What is back labor

“Back labor” is a term used to describe intense lower back pain and cramping during and sometimes between labor contractions. Back labor occurs when the baby’s head puts pressure on your lower back. The amount of back pain felt during labor and delivery is different for every woman. The level of back pain depends on many factors, including the size and position of the baby, the woman’s level of comfort with the process, and the strength of her contractions. To prepare for the passage of the baby through the birth canal, a hormone relaxes the ligaments in the joints of your pelvis. This loosening allows the joints to become more flexible, but it also can cause back pain if the joints become too mobile.

Most babies’ heads enter the pelvis facing to one side, and then rotate to face down. Sometimes, a baby will be facing up, towards the mother’s abdomen. Intense back labor often goes along with this position. Your doctor might try to rotate the baby, or the baby might turn on its own.

During the first stage of labor, women usually perceive the visceral pain of diffuse abdominal cramping and uterine contractions. In the second stage of labor, there is a sharper and more continuous somatic pain in the perineum. Pressure or nerve entrapment caused by the fetus’s head can cause severe back or leg pain. A woman who has never given birth (nulliparous woman) generally experiences more sensory pain during early labor ¹, while multiparous women may experience more intense pain during the late first stage and the second stage of labor, as a result of rapid fetal descent ².

Women’s expectations about labor pain often are confirmed by their experience of childbirth ³. Anxiety and fear of pain correlate with a higher reported experience of pain ⁴. A woman’s confidence in her ability to cope with labor is the best predictor of pain during the first stage of labor, accounting for nearly one third of the reported variance in pain ⁵. Cultural values and learned behaviors also influence perception and response to acute pain ⁶.

There are two general ways to relieve pain during labor and delivery: using medications and using “natural” methods (no medications). Some women choose one way or another, while other women rely on a combination of the two. Regional anesthesia methods (epidural, spinal, or epidural-spinal combination) are considered the most popular and most effective methods for addressing labor pain ⁷.

Various noninvasive (hydrotherapy, acupuncture, yoga, music, counter-pressure, acupressure, relaxation, breathing techniques, positioning/movement, and transcutaneous electrical nerve stimulation) and pharmacologic treatments (nitrous oxide, opioids, and regional analgesia techniques: spinal, epidural, and combined epidural analgesia) are available for managing labor pain ⁸.

To ease back pain during labor:

• Try massage. Ask your partner or labor coach to rub your lower back. Counter pressure against your lower back with a closed fist or tennis ball might help. Having one or two people provide pressure against your hips during contractions while you lean forward onto something might help, too. This is known as the double hip squeeze.
• Change positions. Straddle a chair and lean forward or kneel against a pile of pillows or a birthing ball. Take the pressure off your spine by getting on your hands and knees. To give your arms a break, lower your shoulders to the bed or a floor mat and place your head on a pillow. When you’re lying down, lie on your side rather than on your back.
• Consider medication. Epidural and spinal anesthesia can temporarily block pain in your lower body. Although not widely used, some research suggests that shallow injections of sterile water to the lower back can provide temporary — but potentially significant — relief from back pain during labor.
• Hydrotherapy. Soaking in a tub or aiming the shower head at your lower back might provide relief.

A woman should discuss the many aspects of labor with her health care provider well before labor begins to ensure that she understands all of the options, risks, and benefits of pain relief during labor and delivery before making a decision. It might also be helpful to put all the decisions in writing to clarify things for all those who might be involved with delivering the baby.

Work with your health care team to evaluate your options for pain relief during labor. Whether you experience back labor or feel labor pain elsewhere, being familiar with pain management techniques can give you a greater sense of control.

Back labor contractions

Contractions refers to when the muscles in your womb (uterus) contract, causing pain in your lower tummy and/or back. They move from the top of the uterus to the bottom, and you may experience a dull ache. You should be able to relax in between contractions.

You might start having irregular contractions during the last few months of your pregnancy. They will feel like your uterus is tightening and then relaxing. These are called Braxton Hicks contractions.

