This is Vanitha, Non- pharmacological approaches helps in managing labour pain...there are a different techniques like water birth, music, hypnosis, exercises which helpful in managing labour pain and for safe birth. It is there in the syllabus of MSc nursing and BSc nursing syllabus and it will helpful for the students to enhance their knowledge.

1. Ch.Vanitha,
M.Sc Nursing,Ph.D.
Obstetrics and Gynecological Nursing
Mamata college of nursing.

2. Management of second stage of labor
 Birth should be allowed to happen spontaneously with
minimal stimulation of the fetal head, including checking for a
cord around the neck.
 The cord should never be clamped or cut while the head is still
under water.
 If a tight cord delays the birth, the mother must stand or step
out of the pool.
 Once the head is above the water, it must not be allowed to go
back under the water.
 Baby’s head should be brought to the surface immediately after
birth and rest of the body should remain submerged to
promote temperature regulation.

3. Non- Pharmacologic Approaches
To Manage Labor Pain
Giving birth to a child is one of life’s most
intense experience.
Pain during labor is caused by
contractions of the muscles of the uterus
Stretching of the birth canal, vagina and
uterine ligaments
Pressure on the cervix, bladder and bowels by
the baby's head.

4.  Labour pain may be worsened because of a woman's tension,
anxiety and fear.
 Effective pain management is crucial in the labour process.
 There are two general approaches for pain management:
pharmacologic and non-pharmacologic
 Pharmacologic approaches are directed at eliminating or
decreasing the physical sensation of labor pain.
 In contrast, non-pharmacologic(natural birthing)
approaches are largely directed at increasing comfort,
enabling the laboring woman to cope with the pain and
preventing suffering.

5. Natural birthing techniques
 Water birth
 Movement and Position Changes
 Birthing Ball
 Hypnosis
 Acupuncture and Acupressure
 Aromatherapy
 TENS
 Psycho-prophylaxis
 Patterned Breathing
 Superficial Heat and Cold
 Relaxation Techniques (Touch and Massage, Sound,
Taste and Visual imagery)

6. Water birth
 Water birth is the process
of giving birth in a tub of
warm water.
 The theory behind water
birth is that since the baby
has already been in the
amniotic fluid sac for nine
months, birthing in a
similar environment is
gentler for the baby and
less stressful for the
mother.

7. Benefits for Mother
 Warm water is soothing, comforting and relaxing.
 Relaxation–It helps in the rhythmic contractions and
ensures that mother and the baby are not stressed
 The labour period is fast
 Privacy and control
 In the later stages of labor, the water increases the woman’s
energy
 The effect of buoyancy lessens a mother’s body weight,
allowing free movement and new positioning.

8.  Buoyancy promotes more efficient uterine
contractions and improved blood circulation.
 Immersion in water often helps lower high blood
pressure caused by anxiety.
 Water causes the perineum to become more elastic
and relaxed, reducing the incidence and severity of
tearing and the need for an episiotomy and stitches.
 As the laboring woman relaxes physically, she is able to
relax mentally with greater ability to focus on the birth
process.

9. Benefits for Baby
 Provides an environment similar to the
amniotic sac.
 Eases the stress of birth, thus increasing
reassurance and sense of security.

10. Contraindications
 Presence of thick meconium
 Excessive intrapartum bleeding
 Elevated maternal temperature greater than 100.4° F
 Active herpes, untreated skin infection
 Premature Rupture of membranes
 Mal- presentations and Multiple pregnancy
 Pre-eclampsia
 Baby needs continuous monitoring via CTG machine
 Previous caesarean section
 Induced labour

11. Disadvantages
 Lack of pain relief –water birth reduces the
impact of pain, but it does not completely
eradicate pain. If mother can’t have any
opiates, such as pethidine, for at least six
hours before she get into the pool.
 Infections
 Emergency situations – In case of emergencies,
it takes time and effort to get out of the pool

12. Pool setup and Cleaning
 Portable pools and Single-use disposable pools
 Diameter of birth pool is between 110-150 centimeters
 Pools with removable jets and a pipeless system.
 The pool should be deep enough for water immersion.
 Run hot water for 3 minutes before filling the pool.
 Disinfect pool before filling. Use a 1:10 mix of chlorine
bleach: It takes 5 minutes to disinfect the pool.

