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Relief of Pain During Labor Systematic Reviews of Five Methods

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Women's experiences of pharmacological and non-pharmacological pain relief methods for labour and childbirth: a qualitative systematic review

  • Claire Feeley1,
  • Victoria Hall Moran1,
  • Soo Downe1 &
  • Olufemi T. Oladapotwo

Reproductive Health volume 16, Article number:71 (2019) Cite this article

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Abstract

Background

Many women employ pharmacological or non-pharmacological pain relief during childbirth. Prove from Cochrane reviews shows that constructive pain relief is not always associated with loftier maternal satisfaction scores. However, understanding women'south views is important for good quality maternity intendance provision. We undertook a qualitative evidence synthesis of women'southward views and experiences of pharmacological (epidural, opioid analgesia) and non-pharmacological (relaxation, massage techniques) hurting relief options, to understand what affects women's decisions and choices and to inform guidelines, policy, and practice.

Methods

Nosotros searched 7 electronic databases (MEDLINE, CINAHL, PsycINFO, AMED, EMBASE, Global Index Medicus, AJOL), tracked citations and checked references. We used thematic and meta-ethnographic techniques for analysis purposes, and GRADE-CERQual tool to assess confidence in review findings. We developed review findings for each method. We and so re-analysed the review findings thematically to highlight similarities and differences in women'due south accounts of unlike hurting relief methods.

Results

From 11,782 hits, we screened full 58 papers. Twenty-4 studies provided findings for the synthesis: epidural (due north = 12), opioids (n = 3), relaxation (northward = 8) and massage (north = 4) – all conducted in upper-middle and loftier-income countries (HMICs). Re-analysis of the review findings produced five key themes. 'Desires for hurting relief' illuminates different reasons for using pharmacological or not-pharmacological hurting relief. 'Touch on on hurting' describes varying levels of effectiveness of the methods used. 'Influence and experience of support' highlights women'southward positive or negative experiences of back up from professionals and/or birth companions. 'Influence on focus and capabilities' illustrates that all pain relief methods tin can facilitate maternal control, but some found non-pharmacological techniques less constructive than predictable, and others reported complications associated with medication utilize. Finally, 'impact on wellbeing and health' reports that whilst some women were satisfied with their hurting relief method, medication was associated with negative self-reprisals, whereas women taught relaxation techniques often connected to use these methods with beneficial outcomes.

Conclusion

Women report mixed experiences of different pain relief methods. Pharmacological methods can reduce pain but accept negative side-furnishings. Non-pharmacological methods may not reduce labour pain only can facilitate bonding with professionals and birth supporters. Women need information on risks and benefits of all available hurting relief methods.

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Evidently english summary

For most women, labour hurting is the most severe pain they will ever experience. Women regularly use medications and/or natural methods for labour hurting relief. We searched for published studies on women's views and experiences of epidurals, opioid injections such as pethidine, relaxation and massage techniques. We included 24 adept quality studies, all from high and centre-income countries (HMICs). Nosotros adult review findings for each method. We then examined differences and similarities in women's experiences of different hurting relief methods. 'Desires for hurting relief' highlights the different reasons women give for choosing medications or other approaches. 'Impact on hurting' describes how the techniques either were or were non effective in reducing labour pain. 'Influence and experience of support' highlights women'southward experiences of positive or negative back up from professionals and/or nascency companions. 'Influence on focus and capabilities' describes that while all hurting relief methods could help women feel in control, some constitute the natural methods to be less constructive than anticipated, and others disliked complications they experienced after using medication. 'Impact on wellbeing and wellness' reports that whilst women could be satisfied with their pain relief method, some who used medication felt guilty, whereas women taught relaxation techniques oftentimes continued to employ these methods with benefits for women/infants. These findings highlight that women accept mixed experiences of different pain relief methods, and that they need information on risks and benefits of all available pain relief methods.

Background

For many women, the pain they experience during labour and childbirth will exist the near astringent form of pain they accept ever experienced [1]. Pain is considered to be a unique and individual experience. Accounts vary from pleasurable to unbearable, with both extremes sometimes reported to occur meantime [2, 3]. Women'southward perceptions of hurting are affected by physiological (e.g. birth position) and/or psychological issues (eastward.one thousand. fear, anxiety) [4], and the quality of the woman-provider relationship [2]. Some women cope well with labour pain without any intervention, whereas others require pharmacological and/or non-pharmacological methods for pain relief [5]. Effective pain management has get an essential component of the intendance plan for childbearing women.

Globally, pharmacological interventions are oft used during labour and childbirth. Epidural analgesia is regarded to be an effective class of pain relief [5], however, it is not necessarily associated with a positive experience of birth [6]. In addition, this course of hurting relief is expensive, tin subtract women'southward feelings of control, delay 2d stage of labour and increase the likelihood of farther interventions (such as instrumental nascency, and caesarean section) [6]. Some other ordinarily practical pharmacological method is opioids, particularly pethidine [7]. This method can assist women relax and cope with pain due to potent uterine contractions, but unlike an epidural, enable women to retain mobility. Nonetheless, unwanted side furnishings include nausea, sedation and a negative impact on women'south ability to safely breastfeed their infant [8], and multiple doses can atomic number 82 to the aggregating of metabolites, such as normeperidine, associated with narcotic-induced depression in infants [9].

