NOTE: For guiding care, Childbirth Connection gives priority to systematic reviews. These rigorous summaries of best available evidence are the most trustworthy way to know the benefits and harms of specific practices.

There are many drug and drug-free ways to help you cope with labor pain. The benefits of some methods are better understood than others. Many women want to know about the effectiveness and downsides of specific methods of pain relief; researchers have given more attention to effectiveness and less to possible downsides.

In this section, we summarize labor pain relief options based on systematic reviews published since 2005. Some pain relief strategies (e.g., showers, warm packs, music, visualization) are not covered below because we did not find systematic reviews about their effects.

Despite the challenges of conducting research on labor pain relief and limitations within the best available research, the following conclusions seem clear:

• A woman’s labor pain relief options depend in large measure on where and with whom she chooses to give birth.
• Receiving continuous support during labor decreases the probability of using pain medication and increases the likelihood of satisfaction with the birth experience.Hodnett, E.D., Gates, S., Hofmeyr, G.J., & Sakala, C. (2013). Continuous support for women during childbirth. Cochrane Database of Systematic Reviews, 7, CD003766.
• Various non-drug techniques can offer pain relief and comfort in labor and have a low probability of causing adverse effects (see below). They can readily be discontinued if not helpful or not appreciated.
• The epidural/spinal family has become the most common approach to labor pain relief in the United States. It is the only pain relief method that can completely abolish pain, but it also has a high profile of adverse effects, both minor and major.Anim-Somuah, M., Smyth, R.M., & Jones, L. (2011). Epidural versus non-epidural or no analgesia in labour. Cochrane Database of Systematic Reviews, 7(12), CD000331.
• Although widely used in some U.S. settings and elsewhere, injected narcotics appear to have little effect on pain and considerable potential for adverse effects.Ullman, R., Smith, L.A., Burns, E., Mori, R., & Dowswell, T. (2010). Parenteral opioids for maternal pain relief in labour. Cochrane Database Systematic Review, 9, CD007396
• Nitrous oxide is making a comeback and is increasingly available in the United States. It can help women cope with labor pain.Klomp, T., van Poppel, M., Jones, L., Lazet, J., Di Nisio, M., & Lagro-Janssen, A.L.M. (2012). Inhaled analgesia for pain management in labour. Cochrane Database of Systematic Reviews, 9, CD009351; Likis, F.E., Andrews, J.C., Collins, M.R., Lewis, R.M., Seroogy, J.J., Starr, S.A., Walden, R.R., & McPheeters, M.L. (2014). Nitrous oxide for the management of labor pain: a systematic review. Anesthesia and Analgesia, 118(1), 153-167.

Below we summarize the best available research on methods for relieving labor pain.

Clearly helpful for labor pain relief: Evidence is robust

See tables that summarize labor pain relief options here.

Continuous labor support (doula support)

Continuous support includes emotional support, comfort measures, information and advocacy. It effectively reduces use of epidural and other pain medications and has no known side effects. Few women in the United States experience continuous support from a doula when giving birth. However, a systematic review found that women with continuous support were less likely to use epidural and any pain medications and experienced fewer cesareans, among other benefits. It found no negative effects of continuous support.Hodnett, E.D., Gates, S., Hofmeyr, G.J., & Sakala, C. (2013). Continuous support for women during childbirth. Cochrane Database of Systematic Reviews, 7, CD003766.

Immersion in water

Most women who give birth in U.S. hospitals are in bed throughout labor and birth. However, a systematic review found that immersion in water (e.g., tub or pool) during labor reduces the use of epidural and spinal pain relief. It found no evidence of negative effects on mom or baby from laboring in water.Cluett, E.R.& Burns, E. (2009). Immersion in water in labour and birth. Cochrane Database of Systematic Reviews, 2, CD000111.

Maternal positions and mobility

Most women who give birth in U.S. hospitals lie in bed throughout labor and birth. A systematic review found that women who were upright and walking in labor before the time of pushing were less likely to have an epidural and experienced fewer cesareans, among other benefits.Lawrence, A., Lewis, L., Hofmeyr, G.J., & Styles, C. (2013). Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews, 10, CD003934.

Nitrous oxide

Nitrous oxide provides pain relief, but is generally less effective than epidural pain relief. However, unlike epidural (see next), nitrous oxide has no known negative effects on labor and the baby. The main side effects of nitrous oxide are possible nausea, vomiting, dizziness or drowsiness in women. Also, unlike epidural pain relief, the woman herself controls nitrous oxide with a hand-held mask, gets instant pain relief effects and can immediately discontinue use.Klomp, T., van Poppel, M., Jones, L., Lazet, J., Di Nisio, M., & Lagro-Janssen, A.L.M. (2012). Inhaled analgesia for pain management in labour. Cochrane Database of Systematic Reviews, 9, CD009351; Likis, F.E., Andrews, J.C., Collins, M.R., Lewis, R.M., Seroogy, J.J., Starr, S.A., Walden, R.R., & McPheeters, M.L. (2014). Nitrous oxide for the management of labor pain: a systematic review. Anesthesia and Analgesia, 118(1), 153-167.

