17.2: Nonpharmacological Pain Management
By the end of this section, you will be able to:
- Explain various measures implemented in the physical environment during labor and birth to aid in relaxation
- Describe comfort measures used to decrease the pain during the process of labor and birth
- Explain various movement and position changes used during the process of labor and birth
- Implement controlled breathing as needed for the person during labor and birth
- Explain complementary and alternative pain relief measures used during the process of labor and birth
Nonpharmacologic pain management includes multiple options. Creating a relaxing, welcoming environment addresses the psychologic aspect of pain, allows the laboring person to feel safe in the labor space, and decreases their anxiety . Anxiety stimulates the sympathetic nervous system to release stress hormones, namely, cortisol . The resulting “ fight-or-flight ” response causes longer labor and increases the perception of pain. Comfort measures focus on the physical aspects of labor pain. Movement allows the laboring person to position themselves in ways that feel better and encourages progression of labor. Controlled breathing focuses on the psychologic and physical aspects of labor, lowering anxiety, promoting relaxation, and decreasing pain. Other nonpharmacologic methods for pain management during labor include hydrotherapy , hypnosis , acupuncture , biofeedback , use of doula s, and childbirth education. Nursing interventions will include assisting and supporting the laboring person and partner. The nurse can use labor balls and pillows for positioning. Nursing interventions include offering massage , demonstrating breathing techniques, and assisting the person to walk and move into different positions. Being supportive of the person’s plan for their birth is a major role of the nurse. The nurse also involves the partner by demonstrating techniques the partner can use to help the person. (These topics are discussed in Chapter 14 Childbirth Education Options and Chapter 18 Nursing Care and Interventions During Labor and Birth.)
Physical Environment
The physical environment for labor sets the mood for the laboring person. The environment can benefit or inhibit labor. When the laboring person has a feeling of safety, comfort, and control, labor progresses with less pain. Bright lights, excessive noise, fear, or feeling out of control can inhibit labor progression and cause more pain. A quiet, relaxing environment allows the person to focus on their body and what they are feeling. Many laboring persons enjoy aromatherapy, music, and low lighting. Guided imagery and the use of focal points allow the person to focus on other things outside of labor and pain (Kaplan & Cevik, 2021). The nurse should inquire about the person’s wishes for how the labor room should look and feel and strive to make it so. The nurse can communicate these wishes to the health-care provider and other nursing staff to ensure a calm environment.
Pregnancy and Postpartum TV produced this video, which provides numerous tips and techniques for a successful unmedicated labor.
Aromatherapy
The use of essential oils to aid in relaxation is called aromatherapy . It can be used through inhalation, massage, bath, and acupressure points. Tabatabaeichehr and Mortazavi’s (2020) meta-analysis found the most commonly used essential oil in labor was lavender. Studies showed that lavender reduced labor pain and anxiety 30 to 60 minutes after inhalation and reduced pain better than biofeedback or breathing techniques. Aromatherapy massage was more effective than massage only. Tabatabaeichehr and Mortazavi also found that geranium, orange, frankincense, and chamomile were effective in reducing anxiety and pain in labor. No studies in the meta-analysis revealed any negative side effects of aromatherapy. The nurse can assist the laboring person by offering to massage their back or other areas of pain with an aromatic massage oil or lotion of the patient’s choice.
Imagery
Pain control that uses the mind-body connection to focus the laboring person’s awareness on a positive image using all the senses is called imagery . The laboring person might imagine seeing a beautiful beach, smelling the ocean, feeling the sand and sun, and hearing the ocean waves. Guided imagery refocuses the mind away from pain and stress to a state of deep relaxation. Imagery also allows a sense of control over the situation. Research has shown that using imagery decreases pain by reducing the fear of birth and allowing a distraction from pain (Yavari et al., 2019). The nurse can help the laboring person by guiding them to stay focused during contractions. If the person has not practiced imagery, the nurse can explain how to use imagery, ask the person for their idea of a relaxing image, and talk them through the contraction.
Music
Music has been shown to affect the laboring person’s physiologic, psychologic, and socio-emotional state. Certain music can reduce stress, provide comfort and relaxation, and decrease pain (Surucu et al., 2018). Music can also reduce anxiety. Many laboring persons choose music that is inspiring, comforting, or religious. Music is a very effective and inexpensive technique to reduce pain in labor. The nurse supports the laboring person by asking if they have music they want to use, assisting them with changing the music, and keeping the environment calm.
