Relaxation techniques for pain management in labour

Caroline A Smith; Kate M Levett; Carmel T Collins; Mike Armour; Hannah G Dahlen; Machiko Suganuma

doi:10.1002/14651858.CD009514.pub2

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Figure 1

Study flow diagram

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

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Analysis 1.1

Comparison 1 Relaxation versus usual care, Outcome 1 Pain intensity.

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Analysis 1.2

Comparison 1 Relaxation versus usual care, Outcome 2 Pain intensity.

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Analysis 1.3

Comparison 1 Relaxation versus usual care, Outcome 3 Satisfaction with pain relief.

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Analysis 1.4

Comparison 1 Relaxation versus usual care, Outcome 4 Satisfaction with childbirth experience.

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Analysis 1.5

Comparison 1 Relaxation versus usual care, Outcome 5 Assisted vaginal birth.

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Analysis 1.6

Comparison 1 Relaxation versus usual care, Outcome 6 Caesarean section.

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Analysis 1.7

Comparison 1 Relaxation versus usual care, Outcome 7 Admission to special care nursery.

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Analysis 1.8

Comparison 1 Relaxation versus usual care, Outcome 8 Low Apgar score < 7 at 5 minutes.

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Analysis 1.9

Comparison 1 Relaxation versus usual care, Outcome 9 Use of pharmacological pain relief.

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Analysis 1.10

Comparison 1 Relaxation versus usual care, Outcome 10 Length of labour.

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Analysis 1.11

Comparison 1 Relaxation versus usual care, Outcome 11 Need for augmentation with oxytocin.

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Analysis 1.12

Comparison 1 Relaxation versus usual care, Outcome 12 Anxiety.

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Analysis 1.13

Comparison 1 Relaxation versus usual care, Outcome 13 Non‐prespecified: vitality.

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Analysis 1.14

Comparison 1 Relaxation versus usual care, Outcome 14 Non‐prespecified: fatigue in labour.

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Analysis 2.1

Comparison 2 Yoga versus control, Outcome 1 Pain intensity.

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Analysis 2.2

Comparison 2 Yoga versus control, Outcome 2 Satisfaction with pain relief.

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Analysis 2.3

Comparison 2 Yoga versus control, Outcome 3 Satisfaction with childbirth experience.

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Analysis 2.4

Comparison 2 Yoga versus control, Outcome 4 Low Apgar score < 7 at 5 minutes.

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Analysis 2.5

Comparison 2 Yoga versus control, Outcome 5 Use of pharmacological pain relief.

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Analysis 2.6

Comparison 2 Yoga versus control, Outcome 6 Length of labour.

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Analysis 2.7

Comparison 2 Yoga versus control, Outcome 7 Need for augmentation with oxytocin.

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Analysis 3.1

Comparison 3 Music versus control, Outcome 1 Pain intensity.

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Analysis 3.2

Comparison 3 Music versus control, Outcome 2 Assisted vaginal birth.

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Analysis 3.3

Comparison 3 Music versus control, Outcome 3 Caesarean section.

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Analysis 3.4

Comparison 3 Music versus control, Outcome 4 Admission to special care nursery.

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Analysis 3.5

Comparison 3 Music versus control, Outcome 5 Use of pharmacological pain relief.

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Analysis 3.6

Comparison 3 Music versus control, Outcome 6 Length of labour.

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Analysis 3.7

Comparison 3 Music versus control, Outcome 7 Anxiety.

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Analysis 4.1

Comparison 4 Audio‐analgesia versus control, Outcome 1 Satisfaction with pain relief.

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Analysis 5.1

Comparison 5 Mindfulness training versus usual care, Outcome 1 Sense of control in labour.

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Analysis 5.2

Comparison 5 Mindfulness training versus usual care, Outcome 2 Satisfaction with childbirth.

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Analysis 5.3

Comparison 5 Mindfulness training versus usual care, Outcome 3 Assisted vaginal birth.

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Analysis 5.4

Comparison 5 Mindfulness training versus usual care, Outcome 4 Caesarean section.

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Analysis 5.5

Comparison 5 Mindfulness training versus usual care, Outcome 5 Need for pharmacological pain relief.

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Summary of findings for the main comparison. Relaxation compared to usual care for pain management in labour

Relaxation compared to usual care for pain management in labour
Patient or population: women in labour Setting: hospital settings in Brazil, Italy, Sweden, Turkey, UK Intervention: relaxation Comparison: usual care
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with usual care	Risk with relaxation
Pain intensity: active phase (lower scores indicate less intense pain)	The mean pain intensity ‐ active phase was 7.8	MD 1.08 lower (2.57 lower to 0.41 higher)	‐	271 (4 RCTs)	⊕⊝⊝⊝ Very low^1,2,3,4
Satisfaction with pain relief (higher proportion high satisfaction)	Study population		RR 8.00 (1.10 to 58.19)	40 (1 RCT)	⊕⊝⊝⊝ Very low^5,6
	50 per 1000	400 per 1000 (55 to 1000)
Sense of control in labour	‐	‐	‐	‐	‐	No trial reported this outcome
Satisfaction with childbirth experience (higher scores indicate more satisfaction)	The mean satisfaction with childbirth experience using a variety of outcome measures was 27.1	SMD 0.03 lower (0.37 lower to 0.31 higher)	‐	1176 (3 RCTs)	⊕⊝⊝⊝ Very low^2,4,7
Breastfeeding	‐	‐	‐	‐	‐	No trial reported this outcome
Assisted vaginal birth	Study population		Average RR 0.61 (0.20 to 1.84)	1122 (4 RCTs)	⊕⊝⊝⊝ Very low^2,8,9
	149 per 1000	91 per 1000 (30 to 275)
Caesarean section	Study population		Average RR 0.73 (0.26 to 2.01)	1122 (4 RCTs)	⊕⊝⊝⊝ Very low^2,8,9
	214 per 1000	157 per 1000 (56 to 431)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RCT: randomised controlled trial; RR: Risk ratio; SMD: standardised mean difference
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect
¹Downgraded one level: most of the pooled effect provided by studies with high risk of bias in allocation concealment and/or blinding. ²Downgraded one level: severe unexplained heterogeneity. ³Downgraded one level: small sample size. ⁴Downgraded one level: wide confidence intervals crossing the line of no effect. ⁵Downgraded one level: one included study has high risk of bias in blinding. ⁶Downgraded two levels: small sample size and rare events. ⁷Downgraded one level: all included studies at high risk of bias for blinding. ⁸Downgraded one level: all included studies are at a high risk of bias in at least one domain. ⁹Downgraded two levels: small sample size, few events and wide confidence interval crossing the line of no effect.

Summary of findings for the main comparison. Relaxation compared to usual care for pain management in labour

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Summary of findings 2. Yoga compared to control for pain management in labour

Yoga compared to control for pain management in labour
Patient or population: women in labour Setting: hospital settings in Thailand Intervention: yoga Comparison: control
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
Outcomes	Risk with control	Risk with yoga	Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
Pain intensity (lower scores indicate less intense pain)	The mean pain intensity was 57.91	MD 6.12 lower (11.77 lower to 0.47 lower)	‐	66 (1 RCT)	⊕⊕⊝⊝ Low^1,2
Satisfaction with pain relief Higher scores indicate greater satisfaction with pain relief	The mean satisfaction with pain relief was 45	MD 7.88 higher (1.51 higher to 14.25 higher)	‐	66 (1 RCT)	⊕⊕⊝⊝ Low^1,2
Sense of control in labour	‐	‐	‐	‐	‐	No trial reported this outcome
Satisfaction with childbirth experience (higher scores indicate greater satisfaction)	The mean satisfaction with childbirth experience was 150.36	MD 6.34 higher (0.26 higher to 12.42 higher)	‐	66 (1 RCT)	⊕⊕⊝⊝ Low^1,2
Breastfeeding	‐	‐	‐	‐	‐	No trial reported this outcome
Assisted vaginal birth	‐	‐	‐	‐	‐	No trial reported this outcome
Caesarean section	‐	‐	‐	‐	‐	No trial reported this outcome
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; MD: mean difference; RCT: randomised controlled trial; RR: Risk ratio
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect
¹Downgraded one level: high risk of bias in blinding domains. ²Downgraded one level: small sample size.

