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Nonpharmacological approaches to management of

Authors

Penny Simkin, PTMichael !lein, M",#P, #$$P, ##P,$%#P

Section Editor

harles & 'ockwood,M"

Last literature review version 1!"#September ()** + This topic last updat

$NT%&DU'T$&N- The manaement of labor pain isa maor oal of intrapartum care. There are two

eneral approaches: pharmacoloic andnonpharmacoloic. Pharmacoloic approaches aredirected at eliminatin the physical sensation of laborpain, whereas nonpharmacoloic approaches arelarely directed at prevention of sufferin. Sufferinmay be defined in terms of any of the followinpsycholoical elements: a perceived threat to thebody and/or psyche0 helplessness and loss of control0distress0 insufficient resources for copin with thedistressin situation0 fear of death of the mother orbaby 1*2. $lthouh pain and sufferin often occur

toether, one may suffer without pain or have painwithout sufferin.

The nonpharmacoloic approach to pain manaementincludes a wide variety of techni3ues that address notonly the physical sensations of pain, but also attemptto prevent sufferin by enhancin the psycho4
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emotional and spiritual components of care. 5n thisapproach, pain is perceived as a normalaccompaniment of most labors. The woman iseducated and assisted by her careivers, childbirtheducators, and support people to take an active role

in decision4makin and in usin self4comfortintechni3ues and nonpharmacoloic methods to relievepain. 6er careivers and support people also help herby providin reassurance, uidance, encouraement,and unconditional acceptance of her copin style. %ytakin an active role in decision4makin and receivinappropriate support, women are more likely to beable to transcend their pain and e7perience a sense ofmastery, control, and well4bein, factors associatedwith their ability to cope with labor 1*2.

$ systematic review of studies on women8se7pectations and e7periences of pain and pain reliefdurin labor and their involvement in the decision4makin process found a ap between theire7pectations and their actual e7periences 1(2. Theywere inade3uately prepared for the reality of laborpain and were unable to make informed choices aboutpain relief.

5n order to close this ap, women need information

prenatally about the risks and benefits of bothpharmacoloic and nonpharmacoloic methods ofpain manaement, and opportunities to practice innonpharmacoloic pain relief methods.

This topic will e7plore the variety ofnonpharmacoloic methods of manaement of paindurin labor and the evidence of their efficacy. Mostbirthin facilities offer at least some of thesetechni3ues0 however, some procedures, such asacupuncture, usually re3uire credentialin and may

not be available in all birth settins. Pharmacoloicmethods of pain relief are reviewed separately. 9SeePharmacoloic manaement of pain durin labor anddelivery.;

E(ALUAT$N) T*E &UT'&+E &,N&N-*A%+A'&L&)$' -A$N %EL$E,

+ET*&DS-


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manaement of labor pain can be combined or usedse3uentially to increase their effectiveness. 6owever,data reardin the safety and efficacy of theseinterventions are limited since few randomi=ed trialshave been performed and most studies enrolled a

small number of subects, had wide variations inpatient populations or study desin, and hadmethodoloical flaws 12.

Most studies of nonpharmacoloical approaches tolabor pain used either the woman>s ratin of her painor her use of pain medications as outcome measures0however, these measures can be misleadin. #ore7ample, if a woman rates her pain as severe, oneshould not assume that she cannot cope with it orthat she is overwhelmed by it. Most women who usenonpharmacoloical methods of pain relief e7pressedsatisfaction with these methods and desired to usethem in subse3uent prenancies, despitee7periencin pain durin labor. This suests thatwomen see value in these methods that are not fullyappreciated in studies that merely determine painscores.

The use of pharmacoloical analesia, representin afailure of nonpharmacoloical approaches, as an

outcome also may be misleadin, as it may reflect theusual care practices of the hospital. 5n hospitalswhere most women receive epidural analesia, thestaff may be unfamiliar with nonpharmacoloicalmethods of labor support and labor pain reduction,and the facilities and policies may not support thesemeasures. $nother way to measure the effect ofnonpharmacoloical methods is to record when inlabor the woman receives medication, asnonpharmacoloical methods may delay the use ofpharmacoloical analesia and avoid some

undesirable duration4related side effects ofmedication, such as maternal fever. 9See5ntrapartum fever, section on 8#etal/


