Inhaled analgesia for pain management in labour

Massage, reflexology and other manual methods for pain management in labour

BACKGROUND

Many women would like to avoid pharmacological or invasive methods of pain management in labour, and this may contribute towards the popularity of complementary methods of pain management. This review examined the evidence currently available on manual methods, including massage and reflexology, for pain management in labour. This review is an update of the review first published in 2012.

OBJECTIVES

To assess the effect, safety and acceptability of massage, reflexology and other manual methods to manage pain in labour.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register (30 June 2017), the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 6), MEDLINE (1966 to 30 June 2017, CINAHL (1980 to 30 June 2017), the Australian New Zealand Clinical Trials Registry (4 August 2017), Chinese Clinical Trial Registry (4 August 2017), ClinicalTrials.gov, (4 August 2017), the National Center for Complementary and Integrative Health (4 August 2017), the WHO International Clinical Trials Registry Platform (ICTRP) (4 August 2017) and reference lists of retrieved trials.

SELECTION CRITERIA

We included randomised controlled trials comparing manual methods with standard care, other non-pharmacological forms of pain management in labour, no treatment or placebo. We searched for trials of the following modalities: massage, warm packs, thermal manual methods, reflexology, chiropractic, osteopathy, musculo-skeletal manipulation, deep tissue massage, neuro-muscular therapy, shiatsu, tuina, trigger point therapy, myotherapy and zero balancing. We excluded trials for pain management relating to hypnosis, aromatherapy, acupuncture and acupressure; these are included in other Cochrane reviews.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality, extracted data and checked data for accuracy. We contacted trial authors for additional information. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included a total of 14 trials; 10 of these (1055 women) contributed data to meta-analysis. Four trials, involving 274 women, met our inclusion criteria but did not contribute data to the review. Over half the trials had a low risk of bias for random sequence generation and attrition bias. The majority of trials had a high risk of performance bias and detection bias, and an unclear risk of reporting bias. We found no trials examining the effectiveness of reflexology.MassageWe found low-quality evidence that massage provided a greater reduction in pain intensity (measured using self-reported pain scales) than usual care during the first stage of labour (standardised mean difference (SMD) -0.81, 95% confidence interval (CI) -1.06 to -0.56, six trials, 362 women). Two trials reported on pain intensity during the second and third stages of labour, and there was evidence of a reduction in pain scores in favour of massage (SMD -0.98, 95% CI -2.23 to 0.26, 124 women; and SMD -1.03, 95% CI -2.17 to 0.11, 122 women). There was very low-quality evidence showing no clear benefit of massage over usual care for the length of labour (in minutes) (mean difference (MD) 20.64, 95% CI -58.24 to 99.52, six trials, 514 women), and pharmacological pain relief (average risk ratio (RR) 0.81, 95% CI 0.37 to 1.74, four trials, 105 women). There was very low-quality evidence showing no clear benefit of massage for assisted vaginal birth (average RR 0.71, 95% CI 0.44 to 1.13, four trials, 368 women) and caesarean section (RR 0.75, 95% CI 0.51 to 1.09, six trials, 514 women). One trial reported less anxiety during the first stage of labour for women receiving massage (MD -16.27, 95% CI -27.03 to -5.51, 60 women). One trial found an increased sense of control from massage (MD 14.05, 95% CI 3.77 to 24.33, 124 women, low-quality evidence). Two trials examining satisfaction with the childbirth experience reported data on different scales; both found more satisfaction with massage, although the evidence was low quality in one study and very low in the other.Warm packsWe found very low-quality evidence for reduced pain (Visual Analogue Scale/VAS) in the first stage of labour (SMD -0.59, 95% CI -1.18 to -0.00, three trials, 191 women), and the second stage of labour (SMD -1.49, 95% CI -2.85 to -0.13, two trials, 128 women). Very low-quality evidence showed reduced length of labour (minutes) in the warm-pack group (MD -66.15, 95% CI -91.83 to -40.47; two trials; 128 women).Thermal manual methodsOne trial evaluated thermal manual methods versus usual care and found very low-quality evidence of reduced pain intensity during the first phase of labour for women receiving thermal methods (MD -1.44, 95% CI -2.24 to -0.65, one trial, 96 women). There was a reduction in the length of labour (minutes) (MD -78.24, 95% CI -118.75 to -37.73, one trial, 96 women, very low-quality evidence). There was no clear difference for assisted vaginal birth (very low-quality evidence). Results were similar for cold packs versus usual care, and intermittent hot and cold packs versus usual care, for pain intensity, length of labour and assisted vaginal birth.Music One trial that compared manual methods with music found very low-quality evidence of reduced pain intensity during labour in the massage group (RR 0.40, 95% CI 0.18 to 0.89, 101 women). There was no evidence of benefit for reduced use of pharmacological pain relief (RR 0.41, 95% CI 0.16 to 1.08, very low-quality evidence).Of the seven outcomes we assessed using GRADE, only pain intensity was reported in all comparisons. Satisfaction with the childbirth experience, sense of control, and caesarean section were rarely reported in any of the comparisons.

AUTHORS' CONCLUSIONS

Massage, warm pack and thermal manual methods may have a role in reducing pain, reducing length of labour and improving women's sense of control and emotional experience of labour, although the quality of evidence varies from low to very low and few trials reported on the key GRADE outcomes. Few trials reported on safety as an outcome. There is a need for further research to address these outcomes and to examine the effectiveness and efficacy of these manual methods for pain management.

Relaxation techniques for pain management in labour

BACKGROUND

Many women would like to avoid pharmacological or invasive methods of pain management in labour and this may contribute to the popularity of complementary methods of pain management. This review examined currently available evidence on the use of relaxation therapies for pain management in labour. This is an update of a review first published in 2011.

OBJECTIVES

To examine the effects of mind-body relaxation techniques for pain management in labour on maternal and neonatal well-being during and after labour.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (9 May 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 5 2017), MEDLINE (1966 to 24 May 2017), CINAHL (1980 to 24 May 2017), the Australian New Zealand Clinical Trials Registry (18 May 2017), ClinicalTrials.gov (18 May 2017), the ISRCTN Register (18 May 2017), the WHO International Clinical Trials Registry Platform (ICTRP) (18 May 2017), and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (including quasi randomised and cluster trials) comparing relaxation methods with standard care, no treatment, other non-pharmacological forms of pain management in labour or placebo.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We attempted to contact study authors for additional information. We assessed evidence quality with GRADE methodology.

MAIN RESULTS

This review update includes 19 studies (2519 women), 15 of which (1731 women) contribute data. Interventions examined included relaxation, yoga, music and mindfulness. Approximately half of the studies had a low risk of bias for random sequence generation and attrition bias. The majority of studies had a high risk of bias for performance and detection bias, and unclear risk of bias for, allocation concealment, reporting bias and other bias. We assessed the evidence from these studies as ranging from low to very low quality, and therefore the effects below should be interpreted with caution.RelaxationWe found that relaxation compared to usual care provided lowered the intensity of pain (measured on a scale of 0 to 10 with low scores indicating less pain) during the latent phase of labour (mean difference (MD) -1.25, 95% confidence interval (CI) -1.97 to -0.53, one trial, 40 women). Four trials reported pain intensity in the active phase; there was high heterogeneity between trials and very low-quality evidence suggested that there was no strong evidence that the effects were any different between groups for this outcome (MD -1.08, 95% CI -2.57 to 0.41, four trials, 271 women, random-effects analysis). Very low-quality evidence showed that women receiving relaxation reported greater satisfaction with pain relief during labour (risk ratio (RR) 8.00, 95% CI 1.10 to 58.19, one trial, 40 women), and showed no clear benefit for satisfaction with childbirth experience (assessed using different scales) (standard mean difference (SMD) -0.03, 95% CI -0.37 to 0.31, three trials, 1176 women). For safety outcomes there was very low-quality evidence of no clear reduction in assisted vaginal birth (average RR 0.61, 95% CI 0.20 to 1.84, four trials, 1122 women) or in caesarean section rates (average RR 0.73, 95% CI 0.26 to 2.01, four trials, 1122 women). Sense of control in labour, and breastfeeding were not reported under this comparison.YogaWhen comparing yoga to control interventions there was low-quality evidence that yoga lowered pain intensity (measured on a scale of 0 to 10) with low scores indicating less pain) (MD -6.12, 95% CI -11.77 to -0.47, one trial, 66 women), greater satisfaction with pain relief (MD 7.88, 95% CI 1.51 to 14.25, one trial, 66 women) and greater satisfaction with childbirth experience (MD 6.34, 95% CI 0.26 to 12.42 one trial, 66 women (assessed using the Maternal Comfort Scale with higher score indicating greater comfort). Sense of control in labour, breastfeeding, assisted vaginal birth, and caesarean section were not reported under this comparison.MusicWhen comparing music to control interventions there was evidence of lower pain intensity in the latent phase for women receiving music (measured on a scale of 0 to 10 with low scores indicating less pain) (MD -0.73, 95% CI -1.01 to -0.45, random-effects analysis, two trials, 192 women) and very low-quality evidence of no clear benefit in the active phase (MD -0.51, 95% CI -1.10 to 0.07, three trials, 217 women). Very low-quality evidence suggested no clear benefit in terms of reducing assisted vaginal birth (RR 0.41, 95% CI 0.08 to 2.05, one trial, 156 women) or caesarean section rate (RR 0.78, 95% CI 0.36 to 1.70, two trials, 216 women). Satisfaction with pain relief, sense of control in labour, satisfaction with childbirth experience, and breastfeeding were not reported under this comparison.Audio analgesiaOne trial evaluating audio analgesia versus control only reported one outcome and showed no evidence of benefit in satisfaction with pain relief.MindfulnessOne trial evaluating mindfulness versus usual care found an increase in sense of control for the mindfulness group (using the Childbirth Self-Efficacy Inventory) (MD 31.30, 95% CI 1.61 to 60.99, 26 women). There is no strong evidence that the effects were any different between groups for satisfaction in childbirth, or for caesarean section rate, need for assisted vaginal delivery or need for pharmacological pain relief. No other outcomes were reported in this trial.

