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Nonpharmacological approaches to management of labor p

Authors
Penny Simkin, PT
Michael C Klein, MD,
CCFP, FAAP, FCFP,
ABFP

Section Editor
Charles J Lockwood,
MD

Last literature review version 19.3: September 2011 | This topic last updated: Se
INTRODUCTION The management of labor pain is
a major goal of intrapartum care. There are two
general approaches: pharmacologic and
nonpharmacologic. Pharmacologic approaches are
directed at eliminating the physical sensation of labor
pain, whereas nonpharmacologic approaches are
largely directed at prevention of suffering. Suffering
may be defined in terms of any of the following
psychological elements: a perceived threat to the
body and/or psyche; helplessness and loss of control;
distress; insufficient resources for coping with the
distressing situation; fear of death of the mother or
baby [1]. Although pain and suffering often occur
together, one may suffer without pain or have pain
without suffering.
The nonpharmacologic approach to pain management
includes a wide variety of techniques that address not
only the physical sensations of pain, but also attempt
to prevent suffering by enhancing the psycho-

emotional and spiritual components of care. In this

approach, pain is perceived as a normal
accompaniment of most labors. The woman is
educated and assisted by her caregivers, childbirth
educators, and support people to take an active role
in decision-making and in using self-comforting
techniques and nonpharmacologic methods to relieve
pain. Her caregivers and support people also help her
by providing reassurance, guidance, encouragement,
and unconditional acceptance of her coping style. By
taking an active role in decision-making and receiving
appropriate support, women are more likely to be
able to transcend their pain and experience a sense of
mastery, control, and well-being, factors associated
with their ability to cope with labor [1].
A systematic review of studies on women's
expectations and experiences of pain and pain relief
during labor and their involvement in the decisionmaking process found a gap between their
expectations and their actual experiences [2]. They
were inadequately prepared for the reality of labor
pain and were unable to make informed choices about
pain relief.
In order to close this gap, women need information
prenatally about the risks and benefits of both
pharmacologic and nonpharmacologic methods of
pain management, and opportunities to practice in
nonpharmacologic pain relief methods.
This topic will explore the variety of
nonpharmacologic methods of management of pain
during labor and the evidence of their efficacy. Most
birthing facilities offer at least some of these
techniques; however, some procedures, such as
acupuncture, usually require credentialing and may
not be available in all birth settings. Pharmacologic
methods of pain relief are reviewed separately. (See
"Pharmacologic management of pain during labor and
delivery".)
EVALUATING THE OUTCOME OF
NONPHARMACOLOGIC PAIN RELIEF
METHODS Nonpharmacologic techniques for

management of labor pain can be combined or used

sequentially to increase their effectiveness. However,
data regarding the safety and efficacy of these
interventions are limited since few randomized trials
have been performed and most studies enrolled a
small number of subjects, had wide variations in
patient populations or study design, and had
methodological flaws [3].
Most studies of nonpharmacological approaches to
labor pain used either the womans rating of her pain
or her use of pain medications as outcome measures;
however, these measures can be misleading. For
example, if a woman rates her pain as severe, one
should not assume that she cannot cope with it or
that she is overwhelmed by it. Most women who use
nonpharmacological methods of pain relief expressed
satisfaction with these methods and desired to use
them in subsequent pregnancies, despite
experiencing pain during labor. This suggests that
women see value in these methods that are not fully
appreciated in studies that merely determine pain
scores.
The use of pharmacological analgesia, representing a
failure of nonpharmacological approaches, as an
outcome also may be misleading, as it may reflect the
usual care practices of the hospital. In hospitals
where most women receive epidural analgesia, the
staff may be unfamiliar with nonpharmacological
methods of labor support and labor pain reduction,
and the facilities and policies may not support these
measures. Another way to measure the effect of
nonpharmacological methods is to record when in
labor the woman receives medication, as
nonpharmacological methods may delay the use of
pharmacological analgesia and avoid some
undesirable duration-related side effects of
medication, such as maternal fever. (See
"Intrapartum fever", section on 'Fetal/Neonatal
issues'.)
CHILDBIRTH EDUCATION Childbirth education
(ie, prenatal or antenatal education) consists of

