to move the baby downward into the

pelvis by gravity.

If a mother is unable to receive an epidural or chooses to not receive any pain

medications, the birthing ball may offer some relief. She might also choose to use it alongside

her pharmacological intervention. Birthing balls can be used during any stage of labor, but are

often used during the first stage to ease contractions. Birthing balls can also help to reduce back

pain during labor. Spinal pressure can be reduced by equal weight distribution by using back and

stomach muscles to keep in the upright position.

One study analyzed the pain in women who chose to use the birthing ball versus women

who chose not to. In this study, seven different trials were analyzed that included 533 pregnant

women. The intervention group (the women who used birthing balls) consisted of 53.8% and the

control group (women who did not use birthing balls) consisted of 46.2%. The birthing ball was

used during the first stage of labor in this study. During the study, the women sat on the birthing

balls while doing pelvic rotation and rocking back and forth during contractions. Women who

use birthing balls experience significantly less labor pain. The study concluded that “the birthing

ball is an effective pain relief strategy during labor for women going through the birthing process

without an epidural” (Grenvik et al., 2021).

There is another study that proves this intervention effective and it was done by The

International Journal of Women's Health and Reproductive Sciences. They used the visual analog

scale (VAS) to analyze the pain relief benefit of the birthing ball. The VAS showed a decrease of

2.65 points in women who used the birthing ball during labor versus women who did not.
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Overall, various studies showed evidence that the use of birthing balls decreased pain during the

labor process (Shirazi et al.,2019).

The final non-pharmacological pain relief method used during labor that was evaluated in

this review is deep tissue massage. “Massage is systematic touch and manipulation of the soft

tissues of the body that is increasingly being used as therapy for stress relief and to improve

relaxation and pain during pregnancy and as an alternative to pharmacologic treatments during

labor” (Shetty et al., 2021). Massages performed during labor are mostly focused on the mother’s

shoulders, back, neck, and hips due to built-up tension and pressure in the mother’s body from

carrying a baby. Massage during labor is said to help reduce stress, anxiety and help with pain

during contractions. Massage can be used from the first stage of labor up until the birth of the

baby.

One study focused on the effects of massage during labor and how it affected the

mother’s birthing experience. “Massage promotes relaxation during labor, decreases the severity

of pain, relaxes muscles, helps divert the attention of the mother, and contributes to an overall

better birthing experience” (Gonek et al., 2020). The study analyzed pain during labor using the

visual analog scale which is a validated, subjective scale for chronic and intermittent pain. The

results showed a decrease in pain and an increase in satisfaction with the women who received

massage during labor. The visual analog scale showed a decrease of 1.6 points in the women who

received massage therapy. This research showed that massage therapy is effective in decreasing

anxiety and pain during labor and delivery.

There was a study found in the Journal of Nursing Research that used the same Visual

Analog Scale mentioned above. There was a group of laboring mom’s that received deep tissue

massage and a group that did not. The experimental group had an average pain score of 7.57 ±
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1.69 while the control group had a higher score of 9.29 ± 1.10. This study proved the pain relief

intervention of massage to be very effective once again (GÖNENÇ et al., 2020).

It is very important that physicians, nurses, and mothers all understand both the pain that

women experience during labor and the interventions available for pain relief. The entire labor

process is long and grueling for mothers and it is critical that they know that they have more than

one option for pain relief throughout. While there are effective pharmacological pain relief

strategies, there are also multiple non-pharmacological pain relief methods women can choose as

well. Further, women can also choose to use both methods at the same time. Using a

combination of the non-pharmacological pain relief strategies explained in this review alongside

medications can benefit the mother’s experience immensely. This literature review proves

hydrotherapy, breathing techniques, the use of the birthing ball, and massage therapy are all

effective pain relieving techniques during labor. As a result, they should most definitely be

presented to all laboring mothers to lessen their pain while bringing their babies into the world.
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