• Pain relief for labour pains should be administered promptly, and according to the mother’s wishes.
• Women need access to good information in order to be able to make informed choices; this should ideally occur in the antenatal period.
• General pain-relieving strategies include: a supportive birth partner or midwife, acupuncture, acupressure, aromatherapy, hypnosis, water baths and TENS machine.
• Entonox and pethidine are available on the labour ward and the birthing suites.
• Local anaesthetic blocks or infiltration can be given for an episiotomy or repair of perineal trauma, or as a pudendal nerve block to aid instrumental delivery

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Abbreviations

• Pain relief should be administered promptly, and according to the mother’s wishes.

• Women need access to good information in order to be able to make informed choices and this should ideally take place in the antenatal period. However, if this has not happened, midwives from the labour ward, birth centre, triage or antenatal ward must take responsibility for offering it. The discussion should be recorded in the notes.

• 78% of the members of the Cochrane Pregnancy and Childbirth Consumers’ Group identified pain relief in labour as the topic of most importance to them.

• Labour pain may not be completely relieved through the use of analgesic drugs such as Pethidine and Entonox. It is important that midwives acknowledge this with labouring women. In addition, all pharmacological methods of pain relief have side effects: careful account must be taken of those that may be undesirable for both the woman and her baby. The ideal is to provide a maternally acceptable degree of pain relief while causing the minimum compromise to the health and well-being of the mother & fetus.

• Analgesia may be especially useful in some patients to relieve the stress response e.g., patients with cardiac disease.

2.1 The constant presence of a supportive birth companion and continuous midwifery care has been shown to: ¹

• Reduce the use of pain relief

• Reduce the incidence of assisted vaginal delivery and caesarean section.

• Result in better 5-minute Apgar scores

• Reduce perineal trauma

• Increase the incidence of breast feeding at six weeks

• Result in a more positive experience of childbirth, less postnatal depression & improved bonding between mother and baby

3.1 The following are NICE recommendations²:

• Women should be supported by their partner or midwifery team to use breathing and relaxation techniques in labour.

• Women who choose to use massage techniques in labour including from their birth partners should be supported in their choice.

• The opportunity to labour in water is recommended for pain relief. The birthing pool water temperature should not be above 37.5°C and should be monitored hourly. The maternal temperature should be monitored hourly to maintain comfort and avoid pyrexia. The birthing pool should be kept clean using a protocol agreed with the microbiology department and in accordance with the manufacturer's guidelines.

• The use of injected water papules is not recommended.

• Women who wish to use acupuncture, acupressure, aromatherapy and hypnosis should be supported in their choices. This includes the provision of any resources that the woman may need, that are available within the Trust.

• Music of the woman's choice can be played in the woman’s birthing room, and should be supported.

4.1 Transcutaneous electrical nerve stimulation (TENS) uses a device which emits low voltage electrical impulses which vary in frequency and intensity. In labour, the electrodes from the TENS machine are usually attached to the lower back and women themselves control the electrical currents using a hand-held device. The electrical pulses are thought to stimulate nerve pathways in the spinal cord which block the transmission of pain (Gate Theory of Pain). It is further thought that by reducing anxiety, increasing a sense of control, and by providing distraction, TENS increases a woman's sense of well-being and thereby reduces pain in labour.

4.2 Overall studies conclude that there is little difference between usual care and TENS for pain intensity, satisfaction with pain relief or assisted vaginal birth.¹ NICE guidance suggests that the use of TENS is not offered to women in established labour; however women should not be discouraged if they wish to use this device.²

4.3 NICE guidance suggests that there is little evidence of its effectiveness in established labour, but also no harm. Women should not be discouraged if they wish to use this device.²

5.1 Entonox consists of a mixture of 50% oxygen and 50% nitrous oxide. It is administered via inhalation through a mouth piece or face mask. Entonox has a low lipid solubility and so has a very fast onset and offset of analgesic action, taking 30-45 seconds to reach peak maternal blood concentrations. Its use should start just before the contraction starts to ensure peak Entonox concentration corresponds with the peak of the contraction. The teaching of the correct method of inhalation is a multi-disciplinary responsibility, and should be tackled pre-emptively at antenatal clinic, as well as in labour. In studies comparing Entonox with placebo or no treatment, it was found to offer better pain relief but was associated with more adverse effects for women such as nausea, vomiting, dizziness and drowsiness. ¹ When using Entonox the room should be well ventilated and the MDU (Mobile Destruction Unit) should always be in use. See Entonox guideline.