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individual or roup classes desined to informprenant women and their partners about labor andbirth, common clinical care practices, earlyparenthood, and infant feedin. These classes coverpain control, includin self4help measures. 9See

Preparation for labor and childbirth.;

5nterpretation of observational studies on the effectsof antenatal education on labor pain and use ofmedication in labor is limited by selection bias9women who take these classes tend to be hihlymotivated and educated; and lack of appropriatecontrols. "ata from randomi=ed trials are sparse:

? $ sinle randomi=ed trial randomly assined **@

women to receive nine hours of antenatal childbirthtrainin or no formali=ed trainin 1A2. The traininconsisted of lectures on, and discussion of, laboronset, the birth process, the support person, painrelief, birth interventions, fear of childbirth, and a filmon ivin birth. Bomen who received trainin weresinificantly less likely to undero epidural analesiadurin labor 9CC ).DA, @EF 5 ).G4).@G;, but werenot less likely to re3uest pain medication. Thefre3uency of medical interventions and the women8s

self4reported assessments of their birth e7perienceswere similar for both roups.

The content of childbirth education is likely toinfluence the benefits derived by e7pectant parents.5n addition to the usual rhythmic breathintechni3ues 9see 8Cela7ation and breathin8 below;,the followin concepts from behavioral medicine meritevaluation 1E2:

? 5ncrease the rane of copin strateies, in particularby includin conitively4based strateies.

? 6elp women identify and understand the nature oftheir own copin styles and preferences, includinany unhelpful beliefs about, and reactions to, patternsof pain.

? 6elp women develop their own copin strateies for
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labor, based on past copin e7periences or throuhpreferences identified in class.

? Strenthen feelins of copin self4efficacy by practicein class and reinforcement by the class teacher.

%ELA/AT$&N AND .%EAT*$N)- Most childbirtheducation classes and most books on childbirthpresent rela7ation techni3ues, alon with a variety ofrhythmic breathin patterns intended to complementand promote rela7ation or to provide distraction fromlabor pain. These techni3ues are also used toenhance a woman8s sense of control 1H,G2. Thethorouhness of the teachin alon with the amountof time devoted to rehearsin these techni3ues varywidely, from a 3uick mention or demonstration, torepeated practice and adaptation to the individuals8preferences, desined with the oals of enhancinmastery and confidence. Cela7ation and breathintechni3ues have not been studied as independentvariables in randomi=ed trials.

$ survey of women in the Inited States who avebirth in ())E found that A@ percent of therespondents used breathin techni3ues, and of those,GG percent rated them as very or somewhathelpful, while (( percent rated them as not very

helpful or not helpful at all 1D2. This findin mayreflect differences in the 3uality of the teachinreceived by the women, or indicate that breathintechni3ues are not helpful for everyone. $ survey of%ritish women found that DD percent of women whoreported usin rela7ation techni3ues found them tobe ood or very ood 1@2.

There are no known drawbacks to the use of properlyperformed rela7ation and breathin techni3ues,e7cept that women sometimes e7pect more pain

relief from them than they actually receive durinlabor, and then e7press disappointment. Properperformance includes rhythmic breathin durincontractions, while releasin tension on thee7halations. %ein able to do this withouthyperventilatin, at both a slow pace 9H to *( breathsper minute; and at a moderately fast pace 9) to H)
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breaths per minute;, allows the woman to adapt herbreathin pattern to the intensity of the contractions.

Chythmic breathin may contribute more to awoman8s ability to cope with labor pain than to

actually reducin that pain. 5ncorporatin rela7ationwith rhythmic breathin helps avoid tension and itspain4aumentin effects 1*),**2. The continued hihsatisfaction with breathin techni3ues e7pressed bythe maority of surveyed women ustifies theircontinued inclusion in childbirth classes andencouraement of their use by maternity staff.

