Dear Henci,
I currently work in a highly medicalised unit. However we are consistently working to try to promote a more physiological birth, something which I greatly believe in. I just purchased your book Optimal Care in Pregnancy and Childbirth: The Case for a Physiologic Approach which I am really looking forward to read once it arrives. Meanwhile I wished to ask your guidance on an issue which I believe is central to promoting physiological birth; non-pharmacological methods of pain relief. I have used water, some massage, mobilizing and support. I wish to know where I can locate the best source of information, directions for use and evidence-base for other methods such as acupressure, aromatherapy, hypnobirthing, and any others?

Thanks

You are in luck. Here is a recent (Mar 2012) Cochrane overview of systematic reviews of strategies for coping with labor pain. It includes systematic reviews of hypnosis; biofeedback; intra- or subcutaneous sterile water injection; immersion in water; aromatherapy; relaxation techniques; acupuncture or acupressure; massage, reflexology, and other manual methods; and TENS as well as inhaled analgesia, parenteral opioids, epidural vs. nonepidural, and combined spinal-epidural vs. epidural. If you want more detail, you will then have the citations for the individual systematic reviews covering these modalities. The overview concludes that data are sparse, but the nonpharmacologic strategies do relieve pain, although not as effectively as regional analgesia (no surprise there), but regional analgesia has adverse effects while nonpharmacologic strategies don't. Listening to Mothers II, a survey of 1600 U.S. women giving birth in 2005, reported that many women found that comfort measures and nonpharmacologic strategies to be helpful for coping with pain. (FYI: The results of Listening to Mothers III, a new survey, are due out in 2013.) So between the systematic reviews and the self-report of women, you have your evidence basis for arguing that women should have a range of options from which to choose.

In addition, a Cochrane systematic review of one-on-one continuous care in labor from a trained or experienced woman who is not a medical professional--in other words, a doula--reports that doula care reduces use of pain medication, including epidural analgesia. Doubtless this is partly because doulas are trained in nonpharmacologic pain relief strategies and partly because continuous supportive care reduces anxiety, which in turn reduces pain. 

As for learning these strategies, If you're interested in something formal, I recommend contacting DONA International to set up a training workshop for your intrapartum nurses or more informally, you could contact local doulas to see if they would be interested in doing some inservice presentations. Implementing change, though, may not be easy. Here's a couple of websites on the topic that might prove helpful: Institute for Healthcare Improvement and Kotter's 8-Step Change Model.

I'd love to know how things work out for you.

~ Henci