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Complementary and Alternative Approaches to Pain Relief during Labor

Complementary and Alternative Approaches to Pain Relief during Labor Advance Access Publication 15 March 2007 eCAM 2007;4(4)409–417 doi:10.1093/ecam/nem012 Review Complementary and Alternative Approaches to Pain Relief During Labor Michel Tournaire and Anne Theau-Yonneau Obstetrics and Gynecology Department, Saint Vincent de Paul Hospital, University of Paris, Paris, France This review evaluated the effect of complementary and alternative medicine on pain during labor with conventional scientific methods using electronic data bases through 2006 were used. Only randomized controlled trials with outcome measures for labor pain were kept for the conclusions. Many studies did not meet the scientific inclusion criteria. According to the randomized control trials, we conclude that for the decrease of labor pain and/or reduction of the need for conventional analgesic methods: (i) There is an efficacy found for acupressure and sterile water blocks. (ii) Most results favored some efficacy for acupuncture and hydrotherapy. (iii) Studies for other complementary or alternative therapies for labor pain control have not shown their effectiveness. Keywords: acupuncture – biofeedback – complementary and alternative medicine – delivery – homeopathy – hydrotherapy – hypnosis – labor – labor pain – manual healing – pain – sophrology – sterile water blocks – stimulation – transcutaneous electrical nerve stimulation – yoga that such therapies are more in harmony with their personal Introduction philosophies. The conventional medical community usually Even though delivery is a natural phenomenon, it has been offers traditional choices of analgesia, such as epidural and demonstrated that the accompanying pain is considered intravenous drugs. Patients may have access to alternative severe or extreme in more than half of cases. Besides methods, but will generally be obliged to do the relevant conventional approaches, such as epidural analgesia, many research themselves beforehand. Those seeking alternatives complementary or alternative methods have been reported are not necessarily dissatisfied with conventional medicine, to reduce pain during labor and delivery. Complementary but attempt to supplement rather than replace traditional or Alternative Medicine (CAM) can be defined as theories care. Quite often, users of complementary medicine do not or practices that are not part of the dominant or inform the practitioners in charge of their pregnancy and conventional medical system. Some of them have been delivery. There are also different expectations for the reclassified as part of conventional medicine when sup- management of pain during labor according to the category ported by clinical experience or scientific data (1). of professionals. Physicians are expected to provide These methods are popular because they emphasize the pharmacological therapy, whereas midwives, nurses and individual personality, and the interaction between mind, other auxiliaries are required to assist patients with body and environment (2). They are attractive to people psychological methods, and in fact use alternative who want to be more involved in their own care and feel approaches more often. The theoretical bases for many alternative methods derive from Eastern tradition or philosophy. For reprints and all correspondence: Michel Tournaire, Obstetrics and Gynecology Department, Saint Vincent de Paul Hospital - University of After a description of labor pain, we shall mention the Paris, 82 Avenue Denfert Rochereau 75014 Paris, France. Tel: þ33 (0) conventional treatments and describe the different 1 40 48 81 43; Fax: þ33 (0) 1 40 48 83 97; complementary methods applicable to labor pain. E-mail: [email protected] 2007 The Author(s) This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/2.0/uk/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original workis properly cited. 410 Alternative Approaches to Pain Relief During Labor Nature of Pain During Labor and Delivery Age Tissue damage Socio- A scientific definition of pain is ‘an unpleasant Birth economic preparation sensory and emotional experience associated with actual level Stage of or potential tissue damage’ (3). Acute pain such as labor Religion labor pain has two dimensions: a sensory or physical Emotional Cervix Physical dimension, with the transmission of information, the pain stimuli, to the brain, and an affective dimension due to interpretation of these stimuli through the interaction of a wide variety of emotional, social, cultural and cognitive variables unique to the individual (Fig. 1). Muscular Language Behavior For the management of pain, conventional medicine reaction crying focuses more on the physical side, while alternative Figure 1. Components of pain (6). methods deal mainly with emotional considerations. In the laboring patient, the two stages of labor correspond to different types of pain and routes of pain, which can now be quantified, is only one transmission. During dilatation (first stage), visceral pain component of a woman’s overall experience of labor predominates, due to mechanical distention of the cervix and birthing. Personal satisfaction is not always corre- and of the lower part of the uterus. These stimuli are lated with the level of pain and although difficult transmitted to the spinal cord at the level of the tenth to quantify should be included in the evaluations. thoracic to the first lumbar root. Uterine contractions Note that the term analgesia means pain relief without may be felt as back pain because the nerves that supply total loss of sensation, while anesthesia is defined as pain the uterus also supply the skin on the lower back or relief with total loss of sensation. lumbosacral area. During the descent phase (second stage), pain is also caused by distension and stretching of the pelvic floor and perineum. These stimuli are Conventional Treatments transmitted via the pudendal nerve to the second to fourth sacral nerves. Regional Analgesia: Epidural Even though pain is a personal experience, it can be An epidural involves the introduction of a local analyzed by means of quantitative pain measures. Verbal anesthetic agent to the sensitive nerves conducting the reports using standardized instruments, such as the pain messages on their way to the spine. A catheter McGill Pain Questionnaire and the Visual Analogue (fine flexible tube) is usually placed in the epidural space, Scale (VAS), have been the most common methods of allowing intermittent or continuous infusion throughout pain assessment both in clinical practice and research (4). the delivery. A Canadian study comparing different pain syndromes The epidural is the most efficient way of reducing labor found that average labor pain scores were higher in both pain (Fig. 2). A total of 85–95% of women report nulliparous (first delivery) and multiparous women than complete relief of pain during the two phases of delivery: the average scores previously recorded for out-patients cervical dilatation and descent of the baby (8). Complete with sciatic pain, toothache and fracture pain (5,6) failure is rare and usually due to technical problems, (Fig. 2). However, whereas the average score is higher, as when the epidural space cannot be reached with the its exact value differs greatly from one woman to catheter. Delivery pain relief can be partial. The painful another. Bonica found that labor pain was mild in 15% feeling of contractions persists, but at a lower intensity. of cases, moderate in 35%, severe in 30% and extreme Sometimes the area of analgesia is incomplete. in 20% (7). For example, the pain can be felt laterally in half of Some factors are associated with increased pain: first the abdomen. When the lower nerves are not, or are delivery, history of dysmenorrhea (painful periods), fear insufficiently, dulled, pain may develop during the second of pain, a religious practice. Some factors diminish pain: phase of labor. One of the main advantages of the childbirth preparation classes, complications during epidural is that it is efficient regardless of the cultural pregnancy, wish to breast feed, high socio-economic context, with few side effects. But it is not always status, older age (5). available. To evaluate the efficiency of the different therapies, we have applied conventional scientific methods to published studies. In other words, do these studies Injected Drugs report a statistically significant reduction in labor pain? As we shall see, few publications in the field of CAM Morphine-like drugs (opioids) can be given continuously meet these standards. However, we should consider that or in intermittent doses at the patient’s request or via Contractions Personality Environment Pain eCAM 2007;4(4) 411 affect the other. Many mind–body interventions are 50 applied to chronic illness, but this technique also appears to be applicable to the acute situation of delivery. Psychoprophylactic Methods 1st delivery Grantly Dick-Read introduced ‘natural childbirth’ without preparation in 1933. He believed that childbirth pain was a pathologic 1st delivery with preparation response produced by fear, apprehension and tension. Other delivery with or He felt it essential to teach women the anatomic and without preparation physiologic facts of childbirth, and to instruct them in Sciatic physical and mental relaxation. Both approaches are alleged to diminish pain by familiarizing the pregnant woman with the process of childbirth and by creating an Tooth pain atmosphere of confidence. Fracture Delivery with Fernand Lamaze introduced his method in France in epidural 1951 after a visit to Russia. This method was first optimistically called ‘painless childbirth’, but later the Figure 2. Pain scores (4–6). more appropriate term ‘fearless childbirth’ was applied. It is based on the Pavlovian concept of conditioned reflex training. By focusing on certain breathing patterns or patient-controlled administration. Recent reports suggest concentration points such as a mark on a nearby wall, that the analgesic effect of these agents in labor is limited it should be possible to block pain messages to the brain. and that the primary mechanism of action is heavy Bradley’s method emphasizes natural childbirth, with sedation, which means that consciousness is reduced the parents working as a team. Students of this method during delivery. Such drugs may also have some effect on are taught about deep abdominal breathing and an the newborn, with rare but possible breathing difficulties understanding of the labor and delivery process. Rather that may require assistance. Few studies have dealt with than trying to block out pain, Bradley’s method efficiency. Most were done in the 1960s