individual or group classes designed to inform

pregnant women and their partners about labor and
birth, common clinical care practices, early
parenthood, and infant feeding. These classes cover
pain control, including self-help measures. (See
"Preparation for labor and childbirth".)
Interpretation of observational studies on the effects
of antenatal education on labor pain and use of
medication in labor is limited by selection bias
(women who take these classes tend to be highly
motivated and educated) and lack of appropriate
controls. Data from randomized trials are sparse:
A single randomized trial randomly assigned 1193
women to receive nine hours of antenatal childbirth
training or no formalized training [4]. The training
consisted of lectures on, and discussion of, labor
onset, the birth process, the support person, pain
relief, birth interventions, fear of childbirth, and a film
on giving birth. Women who received training were
significantly less likely to undergo epidural analgesia
during labor (RR 0.84, 95% CI 0.73-0.97), but were
not less likely to request pain medication. The
frequency of medical interventions and the women's
self-reported assessments of their birth experiences
were similar for both groups.
The content of childbirth education is likely to
influence the benefits derived by expectant parents.
In addition to the usual rhythmic breathing
techniques (see 'Relaxation and breathing' below),
the following concepts from behavioral medicine merit
evaluation [5]:
Increase the range of coping strategies, in particular
by including cognitively-based strategies.
Help women identify and understand the nature of
their own coping styles and preferences, including
any unhelpful beliefs about, and reactions to, patterns
of pain.
Help women develop their own coping strategies for

labor, based on past coping experiences or through

preferences identified in class.
Strengthen feelings of coping self-efficacy by practice
in class and reinforcement by the class teacher.
RELAXATION AND BREATHING Most childbirth
education classes and most books on childbirth
present relaxation techniques, along with a variety of
rhythmic breathing patterns intended to complement
and promote relaxation or to provide distraction from
labor pain. These techniques are also used to
enhance a woman's sense of control [6,7]. The
thoroughness of the teaching along with the amount
of time devoted to rehearsing these techniques vary
widely, from a quick mention or demonstration, to
repeated practice and adaptation to the individuals'
preferences, designed with the goals of enhancing
mastery and confidence. Relaxation and breathing
techniques have not been studied as independent
variables in randomized trials.
A survey of women in the United States who gave
birth in 2005 found that 49 percent of the
respondents used breathing techniques, and of those,
77 percent rated them as "very" or "somewhat"
helpful, while 22 percent rated them as "not very
helpful" or "not helpful at all" [8]. This finding may
reflect differences in the quality of the teaching
received by the women, or indicate that breathing
techniques are not helpful for everyone. A survey of
British women found that 88 percent of women who
reported using relaxation techniques found them to
be "good" or "very good" [9].
There are no known drawbacks to the use of properly
performed relaxation and breathing techniques,
except that women sometimes expect more pain
relief from them than they actually receive during
labor, and then express disappointment. Proper
performance includes rhythmic breathing during
contractions, while releasing tension on the
exhalations. Being able to do this without
hyperventilating, at both a slow pace (6 to 12 breaths
per minute) and at a moderately fast pace (30 to 60

breaths per minute), allows the woman to adapt her

breathing pattern to the intensity of the contractions.
Rhythmic breathing may contribute more to a
woman's ability to cope with labor pain than to
actually reducing that pain. Incorporating relaxation
with rhythmic breathing helps avoid tension and its
pain-augmenting effects [10,11]. The continued high
satisfaction with breathing techniques expressed by
the majority of surveyed women justifies their
continued inclusion in childbirth classes and
encouragement of their use by maternity staff.
BIRTH ENVIRONMENT The ideal birth
environment for a nonpharmacologic approach to pain
management is comfortable and private, and provides
places to walk, bathe, and rest. This setting may be
available in a conventional labor and delivery unit,
and is usually available in birth centers. (See "Birth
centers".)
A systematic review of randomized trials of hospitalbased alternative birth settings versus conventional
hospital labor and delivery units found that home-like
settings increased the likelihood that the woman
would not use intrapartum analgesia/anesthesia (RR
1.17, 95% CI 1.01- 1.35; five trials, n = 7842), and
that she would have a spontaneous vaginal birth (RR
1.04, 95% CI 1.02-1.06; eight trials, n = 10,218), be
breastfeeding at six to eight weeks (RR 1.04, 95% CI
1.02-1.06; one trial, n = 1147) and have a very
positive view of her care (RR 1.96, 95% CI 1.782.15; two trials, n = 1207) [12]. The alternative birth
setting was also associated with significantly lower
rates of obstetrical interventions (epidural analgesia,
oxytocin augmentation, episiotomy). There were no
significant effects on serious perinatal or maternal
morbidity/mortality, other adverse neonatal
outcomes, or postpartum hemorrhage. A limitation of
these findings is that women willing to participate in
such trials may not be representative of most
laboring women.

