Pain in labour is significant, and the way it is discussed in antenatal preparation is sometimes less than honest. The idea that breathing through contractions will be sufficient, that the pain is manageable with the right mindset, does not reflect the range of what labour actually feels like – which spans from manageable to among the most intense pain reported in medical literature.
Planning for pain relief is not giving up or failing. It is sensible preparation. The plan may change when labour is actually under way, and knowing all the options – what each involves, how effective it is, and what the trade-offs are – means that whatever you choose, you have chosen it with understanding.
Healthbooq (healthbooq.com/apps/healthbooq-kids) covers birth preparation and labour.
How Labour Pain Works
Labour pain has two distinct phases. In the first stage, contractions dilate the cervix. This pain is carried by visceral nerve fibres and is felt as a deep, cramping, diffuse pain in the lower abdomen, back, and thighs. The pain is intermittent, building with each contraction and easing between.
In the second stage (pushing), as the baby descends through the pelvis and birth canal, somatic nerve fibres are activated, producing a more localised, sharp pain in the perineum and vagina. Some women describe a strong urge to push that momentarily overrides other sensations.
Each contraction typically lasts 45-90 seconds at peak labour. The pain between contractions is usually absent or minimal. This intermittent pattern is what makes non-pharmacological methods viable even in active labour.
Non-Pharmacological Methods
Breathing and relaxation techniques: structured breathing (such as that taught in hypnobirthing, or in NHS antenatal classes) activates the parasympathetic nervous system, reduces the cortisol and adrenaline response that heightens pain perception, and gives the labouring person a focus. They do not eliminate the pain, but for some women in early-to-active labour, they reduce it to tolerable levels.
Movement and positions: walking, rocking, and changing position during contractions shifts the baby's position and reduces pressure on particular points. An upright or forward-leaning position is generally more effective than lying on the back, which increases back pain and reduces the efficiency of contractions.
Water immersion: labouring in a pool or birthing pool reduces pain by mechanisms that include reduced gravitational pressure, warmth, and possibly endorphin release. A Cochrane review by Cluett et al. (2018) found that water immersion in first stage labour significantly reduced epidural use. Water birth (delivering in the pool) is available in many NHS midwife-led units and some obstetric units, but is only appropriate for low-risk, uncomplicated pregnancies.
TENS (transcutaneous electrical nerve stimulation): small electrical pulses delivered to the lower back via pads. TENS is thought to work by the gate control theory of pain – stimulating sensory nerve fibres that close the "gate" to pain signals. It is most useful in early labour and less so in active labour, and the evidence for effectiveness is modest. It causes no harm, requires no clinical settings, and can be started at home. TENS machines can be hired from many pharmacies.
Massage: counter-pressure to the lower back during contractions, provided by a birth partner, significantly reduces back pain in labour. This requires a willing and prepared birth partner.
Entonox (Gas and Air)
Entonox is a mixture of 50% nitrous oxide and 50% oxygen, inhaled through a mouthpiece during contractions. It takes around 20-30 seconds to take effect, so it needs to be started at the beginning of the contraction rather than when the pain peaks. It works by a mild anaesthetic and dissociative effect, changing the perception of pain rather than eliminating it. Many women describe it as making them feel lightheaded or slightly detached.
It is available in all UK birthing settings, including midwife-led units and at home births (via a portable canister). Side effects include dizziness, nausea, and a feeling of disorientation. It leaves the system within minutes of stopping use and has no effect on the baby. It is not sufficient for everyone in active labour.
Pethidine and Diamorphine
Pethidine (meperidine) is an opioid given by intramuscular injection. It reduces the perception of pain and can cause drowsiness and nausea. Side effects are significant: pethidine crosses the placenta and can cause respiratory depression in the newborn if given within 2-4 hours of delivery. Naloxone, the opioid reversal agent, is kept in all delivery suites for this reason. Pethidine also suppresses the newborn's early feeding instinct if given close to delivery.
Some units offer diamorphine (heroin) rather than pethidine; it has a slightly more favourable side effect profile but similar limitations. Meptazinol is an alternative used in some centres.
Remifentanil Patient-Controlled Analgesia
Remifentanil PCA is an intravenous opioid that the labouring person controls, pressing a button to deliver a small bolus at the start of each contraction. Remifentanil has an extremely short half-life (3-5 minutes), which means blood levels fall rapidly and the drug does not accumulate. Studies by Harrison et al. and others have shown it to be more effective than pethidine and with less neonatal respiratory depression, though its analgesic effectiveness is less than epidural. Because remifentanil can cause maternal apnoea at effective doses, it requires one-to-one midwifery care and continuous oxygen saturation monitoring. It is not available in all units.
Epidural Analgesia
An epidural is the most effective method of pain relief available in labour. Local anaesthetic and/or opioid is delivered into the epidural space in the lower back through a thin catheter placed by an anaesthetist. The catheter remains in place throughout labour, allowing top-up doses to be given.
A combined spinal-epidural (CSE) gives immediate analgesia via the spinal route and longer-term control via the epidural catheter. A low-dose mobile epidural allows more sensation and movement than traditional epidurals, though not all women can mobilise even with these.
The evidence on epidural effectiveness is unambiguous. Epidurals reduce pain scores by 80-90% in most women. The Cochrane review by Anim-Somuah et al. (most recent update 2018) found that epidural analgesia provides better pain relief than other pharmacological methods, but is associated with: longer first and second stages of labour; higher rates of instrumental delivery (forceps or ventouse); higher rates of maternal fever; oxytocin augmentation to maintain contractions; and temporary fetal heart rate abnormalities that usually resolve. Caesarean rates are not significantly increased by epidural analgesia.
Postdural puncture headache (PDPH) – caused by inadvertent puncture of the dura during insertion – occurs in approximately 1% of epidurals and can cause severe positional headache, usually treated with a blood patch procedure.
Epidurals are not available at all birth settings: they require an anaesthetist present and are not offered at home births or in most midwife-led units without transfer.
Key Takeaways
Labour pain is the most intense pain most people will experience, and managing it effectively is a legitimate and important part of birth care. Available options in the UK range from non-pharmacological techniques (breathing, movement, water immersion, TENS) to pharmacological options (Entonox, pethidine, remifentanil, epidural). Epidural analgesia is the most effective method for pain relief in labour, reducing pain scores by 80-90%, though it carries a small risk of side effects including longer labour, instrumental delivery, and postdural puncture headache. No single pain relief method is universally best: the choice depends on the individual's preferences, health, how labour is progressing, and what is available at the birth setting.
