Advertisement
JOGC

No. 355-Physiologic Basis of Pain in Labour and Delivery: An Evidence-Based Approach to its Management

      Abstract

      Objective

      To review the evidence relating to nonpharmacological approaches in the management of pain during labour and delivery. To formulate recommendations for the usage of nonpharmacological approaches to pain management.

      Options

      Nonpharmacological methods available for pain management during labour and delivery exist. These should be included in the counselling and care of women.

      Evidence

      PubMed and Medline were searched for articles in French and English on subjects related to “breastfeeding,” “pain,” “epidural,” “anaesthesia,” “analgesia,” “labour,” “labor,” and combined with “gate control theory,” “alternative therapies,” “massage,” “position,” “mobility,” “TENS,” “bathing,” “DNIC,” “acupuncture,” “acupressure,” “sterile water injection,” “higher center,” “control mind,” “cognitive structuring,” “holistic health,” “complementary therapy(ies),” “breathing,” “relaxation,” “mental imagery,” “visualization,” “mind focusing,” “hypnosis,” “auto-hypnosis,” “sophrology,” “mind and body interventions,” “music,” “odors,” “biofeedback,” “Lamaze,” “Bonapace,” “prenatal training,” “gymnastic,” “chanting,” “haptonomy,” “environment,” “transcutaneous electrical stimulus-stimulation,” “antenatal education,” “support,” “continuous support,” “psychosocial support,” “psychosomatic medicine,” “supportive care,” “companion,” “intrapartum care,” “nurse,” “midwife(ves),” “father,” “doula,” “caregiver,” “ hormones,” “oxytocin,” “endorphin,” “prolactin,” “catecholamine,” “adrenaline,” and “noradrenaline” from 1990 to December 2015. Additional studies were identified by screening reference lists from selected studies and from expert suggestions. No language restrictions were applied.

      Validation methods

      The quality of the evidence is rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice are ranked according to the method described in this report.

      Benefits, risks, and cost

      The nonpharmacological method encourages an incremental approach to pain management that contributes to reduced interventions through optimal use of the woman's neurophysiologic and endocrine resources and a better understanding of the physiology of stress and pain during labour.

      Guideline update

      The guideline will be reviewed 5 years after publication to decide whether all of part of the guideline should be updated. However, if important new evidence is published prior to the 5-year cycles, the review process may be accelerated for a more rapid update of some recommendations.

      Sponsors

      This guideline was developed with resources funded by The Society of Obstetricians and Gynaecologists of Canada.

      Summary Statements

      • 1.
        It is important that all health care professionals have a good understanding of pain in childbirth including its physiological and psychological management whether or not a person in labour also chooses pharmacological relief (III).
      • 2.
        A growing body of scientific literature supports the use of nonpharmacological approaches to pain management during childbirth due to their numerous benefits for the mother and child, including a reduction in the need for obstetrical interventions, labour augmentation, or Caesarean section (l).
      • 3.
        Suffering, as opposed to pain, occurs when a woman is unable to activate her own mechanisms for coping with pain, or when her own mechanisms are insufficient to deal with the situation (III).
      • 4.
        The Gate Control Theory mechanism, which consists of creating pleasant stimulations in the painful area between or during contractions is best achieved through ambulation, gentle massage, stroking, water, or vibrations (I).
      • 5.
        The Diffuse Noxious Inhibitory Control (which consists of applying painful stimulations at any site on the body for the duration of each painful contraction) is best achieved through acupressure, sterile water injections, or deep massage (I).
      • 6.
        The Central Nervous System Control mechanism, which consists of deviating or focussing the woman's attention is best activated through labour support and the practice of yoga, relaxation, visualization, breathing, auto-hypnosis and cognitive restructuring (I).
      • 7.
        Continuous labour support, as part of nonpharmacological approaches to pain management during childbirth, reduces stress, fear, and anxiety, which in turn decreases the frequency of obstetrical interventions (I).
      • 8.
        Natural oxytocin is not only important for uterine contractions; it enhances a sense of calmness and reduces pain. Because synthetic oxytocin does not cross the blood-brain barrier in a significant manner, the analgesic and psychological effects on the mother of calmness and well-being are lost (II).
      • 9.
        Elevated endorphins in labour help reduce maternal stress and pain and may assist in newborn adaptations (II).
      • 10.
        Health care providers and the birthing environment can have a major impact on labour progress and experience by paying attention to and reducing a woman's stress level (I).
      • 11.
        Prolactin not only promotes breast milk production, it optimizes the mother's physiologic and behavioural responses in adapting to her role (II).
      • 12.
        Creating a calm, stress-free environment, encouraging women, and having a positive attitude where possible play an important role to stimulate the endogenous hormone production that promotes and supports the physiologic progress of labour (II).
      • 13.
        Neurophysiologic and hormonal mechanisms contribute to help women cope with the intensity of labour (l).

      Recommendations

      • 1.
        Health care providers should be familiar with the neurophysiological and hormonal mechanisms and related methods in physiological labour and birth (III-A).
      • 2.
        To help women cope with normal labour, nonpharmacological approaches are recommended as a safe first-line method for pain relief and should be continued throughout labour whether or not pharmacologic methods are used (I-A).
      • 3.
        To prevent suffering, health professionals should address the emotional component of pain (pain unpleasantness). This is most effectively achieved through support and nonpharmacological approaches to pain management.
      • 4.
        To develop support measures consistent with the wishes of women, health professionals should work with women and listen to their needs (III-A).
      • 5.
        To further reduce the need for obstetric interventions and avoid associated risks and side-effects, health professionals should provide continuous labour support with the addition of at least one other nonpharmacological pain modulating mechanism (I-A).
      • 6.
        Health professionals should, where possible, promote and support the physiological progress of labour, delivery, and the postpartum period trusting the woman's ability to work with her pain and encouraging her to rely on her ability to give birth (III-A).
      • 7.
        To enhance the endogenous hormone production that promotes and supports the physiologic process of labour, health care providers should reduce a woman's stress level by encouraging her and having a positive attitude where possible and by creating a calm, stress-free environment (I-A).
      • 8.
        Continuous labour support, as part of nonpharmacological approaches to pain management during childbirth for women should be promoted and provided for all women in labour (I-A).
      • 9.
        Health professionals should encourage parents and the people assisting them to prepare for the birth by learning about birth physiology and gaining skills in working with pain (III-A).

      Key Words

      Abbreviations:

      CNS (central nervous system), CNSC (control of the higher centres of the CNS), DNIC (diffuse noxious inhibitory control), OR (odds ratio), RCT (randomized controlled trial), SOGC (Society of Obstetricians and Gynaecologists of Canada), TENS (transcutaneous electrical nerve stimulation)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Obstetrics and Gynaecology Canada
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Joint Policy Statement on Normal Childbirth
        Continuous support for women during childbirth.
        J Obstet Gynaecol Can. 2008; 30: 1163-1165
        • Lee L.
        • Dy J.
        • Azzam H.
        Management of spontaneous labour at term in healthy women.
        J Obstet Gynaecol Can. 2016; 38: 843-865
        • Chaillet N.
        • Belaid L.
        • Crochetière C.
        • et al.
        Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis.
        Birth. 2014; 41: 122-137
        • Dozier A.M.
        • Howard C.R.
        • Brownell E.A.
        • et al.
        Labor epidural anesthesia, obstetric factors and breastfeeding cessation.
        Matern Child Health J. 2013; 17: 689-698
        • Hodnett E.D.
        Pain and women's satisfaction with the experience of childbirth: a systematic review.
        Am J Obstet Gynecol. 2002; 186: S160-S172
        • Hodnett E.D.
        • Gates S.
        • Hofmeyr G.J.
        • et al.
        Continuous support for women during childbirth.
        Cochrane Database Syst Rev. 2013; (CD003766)
        • Ullman R.
        • Smith L.A.
        • Burns E.
        • et al.
        Parenteral opioids for maternal pain relief in labour.
        Cochrane Database Syst Rev. 2010; (CD007396)
        • Simkin P.
        • Bolding A.
        Update on nonpharmacologic approaches to relieve Labor pain and prevent suffering.
        J Midwifery Womens Health. 2004; 49: 489-504
        • Leap N.
        • Dodwell M.
        • Newburn M.
        Working with pain in labour: an overview of evidence.
        New Digest. 2010; 49: 22-26
        • Lowe N.K.
        The nature of labor pain.
        Am J Obstet Gynecol. 2002; 186: S16-S24
        • Lundgren I.
        • Dahlberg K.
        Women's experience of pain during childbirth.
        Midwifery. 1998; 14: 105-110
        • Buckley S.J.
        Hormonal physiology of childbearing: evidence and implications for women, babies and maternity care.
        National Partnership for Women & Families, Washington, DC2015
        • Lindblom U.
        • Merskey H.
        • Mumford J.M.
        • et al.
        Pain terms—a current list with definitions and notes on usage with definitions and notes on usage.
        Pain. 1985; 3: 215-221
        • Fuchs A.R.
        • Fuchs F.
        • Husslein P.
        • et al.
        Oxytocin receptors and human parturition: a dual role for oxytocin in the initiation of labor.
        Science. 1982; 215: 1396-1398
        • Fuchs A.R.
        • Fuchs F.
        • Husslein P.
        • et al.
        Oxytocin receptors in the human uterus during pregnancy and parturition.
        Am J Obstet Gynecol. 1984; 150: 734-741
        • Buckley S.J.
        Ecstatic Birth: Nature's Hormonal Blueprint for Labor.
        (EBook; Available at:)
        http://sarahbuckley.com/subscribe-to-sarahs-updates
        Date: 2010
        Date accessed: March 7, 2013
        • Bonica J.
        Labour pain.
        in: McMahon S. Koltzenburg M. Tracey I. Wall & Melzack's textbook of pain. Churchill Livingston, New York1994
        • Odent M.
        The fetus ejection reflex.
        Birth. 1987; 14: 104-105
        • Marchand S.
        The Phenomenon of Pain.
        (IASP)2015
        • McDonald J.S.
        Pain of childbirth.
        in: Loeser J.D. Bonica's management of pain. 3rd ed. Lippincott Williams & Wilkins, Philadelphia2001: 1388-1414
        • Wei S.
        • Wo B.L.
        • Qi H.P.
        • et al.
        Early amniotomy and early oxytocin for prevention of, or therapy for, delay in first stage spontaneous labour compared with routine care.
        Cochrane Database Syst Rev. 2013; (CD006794)
        • National Childbirth Trust
        Rupture of the membranes in labour.
        NCT, London1989
        • Simkin P.
        Stress, pain, and catecholamines in labor: part 1. A review.
        Birth. 1986; 13: 227-233
        • Bonapace J.
        Trusting birth with the Bonapace method. Keys to loving your birth experience.
        Juniper Publishing, Montreal2015
        • Foureur M.
        Creating birth space to enable undisturbed birth.
        in: Fahy K. Foureur M. Hastie C. Birth territory and midwifery guardianship: theory for practice, education and research. Books for Midwives, Edinburgh2008: 57-78
        • Sheiner E.K.
        • Sheiner E.
        • Shoham-Vardi I.
        • et al.
        Ethnic differences influence care giver's estimates of pain during labour.
        Pain. 1999; 81: 299-305
        • Sheiner E.
        • Sheiner E.K.
        • Hershkovitz R.
        • et al.
