Women have sought relief from the pain of giving birth for centuries [*]. Today, 60-70% of U.S. women get an epidural analgesic to manage the pain of childbirth and it is generally regarded as the gold standard.
While the experience of childbirth is very individual and subject to many factors, women give the epidural the best ratings for pain management when compared with other medical and non-medical pain management options [*][*].
But the epidural isn't the only method to manage labor pain, and for some women, it may not be an option at all — or it simply may not work. So even if you’ve already decided the epidural is the way to go, it’s a good idea to know your options.
Here are the most common alternatives to the epidural — medical and non-medical — with an explanation of how they can alter the birth experience, whether they can affect the baby, and any known side effects or complications for the mother.
What Is an Epidural?
Epidural anesthesia is an injection into the lining of the spinal cord through the lower back that numbs you to a large extent from the waist down.
The epidural is typically administered in the first stage of labor when it’s clear that labor is progressing and you’re having regular contractions. Prior to the injection, the site is numbed with local analgesic. It is usually performed while the mother is sitting up. You may feel a slight pinch but it is not painful to get an epidural.
An epidural takes effect in 5-15 minutes. A flexible catheter about the size of angel hair pasta is inserted at the site of the injection to administer more anesthesia (or a combination of anesthesia and opioids) during the course of your labor.
The epidural can take several forms: Epidural (alone) or Combined Spinal Epidural (CSE), which combines a nerve block and epidural analgesics. Generally speaking, when opioids are mixed with the local anesthetic, as with CSE, doctors can administer 40-50% less of the local anesthetic [*].
The analgesic formula and its application varies among different hospitals, but generally speaking, the pain relief from an epidural is very significant. You will feel some pressure as the fetus moves through the birth canal, cueing you to push. You may be able to walk around some but if your birth plan involves a lot of moving, you’ll want to know ahead of time what the hospital’s policy is regarding movement once an epidural is administered. Some hospitals offer what they call a “walking” epidural.
Many women opt for the epidural because it allows them to stay awake and alert for the birth while also managing the worst of the pain most effectively. It’s also a low-risk procedure for mother and baby.
The first epidural for childbirth dates back to 1931 and was performed by a Romanian obstetrician [*]. By the 1980s, the epidural became common practice, replacing the rather dangerous and delirium-inducing Twilight Sleep concoction of morphine and scopolamine that persisted until the early 1970s [*].
That said, in the U.K., only 33% of women get an epidural and in Japan, only 5% do. And countries that are close and culturally similar may still vary widely, like Belgium (74%) and The Netherlands (5-38%) [*].
The use of epidural, alone or in combination with neuraxial analgesic, is a lifesaver — literally. A 2022 study found a significantly decreased risk (14%) of preventable maternal morbidity and postpartum hemorrhaging among women who opted for an epidural. This was especially true of racial and non-Hispanic ethnic minority women, for whom the risk of maternal morbidity is three times higher [*]. The study also notes that about 75% of pregnant women with health insurance receive labor neuraxial analgesia, but only half of uninsured pregnant women do.
Why Some Women Cannot Have an Epidural
There are instances when a woman cannot have an epidural, because:
They are not at the point in their labor that the hospital deems appropriate to administer an epidural, or they are past that point or fully dilated. Although the American Society of Anesthesiologists (ASA) states that a woman can get an epidural at any point in their labor, the decision is ultimately that of the administering doctors [*].
They have a blood clotting disorder or are taking blood thinners.
They have very low blood pressure.
They have a current infection.
They are allergic to anesthesia.
They have had certain back surgeries or a spinal disorder like scoliosis that makes finding the epidural space impossible.
They are bleeding heavily.
They are unable to remain still due to intense labor pain.
There is no anesthesiologist available.
Why Some Women Don’t Want An Epidural
There are a number of reasons why women opt out of an epidural even when it is available:
They want their body to naturally progress through labor.
They think an epidural may slow down their labor or lead to a C-section (recent studies have debunked these myths) [*].
They are afraid they won’t be able to walk. In debunking this myth, the ASA argues that your legs shouldn't be so numb that you don’t feel them, but they also advise against trying to walk right after the epidural has been administered [*].
They won’t be able to feel a contraction or push properly. This long-held belief was debunked in 2017 [*].
They think the epidural drugs can harm the baby or cause Cerebral Palsy. There is no evidence to support either notion [*].
Their own past experience.
They are uninsured and concerned about the cost.
They are concerned about the risks, side effects, or complications.