AUTHORS' CONCLUSIONS

Relaxation, yoga and music may have a role with reducing pain, and increasing satisfaction with pain relief, although the quality of evidence varies between very low to low. There was insufficient evidence for the role of mindfulness and audio-analgesia. The majority of trials did not report on the safety of the interventions. Further randomised controlled trials of relaxation modalities for pain management in labour are needed. Trials should be adequately powered and include clinically relevant outcomes such as those described in this review.

[Pain therapy during labour]

To date the gold standard of treating labour pain is regional analgesia by application of epidural analgesia. When offering epidural analgesia, the programmed intermittent epidural bolus (PIEB) is more effective in terms of pain reduction, less motor blocks and higher satisfaction of the parturient compared to continuous application via perfusor pump. An upcoming alternative to epidural analgesia is remifentanil, a short acting and potent opioid. Remifentanil, however, requires haemodynamic monitoring as cardiac and respiratory impairment has been described. Nitrous oxide has been used for decades in the Anglosphere but it is a greenhouse gas, and interactions with Vitamin B₁₂ are possible. Using novel extraction systems, nitrous oxide has become more attractive for treatment of the initial phase of labour pain in Central Europe. In order to provide the parturient with the best possible and with a tailored pain concept an interdisciplinary approach with obstetricians, midwives and anaesthesiologists is required.

Hypnosis for pain management during labour and childbirth

BACKGROUND

This review is one in a series of Cochrane Reviews investigating pain management for childbirth. These reviews all contribute to an overview of systematic reviews of pain management for women in labour, and share a generic protocol. We examined the current evidence regarding the use of hypnosis for pain management during labour and childbirth. This review updates the findings regarding hypnosis from an earlier review of complementary and alternative therapies for pain management in labour into a stand-alone review.

OBJECTIVES

To examine the effectiveness and safety of hypnosis for pain management during labour and childbirth.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (11 January 2012) and the reference lists of primary studies and review articles.

SELECTION CRITERIA

Randomised controlled trials and quasi-randomised controlled trials comparing preparation for labour using hypnosis and/or use of hypnosis during labour, with or without concurrent use of pharmacological or non-pharmacological pain relief methods versus placebo, no treatment or any analgesic drug or technique.

DATA COLLECTION AND ANALYSIS

Two assessors independently extracted data and assessed trial quality. Where possible we contacted study authors seeking additional information about data and methodology.