        Overestimation and underestimation of labor pain.
        Eur J Obstet Gynecol Reprod Biol. 2000; 91: 37-40
        • Melzack R.
        • Katz J.
        Pain measurement in persons in pain.
        in: McMahon S. Koltzenburg M. Tracey I. Wall & Melzack's textbook of pain. 4th ed. Churchill Livingstone, Edinburgh1999: 337-351
        • Price D.D.
        • Harkins S.W.
        • Baker C.
        Sensory-affective relationships among different types of clinical and experimental pain.
        Pain. 1987; 28: 297-307
        • Chapman C.R.
        • Gavrin J.
        Suffering and its relationship to pain.
        J Palliat Care. 1992; 9: 5-13
        • Lederman R.P.
        • Lederman E.
        • Work Jr, B.A.
        • et al.
        The relationship of maternal anxiety, plasma catecholamines, and plasma cortisol toprogress in labor.
        Am J Obstet Gynecol. 1978; 132: 495-500
        • Melzack R.
        • Wall P.D.
        Pain mechanisms: a new theory.
        Science. 1965; 150: 971-979
        • Le Bars D.
        • Dickenson A.H.
        • Besson J.M.
        Diffuse noxious inhibitory controls (DNIC). I. Effects on dorsal horn convergent neurones in the rat.
        Pain. 1979; 6: 283-304
        • Le Bars D.
        • Dickenson A.H.
        • Besson J.M.
        Diffuse noxious inhibitory controls (DNIC). II. Lack of effect on non-convergent neurones, supraspinal involvement and theoretical implications.
        Pain. 1979; 6: 305-327
        • Uvnas-Moberg K.
        Oxytocin: the biological guide to motherhood.
        Hale Publishing, Amarillo, TX2015
        • Tom N.
        • Assinder S.J.
        Oxytocin in health and disease.
        Int J Biochem Cell Biol. 2010; 42: 202-205
        • Alves E.
        • Fielder A.
        • Ghabriel N.
        • et al.
        Early social environment affects the endogenous oxytocin system: a review and future directions.
        Front Endocrinol (Lausanne). 2015; 6: 32
        • Heinrichs M.
        • Meinlschmidt G.
        • Wippich W.
        • et al.
        Selective amnesic effects of oxytocin on human memory.
        Physiol Behav. 2004; 83: 31-38
        • Nissen E.
        • Lilja G.
        • Widstrom A.M.
        • et al.
        Elevation of oxytocin levels early post partum in women.
        Acta Obstet Gynecol Scand. 1995; 74: 530-533
        • Matthiesen A.S.
        • Ransjo-Arvidson A.B.
        • Nissen E.
        • et al.
        Postpartum maternal oxytocin release by newborns: effects of infant hand massage and sucking.
        Birth. 2001; 28: 13-19
        • Kennell J.H.
        • McGrath S.
        What babies teach us: the essential link between baby's behavior and mother's biology.
        Birth. 2001; 28: 20-21
        • Russell J.A.
        • Leng G.
        • Douglas A.J.
        The magnocellular oxytocin system, the fount of maternity: adaptations in pregnancy.
        Front Neuroendocrinol. 2003; 24: 27-61
        • Mens W.B.
        • Witter A.
        • van Wimersma Greidanus T.B.
        Penetration of neurohypophyseal hormones from plasma into cerebrospinal fluid (CSF): half-times of disappearance of these neuropeptides from CSF.
        Brain Res. 1983; 262: 143-149
        • Leng G.
        • Caquineau C.
        • Sabatier N.
        Regulation of oxytocin secretion.
        Vitam Horm. 2005; 71: 27-58
        • Phaneuf S.
        • Rodriguez Linares B.
        • TambyRaja R.L.
        • et al.
        Loss of myometrial oxytocin receptors during oxytocin-induced and oxytocin-augmented labour.
        J Reprod Fertil. 2000; 120: 91-97
        • Al-Zirqi I.
        • Vangen S.
        • Forsen L.
        • et al.
        Effects of onset of labor and mode of delivery on severe postpartum hemorrhage.
        Am J Obstet Gynecol. 2009; 201: e1-e9
        • Grotegut C.A.
        • Paglia M.J.
        • Johnson L.N.
        • et al.
        Oxytocin exposure during labor among women with postpartum hemorrhage secondary to uterine atony.
        Am J Obstet Gynecol. 2011; 204: e1-e6
        • Selo-Ojeme D.
        • Rogers C.
        • Mohanty A.
        • et al.
        Is induced labour in the nullipara associated with more maternal and perinatal morbidity?.
        Arch Gynecol Obstet. 2011; 284: 337-341
        • Gu V.
        • Feeley N.
        • Gold I.
        • et al.
        Intrapartum synthetic oxytocin and its effects on maternal well-being at 2 months postpartum.
        Birth. 2016; 43 (e-pub ahead of print): 28-35https://doi.org/10.1111/birt.12198
        • Caldeyro-Barcia R.
        • Poseiro J.J.
        Oxytocin and contractility of the pregnant human uterus.
        Ann N Y Acad Sci. 1959; 75: 813-830
        • Jonas K.
        • Johansson L.M.
        • Nissen E.
        • et al.
        Effects of intrapartum oxytocin administration and epidural analgesia on the concentration of plasma oxytocin and prolactin, in response to suckling during the second day postpartum.
        Breastfeed Med. 2009; 4: 71-82
        • Bell A.F.
        • White-Traut R.
        • Rankin K.
        Fetal exposure to synthetic oxytocin and the relationship with prefeeding cues within one hour postbirth.
        Early Hum Dev. 2013; 89: 137-143
        • Olza Fernandez I.
        • Marin Gabriel M.
        • Malalana Martinez A.
        • et al.
        Newborn feeding behaviour depressed by intrapartum oxytocin: a pilot study.
        Acta Paediatr. 2012; 101: 749-754
        • Wiklund I.
        • Norman M.
        • Uvnas-Moberg K.
        • et al.
        Epidural analgesia: breast-feeding success and related factors.
        Midwifery. 2009; 25: e31-e38
        • Behrens O.
        • Goeschen K.
        • Luck H.J.
        • et al.
        Effects of lumbar epidural analgesia on prostaglandin F2 alpha release and oxytocin secretion during labor.
        Prostaglandins. 1993; 45: 285-296
        • Rahm V.A.
        • Hallgren A.
        • Hogberg H.
        • et al.
        Plasma oxytocin levels in women during labor with or without epidural analgesia: a prospective study.
        Acta Obstet Gynecol Scand. 2002; 81: 1033-1039
        • Scull T.J.
        • Hemmings G.T.
        • Carli F.
        • et al.
        Epidural analgesia in early labour blocks the stress response but uterine contractions remain unchanged.
        Can J Anaesth. 1998; 45: 626-630
        • Stocche R.M.
        • Klamt J.G.
        • Antunes-Rodrigues J.
        • et al.
        Effects of intrathecal sufentanil on plasma oxytocin and cortisol concentrations in women during the first stage of labor.
        Reg Anesth Pain Med. 2001; 26: 545-550
        • Anim-Somuah M.
        • Smyth R.M.
        • Jones L.
        Epidural versus non-epidural or no analgesia in labour.
        Cochrane Database Syst Rev. 2011; (CD000331)
        • Goodfellow C.F.
        • Hull M.G.
        • Swaab D.F.
        • et al.
        Oxytocin deficiency at delivery with epidural analgesia.
        BJOG. 1983; 90: 214-219
        • Szabo A.L.
        Review article: intrapartum neuraxial analgesia and breastfeeding outcomes: limitations of current knowledge.
        Anesth Analg. 2013; 116: 399-405
        • Brimdyr K.
        • Cadwell K.
        • Widstrom A.M.
        • et al.
        The association between common labor drugs and suckling when skin-to-skin during the first hour after birth.
        Birth. 2015; 42: 319-328
        • Ransjo-Arvidson A.B.
        • Matthiesen A.S.
        • Lilja G.
        • et al.
        Maternal analgesia during labor disturbs newborn behavior: effects on breastfeeding, temperature, and crying.
        Birth. 2001; 28: 5-12
        • Riordan J.
        • Gross A.
        • Angeron J.
        • et al.
        The effect of labor pain relief medication on neonatal suckling and breastfeeding duration.
        J Hum Lact. 2000; 16: 7-12
        • Baumgarder D.J.
        • Muehl P.
        • Fischer M.
        • et al.
        Effect of labor epidural anesthesia on breast-feeding of healthy full-term newborns delivered vaginally.
        J Am Board Fam Pract. 2003; 16: 7-13
        • Beilin Y.
        • Bodian C.A.
        • Weiser J.
        • et al.
        Effect of labor epidural analgesia with and without fentanyl on infant breast-feeding: a prospective, randomized, double-blind study.
        Anesthesiology. 2005; 103: 1211-1217
        • Torvaldsen S.
        • Roberts C.L.
        • Simpson J.M.
        • et al.
        Intrapartum epidural analgesia and breastfeeding: a prospective cohort study.
        Int Breastfeed J. 2006; 1: 24
        • Yim I.S.
        • Glynn L.M.
        • Schetter C.D.
        • et al.
        Prenatal beta-endorphin as an early predictor of postpartum depressive symptoms in euthymic women.
        J Affect Disord. 2010; 125: 128-133
        • Hoffman D.I.
        • Abboud T.K.
        • Haase H.R.
        • et al.
        Plasma beta-endorphin concentrations prior to and during pregnancy, in labor, and after delivery.
        Am J Obstet Gynecol. 1984; 150: 492-496
        • Nelson E.E.
        • Panksepp J.
        Brain substrates of infant-mother attachment: contributions of opioids, oxytocin, and norepinephrine.
        Neurosci Biobehav Rev. 1998; 22: 437-452
        • Rivier C.
        • Vale W.
        • Ling N.
        • et al.
        Stimulation in vivo of the secretion of prolactin and growth hormone by beta-endorphin.
        Endocrinology. 1977; 100: 238-241
        • Zanardo V.
        • Nicolussi S.
        • Giacomin C.
        • et al.
        Labor pain effects on colostral milk beta-endorphin concentrations of lactating mothers.
        Biol Neonate. 2001; 79: 87-90
        • Alehagen S.
        • Wijma B.
        • Lundberg U.
        • et al.
        Fear, pain and stress hormones during childbirth.
        J Psychosom Obstet Gynaecol. 2005; 26: 153-165
        • Neumark J.
        • Hammerle A.F.
        • Biegelmayer C.
        Effects of epidural analgesia on plasma catecholamines and cortisol in parturition.
        Acta Anaesthesiol Scand. 1985; 29: 555-559
        • Odent M.R.
        Position in delivery.
        Lancet. 1990; 335: 1166
        • Lagercrantz H.
        • Slotkin T.A.
        The “stress” of being born.
        Sci Am. 1986; 254: 100-107
        • Hillman N.H.
        • Kallapur S.G.
        • Jobe A.H.
        Physiology of transition from intrauterine to extrauterine life.
        Clin Perinatol. 2012; 39: 769-783
        • Segal S.
        • Csavoy A.N.
        • Datta S.
        The tocolytic effect of catecholamines in the gravid rat uterus.
        Anesth Analg. 1998; 87: 864-869
        • Hodnett E.D.
        • Gates S.
        • Hofmeyr G.J.
        • et al.
        Continuous support for women during childbirth.
        Cochrane Database Syst Rev. 2013; (CD003766)
        • Sandall J.
        • Soltani H.
        • Gates S.
        • et al.
        Midwife-led continuity models versus other models of care for childbearing women.
        Cochrane Database Syst Rev. 2013; (CD004667)
        • Hodnett E.D.
        • Downe S.
        • Walsh D.
        Alternative versus conventional institutional settings for birth.
        Cochrane Database Syst Rev. 2012; (CD000012)
        • Hutton E.K.
        • Cappelletti A.
        • Reitsma A.H.
        • et al.
        Outcomes associated with planned place of birth among women with low-risk pregnancies.
        CMAJ. 2016; 188: E8-90
        • Hutton E.K.
        • Reitsma A.H.
        • Kaufman K.
        Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003–2006: a retrospective cohort study.
        Birth. 2009; 36: 180-189
        • Grattan D.R.
        • Kokay I.C.
        Prolactin: a pleiotropic neuroendocrine hormone.
        J Neuroendocrinol. 2008; 20: 752-763
        • Doan T.
        • Gardiner A.
        • Gay C.L.
        • et al.
        Breast-feeding increases sleep duration of new parents.
        J Perinat Neonatal Nurs. 2007; 21: 200-206
        • Doan T.
        • Gay C.L.
        • Kennedy H.P.
        • et al.
        Nighttime breastfeeding behavior is associated with more nocturnal sleep among first-time mothers at one month postpartum. Journal of clinical sleep medicine.
        J Clin Sleep Med. 2014; 10: 313
        • Storey A.E.
        • Walsh C.J.
        • Quinton R.L.
        • et al.
        Hormonal correlates of paternal responsiveness in new and expectant fathers.
        Evol Hum Behav. 2000; 21: 79-95
        • Grattan D.
        A mother's brain knows.
        J Neuroendocrinol. 2011; 23: 1188-1189
        • Bancroft J.
        The endocrinology of sexual arousal.
        J Endocrinol. 2005; 186: 411-427
        • Buhimschi C.S.
        Endocrinology of lactation.
        Obstet Gynecol Clin North Am. 2004; 31: 963-979
        • Stefos T.
        • Sotiriadis A.
        • Tsirkas P.
        • et al.
        Maternal prolactin secretion during labor. The role of dopamine.
        Acta Obstet Gynecol Scand. 2001; 80: 34-38
        • De Carvalho M.
        • Robertson S.
        • Friedman A.
        • et al.
        Effect of frequent breast-feeding on early milk production and infant weight gain.
        Pediatrics. 1983; 72: 307-311
        • Cluett E.R.
        • Burns E.
        Immersion in water in labour and birth.
        Cochrane Database Syst Rev. 2009; (CD000111)
        • Da Silva F.M.B.
        • de Oliveira S.M.J.V.
        • Nobre M.R.C.
        A randomised controlled trial evaluating the effect of immersion bath on labour pain.
        Midwifery. 2009; 25: 286-294
        • Taha M.
        The effects of water on labour: a randomised controlled trial.
        Rand Afrikaans University, Johannesburg, South Africa2000
        • Kimber L.
        • McNabb M.
        • Haines A.
        • et al.
        Massage or music for pain relief in labour: a pilot randomised placebo controlled trial.
        Eur J Pain. 2008; 12: 961-969
        • Smith C.A.
        • Levett K.M.
        • Collins C.T.
        • et al.
        Massage, reflexology and other manual methods for pain management in labour.
        Cochrane Database Syst Rev. 2012; (CD009290)
        • Silva Gallo R.B.
        • Santana L.S.
        • Jorge Ferreira C.H.
        • et al.
        Massage reduced severity of pain during labour: a randomised trial.
        J Physiother. 2013; 59: 109-116
        • Janssen P.
        • Shroff F.
        • Jaspar P.
        Massage therapy and labor outcomes: a randomized controlled trial.
        Int J Ther Massage Bodywork. 2012; 5: 15
        • Mortazavi S.H.
        • Khaki S.
        • Moradi R.
        • et al.
        Effects of massage therapy and presence of attendant on pain, anxiety and satisfaction during labor.
        Arch Gynecol Obstet. 2012; 286: 19-23
        • Chang M.Y.
        • Wang S.Y.
        • Chen C.H.
        Effects of massage on pain and anxiety during labour: a randomized controlled trial in Taiwan.
        J Adv Nurs. 2002; 38: 68-73
        • Zwelling E.
        Overcoming the challenges: maternal movement and positioning to facilitate labor progress.
        MCN Am J Matern Child Nurs. 2010; 35: 72
        • Lawrence A.
        • Lewis L.
        • Hofmeyr G.J.
        • et al.
        Maternal positions and mobility during first stage labour.
        Cochrane Database Syst Rev. 2009; (CD002006)
        • Gupta J.K.
        • Hofmeyr G.J.
        • Smyth R.
        Position in the second stage of labour for women without epidural anaesthesia.
        Cochrane Database Syst Rev. 2009; (CD002006)
        • Spiby H.
        • Slade P.
        • Escott D.
        • et al.
        Selected coping strategies in labor: an investigation of women's experiences.
        Birth. 2003; 30: 189-194
        • Albers L.L.
        The evidence for physiologic management of the active phase of the first stage of labor.
        J Midwifery Womens Health. 2007; 52: 207-215
        • Smith C.A.
        • Collins C.T.
        • Crowther C.A.
        • et al.
        Acupuncture or acupressure for pain management in labour (Review).
        Cochrane Database Syst Rev. 2011; (CD009232)
        • Borup L.
        • Wurlitzer W.
        • Hedegaard M.
        • et al.
        Acupuncture as pain relief during delivery: a randomized controlled trial.
        Birth. 2009; 36: 5-12
        • Cho S.H.
        • Lee H.
        • Ernst E.
        Acupuncture for pain relief in labour: a systematic review and meta-analysis.
        BJOG. 2010; 117: 907-920
        • Ma W.
        • Bai W.
        • Lin C.
        • et al.
        Effects of Sanyinjiao (SP6) with electroacupuncture on labour pain in women.
        J Altern Complement Med. 2011; 19S: 13-18
        • Qu F.
        • Zhou J.
        Electro-acupuncture in relieving labor pain.
        Evid Based Complement Alternat Med. 2007; 4: 125-130
        • Lee E.J.
        • Frazier S.K.
        The efficacy of acupressure for symptom management: a systematic review.
        J Pain Symptom Manage. 2011; 42: 589-603
        • Wiruchpongsanon P.
        Relief of low back labor pain by using intracutaneous injections of sterile water : a randomized clinical trial.
        J Med Assoc Thai. 2006; 89: 571
        • Bahasadri S.
        • Ahmadi-Abhari S.
        • Dehghani-nik M.
        • et al.
        Subcutaneous sterile water injection for labour pain: a randomised controlled trial.
        Aust N Z J Obstet Gynaecol. 2006; 46: 102-106
        • Mårtensson L.
        • Wallin G.
        Sterile water injections as treatment for lowback pain during labour: a review.
        Aust N Z J Obstet Gynaecol. 2008; 48: 369-374
        • Hutton E.K.
        • Kasperink M.
        • Rutten M.
        • et al.
        Sterile water injection for labour pain : a systematic review and meta-analysis of randomised controlled trials.
        BJOG. 2009; 116: 1158-1166
        • Derry S.
        • Straube S.
        • Moore R.A.
        • et al.
        Intracutaneous or subcutaneous sterile water injection compared with blinded controls for pain management in labour.
        Cochrane Database Syst Rev. 2012; (CD009107)
        • Jones L.
        • Othman M.
        • Docwswell T.
        • et al.
        Pain management for women in labour: an overview of systematic reviews.
        Cochrane Database Syst Rev. 2012; (CD009234)
        • Hajiamini Z.
        • Masoud S.N.
        • Ebadi A.
        • et al.
        Comparing the effects of ice massage and acupressure on labor pain reduction.
        Complement Ther Clin Pract. 2012; 1: 169-172
        • Field T.
        Pregnancy and labor alternative therapy research.
        Altern Ther Health Med. 2008; 14: 28
        • Bundsen P.
        • Peterson L.E.
        • Selstam U.
        Pain relief in labor by transcutaneous electrical nerve stimulation: a prospective matched study.
        Acta Obstet Gynecol Scand Suppl. 1981; 60: 459-468
        • Chao A.S.
        • Chao A.
        • Wang T.H.
        • et al.
        Pain relief by applying transcutaneous electrical nerve stimulation (TENS) on acupuncture points during the first stage of labor: a randomized double-blind placebo-controlled trial.
        Pain. 2007; 127: 214-220
        • Dowswell T.
        • Bedwell C.
        • Lavender T.
        • et al.
        Transcutaneous electrical nerve stimulation (TENS) for pain management in labour.
        Cochrane Database Syst Rev. 2011; (CD007214)
        • Marks G.K.
        Alternative therapies.
        in: Nichols F.H. Humenick S.S. Childbirth education: practice, research and theory. Saunders, Philadelphia2000: 376-398
        • Kumar S.B.
        • Yadav R.
        • Yadav R.K.
        • et al.
        Telomerase activity and cellular aging might be positively modified by a yoga-based lifestyle intervention.
        J Altern Complement Med. 2015; 21 (e-pub ahead of print): 370-372https://doi.org/10.1089/acm.2014.0298
        • Dykema R.
        Yoga for fitness and wellness.
        Thomson/Wadsworth, Belmont, CA2006: 192
        • Marc I.
        • Toureche N.
        • Ernst E.
        • et al.
        Mind-body interventions during pregnancy for preventing or treating women's anxiety.
        Cochrane Database Syst Rev. 2011; (CD007559)
        • Smith C.
        • Levett K.M.
        • Collins C.T.
        • et al.
        Relaxation techniques for pain management.
        Cochrane Database Syst Rev. 2011; (CD009514)
        • Curtis K.
        • Weinrib A.
        • Katz J.
        Systematic review of yoga for pregnant women: current status and future directions.
        Evid Based Complement Alternat Med. 2012; 2012: 1-13
        • Urech C.
        • Fink N.S.
        • Hoesli I.
        • et al.
        Effects of relaxation on psychobiological wellbeing during pregnancy: a randomized controlled trial.
        Psychoneuroendocrinology. 2010; 35: 1348-1355
        • Gedde-Dahl M.
        • Fors E.A.
        Impact of self-administered relaxation and guided imagery techniques during final trimester and birth.
        Complement Ther Clin Pract. 2012; 18: 60-65
        • Hunter L.P.
        A descriptive study of “being with woman” during labor and birth.
        J Midwifery Womens Health. 2009; 54: 111-118
        • Adam E.D.
        • Bianchi A.L.
        A practical approach to labor support.
        J Obstet Gynecol Neonatal Nurs. 2008; 37: 106-115
        • Nabb M.T.M.
        • Kimber L.
        • Haines A.
        • et al.
        Does regular massage from late pregnancy to birth decrease maternal pain perception during labour and birth?—A feasibility study to investigate a programme of massage, controlled breathing and visualization, from 36 weeks of pregnancy until birth.
        Complement Ther Clin Pract. 2006; 12: 222-231
        • Thomas M.E.
        • Dhiwar M.S.
        Effectiveness of patterned breathing technique in reduction of pain during first stage of labour among primigravidas.
        Sinhgad e-J Nurs. 2011; 1: 6-8
        • VandeVusse L.
        • Irland J.
        • Healthcare W.F.
        • et al.
        Hypnosis for childbirth: a retrospective comparative analysis of outcomes in one obstetrician's practice.
        Am J Clin Hypn. 2007; 50: 109-119
        • Brown D.C.
        • Hammond D.C.
        Evidence-based clinical hypnosis for obstetrics, labor and delivery, and preterm labor.
        Int J Clin Exp Hypn. 2007; 55: 355-371
        • Cyna A.M.
        • Andrew M.I.
        • Robinson J.S.
        • et al.
        Hypnosis Antenatal Training for Childbirth (HATCh): a randomised controlled trial [NCT00282204].
        BMC Pregnancy Childbirth. 2006; 6: 1-12
        • Ernst E.
        • Pittler M.
        • Wider B.
        • et al.
        Mind-body therapies: are the trial data getting stronger?.
        Altern Ther Health Med. 2007; 13: 62
        • Smith C.A.
        • Collins C.T.
        • Cyna A.M.
        • et al.
        Complementary and alternative therapies for pain management in labour.
        Cochrane Database Syst Rev. 2006; (CD003521)
        • Madden K.
        • Middleton P.
        • Cyna A.M.
        • et al.
        Hypnosis for pain management during labour and childbirth.
        Cochrane Database Syst Rev. 2012; (CD009356)
        • Boso M.
        • Politi P.
        • Barale F.
        • et al.
        Neurophysiology and neurobiology of the musical experience.
        Funct Neurol. 2006; 21: 187-191
        • Trout K.K.
        The neuromatrix theory of pain: implications for selected nonpharmacologic methods of pain relief for labor.
        J Midwifery Womens Health. 2004; 49: 482-488
        • Menon V.
        • Levitin D.J.
        The rewards of music listening: response and physiological connectivity of the mesolimbic system.
        Neuroimage. 2005; 28: 175-184
        • Browning C.A.
        Using music during childbirth.
        Birth. 2000; 27: 272-276
        • Gagnon A.J.
        • Sandall J.
        Individual or group antenatal education for childbirth or parenthood, or both.
        Cochrane Database Syst Rev. 2007; (CD002869)
        • Mehdizadeh A.
        • Roosta F.
        • Chaichian S.
        • et al.
        Evaluation of the impact of birth preparation courses on the health of the mother and the newborn.
        Am J Perinatol. 2005; 22: 7-9
        • Ip W.Y.
        • Tang C.S.
        • Goggins W.B.
        An educational intervention to improve women's ability to cope with childbirth.
        J Clin Nurs. 2009; 18: 2125-2135
        • Escott D.
        • Slade P.
        • Spiby H.
        Preparation for pain management during childbirth: the psychological aspects of coping strategy development in antenatal education.
        Clin Psychol Rev. 2009; 29: 617-622
        • McDonald S.J.
        • Middleton P.
        • Dowswell T.
        • et al.
        Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes.
        Cochrane Database Syst Rev. 2013; (CD004074)
        • Begley C.M.
        • Gyte G.M.L.
        • Devane D.
        • et al.
        Active versus expectant management for women in the third stage of labour.
        Cochrane Database Syst Rev. 2015; (CD007412)