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

Application of Heat and Cold

Superficial applications of heat and/or cold, in various forms, are popular with laboring women. They are easy to use, inexpensive, require no prior practice, and have minimal negative side effects when used properly. Although there are no RCTs on the use of heat or cold during labor, these modalities have been studied for their effects on pain induced under experimental conditions.[66]

Heat is typically applied to the woman's back, lower abdomen, groin and/or perineum. Heat sources include a hot water bottle, heated rice-filled sock, warm compress (wash clothes soaked in warm water and wrung out), electric heating pad, warm blanket, and warm bath or shower. In addition to being used for pain relief, heat is used to relieve chills or trembling, decrease joint stiffness, reduce muscle spasm, and increase connective tissue extensibility.

There are no researched temperature guidelines, so using common sense is of key importance. The use of heat is contraindicated if the woman has a fever or is prone to hemorrhage, and it should not be used in regions of impaired sensation (as with analgesia or anesthesia). Because trials have correlated an increase in maternal temperature with the duration of the epidural,[67] it seems advisable to refrain from covering women who have epidural analgesia with warm blankets and to keep the ambient room temperature cool.[68]

Cold or cryotherapy is usually applied on the woman's back, chest, and/or face during labor. Forms of cold include a bag or surgical glove filled with ice, frozen gel pack, camper's "ice," a hollow, plastic rolling pin or bottle filled with ice, a washcloth dipped in cold water, soda cans chilled in ice, and even a frozen bag of vegetables. "Instant" cold packs, often available in hospitals, usually are not cold enough to effectively relieve labor pain. Women who already feel cold usually need to feel warm before they can comfortably tolerate using a cold pack. Chilled soda cans and rolling pins filled with ice give the added benefit of mechanical pressure when rolled on the low back. Cold has the additional effects of relieving muscle spasm and reducing inflammation and edema.[66]

A recent controlled study using a before and after study design evaluated the pain relief experienced by 49 women after applying ice massage to an acupuncture point on the hands.[69] The Hoku point, also called Large Intestine 4 (LI4), is located in the web space between the index finger and thumb on the hand. A washcloth filled with ice was rubbed over the Hoku point on the palmar surface of the hand during contractions and discontinued between contractions. The ice massage was carried out on one hand for 20 minutes and then was repeated on the other hand. The results revealed a significant reduction in pain when measured on a visual analog scale after the ice massage was applied.

Precautions and contraindications for cold application include cryoglobulinemia (gelling of blood), cold urticaria/hypersensitivity (cold-induced blisters, hives, prolonged "goose bumps," itching), hypertension (because of vasoconstriction), Raynaud's phenomenon (blanching and paresthesias of the digits), or sickle cell anemia. Furthermore, cultural proscriptions and women's personal choice are factors to consider with the use of cold.

With both heat and cold, placing one or two layers of cloth between the woman's skin and the hot or cold pack is required to protect from the possibility of skin damage. In addition, it is imperative that the woman has intact sensation if heat or cold is to be applied. If a woman has an epidural/regional block, applying heat or cold to the anesthetized region is absolutely contraindicated because it could damage her skin. Because a woman may tolerate more extreme temperatures during labor than usual, partners or caregivers should test the temperature of the hot or cold pack first on themselves. If they can comfortably tolerate the hot or cold pack pressing on their forearm for several seconds, then it is safe to apply it to the mother with intact sensation.

In conclusion, except for one trial of ice massage, heat and cold have not been studied for their effectiveness in relieving labor pain. Efficacy has been established in reducing pain under other conditions, however, as well as reducing inflammation, edema, and muscle spasm. With appropriate safety precautions, heat and cold offer comfort and relief, and their use should be dictated by the desires and responses of the laboring woman.


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