Use of electromyographic and skin-conductance biofeedback relaxation training of facilitate childbirth in primiparae

Reducing Psychological Stress in Peripartum Women With Heart Rate Variability Biofeedback: A Systematic Review

Peripartum women are exposed to a variety of stressors that have adverse health consequences for the maternal-child dyad (e.g., impaired bonding). To combat these adverse health consequences, heart rate variability biofeedback (HRVBF) may be implemented by holistic nurses to aid peripartum women experiencing a high level of stress. A systematic review was completed using the guidelines established in the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. To be included in the review, studies had to meet the following criteria: (a) published scientific articles, (b) studies published in English, (c) experimental, quasi-experimental, or case reports, (d) use of HRVBF as the main treatment, (e) use of psychological stress as a dependent variable, and (f) studies published until December 2017. The major findings of this review can be described as follows: (a) HRVBF and psychological stress in peripartum women are related concepts, (b) peripartum women who completed HRVBF report a reduction in stress compared with participants who did not receive HRVBF, and (c) there is currently no information on the effectiveness of HRVBF on psychological stress in the first and early second trimester of pregnancy. Overall, this systematic review of the literature provides objective evidence that HRVBF may be a potential beneficial adjuvant treatment for stress management in peripartum women.

Mind-body interventions during pregnancy for preventing or treating women's anxiety

BACKGROUND

Anxiety during pregnancy is a common problem. Anxiety and stress could have consequences on the course of the pregnancy and the later development of the child. Anxiety responds well to treatments such as cognitive behavioral therapy and/or medication. Non-pharmacological interventions such as mind-body interventions, known to decrease anxiety in several clinical situations, might be offered for treating and preventing anxiety during pregnancy.

OBJECTIVES

To assess the benefits of mind-body interventions during pregnancy in preventing or treating women's anxiety and in influencing perinatal outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2010), MEDLINE (1950 to 30 November 2010), EMBASE (1974 to 30 November 2010), the National Center for Complementary and Alternative Medicine (NCCAM) (1 December 2010), ClinicalTrials.gov (December 2010) and Current Controlled Trials (1 December 2010), searched the reference lists of selected studies and contacted professionals and authors in the field.

SELECTION CRITERIA

Randomized controlled trials, involving pregnant women of any age at any time from conception to one month after birth, comparing mind-body interventions with a control group. Mind-body interventions include: autogenic training, biofeedback, hypnotherapy, imagery, meditation, prayer, auto-suggestion, tai-chi and yoga. Control group includes: standard care, other pharmacological or non-pharmacological interventions, other types of mind-body interventions or no treatment at all.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for inclusion all assessed risk of bias for each included study. We extracted data independently using an agreed form and checked it for accuracy.

MAIN RESULTS

We included eight trials (556 participants), evaluating hypnotherapy (one trial), imagery (five trials), autogenic training (one trial) and yoga (one trial). Due to the small number of studies per intervention and to the diversity of outcome measurements, we performed no meta-analysis, and have reported results individually for each study. Compared with usual care, in one study (133 women), imagery may have a positive effect on anxiety during labor decreasing anxiety at the early and middle stages of labor (MD -1.46; 95% CI -2.43 to -0.49; one study, 133 women) and (MD -1.24; 95% CI -2.18 to -0.30). Another study showed that imagery had a positive effect on anxiety and depression in the immediate postpartum period. Autogenic training might be effective for decreasing women's anxiety before delivering.

AUTHORS' CONCLUSIONS

Mind-body interventions might benefit women's anxiety during pregnancy. Based on individual studies, there is some but no strong evidence for the effectiveness of mind-body interventions for the management of anxiety during pregnancy. The main limitations of the studies were the lack of blinding and insufficient details on the methods used for randomization.

Biofeedback for pain management during labour

BACKGROUND

Labour is often associated with pain and discomfort caused by a complex and subjective interaction of multiple factors, and should be understood within a multi-dimensional and multi-disciplinary framework. Within the non-pharmacological approach, biofeedback has focused on the acquisition of control over some physiological responses with the aid of electronic devices, allowing individuals to regulate some physical processes (such as pain) which are not usually under conscious control. The role of this behavioural approach for the management of pain during labour, as an addition to the standard prenatal care, has been never assessed systematically. This review is one in a series of Cochrane reviews examining pain relief in labour, which will contribute to an overview of systematic reviews of pain relief for women in labour (in preparation).

OBJECTIVES

To examine the effectiveness of the use of biofeedback in prenatal lessons for managing pain during labour.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2011), CENTRAL (The Cochrane Library 2011, Issue 1), PubMed (1950 to 20 March 2011), EMBASE (via OVID) (1980 to 24 March 2011), CINAHL (EBSCOhost) (1982 to 24 March 2011), and PsycINFO (via Ovid) (1806 to 24 March 2011). We searched for further studies in the reference lists of identified articles.

