I will not sugarcoat it: labor without pain medication really hurts. This doesn’t necessarily mean you don’t want to have an unmedicated birth (I did), but it does explain why pain relief during labor has been a subject of intense interest over the years.
In the U.S., the most common approach to pain relief during labor is the epidural. This is because an epidural is really effective for most women. But it’s not the only option! For decades, women outside the U.S. (mostly in Europe) have used other forms of pain relief, one of the more popular being nitrous oxide. And now, increasingly, it is becoming available in the U.S.
So, what are the various forms of pain relief, do they work, and are they safe? Evidence review, here we come.
Note: In the case of an emergency or planned C-section, your doctor will determine the best choice of pain relief. Always discuss your options when possible.
Epidurals
What is it?
Epidurals are extremely popular — about two-thirds of births in the U.S. use one. The epidural works by numbing some area of the body, notably including the uterus area, and it can reduce or eliminate pain during contractions and pushing.
You can get an epidural during the first stage of labor, when the cervix is dilating. During the procedure, a needle is inserted in your back, into the membrane that surrounds the spine, and a catheter is threaded in. Anesthesia is then delivered through the catheter. The “epidural” is the procedure — it may use different types of medication for the anesthesia.
Does it work?
Yes, the epidural is considered the most effective pain relief during labor. In randomized trials, women who received an epidural reported less pain during labor than those who received other forms of pain relief.
Also, because it reduces or eliminates pain, an epidural can help you rest before the pushing stage, which is quite physically taxing.
Is it safe?
There are many randomized controlled trials that look at the impact of an epidural on the baby and the mom.
From the standpoint of the baby, the epidural mostly doesn’t matter. Babies who are born to mothers who have an epidural are no more likely to spend time in the NICU and no more likely to have low Apgar scores (meaning they are not more likely to be “lethargic”).
One possible negative consequence for the baby is receiving unnecessary antibiotics. Women who get an epidural are much more likely to run a fever during labor, which results in the baby being treated with antibiotics. In one study, 90% of babies born to women with a fever during labor were given antibiotics, versus only 7% of babies born to women without a fever. In the end, none of the babies in either group actually needed the drugs. This isn’t ideal, but it’s also a relatively minor complication.
When it comes to the mom, epidurals can lead to increased use of forceps or a vacuum extractor during delivery. While these are both safe for the baby, they increase the chance of vaginal tearing. The epidural also seems to lengthen the pushing stage just a bit, which is likely due to a lack of movement after the epidural is given. However, the first stage of labor (before pushing) is a similar length for those with and without an epidural.
As for whether epidurals increase the likelihood of C-sections, the evidence is mixed, and more work likely needs to be done to understand this link better. (You can read more on the evidence we do have in Expecting Better.)
Are there other downsides?
With an epidural, there is an increase in the use of the medication Pitocin, a synthetic version of oxytocin, to get labor going. This is true almost by definition, because when you get an epidural it slows down contractions. Pitocin is needed to speed them up again.
It also increases the chance of low blood pressure (for the mother) and the need for a catheter. This might seem like a big deal, but it’s not really: usually the catheter goes in after the epidural and comes out before the epidural is turned off, so you might not even notice.
Another downside is the inability to walk until the epidural wears off and a small risk of a postdural puncture headache. The headache is much more common if you have a doctor who hasn’t done many procedures before, so you definitely want to check that you are not getting some resident who’s trying their first epidural.
Who is it right for?
Ultimately, the decision to get an epidural is a personal one. For many (most) people, the pain relief is worth it given the very limited risks. For others, they may want the experience of labor. People often ask me why I chose not to have an epidural. The answer is, basically, that I was curious about labor. The decision largely comes down to preferences.
Nitrous
What is it?
It’s a mix of nitrous oxide and oxygen (usually a 50/50 combo), which is inhaled through a mask at the start of a contraction (or, ideally, shortly before it starts). The laboring woman holds the mask over her own mouth and breathes in. The gas provides temporary pain relief. You take the mask off as the contraction ends. You can choose to use it or not for each contraction.
Does it work?
We do not have amazing data on this. There are a few small randomized trials (by “small,” think: a few hundred people). A 2012 Cochrane review provides a nice summary. Relying on these small samples, the answer seems to be that, yes, it can provide some pain relief. Women in the nitrous group were much, much less likely to rate their pain as severe/extreme (something like 95% less likely) than those in the placebo group.
However, the pain relief from this is temporary and intermittent. You probably want to think of it more like “taking the edge off” than “making me feel awesome.” If you are looking for fuller pain relief, it’s pretty clear the epidural is the way to go. The Cochrane review describes nitrous as “not remotely similar” to the epidural in this dimension.
Consistent with this last point, in at least one case when a hospital introduced this option, it did not change the share of women who had an epidural. In other words, in that case it didn’t seem like women who would otherwise have had the epidural opted for the nitrous.
Is it safe?
Yes. At least for the laboring woman and baby. The short-term nature of the treatment means it is cleared from the system quickly, and the fact that the woman controls the mask herself limits the risk of inhaling too much (basically, you’ll get drowsy and drop the mask if you overdo it). Randomized trials show no excess risk of bad outcomes for infants and no changes in Apgar scores.
Nitrous also doesn’t seem to affect the progress of labor. There’s no evidence of an increased risk of C-section or need for forceps or a vacuum delivery as a result. These are risks that do come up in the context of an epidural.
The one group who may be affected are hospital workers; continual exposure to nitrous oxide isn’t thought to be healthy. This is an issue for hospitals to contend with, and probably not a major part of the decision for most pregnant women.
Are there downsides?
Nitrous can make you nauseous, cause you to vomit, or make you dizzy and tired. Indeed, in randomized trials, these outcomes are very, very elevated. Relative to women who use no pain relief, those with nitrous are 43 times as likely to be nauseous, 9 times as likely to vomit, and 113 times as likely to report dizziness. These are consistent with our basic understanding of non-pregnant reactions to the gas, so this isn’t surprising.
Who is it right for?
This may be a good option for women who would like to labor without an epidural but are looking for some temporary relief during the most intense periods. An advantage of the nitrous is you can decide to use or not use it at any time. Some contractions on, some off, etc.
Alternative pain relief
There is a set of natural pain relief options, most of which involve breathing or some kind of visualization — Lamaze, the Bradley method, Hypnobabies. For the most part, evidence on these is thin, for the simple reason that the kind of women who invest in learning these techniques are particularly committed to an unmedicated childbirth. It certainly will not hurt you to learn a breathing technique, and it may well be effective; we just can’t say based on data. (One natural form of pain relief that does have some randomized evidence is aromatherapy. It appears to have no impact on anything.)
There is a bit of evidence that acupuncture during labor improves pain management and reduces the use of other drugs. But the studies are small, and the evidence is somewhat mixed. It’s probably not relevant in any case; most hospitals do not have an acupuncturist on staff.
Many people like acupressure and massage during labor, although these are more for comfort than pain relief.
The bottom line
- Epidurals are a very effective form of pain relief, although they do increase some complications for the mother.
- If available, nitrous oxide may provide temporary and less complete pain relief, with limited risk.
- Natural pain relief methods don’t have much evidence to back them up but can’t hurt to try if you find them helpful.
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