.$%T* EN($%&N+ENT- The ideal birthenvironment for a nonpharmacoloic approach to painmanaement is comfortable and private, and provides

places to walk, bathe, and rest. This settin may beavailable in a conventional labor and delivery unit,and is usually available in birth centers. 9See %irthcenters.;

? $ systematic review of randomi=ed trials of hospital4based alternative birth settins versus conventionalhospital labor and delivery units found that home4likesettins increased the likelihood that the womanwould not use intrapartum analesia/anesthesia 9CC*.*G, @EF 5 *.)*4 *.E0 five trials, n J GDA(;, andthat she would have a spontaneous vainal birth 9CC*.)A, @EF 5 *.)(4*.)H0 eiht trials, n J *),(*D;, bebreastfeedin at si7 to eiht weeks 9CC *.)A, @EF 5*.)(4*.)H0 one trial, n J **AG; and have a verypositive view of her care 9CC *.@H, @EF 5 *.GD4(.*E0 two trials, n J *()G; 1*(2. The alternative birthsettin was also associated with sinificantly lowerrates of obstetrical interventions 9epidural analesia,o7ytocin aumentation, episiotomy;. There were no

sinificant effects on serious perinatal or maternalmorbidity/mortality, other adverse neonataloutcomes, or postpartum hemorrhae. $ limitation ofthese findins is that women willin to participate insuch trials may not be representative of mostlaborin women.
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'&NT$NU&US LA.&% SU--&%T- The termcontinuous labor support refers to the use of a trainedcompanion to provide nonmedical care of the laborinwoman throuhout labor and birth 9usually with adoula;. $ nurturin, supportive companion durin

labor, who is neither a family member/close friend ofthe laborin woman, nor a member of the hospitalstaff, can help the woman cope with pain and an7ietyand improve obstetrical outcomes 1*2. This topic isdiscussed in detail separately. 9See ontinuousintrapartum support.;

+ATE%NAL +&(E+ENT AND-&S$T$&N$N)- 'aborin women have alwayswalked, moved, and chaned positions to makethemselves more comfortable 1*A4*G2. Pelvicdimensions vary with differences in maternalpositions, thus these chanes may help to amelioratelabor pain 1*D2. %esides these self4initiated comfort4seekin movements, careivers often suest specificpositions to accelerate labor proress or correct afetal or maternal problem 9e, fetal heart ratedecelerations or malposition, maternal hypotension;.

$ national survey of childbearin e7periences in theInited States in ())E reported that GH percent of

women did not walk around after admission to thehospital 1D2. This percentae was slihtly hiher thanin a similar survey conducted three years earlier 1*@2.$t that time, the most common reason women avefor not walkin was that they were connected tothins 9HG percent;, unable to support self due topain medication 9( percent;, and told not to walkaround 9(D percent;.


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? $t least *H controlled trials of positionin durin thefirst stae of labor have been performed in healthywomen at term 1(),(*2. Kiht of these trials usedeach woman as her own control by havin her take

one specified position for *E to ) minutes, and thenhavin her alternate to another position for the samelenth of time. 5n seven of the eiht trials, womenwere asked to alternate positions several times oruntil complete dilation0 in one, they took eachposition only once 1(*2. Positions evaluated includedsittin, standin, or walkin compared to supine orlyin on the side0 restin on hands and kneescompared to supine or lyin on the side0 as well assome other combinations. The women8s pain andproress were assessed in each position.Bomenreported less pain while standin than sittin, andless pain sittin than bein supine, which wasconsistently the least comfortable position. Bhencomparin sittin with lyin on the side, womenreported less pain with sittin until H cm, then withlyin on the side throuh *) cm. Other comparisonsrevealed few differences in pain indicators. Standinand side4lyin positions were accompanied by moreproress than sittin or supine positions.Si7 trialscompared two roups: an e7perimental roup, which

was encouraed to remain upriht 9sit up, stand, orwalk; durin the first stae, and a control roup,which remained lyin on the side or supine 1()2.K7cept for one trial, the upriht women were allowedto lie down if they wished. Of these si7 trials, threereported decreased pain in upriht positions, twofound no difference, and one 9in which women wereforced to remain upriht throuhout the first stae;observed increased pain. One trial assessedsatisfaction with the option of walkin, which was

very hih in the upriht roup.%irth ball - The %irth %all for movement and painrelief in labor is a lare inflated e7ercise ball that hasbeen adopted into maternity care to aid rela7ationand movement 1**,((2. The woman can sit on or leanaainst the ball, which provides soft support. The ballalso e7pands the number of positions the woman can
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assume for comfort and offers a means for movement9e, bouncin, rollin; in these positions, whichprovides a counter4distraction durin contractions.Many hospitals have birth balls in their maternitydepartments and encourae laborin women to use

them for comfort.