Lighting
Lighting in the labor room is important to the laboring person. Lighting sets the mood. Bright exam lights can make persons feel that they are being scrutinized and lack control. Bright lights in the room can also prohibit rest. Dim lighting has been shown to stimulate the hypothalamus to produce endorphins that can act like natural painkillers similar to morphine (Maria et al., 2022). Dim lighting has also been shown to decrease active labor length (Maria et al., 2022).
Focal Points
Focal points are used during contractions. In using focal points , the laboring person centers attention on a picture or an object during the contraction to direct attention away from the contraction. The person will focus on the object and concentrate on breathing through the contraction. The nurse can support the laboring person by suggesting they use a picture on their phone, a baby outfit or blanket, or art on the wall as their focal point. The nurse explains that the person will focus on that point while breathing through the contraction. During the contraction, the nurse can help the person by gently reminding them to stay focused on the object.
Comfort Measures
Comfort measure s are designed to address the physical challenges of labor. Hydrotherapy and massage aid in relaxing the muscles. Fluids and cool cloths keep the laboring person hydrated and comfortable. Counter pressure is very successful in decreasing pain during contractions, and effleurage is soothing and relaxing.
Hydrotherapy
The process of the laboring person submerging in water for pain relief is called hydrotherapy . If a tub is not available, a shower can also be used for hydrotherapy. Hydrotherapy has been shown to decrease pain, encourage movement, lower anxiety, shorten labor, and improve labor satisfaction (Tuncay et al., 2019). Research has shown no negative side effects of hydrotherapy in the first stage of labor. Hydrotherapy allows the laboring person to float, decreasing the weight of the uterus and fetus on the pelvis. Hydrotherapy is different from waterbirth. Waterbirth is immersion in water during the second stage of labor and birth. The nurse prepares the warm water, assists the laboring person into the shower or tub, and ensures safety while the person is in the shower or tub. The nurse can also encourage the partner to help by being in the shower or tub or by pouring warm water over the person’s back or abdomen. The nurse can help position the person so that the shower is on the area that feels best. Intermittent monitoring or waterproof continuous monitoring can be used by the nurse. Immersion and waterbirth are contraindicated with maternal fever, vaginal bleeding, preterm gestation, or the presence of infectious diseases, and they are not available at every birthing place.
Fetal Monitoring of a Person in a Birthing Tub
Laboring persons who choose hydrotherapy are usually required to be low risk as determined by their health-care provider. Fetal monitoring occurs at the same intervals as intermittent auscultation. The waterproof Doppler or monitor is placed into the water over the abdomen closest to the fetal back. The nurse follows institutional policy on standard precautions to prevent communicable disease while monitoring the fetus. The fetal heart rate (FHR) is monitored before, during, and after the contraction. If the facility has waterproof remote monitors, the monitors can be used for continuous monitoring if the laboring person qualifies for continuous monitoring. If no waterproof Dopplers or monitors are available, the nurse will ask the person to stand and will perform intermittent monitoring. The laboring person should not need to get completely out of the tub for monitoring. (See Chapter 16 Electronic Fetal and Uterine Contraction Monitoring for more information on monitoring.)
Massage
Massage is defined as a physical manipulation of tissue. The manipulation can be provided in different ways, depending upon the preference of the laboring person. Massage can be soft or hard, moving or still, and skin-to-skin or with a massage tool. Labor massage has been shown to decrease anxiety , provide comfort, and release endorphins (Nikmah et al., 2022).
The back and sacrum are common areas of discomfort in labor. Several techniques have been proven to help relieve back and sacral pain. The nurse or support person can use a tennis ball to massage the low back and sacrum. Massaging with essential oils such as jasmine, clary sage, rose, and lavender aids in the effectiveness of the massage. Massage may be uncomfortable for laboring persons in some cultures or for those who have experienced sexual assault (Ingram et al., 2022). The feature box provides a link to demonstrate multiple types of massage for labor.
This video presents multiple massage techniques that can be used by the nurse, partner, or doula during labor.
Fluids
Fluids during labor are essential for the laboring person. In most labor and delivery units, an intravenous (IV) or saline lock is required; however, the IV solution does not quench thirst. The laboring person breathes in and out through the mouth often. This causes dry mouth and thirst. Offering the person frequent small sips of water or juice, ice chips, or ice pops quenches their thirst and provides calories.
