Labor Pain Management: Comprehensive Guide for the First Stage
Evidence-based approaches for nursing practice
Table of Contents
Illustration of pharmacological and non-pharmacological pain relief techniques during the first stage of labor
Introduction to Labor Pain
Labor pain is a complex physiological and psychological experience that varies greatly among women. Understanding its mechanisms, progression, and management options is essential for providing effective nursing care during childbirth. Labor pain management requires a thorough assessment and individualized approach that considers the woman’s preferences, medical history, and specific labor conditions.
Clinical Pearl
Labor pain differs from other types of pain as it is not associated with pathology but with a normal physiological process. The intensity of labor pain typically increases with cervical dilation and can be influenced by various factors including parity, fetal position, and the woman’s psychological state.
The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage.” During labor, pain serves as a signal for the progression of the birth process but can also cause significant distress and anxiety if not adequately managed.
Understanding the First Stage of Labor
The first stage of labor is the period from the onset of regular contractions until the cervix is fully dilated (10 cm). It consists of three phases:
| Phase | Cervical Dilation | Duration (Primipara) | Duration (Multipara) | Pain Characteristics |
|---|---|---|---|---|
| Latent Phase | 0-3 cm | 8-12 hours | 5-7 hours | Mild to moderate, irregular contractions |
| Active Phase | 4-7 cm | 3-5 hours | 2-3 hours | Moderate to strong, regular contractions |
| Transition Phase | 8-10 cm | 30 min-2 hours | 15-60 minutes | Intense, frequent contractions, peak pain intensity |
During the first stage of labor, pain primarily originates from:
- Uterine contractions causing ischemia of the myometrium
- Distention and stretching of the lower uterine segment
- Cervical dilation and effacement
- Pressure on adjacent structures
- Stretching of pelvic floor and perineal tissues
Pain signals travel through different neural pathways:
- T10-L1 nerve pathways: Pain from uterine contractions and cervical dilation
- S2-S4 nerve pathways: Pain from descent of the presenting part and pressure on pelvic structures
Understanding these pathways is crucial for selecting appropriate pain management strategies, as different interventions target different pain pathways.
Pain Assessment During Labor
Accurate pain assessment is the foundation for effective pain management. Nurses should conduct regular assessments using validated tools while considering the dynamic nature of labor pain.
Assessment Tools:
- Numeric Rating Scale (NRS): 0-10 scale, where 0 represents no pain and 10 represents the worst pain imaginable
- Visual Analog Scale (VAS): A 10 cm line where the woman marks her pain level
- Behavioral observation: Assessing facial expressions, vocalization, body movements, and breathing patterns
Beyond intensity, assess:
- Pain location and radiation
- Quality (sharp, dull, cramping, etc.)
- Timing in relation to contractions
- Factors that worsen or alleviate pain
- Emotional and psychological response to pain
Clinical Pearl
Observe for discrepancies between verbal and non-verbal pain cues. Cultural factors may influence how women express pain during labor. Some cultures encourage vocalization while others value stoicism. Assess within the individual’s cultural context.
Non-Pharmacological Pain Relief Methods
Non-pharmacological interventions are often preferred as first-line approaches as they have minimal side effects, promote a sense of control, and can be used alongside pharmacological methods if needed. These techniques fall into several categories:
1. Movement and Positioning
Encouraging mobility and positional changes helps optimize fetal descent, reduces pain perception, and increases maternal comfort.
| Technique | Benefits | Nursing Considerations |
|---|---|---|
| Upright positions (standing, walking, sitting) | Utilizes gravity, enhances fetal descent, increases pelvic diameter, improves uterine blood flow | Monitor maternal fatigue, ensure safety, provide support equipment |
| Hands and knees position | Reduces back pain, assists with fetal rotation, relieves pressure on spine | Provide cushioned surface, monitor for knee discomfort |
| Birthing ball | Promotes pelvic mobility, provides perineal support, encourages optimal positioning | Ensure proper size, maintain safety with stability assistance |
| Side-lying position | Reduces pressure on major blood vessels, promotes rest between contractions | Provide pillows for support, assist with position changes |
| Pelvic rocking | Relieves back pain, facilitates fetal rotation | Demonstrate technique, provide support during movements |
2. Hydrotherapy
Water immersion during labor provides pain relief through several mechanisms: buoyancy, hydrostatic pressure, and gate control theory activation.