Summary of findings 2. Yoga compared to control for pain management in labour

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Summary of findings 3. Music compared to control for pain management in labour

Music compared to control for pain management in labour
Patient or population: women in labour Setting: hospital settings in Italy, Taiwan, and Turkey Intervention: music Comparison: control
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with control	Risk with music
Pain intensity ‐ active phase (lower scores indicate less intense pain)	The mean pain intensity ‐ active phase was 8.61	MD 0.51 lower (1.10 lower to 0.07 higher)	‐	217 (3 RCTs)	⊕⊝⊝⊝ Very low^1,2,3
Satisfaction with pain relief	‐	‐	‐	‐	‐	No trial reported this outcome
Sense of control in labour	‐	‐	‐	‐	‐	No trial reported this outcome
Satisfaction with childbirth experience	‐	‐	‐	‐	‐	No trial reported this outcome
Breastfeeding	‐	‐	‐	‐	‐	No trial reported this outcome
Assisted vaginal birth	Study population		RR 0.41 (0.08 to 2.05)	156 (1 RCT)	⊕⊝⊝⊝ Very low^4,5
	63 per 1000	26 per 1000 (5 to 130)
Caesarean section	Study population		RR 0.78 (0.36 to 1.70)	216 (2 RCTs)	⊕⊝⊝⊝ Very low^1,5
	119 per 1000	93 per 1000 (43 to 203)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RCT: randomised controlled trial; RR: Risk ratio
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect
¹Downgraded two levels: all included studies had at least two domains with high risk of bias ²Downgraded one level: small sample size. ³Downgraded one level: severe unexplained heterogeneity. ⁴Downgraded two levels: the included study was at a high risk of bias in four domains. ⁵Downgraded two levels: small sample size, few events, and wide confidence interval crossing the line of no effect.

Summary of findings 3. Music compared to control for pain management in labour

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Comparison 1. Relaxation versus usual care

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain intensity Show forest plot	4		Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 Latent phase	1	40	Mean Difference (IV, Random, 95% CI)	‐1.25 [‐1.97, ‐0.53]
1.2 Active phase	4	271	Mean Difference (IV, Random, 95% CI)	‐1.08 [‐2.57, 0.41]
1.3 Transition	1	40	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Pain intensity Show forest plot	1	977	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐0.23, 0.23]

3 Satisfaction with pain relief Show forest plot	1	40	Risk Ratio (M‐H, Fixed, 95% CI)	8.0 [1.10, 58.19]

4 Satisfaction with childbirth experience Show forest plot	3	1176	Std. Mean Difference (IV, Random, 95% CI)	‐0.03 [‐0.37, 0.31]

5 Assisted vaginal birth Show forest plot	4	1122	Risk Ratio (M‐H, Random, 95% CI)	0.61 [0.20, 1.84]

6 Caesarean section Show forest plot	4	1122	Risk Ratio (M‐H, Random, 95% CI)	0.73 [0.26, 2.01]

7 Admission to special care nursery Show forest plot	1	59	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.07, 15.77]

8 Low Apgar score < 7 at 5 minutes Show forest plot	1	34	Risk Ratio (M‐H, Fixed, 95% CI)	0.47 [0.02, 10.69]

9 Use of pharmacological pain relief Show forest plot	2	1036	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.88, 1.11]

9.1 Epidural	1	977	Risk Ratio (M‐H, Fixed, 95% CI)	1.00 [0.88, 1.13]
9.2 Any additional pharmacological intervention	1	59	Risk Ratio (M‐H, Fixed, 95% CI)	0.89 [0.61, 1.28]
10 Length of labour Show forest plot	3	224	Mean Difference (IV, Random, 95% CI)	39.30 [‐41.34, 119.93]

11 Need for augmentation with oxytocin Show forest plot	1	34	Risk Ratio (M‐H, Fixed, 95% CI)	1.14 [0.82, 1.59]

12 Anxiety Show forest plot	1	140	Mean Difference (IV, Fixed, 95% CI)	0.30 [‐4.15, 4.75]

13 Non‐prespecified: vitality Show forest plot	1	117	Mean Difference (IV, Fixed, 95% CI)	13.10 [10.58, 15.62]

14 Non‐prespecified: fatigue in labour Show forest plot	1	140	Mean Difference (IV, Fixed, 95% CI)	0.5 [‐1.44, 2.44]

Comparison 1. Relaxation versus usual care

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Comparison 2. Yoga versus control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain intensity Show forest plot	1	66	Mean Difference (IV, Fixed, 95% CI)	‐6.12 [‐11.77, ‐0.47]

1.1 Latent phase	1	66	Mean Difference (IV, Fixed, 95% CI)	‐6.12 [‐11.77, ‐0.47]
2 Satisfaction with pain relief Show forest plot	1	66	Mean Difference (IV, Fixed, 95% CI)	7.88 [1.51, 14.25]

2.1 Latent phase	1	66	Mean Difference (IV, Fixed, 95% CI)	7.88 [1.51, 14.25]
3 Satisfaction with childbirth experience Show forest plot	1	66	Mean Difference (IV, Fixed, 95% CI)	6.34 [0.26, 12.42]

4 Low Apgar score < 7 at 5 minutes Show forest plot	1	66	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

5 Use of pharmacological pain relief Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

5.1 Usual care	1	66	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.49, 1.38]
5.2 Supine position	1	83	Risk Ratio (M‐H, Fixed, 95% CI)	0.05 [0.01, 0.35]
6 Length of labour Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

6.1 Usual care	1	66	Mean Difference (IV, Fixed, 95% CI)	‐139.91 [‐252.50, ‐27.32]
6.2 Supine position	1	83	Mean Difference (IV, Fixed, 95% CI)	‐191.34 [‐243.72, ‐138.96]
7 Need for augmentation with oxytocin Show forest plot	1	66	Risk Ratio (M‐H, Fixed, 95% CI)	0.76 [0.45, 1.31]

Comparison 2. Yoga versus control

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Comparison 3. Music versus control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain intensity Show forest plot	3		Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 Latent phase	2	192	Mean Difference (IV, Random, 95% CI)	‐0.73 [‐1.01, ‐0.45]
1.2 Active phase	3	217	Mean Difference (IV, Random, 95% CI)	‐0.51 [‐1.10, 0.07]
1.3 Transition	1	132	Mean Difference (IV, Random, 95% CI)	‐0.70 [‐0.86, ‐0.54]
2 Assisted vaginal birth Show forest plot	1	156	Risk Ratio (M‐H, Fixed, 95% CI)	0.41 [0.08, 2.05]

3 Caesarean section Show forest plot	2	216	Risk Ratio (M‐H, Fixed, 95% CI)	0.78 [0.36, 1.70]

4 Admission to special care nursery Show forest plot	1	155	Risk Ratio (M‐H, Fixed, 95% CI)	0.23 [0.05, 1.01]

5 Use of pharmacological pain relief Show forest plot	1	60	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.53, 1.32]

6 Length of labour Show forest plot	1	60	Mean Difference (IV, Fixed, 95% CI)	‐2.60 [‐11.58, 6.38]

6.1 Second stage	1	60	Mean Difference (IV, Fixed, 95% CI)	‐2.60 [‐11.58, 6.38]
7 Anxiety Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Subtotals only

7.1 Latent phase	2	192	Mean Difference (IV, Random, 95% CI)	0.08 [‐1.86, 2.02]
7.2 Active phase	2	192	Mean Difference (IV, Random, 95% CI)	‐0.30 [‐1.74, 1.13]
7.3 Transition	1	132	Mean Difference (IV, Random, 95% CI)	‐0.66 [‐0.82, ‐0.50]

Comparison 3. Music versus control

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Comparison 4. Audio‐analgesia versus control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Satisfaction with pain relief Show forest plot	1	24	Risk Ratio (M‐H, Fixed, 95% CI)	2.0 [0.82, 4.89]

Comparison 4. Audio‐analgesia versus control

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Comparison 5. Mindfulness training versus usual care

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Sense of control in labour Show forest plot	1	26	Mean Difference (IV, Fixed, 95% CI)	31.30 [1.61, 60.99]

2 Satisfaction with childbirth Show forest plot	1	26	Mean Difference (IV, Fixed, 95% CI)	‐4.5 [‐17.61, 8.61]

3 Assisted vaginal birth Show forest plot	1	29	Risk Ratio (M‐H, Fixed, 95% CI)	0.31 [0.01, 7.09]

4 Caesarean section Show forest plot	1	29	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.15, 5.76]

5 Need for pharmacological pain relief Show forest plot	1	26	Risk Ratio (M‐H, Fixed, 95% CI)	0.5 [0.20, 1.26]

Comparison 5. Mindfulness training versus usual care

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