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AJOG REVIEWS
KEY WORDS
Labor pain
Complementary and
alternative medicine
Objectives: The purpose of this study was to systematically review the literature for, and critically
appraise, randomized controlled trials of any type of complementary and alternative therapies for
labor pain.
Study design: Six electronic databases were searched from their inception until July 2003. The inclusion criteria were that they were prospective, randomized controlled trials, involved healthy
pregnant women at term, and contained outcome measures of labor pain.
Results: Our search strategy found 18 trials. Six of these did not meet our inclusion criteria. The
remaining 12 trials involved acupuncture (2), biofeedback (1), hypnosis (2), intracutaneous sterile
water injections (4), massage (2), and respiratory autogenic training (1).
Conclusion: There is insucient evidence for the ecacy of any of the complementary and alternative therapies for labor pain, with the exception of intracutaneous sterile water injections. For
all the other treatments described it is impossible to make any denitive conclusions regarding
eectiveness in labor pain control.
2004 Elsevier Inc. All rights reserved.
The experience of pain during labor is a complex, individual, and multi-faceted response to sensory stimuli
generated during childbirth. Labor pain and methods
to relieve it are a major concern for the mother and
child, with considerable implications for intra- and postpartum care. The conventional medical approach to the
management of pain in labor and delivery has increasingly come to rely on the use of anesthetic and analgesic
drugs, in spite of reservations within the medical estab* Reprint requests: Alyson L. Huntley, PhD, Complementary
Medicine, Peninsula Medical School, Universities of Exeter and
Plymouth, 25, Victoria Park Road, Exeter, EX2 4NT, UK.
E-mail: alyson.huntley@pms.ac.uk
0002-9378/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.ajog.2003.12.008
37
Methods
The computerized literature searches were performed
with the following electronic databases: Medline (from
1953 to July 2003); Embase (from 1974 to July 2003);
Cinahl (from 1982 to July 2003); AMED (from 1985 to
July 2003); PsychInfo (from the 1800s to July 2003); and
The Cochrane Library (from 1996 to July 2003). The
search terms were labor, birth, parturi, contractions,
obstetric, pain, complementary medicine, alternative
medicine, aromatherapy, therapeutic touch, reexology,
massage, spiritual healing, relaxation, meditation, yoga,
autogenic training, herbal medicine, traditional Chinese
medicine, medicinal plant, ayurvedic, acupuncture, acupressure, chiropractic, osteopathy, homeopathy, ower
remedies, hypno, Feldenkrais, music therapy, rolng,
shiatsu, randomized controlled trial.
The bibliography of papers found by the search and
relevant reviews were examined for references of further
trials. Colleagues both within Complementary Medicine
at the Peninsula Medical School, Exeter University, and
experts in the elds were consulted as to the existence of
any additional studies. There were no restrictions on the
language of publication.
The inclusion criteria for the studies were that they
involved healthy pregnant women at term. The type of
intervention could be any type of CAM for pain relief
during labor. This review excluded any studies of articially induced labor pains or trials that had other obstetric outcomes. The denition of CAM for this review is
dened as those medical systems, professions, practices, interventions, modalities, therapies, applications,
theories, or claims that are currently not a part of the
dominant or conventional medical system.9 Thus, this
review excluded such treatments as hydrotherapy or
the use of transcutaneous electrical nerve stimulation
(TENS). The use of a doula during labor has been reviewed extensively recently, and thus, this supportive
therapy was not included.10
All interventions, or strategies including other therapies, no treatment, or placebo, were considered as suit-
Results
Our search strategy found 18 RCTs investigating CAM
therapies for labor. Six of these did not meet our inclusion criteria because they either studied laboratorysimulated labor pains or did not use specic pain
outcome measures.12-17 The remaining 12 trials involved
acupuncture (2), biofeedback (1), hypnosis (2), intracutaneous sterile water injections (4), massage (2), and
respiratory autogenic training (1) The putative mode
of action of these therapies for labor pain is listed in
Table I, and these RCTs are summarized in Table II
and described in detail below.
Acupuncture
A study by Ramnero et al involved 90 parturients both
primiparous and multiparous.18 The women were randomized either to receive acupuncture or no additional
treatment during labor. The acupuncture treatment was
individualized, whereby each midwife chose points suitable for the pain localization as labor progressed. As a
rule, relaxing points were combined with local and distant
analgesic points. Pain intensity was assessed hourly before any given analgesia and 15 minutes after by a pain
score (rated 0-10). Painless and well-relaxed were dened
as 0, worst pain imaginable, and very tensed were dened
as 10.
Assessments of pain intensity were equal between the
2 groups (mean difference 0.29, (95% CI 0.9 to 0.32).
