Non-pharmacological Pain Relief Intervention in Labour


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Review of literature is an important step in the development of any research project. This chapter deals with the information collected with relevant to the present study through the published and unpublished materials. These publications were the foundation to carry out the research work. This helps the investigator to analyze what is already known about the topic and to describe the methods of inquiry.

Research literatures are reviewed under the following headings:

A: Literature related to non-pharmacological pain relief intervention.

B: Literature related to back massage as a complementary therapy for pain management in labour.

A: Literature related to non-pharmacological pain relief intervention.

Davim, Torres & Dantas (2009) conducted a study to evaluate the effectiveness of non- pharmacological strategies to relieve pain in parturient in labour. This is before and after therapeutic intervention clinical trial, performed with 100 parturients applying breathing exercise, muscle relaxation, lumbosacral massage and shower. A visual analogue scale was used for data collection. Oxytocin was administered in 81% of cases, but 15% did not receive any medication. A significant difference was observed in pain relief after using non- pharmacological strategies, showing reduced pain as cervical dilatation increased.

Penny & April (2004) The control of labour pain and prevention of suffering are major concerns of clinicians and their clients. Nonpharmacologic approaches toward these goals are consistent with midwifery management and the choices of many women. They undertook a literature search of scientific articles cataloged in CINAHL, PUBMED, the Cochrane Library, and AMED databases relating to the effectiveness of 13 non-pharmacologic methods used to relieve pain and reduce suffering in labour.


Acupuncture, an important and ancient component of traditional Chinese medicine, is gradually being integrated with conventional medicine in the West. Acupuncture is believed to initiate, control, or accelerate physiologic functions, and thus, correct organ malfunctions, heal illnesses, or relieve discomforting symptoms through insertion of fine needles into the skin at a combination of specific points along meridians (channels of energy, called “Qi,” pronounced “chee”) in the body, followed by rotation, heating, or electrical stimulation

(electro-acupuncture) of the needles.

Smith, Collins, Cyna, & Crowther (2006)A systematic review of acupuncture for pain relief in labor reported that acupuncture was associated with a trend toward less use of pharmacological analgesia (RR 0.70, 95% CI 0.49-1.00) .Compared to controls who had no or sham acupuncture, women who underwent acupuncture were more relaxed and used less pharmacological pain relief, but did not have lower pain intensity scores. Maternal satisfaction was high among all the women in both the acupuncture and control groups.


Acupressure, or Shiatsu, a simpler alternative to acupuncture, is pressure with fingers or small beads at acupuncture points.

Chung, Hung, Kuo & Huang (2003). A study to determine L14 and BL67 acupressure on labour pain during first stage of labour .A total of 127 parturient were randomly assigned to three groups. Each group received only one of the following treatments: L14 and BL67 acupressure, light skin stroking or no treatment. There was a significant difference in labour pain in the first group compared with the two others.


Aromatherapy is “the science of using highly concentrated essential oils or essences distilled from plants in order to utilize their therapeutic properties” .

Abbaspoor and Mohammadkhani (2013) The aim of this study was to investigate the effect of aromatherapy massage with Lavender oil. This was a prospective, randomized, controlled trial that was conducted in 2008 Tehran, Iran. The subjects included N=60 primiparous women in 38–42 week gestational age, who were expected to have a normal delivery. They were randomly assigned to two groups. The first group received only massage (n=30) and the second group received aromatherapy massage with Lavender oil (n=30). The intensity of pain was measured with the visual analogue scale (VAS). Results showed that pain intensity before and after intervention were significantly lower in the lavender aromatherapy massage group in the latent and active phase, and they had a lower duration of first and second stage of labour.

Reeja Mariam Joseph & Philomena Fernandes(2013) The study was conducted to assess the effectiveness of jasmine oil massage on labour pain during first stage of labour among 40 primigravida women. The study design adopted was true experimental approach with pre-test – post-test control group design. The demographic Proforma were collected from the women by interview and Visual analogue scale was used to measure the level of labour pain in both the groups. Data obtained in these areas were analysed by descriptive and inferential statistics. A significant difference was found in the experimental group( t 9.869 , p<0.05) . A significant difference was found between experimental group and control group. The pre-test ('t ' 0.36, p>0.05) and the post-test (t 11.75, p<0.05). No significant association was found between the level of labour pain and demographic variables in the experimental group. In this study Jasmine oil massage proved to reduce first stage labour pain.

Breathing exercises

Kamalifard et al.,(2000) A quasi-experimental study was conducted for 42 mothers selected randomly divided into two groups of massage 2 and breathing 2. The breathing groups employed the techniques during the first or second stage of labour at 4, 6, 8 and 10 centimeter of dilatation for 30 minutes. The intensity of pain was measured by a numerical rating scale (NRS) 30 minutes after determining dilatation. The ERA performed massaging at the same dilatations for M1 and M2 groups. Massage at 4 and 6 cm dilatations and breathing at most dilatations decreased pain scores significantly. The choosing of one or both methods for labour pain relief and decreasing caesarean section rate is suggested.


Hydrotherapy is an effective, alternative intervention that can be used by care providers as a nonpharmacological pain relief method to help labouring women cope with labour. A wide variety of pain relief measures are available to women in labour.

Entisar & Manal (2012) This study assessed nurses’ knowledge about the use of hydrotherapy as a Nonpharmacologic pain-relief techniques during labour and identify the barriers of hydrotherapy to be used in Women’s Health Center, Egypt. A descriptive study design was utilized in this study. The 120 nurses who works in obstetrics department. They showed that approximately three quarter (73.3%) of the participant nurses’ knowl-edge were adequate, while (26.7) of nurses had inadequate knowledge about the use of hydrotherapy in labour. Nurses encounter that hospital policy (100%) followed by environ-mental factors (52%) are the major barriers to the use of hydrotherapy in labour. Effort required for hydrotherapy (48%) and human resources (41%) are indicated to be equivalent barrier of the use of hydrotherapy in labour. Their knowledge represented (26.7%) and not considered to be a major contributing barrier to the use of hydrotherapy during labour.


Cyna, McAuliffe & Andrew (2004) They examined the evidence regarding the effects of hypnosis for pain relief during childbirth. Five RCTs and 14 non-randomized comparisons (NRCs) studying 8395 women were identified where hypnosis was used for labour analgesia. Four RCTs including 224patients examined the primary outcomes of interest. One RCT rated poor on quality assessment. Meta-analyses of the three remaining RCTs showed that, compared with controls, fewer parturients having hypnosis required analgesia, relative risk=0.51 (95% confidence interval 0.28, 0.95). Of the two included NRCs, one showed that women using hypnosis rated their labour pain less severe than controls (P<0.01). The other showed that hypnosis reduced opioid (meperidine) requirements (P<0.001), and increased the incidence of not requiring pharmacological analgesia in labour (P<0.001).

Music therapy

Phumdoung & Good (2003) A randomized controlled trial of 110 primiparous women in active phase of labour were assigned to soft music group for 3hrs (n=55) or a control group (n=55). Dual VAS were used to measure pain before starting the study and every 3 hrs. The results indicate that music group women had significantly less pain sensation(p<0.001).


DeClercq et al., (2006) A national survey of childbearing experiences in the United States in 2005 reported that after admission to the hospital, most women (76 percent) did not walk around. This percentage was slightly higher than in a similar survey conducted three years earlier. At that time, the most common reason the women gave for not walking was that they were “connected to things” (67percent), “unable to support self due to pain medication” (32 percent), and “told not to walk around” (28 percent). However, 58 to 60 percent of the women did report changing positions to relieve pain during labour.


Chuntharapat et al.,(2008) A randomized trial was conducted using 74-primigravid Thai women who were equally divided into two groups (experimental and control). The yoga program involved six, 1-h sessions at prescribed weeks of gestation. The experimental group was found to have higher levels of maternal comfort during labour and 2 h post-labour, and experienced less subject evaluated labour pain than the control group. In each group, pain increased and maternal comfort decreased as labour progressed. The experimental group was found to have a shorter duration of the first stage of labour, as well as the total time of labour.

B: Literature related to back massage as a complementary therapy for pain management in labour.

Patricia, Farah & Paula (2012) A study conducted to evaluate the effectiveness of massage therapy in managing labour pain among women in active labour. A randomized controlled trial in Vancouver of 77 healthy nulliparous women presenting in spontaneous labour, upto 5 hours the massage therapy was given. The mean cervical dilataion at the time of epidural insertion was 5.9cm(95% CI 5.2-6.7) compared to 4.9 in the control group. (95% CI 4.2-5.8) scores on the McGrill pain scale were consistently lower in the massage therapy group (13.3 vs 15.8 at 5-6cm &19.4 vs 28.3 at 7.8cm) although these differences were not satisfically significant.

Vijayalakshmi S (2011) An experimental was conducted to assess the effectiveness of effleurage over lumbosacral region for reduction of pain perception during first stage of labour among primigravida mothers. The study samples were 60 primigravida mothers (30 in experimental group 30 in control group). The samples were selected using lottery method comes under probability simple random sampling technique. A combined numerical categorical scale was used to assess the level of pain perception among primigravida mothers during first stage of labour. The findings revealed that marked decrease in mean value from 3.43 in pre assessment level to 2.30 in post assessment level and the improvement mean was 2.86 and SD was 0.27 in experimental group.

Umarani (2010) conducted a quasi experimental pretest posttest control group design to assess the effectiveness of back massage during the first stage of labour among primigravida mothers. 30 primigravida mothers were taken and assigned for experimental and control group equally. Pain perception was measured by using 0-10 numerical pain intensity scale. 20 minutes back massage was given to the experimental group after the 3cm cervical dilatation, when contractions started. Control group was allowed to follow the conventional method. The results showed that there was a significant reduction on pain perception of 2.2 than 3.6 in control group.