13. Temperature of Water
 The temperature of the water must be
comfortable for the mother and below 100.4° F
(38°C).
 The water temperature and documented in the
chart.

14. Water Immersion Procedure
 It is best if the mother is in active labor.
 The water must completely cover the mother’s
abdomen, but not reach to the level of her neck.
 Maternal vital signs and fetal heart rate should be
monitored regularly
 Encouraged to remain hydrated (drinking water and
electrolytes).
 Empty her bladder regularly on the toilet.

15.  Fecal matter or other contamination should be
removed from the water immediately..
 The midwife should prepare a safe birth
environment outside the pool(towls,blanket
and mattress near the pool) in case evacuation
of the birth pool is necessary.
 Special attention should be provided to
prevent slipping(towels or mop should be
nearby).

16. Management of second stage of labor
 Birth should be allowed to happen spontaneously with
minimal stimulation of the fetal head, including
checking for a nuchal cord.
 The cord should never be clamped or cut while the head
is still under water.
 If a tight cord delays the birth, the mother must stand or
step out of the pool.
 Once the head is above the water, it must not be allowed
to go back under the water.

17. Management of second stage of labor
cont…
 Infant’s head should be brought to the surface
immediately after birth, taking care to prevent cord
avulsion. The rest of the infant’s body should
remain submerged to promote temperature
regulation.
 If the cord is short, preventing the infant’s head
from comfortably sitting above the water, the
mother may need to quickly vacate the pool.

18. Management of third stage of labor
 If bleeding is minimal, third stage may be
managed in the pool.
 If the water becomes clouded with blood , the
mother and infant should be quickly removed
from the pool.
 Maternal vital signs and the mother’s emotional
and physical response should also be considered
in decision to leave the pool.

19. Newborn Resuscitation
 Generally, breathing is triggered in babies when they
experience a change in temperature. If the pool is at a
safe temperature, the baby continues to receive oxygen
through its umbilical cord and takes the first breath after
it is brought out of the water.
 Be prepared for the possibility that it might be difficult
to keep the newborn’s airway open and assure a good seal
when resuscitating the infant while the mother is in the
pool. The ventilations must be effective in order for them
to work.

20. Newborn Resuscitation cont….
 Either have a firm surface nearby or have a CPR board
with heating pad, towels prepared near the pool.
 If mother can evacuate pool quickly, it may be possible
to leave cord intact.
 If you have to move the infant, you will most likely have
to cut the cord. Milking the cord from the introitus or
base of placenta can be effective before cutting the cord.
 Dry the baby’s face prior to mouth to mouth or
bag/mask if needed.

21. Emptying the Pool
 Dispose of all debris - blood clots and feces - before
it can flow into the drain pipe.
 Empty the pool every 6 hours.
 If you are going to refill the pool for the same client
and there is visible contamination, clean and
disinfect pool.
 Clean and disinfect all semi-critical and non-critical
items used in the birth pool.
 No additives should be added to the water.

22. Reasons for Leaving the Pool
 Elevated maternal temperature or abnormal vital signs
 Slow progress and hypotonic contractions
 Lack of descent during second stage
 Water temperature too hot or cold
 Fecal matter or other contamination that cannot be
removed, unless birth is imminent
 Short umbilical cord
 Excessive bleeding
 Use of agents causing sedation

23. Hanna Ulfsdottir, Sissel Saltvedt et al., (2017)
conducted a retrospective study on characteristics
and outcome of waterbirths in Sweden among 306
women having conventional spontaneous vaginal
births. The results shows labor was shorter (6 h
3 min vs. 7 h 52 min) and there were significantly
fewer interventions than in the comparison group;
amniotomy (13.7 vs. 35.3%), internal
cardiotocography (11.1 vs. 56.8%), and
augmentation with oxytocin (5.2 vs. 31.3%).