and provide encourages concentrated awareness that works through information on patient satisfaction (generally good in the pain. about half of the cases), but without quantitative These methods are expected to provide better informa- evaluation of pain reduction. tion about the process of delivery, reduce fear, give greater satisfaction with a sense of achievement and happiness, and create a better child–mother relationship. Nitrous Oxide The importance of a good relationship between the Nitrous oxide gas is given for inhalation at subanesthetic patient and the care-giving team is also emphasized. concentrations. Despite being used for more than Of these approaches, we have only found an evaluation 100 years, there is no clear quantitative evidence of of the Lamaze method: a study by Melzack in 1984 (5) the efficacy of nitrous oxide in relieving labor pain. using the McGill pain scale found a slight decrease in The subjective feelings of mothers giving birth suggest, average pain score in patients using the Lamaze method, however, that nitrous oxide is beneficial in many cases. but this was not statistically significantly different from Many women report significant analgesia with it, and the control group (Fig. 2). many would choose it again for another delivery. This study also showed that the average pain score is slightly higher at the first delivery, compared with subsequent deliveries, but the difference is not statistically Alternative Approaches significant. Complementary and alternative methods applicable to Leboyer’s Method labor pain can be divided into mind–body interventions, alternative systems of medical practice, manual healing, Fre´ de´ ric Leboyer described his method in France in 1974 bioelectromagnetic and physical methods, and alternative in his book ‘Birth without violence’. Inspired by Indian medication (1). yoga, this method focuses on providing a better welcome for the newborn. In contrast to the usual environment, with too much light and noise stressing the baby, Mind–Body Interventions Leboyer proposes calm for mother, father and Mind–body interventions are based on the interconnect- professionals, and darkness, little noise and a warm edness of mind and body and on the power of each to bath for the newborn. For the comfort of the mother 412 Alternative Approaches to Pain Relief During Labor during delivery, Leboyer considers that serenity obtained Biofeedback through attention to the baby raises the pain threshold. Biofeedback uses monitoring instruments to provide feed- There has been no specific evaluation of the effects on back to patients, i.e. physiological information of which labor pain. However, couples express a high degree of they are normally unaware. Electrodes feed information to satisfaction. Although Leboyer’s method is rarely used a monitoring box that registers the results by a sound or a now as described in the 1970s, many birth practitioners visual meter that varies as the monitored function increases still consider it to have a positive effect, with gentle and or decreases. For women in labor, several biofeedback- heightened attention for the newborn. assisted relaxation techniques have been introduced. Duchene (12) completed in 1989 a prospective random- ized trial in which tension of the abdominal muscles was Hypnosis monitored. As uterine contractions occurred the women The word hypnosis originates from the Greek ‘hypnos’ focused on relaxing the abdominal muscles. The reports of meaning ‘sleep’. In fact, it is not sleep but a state of focused pain using VASs and verbal description scales showed concentration in which the patient can be relatively significantly lower pain values in the biofeedback unaware, but not completely blind to her surroundings group and less medication. In 1992, Bernat et al. (13) (2). During hypnosis, suggestions may be made, focusing used a fingertip thermometer. When the patient relaxes, on diminishing awareness of pain, fear and anxiety. The vasodilation occurs and the finger temperature increases. woman is prepared with initial hypnotic experiences that However, none of the experimental subjects attempted to include three steps: absorption of the words or images use fingertip temperature control as a coping technique presented by the therapist, dissociation, a suspension of during labor. The authors concluded that a lack of hospital staff support may have contributed to this study’s outcome. critical judgment, and responsiveness. A few comparative In conclusion, biofeedback-assisted relaxation tech- studies have evaluated the efficiency of hypnosis. niques applied to pain control yield contradictory results. In 1962, Davidson (9) compared 70 patients who had Their efficiency is certainly contingent on strong support six lessons of autohypnosis with 70 who had received from caregivers to facilitate the use of the technique. Dick-Read’s training and with 71 who had no special antenatal training. The study was not randomized as Yoga patients were allowed to choose their group. A statistically significant reduction in the duration of the first stage of Yoga, a method of Indian origin, proposes control of labor was found in the hypnosis group as compared with mind and body. Between the different types of yoga, the two other groups. Autohypnosis was effective on labor ‘energy yoga’ can be applied to pregnancy and delivery. pain: 59% of this group required no analgesia, compared Through special training of breathing, it achieves changes with 1.4% in the control group. All patients required in levels of consciousness, relaxation, receptivity to the analgesia in the Dick-Read training group. The subjective world and inner peace. According to professionals impression of labor was much more pleasant in the who use this technique for delivery, yoga shortens the autohypnosis group. In 1990, Harmon et al. (10) completed duration of labor, decreases pain and reduces the need a randomized study showing shorter stage 1 labor, less for analgesic medication. However, we have not found medication and higher pain thresholds in the hypnosis any scientific confirmation of these assertions. group than in the control group. In 1995, Mairs (11) compared 29 primigravida women who chose to join Sophrology ‘hypnosis for childbirth’ classes and 29 in a control group. The word sophrology derives from two Greek words, The trained group reported statistically significantly lower ‘sos’ harmony or serenity and ‘phren’ conscience or spirit. ratings of both pain and anxiety. However, there was no This technique derived from Indian yoga was introduced statistically significant difference between the two groups in in Europe during the 1960s. Its purpose is to improve their drug usage during labor. the control of body and spirit through three degrees of A few negative effects of hypnosis have been reported, dynamic relaxation: concentration, contemplation and including mild dizziness, nausea and headache. These meditation. Applied to obstetrics, better control of the seem to be associated with failure to dehypnotize the delivery process is expected. Patients individually report patient properly. Caution should be used in patients a high degree of satisfaction with this experience of vulnerable to psychotic decompensation. relaxation during prenatal classes and delivery, but there To summarize, hypnosis seems to reduce fear, tension is no controlled evaluation in the literature. and pain during labor and to raise the pain threshold. It reduces the need for chemical analgesia. Patients have Haptonomy a greater sense of control over painful contractions. Hypnosis, therefore, can be considered as a helpful Derived from the Greek words ‘hapsis’ affectivity and adjunct during the course of labor and delivery. ‘nomos’ knowledge, haptonomy can be defined as the eCAM 2007;4(4) 413 science of affectivity. This approach was proposed by Acupuncture is based on the balance between Yin and Frans Vedman (14) in the Netherlands during the 1940s. Yang. Treatment is aimed at reconstituting the normal movement between these two opposites. The meridians Specific zones of affectivity are reported to improve the are considered as energy channels. Most treatments of contact between father, mother and baby and to help to obstetrical and gynecological problems involve the use of share emotions. In practice, haptonomy is appreciated points on different meridians: spleen-pancreas located by couples during pregnancy, but it seems to be used on the inside of the ankle bone, conception, governing irregularly during labor, particularly because teams in or penetrating vessel. charge of delivery are not always aware of its existence. Acupuncture may produce effects through several Practitioners expect a quicker and easier delivery as well different mechanisms. One hypothesis is that acupuncture as a better relationship between parents and newborn. points have electrical properties that, when stimulated, There is no published evaluation of haptonomy and may alter the level of chemical neurotransmitters in the in fact such an assessment should not be expected body. Another hypothesis is that endorphins are released because, as the specialists of this method say, ‘affectivity due to activation of the hypothalamus. The effects of cannot be put into numbers’. acupuncture have also been attributed to alterations in the natural electrical currents or electromagnetic fields Music Therapy in the body. The use of acupuncture for pain relief has given Music addresses many of the physical and psychological equivocal results. Wallis et al. (18) in San Francisco needs of patients. In obstetrics, a slow and restful type of in 1974 found that 19 of 21 patients had inadequate pain music may be used as a sedative to promote relaxation relief based on pain scores and none of the 21 subjects during the early stage of labor. Music with a steady beat was judged by investigators to have adequate analgesia. may be used as a stimulant to promote movement during Abouleish and Depp (19) in the USA in 1970 used the latter stages. The literature findings are discordant. electroacupuncture and described relief of pre-existing In Austin, Texas, a music program is used during the pain in 7 of 12 participants. The investigators, who found third trimester of pregnancy (15). The prospective mother the technique time-consuming, cited some disadvantages: and her partner are allowed to select the kind of music inconsistency, unpredictability and lack of completeness. they like for the different stages of labor. After a study Hyodo and Gega (20) in Japan in 1977 in a study of of 30 deliveries, only one half of the women who subjective and objective relief of labor pain in 32 women had listened to music required analgesia. However, in described an improvement in 60% of 16 primiparous a randomized study Durham and