American Journal of Obstetrics and Gynecology
Nonpharmacologic relief of pain during labor: Systematic reviews of five methods☆
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.
References (112)
- et al.
A comparison of intermittent and continuous support during labor: a meta-analysis
Am J Obstet Gynecol
(1999) - et al.
Effects of providing hospital-based doulas in health maintenance organization hospitals
Obstet Gynecol
(1999) - et al.
Langer. “Alone, I wouldn't have known what to do”: a qualitative study on social support during labor and delivery in Mexico
Soc Sci Med
(1998) - et al.
Epidural analgesia side effects, co-interventions, and care of women during childbirth: a systematic review
Am J Obstet Gynecol
(2002) Birth under water
Lancet
(1983)Water birth: one birthing center's observations
J Nurse Midwifery
(1989)- et al.
A retrospective comparison of water births and conventional vaginal deliveries
Eur J Obstet Gynecol Reprod Biol
(2000) - et al.
Early or late bath during the first stage of labour: a randomised study of 200 women
Midwifery
(1997) - et al.
Water immersion and the effect on labor
J Nurse Midwifery
(1993) The nature of labor pain
Am J Obstet Gynecol
(2002)
The relationship of maternal anxiety, plasma catecholamines, and plasma cortisol to progress in labor
Am J Obstet Gynecol
Anxiety and epinephrine in multiparous women in labor: relationship to duration of labor and fetal heart rate pattern
Am J Obstet Gynecol
Maternal pyrexia associated with the use of epidural analgesia in labour
Lancet
Maternal temperature regulation during extradural analgesia for labour
Br J Anaesth
Can water immersion stop labor?
J Nurse Midwifery
Staying in control: women's experiences of labour in water
Midwifery
Effect of position changes on intensity and frequency of uterine contractions during labor
Am J Obstet Gynecol
Maternal positions and pushing techniques in a nonprescriptive environment
J Obstet Gynecol Neonat Nurs
Labor pain: effect of maternal position on front and back pain
J Pain Symptom Manage
Pain in the first stage of labor: relationship with the patient's position
J Pain Symptom Manag
Ambulation and delayed amniotomy in the first stage of labor
Eur J Obstet Gynecol Reprod Biol
Maternal position, labor, and comfort
Appl Nurs Res
Low-back pain during labor
Am J Obstet Gynecol
Undertaking systematic reviews of research on effectiveness: CRD guidelines for those carrying out commissioning reviews (CRD report 4)
Cochrane Reviewers' Handbook, version 4.1.1, updated March 2001
Transcutaneous electrical nerve stimulation in labour pain: a systematic review
Br J Obstet Gynaecol
The effect of a supportive companion on perinatal problems, length of labor, and mother-infant interaction
N Engl J Med
Effects of social support during parturition on maternal and infant morbidity
BMJ
Continuous labor support from labor attendant for primiparous women: a meta-analysis
Obstet Gynecol
The doula: an essential ingredient of childbirth rediscovered
Acta Paediatr
The obstetrical and postpartum benefits of continuous support during childbirth
J Womens Health Gender Based Med
Caregiver support for women during childbirth (Cochrane Review)
The Cochrane Library
Companionship to modify the clinical birth environment: effects on progress and perceptions of labour and breastfeeding
Br J Obstet Gynaecol
Effects of psychosocial support during labour and childbirth on breast-feeding, medical interventions, and mothers' well-being in a Mexican public hospital: a randomised clinical trial
Br J Obstet Gynaecol
Effects of continuous intrapartum professional support on childbirth outcomes
Res Nurs Health
Continuous emotional support during labor in a US hospital
JAMA
Evaluation of different policies of management of labour for primiparous women. Trial B: results of the continuous professional support trial. Evaluation in pre-, peri-, and post-natal care systems
A trial on continuous human support during labor: feasibility, interventions and mothers' satisfaction
J Psychosom Obstet Gynecol
Labor support by a doula for middle-income couples: the effect on cesarean rates
Pediatr Res
Social support during premature labor: effects on labor and the newborn
J Psychosom Obstet Gynaecol
A randomized trial of one-to-one nurse support of women in labor
Birth
Doula support vs epidural analgesia: impact on cesarean rates
Pediatr Res
Alternative strategy to decrease cesarean section: support by doulas during labor
J Perinat Educ
Effects of female relative support in labor: a randomized controlled trial
Birth
A randomized trial of the effects of monitrice support during labor: mothers' views two to four weeks postpartum
Birth
One-to-one nurse support in labor
Birth
Warm tub bath after spontaneous rupture of the membranes
Birth
Warm tub bath during labor: a study of 1385 women with prelabor rupture of the membranes after 34 weeks of gestation
Acta Obstet Gynecol Scand
Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey
BMJ
Cited by (0)
- ☆
Reprint requests: Penny Simkin, PT, 1100 23rd Ave East, Seattle, WA 98112.