The efficacy of hypnosis as an intervention for labor and delivery pain: a comprehensive methodological review

The trends and hotspots of research on non-pharmacological interventions for labor pain management: a bibliometric analysis

INTRODUCTION

This study aimed to examine important points of focus, trends, and depth of research on non-pharmacological interventions for the management of labor pain worldwide from a macro perspective and present an extensive definition of research fields regarding non-pharmacological interventions.

METHODS

Bibliometric methods were used in this study. With comprehensive keyword lists, the Web of Science and PubMed databases were searched using different screening strategies for publications made until 25 February 2023.

RESULTS

Studies on non-pharmacological interventions in the management of labor pain have continued to develop since 2003 with great momentum. In this study, the most productive country in research on non-pharmacological interventions was found to be Iran, while Australia, the USA, China, and the United Kingdom were the most notable ones in terms of collaboration. The most prevalently studied non-pharmacological interventions were hydrotherapy and acupuncture. The results of the co-word analysis revealed 5 main themes about this field of research.

CONCLUSION

The results of this study showed that interest in studies on non-pharmacological interventions in the management of labor pain has increased, the quality of research in the field is high, international collaboration is increasingly higher, and technological approaches have started to emerge in relevant studies.

[HYPNOSTRESS study: Interest of medical hypnosis in the evaluation of perceived stress and the experience of hospitalization in an internal medicine department]

BACKGROUND

Patients with chronic illnesses, especially rare autoimmune and/or systemic diseases associated with significant diagnostic uncertainty, have a representation of their illness and a sometimes prolonged hospitalization experience that can be traumatic and anxiety-provoking.

OBJECTIVE

The aim of this study was to evaluate the impact of a non-medicinal medical hypnosis intervention in reducing the stress state and improving the experience of patients hospitalized in an internal medicine department.

METHODS

We conducted a prospective study of 24 patients hospitalized in the Internal Medicine Department of Lille University Hospital in 2023. Twelve patients received a non-drug medical hypnosis intervention known as the "place of safety" (case group) and were compared with 12 patients who did not (control group). Stress was assessed by the STAI questionnaire and hospitalization experience by a satisfaction questionnaire.

RESULTS

The 24 patients, 13 of whom were women, had a mean age of 55±17 years at inclusion. On admission to hospital, the median STAI-ETAT between the two groups was 43.5 (38.0; 56.6) in the case group versus 42.0 (37.0; 48.5) in the control group (P=0.45). In the case group, the median STAI-ETAT questionnaire taken immediately after the hypnosis session was significantly lower than at the start of hospitalization (30.0 [25.5; 36.5] vs. 43.5 [38.0; 56.5] P=0.003), indicating a significant reduction in stress. At the end of hospitalization, there was also a significant persistence of the median significant reduction between cases and controls (29.5 [26.5; 35.0] for cases vs. 41.5 [33.5; 45.5] for controls P=0.002). Experience of hospitalization was better in the case group (median 5.0 [4.5; 5.0] vs. 4.0 [4.0; 4.5], P=0.016).

CONCLUSION

This study suggests that medical hypnosis is a promising non-medicinal supportive intervention for reducing perceived stress and improving the experience of stress in patients hospitalized on an internal medicine ward.

Pain control and neonatal outcomes in 211 women under epidural anesthesia during childbirth at high altitude in Qinghai, China

Background

High altitudes are characterized by low-pressure oxygen deprivation. This is further exacerbated with increasing altitude. High altitudes can be associated with reduced oxygenation, which in turn, can affect labor, as well as maternal and fetal outcomes. Epidural anesthesia can significantly relieve labor pain. This study aimed to assess the effects of elevation gradient changes at high altitude on the analgesic effect of epidural anesthesia, labor duration, and neonatal outcomes.

Methods

We divided 211 women who received epidural anesthesia into groups according to varying elevation of their residence (76 in Xining City, mean altitude 2,200 m; 63 in Haibei Prefecture, mean altitude 3,655 m; and 72 in Yushu Prefecture, mean altitude 4,493 m). The analgesic effect was assessed using a visual analog scale (VAS). Labor duration was objectively recorded. The neonatal outcome was assessed using Apgar scores and fetal umbilical artery blood pH.

Results

VAS scores among the three groups did not differ significantly (p > 0.05). The neonatal Apgar scores in descending order were: Xining group > Haibei group > Yushu group (p < 0.05). The stage of labor was similar among the three groups (p > 0.05). Fetal umbilical artery blood pH in descending order were: Xining group > Haibei group > Yushu group (p < 0.05).

Conclusion

Elevation gradient changes in highland areas did not affect the efficacy of epidural anesthesia or labor duration. However, neonatal outcomes were affected.

Psychological impact of hypnosis for pregnancy and childbirth: A systematic review

BACKGROUND

The use of hypnosis as a complementary therapy in the perinatal field is expanding, however, there is little research for its impact on perinatal mental health. Here, we review studies that evaluate the effect of hypnosis on women's mental health and subjective experiences.

METHODS

A systematic review was conducted according to the PRISMA protocol for articles with experimental designs of hypnosis that measured their impact on several psychological variables, such as the presence of symptoms of anxiety, depression or fear of childbirth. Studies were evaluated according to the Critical Appraisal Skills Program Checklists (CASP), and analyzed for their designs and intervention themes.

RESULTS

Seven studies were included and six themes emerged: preparation for birth and unexpected events; change in the perception and experience of pain; pregnant body as a natural process; connection with the baby during pregnancy; development of inner resources; and progressive relaxation and guided imagery. Although results were partly mitigated, most studies found positive effects of hypnosis in alleviating anxiety, depression, and fear towards birth, empowering women with a higher sense of confidence and improving the overall emotional experience. Two studies also indicate encouraging outcomes in postnatal wellbeing.

CONCLUSION

While it is still argued as to what extent hypnosis has positive effects on physical aspects of labor, the empowerment and the increase in confidence associated with hypnosis seem to bring a significant contribution to a more positive subjective experience of pregnancy and childbirth, and on women's overall wellbeing in the perinatal period.

Beyond the epidural: Alternatives to neuraxial labor analgesia

Labor creates an intense pain experienced by women across the world. Although neuraxial analgesia is the most effective treatment of labor pain, in many cases, it may not be undesired, not available, or have contraindications. In addition, satisfaction with labor analgesia is not only determined by the efficacy of analgesia but a woman's sense of agency and involvement in the childbirth experience are also key contributors. Providing safe choices for labor analgesia and support is central to creating a tailored, safe, and effective analgesic treatment plan with high maternal satisfaction. Healthcare provider knowledge of various nonneuraxial analgesic options, including efficacy, contraindications, safe clinical implementation, and side effects of various techniques is needed for optimal patient care and satisfaction. Future rigorous scientific studies addressing all of these labor analgesia options are needed to improve our understanding. This review summarizes the current published literature for commonly available non-neuraxial labor analgesic options.

Implications on hypnotherapy: Neuroplasticity, epigenetics and pain

We provide a brief review about the significance of hypnosis with respect to applications and physiological processes in hypnotherapy. Our review concludes that hypnosis is a promising method to manage acute and chronic pain. In addition, we discuss indications pointing toward the view that hypnosis can induce changes in neuroplasticity possibly involving epigenetic mechanisms.

A Quasi-Experimental Study to Assess Hypnobirthing Educational Intervention on Labor Pain and Fear of Childbirth—The Case of Eskisehir/Turkey

PURPOSE

To determine the effectiveness of antenatal period hypnobirthing education for childbirth fear and labor pain management during labor.

STUDY DESIGN

A quasi-experimental methodological study to assess the education of hypnobirthing. Women were recruited from Eskişehir State Hospital Obstetrics and Gynecology Clinic in Turkey between 24 and 26 pregnancy weeks and July 1–September 1, 2016 and the hypnobirthing education was given 5 weeks in the antenatal period. Participants; 30 Turkish-speaking pregnant women. Following labor, questionnaires were completed in hospital by women in order to assess the mother and infant after birth and determine the effect of education first 24 hours after birth.

