Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Meta-Analysis
. 2018 Mar 28;3(3):CD009514.
doi: 10.1002/14651858.CD009514.pub2.

Relaxation techniques for pain management in labour

Caroline A Smith  1 , Kate M Levett, Carmel T Collins, Mike Armour, Hannah G Dahlen, Machiko Suganuma
Affiliations
Meta-Analysis

Relaxation techniques for pain management in labour

Caroline A Smith et al. Cochrane Database Syst Rev. .

Abstract

Background: Many women would like to avoid pharmacological or invasive methods of pain management in labour and this may contribute to the popularity of complementary methods of pain management. This review examined currently available evidence on the use of relaxation therapies for pain management in labour. This is an update of a review first published in 2011.

Objectives: To examine the effects of mind-body relaxation techniques for pain management in labour on maternal and neonatal well-being during and after labour.

Search methods: We searched Cochrane Pregnancy and Childbirth's Trials Register (9 May 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 5 2017), MEDLINE (1966 to 24 May 2017), CINAHL (1980 to 24 May 2017), the Australian New Zealand Clinical Trials Registry (18 May 2017), ClinicalTrials.gov (18 May 2017), the ISRCTN Register (18 May 2017), the WHO International Clinical Trials Registry Platform (ICTRP) (18 May 2017), and reference lists of retrieved studies.

Selection criteria: Randomised controlled trials (including quasi randomised and cluster trials) comparing relaxation methods with standard care, no treatment, other non-pharmacological forms of pain management in labour or placebo.

Data collection and analysis: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We attempted to contact study authors for additional information. We assessed evidence quality with GRADE methodology.

Main results: This review update includes 19 studies (2519 women), 15 of which (1731 women) contribute data. Interventions examined included relaxation, yoga, music and mindfulness. Approximately half of the studies had a low risk of bias for random sequence generation and attrition bias. The majority of studies had a high risk of bias for performance and detection bias, and unclear risk of bias for, allocation concealment, reporting bias and other bias. We assessed the evidence from these studies as ranging from low to very low quality, and therefore the effects below should be interpreted with caution.RelaxationWe found that relaxation compared to usual care provided lowered the intensity of pain (measured on a scale of 0 to 10 with low scores indicating less pain) during the latent phase of labour (mean difference (MD) -1.25, 95% confidence interval (CI) -1.97 to -0.53, one trial, 40 women). Four trials reported pain intensity in the active phase; there was high heterogeneity between trials and very low-quality evidence suggested that there was no strong evidence that the effects were any different between groups for this outcome (MD -1.08, 95% CI -2.57 to 0.41, four trials, 271 women, random-effects analysis). Very low-quality evidence showed that women receiving relaxation reported greater satisfaction with pain relief during labour (risk ratio (RR) 8.00, 95% CI 1.10 to 58.19, one trial, 40 women), and showed no clear benefit for satisfaction with childbirth experience (assessed using different scales) (standard mean difference (SMD) -0.03, 95% CI -0.37 to 0.31, three trials, 1176 women). For safety outcomes there was very low-quality evidence of no clear reduction in assisted vaginal birth (average RR 0.61, 95% CI 0.20 to 1.84, four trials, 1122 women) or in caesarean section rates (average RR 0.73, 95% CI 0.26 to 2.01, four trials, 1122 women). Sense of control in labour, and breastfeeding were not reported under this comparison.YogaWhen comparing yoga to control interventions there was low-quality evidence that yoga lowered pain intensity (measured on a scale of 0 to 10) with low scores indicating less pain) (MD -6.12, 95% CI -11.77 to -0.47, one trial, 66 women), greater satisfaction with pain relief (MD 7.88, 95% CI 1.51 to 14.25, one trial, 66 women) and greater satisfaction with childbirth experience (MD 6.34, 95% CI 0.26 to 12.42 one trial, 66 women (assessed using the Maternal Comfort Scale with higher score indicating greater comfort). Sense of control in labour, breastfeeding, assisted vaginal birth, and caesarean section were not reported under this comparison.MusicWhen comparing music to control interventions there was evidence of lower pain intensity in the latent phase for women receiving music (measured on a scale of 0 to 10 with low scores indicating less pain) (MD -0.73, 95% CI -1.01 to -0.45, random-effects analysis, two trials, 192 women) and very low-quality evidence of no clear benefit in the active phase (MD -0.51, 95% CI -1.10 to 0.07, three trials, 217 women). Very low-quality evidence suggested no clear benefit in terms of reducing assisted vaginal birth (RR 0.41, 95% CI 0.08 to 2.05, one trial, 156 women) or caesarean section rate (RR 0.78, 95% CI 0.36 to 1.70, two trials, 216 women). Satisfaction with pain relief, sense of control in labour, satisfaction with childbirth experience, and breastfeeding were not reported under this comparison.Audio analgesiaOne trial evaluating audio analgesia versus control only reported one outcome and showed no evidence of benefit in satisfaction with pain relief.MindfulnessOne trial evaluating mindfulness versus usual care found an increase in sense of control for the mindfulness group (using the Childbirth Self-Efficacy Inventory) (MD 31.30, 95% CI 1.61 to 60.99, 26 women). There is no strong evidence that the effects were any different between groups for satisfaction in childbirth, or for caesarean section rate, need for assisted vaginal delivery or need for pharmacological pain relief. No other outcomes were reported in this trial.

