Massage, reflexology and other manual methods for pain management in labour

Abstract

Background: Many women would like to avoid pharmacological or invasive methods of pain management in labour, and this may contribute towards the popularity of complementary methods of pain management. This review examined the evidence currently available on manual methods, including massage and reflexology, for pain management in labour. This review is an update of the review first published in 2012.

Objectives: To assess the effect, safety and acceptability of massage, reflexology and other manual methods to manage pain in labour.

Search methods: For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register (30 June 2017), the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 6), MEDLINE (1966 to 30 June 2017, CINAHL (1980 to 30 June 2017), the Australian New Zealand Clinical Trials Registry (4 August 2017), Chinese Clinical Trial Registry (4 August 2017), ClinicalTrials.gov, (4 August 2017), the National Center for Complementary and Integrative Health (4 August 2017), the WHO International Clinical Trials Registry Platform (ICTRP) (4 August 2017) and reference lists of retrieved trials.

Selection criteria: We included randomised controlled trials comparing manual methods with standard care, other non-pharmacological forms of pain management in labour, no treatment or placebo. We searched for trials of the following modalities: massage, warm packs, thermal manual methods, reflexology, chiropractic, osteopathy, musculo-skeletal manipulation, deep tissue massage, neuro-muscular therapy, shiatsu, tuina, trigger point therapy, myotherapy and zero balancing. We excluded trials for pain management relating to hypnosis, aromatherapy, acupuncture and acupressure; these are included in other Cochrane reviews.

Data collection and analysis: Two review authors independently assessed trial quality, extracted data and checked data for accuracy. We contacted trial authors for additional information. We assessed the quality of the evidence using the GRADE approach.

Main results: We included a total of 14 trials; 10 of these (1055 women) contributed data to meta-analysis. Four trials, involving 274 women, met our inclusion criteria but did not contribute data to the review. Over half the trials had a low risk of bias for random sequence generation and attrition bias. The majority of trials had a high risk of performance bias and detection bias, and an unclear risk of reporting bias. We found no trials examining the effectiveness of reflexology.MassageWe found low-quality evidence that massage provided a greater reduction in pain intensity (measured using self-reported pain scales) than usual care during the first stage of labour (standardised mean difference (SMD) -0.81, 95% confidence interval (CI) -1.06 to -0.56, six trials, 362 women). Two trials reported on pain intensity during the second and third stages of labour, and there was evidence of a reduction in pain scores in favour of massage (SMD -0.98, 95% CI -2.23 to 0.26, 124 women; and SMD -1.03, 95% CI -2.17 to 0.11, 122 women). There was very low-quality evidence showing no clear benefit of massage over usual care for the length of labour (in minutes) (mean difference (MD) 20.64, 95% CI -58.24 to 99.52, six trials, 514 women), and pharmacological pain relief (average risk ratio (RR) 0.81, 95% CI 0.37 to 1.74, four trials, 105 women). There was very low-quality evidence showing no clear benefit of massage for assisted vaginal birth (average RR 0.71, 95% CI 0.44 to 1.13, four trials, 368 women) and caesarean section (RR 0.75, 95% CI 0.51 to 1.09, six trials, 514 women). One trial reported less anxiety during the first stage of labour for women receiving massage (MD -16.27, 95% CI -27.03 to -5.51, 60 women). One trial found an increased sense of control from massage (MD 14.05, 95% CI 3.77 to 24.33, 124 women, low-quality evidence). Two trials examining satisfaction with the childbirth experience reported data on different scales; both found more satisfaction with massage, although the evidence was low quality in one study and very low in the other.Warm packsWe found very low-quality evidence for reduced pain (Visual Analogue Scale/VAS) in the first stage of labour (SMD -0.59, 95% CI -1.18 to -0.00, three trials, 191 women), and the second stage of labour (SMD -1.49, 95% CI -2.85 to -0.13, two trials, 128 women). Very low-quality evidence showed reduced length of labour (minutes) in the warm-pack group (MD -66.15, 95% CI -91.83 to -40.47; two trials; 128 women).Thermal manual methodsOne trial evaluated thermal manual methods versus usual care and found very low-quality evidence of reduced pain intensity during the first phase of labour for women receiving thermal methods (MD -1.44, 95% CI -2.24 to -0.65, one trial, 96 women). There was a reduction in the length of labour (minutes) (MD -78.24, 95% CI -118.75 to -37.73, one trial, 96 women, very low-quality evidence). There was no clear difference for assisted vaginal birth (very low-quality evidence). Results were similar for cold packs versus usual care, and intermittent hot and cold packs versus usual care, for pain intensity, length of labour and assisted vaginal birth.Music One trial that compared manual methods with music found very low-quality evidence of reduced pain intensity during labour in the massage group (RR 0.40, 95% CI 0.18 to 0.89, 101 women). There was no evidence of benefit for reduced use of pharmacological pain relief (RR 0.41, 95% CI 0.16 to 1.08, very low-quality evidence).Of the seven outcomes we assessed using GRADE, only pain intensity was reported in all comparisons. Satisfaction with the childbirth experience, sense of control, and caesarean section were rarely reported in any of the comparisons.

Authors' conclusions: Massage, warm pack and thermal manual methods may have a role in reducing pain, reducing length of labour and improving women's sense of control and emotional experience of labour, although the quality of evidence varies from low to very low and few trials reported on the key GRADE outcomes. Few trials reported on safety as an outcome. There is a need for further research to address these outcomes and to examine the effectiveness and efficacy of these manual methods for pain management.

Conflict of interest statement

Caroline A Smith: As a medical research institute, NICM receives research grants and donations from foundations, universities, government agencies and industry. Sponsors and donors provide untied and tied funding for work to advance the vision and mission of the Institute. I am an author on one of the papers included in this review (Levett 2016).

Kate M Levett: Kate is the primary author on one of the papers included in the review (Levett 2016). Data extraction of this paper was performed by co‐author Machiko Suganuma and Therese Dowswell, Research Associate, Cochrane Pregnancy and Childbirth. Kate is employed at The University of Notre Dame, School of Medicine Sydney, and as a medical school receives research grants and donations from Foundations, Government agencies and industry. Kate Levett offers private acupressure for labour and birth education classes in Sydney Australia, these classes include complementary therapy strategies, such as relaxation and massage, for pain relief in labour.

Carmel T Collins: none known.

Hannah G Dahlen: I am an author on one of the papers included in the review (Levett 2016).

Carolyn C Ee: As a medical research institute, NICM receives research grants and donations from foundations, universities, government agencies and industry. Sponsors and donors provide untied and tied funding for work to advance the vision and mission of the Institute.

Machiko Suganuma: none known.

Figures

1

Trial flow diagram.

2

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

3

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

1.1. Analysis

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

1.2. Analysis

Comparison 1 Massage versus usual care, Outcome 2 Sense of control in labour.

1.3. Analysis

Comparison 1 Massage versus usual care, Outcome 3 Sense of control in labour (shortened Labour Agentry Scale).

1.4. Analysis

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

1.5. Analysis

Comparison 1 Massage versus usual care, Outcome 5 Satisfaction with childbirth experience.

1.6. Analysis

Comparison 1 Massage versus usual care, Outcome 6 Assisted vaginal birth.

1.7. Analysis

Comparison 1 Massage versus usual care, Outcome 7 Caesarean section.

1.8. Analysis

Comparison 1 Massage versus usual care, Outcome 8 Admission to neonatal intensive care unit.

1.9. Analysis

Comparison 1 Massage versus usual care, Outcome 9 Apgar score

1.10. Analysis

Comparison 1 Massage versus usual care, Outcome 10 Use of pharmacological pain relief.

1.11. Analysis

Comparison 1 Massage versus usual care, Outcome 11 Length of labour (minutes).

1.12. Analysis

Comparison 1 Massage versus usual care, Outcome 12 Need for augmentation with oxytocin.

1.13. Analysis

Comparison 1 Massage versus usual care, Outcome 13 Perineal trauma.

1.14. Analysis

Comparison 1 Massage versus usual care, Outcome 14 Postpartum haemorrhage.

1.15. Analysis

Comparison 1 Massage versus usual care, Outcome 15 Women's emotional experience of the intervention (reduced anxiety) in labour.

1.16. Analysis

Comparison 1 Massage versus usual care, Outcome 16 Spontaneous vaginal birth (not pre‐specified).

1.17. Analysis

Comparison 1 Massage versus usual care, Outcome 17 Resuscitation of newborn (not pre‐specified).

2.1. Analysis

Comparison 2 Warm pack versus usual care, Outcome 1 Pain intensity.

2.2. Analysis

Comparison 2 Warm pack versus usual care, Outcome 2 Length of labour (minutes).

3.1. Analysis

Comparison 3 Thermal manual methods versus usual care, Outcome 1 Pain intensity.

3.2. Analysis

Comparison 3 Thermal manual methods versus usual care, Outcome 2 Assisted vaginal birth.

3.3. Analysis

Comparison 3 Thermal manual methods versus usual care, Outcome 3 Length of labour (minutes).

3.4. Analysis

Comparison 3 Thermal manual methods versus usual care, Outcome 4 Need for augmentation with oxytocin.

3.5. Analysis

Comparison 3 Thermal manual methods versus usual care, Outcome 5 Episiotomy.

3.6. Analysis

Comparison 3 Thermal manual methods versus usual care, Outcome 6 First degree tear (not pre‐specified).

4.1. Analysis

Comparison 4 Massage versus music, Outcome 1 Pain intensity.

4.2. Analysis

Comparison 4 Massage versus music, Outcome 2 Use of pharmacological pain relief.

References

References to studies included in this review Abasi 2009 {published data only}

Behmanesh 2009 {published data only} Bolbol‐Haghighi 2016 {published data only} Chang 2002 {published data only} Field 1997 {published data only} Ganji 2013a {published data only} Janssen 2008 {published data only} Karami 2007 {published data only} Kimber 2008 {published data only} Levett 2016 {published data only} Mortazavi 2012 {published data only} Silva 2013 {published data only} Taavoni 2013 {published data only} Taghinejad 2010 {published data only} References to studies excluded from this review Akbarzadeh 2014 {published data only} Bastani 2016 {published data only} Dehcheshmeh 2015 {published data only} Fili 2017 {published data only} Hajiamini 2012 {published data only} Mafetoni 2015 {published data only} Nourbakhsh 2012 {published data only} Ozgoli 2016 {published data only} Torkzahrani 2017 {published data only} Valiani 2010 {published data only} Yildirim 2004 {published data only} References to studies awaiting assessment Askari 2016 {published data only} Azima 2012 {published data only} Can 2015 {published data only} Dolatian 2011 {published data only} Faezah 2010 {published data only} Hanjani 2013 {published data only} Haseli 2014 {published data only} Jenabi 2012 {published data only} Kuo 2014 {published data only} Mirzaee 2010 {published data only} Mohammadkhani 2012 {published data only} Sereshti 2013 {published data only} Shafai 2013 {published data only} Zhang 2000 {published data only} References to ongoing studies Quintana 2011 {published data only} Quintana 2012 {published data only} Ying 2009 {published data only} Additional references Aasheim 2017 Adams 2009 Anim‐Somuah 2005 Barragán 2011 Bennett 1999 Borggren 2007 Botting 1997 Buckley 2003 Buckley 2015 Cluett 2009 Cochrane 2006 Craig 2006 Denner 2009 Derry 2011 Dommerholt 2012 Dowswell 2009 Ernst 1997 Fang 2013 Field 2005 Field 2007 Field 2010 Ganji 2013b Goodman 2004 Greggus 2004 Hall 2012 Hayes 2000 Higgins 2011 Hodnett 2002 Janssens 1992 Jones 2011 Jones 2012 King 2003 Klomp 2011 Leap 1997 Leap 2010 Long 2009 Lundgren 1998 Madden 2016 Maimburg 2016 Martin 2013 McCaffery 1989 McCrea 2000 McNabb 2006 Melzack 1965 Melzack 1984 Melzack 2001 Morgan 1982 Nagata 1997 Niven 2000 Novikova 2011 Othman 2011 Porth 1990 Posadzki 2011 Rapaport 2012 RevMan 2014 [Computer program] Rich 2002 Robinson 2011 Seifert 2011 Shirvani 2014 Simmonds 2012 Simmons 2007 Smith 2006 Smith 2011a Smith 2011b Smith 2011c Steel 2012 Steel 2014 Trout 2004 Ullman 2010 Uvnäs‐Moberg 2014 Waldenstrom 1999 Wang 2005 Wang 2008 Windridge 1999 References to other published versions of this review Smith 2012