MAIN RESULTS

We included seven trials randomising a total of 1213 women. All but one of the trials were at moderate to high risk of bias. Although six of the seven trials assessed antenatal hypnotherapy, there were considerable differences between these trials in timing and technique. One trial provided hypnotherapy during labour. No significant differences between women in the hypnosis group and those in the control group were found for the primary outcomes: use of pharmacological pain relief (average risk ratio (RR) 0.63, 95% confidence interval (CI) 0.39 to 1.01, six studies, 1032 women), spontaneous vaginal birth (average RR 1.35, 95% CI 0.93 to 1.96, four studies, 472 women) or satisfaction with pain relief (RR 1.06, 95% CI 0.94 to 1.20, one study, 264 women). There was significant statistical heterogeneity in the data for use of pharmacological pain relief and spontaneous vaginal birth. The primary outcome of sense of coping with labour was reported in two studies as showing no beneficial effect (no usable data available for this review).  For secondary outcomes, no significant differences were identified between women in the hypnosis group and women in the control group for most outcomes where data were available. For example, there was no significant difference for satisfaction with the childbirth experience (average RR 1.36, 95% CI 0.52 to 3.59, two studies, 370 women), admissions to the neonatal intensive care unit (average RR 0.58, 95% CI 0.12 to 2.89, two studies, 347 women) or breastfeeding at discharge from hospital (RR 1.00, 95% CI 0.97 to 1.03, one study, 304 women). There was some evidence of benefits for women in the hypnosis group compared with the control group for pain intensity, length of labour and maternal hospital stay, although these findings were based on single studies with small numbers of women. Pain intensity was found to be lower for women in the hypnosis group than those in the control group in one trial of 60 women (mean difference (MD) -0.70, 95% CI -1.03 to -0.37). The same study found that the average length of labour from 5 cm dilation to birth (minutes) was significantly shorter for women in the hypnosis group (mean difference -165.20, 95% CI -223.53 to -106.87, one study, 60 women). Another study found that a smaller proportion of women in the hypnosis group stayed in hospital for more than two days after the birth compared with women in the control group (RR 0.11, 95% CI 0.02 to 0.83, one study, 42 women).

AUTHORS' CONCLUSIONS

There are still only a small number of studies assessing the use of hypnosis for labour and childbirth. Although the intervention shows some promise, further research is needed before recommendations can be made regarding its clinical usefulness for pain management in maternity care.

Non-opioid drugs for pain management in labour

BACKGROUND

Labour is a normal physiological process, but is usually associated with pain and discomfort. Numerous methods are used to relieve labour pain. These include pharmacological (e.g. epidural, opioids, inhaled analgesia) and non-pharmacological (e.g. hypnosis, acupuncture) methods of pain management. Non-opioid drugs are a pharmacological method used to control mild to moderate pain.

OBJECTIVES

To summarise the evidence regarding the effects and safety of the use of non-opioid drugs to relieve pain in labour.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (15 February 2012).

SELECTION CRITERIA

Randomised controlled trials (RCTs) using non-opioid drugs (non-steroidal anti-inflammatory drugs (NSAIDs); paracetamol; antispasmodics; sedatives and antihistamines) in comparison with placebo or standard care; different forms of non-opioid drugs (e.g. sedatives versus antihistamines); or different interventions (e.g. non-opioids versus opioids) for women in labour. Quasi-RCTs and trials using a cross-over design were not included. Cluster-randomised RCTs were eligible for inclusion but none were identified for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed for inclusion all studies identified by the search strategy, carried out data extraction and assessed risk of bias. We resolved any disagreement through discussion with a third author. Data were checked for accuracy.