Authors' conclusions: Relaxation, yoga and music may have a role with reducing pain, and increasing satisfaction with pain relief, although the quality of evidence varies between very low to low. There was insufficient evidence for the role of mindfulness and audio-analgesia. The majority of trials did not report on the safety of the interventions. Further randomised controlled trials of relaxation modalities for pain management in labour are needed. Trials should be adequately powered and include clinically relevant outcomes such as those described in this review.

PubMed Disclaimer

Conflict of interest statement

Caroline A Smith: as a medical research institute, National Institute of Complementary Medicine (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. This systematic review was not specifically supported by donor or sponsor funding to NICM.

Kate M Levett: is employed at The University of Notre Dame, School of Medicine, 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.

Mike Armour: is an acupuncturist, not current in clinical practice and until recently was a director of an acupuncture and physiotherapy clinic. As a medical research institute, National Institute of Complementary Medicine (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. This systematic review was not specifically supported by donor or sponsor funding to NICM.

Hannah G Dahlen: none known

Machiko Suganuma: none known.

Figures

1
1
Study flow diagram
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study
1.1
1.1. Analysis
Comparison 1 Relaxation versus usual care, Outcome 1 Pain intensity.
1.2
1.2. Analysis
Comparison 1 Relaxation versus usual care, Outcome 2 Pain intensity.
1.3
1.3. Analysis
Comparison 1 Relaxation versus usual care, Outcome 3 Satisfaction with pain relief.
1.4
1.4. Analysis
Comparison 1 Relaxation versus usual care, Outcome 4 Satisfaction with childbirth experience.
1.5
1.5. Analysis
Comparison 1 Relaxation versus usual care, Outcome 5 Assisted vaginal birth.
1.6
1.6. Analysis
Comparison 1 Relaxation versus usual care, Outcome 6 Caesarean section.
1.7
1.7. Analysis
Comparison 1 Relaxation versus usual care, Outcome 7 Admission to special care nursery.
1.8
1.8. Analysis
Comparison 1 Relaxation versus usual care, Outcome 8 Low Apgar score < 7 at 5 minutes.
1.9
1.9. Analysis
Comparison 1 Relaxation versus usual care, Outcome 9 Use of pharmacological pain relief.
1.10
1.10. Analysis
Comparison 1 Relaxation versus usual care, Outcome 10 Length of labour.
1.11
1.11. Analysis
Comparison 1 Relaxation versus usual care, Outcome 11 Need for augmentation with oxytocin.
1.12
1.12. Analysis
Comparison 1 Relaxation versus usual care, Outcome 12 Anxiety.
1.13
1.13. Analysis
Comparison 1 Relaxation versus usual care, Outcome 13 Non‐prespecified: vitality.
1.14
1.14. Analysis
Comparison 1 Relaxation versus usual care, Outcome 14 Non‐prespecified: fatigue in labour.
2.1
2.1. Analysis
Comparison 2 Yoga versus control, Outcome 1 Pain intensity.
2.2
2.2. Analysis
Comparison 2 Yoga versus control, Outcome 2 Satisfaction with pain relief.
2.3
2.3. Analysis
Comparison 2 Yoga versus control, Outcome 3 Satisfaction with childbirth experience.
2.4
2.4. Analysis
Comparison 2 Yoga versus control, Outcome 4 Low Apgar score < 7 at 5 minutes.
2.5
2.5. Analysis
Comparison 2 Yoga versus control, Outcome 5 Use of pharmacological pain relief.
2.6
2.6. Analysis
Comparison 2 Yoga versus control, Outcome 6 Length of labour.
2.7
2.7. Analysis
Comparison 2 Yoga versus control, Outcome 7 Need for augmentation with oxytocin.
3.1
3.1. Analysis
Comparison 3 Music versus control, Outcome 1 Pain intensity.
3.2
3.2. Analysis
Comparison 3 Music versus control, Outcome 2 Assisted vaginal birth.
3.3
3.3. Analysis
Comparison 3 Music versus control, Outcome 3 Caesarean section.
3.4
3.4. Analysis
Comparison 3 Music versus control, Outcome 4 Admission to special care nursery.
3.5
3.5. Analysis
Comparison 3 Music versus control, Outcome 5 Use of pharmacological pain relief.
3.6
3.6. Analysis
Comparison 3 Music versus control, Outcome 6 Length of labour.
3.7
3.7. Analysis
Comparison 3 Music versus control, Outcome 7 Anxiety.
4.1
4.1. Analysis
Comparison 4 Audio‐analgesia versus control, Outcome 1 Satisfaction with pain relief.
5.1
5.1. Analysis
Comparison 5 Mindfulness training versus usual care, Outcome 1 Sense of control in labour.
5.2
5.2. Analysis
Comparison 5 Mindfulness training versus usual care, Outcome 2 Satisfaction with childbirth.
5.3
5.3. Analysis
Comparison 5 Mindfulness training versus usual care, Outcome 3 Assisted vaginal birth.
5.4
5.4. Analysis
Comparison 5 Mindfulness training versus usual care, Outcome 4 Caesarean section.
5.5
5.5. Analysis
Comparison 5 Mindfulness training versus usual care, Outcome 5 Need for pharmacological pain relief.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Almeida 2005 {published data only}
    1. Almeida NA, Sousa JT, Bachion MM, Silveira NA. The use of respiration and relaxation techniques for pain and anxiety relief in the parturition process [Utilizacao de tecnicas de respiracao e relaxamento para alivio de dor e ansiedade no processo de parturicao]. Revista Latino‐Americana de Enfermagem 2005;13(1):52‐8. - PubMed
Bagharpoosh 2006 {published data only}
    1. Bagharpoosh M, Sangestani G, Goodarzi M. Effect of progressive muscle relaxation technique on pain relief during labor. Acta Medica Iranica 2006;44(3):187‐90.
Bahadoran 2010 {published data only}
    1. Bahadoran P, Asefi F, Oreyzi H, Valiani M. The effect of participating in the labor preparation classes on maternal vitality and positive affect during the pregnancy and after the labor. Iranian Journal of Nursing and Midwifery Research 2010;15(Suppl 1):331‐6. - PMC - PubMed
Bergstrom 2009 {published data only}
    1. Bergstrom M, Kieler H, Waldenstrom U. A randomised controlled multicentre trial of women's and men's satisfaction with two models of antenatal education. Midwifery 2011;27(6):e195‐200. - PubMed
    1. Bergstrom M, Kieler H, Waldenstrom U. Effects of natural childbirth preparation versus standard antenatal education on epidural rates, experience of childbirth and parental stress in mothers and fathers: a randomised controlled multicentre trial. BJOG 2009;116(9):1167‐76. - PMC - PubMed
    1. Bergstrom M, Kieler H, Waldenstrom U. Effects of natural childbirth preparation versus standard antenatal education on epidural rates, experience of childbirth and parental stress in mothers and fathers: a randomised controlled multicentre trial. International Journal of Gynaecology & Obstetrics 2009;107(Suppl 2):S546. - PMC - PubMed
    1. Bergstrom M, Kieler H, Waldenstrom U. Psychoprophylaxis during labor: associations with labor‐related outcomes and experience of childbirth. Acta Obstetricia et Gynecologica Scandinavica 2010;89(6):794‐800. - PubMed
    1. Bergstrom M, Rudman A, Waldenstrom U, Kieler H. Fear of childbirth in expectant fathers, subsequent childbirth experience and impact of antenatal education: subanalysis of results from a randomized controlled trial. Acta Obstetricia et Gynecologica Scandinavica 2013;92(8):967‐73. - PubMed
Boaviagem 2017 {published data only}
    1. Boaviagem A, Belo MCF, Lemos A, Melo Jr EF, Souza P, Lubambo L. Efficacy of breathing patterns in the first stage of labor for maternal pain, anxiety, and satisfaction. Obstetrics & Gynecology 2015;125(5 Suppl):94S.
    1. Boaviagem A, Melo Junior E, Lubambo L, Sousa P, Aragao C, Albuquerque S, et al. The effectiveness of breathing patterns to control maternal anxiety during the first period of labor: a randomized controlled clinical trial. Complementary Therapies in Clinical Practice 2017;26:30‐5. - PubMed
Chuntharapat 2008 {published data only}
    1. Chuntharapat S, Petpichetchian W, Hatthakit U. Yoga during pregnancy: effects on maternal comfort, labor pain and birth outcomes. Complementary Therapies in Clinical Practice 2008;14(2):105‐15. - PubMed
Dizavandi 2012 {published data only}
    1. Dizavandi EB, Movaghati MA, Rezaean SM. The effect of music therapy on labour pain in nulliparous women in Mashad, Iran in 2010. Pain Practice 2012;12:81.
Dolcetta 1979 {published data only}
    1. Dolcetta G, Azzini V, Zacche G, Tansella CZ, Bertagni P, Siani R, et al. Traditional and respiratory autogenic training in psychoprophylaxis for childbirth. A controlled study on psychological and clinical effects in primiparous. 5th International Congress on Psychosomatic Medicine in Obstetrics and Gynaecology, "Emotion and Reproduction"; 1977 November 13‐19; Rome, Italy. London: Academic Press, 1979:929‐36.
Duncan 2017 {published data only}
    1. Duncan L, Cohn M, Chao M, Cook J, Riccobono J, Bardacke N. Mind in labor: effects of mind/body training on childbirth appraisals and pain medication use during labor. Journal of Alternative & Complementary Medicine 2014;20(5):A17.
    1. Duncan LG, Cohn MA, Chao MT, Cook JG, Riccobono J, Bardacke N. Benefits of preparing for childbirth with mindfulness training: a randomized controlled trial with active comparison. BMC Pregnancy and Childbirth 2017; Vol. 17, issue 1:140. [1471‐2393: (Electronic)] - PMC - PubMed
    1. Weng H, Duncan L, Cohn M, Cook J, Hecht F, Bardacke N, et al. Mindfulness to alleviate fear and pain in childbirth increases body awareness and decreases pain catastrophizing. Journal of Alternative and Complementary Medicine 2016;22(6):A90.
Durham 1986 {published data only}
    1. Durham L, Collins M. The effect of music as a conditioning aid in prepared childbirth education. Journal of Obstetric, Gynecologic and Neonatal Nursing 1986;15:268‐70. - PubMed
Gatelli 2000 {published data only}
    1. Gatelli L, Panzeri M, Casadei D, Pagan F. Obstetric psychophysiology and quality of the experience of labour/delivery: application within hospitals. Medicina Psicosomatica 2000;45:89‐100.
Gedde‐Dahl 2012 {published data only}
    1. Gedde‐Dahl M, Fors EA. Impact of self‐administered relaxation and guided imagery techniques during final trimester and birth. Complementary Therapies in Clinical Practice 2012;18(1):60‐5. - PubMed
Hosseini 2013 {published data only}
    1. Hosseini SE, Bagheri M, Honarparvaran N. Investigating the effect of music on labor pain and progress in the active stage of first labor. European Review for Medical and Pharmacological Sciences. 2013/07/31 2013; Vol. 17, issue 11:1479‐87. [1128‐3602: (Print)] - PubMed
Kimber 2008 {published data only}
    1. ISRCTN43151584. Alternative labour pain strategies study. www.isrctn.com/ISRCTN43151584 (first received: 21 September 2005).
    1. Kimber L, McNabb M, Court C, Haines A, Brocklehurst P. Massage or music for pain relief in labour: a pilot randomised placebo controlled trial. European Journal of Pain 2008;12(8):961‐9. [1090‐3801] - PubMed
Liu 2010 {published data only}
    1. Liu YH, Chang MY, Chen CH. Effects of music therapy on labour pain and anxiety in Taiwanese first time mothers. Journal of Clinical Nursing 2010;19(7‐8):1065‐72. [PUBMED: 20492051] - PubMed
Moore 1965 {published data only}
    1. Moore WMO, Browne JCM. Clinical trial of audio analgesia in childbirth. Journal of Obstetrics and Gynaecology of the British Commonwealth 1965;72:626‐9. - PubMed
Phumdoung 2007 {published data only}
    1. Phumdoung S, Youngvanichsate S, Jongpaiboonpatana W, Leetanaporn R. The effects of the PSU Cat position and music on length of time in the active phase of labor and labor pain. Thai Journal of Nursing Research 2007;11(2):96‐105.
Simavli 2014 {published data only}
    1. Simavli S, Gumus I, Kaygusuz I, Yildirim M, Usluogullari B, Kafali H. Effect of music on labor pain relief, anxiety level and postpartum analgesic requirement: a randomized controlled clinical trial. Gynecologic and Obstetric Investigation 2014;78:244‐50. - PubMed
    1. Simavli S, Kaygusuz I, Gumus I, Usluogullari B, Yildirim M, Kafali H. Effect of music therapy during vaginal delivery on postpartum pain relief and mental health. Journal of Affective Disorders 2014;156:194‐9. - PubMed
Yildirim 2004 {published data only}
    1. Yildirim G, Sahin NH. The effect of breathing and skin stimulation on labour pain perception of Turkish women. Pain Research & Management 2004;9(4):183‐7. - PubMed
    1. Yildirim G, Sahin NH. The effects of breathing and tactile stimulation techniques on the pain perception of pregnants during labour. Jinekoloji Ve Dergisi 2004;18(2):115‐21.

