Labor pain is real, physiologic pain with both physical and emotional components. Its perception is shaped by fear, fatigue, previous experience, culture, support, and expectations.

Sources of labor pain

Gate-control theory: non-painful stimuli (touch, massage, heat, TENS) and attention-focusing activities compete with pain signals in the spinal cord, reducing perceived pain. This is the basis of many nonpharmacologic methods.

Fear–tension–pain cycle: anxiety raises catecholamines, which increase muscle tension, can reduce uterine blood flow, and can slow labor. Support and information break the cycle.

Principle: the client's own choice guides pain management. Pain is whatever the client says it is; the nurse provides information about options, risks, and benefits and supports the decision. Many clients combine nonpharmacologic and pharmacologic methods.

• Pain intensity (0–10 scale), location, and character; back pain suggests occiput posterior position
• Coping behaviors (breathing rhythm, ability to rest between contractions, vocalizing) — some clients cope well with high pain scores
• Stage of labor, cervical dilation, and expected time to birth (affects choice of opioid timing)
• Birth plan and preferences, previous experiences, cultural expectations
• Contraindications to specific methods: coagulation status and anticoagulant use (neuraxial), history of substance use disorder, allergies, pacemaker (TENS)
• Signs of hyperventilation with rapid breathing: lightheadedness, tingling of the fingers and lips, carpopedal spasm

• Platelet count and coagulation studies before neuraxial analgesia when clinically indicated (e.g., preeclampsia, bleeding disorder, anticoagulant use). Many anesthesiologists consider a platelet count of about 70,000/mm³ (70 × 10⁹/L) or higher acceptable in the absence of other risks
• Baseline vital signs and FHR before any pharmacologic method
• Timing of the last anticoagulant dose (commonly, 12 hours after a prophylactic dose of low-molecular-weight heparin and 24 hours after a therapeutic dose before neuraxial placement)

Nonpharmacologic methods

• Continuous labor support (nurse, doula, partner) — improves satisfaction and reduces the need for analgesia
• Breathing techniques (e.g., Lamaze patterned breathing): slow-paced breathing early, modified-paced and patterned ("pant-blow") breathing in transition; the pattern changes as labor progresses
• Relaxation, visualization, hypnosis, music
• Position changes, walking, birth ball, hands-and-knees
• Hydrotherapy (shower or tub immersion in the first stage) — buoyancy and warmth relax muscles
• Massage and counterpressure to the sacrum (back labor); warm packs to the lower back
• TENS — low-voltage current through electrodes on the lower back blocks pain transmission; avoid with a pacemaker or implanted defibrillator and in water
• Acupressure, sterile water injections for back pain, aromatherapy

Systemic opioids

• Opioids cross the placenta: decreased FHR variability and neonatal respiratory depression, especially if birth occurs near peak drug effect
• Nursing: check maternal respiratory rate, sedation, and blood pressure, and monitor FHR after administration; raise side rails, fall precautions
• The newborn team should be informed of timing; resuscitation focuses on ventilation first
• Keep naloxone available for maternal respiratory depression (e.g., RR < 12/min or excessive sedation). Naloxone is not part of initial newborn resuscitation, and it must not be given to the newborn of an opioid-dependent mother (acute withdrawal, seizures)

Nitrous oxide (50% nitrous oxide / 50% oxygen)

• Self-administered: the client holds her own mask and starts inhaling about 30 seconds before the contraction (or at its first sign); fast onset and offset
• Side effects: nausea, dizziness, drowsiness. Not used with inability to hold the mask, recent systemic opioids (additive sedation), vitamin B12 deficiency, or trapped-gas conditions (e.g., pneumothorax)

Neuraxial analgesia and anesthesia

• A client's request is sufficient reason for an epidural — there is no required cervical dilation (e.g., waiting for 4–5 cm is outdated)
• Contraindications: client refusal, coagulopathy or significant thrombocytopenia, recent anticoagulant dose, infection at the insertion site, uncorrected hypovolemia or hemorrhage, some increased intracranial pressure lesions

Regional blocks

• Pudendal block: local anesthetic near the pudendal nerves (transvaginal) — relieves perineal pain in the second stage, for birth and episiotomy repair; does not relieve contraction pain
• Local perineal infiltration for repair
• Paracervical block: rarely used (fetal bradycardia)

General anesthesia: for emergency cesarean when neuraxial is not possible; risks aspiration and failed intubation. Give aspiration prophylaxis as ordered (sodium citrate, H2 blocker, metoclopramide); volatile agents relax the uterus (bleeding risk).

Listed in priority order.

1. Before neuraxial analgesia
   • Obtain consent (anesthesia), baseline BP, pulse, and FHR; establish IV access and give fluid per protocol (preloading or co-loading is commonly used to reduce hypotension)
   • Position sitting upright or lateral, curling the back; stay with the client
2. After epidural or spinal — watch for hypotension first
   • Maternal hypotension (sympathetic blockade → vasodilation) is the most common complication and can reduce placental perfusion → FHR decelerations
   • Check BP every 5 minutes for about 15 minutes after the initial dose and after boluses (per protocol), then regularly
   • If hypotension: lateral uterine displacement (left or right side), IV fluid bolus, notify anesthesia; vasopressors (phenylephrine or ephedrine) as ordered
   • Continuous FHR monitoring
3. Detect serious complications
   • High or total spinal: difficulty breathing, weak hand grip, inability to speak, loss of consciousness → call for help, airway support
   • Local anesthetic systemic toxicity: metallic taste, perioral numbness, tinnitus, confusion, seizures, dysrhythmias → stop infusion, call for help; 20% lipid emulsion is the specific treatment
   • Respiratory depression with neuraxial opioids — may be delayed up to about 24 hours with neuraxial morphine
4. Bladder and safety
   • Sensation to void is lost → palpate for bladder distension every 1–2 hours; catheterize as needed
   • Fall risk — no unassisted ambulation; turn side to side regularly
5. Comfort measures
   • Pruritus (opioid effect), shivering, fever (epidural-associated fever can occur; still assess for infection)
6. Nonpharmacologic support throughout
   • Stay with the client; coach breathing; use touch, counterpressure, and heat
   • Hyperventilation: slow the breathing and breathe into cupped hands (paper-bag rebreathing is discouraged)
   • Use therapeutic communication — e.g., ask which breathing technique has been helping rather than telling her to endure it

• Review all options during pregnancy; plans can change during labor
• Epidural: explain possible hypotension, itching, leg weakness, need for a bladder catheter, and that it may slightly lengthen the second stage
• Post-dural puncture headache after spinal or accidental dural puncture: headache that is worse when sitting or standing and better lying flat; report it. Treatment includes fluids, caffeine, analgesics, and possibly an epidural blood patch
• Opioids may cause drowsiness; call for help before getting up
• Nitrous oxide: start inhaling about 30 seconds before the contraction (or at its first sign); only the client holds the mask

• First-stage pain T10–L1; second-stage pain S2–S4 (pudendal)
• Client preference guides pain management
• Epidural's most common complication: hypotension → lateral position, IV fluids, notify
• No minimum cervical dilation is required for an epidural
• Spinal = injection into CSF, rapid onset, smaller dose; used for cesarean
• Pudendal block = second-stage perineal pain
• Opioids near birth → neonatal respiratory depression; monitor FHR
• Nalbuphine/butorphanol → withdrawal in opioid-dependent clients
• Nitrous oxide is self-administered
• Post-dural puncture headache is relieved by lying flat