Advance Access Publication 15 March 2007

eCAM 2007;4(4)409417
doi:10.1093/ecam/nem012

Review

Complementary and Alternative Approaches to Pain Relief

During Labor
Michel Tournaire and Anne Theau-Yonneau
Obstetrics and Gynecology Department, Saint Vincent de Paul Hospital, University of Paris, Paris, France
This review evaluated the effect of complementary and alternative medicine on pain during
labor with conventional scientific methods using electronic data bases through 2006 were used.
Only randomized controlled trials with outcome measures for labor pain were kept for the
conclusions. Many studies did not meet the scientific inclusion criteria. According to the
randomized control trials, we conclude that for the decrease of labor pain and/or reduction of
the need for conventional analgesic methods: (i) There is an efficacy found for acupressure
and sterile water blocks. (ii) Most results favored some efficacy for acupuncture and
hydrotherapy. (iii) Studies for other complementary or alternative therapies for labor pain
control have not shown their effectiveness.
Keywords: acupuncture biofeedback complementary and alternative medicine delivery
homeopathy hydrotherapy hypnosis labor labor pain manual healing pain
sophrology sterile water blocks stimulation transcutaneous electrical nerve
stimulation yoga

Introduction
Even though delivery is a natural phenomenon, it has been
demonstrated that the accompanying pain is considered
severe or extreme in more than half of cases. Besides
conventional approaches, such as epidural analgesia, many
complementary or alternative methods have been reported
to reduce pain during labor and delivery. Complementary
or Alternative Medicine (CAM) can be defined as theories
or practices that are not part of the dominant or
conventional medical system. Some of them have been
reclassified as part of conventional medicine when supported by clinical experience or scientific data (1).
These methods are popular because they emphasize the
individual personality, and the interaction between mind,
body and environment (2). They are attractive to people
who want to be more involved in their own care and feel
For reprints and all correspondence: Michel Tournaire, Obstetrics and
Gynecology Department, Saint Vincent de Paul Hospital - University of
Paris, 82 Avenue Denfert Rochereau 75014 Paris, France. Tel: 33 (0)
1 40 48 81 43; Fax: 33 (0) 1 40 48 83 97;
E-mail: [email protected]

that such therapies are more in harmony with their personal

philosophies. The conventional medical community usually
offers traditional choices of analgesia, such as epidural and
intravenous drugs. Patients may have access to alternative
methods, but will generally be obliged to do the relevant
research themselves beforehand. Those seeking alternatives
are not necessarily dissatisfied with conventional medicine,
but attempt to supplement rather than replace traditional
care. Quite often, users of complementary medicine do not
inform the practitioners in charge of their pregnancy and
delivery. There are also different expectations for the
management of pain during labor according to the category
of professionals. Physicians are expected to provide
pharmacological therapy, whereas midwives, nurses and
other auxiliaries are required to assist patients with
psychological methods, and in fact use alternative
approaches more often. The theoretical bases for many
alternative methods derive from Eastern tradition or
philosophy.
After a description of labor pain, we shall mention the
conventional treatments and describe the different
complementary methods applicable to labor pain.

2007 The Author(s)

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Alternative Approaches to Pain Relief During Labor

Nature of Pain During Labor and Delivery

A scientific definition of pain is an unpleasant
sensory and emotional experience associated with actual
or potential tissue damage (3). Acute pain such as
labor pain has two dimensions: a sensory or physical
dimension, with the transmission of information, the pain
stimuli, to the brain, and an affective dimension due to
interpretation of these stimuli through the interaction of
a wide variety of emotional, social, cultural and cognitive
variables unique to the individual (Fig. 1).
For the management of pain, conventional medicine
focuses more on the physical side, while alternative
methods deal mainly with emotional considerations.
In the laboring patient, the two stages of labor
correspond to different types of pain and routes of
transmission. During dilatation (first stage), visceral pain
predominates, due to mechanical distention of the cervix
and of the lower part of the uterus. These stimuli are
transmitted to the spinal cord at the level of the tenth
thoracic to the first lumbar root. Uterine contractions
may be felt as back pain because the nerves that supply
the uterus also supply the skin on the lower back or
lumbosacral area. During the descent phase (second
stage), pain is also caused by distension and stretching
of the pelvic floor and perineum. These stimuli are
transmitted via the pudendal nerve to the second to
fourth sacral nerves.
Even though pain is a personal experience, it can be
analyzed by means of quantitative pain measures. Verbal
reports using standardized instruments, such as the
McGill Pain Questionnaire and the Visual Analogue
Scale (VAS), have been the most common methods of
pain assessment both in clinical practice and research (4).
A Canadian study comparing different pain syndromes
found that average labor pain scores were higher in both
nulliparous (first delivery) and multiparous women than
the average scores previously recorded for out-patients
with sciatic pain, toothache and fracture pain (5,6)
(Fig. 2). However, whereas the average score is higher,
its exact value differs greatly from one woman to
another. Bonica found that labor pain was mild in 15%
of cases, moderate in 35%, severe in 30% and extreme
in 20% (7).
Some factors are associated with increased pain: first
delivery, history of dysmenorrhea (painful periods), fear
of pain, a religious practice. Some factors diminish pain:
childbirth preparation classes, complications during
pregnancy, wish to breast feed, high socio-economic
status, older age (5).
To evaluate the efficiency of the different therapies,
we have applied conventional scientific methods to
published studies. In other words, do these studies
report a statistically significant reduction in labor pain?
As we shall see, few publications in the field of CAM
meet these standards. However, we should consider that

Contractions
Stage of
labor
Cervix

Language
crying

Tissue
damage

Pain

Emotional
Physical

Behavior

Age
Birth
preparation

Socioeconomic
level

Personality Religion
Environment

Muscular
reaction

Figure 1. Components of pain (6).

pain, which can now be quantified, is only one

component of a womans overall experience of labor
and birthing. Personal satisfaction is not always correlated with the level of pain and although difficult
to quantify should be included in the evaluations.
Note that the term analgesia means pain relief without
total loss of sensation, while anesthesia is defined as pain
relief with total loss of sensation.

Conventional Treatments
Regional Analgesia: Epidural
An epidural involves the introduction of a local
anesthetic agent to the sensitive nerves conducting the
pain messages on their way to the spine. A catheter
(fine flexible tube) is usually placed in the epidural space,
allowing intermittent or continuous infusion throughout
the delivery.
The epidural is the most efficient way of reducing labor
pain (Fig. 2). A total of 8595% of women report
complete relief of pain during the two phases of delivery:
cervical dilatation and descent of the baby (8). Complete
failure is rare and usually due to technical problems,
as when the epidural space cannot be reached with the
catheter. Delivery pain relief can be partial. The painful
feeling of contractions persists, but at a lower intensity.
Sometimes the area of analgesia is incomplete.
For example, the pain can be felt laterally in half of
the abdomen. When the lower nerves are not, or are
insufficiently, dulled, pain may develop during the second
phase of labor. One of the main advantages of the
epidural is that it is efficient regardless of the cultural
context, with few side effects. But it is not always
available.

Injected Drugs
Morphine-like drugs (opioids) can be given continuously
or in intermittent doses at the patients request or via

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411

affect the other. Many mindbody interventions are

applied to chronic illness, but this technique also appears
to be applicable to the acute situation of delivery.

50

Psychoprophylactic Methods
40
1st delivery
without preparation
1st delivery
with preparation
Other delivery with or
without preparation

30
Sciatic

20
Tooth pain

Delivery with
epidural

10

Fracture

Figure 2. Pain scores (46).

patient-controlled administration. Recent reports suggest

that the analgesic effect of these agents in labor is limited
and that the primary mechanism of action is heavy
sedation, which means that consciousness is reduced
during delivery. Such drugs may also have some effect on
the newborn, with rare but possible breathing difficulties
that may require assistance. Few studies have dealt with
efficiency. Most were done in the 1960s and provide
information on patient satisfaction (generally good in
about half of the cases), but without quantitative
evaluation of pain reduction.
Nitrous Oxide
Nitrous oxide gas is given for inhalation at subanesthetic
concentrations. Despite being used for more than
100 years, there is no clear quantitative evidence of
the efficacy of nitrous oxide in relieving labor pain.
The subjective feelings of mothers giving birth suggest,
however, that nitrous oxide is beneficial in many cases.
Many women report significant analgesia with it, and
many would choose it again for another delivery.