Collins (16) could not women and 90% of 16 multiparous women. However, demonstrate the value of music in reducing the need for all patients received systemic sedation. The authors analgesic medication. But the subjective sense of satisfac- concluded that acupuncture is useful for delivery because tion appeared to be higher in the group that listened of its safety, despite erratic and less potent results to music. In a randomized controlled trial by Phumdoung than conventional analgesic techniques. In Nigeria in and Good (17), 110 primiparous women, during the 1986, 19 of 30 women (63.3%) given sacral acupuncture active phase of labor, were assigned to a soft music group by Umeh (21) indicated that they had adequate pain for 3 h (n¼ 55) or a control group (n¼ 55). Dual VAS relief by responses on a visual scale and did not request were used to measure the sensation of pain before another form of analgesia. Yanai et al. (22) in Israel starting the study and every three hours. The results in 1987 evaluated electroacupuncture during the labor of indicate that in the music group women had significantly 16 parturients. Fifty-six percent of the women reported less sensation of pain (P50.001). After these contra- mild to good pain relief and 81% described increased dictory results concerning the effects of music therapy relaxation. The perceived positive effects led the authors there is a need for further scientific analyses. to believe that acupuncture should be pursued as an additional method of pain control. In 1999, Lyrenas et al. (23) in Sweden studied 31 primiparous women who had Alternative Systems of Medical Practice received repeated acupuncture compared with untreated women. Pain assessed on a VAS was not reduced in Acupuncture women treated with acupuncture, and the acupuncture Acupuncture has been used in China for more than 2000 did not reduce the need for analgesics during labor. years. Specific anatomic parts of the body are stimulated In 2002 Ramnero et al. (24) in Sweden reported for therapeutic purposes. This can be done in the usual a randomized, controlled study in 90 parturients, way with needles, but practitioners may also use heat, 46 of whom received acupuncture during labor as a pressure, impulse of magnetic energy, burning by a complement or alternative to conventional analgesia. preparation of the herb Artemia vulgaris, electrical Acupuncture significantly reduced the need for epidural stimulation or surface electrodes at acupuncture loci. analgesia (12% vs. 22%). Patients in the acupuncture 414 Alternative Approaches to Pain Relief During Labor group reported a significantly greater degree of relaxation lower back. Pressure against spots that are sensitive can compared with the control group. The authors considered be particularly efficacious. Force is initially applied these results to suggest that acupuncture could be a good during contractions and then continuously. alternative or complement for women who seek an The purpose of the study of Chung et al. (28) is to alternative to pharmacological analgesia in childbirth, determine the effect of L14 and BL67 acupressure on but further trials are required to clarify whether the labor pain during the first stage of labor. A total of main effect of acupuncture during labor is analgesic or 127 parturient women were randomly assigned to three relaxing. In the trial by Skilnand et al. (25), 210 groups. Each group received only one of the following parturients were randomly assigned to receive either treatments: L14 and BL67 acupressure, light skin real acupuncture or false acupuncture. Real acupuncture stroking or no treatment. There was a significant consisted of a treatment protocol from the Norwegian difference in decreased labor pain in the first group School of Acupuncture. The same type and number of compared with the two others. needles were used not on the classic meridians. Pain was A study of Lee et al. (29) evaluated the effects of SP6 assessed using a linear VAS (rated 0–10) recorded at 30, acupressure on labor pain. 75 women in labor were 60 and 120 min after treatment. There were significantly randomly assigned to either the SP6 acupressure (n¼ 36) lower pain scores at 30, 60, 120 min after treatment or SP6 touch control (n¼ 39) group using double-blinded (P50.001), and significantly less need for epidural method. Labor pain was measured four times using VAS. analgesia and intramuscular pethidine (P¼ 0.01 There were significant differences between the groups et P50.001, respectively). Qu and Zhou (26) compared in pain scores at all times following the intervention: in a prospective randomized study 20 primipara with immediately after the intervention (P¼ 0.012), 30 min electro-acupuncture and 19 as controls. The electro- after the intervention (P¼ 0.021) and 60 min after the acupuncture group was found to exhibit a lower pain intervention (P¼ 0.012). The total labor time (3 cm of intensity and a better degree of relaxation than the dilatation to delivery) was significantly shorter in the SP6 control group (P¼ 0.018 and 0.031). acupressure intervention group than in the control group To summarize, acupuncture studies are difficult to (P¼ 0.006). conduct and analyze for several reasons, including lack of standardization with use of multiple acupuncture points, Homeopathy and the difficulty of choosing a control group. Within the control group the needles might be correctly placed Homeopathy involves the use of diluted substances that but not stimulated, or needles could be placed in cause symptoms in their undiluted form. According to inappropriate sites. There were no reported complications homeopathic theory, remedies stimulate the self-healing in any of the studies but there is a potential risk of mechanism. The amount of medicine prescribed is so infection. To achieve a good analgesic effect during small that it often cannot be measured in molecular labor, a relatively long induction period may be required. amounts (30). We found no studies evaluating the It is difficult for a woman in labor to remain still for effect of homeopathic treatment on labor pain. Smith 15–30 min, and some patients felt discomfort because (31) has reviewed cervical ripening and labor induction of the restrictions in movement. by ‘‘caulophyllum’’. There were no differences between Overall, a beneficial therapeutic effect on labor pain of the homeopathy and control groups in a randomized, acupuncture is not certain. Better designed studies need controlled trial involving 40 women. to be completed with, if possible, standardization of the points used, and better control groups. However, Manual Healing it should be recognized that the procedure is time- consuming, and that the required training of patients and Manual healing methods used today during delivery personnel may be considerable. include therapeutic touch and massage therapy. Acupressure Systems Therapeutic Touch Acupressure is a descendant of Chinese manipulative The purpose of therapeutic touch in labor is to therapy in which points are stimulated by pressure, using communicate caring and reassurance. Painful contrac- hands, fingers and thumbs (27). Acupressure supposedly tions of the uterus can be treated by the application of promotes the circulation of blood, the harmony of yin pressure with the hands to the woman’s back, abdomen, and yang and the secretion of neurotransmitters, hips, thighs, sacrum or perineum. Whether touch is thus maintaining the normal functions of the human perceived as positive or not is dependent on who is body and enhancing well being. Some midwives use touching the patient: in one study, touching was acupressure to release the pain of labor. Pressure is perceived positively by 94% of patients when they were applied simultaneously to both sides of the spine in the touched by a relative or friend, 86% by their husbands, eCAM 2007;4(4) 415 73% by a nurse and 21% by a physician (32). Anxiety is dermatomal distribution. For example, the uterus is reported to be reduced in patients who receive reassuring supplied by the lower thoracic spinal cord segments. touch. In a retrospective study of 30 patients, 77% Some of these receive stimuli from the skin of the lower experienced ‘less pain’ when they were touched during back and the sacrum. Labor analgesia may be produced labor, and 40% reported less need for pain medication. by counter-irritation of this area. Irritation can be achieved by intracutaneous injection of sterile water Massage Therapy papules over the sacrum with a fine needle. Lytzen et al. (38) in Sweden noted instant and complete relief of The practice of massage varies from the tickling massage lower back pain in the first stage of labor in 83 women. of ‘kung fu’ to a firm massage. The effect of a gentle Pain relief lasted as long as 3 h. In some women, the massage of the periumbilical area by their partner was block was repeated. Half of the women required no other studied in nine women compared with six who received form of analgesia. Martensson and Wallin (39) compared no massage (33). There was no significant difference in a randomized study pregnant women with severe labor between the two groups in pain evaluated by means of pain treated by injections of water intracutaneously and visual scale, and no difference in the time of use of isotonic saline subcutaneously injections (placebo). Labor epidural analgesia for labor. pain was significantly lower in the first group compared In a randomized controlled study by Chang et al. (34), with the placebo group (P¼ 0.002 and 0.006). Labrecque 60 primiparous women expected to have a normal child- et al. (40) compared water blocks with TENS for the birth were randomly assigned to either the experimental treatment of lower back pain during labor. Women who (n¼ 30) or the control (n¼ 30) group. The experimental received the sterile water injections rated the intensity of group received massage intervention comprising abdominal pain lower than did women in the TENS group. effleurage, sacral pressure and shoulder/back kneading Intracutaneous water injections are associated with a during labor. In the massage group, the woman received sharp injection pain that lasts between 20 and 30 sec, a 30-min massage during uterine contractions first by the which some women find less acceptable than lower back researcher and then by the partner during each of the three pain. This method may be an alternative for women who phases of labor. The intensity of pain between the two have lower back pain during labor but wish to avoid groups was compared in the latent phase (cervix dilated epidural analgesia. 