Pain relief: Poor evidence for non-drug approaches in labor
There is better evidence for the effectiveness of drug-based approaches for relieving labour pains than non-drug approaches. These are the findings of an all-encompassing publishing in The Cochrane Library, which draws together results from a number of previous reviews on the subject.
Many different approaches are used to relieve pain in labour, but not all are supported by strong evidence. The researchers brought together the results of 15 previous Cochrane reviews and three non-Cochrane reviews, including data from 310 trials in total. To try to distinguish between well-supported and less well-supported pain relief approaches, they decided to split interventions into three categories.
Painkilling drugs given by epidural, combined spinal epidural (CSE) and inhalation fell under the first category, “what works”. There was less evidence for immersion in water, relaxation, acupuncture, massage and local anaesthetic nerve blocks or non-opioid drugs. The authors classed these interventions as “may work”. However, more adverse effects were associated with the interventions for which there was the best evidence, including nausea and vomiting caused by inhaled painkillers and hypotension due to epidural. The second group of pain relief approaches, although less well-supported by clinical evidence, were better tolerated, with women reporting improved satisfaction with pain relief for all except massage. The least supported or “insufficient evidence” group of pain relief interventions included hypnosis, biofeedback, sterile water injection, aromatherapy, transcutaneous electrical nerve stimulation (TENS) and injected or intravenous opioids.
“Women should be told about the benefits and adverse effects of different pain relief methods, but should feel free to choose whatever form of pain relief they feel would help them most during labour,” said lead author of the study, James Neilson of the Department of Women’s and Children’s Health at the University of Liverpool in Liverpool, UK. “It remains important to tailor approaches to women’s individual needs and circumstances.”
The overview study calls for more research on the non-drug interventions that researchers grouped into the second and third categories. Although generally safe, for most of these interventions, evidence was based on just one or two trials. Fewer than 1,000 women have taken part in trials for each of hypnosis, biofeedback, sterile water injection, aromatherapy and massage. TENS is popular and widely recommended by midwives but not by the National Institute for Health and Clinical Excellence. “The discordance of views between women, clinicians and guidelines reflects a poor evidence base and the uncertainty should be resolved by a definitive clinical trial,” said Neilson.
Will my painkillers be given in combination with any other medicines?
You may be given other medicines such as antidepressants, antiepileptics (drugs that prevent fits or seizures but are also used for neuropathic pain) and muscle relaxants to take with your painkillers. These medicines will also help to control your pain, but will do so in a different way from your painkillers.
Will I become addicted to painkillers?
Many people who are prescribed strong opioid painkillers such as morphine ask if they will get addicted to it or if they will become confused and unable to look after themselves. This is unlikely to happen. People who become addicted to drugs usually initially choose to take them and then keep taking them because they have a psychological need. For example, they may crave feeling disconnected or ’high’ when they take them. This is very different to someone who is in physical pain and needs to take the drug to control their pain.
What is the right dose of a strong opioid painkiller?
Unlike many other drugs, there is no standard dose for morphine or other strong opioid painkillers. The right dose is the one that controls your pain, and this varies from person to person.
Is there a maximum dose you can take?
If morphine or other painkillers are taken as prescribed, you will not overdose. There is no maximum dose for strong opioid painkillers. However, suddenly increasing the dose is dangerous, so never increase the dose or take extra doses without talking to your doctor first.
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Jennifer Beal
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Wiley-Blackwell