Alternative Approaches
Complementary and alternative methods applicable to
labor pain can be divided into mindbody interventions,
alternative systems of medical practice, manual healing,
bioelectromagnetic and physical methods, and alternative
medication (1).
MindBody Interventions
Mindbody interventions are based on the interconnectedness of mind and body and on the power of each to

Grantly Dick-Read introduced natural childbirth

in 1933. He believed that childbirth pain was a pathologic
response produced by fear, apprehension and tension.
He felt it essential to teach women the anatomic and
physiologic facts of childbirth, and to instruct them in
physical and mental relaxation. Both approaches are
alleged to diminish pain by familiarizing the pregnant
woman with the process of childbirth and by creating an
atmosphere of confidence.
Fernand Lamaze introduced his method in France in
1951 after a visit to Russia. This method was first
optimistically called painless childbirth, but later the
more appropriate term fearless childbirth was applied.
It is based on the Pavlovian concept of conditioned reflex
training. By focusing on certain breathing patterns or
concentration points such as a mark on a nearby wall,
it should be possible to block pain messages to the brain.
Bradleys method emphasizes natural childbirth, with
the parents working as a team. Students of this method
are taught about deep abdominal breathing and an
understanding of the labor and delivery process. Rather
than trying to block out pain, Bradleys method
encourages concentrated awareness that works through
the pain.
These methods are expected to provide better information about the process of delivery, reduce fear, give
greater satisfaction with a sense of achievement and
happiness, and create a better childmother relationship.
The importance of a good relationship between the
patient and the care-giving team is also emphasized.
Of these approaches, we have only found an evaluation
of the Lamaze method: a study by Melzack in 1984 (5)
using the McGill pain scale found a slight decrease in
average pain score in patients using the Lamaze method,
but this was not statistically significantly different from
the control group (Fig. 2).
This study also showed that the average pain score is
slightly higher at the first delivery, compared with
subsequent deliveries, but the difference is not statistically
significant.
Leboyers Method
Frederic Leboyer described his method in France in 1974
in his book Birth without violence. Inspired by Indian
yoga, this method focuses on providing a better welcome
for the newborn. In contrast to the usual environment,
with too much light and noise stressing the baby,
Leboyer proposes calm for mother, father and
professionals, and darkness, little noise and a warm
bath for the newborn. For the comfort of the mother

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Alternative Approaches to Pain Relief During Labor

during delivery, Leboyer considers that serenity obtained

through attention to the baby raises the pain threshold.
There has been no specific evaluation of the effects on
labor pain. However, couples express a high degree of
satisfaction. Although Leboyers method is rarely used
now as described in the 1970s, many birth practitioners
still consider it to have a positive effect, with gentle and
heightened attention for the newborn.
Hypnosis
The word hypnosis originates from the Greek hypnos
meaning sleep. In fact, it is not sleep but a state of focused
concentration in which the patient can be relatively
unaware, but not completely blind to her surroundings
(2). During hypnosis, suggestions may be made, focusing
on diminishing awareness of pain, fear and anxiety. The
woman is prepared with initial hypnotic experiences that
include three steps: absorption of the words or images
presented by the therapist, dissociation, a suspension of
critical judgment, and responsiveness. A few comparative
studies have evaluated the efficiency of hypnosis.
In 1962, Davidson (9) compared 70 patients who had
six lessons of autohypnosis with 70 who had received
Dick-Reads training and with 71 who had no special
antenatal training. The study was not randomized as
patients were allowed to choose their group. A statistically
significant reduction in the duration of the first stage of
labor was found in the hypnosis group as compared with
the two other groups. Autohypnosis was effective on labor
pain: 59% of this group required no analgesia, compared
with 1.4% in the control group. All patients required
analgesia in the Dick-Read training group. The subjective
impression of labor was much more pleasant in the
autohypnosis group. In 1990, Harmon et al. (10) completed
a randomized study showing shorter stage 1 labor, less
medication and higher pain thresholds in the hypnosis
group than in the control group. In 1995, Mairs (11)
compared 29 primigravida women who chose to join
hypnosis for childbirth classes and 29 in a control group.
The trained group reported statistically significantly lower
ratings of both pain and anxiety. However, there was no
statistically significant difference between the two groups in
their drug usage during labor.
A few negative effects of hypnosis have been reported,
including mild dizziness, nausea and headache. These
seem to be associated with failure to dehypnotize the
patient properly. Caution should be used in patients
vulnerable to psychotic decompensation.
To summarize, hypnosis seems to reduce fear, tension
and pain during labor and to raise the pain threshold.
It reduces the need for chemical analgesia. Patients have
a greater sense of control over painful contractions.
Hypnosis, therefore, can be considered as a helpful
adjunct during the course of labor and delivery.