- Shower therapy: Warm water directed at the back or abdomen can reduce pain perception during contractions
- Warm bath/tub immersion: Provides significant pain relief, reduces anxiety, and promotes relaxation
Clinical Pearl
Water temperature should be maintained between 36-37°C (97-99°F) to prevent maternal hyperthermia or hypothermia. Hydrotherapy is most effective when used during the active phase (4-7 cm dilation) and should be limited to 1-2 hours to prevent potential complications like prolonged labor.
3. Relaxation and Breathing Techniques
These techniques help manage pain by reducing anxiety, promoting relaxation, and providing distraction.
- Progressive muscle relaxation: Systematically tensing and relaxing muscle groups
- Guided imagery: Using mental visualization of peaceful scenes
- Focused breathing: Slow, deep breathing techniques during contractions
- Mindfulness: Maintaining awareness of the present moment without judgment
4. Tactile Therapies
Touch-based interventions stimulate large diameter nerve fibers, potentially inhibiting pain transmission per gate control theory.
- Massage: Effleurage, counter-pressure, and firm sacral pressure reduce pain and anxiety
- Acupressure: Pressure on specific points (SP6, LI4, BL32) may reduce pain intensity
- Heat and cold therapy: Warm compresses on the lower back/abdomen or cool cloths on the face/neck
5. Transcutaneous Electrical Nerve Stimulation (TENS)
TENS involves applying mild electrical impulses through electrodes placed on the skin, typically along the spine.
- Works through gate control theory and endorphin release
- Most effective when started early in labor
- Woman controls intensity via handheld device
- Contraindicated with electronic fetal monitoring or when using water immersion
Memory Aid: “COMFORT”
Change positions frequently
Offer hydrotherapy options
Massage key pressure points
Facilitate focused breathing
Optimize environment (dim lights, reduce noise)
Relaxation techniques practice
TENS application when appropriate
Pharmacological Pain Relief Methods
When non-pharmacological methods are insufficient or not preferred by the laboring woman, various pharmacological options are available. These methods offer more substantial pain relief but may have side effects and require closer monitoring.
1. Inhalation Analgesia (Nitrous Oxide)
A 50:50 mixture of nitrous oxide and oxygen (Entonox) provides mild to moderate pain relief during labor.
- Mechanism: Increases endorphin release and modifies pain perception
- Administration: Self-administered via mask or mouthpiece during contractions
- Onset: 30-60 seconds, with maximum effect at 45 seconds
- Duration: Effects dissipate within minutes after discontinuation
- Advantages: Rapid onset/offset, self-administration, minimal fetal effects, no interference with labor progression
- Side effects: Dizziness, nausea, light-headedness, drowsiness
Clinical Pearl
Instruct women to begin inhalation 30 seconds before a contraction begins (when possible) to achieve maximum effect during the peak of the contraction. The woman should discontinue use between contractions to minimize side effects.
2. Systemic Opioids
Parenteral opioids can provide moderate pain relief during labor, though their effectiveness varies significantly between individuals.