MAIN RESULTS

Nineteen studies randomising a total of 2863 women were included in this review. There were three main comparison groups: 15 studies compared non-opioid drugs with placebo or no treatment (2133 women); three studies compared non-opioid drugs with opioids (563 women); and three studies compared one type of non-opioid drug with a different type or dose of non-opioid drug (590 women). Some of the studies included three or more groups and so have been put in more than one comparison. Overall, there was little difference between groups for most of the comparisons. Any differences observed for outcomes were mainly limited to one or two studies. Non-opioid drugs (sedatives) were found to offer better pain relief (mean difference (MD) -22.00; 95% confidence interval (CI) -35.86 to -8.14, one trial, 50 women), better satisfaction with pain relief (sedatives and antihistamines) (risk ratio (RR) 1.59; 95% CI 1.15 to 2.21, two trials, 204 women; RR 1.80; 95% CI 1.16 to 2.79, one trial, 223 women) and better satisfaction with the childbirth experience (RR 2.16; 95% CI 1.34 to 3.47, one trial, 40 women) when compared with placebo or no treatment. However, women having non-opioid drugs (NSAIDs or antihistamines) were less likely to be satisfied with pain relief compared with women having opioids (RR 0.50; 95% CI 0.27 to 0.94, one trial, 76 women; RR 0.73; 95% CI 0.54 to 0.98, one trial, 223 women). Women receiving the antihistamine hydroxyzine were more likely to express satisfaction with pain relief compared with the antihistamine promethazine (RR 1.21; 95% CI 1.02 to 1.43, one trial, 289 women). Women receiving sedatives were more likely to express satisfaction with pain relief compared with antihistamines (RR 1.52; 95% CI 1.06 to 2.17, one study, 157 women). The majority of studies were conducted over 30 years ago. The studies were at unclear risk of bias for most of the quality domains.Opioids appear to be superior to non-opioids in satisfaction with pain relief, while non-opioids appear to be superior to placebo for pain relief and satisfaction with the childbirth experience. There were little data and no evidence of a significant difference for any of the comparisons of non-opioids for safety outcomes. 

AUTHORS' CONCLUSIONS

Overall, the findings of this review demonstrated insufficient evidence to support a role for non-opioid drugs on their own to manage pain during labour.

Local anaesthetic nerve block for pain management in labour

BACKGROUND

Local anaesthetic nerve block is an important modality for pain management in labour. Pudendal and paracervical block (PCB) are most commonly performed local anaesthetic nerve blocks which have been used for decades.

OBJECTIVES

To establish the efficacy and safety of local anaesthetic nerve blocks for pain relief in labour.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 February 2012).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) assessing pain management in labour with the use of local anaesthetic nerve blocks. We did not include results from quasi-RCTs.

DATA COLLECTION AND ANALYSIS

We designed a form to extract data. For eligible studies, two review authors extracted the data using the agreed form. We resolved discrepancies through discussion or, if required, we consulted a third person. We entered and analysed data using Review Manager software and checked for accuracy.

MAIN RESULTS

We found 41 trials for consideration of inclusion into this review. We included only 12 RCTs (1549 participants) of unclear quality. We excluded 29 studies (30 reports). The majority of excluded studies were not relevant to this review, and a few were not randomised.Local anaesthetic nerve block versus placebo or no treatment. We found that more women were satisfied with pain relief after local anaesthetic nerve block (in particular 2% lidocaine PCB) than after placebo (one study, 198 participants, risk ratio (RR) 32.31, 95% confidence interval (CI) 10.60 to 98.54). Local anaesthetic nerve block was associated with more side effects (one study, 200 participants, RR 29.0, 95% CI 1.75 to 479.61).Local anaesthetic nerve block (in particular, PCB) versus opioid Local anaesthetic nerve block (in particular, PCB) in comparison with opioid (in particular, intramuscular pethidine or fentanyl patient-controlled analgesia) was found to be more effective for pain relief (one study, 109 participants, RR 2.52, 95% CI 1.65 to 3.83) and was not associated with an increased rate of assisted vaginal birth (two studies, 129 participants, RR 1.02, 95% CI 0.56 to 1.87) or with an increased caesarean section rate (two studies, 129 participants, RR 0.23, 95% CI 0.03 to 1.87).Local anaesthetic nerve block versus non-opioid agents Satisfaction with pain relief and rate of caesarean sections were found to be the same in women receiving local anaesthetic nerve block and non-opioid agents (one study, 100 participants, RR 1.11, 95% CI 0.67 to 1.84; RR 2.0, 95% CI 0.19 to 21.36, respectively). More women who received non-opioid agent in comparison with women who received local anaesthetic nerve block required additional interventions for pain relief (one study, 100 participants, RR 0.06, 95% CI 0.02 to 0.25).Local anaesthetic nerve block using different anaesthetic agents There was no difference in pain relief satisfaction, assisted vaginal birth, caesarean section, side effects for mother, Apgar score or admission to the neonatal intensive care unit between different anaesthetic agents, e.g. bupivacaine, carbocaine, lidocaine, chloroprocaine.