CONTINUOUS LABOR SUPPORT The term

continuous labor support refers to the use of a trained
companion to provide nonmedical care of the laboring
woman throughout labor and birth (usually with a
doula). A nurturing, supportive companion during
labor, who is neither a family member/close friend of
the laboring woman, nor a member of the hospital
staff, can help the woman cope with pain and anxiety
and improve obstetrical outcomes [13]. This topic is
discussed in detail separately. (See "Continuous
intrapartum support".)
MATERNAL MOVEMENT AND
POSITIONING Laboring women have always
walked, moved, and changed positions to make
themselves more comfortable [14-17]. Pelvic
dimensions vary with differences in maternal
positions, thus these changes may help to ameliorate
labor pain [18]. Besides these self-initiated comfortseeking movements, caregivers often suggest specific
positions to accelerate labor progress or correct a
fetal or maternal problem (eg, fetal heart rate
decelerations or malposition, maternal hypotension).
A national survey of childbearing experiences in the
United States in 2005 reported that 76 percent of
women did not walk around after admission to the
hospital [8]. This percentage was slightly higher than
in a similar survey conducted three years earlier [19].
At that time, the most common reason women gave
for not walking was that they were "connected to
things" (67 percent), "unable to support self due to
pain medication" (32 percent), and "told not to walk
around" (28 percent). Nevertheless, about 60 percent
of the women reported changing positions
(presumably while in bed) to relieve pain during labor.
First stage of labor Most trials of movement and
positioning during labor have compared various
upright positions with horizontal positions for their
effects on pain and labor progress. Early in labor, the
use of upright positions (standing, walking, sitting up)
interspersed with other positions appears to be
associated with less painful labor.

 At least 16 controlled trials of positioning during the

first stage of labor have been performed in healthy
women at term [20,21]. Eight of these trials used
each woman as her own control by having her take
one specified position for 15 to 30 minutes, and then
having her alternate to another position for the same
length of time. In seven of the eight trials, women
were asked to alternate positions several times or
until complete dilation; in one, they took each
position only once [21]. Positions evaluated included
sitting, standing, or walking compared to supine or
lying on the side; resting on hands and knees
compared to supine or lying on the side; as well as
some other combinations. The women's pain and
progress were assessed in each position.Women
reported less pain while standing than sitting, and
less pain sitting than being supine, which was
consistently the least comfortable position. When
comparing sitting with lying on the side, women
reported less pain with sitting until 6 cm, then with
lying on the side through 10 cm. Other comparisons
revealed few differences in pain indicators. Standing
and side-lying positions were accompanied by more
progress than sitting or supine positions.Six trials
compared two groups: an experimental group, which
was encouraged to remain upright (sit up, stand, or
walk) during the first stage, and a control group,
which remained lying on the side or supine [20].
Except for one trial, the upright women were allowed
to lie down if they wished. Of these six trials, three
reported decreased pain in upright positions, two
found no difference, and one (in which women were
forced to remain upright throughout the first stage)
observed increased pain. One trial assessed
satisfaction with the option of walking, which was
very high in the upright group.
Birth ball The Birth Ball for movement and pain
relief in labor is a large inflated exercise ball that has
been adopted into maternity care to aid relaxation
and movement [11,22]. The woman can sit on or lean
against the ball, which provides soft support. The ball
also expands the number of positions the woman can

assume for comfort and offers a means for movement

(eg, bouncing, rolling) in these positions, which
provides a counter-distraction during contractions.
Many hospitals have birth balls in their maternity
departments and encourage laboring women to use
them for comfort.
One randomized trial that compared pain (measured
by Visual Analogue Scale, Verbal Response Scale, and
the Present Pain Intensity Scale) and self-efficacy
(measured with the Childbirth Self-Efficacy Inventory)
in 48 laboring women who used a large exercise ball
(birth ball) for comfort and movement versus 39
women who received usual care found that birth ball
users exhibited statistically significant improvements
in childbirth self-efficacy and pain at both 4 and 8 cm
[23]. The women in the experimental group had
practiced with the birth ball antepartum. During labor,
they spent more time in an upright position, had
shorter first stages, and felt greater satisfaction with
their partners participation than women in the usual
care group. Results of the Sobel test to measure the
mediated effect of the prenatal birth ball exercises on
childbirth pain indicated that having done the
exercises prenatally led to feelings of self-efficacy
(confidence in their ability to cope with childbirth
pain) [24].
A second trial randomly assigned 60 nulliparas to use
or not use a birth ball during labor [24]. The birth ball
group had no prior instruction in the use of the birth
ball, and was instructed to sit in the ball for 30
minutes, rocking back and forth or in a circle for 30
minutes. The control group received routine care,
which consisted of reclining in bed. Pain was
measured by a visual analogue scale. Pain scores in
the birth ball group were significantly lower at 30, 60,
and 90 minutes. There were no differences in the
contractions or duration of active labor between the
two groups.
Second stage of labor Women should be
encouraged to give birth in the position they find
most comfortable [25,26]. No trial has found any