References to studies excluded from this review

Ahmadi 2017 {published data only}
    1. Ahmadi Z, Torkzahrani S, Roosta F, Shakeri N, Mhmoodi Z. Effect of breathing technique of blowing on the extent of damage to the perineum at the moment of delivery: a randomized clinical trial. Iranian Journal of Nursing and Midwifery Research. 2017/04/07 2017; Vol. 22, issue 1:62‐6. [1735‐9066: (Print)] - PMC - PubMed
Ahmadian 2009 {published data only}
    1. Ahmadian Heris S, Taghavi S, Hoseininasab D. The effect of antenatal education interventions on state‐trait anxiety in the parturition process. International Journal of Gynecology & Obstetrics 2009;107(Suppl 2):S548.
Barbieri 2013 {published data only}
    1. Barbieri M, Henrique AJ, Chors FM, Maia NL, Gabrielloni MC. Warm shower aspersion, perineal exercises with Swiss ball and pain in labor [Banho quente de aspersão, exercícios perineais com bola suíça e dor no trabalho de parto]. Acta Paulista de Enfermagem 2013;26(5):478‐84.
Bastani 2006 {published data only}
    1. Bastani F, Hidarnia A, Montgomery KS, Aguilar‐Vafaei ME, Kazemnejad A. Does relaxation education in anxious Iranian women influence adverse pregnancy outcomes?. Journal of Perinatal and Neonatal Nursing 2006;20(2):138‐46. - PubMed
Browning 2000 {published data only}
    1. Browning CA. Using music during childbirth. Birth 2000;27(4):272‐6. - PubMed
Buxton 1973 {published data only}
    1. Buxton R St J. Maternal respiration in labour. Nursing Mirror 1973;137:22‐5.
Chuang 2012 {published data only}
    1. Chuang LL, Lin LC, Cheng PJ, Chen CH, Wu SC, Chang CL. The effectiveness of a relaxation training program for women with preterm labour on pregnancy outcomes: a controlled clinical trial. International Journal of Nursing Studies 2012;49(3):257‐64. [0020‐7489] - PubMed
Dehcheshmeh 2015 {published data only}
    1. Dehcheshmeh FS, Rafiei H. Complementary and alternative therapies to relieve labor pain: a comparative study between music therapy and Hoku point ice massage. Complementary Therapies in Clinical Practice 2015;21(4):229‐32. [1744‐3881] - PubMed
Delgado‐Garcia 2012 {published data only}
    1. Delgado‐Garcia BE, Orts‐Cortes MI, Poveda‐Bernabeu A, Caballero‐Perez P. Randomised controlled clinical trial to determine the effects of the use of birth balls during labour [Ensayo clínico controlado y aleatorizado para determinar los efectos del uso de pelotas de parto durante el trabajo de parto]. Enfermeria Clinica 2012;22(1):35‐40. - PubMed
Drzymalski 2017 {published data only}
    1. Drzymalski D, Tsen L, Palanisamy A, Zhou J, Kodali B. Is music beneficial during labor epidural technique placement? Unexpected findings from a randomized controlled trial. In: Society for Obstetric Anesthesia and Perinatology (SOAP) 48th Annual Meeting;2016 May 18‐22; Boston USA. 2016:01‐06.
    1. Drzymalski DM, Tsen LC, Palanisamy A, Zhou J, Huang CC, Kodali BS. A randomized controlled trial of music use during epidural catheter placement on laboring parturient anxiety, pain, and satisfaction. Anesthesia and Analgesia 2017;124(2):542‐7. - PubMed
Escott 2005 {published data only}
    1. Escott D, Slade P, Spiby H, Fraser RB. Preliminary evaluation of a coping strategy enhancement method of preparation for labour. Midwifery 2005;21(3):278‐91. - PubMed
Field 1999 {published data only}
    1. Field T, Hernandez‐Reif M, Hart S, Theakston H, Schanberg S, Kuhn C. Pregnant women benefit from massage therapy. Journal of Psychosomatic Obstetrics and Gynaecology 1999;20(1):31‐8. [0167‐482X: (Print)] - PubMed
Firouzbakht 2014 {published data only}
    1. Firouzbakht M, Nikpour M, Salmalian H, Ledari FM, Khafri S. The effect of perinatal education on Iranian mothers' stress and labor pain. Global Journal of Health Science 2014;6(1):61‐8. - PMC - PubMed
Gau 2011 {published data only}
    1. Gau ML, Chang CY, Tian SH, Lin KC. Effects of birth ball exercise on pain and self‐efficacy during childbirth: a randomised controlled trial in Taiwan. Midwifery 2011;27(6):e293‐300. - PubMed
Geden 1989 {published data only}
    1. Geden E, Lower M, Beattie S, Beck N. Effects of music and imagery on physiologic and self report of analogues labour pain. Nursing Research 1989;38(1):37‐41. - PubMed
Hao 1997 {published data only}
    1. Hao TY, Li YH, Yao SF. Clinical study on shortening birth process by psychological suggestion therapy. Chinese Journal of Nursing 1997;32(10):568‐670. - PubMed