AUTHORS' CONCLUSIONS

Local anaesthetic nerve blocks are more effective than placebo, opioid and non-opioid analgesia for pain management in labour based on RCTs of unclear quality and limited numbers. Side effects are more common after local anaesthetic nerve blocks in comparison with placebo. Different local anaesthetic agents used for pain relief provide similar satisfaction with pain relief. Further high-quality studies are needed to confirm the findings, to assess other outcomes and to compare local anaesthetic nerve blocks with various modalities for pain relief in labour.

Massage, reflexology and other manual methods for pain management in labour

BACKGROUND

Many women would like to avoid pharmacological or invasive methods of pain management in labour, and this may contribute towards the popularity of complementary methods of pain management. This review examined currently available evidence supporting the use of manual healing methods including massage and reflexology for pain management in labour.

OBJECTIVES

To examine the effects of manual healing methods including massage and reflexology for pain management in labour on maternal and perinatal morbidity.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2 of 4), MEDLINE (1966 to 30 June 2011), CINAHL (1980 to 30 June 2011), the Australian and New Zealand Clinical Trial Registry (30 June 2011), Chinese Clinical Trial Register (30 June 2011), Current Controlled Trials (30 June 2011), ClinicalTrials.gov, (30 June 2011) ISRCTN Register (30 June 2011), National Centre for Complementary and Alternative Medicine (NCCAM) (30 June 2011) and the WHO International Clinical Trials Registry Platform (30 June 2011).

SELECTION CRITERIA

Randomised controlled trials comparing manual healing methods with standard care, no treatment, other non-pharmacological forms of pain management in labour or placebo.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We attempted to contact study authors for additional information.

MAIN RESULTS

We included six trials, with data reporting on five trials and 326 women in the meta-analysis. We found trials for massage only. Less pain during labour was reported from massage compared with usual care during the first stage of labour (standardised mean difference (SMD) -0.82, 95% confidence interval (CI) -1.17 to -0.47), four trials, 225 women), and labour pain was reduced in one trial of massage compared with music (risk ratio (RR) 0.40, 95% CI 0.18 to 0.89, 101 women). One trial of massage compared with usual care found reduced anxiety during the first stage of labour (MD -16.27, 95% CI -27.03 to -5.51, 60 women). No trial was assessed as being at a low risk of bias for all quality domains.

AUTHORS' CONCLUSIONS

Massage may have a role in reducing pain, and improving women's emotional experience of labour. However, there is a need for further research.

Intracutaneous or subcutaneous sterile water injection compared with blinded controls for pain management in labour

BACKGROUND

Intracutaneous or subcutaneous injection of sterile water is rapidly gaining popularity as a method of pain relief in labour and it is therefore essential that it is properly evaluated. Adequate analgesia in labour is important to women worldwide. Sterile water injection is inexpensive, requires basic equipment, and appears to have few side effects. It is purported to work for labour pain.

OBJECTIVES

To determine the efficacy of sterile water injections for relief of pain (both typical contraction pain and intractable back pain) during labour compared to placebo (isotonic saline injections) or non-pharmacological interventions, and to identify any relevant effects on mode and timing of delivery, or safety of both mother and baby.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 May 2011), MEDLINE, and EMBASE (January 2010 to 30 May 2011), together with reference lists in retrieved studies and review articles.

SELECTION CRITERIA

We included randomised, double blind, controlled studies using intracutaneous or subcutaneous sterile water injections for pain relief during labour. There were no restrictions on birth place, parity, risk, age, weight, gestation, or stage of labour. Potential comparators were placebo (saline) and non-pharmacological interventions (e.g. hypnosis or biofeedback).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility and quality of trials, and extracted data. We resolved any disagreements or uncertainties by discussion with a third review author. Primary outcome measures were at least 50% pain relief, or at least 30%, pain relief, patient global impression of change of at least 'good', mode of delivery, perinatal morbidity and mortality, maternal complications and adverse events. Secondary outcomes were women with any pain relief, use of rescue analgesia, and treatment group average pain relief. We made explicit judgements about potential biases in the studies.

