Update on Nonpharmacologic Approaches to Relieve Labor Pain and Prevent Suffering

Penny Simkin, PT; April Bolding, PT


J Midwifery Womens Health. 2004;49(6) 

In This Article

Continuous Labor Support

The term "continuous labor support" refers to non-medical care of the laboring woman throughout labor and birth by a trained person. The word "continuous," as it pertains to labor support, has been defined in various ways. In one study, in which staff nurses were the support providers, "continuous" was defined as "a minimum of 80% of the time from randomization to delivery."[6] In a meta-analysis of trials of labor support, "continuous" was defined as "without interruption, except for toileting, from shortly after admission to the hospital or entry into the study, and during the birth of the child."[7]

Labor support includes continuous presence, emotional support (reassurance, encouragement, and guidance); physical comforting (assistance in carrying out coping techniques, use of touch, massage, heat and cold, hydrotherapy, positioning, and movement); information and guidance for the woman and her partner; facilitation of communication (assisting the woman to express her needs and wishes); and nonmedical information and advice, anticipatory guidance, and explanations of procedures. Terms such as "doula," "labor assistant," "birth companion," "labor support specialist," "professional labor assistant," and "monitrice" refer to providers of this type of support. None of the included studies examined the effects of support by the woman's partner or husband, although untrained female family members or friends did fill that role in one published trial.[8]

Effectiveness of Continuous Labor Support in Reducing Pain and Suffering During Labor

Two recent systematic reviews of continuous labor support, a Cochrane Review[9] of all randomized controlled trials (RCTs), and a review of North American trials only,[10] reached similar conclusions.

The Cochrane Review examined 15 RCTs, including 12,791 women. Labor support was provided by a variety of people -- staff nurses (in 2 trials), staff midwives (4 trials), staff student midwives (2 trials), retired nurses and trained lay women (1 trial), trained lay women (doulas [3 trials], lay midwives [1 trial], childbirth educators [1 trial]), and untrained female relatives (1 trial).

Despite the variety of caregivers and settings in which the trials took place, the meta-analysis revealed that women who received continuous labor support were less likely to experience analgesia or anesthesia (including epidurals and opioids); instrumental delivery; cesarean birth; and were less likely to report dissatisfaction or a negative rating of their birth experience. Further analysis of the results indicated greater benefit if the labor support provider was not a member of the hospital staff with clinical care responsibilities, and whose only task was to provide continuous support to one laboring woman throughout her labor.[9] Women receiving support from non-hospital staff, compared to women who received no extra support, had 26% fewer cesarean births and 41% fewer instrumental deliveries. They were also 28% less likely to use any analgesia or anesthesia and 33% less likely to be dissatisfied or to rate their birth experience negatively.[11]

Continuous Labor Support in North American Hospital Settings

A systematic review of 9 trials was conducted to compare outcomes of continuous labor support versus "usual care" in North American settings, where baseline obstetric intervention rates are high and midwifery care is rare (as opposed to the study settings in Europe and Africa where intervention rates were low and midwifery care was standard).[10] The findings were similar to those reported in the Cochrane meta-analysis, although the benefits of continuous support were not as striking in the North American settings. In 7 of the 9 trials, comprising a total of 2259 women, the labor support was provided by trained lay women (doulas). In the other 2, plus a third trial[6] that was published after the systematic review, the support was provided by either retired nurses or staff nurses. These 3 trials, in which nurses provided continuous support, included 8052 women. They found no differences in pain medication use or other obstetric outcomes, compared with usual care. The 2 trials that reported on maternal satisfaction, however, found increased satisfaction in the continuous support groups.

Table 2 and Table 3 summarize the outcomes of the 10 trials of continuous labor support that have been conducted in North American hospitals to date.

In summary, in all the RCTs of continuous labor support published to date, both in North America and throughout the world, pain and pain relief were measured indirectly by using rates of pain medication as the indicator of effectiveness of pain relief. Pain was reduced by continuous labor support in most of the trials, particularly those in which laypersons trained as doulas provided the support. The trials in which nurses provided the support (either hospital employees or independent nurses) showed the least benefit. Furthermore, support begun in early labor seems to have provided greater benefit than when begun in active labor. Maternal satisfaction, though not assessed in every trial, was higher in the supported groups. A common model of labor support in North America -- the private practice doula who is chosen by and becomes known to the woman or couple prior to labor -- has never been studied in RCTs.


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