Your pain relief options in NHS Lothian

This page was last updated on 11th February 2024

This section was developed by NHS Lothian Consultant Obstetric Anaesthetists in collaboration with Lothian Maternity Voices Partnership. It provides information about the various options for pain relief available to you in NHS Lothian Maternity Units.

Labour ‘pain’ comes mainly from the stretching of the muscles of the uterus (womb) and cervix (neck of the womb) and is experienced differently by everyone. When in labour your body produces natural painkillers called endorphins. To help you adapt to the extra demands of carrying a baby, endorphin levels rise as pregnancy progresses, and even more during labour. These endorphins act in three ways:

They reduce physical pain.
They create a sense of well-being.
They have a memory-loss effect.

This helps explain why many women cope well with labour and birth yet may remember little of the pain afterwards. Some women do not describe their labour as painful at all and instead describe the contractions as just very intense. Labour pain and contractions may also change in sensation, frequency and duration throughout labour and each individual will experience and cope with pain differently, so you may consider trying a variety of different methods to help you throughout your labour. It can therefore be helpful to know what pain relief options are available to you before you go into labour. It can also be helpful for whoever is going to be with you during your labour to know about the different options, as well as how they can support you. You may also find it helpful to:

Talk to your midwife about what pain relief will be available to you, so you can decide what’s best for you.
Write down your wishes in your birth plan.
Learn as much as you can about labour – for example by talking to your midwife and going to some antenatal classes.
Keep moving and try different positions during labour.
Arrange to have a birth partner who can support you, if you can.

Remember that you can think ‘BRAiN’ to help you think about what is best for you and to help you to ask questions about your pregnancy:

You can watch an NHS Lothian video about your pain relief options here

1. Methods Without Medication

Breathing and Relaxation Techniques

Breathing and relaxation techniques can help you cope with the intensity of the contractions and keep you calm and relaxed. Slow rhythmic breathing can help you get into a more relaxed state. You will find that you cope less well when you’re tense and anxious. When you are relaxed, your body releases its own hormone-like pain relievers called endorphins and these help you to cope better.

It can be difficult to relax when you are in pain, so it can be helpful to practise before you actually go into labour. There are a number of different ways you can learn to relax.

You can use breathing techniques at the same time as using other pain relief options.

Aromatherapy

A full range of aromatherapy oils is available in the NHS Lothian hospital labour wards and the Lothian Birth Centre. Aromatherapy can help relax you and invigorate your senses to support you through your labour and birth experience. Different oils have different purposes. Your midwife (trained in aromatherapy) can guide you to create your own combination of oils for diffusing or for massage.

TENS Machines

(Transcutaneous Electrical Nerve Stimulation)

A TENS machine sends small electrical pulses to your body when you are having contractions, via sticky electrode pads attached to your back. This creates a tingling feeling. Many women find this can help reduce the pain experienced during labour. While it’s not known exactly how a TENS machine helps to relieve pain, it’s thought that the pulses ‘distract’ the nerves that are transmitting pain.

Using one may also boost your endorphin levels – your body’s natural form of pain defence.

You can hire or buy a TENS machine, so you have it ready at the start of labour. For the best results you should start using it early in your labour.

Pros of TENS Machine

A TENS machine doesn’t affect your baby.
You can stay in control of it yourself by pressing a button to control the strength of the current
You can use other pain relief at the same time.
You can use it wherever you’re planning to give birth.

Cons of TENS Machine

If you wait and start using a TENS machine when you’re in active labour, it will not be as effective.
It may not work for all women.
You can’t use it in a birthing pool, bath or shower as there is a danger of electrocution.

Water for Labour and Birth (Birthing pool)

Birthing pool in the labour ward at the Royal Infirmary of Edinburgh

Some women find that being in the water helps them to relax and cope better. The water also provides support for your body so you can move more freely. A birth pool is larger and deeper than a bath so there is space to move in the water. You can hire or purchase a birth pool to use at home and they are available in our maternity units – in all the rooms at the Lothian Birth Centre but only in some of the rooms on the labour wards at the Royal Infirmary of Edinburgh and St John’s Hospital.

There may be some reasons why you might be advised not to labour or birth in the pool, such as complications in your pregnancy. Your midwife or obstetrician will discuss these with you.

