Non-Pharmacological Pain Management in Labor: Comparison
Please note this is a comparison between Version 1 by Alexandru Cosmin Pantazi and Version 2 by Camila Xu.

Childbirth is a remarkable, life-changing process and is frequently regarded as an excruciating, physically and emotionally demanding experience that women endure. Labor pain management poses a significant challenge for obstetricians and expectant mothers.

  • non-pharmacological pain management
  • pregnancy
  • mothers
  • labor
  • obstetrician efficacy

1. Introduction

Historically, labor pain has been recognized as an inherent part of childbirth, although approaches to its management have varied across cultures and time periods [1]. With the advent of modern medicine, the focus shifted toward pharmacological interventions. By the late 19th century, interventions such as chloroform and ether were used for labor pain, followed by the introduction of “twilight sleep” in the early 20th century—a combination of morphine and scopolamine that induced a state of semi-consciousness [2][3][2,3].
In the latter half of the 20th century, advances in anesthesia led to the widespread use of regional analgesics, such as epidurals and spinal blocks, for labor pain [4]. These methods became the gold standard in many high-income countries due to their effectiveness in reducing pain [5]. In recent decades, the use of opioids such as fentanyl and morphine has also become common [6]. Although they do not eliminate pain, they can help to make it more manageable. However, pharmacological pain management methods (PPM) have been associated with various side effects and risks despite their effectiveness. For example, epidurals can lead to a drop in blood pressure, fever, and a raised need for assisted delivery [7]. Moreover, they lengthen the labor’s duration. Opioids induce nausea and affect the neonate (breathing and heart tracing) if admitted too soon [8][9][8,9]. Pain is the norm of childbirth; reducing pain via drugs makes laboring women lose essential feedback, potentially leading to more prolonged labor or increased intervention. Some forms of PPM reduce a woman’s motility or the ability to take different positions to alleviate discomfort; this lack of control over pain is distressing to women [10]. Over the past few decades, a growing interest has been expressed in revisiting non-pharmacological pain management techniques (NPPM) to reduce labor pain [11][12][11,12]. This shift is driven by a confluence of factors, including increasing evidence of pharmacological interventions’ side effects and risks. Additionally, there has been a broader societal shift towards more patient-centered and holistic healthcare, emphasizing personal autonomy, shared decision-making, and natural and complementary therapies [13]. These trends have led to an increased interest in NPPM, which relieves pain and empowers women to actively engage in the birth experience. NPPMs have demonstrated encouraging outcomes in diminishing pain intensity and enhancing satisfaction and are commonly regarded as safe, with minimal adverse effects compared to pharmacological interventions [3][5][8][3,5,8].

2. Understanding Pain in Labor

The nature of pain experienced during labor undergoes modifications as the process progresses. During the first stage of labor, the primary source of pain is visceral in nature, originating mostly from the cervix, uterus, and adnexa. This pain is mediated by sympathetic fibers that transmit signals to the ganglia of the posterior nerve roots located at the T10-L1 spinal levels [5]. During the late first stage and early second stage of labor, pain arises from the distention and traction of the pelvic organs. The pudendal nerve is responsible for transmitting pain signals to the ganglia of the posterior nerve roots located at spinal levels S2 to S4. During the second stage of labor, the sensation of pain is elicited by the stretching of the perineal structures as the fetus descends [5][11][5,11]. Comprehending the complexities of labor pain goes beyond the physiological aspects; it necessitates an understanding of psychological and socio-cultural elements. It is crucial to grasp the multifaceted nature of labor pain to assess NPPM better. From a physiological standpoint, uterine contractions and cervical dilation are the main causes of labor pain, because they activate pain receptors (nociceptors) and send signals to the brain [11]. The intensity of labor pain can vary greatly among women, between different labors in the same woman, and it is affected by various factors such as the baby’s position, size, and the speed of labor [12]. On a psychological level, labor pain is influenced by a woman’s emotions, expectations, and previous experiences [13][14][13,14]. Fear and anxiety can heighten pain perception by increasing tension and resistance. As confidence, relaxation, the feeling of control in their labor, and continuous support are all less likely to result in severe pain, the women are more likely to cope and have a positive birth experience [15][16][17][18][15,16,17,18]. Psychological preparation for childbirth can reduce the need for analgesia and increase satisfaction with pain management [19][20][19,20]. Socio-cultural factors, cultural beliefs, and societal attitudes toward childbirth can influence a woman’s expectations and coping strategies. In some cultures, labor pain is viewed as a natural and empowering part of childbirth, while in others, it is seen as something to be avoided or feared [21][22][21,22]. Furthermore, social support is crucial during labor. Having a supportive companion can significantly improve a woman’s experience of pain and reduce her need for pharmacological analgesia [23][24][23,24].