harm associated with the upright position; some trials

have reported that women have more pain in the
supine or sitting position.
A systematic review of trials comparing the routine
use of the supine position to other positions during
the second stage of labor found that women
experienced more severe pain in the supine position
and had a preference for other birthing positions
[25]. Data from the nine randomized trials and one
cohort study could not be pooled, given the number
of methodological problems with many of these
studies and differences in study populations and
design.
A randomized trial assigned primiparous subjects to a
kneeling or a sitting position during the second stage
of labor [25]. Compared to the kneeling position, the
sitting position during the second stage was
associated with significantly more severe delivery
pain, more frequent perception of the second stage
as being long, less comfort while giving birth, and
more frequent feelings of vulnerability and exposure.
WATER IMMERSION Women generally like the
feelings associated with taking a warm bath, and it
appears to be a safe intervention. Immersion in warm
water deep enough to cover the woman's abdomen is
thought to enhance relaxation and reduce labor pain.
Women usually remain in the bath for a few minutes
to hours during the first stage of labor. The water
should be at or slightly above body temperature so as
not to increase the woman's core temperature, and
her temperature should be monitored. Elevated
maternal temperature may have adverse
fetal/neonatal consequences. (See "Intrapartum
fever", section on 'Fetal/Neonatal issues'.)
Delivery in water does not significantly increase
adverse perinatal outcomes, although one survey of
outcomes of 4032 births in water revealed two cases
of water aspiration and five cases of snapped
umbilical cords, which appear to be risks of this
method of delivery [27].

Showers during labor, although commonly used, have

not been evaluated in outcome studies.
There are mixed results reported on the effect of
water immersion on labor progress and need for
interventions, or for making recommendations on the
timing or duration of water immersion.
A Cochrane review of randomized trials that evaluated
the safety and efficacy of water immersion during the
first stage of labor found use of epidural, spinal,
paracervical analgesia/anesthesia was significantly
lower for immersion groups compared to controls
(38.1 versus 42.4 percent; OR 0.82, 95% CI 0.700.98; six trials) [28]. There were no significant
differences in narcotic/pethidine use or overall
analgesia outcome, labor duration, operative delivery
rates, or neonatal outcomes. Bathing did not increase
the risk of maternal or neonatal infection, even in
women with ruptured membranes [20].
Prolonged immersion (more than two hours) has been
reported to prolong labor and slow uterine
contractions by suppressing oxytocin production. It is
hypothesized that during immersion in deep water,
the hydrostatic pressure of the water on the mothers
edematous tissue causes the fluid to be moved into
the intravascular space, which leads to increased
blood volume [29]. This results in increased
production of ANF (atrial natriuretic factor), which
eventually suppresses the production of vasopressin
(a fluid-regulating hormone) by the pituitary gland;
an accompanying effect is the suppression of
production of oxytocin.
This phenomenon was supported in a study of water
immersion during labor in 11 women [30]. At 15
minutes and at 45 minutes after immersion in the
water, there were decreases in vasopressin and
oxytocin levels (P<0.05) compared with preimmersion levels.
STERILE WATER INJECTION Low back pain is
estimated to occur in 15 to 74 percent of all labors

[31]. Possible etiologies include fetal occiput posterior

position, persistent asynclitism or other malposition,
the woman's lumbopelvic characteristics, and referred
pain from the uterus. There is anatomical support for
the hypothesis that at least some low back pain
during labor is actually referred pain since the nerves
originating from the corpus uteri and cervix terminate
in the dorsal horns of the spinal segments T10 to L1
and reflect visceral pain, which is often referred to
the lower back [32]. Back pain can occur with
contractions or it can be constant.
Intracutaneous sterile water injections (also called
water blocks) are used intrapartum primarily to
decrease pain in the lower back, and occasionally to
relieve the abdominal pain of labor [20]. While the
mechanism of action is not known, it is hypothesized
that the firing of A-delta fibers overwhelms the
visceral pain input from C fibers such that the visceral
pain is not noticeable; this hypothesis is based upon
the gate control theory of pain. Alternatively, release
of local endorphins may be responsible for the
analgesic effect.
Water blocks consist of four intracutaneous or
subcutaneous injections of 0.05 to 0.1 mL sterile
water (using four 1 mL or two 2 mL syringes with 25gauge needles) to form four small blebs or papules
(similar to a tuberculin skin test). The use of
"unphysiological" sterile water is required. Although
physiological saline does not burn, it also does not
work. The injection sites are most commonly located
over the two posterior superior iliac spines and 3 cm
below and 1 cm medial to these two sites.
Alternatively, some clinicians ask the woman to point
to the area where she hurts most and they place the
four injections in that area. The exact location of the
injections does not appear to be critical to the success
of the technique [33,34]. The water blocks can be
repeated as desired.
Intracutaneous injections are usually painful for up to
one or two minutes. To offset the discomfort of
administration, some providers give injections during

a contraction and have two providers give the

injections simultaneously to speed the process.
Women need to be forewarned of the burning
sensations they will experience during the injection.
Since some women find the injections very
uncomfortable and may ask the provider to stop, it is
best to make the first two injections on opposite
sides, as these two injections alone may provide
satisfactory results. Several more recent studies have
reported that injection pain can be reduced by giving
the injection subcutaneously, rather than
intracutaneously. Pain relief appears to be equivalent
[32,34,35].
Eight randomized trials have compared the effect of
intra- or subcutaneous water blocks to a placebo
block (saline) [31,32,35-38] or to an alternative
nonpharmacological method (Transcutaneous
Electrical Nerve Stimulation [TENS], movement,
massage, baths, acupuncture) [31,39] for treatment
of low back pain in labor. Compared to controls, a
meta-analysis found that such water blocks
significantly decreased low back pain scores in
laboring women [40], especially severe low back pain
[41]. This effect was consistent across all trials. Pain
relief began quickly and lasted as long as three hours.
There was also a significant decrease in the cesarean
delivery rate among patients assigned to the sterile
water injection group (RR 0.51, 95% CI 0.30-0.87;
4.6 versus 9.9 percent), which was unexplained [40].
However, there were no statistical differences
between treatment groups in their willingness to have
the intervention again or use of regional analgesia or
anesthesia subsequent to the intervention. Possible
explanations for this latter finding are that the block
decreased only low back pain (not abdominal labor
pain) and that the pain relief lasted only up to 120
minutes, after which the water blocks were not
repeated.
Although sterile water blocks reduce the perception of
severe low back pain in laboring women and without
maternal or fetal side-effects, a survey of American

nurse-midwives found that only one-third of

respondents used them, and with less than 1.5
percent of their clients [34]. Reasons for such low
usage included a lack of training or experience,
discomfort with the technique, and the easy
availability of pharmacological pain relief.
Further research is needed on the effects of repeated
injections, ways to decrease the stinging of the
injections without losing benefits, mode of action, and
the effects of varying dosages, locations, and number
of sites injected.
TOUCH AND MASSAGE Touching another person
can communicate such positive messages as caring,
concern, reassurance, and love. Massage, "the
intentional and systematic manipulation of the soft
tissues of the body to enhance health and healing"
[42], is used during labor to enhance relaxation and
reduce pain. There are no harmful effects to the use
of touch or massage in labor. Women appreciate
these interventions, which appear to reduce pain and
enhance feelings of well-being.
Several randomized trials of touch and massage have
been performed and support this conclusion, but each
used different massage techniques and doses:
In one trial including 90 women, the "touch" group
received 5 to 10 seconds of reassuring touch each
time the woman expressed anxiety during a 30minute period between 8 and 10 cm dilation, while
the controls received usual care [43]. The touch
group had significant decreases in blood pressure and
number of expressions of anxiety.
The second trial randomized 28 women to receive
either usual care (control group) or massage of head,
back, hands and feet by their partners for 20 minutes
per hour for five hours during labor [44]. Frequent
massage reduced the women's pain and anxiety, and
improved their mood.
The third trial randomly assigned 60 women to
receive massage or usual care [45]. Massage was
performed three times, once during each phase of the

first stage of labor (latent, active and transition), and

lasted for 30 minutes in each phase. Pain intensity
was rated by a nurse observing each woman's
manifestations of pain using a present behavioral
intensity (PBI) scale; anxiety was measured using a
visual analog scale for anxiety (VASA). Although pain
intensity increased steadily through progressive
phases of labor, the massage group had significantly
lower pain intensity scores at each phase of labor.
Anxiety levels were significantly lower in the massage
group only during the latent phase. Eighty-seven
percent of the women in the massage group reported
that the massage was helpful in providing pain relief
and psychological support.
In the fourth trial, 60 primiparas in labor were
randomly assigned to either a usual care plus
massage or usual care alone group and evaluated
using a pain questionnaire at cervical dilations of 3 to
4, 5 to 7, and 8 to 10 cm [46]. In both groups, pain
intensity increased as cervical dilation increased.
Massage lessened pain intensity up to 7 cm cervical
dilation, but after that there were no significant
differences between the groups.
ACUPUNCTURE AND ACUPRESSURE (SHIATSU)
Acupuncture Acupuncture involves placement of
needles at specific points on the body (termed
acupuncture points) (see "Acupuncture"). For labor
pain, placement of needles depends on the degree
and location of pain, stage of labor, level of maternal
fatigue, tension, anxiety, and a variety of other
factors [47]. There are no known risks to acupuncture
when practiced by trained practitioners using
disposable needles. Women appear to be very
satisfied with the intervention. Systematic reviews of
acupuncture for pain relief in labor, however, vary in
their conclusions regarding benefits [3,48,49].
However, the included trials generally have not been
of high quality.
One systematic review of 10 randomized trials
involving 2038 women showed that standard

