Physiological birth is defined as an approach to labour and birth that maximizes the inherent strength and normal physiology of the woman and fetus and refrains from outside interventions unless the well-being or safety of the pair are jeopardized. This clinical guideline follows the SOGC Joint Policy Statement on Normal Childbirth No. 221, published in December 2008,1 and the SOGC Guideline on the Management of Spontaneous Labour at Term in Healthy Women,2 which promote, protect, and support normal birth. In response to concerns among many professional associations about the rise in medical interventions during labour and delivery, the statement of principle recommends developing national clinical directives in support of nonpharmacological approaches to pain management based on scientific data.
The purpose of this guideline is to recommend a frame of reference, for health professionals, that promotes physiologic birth while providing physical and emotional relief to women to promote health and well-being for mother and baby, mother-infant attachment, and breastfeeding.
Nonpharmacological methods of pain management, including support during labour, have the potential to reduce obstetrical interventions, increase breastfeeding rates, and improve the mother's satisfaction without increasing morbidity.3, 4, 5, 6 To facilitate the endogenous physiological mechanisms activated during labour and delivery, health professionals, women giving birth, and their birth supporters should have a good understanding of the neurophysiologic and hormonal activity and relevant techniques. A recent meta-analysis (57 randomized studies of a total 34 000 women) assessed the effects of nonpharmacologic approaches organized by mechanism of action rather than by technique, on obstetrical interventions, labour, maternal, and perinatal outcomes.3 This study addressed the lack of systematic reviews assessing the impact of nonpharmacologic approaches on obstetric interventions and outcomes. In this meta-analysis, techniques were divided in three neurophysiologic pain modulating mechanisms: (1) light stimulation of the painful area (Gate Control Theory), (2) second painful stimulation anywhere on the body during a contraction (DNIC), and (3) CNSC activated through continuous labour support and other psychological mechanisms. A sub-group analysis included in this meta-analysis showed a first-line approach that involved continuous support and at least one other nonpharmacological method, and a pharmacological method as needed or requested by the women produced optimal clinical outcomes. These approaches provide benefit by reducing interventions. Usual care compared to these combined nonpharmacological approaches had increased odds of Caesarean delivery (11 studies, 10 338 patients, OR 2.17), instrumental delivery (6 studies, 2281 women, OR 1.78), epidural analgesia (6 studies, 2207 women, OR 1.42), and the need of synthetic oxytocin (6 studies, 2207 patients, OR 1.57). The total duration of labour was reduced compared to usual care (4 studies, 1254 women, average reduction 73.8 minutes).
Nonpharmacological approaches can also benefit women and babies by reducing exposure to the potential risks and side-effects of pharmacological pain management.
It is noteworthy that “The degree to which a woman is satisfied with the birth experience is not solely associated with the pain felt.”7 A systematic review found that the four most important factors for women's birth satisfaction: personal expectations, the amount of support from caregivers, the quality of the caregiver-patient relationship, and involvement in decision-making, overrode all other influences, including self-reported pain and analgesic efficacy.5 In addition, the presence of pain does not necessarily imply a negative birth experience—women can have pain coexisting with satisfaction, enjoyment, and empowerment.8Summary Statements
- 1.
It is important that all health care professionals have a good understanding of pain in childbirth including its physiological and psychological management whether or not a person in labour also chooses pharmacological relief (III).
- 2.
A growing body of scientific literature supports the use of nonpharmacological approaches to pain management during childbirth due to their numerous benefits for the mother and child, including a reduction in the need for obstetrical interventions, labour augmentation, or Caesarean section (I).
Recommendation
- 1.
Health care providers should be familiar with the neurophysiological and hormonal mechanisms and related methods in physiological labour and birth (III-A).
- 2.
To help women cope with normal labour, nonpharmacological approaches are recommended as a safe first-line method for pain relief and should be continued throughout labour whether or not pharmacologic methods are used (I-A).
These clinical findings and a better understanding of the neurophysiologic and endocrine mechanisms involved in labour and delivery suggest a need to replace the paradigm of “pain relief” with that of “working with pain.”
In fact, the paradigm of pain relief is based on a set of assumptions that labour pain is “abnormal” and unnecessary, that the benefits of analgesia will always exceed the risks, and that efficient pain relief is systematically correlated with women's satisfaction with the childbirth experience.9 In terms of satisfaction, studies suggest that factors including the amount of support from caregivers and involvement in decision-making are more important to women than pain relief.5
The “working with pain” paradigm is based on the assumption that pain has a physiologic role in childbirth. When women are properly prepared and supported, they produce endogenous analgesic substances that support them to work with the pain of childbirth. Through working with pain in labour, women can experience a deep sense of satisfaction that enhances their feelings of competency and confidence in rising to the challenges of parenthood.10, 11 With appropriate support, and through a complex hormonal physiology and regulating neurophysiological mechanisms, most women have the resources they need to give birth.9, 12