Commentary on “Nonpharmacological Methods to Reduce Pain During Active Labor in a Real-life Setting”

Comentário sobre “Métodos não farmacológicos para reduzir a dor durante o trabalho de parto ativo em um ambiente da vida real”

Dear Editor,

We have read with interest the article by Silva et al.¹ The study concluded that in a real-life setting there was no difference in the intensity of labor pain between patients who used nonpharmacological methods during the active phase of labor and those who did not. We appreciate the efforts of the research team, as their study undoubtedly contributes to enhance knowledge about labor and childbirth care. We find it crucial to highlight the widespread use of non-pharmacological methods for pain control in the institution in which the study was conducted, a highly recommended practice² that is not frequently available in Brazilian settings.³

While we acknowledge the importance of their results, we would like to raise some concerns we believe are relevant for a more accurate understanding of their findings.

Measuring pain is challenging because pain is a personal, subjective, and multifaceted experience. Labor pain presents additional difficulties because of all the emotions and concerns involved in the process, the duration of the painful sensations (which can last several hours), and the increasing intensity of the pain during the progression of dilation and fetus descent through the maternal pelvis.⁴,⁵

We have considered that one single evaluation using the Visual Analog Scale (VAS) after the delivery would not suffice to measure all multifaceted, variable, and usually long-lasting aspects of labor pain. In most of the studies using VAS included in the Cochrane Systematic Reviews, the tool was applied several times throughout the course of labor and/or before and after the intervention.⁶,⁷ Additionally, although the VAS is widely used, more comprehensive instruments that enable multidimensional assessments of pain and the experience of the parturient are necessary.⁵ Furthermore, regarding the interpretation of results, it would be important to consider not only pain, but also satisfaction, the perception of a safe environment, personal achievement, and situation control.⁸,⁹

Moreover, there is a comparative issue that needs to be taken into consideration. The study compares groups that are not analogous in terms of the time of exposure to non-pharmacological methods. It is important to note that one group had little to no time to become familiar with the resources, and even use them, while the other group had a more extensive opportunity to become familiar with the pain control methods, and a longer active phase period.

Moreover, the abstract and conclusions of the aforementioned study may lead readers to believe that non-pharmacological methods are ineffective, when the measurement of pain was imprecise, and the groups were not comparable. We believe the misconceptions the conclusion produces might restrict women's access to non-pharmacological methods.

Overall, we believe the collected data depict an interesting quantitative analysis of non-pharmacological methods and factors associated with their use. In the abstract, we suggest the authors clarify that the method chosen to measure pain has limitations, and that the use of non-pharmacological methods to cope with pain should be encouraged.

References

• ¹
  Silva CBO, Rodrigues KMD, Zoldan C, Nomura RMY, Araujo Júnior E, Peixoto AB. Nonpharmacological Methods to Reduce Pain During Active Labor in A Real-life Setting. Rev Bras Ginecol Obstet. 2023;45(01):3-10
• ²
  World Health Organization Intrapartum care for a positive childbirth experience [Internet]. 2018. 200 p. Available from: http://www.who.int/reproductivehealth/publications/intrapartum-care-guidelines/en/
  » http://www.who.int/reproductivehealth/publications/intrapartum-care-guidelines/en/
• ³
  Leal M do C, Pereira APE, Domingues RMSM, Theme Filha MM, Dias MAB, Nakamura-Pereira M, et al. Intervenções Obstétricas durante o trabalho de parto e parto em mulheres brasileiras de risco habitual. Cad Saude Publica. 2014;30(x):S17-S47
• ⁴
  Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, et al. Pain management for women in labor: an overview of systematic reviews. Cochrane Database Syst Rev Online. 2012;3:9234
• ⁵
  Blumenstock AK, Mauter D. [Pain assessment during birth: Which assessment tools comprehensibly depict the labor pains during physiological birth?] Schmerz. 2023;x:x
• ⁶
  Smith CA, Levett KM, Collins CT, Armour M, Dahlen HG, Suganuma M. Relaxation techniques for pain management in labour. Cochrane Database Syst Rev. 2018;3(03):CD009514. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6494625/ cited 2023-May 18 [Internet]
  » https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6494625/
• ⁷
  Smith CA, Levett KM, Collins CT, Dahlen HG, Ee CC, Suganuma M. Massage, reflexology and other manual methods for pain management in labor. Cochrane Database Syst Rev. 2018;x(03):CD009290
• ⁸
  Downe S, Finlayson K, Oladapo OT, Bonet M, Gülmezoglu AM. What matters to women during childbirth: A systematic qualitative review. PLoS One. 2018;13(04):e0194906. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0194906 cited-2023 May 18 [Internet]
  » https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0194906
• ⁹
  Chaillet N, Belaid L, Crochetière C, Roy L, Gagné G-P, Moutquin JM, et al. Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Birth. 2014;41 (02):122-137. https://onlinelibrary.wiley.com/doi/abs/10.1111/birt.12103 cited 2023 May 18 [Internet]
  » https://onlinelibrary.wiley.com/doi/abs/10.1111/birt.12103

Publication Dates

• Publication in this collection
  30 Oct 2023
• Date of issue
  2023

History

• Received
  26 May 2023
• Accepted
  31 May 2023