However, the need for epidural analgesia was signicantly reduced in the acupuncture group compared with
the non-acupuncture group (12% vs 22%, relative risk
[RR] 0.52, 95% CI 0.3 to 0.92). Regarding other analgesic methods, no differences were seen except the use of
the non-pharmacologic methods (warm rice bag, bath,
38
Table I
Therapy
Mode of action
Acupuncture
It has been suggested that acupunctures mechanism of pain relief is similar to that of transcutaneous electrical
nerve stimulation (TENS) units, in that stimulating large myelinated fibers blocks the smaller
fibers from transmitting painful stimuli. Other theories include altering the bodys levels of chemical
neurotransmitters and influencing the natural electrical or electromagnetic fields.
Biofeedback
Biofeedback is a treatment that uses monitoring instruments to provide either visual or acoustic feedback to
patients physiologic information of which they are normally unaware. It puts the patients in control and
gives them a sense of self-reliance that is an important factor for the laboring woman.
Hypnosis
Hypnosis is a state of attentive and focused concentration in which the patient can be relatively unaware, but not
completely blind to their surroundings. During this trance-like state, therapeutic suggestions may be given.
Hypnotic suggestions focus on diminishing the awareness of pain, as well as fear and anxiety. The treatment
for preparation for birth is based on the premise that if the patient is sufficiently educated and prepared
regarding the process, her anxiety is reduced, she would require less medication during and after the birth and
recovery, and healing would proceed at a faster pace with fewer complications.
Intracutaneous Counter irritation is the process by which localized pain felt in one part of the body may be relieved by irritating
the skin in same dermatomal distribution with either a hot, cold, scratchy, or electrical stimulus. The sterile
injections
of sterile water water injections are thought to cause distension in the skin, which stimulates nociceptors and
mechanoreceptors. Two intracutaneous injections of 0.1 mL are made bilaterally, approximately 2 cm inferior
and 1 cm medial to the posterior superior iliac spines. The placement of these injections does not need to be
precise. Sterile water is thought to produce a better affect than isotonic saline.
Massage
Massage during labor is most commonly used for its stress reduction and relaxation. Massaging muscles and other
tissues not only relaxes the muscles, it also alleviates pain. Massage can be analgesic through distraction,
although it is also thought to have a physiologic basis, blocking pain impulses by increasing A-fiber
transmission, or by stimulating the local release of endorphins.
Respiratory autogenic training derives from the autogenous training based on progressive relaxation methods. It
Respiratory
comprises a series of exercises in which the woman learns to diminish her muscle tonus by deep relaxation
autogenic
and by concentrating on her body sensations. The autonomic effects of deep relaxation are diametrically
training
opposed to those characteristic of anxiety, and are related to feelings of calmness.
Biofeedback
In a study by Duchene, 55 primigravidas were randomly
assigned to either childbirth classes or childbirth classes
plus training sessions in biofeedback, which was then
used during labor.20 Pain was monitored during labor
with a VAS and a verbal descriptor scale (VDS). Forty
women completed the study (93% white, 7% black); attrition occurred because of the need for cesarean section.
Results showed that women using biofeedback during
childbirth reported signicantly lower pain than control
women at admission (VAS P!.05, VDS P!.01), at delivery (VDS P!.005) and 24 hours postpartum (VDS
P!.01). Seventy percent of the women in the control
group requested and used epidural anesthesia compared
with 40% of the women of the biofeedback group
(P!.05).