3–4 cm), active phase (5–7 cm) and transitional phase (8–10 cm). A t-test demonstrated that the massage group had significantly lower pain reactions in the latent, active Hydrotherapy and transitional phases. The popularity of undergoing part of labor in water has increased dramatically around the world. The expected Bioelectromagnetic Applications and Physical Methods benefits include pain relief and decreased use of analgesia and anesthesia. Several studies have reported use of Transcutaneous Electrical Nerve Stimulation analgesia for women undergoing labor in water, but TENS involves administration of low voltage electrical others have found no difference from control groups. stimuli through flat electrodes applied to the skin. TENS In a 1987 non-randomized, prospective, controlled study, units consist of a stimulator and two pairs of electrodes. The Lenstrup et al. (41) evaluated the effect of a warm upper electrodes are taped at the level of the tenth thoracic bathtub on 88 parturients, and found that cervical to the first lumbar root and the lower pair at the level of the dilatation rate and pain relief could be improved in second to fourth sacral nerves. The stimulator has two patients who had a bath during the first stage of labor. channels for the two pairs of electrodes. Initial reports were In 1988, independent midwives used hydrotherapy in encouraging. Augustinson et al. (1977) (35) found that which a clean bathtub was filled with warm water. The among 147 women, 44% rated pain relief as good or very clinical impression of practitioners who use hydrotherapy good and 44% as moderate. Bundsen et al. (36) found is that their patients experience shorter and less painful TENS to be especially beneficial for labor pain localized in labor. Burn and Greenish (42) studied 302 women who the back. However, a meta-analysis by Carroll et al. (37) used a labor pool. Fifty percent of the primigravidas in of 10 randomized, controlled trials in 877 women, 436 the pool group used pain medication, compared with receiving TENS and 441 as controls, revealed no significant 76% in the control group. Rush et al. (43) found in difference in pain and the use of additional analgesic a randomized study in 785 women that the tub group interventions was not different between the two groups. required fewer pharmacological agents than the control group (66% vs. 59%, P¼ 0.06). Cammu et al. (37) in Sterile Water Blocks a prospective randomized trial using a VAS showed that Counter-irritation is the process by which localized pain absolute values of labor pain were not significantly may be relieved by irritating the skin in the same different between hydrotherapy and control groups. 416 Alternative Approaches to Pain Relief During Labor In the Cochrane Pregnancy and Childbirth register (45), Aromatherapy eight randomized controlled trials (2939 women) Aromatherapy uses essential oils extracted from aromatic comparing bath tub/pool with no immersion during botanical sources to treat and balance the mind, body pregnancy, labor or birth were selected. Women who used and spirit (30). It combines the physiological effects of water immersion during the first stage of labor reported massage with the use of essential oils. One of the statistically significant less pain than those not laboring in purposes of this method is to relieve anxiety and stress water. There was a statistically significant reduction in the and to help relaxation. Massage around the lower back use of epidural/spinal/paracervical/analgesia/anaesthesi with jasmine, juniper, geranium, clary sage, rose and among women allocated to water immersion during the lavender have been reported to provide subjective benefit first stage of labor compared with those not allocated to in labor. water immersion. There were no significant differences incidence of an Apgar score less than 7 at 5 min, neonatal Conclusion unit admissions or neonatal infection rates. Maternal satisfaction with this birth experience has Complementary and alternative medicine can be defined been measured and women report increased levels of as methods that are not currently part of the dominant satisfaction, self-esteem, pain relief and relaxation with or conventional medical system. CAM exists because immersion. Ruptured membranes have been discussed conventional medicine can be limited in its ability to as a potential problem in the use of hydrotherapy, provide relief and to meet patients’ needs. CAM although in the study of Lenstrup et al. they were not and conventional medicine share the responsibility considered a contraindication. Odent (46) reported no for applying evidence-based practice and for seeking infectious complications in patients who gave birth in scientific proof to justify a planned intervention, as well water, even if the membranes were already ruptured. as the obligation to avoid harmful or useless practices. For labor pain, most studies demonstrate the greatest benefit during the beginning of the dilatation phase. When women enter the active phase of dilatation or Alternative Medications during delivery itself, there is more need for additional conventional analgesics. This suggests that complemen- Herbal Medicine tary medicine may be useful for the early onset of pain or Herbal medicine is described as the use of plant materials as a distracter, diverting women’s attention from the in medicine and food for therapeutic purposes. Various source of pain. In some cases the number of parturients herbal remedies are used during the prenatal period to who successfully use alternative methods is greater than ‘prepare’ the uterus and cervix for childbirth and ease what would be expected from a placebo effect. In a few pain during labor and delivery. cases the amount of pain medication was reduced but In a study of the practice of a group of independent this was not consistently true. The degree of success of midwives in Utah (27), specific herbs were used because a method is correlated with the availability of support of their perceived actions and properties, in particular staff in both educational and trial phases of the studies, and necessarily in clinical practice. Whereas physicians a ‘5-week formula’ which is a combination of 10 herbs do not need to be experts in the management of used during the last 5 or 6 weeks of pregnancy. This is alternative therapies, they should at least possess some said to facilitate birth. Some herbal remedies are used as basic knowledge of complementary medicine. In the the principal method of managing pain and enhancing future, the demand for complementary medicine will endurance during delivery. Practitioners observed that probably continue to rise. Care providers have to these herbal formulas had a calming and relaxing effect. facilitate informed choices through discussion of their Labor pain can also be treated specifically with mother- own experience and knowledge. One of the difficulties wort. The effect of raspberry leaf in facilitating labor in for the physician is to identify studies sufficiently well- 192 multiparous women was studied by Simpson et al. designed to help them guide their patients. (47) in a double-blind, randomized, placebo-controlled This article is an update of a chapter in the book trial in Australia. Raspberry leaf was consumed in tablet complementary and alternative approaches to biomedi- form from 32 weeks of gestation until labor. Contrary to cine with permission of the publisher (48). popular belief, it did not shorten the first stage of labor but rather the second (mean difference 9.59 min), and also lowered the rate of forceps deliveries (19.3% vs. References 30.4%). The difficulty with herbal remedies is that few 1. Chez RA, Jonas WB. The challenge of complementary and alternative medicine. Am J Obstet Gynecol 1997;177:1156–61. have undergone scientific scrutiny, chemical isolation, or 2. Gentz BA. Alternative therapies for the management of pain in labor extraction to identify the pharmacologically active agent and delivery. Clinical Obstet Gynecol 2001;44:704–35. or to enable toxicity testing. 3. Lowe NK. The nature of labor pain. Am J Obstet 2002;186:16–24. eCAM 2007;4(4) 417 4. Melzack R. The McGill Pain Questionnaire: major properties and 29. Lee MK, Chang SB, Kang DH. Effects of SP6 acupressure on labor scoring methods. Pain 1975;1:277–99. pain and length of delivery time in women during labor. J Altern 5. Melzack R. The myth of painless childbirth. Pain 1984;19:321–37. Complement Med 2004;10:959–65. 6. Cardin H, Moisson Tardieu MT, Tournaire M. La pe´ridurale. 30. Allaire AD. Complementary and alternative medicine in the labor Balland, Paris: 1986. and delivery suite. Clinical Obstet Gynecol 2001;44:681–91. 7. Bonica JJ. Textbook of Pain, Edinburgh: Churchill-Livingstone, 31. Smith CA. Homeopathy for induction of labour. Cochrane Database Sys Rev CD 003399:2001. 8. Brownridge P, Cohen S. Neural blockade for obstetrics and 32. Penny KS. Postpartum perceptions of touch received during labor. gynecologic surgery. In Neural Blockade in Clinical Anesthesia and Res Nurs Health 1979;2:9–16. Management of Pain. Philadelphia: J. P. Lippincott Company, 1988. 33. Hedstrom LW, Newton N. Touch in labor: a comparison of 9. Davidson JA. An assessment of the value of hypnosis in pregnancy cultures and eras. Birth 1986;13:181–6. and labor. Br Med J 1962;2:951–3. 34. Chang M, Wang S, Chen C. Effects of massage on pain and anxiety 10. Harmon TM, Hynan MJ, Tyre TE. Improved obstetric outcomes during labour: a randomized controlled trial in Taiwan. J Adv Nurs using hypnotic analgesia and skill mastery combined with childbirth 2002;38:68–73. education. J Consult Clin Psychol 1990;58:525–30. 35. Augustinsson LE, Bohlin P, Bundsen P, Carlsson CA, Forssman L, 11. Mairs D. Hypnosis and Pain in Childbirth. Contemp Hypnosis Sjoberg P, et al. Pain relief during delivery by transcutaneous 1995;12:111–18. electrical nerve stimulation. Pain 1977;4(1): 59–65. 12. Duchene P. Effects of biofeedback on childbirth pain. J Pain 36. Bundsen P, Peterson LE, Selstam U. Pain relief labor by Symptom Manage 1989;4:117–23. transcutaneous electrical nerve stimulation, a prospective matched 13. Bernat SH, Wooldridge PJ, Marecki M, Snell L. Biofeedback- study. Acta Obstet Gynecol Scand 1981;60:459–468. assisted relaxation to reduce stress in labor. J Obstet Gynecol 37. Carroll D, Moore RA, Tramer MR, Mc Quay HJ. Transcutaneous Neonatal Nurs 1992;21:295–303. electrical nerve stimulation does not relieve labor pain: 14. Veldman F. Haptonomy science de l’affectivite. Paris: Presse updated systematic review. Contemp, Rev Obstet Gynecol 1997; Universitaire de France, 1989. 195–205. 15. Marwick C. Leaving concert hall for clinic, therapists now test 38. Lytzen T, Cederberg L, Moller Nielsen J. Relief of low back pain in music’s ‘‘charms’’. Jama 1996;275:267–8. labor by using intracutaneous nerve stimulation (INS) with sterile 16. Durham L, Collins M. The effect of music as a conditioning aid water papules. Acta Obstet Gynecol Scand 1989;6:341–3. in prepared childbirth education. J Obstet Gynecol Neonatal Nurs 39. Martensson L, Wallin G. Labour pain treated with cutaneous 1986;15:268–70. injections of sterile water: randomized controlled trial. 