? One randomi=ed trial that compared pain 9measuredby Lisual $naloue Scale, Lerbal Cesponse Scale, andthe Present Pain 5ntensity Scale; and self4efficacy9measured with the hildbirth Self4Kfficacy 5nventory;in AD laborin women who used a lare e7ercise ball9birth ball; for comfort and movement versus @women who received usual care found that birth ballusers e7hibited statistically sinificant improvementsin childbirth self4efficacy and pain at both A and D cm1(2. The women in the e7perimental roup hadpracticed with the birth ball antepartum. "urin labor,they spent more time in an upriht position, hadshorter first staes, and felt reater satisfaction withtheir partners> participation than women in the usualcare roup. Cesults of the Sobel test to measure themediated effect of the prenatal birth ball e7ercises onchildbirth pain indicated that havin done thee7ercises prenatally led to feelins of self4efficacy

9confidence in their ability to cope with childbirthpain; 1(A2.? $ second trial randomly assined H) nulliparas to use

or not use a birth ball durin labor 1(A2. The birth ballroup had no prior instruction in the use of the birthball, and was instructed to sit in the ball for )minutes, rockin back and forth or in a circle for )minutes. The control roup received routine care,which consisted of reclinin in bed. Pain wasmeasured by a visual analoue scale. Pain scores inthe birth ball roup were sinificantly lower at ), H),and @) minutes. There were no differences in thecontractions or duration of active labor between thetwo roups.

Second stae of labor - Bomen should beencouraed to ive birth in the position they findmost comfortable 1(E,(H2.


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harm associated with the upriht position0 some trialshave reported that women have more pain in thesupine or sittin position.

? $ systematic review of trials comparin the routineuse of the supine position to other positions durinthe second stae of labor found that womene7perienced more severe pain in the supine positionand had a preference for other birthin positions1(E2. "ata from the nine randomi=ed trials and onecohort study could not be pooled, iven the numberof methodoloical problems with many of thesestudies and differences in study populations anddesin.

? $ randomi=ed trial assined primiparous subects to akneelin or a sittin position durin the second staeof labor 1(E2. ompared to the kneelin position, thesittin position durin the second stae wasassociated with sinificantly more severe deliverypain, more fre3uent perception of the second staeas bein lon, less comfort while ivin birth, andmore fre3uent feelins of vulnerability and e7posure.

0ATE% $++E%S$&N- Bomen enerally like thefeelins associated with takin a warm bath, and it

appears to be a safe intervention. 5mmersion in warmwater deep enouh to cover the woman8s abdomen isthouht to enhance rela7ation and reduce labor pain.Bomen usually remain in the bath for a few minutesto hours durin the first stae of labor. The watershould be at or slihtly above body temperature so asnot to increase the woman8s core temperature, andher temperature should be monitored. Klevatedmaternal temperature may have adversefetal/neonatal conse3uences. 9See 5ntrapartumfever, section on 8#etal/


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Showers durin labor, althouh commonly used, havenot been evaluated in outcome studies.

There are mi7ed results reported on the effect ofwater immersion on labor proress and need for

interventions, or for makin recommendations on thetimin or duration of water immersion.

? $ ochrane review of randomi=ed trials that evaluatedthe safety and efficacy of water immersion durin thefirst stae of labor found use of epidural, spinal,paracervical analesia/anesthesia was sinificantlylower for immersion roups compared to controls9D.* versus A(.A percent0 OC ).D(, @EF 5 ).G)4).@D0 si7 trials; 1(D2. There were no sinificant

differences in narcotic/pethidine use or overallanalesia outcome, labor duration, operative deliveryrates, or neonatal outcomes. %athin did not increasethe risk of maternal or neonatal infection, even inwomen with ruptured membranes 1()2.

Proloned immersion 9more than two hours; has beenreported to prolon labor and slow uterinecontractions by suppressin o7ytocin production. 5t ishypothesi=ed that durin immersion in deep water,

the hydrostatic pressure of the water on the mother>sedematous tissue causes the fluid to be moved intothe intravascular space, which leads to increasedblood volume 1(@2. This results in increasedproduction of $


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1*2. Possible etioloies include fetal occiput posteriorposition, persistent asynclitism or other malposition,the woman8s lumbopelvic characteristics, and referredpain from the uterus. There is anatomical support forthe hypothesis that at least some low back pain

durin labor is actually referred pain since the nervesoriinatin from the corpus uteri and cervi7 terminatein the dorsal horns of the spinal sements T*) to '*and reflect visceral pain, which is often referred tothe lower back 1(2. %ack pain can occur withcontractions or it can be constant.

