Virtually all labor is accompanied by pain. Uterine contractions, cervical dilation, fetal descent, and perineal stretching (and, when it occurs, laceration) are all associated with pain. Although pain accompanies all labor, the patient’s perception of and response to pain is highly variable. Providers must be aware of all factors that contribute to the patient’s pain and adequately address each of these factors in order to achieve appropriate pain control.

Although the patient’s perception of pain depends on a variety of factors, the physiological basis of pain is reasonably well described. In the first stage of labor, most pain is secondary to uterine contractions, intermittent ischemia, and cervical dilation. The primary neurological innervation associated with these components is located at the level of T10–L1. In the second stage of labor, vaginal and perineal distentions are the primary source of pain. Innervation is at the level of S2–S4, the pudendal nerve.

Options for pain management include pharmacological and nonpharmacological modalities with which providers should be familiar. Among the nonpharmacological options are hydrotherapy, hypnotherapy, positioning, and support. Pharmacological options include epidural–spinal anesthesia, narcotic pain management, and local anesthesia.