Epidural

Epidurals (and their variant, combined spinal-epidural; see next section) are widely understood to offer the most effective pain relief to laboring women. However, such relief comes with important trade-offs of many increased risks and a substantial impact on the experience of labor. Epidurals involve increased use of interventions to monitor, prevent or treat side effects, keeping women in bed and attached to equipment. Most studies have compared epidural with opioids (narcotics). A systematic reviewAnim-Somuah, M., Smyth, R.M., & Jones, L. (2011). Epidural versus non-epidural or no analgesia in labour. Cochrane Database of Systematic Reviews, 7(12), CD000331. found that epidurals cause increased:

• Use of “assisted” birth (vacuum extraction or forceps).
• Maternal low blood pressure (leading to use of additional drugs).
• Use of synthetic oxytocin to speed labor.
• Maternal retention of urine.
• Maternal fever (which can lead to invasive procedures in the newborn to rule out and treat suspected infection).
• Length of the pushing phase of labor.
• Cesarean section because the baby is having trouble handling labor.

The following are also routine or common with epidurals: continuous electronic fetal monitoring, intravenous lines, frequent blood pressure checks and medication for itching.

Combined spinal-epidural (CSE)

Both epidurals (see above) and combined spinal-epidural (CSE) are widely understood to offer the most effective pain relief to laboring women. A systematic reviewSimmons, S.W., Taghizadeh, N., Dennis, A.T., Hughes, D., & Cyna, A.M. (2012). Combined spinal-epidural versus epidural analgesia in labour. Cochrane Database of Systematic Reviews, 10, CD003401. found that the following effects were similar in both CSE and epidural:

• Maternal inability to move around and use the lower body (leading to use of bladder catheters).
• Maternal low blood pressure (leading to use of additional drugs).
• Maternal headache.

The systematic reviewSimmons, S.W., Taghizadeh, N., Dennis, A.T., Hughes, D., & Cyna, A.M. (2012). Combined spinal-epidural versus epidural analgesia in labour. Cochrane Database of Systematic Reviews, 10, CD003401. also found that combined spinal-epidural pain relief appears to have a few advantages in comparison with epidurals:

• Quicker-acting pain relief.
• Less use of added pain relief drugs.
• Less retention of urine.
• Less use of “assisted” birth (vacuum extraction or forceps).

Opioids (narcotics) by intravenous (IV) line

A systematic reviewUllman, R., Smith, L.A., Burns, E., Mori, R., & Dowswell, T. (2010). Parenteral opioids for maternal pain relief in labour. Cochrane Database Systematic Review, 9, CD007396 of opioid (narcotic) drugs by intravenous (IV) line for labor pain relief found that they provide some pain relief and – when reported – moderate satisfaction with pain relief. The following were notable downsides:

• The need to provide additional pain relief.
• Maternal nausea, vomiting and drowsiness.

The studies were generally of poor quality and were unable to clarify possible effects on the baby and breastfeeding.

Appears to be at least somewhat helpful for labor pain relief: Evidence is less robust

See tables that summarize labor pain relief options here.

Relaxation, yoga

A systematic review found that relaxation reduced pain intensity in both early and later, “active” labor leading to the time of pushing. Women taught methods of relaxation were more satisfied with labor and experienced less “assisted” birth (with forceps or vacuum) than women without such guidance. Yoga specifically was associated with less pain and greater satisfaction with pain relief, among other benefits compared to usual care.Smith, C.A., Levett, K.M., Collins, C.T., & Crowther, C.A. (2011). Relaxation techniques for pain management in labour. Cochrane Database of Systematic Reviews, 12, CD009514.

Acupuncture or acupressure

A systematic review included one to three studies each that found that acupuncture was associated with less intense pain, greater satisfaction with pain relief, less use of pain medications and less use of “assisted” birth (with vacuum extraction or forceps).Smith, C.A., Collins, C.T., Crowther, C.A., & Levett, K.M. (2011). Acupuncture or acupressure for pain management in labour. Cochrane Database of Systematic Reviews, 7, CD009232 A systematic review found less use of pain medications with acupuncture than without. It also found less pain intensity with electro-acupuncture compared with placebo electro-acupuncture for reduction in pain intensity for a short amount of time after treatment, but the effect did not last for one hour or more . There are no known adverse effects related to acupuncture treatment.Cho, S.H., Lee, H., & Ernst, E. (2010). Acupuncture for pain relief in labour: a systematic review and meta-analysis. BJOG, 117(8), 907-920.

