Coping with pain without medicine

Labour hurts, and it is honest to say so. It is also a pain unlike most others: it comes in waves with rest between them, it has a purpose, and it ends. Some people use only the methods in this chapter; others add medicine later (see "Pain relief with medicine"). Either way these tools help at every stage, and none of them affects your baby.

Why labour hurts

Pain in the first stage comes mainly from the uterus contracting hard and from the cervix stretching open. It is often felt low in the belly, in the lower back and sometimes down the thighs. Later, as your baby moves down, the pressure and stretching of the vagina and perineum add a strong, deep, bearing-down feeling and, as the head is born, a burning sting.

Your body also has its own pain relief. As labour builds, it releases endorphins, natural chemicals that dull pain and can create a dreamy, faraway feeling. Oxytocin, the hormone that drives contractions, flows best when you feel safe, warm and unobserved. Adrenaline, the stress hormone, works against it: a frightened, cold or disturbed labouring person may find contractions slow down and hurt more. Much of what follows is about tipping that balance towards oxytocin and endorphins.

The fear-tension-pain cycle

Fear makes muscles tense. Tense muscles, including those around the cervix and pelvic floor, resist the work of the uterus, and that makes contractions hurt more. More pain brings more fear. Breaking this loop at any point helps: understanding what is happening (fear), softening your body (tension), and using comfort measures (pain). Simply knowing that a sensation is normal often makes it easier to bear.

Breathing and relaxation

There is no single correct way to breathe in labour. What helps is slow, steady breathing with a long out-breath, because a long exhale calms the nervous system.

At the start of a contraction, take a deep breath in through your nose and let it out slowly through your mouth, like a sigh.

Keep breathing slowly through the contraction, perhaps counting to four in and six out.

If it becomes intense, lighter and quicker breaths high in the chest can help, but return to slow breaths as it fades.

When it ends, take a full cleansing breath and let everything go. Between contractions, scan your body for tension: forehead, jaw, shoulders, hands. A loose jaw and open mouth often help the pelvic floor relax too. Practise this in late pregnancy so it is automatic on the day.

Moving and upright positions

Being upright and mobile in the first stage is linked to a shorter labour and less need for epidurals. Gravity helps your baby press on the cervix, and changing position gives your baby room to turn. Let your body guide you, and try changing position every 30 minutes or so if you feel stuck. Positions many people find helpful:

Standing and leaning forward on a counter, the bed or your partner, swaying your hips.

Slow dancing: arms around your partner's neck, swaying together. Kneeling on all fours or leaning over a pile of pillows or the raised head of the bed. This is especially good for back pain.

Sitting backwards on a chair, leaning on a pillow over its back. Lying on your side when you need rest, with a pillow between your knees.

Birth ball and peanut ball

A birth ball is a large exercise ball. Sitting on it keeps you upright, eases pressure, and lets you rock, circle or bounce your hips gently. You can also kneel and drape yourself over it. Choose a size that puts your hips slightly higher than your knees.

A peanut ball is shaped like a peanut and is placed between your knees while you lie on your side. It keeps your pelvis open when you are in bed, for example with an epidural, and some studies suggest it may shorten labour. Ask your team to help you switch sides every hour or so.

Water

Warm water is one of the most effective drug-free comforts. Immersion in a bath or birth pool during the first stage reduces the use of epidurals and does not seem to lengthen labour or harm babies.

A warm shower aimed at your lower back or belly can be wonderful, at home in early labour or at the hospital. Sitting on a ball or stool in the shower lets you stay longer.

A bath or birth pool supports your weight, so you can move and float more easily. Many people find it helps most once labour is well established, as getting in very early can sometimes slow things down. Keep the water at body temperature or slightly less, drink often, and get out if you feel faint or too hot.

Giving birth in the water itself is covered in "Special situations".

Heat and cold

A warm pack, heated wheat bag or hot water bottle wrapped in a towel on your lower back, lower belly or groin can ease aching. Wrap it well and check the temperature often: labouring skin can burn without your noticing, and it must never be used over numb skin after an epidural. A cool damp cloth on your face, neck or chest helps when you feel hot, sick or overwhelmed, and an ice pack in a cloth on your lower back suits some people better than heat.

Massage and counter-pressure

Touch releases oxytocin, distracts the nerves carrying pain signals, and makes you feel cared for. Some people want lots of it; others cannot bear to be touched once labour is strong. Both are normal, and the person labouring is always in charge.

A how-to for partners

Light stroking: slow, gentle strokes with fingertips down the back, arms or thighs, often best between contractions.