24. Movement and Position Changes
Postion change during labor is usually more comfortable
than staying in the same position
Advantages:
 Get the baby into position
 Produce stronger, more efficient, and less painful
contractions
 Lessen the need for medication
 Reduce the likelihood of an assisted birth or caesarean
section

25. BEST BIRTHING POSITIONS
A)Squatting
Pros:
 Gravity kicks in, the pelvis expands
further and labour may be faster as a
result. Squatting also requires less effort
for bearing down.
 Decreases the need for forceps or a
vacuum
 Helps in dilation
Cons:
 Baby’s position may not be right for
squatting
 Can lead to more tearing if done
without a birthing stool or other aid

26. B)Reclining birth position
Mother can lie down in bed, but can
also recline against a wall, a chair or
another person.
Pros:
 Can release tension and relax the
muscles
 May be a good alternative if a
woman is tired but doesn’t want to
lie down completely
Cons:
 Can work against gravity

27. C)Birthing stool positions
It can be used in a variety of birthing
positions: Women can squat on it, get in
the all fours position and use it to
support the arms and even rock back
with it, depending on the design of the
stool.
Pros:
 Can help baby move farther down
 Relieves stress on the back
 Can increase dilation of the cervix
Cons:
 Women may experience
increased blood loss

28. Birthing bar positions
 The birthing bar(cousin of
birthing stool) is an attachment
that can be added to many labor
beds to help support birthing
positions.
 With a birthing bar, mother can
sit up at any time and squat,
leaning on the bar for support.
“The birthing bar can be an
awesome tool.

29. Other positions
Hands and knees
Pros: All-fours may help to
reduce back pain, and
gravity can help to get the
baby into position.
Cons: Can be tiring and
uncomfortable after time.

30. A sitting position
Pros: With the use of a birth stool
intermittently in second stage this
can feel like a more natural way to
push for many women.
Cons: Long periods in this position
can lead to swelling in the perineal
area, which comes with an increased
risk of perineal trauma

31. Standing up
Pros: Contractions can often be
more effective and less painful and
it may speed up labour.
 Standing upright bent over,
while rocking can ease pressure
on the pelvic area and help the
baby to move into position.
Cons: Less control at the time of
birth.

32. Lunging
Pros: lunging against a chair,
for example, can help the
baby rotate or descend and
open the pelvis.
Cons: Can be tiring and may
need help keeping mother in
balance.

33. Stair climbing
Pros: Helps baby rotation and get into
a good birthing position aiding the
baby’s descent into the cervix and
therefore stimulating release of
oxytocin providing better
contractions.
 This is a good way to help intensify
labour if labour is prolonged.
Cons: Can be tiring and may not have
easy access to stairs.

34. Birthing ball
 Few labor tools are as simple, beneficial, and
versatile as the birthing ball.
 The safest way for birthing ball is birth partner to
spot with women and sit in a chair with legs apart,
while she sit on the birthing ball positioned in
between them.
 USES: Sitting on the birthing ball keeps the baby
properly aligned in the pelvis and it encourages the
baby to drop down further (descend) into the pelvis.

35. Birthing ball features
 Birthing balls and gym balls are basically the same.
 Both can be made from anti-burst materials. This means
they deflate slowly rather than with a bang if punctured.
 keep sharp objects away from it.
 Don’t store it on rough surfaces or near heat like
radiators, stoves and open fires.
 if the women is 5ft 8in height, it's best to get a 65cm ball
and 5ft 9 best to use a 75cm ball

36. Ways to use birth ball during labour
Sitting astride the ball and rocking your pelvis from side to
side or back and forth.

37. Leaning on birthing ball from a kneeling
position on the floor.

38. Getting into a hands-and-knees position by
hugging birthing ball and lifting bottom up
from a kneeling position.

39. Leaning over ball from a standing
position, with the ball on the bed or
another

40. Winny KWAN, Lorraine Siu-King MAN et al., (2012)
conducted a study “To evaluate the effectiveness of
birth ball as a method of pain management in labour”
Hong Kong among 217 (110 were in the study group and
107 were in control group) labouring women. The
results shows the mean duration of the first stage of
labour was significantly shorter in the study group 5.3
vs 7.1 hr, significantly lower mean VAS scores in study
group 6.1 vs 7.0, the episiotomy rate in the study group
was 10% lower and 2.9 vs 4.8 for anxiety. The study group
after delivery, 85% reported that they were satisfied
with the use of birth ball, and 12% stated they were
highly satisfied. The study provided evidence that the
use of birth ball was safe, and offered women an
alternate means of pain management during labour.

41. Hypnosis for labor
 Hypnobirthing was introduced in
the nineteenth century
 Hypnosis is a state of deep mental
and physical relaxation that
enables the hypnotized person to
focus intensely on a thought or
feeling, blocking outside
distractions.

42. Procedure
 Hypnobirthing classes often meet once a week for 2 h.
 The class beginning at the 30th week of pregnancy over a
4- to 5-weeks period.
 When a woman prepares for childbirth with hypnosis,
these suggestions aim to replace fear and confident
expectations of a safe, gentle – even comfortable – birth.
 For example, a woman using this technique may
concentrate on the sound of her deep breathing, taking
her further into a hypnotic state, and visualize her baby
easing downward with each breath.

43. Advantages
 Reduced need for pain medications,
less fatigue from labor, bringing
together mother and the baby, and
decreasing hyperventilation.
 Hypnotherapy is one of the safe
method

44. Disadvantages
 Learning self-hypnosis(classes and
adequate preparation) takes time and
money.
 Disappointed with the fail of hypnosis

45. Acupuncture
 fine needles placement at specific
points on the body to reduce pain by
stimulating the production of
endorphins.
 To correct the imbalance of energy in
the body.
 In electro-acupuncture, needles are
connected to wires that deliver low or
high frequencies of electrical currents.
 Acupuncture is a safe and effective
treatment for pain relief.

46. Acupressure
 Acupressure is based on the same theory as
acupuncture, but instead of using needles,
acupressure is delivered in a noninvasive way using
fingers, thumbs, knuckles or other tools to put firm
pressure on different areas of the body
 Acupressure might increase blood flow to the uterus,
influence hormonal responses, and stimulate
uterine contractions.

47. There are 9 Useful Acupressure
Points to Relieve Labor Pain
1. B48
 Bladder48 is one of the vital
pressure points for labor that is
located to the side of the sacrum, in
the middle of the gluteal muscle of
the buttocks.
 It is a local point for lower back
pain, hip pain, sciatica and pelvic
tension.

48. B28
 Bladder 28 is located on the
lower back. It is also called the
Bladder Shu, and it can be
found midway between the top
and bottom of the sacrum,
halfway between the middle
and the outer edge.
 Stimulating this point on both
sides helps in alleviating lower
and sacral back pain.

49. St29
 significant pressure 29 point
for labor pain relief that is
located on the outer brink of
the pubic bone, two chons
from the midline.
 This point is also named the
Return point, and it helps in
stimulating and balancing the
qi flow to the female
reproductive organs.

50.  Sp6
 Spleen 6 is an extremely important
acupressure point that helps in
relieving all types of women
problems.
 This point can be found three
finger widths above the inner
ankle bone, along the back of the
tibia.
 Stimulating this point on both the
legs regulates the labor by
stimulating uterine contractions.

51. LI4
 Large Intestine 4 is undoubtedly the
most famous acupressure point for
healing a wide range of health
issues.
 It is located on the fleshy webbing
between the thumb and the index
finger.
 stimulating this point on both
hands helps in stimulating labor
and encouraging the downward flow
of energy.

52.  GB21
 Gall Bladder 21 is one of the
functional pressure points for pain
relief and easing labor pain that is
located on the top of the shoulder,
halfway between the edge of the
shoulder and the base of the neck,
in the middle of the muscle.
 This point is called the Shoulder
Well, and it is stimulated to
promote the downward flow of
energy.

53. K1
 K1 or Kidney 1 acupressure point is
also known as the Gushing Spring
and this point is located at the
bottom of the foot, in the
depression when the foot is set in
plantar flexion.
 This is one of the essential
acupuncture pressure points that
help in pulling the energy downward
and calming the stress and anxiety
of the mother.

