Category Archives: labor pain

Wallet Cards for Birth Classes

Long ago, I made small cards of the Key Questions for Informed Choice that I gave to students to keep in their wallets as a reminder. Recently, someone asked me for a copy of the file so they could print their own, and I discovered I had mis-placed it.

So, today, I created some new wallet cards, that you are welcome to use with doula clients, childbirth education students, or whoever would find them helpful.

Key Questions for Informed Choice

card listing key questions - benefits, risks, alternatives, timing

This file contains two versions of the key questions. Refer your clients to podcast episode 8 (or its transcript) to learn more about maternity care choices.

To learn more about how I teach clients the questions and how to weigh those against their personal goals and values, read about Teaching Decision Making.

Labor Comfort Techniques Reminder Card

labor comfort techniques card

I already had a two-page cheat sheet Guide to Labor Support. I created a comfort techniques wallet card to accompany it. Your clients can find the full Guide on the transcript of podcast episode 1 on Your Toolbox for Coping with Labor Pain.

There is more on the 3R’s in my episode on the Stages of Labor.

Visual Reminder of Comfort Techniques

comfort technique reminder card

If you feel like that first card is too wordy, and want something more visual, check out my visual comfort cards. These are not intended to stand alone. They would be best as reminders of concepts and techniques that you taught them, or that they can find in episode 4 – comfort techniques for labor. (The transcript for the episode includes a printable 2 page handout on these techniques.)

Printing the Cards

You could easily print these on paper or cardstock and cut them apart by hand.

I print my own nametags, so I always have “Name Badge Insert Refills” on hand, so I designed them to print on those. (They would also print on any of these products: 74461, 74549 or these Amazon brand cards. Note, those links are affiliate links, and I get a small referral fee from Amazon if you purchase after clicking on those links.)  These can easily be broken apart to create nice professional looking wallet size cards you can share.

Comfort Techniques for Labor

Learn comfort techniques and learn why they work. Cognitive strategies include education, visualization, affirmations, and choosing to view pain as a positive sign of labor progress. Gate Control techniques work by focusing  your attention on something pleasant (like music, a beautiful view or aromatherapy) instead of focusing on the labor pain – this blocks pain signals from reaching the brain, so you’ll experience less pain. Counter-irritants include things like biting your lip – a pain you control – to help make the pain you can’t control feel more manageable. And body mechanics involves using position, movement and massage to encourage baby to move into the best position to help labor to progress and be less painful. Here’s a printable handout that summarizes comfort techniques for labor.

[Transcription of episode and checklist of comfort measures available at]

Stages of Labor and the 3R’s

An overview of the stages of labor and comfort techniques for the first stage of labor: Early labor, as the cervix moves from 0 to 5 cm dilated is the longest phase of labor, but also the least intense. The focus is on Relaxation, so techniques like slow deep breathing visualization, massages and baths all help. In active labor as the cervix goes from 5 to 8 cm, contractions are longer, stronger, and closer together and take more work to cope with. The focus is on Rhythm, so rhythmic breathing helps, as does movement such as walking, slow dancing, or rocking on a birth ball or in a rocking chair. In transition, as the cervix dilates to 10 cm, contractions are coming hard and fast and it can be very overwhelming. So, the focus is Ritual – find something that works to reduce pain, and just keep doing it on every contraction to help feel like there’s some control over the process. [Transcript of podcast episode 3 at:]

Understanding Labor Pain

I discuss the physiology of pain and ways that people who have been through birth  describe how contractions feel. Given all of the physical changes and challenges of labor, it’s not surprising it is painful for many people. The acronym P.A.I.N. can remind us that labor pain is Purposeful, Anticipated, Intermittent, and Normal. However, understanding what factors make that pain worse than it has to be helps us learn how to reduce it. The Fear Tension Pain Triangle theory tells us that when we’re fearful, we tense up. As we tense, the pain increases, which frightens us more…. the fear increases, and so on. Instead, we want to explore ways to shift this to the Confidence Relaxation Comfort Triangle to make labor more manageable. [Transcript of podcast episode.]