5ntracutaneous sterile water inections 9also calledwater blocks; are used intrapartum primarily todecrease pain in the lower back, and occasionally torelieve the abdominal pain of labor 1()2. Bhile themechanism of action is not known, it is hypothesi=edthat the firin of $4delta fibers overwhelms thevisceral pain input from fibers such that the visceralpain is not noticeable0 this hypothesis is based uponthe ate control theory of pain. $lternatively, releaseof local endorphins may be responsible for theanalesic effect.

Bater blocks consist of four intracutaneous orsubcutaneous inections of ).)E to ).* m' sterile

water 9usin four * m' or two ( m' syrines with (E4aue needles; to form four small blebs or papules9similar to a tuberculin skin test;. The use ofunphysioloical sterile water is re3uired. $lthouhphysioloical saline does not burn, it also does notwork. The inection sites are most commonly locatedover the two posterior superior iliac spines and cmbelow and * cm medial to these two sites.$lternatively, some clinicians ask the woman to pointto the area where she hurts most and they place thefour inections in that area. The e7act location of the

inections does not appear to be critical to the successof the techni3ue 1,A2. The water blocks can berepeated as desired.

5ntracutaneous inections are usually painful for up toone or two minutes. To offset the discomfort ofadministration, some providers ive inections durin
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a contraction and have two providers ive theinections simultaneously to speed the process.Bomen need to be forewarned of the burninsensations they will e7perience durin the inection.Since some women find the inections very

uncomfortable and may ask the provider to stop, it isbest to make the first two inections on oppositesides, as these two inections alone may providesatisfactory results. Several more recent studies havereported that inection pain can be reduced by ivinthe inection subcutaneously, rather thanintracutaneously. Pain relief appears to be e3uivalent1(,A,E2.

? Kiht randomi=ed trials have compared the effect ofintra4 or subcutaneous water blocks to a placeboblock 9saline; 1*,(,E4D2 or to an alternativenonpharmacoloical method 9TranscutaneousKlectrical


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nurse4midwives found that only one4third ofrespondents used them, and with less than *.Epercent of their clients 1A2. Ceasons for such lowusae included a lack of trainin or e7perience,discomfort with the techni3ue, and the easy

availability of pharmacoloical pain relief.

#urther research is needed on the effects of repeatedinections, ways to decrease the stinin of theinections without losin benefits, mode of action, andthe effects of varyin dosaes, locations, and numberof sites inected.

T&U'* AND +ASSA)E- Touchin another personcan communicate such positive messaes as carin,concern, reassurance, and love. Massae, the

intentional and systematic manipulation of the softtissues of the body to enhance health and healin1A(2, is used durin labor to enhance rela7ation andreduce pain. There are no harmful effects to the useof touch or massae in labor. Bomen appreciatethese interventions, which appear to reduce pain andenhance feelins of well4bein.

Several randomi=ed trials of touch and massae havebeen performed and support this conclusion, but eachused different massae techni3ues and Ndoses:

? 5n one trial includin @) women, the touch roupreceived E to *) seconds of reassurin touch eachtime the woman e7pressed an7iety durin a )4minute period between D and *) cm dilation, whilethe controls received usual care 1A2. The touchroup had sinificant decreases in blood pressure andnumber of e7pressions of an7iety.

? The second trial randomi=ed (D women to receive

either usual care 9control roup; or massae of head,back, hands and feet by their partners for () minutesper hour for five hours durin labor 1AA2. #re3uentmassae reduced the women8s pain and an7iety, andimproved their mood.

