Non-pharmacological measures for pain relief in childbirth: a systematic review

this is a systematic review of the databases carried out in the United States National Library of Medicine, Cumulative Index to Nursing and Allied Heal Literature, Scopus, Web of Science and Latin American and Caribbean Literature in Health Sciences, the descriptors were: labor pain, labor, obstetric and obstetric nursing. The search and selection followed the PRISMA recommendations, were carried out from August to September 2020, and randomized clinical trials were eligible and analyzed using descriptive statistics.

Results:

17 clinical trials made up the final sample, which highlight the use of non-pharmacological measures with diversified benefits for labor, namely: thermal therapy (20%); massage/sacral massage (15%); Swiss ball exercises (15%); acupressure (15%); auriculotherapy (10%); music therapy (10%); aromatherapy (5%); acupuncture (5%); and dance (5%).

Conclusion:

the non-pharmacological measures found in this review are efficient to promote pain reduction during labor, associated with a decrease in the use of drug interventions.

Key words
Labor pain; Labor obstetric; Obstetric nursing; Systematic review

Code	Author/ Year^* * in years ; /Country	Sample	Measure		Intervention Data
Code	Author/ Year^* * in years ; /Country	Sample	Experiment	Control	Intervention Data
E1	Chang et al.,¹⁴14 Chang MY, Chen CH, Huang KF. A Comparison of Massage Effects on Labor Pain Using the McGill Pain Questionnaire. J Nurs Res. 2006; 14 (3): 190-7. 2006^* * in years ; / China	60 primiparous women	Massage	Standard nursing care	The measures were applied in three phases, at dilations of 3 to 4 cm, 5 to 7 cm and 8 to 10 cm.
E2	Taghinejad et al.,¹⁵15 Taghinejad H, Delpisheh A, Suhrabi Z. Comparison between massage and musictherapies to relieve the severity of labor pain. Womens Health (Lond) 2010; 6 (3): 377-81. 2010^* * in years ; / Iran	101 primiparous women	Massage / Music therapy	Own group	When the cervix was dilated up to 3 to 4 cm, women in the massage therapy group were asked to close their eyes and breathe deeply. Women in music therapy group were asked to listen to soft traditional music, using headphones for 30 min, starting at the beginning of the active phase of labor.
E3	Fahami et al.,¹⁶16 Fahami F, Behmanesh, Valian, Ashouri E. Effect of heat therapy on pain severity in primigravida women. Iran J Nurs Midwifery Res. 2011; 16 (1): 113-6. 2011^* * in years ; / Iran	64 nulliparous women	Thermal therapy	Standard nursing care	A thermal bag was applied in the first and second phase of labor, considering a minimum of 80 min on the first occasion, where the lumbar region was targeted, and at least 5 min on the second, which focused on the perineal region. .
E4	Barbieri et al.,¹⁷17 Barbieri M, Henrique AJ, Maia NL, Gabrielloni MC. Warm shower aspersion, perineal exercises with Swiss ball and pain in labor. Acta Paul Enferm. 2013; 26 (5): 478-84. 2013^* * in years ; / Brazil	15 ^ Information not found; SP6: point located four fingers of the receiver above the medial malleolus (ankle); BL32: point used in acupressure, located on the second hole of the sacral bone.	Hot bath/ Perineal exercise / Combined intervention	Own group	The bath was performed at a temperature of 37° C, where a jet of water was directed to the sacral region for 30 minutes. Regarding perineal exercise, a Swiss ball was used, and the parturient woman sat with her legs flexed at 90°, performing propulsion and rotation movements for 30 minutes. In the group in which the measures were combined, the same steps were followed as when they were applied alone.
E5	Abdolahian et al.,¹⁸18 Abdolahian S, Ghavi F, Abdollahifard S, Sheikhan F. Effect of dance labor on the management of active phase labor pain & clients’ satisfaction: a randomized controlled trial study. Glob J Health Sci. 2014; 6 (3): 219-26. 2014^* * in years ; / Iran	60 primiparous women	Dance	Standard nursing care	In the dance work group, women were instructed to stand with pelvic tilt and sway their hips back and forth or in a circle while their partner-who was instructed to stand in front of them, massaged their back and sacrum for at least 30 minutes. In the control group, the participants were allowed to choose their own position and receive the usual care during physiological labor, without ambulation or any intervention. In both groups the same environmental conditions were offered.
E6	Calik e Komurcu¹⁹19 Calik KY, Komurcu N. Effects of SP6 acupuncture point stimulation on labor pain and duration of labor. Red Crescent Med J. 2014; 16 (10): e16461. 2014^* * in years ; /Turkey	100 primiparous women	Acupressure SP6	Standard nursing care	Acupressure SP6 was applied by placing the thumbs on both legs at the same time from the beginning to the end of the contraction, with the average pressure around 3-5 kg, being 35 times during uterine contractions, 15 times at 2-3 cm of cervical dilation, and 10 times at 5-6 cm and 8-9 cm of cervical dilation.
E7	Namazi et al.,²⁰20 Namazi M, Akbari SA, Mojab F, Talebi A, Majd HA, Jannesari S. Effects of citrus aurantium (Bitter Orange) on the severity of first-stage labor pain. Iran J Pharm Res. 2014; 13 (3): 1011-8. 2014^* * in years ; / Iran	126 primiparous women	Aromatherapy	Placebo	In the aromatherapy group, gauze squares were soaked in 4 mL of C. aurantium distilled water. In the control group, gauze squares were soaked in 4 mL of saline and attached to necklaces on the participants.
E8	Akbarzadeh et al.,²¹21 Akbarzadeh M, Masoudi Z, Hadianfard Mj, Kasraeian M, Zare N. Comparison of the effects of maternal supportive care and acupressure (BL32 Acupoint) on pregnan women’s pain intensity and delivery outcome. J Pregnancy. 2014; 7 (4): 1-7. 2014^* * in years ; /Iran	150 primiparous and multiparous women	Acupressure at point BL32	Standard nursing care	In the control (support)-group the midwife accompanies the woman until the end of the second stage of labor. In the acupressure group the BL32 point was located and pressed.
E9	Asadi et al.,²²22 Asadi N, Maharlouei N, Khalili A, Darabi Y, Davoodi S, Shahraki HR, et al. Effects of LI-4 and SP-6 acupuncture on labor pain, cortisol level and duration of labor. J Acupunct Meridian Stud. 2015; 8 (5): 249-54. 2015^* * in years ; / Iran	63 nulliparous women	Acupuncture	Placebo	At the beginning of the active phase acupuncture was performed for the study group and sham acupuncture for the control group.
E10	Taavoni et al.,²³23 Taavoni S, Sheikhan F, Abdolahian S, Ghavi F. Birth ball or heat therapy? A randomized controlled trial to compare the effectiveness of birth ball usage with sacrum-perineal heat therapy in labor pain management. Complement Ther Clin Pract. 2016; 24 (2): 99-102. 2016^* * in years ; / Iran	90 primiparous women	Delivery ball/ Thermal therapy	No intervention	At the first stage of the active phase with dilation between 4 to 8 cm were allocated to two intervention (thermal therapy and delivery ball) and control groups, while pregnant women in the latent phase were observed until the beginning of the active phase.
E11	Mafetoni and Shimo²⁴24 Mafetoni RR, Shimo AKK. The effects of acupressure on labor pains during child birth: Randomized clinical trial. Rev Latino-Am Enferm: 2016; 24: e2738. 2016^* * in years ; / Brazil	156 nulliparous and multiparous women	Acupressure in SP6	Placebo / No intervention	The parturients in the BP6 acupressure group received deep pressure (± 5kg), with sudden and rapid decompression with the thumb, without causing discomfort. In the touch group they received a superficial, very low intensity touch (± 100g). In both groups the contact was on the bilateral BP6 point, during contractions, in a single 20-minute period. The control group received only routine care.
E12	Abedi et al.,²⁵25 Abedi P, Rastegar H, Valiani M, Saadati N. The effect of auriculotherapy on labor pain, length of active phase and episiotomy rate among reproductive aged women. J Family Reprod Health. 2017: 11 (4): 185-90. 2017^* * in years ; / Iran	80 nulliparous women	Auriculotherapy	Standard nursing care	Specific ear points were stimulated between intervals of uterine contractions when the uterus reaches dilations of 4, 6 and 8 cm.
E13	Karkal et al.,²⁶26 Karkal E, Kharde S, Dhumale H. Effectiveness of music therapy in reducing pain and anxiety among primigravid women during active phase of first stage of labor. Int J Nurs Educ. 2017; 9 (2): 57-60. 2017^* * in years ; / India	60 primiparous women	Music therapy	No intervention	Music therapy was applied with primigravidae during the active phase of the first stage of labor and pain was measured by applying the visual analog pain scale.
E14	Yazdkhasti et al.,²⁷27 Yazdkhasti M, Hanjani SM, Tourzani ZM. The effect of localized heat and cold therapy on pain intensity, duration of phases of labor, and birth outcomes among primiparous females: a randomized, controlled trial. Shiraz E-Med J. 2018: 19 (8): 23-30. 2018^* * in years ; / Iran	120 primiparous women	Heat and cold therapies	Standard nursing care	Heat thermotherapy was applied to the lumbar and abdominal regions for at least 60 minutes during the first stage of labor, whereas in the second stage the focus was on the perineal region, in which the heated source acted for at least 4 minutes. In the intervention that used cold, an ice pack was applied for 10 minutes with half hour intervals during the first stage, and on the perineum for 5 minutes every 15 minutes during the second stage. The control group received only routine care.
E15	Valiani et al.,²⁸28 Valiani M, Azimi M, Dehnavi ZM, Mohammadi S, Pirhadi M. The effect of auriculotherapy on the severity and duration of labor pain. J Edu Health Promot. 2018: 7 (10): 1-5. 2018^* * in years ; / Iran	84 primiparous women	Auriculotherapy	Standard nursing care	Auriculotherapy was applied in the course of uterine dilations for 1 minute. .
E16	Wang et al.,²⁹29 Wang J, Lu X, Wang C, Li X. The effectiveness of delivery ball use versus conventional nursing care during delivery of primiparae. Pak J Med Sci. 2020; 36 (3): 550-4. 2020^* * in years ; / China	110 primiparous women	Free-position delivery ball	Standard nursing care	The parturients used the free-position delivery ball, in which they could choose to perform the exercises in the standing, sitting, squatting, kneeling, or prone position.
E17	Çevik e Karaduma³⁰30 Çevik AS, Karaduman. The effect of sacral massage on labor pain and anxiety: A randomized controlled trial. Jpn J Nurs Sci. 2020 Jan; 17 (1): e12272. 2020^* * in years ; /Turkey	60 primiparous women	Sacral massage	Standard nursing care	Women in the experimental group received a sacral region massage for 30 min. While the other women received only routine care. .

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[TFN1] ^*
in years ;

[TFN2] ^**
Information not found; SP6: point located four fingers of the receiver above the medial malleolus (ankle); BL32: point used in acupressure, located on the second hole of the sacral bone.