FINDINGS

It was determined that hypnobirthing knowledge scores after education of the participating pregnancies decreased significantly, Wijma Delivery Expectancy/Experience Questionnaire-Version B (WDEQ-B) scale score decreased significantly (p = 0.002). Participating laborers; (p = 0.448), but there was also no significant relationship between birth satisfaction scores (p = 0.540) and posttraining hypnobirthing information status scores and Visual Analogue Scale (VAS) scores.

MAIN CONCLUSION

Hypnobirthing training has an effect on fear of childbirth but has no effect on birth satisfaction and labor pain.

Hypnotherapy in management of delivery pain: a review

Hypnosis in obstetrics is available for more than one hundred years, but the development of inhalational anesthetic and chemotherapy agents and anesthesia drugs pending the 19th century induced the decrement of its application. However, experimental assessment of this type of intervention on labor and delivery in not high yet. For this reason, evaluation of hypnotic techniques in preparing childbirth should be carried out. One of the main unified mind-body healing practices, which has a great remedial potential in different applications of health care like labor and delivery. Assessment of effectiveness of this procedure in various administered trials is not easy, due to methodologic challenges, like normalizing trial conditions and picking up sufficient sizes of sample. Applying techniques of hypnosis for childbirth within hospital settings makes women to easily overcome barriers associated with institutional policies or caregiver resistance. Potential analgesic and anxiolytic clinical hypnosis effects for childbirth deserve more clinical trials. In this regard, nurses who manage women pending labor and delivery could easily enhance their skills and related understandings for contributing to techniques of hypnotherapy.

Hypnosis: A Psychodynamic Perspective

The relationship between hypnosis and psychoanalysis has always been complex, and often acrimonious. When Freud abandoned hypnosis as both the foundation of his theory building and his clinical intervention of choice, the two approaches and the theories associated with them have often seemed separated by enormous rifts, theoretical, clinical, and political. Yet throughout their considerable estrangement for over more than a century, each has much to offer to the other. In this contribution, I briefly review efforts by psychoanalysts to conceptualize and understand hypnosis, offer an introduction to the relatively new post-modern intersubjective approach to psychoanalysis, and demonstrates how the relational concepts associated with that perspective can be of significant help in preparing patients for hypnosis, and in crafting interventions geared to the dynamics of the individual patient, which enhance the likelihood of clinical success. Key relational elements are illustrated with clinical vignettes.

Effects of a Hypnotic Induction and an Unpleasantness-Focused Analgesia Suggestion on Pain Catastrophizing to an Experimental Heat Stimulus: A Preliminary Study

Pain catastrophizing is associated with greater levels of pain. While many studies support the efficacy of hypnosis for pain, the effect on pain catastrophizing remains unclear. The present study evaluated the effect of hypnosis on pain catastrophizing using experimental heat stimulation. Twenty-two pain patients engaged in 3 conditions: baseline (no suggestion), hypnotic induction, and hypnotic induction plus analgesia suggestion. Participants with higher baseline pain showed a significant reduction in rumination following hypnotic induction plus analgesia suggestion and significant reductions in pain due to both the hypnotic induction alone and the hypnotic induction plus analgesia suggestion. The findings suggest that unpleasantness-focused hypnotic analgesia reduces pain via its effect on the rumination component of pain catastrophizing.

The Influence of Nature Stimulus in Enhancing the Birth Experience

The physical environment is one of the factors that affect women's experience of labor. The basics of the childbirth process have not changed since the beginning of human existence; however, the environment in which women today give birth has changed significantly. Incorporating design elements and strategies that calm and reduce negative emotions may create positive experiences for women in labor. The purpose of this study was to examine the impact of one such strategy, namely, the presentation of images of nature, on the labor and delivery experience. The study findings showed that the experimental condition has a higher score on the Quality of Care From the Patient's Perspective (QPP) subscale. In addition, there was an increase in the QPP scores associated with the increase in Nature TV watching time, QPP mean of watching time (less than 1 hr) group, m = 4.5 and QPP mean of watching time (more than 3 hs), m = 4.8. The mean score for the heart rate was lower in the experimental condition, m = 84.60, than in the control one, m = 90.49. For Apgar, the mean score was higher for Group A, m = 8.65, and Group B, m = 8.92. These findings support the study hypothesis which states that the nature images would influence the labor experience positively. In addition, the findings emphasize the importance of incorporating nonpharmacological techniques in the labor and delivery room (LDR) units to sooth the pain. Adding nature imagery to the LDR environment can be one of these techniques.

