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Pain Management for Women in Labor: A Research Review

As a childbirth professional or an expectant parent, do you wonder about the multitude of pain management techniques offered for childbirth?

As part of the Cochrane Collaboration, Leanne Jones and eight of her colleagues (2012) has published new research synthesizing divergent data constructs and summarizing 355 trials on pain management during childbirth. There are many detailed data tables associated with this study.

To view the entire study, Lamaze members can access the full Cochrane Library, via the Members Only Section.

A summary of the study is below.

Background

In 2007, the Cochrane Pregnancy & Childbirth Group (PCG) consumer’s group identified pain relief in childbirth as the topic of most importance to them.

This study was funded to provide an evidence-based summary of the efficacy and safety of pain management methods in childbirth for consumers, policy-makers, and childbirth educators.

Women experience pain in childbirth in varying degrees of intensity, influenced by physiological and psychosocial factors. Most women require some type of pain relief. Both non-pharmacological and pharmacological methods are used for pain management.

312 Studies Reviewed

Collecting the totality of evidence from existing randomized controlled trials, the researchers identified 18 total systematic reviews for inclusion in their study. 15 reviews were Cochrane reviews (257 included trials) and 3 were non-Cochrane reviews (55 included trials). Data from a total of 312 studies were reviewed in this study.

There were more studies of pharmacological interventions than non-pharmacological interventions.

13 Outcomes Identified for Inclusion

The researchers, in partnership with the PCG consumer group, identified these outcomes for inclusion in the study.

Effects of interventions

  • Pain intensity (as defined by trialists)
  • Satisfaction with pain relief (as defined by trialists)
  • Sense of control in labor (as defined by trialists)
  • Satisfaction with childbirth experience (as defined by trialists)

Safety of interventions

  • Effect (negative) on mother/baby interaction
  • Breastfeeding (at specified time points)
  • Assisted vaginal birth
  • Cesarean section
  • Adverse effects (for women & babies)
  • Admission to special care baby unit / NICU
  • Apgar score less than at five minutes
  • Poor infant outcomes at long-term follow-up (as defined by trialists)

15 Childbirth Management Methods Identified

The researchers identified a list of 15 childbirth pain management methods:

  • placebo/no treatment
  • hypnosis
  • biofeedback
  • intracutaneous or subcutaneous sterile water injection
  • immersion in water
  • aromatherapy
  • relaxation techniques (yoga, music, audio)
  • acupuncture or acupressure
  • massage, reflexology or manual methods
  • TENS
  • inhaled analgesia
  • opioid
  • non-opioid drugs
  • local anesthetic nerve blocks
  • epidural

 As a Lamaze childbirth educator, how will you incorporate respect for your client’s individual decisions while presenting the Six Lamaze Healthy Birth Practices?

Results: Non-pharmacological Studies

The authors found that non-pharmacological methods are mostly used in midwife-led continuity of care births and/or where women had continuous intrapartum support. Such non-pharmacological methods are meant to break the fear-pain-tension cycle and to work within the pain paradigm. The pain paradigm of birth is a philosophy based on the idea that pain is a normal part of the physiology of labor and that women can use coping methods to manage the pain (Leap, 2008; as cited in Jones et al, 2012).

The researchers found the evidence for many non-pharmacological methods to be mostly incomplete as there is an average of only two studies for each method.

However, the following non-pharmacological methods are shown to provide pain relief and positive maternal psychological outcomes without invasive side effects: immersion in water, relaxation, acupuncture/acupressure and massage.

In addition, women report greater emotional satisfaction with childbirth when using immersion and relaxation. With the use of relaxation and acupuncture/acupressure, there is a decrease in the use of forceps and ventouse. There is a decrease in the amount of cesarean section associated with the use of acupuncture/acupressure.

The researchers report there is insufficient evidence to report on pain relief using the following methods: hypnosis, biofeedback, sterile water injection, aromatherapy and TENS.

Results: Pharmacological Studies

There are more studies of pharmacological methods versus non-pharmacological methods. The authors found that pharmacological methods relieve pain and have side effects.

Pharmacological methods are most likely to be used in settings with a pain relief paradigm. In the pain relief paradigm of labor, pain is considered barbaric, the benefits of analgesia outweigh the risks, and women should be free to use whatever pain relief methods she wishes, without guilt (Leap, 2008; as cited in Jones et al, 2012).

Comparative Pain Relief & Side Effects

Epidural, combined spinal epidural (CSE) and inhaled nitrous oxide & oxygen relieve pain better when compared to opioids (Jones et al, 2012).

Epidurals are associated with an increase of the use of forceps or ventouse, an increase in the risk of low blood pressure, low motor blocks, fever and urine retention (Amin-Somanuh, 2005; as cited in Jones et al, 2012). In addition, other side effects such as shivering, tinnitus, and respiratory or cardiovascular depression may occur. The authors state it is uncertain whether the use of epidurals interfere with breastfeeding (Reynolds, 2011; as cited in Jones et al, 2012).

Combined spinal epidurals (CSE) provide faster pain relief than traditional epidurals, but are associated with more feelings of itchiness, giddiness, sweating, and tingling (Jones et al, 2012).

Inhaled nitrous oxide is associated with minimal toxicity and rapid maternal and neonate elimination, but can cause feelings of nausea, drowsiness and sickness (KNOV, 2009; Rosen, 2002; as cited in Jones et al, 2012).

Non-opioid drugs (acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDS)) relieve pain for shorter periods of time as compared to opioid drugs (Bayarski, Hebbes, 200; as cited in Jones et al, 2012).

Opioid drugs (morphine, nalbuphine, fentanyl, parenteral and pethidine) are used worldwide. Parenteral opioids are reported to provide less pain relief than epidurals. Side-effects include impaired maternal capacity for decision-making, sedation, hypoventilation, hypotension and urine retention. Opioids readily cross the placenta, thus neonatal respiratory depression and hypothermia are also concerns. Pethidine is shown to affect fetal heart rate variability during labor (Sekhavat, 2009; Solt, 2002; as cited in Jones et al, 2012), thus continuous fetal monitoring is recommended. Neonatal effects are inhibited and early cessation of breastfeeding and decreased alertness (Nissen, 1995; Ransjo-Arvidsen, 2001; Righard, 1990; Rajan, 1994; as cited in Jones et al, 2012).

Limitations Found in the Studies

The authors state the studies use differing methods to measure pain management outcomes. Many do not at all measure maternal psychological outcomes (feelings of intrinsic self-control), mom-baby interaction, or breastfeeding and infant outcomes.

Conclusions

This study shows consumers rate pain management as a high priority in childbirth, however, after 30 years of research, standardized pain management and outcome measurements have not been created.

The authors suggest their outcome guidelines, developed with consumer input, be adopted for use in future research.

Overall, women should feel free to choose whatever methods of pain relief they wish, both non-pharmacological and pharmacological, for their individual childbirth experience.

As part of a childbirth preparation program, women should be informed of the efficacy and potential side-effects on both themselves and their babies of non-pharmacological and pharmacological methods of pain relief for childbirth.

Hopefully this study will generate an effort to standardize the constructs associated with research of measurements of pain management in labor, maternal psychosocial satisfaction, and maternal-baby outcomes.

References

Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, Jordan S, Lavender T, Neilson JP. Pain management for women in labour: an overview of systematic reviews. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD009234. DOI: 10.1002/14651858.CD009234.pub2

Babies, Cesarean Birth, Do No Harm, Epidural Analgesia, Evidence Based Medicine, Fetal Monitoring, Healthy Birth Practices, informed Consent, Medical Interventions, Midwifery, New Research, News about Pregnancy, Pain Management, Practice Guidelines, Research , , , , , , , , ,

  1. April 11th, 2012 at 10:19 | #1

    This is pretty interesting …. not enough evidence for non-pharma pain management because medications have dominated pain management in labor. This I hope will change as the midwifery model of care gets stronger as THE model of maternity careand where options are discussed more openly.

  2. April 11th, 2012 at 11:31 | #2

    Kathy,

    As I read this summary, I was struck again by how much information seems to be left out of the education process for pregnant women. It would seem as though education has to become more thorough in order for the goal of women being fully in control of their birth process to be realized. Thanks for taking the time to break this down!

    Warmly,
    Ann

  3. April 11th, 2012 at 12:36 | #3

    Kathy, So very interesting. I would love it if all the research would lead to helping each individual woman make the best choice for herself, that will allow the best outcome for her. More education, more research, more blog post like this will allow for that. Thanks so much. Allison

  4. April 11th, 2012 at 12:48 | #4

    @Lesly Federici
    Hi Lesley – I know, pretty amazing to me that mindbody therapies, which have LOTS of supportive research about how they reduce blood pressure, manage stress, reduce depression & anxiety symptoms, improve quality of life, improve balance etc, have hardly been studied in childbirth. They are widely suggested and used, even if medication is also used. If mindbody therapies were able to be manufactured & sold, there w/b lots of studies in the pike for them. Thanks for your comments.

  5. April 11th, 2012 at 12:52 | #5

    @Ann Becker-Schutte, Ph.D.
    Hi Ann – Yes we are learning more & more about what works, what’s out there, what can be combined. This research was the first to pull so much research abt pain mgmt in childbirth together. Such an important part of life, yet so little has been done to operationalize the research constructs. The consumer group asked for the research and designed the proposed operationalized constructs. Wassup? Whenzit gonna happen?

  6. April 11th, 2012 at 12:56 | #6

    @Allison Andrews
    Hi Allison – I was so happy when Lamaze asked me to review this study. So many of us have been teaching & using mindbody therapies for comfort & pain management in childbirth for so long. I was so pleased to see acupressure was found to have some efficacy and also women experienced higher satisfaction ….I would daresay that feeling more empowered (no matter what methods are used) would feed into mitigating PPD symptoms.

  7. April 11th, 2012 at 15:12 | #7

    What I’d like to see is evidence on combined non-pharma pain relieving techniques. In my experience, when we layer techniques, we get better results. So, position, movement, massage, heat/cold, and water all together make for a better pain management regiment then just doing one at a time.

    I also note that labor support isn’t listed as pain management technique.

    What I find interesting is that we have more studies on mindbody techniques with regards to ailments of the body, rather than the normal pain of birth.

    All in all, good stuff to report, Kathy!

  8. April 11th, 2012 at 16:15 | #8

    @Deena Blumenfeld RYT, RPYT, LCCE
    Hi Deena – Great ideas about using multi-modal techniques for support. It feels disconcerting the research has not yet operationalized constructs as of yet, but it is a step forward to identify the situation. Hmm, labor support was not one of the techniques identified by the public/team….maybe it is too broad a topic? But good thoughts!
    thanks, Deena

  9. April 13th, 2012 at 08:26 | #9

    Given these results, I would love to see a Webinar on better ways to teach all of these pain management options! Help us put this into practice.

  10. April 13th, 2012 at 08:44 | #10

    Hi Kathy – Great idea! Will keep you posted! Warmly, Kathy

  11. April 22nd, 2012 at 10:33 | #11

    Hi Kathy,
    Thanks for the review. You’ve presented a lot of data quite clearly. It’s very impressive to see the range of side effects with epidurals when I know that they are so commonly recommended and opted for. Great education.
    Thanks,
    Carolyn

  1. April 11th, 2012 at 07:02 | #1
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