SELECTION CRITERIA

Randomised controlled trials of any form of prenatal classes which included biofeedback, in any modality, in women with low-risk pregnancies.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data.

MAIN RESULTS

The review included four trials (186 women) that hugely differed in terms of the diversity of the intervention modalities and outcomes measured. Most trials assessed the effects of electromyographic biofeedback in women who were pregnant for the first time. The trials were judged to be at a high risk of bias due to the lack of data describing the sources of bias assessed. There was no significant evidence of a difference between biofeedback and control groups in terms of assisted vaginal birth, caesarean section, augmentation of labour and the use of pharmacological pain relief. The results of the included trials showed that the use of biofeedback to reduce the pain in women during labour is unproven. Electromyographic biofeedback may have some positive effects early in labour, but as labour progresses there is a need for additional pharmacological analgesia.

AUTHORS' CONCLUSIONS

Despite some positive results shown in the included trials, there is insufficient evidence that biofeedback is effective for the management of pain during labour.

Individual or group antenatal education for childbirth or parenthood, or both

BACKGROUND

Structured antenatal education programs for childbirth or parenthood, or both, are commonly recommended for pregnant women and their partners by healthcare professionals in many parts of the world. Such programs are usually offered to groups but may be offered to individuals.

OBJECTIVES

To assess the effects of this education on knowledge acquisition, anxiety, sense of control, pain, labour and birth support, breastfeeding, infant-care abilities, and psychological and social adjustment.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2006), CINAHL (1982 to April 2006), ERIC (1984 to April 2006), EMBASE (1980 to April 2006) and PsycINFO (1988 to April 2006). We handsearched the Journal of Psychosomatic Research from 1956 to April 2006 and reviewed the reference lists of retrieved studies.

SELECTION CRITERIA

Randomized controlled trials of any structured educational program provided during pregnancy by an educator to either parent that included information related to pregnancy, birth or parenthood. The educational interventions could have been provided on an individual or group basis. Educational interventions directed exclusively to either increasing breastfeeding success, knowledge of and coping skills concerning postpartum depression, improving maternal psycho-social health including anxiety, depression and self-esteem or reducing smoking were excluded.

DATA COLLECTION AND ANALYSIS

Both authors assessed trial quality and extracted data from published reports.

MAIN RESULTS

Nine trials, involving 2284 women, were included. Thirty-seven studies were excluded. Educational interventions were the focus of eight of the studies (combined n = 1009). Details of the randomization procedure, allocation concealment, and/or participant accrual or loss for these trials were not reported. No consistent results were found. Sample sizes were very small to moderate, ranging from 10 to 318. No data were reported concerning anxiety, breastfeeding success, or general social support. Knowledge acquisition, sense of control, factors related to infant-care competencies, and some labour and birth outcomes were measured. The largest of the included studies (n = 1275) examined an educational and social support intervention to increase vaginal birth after caesarean section. This high-quality study showed similar rates of vaginal birth after caesarean section in 'verbal' and 'document' groups (relative risk 1.08, 95% confidence interval 0.97 to 1.21).

AUTHORS' CONCLUSIONS

The effects of general antenatal education for childbirth or parenthood, or both, remain largely unknown. Individualized prenatal education directed toward avoidance of a repeat caesarean birth does not increase the rate of vaginal birth after caesarean section.

Complementary and alternative medicine for labor pain: a systematic review

OBJECTIVES

The purpose of this study was to systematically review the literature for, and critically appraise, randomized controlled trials of any type of complementary and alternative therapies for labor pain.

STUDY DESIGN

Six electronic databases were searched from their inception until July 2003. The inclusion criteria were that they were prospective, randomized controlled trials, involved healthy pregnant women at term, and contained outcome measures of labor pain.

RESULTS

Our search strategy found 18 trials. Six of these did not meet our inclusion criteria. The remaining 12 trials involved acupuncture (2), biofeedback (1), hypnosis (2), intracutaneous sterile water injections (4), massage (2), and respiratory autogenic training (1).

CONCLUSION

There is insufficient evidence for the efficacy of any of the complementary and alternative therapies for labor pain, with the exception of intracutaneous sterile water injections. For all the other treatments described it is impossible to make any definitive conclusions regarding effectiveness in labor pain control.

Complementary and alternative therapies for pain management in labour

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 currently available evidence supporting the use of alternative and complementary therapies for pain management in labour.

OBJECTIVES

To examine the effectiveness of complementary and alternative therapies for pain management in labour on maternal and perinatal morbidity.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (July 2002), the Cochrane Controlled Trials Register (The Cochrane Library Issue 2, 2002), MEDLINE (1966 to July 2002), EMBASE (1980 to July 2002) and CINAHL (1980 to July 2002).

SELECTION CRITERIA

The inclusion criteria included published and unpublished randomised controlled trials comparing complementary and alternative therapies with placebo, no treatment or pharmacological forms of pain management in labour. All women whether primiparous or multiparous, and in spontaneous or induced labour, in the first and second stage of labour were included.