MAIN RESULTS

We included seven studies, with 766 participants: four used intracutaneous injections, two subcutaneous, and one both. All reported on low back pain in labour only. Methodological quality was good, but four studies were at high risk of bias due to small size of treatment groups, incomplete outcome data, and performance bias.All studies reported treatment group mean or median scores, finding greater reduction in pain for sterile water. However, failure to demonstrate a normal distribution for pain intensity or relief, and use of different scales, meant meta-analysis was inappropriate. No study reported primary dichotomous efficacy outcomes. One reported the number self-scoring 4/10 cm or more reduction in pain; significantly more had this outcome with sterile water (50% to 60%) than with placebo (20% to 25%).There was no significant difference between sterile water and saline for rates of caesarean section (risk ratio (RR) 0.58, 95% confidence interval (CI) 0.33 to 1.02), instrumental delivery (RR 1.31, 95% CI 0.79 to 2.18), rescue analgesia (RR 0.86, 95% CI 0.44 to 1.69), timing of delivery, or Apgar scores. Two studies reported that more women treated with sterile water would request the same analgesia in future.No study reported on women's satisfaction with pain relief, women's sense of control in labour, women's satisfaction with the childbirth experience, mother/baby interaction, rates of breastfeeding, maternal morbidity, infant long-term outcomes, or cost. No adverse events were reported other than transient pain with injection, which was worse with sterile water.

AUTHORS' CONCLUSIONS

The outcomes reported severely limit conclusions for clinical practice. We found little robust evidence that sterile water is effective for low back or any other labour pain. Neither did we find any difference in delivery or other maternal or fetal outcomes. Further large, methodologically rigorous studies are required to determine the efficacy of sterile water to relieve pain in labour.

Relaxation techniques for pain management in labour

BACKGROUND

Many women would like to avoid pharmacological or invasive methods of pain management in labour and this may contribute towards the popularity of complementary methods of pain management. This review examined currently available evidence supporting the use of relaxation therapies for pain management in labour.

OBJECTIVES

To examine the effects of relaxation methods for pain management in labour on maternal and perinatal morbidity.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2010), The Cochrane Complementary Medicine Field's Trials Register (November 2011), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 4), MEDLINE (1966 to 30 November 2010), CINAHL (1980 to 30 November 2010), the Australian and New Zealand Clinical Trial Registry (30 November 2010), Chinese Clinical Trial Register (30 November 2010), Current Controlled Trials (30 November 2010), ClinicalTrials.gov, (30 November 2010) ISRCTN Register (30 November 2010), National Centre for Complementary and Alternative Medicine (NCCAM) (30 November 2010) and the WHO International Clinical Trials Registry Platform (30 November 2010).

SELECTION CRITERIA

Randomised controlled trials comparing relaxation methods with standard care, no treatment, other non-pharmacological forms of pain management in labour or placebo.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for inclusion and extracted data. Data were checked for accuracy. Two review authors independently assessed trial quality. We attempted to contact study authors for additional information.

MAIN RESULTS

We included 11 studies (1374 women) in the review. Relaxation was associated with a reduction in pain intensity during the latent phase (mean difference (MD) -1.25, 95% confidence interval (CI) -1.97 to -0.53, one trial, 40 women) and active phase of labour (MD -2.48, 95% CI -3.13 to 0.83, two trials, 74 women). There was evidence of improved outcomes from relaxation instruction with increased satisfaction with pain relief (risk ratio (RR) 8.00, 95% CI 1.10 to 58.19, one trial, 40 women) and lower assisted vaginal delivery (RR 0.07, 95% CI 0.01 to 0.50, two trials, 86 women). Yoga was associated with reduced pain (mean difference (MD) -6.12, 95% CI -11.77 to -0.47), one trial, 66 women), increased satisfaction with pain relief (MD 7.88, 95% CI 1.51 to 14.25, one trial, 66 women), satisfaction with the childbirth experience (MD) 6.34, 95% CI 0.26 to 12.42, one trial, 66 women), and reduced length of labour when compared to usual care (MD -139.91, 95% CI -252.50 to -27.32, one trial, 66 women) and when compared with supine position (MD -191.34, 95% CI -243.72 to -138.96, one trial, 83 women). Trials evaluating music and audio analgesia found no difference between groups in the primary outcomes pain intensity, satisfaction with pain relief, and caesarean delivery. The risk of bias was unclear for the majority of trials.

