Study Design

To achieve the proposed objectives, we have carried out a critical, or integrative review (IR), of the literature, based mainly on primary studies and previous reviews. The IR allows the incorporation of evidence into clinical practice through a search, followed by the critical evaluation and synthesis of the information compiled, to implement effective healthcare interventions and produce homogenous nursing knowledge. Along the same lines, we formulated the following research question based on the PICO strategy ( P- Population, I- Intervention, C- Comparison, and O- Outcome)¹⁴⁾ - “Is the use of complementary therapies effective to manage pain during childbirth in puerperal women?”

Data Collection

Under the stated purpose, the search strategy structure used in this review takes into account terms combined with the Boolean operator AND. The descriptors used were: “non-pharmacological methods”, “complementary therapies” “alternative therapies”, “pain”, “birth”, and “labor”. The search was carried out in Spanish and English, adapting to the specifications of each database.

Period and Search Criteria

It was conducted between October 2020 and April 2021 in the following databases: PubMed, Scopus, and Dialnet. To narrow the search scope of the study articles, we used the following inclusion criteria: articles published in 2010 onwards (in the last ten years), written or published in Spanish, English, or Portuguese, in digital format, and with access to the full text.

Exclusion criteria included: articles that did not meet the previous criteria, experimental works with non-human samples, and duplicate publications.

Simultaneously with this search, we created a descriptive Table including a synthesis of the documents we consulted, which included the following information: author, year of publication, country promoting the research, the title of the article, stated objectives, study design, sample, intervention, and outcomes, all of which contributed to the development of this work.

Mind-body interventions

The use of relaxation techniques helps reduce the intensity of pain during the latent and active phases of childbirth, thus promoting a comforTable environment for the pregnant woman, and reducing stress and anxiety¹⁶. Moreover, a significant decrease in the number of assisted vaginal births through the use of this technique has been recorded²⁰. However, other studies show the ineffectiveness of this method during labor, considering it more useful in the postnatal period²¹. We have drawn this conclusion from a literature review carried out in 2019 that revealed that the effectiveness of relaxation techniques is highly variable, but so is the range of application, therefore making it difficult to ensure the usefulness of this technique to relieve pain during childbirth²¹.

Hypnosis, on the other hand, is accomplished by the application of unified guidelines aiming at reaching an altered state of consciousness which is linked to a reduced perception of the surroundings^20,22. The responsiveness of individuals can facilitate changes in perception and behavior. This way, the attention is focused on feelings of comfort or numbness, thereby enhancing women's relaxation and sense of security. It helps reduce pain intensity and shorten labor duration and hospital stay, while it provides a safe environment without any identified adverse effects²².

Nevertheless, the professional practicing hypnosis and the woman in labor must possess previous knowledge of this therapy, which implies a prior investment of their time and effort¹⁵. Bearing in mind that this technique may inhibit the emotional interpretation of painful sensations, it is worth considering it as a safe and effective complementary therapy^15,20.

Lastly within this group is yoga, a discipline designed to induce calm and distractions, facilitating pain relief during childbirth. It involves becoming aware of our breathing and the ability to ignore external concerns, thus eliminating toxins present in the body and allowing the release of mental and emotional blocks¹⁶.

According to the literature reviewed, practicing yoga during labor and delivery facilitates and encourages positive reinforcement in pregnant women by enabling them to experience certain control over the situation and their own bodies²¹. It also helps reduce pain during childbirth which increases satisfaction with the whole experience¹⁶.

Alternative medical practice (traditional Chinese medicine)

There are various alternatives within this section, such as acupuncture and acupressure. The stimulation of strategic points located near neural structures through this type of practice can increase satisfaction with pain treatment, reducing its intensity and the need for pharmacological analgesia^20,23.

The existing literature shows that techniques such as acupuncture reduce the number of assisted vaginal deliveries and cesarean sections²⁰, while acupressure can be used to reduce anxiety at the time of childbirth²³. However, despite acknowledging its benefits, some authors emphasize the importance of choosing highly trained professionals in this area, as not doing so may result in a lack of benefits and even adverse effects^15,16.

Manual healing methods

In the category of manual healing methods, reflexology and massage are worth mentioning due to their ability to improve the satisfaction and experience of childbirth. Through the manipulation of the soft tissues of the body, strained muscles become relaxed, helping individuals reach a state of peacefulness¹⁵. Subsequently, this helps reduce pain by inhibiting sensory transmission, improving blood flow and tissue oxygenation²⁴.

Based on the above, the use of these disciplines entails multiple positive effects as mentioned in other studies as well. The most usual benefit is the increased perception of external affection that women feel with these therapies, which increases the feelings of care, well-being, and comfort^15,21,24.

Water immersion and Swiss ball

Water immersion is another remarkable method that is being used more frequently. Women who use this method report feeling safe, relaxed, and in control of the situation²⁵. Water allows the pelvic tissues to be more flexible and elastic, reducing pain during contractions, as well as the number of instrumental interventions during childbirth. This technique is well-accepted and it has been associated with greater satisfaction among parturient women^25,26.

A clinical trial carried out in Brazil emphasizes the usefulness of hot water in this process, which stimulates the redistribution of muscle blood flow and the release of endorphins, providing comfort and improving the metabolism and elasticity of some tissues²⁶.

Likewise, it has also been proven that the complementary use of hot bath therapies and perineal exercises with a Swiss ball leads to optimal outcomes in parturient women²⁶. The joint use of both techniques helps significantly reduce the intensity of pain during labor, which consists of a positive advantage on a psychological level^27,28. These techniques help to improve body posture, balance, and coordination as a result of their dynamic nature, which also helps the mother to maintain control of her body and develop confidence in her body and herself²⁸.

Aromatherapy and auriculotherapy

Additional auxiliary treatments for managing pain and stress during childbirth are aromatherapy and auriculotherapy which have been gaining popularity in recent times.

Both techniques are useful for reducing pain, anxiety, and the duration of labor, and they are also safe for mothers. It is worth noting that through auriculotherapy parturient women can manage pain more successfully. Although the studies analyzed do not provide sufficient significant evidence to support the benefits of these techniques, they have not been associated with any risks^17,18.

Transcutaneous electrical nerve stimulation (TENS)

Finally, the literature includes transcutaneous electrical nerve stimulation (TENS) as a complementary and useful method for analgesia during labor, although not all studies agree with this statement. A clinical trial carried out in 2018 in Poland shows ineffective pain reduction and poor acknowledgment of its potential benefits by parturient women. Therefore, the TENS method is considered the least satisfactory pain management method, compared to the use of EA and other complementary techniques²⁶.

Other studies support the statement that although most non-pharmacological methods for pain treatment are non-invasive and seem to be safe for the mother and the newborn, there is not enough evidence to make real clinical judgments^15,25.

Authors seem to agree that AE continues to be the gold standard for pain relief, but they do not rule out TENS when used in combination with nitrous oxide, given that some studies show a decrease in pain intensity during the different stages of labor^15,29.

The usefulness of complementary therapies

Thus, given the availability of the different techniques mentioned above, many studies reached the consensus that they should be offered in advance^29,30. Prenatal education with CT training is an effective and viable method to manage pain and reduce medical interventions. This novel approach consists of a unique set of tools for women and couples to practice during pregnancy and labor. Furthermore, providing different options for the pregnant woman to manage her pain during labor and delivery favors more humanized, safe, and quality obstetric care^19)(29)(30.

Pain relief in labor is an essential aspect of the labor process and every woman should have access to a wide variety of CTs, which offer multiple benefits^15,19.

Most women define the pain of childbirth as the most intense pain they have experienced. Alleviating this pain completely or largely implies a great challenge for the professionals accompanying women during this process²⁵.

In the process of overcoming the biomedical paradigm treasured during the last decades, increasingly more women demand more respectful delivery assistance³⁰. Integrating the social reality and the access to information and knowledge of each pregnant woman is the foundation of their decision-making process. For all of the above, learning and understanding the different methods that can provide adequate pain management is a necessity, as is receiving proper training to provide quality care, according to the unique and specific situation of each woman. In addition to this, we must not forget the importance of sharing complete and up-to-date information based on the best scientific evidence available, so that they can freely choose which method suits them and which they wish to use^15,29.

Some of the studies reviewed contemplate the combination of different techniques, contributing to increasing their effectiveness and achieving better results. Likewise, women can use them autonomously, improving their self-confidence, control, and well-being^15,26.

Finally, regarding the debate about pharmacological and complementary therapies, the literature concurs with the effectiveness of CTs in childbirth; however, further research is needed^19)(20)(29. We have not detected any case in which CTs alone have caused harm. Therefore, obtaining substantial evidence allows us to identify the benefits and possibilities of these techniques and establish protocols and guidelines for maternity care.

In future lines of research, conducting studies with a larger sample and specifically focused on each therapy will help obtain clearer results. Considering the benefits exposed in this review, additional studies should also focus on determining the effectiveness and outcomes regarding the intensity and satisfaction of pain relief.