A systematic review reported that limited research also found less pain intensity with acupressure.Smith, C.A., Collins, C.T., Crowther, C.A., & Levett, K.M. (2011). Acupuncture or acupressure for pain management in labour. Cochrane Database of Systematic Reviews, 7, CD009232

Massage

A systematic review summarized a small body of evidence that found that massage was associated with less pain during labor than usual care.Smith, C.A., Levett, K.M., Collins, C.T., & Jones, L. (2012). Massage, reflexology and other manual methods for pain management in labour. Cochrane Database of Systematic Reviews, 2, CD009290.

Birth ball

A systematic review of a small number of better-quality studies found that birth ball exercises were associated with reduced labor pain.Makvandi, S., Latifnejad Roudsari, R., Sadeghi, R., & Karimi, L. (2015). Effect of birth ball on labor pain relief: a systematic review and meta-analysis. Journal of Obstetrics and Gynaecology Research, 41(11),1679-1686.

Sterile water injections (for low-back pain)

One systematic review summarized results of six studies and reported that injections of sterile water into the skin have “powerful analgesic benefits” for women experiencing low-back pain in labor.Fogarty, V. (2008). Intradermal sterile water injections for the relief of low back pain in labour: a systematic review of the literature. Women and Birth, 21(4), 157-163. A second systematic review summarized results of five studies and also found more favorable pain scores in laboring women with low-back pain.Hutton, E.K., Kasperink, M., Rutten, M., Reitsma, A., & Wainman, B. (2009). Sterile water injection for labour pain: a systematic review and meta-analysis of randomised controlled trials. BJOG, 116(9), 1158-1166 However, a third systematic review reported contradictory results, that current research does not clarify whether sterile water injections are helpful for low-back pain during labor. Apart from discomfort at the time of the injection, no harms were identified.Derry, S., Straube, S., Moore, R.A., Hancock, H., & Collins, S.L. (2012). Intracutaneous or subcutaneous sterile water injection compared with blinded controls for pain management in labour. Cochrane Database of Systematic Reviews, 1, CD009107.

Best current research does not show clear help for labor pain relief

See tables that summarize labor pain relief options here.

Hypnosis (self- and practitioner-guided)

A systematic review summarized better quality available studies of effects of hypnosis during labor. At best, small individual studies suggest that hypnosis may help with labor. However, overall, this body of research is limited and does not clarify whether hypnosis is helpful for labor pain.Madden, K., Middleton, P., Cyna, A.M., Matthewson, M., & Jones, L. (2012). Hypnosis for pain management during labour and childbirth. Cochrane Database of Systematic Reviews, 11, CD009356.

Aromatherapy

A systematic review found and summarized just two small studies of aromatherapy for labor pain relief. They found no difference in use of epidural and in intensity of labor pain.Smith, C.A., Collins, C.T., & Crowther, C.A. (2011). Aromatherapy for pain management in labour. Cochrane Database of Systematic Reviews, 7, CD009215.

Music

A systematic review of limited studies found that music and audio analgesia did not appear to reduce pain intensity or improve satisfaction with pain relief compared with usual care.Smith, C.A., Levett, K.M., Collins, C.T., & Crowther, C.A. (2011). Relaxation techniques for pain management in labour. Cochrane Database of Systematic Reviews, 12, CD009514.

Biofeedback

A systematic review found and summarized results of four small studies of use of biofeedback in labor. Despite some positive results, the studies cannot clarify whether biofeedback is helpful for labor pain.Barragán Loayza, I.M., Solà, I., & Juandó Prats, C. (2011). Biofeedback for pain management during labour. Cochrane Database of Systematic Review, 6, CD006168.

TENS (trans-cutaneous electrical stimulation)

Systematic reviews found that the use of transcutaneous electrical nerve stimulation (TENS) did not contribute to greater labor pain relief or reduce use of pain medicationsMello, L.F.D., Nóbrega, L.F., & Lemos, A. (2011). Transcutaneous electrical stimulation for pain relief during labor: a systematic review and meta-analysis. Revista Brasileira de Fisioterapia, 15(3), 175-184 or, at best, had a very limited effect on severe pain (when applied to acupuncture points).Dowswell, T., Bedwell, C., Lavender, T., & Neilson, J.P. (2009). Transcutaneous electrical nerve stimulation (TENS) for pain relief in labour. Cochrane Database of Systematic Reviews, 2, CD007214.

NSAIDs (non-steroidal anti-inflammatory drugs), antihistamines, sedatives

A systematic review summarized best available research about several types of non-opioid drug for labor pain: NSAIDs, antihistamines and sedatives. In general, the studies were quite old, of poor quality, and provided little evidence for labor pain relief. Some individual studies found favorable effects. Few data were available about possible harms of these drugs.Othman, M., Jones, .L, & Neilson, J.P. (2010). Non-opioid drugs for pain management in labour. Cochrane Database Systematic Review, 7, CD009223.