Hypnosis
In the study by Freeman et al, 82 primigravidas were assessed for hypnotic susceptibility and randomized to receive weekly, individual hypnosis sessions for relaxation
39
Randomized controlled trials of acupuncture, biofeedback, hypnosis, ISW injections, and massage for labor pain
Citation
Acupuncture
Ramnero,
2002
Jadad
Score Participants
Treatment
Control
treatment
Pain outcome
measures
Pain score
(0-10) hourly
and 15
minutes after
analgesia
VAS score
before
treatment,
30, 60, 120
minutes and
hours after
delivery
90 women (n = 42
primiparas and
n = 48
multiparas)
Individualized
acupuncture
No
acupuncture
210 women
(n = 101
primiparas
and n = 107
multiparas)
in spontaneous,
active labor
Real acupuncture
False
acupuncture
Biofeedback
Duchene,
1989
40 women
(primpars)
Series of training
sessions in
biofeedback
as an adjunct
to childbirth
classes
Childbirth
classes
Hypnosis
Freeman,
1986
82 women
(primiparas)
expecting
a normal
pregnancy
60 women
(primiparas)
screened for
hypnotic
susceptibility
Routine
Routine weekly
weekly
antenatal classes
antenatal
plus weekly
classes
individual
hypnosis
sessions for
relaxation and
pain relief
Hypnotic induction Relaxation and
breathing
as an adjunct to
exercises
childbirth class
typically
used in
childbirth
classes
Skilnand,
2002
Harmon,
1990
ISW injections
Ader, 1990 4
Trolle, 1991 3
45 women (n = 30
primiparas and
n = 15
multiparas)
ISW injections
ISW injections
272 women in
labor complaining
of severe lower
back pain (both
primiparas and
multiparas-no
further details
provided)
Reports of
pain by VAS
and VDS at
admission,
delivery, and
postpartum
Main results
No significant
difference between
groups
Significant
improvement in real
acupuncture group
compared with
control at 30, 60,
120 minutes and 2
hours after birth
(P!.00)
Biofeedback group
reported less pain
at admission (VAS
P!.01, VDS P!.05)
At delivery (VDS
P!.01)
24 hours postpartum
(VDS P!.01)
No significant difference
Linear analog
between the groups
scale for pain
relief,
retrospectively
McGill Pain
Questionnaire
(MPQ) within
24 hours of
delivery
Subcutaneous
injections
of isotonic
saline
40
Table II
continued
Citation
Jadad
Score Participants
ISW injections
Martensson, 4
1999
Labrecque,
1999
Treatment
Control
treatment
Pain outcome
measures
Placebo
VAS score
99 women at 37 to Four injections of
treatment
at 10 and 45
0.1 mL sterile
42 weeks
minutes after
water
gestation (n = 40
treatment
intracutaneously
primiparas and
or subcutaneously
n = 59 multiparas),
requiring pain
relief for severe
lower back pain
VAS scales for
ISW injections
Standard care
34 women (n = 22
intensity and
including
primiparas and
affective
back massage,
n = 12 multiparas),
dimensions of
whirlpool,
considered low risk
pain at 15, 60,
liberal
and suffering from
90, 120, and
mobilization
lower back pain
180 minutes
or TENS
during labor
after initial
intervention
Main results
Both treatment groups
had reduced pain
compared with placebo
at 10 and 45 minutes
(P = .002, P = .006)
Reduction of intensity
and unpleasantness of
pain in ISW group
compared with control
and TENS (P = .011,
P = .03)
Massage
Field, 1997 2
and pain relief, in addition to the routine weekly antenatal classes or the antenatal classes alone (control
group).21 Pain relief was recorded with a VAS and no
signicant differences were seen between the 2 groups.
In addition, there was no signicant difference in the
use of Entotox, pethidine, or epidural analgesia between
the groups.
Harmon et al studied the benets of hypnotic analgesia as an adjunct to childbirth education in 60 primiparous, white women.22 Subjects were assessed for
hypnotic susceptibility, and then randomized to receive
either hypnotic induction classes or relaxation and
breathing exercises during 6 childbirth classes. They measured thresholds for ischemic pain before labor, and then
41
Massage
A study by Field et al involved 28 middle socioeconomic
status women (34% white, 9% black, and 57% Hispanic) who were randomized to receive massage (head,
shoulder/back, hand, and foot) in addition to coaching
in breathing, or to receive coaching in breathing alone
(control).28 The mothers self-rated their labor pains on
the 5-point Likert scale before and after massage or control procedure. There was a reduction in pain from 5.0
to 3.5 in the massage group, and an increase in pain
from 4.3 to 5.0 in the control group. Statistical reporting
was difcult to interpret as signicant differences were
pre- and post- within groups or between groups. No information was reported of other analgesic support, conventional or otherwise.
In the study by Chang et al, 60 primiparous women
expected to have a normal childbirth were randomly assigned to either receive massage intervention comprising
abdominal efeurage, sacral pressure, and shoulder/
back kneading during their labor, or attention control.29
In the massage group, the woman received a 30-minute
massage during uterine contractions rst by the researcher and then by the partner during each of the
42
3 phases of labor. The standard care group received the
researchers attendance and causal conversation for the
same time periods. The nurse-rated present behavorial
intensity (PBI) was used as a measure of labor pain, with
use of the self-reported present pain intensity (PPI) scale
to validate. Signicantly lower PBI scores were recorded
in the massage group compared with the control group
during all 3 phases of labor (P = .00, P = .002, P =
.000, respectively), and these data were validated by
the PPI scales. No information was reported of other
analgesic support, conventional or otherwise.
Comment
In total we identied 12 RCTs that met our inclusion
criteria. They were all published during the last 2 decades, mostly by US authors, and frequently in conventional medicine journals. Their methodologic quality is
variable and often low. Their sample size is generally
small.
There is insufcient evidence for the efcacy of any of
the CAM therapies described for labor pain, with the exception of ISW treatments. There is some evidence for
the benet of massage therapy during labor. For all
43
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