Huang 2015 {published data only}
    1. Huang J, Li HJ, Wang J, Mao HJ, Jiang WY, Zhou H, et al. Prenatal emotion management improves obstetric outcomes: a randomized control study. International Journal of Clinical and Experimental Medicine 2015;8(6):9667‐75. - PMC - PubMed
Jain 2015 {published data only}
    1. Jain P, Srivastava H, Goel N, Khaliq F, Dewan P, Sharma R, et al. Effect of antenatal exercises on pulmonary functions and labour outcome in uncomplicated primigravida women: a randomized controlled study. International Journal of Reproduction, Contraception, Obstetrics and Gynecology 2015;4(5):1478‐84.
Janke 1999 {published data only}
    1. Janke J. The effect of relaxation therapy on preterm labor outcomes. Journal of Obstetric, Gynecologic, and Neonatal Nursing 1999;28(3):255‐63. [0884‐2175: (Print)] - PubMed
Kamalifard 2012 {published data only}
    1. Kamalifard M, Shahnazi M, Sayyah Melli M, Allahverdizadeh S, Toraby S, Ghahvechi A. The efficacy of massage therapy and breathing techniques on pain intensity and physiological responses to labor pain. Jounal of Caring Sciences 2012;1(2):73‐8. [2251‐9920] - PMC - PubMed
Korol 1992 {published data only}
    1. Korol C, Baeyer C. Effects of brief instruction in imagery and birth visualization in prenatal education. Journal of Mental Imagery 1992;16(3‐4):167‐72.
Levett 2016b {published data only}
    1. Levett KM, Smith CA, Dahlen HG, Bensoussan A. Complementary therapies for labour and birth: results from a mixed methods study. Journal Paediatrics and Child Health 2014;50(Suppl 1):19.
Mathew 2012 {published data only}
    1. Mathew A, Nayak S, Vandana K. A comparative study on effect of ambulation and birthing ball on maternal and newborn outcome among primigravida mothers in selected hospitals in Mangalore. Nitte University Journal of Health Science 2012;2(2):2‐5.
Miquelutti 2015 {published data only}
    1. Miquelutti MA, Cecatti JG, Makuch MY. Developing strategies to be added to the protocol for antenatal care: an exercise and birth preparation program. Clinics (Sao Paulo, Brazil) 2015;70(4):231‐6. - PMC - PubMed
    1. Miquelutti MA, Cecatti JG, Makuch MY. Evaluation of a birth preparation program on lumbopelvic pain, urinary incontinence, anxiety and exercise: a randomized controlled trial. BMC Pregnancy and Childbirth 2013;13:154. - PMC - PubMed
    1. Miquelutti MA, Cecatti JG, Makuch MY. Evaluation of the efficacy of an antenatal birth preparation program. International Journal of Gynecology and Obstetrics 2012;119(Suppl 3):S414.
Mirzakhani 2015 {published data only}
    1. Mirzakhani C, Hejazinia Z, Golmakani N, Mirteimouri M, Sardar MA, Shakeri MT. The effect of exercise with special ball during pregnancy on duration of active phase of first stage of birth in nulliparous women. Iranian Journal of Obstetrics, Gynecology and Infertility 2015;18(174):12‐21.
Musa 2011 {published data only}
    1. Musa DI, Daniel J. Effect of exercise on labour duration and pain in pregnant women at Aminu Kano teaching hospital Kano Nigeria. 16th International WCPT Congress; 2011 June 20‐23; Amsterdam, Holland. 2011.
Narendran 2005 {published data only}
    1. Narendran S, Nagarathna R, Narendran V, Gunasheela S, Nagendra HR. Efficacy of yoga on pregnancy outcome. Journal of Alternative and Complementary Medicine 2005;11(2):237‐44. [1075‐5535: (Print)] - PubMed
NCT01389128 {published data only}
    1. NCT01389128. Non‐pharmacological resources in assisting labor. clinicaltrials.gov/ct2/show/NCT01389128 (first received: 30 June 2011).
NCT01601860 {published data only}
    1. NCT01601860. Evaluation of maternal and perinatal outcomes associated with the use of non‐pharmacological in parturients in active phase of labor. clinicaltrials.gov/ct2/show/NCT01601860 Date first received: 19 September 2011.
NCT02190591 {published data only}
    1. NCT02190591. Use of peanut labor ball for pelvic positioning for nulliparous patients following epidural. clinicaltrials.gov/ct2/show/NCT02190591 (first received: 16 May 2014).
Phumdoung 2003 {published data only}
    1. Phumdoung S, Good M. Music reduces sensation and distress of labor pain. Pain Management Nursing 2003;4(2):54‐61. - PubMed
Phumdoung 2010 {published data only}
    1. Phumdoung S, Morkruengsai S, Tachapattarakul S, Lawantrakul J, Junsuwan P. Effect of the Prince of Songkla University locked‐upright position on the duration, pain and comfort of second‐stage labor in primiparous women. Pacific Rim International Journal of Nursing Research 2010;14(2):112‐21.
Podder 2007 {published data only}
    1. Podder L. Effects of music therapy on anxiety levels and pain perception. Nursing Journal of India 2007;98(7):161. - PubMed
Ran 2005 {published data only}
    1. Ran KQ, He AM, Han QR, Tang ZL, Lei FH. Comfortable nursing and the mental state in parturient women. Chinese Journal of Clinical Rehabilitation 2005;9(32):62‐3.
Roth 2016 {published data only}
    1. Roth C, Dent SA, Parfitt SE, Hering SL, Curtis Bay R. Use of the peanut ball during labor. MCN. The American Journal of Maternal Child Nursing 2016;41:140‐6. - PubMed
Sammons 1984 {published data only}
    1. Sammons LN. The use of music by women during childbirth. Journal of Nurse Midwifery 1984;29:266‐70. - PubMed
Schorn 2009 {published data only}
    1. Schorn MN. The effect of guided imagery on the third stage of labor: a pilot study. Journal of Alternative and Complementary Medicine 2009;15(8):863‐70. - PubMed
Shim 2012 {published data only}
    1. Shim CS, Lee YS. Effects of a yoga‐focused prenatal program on stress, anxiety, self confidence and labor pain in pregnant women with in vitro fertilization treatment. Journal of Korean Academy of Nursing. 2012/08/03 2012; Vol. 42, issue 3:369‐76. [2005‐3673] - PubMed
Sun 2010 {published data only}
    1. Sun YC, Hung YC, Chang Y, Kuo SC. Effects of a prenatal yoga programme on the discomforts of pregnancy and maternal childbirth self‐efficacy in Taiwan. Midwifery. 2009/02/28 2010; Vol. 26, issue 6:e31‐6. [0266‐6138] - PubMed
Taavoni 2016 {published data only}
    1. Taavoni S, Abdolahian S, Haghani H. Effect of birth ball on active phase of physiologic labor: randomized control trial study. International Journal of Medicine 2010;40(Suppl 1):171.
    1. Taavoni S, Abdolahian S, Haghani H. Effect of pelvic tilt by birth ball usage on active phase labor pain during physiologic labor: a randomized control trial. Regional Anesthesia and Pain Medicine 2013;38(5 Suppl 1):E163.
    1. Taavoni S, Abdolahian S, Haghani H. Effect of pelvic tilt by birth ball usage, sacrum‐perinea heat therapy and combination of them on active phase of physiologic labor. International Confederation of Midwives 30th Triennial Congress. Midwives: Improving Women’s Health; 2014 June 1‐4; Prague, Czech Republic. 2014:C169.
    1. Taavoni S, Abdolahian S, Haghani H, Neisani L. Effect of pelvic tilt by using birth ball on active phase of physiologic labor: a randomized control trial study. International Journal of Gynecology and Obstetrics 2012;119(Suppl 3):S496.
    1. Taavoni S, Abdolahian S, Haghani H, Neysani L. Effect of birth ball usage on pain in the active phase of labor: a randomized controlled trial. Journal of Midwifery & Women's Health 2011;56(2):137‐40. - PubMed
Taghavi 2009 {published data only}
    1. Taghavi S, Hoseininasab D, Ahmadian heris S. The effect of antenatal education on pain intensity and labor. International Journal of Gynecology & Obstetrics 2009;107(Suppl 2):S493.
Taghinejad 2010 {published data only}
    1. Taghinejad H, Delpisheh A, Suhrabi Z. Comparison between massage and music therapies to relieve the severity of labor pain. Women's Health (London, England) 2010;6(3):377‐81. [1745‐5057] - PubMed
Tragea 2014 {published data only}
    1. Tragea C, Chrousos GP, Alexopoulos EC, Darviri C. A randomized controlled trial of the effects of a stress management programme during pregnancy. Complementary Therapies in Medicine 2014;22(2):203‐11. - PubMed
Tussey 2015 {published data only}
    1. Tussey C, Botsios E. Use of a labor ball to decrease the length of labor in patients who receive an epidural. JOGN Nursing; Journal of Obstetric, Gynecologic, and Neonatal Nursing 2011;40:S105‐6.
    1. Tussey CM, Botsios E, Gerkin RD, Kelly LA, Gamez J, Mensik J. Reducing length of labor and cesarean surgery rate using a peanut ball for women laboring with an epidural. Journal of Perinatal Education 2015;24(1):16‐25. - PMC - PubMed
Zilcha‐Mano 2016 {published data only}
    1. Zilcha‐Mano S, Langer E. Mindful attention to variability intervention and successful pregnancy outcomes. Journal of Clinical Psychology 2016;72(9):897‐907. [0021‐9762] - PubMed