54.  K3
 K3 or Kidney3 is one of the
beneficial pressure points for
labor pain which is located on
the inner side of the feet,
halfway between the Achilles
tendon and the inner ankle
bone.
 This point is also called the
Great Ravine, and it helps in
relieving labor pain.

55. UB60
 UB60 or Urinary Bladder 60
enhances blood circulation and
provide pain relief.
 This point is named the Kunlun
Mountains and it is located on the
foot, in the dint between the tip of
the external malleolus and tendo
calcaneus.

56. Reginaldo Roque Mafetoni and Antonieta Keiko
Kakuda Shimo (2016) conducted a randomized
clinical trial on “The effects of acupressure on
labor pains during child birth” among 156
pregnant women (≥ 37 week/s, who had cervical
dilations of ≥ 4 cm) in Brazil. The acupressure
was applied on the sanyinjiao point during the
contractions for 20 minutes. Then the intensity
of the pain was evaluated using the Visual
Analogue Scale (VAS).The results shows that the
pain were less in the acupressure groups 65.4%,
in control group it was 1.9% and pain is worse as
1.9% cases in study group and 51.9 % in control
group . the use of acupressure is a useful way to
alleviate pain in a non-invasive manner. It can
improve the quality of care given to pregnant
women in labor.

57. Aromatherapy
 Aromatherapy pro-mote stress relief during labor.
 Essential oils of rose, lavender, neroli, clary sage, and
others are placed in baths, on cloths, in massage oil,
or directly on the laboring mother’s skin.
 calming oil - first stage of labor before the baby
begins to descend.
 As stage 2 of labor - peppermint has been found by
many to pro-mote a sense of strength.

58. Limitations
 Absence of direct effect on pain relief,
 some women may have allergic reactions
to particular oil preparations, and many
laboring women are particularly sensitive
to certain smells that may enhance nausea
and vomiting associated with labor.

59. TENS(Transcutaneous Electrical
Nerve Stimulation)
 TENS, a machine sends low-voltage
electrical current to body through
electrodes stuck to the skin of back.
 TENS doesn’t involve needles or drugs.
 It’s possible that it blocks pain signals
by stimulating different nerves in
spinal cord.
 It might also cause the release of
endorphins, which are the body’s
natural pain.

60. Advantages
 It doesn’t require medicines or injections
 It may give you some control over pain relief
 Mother can go for other methods if TENS does not give
you enough pain relief
 There is no harm to mother and baby
 It can be used at home during early labour

61. Disadvantages
 It doesn’t work for everybody
 TENS machines can’t be used in the bath
or shower

62. TENS shouldn’t be used in
 On an open wound or if your skin is irritated
 Who are pregnant but not in labour
 Who have a pacemaker
 People with epilepsy

63. Psychoprophylaxis
 Psychoprophylactic method also known as Lamaze
technique
 This technique involves education of mother regarding
“positive” conditioned reflexes. It involves continuous
labor support and the use of relaxation and breathing
strategies.
 Lamaze believed that controlled, conditioned
breathing exercises were effective in blocking women’s
perception of pain of contractions.

64. Patterned Breathing During Labor
 It refers to the act of breathing at any
number of possible rates and depths.
 Breathing should be at a comfortable rate.
 Patterned breathing is helpful in coping
with various types of pain, discomfort,
anxiety and fear.

65. Benefits
 Breathing becomes an automatic response to pain
 The mother remains in a more relaxed state and will
respond more positively to the onset of pain
 The steady rhythm of breathing is calming during labor
 Provides a sense of well being and control
 Increased oxygen provides more strength and energy for
both the mother and baby
 Brings purpose to each contraction, making contractions
more productive

66. Technique
 At the beginning and end of each contraction take a
deep and relaxing breath.
 The first stage of labor: Begin slow breathing when
contractions are intense.
 Focus attention.
 Slowly inhale through nose and exhale through
mouth, allowing all air to flow out with a contraction.
 With each exhale, focus on relaxing a different part of
body

67. Light Accelerated Breathing
 In the active phase of labor.
 Accelerate and lighten breathing as the contraction
increases in intensity. Keep mouth and shoulders
relaxed.
 As the contraction decreases in intensity, gradually
slow breathing rate.
 When the contraction ends, take finishing breath

68. Variable (Transition) Breathing
 Light shallow breaths at a rate of 5-20 breaths in
10 seconds through mouth , throughout the
contraction.
 After every second, third, fourth, or fifth breath,
blow out a longer breath.
 When the contraction ends take one or two deep
relaxing.