? The third trial randomly assined H) women toreceive massae or usual care 1AE2. Massae wasperformed three times, once durin each phase of the
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first stae of labor 9latent, active and transition;, andlasted for ) minutes in each phase. Pain intensitywas rated by a nurse observin each woman8smanifestations of pain usin a present behavioralintensity 9P%5; scale0 an7iety was measured usin a

visual analo scale for an7iety 9L$S$;. $lthouh painintensity increased steadily throuh proressivephases of labor, the massae roup had sinificantlylower pain intensity scores at each phase of labor.$n7iety levels were sinificantly lower in the massaeroup only durin the latent phase. Kihty4sevenpercent of the women in the massae roup reportedthat the massae was helpful in providin pain reliefand psycholoical support.

? 5n the fourth trial, H) primiparas in labor wererandomly assined to either a usual care plusmassae or usual care alone roup and evaluatedusin a pain 3uestionnaire at cervical dilations of toA, E to G, and D to *) cm 1AH2. 5n both roups, painintensity increased as cervical dilation increased.Massae lessened pain intensity up to G cm cervicaldilation, but after that there were no sinificantdifferences between the roups.

A'U-UN'TU%E AND A'U-%ESSU%E 2S*$ATSU3

$cupuncture - $cupuncture involves placement ofneedles at specific points on the body 9termedacupuncture points; 9see $cupuncture;. #or laborpain, placement of needles depends on the dereeand location of pain, stae of labor, level of maternalfatiue, tension, an7iety, and a variety of otherfactors 1AG2. There are no known risks to acupuncturewhen practiced by trained practitioners usindisposable needles. Bomen appear to be verysatisfied with the intervention. Systematic reviews ofacupuncture for pain relief in labor, however, vary intheir conclusions reardin benefits 1,AD,[email protected], the included trials enerally have not beenof hih 3uality.

? One systematic review of *) randomi=ed trialsinvolvin ()D women showed that standard
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acupuncture was not superior to minimal acupuncture9sham control; at one or two hours 1AD2. omparedwith no intervention, acupuncture reduced pain byonly ** percent for the first ) minutes. omparedwith conventional analesia, however, women

receivin acupuncture re3uested lessmeperidine 9pooled risk ratio ).()0 @EF 5 ).*(4).; and other analesic methods 9CC ).GE0 @EF 5).HH4).DE;.

? $nother systematic review of nine randomi=ed trialsinvolvin appro7imately *EE) women concluded thatacupuncture and acupressure may help relieve laborpain 1A@2. Bhen compared with placebo or nointervention, acupuncture was associated withsuperior pain relief 9standard mean difference 9SM";4*, @EF 5 4*. to 4).HG0 in one trial, *H women;,increased satisfaction with pain relief 9CC (.D, @EF5 *.GD4.*@0 one trial, *E) women;, and reduceduse of pharmacoloical analesia 9CC ).G(, @EF 5).ED to ).DD0 one trial, *H women;. ompared withstandard care, acupuncture reduced use ofpharmacoloical analesia 9CC ).HD, @EF 5 ).EH4).D0 three trials, G)A women; and instrumentaldeliveries 9CC ).HG, @EF 5 ).AH4).@D0 three trials,G)A women;. 6owever, there was sinificantheteroeneity.

The inclusion criteria were different in the twosystematic reviews, which reduced the number ofwomen in the second review, and may have led to thedifferent conclusions.

Subse3uently, a randomi=ed trial of acupuncturedurin induced labor in *)E primiparas used twodesins: a double blind study of manual, electro, andsham acupuncture0 and a sinle4blind studycomparin acupuncture with an untreated controlroup 1E)2. There were no differences in use ofepidural analesia amon the roups and nodifferences in the secondary end points of parenteralanalesia use, duration of labor, delivery mode,neonatal condition or postpartum hemorrhae.

More studies are warranted to establish acupuncture>s
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cost4effectiveness and practicality, implementation inmaternity care settins, and acceptance bychildbearin women. Ise of sham acupuncture incontrol roups is important, iven that acupuncture isassociated with a powerful placebo effect 1E*2.

$cupressure - $cupressure, or Shiatsu, a simpleralternative to acupuncture, is pressure with finers orsmall beads at acupuncture points. 'imited datasuest a benefit:

? $ meta4analysis of four randomi=ed trials ofacupressure for pain manaement in labor found thatpain intensity was sinificantly reduced in theacupressure roup compared with a placebo control

9liht touch; or compared with a combined control9liht touch or no treatment;0 however, there was nosinificant difference between intervention andcontrol roups in use of pharmacoloic analesia 12.