D’souza (2010) conducted a study on effectiveness of ice massage (acupressure L14) for the reduction of labour pain among intranatal women. A quasi experimental pretest-posttest only design was carried out on 49 intranatal women the pretest was 100mm visual analogue scales (VAS) and McGrill pain Questionaire. In the experimental group the mean posttest pain score (2.1) which is significantly lower than the mean pretest score (5.0) with a mean difference of (2.9).The calculated value(11.588) was more than the table value (2.093,p<0.05) at 0.05 level of significance.

Zahrani (2008). This study has been conducted to determine the effects of massage on intensity of pain during the first stage of labour in primiparous women who have attended Isfahan Shahid Beheshti hospital in 2005. In this randomize clinical trial, a total of 75 primiparous women in 38-42 week of low risk pregnancy were randomly divided in 3 groups. First group received 20 minutes of back effleurage massage at the periods of 4-5 cm, 6-7 cm, 8-10 cm, cervical dilation. An emotional support was offered for second group in the same duration of time and the same cervical dilation. Third group just received routine care during labour. In all groups, pregnant women were asked to evaluate their severity of pain before and after intervention. Data being obtained through the visual analogue scale, check list and inspection form. Results: Study result demonstrated that intensity of pain was significantly lower in massage group (p<0.001). Intensity of pain in supported group was consistent during 4-5 cm dilatation period and 8-10cm but during 6-7cm period there was an increase in severity of pain.

Refined olive oil is obtained from virgin olive oils by refining methods, which do not lead to alterations in the initial glyceridic structure. It has a free acidity, expressed as oleic acid, of not more than 0.3 grams per 100 grams (0.3%) and its other characteristics correspond to those fixed for this category in this standard.

The medicinal use of olive oil is a non-selective inhibitor of cyclo-oxygenase similar to classical NSAIDs like ibuprofen. Fifty grams of extra virgin olive oil is equivalent to about the tenth of a dose of ibuprofen. Health benefits of olive oil are analgesia, Oil massage, bone growth, decreased aging, and decreased cardiovascular problems.

Jeyalakshmi, Latha Venkatesan, Jamuna (2008) conducted a study on effectiveness of olive oil massage therapy upon low back pain of parturient mothers in the first stage of labour at Andhra mahila sabha,Chennai. 60 mothers were randomly selected for experimental and control group. Before and after massage therapy low back pain and feto maternal parameter was assessed in both groups. In experimental group 100% of them experienced moderate level of pain after massage therapy. The mean and standard deviation of low back pain score of the control group were high in comparison with olive oil therapy group (p=0.001).

Kuhn (2004) conducted a study to assess the effectiveness of massage therapy on depressed pregnant women. 84 depressed pregnant women were recruited during the second trimester of pregnancy and randomly assigned to a massage therapy group and control group that received standard prenatal care alone. These groups were compared to each other. The massage therapy was for 20 minutes for 2 sessions by their significant other each week for 16 weeks of pregnancy. Immediately after the massage therapy sessions on the first and last days the woman reported lower levels of anxiety and depressed mood and less leg and back pain and also the massage group had higher dopamine and serotonin levels and lower levels of cortisol and norepinephrine.

Chang, Wang, Chen,(2002) The third trial randomly assigned 60 women to receive massage or usual care. Massage was performed three times, once during each phase of the first stage of labour (latent, active and transition) and lasted for 30 minutes in each phase. Pain intensity was rated by a nurse observing each woman’s manifestations of pain using a present behavioral intensity (PBI) scale. Anxiety was measured using a visual analogue scale for anxiety (VASA). Although pain intensity increased steadily through progressing phases of labor, the massage group had significantly lower pain intensity scores at each phase of labor (0.73 versus 1.30 in latent, 1.73 versus 2.17 in active, and 2.17 versus 2.87 in transition phases). Anxiety levels were significantly lower in the massage group only during the latent phase (37.2 versus 53.5 on a 100 point scale). Eighty-seven percent of the women in the massage group reported that the massage was helpful in providing pain relief and psychological support.

Field et al., (1999) A study which involved 26 pregnant women were assigned to massage or relaxation therapy group for five weeks. The therapies consisted of 20 minute session twice a weeks. MANOVAs and ANOVAs were conducted for repeated measures. A significant group by pre-post session MANOVA, F(4,21) = 2.86;p< 0.05, was obtained on the short term measures(STAI-anxiety, POMS-mood, VITAS-back & leg pain)and a significant group by days MANOVA, F(11,14) = 4.45; p<0.01, was obtained on the longerterm measures(CES-D depression, perinatal anxieties, maternal-fetal attachment scale & sleep diary). ANOVAs were subsequently conducted to determine specific effects.