| Medication | Dose | Route | Onset | Duration | Key Considerations |
|---|---|---|---|---|---|
| Morphine | 2.5-5 mg | IV IM |
5 min 20-30 min |
2-4 hrs | High risk of neonatal respiratory depression |
| Fentanyl | 50-100 μg | IV | 2-3 min | 30-60 min | Short-acting, less nausea than morphine |
| Remifentanil | 0.25-1.0 μg/kg PCA | IV | 1 min | 3-4 min | Ultra-short acting, rapid clearance from fetal circulation |
| Pethidine (Meperidine) | 50-100 mg | IV IM |
5 min 30-40 min |
2-4 hrs | Active metabolite (normeperidine) can cause neonatal neurobehavioral effects |
Advantages: Readily available, easy administration, may provide anxiolysis in addition to analgesia
Disadvantages: Limited efficacy, maternal side effects (nausea, vomiting, drowsiness), potential neonatal respiratory depression
Clinical Pearl
Avoid administering systemic opioids if delivery is anticipated within 2-3 hours to minimize neonatal respiratory depression. Have naloxone readily available for reversal if needed. Consider remifentanil PCA when regional analgesia is contraindicated but close monitoring is essential due to respiratory depression risk.
3. Regional Analgesia
Regional analgesia techniques provide the most effective pain relief during labor, with epidural analgesia being the gold standard in many settings.
A. Epidural Analgesia
Involves injection of local anesthetic (with or without opioid) into the epidural space, blocking pain transmission.
- Medications: Typically bupivacaine or ropivacaine (0.0625-0.125%) with fentanyl (2-3 μg/ml) or sufentanil
- Technique: Catheter placement allows continuous infusion or intermittent boluses
- Onset: 10-20 minutes for significant pain relief
- Patient-controlled epidural analgesia (PCEA): Allows woman to self-administer additional doses within preset limits
Advantages:
- Most effective form of labor analgesia
- Can be maintained throughout labor and for cesarean delivery if needed
- Preserves maternal consciousness and cooperation
- Modern low-dose techniques preserve motor function and ambulation (walking epidural)
Disadvantages/Side effects:
- Maternal hypotension (requires IV preloading and monitoring)
- Potential for motor block
- Risk of post-dural puncture headache (1-2%)
- Pruritis (opioid-related)
- Urinary retention
- Fever (associated with prolonged use)
- Requires anesthesia specialist for administration
B. Combined Spinal-Epidural (CSE)
Combines the rapid onset of spinal analgesia with the flexibility of epidural technique.
- Small dose of opioid (with/without local anesthetic) injected into intrathecal space
- Epidural catheter placed for ongoing analgesia
- Provides rapid onset (3-5 minutes) with more reliable analgesia in early phase
- May allow greater mobility in early labor
Memory Aid: “BLOCK PAIN”
Bupivacaine/ropivacaine (local anesthetics used)
Low concentration preserves motor function
Opioid addition enhances analgesia
Catheter allows continued administration
Keep patient monitored for side effects
Position patient carefully (lateral or sitting)
Assess vital signs before and after
Inform about potential side effects
Nurse’s role: monitoring and support
4. Nursing Care During Pharmacological Pain Management
Effective nursing care is crucial when pharmacological methods are used for labor pain management:
- Obtain informed consent after explaining benefits, risks, and alternatives
- Monitor maternal vital signs, fetal heart rate, and contraction patterns
- Assess pain levels and effectiveness of interventions
- Position woman to maximize comfort and prevent complications
- Monitor for side effects and implement appropriate interventions
- Document administration, effectiveness, and adverse reactions
- Continue to offer complementary non-pharmacological techniques
Best Practices & Recent Updates
Best Practice #1: Early Labor Management
Recent research supports the use of delayed hospital admission for women in early labor. Women who remain at home during the latent phase (until 3-4 cm dilation) typically experience:
- Reduced anxiety and improved coping
- Decreased use of pharmacological pain interventions
- Lower rates of augmentation and cesarean delivery
Nursing implications: Provide clear guidance on home management techniques, establish telephone triage protocols, and create supportive environments for early labor assessment that allow women to return home when appropriate.
Best Practice #2: Intermittent Auscultation for Low-Risk Labors
For low-risk labors with non-pharmacological pain management, intermittent auscultation (IA) rather than continuous electronic fetal monitoring (EFM) supports physiologic birth while maintaining safety.
