ļ»æEpisode 20 - Sterile water injections and hypnobirthing
Mel:
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host Dr Melanie Jackson. I'm a clinical and research midwife with my PhD and each episode I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth and postpartum journey.
Mel:
[0:25] Welcome to today's episode of the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson, and I've been a midwife for 18 years now. The bulk of my work has been caring for women through their pregnancy, birth, and postpartum in a full continuity of care midwifery model. And what that means is that I've been intimately involved in how to help women prepare for their labor and birth, the intensity of it, the sensation, the contractions, and the challenges. And one of the challenges for labor and birth can be how you are going to manage the pain of labor. The pain of labor is different to a pathological pain, the pain of illness. The pain of labor is productive and purposeful and so there's some real benefits to working with instead of against the pain of labor and instead of trying to take it away. So this episode is in part about how to navigate the pain of labor using evidence-based strategies. And I've invited Nigel Lee, who is a midwife and now researcher, and a lot of his work centers around the use of sterile water injections.
Mel:
[1:36] And now his new research around hypnobirthing for the management of labor pain. We're going to go through those three papers with Nigel Lee in just a minute. But before we do, For the next two weeks, I am offering my introductory price. It's $27. I have a guide to giving birth without pain medication. And inside that guide are all the strategies that I've helped my clients use in order to navigate the pain of labor. Because I've been a home birth midwife for most of my career, I've been a home birth.
Mel:
[2:13] All of the clients that I care for give birth without the option of pharmaceutical pain relief. And so in this guide to giving birth without pain relief, I've put all of those strategies in, all the strategies that I've ever seen work for managing the pain of labor. Nearly 2,000 women have purchased the guide. It's only been out for six months and I started it off with a $27 introductory price. It's far too cheap for what you get in the guide. So I'm about to increase the price to $47, which is where I want to leave it. But the $27 was an introductory one and it's still available to you for the next two weeks through July until the last week of July, 2026. Don't worry if you're listening to this in a back episode, the guide to giving birth without pain relief is still available. It's just a little bit more expensive, but honestly, you'd pay that much for lunch at a nice cafe.
Mel:
[3:11] So the guide to giving birth without pain medication, the link is in the show notes and for the next two weeks, still available for the introductory price of $27. And what you'll also hear from Nigel in this episode is some new research about the hypnobirthing method. And Poppy Child, who is a long-term sponsor of this podcast, has an epic hypnobirthing course that she offers online for anybody to access. And it's called the oxytocin bubble in the birth. The birth box has the oxytocin bubble in it.
Mel:
[3:46] And in that is all the hypnobirthing strategies and education that you'll need to prepare for your labor and birth, especially if you want to avoid pharmaceutical pain medication. And later in this episode, you'll hear Nigel talk about his research about the impact on epidural use and cesarean section if you use hypnobirthing as part of your preparation for labor and birth. Again, the link to purchase Poppy's birth box is in the show notes. Go ahead, listen to the episode and then choose the strategies you feel like you might want to use in order to get ready for your labor and birth. Now let's kick off and hear what Nigel has to say about the use of sterile water injections and hypnobirthing techniques to help you get ready for labor and birth. Beautiful. Welcome to the Great Birth Rebellion podcast, Nigel. Today, we're going to talk all about pain management strategies, but maybe not the ones that people have thought of. And also, we want to share with them the research, some of the research on that. And you seem to be prolific in the research that we're going to talk about today. So welcome and thank you all.
Nigel:
[4:55] Right thank you thanks for having me back
Mel:
[4:56] So i want you to introduce yourself as you would like to be introduced because many people might not know about you they may know about your work but i do feel like you just quietly get on with it in the background um and yeah so introduce yourself to our audience.
Nigel:
[5:15] So, I'm Nigel. I'm a midwife. This is my 39th year of midwifery. I know. I was thinking about that today.
Mel:
[5:25] Well, I'm 42. So, I was three when you went ahead and started midwifery. Amazing.
Nigel:
[5:31] Yeah. So I spent probably nearly 30 years in clinical practice, mainly in working in birth suites around Australia and a couple in the UK before sort of going into what I call semi-retirement back into academia because it was no night shift and weekends off, which felt like retirement at the time. So now I'm a senior research fellow in midwifery research at the University of Queensland and an NHMRC investigator fellow as well.
Mel:
[6:00] And so the three papers of yours that we're going to look at today are about sterile water injections for back pain, which is typically what midwives have come to know about sterile water injections. But recently, you've done some research along with your colleagues on sterile water injections on women's bellies, on their abdomen for labor pain. So we'll go through that paper as well. And then in the same year, 2026, you've also released a paper on hypnobirthing and its impact on epidural use and, as it turns out, cesarean section. So I'm super excited to dive into those three papers of yours today. Yeah. Are you ready to go?
Nigel:
[6:46] Oh, absolutely. Let's go.
Mel:
[6:47] Amazing. All right. Before we get started, though, can you give a little explanation? Because we're going to start with sterile water injections. Can you explain what they are, what a woman could expect if they were going to accept a sterile water injection?
Nigel:
[7:02] So sterile water, well, as I say, they're very small injections of sterile water between about 0.1 and 0.3 of a mil. And they're given intradermally, so just literally just under the skin layer. For back pain, it's at four different points around the pain. There's two ways of determining where the injections are given. There are specific sort of anatomical points that midwives can give them in around the lower lumbar region. Or often we just get the woman to point to where the pain is and then plot four points around that. But sometimes the pain's not always in the same spot. Sometimes it moves up and down a little bit, so we can adjust that around. The idea of using water is there's no chemical or pharmacological change by injecting water. It's simply a mechanism for giving a very short, sharp, but significantly painful sensation that lasts for about 10 to 20 seconds. And then that triggers the body's own pain modulating systems or pain relieving systems. And there are a number of these. One of them is, we call it gait control theory. That's been around since the 1960s. It's just the idea that the brain can really only focus on one pain at a time. So by giving that very short shot stimulus, it distracts or moves the brain's focus away from the back pain to that pain on the skin. And then it goes away, but the focus seems to stay on there. That's probably one of the reasons why the water injections work so quickly.
Nigel:
[8:29] And the other one is the relief of endorphins. They're kind of morphine-like substances that your brain produces to relieve pain. And there are different types of endorphins for different types of pain. So the endorphins that release when you burn yourself are going to be different to those that get released when you use water injections. And they work quite locally as well. So they're probably the reason why we get sort of, you know, 90 minutes sometimes out to about two hours of effect from the water injections themselves. But the benefits of water injections are that, you know, it's only water. No one's allergic to water.
Nigel:
[9:02] It doesn't interfere with a woman's ability to move around. There are no other equipment available. It's very, very simple, which means it can be given in any sort of setting, in a hospital or a home birth or anything like that. And it's pretty reliable and pretty effective. Our research generally states that around about 80%, 85% of women will get some degree of pain relief. The total failure rate's really only about sort of 10% or 15%, which, you know, as far as analgesics go is not bad.
Mel:
[9:33] And a few things you highlighted there was that a woman could kind of point to where the pain is and the midwife can plot spots around that pain, I think this sometimes catches midwives out because they kind of get spooked by maybe not putting them in the right spot or they kind of go, oh my gosh, I get the idea, I get the theory, but what if I put it in the wrong spot? So I want to say firstly to midwives that it's pretty hard to get sterile water injections wrong in terms of positioning and that if you get it in the vague area, it's still going to have an impact. As we'll know we will discover in the next paper which none of them were in the back at all they were all put in the abdomen, and i recall being in one of your workshops it was probably now over 10 years ago maybe nine or 10 years ago i vaguely recall you mentioning that actually, sterile water injections the theory of it did not come from pain management in labor Do they use sterile water injections in other contexts for pain management or is this brand new for labour and birth management?
Nigel:
[10:42] As a concept, it's been around for about 150 years. So it was kind of the original analgesic were used as an anaesthetic to numb the skin because I found if you put two lines of water injections, the skin in between the two lines would become anaesthetised and then they could make their incision. This was before the use of cocaine and other kind of anaesthetics. And then it was probably, the more common use after that was probably in the sort of 60s and 70s for relieving renal colic, and it's quite effective for that, and that's still used in some areas. We've done a little bit of research in that ourselves. And, you know, renal colic has the reputation of being almost as painful as labor. So it's kind of up there in terms of severe pain. And again, it's what they call a referred pain syndrome. So water injections works quite well for it. Again, you don't get the side effects of the large amounts of narcotics that they often use for renal colic. And it was really probably the late, great Michel O'Donnell who first sort of introduced it into maternity care and started using it for the years in his birth centre there for relieving back pain.
Mel:
[11:50] Yeah, right. So brief summary, small amount of water, 0.1 to 0.3 of a mil, and it's injected with a small needle underneath the skin. And typically midwives will do this at the peak of a contraction to kind of just put all the pain in at once and ideally there's two midwives acting on, the points so that it shortens the amount of time that the procedure takes to complete, and you mentioned it works on the gate the pain control theory the gate theory and that theory is if you yeah if you overwhelm the nervous system with pain sensations it can't it kind of shuts off, the pain messages to your brain effectively reducing your pain sensation and interestingly yet quite quickly, acts on the back pain or I've heard midwives also use it for pelvic pain for women, and in your paper you mention it as being a referred pain so it's not like the woman is getting back pain because there's something in her back she's feeling it there because whatever's happening during labor and birth is referring the pain to that spot.
Nigel:
[13:01] That's right, yes, which kind of goes to a bit of a sideline about the relationship or what we think causes back pain in labour. We've often had that idea that it's the occipital posterior position. You know, the back of the baby's head is kind of pressing against the spine and that causes the back pain. But in our research, more women with non-OPs actually had back pain than those with OPs. So we never found any sort of real relationship between occipital posterior or OP position and back pain. It was purely, you know, probably a referred pain just from the pressure of the head on the cervix and the surrounding structures.
Mel:
[13:36] Yeah, right. And so the thing for women to remember too is the idea of this, is that it hurts to have the injection. Yes. Becauseā€¦, that's the that's what the therapeutic result is from so women need to be prepared for uh midwives describe it as like a um a wasp sting or a bee sting, and I have to admit when we did the workshop, I declined the opportunity to test out the sterile water and I opted for to be practiced on with, the saline because that doesn't create the pain, but it allows us to practice their technique. I personally have not felt what a sterile water injection feels like. Have you had it done on you, Nigel?
Nigel:
[14:27] Yes, a couple of times, yes.
Mel:
[14:29] Would you describe it like a wasp sting?
Nigel:
[14:32] It is, yeah. I mean, it does vary from person to person, but it's definitely, it comes on extremely quickly and it suddenly, and it peaks very, very quickly within, you know, less than a second. It's just kind of, oh, wow, that really hurt. And then it eases off very quickly as well. So it's a very sort of short, sharp, but significant pain.
Mel:
[14:52] Okay. The times I've used it, I've tried it three times in a home birth setting and all three times the women have said, stop. I keep going. I'm like, oh, you're so close. I can see like little, these half little blebs. Oh, it's so close. But the important thing is, is that it's short, sharp.
Nigel:
[15:11] Yes.
Mel:
[15:12] It goes away and the pain is part of the process of this working.
Nigel:
[15:18] That's right. Yes.
Mel:
[15:19] Okay. Well, let's get into this paper because actually the women, we'll have a look at what their experience was. Can you talk us through the first paper about sterile water for back pain? What did you do and what did you find? Yes.
Nigel:
[15:35] So this was our Icarus trial, which we ran from about sort of a bit after 2012 through to about 2018. And this was a placebo-controlled trial. So we had two arms. One group of women got sterile water injections, and the other group of women got the normal saline placebo, which we call a placebo because it doesn't create anywhere near the same degree of pain as when it's injected. But it's because you're breaking the skin and distending the tissue with the injection, it still triggers a mild analgesic response. And it's still an injection, so they weren't able to really sort of tell just from injection itself which one they were getting. So we ran this study in 15 hospitals across Australia and one in the UK. So it was a big multi-centre trial. In fact, we think it was probably the largest middle-free-led clinical trial ever undertaken, was quite an undertaking. We recruited 1,166 women over a six-year period.
Mel:
[16:40] And for some context for that, for some studies that would be considered a small study, the, For people who aren't researchy, to me this sounded like an adequate number and I read further on in the paper that you'd feel like it didn't quite meet the recruitment that you wanted. But with over 1,000 women with this one single intervention, especially with a randomized control trial, it's pretty good.
Nigel:
[17:09] Yes. I mean, all trials are powered for kind of different types of outcomes And our main outcome in that particular paper was looking at the differences in caesarean section rates because there had been a question, you know, an idea that giving still water injections have been able to relieve the back pain and help progress the labour might decrease the caesarean section rate. And that had been hinted at in a couple of early RCTs. So that's essentially what we were looking for. And that's why we had so many women in that particular study, because it takes around about 1,800 women split evenly between two groups to tell you whether you're going to get a true effect in terms of reducing rates of cesarean section. And then our kind of main secondary outcome was the impact on pain. So we were well and truly empowered for that. And we just fell a little bit short of the power for the cesarean section one, simply because we were taking so long to recruit that many women.
Mel:
[18:06] And so then the women didn't know what they were getting, their midwives didn't know what they were getting. Because I had to read, this was quite the undertaking, that the pharmacist had to do the vials and make sure there was no identifying features. And then some different midwives that were caring for the women had to administer the sterile water injections. Obviously, everyone had to not know what was going on, but there was in the background a way to identify which women had it and which women didn't so that you could then do the analysis on the data.
Nigel:
[18:44] That's right. So, there were really only three people who knew who was getting what, and that was our statistician and the two pharmacists who prepared the ampoules, one in Australia and one in the UK. And even when we get to the point of analysis, they just give us a list with, okay, this is group A, this is group B, go away and analyze like that. So, we don't even know who's getting what's when we're doing the analysis. It's only until we finish the analysis, they literally, like at the Oscars, tear open the envelope and let us know who was who.
Mel:
[19:15] Right. So what this does, blinded trial like this and a randomized blinded trial like this, means that there's less opportunity for the researchers to inject their own biases or, play with the statistics to create findings that they want to create. Okay. So what happened next when you analyzed the data?
Nigel:
[19:37] Well, when we analysed the data, unfortunately we found there was no difference in cesarean section rates. That was kind of disappointing, but, you know, that's kind of life with research. It doesn't always give you what you want. Yes. But, you know, we had a huge number of women and were able to clearly demonstrate that water injections reduces back pain in labour by really quite a significant amount.
Mel:
[20:01] Talk to me about how many women, what percentage of women said that they would, use the sterile water injections again.
Nigel:
[20:12] That was just about 75%, which was similar to what we'd seen in previous studies.
Mel:
[20:18] The length of time that they got pain relief for, was this the paper that you looked at 30 minutes, 60 minutes, and 90, or was this just 60 and 90 compared to the...
Nigel:
[20:28] No, 30 minutes, 60 minutes, and 90 minutes.
Mel:
[20:30] Yeah. What percentage of women had still satisfactory pain relief by 90 minutes?
Nigel:
[20:39] What we looked at was the number of women who had an at least 30% reduction in pain or an at least 50% reduction in pain, which is a common way of kind of looking at the effectiveness of analgesics. And the idea is that if an analgesic can't achieve at least a 30% reduction in pain in the majority of people who use it, then it's probably not really that kind of worthwhile using. So what we found was that just over 60% of the women who received the water injections had an at least 30% reduction in pain. And that was compared to around about 30% in the placebo. So twice as many women in the water injection group got an at least 30% reduction in pain at 30 minutes. And that was kept fairly proportionate all the way through until about 90 minutes. It did drop off a little bit. I think it dropped off down to about sort of half and then half again because we hear women went on and used other sorts of forms of analgesia. And 43% of the women got an at least 50% reduction in pain. So just over 40% of the women had an absolute halving in their pain or a minimum of a harping in their pain level.
Mel:
[21:52] And you can just keep repeating sterile water injections because it's not medicine.
Nigel:
[21:57] That's right, yes.
Mel:
[21:59] And there's no side effects outside of that local reaction that really you're supposed to have with the treatment.
Nigel:
[22:06] Yes, and there's no limit to the amount of times you repeat it. In one of our recent studies, I think one woman had five or six rounds of injections through her labour.
Mel:
[22:15] Yeah, because it's kind of a short-term pain relief if you think about, if you compare it to an epidural, like obviously other than it. Yeah, yeah. What impact did it have on epidural use? Did you have a look at that in this paper?
Nigel:
[22:29] We did. And it didn't actually reduce the use of epidurals. And that's really not all that unusual. We see that a lot in other, I just say transient analgesic used in durian labour. Even things like nitrous oxide and the use of morphine and other opioids don't seem to impact upon the amount of epidurals that are actually being used. And I think the reason behind that is, well, there's two reasons behind that. But the main one is that we know that women will use various different types of analgesics, various different types of their labor, and labors are a dynamic process. So it gets more painful, it becomes more, the contractions get stronger as the labor progresses. So women will use, quite normally use, one analgesic at one particular point in their labor, and then as the labor progresses, they'll move on to others. And back pain does tend to occur earlier in labor. So it usually starts occurring when women are around about sort of somewhere between about three and five centimeters. So by the time they've got the injections and their back pain's gone away, because that's all really treating at this point, an hour and a half, two hours later, their labor has progressed. Their abdominal labor pain is becoming much, much stronger. So they're kind of after something for that. Their labor has moved on and their expectations for their analgesia have moved on. So that's pretty well the reason why we weren't really expecting any particular decrease in the epidural rate, because they're really kind of addressing different things during the course of the labor.
Mel:
[23:53] Yeah, absolutely. But what you did definitely discover in this paper is that sterile water injections can reduce the sensation of pain somewhere in the vicinity of 30 to 50% less pain compared to the placebo of sterile water of, saline, which means that it becomes, and because it doesn't have that, any side effects, it becomes an option for women to explore all of their pain management options prior to considering pharmaceutical ones.
Nigel:
[24:24] It is. And the other thing about back pain is that it's qualitatively different from that normal abdominal contraction pain because that contraction pain comes and goes. It was always kind of a bit of a break there and women are kind of psyched up to think, okay, this is what I'm going to get. This is what I'm going to do when I get that. But back pain is unpredictable. You can't tell when someone's going to get back pain. There's just no way. It just kind of appears. And it's often continuous, which means there's no kind of resting phase. It's there all the time. It just gets worse when the contraction comes along. So these water injections are targeting particularly that type of pain. And it's the only thing we have that really specifically targets that type of pain. You can try nitrous and opioids. Older studies have kind of looked at comparisons and found that water injections were more effective than those two.
Mel:
[25:13] Yeah, absolutely. And when I've used them, we've also had TENS machines on. And then the same woman who had been using the TENS was then in the pool and we could administer the sterile water injections while she was in the pool because her back was exposed. So, you know, it's like you said, there's a lot of bonuses because it's, it can be done anywhere. The technique is fairly simple. There's no side effects. And I've also have heard midwives yet use it for deep pelvic pain as well. It seems to be quite effective.
Nigel:
[25:47] Yes. I mean, I've used it for women who've had, you know, very intense pain over each hip or one side or the other simply by, you know, instead of giving four injections around the centre of the lower area, giving two injections over each hip.
Mel:
[25:59] Yeah, I've heard the same thing, midwives saying, well, we just put them wherever the hurt is.
Nigel:
[26:03] Basically, yes.
Mel:
[26:05] Yes. And it was interesting because one colleague that I was talking to, they had been doing these sterile water injections at home and eventually had transferred the woman into hospital for another reason. And then in the handover, she said, oh, she's been getting this hip pain. We've done two or three sets of zero water injections over the site which has been quite effective and the midwife went oh no no no you cannot put it there, So you can, you absolutely can put it there.
Nigel:
[26:33] Absolutely. Yes. It's interesting we kind of make up these little rules as we go along sometimes.
Mel:
[26:37] Yeah. And that's what I was curious to know too about the origins because I remember you talking about, you know, this has historically been used for pain relief. You could put a bleb anywhere in order to elicit some pain relief. So I've taken that into my midwifery career and gone, well, just put it where the pain is. But I think maybe some people take the training quite literally of like you can go there, there, and there. But just take heart. If the thing that's holding you back is, oh, my gosh, I've forgotten the positioning, just put it where it hurts.
Nigel:
[27:08] Basically, yes. I mean, we've looked at just using one injection over the painful site compared to four. Four is more effective but even one will work to some degree.
Mel:
[27:20] Which is great news if you're on your own or if the woman wants to abandon the procedure.
Mel:
[27:26] Excellent. And so, well, let's move on to the next paper because the next one was about abdominal pain in labour. So the title of that one, and that was 2026. So the first one we did was 2020. And for those playing at home, all of the links to these papers are in the resource folder for the podcast. So you can actually click on the link and read them yourself. But that one we just did was the 2021. And this one you did 2026. and it's called Sterile Water Injections for Managing Abdominal Labor Contraction Pain, another randomized double-blind placebo-controlled trial. So it's very similar to the process and method that you used the previous one. And where did you position the sterile water blembs?
Nigel:
[28:16] So we put them at, there were six injections for this. And because it, you know, now we've got the front of the woman covering her pregnancy and she's likely to get pain in kind of various different spots around this. Some women get up in the fundus, some get concentrated down around the area just above the pubic bone. So interestingly, we found a couple of studies, one from 1906 and one from 1942, too, where they'd injected small amounts of local anaesthetic lidocaine at various points along the abdomen, and that appeared to have achieved some pain relief during labor. And we theorized that it was probably the pain of the lignocaine being injected, because that local hurts quite a bit when it's injected, as opposed to just having a little bit of local anaesthetic in your skin. So we had a look at their injection points, and they had used a number of injection points, one at the fundus, one just between the fundus and the belly button, the umbilicus, and then four sort of around the suprapubic area or that area just above the pubic bone. So that's where we got our injection sites for because we thought, well, you know, they've been used with some success prior, so we might as well go with those. And it gave a, it kind of followed the nerve patterns along the abdomen as well and gave us coverage from the fundus or the top of the uterus, top of the belly, just down towards the cubic bone.
Mel:
[29:37] Yeah. And I can see there's two sighted lower on the abdomen as well, sort of maybe sort of in line with the hips a little bit.
Nigel:
[29:46] Yes. Yeah. So we had four just below the umbilicus and they were kind of spread out just above the pubic area.
Mel:
[29:53] Amazing. And if you've got the paper guys, the ones who are playing at home, there's an image of where they were positioned.
Nigel:
[29:59] We use particular anatomical spots because we're doing research. So we want something that's repeatable all the time. But in practice, again, it's probably a matter of getting on to the point where it's most painful and plotting some injections around that.
Mel:
[30:12] And I've heard some midwives theorise about the way that it works. Is there anything about, interrupting nerve pathways or interfering with nerve pathways or is it it's most likely to be based on this gait this pain gait theory.
Nigel:
[30:31] It's more likely to be based on the gait control theory and the release of endorphins. It doesn't, as you know, as I said before, it doesn't interfere with nerve pathways. It doesn't disrupt them at all. It doesn't do any sort of anatomical, make any sort of anatomical or pharmacological changes. So it's really just that counter irritation from that very short, sharp stimulus.
Mel:
[30:52] So for this study, it was smaller. 160 women were randomized. So can you tell us about how you did this one?
Nigel:
[31:02] So much the same. Again, we had those blinded ampoules that were prepared by our pharmacist. And 80 women got the water injections and then 80 women got the saline, which is essentially, you know, a placebo is designed not to work.
Mel:
[31:16] And this one could be smaller because you weren't trying to power it for cesarean section. We're just trying to work out, did it reduce the pain?
Nigel:
[31:25] That's right. It was just powered for the reduction in pain. So you have a much smaller sample size.
Mel:
[31:30] So what did you discover with the front side sterile water injections and the impact on labour and birth?
Nigel:
[31:39] So we found that it worked, but not as well as it did for back pain. So in this one, we got about 40% or just about 45% of women had an at least 30% reduction in pain. We did find that both groups had started out with a pain score of about 80. And the water injection generally in the women who received it dropped that down to about a 50, 52. So we got quite a bit of a reduction. But it didn't last as long. We really only, by 90 minutes, there was no real difference between the two. So it had worn off by the hour and a half, whereas usually in the back pain, we get a little bit beyond the hour and a half. For the abdomen, it was probably more between sort of an hour to an hour and 15 minutes that we got the reduction for. And it wasn't really surprising. The abdominal contraction pain is much, much more complicated in terms of where it occurs and how it's transmitted and what's contributing to it rather than back pain, which tends to be very, very localized. There are a number of things that contribute to abdominal contraction pain. So having that kind of, you know, even though we still got a good effect, just not as good as the back pain, we weren't all that surprised about that.
Mel:
[32:54] Yeah, and I wonder too, sometimes back pain can be quite transient in labour and birth, so maybe whatever was causing it resolves over the hour or hour and a half, whereas, the abdominal experience of labour and birth is kind of consistently part of the labour process. So it does kind of make sense that maybe a more physiological pain is.
Nigel:
[33:20] Yes, yeah. And water injections is, like other counter-irrotations, is very good at treating referred pain, that pain that's kind of occurs in one spot, the felt in another. And I think there's probably a mix of referred and unreferred pain in abdominal contraction pain. So I think that's another reason why we didn't see the same degree of analgesia.
Mel:
[33:43] But there was some effect, which is good to know.
Nigel:
[33:47] And one of the things we thought, you know, if this works, we really sort of thought it's probably going to be good as another layer or contributor or running alongside other transient analgesics, whether they, even things like nitrous oxide, you know, if you're using nitrous oxide, then maybe having water injections for your abdominal contraction pain, if it's going to drop the pain by about 30%, will make the nitrous oxide more effective, particularly as the labour progresses. And similarly, if you're getting in the bath using water immersion as an analgesic, then having some water injections and then getting in the bath or being in the bath with water injections will make that more effective. So, you know, it's not often that men kind of use just one analgesic at a time. They will often combine things together. So women getting in the bath with nitrous oxide, which we used to call the birth center epidural, was, you know, that's clearly, you know, one potentiates the effect of the other.
Mel:
[34:41] Absolutely. And this is typically what women do. They're getting a massage with a heat pack and also a tongs machine and they've got their sterile water injections and maybe they're also using the gas and, there's a relaxation track going on in the background and everyone's talking them through each contraction. Women absolutely layer upon layer manage the stretch for pain. So this is conveniently another option that you can add to that. And even more conveniently is it doesn't have any side effects.
Nigel:
[35:12] It's almost the perfect analgesia because it's pretty reliable. It's very simple to give and there are no side effects other than the injection pain that goes away very quickly.
Mel:
[35:22] So essentially, and this is within the scope of midwives, we give injections all the time. This is just intradermal. So it's the technique. I mean, I've done it. How would you describe the angle that you go in with the needle it's bevel up.
Nigel:
[35:38] It's the needle is almost it's very very close to the skin so it's almost like running on the needle just above just above the skin just enough for the bevel or the tip of the needle to enter the skin almost so you can see still see it under the skin and then as you inject you immediately you'll see a little blister start to appear
Mel:
[35:55] Yeah and that's the idea you want to see that blister appear the little bleb appear and that's what generates the pain. And because it's water, it stays there for a while. It's not saline where it can easily be disturbed.
Nigel:
[36:09] That's right. Yeah. So you want to kind of get, you know, the nerves to your skin are the most sensitive ones, so they're the ones we're trying to stimulate.
Mel:
[36:16] Incredible. Is there anything else you want to say about sterile water injections before we move on to your next study? Okay.
Nigel:
[36:25] Just the fact that we talk about the injection pain being the trigger. What we don't know is how much of that do we actually have to give to trigger the analgesia. So that's one of the things we're kind of working on at the moment is can we reduce the injection pain while still maintaining the analgesia?
Mel:
[36:42] How would you reduce the injection pain?
Nigel:
[36:45] Well, we've tried a few things. We've played around with a number of injections that didn't really seem to have much effect. We tried using one of those freezing sprays, vapor coolant sprays, compared to ice packs, which we've just published. Unfortunately, that didn't have much effect either, but we keep trying. At the moment, we're looking at actually playing around with the constituents of water by adding a little bit of saline to the water, because we know the saline doesn't hurt us much. So maybe if we take a little bit of salt irons or a little bit of saline, mix that with the sterile water, will that reduce the pain to the point we're still getting an analgesic response? But won't be as intensely painful as it normally is. So that's kind of a branch of research we're doing at the moment.
Mel:
[37:28] Okay, so watch this space.
Nigel:
[37:30] Watch this space, yeah.
Mel:
[37:31] When you've worked out how to make it less painful but just as effective, we'd love to hear from you.
Nigel:
[37:35] Yes, well, that's, you know, and just the thing is to keep trying to refine the technique and make it more acceptable.
Mel:
[37:42] Yeah, that's the thing, is making it more acceptable because, I mean, it's very hard to talk to a woman about giving them more pain to relieve the pain that they're currently in.
Nigel:
[37:54] It is. And it's sometimes hard to talk to midwives about it because it's counterintuitive. We're not there to cause pain. We're there to relieve pain. So the idea of causing pain to relieve pain is sometimes a bit of a tough nut to crack.
Mel:
[38:07] I think the solution as well for women is to talk to them about it before they're in labour, like during the age and age period, where you can say, look, let's have a full conversation about this while you're not also trying to deal with actual pain. And then they can almost make a decision prior to, birth, this is something they'd even be willing to accept. All right, that's sterile water injections. Take-home message. Midwives can do it. It's easy to administer. It does hurt, but that's the idea. And the pain is short, sharp, and fleeting. And around 70% of women will get a 30% to 50% reduction in the pain. Have I interpreted those stats? That's right.
Nigel:
[38:49] You have a back pain.
Mel:
[38:50] And then it's slightly lower for the abdominal pain.
Nigel:
[38:52] That's right. Yes.
Mel:
[38:54] Beautiful. All right. I feel like that's what we need to know about sterile water injections. Moving on to the next paper, also of 2026 origin. And this one is super exciting. It is.
Nigel:
[39:07] Yes.
Mel:
[39:08] Oh my gosh. This paper was quite a significant kind of breakthrough, I think, because women report, yes, that hypnobirthing has worked for them, but this really writes it down and gives us some hard data. So the paper is called The Association Between Women's Use of Hypnobirthing and Maternal Labor Analgesia Use and Mode of Birth. And this one was done slightly differently. It's a retrospective propensity score match study. We'll explain that in a second. But do you want to give us a little bit of an overview of what this study was about?
Nigel:
[39:48] All right. So, well, as you were saying, hypnobirthing has been around for some time and there are quite a few women who use it. In fact, I trained as a hypnobirthing instructor way back in 2016, I think. And it really is that mix of self-hypnosis techniques and just kind of the philosophy and knowledge around physiological birth. And put together by Maureen Mongan quite some years ago. So the style of hypnobirthing we were looking at was what they call the Mongan method. And interestingly enough, even though it's been around for that quite period of time, there hasn't been previous prior to ours a really sort of large study looking at the analgesic effect or its impact upon mode of birth, which I kind of found was a bit surprising really since it's been used by so many women over the years. And we've been, as you say, being reliant on that anecdotal evidence of effect. Now we have something.
Mel:
[40:44] Now we have something. So what we have is 1,322 pairs. So what you did was is you had women who had done hypnobirthing and then you paired them statistically, all that kind of, I'm using bad words, but you paired them with a similar woman who didn't use hypnobirthing. So each woman who used hypnobirthing was compared to a similar woman who didn't. And you times that by, so there was, ended up being 885 women having their first baby and 437 having their second baby who used hypnobirthing. And they were paired with a woman similar who didn't. Have I explained that correctly?
Nigel:
[41:32] Yeah, that's right. I mean, you know, in research, the ideal situation is that randomized control trial where you randomly take away the choice and you randomly allocate women to one or the other. And that balances out all the confounders and all the other demographic issues, age and size and attitude and all that sort of thing, equally between two groups. When you're working with data that's been collected routinely, probably for another reason, and this data was collected at the Mater Mothers Hospital in Brisbane, and big shout out to the Mater Mothers, because one thing they do well is they have a really beautiful data set, a neonatal data set. They collect a lot of very detailed data. So when you're dealing with that, women have already self-selected which group they want to be in. So we've got the women who've decided to use hypnobirthing and those that don't. There may well be a number of differences between those groups that are going to impact upon things like analgesia use and how they give birth. So we used a process called propensity score matching, which as you said, is just a nice little sort of statistical approach. But what it does is it takes particular characteristics that we provide a list for and their demographic things like age and size and
Nigel:
[42:40] How many babies they've had before and also things that may have occurred during their pregnancy that will impact upon how they labor and birth. So whether they've got diabetes or anemia or something like that or asthma. And then things that happened at the beginning or during their labor like, you know, whether they were induced and things like that. So all these things might impact upon what energy they use and what sort of birth they had. And then we match them one-to-one. So we pick a woman out of this group and find a woman in the other group with very, very similar characteristics and it matches them together. So then we get these two equal groups of women who hopefully, one by one, have the same sorts of characteristics.
Mel:
[43:19] Yes. So it's kind of the next best option, the best you can do with a retrospective cohort of women and data.
Nigel:
[43:27] That's right. Yes.
Mel:
[43:28] And so the data was collected over from 2011 till 2024 from memory? Yes. And the women self-reported their use of hypnobirthing and then the midwives ticked the box this woman had used hypnobirthing in her birth.
Nigel:
[43:44] That's right. Yeah.
Mel:
[43:45] Right. And if you're not familiar with hypnobirthing, like Nigel said, it's a technique, but also when you do a hypnobirthing course, when you go to learn the hypnobirthing technique, you're also taught a lot about how your body works in labor and what normal labor birth looks and feels like. And you're given some strategies and education around that. So that's all kind of part and parcel with the hypnobirth education. It's not just kind of being hypnotized for labor and birth. So there's an element where the women are educated about what's about to happen. So what did you discover about the women who had done hypnobirthing?
Nigel:
[44:23] Well, we found was, and I think it's important to say that these studies don't give you cause and effect. So it's not like a randomized trial. We can say, okay, confidently this caused this. What we talk about is the odds or the chance that you're going to need something based upon being in one group or another. That's a fairly subtle difference there is. So, what we found was that for women who were having their first baby, they were 50% less likely or had less chance of using an epidural.
Mel:
[44:49] It's significant. It's huge. 50%. Oh, that's what struck me initially. I was like, 50%?
Nigel:
[44:57] Yes.
Mel:
[44:58] Okay. Okay, so 50% less chance of an epidural. And that was the first thing you wanted to find out. But there was other outcomes that you were looking to measure, the secondary outcomes.
Nigel:
[45:10] Yeah, so we also saw reductions in nitrous oxide use and opioid use. They were four times more likely to get in the bath and use water immersion than women who didn't.
Mel:
[45:21] I was just going to say, I think part of that is about the educational element of hypnobirthing.
Nigel:
[45:26] It is, yes. And similarly, they were two and a half times more likely to use the shower and get in the shower. They were 1.4 times more likely to have a spontaneous vaginal birth, and they reduced their reliance or their chance or their odds of having a cesarean section by 38%.
Mel:
[45:44] It's a lot. It's a lot.
Nigel:
[45:46] It's just, I can tell you, when I ran this analysis, I was kind of looking at it going, Oh, really? And then I thought, no, I must have made a mistake somewhere. So I went back and re-ran the analysis right through from the matching, the density score matching through. I did that three or four times, just keep checking it. And then my lead statistician checked it again. Okay.
Mel:
[46:05] So what we know from this study is that if, you do hypnobirthing, which includes the educational element and the actual technique of hypnobirthing, which involves kind of a form of self-hypnosis, breathing, affirmations. It's kind of a relaxation process. That you can reduce your caesarean section chances by, did you say 38%?
Nigel:
[46:34] Yeah, by over a third, yep.
Mel:
[46:37] And epidural by 50%. Half, yep. Half of it. And similar reductions in the use of nitrous and morphine or pethidine.
Nigel:
[46:49] Yeah, it was about 25% reduction in nitrous oxide use and about a 30% to 40% reduction in opioids. Thankfully, we don't use opioids much anymore. So those numbers were pretty small. But the big deal was the 50% less likely to need an epidural.
Mel:
[47:07] Yeah, and less likely to need a cesarean section and more likely to utilize other types of pain management like the shower and the bath.
Nigel:
[47:15] Yes, yeah. We only looked at those two because there are myriads of different types of non-pharmacological, but they were the two that we were really kind of interested in.
Mel:
[47:24] And part of me wanted to, like whenever I'm looking at research papers, I'm always trying to be super critical because obviously I have an absolute bias towards physiological birth and any paper that sort of, encourages the thing that agree with my confirmation bias, I'm like, go for it. Don't even look at the details because the findings are fantastic. But part of me sort of picked it apart and went, well, how many of them actually practice hypnobirthing? Did they just go and then think nothing of it? And was it the technique or was it the education? And also if the women self-declared that they had, done hypnobirthing or they wanted a midwife who was going to be hypnobirthing kind of adjacent and sensitive, were they allocated a midwife who was more likely to kind of encourage them towards, I guess, using a warder and using the technique? So I feel like there were other elements that could have created it, except that what we do, I think what we can assume is that women who prepare for labor and birth using, you know, in this study, it was hypnobirthing. But potentially, if you invest in preparation, could get the same result. I'm speculating.
Nigel:
[48:47] Oh, no, look, it's a really valid point. You know, from the data, we can't tell what sort of course a woman went to, whether they went to the whole five classes of the hypnobirthing course or whether they just bought the book or whether they did it online. So, you know, all we know is yes, no, they either did it or they didn't, or they had some exposure to hypnobirthing or they didn't. And one of the limitations of propensity score matching is you can only match for what you've got data for. So the other issues are, and I think there's always a huge amount of interplay between the woman's own confidence and attitude towards wanting a physiological birth. So women who go to hypnobirthing probably want to have a physiological birth and not use pain relief to begin with. And things like hypnobirthing just clearly support that. So other courses or other processes that do the same thing may well have a similar effect. It's just we need to do the research into those.
Mel:
[49:44] Yeah, that was my other feeling is I was like, oh, the ones who probably went off to hypnobirth were already inclined to maybe like gear themselves up for these kind of outcomes. But I think nonetheless, the findings speak to the very real opportunity that if women are prepared, and obviously part of it is that you have a midwife who's aligned with your preparation.
Nigel:
[50:12] Yes.
Mel:
[50:13] That you can impact on the outcome of the pain management, like the pharmaceutical pain management use. And as you've demonstrated earlier, the need for cesarean section.
Nigel:
[50:25] Oh, yeah. Look, I think what it does is demonstrate that if you affirm a woman's self-confidence and self-efficacy and believe in herself that she can birth, and you give her some techniques and strategies to kind of support that, and then you support that not only antenatally, but as you say, with the midwife within the birth suite as well, then we can significantly reduce all these other kind of unnecessary interventions that we often kind of associate particularly with giving birth in hospitals.
Mel:
[50:57] So what we've learned already today, Nigel, from the work that you've been doing is sterile water injections can help with the management of both back and abdominal pain in labour and birth with no side effects, but also the use of hypnobirthing and potentially some form of just education about how your body's going to work in labor and birth can reduce your chances of a caesarean section and the need for an epidural. All of these things have no side effects to use hypnobirthing.
Nigel:
[51:27] No, it's, you know, one of the great things about hypnobirthing is it's just used by women for themselves. It's not something we do to them.
Nigel:
[51:34] It's not something they utilize themselves.
Mel:
[51:36] Incredible. I love that. Now, the final thing I want to ask you about is you're currently in the middle of another research project, which you are still collecting data for. So can we put the link to that data collection form in the show notes?
Nigel:
[51:53] Oh, absolutely, yes.
Mel:
[51:54] For people to participate. Can you tell us about what that study is so that, you know, it's for midwives?
Nigel:
[51:59] It's for midwives. And what we're wanting to do is get a bit of a snapshot of what midwives are doing for perineal protection, for preventing perineal tears, whatever they're doing sort of antenatally and during the labour as well. And we want to have a look at this because there's still, you know, a great deal of discussion around what we, you know, should or should not be doing in this respect. and there's always sort of a number of different sort of trains of thought. And we've also had the introduction of the old perennial bundle, which is now eight years on. And we want to find out, okay, what sort of influences that had in attitudes and how did midwives react to that and did they change their practice or did they continue on or did they do a bit of subversion or were they welcoming of it? So that's why we've got this survey out at the moment. We're hoping to get lots of midwives to respond so we can get a good kind of snapshot of what's happening nationally in terms of what people are doing for perineal protection.
Mel:
[52:55] Great. So specifically for Australian midwives? Yes. I answered the survey. It's super easy. It took me five to ten minutes. So, you know, it's going to be really easy for you if you're a midwife. Just scroll down if you're in Australia. Scroll down to the show notes, click the link, push the little button so that Nigel's research team can keep putting out incredible research for us to use and apply and for women to use. Thank you so much, Nigel, for your time. If you've been listening here to the Great Birth Rebellion podcast and you want to have a read of these papers, make sure that you're on the mailing list because you get access to the resource folders which has all the links to all the full-text papers. Thanks so much, Nigel.
Nigel:
[53:35] All right, thank you.
Mel:
[53:36] Yeah. Hopefully we'll have you on again once all of your research is done for the perineal study. Uh we can you know sounds like you're publishing papers every month and a half well.
Nigel:
[53:48] I wish but anyway no there's a lot of work behind those papers
Mel:
[53:52] Oh yeah i know i can i remember it very clearly the amount of, people and eyes that go all over everything. Amazing. Thank you so much, Nigel. And we will see you all in the next episode of the Great Birth Rebellion podcast. To get access to the resources for each podcast episode, join the mailing list at melaniethemidwife.com. And to support the work of this podcast, wear the rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, @MelanietheMidwife on socials, and the show @TheGreatBirthRebellion. All the details are in the show notes.
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