One common point is Spleen H on each tibia. Thispoint is located four finer4breadths above the medialmalleolus, and pressure is applied to the tibia anddiaonally forward. The point is more sensitive thanthe surroundin areas. $nother common point is

'are 5ntestine A, located on the back of the hand,where the metacarpal bones of the thumb and inde7finer come toether. Pressure is applied at the baseof the inde7 finer.

Three randomi=ed controlled trials of acupressure atSpleen H found benefit in decreasin labor pain andtwo also found that the duration of labor wasshortened. These small trials included GE, (*(, and*() women, respectively 1E(4EA2.

*4-N&S$S- 6ypnosis is a state of deep physicalrela7ation with an alert mind producin alpha waves,and it is in this state that critical faculties aresuspended and the subconscious mind can be morereadily accessed and respond to suestions 1EE2.6ypnosis used for childbirth is almost always self4hypnosis: the hypnotherapist teaches the woman toinduce the hypnotic state in herself durin labor.
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Sometimes her partner is tauht to sinal her into thehypnotic state.

ommon hypnotic pain relief techni3ues are loveanesthesia, in which the woman imaines that her

hand is numb and that it can spread numbness toother areas by placin her hand on painful areas0time distortion, which enables the woman toperceive the time between painful contractions asloner and the painful period as shorter than it reallyis0 and imainative transformation, in which thepain is interpreted as benin and acceptable, andcontractions are seen as sures of enery that causeonly a liht pressure sensation 1EH2.

6ypnosis may be an effective techni3ue for manain

labor pain and enhancin maternal satisfaction durinchildbirth 12. More lare trials are necessary toestablish its true value.

? $ systematic review of complementary andalternative therapies for pain manaement in laborfound use of hypnosis was associated with asinificant reduction in re3uests for pharmacoloicalanalesia 9CC ).E, @EF 5 ).H4).G@0 five trials, nJ G(@ women; 12. One trial also reported asinificant decrease in use of epidural anesthesia.There were no differences in adverse obstetric orneonatal outcomes between hypnosis and controlroups.

? $ review of the efficacy of hypnosis for reducin laborpain identified * studies that used a between4subects or mi7ed model desin, in which hypnosiswas compared with a control condition, such assupportive counselin, childbirth education, orstandard medical care 1EG2. 6ypnosis was

consistently found superior to all the controlconditions in reducin pain, and also shortenin laborand improvin $par scores. #ailure to randomi=e theparticipants was a common drawback to the studies.5t may be difficult to randomi=e participants, sincecompliance with hypnosis trainin usually re3uirese7tensive rehearsal of the techni3ues and hih
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motivation 1ED2. Patients who want to use hypnosisare unlikely to accept the risk of bein randomi=edout of the hypnosis roup.

6ypnosis is contraindicated in persons with any

history of psychosis 1EE2. $ny phobias or distressinsituations need to be ascertained and avoided whensuestin a visuali=ation intended to be rela7in1EE2. There are no apparent risks to the use ofhypnosis for childbirth, e7cept that it re3uiresprenatal trainin by a trained hypnotherapist, whichinvolves financial costs.

T%ANS'UTANE&US ELE'T%$'AL NE%(E

ST$+ULAT$&N- Transcutaneous Klectrical


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@EF 5 ).(4).EE;. There was no benefit in usinTK


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warm water and wrun out;, electric heatin pad, orwarm blanket.


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any perineal suturin. The absence of a control roupwho received a room temperature pack limits theability to make conclusions about warmth versustouch from this trial.

+US$' AND AUD$&ANAL)ES$A- $udioanalesiais the use of auditory stimulation, such as music,white noise, or environmental sounds to decreasepain perception. 5t is popular for the relief of paindurin dental work, after surery, and for otherpainful situations, such as labor. There are no knownadverse effects of audioanalesia and it appears to bea popular option for laborin women, althouh thereare no stron data that it sinificantly reduces painintensity and analesic re3uirements in labor.

Most studies of audioanalesia durin labor havereported that it can increase pain tolerance, reinforceor elevate moods, or cue the woman to move orbreathe rhythmically, especially if she has conditionedherself to do so before the onset of labor. $ll thestudies, however, have suffered from small samplesi=es, inade3uate controls, or lack of true differencesbetween control and e7perimental roups 1H4HE2. 5thas not been clearly demonstrated thataudioanalesia has any of the benefits claimed for it

1HH2.