Labor Pain Toolbox

Podcast Episode 1: The most common question from people preparing for labor is ‘how will we handle the pain’? This episode provides an overview of all the tools that we can stock in a Toolbox for Coping with Labor Pain. It introduces both non-drug comfort techniques and pain medications, explores how the choice of pain coping techniques influences the whole experience of labor, and discusses the Pain Medication Preference Scale, a helpful tool for clarifying and summarizing priorities related to pain medication. Knowing someone’s preference helps to guide the labor support team in how to support them through the challenges of labor. Learn about all these tools by listening to more episodes of this podcast, or by reading Pregnancy, Childbirth, and the Newborn.

[Transcript of this episode, with links to more info.]

Nitrous Oxide for Labor Pain

Nitrous oxide (also called “laughing gas” or “gas and air”) has long been in common use for labor pain in other countries, being used by more than half of laboring women in such countries as England, Finland, Sweden, and Canada. It has not been common in the United States in recent decades (it was only available at 5 hospitals in 2012); however, its popularity is now increasing as equipment becomes more widely available, and may soon be seen in more hospitals and out of hospital birth centers. This online article is intended as a supplement to chapter 13 of the 2016 edition of Pregnancy, Childbirth, and the Newborn which does not cover nitrous oxide.

How Administered

Nitrous oxide is a gas. It is mixed 50/50 with oxygen, and inhaled through a mask. (Note: If you’ve had nitrous at the dentist, that’s a 70/30 or 80/20 mixture. So the dose given in labor is lower than the dose at dental procedures, and has a milder effect.) The laboring mother holds the mask to her face whenever she wants a dose. The gas only flows when she inhales. When she moves the mask away, the medication stops. (To see what the equipment looks like in use, do an online image search for “nitrous oxide in labor.”)

The peak pain relief effect kicks in about 50 seconds after you start inhaling. But the peak intensity of contraction pain tends to be 25 – 45 seconds into a contraction. That means you need to start inhaling 30 seconds BEFORE the next contraction is expected so the gas is in full effect when the contraction pain peaks. It can be tricky to get timing just right.


Nitrous oxide stimulates the brain to release endorphins and dopamine, hormones that help to reduce pain. Nitrous oxide does not completely relieve labor pain, but women are less bothered by the pain. It reduces anxiety, and can cause a mildly euphoric feeling. Women describe themselves as feeling relaxed and calm while using it. Women report that they liked the fact that they had control over the administration. (To learn more about the laboring person’s experience of nitrous, watch this video from Vanderbilt at

Other benefits are that it’s inexpensive (at some hospitals, there’s no extra charge – it’s included in room cost), it takes effect quickly, and if you stop using it, the effects fade quickly (it has a half-life of 3 minutes) rather than remaining in your system for a long time. That means that if you decide nitrous does not provide enough pain relief, it’s easy to move on to other options, such as epidural analgesia.


One study (Pasha, 2012) found that 92% of women had less pain with nitrous than without. They were also less likely to have severe pain. On nitrous, 41% reported severe pain and 10% reported very severe pain. In the no-nitrous group, 55% had severe pain and 27% had very severe pain.

It’s important to note that nitrous oxide is a mild pain reliever. You should not expect it to take away all your pain. An epidural is much more effective at that; however, an epidural also has more tradeoffs and side effects, so you may choose to start with nitrous and see if that offers enough relief. Some nurses describe the choice to have nitrous as “why not try it and see if it helps.”

Rather than thinking of nitrous as pain relief, it may help to think of it as a ‘coping boost.’ One study showed that it did not reduce the intensity of pain much (as measured on a visual analog pain scale), but after the study period, when given the option to stop using it, women wanted to continue using it anyway. (Carstinou, 1994) The unpleasantness of the pain was reduced, and seemed more manageable. Another study found that 98% of users were satisfied with the experience of using nitrous oxide. (Pasha, 2012) Studies also show that women say they would use it again in a subsequent labor.