Recent guidelines recommend:
- First stage: Auscultation every 15-30 minutes
- Assessment for 60 seconds after a contraction
- Documentation of rate, rhythm, and accelerations/decelerations
This practice enables greater mobility and access to non-pharmacological pain management techniques while providing appropriate monitoring.
Best Practice #3: Programmed Intermittent Epidural Bolus (PIEB)
A shift from continuous epidural infusion to programmed intermittent epidural bolus (PIEB) technique is improving labor analgesia. This newer approach:
- Delivers automated, regular boluses rather than continuous infusion
- Provides more uniform spread of anesthetic in the epidural space
- Results in reduced total anesthetic dose
- Improves maternal satisfaction and mobility
- Decreases breakthrough pain episodes and motor blockade
Nursing implications: Understand the differences in monitoring requirements, explain the bolus sensations to patients, and recognize that motor function may be better preserved with this technique.
Memory Aids for Nursing Students
Pain Assessment: “LOCATES”
Location – Where is the pain? Lower back, abdomen, radiating?
Onset – When did it start? Related to contractions?
Character – Sharp, cramping, burning, pressure?
Aggravating/Alleviating factors – What makes it better or worse?
Timing – Duration, frequency, relation to contractions
Environment – How does the birthing environment affect pain?
Severity – Intensity on a scale (0-10)
Non-Pharmacological Methods: “MIRACLES”
Movement and positioning changes
Immersion in water (hydrotherapy)
Relaxation and breathing techniques
Acupressure and massage
CounterPressure for back pain
Labor support (doula, partner)
Environmental modifications
Sounds/music therapy
Epidural Side Effects: “HAVE BABY”
Hypotension
Allergic reactions (rare)
Voiding difficulties/urinary retention
Epidural failure or one-sided block
Backache (insertion site)
Advanced motor blockade
Barriers to pushing effectively
Yield to monitoring requirements
Monitoring After Opioid Administration: “RAMPS”
Respiratory rate and pattern
Alertness and level of consciousness
Maternal vital signs
Pain relief effectiveness
Side effects (nausea, pruritus, etc.)
References
- American College of Obstetricians and Gynecologists. (2019). ACOG Committee Opinion No. 766: Approaches to limit intervention during labor and birth. Obstetrics & Gynecology, 133(2), e164-e173.
- Bohren, M. A., Hofmeyr, G. J., Sakala, C., Fukuzawa, R. K., & Cuthbert, A. (2017). Continuous support for women during childbirth. Cochrane Database of Systematic Reviews, 7, CD003766.
- Jones, L., Othman, M., Dowswell, T., Alfirevic, Z., Gates, S., Newburn, M., Jordan, S., Lavender, T., & Neilson, J. P. (2012). Pain management for women in labour: an overview of systematic reviews. Cochrane Database of Systematic Reviews, 3, CD009234.
- Sng, B. L., Zeng, Y., de Souza, N. N., Leong, W. L., Oh, T. T., Siddiqui, F. J., Assam, P. N., Han, N. L., Chan, E. S., & Sia, A. T. (2018). Automated mandatory bolus versus basal infusion for maintenance of epidural analgesia in labour. Cochrane Database of Systematic Reviews, 5, CD011344.
- Smith, C. A., Levett, K. M., Collins, C. T., Armour, M., Dahlen, H. G., & Suganuma, M. (2018). Relaxation techniques for pain management in labour. Cochrane Database of Systematic Reviews, 3, CD009514.
- Anim-Somuah, M., Smyth, R. M., Cyna, A. M., & Cuthbert, A. (2018). Epidural versus non-epidural or no analgesia for pain management in labour. Cochrane Database of Systematic Reviews, 5, CD000331.
- World Health Organization. (2018). WHO recommendations: Intrapartum care for a positive childbirth experience. World Health Organization.
- Cluett, E. R., Burns, E., & Cuthbert, A. (2018). Immersion in water during labour and birth. Cochrane Database of Systematic Reviews, 5, CD000111.