Epidural Risks, Side Effects, and Complications
According to Johns Hopkins Medical, risks from an epidural include:
Low blood pressure (10-20%)
Infection (less than .01%)
Bleeding (less than 1%)
Puncture in the spinal cord (1%)
Spinal Headache (less than 1%)
Allergic reaction (less than 1%)
Failed block (less than 1%)
Intravascular injection (1%)
These risks are understood by your care team and are very likely to be safely treated. It’s also worth noting the risks of going it alone, with no pain management, as the pain and stress of childbirth without pain management can decrease oxygen and blood flow to your baby [*]. In any case, when an epidural is used, your contractions and the baby’s heart rate will be continuously monitored.
Side effects and complications arising from epidural during childbirth are fairly rare. They may include:
Trouble passing urine
Nausea and mild back pain after delivery
Failure to work
There are a few reasons why epidural catheters may fail to work [*]:
Initial misplacement outside the epidural space
Movement over time
Poor distribution of medication within the epidural space
Inadequate dose of medication
Alternatives to Epidural
There are a number of medical and drug-free options for labor pain management. Studies show that a combination of medical and non-medical pain management techniques yields the most positive experience [*].
Medical Alternatives to Epidural
Medical alternatives to the epidural may take the edge off but they can adversely affect mother and baby in the short term. If you’re sensitive to opioids (like codeine, hydrocodone, or vicodin), you may want to avoid the opioid options administered for labor.
Nitrous oxide, aka laughing gas, can take the edge off the pain by delivering a pleasant, euphoric effect. The mother applies the mask herself, and the agency in so doing may contribute to the positive ratings. On the downside, too much laughing gas will not have you laughing: Nausea, vomiting, dizziness, and drowsiness are common side effects.
Pethidine is a synthetic opioid that is injected into your thigh or buttock to relieve pain and help you relax. It takes about 20 minutes to work and lasts 2-4 hours so it’s best not to use it if you are approaching the second (pushing) stage of labor. Pethidine side effects include feeling woozy, nauseous, or itchy. If given too close to the delivery, it can affect the baby’s breathing, as well as its first feed [*].
Remifentanil is administered via a vein in your arm. It is a short-acting synthetic opioid with a rapid onset (about a minute) and current clinical evidence supports its use in the first stage of labor. Its effects last for about 3 minutes, and it does not accumulate. Remifentanil may be safer than other opioids for the fetus, because, although it does cross into the placenta, it undergoes rapid fetal elimination. One study found that Remifentanil resulted in less crossover to epidural analgesia compared with pethidine, but respiratory depression is more common with remifentanil so when it is used, close monitoring is required [*]. Remifentanil side effects include nausea, vomiting, sedation, and itching [*].
Spinal Nerve Block
With a spinal block, the injection is closer to the spinal cord and will take effect in about 5 minutes and last 1-2 hours, numbing you below the waist. It is often used in tandem with epidural analgesia in the Combined Spinal Epidural (CSE).
Drug-Free Alternatives to Epidural
There are a number of options for pain management during labor without epidural or opiates. Many women combine medical and drug-free alternatives to minimize the amount of medication they receive while reducing their anxiety and giving them some agency over their bodies. As an added bonus, there are no risks or side effects associated with non-medical pain management.
Comfort With Your Care Team
Studies have shown that fear and anxiety while in labor release cortisol (a stress hormone), can increase feelings of pain, increase medical interventions such as oxytocin, use of epidural, and even lengthen the duration of your labor [*]. The first step to reducing anxiety is to be comfortable with your care team. Talk to your OB-GYN or midwife about your birth plan to understand how they intend to meet your needs.
Doula or Midwife Support
Continuous support during labor from a doula or midwife consistently yields shorter labors and higher satisfaction ratings from mothers [*]. Midwives focus on the clinical aspects of your care while doulas focus on the emotional and practical aspects.
There are a number of childbirth classes you can participate in to know what to expect and have some feeling of control over your body. These include Lamaze, The Bradley Method, The Mongan Method, and The Alexander Technique [*]. Studies have shown that childbirth education relieves anxiety and decreases the amount of pain medication and medical interventions required, as well as helping parents transition to caring for their newborn [*].
Multiple studies have shown yoga to offer positive outcomes for mother and baby and reduce the potential complications associated with childbirth. In one study that had women practicing yoga twice a week for 75 minutes, yoga was shown to reduce the need to induce labor, positively affect the duration of labor, mitigate the need for medical interventions, and improve Apgar scores among newborns [*].