Unlike epidural analgesia, nitrous does not require extra procedures or extra monitoring. You will not need an IV or continuous fetal monitoring. You are also able to stand, move, and change positions. (If the oxygen comes from a portable tank, you can move around with it, but if the oxygen is piped in from the wall, you’ll need to stay near the bed.)

Possible Side Effects

Side effects on mother and baby are minimal, and less than those experienced with epidural analgesia and with IV / IM narcotics. They can include nausea, dizziness, drowsiness and a hazy memory of events. There is a small chance you could lose consciousness, but if you do, you drop the mask away from your face, and quickly recover. Nitrous does not slow labor and does not affect your ability to push. It does not appear to affect baby at birth. The portable pump is loud, but nurses report this does not seem to bother the user.

Nitrous is contra-indicated if you have persistent anemia / vitamin b12 deficiency.

Timing in Labor

Can be used at any time in labor, except you cannot have nitrous if you have had narcotics in the past two hours. You must wait for them to wear off.

Some cases where it might be especially helpful: during transition, during anxiety provoking procedures (such as vaginal exams, IV starts, stitches for a tear), for women who arrive at the hospital in heavy labor and need quick relief, and at any time by someone who wants to delay getting an epidural. Birth center midwives also report using it when a mom is considering a transfer to the hospital for pain medication. Anecdotally, they say that about half the time it has allowed the client to remain at the birth center.

Comparison to Other Methods

On page 211 – 212 of the book, we offer a chart called “Nonmedicated Labor versus Medicated Labor” that compares what labor is like if no pain medications are used, or if IV narcotics or epidural analgesia are used. Here is that same information for nitrous oxide, so you can easily compare and contrast to the other options.

Pain-Relief Option Used Nitrous Oxide
How it affects your experience of pain Increases pain-relieving endorphins, eases anxiety or fear, and enhances your mood. Small decrease in pain intensity, but makes pain less unpleasant. Can boost your ability to cope.
Feedback from women who used it “Labor was still intense, but it took my fear away and helped me calm down. It made it seem like coping with the pain was doable.”
How it affects your mental state You’re relaxed, calm, may be drowsy or light-headed.
How it affects your mobility You can walk, move around and change positions. If the equipment is hooked up to the wall (rather than being on a mobile cart), you will have to stay close to the bed.
What you’ll need from your support people You’ll still be experiencing pain (though you’ll be less distressed by it). You’ll still want support with comfort techniques and emotional support. Also, they can tell you when a contraction is about to start so you can begin inhaling. (Nitrous oxide is most effective if you start 30 seconds before the contraction.)
Equipment and precautions required You’ll hold the mask that dispenses the nitrous, inhaling from it as desired. Some women need an oxygen sensor on their fingers.
Impact on labor progress Does not affect labor progress.
Timing Can be used at any time, especially during anxiety provoking times in labor.
Availability Very limited availability in the U.S.
Possible risks to you Minimal. (See above.)
Possible risks to baby No apparent risks
Cost Inexpensive
Best option for you if… You just need a little boost to your ability to cope, or need to reduce your anxiety.

For more information:

Source for study data cited: Pasha, et al. Maternal expectations and experiences of labor analgesia with nitrous oxide. Iran Red Crescent Medical Journal, 2012.


Labor Hormones in under 10 minutes

Note: this page is about how professionals can TEACH this concept to expectant parents. If you’re an expectant parent looking for info on labor hormones, their effect on labor pain, and what your partner can do to help you have a shorter and less painful labor, read Hormones and Labor Pain or listen to episode 5 of my podcast – Labor Support.

In my childbirth classes, and with doula clients, I want them to understand that our emotions, and the support we receive, absolutely affect labor on a physiological basis, by influencing our hormones. The big message is that fear and anxiety slow labor down and make it more painful. Support and feeling safe make labor faster and easier. I have simplified the complex details into a simple stick figure drawing that takes 5-10 minutes.

