Managing Pain During Labor: What Works, What Doesn’t

Which pharmacological and nonpharmacological options are safe and effective in reducing pain during labor? To answer this question, researchers conducted a meta-analysis of randomized controlled trials that looked at various interventions commonly used during labor. The findings were published in the Cochrane Database of Systematic Reviews.

The researchers included 15 Cochrane reviews and 3 non-Cochrane reviews in their analysis. The interventions employed in the studies included nonpharmacological interventions (i.e., hypnosis, biofeedback, intracutaneous or subcutaneous sterile water injection, water immersion in water, aromatherapy, relaxation techniques, acupuncture or acupressure, massage/reflexology, and transcutaneous electrical nerve stimulation [TENS]). Studies looking at pharmacological interventions (i.e., inhaled analgesia, opioids, non-opioid drugs, local anesthetic nerve blocks, epidurals, and intrathecal injections of local anesthetics or opioids) were also included. In analyzing the data, the researchers looked at pain intensity, satisfaction with pain relief, and safety factors.

Based on the study data, the authors divided the interventions into one of three groups: what works, what may work, and insufficient evidence. Most pharmacological interventions fell in the “what works” category, but they were associated with a greater possibility of adverse events. In comparing a few of these interventions, the researchers noted that combined-spinal epidurals relieved pain more quickly than traditional or low dose epidurals.

While epidural, combined spinal epidural, and inhaled analgesia were found to effectively manage pain during labor, the researchers noted that these agents could lead to adverse events. For instance, a greater number of instrumental vaginal births and caesarean sections for fetal distress were found among women who received epidural analgesia when compared with women who received placebo or opioids. In addition, these women also experienced hypotension, motor blockade, fever, or urinary retention more than women in the other groups.

Both pharmacological and nonpharmacological agents were placed in the “what may work” category, as there was evidence, albeit limited, that these interventions were effective. These included local anesthetic nerve blocks and non-opioid drugs as well as relaxation interventions including immersion in water, relaxation techniques, acupuncture, and massage.
Interventions in the “what may work” category relieved pain and improved satisfaction with pain relief and childbirth experience when compared to placebo or standard treatment. Women who received relaxation techniques and acupuncture were also less likely to have assisted vaginal births; acupuncture was also associated with fewer caesarean sections.

Finally, the researchers found insufficient evidence for efficacy of hypnosis, biofeedback, sterile water injection, aromatherapy, TENS, or parenteral opioids. They further found that pethidine was more often associated with adverse effects including drowsiness and nausea as compared to other opioids.

“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,” the authors concluded. “There is more evidence to support the efficacy of pharmacological methods, but these have more adverse effects.”

They added, “It remains important to tailor methods used to each woman’s wishes, needs and circumstances, such as anticipated duration of labor, the infant’s condition, and any augmentation or induction of labor.”

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References:

Jones L, Othman M, Dowswell T, et al. Pain management for women in labour: an overview of systematic reviews. Cochrane Database Syst Rev. 2012;3:CD009234.