acupuncture was not superior to minimal acupuncture

(sham control) at one or two hours [48]. Compared
with no intervention, acupuncture reduced pain by
only 11 percent for the first 30 minutes. Compared
with conventional analgesia, however, women
receiving acupuncture requested less
meperidine (pooled risk ratio 0.20; 95% CI 0.120.33) and other analgesic methods (RR 0.75; 95% CI
0.66-0.85).
Another systematic review of nine randomized trials
involving approximately 1550 women concluded that
acupuncture and acupressure may help relieve labor
pain [49]. When compared with placebo or no
intervention, acupuncture was associated with
superior pain relief (standard mean difference (SMD)
-1, 95% CI -1.33 to -0.67; in one trial, 163 women),
increased satisfaction with pain relief (RR 2.38, 95%
CI 1.78-3.19; one trial, 150 women), and reduced
use of pharmacological analgesia (RR 0.72, 95% CI
0.58 to 0.88; one trial, 136 women). Compared with
standard care, acupuncture reduced use of
pharmacological analgesia (RR 0.68, 95% CI 0.560.83; three trials, 704 women) and instrumental
deliveries (RR 0.67, 95% CI 0.46-0.98; three trials,
704 women). However, there was significant
heterogeneity.
The inclusion criteria were different in the two
systematic reviews, which reduced the number of
women in the second review, and may have led to the
different conclusions.
Subsequently, a randomized trial of acupuncture
during induced labor in 105 primiparas used two
designs: a double blind study of manual, electro, and
sham acupuncture; and a single-blind study
comparing acupuncture with an untreated control
group [50]. There were no differences in use of
epidural analgesia among the groups and no
differences in the secondary end points of parenteral
analgesia use, duration of labor, delivery mode,
neonatal condition or postpartum hemorrhage.
More studies are warranted to establish acupunctures

cost-effectiveness and practicality, implementation in

maternity care settings, and acceptance by
childbearing women. Use of sham acupuncture in
control groups is important, given that acupuncture is
associated with a powerful placebo effect [51].
Acupressure Acupressure, or Shiatsu, a simpler
alternative to acupuncture, is pressure with fingers or
small beads at acupuncture points. Limited data
suggest a benefit:
A meta-analysis of four randomized trials of
acupressure for pain management in labor found that
pain intensity was significantly reduced in the
acupressure group compared with a placebo control
(light touch) or compared with a combined control
(light touch or no treatment); however, there was no
significant difference between intervention and
control groups in use of pharmacologic analgesia [3].
One common point is Spleen 6 on each tibia. This
point is located four finger-breadths above the medial
malleolus, and pressure is applied to the tibia and
diagonally forward. The point is more sensitive than
the surrounding areas. Another common point is
Large Intestine 4, located on the back of the hand,
where the metacarpal bones of the thumb and index
finger come together. Pressure is applied at the base
of the index finger.
Three randomized controlled trials of acupressure at
Spleen 6 found benefit in decreasing labor pain and
two also found that the duration of labor was
shortened. These small trials included 75, 212, and
120 women, respectively [52-54].
HYPNOSIS Hypnosis is "a state of deep physical
relaxation with an alert mind producing alpha waves,
and it is in this state that critical faculties are
suspended and the subconscious mind can be more
readily accessed" and respond to suggestions [55].
Hypnosis used for childbirth is almost always selfhypnosis: the hypnotherapist teaches the woman to
induce the hypnotic state in herself during labor.

Sometimes her partner is taught to signal her into the

hypnotic state.
Common hypnotic pain relief techniques are "glove
anesthesia," in which the woman imagines that her
hand is numb and that it can spread numbness to
other areas by placing her hand on painful areas;
"time distortion," which enables the woman to
perceive the time between painful contractions as
longer and the painful period as shorter than it really
is; and "imaginative transformation," in which the
pain is interpreted as benign and acceptable, and
contractions are seen as surges of energy that cause
only a light pressure sensation [56].
Hypnosis may be an effective technique for managing
labor pain and enhancing maternal satisfaction during
childbirth [3]. More large trials are necessary to
establish its true value.
A systematic review of complementary and
alternative therapies for pain management in labor
found use of hypnosis was associated with a
significant reduction in requests for pharmacological
analgesia (RR 0.53, 95% CI 0.36-0.79; five trials, n
= 729 women) [3]. One trial also reported a
significant decrease in use of epidural anesthesia.
There were no differences in adverse obstetric or
neonatal outcomes between hypnosis and control
groups.
A review of the efficacy of hypnosis for reducing labor
pain identified 13 studies that used a betweensubjects or mixed model design, in which hypnosis
was compared with a control condition, such as
supportive counseling, childbirth education, or
standard medical care [57]. Hypnosis was
consistently found superior to all the control
conditions in reducing pain, and also shortening labor
and improving Apgar scores. Failure to randomize the
participants was a common drawback to the studies.
It may be difficult to randomize participants, since
compliance with hypnosis training usually requires
extensive rehearsal of the techniques and high

