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Systematic review
Cochrane review: relaxation and yoga may decrease pain during labour and increase satisfaction with pain relief, but better quality evidence is needed
  1. Pamela Reis
  1. College of Nursing, East Carolina University, Greenville, North Carolina, USA
  1. Correspondence to Pamela Reis
    College of Nursing, East Carolina University, 600 Moye Boulevard, 3159 Health Sciences Building, Greenville, NC 27834, USA; reisp{at}ecu.edu

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Implications for practice and research

  • Evidence suggests a beneficial effect of relaxation techniques and yoga in reduction of pain intensity during labour, and reduced likelihood of assisted vaginal delivery.

  • Well-designed randomised controlled trials (RCT) that further examine the efficacy and safety of relaxation, yoga, music and audio-analgesia are needed.

Context

Complementary and alternative medicine (CAM) is widely practiced around the world, especially among women of childbearing age.1 The incidence of CAM use during pregnancy may be as high as 87%.2 Nurse-midwives play a crucial role in the care of women during pregnancy and childbirth and are avid supporters of CAM use during pregnancy.3 Common CAM therapies used by women for pain relief during labour include herbal preparations, homeopathy, aromatherapy, mind–body interventions (such as yoga, hypnosis, biofeedback and relaxation techniques), massage therapy, reflexology, chiropractic care and acupuncture.4 The use of CAM therapies may be congruent with user's values and belief systems and offer a mechanism of control over pain.5

Methods

Smith and colleagues' review of RCTs is one in a series of Cochrane reviews that explore pain management during labour. Comparisons of relaxation, yoga, music and audio-analgesia with placebo, usual care, or no care, were analysed. Primary outcomes of interest were pain management in labour, maternal satisfaction with pain relief, and safety of the method for the mother and infant.

The review included 11 RCTs of women in labour (1374 women). The sample size ranged from 25 to 1087. Studies were undertaken in Italy, Thailand, Brazil, Iran, Sweden, Taiwan, Turkey, the UK and the USA. The study designs included parallel designs, factorial design, cluster randomisation and control groups were varied. Several mind–body interventions used by women during labour were identified: yoga; hypnosis; relaxation therapies; acupuncture and acupressure; aromatherapy; massage; homeopathy; and chiropractic care.

Findings

Relaxation techniques were associated with reduction in labour pain intensity, greater satisfaction with pain relief and lower rates of assisted vaginal delivery. Yoga was associated with reduced pain intensity, reduced length of labour, greater satisfaction with pain relief and satisfaction with the childbirth experience. Evidence about the potential benefits of music and audio-analgesia was limited with no differences found regarding labour pain intensity, satisfaction with pain relief or mode of birth. The authors reported that no study in their review was at low risk of bias on all domains.

Commentary

CAM practices such as relaxation techniques and yoga are safe and effective in reducing labour pain and impact positively on women's birth experiences. However, providers and consumers of healthcare should be aware of inconsistencies in the findings of CAM therapy research to date. Methodological issues, such as lack of standardisation in design, threaten the internal and external validity of CAM trials. Limitations could be at least partly addressed through adherence to recommendations within the CONSORT (Consolidated Standard of Reporting Trials) statement.6 While there are methodological issues unique to CAM research which are difficult to address within the CONSORT guidelines, poorly designed studies with inherent biases can negatively impact healthcare decision making.

Bias in CAM research can be minimised by careful assessment of the characteristics of study participants to avoid threats to external validity of findings; utilising a rigorous definition of ‘dose’ in mind–body interventions (number of sessions, duration of each session and the amount of time between sessions); standardised training for both the treatment and placebo providers; and recognising that simple randomisation may not identify prognostic factors that can influence outcomes.7

References

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Footnotes

  • Competing interests None.

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