Biofeedback
Biofeedback uses monitoring instruments to provide feedback to patients, i.e. physiological information of which
they are normally unaware. Electrodes feed information to
a monitoring box that registers the results by a sound or a
visual meter that varies as the monitored function increases
or decreases. For women in labor, several biofeedbackassisted relaxation techniques have been introduced.
Duchene (12) completed in 1989 a prospective randomized trial in which tension of the abdominal muscles was
monitored. As uterine contractions occurred the women
focused on relaxing the abdominal muscles. The reports of
pain using VASs and verbal description scales showed
significantly lower pain values in the biofeedback
group and less medication. In 1992, Bernat et al. (13)
used a fingertip thermometer. When the patient relaxes,
vasodilation occurs and the finger temperature increases.
However, none of the experimental subjects attempted to
use fingertip temperature control as a coping technique
during labor. The authors concluded that a lack of hospital
staff support may have contributed to this studys outcome.
In conclusion, biofeedback-assisted relaxation techniques applied to pain control yield contradictory results.
Their efficiency is certainly contingent on strong support
from caregivers to facilitate the use of the technique.
Yoga
Yoga, a method of Indian origin, proposes control of
mind and body. Between the different types of yoga,
energy yoga can be applied to pregnancy and delivery.
Through special training of breathing, it achieves changes
in levels of consciousness, relaxation, receptivity to the
world and inner peace. According to professionals
who use this technique for delivery, yoga shortens the
duration of labor, decreases pain and reduces the need
for analgesic medication. However, we have not found
any scientific confirmation of these assertions.
Sophrology
The word sophrology derives from two Greek words,
sos harmony or serenity and phren conscience or spirit.
This technique derived from Indian yoga was introduced
in Europe during the 1960s. Its purpose is to improve
the control of body and spirit through three degrees of
dynamic relaxation: concentration, contemplation and
meditation. Applied to obstetrics, better control of the
delivery process is expected. Patients individually report
a high degree of satisfaction with this experience of
relaxation during prenatal classes and delivery, but there
is no controlled evaluation in the literature.
Haptonomy
Derived from the Greek words hapsis affectivity and
nomos knowledge, haptonomy can be defined as the

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science of affectivity. This approach was proposed by

Frans Vedman (14) in the Netherlands during the 1940s.
Specific zones of affectivity are reported to improve the
contact between father, mother and baby and to help to
share emotions. In practice, haptonomy is appreciated
by couples during pregnancy, but it seems to be used
irregularly during labor, particularly because teams in
charge of delivery are not always aware of its existence.
Practitioners expect a quicker and easier delivery as well
as a better relationship between parents and newborn.
There is no published evaluation of haptonomy and
in fact such an assessment should not be expected
because, as the specialists of this method say, affectivity
cannot be put into numbers.
Music Therapy
Music addresses many of the physical and psychological
needs of patients. In obstetrics, a slow and restful type of
music may be used as a sedative to promote relaxation
during the early stage of labor. Music with a steady beat
may be used as a stimulant to promote movement during
the latter stages. The literature findings are discordant.
In Austin, Texas, a music program is used during the
third trimester of pregnancy (15). The prospective mother
and her partner are allowed to select the kind of music
they like for the different stages of labor. After a study
of 30 deliveries, only one half of the women who
had listened to music required analgesia. However, in
a randomized study Durham and Collins (16) could not
demonstrate the value of music in reducing the need for
analgesic medication. But the subjective sense of satisfaction appeared to be higher in the group that listened
to music. In a randomized controlled trial by Phumdoung
and Good (17), 110 primiparous women, during the
active phase of labor, were assigned to a soft music group
for 3 h (n 55) or a control group (n 55). Dual VAS
were used to measure the sensation of pain before
starting the study and every three hours. The results
indicate that in the music group women had significantly
less sensation of pain (P50.001). After these contradictory results concerning the effects of music therapy
there is a need for further scientific analyses.

