No. 355-Physiologic Basis of Pain in Labour and Delivery: An Evidence-Based Approach to its Management



      To review the evidence relating to nonpharmacological approaches in the management of pain during labour and delivery. To formulate recommendations for the usage of nonpharmacological approaches to pain management.


      Nonpharmacological methods available for pain management during labour and delivery exist. These should be included in the counselling and care of women.


      PubMed and Medline were searched for articles in French and English on subjects related to “breastfeeding,” “pain,” “epidural,” “anaesthesia,” “analgesia,” “labour,” “labor,” and combined with “gate control theory,” “alternative therapies,” “massage,” “position,” “mobility,” “TENS,” “bathing,” “DNIC,” “acupuncture,” “acupressure,” “sterile water injection,” “higher center,” “control mind,” “cognitive structuring,” “holistic health,” “complementary therapy(ies),” “breathing,” “relaxation,” “mental imagery,” “visualization,” “mind focusing,” “hypnosis,” “auto-hypnosis,” “sophrology,” “mind and body interventions,” “music,” “odors,” “biofeedback,” “Lamaze,” “Bonapace,” “prenatal training,” “gymnastic,” “chanting,” “haptonomy,” “environment,” “transcutaneous electrical stimulus-stimulation,” “antenatal education,” “support,” “continuous support,” “psychosocial support,” “psychosomatic medicine,” “supportive care,” “companion,” “intrapartum care,” “nurse,” “midwife(ves),” “father,” “doula,” “caregiver,” “ hormones,” “oxytocin,” “endorphin,” “prolactin,” “catecholamine,” “adrenaline,” and “noradrenaline” from 1990 to December 2015. Additional studies were identified by screening reference lists from selected studies and from expert suggestions. No language restrictions were applied.

      Validation methods

      The quality of the evidence is rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice are ranked according to the method described in this report.

      Benefits, risks, and cost

      The nonpharmacological method encourages an incremental approach to pain management that contributes to reduced interventions through optimal use of the woman's neurophysiologic and endocrine resources and a better understanding of the physiology of stress and pain during labour.

      Guideline update

      The guideline will be reviewed 5 years after publication to decide whether all of part of the guideline should be updated. However, if important new evidence is published prior to the 5-year cycles, the review process may be accelerated for a more rapid update of some recommendations.


      This guideline was developed with resources funded by The Society of Obstetricians and Gynaecologists of Canada.

      Summary Statements

      • 1.
        It is important that all health care professionals have a good understanding of pain in childbirth including its physiological and psychological management whether or not a person in labour also chooses pharmacological relief (III).
      • 2.
        A growing body of scientific literature supports the use of nonpharmacological approaches to pain management during childbirth due to their numerous benefits for the mother and child, including a reduction in the need for obstetrical interventions, labour augmentation, or Caesarean section (l).
      • 3.
        Suffering, as opposed to pain, occurs when a woman is unable to activate her own mechanisms for coping with pain, or when her own mechanisms are insufficient to deal with the situation (III).
      • 4.
        The Gate Control Theory mechanism, which consists of creating pleasant stimulations in the painful area between or during contractions is best achieved through ambulation, gentle massage, stroking, water, or vibrations (I).
      • 5.
        The Diffuse Noxious Inhibitory Control (which consists of applying painful stimulations at any site on the body for the duration of each painful contraction) is best achieved through acupressure, sterile water injections, or deep massage (I).
      • 6.
        The Central Nervous System Control mechanism, which consists of deviating or focussing the woman's attention is best activated through labour support and the practice of yoga, relaxation, visualization, breathing, auto-hypnosis and cognitive restructuring (I).
      • 7.
        Continuous labour support, as part of nonpharmacological approaches to pain management during childbirth, reduces stress, fear, and anxiety, which in turn decreases the frequency of obstetrical interventions (I).
      • 8.
        Natural oxytocin is not only important for uterine contractions; it enhances a sense of calmness and reduces pain. Because synthetic oxytocin does not cross the blood-brain barrier in a significant manner, the analgesic and psychological effects on the mother of calmness and well-being are lost (II).
      • 9.
        Elevated endorphins in labour help reduce maternal stress and pain and may assist in newborn adaptations (II).
      • 10.
        Health care providers and the birthing environment can have a major impact on labour progress and experience by paying attention to and reducing a woman's stress level (I).
      • 11.
        Prolactin not only promotes breast milk production, it optimizes the mother's physiologic and behavioural responses in adapting to her role (II).
      • 12.
        Creating a calm, stress-free environment, encouraging women, and having a positive attitude where possible play an important role to stimulate the endogenous hormone production that promotes and supports the physiologic progress of labour (II).
      • 13.
        Neurophysiologic and hormonal mechanisms contribute to help women cope with the intensity of labour (l).


      • 1.
        Health care providers should be familiar with the neurophysiological and hormonal mechanisms and related methods in physiological labour and birth (III-A).
      • 2.
        To help women cope with normal labour, nonpharmacological approaches are recommended as a safe first-line method for pain relief and should be continued throughout labour whether or not pharmacologic methods are used (I-A).
      • 3.
        To prevent suffering, health professionals should address the emotional component of pain (pain unpleasantness). This is most effectively achieved through support and nonpharmacological approaches to pain management.
      • 4.
        To develop support measures consistent with the wishes of women, health professionals should work with women and listen to their needs (III-A).
      • 5.
        To further reduce the need for obstetric interventions and avoid associated risks and side-effects, health professionals should provide continuous labour support with the addition of at least one other nonpharmacological pain modulating mechanism (I-A).
      • 6.
        Health professionals should, where possible, promote and support the physiological progress of labour, delivery, and the postpartum period trusting the woman's ability to work with her pain and encouraging her to rely on her ability to give birth (III-A).
      • 7.
        To enhance the endogenous hormone production that promotes and supports the physiologic process of labour, health care providers should reduce a woman's stress level by encouraging her and having a positive attitude where possible and by creating a calm, stress-free environment (I-A).
      • 8.
        Continuous labour support, as part of nonpharmacological approaches to pain management during childbirth for women should be promoted and provided for all women in labour (I-A).
      • 9.
        Health professionals should encourage parents and the people assisting them to prepare for the birth by learning about birth physiology and gaining skills in working with pain (III-A).

      Key Words


      CNS (central nervous system), CNSC (control of the higher centres of the CNS), DNIC (diffuse noxious inhibitory control), OR (odds ratio), RCT (randomized controlled trial), SOGC (Society of Obstetricians and Gynaecologists of Canada), TENS (transcutaneous electrical nerve stimulation)
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