Non-pharmacological pain relief methods associated with relaxation and massage are referred to as mind-body interventions [5]. Relaxation methods such as yoga, music and animate techniques, and unlike forms of massage (eastward.g. shiatsu, reflexology) are designed to induce at-home and to distract/alleviate pain in labouring women. Trials of relaxation techniques during labour accept reported less intense pain, increased satisfaction with pain relief and childbirth [v], and lower rates of assisted vaginal birth [x], without any agin outcomes [5]. However, there was a large variation in how these relaxation techniques were practical [eleven]. A Cochrane systematic review [5] identified relaxation and massage methods as safe and not-invasive, based on depression quality evidence.

In 2016 the World Wellness Organisation recognised the importance of shaping new antenatal guidelines through finding out what mattered to pregnant women [12]. This piece of work involved quantitative systematic reviews to inform the safe, efficacy and cost of antenatal interventions, together with qualitative prove syntheses relating to the views and experiences of service users and service providers to inform the values, equity, and acceptability components of each guideline recommendation. A similar mixed evidence approach has been used for the forthcoming WHO intrapartum guidelines for healthy women and infants.

This written report was conducted to support guidance on pain relief as part of prove base of operations training for the WHO recommendations on intrapartum care for a positive childbirth experience. A qualitative prove synthesis that comprised four split searches into women's views and experiences of pharmacological (epidural and opioids) and non-pharmacological (relaxation and massage techniques) pain relief methods used during labour and childbirth was undertaken. Here we report the review findings of each pain relief method. Further analysis of the review findings to highlight similarities and differences in women's experiences of pharmacological or non-pharmacological pain relief methods is too presented.

Methods

This review was informed by four separate searches into women's experiences of using epidurals, opioids, massage and relaxation. Our methods incorporated a pre-designed search strategy, quality appraisal techniques [13], and an assessment of confidence in the findings using the GRADE-CERQual tool [fourteen]. Data assay was carried out using thematic [15] and meta-ethnographic techniques [16].

Reflexivity

Quality standards for qualitative research and qualitative bear witness syntheses ideally include writer reflexivity prior and during the research process [17]. Therefore, the authors considered their views and opinions on methods of pain relief from women's perspectives. All authors believe in endeavours that support women to accept a positive nativity experience. While all authors take concerns most rising intervention rates, we consider it of import for women to have their individual needs met, whether that is access to pharmacological pain relief, or not. We believe that women's individualised needs are all-time served through respectful, meaningful relationships with caregivers who are able to respond and deliver pain relief methods as required.

Search strategy

Searches were adult using a population, exposure and outcome (PEO) strategy (see tabular array i). Search terms related to study blazon was added if the hits from the initial search exceeded thousand. These terms were designed to identify studies that had a specific qualitative focus or mixed-methods studies that included a substantial qualitative component. We developed search terms post-obit a priori scoping exercises in titles and abstracts, adapted for specific database compages. Table 1 details all the search terms. We searched MEDLINE, CINAHL, PsycINFO, AMED, EMBASE, Global Index Medicus, and AJOL (for studies conducted in Africa). Additional search strategies included commendation tracking and reference checking.

Tabular array ane Details of PEO search terms used in all four searches

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Inclusion/exclusion criteria

No linguistic communication restriction was imposed. Papers not in English were translated via Google translate where possible. Only papers that reported the views and experiences of healthy women who had experience of using at least i of the four methods of interest were included. Studies published before 1996 were excluded, to ensure the findings reverberate current service provision, since epidural analgesia, in particular, was not commonly used before the mid 1990s. Nosotros also excluded studies of hypothetical views of hurting relief, the views and experiences of partners or healthcare providers, and populations of women with complications.

Study selection

Searches were carried out during June–July 2017. GT screened the initial hits (title and abstracts) confronting the inclusion criteria. Total texts were blind screened past GT and CF, and inclusion agreed past consensus. Where there was disagreement, a third writer (VHM) screened the text, later on which concluding consensus was reached.

Quality cess

All eligible papers were quality appraised using an instrument adult by Walsh and Downe [17] and modified by Downe, Walsh, Simpson & Steen [xiii]. The framework was used to assess studies against pre-defined criteria, and and then allocate a score from A-D (Table 2). Only studies that scored C- or higher were to be included in the concluding analysis.

Table 2 Scoring criteria for quality appraisement

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Data analysis

Data analysis was carried out in ii stages.

Stage ane

Nosotros used a general thematic approach [15], meta-ethnography [16], and CERQual (Confidence in the Evidence from Reviews of Qualitative Inquiry [14]. All belittling stages were undertaken individually and then together by GT and CF. All decisions were shared and discussed with all members of the review team. Data were logged on excel.

We undertook an initial reading of each paper to identify relevant sections of text reported in quote textile, author themes and statements ('starting time gild constructs') [15]. These were then grouped into descriptive themes ('second order constructs'). During this process, nosotros used meta-ethnographic [15] techniques to identify what was similar ('reciprocal data') across the included studies, and what contradicted our emerging assay ('refutational data'). Nosotros reframed the themes as the analysis progressed, to account for both reciprocal and refutational data as we identified it. We and then translated the themes into Summary of Findings statements. These were assessed for confidence using the GRADE-CERQual [fourteen] approach, in which the studies that contribute to each summary of findings statement are assessed for methodological limitations, relevance to the review question, coherence in terms of whether clear patterns across the studies could exist identified and adequacy with regard to the coverage of the elements of the review finding, and of the geographical area/contexts it related to [xiv]. Following an assessment of the four criteria, each review finding was graded for confidence on a scale of 'loftier', 'moderate', 'depression', or 'very low'.

Stage two

The results of the start stage indicated that there were primal areas of convergence and divergence in women'south experiences of unlike pain relief methods. We considered that a comparative focus would enable a deeper agreement of how varying methods of pain relief are experienced, and how those experiences are internalised psychologically over time. During this phase, we used a basic thematic approach [14] to re-analyse all the commencement-order constructs into key themes that compared and assorted women'due south accounts of different pain relief methods. Assay was initially undertaken past GT and CF, with all decisions shared and agreed by all authors.

Results

The pharmacological pain relief searches generated 5914 hits (run into Fig. 1 for PRISMA). Post-obit screening and quality appraisal 12 studies met inclusion criteria for the epidural review (north = 1507 women). Studies were undertaken in USA (n = 7), U.k. (n = 2), Denmark (n = i), New Zealand (due north = 1) and Canada (n = ane)). Three studies were included in the opioids review (n = 412 women) undertaken in the Great britain (n = one), Australia (n = 1) and S Africa (due north = 1). One of the studies contained information relevant to both reviews [18]. I written report was unable to be translated [19]. We also excluded three studies that scored a D rating at quality appraisement [twenty,21,22]. The included studies were of mixed-methods (n = one), general qualitative (due north = 7) or phenomenological (n = i) designs, and five nerveless qualitative data through open text questions on a survey.

Fig. ane
figure 1

PRISMA Diagram Epidurals and Opioids

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The non-pharmacological review generated 5868 hits (come across Fig. 2 for PRISMA). Post-obit screening and quality appraisal, 4 studies were included in the massage review (n = 94 women). Studies were undertaken in Commonwealth of australia (n = one), Brazil (n = 1), UK (due north = 1) and Sweden (n = one). Eight studies were included in the relaxation review (n = 99 women) undertaken in Australia (n = two), Brazil (n = two), Turkey (n = one), Canada (north = 1) and Us (n = 2). 2 contained information that were relevant to both reviews [23, 24]. Two of the studies translated using Google interpret were comprehensible in English, and suitable for inclusion [25, 26]. The included studies were of mixed-methods (n = 3), full general qualitative (n = 3) or phenomenological (n = one) designs and the remaining studies nerveless qualitative data every bit part of a feasibility study (n = 1) or through open text survey questions (n = 2).

Fig. 2
figure 2

PRISMA Diagram Massage and Relaxation

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Study characteristics and quality ratings for the four hurting relief methods are presented in Tabular array iii. Apart from iii studies undertaken in an upper-heart income state (Brazil (northward = 2), South Africa (northward = 1)) the remaining studies took identify in a high-income context.

Table 3 Study characteristics and quality ratings for all included studies

Full size tabular array

The Summary of Findings and CERQual ratings for each pain relief method from phase i analysis are detailed in Table 4 (full CERQual assessments are available on request). The themes arising from stage ii analysis are mapped to these Summary of Findings statements and are discussed in detail in the adjacent section.

Table 4 Review findings and CERQual ratings

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Themes arising from phase ii analysis

Five themes emerged from stage two assay. Theme 1 ('desires for hurting relief') illuminates dissimilar reasons for using pharmacological or non-pharmacological hurting relief. Theme 2 ('bear upon on pain') describes varying levels of effectiveness of the methods used. Theme three ('influence and experience of back up') highlights women'southward positive (pharmacological/non-pharmacological) or negative (pharmacological) experiences of support from professionals and/or birth companions. Theme 4 ('influence on focus and capabilities') illustrates that while all pain relief methods could help women feel in control, some plant non-pharmacological techniques less constructive than anticipated, and others disliked complications associated with medication utilize. The final theme ('impact on wellbeing and wellness') reports that whilst some women were satisfied with their pain relief method, medication was associated with feelings of guilt and failure, whereas women taught relaxation techniques often connected to apply these methods with benign outcomes. These themes are discussed in more than item below.

Desire for pain relief

Some women made the conclusion to have an epidural analgesia (EA) in labour while they were pregnant [18, 27,28,29,30,31,32]. This decision was based on a woman's previous positive experience of EA [33], or a negative feel of a medication-gratuitous labour:

'I'm not into hurting, I wanted an epidural. I spent most of the time screaming, "I want an epidural; I'm not doing this, I'thousand going domicile!" I gave nascency completely natural with no medication whatsoever, and I was hysterical. I did not want that. I don't similar pain, and it hurts very bad, and I don't understand why whatsoever adult female would desire to birth naturally' (p.xxx) [28].

Other pre-nascency desires for an EA related to the letters received via the media, health professionals (due east.g. at antenatal classes) or social network members. Stories of insufferable pain or complications instilled fear, where women felt 'warned to have [an] epidural' (p.seven) [18]. Whereas positive accounts provided encouragement [28,29,xxx]:

'I heard from a adult female who had a childbirth before than me and had an epidural. A (Japanese) adult female who experienced epidural anesthesia told me that it was comfortable and the experience was good. Then I was wondering if I should try it for my second infant' (p.313) [29].

The widespread availability of EA (and associated perceptions of prophylactic) too served to normalise EA equally an expected and prophylactic intervention [28, 29, 34, 35]:

'I think like 75 or 85 percent of women have epidurals now. Ok? It's pretty mutual to accept epidurals, and they talked a lot most information technology... That definitely opened my eyes to considering an epidural' (p.191–192) [35].

Common reasons for a pre-birth desire for EA were fear of hurting, a need to remain in command and wanting a pain-free labour [18, 27, 28, 31, 34]:

'I don't similar pain every bit any human being, and if I can avert it without harm to my baby I did just that' (p.328) [27].

For other women their decision to accept an EA [27, 29, 32,33,34, 36] or opioids [37] was made during the intrapartum flow. These women opted to receive medication at a critical bespeak in their labour when they felt out of control, depleted of energy, and the level of pain was intolerable and unmanageable:

'…I was just like almost on the flooring, similar it [the pain] was really bad…you don't want to overreact, simply it is so much pain that y'all do non know what to do' (p.473) [33].

The relaxation and massage studies did not generally describe why women sought these methods of pain relief. This was often considering participating women used/were taught these methods as role of their involvement in a research study. All the same, a woman from Klimi et al'south [26] music therapy study offered a unlike perspective than those who planned to use an EA. She described how music coalesced with her desire for a tranquil, intervention-free nascence:

'I wanted a familiar environment with my ain people, music, tranquillity….Permit my infant come to life calmly, without medication and, of course, with a normal childbirth' (p. 300) [26].

Overall, in that location were similarities and differences in how the unlike methods of pain relief influenced women in the pre-birth menstruation. For some women, knowing an EA was available helped to alleviate fears and provided a sense of reassurance [18, 33, 34]:

'A good matter [in New Zealand] is that an epidural is right there as an pick. In Japan, Since the place I lived was in the country, there was nowhere and no infirmary to practice such a affair. I was thinking that I really did not want to give nascency in Japan because I was sensitive to pain' (#9 p.123) [34].

Similarly, women who received antenatal grooming in massage and/or relaxation methods referred to how knowledge of these pain-relief methods provided a sense of relief [23, 24]:

'I think for me it was the acupressure, knowing that in that location was something that could assistance without drugs or an epidural' (Mia, p.128) [24].

Grooming in the use of non-pharmacological techniques enabled women to experience 'prepared', 'calm' and 'empowered' for childbirth [24, 38, 39]:

'So I found that this workshop [MBCE] gave me a lot more empowerment and a lot more information about alternate courses of action and unlike scenarios, and then I'd exist prepared [during labour]' (mother 3, p.vi) [39].

Some women used the relaxation techniques in the antenatal period to reduce childbirth fears: 'When I got actually worried about the birth, I would but breathe to terminate my listen from going all sorts of bad places' (p.198) [38]. Whereas women who had fabricated a decision for an EA worried near needle placement, ineffectiveness and negative implications [28, 29, 33, 35, 36]:

'I recollect worrying considering of what I heard about the use of a big needle, and the risks and complications' (p27) [36].

Impact on hurting

Overall, there were alien accounts on the effectiveness of the different pain relief methods in alleviating pain. A number of studies reported that EA [18, 27, 30, 36, 40] and opioids [41] had a positive influence on pain. One report [41] involved interviews with women who had been randomly allocated to three different forms of opioid-based pain relief; intramuscular pethidine, intranasal remifentanil and subcutaneous fentanyl. Some women from each of the different intervention arms expressed how the medication had had a positive impact on hurting and/or shortened and reduced the intensity of the contractions. Patient-administered medication enabled women to feel in control over their labour pain [33, 41].

In contrast, others stated that the EA [27, 33, 35, 40] or opioids [18, 37, 41] had been ineffective. Negative accounts of pethidine were reported beyond all the studies (n = 3) – where women described it as 'useless' and how '[it] did not work' (p.6) [18]:

'When I get the hurting and then I recall to myself I got the injection [pethidine], why am I still getting pain' (p.87) [37].

Some women in the Fleet et al. [41] report did non observe the intranasal fentanyl to be helpful in managing their labour pain, just when women compared intranasal fentanyl with their experience of intramuscular pethidine, they reported that intranasal fentanyl was more constructive:

'I felt actually out of it. At the fourth dimension I wasn't certain if the intranasal fentanyl was still helping but after using the Pethidine I was more aware that it had been, without causing the high or sedation' (p.eighteen) [41].

Some of the difficulties associated with pharmacological methods related to women experiencing pain at needle citation [40], quantum pain (i.e. where women proceed to feel pain or pressure following EA citing) [33], the half-life of the medication [35, 40, 41], and epidurals needing to be placed more than in one case [35, 40]. Other problems related to delays in receiving the medication, or the medication being provided besides late to exist effective [33, 40]:

'I was hoping to get [the epidural] right away, but when they told me 30 minutes, I surrender…so I started to scream' (p. 473 multiparous) [33].

Variations in effectiveness of non-pharmacological methods in reducing labour pain was also noted. Some women who used relaxation and/or massage [23, 25, 26, 38, 39, 42,43,44] techniques reported how these methods helped to make the pain more bearable. Women who received music therapy highlighted how 'it hurt less' (p.445) when the music was playing and how their pain increased during the planned two-h non-music intervals [43]. Massage techniques also helped to reduce the contractions and make them easier to manage and provided women with a 'lifeline' to cope:

'Where the pains overwhelm me and I experience like falling into a void and getting lost, the music was exactly similar this: A lifeline that somewhere I was saying, say, something I recognized, gave me strength and I continued ...' (p.302) [26].

All the same, a few women in the non-pharmacological studies reported how these methods had been less effective than anticipated [23, 44, 45]: '[but toning - extended vocal sounds on a unmarried vowel] did not feel as effective every bit I'd hoped during labour' (p.221) [44]. Difficulties related to the intensity of the pain, and subsequent loss of control; 'No, no control… intense pain, emotionally exhausted; I was non in control at all' (p.4) [23]. Other criticisms related to the volume of the music (i.east. not loud plenty), or music stopping at crucial points [26, 42, 43]. Women in 1 written report [26] besides complained of distractions when hearing sounds other than the music, e.k. traffic.

Influence and experience of support

Some of the women who received EA valued the fact that wellness providers had respected and supported their pain relief choice [28,29,30, 33, 35, 40]; a position considered important to prevent against maternal guilt:

'Actually the nurse and the physician came by a few times and because they say I was really suffering, they said "Y'all know if you want it (the epidural) information technology'south okay". I thought that that was wonderful. It makes you feel better, 'cause I remember there is often a tendency to make you feel guilty…You lot are the one, you know, going through the labour'. (p. 474 multiparous) [33].

Nevertheless, others reported on how healthcare staff had 'hounded' or pressured women into having an EA [27, 28, 34, 35, 40], such as through instilling unnecessary fears:

'But my midwives recommended that I should use epidural by telling me that I had been doing my best and that the baby's health is the most of import although the babe had not shown whatsoever problems' (p.123) [34].

In Morris & Schulman'south [35] study they report how women from an indigenous minority background and low education were more probable to experience 'pressure' from clinicians to receive an EA. This was due to being more likely to be induced, and through offering 'false' choice: 'The nurse asking me – did I desire to go accept a C-department or get the epidural shot?' (p.193).

Women inside the pharmacological and non-pharmacological studies reported how standard, traditional pre-natal classes focused on, or promoted medication [xviii, 28, xxx, 35]. At that place were also occasions of a lack of consent in the pharmacological studies. A woman who received pethidine in Jantjes et al.'s study [37] stated; 'the doctor just walked in and said they are going to give me an injection' (p.87–88). While some women felt well informed about procedures and risks for EA utilise [29], for others, this information was lacking [28, 32, 34, 36, 40]:

'My blood pressure dropped. The baby's center rate dropped to [the] seventies. I've heard a lot about epidurals from television and friends, only I didn't know that could happen' (p.29) [36].

Accounts of women feeling pressured or ill-informed were not evident within the non-pharmacological studies. There were, however, variations in how the pain relief methods influenced women-nascency supporters' relationships. Women who used relaxation or massage techniques frequently recounted how these methods had encouraged and enabled connections with their healthcare providers and/or birth companions [24, 25, 38, 39, 42,43,44]:

'I felt very connected to my partner, the class taught u.s.a. how to work as a team and be fully present in the moment and that connectedness got me through commitment and the postal service-partum period' (p.198) [38].

Not-pharmacological methods appeared to facilitate teamwork, a 'bail', with their nascency companions, which in turn induced a sense of security, calmness and being cared for [23,24,25, 38, 42,43,44,45]; 'Information technology was felt that I was not alone and I felt more relaxed' (p.12) [25].

Some women using pharmacological pain relief reported positive interactions with caregivers and birth companions following administration of analgesia [32, 36]. More commonly, were accounts of negative women-provider relationships. Some women blamed their pick of pain relief (i.east. EA) on insufficient nursing back up [33]. Other women expressed negativity due to: lack of caregiver support for their choice of hurting relief [32, 33]; existence reliant on staff to administrate ongoing pain relief [40, 41]; or how it had alienated them from their intendance providers [36, 37, 40]. Some expressed that interactions with care providers became more than distant afterward they chose to receive pharmacological pain relief, especially when there was no continuity of care; 'The second midwife, she came in when I was totally doped – there was no contact' (p.101) [32]. These experiences thereby indicate how the use of medication replaced the availability of personal intendance:

'I didn't want to keep anymore every bit I was alone and there was nobody to back up me…..I needed somebody at that time only to concord onto' (p.87) [37].

Influence on focus and capabilities

Overall there were like accounts in women's experiences of the different pain relief methods in how they had enabled them to relax, feel calm, and in control [eighteen, 23,24,25,26, 28, 30,31,32,33, 36, 38, 39, 41,42,43,44]:

[in context of receiving an EA]'You're kind of euphoric for a 2nd. All pains are gone. You aren't tensed upward anymore. You are relaxed and feel so much ameliorate. You tin can all the same feel some pressure level of contractions, but you don't have constant pain going through your entire body' (p.27) [36].

'Information technology [mindfulness] provided me with....a sense of at-home and a sense of being in control, even though everything around me was out of control' (p.vi, mother 7) [39].

A means to eradicate or manage their hurting enabled women to rest and to restore and re-focus their energy [23,24,25,26, 32, 33, 41]; 'Mayhap information technology [epidural analgesia] was a regain of command – I got new energy' (p.100) [32]:

'While I was pushing, once the tone got loftier and frantic. I could tell that I was tensing and non relaxing. Bringing the tone down low and slowing information technology downwardly helped me feel relaxed and open again' (p.220) [44].

A number of the women, irrespective of the pain approach used, considered that their pain relief method had been crucial for them to achieve a vaginal birth [18, 27, 30, 36, 43,44,45]:

'I would never have washed information technology [given birth] without the epidural' (p.6) [18].

'I could non accept done what I did without music' (p.445) [43].

A key deviation between the pharmacological and not-pharmacological methods concerned how they directed women's attention, focus and capabilities. From a negative perspective, pharmacological methods were reported to have 'slowed the labour down' [41]; negatively impacted on women's ability to push button [27, 40, 41] and for women to feel disconnected from the infant and childbirth [32, 41]. For some women, a lack of mobility (following EA citing) induced discomfort, anxiety, fear [33, 36], whereas pethidine led to cognitive distortions [37, 41]:

'The Pethidine knocked me out, didn't help with the pain. Made me slumber between contractions but wasn't a proficient feel' (p.18) [41].

Pharmacological hurting relief acquired side effects such as nausea, numbness, itching, coldness and a decrease in claret force per unit area [33, 37, 40, 41].

However, when EA was effective, some women described how they were able to focus on the external surround. Once women'due south physiological and emotional responses had been stabilised, they could observe what was happening, focus on the baby, and regain participation [28, 31,32,33, 36]:

My body was only concentrated in pain. It was almost like I was not in the present. In one case the pain was gone, I was able to concentrate on [the experience], concentrate on my husband, my sister, my nurse, the doctor. I could hear what [they] said, and [understood] what I needed to do. I do not recollect all those things would have been possible without the epidural.' (p.28) [36].

While massage techniques could non always be effectively applied, e.chiliad. due to maternal position [23], women who used non-pharmacological methods recounted how the techniques provided a lark that enabled women to 'face up up to' (p.40) [45] and 'release into the hurting' (p.221) [44] and manage their contractions. Their focus turned in equally they flexibly and actively worked with their bodies through using taught or adapted techniques [23,24,25, 42, 44, 45]:

'The breathing exercises, the massages, the baths, and then, I did everything, and the positions I adopted… Because if I only stayed lying downwardly, and so the hurting felt fifty-fifty worse; then when I sat upward in that butterfly position or with my two anxiety together, I could put more effort into it when it contracted, and with my animate, I could relax, and when I was able to relax, the pain was less. (24 years old p.4) [23].

Touch on wellbeing and health

Many of the women who used pharmacological or non-pharmacological methods expressed positive feelings towards their chosen method. Some women who used pharmacological pain relief reported how their fears had been unfounded [28, 36] and expressed gratitude every bit EA had enabled them to enjoy their birth experience [27, 30, 31, 33, 36, 40]. For women who received non-pharmacological pain relief, this was expressed as feelings of control, joy and empowerment [23,24,25,26, 38, 39, 42, 44, 45]. However, some women irrespective of which method of hurting relief used reported more ambivalent responses, albeit for unlike reasons. For case, a few women who used medication reported how their initial disappointment eventually dissipated into acceptance [32, 34, 36, 40]:

'I originally wanted to give birth without an epidural, only inverse my heed about fourteen hours later on labor began. For a while I felt a little guilt about "giving in" but came to realize that each labor is dissimilar and a "woman's got to exercise what a adult female's got to practice"' (p.6) [40].

Whereas one adult female in Kimber'southward [45] study held a more equivocal opinion in that while the method had helped her to manage their hurting, she had been unable to keep its utilise due to labour complications:

'Very useful as a ways of pain relief. Used for the commencement ten hours with breathing techniques as the sole means of relief. Information technology proved very good and I feel it would accept been possible to rely on massage, had I non failed to progress for the entire labour'. (nullipara p.twoscore) [45].

Yet, dissimilar the experiences reported in the not-pharmacological studies, a number of women who used medication reported negative self-reprisals, such as feeling guilty and a failure [32,33,34, 37, 41], which for some, every bit reflected by a Japanese mother, was related to pharmacological methods not being her cultural norm:

'….I cried because of guilt to the midwife and my married man. I felt similar "I am sorry I did not endeavor hard enough" and "I am pitiful I failed"' (p.123) [34].

Some of the women who had used an EA every bit a method of pain relief referred to ongoing 'dorsum problems' [27] and held fears over potential future complications [33]. One adult female who had used pethidine also reported how it had affected her postnatal memory recall:

'Don't even call back the early on menses after birth, looked at photos and didn't remember it happening' (P.137, p.18) [41].

A stark point of difference between the hurting relief methods related to how mothers connected to use the relaxation techniques in the postnatal period, with positive impacts for mothers and infants [26, 38, 39, 42, 43]. Women referred to how they used the techniques to help deal with the demands of new motherhood:

'I take also used mindfulness to observe when emotions crop up such equally feeling overwhelmed, sad, or resentful of my husband equally he sleeps and I become up in the wee hours to nurse. Instead of reacting to these emotions I'm able to just note them in a not-judgmental fashion. From there I tin can either call back through what fabricated me feel that style or bring them upwardly and talk with my husband about them' (p.198) [38].

Women within the music studies also referred to how music was used as an effective means to settle and soothe their baby [26, 42, 43], and to facilitate breastfeeding:

'yesterday, she wouldn't latch on properly, and she was a lilliputian, um, finicky, and we put the music on and right away she latched on, she fed, she had a good feeding and so she went to sleep right away. Information technology was great! It was astonishing the divergence information technology made to her…' (p.275) [42].

Give-and-take

Overall, the findings revealed mixed experiences of the pharmacological (epidurals and opioids) and non-pharmacological (massage, relaxation) methods of hurting relief included in the review. In terms of pharmacological pain relief, planned utilise of these methods in labour was initiated by negative previous experiences of labour pain past some, and by positive previous experiences of using these methods past others. Some did not plan to use these methods when they were pregnant, only did and so once in labour. This was sometimes related to the unexpected intensity of labour pains, merely it was notable that women using these methods were more likely to recount negative experiences of health provider support. Given the association between labour back up and decreased labour pain that is evident in clinical trials, poor caregiver back up, in contrast, could be a factor in unanticipated demand for pharmacological hurting relief. Women in this group were as well more likely to study feelings of guilt and failure due to their unexpected demand to use medication for labour pain relief. Many of the women who used non-pharmacological methods more likely to express behavior aligned with a natural physiological arroyo, and their accounts suggested that they felt prepared for childbirth. In dissimilarity to the women using pharmacological methods, those who used non-pharmacological techniques referred to how these methods encouraged and facilitated positive support from wellness providers and birth companions. Pharmacological and non-pharmacological pain relief methods had the potential to assistance women experience in control. However, women reported negative effects of both. Some women who used using relaxation/massage techniques reported them to be less effective than anticipated, but others who had been taught relaxation methods connected their employ in the postnatal menstruum, with reported positive effects for themselves, their babies and/or their families. Overall, the findings offer some support to the contempo effectiveness systematic review of reviews of methods for labour pain relief [5] in which, while epidurals were the about effective arroyo to alleviate pain, they were associated with more agin effects, and lower rates of satisfaction. In the aforementioned review, while relaxation/massage techniques were not necessarily effective for pain relief, they were more likely to be associated with other positive outcomes.

The strengths of this study are that a comprehensive and rigorous search strategy was undertaken. We too took care to capture and reverberate variations across the studies, such as through including non-English papers. While a qualitative evidence synthesis is an interpretative process, the adventure of over or under estimation of the data was minimized through author reflexivity to ensure that personal beliefs and values did not obscure important data within the included studies, and through rigor in study selection and analysis. There were however limitations. Outset, the review focused on specific hurting relief techniques, and others e.g. acupuncture, sterile water injections were non included. There is no guarantee that nosotros captured all published studies in our search strategy. We found few studies that related to women'south experiences of opioids [eighteen, 37, 41] or massage techniques [23,24,25, 45], and none of the studies were undertaken in depression-centre income countries. Furthermore, every bit only four of the included studies were published in the final five years, this suggests that more gimmicky insights should be sought. Some of the relaxation/massage studies also combined different techniques, which fabricated it challenging to differentiate between the approaches. Few studies focused upon women from marginalised populations i.e. low didactics, teenage parents, ethnic minorities, thereby limiting the generalisability of the findings.

Our findings support those of others that coping with the pain of childbirth is circuitous and multifaceted [46]. In our review, while all the included studies were from upper-middle/high income countries where the utilize of pharmacological methods of hurting relief is common practise, we identified a wide range of preferences for pain relief. In particular, at that place was divergence between those who did and who did not plan to utilize medication in labour. Some women appeared to hold an uncritical acceptance of epidural analgesia, due its widespread utilise and associated perceptions of safety [27,28,29,30, 32,33,34,35]. Utilize of pharmacological pain relief was associated with increased control by some [27, 28, 30, 31, 34, 41]. Acceptance of intrapartum interventions that reduce and control the uncertainties and discomfort of childbirth has been described in other studies [31, 47,48,49]. However, as Lally noted [31], in this review, many of those who preferred not to use pharmacological pain relief ended up with it anyway, and this group of women were peculiarly likely to limited feelings of guilt and failure. Women's attitudes towards technical solutions for pain relief are inevitably influenced past cultural norms that value technological progress, and that nowadays detail solutions as mainstream and freely available.

Where the methods used fitted with the a priori frame of reference of the woman, or where they accepted that the uncertainties of labour were the basis for using methods they might not accept chosen, women seemed to find whatever method(s) they used effective in enabling them to relax and regain a sense of control over the nascency. However, there were notable differences between the hurting relief approaches related to how they directed women's attending and focus. Pharmacological methods, particularly when effective, enabled women to focus on the external environs to antipodal with others and observe their labour progress objectively [28, 31,32,33, 36]. In contrast, non-pharmacological methods were associated with an internal focus, in which the women seemed to be more actively engaged with and responsive to their body as it experienced the dynamic physiological responses of labour over time [23, 24, 42, 44, 45]. As Leap et al. accept noted, this is the deviation betwixt 'pain relief', and 'working with pain' [50].

A key finding from our review was how the demand for/availability of social back up differed for women using medication and those who used other methods. Specifically, our findings extend those by Jones et al. [5] in that the efficacy and satisfaction of the chosen methods related to the quality of the female parent-midwife relationship. In our review, women reported mixed feelings regarding their caregivers in relation to their decision to have an epidural and/or opioids. Some women who received medication felt supported in their choice [28,29,30, 33, 35, twoscore]. However, more than unremarkably in that location were complaints of women feeling pressured to receive medication, lack of consent/data on risks, tension due to opposing women-provider views of medication use, or women being left unattended subsequently medication assistants [27, 28, 32, 34,35,36,37, 40]. Relaxation and massage techniques, on the other hand, facilitated meaningful and continued women-provider relationships [24, 38, 39, 42,43,44]. This approach aligns with a midwifery philosophy of continuous, woman-centred care [51] to facilitate the biopsychosocial physiology of childbirth [12]; with maternity professionals who utilize complementary therapy approaches referring to how they promoted confidence and pride in their profession [24, 52, 53]. Equally relational intendance, and in particular, continuous intendance during labour is associated with positive outcomes (increased vaginal births, fewer interventions, fewer pharmacological pain relief) and increased levels of women'south satisfaction [54, 55], it should be provided irrespective of the type of pain relief method used. Efforts to promote labour support may aid to better women's coping skills [46, 56, 57], and helping women to avert medication if this is their preference could also result in clinical benefits for the mother and/or baby [26, 39, 42, 43]. While farther research is needed, the insights suggest that not-pharmacological methods, fifty-fifty in combination with pharmacological methods, could be beneficial for women and providers.

Survey information from low income settings bespeak that women'due south access to and cognition of pharmacological hurting relief is low [58,59,sixty]. Where women do know about these options, similar variation in values and beliefs are evident as in the electric current review. Some women believe in the need for effective pain relief [58, 61], and others placed intrinsic value on the feel of 'natural' childbirth [59, 60]. Our findings from high and middle income settings, and those for low income settings from survey information, back up the observation that choices for pain relief are influenced by cultural [62] and personal factors [63] as to how childbirth is perceived. Women may be more likely to opt for medication if they view childbirth equally a medical condition with risks, whereas those who view information technology equally a normal, natural upshot may exist more likely to employ natural, or not-pharmacological approaches [63]. A more than recent innovation designed to address the shortcomings of numerical hurting rating scales, that recognises the complexity and multifaceted nature of pain direction, and to offer support aligned with women's needs during childbirth is the Coping with Labor Algorithm [64, 65]. The tool involves asking women how they feel they are coping, with detailed cues (psychological, behavioural, physiological) used past maternity professionals to arm-twist whether the women is coping well (or non coping) with labour. Depending on these assessments, connected support (if coping well) or specific interventions (if non coping well) are offered that include unlike hurting relief methods, changes to the physical environment and boosted emotional support (Roberts et al., 2010). Maternity care professionals' evaluations of the tool have been very positive due east.g. in enhancing respectful, adult female-centred care [64, 66], although further piece of work to test its efficacy on women's experiences is needed.

Determination

Women take mixed experiences of different pharmacological and non-pharmacological pain relief methods. Women varied in their stance as to whether the different pain relief methods were constructive in reducing their labour hurting. The different pain relief approaches could enable women to relax and feel in control. All the same, women who used medication were more likely to experience negative side furnishings, negative encounters with healthcare providers, and a sense of guilt and/or failure. While non-pharmacological methods did not necessarily reduce labour pain or facilitate a vaginal nascence, they could enable women to actively work with their physiological responses and facilitate a 'squad' approach with their birth supporters. Continued employ of relaxation methods in the post-natal period by some women also provided benefits for them, their babies, and their families, suggesting that learning these techniques provided the basis for self-help in the longer term. The findings highlight the demand for women to receive complete data on the risks besides every bit the benefits of the range of methods that will be bachelor to them in labour. They likewise highlight a need to promote and provide equally many approaches as possible, so that women take access to methods that meet with their prior values and beliefs, too as to those that they may need if their experiences differ from their expectations. The value of social support in labour should be recognised by funders and providers, and prioritised in service provision and staffing, every bit this was seen every bit valuable by women from both groups.

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Acknowledgements

The authors are grateful to the steering group for the WHO recommendations on intrapartum care for a positive childbirth experience for their contributions to the evolution of the research objectives.

Funding

This work was deputed to the University of Central Lancashire, UK by the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Inquiry, Evolution and Research Grooming in Human Reproduction (HRP), Department of Reproductive Health and Research, Globe Health System, Switzerland as part of the show base training for the WHO recommendations on intrapartum care. The development of the WHO recommendations on intrapartum care was financially supported by USAID. OTO is a paid staff member of the Section of Reproductive Health and Research, Earth Health Organization. GT and VHM are members of Research in Childbirth and Health (ReaCH) group, University of Cardinal Lancashire, Great britain. CF is a PhD Pupil within the same department. The manuscript represents the views of the named authors but.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Author information

Affiliations

  1. Schoolhouse of Community Wellness & Midwifery, University of Central Lancashire, Preston, Lancashire, PR1 2HE, UK

    Gill Thomson, Claire Feeley, Victoria Hall Moran & Soo Downe

  2. Development and Research Training in Human being Reproduction (HRP), Department of Reproductive Wellness and Research, Globe Health Organisation, xx Avenue Appia, 1211, Geneva, Switzerland

    Olufemi T. Oladapo

Contributions

OTO and SD conceived the report. GT and VHM adult the review protocol, and OTO and SD reviewed and provided comments. GT carried out the search, contributed to the study selection, quality appraisement, information analysis, interpretation and co-drafted the first draft of the manuscript with CF. CF also contributed to the study option, quality appraisal, data analysis, and interpretation. VHM contributed to report pick and drafting of the manuscript. OTO and SD revised the typhoon of the manuscript for intellectual content. All authors reviewed and approved the final manuscript.

Corresponding author

Correspondence to Gill Thomson.

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Competing interests

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Thomson, G., Feeley, C., Moran, 5.H. et al. Women'due south experiences of pharmacological and not-pharmacological pain relief methods for labour and childbirth: a qualitative systematic review. Reprod Health 16, 71 (2019). https://doi.org/10.1186/s12978-019-0735-4

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Keywords

  • CERQual
  • Childbirth
  • Epidural
  • Labour
  • Massage
  • Opiates
  • Opioids
  • Pain relief
  • Qualitative
  • Relaxation

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Source: https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-019-0735-4

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