Alternative Systems of Medical Practice

Acupuncture
Acupuncture has been used in China for more than 2000
years. Specific anatomic parts of the body are stimulated
for therapeutic purposes. This can be done in the usual
way with needles, but practitioners may also use heat,
pressure, impulse of magnetic energy, burning by a
preparation of the herb Artemia vulgaris, electrical
stimulation or surface electrodes at acupuncture loci.

413

Acupuncture is based on the balance between Yin and

Yang. Treatment is aimed at reconstituting the normal
movement between these two opposites. The meridians
are considered as energy channels. Most treatments of
obstetrical and gynecological problems involve the use of
points on different meridians: spleen-pancreas located
on the inside of the ankle bone, conception, governing
or penetrating vessel.
Acupuncture may produce effects through several
different mechanisms. One hypothesis is that acupuncture
points have electrical properties that, when stimulated,
may alter the level of chemical neurotransmitters in the
body. Another hypothesis is that endorphins are released
due to activation of the hypothalamus. The effects of
acupuncture have also been attributed to alterations in
the natural electrical currents or electromagnetic fields
in the body.
The use of acupuncture for pain relief has given
equivocal results. Wallis et al. (18) in San Francisco
in 1974 found that 19 of 21 patients had inadequate pain
relief based on pain scores and none of the 21 subjects
was judged by investigators to have adequate analgesia.
Abouleish and Depp (19) in the USA in 1970 used
electroacupuncture and described relief of pre-existing
pain in 7 of 12 participants. The investigators, who found
the technique time-consuming, cited some disadvantages:
inconsistency, unpredictability and lack of completeness.
Hyodo and Gega (20) in Japan in 1977 in a study of
subjective and objective relief of labor pain in 32 women
described an improvement in
60% of 16 primiparous
women and 90% of 16 multiparous women. However,
all patients received systemic sedation. The authors
concluded that acupuncture is useful for delivery because
of its safety, despite erratic and less potent results
than conventional analgesic techniques. In Nigeria in
1986, 19 of 30 women (63.3%) given sacral acupuncture
by Umeh (21) indicated that they had adequate pain
relief by responses on a visual scale and did not request
another form of analgesia. Yanai et al. (22) in Israel
in 1987 evaluated electroacupuncture during the labor of
16 parturients. Fifty-six percent of the women reported
mild to good pain relief and 81% described increased
relaxation. The perceived positive effects led the authors
to believe that acupuncture should be pursued as an
additional method of pain control. In 1999, Lyrenas et al.
(23) in Sweden studied 31 primiparous women who had
received repeated acupuncture compared with untreated
women. Pain assessed on a VAS was not reduced in
women treated with acupuncture, and the acupuncture
did not reduce the need for analgesics during labor.
In 2002 Ramnero et al. (24) in Sweden reported
a randomized, controlled study in 90 parturients,
46 of whom received acupuncture during labor as a
complement or alternative to conventional analgesia.
Acupuncture significantly reduced the need for epidural
analgesia (12% vs. 22%). Patients in the acupuncture

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Alternative Approaches to Pain Relief During Labor

