Update on Nonpharmacologic Approaches to Relieve Labor Pain and Prevent Suffering

Penny Simkin, PT; April Bolding, PT


J Midwifery Womens Health. 2004;49(6) 

In This Article

Abstract and Introduction


The control of labor pain and prevention of suffering are major concerns of clinicians and their clients. Nonpharmacologic approaches toward these goals are consistent with midwifery management and the choices of many women. We undertook a literature search of scientific articles cataloged in CINAHL, PUBMED, the Cochrane Library, and AMED databases relating to the effectiveness of 13 non-pharmacologic methods used to relieve pain and reduce suffering in labor. Suffering, which is different from pain, is not an outcome that is usually measured after childbirth. We assumed that suffering is unlikely if indicators of satisfaction were positive after childbirth. Adequate evidence of benefit in reducing pain exists for continuous labor support, baths, intradermal water blocks, and maternal movement and positioning. Acupuncture, massage, transcutaneous electrical nerve stimulation, and hypnosis are promising, but they require further study. The effectiveness of childbirth education, relaxation and breathing, heat and cold, acupressure, hypnosis, aromatherapy, music, and audioanalgesia are either inadequately studied or findings are too variable to draw conclusions on effectiveness. All the methods studied had evidence of widespread satisfaction among a majority of users.


The management of labor pain is one of the main goals of maternity care. The two models of care, often referred to as the medical model and the midwifery model, use fundamentally different means to achieve that end. In the former, the emphasis is largely on the elimination of the physical sensation of labor pain, whereas in the latter, emphasis is largely on the prevention of suffering. Suffering includes any of the following psychological elements: a perceived threat to the body and/or psyche; helplessness and loss of control; distress; insufficient resources for coping with the distressing situation; even fear of death of the mother or baby.[1] This description of suffering resembles the American Psychiatric Association's diagnostic criteria for trauma.[2]

Although pain and suffering often occur together, one may suffer without pain or have pain without suffering. Furthermore, one can have pain coexisting with satisfaction, enjoyment, and empowerment. Loneliness, ignorance, unkind or insensitive treatment during labor, along with unresolved past psychological or physical distress, increase the chance that the woman will suffer. The physical sensation of pain is magnified and frequently becomes suffering when it coexists with these negative psychological influences.[3]

The goal of eliminating labor pain is based on the assumption that pain inevitably equals suffering. Such a goal requires not only pain medications, but also other medications, interventions, complex technology, and highly skilled personnel to control the accompanying undesirable side effects. Furthermore, the birthing environment must be designed for quick accessibility to these safety features. This model places the burden of pain control solely on medical professionals, and the woman's role is one of passive compliance. It requires that the care providers take the lead and dictate such basic human actions as eating, drinking, using the toilet, even rolling over in bed. As effective as the epidural is in reducing pain, it has psychological ramifications. Because the key to pain relief is held by others, the woman becomes more dependent and powerless, not only in managing her pain but in all other aspects of labor and birth. Self-confidence in the woman's own resources and capabilities and a willingness to be an active participant in her care are not assets in this model. Ironically, the intention to eliminate pain may increase the likelihood of some elements of suffering (i.e., helplessness, and insufficient resources for coping with distressing aspects of the birth).

The nonpharmacologic approach to pain includes a wide variety of techniques to address not only the physical sensations of pain but also to prevent suffering by enhancing the psychoemotional and spiritual components of care. Pain is perceived as a side effect of a normal process, not a sign of damage, injury, or abnormality. Rather than making the pain disappear, the midwife and other caregivers assist the woman to cope with it, build her self-confidence, and maintain a sense of mastery and well-being. In fact, the element that best predicts a woman's experience of labor pain is her level of confidence in her ability to cope with labor.[1] Reassurance, guidance, encouragement, and unconditional acceptance of her coping style are used. The woman and her partner or support persons are guided and supported in using self-comforting techniques and non-pharmacologic methods to relieve pain and enhance labor progress. With this kind of care, women perceive that they coped successfully with the pain and stress of labor and state that they were "able to transcend their pain and experience a sense of strength and profound psychologic and spiritual comfort during labor."[1]

The ideal environment for this approach fosters a sense of comfort and privacy and reflects the expectation that the woman will remain active and use a variety of techniques. It contains comfort aids and places to walk, bathe, and rest. Satisfaction, fulfillment, and a sense of accomplishment are often high, and suffering avoided, even when pain is great.[1] In fact, these positive reactions to childbirth are associated more with how a woman believes she was treated by her caregivers, her involvement in decision making, and whether her expectations were met, than with the amount of pain she feels.[4,5]

In this article, we review the effectiveness of the most widely used nonpharmacologic techniques, not only in relieving labor pain, but also in preventing suffering -- feeling overwhelmed, helpless, out of control, or in danger. Because there are few published articles that have examined degree of suffering as an outcome of childbirth, this article is based on the assumption that women who express satisfaction with a particular technique and/or with their childbirth experience overall are unlikely to have suffered.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: