There are few, if any, experiences in a woman's life both more dreamed-of and dreaded than childbirth, with its notorious pain and unmatched joy. As comedienne Joan Rivers succinctly puts it, "Having a baby is definitely a labor of love."

How to ease the discomfort of labor without dulling the emotional intensity of childbirth or causing ill effects to mother or child is a question that virtually every mother-to-be confronts as her due date nears. According to Holly Muir, MD, chief of women's anesthesiology at Duke, expectant mothers should know that a broad range of pain relief options is available.

"We understand that some women want to experience childbirth with as little outside intervention as possible," Muir says. "But we also want them to know that, if the pain becomes severe, we can help them -- it's their choice. No woman should ever be made to feel guilty if she chooses to use medications to control pain during labor."

In many large hospitals in the United States, epidural analgesia has become the most popular technique to provide pain relief during labor. More than 80 percent of the women who give birth at Duke's Birthing Center now request it. The superior pain relief provided by an epidural allows the woman to relax and focus more on the experience and less on the discomfort. That, in turn, can enhance not only the woman's outlook, but the entire birth's outcome.

"Pain causes adrenalin levels to increase, which decreases circulation, and that limits the amount of flow to the placenta," explains Muir. "So decreasing pain is particularly important if the woman has preeclampsia, diabetes, or other conditions where placental blood flow is marginal."

Typically, women who have gone into labor naturally don't request epidural analgesia during early labor. "Some patients want to go as far as they possibly can before accepting analgesia, and we respect that," says Muir. "But if someone is extremely uncomfortable at two centimeters, I say get your epidural and get comfortable. You don't have to be a hero about it." At the other extreme, it's almost never too late to choose an epidural: Women have even had epidurals between the birth of one twin and another.

At Duke, laboring women have the option to control the amount of analgesia they receive through PCA, or patient-controlled analgesia, in which the patient uses a small pump to dose herself with pain medication as needed. "Patient controlled devices are used both to deliver narcotics intravenously or to give medication into the epidural space through the epidural catheter," Muir explains. "PCA is very satisfying for women -- they love having control over their pain. We find that patients actually end up using less medication and have higher levels of satisfaction overall."

For women in early labor that is painful but progressing slowly or who have contraindications for an epidural, narcotics -- such as morphine or newer synthetic formulations -- offer additional options for pain control. According to Muir, fentanyl [PCA] is often provided in these cases: "It provides good pain control and washes out of the mother's and the baby's bloodstream quickly."

At the Duke Birthing Center, women who are having uncomplicated childbirths can spend their entire stays -- labor, delivery, recovery, and postpartum care -- in one room (with sophisticated equipment, should it be needed, tucked discreetly into cabinets and closets).

Within this homelike atmosphere, knowing that modern medicine's bells and whistles are available if needed, many women try alternative techniques to control labor pain. "We encourage our patients to explore these different approaches," Muir says. "But we do suggest that, if they're using alternative techniques, they start them early in their labor to get ahead of the pain.

"Early on, distraction and relaxation are key," Muir says. "We sometimes encourage women in very early labor to take walks to distract themselves from those early pains. And relaxation between contractions is so important. There's no denying that contractions hurt -- but if you stay tense between them, the next one hurts even more. If you can relax between contractions, you don't feed into that cycle of pain."

Breathing techniques have become an important aspect of most birthing preparation classes these days. "Women can and do go through labor and delivery using only those techniques," Muir says. "And even if you're using other forms of pain relief, controlled breathing is still helpful, as it helps relax the mother and reduce her perception of pain."

Muir often suggests that women in early labor try a warm bath or shower. "I've seen patients get into a bath in early labor and come out fully dilated," she says. Many laboring women also find massages comforting. Along with providing the classic lower-back massage, partners should target the shoulders and some of the pain-relieving acupuncture sites: The web space on the palm, between the thumb and index finger; the soles of the feet; and the sides of the legs. "If you do want to try a massage, be sure to use massage oil," Muir cautions. "I've seen women with first-degree burns from massage because their partner used hand lotion, which gets absorbed into the skin and stops protecting it from the friction of the rub."

Although certain acupuncture sites work well during massage therapy, acupuncture alone for pain control generally does not, because the needles are so fine and the person receiving the treatment needs to remain still -- difficult for a laboring mother. However, a technique called TENS (transdermal electrical nerve stimulation), often used to relieve back pain, does seem to work. The patient applies constant, low-level electrical stimulation to two pads placed in the middle of her back just below her rib cage, then adds stronger, slightly painful stimulation to another set of pads on her lower back during contractions.

The resulting sensations provide helpful distraction from labor pains. TENS doesn't affect the progress of labor or the baby, and the units, available for rent from medical supply stores, can be used while walking. "It's an especially good technique for women whose labor is concentrated in the back," Muir says.

Women with experience in techniques such as self-hypnosis and meditation can often effectively employ them to ease pain. "But you need to already know what you’re doing -- labor isn’t the time to learn," Muir says. "Also, these approaches call for a quiet, interruption-free atmosphere, and that can be hard to come by during labor."

Many women bring a heating pad with them to the hospital to relieve back pain. Muir suggests that, instead, women follow the cue of sports medicine and use ice packs instead, saving the heat therapy for postpartum pain.

Remaining mobile for as long as possible is also tremendously helpful, says Muir. "Just being able to get up and sit in a chair or use the bathroom is much better than spending hours lying in bed watching the monitor," she says.

In the time-honored tradition of women helping women through this most profound of life transitions, some women hire trained labor coaches, known as doulas, to help them through labor and delivery. A doula -- the Greek word for servant -- is sometimes described as the "mother’s mother." Familiar with alternative techniques for pain control, doulas help women mentally prepare for labor and develop a birth plan.

Ultimately, each childbirth is a unique event, and it’s impossible to predict exactly how a childbirth experience will go. "Studies have shown that women who prepare for childbirth by learning breathing exercises and understanding pain relief options experience less pain than those who are unprepared," Muir says. "So consider your own medical situation and goals. Learn as much as you can about your choices. Talk them over with your ob-gyn and, if possible, the anesthesiologists where you’ll be delivering, and make your initial decisions.

"Then, when labor begins, see how it’s going, see how you’re doing, and stay open to making adjustments to your plan if needed."