Historically, eating and drinking in labor were thought to be dangerous due to the potential of aspirating food and drink. This idea was based on information from the 1940s, when general anesthesia was used in many births and prior to the use of anesthesiologists (Tillett & Hill, 2016). Epidural and spinal anesthesia are now the most common types of anesthesia, and with them, the risk of aspiration is very low. The research of Shea-Lewis et al. (2018) found that limiting laboring persons to ice chips and fasting can cause ketosis and hyponatremia for the person and fetus. They found no adverse effects of oral intake on the laboring person or fetus. Offering oral intake decreased stress and provided comfort to the laboring person. The nurse explains to the laboring person that the digestive system slows during labor because the body is focused on contractions and birth. This increases the potential for nausea and vomiting. Therefore, the nurse may provide small amounts of fluids to help prevent vomiting based on facility protocols.
Cool Cloth
Labor is very physical work. The laboring person can become hot and sweaty. The nurse can provide a cool cloth, which is soothing and allows the person to cool down. A cool cloth is also helpful with nausea. The nurse is aware that many persons become nauseated during labor and places a cool cloth to the person’s face and neck to decrease those feelings.
Counter Pressure
The act of giving sustained pressure to the back, hips, sacrum, or other joints is called counter pressure (Figure 17.2). A common type of counter pressure in labor is a “hip squeeze.” The nurse or support person places their palms on the hips and applies firm pressure in pushing the hips toward each another. This relieves pain and also opens the pelvis to allow descent of the fetus. Figure 17.3 demonstrates the hip squeeze.
Effleurage
Light stroking massage using the tips of the fingers in slow, long strokes is called effleurage . It relaxes the laboring person, closes the pain gate, and releases endorphins (Yosepha et al., 2019). Effleurage is normally used on the abdomen of the laboring person. The advantage of this massage is that the laboring person can do this without assistance. For those persons who are averse to other people’s touch during labor, effleurage is a good comfort technique. The nurse can demonstrate how to perform effleurage to the laboring person. The nurse explains the gate control pain theory and the release of endorphins as a result of effleurage. Figure 17.4 demonstrates effleurage.
Movement and Position
Maternal movement in labor assists the fetus into an optimal position for birth. Walking and rocking move the pelvis, aiding the fetus’s movement. Squatting and hands-and-knees positions can open the pelvis and relieve back pain. Side-lying positions are relaxing. The nurse can place pillows behind the person’s back, between their legs, and under the abdomen to support the side-lying position. Movement can also be used as a distraction for pain control. Changing positions in labor leads to an easier birth, a greater sense of control, and an increased incidence of vaginal birth (Karaman & Yildiz, 2022). Nurses encourage frequent position changes during first and second stage labor. The nurse can assist in placing the person in different positions. When the person is pushing, the nurse will help the person to move to their side, to squat, or to assume a hands-and-knees position. These positions are associated with fewer perineal lacerations.
Walking
Walking in labor allows the laboring person to get out of the bed, have freedom of movement, and loosen the muscles. In some labor and delivery units, a wireless monitor can be used while the person is walking if there are no contraindications. If the person does not have a risk factor, intermittent auscultation allows the laboring person to walk without monitors. Walking moves the pelvis, which also moves the fetus. These movements can encourage the fetal presenting part to descend into the pelvis in a more optimal position (Garbelli & Lira (2021).
Squatting
Squatting is a good position for opening the pelvis in labor. Squatting opens the pelvic outlet, providing more room for the fetal presenting part to descend and for birth to proceed. Squatting can be done while being supported by the partner, doula , or nurse. This position can be challenging if the pregnant person has not practiced getting into and holding the squat. The nurse will assist the person to a squatting position. The nurse can offer a squat stool or a squat bar attached to the bed to support the laboring or birthing person in the squat (Figure 17.5).
Rocking
Rocking in labor can be very soothing. Rocking is rhythmic and can be used as a distraction during a contraction. Many different tools can help the person rock, such as a rocking chair, ball, or toilet. The laboring person can also sit on a birthing ball and rock back and forth and side to side. The nurse can assist the laboring person to the toilet. If there are no contraindications, the person can sit forward or backward on the toilet, allowing for a rocking motion. The nurse can place the person in a side-lying position and help rock their hips. This relieves tension in the hips and aids in repositioning the fetus.
Hands and Knees
Being on the hands and knees is a very common position, especially for those persons with back labor. The laboring person can get on hands and knees and perform pelvic tilts , or cat-cow yoga positions. Pelvic tilts are the rocking of the pelvis by moving the back up, then sinking the back down. When pelvic tilts are performed in the hands-and-knees position, the tilts encourage a fetus in the occiput posterior position to assume the occiput anterior position, as the heaviest part of the fetus (buttocks and back) is drawn to the anterior side by gravity (Garbelli & Lira (2021). This position allows the nurse or support person to massage the back, apply counter pressure , and hold a hot or cold pack onto the back. Figure 17.6 demonstrates different positions for labor.
Positioning with Birthing and Peanut Balls
Birthing balls and peanut ball s are used to assist laboring persons to open the hips and mimic a squatting position. Birthing balls have been shown to decrease discomfort during the first stage of labor, aid in descent of the fetus through the pelvis, and decrease the length of labor in laboring persons who choose to labor and deliver without an epidural (Grenvik et al., 2023). According to the evidence of a meta-analysis of the literature, the same results have not consistently been shown when the laboring person elects to have an epidural placed for the discomfort of labor and delivery (Grenvik et al. 2023). Figure 17.7 shows placement of the peanut ball during labor in the side-lying position.
Controlled Breathing
Controlled breathing has been used for labor pain for generations. It is also used for relaxation and pain control in situations beyond labor pain. Many different styles of breathing have been introduced in varying types of childbirth education. Controlled breathing is considered a type of relaxation and distraction during contractions. If the laboring person has not learned breathing techniques through childbirth education, the nurse can teach the person and partner different techniques. The nurse can demonstrate the different types of controlled breathing . During a contraction, the nurse can breathe with the person to help them through it.
Cleansing Breath
A cleansing breath is a slow, deep inhalation through the nose and exhalation through the mouth. It can be used before a contraction for preparation and after a contraction for release of tension from the contraction. The nurse teaches the partner to watch for the cleansing breath to recognize the beginning and end of the contraction.
Deep Abdominal Breathing
Deep abdominal breathing, or belly breathing, is the process of inhaling and expanding the belly and exhaling and releasing the belly. The laboring person can put their hand on their belly to guide the breath to their belly. Visualizing the breath going in and out of the belly is helpful during the contraction. This type of breathing is often used in early labor.
High Chest Breathing
High chest breathing is the process of inhaling while expanding the chest and exhaling the air as the chest falls. The hands can be placed on the chest and abdomen. The focus is on expanding only the chest and allowing the abdomen to remain still. This type of breathing is often used in active labor.
Chanting
Chanting during labor is similar to chanting during yoga or prayer. Laboring persons can listen to music of others chanting or chant without music. Mostly vowel sounds are used to keep the throat open and relaxed. Many labor supporters feel that as the throat stays relaxed, the cervix will stay relaxed and open more easily.
Panting
Panting is the pattern of short and long breaths. It may sound like “hee-hee-hoo.” This type of breathing is used as labor is progressing and contractions become more intense. Panting is done in a rhythmic pattern from the beginning to the end of the contraction, typically followed by a deep cleansing breath (Leutenegger et al., 2022).
Pushing
Breathing while pushing can be performed in different ways. Some laboring people are taught to take a large inhale, hold their breath, and push while counting to ten. Others are taught to take a deep inhale and slowly exhale as they bear down to push. These are called open and closed glottis breathing. Research has found that both open glottis and closed glottis breathing are effective in pushing, and the laboring person should be allowed to choose which type of breathing is more comfortable (Barasinski et al., 2020). The nurse should understand both types of breathing and support the person in their choice of technique.
Complementary and Alternative Pain Relief Measures
Complementary and alternative pain relief measures are methods outside conventional medical measures. People seeking these measures are usually looking for an alternative to the traditional methods of pain relief or a method that works with their philosophy of natural childbirth. Examples of complementary and alternative pain relief measures are biofeedback, hypnosis, acupuncture , massage , aromatherapy , and others. The nurse can support and assist the laboring person in using nontraditional pain methods.
Biofeedback
The mind-body practice called biofeedback involves a sensor that monitors different pain reactions in the body while the person uses techniques to control those reactions. For example, during a contraction, the pulse increases, as seen on the pulse oximeter. The laboring person uses breathing techniques to control the pulse during the contraction. Biofeedback works because the person believes the mind has control over the body. The person using biofeedback in labor may have been taught this method in childbirth education and will have practiced to become proficient prior to labor. This technique has been used for many different disciplines such as psychology, sports, and business (Raju & Singh, 2013).
Hypnosis
Hypnosis for labor is a process used to cope with labor pain. Hypnosis works by inhibiting neuronal communication between the sensory cortex, amygdala, and limbic system, inhibiting pain sensations (Michal et al., 2018). Pregnant persons take classes to learn the method of hypnosis using breathing, relaxation, and visualization during contractions. As an adjunct to classes, persons are provided self-hypnosis sessions to listen to and practice during their pregnancy. Different sessions provide affirmations, visualizations, and instructions on getting into a hypnotic state. Laboring persons listen to the sessions while in labor. The person turns inward and should not be disturbed during the contraction. The nurse is aware that the environment should be quiet with dim lighting to promote the hypnotic state.
Acupressure
The practice of stimulating specific areas of the body to elicit a specific action is called acupressure . It increases the release of neurotransmitters such as serotonin and dopamine, causing an analgesic effect (Michal et al., 2018). Certain pressure points throughout the body are thought to aid in pain relief, while other areas are thought to increase labor contractions to expedite birth. The most common areas for acupressure in labor are in the hands, feet, and ears. The pressure points can be stimulated using fingers, massagers, tools, and electrical impulses. Research has shown that acupressure decreases labor pain and also provides increased comfort during the postpartum period (Solt Kirca & Kanza Gul, 2022). The nurse can help support the laboring person while they are stimulating pressure points. Acupressure is usually performed by a practitioner such as a traditional Chinese medicine specialist, chiropractor, or massage therapist. A nurse needs special training to become proficient in acupressure and to learn which points are safe and not safe during pregnancy and labor.
This video from Evidence-Based Birth discusses how acupressure and acupuncture can be used for labor.
Doulas
A trained support layperson who provides emotional, physical, and social support during pregnancy, labor, and postpartum is called a doula . Training and certification programs are available for persons desiring to become doulas. Their training involves a variety of nonpharmacologic techniques to assist the laboring person. Doulas are not trained to provide medical support. They accompany laboring persons to hospitals and birthing centers, or come to homes, to provide continuous support to the person and partner. Some labor and delivery units have volunteer doulas available for persons in need of support during labor. Patients may hire a doula and work with them throughout the pregnancy. Evidence has shown a decrease in labor interventions, increased breast-feeding rates, greater emotional well-being, and increased birth satisfaction with patients using doulas (McLeish & Redshaw, 2018). The nurse works in conjunction with the doula to support the laboring person. The nurse can also advocate for the person’s doula to remain in the room during labor and birth. Doulas and nurses work very well together to achieve the type of birth the person desires. Most laboring persons pay a fee for doula support, and some facilities are just beginning to hire doulas. Table 17.1 summarizes the nonpharmacologic comfort measure s for labor presented in this chapter.
| Nonpharmacologic Measure | Positive Effects | Required Tools |
|---|---|---|
| Supportive care/Doula |
|
Support person |
| Childbirth education |
|
Classes, in person or online |
| Breathing techniques |
|
|
| Hypnosis |
|
Classes and practice |
| Biofeedback |
|
Biofeedback monitor and practice |
| Hydrotherapy |
|
Pool, tub, whirlpool, shower |
| Aromatherapy |
|
Oils, diffuser |
| Massage |
|
Support person, tennis balls, massage oil, massage tools |
| Acupressure |
|
Support person |
Childbirth Preparation
Many childbirth education and preparation programs are available to the pregnant person. Different programs address different philosophies of birth. The pregnant person can choose which program is most aligned with their ideas for birth or combine techniques from different childbirth educational programs. Some programs are taught at the birthing facility, while others are held in community centers or private residences. Hospital-based programs discuss childbirth options, including those at the facility. Birthing center programs are usually held in the center and review options for birth as well as nonpharmacologic techniques for pain relief and relaxation. Other programs are aligned with an organization that provides education materials and philosophies for childbirth. Online classes can encompass all types of methods. (See Chapter 14 Childbirth Education Options for more information.)
Taking Action to Support the Laboring Person Using Nonpharmacologic Pain Relief Measures
Bea’s spouse Alex asks the nurse to assist him in decreasing the back discomfort Bea is experiencing with the contractions. Alex informs the nurse they have tried massaging her lower back and Bea has been in the shower using warm water on her back. Bea tells the nurse the pain is so intense she is considering asking for a pain medication, but she really desires an unmedicated labor and birth.
At this time, the nurse considers their next actions, which are performing an interval labor assessment for current contraction pattern and assessing FHR pattern, vital signs, and coping mechanisms. Next, the nurse considers whether a vaginal exam is appropriate. If it has been more than an hour since the previous exam and the contraction pattern is adequate, then a vaginal exam is appropriate.
Next, the nurse considers other nonpharmacologic pain relief measures to discuss with Bea, including tennis balls within a sock, alternating ice and heat to the lower back, counter pressure to the lower back, and pelvic rock to use gravity to change the fetus’s position.
Finally, the nurse considers whether administration of a narcotic is indicated. Since Bea is asking for nonpharmacologic measures at this time, the nurse would not pursue narcotics, but they might have a discussion to discover what Bea knows about analgesics during labor.