BY Christine Gates Horstmeyer, Family Medicine Interest Group Co-President, Students Together for Service, Board Member School of Medicine, Class of 2013 and Julie McKe, MD, ABFM, ABIHM, Director, Women’s Health and Maternity Care, UTMB Distinguished Teaching Professor Department of Family Medicine, UTMB
Childbirth is a momentous experience in a woman’s life. Currently labor in the U.S. is commonly managed by standard of care obstetric practices, with the physician turning to an epidural analgesia for pain management before using less invasive approaches. The epidural rate in the United States has been found to be as high as 71%, and several studies have shown women who received an epidural had less satisfaction with the childbirth experience compared to those who did not.1 There are many options available for women and care givers to make childbirth a less painful and more joyous experience. Integrative therapies include continuous labor support, massage, acupuncture, intradermal sterile water injections, aromatherapy, and hypnosis.4 While there is a great need for more research in these areas, there have already been several studies published showing women who used integrative therapies were more satisfied with childbirth.
An important place to start when preparing for labor is discussion. The physician and patient should discuss the upcoming delivery and develop a plan. It is essential the mother is aware of all the different therapies available and that the physician helps the mother make educated decisions about which methods would be best for her. Childbirth education is very important. This can be through hospital based classes or classes outside of a hospital, such as Lamaze, Psychoprophylaxis, Bradley method, Birthworks, or Birthing From Within.
Continuous labor support is an invaluable option for women. The person providing support can be a relative, a nurse, or a trained doula. Studies have shown that with continuous labor support labor is shorter, there is less use of epidural anesthesia, there are fewer cesarean sections, and fewer newborns are admitted to neonatal intensive care units.13 Other benefits include positive feelings about the birthing experience, reduced anxiety, decreased depressive symptoms, improved self-esteem, and increased rates of breastfeeding initiation and exclusive breastfeeding.
Ambulation and labor position can have a significant effect on delivery as well. Historically women ambulated during labor, but today it is uncommon in hospital births. Studies have shown that women who were able to ambulate were more satisfied with the delivery process.3 Position is also a vital component of labor management. It effects the pelvis position and thus the diameter the baby’s head must travel through, affecting the length of labor. It has been shown that women experience less pain with delivery in a squatting or standing position as opposed to a sitting or supine position.3
Massage is another low risk therapy that can be used during labor. It has been shown to decrease anxiety and pain as well as shorten labor duration by up to three hours.3 Studies have also shown that antenatal perineal massage decreases rate of tears, cesarean sections, and instrumental deliveries.1 Massage during labor and antenatal perineal massage should be encouraged to help decrease labor pain and improve overall satisfaction with delivery.
Intradermal sterile water block can be used to decrease low back pain during delivery by injecting sterile water into four different locations in the low back. This procedure can give low back pain relief for at least ten minutes and up to two hours after administration.2 It is a relatively safe procedure that is an alternative treatment for the pain experienced during the first stage of labor.
Transcutaneous electrical nerve stimulation (TENS) is performed by placing electrodes on the lower back and attaching them to a battery-operated generator which causes stimulation at those sites.2 TENS helps alleviate labor pain and can decrease the duration of the first stage of labor.4 TENS also has been found to give women a sense of improved control of labor pain. However, it can interfere with fetal monitoring equipment and so is not recommended in those circumstances.
Acupuncture has been a therapy practiced for thousands of years with many different indications. Studies on its use during labor have shown it is effective in relieving pain, as well as strengthening contractions, shortening labor, and relaxing a mother’s mood. The two common points used to relieve pain during labor are Sp (spleen)6, also known as Sanyinjiao, located on the inner leg and LI (large intestine)4, also known as Hegu, located on the hand. While still more research is needed, acupuncture is safe and has been shown to decrease the need for additional analgesia and as such is a therapy option that should be discussed with expecting mothers.
Self-hypnosis is a therapy used by women in labor and several trials have showed decreased pain intensity, decreased length of labor, and decreased hospital stay. This therapy should not be recommended in women with psychiatric disorders and can also cause mild dizziness, nausea, and headache.
Mind body therapies are among the most common therapies used in labor management in our society. It can help distract a woman from pain and decrease her fear and anxiety during childbirth. Studies have found relaxation is associated with decreased pain during the latent and active phase of labor as well as increased satisfaction with pain relief and a lower rate of assisted vaginal deliveries. Yoga was found to be associated with reduced pain, increased satisfaction with pain relief, increased satisfaction with childbirth experience, and decreased length of labor. However music and audio-analgesia have shown no difference in pain level or caesarean delivery rate.4 But breathing and relaxation are safe and helpful methods for a delivering mother to use.
There are many alternative and complementary therapies available for labor management that can be incorporated into our approach. While there is strong research on some therapies, many others are lacking substantial research. However, many have minimal if any risks to the mother or baby. It is important to discuss with expectant mothers the options for managing childbirth and develop a plan with which the mother and her care givers are comfortable with. Continuous labor support, massage, and breathing and relaxation therapies should be encouraged, as well as ambulation and position changes if possible. The other options to discuss are intradermal sterile water injections, TENS, acupuncture, and self hypnosis.
Kannan S, Jamison RN, Datta S: Maternal satisfaction and pain control in women electing natural childbirth. Reg Anesth Pain Med 26:468, 2001.
Rakel, David. “Chapter 25 Labor Pain Management.” Integrative Medicine. Second ed. Philadelphia, PA: Saunders Elsevier, 2007. 571-79. Print.
Simkin P, O’Hara M: Nonpharmacologic relief of pain during labor: Systematic review of five methods. Am J Obstet Gynecol 186:S131-S159, 2002.
Smith CA, Collins CT, Cyna AM, Crowther CA. Complementary and alternative therapies for pain management in labour. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD003521. Review. PubMed PMID: 17054175.