3. Categorization of Non-Pharmacological Methods for Pain Relief in Labor

These can be categorized based on the mechanisms of action into physical, psychological, and complementary techniques.

3.1. Physical Modalities

There are several physical methods listed under NPPM during labor. These methods include massage, pressure on precise anatomical locations, Transcutaneous Electrical Nerve Stimulation (TENS), water immersion, heat and cold therapy, breathing techniques, positioning, and movement [25][26][28,29]. The sub-types of each method, mechanism of action, perceived benefits, and supporting references are all summarized in Table 1.
Table 1. Non-pharmacological pain management in labor: An in-depth analysis of physical modalities concerning the mechanism of action, perceived benefit, and the supporting references.
][57]. Cognitive behavioral therapy helps individuals have a sense of control in coping with pain, develop pain-coping behaviors, and increase self-respect [54][56][57,59]. The main methods of CBT include:
  • Relaxation techniques;
  • Virtual reality (VR);
  • Music;
  • Distraction technique.
The main mechanism and benefits of each are summarized in Table 2.
Table 2. Summary of non-pharmacological pain management in labor: An in-depth analysis of psychological modalities, concerning the mechanism of action, perceived benefit, and the supporting references.
Figure 23.
The main pathways by which music conducts its beneficial effect in alleviating labor pain.

3.3. Complementary and Alternative Approaches

Over the past decade, there has been a growing scholarly focus on literature examining the role of Complementary and Alternative Approaches (CAA) in mitigating pain during childbirth [70][73]. CAA exhibits a higher prevalence among women within the reproductive age range [71][74]. The utilization of this intervention during childbirth is quite prevalent, as indicated by a survey conducted in Australia, with a reported rate of 75% [72][75]. Complementary and Alternative Medicine is a term employed by the U.S. National Center for Complementary and Integrative Health to denote a range of practices that can be utilized in conjunction with conventional and established medical care (complementary) or as a substitute for it (alternative) [73][76]. An in-depth analysis of complementary and alternative approaches concerning the mechanism of action, perceived benefit, and the supporting references [74][75][76][77][78][79][80][81][82][83][84][85][86][87][88][89][77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92] are summarized in Table 3.
Table 3. Summary of non-pharmacological pain management in labor: An in-depth analysis of complementary and alternative approaches concerning the mechanism of action, perceived benefit, and the supporting references.
Methods Methods Sub-Types Proposed Mechanism of Action Perceived Benefit Authors’ Name; Publication Year
Hypnosis
Natural hypnosis
Self-hypnosis
Stage hypnosis
Hypnotherapy
Modulates pain intensity caused in the primary somatosensory cortex.
Relaxes and distracts attention from the pain sensation.
Reduces net use of analgesia during childbirth.
No clear evidence of pain satisfaction relief or coping sensation
Madden et al. [74][77]; 2016

Cyna et al. [75][78]; 2013

Downe et al. [76][79]; 2015
Integration of religion/health and well-being
Praying,
Reciting the Quran,
Fasting,
Islamic meditation (dhikr) has been shown to relieve stress, improve health, increase productivity, and enhance quality of life.
Distracts and inhibits the pain perception.
It efficiently reduced labor pain and improved the score of pain behaviors.
McLaren H et al. [77][80]; 2021

Desmawati et al. [78]][65]; 2022
[81]; 2019

Kocak et al. [79][82]; 2022
Transcutaneous Electrical Nerve Stimulation (TENS)
Conventional TENS: reduces labor pain.
Acupuncture TENS
Intense TENS
Burst mode TENS
Modulated TENS
Applying low-intensity electrical pulses to targeted regions of the body via electrodes affixed to the skin.
Music
--
  • Modulation of pain responses and neuronal activity in CNS while engaging with music.
  • Increases pain tolerance and lowers pain intensity.
  • For further details, see Figure 2
It inhibits the pain signals’ transmission to the nervous system.
  • 3
  • .
It significantly reduces pain intensity; however, the evidence was low.
A significant reduction in pain score and improved women’s satisfaction.
  • They experience natural delivery with less stress and less medication.
Dancing --
Dancing combines the beneficial effects of music and the effects of upright position and movements, such as pelvic tilting and rocking.
  • Reduces pain score by 3.4 times.
Mean scores of pain were lower.
The level of birth satisfaction was significantly higher.
Thuvarakan et al. [33][36]; 2020

Gibson et al. [34][37]; 2019

Daniel et al.
Abdolahian et al. [80[35][38]; 2021
Timmerman et al. [63][66]; 2023