17. Phumdoung S, Good M. Music reduces sensation and distress of Br J Obstetric Gynaecology 1999;106:633–7. labor pain. Pain Manag Nurs 2003;2:54–61. 40. Labrecque M, Nouwen A, Bergeron M, Rancourt JF. 18. Wallis L, Shnider SM, Palahniuk RJ, Spivey HT. An evaluation A randomized controlled trial of nonpharmacologic approaches of acupuncture analgesia in obstetrics. Anesthesiology 1974;41(6): for relief of low back pain during labor. J Fam Pract 1999;48(4): 596–601. 259–63. 19. Abouleish E, Depp R. Acupuncture in obstetrics. Anesth Analg 41. Lenstrup, Schantz A, Berget A, Feder, Roseno H, Hertel J. 1975;54:82–8. Warm tub bath during delivery. Acta Obstet Gynecol Scand 20. Hyodo M, Gega O. Use of Acupuncture Anesthesia for Normal 1987;66:709–12. Delivery. Am J Chin Med 1977;5:63–9. 42. Burn E, Greenish K. Water birth. Pooling information. Nurs Times 21. Umeh B. Sacral acupuncture for pain relief in labor: initial clinical 1993;89:47–9. experience in Nigerian women. Acupunct Electrother Res 1986; 43. Rush J, Burlock S, Lambert K, Loosley-Millman M, Hutchison B, 11:147–51. Enkin M. The effects of whirlpool baths in labor: a randomized 22. Yanai N, Shalev E, Yagudin E, Zuckerman H. The use of controlled trial. Birth 1996;23:136–43. acupuncture during labor. Am J Acupunct 1987;15:311–12. 44. Cammu H, Clasen K, Van Wettere L, Derde M. ‘‘To bathe or not 23. Lyrenas S, Lutsch H, Hetta J, Nyberg F, Willdeck-Lundh G, to bathe’’ during the first stage of labor. Acta Obstet Gynecol Scand Lindberg B. Acupuncture before delivery: effect on Pain Perception 1994;73:468–72. and the Need for Analgesics. Gynecol Obstetric Invest 1999;29(2): 45. Cluett E, Nikodem V, McCandlish R, Burns E. Immersion in water 118–24. in pregnancy, labour and birth. Cochrane Database Syst Rev 24. Ramnero A, Hanson V, Kihlgren M. Acupuncture treatment during 2004;2:CCD000111. labour. A randomised controlled trial. BJOG 2002;109:637–44. 46. Odent M. Birth under water. Lancet 1983;2(8365–6): 1476–7. 25. Skilnand E, Fossen D, Heiberg E. Acupuncture in the management 47. Simpson M, Parsons M, Grenwood J, Wade K. Raspberry leaf of pain in labor. Acta Obstet Gynecol Scand 2002;81:943–8. in pregnancy: its safety and efficacy in labor. J Midwifery Womens 26. Qu F, Zhou J. Electro-acupuncture in relieving Labor Pain. ECam J Health 2001;46:51–9. (in press) 2007. (Advance access published on August 17, 2006). 48. Tournaire M. Alternative approaches to pain relief during labor and 27. Sakala C. Content of care by independent midwives: assistance with delivery. In: Cooper E, Yamaguchi N (eds). Complementary and pain in labor and birth. Soc Sci Med 1988;26:1141–58. Alternative Approaches to Biomedicine. New-York: Kluwer 28. Chung UL, Hung LC, Kuo SC, Huang CL. Effects of L14 and Academic/Plenum publishers, 2004, 193–206. BL67 acupressure on labor pain and uterine contractions in the first stage of labor. J Nurs Res 2003;4:251–60. Received November 5, 2006; accepted January 16, 2007 MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Evidence-Based Complementary and Alternative Medicine Hindawi Publishing Corporation

Complementary and Alternative Approaches to Pain Relief during Labor

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Copyright © 2007 Michel Tournaire and Anne Theau-Yonneau. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Advance Access Publication 15 March 2007 eCAM 2007;4(4)409–417 doi:10.1093/ecam/nem012 Review Complementary and Alternative Approaches to Pain Relief During Labor Michel Tournaire and Anne Theau-Yonneau Obstetrics and Gynecology Department, Saint Vincent de Paul Hospital, University of Paris, Paris, France This review evaluated the effect of complementary and alternative medicine on pain during labor with conventional scientific methods using electronic data bases through 2006 were used. Only randomized controlled trials with outcome measures for labor pain were kept for the conclusions. Many studies did not meet the scientific inclusion criteria. According to the randomized control trials, we conclude that for the decrease of labor pain and/or reduction of the need for conventional analgesic methods: (i) There is an efficacy found for acupressure and sterile water blocks. (ii) Most results favored some efficacy for acupuncture and hydrotherapy. (iii) Studies for other complementary or alternative therapies for labor pain control have not shown their effectiveness. Keywords: acupuncture – biofeedback – complementary and alternative medicine – delivery – homeopathy – hydrotherapy – hypnosis – labor – labor pain – manual healing – pain – sophrology – sterile water blocks – stimulation – transcutaneous electrical nerve stimulation – yoga that such therapies are more in harmony with their personal Introduction philosophies. The conventional medical community usually Even though delivery is a natural phenomenon, it has been offers traditional choices of analgesia, such as epidural and demonstrated that the accompanying pain is considered intravenous drugs. Patients may have access to alternative severe or extreme in more than half of cases. Besides methods, but will generally be obliged to do the relevant conventional approaches, such as epidural analgesia, many research themselves beforehand. Those seeking alternatives complementary or alternative methods have been reported are not necessarily dissatisfied with conventional medicine, to reduce pain during labor and delivery. Complementary but attempt to supplement rather than replace traditional or Alternative Medicine (CAM) can be defined as theories care. Quite often, users of complementary medicine do not or practices that are not part of the dominant or inform the practitioners in charge of their pregnancy and conventional medical system. Some of them have been delivery. There are also different expectations for the reclassified as part of conventional medicine when sup- management of pain during labor according to the category ported by clinical experience or scientific data (1). of professionals. Physicians are expected to provide These methods are popular because they emphasize the pharmacological therapy, whereas midwives, nurses and individual personality, and the interaction between mind, other auxiliaries are required to assist patients with body and environment (2). They are attractive to people psychological methods, and in fact use alternative who want to be more involved in their own care and feel approaches more often. The theoretical bases for many alternative methods derive from Eastern tradition or philosophy. For reprints and all correspondence: Michel Tournaire, Obstetrics and Gynecology Department, Saint Vincent de Paul Hospital - University of After a description of labor pain, we shall mention the Paris, 82 Avenue Denfert Rochereau 75014 Paris, France. Tel: þ33 (0) conventional treatments and describe the different 1 40 48 81 43; Fax: þ33 (0) 1 40 48 83 97; complementary methods applicable to labor pain. E-mail: [email protected] 2007 The Author(s) This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/2.0/uk/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original workis properly cited. 410 Alternative Approaches to Pain Relief During Labor Nature of Pain During Labor and Delivery Age Tissue damage Socio- A scientific definition of pain is ‘an unpleasant Birth economic preparation sensory and emotional experience associated with actual level Stage of or potential tissue damage’ (3). Acute pain such as labor Religion labor pain has two dimensions: a sensory or physical Emotional Cervix Physical dimension, with the transmission of information, the pain stimuli, to the brain, and an affective dimension due to interpretation of these stimuli through the interaction of a wide variety of emotional, social, cultural and cognitive variables unique to the individual (Fig. 1). Muscular Language Behavior For the management of pain, conventional medicine reaction crying focuses more on the physical side, while alternative Figure 1. Components of pain (6). methods deal mainly with emotional considerations. In the laboring patient, the two stages of labor correspond to different types of pain and routes of pain, which can now be quantified, is only one transmission. During dilatation (first stage), visceral pain component of a woman’s overall experience of labor predominates, due to mechanical distention of the cervix and birthing. Personal satisfaction is not always corre- and of the lower part of the uterus. These stimuli are lated with the level of pain and although difficult transmitted to the spinal cord at the level of the tenth to quantify should be included in the evaluations. thoracic to the first lumbar root. Uterine contractions Note that the term analgesia means pain relief without may be felt as back pain because the nerves that supply total loss of sensation, while anesthesia is defined as pain the uterus also supply the skin on the lower back or relief with total loss of sensation. lumbosacral area. During the descent phase (second stage), pain is also caused by distension and stretching of the pelvic floor and perineum. These stimuli are Conventional Treatments transmitted via the pudendal nerve to the second to fourth sacral nerves. Regional Analgesia: Epidural Even though pain is a personal experience, it can be An epidural involves the introduction of a local analyzed by means of quantitative pain measures. Verbal anesthetic agent to the sensitive nerves conducting the reports using standardized instruments, such as the pain messages on their way to the spine. A catheter McGill Pain Questionnaire and the Visual Analogue (fine flexible tube) is usually placed in the epidural space, Scale (VAS), have been the most common methods of allowing intermittent or continuous infusion throughout pain assessment both in clinical practice and research (4). the delivery. A Canadian study comparing different pain syndromes The epidural is the most efficient way of reducing labor found that average labor pain scores were higher in both pain (Fig. 2). A total of 85–95% of women report nulliparous (first delivery) and multiparous women than complete relief of pain during the two phases of delivery: the average scores previously recorded for out-patients cervical dilatation and descent of the baby (8). Complete with sciatic pain, toothache and fracture pain (5,6) failure is rare and usually due to technical problems, (Fig. 2). However, whereas the average score is higher, as when the epidural space cannot be reached with the its exact value differs greatly from one woman to catheter. Delivery pain relief can be partial. The painful another. Bonica