group reported a significantly greater degree of relaxation

compared with the control group. The authors considered
these results to suggest that acupuncture could be a good
alternative or complement for women who seek an
alternative to pharmacological analgesia in childbirth,
but further trials are required to clarify whether the
main effect of acupuncture during labor is analgesic or
relaxing. In the trial by Skilnand et al. (25), 210
parturients were randomly assigned to receive either
real acupuncture or false acupuncture. Real acupuncture
consisted of a treatment protocol from the Norwegian
School of Acupuncture. The same type and number of
needles were used not on the classic meridians. Pain was
assessed using a linear VAS (rated 010) recorded at 30,
60 and 120 min after treatment. There were significantly
lower pain scores at 30, 60, 120 min after treatment
(P50.001), and significantly less need for epidural
analgesia and intramuscular pethidine (P 0.01
et P50.001, respectively). Qu and Zhou (26) compared
in a prospective randomized study 20 primipara with
electro-acupuncture and 19 as controls. The electroacupuncture group was found to exhibit a lower pain
intensity and a better degree of relaxation than the
control group (P 0.018 and 0.031).
To summarize, acupuncture studies are difficult to
conduct and analyze for several reasons, including lack of
standardization with use of multiple acupuncture points,
and the difficulty of choosing a control group. Within
the control group the needles might be correctly placed
but not stimulated, or needles could be placed in
inappropriate sites. There were no reported complications
in any of the studies but there is a potential risk of
infection. To achieve a good analgesic effect during
labor, a relatively long induction period may be required.
It is difficult for a woman in labor to remain still for
1530 min, and some patients felt discomfort because
of the restrictions in movement.
Overall, a beneficial therapeutic effect on labor pain of
acupuncture is not certain. Better designed studies need
to be completed with, if possible, standardization of the
points used, and better control groups. However,
it should be recognized that the procedure is timeconsuming, and that the required training of patients and
personnel may be considerable.

lower back. Pressure against spots that are sensitive can

be particularly efficacious. Force is initially applied
during contractions and then continuously.
The purpose of the study of Chung et al. (28) is to
determine the effect of L14 and BL67 acupressure on
labor pain during the first stage of labor. A total of
127 parturient women were randomly assigned to three
groups. Each group received only one of the following
treatments: L14 and BL67 acupressure, light skin
stroking or no treatment. There was a significant
difference in decreased labor pain in the first group
compared with the two others.
A study of Lee et al. (29) evaluated the effects of SP6
acupressure on labor pain. 75 women in labor were
randomly assigned to either the SP6 acupressure (n 36)
or SP6 touch control (n 39) group using double-blinded
method. Labor pain was measured four times using VAS.
There were significant differences between the groups
in pain scores at all times following the intervention:
immediately after the intervention (P 0.012), 30 min
after the intervention (P 0.021) and 60 min after the
intervention (P 0.012). The total labor time (3 cm of
dilatation to delivery) was significantly shorter in the SP6
acupressure intervention group than in the control group
(P 0.006).
Homeopathy
Homeopathy involves the use of diluted substances that
cause symptoms in their undiluted form. According to
homeopathic theory, remedies stimulate the self-healing
mechanism. The amount of medicine prescribed is so
small that it often cannot be measured in molecular
amounts (30). We found no studies evaluating the
effect of homeopathic treatment on labor pain. Smith
(31) has reviewed cervical ripening and labor induction
by caulophyllum. There were no differences between
the homeopathy and control groups in a randomized,
controlled trial involving 40 women.
Manual Healing
Manual healing methods used today during delivery
include therapeutic touch and massage therapy.

Acupressure Systems

Therapeutic Touch

Acupressure is a descendant of Chinese manipulative

therapy in which points are stimulated by pressure, using
hands, fingers and thumbs (27). Acupressure supposedly
promotes the circulation of blood, the harmony of yin
and yang and the secretion of neurotransmitters,
thus maintaining the normal functions of the human
body and enhancing well being. Some midwives use
acupressure to release the pain of labor. Pressure is
applied simultaneously to both sides of the spine in the

The purpose of therapeutic touch in labor is to

communicate caring and reassurance. Painful contractions of the uterus can be treated by the application of
pressure with the hands to the womans back, abdomen,
hips, thighs, sacrum or perineum. Whether touch is
perceived as positive or not is dependent on who is
touching the patient: in one study, touching was
perceived positively by 94% of patients when they were
touched by a relative or friend, 86% by their husbands,