References to studies awaiting assessment

Jahdi 2017 {published data only}
    1. Jahdi F, Sheikhan F, Haghani H, Sharifi B, Ghaseminejad A, Khodarahmian M, et al. Yoga during pregnancy: the effects on labor pain and delivery outcomes (a randomized controlled trial). Complementary Therapies in Clinical Practice 2017;27:1‐4. - PubMed
Salem 2004 {published data only}
    1. Salem SG. The Effect of Music on Pain During the First Stage of Labor in Egypt [thesis]. Cleveland, OH: Case Western Reserve University, 2004.
Shafai 2013 {published data only}
    1. Shafai FS, Kazemi S, Ghojazadeh M. Comparing maternal outcomes in nulliparous women in labor in physiological and conventional labor: a randomized clinical trial. Journal of Mazandaran University of Medical Sciences 2013;23(97):122‐31.
Tehrani 2006 {published data only}
    1. Tehrani GS. The effect of meditation and relaxation techniques on pain during the active phase of labor in nulliparous women. HAYAT 2006;12(3):51‐61.

References to ongoing studies

NCT00917332 {published data only}
    1. NCT00917332. Effects of relaxation and guided imagery training on pain at childbirth. clinicaltrials.gov/show/NCT00917332 (first received: 8 June 2009).
NCT03066973 {published data only}
    1. NCT03066973. The effectiveness of breathing exercises to labor pain and duration: a randomized controlled trial. clinicaltrials.gov/ct2/show/NCT03066973 (first received: 21 February 2017).