Research into use of water for labour and birth is limited and there have been no large, collaborative, randomised controlled trials to date. However, there is some evidence that shows birthing pools might reduce the length of the first stage of labour and reduce the need for epidural analgesia. Current evidence has not shown any increase in adverse outcomes (for mother or baby) for women using the pool who are in spontaneous labour after an uncomplicated pregnancy. If there are any concerns about you or your baby’s well-being then you may be advised to leave the birthing pool.

Pros of Birthing Pool

The water allows you to experience a ‘weightless’ feeling and can reduce both your body’s production of stress-related hormones and increase the body’s own pain-relieving hormones.
You stay in control because you can get out at any time.
You can also use gas and air (Entonox).
Water can help the tissues of the perineum to stretch and relax. This is known to reduce the chance of having severe tears or the need for an episiotomy.

Cons of Birthing Pool

Pain relief options are limited as you are not able to continue using a TENS machine or have a morphine injection or epidural whilst in the pool.
A birth pool may not be available if these rooms are already in use.
Birth pools take time to fill, so if things happen quickly you might not have time to use it.
There have been concerns of breathing problems and infections carried in the water as being a rare risk to babies born in birthing pools. However, a large 2018 UK review states there is no evidence of harm but that the evidence is limited

Sterile Water Injections

The Royal Infirmary labour ward and Lothian birth centre offer sterile water injections as pain relief. This is not available for homebirths yet. This procedure uses sterile water to help with counteracting back pain. The effect lasts between 90 mins and 2 1/5 hours.

You can have this several times and you can go home after it. It can be used with other pain relief options. It is particularly useful in early labour and we have seen great results with this form of pain relief.

Pros of Sterile Water Injections

Instant pain relief
Drug free

Cons of Sterile Water Injections

Painful, like bee-stings when the water is injected but this is short-lasting.

2. Methods With Medication

Gas and Air (Entonox)

Gas and Air is a mixture of oxygen and nitrous oxide gas. It will not remove all of the intensity from the contraction but it can help reduce it and make it more manageable. This is available in all the birth settings, including for a home birth.

You breathe it in just as a contraction begins using a mouthpiece, which you hold yourself. It works best if you take slow, deep breaths. Many women like it because it’s easy to use and they control it themselves. It takes about 15-20 seconds to work, so you breathe it in just as a contraction begins.

You may have read about concerns for midwives being exposed to Entonox during their work . An air quality survey was done across all NHS Lothian premises in September 2022, when this was first alerted as a risk, and levels were found to be well within the recommended workplace exposure limits. We are continuing to work with occupational health to mitigate exposure.

Pros of Gas and Air

It takes the edge off the contraction and is easy to use.
It works quickly.
It can be used at any time during labour.
It can be used with other forms of pain relief.
You are in control of how often and when to use it.
There are no effects to the baby.
You can stop using it at any point and the effects go away quickly.
No effects on labour or delivery

Cons of Gas and Air

The pain relief effect can be mild.
It might make your mouth feel dry (sipping water or sucking ice cubes will help with this).
Prolonged use can be tiring
It may make you feel sick or lightheaded, if this happens you can stop using it and the effects will ease.

Morphine Injection

Available in all the NHS Lothian labour wards and the NHS Lothian birth centre. It may help you if you are feeling overwhelmed in labour. Morphine is an opioid drug. These are strong painkillers. Morphine is given as an injection into a big muscle, such as your buttock or the top of your leg. It takes around about 20 minutes to work and the effects tend to last for around 2 and 4 hours.

Morphine can affect your baby’s breathing when they are born, particularly if it’s given shortly before you give birth. If you’re about to give birth your midwife or doctor may suggest you do not have the injection for this reason and will try to offer you alternatives.

Pros of Morphine Injection

Morphine and opioid drugs work relatively quickly and last for a few hours.
They may help you cope better with contractions.
You may be able to sleep through contractions.
They can help you to relax.
You can have more than one dose.

Cons of Morphine Injection

It can cause nausea and vomiting, anti-sickness medication is therefore usually given at the same time to help with this.
It can make you feel sleepy and not in control.
It crosses the placenta and may affect you baby’s breathing after the birth and they may be drowsy, which could affect breastfeeding.
You won’t be able to use the birthing pool for at least 2 hours after you’ve had an injection.