Shoulder and hand massage: firm, slow kneading of the shoulders, or pressing the palms with your thumbs.

Sacral pressure: find the flat, triangular bone at the base of the spine, just above the buttocks. Place the heel of your hand on it and lean your body weight in, steady and firm, during each contraction. This is often what helps most with back labour.

Double hip squeeze: with the labouring person leaning forward on all fours or over the bed, place your hands on the fleshy top of each buttock, fingers pointing inwards, and press firmly inwards and slightly upwards, as if squeezing the hips together. Hold through the contraction, then release.

Knee press: with them sitting upright, kneel in front, cup both knees and lean in towards their hips during a contraction.

Ask "harder, softer, higher, lower?" and follow the answers. Counter-pressure is tiring, so take turns if there is more than one support person. More on this in "The partner's guide to labour and birth".

Tens

A TENS machine is a small battery-powered device with sticky pads placed on your lower back. It sends mild electrical pulses that feel like tingling or buzzing, and you press a button to boost them during contractions. It may work by blocking pain signals and encouraging endorphins. Research has not shown clear benefits, but many people like it, particularly in early labour, and it is safe. Start it early, as it seems to help less when labour is already intense. It cannot be used in water and is removed if an epidural is placed.

Sterile water injections

For strong lower back pain, some units offer sterile water injections. A midwife or doctor injects tiny amounts of sterile water just under the skin at four points on your lower back. They sting sharply for about 20 to 30 seconds, and then, for many people, back pain eases a lot for up to an hour or two. They can be repeated, have no effect on your baby and do not stop you moving or using water. Not every hospital offers them, so ask.

Hypnobirthing and similar courses

Hypnobirthing and other courses teach deep relaxation, self-hypnosis, visualization, positive language ("surges" instead of "contractions") and breathing. People who take them often say they felt calmer and more in control. Research is mixed: some studies suggest less use of pain medicine and a more positive experience, while others find little difference in pain or the way the birth happens. What these courses do reliably is give you practice and a plan, which counters fear. If you take one, hold it lightly: needing medicine or help is not a failure of technique.

Continuous support

Of everything in this chapter, this has the strongest evidence. People who have one person with them continuously through labour, offering comfort, reassurance and practical help, are more likely to have a spontaneous vaginal birth, less likely to need pain medicine or a caesarean, tend to have slightly shorter labours, and are more likely to feel positive about the birth. Support from someone who is not part of the hospital staff, such as a doula or an experienced friend or relative, seems to help most.

A doula is a trained birth companion who does not give medical care but stays with you, suggests positions and comfort measures, and supports your partner too. A partner and a doula work well together. If a doula is not an option, a calm, prepared partner, friend or relative who stays with you makes a real difference.

Sound and vocalizing

Many people moan, groan, hum or sing through contractions. Low, open sounds ("ohhh", "ahhh") help relax the jaw and pelvic floor and release tension; high-pitched, tight sounds tend to do the opposite, so try bringing your voice down. Nobody in a labour ward is shocked by noise. Others go silent and inward. Do whatever comes.

Music, darkness and privacy

Mammals labour best in a place that feels safe and private, and humans are no exception. Small changes help:

Dim the lights, close the curtains, or use battery candles or a string of lights.

Play a calm playlist, or something you love that lifts you, through a small speaker or headphones.

Ask for the door to be kept closed and for people to knock and speak quietly.

Keep the room warm, and cover the clock if watching it makes things harder.

Mental strategies

Labour is long; a contraction is about a minute. Take it one contraction at a time. When one ends, it is gone forever, and you never have to do it again. Some people count breaths, focus on one spot, repeat a phrase ("I can do this for one minute", "open"), or picture each contraction as a wave rising, peaking and falling away.

Rest between contractions, fully. The gaps are as important as the contractions. Eat light food and drink to thirst if your team agrees, and pee every hour or two.

Finally, you can use all of these and still want medicine, and that is a reasonable choice. Coping well does not mean feeling no pain; it means feeling able to carry on. If you no longer feel that, tell your team.

In short

Your body makes its own pain relief, which works best when you feel safe, warm and private.

Breathing with long out-breaths, relaxing your jaw and shoulders, and moving upright all help.

Warm water, heat, massage and counter-pressure are powerful, low-risk comforts; partners can learn sacral pressure and the double hip squeeze. TENS and sterile water injections are options for back pain, and courses like hypnobirthing can reduce fear.

Continuous support from a doula or companion has the strongest evidence of all.

Take labour one contraction at a time, and remember you can add medicine whenever you want.