There are examples of CAM techniques widely used in obstetrics throughout the world that illustrate the challenges of evaluating CAM with the rigor of evidence-based medicine (EBM). The use of moxibustion techniques for the treatment of breech presentation provides a nice example of such challenges because the outcome is objective, unlike analgesic outcomes in which the outcome can be quite subjective.

Generally speaking, moxibustion (moxa) refers to the traditional Chinese medicine (TCM) technique of igniting slow-burning substances on or near certain acupuncture points for the purpose of stimulating or maintaining a particular desired health outcome. Specifically, moxibustion involving the burning of herbal preparations of mugwort (Artemisia vulgaris) to acupoint bladder (BL) 67 (Zhi Yin, located at the outside corner of the fifth toenail) has been used since ancient times to promote cephalic version of fetuses in the breech position. In 1998, Cardini and Weixin reported in the Journal of the American Medical Association (JAMA) that among Chinese primigravidas with breech presentation at 33 weeks’ gestation, moxibustion increased fetal activity during treatment and resulted in cephalic presentation after the 7- to 14-day treatment period as well as the cephalic presentation at delivery in comparison to observation alone (3).

Since this study, Cardini et al. attempted to evaluate the efficacy of moxibustion on a non-Chinese population
by performing a similar study at six Italian hospitals. They found difficulties in evaluating this CAM in its nontraditional setting (4). Because of a “high number of treatment interruptions,” only 46% of the planned sample was able to be recruited and no difference was found between the groups. Further, it was noted that 27 out of 65 women in the moxa group complained of unpleasant side effects with 14 interrupting treatment as a result. Interestingly, the authors go on to conclude that “the significance of this study is to underline several problems concerning the ability to transfer the investigated treatment from the original ethnic, social and cultural context … and to draw some deductions on methodology of clinical research in traditional medicine.” The inability to blind patients, a placebo effect, or even positive thinking and “buy in” from subjects in evaluating CAM techniques in obstetrics must be noted as randomized controlled trials (RCTs) are evaluated in the context of CAM techniques.

Since the 1998 JAMA article, others have found moxibustion, acupuncture, electroacupuncture, or laser stimulation at BL 67 to be more effective in correcting breech presentation than observation (5,6) or knee to chest positioning (7) in women willing to be randomized in a moxibustion study. However, a 2005 Cochrane review attempted to evaluate cephalic version by moxibustion (only) for breech presentation. The authors used stricter inclusion criteria, did not include the Chinese sources of studies, and looked only at moxibustion stimulation of BL 67. The authors determined that because of differences in interventions and small sample size it was not appropriate to perform a meta-analysis to determine the efficacy of moxibustion for cephalic version (8). It is important to note that this therapy appears to be safe. Fetal cardiotocography of 12 women receiving moxibustion therapy demonstrated no non-reassuring interpretations (9).

Overall, it appears that stimulation at BL 67 is safe and possibly effective in cephalic version of breech presentation. However, it seems to be more accepted by the Chinese than Western culture (3,4). If prior to the technique, the parturient, partner, and provider are accepting of this CAM, the therapy generally is well tolerated (10). Studies evaluating the analgesic efficacy of CAM techniques for labor pain are plagued by similar difficulties, cultural and regional differences in acceptance of various analgesic techniques, selection bias within studies (women willing to be in the studies may be more likely to “buy in” to alternative therapies), and differences in techniques in the performance of alternative therapies.

When discussing efficacy of CAM techniques or birth philosophies for decreasing pain during labor, the subjective nature of the outcome must be considered. While anesthesiologists may provide neuraxial techniques to decrease pain with a potential goal of a pain-free birth, proponents of CAM techniques or alternative birth philosophies may work with a parturient toward the goal of giving a woman the tools and strength to mitigate and cope with the pain. The role of this type of caregiver may not be to decrease pain, but instead to decrease suffering. Since suffering is defined individually by each parturient, the pain of childbirth to some women may not be something to eliminate or avoid. Therefore, outcomes of CAM techniques may include decreasing suffering and increasing satisfaction, which may or may not involve the mitigation of physical pain.

