Relaxation techniques for pain management in labour

What is the issue?

This Cochrane Review looked at whether mind-body techniques for relaxation such as breathing techniques, visualisation, yoga or music would help with reducing pain, and improve women’s experiences of labour. We collected and analysed all relevant studies to answer this question (date of search: May 2017).

Why is this important?

The pain of labour can be intense, with body tension, anxiety and fear making it worse. Many women would like to go through labour without using drugs, or invasive methods such as an epidural. These women often turn to complementary therapies to help to reduce the intensity of pain in labour and improve their experiences of labour.

Many complementary therapies are used by women in labour, including acupuncture, mind-body techniques, massage, reflexology, herbal medicines or homoeopathy, hypnosis, music and aromatherapy. Mind-body techniques for relaxation can be widely accessible to women through the teaching of these techniques during antenatal classes. The relaxation techniques include guided imagery, progressive relaxation and breathing techniques. We also include yoga and music in this review. Other Cochrane Reviews cover hypnosis in labour, manual methods (like massage and reflexology), aromatherapy and acupuncture/acupressure. Many of these relaxation techniques are coping strategies used to reduce the experience of pain. These techniques utilise practices that aim to reduce stress and reduce the perception of pain. It is important to examine if these therapies work and are safe, to enable women to make informed decisions about their care.

What evidence did we find?

We found 15 studies involving 1731 women that contributed data to the analyses. Studies were undertaken across the world, including countries in Europe and Scandinavia, and Iran, Taiwan, Thailand, Turkey and USA.

We found that relaxation techniques, yoga and music may help women manage labour pain, although the quality of the evidence varied between low and very low, and more data are needed. Also, in these trials there were variations in how these techniques were used. There was no clear evidence that these therapies had an impact on assisted vaginal or caesarean birth. There were insufficient data to say if these techniques influenced the baby’s condition at birth.

What does this mean?

The use of some relaxation therapies, yoga, or music may possibly be helpful with reducing the intensity of pain, and in helping women feel more in control and satisfied with their labours. However, the wide variations in types of techniques used in these studies make it difficult to say specifically what might help women. Therefore further research studies are needed.

Authors' conclusions: 

Relaxation, yoga and music may have a role with reducing pain, and increasing satisfaction with pain relief, although the quality of evidence varies between very low to low. There was insufficient evidence for the role of mindfulness and audio-analgesia. The majority of trials did not report on the safety of the interventions. Further randomised controlled trials of relaxation modalities for pain management in labour are needed. Trials should be adequately powered and include clinically relevant outcomes such as those described in this review.

Read the full abstract...
Background: 

Many women would like to avoid pharmacological or invasive methods of pain management in labour and this may contribute to the popularity of complementary methods of pain management. This review examined currently available evidence on the use of relaxation therapies for pain management in labour. This is an update of a review first published in 2011.

Objectives: 

To examine the effects of mind-body relaxation techniques for pain management in labour on maternal and neonatal well-being during and after labour.

Search strategy: 

We searched Cochrane Pregnancy and Childbirth's Trials Register (9 May 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 5 2017), MEDLINE (1966 to 24 May 2017), CINAHL (1980 to 24 May 2017), the Australian New Zealand Clinical Trials Registry (18 May 2017), ClinicalTrials.gov (18 May 2017), the ISRCTN Register (18 May 2017), the WHO International Clinical Trials Registry Platform (ICTRP) (18 May 2017), and reference lists of retrieved studies.

Selection criteria: 

Randomised controlled trials (including quasi randomised and cluster trials) comparing relaxation methods with standard care, no treatment, other non-pharmacological forms of pain management in labour or placebo.

Data collection and analysis: 

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We attempted to contact study authors for additional information. We assessed evidence quality with GRADE methodology.

Main results: 

This review update includes 19 studies (2519 women), 15 of which (1731 women) contribute data. Interventions examined included relaxation, yoga, music and mindfulness. Approximately half of the studies had a low risk of bias for random sequence generation and attrition bias. The majority of studies had a high risk of bias for performance and detection bias, and unclear risk of bias for, allocation concealment, reporting bias and other bias. We assessed the evidence from these studies as ranging from low to very low quality, and therefore the effects below should be interpreted with caution.

Relaxation

We found that relaxation compared to usual care provided lowered the intensity of pain (measured on a scale of 0 to 10 with low scores indicating less pain) during the latent phase of labour (mean difference (MD) -1.25, 95% confidence interval (CI) -1.97 to -0.53, one trial, 40 women). Four trials reported pain intensity in the active phase; there was high heterogeneity between trials and very low-quality evidence suggested that there was no strong evidence that the effects were any different between groups for this outcome (MD -1.08, 95% CI -2.57 to 0.41, four trials, 271 women, random-effects analysis). Very low-quality evidence showed that women receiving relaxation reported greater satisfaction with pain relief during labour (risk ratio (RR) 8.00, 95% CI 1.10 to 58.19, one trial, 40 women), and showed no clear benefit for satisfaction with childbirth experience (assessed using different scales) (standard mean difference (SMD) -0.03, 95% CI -0.37 to 0.31, three trials, 1176 women). For safety outcomes there was very low-quality evidence of no clear reduction in assisted vaginal birth (average RR 0.61, 95% CI 0.20 to 1.84, four trials, 1122 women) or in caesarean section rates (average RR 0.73, 95% CI 0.26 to 2.01, four trials, 1122 women). Sense of control in labour, and breastfeeding were not reported under this comparison.

Yoga

When comparing yoga to control interventions there was low-quality evidence that yoga lowered pain intensity (measured on a scale of 0 to 10) with low scores indicating less pain) (MD -6.12, 95% CI -11.77 to -0.47, one trial, 66 women), greater satisfaction with pain relief (MD 7.88, 95% CI 1.51 to 14.25, one trial, 66 women) and greater satisfaction with childbirth experience (MD 6.34, 95% CI 0.26 to 12.42 one trial, 66 women (assessed using the Maternal Comfort Scale with higher score indicating greater comfort). Sense of control in labour, breastfeeding, assisted vaginal birth, and caesarean section were not reported under this comparison.

Music

When comparing music to control interventions there was evidence of lower pain intensity in the latent phase for women receiving music (measured on a scale of 0 to 10 with low scores indicating less pain) (MD -0.73, 95% CI -1.01 to -0.45, random-effects analysis, two trials, 192 women) and very low-quality evidence of no clear benefit in the active phase (MD -0.51, 95% CI -1.10 to 0.07, three trials, 217 women). Very low-quality evidence suggested no clear benefit in terms of reducing assisted vaginal birth (RR 0.41, 95% CI 0.08 to 2.05, one trial, 156 women) or caesarean section rate (RR 0.78, 95% CI 0.36 to 1.70, two trials, 216 women). Satisfaction with pain relief, sense of control in labour, satisfaction with childbirth experience, and breastfeeding were not reported under this comparison.

Audio analgesia

One trial evaluating audio analgesia versus control only reported one outcome and showed no evidence of benefit in satisfaction with pain relief.

Mindfulness

One trial evaluating mindfulness versus usual care found an increase in sense of control for the mindfulness group (using the Childbirth Self-Efficacy Inventory) (MD 31.30, 95% CI 1.61 to 60.99, 26 women). There is no strong evidence that the effects were any different between groups for satisfaction in childbirth, or for caesarean section rate, need for assisted vaginal delivery or need for pharmacological pain relief. No other outcomes were reported in this trial.

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