motivation [58]. Patients who want to use hypnosis

are unlikely to accept the risk of being randomized
out of the hypnosis group.
Hypnosis is contraindicated in persons with any
history of psychosis [55]. Any phobias or distressing
situations need to be ascertained and avoided when
suggesting a visualization intended to be relaxing
[55]. There are no apparent risks to the use of
hypnosis for childbirth, except that it requires
prenatal training by a trained hypnotherapist, which
involves financial costs.
TRANSCUTANEOUS ELECTRICAL NERVE
STIMULATION Transcutaneous Electrical Nerve
Stimulation (TENS) is the transmission of low voltage
electrical impulses from a hand-held battery-powered
generator to the skin via surface electrodes. TENS
units have been designed for use by the woman in
labor, and are available for rent without a doctor's or
midwife's order in drugstores and medical equipment
companies in some countries.
To relieve labor pain, one pair of electrodes is usually
placed paravertebrally at the level of T10-L1, and
another at the level of S2 to S4. The woman controls
the intensity of the current by turning a dial, and
varies the stimulation pattern with a thumb switch or
by adjusting dials on her TENS unit. TENS causes a
buzzing or prickling sensation that may reduce her
awareness of contraction pain.
There is no strong evidence that TENS provides pain
relief in labor:
A systematic review of trials of TENS for management
of labor pain (19 randomized trials, 1671 women)
included 15 trials where TENS was applied to the
back, two trials with application to acupuncture
points, and two trials with application to the cranium
[59]. Overall, there was no significant difference
between TENS and control groups in pain ratings,
although women receiving TENS to acupuncture
points were less likely to report severe pain (RR 0.41,

95% CI 0.32-0.55). There was no benefit in using

TENS as an adjunct to epidural analgesia and no
consistent evidence that TENS had any impact on
labor interventions and outcomes. No adverse events
were reported. The majority of women using TENS
were satisfied and would use it again in a future labor.
The satisfaction expressed by women with TENS may
relate to other factors besides pain relief. TENS allows
the woman to be in control of the intervention, allows
ambulation, has no effects on her mental state, and
gives an option to those who wish to avoid
medications.
Experienced practitioners state that TENS may be
more effective if initiated in early labor, presumably to
allow for a build-up in endorphin production before
the pain becomes severe. TENS may be more
effective for relief of back pain than labor pain in
general, but only a few observational studies have
investigated this possibility [60,61].
There are few potential side effects from TENS when
used by normal healthy individuals. Though rare with
modern electronic fetal monitoring equipment, it may
interfere with the output from some monitors, in
which case, either the TENS or the monitor should be
discontinued or used intermittently. There is expense
involved in renting or purchasing the units, and
presently, it is difficult for women in the United States
to obtain the units that are especially designed for
use during labor.
APPLICATION OF HEAT AND COLD Superficial
applications of heat and/or cold, in various forms, are
popular with laboring women. They are easy to use,
inexpensive, require no prior practice and have
minimal negative side effects when used properly;
however, there are insufficient data regarding
efficacy.
Heat is typically applied to the woman's back, lower
abdomen, groin and/or perineum. Possible heat
sources include a warm water bottle, heated ricefilled sock, warm compress (wash cloths soaked in

warm water and wrung out), electric heating pad, or

warm blanket. No studies have evaluated the optimal
temperature or duration of heat therapy. Obviously,
care should be taken to avoid burns. In addition to
being used for pain relief, heat is used to relieve chills
or trembling, decrease joint stiffness, reduce muscle
spasm, and increase connective tissue extensibility.
Women who already feel cold usually need to feel
warm before they can comfortably tolerate using a
cold pack. Cold or cryotherapy is usually applied to
the woman's back, chest, and/or face during labor.
Forms of cold include a bag or surgical glove filled
with ice, frozen gel pack, camper's ice, a hollow
plastic rolling pin or bottle filled with ice, soda cans
chilled in ice, or a frozen bag of vegetables. Instant
cold packs, often available in hospitals, usually are
not cold enough to be effective for the pain of labor.
Chilled soda cans and rolling pins filled with ice give
the added benefit of mechanical pressure when rolled
on the lower back. In addition to pain relief, cold has
the additional effects of relieving muscle spasm and
reducing inflammation and edema.
Women's personal choices are key factors in the use
of heat or cold. With both modalities, placing one or
two layers of cloth between the woman's skin and the
hot or cold pack is prudent to protect against the
possibility of skin damage. Additionally, it is
imperative that the woman has intact sensation if
heat or cold is to be applied.
There is one randomized trial on the use of heat
during labor:
In this trial, 717 women in the second stage were
randomly assigned to receive a warm pack (45 to 59
degrees Celsius) or no pack to the perineum [62].
Women who received the warm pack had less
perineal pain during birth and postpartum. The
reduction in postpartum pain may have been due to
the lower incidence of third and fourth degree
lacerations in the warm pack group, although this
group did not have a significant reduction in need for

any perineal suturing. The absence of a control group

who received a room temperature pack limits the
ability to make conclusions about warmth versus
touch from this trial.
MUSIC AND AUDIOANALGESIA Audioanalgesia
is the use of auditory stimulation, such as music,
white noise, or environmental sounds to decrease
pain perception. It is popular for the relief of pain
during dental work, after surgery, and for other
painful situations, such as labor. There are no known
adverse effects of audioanalgesia and it appears to be
a popular option for laboring women, although there
are no strong data that it significantly reduces pain
intensity and analgesic requirements in labor.
Most studies of audioanalgesia during labor have
reported that it can increase pain tolerance, reinforce
or elevate moods, or cue the woman to move or
breathe rhythmically, especially if she has conditioned
herself to do so before the onset of labor. All the
studies, however, have suffered from small sample
sizes, inadequate controls, or lack of true differences
between control and experimental groups [63-65]. It
has not been clearly demonstrated that
audioanalgesia has any of the benefits claimed for it
[66].
Before labor, the woman selects music (sometimes
with the help of a music therapist) or environmental
sounds that have a positive effect on her. She may
use these to rehearse relaxation or self-hypnosis, and
to take her into a relaxed or hypnotic state during
labor. During labor, she chooses selections to help her
relax and lift her spirits [67]. Her selections
personalize the birth event and may give her a
greater sense of control. Some women prefer to use
headphones to listen to music, because this provides
more compelling distraction and the woman is in
constant control of the volume.
Audioanalgesia during labor is worthy of evaluation
with properly controlled trials of adequate size to
establish its true benefit or lack thereof, and whether

music with lyrics has a different effect than music

without lyrics.
AROMATHERAPY Aromatherapy is "the science of
using highly concentrated essential oils or essences
distilled from plants in order to utilize their
therapeutic properties" [68]. Use of aromatherapy
during labor is increasing, although some experts
have stated that, "essential oils are as potent as
pharmacological drugs and are equally open to
misuse or abuse, whether intentional or not" and
"until more clinical research trials have been
undertaken, it would be prudent for midwives to work
cautiously with essential oils, using the lowest
possible dose and on the least number of occasions"
[68]. Available data are limited to the following:
One large, uncontrolled prospective study reported on
the use and effectiveness of aromatherapy in a large
referral maternity unit [69]. During this time, 8058
women received aromatherapy during labor under the
supervision of midwives trained in aromatherapy
(lavender, rose, or frankincense). It was used for a
variety of purposes: to reduce fear, anxiety, and pain;
to reduce nausea or vomiting; to enhance women's
sense of well-being; and to improve contractions.
About one-half of the women found it helpful; 1
percent reported undesired effects, such as nausea
and headache. It is not clear whether these side
effects were caused by the essential oils or other
factors.
A meta-analysis of two randomized trials (n = 535
women) of aromatherapy for pain management in
labor found no difference between groups in pain
intensity or use of pharmacologic pain relief [70]. The
sample size was too small to demonstrate whether
small differences in outcome were statistically
significant. The control groups were very different: in
one trial, controls received usual care (versus one of
five essential oils in the study group); in the other
trial, controls received essential oil of lemon grass
(versus essential oil of ginger in the study group).

BIOFEEDBACK Biofeedback is a therapeutic

technique where individuals receive training to gain
control over physiological responses with the aid of
electronic instruments. It helps the individual to
consciously regulate both psychological and physical
processes, such as pain, that are not usually under
conscious control. Its use in labor is unproven.
A systematic review of biofeedback for pain
management in labor included four trials (186
women) [71]. Most trials assessed the effects of
electromyographic biofeedback in women who were
pregnant for the first time. There was no significant
evidence of a difference between biofeedback and
control groups in terms of use of pharmacological
pain relief, or delivery outcomes. Although
electromyographic biofeedback appeared to have
some positive effects early in labor, there was a need
for additional pharmacological analgesia as labor
progressed. The quality of the trials was poor,
however, and further research in this area needs to
be performed.
SUMMARY AND RECOMMENDATIONS
Nonpharmacologic approaches to labor pain
management do not make pain disappear; instead,
these approaches help women better cope with the
pain of labor and maintain a sense of personal control
over the birth process. (See 'Introduction' above.)
Nonpharmacologic techniques for management of
labor pain can be combined or used sequentially to
increase their effectiveness. However, data regarding
the safety and efficacy of these interventions are
limited since few randomized trials have been
performed and most had a small number of subjects,
wide variations in patient populations or study design,
and methodological flaws. (See 'Evaluating the
outcome of nonpharmacologic pain relief
methods' above.)
We recommend offering women nonpharmacological
methods to help them cope with labor (Grade 1B).
All of the nonpharmacologic methods for

management of labor pain discussed above have few,

if any, serious side effects and require few safety
precautions. They can be combined or used
sequentially to enhance their total effect, and are
generally inexpensive (see above).
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