found that labor pain was mild in 15% feeling of contractions persists, but at a lower intensity. of cases, moderate in 35%, severe in 30% and extreme Sometimes the area of analgesia is incomplete. in 20% (7). For example, the pain can be felt laterally in half of Some factors are associated with increased pain: first the abdomen. When the lower nerves are not, or are delivery, history of dysmenorrhea (painful periods), fear insufficiently, dulled, pain may develop during the second of pain, a religious practice. Some factors diminish pain: phase of labor. One of the main advantages of the childbirth preparation classes, complications during epidural is that it is efficient regardless of the cultural pregnancy, wish to breast feed, high socio-economic context, with few side effects. But it is not always status, older age (5). available. To evaluate the efficiency of the different therapies, we have applied conventional scientific methods to published studies. In other words, do these studies Injected Drugs report a statistically significant reduction in labor pain? As we shall see, few publications in the field of CAM Morphine-like drugs (opioids) can be given continuously meet these standards. However, we should consider that or in intermittent doses at the patient’s request or via Contractions Personality Environment Pain eCAM 2007;4(4) 411 affect the other. Many mind–body interventions are 50 applied to chronic illness, but this technique also appears to be applicable to the acute situation of delivery. Psychoprophylactic Methods 1st delivery Grantly Dick-Read introduced ‘natural childbirth’ without preparation in 1933. He believed that childbirth pain was a pathologic 1st delivery with preparation response produced by fear, apprehension and tension. Other delivery with or He felt it essential to teach women the anatomic and without preparation physiologic facts of childbirth, and to instruct them in Sciatic physical and mental relaxation. Both approaches are alleged to diminish pain by familiarizing the pregnant woman with the process of childbirth and by creating an Tooth pain atmosphere of confidence. Fracture Delivery with Fernand Lamaze introduced his method in France in epidural 1951 after a visit to Russia. This method was first optimistically called ‘painless childbirth’, but later the Figure 2. Pain scores (4–6). more appropriate term ‘fearless childbirth’ was applied. It is based on the Pavlovian concept of conditioned reflex training. By focusing on certain breathing patterns or patient-controlled administration. Recent reports suggest concentration points such as a mark on a nearby wall, that the analgesic effect of these agents in labor is limited it should be possible to block pain messages to the brain. and that the primary mechanism of action is heavy Bradley’s method emphasizes natural childbirth, with sedation, which means that consciousness is reduced the parents working as a team. Students of this method during delivery. Such drugs may also have some effect on are taught about deep abdominal breathing and an the newborn, with rare but possible breathing difficulties understanding of the labor and delivery process. Rather that may require assistance. Few studies have dealt with than trying to block out pain, Bradley’s method efficiency. Most were done in the 1960s and provide encourages concentrated awareness that works through information on patient satisfaction (generally good in the pain. about half of the cases), but without quantitative These methods are expected to provide better informa- evaluation of pain reduction. tion about the process of delivery, reduce fear, give greater satisfaction with a sense of achievement and happiness, and create a better child–mother relationship. Nitrous Oxide The importance of a good relationship between the Nitrous oxide gas is given for inhalation at subanesthetic patient and the care-giving team is also emphasized. concentrations. Despite being used for more than Of these approaches, we have only found an evaluation 100 years, there is no clear quantitative evidence of of the Lamaze method: a study by Melzack in 1984 (5) the efficacy of nitrous oxide in relieving labor pain. using the McGill pain scale found a slight decrease in The subjective feelings of mothers giving birth suggest, average pain score in patients using the Lamaze method, however, that nitrous oxide is beneficial in many cases. but this was not statistically significantly different from Many women report significant analgesia with it, and the control group (Fig. 2). many would choose it again for another delivery. This study also showed that the average pain score is slightly higher at the first delivery, compared with subsequent deliveries, but the difference is not statistically Alternative Approaches significant. Complementary and alternative methods applicable to Leboyer’s Method labor pain can be divided into mind–body interventions, alternative systems of medical practice, manual healing, Fre´ de´ ric Leboyer described his method in France in 1974 bioelectromagnetic and physical methods, and alternative in his book ‘Birth without violence’. Inspired by Indian medication (1). yoga, this method focuses on providing a better welcome for the newborn. In contrast to the usual environment, with too much light and noise stressing the baby, Mind–Body Interventions Leboyer proposes calm for mother, father and Mind–body interventions are based on the interconnect- professionals, and darkness, little noise and a warm edness of mind and body and on the power of each to bath for the newborn. For the comfort of the mother 412 Alternative Approaches to Pain Relief During Labor during delivery, Leboyer considers that serenity obtained Biofeedback through attention to the baby raises the pain threshold. Biofeedback uses monitoring instruments to provide feed- There has been no specific evaluation of the effects on back to patients, i.e. physiological information of which labor pain. However, couples express a high degree of they are normally unaware. Electrodes feed information to satisfaction. Although Leboyer’s method is rarely used a monitoring box that registers the results by a sound or a now as described in the 1970s, many birth practitioners visual meter that varies as the monitored function increases still consider it to have a positive effect, with gentle and or decreases. For women in labor, several biofeedback- heightened attention for the newborn. assisted relaxation techniques have been introduced. Duchene (12) completed in 1989 a prospective random- ized trial in which tension of the abdominal muscles was Hypnosis monitored. As uterine contractions occurred the women The word hypnosis originates from the Greek ‘hypnos’ focused on relaxing the abdominal muscles. The reports of meaning ‘sleep’. In fact, it is not sleep but a state of focused pain using VASs and verbal description scales showed concentration in which the patient can be relatively significantly lower pain values in the biofeedback unaware, but not completely blind to her surroundings group and less medication. In 1992, Bernat et al. (13) (2). During hypnosis, suggestions may be made, focusing used a fingertip thermometer. When the patient relaxes, on diminishing awareness of pain, fear and anxiety. The vasodilation occurs and the finger temperature increases. woman is prepared with initial hypnotic experiences that However, none of the experimental subjects attempted to include three steps: absorption of the words or images use fingertip temperature control as a coping technique presented by the therapist, dissociation, a suspension of during labor. The authors concluded that a lack of hospital staff support may have contributed to this study’s outcome. critical judgment, and responsiveness. A few comparative In conclusion, biofeedback-assisted relaxation tech- studies have evaluated the efficiency of hypnosis. niques applied to pain control yield contradictory results. In 1962, Davidson (9) compared 70 patients who had Their efficiency is certainly contingent on strong support six lessons of autohypnosis with 70 who had received from caregivers to facilitate the use of the technique. Dick-Read’s training and with 71 who had no special antenatal training. The study was not randomized as Yoga patients were allowed to choose their group. A statistically significant reduction in the duration of the first stage of Yoga, a method of Indian origin, proposes control of labor was found in the hypnosis group as compared with mind and body. Between the different types of yoga, the two other groups. Autohypnosis was effective on labor ‘energy yoga’ can be applied to pregnancy and delivery. pain: 59% of this group required no analgesia, compared Through special training of breathing, it achieves changes with 1.4% in the control group. All patients required in levels of consciousness, relaxation, receptivity to the analgesia in the Dick-Read training group. The subjective world and inner peace. According to professionals impression of labor was much more pleasant in the who use this technique for delivery, yoga shortens the autohypnosis group. In 1990, Harmon et al. (10) completed duration of labor, decreases pain and reduces the need a randomized study showing shorter stage 1 labor, less for analgesic medication. However, we have not found medication and higher pain thresholds in the hypnosis any scientific confirmation of these assertions. group than in the control group. In 1995, Mairs (11) compared 29 primigravida women who chose to join Sophrology ‘hypnosis for childbirth’ classes and 29 in a control group. The word sophrology derives from two Greek words, The trained group reported statistically significantly lower ‘sos’ harmony or serenity and ‘phren’ conscience or spirit. ratings of both pain and anxiety. However, there was no This technique derived from Indian yoga was introduced statistically significant difference between the two groups in in Europe during the 1960s. Its purpose is to improve their drug usage during labor. the control of body and spirit through three degrees of A few negative effects of hypnosis have been reported, dynamic relaxation: concentration, contemplation and including mild dizziness, nausea and headache. These meditation. Applied to obstetrics, better control of the seem to be associated with failure to dehypnotize the delivery process is expected. Patients individually report patient properly. Caution should be used in patients a high degree of satisfaction with this experience of vulnerable to psychotic decompensation. relaxation during prenatal classes and delivery, but there To summarize, hypnosis seems to reduce fear, tension is no controlled evaluation in the literature. and pain during labor and to raise the pain threshold. It reduces the need for