Estrella-Juarez et al. ][64][67]; 2023

Chehreh et al. [65][68]; 2023

García González et al. [66][69]; 2018
[83]; 2014

Akin et al. [81][84]; 2020
Water immersion
Distraction
  • Counting numbers
Cold water
  • Remembering poetry, a pleasant memory, or a joke
Hot water
  • Using vulgar cards
Alternating hot/cold water bathing
Aromatherapy Essential oils may be given as:
Massage into the skin,
In a warm bath,
Diffused into the air using a diffuser
Immersing in a bath or utilizing a birthing pool can induce relaxation, diminish pain perception, and facilitate smoother movement during childbirth.
  • Minds occupied by excitement are distracted from the excitement of the pain senses.
  • he technique reduces the pain effect on the CNS and nerve transmitters
Limbic system stimulation; releases serotonin and endorphins. Thereby reduces anxiety and tension, leading to lower pain perception.
Augmenting the production of endogenous stress-alleviating substances within the human body. Such as decreasing cortisol and/or increasing serotonin.
Some essential oils possess direct pain-relieving effects, such as rosemary.
  • Reduction in labor pain and stress
There was low evidence that immersion reduces the need for PPM.
  • No reduction in labor duration
Significant improvement in physical and psychological comfort, and the need for pain relief.
Trend decrease in labor pain.
Trend decrease in anxiety during labor
Cluett et al. [36][39]; 2018

Carlsson et al. [37][40]; 2020

Cooper et al. [38][41]; 2022
Tabatabaeichehr et al. [82][85]; 2020

Sirkeci et al. [83][86]; 2023

Hamdamian et al. [84][87]; 2018
Heat therapy
Warm pack and towels
Hot water bags
Warm shower
Thermal and infra-red belt
Administration of heat to a specific region experiencing pain enhances blood circulation, induces muscle relaxation, and alleviates pain perception.
Photomodulation -- Irradiation induces.
Neural block and modulates neurotransmitters.
Reduced muscle spasms.
Reduced interstitial edema, thereby exhibiting anti-inflammatory effects
Evidence confirmed an effective reduction in labor pain intensity and labor duration.
Significant reduction in post-labor pain
Pain reduction
Analgesic effect
Goswami et al. [39][42]; 2022

Akbarzadeh et al. [40][43]; 2018

Akbarzadeh et al. [41][
Traverzim et al. [8544]; 2016

Dastjerd et al. ][88[42][45]; 2023
]: 2021

Traverzim et al. [86][89]; 2018 Cold therapy
Ice packs
Ice massage
  • Utilization of cold packs or ice to induce numbness in a specific area, thereby mitigating inflammation and offering temporary pain alleviation.
Support therapy
Emotional Support
Advocacy
Significant reduction in pain intensity and duration.
Informational Support
Reduces stress and anxiety by providing reassurance and empathy, thus decreasing pain perception.
Supports women’s autonomy and decision-making, understanding of the labor process, promoting feelings of control and confidence
Reduced perception of pain via reduced stress and anxiety
Decreased use of analgesics,
ncreased overall satisfaction with the birthing process.
Shirvani et al. [43][46]; 2014

Emine et al. [
Akbas et al. [87]44][47]; 2022

Serap et al. [90]; 2022

Bohren et al. [[45][48]; 2022
88][91]; 2017

Ip et al. [89][92]; 2009
Breathing techniques
Deep, slow, and patterned breathing.
Effective in diverting attention from pain and facilitating a state of relaxation.
Effective reduction in labor pain added to a shorter labor duration.
Ineffective in reducing pain in the 1st stage.
Baljon et al. [46][49]; 2022

Issac et al. [47][50]; 2023

Yuksel H et al. [48][51]; 2017

Boaviagem et al. [49][52]; 2017
Positioning and Movement
Changing positions frequently, such as walking, squatting position,
Birthing ball rocking
Helps manage pain by utilizing gravity and promoting optimal fetal positioning.
Effective in reducing pain and duration of labor.
Upright positions and free mobility reduce labor duration and pain and improve women’s satisfaction.
Huang et al. [50][53]; 2019

Ondeck et al. [51][54]; 2019

Borges et al. [52][55]; 2021

Ali SA et al. [53][56]; 2018
Figure 12.
The mechanisms that underlie acupressure’s positive effect in reducing labor pain.

3.2. Psychological Techniques

Cognitive Behavioral Therapy (CBT) aims to identify and modify maladaptive thoughts, emotions, and behaviors. Moreover, CBT assists individuals in cultivating a perception of control in managing pain, fostering the acquisition of pain-coping strategies, and enhancing self-esteem [54][57]. CBT was used to manage labor pain; there was inconsistency in the reported literature; some discussed reduced psychological aspects of pain and improved satisfaction [55][58]. However, pain medication was still needed. Others have discussed how CBT techniques significantly reduced pain intensity and labor duration [54
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