Update on Nonpharmacologic Approaches to Relieve Labor Pain and Prevent Suffering

Penny Simkin, PT; April Bolding, PT

Disclosures

J Midwifery Womens Health. 2004;49(6) 

In This Article

Baths in Labor

Immersion in warm water deep enough to cover the woman's abdomen is used to enhance relaxation, reduce labor pain, and promote labor progress. Baths have become a popular option in many countries, including the United States. Women usually remain in the bath for a few minutes to a few hours during the first stage of labor. Birth in water is not the focus of this article. Showers during labor, though commonly used, have not been subjected to scientific study and are not discussed.

The first scientific publication on the use of water in labor was published in 1973.[21] It reported on the first 100 births in which water was used for labor in a hospital in France. Since then, bathing during labor has been widely studied for its benefits and risks.

Effectiveness of Bathing in Reducing Pain and Suffering in Labor

A recent systematic review analyzed findings of 2 prospective cohort studies and 7 RCTs of bathing published between 1987 and 2001.[10] A total of 3496 women participated in these trials. Sample sizes in the individual trials ranged from 18 to 1237. The trials varied widely in study designs and quality, timing of entry into the water, water temperature, and in baseline rates of epidural analgesia and other interventions, as reflected by the rates in the control ("usual care") groups. Of the 3 best designed RCTs, 2 found a reduction in pain indicators in the bath groups[22,23] 1 one did not.[24] Of the 2 that found decreases in pain in the bath group, 1[22] (N = 109) found an initial decrease in pain upon entering the water, followed by a slower rise in pain scores during the 1-hour study period than the control group, whose pain rose continually and more rapidly to higher levels. Maternal satisfaction was high in the bath group, with 89% stating they would like to use the bath in a future labor. In the other[23] (N = 785), the women randomized to the bath group required fewer epidurals (59.8% vs 66%, P < .02), even though almost half in the bath group opted for an epidural rather than the bath! If the data had been analyzed by using those who actually complied with their assigned protocol, the effects would probably have been more striking, but the requirements of the scientific method are that the analysis be done on the basis of group assignment ("intention to treat"), whether or not they actually received the treatment. The one trial that found no difference in epidural use[24] was a large, well-designed trial, but the baseline rate of epidural analgesia was 20%, which would be difficult to lower with the intervention of a 1-hour bath. Because epidural analgesia was used by only 20% of the laboring women in the participating hospitals, it was unfortunate that other pain indicators, such as maternal assessments of pain or satisfaction, were not assessed in this trial.

One RCT[25] of bathing in labor has been published since the above-mentioned systematic review.[10] Participants included 99 nulliparas with dystocia, who were randomly assigned to a control group to receive usual augmentation procedures (amniotomy and/or oxytocin) or to the experimental group for immersion in a birth pool for up to 4 hours, after which their progress was assessed and the standard dystocia protocol initiated, if necessary. Fewer women in the bath group received epidural analgesia than in the control group (47% vs 66%; RR 0.71, 95% CI 0.49-1.01 -- almost statistically significant). The number who received augmentation in the bath group was significantly lower than in the control group (71% vs 96%; RR 0.74, 95% CI 0.59-0.88). In postpartum interviews, the bath group reported less labor pain 30 minutes after the onset of the allocated management and less overall labor pain. There were no differences in the length of labor or in surgical delivery rates. Overall maternal satisfaction was the same in both groups.

Women's experiences of immersion in water during labor and birth have received little study. A qualitative survey of 189 women was published recently in England.[26] Eighty-one per cent stated they would have another water birth in the future. When asked to describe their feelings when they entered the pool, the most common words were "relaxation" (n = 99); "relief" or "pain relief" (n = 101); and "warmth" (n = 48). Thirty-nine said they felt more in control.

The use of water requires special equipment in the form of bathtubs. Furthermore, there are some practical or safety considerations: the temperature of the water should be at body temperature; the timing of entry and duration of the bath can influence labor progress. Labor progress can be slowed if the woman enters the bath before active labor or stays in for more than 1 or 2 hours.[10] Guidelines for midwives in the safe use of water during labor are available.[27,28]

The results of these studies indicate that, with appropriate attention to water temperature, duration of the bath, and safety considerations, baths in labor are effective in reducing pain and suffering during labor, and should be available as a pain relief option to all laboring women.

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