chemical analgesia. Patients have Haptonomy a greater sense of control over painful contractions. Hypnosis, therefore, can be considered as a helpful Derived from the Greek words ‘hapsis’ affectivity and adjunct during the course of labor and delivery. ‘nomos’ knowledge, haptonomy can be defined as the eCAM 2007;4(4) 413 science of affectivity. This approach was proposed by Acupuncture is based on the balance between Yin and Frans Vedman (14) in the Netherlands during the 1940s. Yang. Treatment is aimed at reconstituting the normal movement between these two opposites. The meridians Specific zones of affectivity are reported to improve the are considered as energy channels. Most treatments of contact between father, mother and baby and to help to obstetrical and gynecological problems involve the use of share emotions. In practice, haptonomy is appreciated points on different meridians: spleen-pancreas located by couples during pregnancy, but it seems to be used on the inside of the ankle bone, conception, governing irregularly during labor, particularly because teams in or penetrating vessel. charge of delivery are not always aware of its existence. Acupuncture may produce effects through several Practitioners expect a quicker and easier delivery as well different mechanisms. One hypothesis is that acupuncture as a better relationship between parents and newborn. points have electrical properties that, when stimulated, There is no published evaluation of haptonomy and may alter the level of chemical neurotransmitters in the in fact such an assessment should not be expected body. Another hypothesis is that endorphins are released because, as the specialists of this method say, ‘affectivity due to activation of the hypothalamus. The effects of cannot be put into numbers’. acupuncture have also been attributed to alterations in the natural electrical currents or electromagnetic fields Music Therapy in the body. The use of acupuncture for pain relief has given Music addresses many of the physical and psychological equivocal results. Wallis et al. (18) in San Francisco needs of patients. In obstetrics, a slow and restful type of in 1974 found that 19 of 21 patients had inadequate pain music may be used as a sedative to promote relaxation relief based on pain scores and none of the 21 subjects during the early stage of labor. Music with a steady beat was judged by investigators to have adequate analgesia. may be used as a stimulant to promote movement during Abouleish and Depp (19) in the USA in 1970 used the latter stages. The literature findings are discordant. electroacupuncture and described relief of pre-existing In Austin, Texas, a music program is used during the pain in 7 of 12 participants. The investigators, who found third trimester of pregnancy (15). The prospective mother the technique time-consuming, cited some disadvantages: and her partner are allowed to select the kind of music inconsistency, unpredictability and lack of completeness. they like for the different stages of labor. After a study Hyodo and Gega (20) in Japan in 1977 in a study of of 30 deliveries, only one half of the women who subjective and objective relief of labor pain in 32 women had listened to music required analgesia. However, in described an improvement in 60% of 16 primiparous a randomized study Durham and Collins (16) could not women and 90% of 16 multiparous women. However, demonstrate the value of music in reducing the need for all patients received systemic sedation. The authors analgesic medication. But the subjective sense of satisfac- concluded that acupuncture is useful for delivery because tion appeared to be higher in the group that listened of its safety, despite erratic and less potent results to music. In a randomized controlled trial by Phumdoung than conventional analgesic techniques. In Nigeria in and Good (17), 110 primiparous women, during the 1986, 19 of 30 women (63.3%) given sacral acupuncture active phase of labor, were assigned to a soft music group by Umeh (21) indicated that they had adequate pain for 3 h (n¼ 55) or a control group (n¼ 55). Dual VAS relief by responses on a visual scale and did not request were used to measure the sensation of pain before another form of analgesia. Yanai et al. (22) in Israel starting the study and every three hours. The results in 1987 evaluated electroacupuncture during the labor of indicate that in the music group women had significantly 16 parturients. Fifty-six percent of the women reported less sensation of pain (P50.001). After these contra- mild to good pain relief and 81% described increased dictory results concerning the effects of music therapy relaxation. The perceived positive effects led the authors there is a need for further scientific analyses. to believe that acupuncture should be pursued as an additional method of pain control. In 1999, Lyrenas et al. (23) in Sweden studied 31 primiparous women who had Alternative Systems of Medical Practice received repeated acupuncture compared with untreated women. Pain assessed on a VAS was not reduced in Acupuncture women treated with acupuncture, and the acupuncture Acupuncture has been used in China for more than 2000 did not reduce the need for analgesics during labor. years. Specific anatomic parts of the body are stimulated In 2002 Ramnero et al. (24) in Sweden reported for therapeutic purposes. This can be done in the usual a randomized, controlled study in 90 parturients, way with needles, but practitioners may also use heat, 46 of whom received acupuncture during labor as a pressure, impulse of magnetic energy, burning by a complement or alternative to conventional analgesia. preparation of the herb Artemia vulgaris, electrical Acupuncture significantly reduced the need for epidural stimulation or surface electrodes at acupuncture loci. analgesia (12% vs. 22%). Patients in the acupuncture 414 Alternative Approaches to Pain Relief During Labor group reported a significantly greater degree of relaxation lower back. Pressure against spots that are sensitive can compared with the control group. The authors considered be particularly efficacious. Force is initially applied these results to suggest that acupuncture could be a good during contractions and then continuously. alternative or complement for women who seek an The purpose of the study of Chung et al. (28) is to alternative to pharmacological analgesia in childbirth, determine the effect of L14 and BL67 acupressure on but further trials are required to clarify whether the labor pain during the first stage of labor. A total of main effect of acupuncture during labor is analgesic or 127 parturient women were randomly assigned to three relaxing. In the trial by Skilnand et al. (25), 210 groups. Each group received only one of the following parturients were randomly assigned to receive either treatments: L14 and BL67 acupressure, light skin real acupuncture or false acupuncture. Real acupuncture stroking or no treatment. There was a significant consisted of a treatment protocol from the Norwegian difference in decreased labor pain in the first group School of Acupuncture. The same type and number of compared with the two others. needles were used not on the classic meridians. Pain was A study of Lee et al. (29) evaluated the effects of SP6 assessed using a linear VAS (rated 0–10) recorded at 30, acupressure on labor pain. 75 women in labor were 60 and 120 min after treatment. There were significantly randomly assigned to either the SP6 acupressure (n¼ 36) lower pain scores at 30, 60, 120 min after treatment or SP6 touch control (n¼ 39) group using double-blinded (P50.001), and significantly less need for epidural method. Labor pain was measured four times using VAS. analgesia and intramuscular pethidine (P¼ 0.01 There were significant differences between the groups et P50.001, respectively). Qu and Zhou (26) compared in pain scores at all times following the intervention: in a prospective randomized study 20 primipara with immediately after the intervention (P¼ 0.012), 30 min electro-acupuncture and 19 as controls. The electro- after the intervention (P¼ 0.021) and 60 min after the acupuncture group was found to exhibit a lower pain intervention (P¼ 0.012). The total labor time (3 cm of intensity and a better degree of relaxation than the dilatation to delivery) was significantly shorter in the SP6 control group (P¼ 0.018 and 0.031). acupressure intervention group than in the control group To summarize, acupuncture studies are difficult to (P¼ 0.006). conduct and analyze for several reasons, including lack of standardization with use of multiple acupuncture points, Homeopathy and the difficulty of choosing a control group. Within the control group the needles might be correctly placed Homeopathy involves the use of diluted substances that but not stimulated, or needles could be placed in cause symptoms in their undiluted form. According to inappropriate sites. There were no reported complications homeopathic theory, remedies stimulate the self-healing in any of the studies but there is a potential risk of mechanism. The amount of medicine prescribed is so infection. To achieve a good analgesic effect during small that it often cannot be measured in molecular labor, a relatively long induction period may be required. amounts (30). We found no studies evaluating the It is difficult for a woman in labor to remain still for effect of homeopathic treatment on labor pain. Smith 15–30 min, and some patients felt discomfort because (31) has reviewed cervical ripening and labor induction of the restrictions in movement. by ‘‘caulophyllum’’. There were no differences between Overall, a beneficial therapeutic effect on labor pain of the homeopathy and control groups in a randomized, acupuncture is not certain. Better designed studies need controlled trial involving 40 women. to be completed with, if possible, standardization of the points used, and better control groups. However, Manual Healing it should be recognized that the procedure is time- consuming, and that the required training of patients and Manual healing methods used today during delivery personnel may be considerable. include therapeutic touch and massage therapy. Acupressure Systems Therapeutic Touch Acupressure is a descendant of Chinese manipulative The purpose of therapeutic touch in labor is to therapy in which points are stimulated by pressure, using communicate caring and reassurance. Painful contrac- hands, fingers and thumbs (27). Acupressure supposedly tions of the uterus can be treated by the application of promotes the circulation of blood, the harmony of yin pressure with the hands to the woman’s back, abdomen, and yang and the secretion of neurotransmitters, hips, thighs, sacrum or perineum. Whether touch is thus maintaining the normal functions of the human