%efore labor, the woman selects music 9sometimeswith the help of a music therapist; or environmentalsounds that have a positive effect on her. She mayuse these to rehearse rela7ation or self4hypnosis, andto take her into a rela7ed or hypnotic state durinlabor. "urin labor, she chooses selections to help herrela7 and lift her spirits 1HG2. 6er selectionspersonali=e the birth event and may ive her areater sense of control. Some women prefer to use

headphones to listen to music, because this providesmore compellin distraction and the woman is inconstant control of the volume.

$udioanalesia durin labor is worthy of evaluationwith properly controlled trials of ade3uate si=e toestablish its true benefit or lack thereof, and whether
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music with lyrics has a different effect than musicwithout lyrics.

A%&+AT*E%A-4- $romatherapy is the science ofusin hihly concentrated essential oils or essences

distilled from plants in order to utili=e theirtherapeutic properties 1HD2. Ise of aromatherapydurin labor is increasin, althouh some e7pertshave stated that, essential oils are as potent aspharmacoloical drus and are e3ually open tomisuse or abuse, whether intentional or not anduntil more clinical research trials have beenundertaken, it would be prudent for midwives to workcautiously with essential oils, usin the lowestpossible dose and on the least number of occasions1HD2. $vailable data are limited to the followin:

? One lare, uncontrolled prospective study reported onthe use and effectiveness of aromatherapy in a larereferral maternity unit 1H@2. "urin this time, D)EDwomen received aromatherapy durin labor under thesupervision of midwives trained in aromatherapy9lavender, rose, or frankincense;. 5t was used for avariety of purposes: to reduce fear, an7iety, and pain0to reduce nausea or vomitin0 to enhance women8s

sense of well4bein0 and to improve contractions.$bout one4half of the women found it helpful0 *percent reported undesired effects, such as nauseaand headache. 5t is not clear whether these sideeffects were caused by the essential oils or otherfactors.

? $ meta4analysis of two randomi=ed trials 9n J EEwomen; of aromatherapy for pain manaement inlabor found no difference between roups in painintensity or use of pharmacoloic pain relief 1G)2. Thesample si=e was too small to demonstrate whether

small differences in outcome were statisticallysinificant. The control roups were very different: inone trial, controls received usual care 9versus one offive essential oils in the study roup;0 in the othertrial, controls received essential oil of lemon rass9versus essential oil of iner in the study roup;.
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.$&,EED.A'5- %iofeedback is a therapeutictechni3ue where individuals receive trainin to aincontrol over physioloical responses with the aid ofelectronic instruments. 5t helps the individual toconsciously reulate both psycholoical and physical

processes, such as pain, that are not usually underconscious control. 5ts use in labor is unproven.

$ systematic review of biofeedback for painmanaement in labor included four trials 9*DHwomen; 1G*2. Most trials assessed the effects ofelectromyoraphic biofeedback in women who wereprenant for the first time. There was no sinificantevidence of a difference between biofeedback andcontrol roups in terms of use of pharmacoloicalpain relief, or delivery outcomes. $lthouhelectromyoraphic biofeedback appeared to havesome positive effects early in labor, there was a needfor additional pharmacoloical analesia as laborproressed. The 3uality of the trials was poor,however, and further research in this area needs tobe performed.

SU++A%4 AND %E'&++ENDAT$&NS

?


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manaement of labor pain discussed above have few,if any, serious side effects and re3uire few safetyprecautions. They can be combined or usedse3uentially to enhance their total effect, and areenerally ine7pensive 9see above;.

Ise of IpTo"ate is subect to the Subscription and'icense $reement.

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H6umenick, S, Shrock, P, 'ibresco, M. Cela7ation. 5n: hildbirth Kduc6umenick 9Kds;, B% Saunders ompany, Philadelphia ())).

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Biruchponsanon P. Celief of low back labor pain by usin intracutaMed $ssoc Thai ())H0 D@:EG*.

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Trolle %, MYller M, !ronbor 6, Thomsen S. The effect of sterile wat*HA:*(GG.

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Sommer, P. Obstetrical patients8 an7iety durin transition of labor anTe7as Bomen8s Iniversity, "allas *@G@.

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