There are a number of studies that attempt to quantify the mechanisms by which hydrotherapy decreases anxiety and promotes relaxation during labor. Given that we are all gestated in fluid and more than half of our bodies are composed of water, it’s no surprise that being immersed in water during labor can create more blood volume to the heart, decrease cortisol, and reduce pain, especially among women in a high degree of pain [*]. Hydrotherapy is not the same as water birth; It is used during labor, not delivery. However, some women also opt for this in tandem with water birth. Ask your birth center if a hydrotherapy tub will be available to you if you want to explore this option.
TENS stands for transcutaneous electrical nerve stimulation. The handheld unit has wires connected to electrodes that are placed on the skin (typically the back) with the intention of disrupting the pain signal to the nerves and generating endorphins. TENS has been used for labor since the 1970s, but researchers say it’s hard to gauge whether it may be effective because it distracts from the pain of contractions or actually manages the pain [*].
Massage during pregnancy has been shown to reduce anxiety and cortisol levels as well as back and leg pain. One study found that during labor, women who received massage on the back and legs from a side-lying position had less pain, less need for medication, and a labor shorter on average by 3 hours. This may be due in part to the “gate theory”, which states that pressure messages travel to the brain faster than pain messages, in effect closing the gate to the pain messages [*].
There is no conclusive evidence that hypnosis offers pain relief during labor, but it may help change the perception of pain, for instance, as a way to feel closer to their baby rather than something associated with injury [*]. The distraction hypnosis may provide may also be useful, in the same way that music might help take your mind off the pain.
Acupuncture and Acupressure
The research surrounding acupuncture and acupressure for labor pain relief is sketchy. Both may help relieve pain somewhat during labor but there is no conclusive evidence of their effectiveness [*].
Sterile Water Injection
Injecting sterile water into the lower back can relieve lower back pain known as back labor [*]. It is typically used for the first stage of labor, even for women who may opt for an epidural when labor proceeds. The pain relief has been shown to last 45-90 minutes and it can be repeated during the course of labor. It can be administered by a midwife and is safe, effective, and low cost. [*] [*]
Swiss Ball or Birthing Ball
A round exercise ball called a birthing ball has been used for decades by nurses and midwives to help reduce pain and move labor along. There is some evidence to support its use. On a scale of 1-10, one study showed it reduced labor pain by 1.7 points [*]. If you’re not using an epidural, changing positions, walking around the bed, and squatting may help as well [*].
Cognitive Behavioral Therapy
If you suffer from tokophobia — an extreme fear of childbirth — tools like behavioral therapy from a qualified mental health professional, hypnotherapy, yoga or meditation, support groups, and prenatal classes can help identify the source of your fear and help you get it under control so you can appreciate the joys of welcoming a new baby into your life.
Epidural Alternatives: Which Is Best?
It’s hard to say which alternative to epidural will be best for you. It really depends on how you hope to experience the birth of your child, the support available to you, and your health and well-being going into the labor.
Studies have shown that vaginal birth offers more positive outcomes to both mother and baby. As a rule of thumb, look to epidural alternatives that empower you to deliver vaginally and minimize your anxiety, maximize your feeling of being in control, and help you be as prepared and comfortable as you can.
Yoga, massage, hydrotherapy, TENS, prenatal education, and even hypnotherapy are things you can experiment with during the course of your pregnancy to alleviate discomfort and anxiety. Knowing what works for you is key. And remember, you don’t have to pick only one alternative to epidural. Certain epidural alternatives may be better during the first stage of labor than the last, for instance.
The Bottom Line
For women who don’t want an epidural for whatever reason or cannot have one, there are plenty of alternatives to an epidural that can help ease the pain, anxiety and shorten the duration of labor.
Talk to your care team if you’re interested in alternatives to epidural so you know what they think will work best for you based on their experience, the position of your baby, your health, and the birth experience you want to have.
Beyond the Birth
As you try to prepare for your child’s birth, it may be hard to imagine anything beyond that magical moment. But saving your baby’s cord blood or tissue could save your baby’s (or a future sibling’s) life down the road. Today, there are more than 80 FDA-approved cord blood stem cell treatments for heritable blood disorders such as leukemia and sickle cell anemia, and more than 700 clinical trials in progress. That’s a lot of good reasons to save your baby’s cord blood.
MiracleCord offers the industry’s most advanced and comprehensive cord blood and tissue banking — at prices families can afford. Learn more by downloading our Free Info Kit, or call 888.743.2673 to speak to one of our knowledgeable customer service representatives.