1. Michelle Dearduff, Mellanie Hopkins, Pamela Mayle, Bradley Shultz
A systematic review of the effectiveness of nonpharmacological pain relief methods during labor and delivery
Michelle Dearduff, Mellanie Hopkins, Pamela Mayle, Bradley Shultz

2. BACKGROUND Nonpharmacological Pain Relief Methods Massage Acupuncture
Acupressure
Hot and cold packs
Aromatherapy
Sterile Water Injections
Research leads to new knowledge and the discovery of solutions to problems or questions. Nurses use research to find new knowledge or refine existing knowledge that will influence nursing practice (Schmidt & Brown, 2009). The aim of this study was to evaluate the efficacy of alternative pain relief measures as standard care options for labor and delivery. Pain is very subjective and so are the variations in what is provided to control pain.

3. Search Strategy Random Controlled Trials
Descriptive and Experimental Studies
CINAHL, MedLine, Electronic Journal Database, Academic Search Premier
Terms searched:
Nonpharmacological pain relief during labor
Specific pain relief measures such as acupressure, acupuncture, aromatherapy, sterile water injections
Alternative therapies for labor and delivery
Scientific research is considered to be the best source of evidence (Schmidt & Brown, 2009). Our strategy to find pertinent articles related to the effectiveness of pattern breathing as pain relief during labor and delivery in teenage mothers was to search CINAHL and Medline. We also went to the to identify articles they have used as evidence based practice. We also searched articles related to prenatal education programs for adolescent mothers. We had trouble finding pertinent articles so we have broadened our topic and are researching the effectiveness of nonpharmacological pain relief methods during labor and delivery.
We are searching various pain relief methods such as acupuncture, acupressure, music therapy, aromatherapy, etc. We are looking at studies of mothers who have had epidurals compared to those who have had alternate pain relief methods.

4. Search Criteria - Inclusions
Random controlled trials and experimental and descriptive studies pertaining to nonpharmacological pain relief techniques for labor and delivery.
Safe management of labor and delivery pain.
In an RCT, individuals are assigned randomly to a treatment group and a control group and the outcomes are compared. With an experimental study the researcher can influence events in the study. A descriptive study design is one in which your primary goal is to assess a sample at one specific point in time without trying to make inferences (Schmidt & Brown, 2009). Inclusion criteria was any random controlled trial, experimental or descriptive study relating to various alternative pain relief methods during labor and delivery. We narrowed down the methods to six.

5. Search Criteria - Exclusions
Studies pertaining to water births or alternative birth plans.
Studies not related to massage, acupuncture, acupressure, hot and cold packs, aromatherapy or sterile water injections.
Pertinent studies in a foreign language without translation.
Excluded were studies associated with water births or alternative birth plans, studies not related to our six focused methods, and studies in a foreign language with no translation provided.

6. Complications Limited samples Highly individualized perception of pain
Underpowered trials
Not one specific method or combination of techniques helps all women or even the same woman throughout labor and delivery
Pain during labor and delivery is subjective and multidimensional (Brown, Douglas & Flood, 2001). As nurses, we need to understand the language of pain to establish good communication with each patient during labor and delivery to provide proper and relevant support throughout the childbirth process (Mei-Yueh, Chung-Hey & Kuo-Feng, 2006).

7. Main Results
9 trials that introduced over 16,000 subjects to different interventions relating to non- pharmacological pain relief.
Interventions
1 relating to a mixture of 10 different interventions
1 relating to hot/cold/perineal massage therapy
2 relating to regular massage
1 relating to sterile water injection
1 relating to acupuncture
2 relating to acupressure
1 relating to aromatherapy
Nine trials were studied to ensure that the findings that were found had reliable outcomes. The more trials and subjects used the more accurate those outcomes will be. After studying all of these trials, it was found that non-pharmacological pain relief in laboring and delivering women has a positive impact on their birthing experience and allows for reduced use of pharmacological pain relief during and after the birth.

8. Results
The first study shown on Table 1 indicated that out of 10 interventions, breathing exercises were most beneficial.
Massage proves to be an acceptable intervention that decreases the intensity of labor pain in the first and second phase of cervical dilation.
Over 90% of the subjects who participated in the sterile water injections stated that they were satisfied to over-satisfied.
After the breathing exercises it was shown that hot/cold packs were most effective followed by acupressure, position change, massage, music, guided imagery, hydrotherapy, relaxation, aromatherapy.
Massage is an excellent source of non-pharmacological pain relief for other reasons than it’s way of relieving pain – it’s cost effective.
The subjects who participated in the sterile water injections claimed that it reduced the intensity of lower back pain that they were experiencing. Sterile water is a safe and effective form of non-pharmacological pain relief that does not jeopardize the health of the baby.

9. Results
The study using acupuncture yielded the highest number of subjects – 15,109 participants
Acupuncture when used as a labor analgesia has decreased the number of epidurals.
Both trials involved with acupressure resulted in a lessening of labor pains.
L14 and BL67 acupressure lessened pains during the active phase of the first stage of labor
SP6 acupressure decreased labor pains and shortened length of delivery.
The study with acupuncture had a large array of subjects, which makes the study’s outcome more reliable. Study supports the use of acupuncture as an analgesic tool in obstetric practice.
Acupressure is a way of relieving pain in one area of the body by putting pressure on the corresponding area of the hands or feet. This is another cost effective way of relieving the pains of labor and delivery.

10. Results
Aromatherapy was used in the trial containing the second largest subject pool – 513.
This trial resulted in lessening the pain perception in nulliparous mothers.
This is a growing intervention in maternity care that is cost effective.
Aromatherapy may be the most cost effective of all between the non-pharmacological trials that were studied. Heated oils were used to provide the aroma in the delivery room. This trial was a pilot trial – there will be more trials in the future with more subjects to identify statistical significance in this growing field of non-pharmacological pain relief.

11. Results
Table 1 on the next slide compares and explains the outcomes of each of the nine trials that were performed.
All of these non-pharmacologic trials reduced the maternal pain perceived during labor and delivery in some form.
Certain interventions worked better on some areas of pain than others and also worked better on some women than others.
Non-pharmacological pain relief during labor and delivery is an area of nursing management in obstetric practice that is growing and will continue to grow. Many women who want a natural birthing experience will look toward these practices in hopes to avoid the use of epidural anesthetics and other forms of pharmacological pain relief. Trials will continue to be performed to ensure outcomes are effective and reliable. These methods of non-pharmacological pain relief are also safe when it comes to the health of the baby and they are effective in reducing perceived pain during labor and delivery.

12. Cost effective treatment
Author
Method Used
Study Type
Variables
Sample Used
Findings
Misc.
Brown et al. (2001)
Combination [1]
Descriptive Survey
Laboring women
46 laboring women
[2]
[3]
Sanders et al. (2005)
Variety [4]
Questionnaire
[5]
207 heads of midwifery
[6]
[7]
Kimber et al. (2008)
Massage or music
Randomized controlled trial
[8]
4 small trials
[9]
[10]
Peart et al. (2008)
Sterile water injection
Study with pre/post test
[11]
60 women during labor
[12]
[13]
Mei-Yueh et al. (2006)
Massage
[14]
60 primiparas in labor
[15]
Cost effective treatment
Nesheim et al. (2006)
acupuncture
[16]
15,109 laboring patients [17]
[18]
[19]
Chung et al. (2003)
Acupressure
[20]
127 parturient women[21]
[22]
[23]
Mi Kyeong et al. (2004)
[24]
75 women in labor [25]
[26]
[27]
Burns et al. (2007)
Aromatherapy
[28]
513 women during labor [29]
[30]
[31]
[1] Breathing, relaxation, acupressure, position changes, massage.
[2] Not one specific technique or combination of interventions helps all women or even the same woman throughout the labor experience. All nonpharmacologic techniques explored in the study were found to be helpful in some degree for some study participants while other participants indicated the same strategies were less effective.
[3] Breathing exercises proved to be the most helpful, followed by hot/cold therapy.
[4] Hot packs, cold packs and perineal massage.
[5] Pharmacological and nonpharmacological methods of perineal analgesia used by midwives during the second stage of labor and perineal repair.
[6] Hot packs were used in 70 (33%) maternity units, cold packs in 44 (21%) and perineal massage in 109 (52%). Midwives in 131 (62%) maternity units used injectable local anesthetics to control the perineal pain. All units advocated use of local anesthetic before episiotomy or or perineal repair, but the reported doses varied widely.
[7] Findings from this survey show that there is considerable variation in what midwives provide to control pain. Formal evaluation of the perineal analgesia offered to women during the second stage of labour is urgently required.
[8] Massage techniques at different frequencies, duration and relaxation techniques for maternal pain and anxiety in labor.
[9] Regular massage with relaxation techniques from late pregnancy to birth is an acceptable coping strategy that merits a large trial with sufficient power to detect differences in reported pain as a primary outcome measure.
[10] The placebo offered a nonpharmacological coping strategy to ensure the use of massage was the only difference between intervention and placebo groups.
[11] Efficacy and acceptability of sterile water injections to relieve lower back pain during labor.
[12] 47 of 52 respondents stated they were satisfied or very satisfied with the sterile water injection for pain relief. Sterile water injections are a safe, effective pain relief measure during labor and should be offered as a further option to manage lower back pain.
[13] Use of a pain relief technique that has no adverse effect on the baby is an important factor and should be a consideration when discussing with women their pain needs during labor.
[14] Characteristics of pain during labor with and without massage.
[15] Massage can effectively decrease the intensity of labor pain only in the 1st and 2nd phase of cervical dilation.
[16] Acupuncture during labor to reduce the use of epidural analgesia and meperidine.
[17] Maternal ages between 14 and 50, duration of pregnancy between 20 and 44 weeks, duration of first stage of labor between 0-24h.
[18] Women having acupuncture as labor analgesia in the clinical setting have a reduced use of epidural analgesia.
[19] Study supports the argument for the place of acupuncture among the analgesic tools in obstetric practice.
[20] Effect of L14 and BL67 acupressure on labor pain and uterine contractions during the first stage of labor.
[21] 127 parturient women assigned to 3 groups (L14 and BL67 acupressure, light skin stroking, no tx/conversation).
[22] Results confirmed the effect of L14 in BL67 acupressure in lessening labor pains during the active phase of the first stage of labor.
[23] There were no verified effects on uterine contractions.
[24] Effect of SP6 acupressure on labor pain and delivery time in women in labor.
[25] randomly assigned to SP6 acupressure or SP6 touch control group.
[26] The SP6 acupressure was effective for decreasing labor pains and shortening the length of delivery time.
[27] SP6 acupressure can be effective nursing management for women in labor.
[28] Aromatherapy during labor as a care option that could improve maternal and neonatal outcomes.
[29] 251 randomised to aromatherapy and 262 controls. Randomly assigned to administration of selected essential oils during labor by midwives specifically trained in their use and modes of application.
[30] Pain perception was reduced in aromatherapy group for nulliparous mothers.
[31] Given the increasing popularity of aromatherapy in maternity care, a study with a larger sample should be done to identify statistical significance on pain relief outcomes.

13. Summary 9 trials that involved over 16,000 participants were studied.
Breathing exercises reported to be the most effective
Aromatherapy was reported to be the least effective
Cost Effective
We studied nine different trials that had over 16,000 people that participated. In one of the trials we studied forty-six laboring women used ten different nonpharmacological strategies and researchers found that breathing exercises were the most effective (Brown, Douglas & Flood, 2001). In the trial that studied aromatherapy, relief of pain was only provided to nulliparous mothers. This trial suggested that a study with a larger sample size should be done to identify how effective the nonpharmocological method was in relieving pain (Burns, Zobbi, Panzeri, Oskrochi, & Regalia, 2007). The use of these nonpharmocological methods is growing in health care because they are cost effective

14. Nursing implication Offer Alternative Methods in nursing practice
Incorporate these nonpharmocological pain relief methods in standards of care
The results of the trials we studied can not say with 100% confidence that these alternative pain relief methods are always effective. The results of these trials does however provide enough significant evidence to support that these methods are effective coping strategies.

15. Acquire more knowledge about alternative therapies
Nursing actions
Acquire more knowledge about alternative therapies
Offer these alternative therapies in other practices as well
Make these alternative therapies more available to laboring women
Midwifery
Requests for alternative pain therapies in laboring women is becoming increasingly popular (Burns et. al, 2007). Therefore, it is crucial that nurses have some type of understanding about these therapies in order to provide our patients with the best quality of care possible. Incorporating these methods into other areas of nursing care may also be beneficial in helping people that experience acute/chronic pain that is not related to childbirth. One of the trials we studied looked at the care that midwives give compared to those nurses in hospitals and there is a considerable difference; midwives use a variety of non-pharmacological methods to control pain during child birth and these laboring women report a significant decrease in pain (Peters & Campbell, 2005).

16. Future Research Effects of non-pharmalogical methods on the newborn
Larger sample size
Length of pain relief effectiveness
Further research would be necessary to successfully provide a further understanding of benefits of nonpharmalogical pain relief measures on women in labor. The potential research question may be: What effects if any, does nonpharmalogical methods used for pain relief measures during labor has on the newborn. The researcher could conduct a randomized controlled trial that consists of a full assessment on the newborn, that either had nonpharmalogical or pharmalogical methods used during the birthing process. Another research question could be: What is the length of time of effectiveness when using nonpharmalogical pain relief methods. The researcher could use a descriptive survey of laboring women that have used nonpharmacological pain relief methods to find out how long each technique used lasted. A larger sample size should be done to identify statistical significance on pain relief outcomes.

17. Proposed Research Design
Use of pain relief technique that has no adverse effect on the baby.
Include full assessment and evaluation of the newborn
Experimental study with pre test and post test
The proposed research design would include an assessment by a doctor that evaluates the possibility of an adverse effect on the newborn. Use of a pain relief technique that has no adverse effect on the baby is an important factor and should be a consideration when discussing with women their pain needs during labor. The proposed study would require a pre test and post test evaluation of the baby in the fetus and then once delivered.

18. Conclusion Options for pain relief during labor
Nonpharmalogical techniques
Managing labor pain safely
In conclusion, evidence based nursing practice should include the understanding and the many options there are for women that are seeking a nonpharmalogical way to give birth. Many women want to give birth without the use of pharmalogical methods. Being able to use other methods are important and has shown to be effective. Regular massage with relaxation techniques from late pregnancy to birth is an acceptable coping strategy and can decrease the intensity of labor (Kimber, McNabb, Mc Court, Haines & Brocklehurst, 2008). Overall the findings in majority of the studies showed that pain perception was reduced and effective for decreasing labor pains and shortening the length of delivery time.

19. References
Brown, S., Douglas, C., & Flood, L. (2001). Women’s evaluation of intrapartum nonpharmacological pain relief methods used during labor. Journal of Perinatal Education, 10(3), 1-8.
Burns, E., Zobbi, V., Panzeri, D., Oskrochi, R., & Regalia, A. (2007). Aromatherapy in childbirth: a pilot randomised controlled trial. BJOG: An International Journal of Obstetrics & Gynaecology, 114(7),
Chung, U., Hung, L., Kuo, S., & Huang, C. (2003). Effects of LI4 and BL 67 acupressure on labor pain and uterine contractions in the first stage of labor. Journal of Nursing Research, 11(4),

20. References
Kimber, L., McNabb, M., Mc Court, C., Haines, A., & Brocklehurst, P. (2008). Massage or music for pain relief in labour: A pilot randomised placebo controlled trial. European Journal of Pain, 12(8),
Mei-Yueh, C., Chung-Hey, C., & Kuo-Feng, H. (2006). A Comparison of Massage Effects on Labor Pain Using the McGill Pain Questionnaire. Journal of Nursing Research, 14(3),
Mi Kyeong, L., Soon Bok, C., & Duck-Hee, K. (2004). Effects of SP6 Acupressure on Labor Pain and Length of Delivery Time in Women During Labor. Journal of Alternative & Complementary Medicine, 10(6),
Nesheim, B., & Kinge, R. (2006). Performance of acupuncture as labor analgesia in the clinical setting. Acta Obstetricia Et Gynecologica Scandinavica, 85(4),

21. References
Peart, K. (2008). Managing labour pain safely. Australian Journal of Advanced Nursing, 25(3),
Rodriguez, M. (2005). Transcutaneous electrical nerve stimulation during birth. British Journal of Midwifery, 13(8),
Sanders, J., Peters, T., & Campbell, R. (2005). Techniques to reduce perineal pain during spontaneous vaginal delivery and perineal suturing: a UK survey of midwifery practice. Midwifery, 21(2),
Schmidt, N. & Brown, N. (2009). Evidence-based practice for nurses: Appraisal and application of research. Boston: Jones and Bartlett Publishing Co.