DATA COLLECTION AND ANALYSIS

Meta-analysis was performed using relative risks for dichotomous outcomes and weighted mean differences for continuous outcomes. The outcome measures were maternal satisfaction, use of pharmacological pain relief and maternal and neonatal adverse outcomes.

MAIN RESULTS

Seven trials involving 366 women and using different modalities of pain management were included in this review. The trials included one involving acupuncture (n = 100), one involving audio-analgesia (n = 25), one involving aromatherapy (n = 22), three trials of hypnosis (n = 189) and one trial of music (n = 30). The trial of acupuncture decreased the need for pain relief (relative risk (RR) 0.56, 95% confidence interval (CI) 0.39 to 0.81). Women receiving hypnosis were more satisfied with their pain management in labour compared with controls (RR 2.33, 95% CI 1.55 to 4.71). No differences were seen for women receiving aromatherapy, music or audio analgesia.

REVIEWER'S CONCLUSIONS

Acupuncture and hypnosis may be beneficial for the management of pain during labour. However, few complementary therapies have been subjected to proper scientific study and the number of women studied is small.

Individual or group antenatal education for childbirth/parenthood

BACKGROUND

Structured antenatal education programs for childbirth and/or parenthood are commonly recommended for pregnant women and their partners by health care professionals in many parts of the world. Such programs are usually offered to groups but may be offered to individuals.

OBJECTIVES

The objective of this review was to assess the effects of this education on knowledge acquisition, anxiety, sense of control, pain, support, breastfeeding, infant care abilities, and psychological and social adjustment.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Controlled Trials Register, and other databases were searched. The date of the last search was December, 1999.

SELECTION CRITERIA

Randomized controlled trials of any structured educational program provided during pregnancy by an educator to either parent, that included information related to pregnancy, birth, or parenthood were included. The educational interventions could have been provided on an individual or group basis. Educational interventions directed exclusively to either increasing breastfeeding success or reducing smoking were excluded, since reviews of these topics can be found elsewhere in The Cochrane Library.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data were extracted by the author from published reports.

MAIN RESULTS

Six trials, involving 1443 women, were included. Twenty-two were excluded. The largest of the included studies (n = 1275) examined an educational intervention to increase vaginal birth after cesarean section. This high quality study showed similar rates of vaginal birth after cesarean section in 'verbal' and 'document' groups, relative risk (RR) 1.1 (95% confidence interval (CI) 1.0-1.2). More general educational interventions were the focus of the other five studies (combined n = 168). The methodological quality of these trials is uncertain, since details of the randomization procedure, allocation concealment, and/or participant accrual/loss were not reported. No consistent results were found. Sample sizes were very small, ranging from 10-67. Interventions, populations, and outcomes measured were different in each study. No data from the five general education trials were reported concerning labour and birth outcomes, anxiety, breastfeeding success, or general social support. Knowledge acquisition and factors related to infant care competencies were measured.

REVIEWER'S CONCLUSIONS

Individualized prenatal education directed toward avoidance of a cesarean birth does not increase the rate of vaginal birth after cesarean section. The effects of general antenatal education for childbirth and/or parenthood remain unknown.

Biofeedback-assisted relaxation to reduce stress in labor

OBJECTIVE

To test the feasibility and effectiveness of incorporating biofeedback-assisted relaxation techniques into routine instruction in Lamaze classes.

DESIGN

A quasi-experimental design (static groups comparison) was used.

SETTING

Lamaze classes.

PARTICIPANTS

A convenience sample of 33 subjects recruited from 12 Lamaze classes.

MEASURES

Duration of first-stage labor, amount of sedation and analgesia during first-stage labor, number of complications, and 1- and 5-minute Apgar scores of the neonates.

RESULTS

The experimental subjects reported greater stress during labor than did the control subjects.

CONCLUSIONS

Although the supplementary instruction in reducing stress seemed to promote relaxation during the prenatal classes, it did not reduce distress during labor and delivery because no mothers attempted to use the technique at that time.

A test of a common assumption regarding the use of antenatal training during labour

The nature and purpose of antenatal classes are reviewed briefly, together with the common assumption that women given antenatal training to cope with their labour pains do all in fact make use of the breathing and postural techniques which have been taught in the classes when they come to labour itself. This assumption was tested by obtaining reports of the use of such techniques from sixty primiparous mothers after their labours. The results showed that the majority of these women did use their coping techniques at the onset of contractions, but as labour progressed toward delivery fewer and fewer mothers did so, less than a third practising any kind of coping techniques by the time they were in the second stage of labour. Of the more than two thirds remaining, a very substantial number could be accounted for by the mothers who had epidural analgesia, but, even allowing for this, more than half of the 'non-epidural' mothers failed to make use of their postural and breathing techniques during the second stage of labour. These findings suggest that it should no longer be assumed that all women taught to cope with labour pains by learning postural and breathing techniques in antenatal classes will necessarily be able to use them throughout labour itself.