Pain Relief Effect of Cryotherapy in Parturients

INTRODUCTION: Pain in childbirth and strategies for relieving it have been a subject of interest to researchers for many years. The use of cold (cryotherapy), as a pain relief technique generally, is quite well known and studied. However, few studies have addressed the use of cryotherapy as a strategy for relieving the pain of childbirth.

OBJECTIVE: To evaluate the effects of cryotherapy in relieving childbirth pain.

METHOD: Pilot intervention study using prospective data in a single intervention group, the outcome being the pain relief in women in labor. The sample comprised 36 parturients at the Hospital Maternidade Carmela Dutra, Rio de Janeiro, Brazil. Cryotherapy was applied to the parturients’ thoracolumbar region at cervical dilation of 5, 7, and/or 9 cm, using an icepack belt. In all, 48 applications were made. The responses regarding the action of cryotherapy on pain were recorded on a specific form. The Numeric Rating Scale (NRS) was used. Following a form, the parturients’ behavior during the application of cryotherapy was also observed.

RESULTS: It was found that 91.67% (outcome) of the women reported pain relief and better conditions in which to experience childbirth. The behavior of 75% of the women in labor was calm and participatory; some slept (5.56%), others took short naps (19.44%).

CONCLUSION: Cryotherapy proved effective in relieving pain in childbirth. Because characteristically, cryotherapy does not interfere in the physiological process of childbirth, it can be used in care for women in labor.

Unexpected consequences: women's experiences of a self-hypnosis intervention to help with pain relief during labour

Background

Self-hypnosis is becoming increasingly popular as a means of labour pain management. Previous studies have produced mixed results. There are very few data on women’s views and experiences of using hypnosis in this context. As part of a randomized controlled trial of self-hypnosis for intra-partum pain relief (the SHIP Trial) we conducted qualitative interviews with women randomized to the intervention arm to explore their views and experiences of using self-hypnosis during labour and birth.

Methods

Participants were randomly selected from the intervention arm of the study, which consisted of two antenatal self-hypnosis training sessions and a supporting CD that women were encouraged to listen to daily from 32 weeks gestation until the birth of their baby. Those who consented were interviewed in their own homes 8–12 weeks after birth. Following transcription, the interviews were analysed iteratively and emerging concepts were discussed amongst the authors to generate organizing themes. These were then used to develop a principal organizing metaphor or global theme, in a process known as thematic networks analysis.

Results

Of the 343 women in the intervention group, 48 were invited to interview, and 16 were interviewed over a 12 month period from February 2012 to January 2013.

Coding of the data and subsequent analysis revealed a global theme of ‘unexpected consequences’, supported by 5 organising themes, ‘calmness in a climate of fear’, ‘from sceptic to believer’, ‘finding my space’, ‘delays and disappointments’ and ‘personal preferences’. Most respondents reported positive experiences of self-hypnosis and highlighted feelings of calmness, confidence and empowerment. They found the intervention to be beneficial and used a range of novel strategies to personalize their self-hypnosis practice. Occasionally women reported feeling frustrated or disappointed when their relaxed state was misinterpreted by midwives on admission or when their labour and birth experiences did not match their expectations.

Conclusion

The women in this study generally appreciated antenatal self-hypnosis training and found it to be beneficial during labour and birth. The state of focused relaxation experienced by women using the technique needs to be recognized by providers if the intervention is to be implemented into the maternity service.

Mechanisms of hypnosis: toward the development of a biopsychosocial model

Evidence supports the efficacy of hypnotic treatments, but there remain many unresolved questions regarding how hypnosis produces its beneficial effects. Most theoretical models focus more or less on biological, psychological, and social factors. This scoping review summarizes the empirical findings regarding the associations between specific factors in each of these domains and response to hypnosis. The findings indicate that (a) no single factor appears primary, (b) different factors may contribute more or less to outcomes in different subsets of individuals or for different conditions, and (c) comprehensive models of hypnosis that incorporate factors from all 3 domains may ultimately prove to be more useful than more restrictive models that focus on just 1 or a very few factors.