Before I talk about my teaching method, let’s start with…

A basic summary* of hormones


  • What it does: Causes labor contractions that dilate cervix (i.e. helps labor progress)
  • What hinders oxytocin production: Anxiety, bright light, feeling observed or judged. Pitocin (if you’re given synthetic oxytocin, you make less hormonal oxytocin)
  • What increases oxytocin: Skin-to-skin contact. Nipple stimulation, making love.


  • What they do: Relieve pain, reduce stress (cause euphoria and feelings of interdependency)
  • What hinders endorphin production: Stress, lack of support. Narcotics (if you have an external opiate, your body will start producing less internal opiate… even after the narcotics wear off, you’ll have less endorphins)
  • What increases endorphins: social contact and support from loved ones.


  • What does it do: In early / active labor: slow labor down(Imagine a rabbit in a field. If it doesn’t feel safe, it wants to keep baby inside to protect it)  In pushing stage: Make you and baby alert and ready for birth, give you energy to push quickly. (If the rabbit is about to have a baby, and something frightens it, it wants to get the baby out as quickly as possible so it can pick it up and run with it.)
  • What increases adrenaline: Stress / anxiety / fear; Lack of control; Feeling trapped; Hunger, cold
  • What increases oxytocin and endorphins and reduces adrenaline: creating an environment where the birthing parent feels private, safe, not judged, loved, respected, protected, free to move about.

Teaching about Hormones

So, in class how do I convey these ideas in just a few minutes, so it’s easy to understand and to remember?

First, I say: “In labor, our emotions and our environment effect our hormones. Our hormones have a huge effect on labor. Let’s look at a couple scenarios for labor.” [I draw two stick figures on the board.] “This one is awash in stress hormones which will make labor longer and more painful. Let’s label it adrenaline. This one is under the influence of oxytocin and endorphins. These help the laboring person shift into an altered state where labor pain is milder (less intense and less unpleasant) and also help labor progress more quickly.” [Add labels to drawings, add sad face and smiley face.]


Then I say “So, you are all probably familiar with adrenaline. What do we call it? Yes, the fight or flight hormone. This is the idea that if an individual ran into a tiger in the woods, they would choose either to fight it or to run away. Do you know what we call oxytocin? Many call it “collect and protect” or “tend and befriend.” If a tiger is coming into our village, we gather everyone together, because we are safest together.” [I add these labels to my drawing.]  (I sometimes throw in the tidbit here that men who are not dads are more likely to release adrenaline during stressful situations; women and dads are more likely to release oxytocin – it’s the “gather the babies and protect them” response.)


“So, what effect do these hormones have?”

“With adrenaline, all your muscles tighten. All your energy goes to your limbs in case you need to fight or run away. So, oxytocin production drops and labor slows down. (It’s hard for your cervix to open when you feel scared…)  You are also more sensitive to pain – this is useful if you’re at risk of injury – your body tells you what to move away from. But, in labor it’s not helpful – it just means labor hurts more!”

“With oxytocin and endorphins all your muscles relax. Energy is sent to the uterus and oxytocin increases. (Oxytocin is often called the love hormone, because it increases when we feel loved, and its peak levels are when we orgasm, when we birth, and when we breastfeed. It’s all about making babies, birthing babies, and feeding babies.) We also get an increased endorphin flow, which makes us less sensitive to pain, can cause euphoria, and can cause feelings of love and dependency in us… “I love you man….””

[As you talk, write the notes, and draw on the figures like this to show effects…]


[If you teach the 3R’s method for coping with labor pain – relaxation, rhythm, and ritual, you can also add in here: If you’ve got oxytocin and endorphins flowing, you may also have more rhythm – you may rock, moan or sway rhythmically. If your partner helps to reinforce your ritual, it will help build your oxytocin and endorphins.]

“So, what causes adrenaline rushes? Fear, anxiety, feeling watched or judged, feeling like you have no control over your situation, being hungry or cold.”

“How can we tell a person in labor is rushing adrenaline? They act vigilant or panicky, have lots of muscle tension, and a high pitched voice.”

“What causes oxytocin and endorphins to flow? Feeling safe, loved, protected, having privacy, having support, eye contact, skin-to-skin contact, and love making.”

“How can we tell if someone is in an endorphin / oxytocin high? They seem open and trusting, their muscles are relaxed, and their voices are low-pitched and husky.”

[Add notes about causes and signs to your picture.]


“So, partners, what’s the big picture summary?”

“If you remember nothing else from this class, remember this: If a person in labor feels safe, loved, and supported, her labor will be faster and less painful. If in doubt about what to do, always return to this! Anything that helps her relax, gain her rhythm and feel cared for will help her.”

More Info

* If you want a great overview of hormones in labor, read Pathways to Birth. If you want all the details on hormones in labor, read Hormonal Physiology of Childbearing. You can find them both at:

Find more thoughts about teaching on my blog for childbirth educators. Check out ideas for interactive activities for childbirth  classes. To learn more about any topic related to the perinatal period, check out our book Pregnancy, Childbirth, and the Newborn: The Complete Guide

Pain Med Preferences

In classes, we talk about the Pain Medication Preference Scale from Pregnancy, Childbirth, and the Newborn. We have the expectant parents look at it together, and then encourage the pregnant parent to choose the number that best represents their preferences, and the support partner to choose what they WISH the pregnant parent would choose.

Then we have them discuss. Often they align, but not always. Sometimes there is a pregnant parent who is hoping for an un-medicated labor who has a partner who can’t bear the idea of seeing them in pain. Sometimes a pregnant parent wants medication, but the partner has concerns about side effects on them or the baby. I would much rather this issue come up during pregnancy when they can resolve it rather than arising without warning in labor.

I have designed a new worksheet that asks more questions about labor coping preferences that they can fill out separately, then discuss, to further illuminate these issues and enhance the discussion they can have about goals and preferences before labor begins. You can see the Pain Preferences Worksheet here – feel free to print and use in class.

Research Summary on Effectiveness of Non-Drug Coping Techniques

There have been several literature reviews of available research on the available non-pharmacological techniques for coping with labor pain. Each of these reviews acknowledges the limitations of the research that they compile: primarily the studies are small sample sizes, and are not properly randomized control trials. (Women are typically allowed to choose which coping techniques to use with their labor.) So, all conclusions come with the caveat that “more research is needed.”

This chart summarizes those reviews. (Note: the birth ball results are based on a single study rather than a review.) Pain coping techniques are compared to “usual care.”

The chart compares the following factors that might be desired outcomes coping measures: less pain intensity, less likelihood that the laboring mother will turn to pain medications (unless that was her goal), higher satisfaction with pain relief, shorter labor, higher chance of spontaneous vaginal delivery (vs. instrumental delivery or cesarean), and less use of Pitocin to augment a slow labor.

Source Less pain? Less pain meds? More satisfaction Shorter labor Spontan. vaginal Less pitocin
Acupressure yes *
Acupuncture yes yes
Acupuncture yes yes * yes * yes *
Aromatherapy NSD
Aromatherapy NSD NSD NSD NSD
Birth Ball yes * NSD
Continuous Support yes yes yes yes yes
Epidural & Pain Meds yes N/A yes no no no
Hypnosis yes * NSD NSD yes * NSD
Hypnosis yes yes yes yes
Immersion in Water yes NSD
Massage yes
Music / audio NSD NSD NSD
Positions & Movement yes yes yes
Relaxation yes yes yes
Sterile Water Inj. yes NSD
Sterile Water Inj. yes yes
TENS yes * NSD
Yoga yes yes yes

* means limited data; NSD means there may have been a difference, but it wasn’t statistically significant

(Note: In a 2014 review by Chaillet, et al, these techniques were pooled into 3 categories, which helped to increase the statistical significance of the findings. Learn more. Also check out more articles about coping with labor pain.)