Cochrane for Clinicians
Putting Evidence into Practice
Complementary and Integrative Treatments for Pain Management in Labor
Am Fam Physician. 2019 Feb 1;99(3):154-156.
Author disclosure: No relevant financial affiliations.
Are complementary and integrative treatments such as massage, thermal interventions, and relaxation techniques effective and safe for managing pain during labor?
There is evidence that all of the studied interventions have some benefit in labor, but the evidence is of low to very low quality. Massage, thermal interventions (warm and cold packs), relaxation techniques, yoga, and music reduce pain during latent labor, but not during active labor.1,2 Thermal interventions and yoga shorten the duration of labor, with a mean difference (MD) of 66 minutes (95% confidence interval [CI], 40 to 92 minutes) for warm packs, 78 minutes (95% CI, 37 to 119 minutes) for cold or intermittent warm and cold packs, and 140 minutes (95% CI, 27 to 252 minutes) for yoga vs. usual care.1,2 Yoga improves satisfaction with pain relief (MD = –1.3 on a 10-point visual analog scale [VAS]; 95% CI, –0.5 to –1.7), and relaxation techniques increase the likelihood that patients will report high satisfaction with pain control (number needed to treat [NNT] = 3; 95% CI, 1 to 200).2 Massage also improved satisfaction with the labor experience (NNT = 3; 95% CI, 2 to 40).1 (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.)
Complementary therapies are popular for pain management in labor. In one study, 70% of patients reported using a nonmedical therapy for labor pain, with 50% of patients using at least two.3 Two recent Cochrane analyses were produced to discern whether these pain management techniques are safe and effective for use in labor.
The first Cochrane review described massage and manual therapies for pain management in labor, evaluating 10 trials involving 1,055 women.1 Trials were performed in various countries, with more than half conducted in Iran. Interventions were compared with usual care in all studies. Low-quality evidence from all 10 trials showed that massage moderately reduced pain during latent labor (NNT = 2; 95% CI, 1 to 3). Massage also mildly improved patients' sense of control in labor and satisfaction with childbirth (NNT = 3; 95% CI, 2 to 40). Very low-quality evidence from a single trial showed that thermal interventions with warm or cold packs reduced pain in latent labor (MD = –1.4 points on a 10-point VAS; 95% CI, –2.2 to –0.6). Thermal intervention also reduced labor duration by 66 minutes (95% CI, 40 to 92 minutes) for warm packs and 78 minutes (95% CI, 37 to 119 minutes) for cold or intermittent warm and cold packs. The primary quality limitation in all studies was due to lack of blinding and small trial sizes, which led to high heterogeneity in results. These therapies did not increase adverse outcomes compared with usual care.
Another recent Cochrane review studied relaxation techniques for pain management in labor, evaluating 15 studies involving 1,731 women.2 Instruction on relaxation mildly reduced latent labor pain (MD = –1.3 on VAS; 95% CI, –1.7 to –0.5) and led to higher satisfaction with pain relief (NNT = 3; 95% CI, 1 to 200). Yoga mildly reduced latent labor pain (MD = –0.6 on VAS; 95% CI, –1.2 to –0.1), and slightly improved satisfaction with pain relief (MD = 0.8 on VAS; 95% CI, 0.2 to 1.4) and childbirth (MD = 6 on maternal comfort scale with a range of 35 to 210; 95% CI, 0.3 to 12). Two small trials demonstrated that yoga also reduced the duration of labor by 140 minutes (95% CI, 27 to 252 minutes) when compared with usual care in one trial and by 191 minutes (95% CI, 139 to 244 minutes) when compared with supine positioning in another trial.
Mindfulness increased patients' sense of control during labor (MD = 31 on the Childbirth Self-Efficacy Inventory with a range of 0 to 150; 95% CI, 2 to 61) based on a small trial with very low-quality evidence. Music slightly reduced latent labor pain compared with usual care based on two trials (MD = –0.7 on 10-point VAS; 95% CI, –1.0 to –0.5) and during transition to active labor based on one trial (MD = –0.7 on 10-point VAS; 95% CI, –0.9 to –0.5). All evidence was low to very low quality, based primarily on lack of blinding and small sample sizes leading to high heterogeneity of results. There was no increase in adverse outcomes in patients treated with relaxation techniques compared with usual care.
Referencesshow all references
1. Smith CA, Levett KM, Collins CT, Dahlen HG, Ee CC, Suganuma M. Massage, reflexology and other manual methods for pain management in labour. Cochrane Database Syst Rev. 2018;(3):CD009290....
2. Smith CA, Levett KM, Collins CT, Armour M, Dahlen HG, Suganuma M. Relaxation techniques for pain management in labour. Cochrane Database Syst Rev. 2018;(3):CD009514.
3. Kozhimannil KB, Johnson PJ, Attanasio LB, Gjerdingen DK, McGovern PM. Use of nonmedical methods of labor induction and pain management among U.S. women. Birth. 2013;40(4):227–236.
4. Madden K, Middleton P, Cyna AM, Matthewson M, Jones L. Hypnosis for pain management during labour and childbirth. Cochrane Database Syst Rev. 2016;(5):CD009356.
5. Smith CA, Collins CT, Crowther CA, Levett KM. Acupuncture or acupressure for pain management in labour. Cochrane Database Syst Rev. 2011;(7):CD009232.
6. Intrapartum care for healthy women and babies. Clinical guideline no. 190. London, UK: National Institute for Health and Care Excellence (NICE); 2014.
7. Committee on Obstetric Practice, American College of Obstetricians and Gynecologists. Committee opinion no. 687. Approaches to limit intervention during labor and birth. Obstet Gynecol. 2017;129(2):e20–e28.
These are summaries of reviews from the Cochrane Library.
This series is coordinated by Corey D. Fogleman, MD, Assistant Medical Editor.
A collection of Cochrane for Clinicians published in AFP is available at https://www.aafp.org/afp/cochrane.
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