AUTHORS' CONCLUSIONS

Relaxation and yoga may have a role with reducing pain, increasing satisfaction with pain relief and reducing the rate of assisted vaginal delivery. There was insufficient evidence for the role of music and audio-analgesia. However, there is a need for further research.

Epidural versus non-epidural or no analgesia in labour

BACKGROUND

Epidural analgesia is a central nerve block technique achieved by injection of a local anaesthetic close to the nerves that transmit pain and is widely used as a form of pain relief in labour. However, there are concerns regarding unintended adverse effects on the mother and infant.

OBJECTIVES

To assess the effects of all modalities of epidural analgesia (including combined-spinal-epidural) on the mother and the baby, when compared with non-epidural or no pain relief during labour.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2011).

SELECTION CRITERIA

Randomised controlled trials comparing all modalities of epidural with any form of pain relief not involving regional blockade, or no pain relief in labour.

DATA COLLECTION AND ANALYSIS

Two of the review authors independently assessed trials for eligibility, methodological quality and extracted all data. We entered data into RevMan and double checked it for accuracy. Primary analysis was by intention to treat; we conducted subgroup and sensitivity analyses where substantial heterogeneity was evident.

MAIN RESULTS

We included 38 studies involving 9658 women; all but five studies compared epidural analgesia with opiates. Epidural analgesia was found to offer better pain relief (mean difference (MD) -3.36, 95% confidence interval (CI) -5.41 to -1.31, three trials, 1166 women); a reduction in the need for additional pain relief (risk ratio (RR) 0.05, 95% CI 0.02 to 0.17, 15 trials, 6019 women); a reduced risk of acidosis (RR 0.80, 95% CI 0.68 to 0.94, seven trials, 3643 women); and a reduced risk of naloxone administration (RR 0.15, 95% CI 0.10 to 0.23, 10 trials, 2645 women). However, epidural analgesia was associated with an increased risk of assisted vaginal birth (RR 1.42, 95% CI 1.28 to 1.57, 23 trials, 7935 women), maternal hypotension (RR 18.23, 95% CI 5.09 to 65.35, eight trials, 2789 women), motor-blockade (RR 31.67, 95% CI 4.33 to 231.51, three trials, 322 women), maternal fever (RR 3.34, 95% CI 2.63 to 4.23, six trials, 2741 women), urinary retention (RR 17.05, 95% CI 4.82 to 60.39, three trials, 283 women), longer second stage of labour (MD 13.66 minutes, 95% CI 6.67 to 20.66, 13 trials, 4233 women), oxytocin administration (RR 1.19, 95% CI 1.03 to 1.39, 13 trials, 5815 women) and an increased risk of caesarean section for fetal distress (RR 1.43, 95% CI 1.03 to 1.97, 11 trials, 4816 women). There was no evidence of a significant difference in the risk of caesarean section overall (RR 1.10, 95% CI 0.97 to 1.25, 27 trials, 8417 women), long-term backache (RR 0.96, 95% CI 0.86 to 1.07, three trials, 1806 women), Apgar score less than seven at five minutes (RR 0.80, 95% CI 0.54 to 1.20, 18 trials, 6898 women), and maternal satisfaction with pain relief (RR 1.31, 95% CI 0.84 to 2.05, seven trials, 2929 women). We found substantial heterogeneity for the following outcomes: pain relief; maternal satisfaction; need for additional means of pain relief; length of second stage of labour; and oxytocin augmentation. This could not be explained by subgroup or sensitivity analyses, where data allowed analysis. No studies reported on rare but potentially serious adverse effects of epidural analgesia.

AUTHORS' CONCLUSIONS

Epidural analgesia appears to be effective in reducing pain during labour. However, women who use this form of pain relief are at increased risk of having an instrumental delivery. Epidural analgesia had no statistically significant impact on the risk of caesarean section, maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores. Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes.