US Midwives' Knowledge and Use of Sterile Water Injections for Labor Pain

Lena Märtensson, CNM, PhD; Maureen McSwiggin, CNM, MS; Judith S. Mercer, CNM, DNSc


J Midwifery Womens Health. 2008;53(2):115-122. 

In This Article


Questionnaires were returned by 132 (29%) of the 450 surveyed members. Demographic data are shown in Table 2 . The majority of respondents worked full time, and 95% were actively attending births. Participants had worked as midwives for an average of 14 years.

The midwives were presented with a list of common pain relief measures used during labor and were asked to estimate the percentage of clients with which they used each method. Table 3 shows the participants' estimated use of specific pain relief techniques and frequency of use. For instance, almost all of the midwives (98%) reported that they cared for women who needed no pain relief approximately 24% of the time. The most commonly used pharmacologic pain relief methods reported by the midwives were intramuscular or intravenous analgesia and traditional epidural analgesia. Thirty-four (32%) midwives reported that they used sterile water injections, and they estimated use of sterile water injections by 1.5% of women. Of the 15 midwives attending births at a birth center, eight (53%) reported using sterile water injections. Two out of the three midwives attending home births stated they incorporated sterile water injections into their practice. Of the midwives who were not using sterile water injections, 58 (80%) were interested in learning more about their use.

Among the 107 midwives actively attending births, 24 (22%) reported informing women about sterile water injections during prenatal care. The majority of the midwives (58%) estimated that none of the women they care for know about sterile water injections. However, 38% of the midwives estimated that up to one-fourth of women they care for know about sterile water injections, and five (4%) midwives estimated that more than one-fourth of their clients know about sterile water injections.

Table 4 shows the reasons why some respondents do not use sterile water injections. The midwives' most frequent response (81%) was that they had no experience or training using sterile water injections. A few midwives reported resistance in the practice setting to the idea of sterile water injections. One commented that the anesthesia department prohibited the use of sterile water injections on the intrapartum floor because their opinions were that there is no evidence about their effectiveness or safety. Some midwives stated that other non-pharmacologic techniques were working and that they did not need to try sterile water injections. Other explanations were as follows:


I have used them in the past... in [the] present setting there is no demand or expectation for "alternative" treatments.


The pain of administration is too great if it doesn't work.


Most of our current population wants epidurals.


Not comfortable... have never seen it... am afraid it would be seen as using a placebo.


Never even heard of this!

The second part of the questionnaire was completed only by those midwives using sterile water injections (n = 34) in clinical practice and included questions about frequency of use, indications, techniques for administration, and choices for methods to offer pain relief. Sixteen midwives answered that they perform sterile water injections intracutaneously, 12 reported using the subcutaneous technique, and six did not respond. The majority of the midwives use between 0.1 and 1.0 mL of sterile water for each injection. Twenty-seven of the midwives used four injections total, four used two injections, and three did not respond. The injections were given between the contractions by 25 midwives and during a contraction by nine midwives. Eleven midwives stated they administered the injections alone some of the time, while 23 administer the injections simultaneously with another person. A registered nurse was the most common assistant when administering bilateral sterile water injections simultaneously.

The midwives were asked what type of labor pain they treat with sterile water injections. Four choices were offered: back pain, abdominal pain, groin pain, and other pain. They could select more than one alternative. All but two midwives stated that they use sterile water injections for back pain; the two remaining midwives used sterile water injections for abdominal pain and other pain. When asked what other methods they used for back pain, 13 of the 34 midwives chose other treatments such as hydrotherapy, massage, and epidural. The midwives reported the quality of relief obtained when using sterile water injections for treating back pain ranged from very good pain relief (70%) to moderate pain relief (18%) to no pain relief (12%).


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