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73% by a nurse and 21% by a physician (32). Anxiety is

reported to be reduced in patients who receive reassuring
touch. In a retrospective study of 30 patients, 77%
experienced less pain when they were touched during
labor, and 40% reported less need for pain medication.
Massage Therapy
The practice of massage varies from the tickling massage
of kung fu to a firm massage. The effect of a gentle
massage of the periumbilical area by their partner was
studied in nine women compared with six who received
no massage (33). There was no significant difference
between the two groups in pain evaluated by means of
visual scale, and no difference in the time of use of
epidural analgesia for labor.
In a randomized controlled study by Chang et al. (34),
60 primiparous women expected to have a normal childbirth were randomly assigned to either the experimental
(n 30) or the control (n 30) group. The experimental
group received massage intervention comprising abdominal
effleurage, sacral pressure and shoulder/back kneading
during labor. In the massage group, the woman received
a 30-min massage during uterine contractions first by the
researcher and then by the partner during each of the three
phases of labor. The intensity of pain between the two
groups was compared in the latent phase (cervix dilated
34 cm), active phase (57 cm) and transitional phase
(810 cm). A t-test demonstrated that the massage group
had significantly lower pain reactions in the latent, active
and transitional phases.
Bioelectromagnetic Applications and Physical Methods
Transcutaneous Electrical Nerve Stimulation
TENS involves administration of low voltage electrical
stimuli through flat electrodes applied to the skin. TENS
units consist of a stimulator and two pairs of electrodes. The
upper electrodes are taped at the level of the tenth thoracic
to the first lumbar root and the lower pair at the level of the
second to fourth sacral nerves. The stimulator has two
channels for the two pairs of electrodes. Initial reports were
encouraging. Augustinson et al. (1977) (35) found that
among 147 women, 44% rated pain relief as good or very
good and 44% as moderate. Bundsen et al. (36) found
TENS to be especially beneficial for labor pain localized in
the back. However, a meta-analysis by Carroll et al. (37)
of 10 randomized, controlled trials in 877 women, 436
receiving TENS and 441 as controls, revealed no significant
difference in pain and the use of additional analgesic
interventions was not different between the two groups.
Sterile Water Blocks
Counter-irritation is the process by which localized pain
may be relieved by irritating the skin in the same

415

dermatomal distribution. For example, the uterus is

supplied by the lower thoracic spinal cord segments.
Some of these receive stimuli from the skin of the lower
back and the sacrum. Labor analgesia may be produced
by counter-irritation of this area. Irritation can be
achieved by intracutaneous injection of sterile water
papules over the sacrum with a fine needle. Lytzen
et al. (38) in Sweden noted instant and complete relief of
lower back pain in the first stage of labor in 83 women.
Pain relief lasted as long as 3 h. In some women, the
block was repeated. Half of the women required no other
form of analgesia. Martensson and Wallin (39) compared
in a randomized study pregnant women with severe labor
pain treated by injections of water intracutaneously and
isotonic saline subcutaneously injections (placebo). Labor
pain was significantly lower in the first group compared
with the placebo group (P 0.002 and 0.006). Labrecque
et al. (40) compared water blocks with TENS for the
treatment of lower back pain during labor. Women who
received the sterile water injections rated the intensity of
pain lower than did women in the TENS group.
Intracutaneous water injections are associated with a
sharp injection pain that lasts between 20 and 30 sec,
which some women find less acceptable than lower back
pain. This method may be an alternative for women who
have lower back pain during labor but wish to avoid
epidural analgesia.
Hydrotherapy
The popularity of undergoing part of labor in water has
increased dramatically around the world. The expected
benefits include pain relief and decreased use of analgesia
and anesthesia. Several studies have reported use of
analgesia for women undergoing labor in water, but
others have found no difference from control groups.
In a 1987 non-randomized, prospective, controlled study,
Lenstrup et al. (41) evaluated the effect of a warm
bathtub on 88 parturients, and found that cervical
dilatation rate and pain relief could be improved in
patients who had a bath during the first stage of labor.
In 1988, independent midwives used hydrotherapy in
which a clean bathtub was filled with warm water. The
clinical impression of practitioners who use hydrotherapy
is that their patients experience shorter and less painful
labor. Burn and Greenish (42) studied 302 women who
used a labor pool. Fifty percent of the primigravidas in
the pool group used pain medication, compared with
76% in the control group. Rush et al. (43) found in
a randomized study in 785 women that the tub group
required fewer pharmacological agents than the control
group (66% vs. 59%, P 0.06). Cammu et al. (37) in
a prospective randomized trial using a VAS showed that
absolute values of labor pain were not significantly
different between hydrotherapy and control groups.

416

Alternative Approaches to Pain Relief During Labor

In the Cochrane Pregnancy and Childbirth register (45),

eight randomized controlled trials (2939 women)
comparing bath tub/pool with no immersion during
pregnancy, labor or birth were selected. Women who used
water immersion during the first stage of labor reported
statistically significant less pain than those not laboring in
water. There was a statistically significant reduction in the
use of epidural/spinal/paracervical/analgesia/anaesthesi
among women allocated to water immersion during the
first stage of labor compared with those not allocated to
water immersion. There were no significant differences
incidence of an Apgar score less than 7 at 5 min, neonatal
unit admissions or neonatal infection rates.
Maternal satisfaction with this birth experience has
been measured and women report increased levels of
satisfaction, self-esteem, pain relief and relaxation with
immersion. Ruptured membranes have been discussed
as a potential problem in the use of hydrotherapy,
although in the study of Lenstrup et al. they were not
considered a contraindication. Odent (46) reported no
infectious complications in patients who gave birth in
water, even if the membranes were already ruptured.

Alternative Medications
Herbal Medicine
Herbal medicine is described as the use of plant materials
in medicine and food for therapeutic purposes. Various
herbal remedies are used during the prenatal period to
prepare the uterus and cervix for childbirth and ease
pain during labor and delivery.
In a study of the practice of a group of independent
midwives in Utah (27), specific herbs were used because
of their perceived actions and properties, in particular
a 5-week formula which is a combination of 10 herbs
used during the last 5 or 6 weeks of pregnancy. This is
said to facilitate birth. Some herbal remedies are used as
the principal method of managing pain and enhancing
endurance during delivery. Practitioners observed that
these herbal formulas had a calming and relaxing effect.
Labor pain can also be treated specifically with motherwort. The effect of raspberry leaf in facilitating labor in
192 multiparous women was studied by Simpson et al.
(47) in a double-blind, randomized, placebo-controlled
trial in Australia. Raspberry leaf was consumed in tablet
form from 32 weeks of gestation until labor. Contrary to
popular belief, it did not shorten the first stage of labor
but rather the second (mean difference 9.59 min), and
also lowered the rate of forceps deliveries (19.3% vs.
30.4%). The difficulty with herbal remedies is that few
have undergone scientific scrutiny, chemical isolation, or
extraction to identify the pharmacologically active agent
or to enable toxicity testing.

Aromatherapy
Aromatherapy uses essential oils extracted from aromatic
botanical sources to treat and balance the mind, body
and spirit (30). It combines the physiological effects of
massage with the use of essential oils. One of the
purposes of this method is to relieve anxiety and stress
and to help relaxation. Massage around the lower back
with jasmine, juniper, geranium, clary sage, rose and
lavender have been reported to provide subjective benefit
in labor.

Conclusion
Complementary and alternative medicine can be defined
as methods that are not currently part of the dominant
or conventional medical system. CAM exists because
conventional medicine can be limited in its ability to
provide relief and to meet patients needs. CAM
and conventional medicine share the responsibility
for applying evidence-based practice and for seeking
scientific proof to justify a planned intervention, as well
as the obligation to avoid harmful or useless practices.
For labor pain, most studies demonstrate the greatest
benefit during the beginning of the dilatation phase.
When women enter the active phase of dilatation or
during delivery itself, there is more need for additional
conventional analgesics. This suggests that complementary medicine may be useful for the early onset of pain or
as a distracter, diverting womens attention from the
source of pain. In some cases the number of parturients
who successfully use alternative methods is greater than
what would be expected from a placebo effect. In a few
cases the amount of pain medication was reduced but
this was not consistently true. The degree of success of
a method is correlated with the availability of support
staff in both educational and trial phases of the studies,
and necessarily in clinical practice. Whereas physicians
do not need to be experts in the management of
alternative therapies, they should at least possess some
basic knowledge of complementary medicine. In the
future, the demand for complementary medicine will
probably continue to rise. Care providers have to
facilitate informed choices through discussion of their
own experience and knowledge. One of the difficulties
for the physician is to identify studies sufficiently welldesigned to help them guide their patients.
This article is an update of a chapter in the book
complementary and alternative approaches to biomedicine with permission of the publisher (48).

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