Ineffective pain management is usually discussed in the context of pharmacologic methods of pain relief. However, women using nonpharmacologic methods of pain management in labor can also encounter periods of time when those tools become less effective and a mother who had previously been managing her labor well finds herself having difficulty coping. The typical medical response to this situation would simply be to offer pharmacologic pain relief. However, there are many alternatives that can be tried before abandoning the plan for an unmedicated birth. An understanding of some of the common patterns of uncontrolled pain can guide care providers and laboring women toward alternatives that may be the most helpful.

Significant Back Pain

“Back labor” is particularly difficult for women to manage with natural techniques. Some women predominantly feel contractions in their back, regardless of fetal position, but if a woman is complaining of strong back pain, a sunny-side up or occiput posterior baby is the usual culprit. In this position, the weight of the back of the baby’s head presses against the sacrum and creates intense discomfort. Alternative maternal positioning can help with both fetal rotation and pain relief, particularly forward-leaning positions.¹ Most mothers find lying in the bed to be a nearly impossible position to maintain when they are suffering through a back labor. Massage is another option that mothers and their labor support team can try to reduce back pain. Generally, for this type of discomfort a higher pressure massage of the lower back, buttocks, and thighs is most helpful, though the pressure should always be modified for the mother’s comfort. Some women may prefer light touch or effleurage massage, where the skin of the back and arms is gently skimmed with the fingertips instead of deeply pressing into the muscles. This also helps relax the muscles underneath and aids in calming the mother. Either technique can be easily performed with the mother in any of the forward-leaning positions and studies, while small in scope, have demonstrated less pain, shorter labors, and reduced feelings of depression and anxiety in massaged mothers.^2,3 The positive psychological effects are likely due to the touch element and more active involvement of the labor support team. Another specific hands-on technique that can be helpful for all laboring women, but particularly those with significant back pain, is counterpressure. Counterpressure is provided by placing the heels of both hands or fists on the woman’s lower back, at the level of the sacrum, directly above the buttocks, and applying strong, steady pressure during contractions. Many women working through a back labor request counterpressure through each contraction and find that it is the only tool that enables them to continue without medical intervention (Figure 11-1).

Hydrotherapy, as previously discussed, is one of the most effective, nonpharmacological methods of pain relief. For women struggling with significant back pain, the shower may be the most useful, as the water pressure and heat against the back aids in muscle relaxation in a manner similar to massage. Generally, however, the shower is only effective in 20-minute intervals and the mother should be encouraged to try alternatives once she finds the shower is no longer helpful. Some women go between the tub and shower, with the buoyancy of the tub relieving back pressure and the shower aiding in muscle relaxation. The best of both worlds can be a labor tub with a hand-held shower attachment which can be directed onto the lower back. On dry land, heat packs on the lower back can also assist a mother with poorly tolerated back pain.

Another option that may be considered is the use of a transcutaneous electrical nerve stimulation device, or TENS unit. The unit should be applied to the back, generally along acupressure points at the level of the sacrum and subscapular regions. TENS units have been studied widely and have not been shown to have significant benefit in labor; however, patients do report less severe pain with its use.⁴ Many labor units provide access to these devices, though they can also be purchased inexpensively by individual women. If other methods are not providing relief, a TENS may take the edge off the labor discomfort to a sufficient degree to enable a naturally laboring mother to avoid pharmacologic options (Figure 11-2).

Significant Hip Pain

Significant hip pain, like back pain, is often an indication of fetal malposition. An occiput transverse (OT) position generally creates hip pain on the side opposite to the direction the baby is facing, as the heavy back of the baby’s head pushes against the hip. An acynclitic position, where the baby’s head is angled against one hip or another, also creates hip pain. Alternative maternal positioning offers a good first step toward correcting these types of malpositions. Side-lying positions, the rollover sequence, and asymmetrical lunges and stances, as described in Chapters 6 and 9, are the best positions to try with a mother complaining of hip pain.