MATERNAL AND EARLY CHILD HEALTH

Health Evidence Bulletins - Wales

Date of Completion: 3.10.97

The contents of this bulletin are likely to be valid for approximately one year, by which time significantly new research evidence may become available


11. Control of pain in labour

(Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation)

There is evidence that support from caregivers reduces the need for analgesia in labouring women but does not reduce the importance of informed choice and availability (i).
 
i. Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press, 1995 p.247 (Type I evidence - systematic review. See pp. 806-807 in Chalmers et al. Effective care in pregnancy and childbirth. Oxford:Oxford University Press, 1989)
The Statements The Evidence
11a. Maternal movement and choice of position may be beneficial in reducing pain in labour (i.ii).

(Health gain notation - 2 "likely to be beneficial")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 p. 896
(Type IV evidence - observational studies. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. pp. 248-249);
ii. MIDIRS and the NHS Centre for Reviews and Dissemination. Positions in labour and delivery. Informed Choice for Professionals Leaflet No.5. MIDIRS, 2nd ed. July 1996 (Type I evidence - systematic review)
11b. Epidural analgesia is the most effective pain relief in labour. Some studies have described an associated increase in assisted delivery, both forceps and Caesarean section(i,ii,iii,iv).

An association between epidural anaesthesia and long term backache has not been substantiated(v,vi).

(Health gain notation - 3 "trade-off between beneficial and adverse effects)

i. Thorp JA, Hu DH, Albin RM et al. The effect of intrapartum epidural analgesia on nulliparous labor: A randomized, controlled, prospective trial. American Journal of Obstetrics and Gynaecology. 1993; 169(4): 851-858
(Type II evidence - randomised controlled trial);
ii. Dewan DM, Cohen SE. Epidural analgesia and the incidence of Caesarean section. Time for a closer look. Anesthesiology. 1994; 80(6): 1189-1192
(Type V evidence - expert opinion);
iii. Morton SC, Williams MS, Keeler EB, Gambone JC, Kahn KL. Effect of epidural analgesia for labour on the Caesarean delivery rate. Obstetrics and Gynecology. 1994; 83(6): 1045-1052
(Type I evidence - meta analysis);
iv. Miller AC. The effects of epidural analgesia on uterine activity and labor. International Journal of Obstetric Anaesthesia. 1997; 6: 2-18 (Type V evidence - expert opinion);
v. MacArthur A, Macarthur C, Weeks S. Epidural anaesthesia and low back pain after delivery: a prospective cohort study. British Medical Journal. 1995: 311: 1336-1339
http://www.bmj.com/cgi/content/full/311/7016/1336
(Type IV evidence - prospective cohort study);
vi. Russell R, Dundas R, Reynolds F. Long term backache after childbirth: prospective search for causative factors. British Medical Journal. 1996; 312: 1384-1388
http://www.bmj.com/cgi/content/full/312/7043/1384

(Type IV evidence - prospective cohort study)

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11c. There is no firm evidence yet to guide the choice of method of epidural analgesia by continuous infusion or intermittent top-ups on maternal request(i).

(Health gain notation -4 "unknown")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 929-930
(Type II evidence - single randomised controlled trial. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 258)
11d. Combined spinal epidural analgesia has the advantage over standard epidural analgesia of faster onset and less motor block, with retention of the ability to walk (i).

(Health gain notation - 2 "likely to be beneficial")

i. Collis RE, Davies DWL, Aveling W. Randomised comparison of combined spinal-epidural and standard epidural analgesia in labour. The Lancet. 1995: 345; 1413-1416
(Type II evidence - randomised controlled trial of 197 women; outcomes assessed by questionnaire)
11e. Epidural/spinal opiates have the advantage over conventional epidural techniques of reducing motor block, prolonging analgesia and reducing shivering but with the problems of respiratory depression and pruritis in the mother (i).
(Cochrame health gain notation - 2 "likely to be beneficial")
i. Expert Anaesthetic Advice to the Internal Review Group (see Contributors)
(Type V evidence - expert opinion)
11f. Epidural instead of narcotic analgesia is likely to be beneficial for preterm labour and birth although there have been no controlled studies to substantiate this view(i)i.

(Health gain notation - 2 "likely to be beneficial")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 p. 1283
(Type V evidence - expert opinion. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 281)

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11g. There is a trade-off between beneficial and adverse effects in the use of inhalation analgesia to relieve pain in labour (i).

(Health gain notation -3 "trade-off between beneficial and adverse effects")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 920-923, 944-945
(Type I evidence - systematic review. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 257)
11h. Intramuscular pethidine (and, to a lesser extent, morphine) is widely used for the relief of pain in labour. Use is associated with an increased risk of respiratory depression in the infant (reversible by the antidote Naloxone)(i,ii). One very small trial has suggested that labour pain is not significantly reduced by intravenously administered morphine or pethidine but that these cause decreased anxiety and increased exhilaration(iii).

(Health gain notation - 3 "trade-off between beneficial and adverse effects")

i. Chalmers I, Enkin M, Keirse MJN (eds.) Effective care in pregnancy and childbirth. Oxford:Oxford University Press, 1989. pp. 917-919. (Type I evidence - systematic review);
ii. British National Formulary March 1997 p.200. (Type V evidence - expert opinion);
iii. Olofsson Ch, Ekblom A, Ekman-Ordeberg G, Hjelm A, Irestedt L. Lack of analgesic effect of systemically administered morphine or pethidine on labour pain. British Journal of Obstetrics and Gynaecology 1996; 103: 968-972. (Type IV evidence - observational study)
11i. The value of the following treatments to relieve pain in labour are, as yet, unknown(i).

(Health gain notation -4):

  • Abdominal decompression;
  • Immersion in water;
    (Further studies in relation to the use of water baths are in progress)
  • Acupuncture; Hypnosis;
  • music and audioanalgesia
  • Intradermal injection of sterile water;
  • Aromatherapy; Acupressure;
  • counterpressure;
  • superficial heat or cold;
  • touch and massage;
  • attention focusing and distraction;
i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 Chapters 56/57.
(Not enough evidence on which to base a clinical judgement. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. pp. 247-255)

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11j. Paracervical block provides adequate analgesia but is little used because of reports of fetal brachycardia (i).

(Health gain notation - 3 "trade-off between beneficial and adverse effects")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 939-944
(Type I evidence - systematic review. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 259)
11k. Sedatives and tranquillizers are unlikely to be beneficial for pain relief in labour(i).

(Health gain notation -5 "unlikely to be beneficial")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 923-924
(Type I evidence - systematic review. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 256)
11l. Transcutaneous electrical nerve stimulation (TENS), while possibly ineffective in providing pain relief during labour (NNT = 14)(i), has no known complications.

(Health gain notation - 4 "unknown")

i. Carroll D, Tramer M, McQuay H, Nye B, Moore A. Transcutaneous electrical nerve stimulation in labour pain: a systematic review. British Journal of Obstetrics and Gynaecology. 1997; 104: 169-175
(Type I evidence - systematic review)
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Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk