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Meta-Analysis
. 2012 Jan 18;1(1):CD009107.
doi: 10.1002/14651858.CD009107.pub2.

Intracutaneous or subcutaneous sterile water injection compared with blinded controls for pain management in labour

Sheena Derry  1 , Sebastian Straube, R Andrew Moore, Heather Hancock, Sally L Collins
Affiliations
Meta-Analysis

Intracutaneous or subcutaneous sterile water injection compared with blinded controls for pain management in labour

Sheena Derry et al. Cochrane Database Syst Rev. .

Abstract

Background: Intracutaneous or subcutaneous injection of sterile water is rapidly gaining popularity as a method of pain relief in labour and it is therefore essential that it is properly evaluated. Adequate analgesia in labour is important to women worldwide. Sterile water injection is inexpensive, requires basic equipment, and appears to have few side effects. It is purported to work for labour pain.

Objectives: To determine the efficacy of sterile water injections for relief of pain (both typical contraction pain and intractable back pain) during labour compared to placebo (isotonic saline injections) or non-pharmacological interventions, and to identify any relevant effects on mode and timing of delivery, or safety of both mother and baby.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 May 2011), MEDLINE, and EMBASE (January 2010 to 30 May 2011), together with reference lists in retrieved studies and review articles.

Selection criteria: We included randomised, double blind, controlled studies using intracutaneous or subcutaneous sterile water injections for pain relief during labour. There were no restrictions on birth place, parity, risk, age, weight, gestation, or stage of labour. Potential comparators were placebo (saline) and non-pharmacological interventions (e.g. hypnosis or biofeedback).

Data collection and analysis: Two review authors independently assessed eligibility and quality of trials, and extracted data. We resolved any disagreements or uncertainties by discussion with a third review author. Primary outcome measures were at least 50% pain relief, or at least 30%, pain relief, patient global impression of change of at least 'good', mode of delivery, perinatal morbidity and mortality, maternal complications and adverse events. Secondary outcomes were women with any pain relief, use of rescue analgesia, and treatment group average pain relief. We made explicit judgements about potential biases in the studies.

Main results: We included seven studies, with 766 participants: four used intracutaneous injections, two subcutaneous, and one both. All reported on low back pain in labour only. Methodological quality was good, but four studies were at high risk of bias due to small size of treatment groups, incomplete outcome data, and performance bias.All studies reported treatment group mean or median scores, finding greater reduction in pain for sterile water. However, failure to demonstrate a normal distribution for pain intensity or relief, and use of different scales, meant meta-analysis was inappropriate. No study reported primary dichotomous efficacy outcomes. One reported the number self-scoring 4/10 cm or more reduction in pain; significantly more had this outcome with sterile water (50% to 60%) than with placebo (20% to 25%).There was no significant difference between sterile water and saline for rates of caesarean section (risk ratio (RR) 0.58, 95% confidence interval (CI) 0.33 to 1.02), instrumental delivery (RR 1.31, 95% CI 0.79 to 2.18), rescue analgesia (RR 0.86, 95% CI 0.44 to 1.69), timing of delivery, or Apgar scores. Two studies reported that more women treated with sterile water would request the same analgesia in future.No study reported on women's satisfaction with pain relief, women's sense of control in labour, women's satisfaction with the childbirth experience, mother/baby interaction, rates of breastfeeding, maternal morbidity, infant long-term outcomes, or cost. No adverse events were reported other than transient pain with injection, which was worse with sterile water.

Authors' conclusions: The outcomes reported severely limit conclusions for clinical practice. We found little robust evidence that sterile water is effective for low back or any other labour pain. Neither did we find any difference in delivery or other maternal or fetal outcomes. Further large, methodologically rigorous studies are required to determine the efficacy of sterile water to relieve pain in labour.

PubMed Disclaimer

Conflict of interest statement

RAM, SS, and SD have received research support from charities, government, academic, and industry sources at various times, but none relating to this review. RAM has consulted for various pharmaceutical companies, and has received lecture fees from pharmaceutical companies related to analgesics and other healthcare interventions, but none related to obstetric care. SS has received fees for presentations in the fields of pain and perinatal medicine. HH and SC have no conflicts of interest to declare.

Figures

1
1
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
2
2
Forest plot of comparison: 1 Sterile water versus normal saline, outcome: 1.2 Assisted vaginal birth.
3
3
Forest plot of comparison: 1 Sterile water versus normal saline, outcome: 1.1 Caesarean section.
4
4
Forest plot of comparison: 1 Sterile water versus normal saline, outcome: 1.3 Use of other (rescue) analgesia.
1.1
1.1. Analysis
Comparison 1 Sterile water versus normal saline, Outcome 1 Assisted vaginal birth.
1.2
1.2. Analysis
Comparison 1 Sterile water versus normal saline, Outcome 2 Caesarean section.
1.3
1.3. Analysis
Comparison 1 Sterile water versus normal saline, Outcome 3 Use of other (rescue) analgesia.
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD009107

References

References to studies included in this review

Ader 1990 {published data only}
    1. Ader L. Injections of sterile water for labour pain. Nursing Times 1991;87:53. - PubMed
    1. Ader L, Hansson B, Wallin G. Parturition pain treated by intracutaneous injections of sterile water. Pain 1990;41:133‐8. - PubMed
Bahasadri 2006 {published data only}
    1. Bahasadri S, Ahmadi‐Abhari S, Dehghani‐Nik M, Habibi GR. Subcutaneous sterile water injection for labour pain: a randomised controlled trial. Australian and New Zealand Journal of Obstetrics and Gynaecology 2006;46:102‐6. - PubMed
Kushtagi 2009 {published data only}
    1. Kushtagi P, Bhanu BT. Effectiveness of subcutaneous injection of sterile water to the lower back for pain relief in labor. Acta Obstetricia et Gynecologica Scandinavica 2009;88(2):231‐3. - PubMed
Martensson 1999 {published data only}
    1. Martensson L, Wallin G. Labour pain treated with cutaneous injections of sterile water: a randomised controlled trial. British Journal of Obstetrics and Gynaecology 1999;106(7):633‐7. - PubMed
Saxena 2009 {published data only}
    1. Saxena KN, Nischal H, Batra S. Intracutaneous injections of sterile water over the sacrum for labour analgesia. Indian Journal of Anaesthesia 2009;53(2):169‐73. - PMC - PubMed
Trolle 1991 {published data only}
    1. Trolle B, Moller M, Kronborg H, Thomsen S. The effect of sterile water blocks on low back labor pain. American Journal of Obstetrics and Gynecology 1991;164:1277‐81. - PubMed
Wiruchpongsanon 2006 {published data only}
    1. Wiruchpongsanon P. Relief of low back labor pain by using intracutaneous injections of sterile water: a randomized clinical trial. Journal of the Medical Association of Thailand 2006;89(5):571‐6. - PubMed

References to studies excluded from this review

Balsbaugh 1999 {published data only}
    1. Balsbaugh TA. Cutaneous injections of sterile water for the relief of labor pain. Journal of Family Practice 1999;48(10):746‐7. - PubMed
Bergmann 1997 {published data only}
    1. Bergmann R. Pain management: an alternative to sterile water injections? [Smertelindring: et alternativ til sterilvannspapler?]. Jordmorbladet 1997, (9):11‐3. - PubMed
Dahl 1991 {published data only}
    1. Dahl V, Aarnes T. Sterile water papulae for analgesia during labor [Sterilvannspapler gir analgesi ved fodsler]. Tidsskrift for den Norske Laegeforening 1991;111:1484‐7. - PubMed
Labrecque 1999 {published data only}
    1. Labrecque M, Nouwen A, Bergeron M, Rancourt JF. A randomized controlled trial of nonpharmacologic approaches for relief of low back pain during labor. Journal of Family Practice 1999;48(4):259‐63. - PubMed
Martensson 1995 {published data only}
    1. Mårtensson L, Ader L, Wallin G. Sterile water papules against labor pain. A simple, safe, effective method [Sterilvattenkvaddlar mot forlossningssmarta. Enkel, riskfri, effektiv metod]. Lakartidningen 1995;92(23):2395‐6. - PubMed
Martensson 2008a {published data only}
    1. Martensson L, Stener‐Victorin E, Wallin G. Acupuncture versus subcutaneous injections of sterile water as treatment for labour pain. Acta Obstetricia et Gynecologica Scandinavica 2008;87(2):171‐7. - PubMed
Tandberg 1990 {published data only}
    1. Tandberg A. Intracutaneous injections of sterile water as analgesia during labor [Intrakutane injeksjoner med sterilt vann som analgesi ved fodsler]. Tidsskrift for den Norske laegeforening 1990;110(18):2349‐50. - PubMed
Trolle 1986 {published data only}
    1. Trolle GB, Hvidman LE, Guldholt IS. Lumbar pain in parturient women treated with sterile water injections [Laendesmerter hos fodende behandlet med steriltvandspapler]. Ugeskrift for Laeger 1986;148(20):1200‐2. - PubMed

References to ongoing studies

Lee 2011 {published data only}
    1. Lee N, Coxeter P, Beckmann M, Webster J, Wright V, Smith T, et al. A randomised non‐inferiority controlled trial of a single versus a four intradermal sterile water injection technique for relief of continuous lower back pain during labour. BMC Pregnancy and Childbirth 2011;11(1):21. - PMC - PubMed

Additional references

Ahmadnia 2004
    1. Ahmadnia H, Younesi Rostami M. Treatment of renal colic using intracutaneous injection of sterile water. Urology Journal 2004;1(2):200‐3. - PubMed
Anim‐Somuah 2005
    1. Anim‐Somuah M, Smyth RMD, Howell CJ. Epidural versus non‐epidural or no analgesia in labour. Cochrane Database of Systematic Reviews 2005, Issue 4. [DOI: 10.1002/14651858.CD000331.pub2] - DOI - PubMed
Barragán 2011
    1. Barragán LIM, Solà I, Juandó PC. Biofeedback for pain management during labour. Cochrane Database of Systematic Reviews 2011, Issue 6. [DOI: 10.1002/14651858.CD006168.pub2] - DOI - PubMed
Bengtsson 1981
    1. Bengtsson J, Woming AM, Gertz J. Pain due to urolithiasis treated by intracutaneous injection of sterile water [Urolithiasissmerter behandletmed intrakutane sterilvandspapler]. Ugeskrift for Laeger 1981;143:3463–5. - PubMed
Cluett 2009
    1. Cluett ER, Burns E. Immersion in water in labour and birth. Cochrane Database of Systematic Reviews 2009, Issue 2. [DOI: 10.1002/14651858.CD000111.pub3] - DOI - PMC - PubMed
Cook 1995
    1. Cook RJ, Sackett DL. The number needed to treat: a clinically useful measure of treatment effect. BMJ 1995;310(6977):452‐4. - PMC - PubMed
Dowswell 2009
    1. Dowswell T, Bedwell C, Lavender T, Neilson JP. Transcutaneous electrical nerve stimulation (TENS) for pain relief in labour. Cochrane Database of Systematic Reviews 2009, Issue 2. [DOI: 10.1002/14651858.CD007214.pub2] - DOI - PMC - PubMed
Fogarty 2008
    1. Fogarty V. Intradermal sterile water injections for the relief of low back pain in labour ‐‐ a systematic review of the literature. Women and Birth 2008;21(4):157‐63. - PubMed
Gaskin 2003
    1. Gaskin IM. 3 The pain/pleasure riddle. Ina May's Guide to Childbirth. New York: Bantem Dell, 2003:150‐66.
Higgins 2011
    1. Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane‐handbook.org.
Huntley 2004
    1. Huntley AL, Coon JT, Ernst E. Complementary and alternative medicine for labor pain: a systematic review. American Journal of Obstetrics and Gynecology 2004;191(1):36‐44. - PubMed
Jadad 1996
    1. Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJM, Gavaghan DJ, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary?. Controlled Clinical Trials 1997;17(1):1‐12. - PubMed
Jones 2011
    1. Jones L, Dou L, Dowswell T, Alfirevic Z, Neilson James P. Pain management for women in labour: generic protocol. Cochrane Database of Systematic Reviews 2011, Issue 6. [DOI: 10.1002/14651858.CD009167] - DOI - PMC - PubMed
Klomp 2011
    1. Klomp T, van PM, Lazet J, Nisio M. Inhaled analgesia for pain management in labour. Cochrane Database of Systematic Reviews 2011, Issue 10. [DOI: 10.1002/14651858.CD009351] - DOI - PMC - PubMed
L'Abbe 1987
    1. L'Abbé KA, Detsky AS, O'Rourke K. Meta‐analysis in clinical research. Annals of Internal Medicine 1987;107(2):224‐33. - PubMed
Lowe 2002
    1. Lowe NK. The nature of pain. American Journal of Obstetrics and Gynecology 2002;186:S16‐S24. - PubMed
Madden 2011
    1. Madden K, Middleton P, Cyna Allan M, Matthewson M. Hypnosis for pain management during labour and childbirth. Cochrane Database of Systematic Reviews 2011, Issue 10. [DOI: 10.1002/14651858.CD009356] - DOI
Martensson 2008b
    1. Mårtensson L, Wallin G. Sterile water injections as treatment for low‐back pain during labour: a review. Australian and New Zealand Journal of Obstetrics and Gynaecology 2008;48(4):369‐74. - PubMed
Melzack 1981
    1. Melzack R. Myofascial trigger points: relation to acupuncture and mechanisms of pain. Archives of Physical Medicine and Rehabilitation 1981;62(3):114‐7. - PubMed
Melzack 1987
    1. Melzack R, Schaffelberg D. Low‐back pain during labor. American Journal of Obstetrics and Gynecology 1987;156(4):901‐5. - PubMed
Moore 1997
    1. Moore S, editor. Understanding Pain and Its Relief in Labour. 1st Edition. Edinburgh: Churchill Livingston, 1997.
Moore 1998
    1. Moore RA, Gavaghan D, Tramer MR, Collins SL, McQuay HJ. Size is everything ‐ large amounts of information are needed to overcome random effects in estimating direction and magnitude of treatment effects. Pain 1998;78(3):209‐16. - PubMed
Moore 2005
    1. Moore RA, Edwards JE, McQuay HJ. Acute pain: individual patient meta‐analysis shows the impact of different ways of analysing and presenting results. Pain 2005;116(3):322‐31. - PubMed
Moore 2008
    1. Moore RA, Barden J, Derry S, McQuay HJ. Managing potential publication bias. In: McQuay HJ, Kalso E, Moore RA editor(s). Systematic Reviews in Pain Research: Methodology Refined. Seattle: IASP Press, 2008:15‐24.
Morris 1995
    1. Morris JA, Gardner MJ. Calculating confidence intervals for relative risk, odds ratios and standardised ratios and rates. In: Gardner MJ, Altman DG editor(s). Statistics with Confidence ‐ Confidence Intervals and Statistical Guidelines. London: BMJ Books, 1995:50‐63. - PMC - PubMed
Neilson 2011
    1. Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, et al. Pain management for women in labour: an overview of systematic reviews. Cochrane Database of Systematic Reviews 2011, Issue 7. [DOI: 10.1002/14651858.CD009234] - DOI - PMC - PubMed
Novikova 2011
    1. Novikova N, Cluver C. Local anaesthetic nerve block for pain management in labour. Cochrane Database of Systematic Reviews 2011, Issue 7. [DOI: 10.1002/14651858.CD009200] - DOI - PMC - PubMed
Othman 2011
    1. Othman M, Jones L, Neilson James P. Non‐opioid drugs for pain management in labour. Cochrane Database of Systematic Reviews 2011, Issue 7. [DOI: 10.1002/14651858.CD009223] - DOI - PMC - PubMed
Raynes‐Greenow 2010
    1. Raynes‐Greenow CH, Nassar N, Torvaldsen S, Trevena L, Roberts CL. Assisting informed decision making for labour analgesia: a randomised controlled trial of a decision aid for labour analgesia versus a pamphlet. BMC Pregnancy and Childbirth 2010;10:15. - PMC - PubMed
RevMan 2011 [Computer program]
    1. The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). Version 5.1. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2011.
Rogers 1999
    1. Rogers RM. Basic neuroanatomy for understanding pelvic pain. Journal of the American Association of Gynecologic Laparoscopists 1999;6(1):15‐29. - PubMed
Simmons 2007
    1. Simmons SW, Cyna AM, Dennis AT, Hughes D. Combined spinal‐epidural versus epidural analgesia in labour. Cochrane Database of Systematic Reviews 2007, Issue 3. [DOI: 10.1002/14651858.CD003401.pub2] - DOI - PubMed
Smith 2008
    1. Smith MD, Russell A, Hodges PW. How common is back pain in women with gastrointestinal problems?. Clinical Journal of Pain 2008;24(3):199‐203. - PubMed
Smith 2011a
    1. Smith CA, Collins CT, Crowther CA. Aromatherapy for pain management in labour. Cochrane Database of Systematic Reviews in press. - PubMed
Smith 2011b
    1. Smith CA, Collins CT, Crowther CA, Levett KM. Acupuncture or acupressure for pain management in labour. Cochrane Database of Systematic Reviews in press. - PubMed
Smith 2011c
    1. Smith CA, Levett KM, Collins CT, Crowther CA. Relaxation techniques for pain management in labour. Cochrane Database of Systematic Reviews 2011 in press. - PubMed
Smith 2011d
    1. Smith CA, Levett KM, Collins CT, Jones L. Manual healing methods including massage and reflexology for pain management in labour. Cochrane Database of Systematic Reviews 2011, Issue 9. [DOI: 10.1002/14651858.CD009290] - DOI
Tramer 1997
    1. Tramèr MR, Reynolds DJM, Moore RA, McQuay HJ. Impact of covert duplicate results on meta‐analysis: a case study. BMJ 1997;315(7109):635‐40. - PMC - PubMed
Ullman 2010
    1. Ullman R, Smith LA, Burns E, Mori R, Dowswell T. Parenteral opioids for maternal pain relief in labour. Cochrane Database of Systematic Reviews 2010, Issue 9. [DOI: 10.1002/14651858.CD007396.pub2] - DOI - PMC - PubMed
Wreje 1995
    1. Wreje U, Brorsson B. A multicenter randomized controlled trial of injections of sterile water and saline for chronic myofascial pain syndromes. Pain 1995;61(3):441‐4. - PubMed
Wright 2000
    1. Wright ME, McCrea H, Stringer M, Murphy‐Black T. Personal control in pain relief during labour. Journal of Advanced Nursing 2000;32(5):1168‐77. - PubMed

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