Nonpharmacologic relief of pain during labor: Systematic reviews of five methods

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Abstract

Nonpharmacologic measures to reduce labor pain have been used throughout history. Despite reports that some of these methods reduce pain, increase maternal satisfaction, and improve other obstetric outcomes, they have received limited attention in the medical literature and are not commonly available to women in North America. The controlled studies of nonpharmacologic methods are limited in number and sometimes provide conflicting results. This systematic review was conducted to assess the safety and efficacy of the best studied techniques, as well as to highlight areas in need of further research. Five comfort measures were selected for review, based on these criteria: they have been evaluated with prospective controlled studies and they require institutional support (eg, skills, policies, equipment). These 5 methods included continuous labor support, baths, touch and massage, maternal movement and positioning, and intradermal water blocks for back pain relief. An extensive search of electronic databases and other sources identified studies for consideration. Critical evaluation of controlled studies of these 5 methods suggests that all 5 may be effective in reducing labor pain and improving other obstetric outcomes, and they are safe when used appropriately. Additional well-designed studies are warranted to further clarify their effect and to evaluate their cost effectiveness. (Am J Obstet Gynecol 2002;186:S131-59.)

Section snippets

Criteria for selection

  • 1.

    The pain relief methods require accommodations by the birth setting, in the form of policies that allow ambulation, bathing, and a woman's choice of support persons; special equipment, such as bathtubs, syringes with sterile water, and aids to movement and positioning; and specialized skills in maternity staff or others, such as intradermal water injections, massage, and labor support.

  • 2.

    The studies were published in the English language and evaluated pain relief with prospective controlled

Background

Until modern times, laboring women were usually attended not only by midwives, but also by experienced supportive (usually female) companions. During most of the twentieth century, however, women in North America gave birth increasingly in hospitals and labored without support. During the 1970s, husbands and fathers were recruited to accompany the women through labor. Labor support from experienced women was re-introduced by John Kennell and Marshall Klaus as an intervention to improve

Background

Many laboring women find a bath soothing and relaxing. They have used baths for years in out-of-hospital birth settings for both labor and birth, and recently, hospitals in North America have installed bathtubs and allowed women to use them, primarily for relaxation and pain relief during labor. This review includes studies of pain indicators and other effects of bathing during labor. Studies of planned water births are not included, because they did not investigate pain indicators; rather,

Conclusion

Bathing during labor is a safe, popular, and promising method of temporary pain relief in labor. Many women seek birthing facilities where baths are available. Women have described appealing features of the bath other than pain relief, such as a sense of personal control in decision making and enhancement of their ability to cope with the pain.64 Baths should be available to laboring women as one component of a comprehensive holistic approach to labor pain management.

More research is needed to

Background

Historically and cross-culturally, laboring women have always tried to find comfort by using a variety of movements and positions. With slow labors, severe pain, or life-threatening problems, their caregivers have moved them in particular ways or into specific positions, sometimes using devices such as ropes, poles, and chairs.65, 66 As the place of birth shifted from home to hospital during the first half of the 20th century, numerous changes in care, such as the use of narcotics or

Results

Details of all included studies and their results are summarized along with validity assessments and presented in Tables IV and V.

Discussion

The trials of positioning during the first stage of labor compared ambulation or upright positions with one or more horizontal positions in bed. Some trials76, 77, 78, 79, 80, 81, 82 used each patient as her own control, alternating between 2 positions for equal periods and checking for effects, such as location and intensity of pain, uterine activity, and labor progress during each period. These are described in Table IV.

Other trials73, 74, 75, 83, 84, 85, 86, 87, 88 assigned subjects to one

Conclusion

No trials have ever compared a policy of freedom to move spontaneously with a policy of restriction to a labor bed for outcomes such as comfort, labor progress, or fetal well-being. Spontaneous movement and position changes to seek greater comfort do not seem to lend themselves to regulation and rigorous scientific inquiry. No harm appears to result for healthy gravidas who move about during labor, and benefits may occur for some in terms of comfort and labor progress. Until freedom to move can

Background

Touch, in the form of hand holding, stroking, caressing, embracing, or patting, communicates caring, reassurance, or love. Massage, “the intentional and systematic manipulation of the soft tissues of the body to enhance health and healing,”89 is widely sought by the general public and frequently recommended by physicians for a variety of ailments ranging from fatigue, tension, emotional distress, and mental illness, to musculo-skeletal injury, chronic and acute pain, and other conditions. The

Conclusion

The interventions of touch and massage have not undergone sufficient scientific study to provide clear conclusions regarding benefits and risks. Given the widespread popularity of massage and the positive messages that can be conveyed by gentle touch, these simple methods deserve further controlled study to help guide practitioners in the provision of appropriate care. It is clear that some women appreciate touch and massage in labor, and these simple interventions may relieve pain and anxiety,

Background

Fifteen percent to 74% of laboring women have back pain.99, 100 Although commonly attributed to a fetal occiput posterior position, back pain in labor may be increased by other factors, such as persistent asynclitism, specific maternal anatomic characteristics, or referred pain from the cervix or uterus.

Of the variety of nonpharmacologic approaches to relieve back pain in labor (including the use of positions or movement, TENS, hot or cold compresses, massage, and intradermal water blocks),

Conclusion

Intradermal water blocks are effective in reducing severe back pain. One small study found that subcutaneous water blocks were also effective. The blocks may have benefits on other obstetric outcomes as well, but most studies were not designed with sufficient power to assess these other outcomes. Only one, the largest trial,109 which was well-designed and had a low risk of bias, did find a significant decrease in cesarean deliveries.

Intradermal water blocks are simple to administer,

Discussion and conclusions

These systematic reviews of 5 nonpharmacologic methods for the relief of labor pain indicate the following common benefits: temporary reduction of labor pain, possible postponement or reduction in use of pain medications, simplicity of application, satisfaction expressed by many women, and a high degree of safety.

Other pain-related effects of these nonpharmacologic methods were found in some of the studies reviewed (eg, enhancement of labor progress, reduction of cesarean section and other

Acknowledgements

We thank Cinda Weber for library assistance, and Carol Sakala and Judith Rooks for editorial assistance.

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