When you go into labor, the contractions change. Unlike Braxton Hicks contractions, these ‘true’ contractions:

• come in a regular pattern and gradually get stronger and closer together
• last about 30 to 70 seconds
• continue when you change position

Contractions are timed from the beginning of one contraction to the beginning of the next. Usually, you will be advised to stay at home until your contractions are coming every 5 minutes.

Having strong, regular contractions before you are 37 weeks pregnant can be one of the signs of premature labor. If you think you are in premature labor, seek medical help immediately. Labor is very hard to stop once it’s established.

Self-help for contractions

The best way to deal with contractions is to relax. Moving around while you are in labor will help to ease the pain. Hot and cold packs or having a warm bath or shower can also help, as can having a massage or listening to relaxing music during each contraction.

There are various medical options for pain relief during labor, including a sterile water injection in your back for lower back pain, gas, pethidine, or an epidural (a local anesthetic injected into your back).

When to seek help for contractions

If you are less than 37 weeks pregnant and you are having strong, regular contractions every 10 minutes — or even more frequently — call a doctor right away.

Other signs you might be in premature labor include:

• fluid leaking from your vagina
• a change in vaginal discharge
• bleeding from your vagina
• a dull backache
• pressure in your vagina or rectum
• cramps that feel like period pain
• your baby stopping moving (or moving less than previously)

Back labor vs Back pain

Pregnancy related pelvic girdle pain and pregnancy-related low back pain are very common, with around 45% of all pregnant women and 25% of all postpartum women suffering from pelvic girdle pain and/or pregnancy-related low back pain ⁹. The main cause of back pain during pregnancy is strain on your back muscles. As your pregnancy progresses, your uterus becomes heavier. Because this increased weight is carried in the front of your body, you naturally bend forward. To keep your balance, your posture changes. You may find yourself leaning backward, which can make the back muscles work harder. This extra strain can lead to pain, soreness, and stiffness.

The following changes during pregnancy can lead to back pain:

• Strain on your back muscles
• Abdominal muscle weakness
• Pregnancy hormones

Your abdominal muscles support the spine and play an important role in the health of the back. During pregnancy, these muscles become stretched and may weaken. These changes also can increase your risk of hurting your back when you exercise.

If you have severe back pain, or if your back pain persists for more than 2 weeks, you should contact your obstetrician or other member of your health care team. Back pain is a symptom of preterm labor, and it also can be a sign of a urinary tract infection. Contact your health care professional right away if you have a fever, burning during urination, or vaginal bleeding in addition to back pain.

What can you do to prevent back pain during pregnancy

To help prevent back pain, be aware of how you stand, sit, and move. Here are some tips that may help:

• Wear shoes with good arch support. Flat shoes usually provide little support unless they have arch supports built in. High heels can further shift your balance forward and make you more likely to fall.
• Consider investing in a firm mattress. A firm mattress may provide more support for your back during pregnancy.
• Do not bend over from the waist to pick things up—squat down, bend your knees, and keep your back straight.
• Sit in chairs with good back support, or use a small pillow behind the low part of your back. Special devices called lumbar supports are available at office- and medical-supply stores.
• Try to sleep on your side with one or two pillows between your legs or under your abdomen for support.

Back pain during pregnancy treatment

Get regular exercise. Exercises for the back strengthen and stretch muscles that support your back and legs and promote good posture. They not only ease back pain but also help prepare you for labor and childbirth. You also can try applying heat or cold to the painful area.

Regular exercise during pregnancy benefits you and your fetus in these key ways:

• Reduces back pain
• Eases constipation
• May decrease your risk of gestational diabetes, preeclampsia, and cesarean delivery
• Promotes healthy weight gain during pregnancy
• Improves your overall general fitness and strengthens your heart and blood vessels
• Helps you to lose the baby weight after your baby is born

If you are healthy and your pregnancy is normal, it is safe to continue or start most types of exercise, but you may need to make a few changes. Physical activity does not increase your risk of miscarriage, low birth weight, or early delivery. However, it is important to discuss exercise with your obstetrician or other member of your health care team during your early prenatal visits. If your health care professional gives you the OK to exercise, you can decide together on an exercise routine that fits your needs and is safe during pregnancy.

Are there certain conditions that make exercise during pregnancy unsafe?

Women with the following conditions or pregnancy complications should not exercise during pregnancy:

• Certain types of heart and lung diseases
• Cervical insufficiency or cerclage
• Being pregnant with twins or triplets (or more) with risk factors for preterm labor
• Placenta previa after 26 weeks of pregnancy
• Preterm labor or ruptured membranes (your water has broken) during this pregnancy
• Preeclampsia or pregnancy-induced high blood pressure
• Severe anemia

What are some safe exercises I can do during pregnancy?

Whether you are new to exercise or it already is part of your weekly routine, choose activities that experts agree are safest for pregnant women:

• Walking—Brisk walking gives a total body workout and is easy on the joints and muscles.
• Swimming and water workouts—Water workouts use many of the body’s muscles. The water supports your weight so you avoid injury and muscle strain. If you find brisk walking difficult because of low back pain, water exercise is a good way to stay active.
• Stationary bicycling—Because your growing belly can affect your balance and make you more prone to falls, riding a standard bicycle during pregnancy can be risky. Cycling on a stationary bike is a better choice.
• Modified yoga and modified Pilates—Yoga reduces stress, improves flexibility, and encourages stretching and focused breathing. There are even prenatal yoga and Pilates classes designed for pregnant women. These classes often teach modified poses that accommodate a pregnant woman’s shifting balance.
• You also should avoid poses that require you to be still or lie on your back for long periods.

If you are an experienced runner, jogger, or racquet-sports player, you may be able to keep doing these activities during pregnancy. Discuss these activities with your health care professional.

Exercises you should avoid during pregnancy

While pregnant, avoid activities that put you at increased risk of injury, such as the following:

• Contact sports and sports that put you at risk of getting hit in the abdomen, including ice hockey, boxing, soccer, and basketball
• Skydiving
• Activities that may result in a fall, such as downhill snow skiing, water skiing, surfing, off-road cycling, gymnastics, and horseback riding
• “Hot yoga” or “hot Pilates,” which may cause you to become overheated
• Scuba diving
• Activities performed above 6,000 feet (if you do not already live at a high altitude)

Precautions you should take when exercising during pregnancy

There are a few precautions that pregnant women should keep in mind during exercise:

• Drink plenty of water before, during, and after your workout. Signs of dehydration include dizziness, a racing or pounding heart, and urinating only small amounts or having urine that is dark yellow.
• Wear a sports bra that gives lots of support to help protect your breasts. Later in pregnancy, a belly support belt may reduce discomfort while walking or running.
• Avoid becoming overheated, especially in the first trimester. Drink plenty of water, wear loose-fitting clothing, and exercise in a temperature-controlled room. Do not exercise outside when it is very hot or humid.
• Avoid standing still or lying flat on your back as much as possible. When you lie on your back, your uterus presses on a large vein that returns blood to the heart. Standing motionless can cause blood to pool in your legs and feet. Both of these positions can decrease the amount of blood returning to your heart and may cause your blood pressure to decrease for a short time.

What are warning signs that I should stop exercising?

Stop exercising and call your obstetrician or other member of your health care team if you have any of these signs or symptoms:

• Bleeding from the vagina
• Feeling dizzy or faint
• Shortness of breath before starting exercise
• Chest pain
• Headache
• Muscle weakness
• Calf pain or swelling
• Regular, painful contractions of the uterus
• Fluid leaking from the vagina

Why is it important to keep exercising after your baby is born?

Exercising after your baby is born may help improve mood and decreases the risk of deep vein thrombosis, a condition that can occur more frequently in women in the weeks after childbirth. In addition to these health benefits, exercise after pregnancy can help you lose the extra pounds that you may have gained during pregnancy.

Back labor pain treatment

Pain medications

Pain-relief drugs fall into two categories: analgesics and anesthetics ¹⁰.

Each category has different forms of medications. Some of these medications carry risks. It is important for women to discuss medications with their health care provider before going into labor to ensure that they are making informed decisions about pain relief.

Analgesics

Analgesics relieve pain without causing total loss of feeling or muscle movement. These drugs do not always stop pain completely, but they reduce it.

• Systemic analgesics affect the whole nervous system rather than a single area. They ease pain but do not cause the patient to go to sleep. Systemic analgesics are often used in early labor. They are not given right before delivery, because they may slow the baby’s breathing and reflexes. They are given in three ways:
  1. Injected into a muscle or vein
  2. Administered through a small tube placed in a vein. The woman can often control the amount of analgesic flowing through the tube.
  3. Inhaled or breathed in with a mixture of oxygen ¹¹. The woman holds a mask to her face, so she decides how much or how little analgesic she receives for pain relief.
• Regional analgesics relieve pain in one region of the body. In the United States, regional analgesia is the most common way to relieve pain during labor ¹². Several types of regional analgesia can be given during labor:
  1. Epidural analgesia, also called an epidural block or an epidural, causes loss of feeling in the lower body while the patient stays awake. The drug starts working about 10 minutes to 20 minutes after it is given. A health care provider injects the drug near the spinal cord. A small tube (catheter) is placed through the needle. The needle is then withdrawn, but the tube stays in place. Small amounts of the drug can then be given through the catheter throughout labor without the need for another injection.
  2. A spinal block is an injection of a much smaller amount of the drug into the sac of spinal fluid around the spine. The drug starts working right away, but it lasts for only 1 to 2 hours. Usually, a spinal block is given only once during labor, to help with pain during delivery.
  3. A combined spinal-epidural block, also called a “walking epidural,” gives the benefits of an epidural block and a spinal block. The spinal part relieves pain immediately. The epidural part allows drugs to be given throughout labor. Some women may be able to walk around after a combined spinal-epidural block.

Gas and air (nitrous oxide)

This is a mixture of oxygen and nitrous oxide gas.Gas and air won’t remove all the pain but it can help to reduce it and make it more bearable. Many women like it because it’s easy to use and they control it themselves.

• How it works:
  • You breathe in the gas and air through a mask or mouthpiece, which you hold yourself. You’ll probably practise using the mask or mouthpiece if you go to an antenatal class. The gas takes about 15 to 20 seconds to work, so you breathe it in just as a contraction begins, before it is painful. It works best if you take slow, deep breaths.
• Side effects:
  • There are no harmful side effects for you or the baby, but it can make you feel light-headed. Some women also find that it makes them feel sick, sleepy or unable to concentrate. If this happens, you can stop using it.

If gas and air doesn’t give you enough pain relief, you can ask for a painkilling injection as well.

Injections

Another form of pain relief is the intramuscular injection (into the muscle of your thigh or buttock) of a drug, such as pethidine or diamorphine. This can help you to relax, which can lessen the pain.

• How it works:
  • You are given an intramuscular injection. It takes about 20 minutes to work and the effects last between two and four hours.
• Side effects:
  • There are some side effects to be aware of:
    • It can make some women feel woozy, sick and forgetful.
    • If it hasn’t worn off towards the end of labour, it can make it difficult to push: you might prefer to ask for half a dose initially to see how it works for you.
    • If pethidine or diamorphine are given too close to the time of delivery, it may affect the baby’s breathing. If this happens, an antidote will be given.
    • The drugs can interfere with breastfeeding.

Epidural anesthesia

An epidural is a special type of local anesthetic. It numbs the nerves that carry the pain from the birth canal to the brain. For most women, an epidural gives complete pain relief. It can be helpful for women who are having a long or particularly painful labor, or who are becoming distressed.

An anesthetist is the only person who can give an epidural, so it won’t be available if you give birth at home and it may not be available in a birth centre. If you think you might want one, check whether anesthetists are always available at your hospital.

The procedure and any side effects will be discussed by the hospital staff and can only proceed with consent.

How it works

To have an epidural:

• A drip will run fluid through a needle into a vein in your arm.
• While you lie on your side or sit up in a curled position, an anesthetist will clean your back with antiseptic and numb a small area with some local anesthetic.
• A very small tube will be placed into your back near the nerves that carry pain from the uterus. Drugs, usually a mixture of local anesthetic and opioid, are administered through this tube. (An opioid is a chemical that works by binding to special opioid receptors in the body, which reduces pain). It takes about 20 minutes to set up the epidural, and another 10 to 15 minutes for it to work. It doesn’t always work perfectly at first, so it may need to be adjusted.
• After it has been set up, the epidural can be topped up by a midwife or doctor, or you may have an epidural infusion that runs through a machine continuously.
• Your contractions and the baby’s heart will need to be continuously monitored by a machine. This means having a belt around your abdomen and possibly a clip attached to the baby’s head.

Side effects

There are some side effects to be aware of:

• An epidural may make your legs feel heavy, depending on the type of epidural. You’ll be advised by the doctor or midwife when you can get out of bed.
• An epidural shouldn’t make you drowsy or sick.
• Your blood pressure can drop; however, this is rare because the drip in your arm will help you to maintain good blood pressure.
• Epidurals can prolong the second stage of labor, when you push and your baby is born. If you can no longer feel your contractions, the midwife will have to tell you when to push. This means that instruments such as forceps may be used to help you deliver your baby (instrumental delivery). However, when you have an epidural, your midwife or doctor will wait longer before they use instruments as long as your baby is fine. Sometimes, less anesthetic is given towards the end so that the effect wears off and you can push the baby out naturally.
• You may find it difficult to urinate as a result of the epidural. If so, a small tube called a catheter may be put into your bladder to help you.
• About one in 100 women gets a headache after an epidural. If this happens, it can be treated.
• Your back might be a bit sore for a day or two but epidurals don’t cause long-term backache.

Some women prefer to avoid the types of pain relief listed on this page, and choose alternative treatments such as acupuncture, aromatherapy, homeopathy, hypnosis, massage and reflexology. However, most of these techniques aren’t proven to provide effective pain relief. Therapies such as acupuncture or acupressure should only be practised by qualified practitioners.

If you’d like to use any of these methods, it’s important to discuss them with your midwife or doctor and let the hospital know beforehand. Most hospitals don’t offer them for pain relief during labor. If you want to try an alternative technique, make sure that the practitioner is properly trained and experienced.

Anesthetics

Anesthetics block all feeling, including pain.

• General anesthesia causes the patient to go to sleep. The patient does not feel pain while asleep.
• Local anesthesia removes all feeling, including pain, from a small part of the body while the patient stays awake. It does not lessen the pain of contractions. Health care providers often use it when performing an episiotomy, a surgical cut made in the region between the vagina and anus to widen the vaginal opening for delivery or when repairing vaginal tears that happen during birth.

Natural childbirth or natural pain relief methods

Nonpharmacologic methods of pain relief are used by virtually all women in labor. Women who choose natural childbirth rely on a number of ways to ease pain without taking medication. These include ¹³:

• The company of others who offer reassurance, advice, or other help throughout labor, also known as continuous labor support ¹⁴
• Relaxation techniques, such as deep breathing, music therapy, or biofeedback
• A soothing atmosphere
• Moving and changing positions frequently
• Using a birthing ball
• Massage
• Yoga
• Taking a bath or shower
• Hypnosis
• Using soothing scents (aromatherapy)
• Acupuncture or acupressure
• Applying small doses of electrical stimulation to nerve fibers to activate the body’s own pain-relieving substances (called transcutaneous electrical nerve stimulation, or TENS)
• Injecting sterile water into the lower back, which can relieve the intense discomfort and pain in the lower back known as back labor.

A systematic review by Simkin and O’Hara ¹⁵ of nonpharmacologic pain relief examined five methods:

1. Continuous labor support,
2. Warm water baths,
3. Intradermal water injections,
4. Maternal movement and positioning,
5. Touch and massage.

Pain-relief methods without prospective studies (e.g., acupuncture) and self-help techniques such as relaxation, breathing, and visualization were not examined.

Continuous labor support

Continuous labor support provided by a doula, a lay woman trained in labor support or a birth companion, consistently has decreased the use of obstetric interventions. A Cochrane meta-analysis ¹⁶ found a decrease in operative vaginal deliveries, cesarean deliveries, and requests for pain medication when continuous labor support was given. Fewer women had unsatisfactory birth experiences ¹⁶.

Intermittent labor support does not convey the same benefits as continuous support ¹⁷. A recent large randomized controlled trial demonstrated that providing continuous labor support with nurses instead of doulas had no effect on cesarean delivery rates or other birth outcomes ¹⁸. Low-income women who otherwise would labor with minimal or no social support receive the greatest benefit from a doula ¹⁵. The review notes the lack of studies of the model of doula care most commonly used in North America, in which women meet their doulas in the prenatal period ¹⁵.

Warm water baths

Warm water baths increasingly are available in hospitals and birth centers. Two prospective cohort studies and seven randomized controlled trials were included in the systematic review ¹⁵. A small randomized controlled trial ¹⁹ that measured pain before, during, and after bathing found that pain was relieved during the bath and returned afterward. A larger small randomized controlled trial ²⁰ that measured pain at 24 to 48 hours and eight months postpartum found no difference in perception of pain.

Warm water baths had no effect on the use of epidural analgesia in the three largest studies ²¹, which may be because of the short duration of pain relief. None of the randomized controlled trials showed increased maternal or neonatal infectious morbidity. One randomized controlled trial ²² found that labor was longer when a bath was used in early labor (less than 5-cm dilation) than when it was used in late labor.

A recent, nationwide survey ²³ found that 6 percent of women used warm water baths during labor, and that 49 percent found them very helpful with pain relief. Warm water baths during labor seem to be safe and possibly effective for limited periods. It has been recommended that physicians wait for active labor to begin before initiating baths, maintain the water at or below body temperature, and limit bath time to one to two hours ¹⁵.

Sterile water injections

Intradermal injections of sterile water in the sacral area may be used to decrease back pain in labor. Sterile-water injection causes a burning sensation that is much more painful than saline injection and is thought to relieve labor pain by counterirritation. Four randomized controlled trials included in one review ¹⁵ found a significant reduction in back pain for 45 to 90 minutes based on a visual analog scale. Three of the trials found that women who received injections of sterile water were more interested in receiving the injections in a subsequent labor than women who received saline injections. None of the trials showed a decrease in requests for pain medicines, perhaps because of the limited time of effectiveness or a lack of effectiveness for abdominal labor pain.

How it works:

Usually injections are given in four different places in your lower back, just beneath the skin. The injections cause a strong stinging sensation, like a bee sting. The injections can bring up to two hours of pain relief to your lower back but you will still feel the contractions. There is not enough research to show that sterile water injections are effective in reducing the need for other pain relief.

Side effects:

There are no side effects for you or your baby.

Positions, touch and massage

When women are not restricted by caregivers or institutional policies, they commonly assume a variety of positions during labor. Fourteen randomized controlled trials included in one review ¹⁵ failed to show consistent findings regarding position and labor pain. Only one of seven randomized controlled trials in which women were randomized to various positions showed a decrease in the use of analgesia ¹⁵.

Two trials of touch and massage during labor met the criteria for the systematic review. The studies were small and have methodologic problems that prevent reaching a conclusion on the effect of touch and massage on labor pain.

TENS (transcutaneous electrical nerve stimulation)

This stands for transcutaneous electrical nerve stimulation. Some hospitals have TENS machines. If not, you can hire your own machine. TENS has not been shown to be effective during the active phase of labour (when contractions get longer, stronger and more frequent). It’s probably most effective during the early stages when many women experience low back pain.

TENS may be useful if you plan to give birth at home or while you’re at home in the early stages of labour. If you’re interested in TENS, learn how to use it in the later months of your pregnancy. Ask your midwife to show you how it works.

How TENS works:

Electrodes are taped onto your back and connected by wires to a small battery-powered stimulator. Holding this, you give yourself small, safe amounts of current through the electrodes. You can move around while you use TENS.

TENS is believed to work by stimulating the body to produce more of its own natural painkillers, called ‘endorphins’. It also reduces the number of pain signals that are sent to the brain by the spinal cord.

Side effects

There are no known side effects for you or the baby.

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