69. Superficial Heat and Cold
 Hot water bottle, hot moist towels, or warm
blankets.
 Hot compresses applied to the lower abdomen,
groin or perineum, a warm blanket over the entire
body and ice packs to the lower back or perineum
can help alleviate labor pain.
 Superficial cold can come from an ice bag,
washcloths soaked in ice water.

70.  Using heat or cold on separate parts of the body
at the same time can provide particularly
effective pain relief.
 For example, apply a cool cloth to the forehead
with warmth on the lower back.
 For maximum effect, change the heat and cold
locations frequently, about every twenty
minutes.

71. Relaxation Techniques
This techniques incorporate all the senses, will
help mother to
 Reduce fear, anxiety, and labour pain.
 Sight: Relaxing environment with soft lighting,
lamps, or candles, will experience feelings of
safety, tranquility, and warmth.

72. Touch and Massage
 The human touch is a powerful way to relieve pain and
reduce anxiety in labor.
 A hand placed on a painful spot, reassurance, stroking
the cheek in an affectionate gesture, or a tight embrace
can communicate a message of caring to the laboring
woman.
 Purposeful massage of the hand or other parts of the
body also communicates caring.

73.  Massage takes the form of light or firm stroking,
vibration, kneading, deep circular pressure, and
continual steady pressure.
 Stroking or rubbing the neck, shoulders, back, thighs,
feet or hands is an effective pain-reliever. Receptors in
the brain receive the sensations of pleasure from the
massage blocking reception of the painful stimuli of
labor.
 Bare skin receives the signal best and unscented
powders and lotions are helpful for massage.

74. Sound
 Audio-analgesia (music, talk) for pain relief consists
of soothing music between and during contractions.
 sounds like ocean waves, birds chirping or bubbling
brooks can help to focus on the waves of contractions.
 Many women have enjoyed the music of Yanni or Enya
in their birth environment.
 Music creates a pleasant and relaxing environment
and music transmitted through earphones can block
out disturbing, distracting, or unpleasant sounds.

75.  The certain intrinsic properties in music that make
music relaxing. These include tempo, harmony,
rhythm, instruments, melody, voices, and pitch.
 Jasmine and clary sage have traditionally been used
during labor to help contractions and ease muscular
pain.
 Carefully chosen music can also reinforce rhythmic
breathing patterns, massage strokes or facilitate
focusing one’s attention.

76. Taste
 Eating foods rich in complex carbohydrates and Vitamin
B is beneficial in the first stage of labor. some nutritious
snacks available that help provide energy and reduce
anxiety and fatigue.
 Kneading: Slow rhythmic kneading is helpful for
reducing tension in the shoulders, thighs or buttocks.
 Grasp the muscle between the heel of hand and closed
fingers.
 Squeeze in with gentle pressure, hold, then release and
repeat, moving across the muscle.

77. Visual Imagery
 Imagine a relaxing place—a sunny beach, a
fireside, a bubbling brook, or a pristine lake
surrounded by mountains.
 Use some pictures from favorite vacation spots
useful in labour pain.

78. Sylvia T. Brown, EdD, RN, Carol Douglas (2001)
conducted a retrospective study on Women's Evaluation
of Intrapartum Nonpharmacological Pain Relief
Methods among 46 women in Russia. The womens
reported that breathing techniques 58.7% as the most
effective pain relieving technique used during labor,
followed by relaxation 21.7%, acupressure 21.7%,
massage19.6%, position change 19.6%, Hot and cold
application 13.0, guided imagery 8.7%, music 4.3% ,
Hydrotherapy 2.25% and aromatherapy 0.0%. the study
concluded that the greater use of non pharmacological
techniques can contribute to better outcomes,