Hypnoanalgesia and the study of pain experience: from Cajal to modern neuroscience

Santiago Ramón y Cajal (1852–1934) did not only contribute to neurobiology and neurohistology. At the end of the 19th century, he published one of the first clinical reports on the employment of hypnotic suggestion to induce analgesia (hypnoanalgesia) in order to relieve pain in childbirth. Today, the clinical application of hypnoanalgesia is considered an effective technique for the treatment of pain in medicine, dentistry, and psychology. However, the knowledge we have today on the neural and cognitive underpinnings of hypnotic suggestion has increased dramatically since Cajal’s times. Here we review the main contributions of Cajal to hypnoanalgesia and the current knowledge we have about hypnoanalgesia from neural and cognitive perspectives.

Hypnotherapy for labor and birth

Hypnotherapy is an integrative mind-body technique with therapeutic potential in various health care applications, including labor and birth. Evaluating the efficacy of this modality in controlled studies can be difficult, because of methodologic challenges, such as obtaining adequate sample sizes and standardizing experimental conditions. Women using hypnosis techniques for childbirth in hospital settings may face barriers related to caregiver resistance or institutional policies. The potential anxiolytic and analgesic effects of clinical hypnosis for childbirth merit further study. Nurses caring for women during labor and birth can increase their knowledge and skills with strategies for supporting hypnotherapeutic techniques.

An hypnotic suggestion: review of hypnosis for clinical emergency care

BACKGROUND

Hypnosis has been used in medicine for nearly 250 years. Yet, emergency clinicians rarely use it in emergency departments or prehospital settings.

OBJECTIVE

This review describes hypnosis, its historical use in medicine, several neurophysiologic studies of the procedure, its uses and potential uses in emergency care, and a simple technique for inducing hypnosis. It also discusses reasons why the technique has not been widely adopted, and suggests methods of increasing its use in emergency care, including some potential research areas.

DISCUSSION

A limited number of clinical studies and case reports suggest that hypnosis may be effective in a wide variety of conditions applicable to emergency medical care. These include providing analgesia for existing pain (e.g., fractures, burns, and lacerations), providing analgesia and sedation for painful procedures (e.g., needle sticks, laceration repair, and fracture and joint reductions), reducing acute anxiety, increasing children's cooperation for procedures, facilitating the diagnosis and treatment of acute psychiatric conditions, and providing analgesia and anxiolysis for obstetric/gynecologic problems.

CONCLUSIONS

Although it is safe, fast, and cost-effective, emergency clinicians rarely use hypnosis. This is due, in part, to the myths surrounding hypnosis and its association with alternative-complementary medicine. Genuine barriers to its increased clinical use include a lack of assured effectiveness and a lack of training and training requirements. Based on the results of further research, hypnosis could become a powerful and safe nonpharmacologic addition to the emergency clinician's armamentarium, with the potential to enhance patient care in emergency medicine, prehospital care, and remote medical settings.

Hypnosis before diagnostic or therapeutic medical procedures: a systematic review

The aim of this systematic review was to estimate the efficiency of hypnosis prior to medical procedures. Different databases were analyzed to identify randomized controlled trials (RCTs) comparing hypnosis to control interventions. All RCTs had to report pain or anxiety. Eighteen RCTs with a total of 968 patients were included; study size was from 20 to 200 patients (14 RCTs ≤ 60 patients). Fourteen RCTs included 830 adults and 4 RCTs included 138 children. Twelve of 18 RCTs had major quality limitations related to unclear allocation concealments, provider's experience in hypnosis, patient's adherence to hypnotic procedures, and intention-to-treat design. This systematic review observed major methodological limitations in RCTs on hypnosis prior to medical procedures.

Butorphanol in labour analgesia: A prospective cohort study

OBJECTIVE

Parenteral opioids can be administered with ease at a very low cost with high efficacy as labour analgesia. However, there are insufficient data available to accept the benefits of parenteral opioids over other proven methods of labour analgesia. Butorphanol, a new synthetic opioid, has emerged as a promising agent in terms of efficacy and a better safety profile. This study investigates the effect of butorphanol as a labour analgesia to gather further evidence of its safety and efficacy to pave the way for its widespread use in low resource settings.

MATERIAL AND METHODS

One hundred low risk term consenting pregnant women were recruited to take part in a prospective cohort study. Intramuscular injections of butorphanol tartrate 1 mg (Butrum 1/2mg, Aristo, Mumbai, India) were given in the active phase of labour and repeated two hourly. Pain relief was noted on a 10-point visual pain analogue scale (VPAS). Obstetric and neonatal outcome measures were mode of delivery, duration of labour, Apgar scores at 1 and 5 minutes and Neonatal Intensive Care Unit admissions. Collected data were analysed for statistically significant pain relief between pre- and post-administration VPAS scores and also for the incidence of adverse outcomes.

RESULTS

Pain started to decrease significantly within 15 minutes of administration and reached the nadir (3.08 SD0.51) at the end of two hours. The pain remained below four on the VPAS until the end of six hours and was still significantly low after eight hours. The incidence of adverse outcomes was low in the present study.

CONCLUSION

Butorphanol is an effective parenteral opioid analgesic which can be administered with reasonable safety for the mother and the neonate. The study has the drawback of lack of control and small sample size.

Nonpharmacologic labor analgesia

A supportive medical team should be well informed on the various pharmacologic and nonpharmacologic modalities of coping with or mitigating labor pain to appropriately support and respectfully care for parturients. Using the methodical rigor of previously published Cochrane systematic reviews, this summary evaluates and discusses the efficacy of nonpharmacologic labor analgesic interventions.

The influence of complementary and alternative medicine use in pregnancy on labor pain management choices: results from a nationally representative sample of 1,835 women

OBJECTIVES

This study examines involvement with a range of complementary and alternative medicine (CAM) during pregnancy on the use of pharmacologic (PPMT) and nonpharmacologic (NPMT) pain management techniques for labor and birth.

DESIGN

Longitudinal analysis of survey data.

PARTICIPANTS

A substudy (n=2445) of the "young" cohort of the nationally representative Australian Longitudinal Study on Women's Health was conducted.

OUTCOME MEASURES

Use of PPMT and NPMT during labor and birth.

RESULTS

The survey was completed by 1835 women (response rate, 79.2%). Most respondents used either intrapartum PPMT (81.9%) or NPMT (74.4%). Many (60.7%) used some form of CAM during pregnancy and also used PPMT during birth. More than two thirds of women (66.7%) who used NPMT used CAM during pregnancy. There was a general trend of increased likelihood of NPMT use by women who applied CAM during pregnancy. There was an inverse effect on use of epidural analgesia for women who consumed herbal teas during pregnancy (odds ratio, 0.60).

CONCLUSIONS

Because of the study design, this paper does not confirm a causative relationship between the use of CAM during pregnancy and intrapartum pain management choices. It does, however, indicate that the use of CAM during pregnancy may not significantly affect the uptake of intrapartum PPMT, despite possible attempts to reduce PPMT by using NPMT. It also highlights the possibility of potential interactions between CAM and PPMT, given the high prevalence of concomitant use.

Pain management for women in labour: an overview of systematic reviews

BACKGROUND

The pain that women experience during labour is affected by multiple physiological and psychosocial factors and its intensity can vary greatly.  Most women in labour require pain relief. Pain management strategies include non-pharmacological interventions (that aim to help women cope with pain in labour) and pharmacological interventions (that aim to relieve the pain of labour).

OBJECTIVES

To summarise the evidence from Cochrane systematic reviews on the efficacy and safety of non-pharmacological and pharmacological interventions to manage pain in labour. We considered findings from non-Cochrane systematic reviews if there was no relevant Cochrane review.

METHODS

We searched the Cochrane Database of Systematic Reviews (The Cochrane Library 2011, Issue 5), The Cochrane Database of Abstracts of Reviews of Effects (The Cochrane Library 2011, Issue 2 of 4), MEDLINE (1966 to 31 May 2011) and EMBASE (1974 to 31 May 2011) to identify all relevant systematic reviews of randomised controlled trials of pain management in labour. Each of the contributing Cochrane reviews (nine new, six updated) followed a generic protocol with 13 common primary efficacy and safety outcomes. Each Cochrane review included comparisons with placebo, standard care or with a different intervention according to a predefined hierarchy of interventions. Two review authors extracted data and assessed methodological quality, and data were checked by a third author. This overview is a narrative summary of the results obtained from individual reviews.

MAIN RESULTS

We identified 15 Cochrane reviews (255 included trials) and three non-Cochrane reviews (55 included trials) for inclusion within this overview. For all interventions, with available data, results are presented as comparisons of: 1. Intervention versus placebo or standard care; 2. Different forms of the same intervention (e.g. one opioid versus another opioid); 3. One type of intervention versus a different type of intervention (e.g. TENS versus opioid). Not all reviews included results for all comparisons. Most reviews compared the intervention with placebo or standard care, but with the exception of opioids and epidural analgesia, there were few direct comparisons between different forms of the same intervention, and even fewer comparisons between different interventions. Based on these three comparisons, we have categorised interventions into: " What works" ,"What may work", and "Insufficient evidence to make a judgement".WHAT WORKSEvidence suggests that epidural, combined spinal epidural (CSE) and inhaled analgesia effectively manage pain in labour, but may give rise to adverse effects. Epidural, and inhaled analgesia effectively relieve pain when compared with placebo or a different type of intervention (epidural versus opioids). Combined-spinal epidurals relieve pain more quickly than traditional or low dose epidurals. Women receiving inhaled analgesia were more likely to experience vomiting, nausea and dizziness.When compared with placebo or opioids, women receiving epidural analgesia had more instrumental vaginal births and caesarean sections for fetal distress, although there was no difference in the rates of caesarean section overall. Women receiving epidural analgesia were more likely to experience hypotension, motor blockade, fever or urinary retention. Less urinary retention was observed in women receiving CSE than in women receiving traditional epidurals. More women receiving CSE than low-dose epidural experienced pruritus.  WHAT MAY WORKThere is some evidence to suggest that immersion in water, relaxation, acupuncture, massage and local anaesthetic nerve blocks or non-opioid drugs may improve management of labour pain, with few adverse effects.  Evidence was mainly limited to single trials. These interventions relieved pain and improved satisfaction with pain relief (immersion, relaxation, acupuncture, local anaesthetic nerve blocks, non-opioids) and childbirth experience (immersion, relaxation, non-opioids) when compared with placebo or standard care. Relaxation was associated with fewer assisted vaginal births and acupuncture was associated with fewer assisted vaginal births and caesarean sections.INSUFFICIENT EVIDENCEThere is insufficient evidence to make judgements on whether or not hypnosis, biofeedback, sterile water injection, aromatherapy, TENS, or parenteral opioids are more effective than placebo or other interventions for pain management in labour. In comparison with other opioids more women receiving pethidine experienced adverse effects including drowsiness and nausea. 

AUTHORS' CONCLUSIONS

Most methods of non-pharmacological pain management are non-invasive and appear to be safe for mother and baby, however, their efficacy is unclear, due to limited high quality evidence. In many reviews, only one or two trials provided outcome data for analysis and the overall methodological quality of the trials was low. High quality trials are needed.There is more evidence to support the efficacy of pharmacological methods, but these have more adverse effects. Thus, epidural analgesia provides effective pain relief but at the cost of increased instrumental vaginal birth.It remains important to tailor methods used to each woman's wishes, needs and circumstances, such as anticipated duration of labour, the infant's condition, and any augmentation or induction of labour.A major challenge in compiling this overview, and the individual systematic reviews on which it is based, has been the variation in use of different process and outcome measures in different trials, particularly assessment of pain and its relief, and effects on the neonate after birth. This made it difficult to pool results from otherwise similar studies, and to derive conclusions from the totality of evidence. Other important outcomes have simply not been assessed in trials; thus, despite concerns for 30 years or more about the effects of maternal opioid administration during labour on subsequent neonatal behaviour and its influence on breastfeeding, only two out of 57 trials of opioids reported breastfeeding as an outcome. We therefore strongly recommend that the outcome measures, agreed through wide consultation for this project, are used in all future trials of methods of pain management.