Additional references

Adams 2009
    1. Adams J, Lui C‐W, Sibbritt D, Broom A, Wardle J, Homer C, et al. Women's use of complementary and alternative medicine during pregnancy: a critical review of the literature. Birth 2009;36(3):237‐45. - PubMed
Anim‐Somuah 2005
    1. Anim‐Somuah M, Smyth R, 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
Bennett 1999
    1. Bennett VR, Brown LK. Myles Textbook for Midwives. 13th Edition. London: Churchill Livingstone, 1999.
Busch 2012
    1. Busch V, Magerl W, Kern U, Haas J, Hajak G, Eichhammer P. The effect of deep and slow breathing on pain perception, autonomic activity, and mood processing—an experimental study. Pain Medicine 2012;13(2):215‐28. - 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
Deeks 2011
    1. Deeks JJ, Higgins JPT, Altman DG (editors). Chapter 9: Analysing data and undertaking meta‐analyses. In: 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 handbook.cochrane.org.
Derry 2011
    1. Derry S, Straube S, Moore RA, Hancock H, Collins SL. Intracutaneous or subcutaneous sterile water injection for relieving pain in labour. Cochrane Database of Systematic Reviews 2011, Issue 5. [DOI: 10.1002/14651858.CD009107] - DOI - PMC - PubMed
Dick‐Read 2004
    1. Dick‐Read G. Childbirth Without Fear: the Principles and Practice of Natural Childbirth. London: Pinter & Martin, 2004.
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
Field 2011
    1. Field T. Yoga clinical research review. Complementary Therapies in Clinical Practice 2011;17(1):1‐8. - PubMed
Fisher 2004
    1. Fisher L. Introduction to yoga. Australian Yoga Life 2004;10:6‐7.
Higgins 2003
    1. Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta‐analyses. BMJ 2003;327:557‐60. - PMC - PubMed
Higgins 2011a
    1. Higgins JPT, Altman DG, Sterne JAC (editors). Chapter 8: Assessing risk of bias in included studies. In: 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 handbook.cochrane.org.
Higgins 2011b
    1. Higgins JPT, Deeks JJ, Altman DG (editors). Chapter 16: Special topics in statistics. In: 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 handbook.cochrane.org.
Jacobson 1938
    1. Jacobson E. Progressive Relaxation. 2nd Edition. Chicago: University of Chicago, 1938.
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
Jones 2012
    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 2012, Issue 3. [DOI: 10.1002/14651858.CD009234.pub2] - DOI - PMC - PubMed
Klarer 2014
    1. Klarer M, Arnold M, Günther L, Winter C, Langhans W, Meyer U. Gut vagal afferents differentially modulate innate anxiety and learned fear. Journal of Neuroscience 2014;34(21):7067‐76. - PMC - PubMed
Klomp 2011
    1. Klomp T, Poppel M, 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
Leap 2010
    1. Leap N, Dodwell M, Newburn M. Working with pain in labour: an overview of evidence. New Digest 2010;49:22‐6.
Levett 2016a
    1. Levett KM, Dahlen HG, Bensoussan A, Smith CA. Complementary therapies for labour and birth study: a randomised controlled trial of antenatal integrative medicine for pain management in labour. BMJ Open 2016;6(7):e010691. [DOI: 10.1136/bmjopen-2015-010691] - DOI - PMC - PubMed
Madden 2016
    1. Madden K, Middleton P, Cyna AM, Matthewson M, Jones L. Hypnosis for pain management during labour and childbirth. Cochrane Database of Systematic Reviews 2016, Issue 5. [DOI: 10.1002/14651858.CD009356.pub3] - DOI - PMC - PubMed
Maimburg 2016
    1. Maimburg, RD, Vaeth M, Dahlen H. Women's experience of childbirth‐a five year follow up of the randomised controlled trial "Ready for Child Trial". Women and Birth 2016;5:450‐4. - PubMed
Manheimer 2008
    1. Manheimer E, Berman B. Cochrane Complementary Medicine. About The Cochrane Collaboration (Fields) 2008, Issue 2. Art. No.: CE000052. [DOI: ]
McCaffery 1979
    1. McCaffery M. Nursing Management of the Patient with Pain. 2nd Edition. Philadelphia: Lippincott, 1970.
Melzack 1984
    1. Melzack R. The myth of painless childbirth. Pain 1984;19:331‐7. - PubMed
Melzack 2001
    1. Melzack R. Pain and neuromatrix in the brain. Journal of Dental Education 2001;65:1378‐82. - PubMed
Morgan 1982
    1. Morgan BM, Bulpitt CJ, Clifton P, Lewis PJ. Analgesia and satisfaction in childbirth (the Queen Charlotte's 1000 mother survey). Lancet 1982;2(8302):808‐10. - 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
RevMan 2014 [Computer program]
    1. Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager 5 (RevMan 5). Version 5.3. Copenhagen: Nordic Cochrane Centre, The Cochrane Collaboration, 2014.
Sharp 2001
    1. Sharp TJ. Chronic pain: a reformulation of the cognitive‐behavioural model. Behaviour Research and Therapy 2001;39:787‐800. - PubMed
Simmons 2007
    1. Simmons S, 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 2011a
    1. Smith CA, Collins CT, Crowther CA, Levett KM. Acupuncture or acupressure for pain management in labour. Cochrane Database of Systematic Reviews 2011, Issue 7. [DOI: 10.1002/14651858.CD009232] - DOI - PubMed
Smith 2011b
    1. Smith CA, Collins CT, Crowther CA. Aromatherapy for pain management in labour. Cochrane Database of Systematic Reviews 2011, Issue 7. [DOI: 10.1002/14651858.CD009215] - DOI - PubMed
Smith 2011c
    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
Steel 2014
    1. Steel A, Adams J, Sibbritt D, Broom A, Frawley J, Gallois C. The influence of complementary and alternative medicine use in pregnancy on labor pain management choices: results from a nationally representative sample of 1,835 women. Journal of Alternative and Complementary Medicine (New York, N.Y.) 2014;20(2):87‐97. - PubMed
Sterne 2011
    1. Sterne JAC, Egger M, Moher D (editors). Chapter 10: Addressing reporting biases. In: Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Intervention. Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from handbook.cochrane.org.
Trout 2004
    1. Trout KK. The neuromatrix theory of pain: implications for selected non‐pharmacological methods of pain relief for labor. Journal of Midwifery & Women's Health 2004;49(6):482‐8. - 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
Velvovsky 1960
    1. Velvovsky IPK, Ploticher V, Shugom E. Painless Childbirth Through Psychoprophylaxis. Moscow: Foreign Languages Publishing House, 1960.
Vickers 1999
    1. Vickers A, Zolloman C. ABC of complementary medicine: hypnosis and relaxation therapies. BMJ 1999;319:1346‐9. - PMC - PubMed
Villemure 2002
    1. Villemure CM, Bushnell MC. Cognitive modulation of pain: how do attention and emotion influence pain processing?. Pain 2002;95:195‐99. - PubMed
Woo 2015
    1. Woo CW, Roy M, Buhle JT, Wager TD. Distinct brain systems mediate the effects of nociceptive input and self‐regulation on pain. PLoS Biology 2015;13(1):e1002036. - PMC - PubMed

References to other published versions of this review

Smith 2006
    1. Smith CA, Collins CT, Cyna AM, Crowther CA. Complementary and alternative therapies for pain management in labour. Cochrane Database of Systematic Reviews 2006, Issue 4. [DOI: 10.1002/14651858.CD003521.pub2] - DOI - PMC - PubMed
Smith 2011
    1. Smith CA, Levett KM, Collins CT, Crowther CA. Relaxation techniques for pain management in labour. Cochrane Database of Systematic Reviews 2011, Issue 12. [DOI: 10.1002/14651858.CD009514] - DOI - PubMed