5.2 The advantages are:

• Reduced intensity of contractions

• No neonatal effects

• Can be used throughout labour in conjunction with alternative analgesic methods

• Is patient controlled

• Does not require additional monitoring

5.3 The disadvantages are:

• Nausea, drowsiness or dizziness²

• Dry mouth

• Technique is crucial to analgesic efficacy

• It is contra-indicated in patients with a known significant, current B12 deficiency as this increases the risk of peripheral neuropathy and confusion.

6.1 Codeine

• Dihydrocodeine 30mg can be given in the latent stage of labour.
• Do not give codeine phosphate to women in labour.

6.2 Pethidine

• Pethidine is the intramuscular drug of choice which can be administered by midwives.

• There are considerable doubts about the effectiveness of pethidine in terms of its analgesic properties, and concerns regarding side effects. Maternal side effects include nausea, vomiting, dizziness, dysphoria and drowsiness. In the neonate, side effects include respiratory depression, impaired suckling and drowsiness. The woman should be informed of these effects prior to administration2.

• Due to nausea related with pethidine, it should be administered with an antiemetic2.

• The woman should not enter the birthing pool or the bath within 2 hours of the administration of pethidine or if they feel drowsy.

• Pethidine can be given to any mother who requests analgesia, as long as she has had no opiates in the previous 4hrs and is not expected to deliver imminently.

• The first dose of intramuscular pethidine can be between 50-100mg and should be varied according to the patient’s size and extent of labour. A further dose of 50-100mg can be given 3-4hrs later.

• If more than 2 doses are required in under 4hrs, alternative forms of pain relief should be considered. Further use of narcotics should be discussed with the anaesthetist.

• If delivery is likely within 2 hours, pethidine should not be given.

• Epidural insertion can be considered after pethidine. However, careful consideration should be made if labour is rapidly progressing or if delivery is anticipated within 4 hours of pethidine administration. This is because the "low dose mix" bag that is administered to women in labour via their epidural contains another opioid (fentanyl). There is a risk of respiratory depression in the neonate with opioid accumulation. See epidural analgesia in labour guideline.

6.3 Remifentanil PCA

• This is a short acting but potent synthetic opioid. It is given via the intravenous route as an alternative to epidural. The directions for using this drug are given in a separate guideline Please refer to “Remifentanil PCA for labour”.

7.1 An intravenous cannula should be sited prior to any local anaesthetic block or infiltration.

7.2 Local infiltration should be used for episiotomy or repair of perineal trauma if the woman has no other form of pain relief.

7.3 A pudendal nerve block and local infiltration may be used for an instrumental delivery in a patient without an epidural or spinal anaesthetic.

7.4 Total safe doses are (1%=10mg/ml, 2%=20mg/ml):

Lidocaine without adrenaline: 3mg/kg (up to a maximum dose of 200mg)

Lidocaine with adrenaline 7mg/kg (up to a maximum dose of 500mg)

7.5 In the event of local anaesthetic toxicity, see ‘Management of LA Toxicity in Obstetric Patients’.

1. Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, Jordan S, Lavender T, Neilson JP. Pain management for women in labour: an overview of systematic reviews. 2012. In: The Cochrane Database of Systematic Reviews [Internet]. Hoboken (NJ): John Wiley & Sons, Ltd. Available from: https://doi.org/10.1002/14651858.cd009234.pub2. Record number.: CD009234.

2. National Institute for Health and Care Excellence. Intrapartum Care [Internet]. London: NICE; 2023 [cited 2024 October 15]. [NG235]. Available from: https://www.nice.org.uk/guidance/ng235/chapter/Recommendations

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. This guideline is for use in Frimley Health Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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