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Level II). Respiratory depression related to epidural or intrathecal opioids during labour was
rare (Carvalho, 2008 Level IV).
Patient‐controlled epidural analgesia (PCEA) can provide effective analgesia but the optimal
settings are not clear (Leo & Sia, 2008 Level IV; Halpern & Carvalho, 2009 Level I). A systematic
review concluded that dilute concentrations of bupivacaine or ropivacaine provide acceptable
analgesia, and that use of large bolus doses and background infusions with PCEA may improve
analgesia (Halpern & Carvalho, 2009 Level I). A comparison of demand dose‐only PCEA, PCEA with
a continuous infusion, and a continuous epidural infusion only during labour, showed that
dose‐only PCEA resulted in less total epidural dose compared with the other modalities; no
differences were noted with respect to pain scores, motor block, duration of labour, number
of staff interventions, delivery outcome, and maternal satisfaction score (Vallejo et al, 2007
Level II). However, a later systematic review of PCEA in labour analgesia concluded that the
use of a continuous background epidural infusion combined with PCEA resulted in improved
maternal analgesia and reduced unscheduled clinician interventions (Halpern & Carvalho 2009,
Level I).
Single‐injection intrathecal opioids were as effective as epidural local anaesthetics for the
management of pain in early labour; there was increased pruritus but no effect on nausea or
mode of delivery (Bucklin et al, 2002 Level I). Intrathecal opioids increased the risk of fetal
bradycardia (NNH 28) and maternal pruritus (NNH 1.7) in comparison with non‐intrathecal
opioid analgesia (Mardirosoff et al, 2002 Level I). Continuous intrathecal infusion improved early
analgesia with no differences in neonatal or obstetric outcomes, but more technical difficulties
when compared with epidural administration (Arkoosh et al, 2008 Level II).
Other regional techniques in labour pain
Paracervical block was more effective than IM opioids (Jensen et al, 1984 Level II) but required
supplementation more frequently than epidural analgesia (Manninen et al, 2000 Level II) and was
less effective than single‐shot intrathecal analgesia (Junttila et al, 2009 Level III‐2). Serious fetal
complications may occur (Shnider et al, 1970), although this technique may have a role in
hospitals without obstetric anaesthesia services (Levy et al, 1999 Level III‐2) or in patients with
contraindications for spinal techniques (Junttila et al, 2009 Level III‐2).
Complementary and other methods of pain relief in labour
Continuous or one‐to‐one support by a midwife or trained layperson during labour reduced
analgesic use, operative delivery and dissatisfaction, especially if the support person was not a
member of the hospital staff, was present from early labour, or if an epidural analgesia service
CHAPTER 11 Non‐pharmacological or complementary therapies may be used during labour. Acupuncture
was not available (Hodnett et al, 2007 Level I).
decreased the need for pain relief (RR 0.7; CI 0.49 to 1.0) and women taught self‐hypnosis had
reduced pharmacological requirements (RR 0.53; CI 0.36 to 0.79), a slight decrease in need for
epidural analgesia (RR 0.30, CI 0.22 to 0.40), and increased satisfaction compared with
controls (Smith et al, 2006 Level I). The efficacy of acupressure, aromatherapy, audio analgesia,
relaxation or massage has not been established (Smith et al, 2006 Level I). TENS reduced reports
of severe pain during labour, but a consistent reduction in pain scores or in requirements for
other analgesia could not be confirmed (Dowswell et al, 2009 Level I). Few complementary
therapies have been carefully studied in well‐designed trials with clinically relevant outcomes,
and sample sizes have been small (Smith et al, 2006 Level I).

388 Acute Pain Management: Scientific Evidence