perceived as positive or not is dependent on who is body and enhancing well being. Some midwives use touching the patient: in one study, touching was acupressure to release the pain of labor. Pressure is perceived positively by 94% of patients when they were applied simultaneously to both sides of the spine in the touched by a relative or friend, 86% by their husbands, eCAM 2007;4(4) 415 73% by a nurse and 21% by a physician (32). Anxiety is dermatomal distribution. For example, the uterus is reported to be reduced in patients who receive reassuring supplied by the lower thoracic spinal cord segments. touch. In a retrospective study of 30 patients, 77% Some of these receive stimuli from the skin of the lower experienced ‘less pain’ when they were touched during back and the sacrum. Labor analgesia may be produced labor, and 40% reported less need for pain medication. by counter-irritation of this area. Irritation can be achieved by intracutaneous injection of sterile water Massage Therapy papules over the sacrum with a fine needle. Lytzen et al. (38) in Sweden noted instant and complete relief of The practice of massage varies from the tickling massage lower back pain in the first stage of labor in 83 women. of ‘kung fu’ to a firm massage. The effect of a gentle Pain relief lasted as long as 3 h. In some women, the massage of the periumbilical area by their partner was block was repeated. Half of the women required no other studied in nine women compared with six who received form of analgesia. Martensson and Wallin (39) compared no massage (33). There was no significant difference in a randomized study pregnant women with severe labor between the two groups in pain evaluated by means of pain treated by injections of water intracutaneously and visual scale, and no difference in the time of use of isotonic saline subcutaneously injections (placebo). Labor epidural analgesia for labor. pain was significantly lower in the first group compared In a randomized controlled study by Chang et al. (34), with the placebo group (P¼ 0.002 and 0.006). Labrecque 60 primiparous women expected to have a normal child- et al. (40) compared water blocks with TENS for the birth were randomly assigned to either the experimental treatment of lower back pain during labor. Women who (n¼ 30) or the control (n¼ 30) group. The experimental received the sterile water injections rated the intensity of group received massage intervention comprising abdominal pain lower than did women in the TENS group. effleurage, sacral pressure and shoulder/back kneading Intracutaneous water injections are associated with a during labor. In the massage group, the woman received sharp injection pain that lasts between 20 and 30 sec, a 30-min massage during uterine contractions first by the which some women find less acceptable than lower back researcher and then by the partner during each of the three pain. This method may be an alternative for women who phases of labor. The intensity of pain between the two have lower back pain during labor but wish to avoid groups was compared in the latent phase (cervix dilated epidural analgesia. 3–4 cm), active phase (5–7 cm) and transitional phase (8–10 cm). A t-test demonstrated that the massage group had significantly lower pain reactions in the latent, active Hydrotherapy and transitional phases. The popularity of undergoing part of labor in water has increased dramatically around the world. The expected Bioelectromagnetic Applications and Physical Methods benefits include pain relief and decreased use of analgesia and anesthesia. Several studies have reported use of Transcutaneous Electrical Nerve Stimulation analgesia for women undergoing labor in water, but TENS involves administration of low voltage electrical others have found no difference from control groups. stimuli through flat electrodes applied to the skin. TENS In a 1987 non-randomized, prospective, controlled study, units consist of a stimulator and two pairs of electrodes. The Lenstrup et al. (41) evaluated the effect of a warm upper electrodes are taped at the level of the tenth thoracic bathtub on 88 parturients, and found that cervical to the first lumbar root and the lower pair at the level of the dilatation rate and pain relief could be improved in second to fourth sacral nerves. The stimulator has two patients who had a bath during the first stage of labor. channels for the two pairs of electrodes. Initial reports were In 1988, independent midwives used hydrotherapy in encouraging. Augustinson et al. (1977) (35) found that which a clean bathtub was filled with warm water. The among 147 women, 44% rated pain relief as good or very clinical impression of practitioners who use hydrotherapy good and 44% as moderate. Bundsen et al. (36) found is that their patients experience shorter and less painful TENS to be especially beneficial for labor pain localized in labor. Burn and Greenish (42) studied 302 women who the back. However, a meta-analysis by Carroll et al. (37) used a labor pool. Fifty percent of the primigravidas in of 10 randomized, controlled trials in 877 women, 436 the pool group used pain medication, compared with receiving TENS and 441 as controls, revealed no significant 76% in the control group. Rush et al. (43) found in difference in pain and the use of additional analgesic a randomized study in 785 women that the tub group interventions was not different between the two groups. required fewer pharmacological agents than the control group (66% vs. 59%, P¼ 0.06). Cammu et al. (37) in Sterile Water Blocks a prospective randomized trial using a VAS showed that Counter-irritation is the process by which localized pain absolute values of labor pain were not significantly may be relieved by irritating the skin in the same different between hydrotherapy and control groups. 416 Alternative Approaches to Pain Relief During Labor In the Cochrane Pregnancy and Childbirth register (45), Aromatherapy eight randomized controlled trials (2939 women) Aromatherapy uses essential oils extracted from aromatic comparing bath tub/pool with no immersion during botanical sources to treat and balance the mind, body pregnancy, labor or birth were selected. Women who used and spirit (30). It combines the physiological effects of water immersion during the first stage of labor reported massage with the use of essential oils. One of the statistically significant less pain than those not laboring in purposes of this method is to relieve anxiety and stress water. There was a statistically significant reduction in the and to help relaxation. Massage around the lower back use of epidural/spinal/paracervical/analgesia/anaesthesi with jasmine, juniper, geranium, clary sage, rose and among women allocated to water immersion during the lavender have been reported to provide subjective benefit first stage of labor compared with those not allocated to in labor. water immersion. There were no significant differences incidence of an Apgar score less than 7 at 5 min, neonatal Conclusion unit admissions or neonatal infection rates. Maternal satisfaction with this birth experience has Complementary and alternative medicine can be defined been measured and women report increased levels of as methods that are not currently part of the dominant satisfaction, self-esteem, pain relief and relaxation with or conventional medical system. CAM exists because immersion. Ruptured membranes have been discussed conventional medicine can be limited in its ability to as a potential problem in the use of hydrotherapy, provide relief and to meet patients’ needs. CAM although in the study of Lenstrup et al. they were not and conventional medicine share the responsibility considered a contraindication. Odent (46) reported no for applying evidence-based practice and for seeking infectious complications in patients who gave birth in scientific proof to justify a planned intervention, as well water, even if the membranes were already ruptured. as the obligation to avoid harmful or useless practices. For labor pain, most studies demonstrate the greatest benefit during the beginning of the dilatation phase. When women enter the active phase of dilatation or Alternative Medications during delivery itself, there is more need for additional conventional analgesics. This suggests that complemen- Herbal Medicine tary medicine may be useful for the early onset of pain or Herbal medicine is described as the use of plant materials as a distracter, diverting women’s attention from the in medicine and food for therapeutic purposes. Various source of pain. In some cases the number of parturients herbal remedies are used during the prenatal period to who successfully use alternative methods is greater than ‘prepare’ the uterus and cervix for childbirth and ease what would be expected from a placebo effect. In a few pain during labor and delivery. cases the amount of pain medication was reduced but In a study of the practice of a group of independent this was not consistently true. The degree of success of midwives in Utah (27), specific herbs were used because a method is correlated with the availability of support of their perceived actions and properties, in particular staff in both educational and trial phases of the studies, and necessarily in clinical practice. Whereas physicians a ‘5-week formula’ which is a combination of 10 herbs do not need to be experts in the management of used during the last 5 or 6 weeks of pregnancy. This is alternative therapies, they should at least possess some said to facilitate birth. Some herbal remedies are used as basic knowledge of complementary medicine. In the the principal method of managing pain and enhancing future, the demand for complementary medicine will endurance during delivery. Practitioners observed that probably continue to rise. Care providers have to these herbal formulas had a calming and relaxing effect. facilitate informed choices through discussion of their Labor pain can also be treated specifically with mother- own experience and knowledge. One of the difficulties wort. The effect of raspberry leaf in facilitating labor in for the physician is to identify studies sufficiently well- 192 multiparous women was studied by Simpson et al. designed to help them guide their patients. (47) in a double-blind, randomized, placebo-controlled This article is an update of a chapter in the book trial in Australia. Raspberry leaf was consumed in tablet complementary and alternative approaches to biomedi- form from 32 weeks of gestation until labor. Contrary to cine with permission of the publisher (48). popular belief, it did not shorten the first stage of labor but rather the second (mean difference 9.59 min), and also lowered the rate of forceps deliveries (19.3% vs. References 30.4%). 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