Labor pain management other than neuraxial: what do we know and where do we go next?

Analgesia and coping with labor pain can prevent suffering during childbirth. Nonpharmacologic methods help women manage labor pain. Strong evidence is available for the efficacy of continuous one-to-one support from a woman trained to provide nonmedical care during labor, immersion in warm water during first-stage labor, and sterile water injected intracutaneously or subcutaneously at locations near a woman's lumbosacral spine to reduce back-labor pain. Sterile water injections also reduce the incidence of cesarean deliveries. Nitrous oxide labor analgesia is not potent, but helps women relax, gives them a sense of control, and reduces and distracts their perception of pain. It is inexpensive; can be administered and discontinued safely, simply, and quickly; has no adverse effects on the normal physiology and progress of labor; and does not require intensive monitoring or co-interventions. Parenteral opioids provide mild-to-moderate labor pain relief, but cause side effects. Although observational studies have found associations between maternal use of opioids and neonatal complications, little higher level evidence is available except that meperidine is associated with low Apgar scores. Patient-controlled intravenous administration of remifentanil provides better analgesia and satisfaction than other opioids, but can cause severe side effects; continuous monitoring of arterial oxygen saturation, anesthesia supervision, one-to-one nursing, and availability of oxygen are recommended. The demand for inexpensive, simple, safe but effective labor pain management for women will undoubtedly increase in places that lack wide access to it now.