Remifentanil

Remifentanil is an opioid drug which is a strong painkiller similar to morphine, however it is very short acting. It is given by a pump connected to a drip in your hand or your arm. You control the medication yourself with a button: this is called patient-controlled analgesia (PCA). You press the button when you feel a contraction building. The machine has a safety mechanism which means you can only give yourself one dose every few minutes. Because you’ll be attached to monitors and a drip, you may not be able to move around as freely. This method is available in the NHS Lothian labour wards.

Pros of Remifentanil

It works quickly- you will usually feel the effects within 20-30 seconds of pressing the button.
It is removed by the body quickly, so it has few side-effects for you and your baby.
As it is removed from the body quickly the side-effects are usually short lived and gone within around 15 minutes.
You are in control of your pain relief.

Cons of Remifentanil

It can make you feel sleepy.
It does not provide total pain relief.
It can cause sickness and itching.
You will need some extra monitoring as it can slow down your breathing and lower your oxygen levels, this will be monitored using a small clip on one of your fingers. Your midwife will observe this closely and you may need a small amount of oxygen.

Epidural

Epidurals are available to you at all times on all our labour wards in NHS Lothian: at the Royal Infirmary of Edinburgh ( Simpson’s Centre for Reproductive Health) and at St John’s Hospital Maternity Unit. It is not possible to have an epidural in the birth centre or at home.

An epidural is a flexible small plastic tube inserted into your back to deliver pain-relieving medicine. It numbs the nerves that carry the pain impulses from the birth canal to the brain. The aim of an epidural is to ease the pain of labour while still letting you move around and push when your baby’s being born.

If you choose to have an epidural, your medical team will recommend that you and your baby are monitored more closely. This usually means that your blood pressure will be checked more often, and you may need to be put on a fluid drip. Closer monitoring means that your baby’s heartbeat will also be monitored using a CTG machine (electronic monitoring). An epidural should continue working until after your baby is born, your placenta is delivered and any stitching you need has been done.

An anaesthetist is the only person who can give an epidural, therefore you can only have an epidural if you are in an NHS Lothian hospital labour ward.

Pros of an Epidural

It usually provides good pain relief.
It takes away the sensation of the contractions and may take away the sensation of giving birth too.
It doesn’t make you sleepy.
It is not linked to a longer first stage of labour or an increased chance of having a caesarean section.
In general epidurals do not affect your baby and you can breastfeed as normal when they are born.
Can be topped up for a forceps delivery or caesarean section if required.

Cons of an Epidural

You will need to be monitored more closely in labour.
You may not be able to move around as much after you’ve had an epidural.
Epidurals are linked to a longer second stage of labour (pushing stage) and an increased chance of an assisted vaginal birth (Ventouse or Forceps)
You may develop low blood pressure, itching or a fever during the epidural.
About 1 in 10 epidurals don’t work perfectly at first. If yours doesn’t work, you may need to have it adjusted or replaced.
The epidural site may be tender but usually only for a few days. Backache is NOT caused by epidurals but is common after any pregnancy.
It can cause bad headaches for a few days or weeks after the birth in about 1 in 100 cases – this can usually be treated with painkillers and fluids but often needs special treatment.
It can cause a long-lasting nerve injury, such as a numb patch on your leg or a slightly weak leg. This is very rare.

NHS Lothian videos about having an epidural in labour

This short video will provide you with information about having an epidural during the birth of your baby.

This short video will provide you with information about the option of moving around safely while you have an epidural during your labour. This is referred to as a ‘mobile epidural’. With a mobile epidural it may be possible for you to adopt different positions in or beside your bed, or even walk carefully around your birthing room, supported by your midwife or birthing partner. NHS Lothian is making ‘mobile epidurals’ more available for women in labour. You can ask your midwife if this is an available and suitable option for you.

3. Pain relief options comparison

The Labour Pains website (public information website of the Obstetric Anaesthetists’ Association) has useful information about the different pain relief options available. There is an online tool to compare the different pain relief options available to you.

There are also translations of the leaflets and resources, available in 33 languages.