Women may have a variety of reasons for choosing (or avoiding) certain interventions or types of birthing experiences. Spiritually, emotionally, physically, or culturally, a non-medicated birth experience holds significant value for many parturients (11). There may be the desire for a woman to birth her child in the same way that her own mother birthed her. There may be the desire to set the particular goal of a non-medicated childbirth and then to have the satisfaction of achieving the goal. There may be the belief that a woman may feel more bonded to her child if she does not mask the pain of the labor. Whatever the reason, we do know that women who have the goal of a non-medicated childbirth and are successful in achieving it are more satisfied than those who do not achieve their goal and use epidural analgesia—even though they report significantly lower pain scores (1). Thus, the elimination of pain is not synonymous with childbirth satisfaction for some women. To add further complexity, the elimination of pain may not be synonymous with one’s satisfaction with pain relief.

A woman’s birth philosophy reflects her individual beliefs and values surrounding childbirth and labor pain. When assessing CAM techniques, it is important that we look at the outcome that a particular study evaluated carefully. Pain relief or elimination, maternal satisfaction with analgesic options, and maternal satisfaction with the childbirth experience are all separate outcomes and should be evaluated accordingly. Proponents of CAM techniques and philosophies believe the latter outcome to be the most important.

It is difficult to scientifically prove if CAM techniques are efficacious in reducing pain in labor. It is even more difficult to prove if one technique is more effective than another. A 2002 literature review by Simkin evaluated five non-pharmacologic methods of labor analgesia: Continuous labor support, baths, touch and massage, maternal movement and positioning, and intradermal water blocks for back pain relief. It was concluded that all five of these techniques were safe although further studies are required to clarify their efficacy (12). A 2004 systematic review of 12 trials utilizing acupuncture, biofeedback, hypnosis, intracutaneous sterile water injections, massage, and respiratory autogenic training concluded that there is insufficient evidence for the efficacy of any of these techniques (with the exception of sterile water injections) in decreasing labor pain (13). In a Cochrane review, Smith and colleagues found acupuncture and hypnosis to be beneficial for the management of pain during labor, but they conceded that the number of women studied has been small (14). Other complementary therapies evaluated in this review included audio-analgesia, acupressure, aromatherapy, hypnosis, massage, and relaxation. The authors concluded that these therapies have not been subjected to proper scientific study to draw conclusions at this time. A 2006 review concluded the following regarding the utility of alternative methods in decreasing labor pain and/or reducing the need for conventional analgesic methods: Efficacy for acupressure and sterile water blocks, possible efficacy for acupuncture and hydrotherapy, and no efficacy established at this time for other CAM therapies (15).

Hypnosis, acupressure, acupuncture, hydrotherapy, and sterile water injections are thought by some to have scientific evidence to support their analgesic efficacy. Of note, reduction of labor pain has been conclusively established with neuraxial anesthesia (16). However, in a 2005 Cochrane review of epidural versus non-epidural or no analgesia in labor, maternal satisfaction with pain relief could not be established (RR 1.18, 95% CI 0.92 to 1.50, 5 trials, 1,940 women). These findings appear to be consistent with what proponents of CAM techniques and philosophies emphasize, that is, pain relief is not the same as satisfaction. Therefore, CAM techniques and philosophies may
have a role in improving parturients’ satisfaction with their pain relief as well as their overall birth experience.

As anesthesiologists, it is important to be open to various CAM techniques and birth philosophies that hold value to individual parturients. Such techniques do not threaten our practice and, in fact, can be used in conjunction with neuraxial or systemic analgesia to achieve greater maternal satisfaction. Such techniques can be used prior to the onset of neuraxial analgesia—especially when the anesthesiologist is delayed. They can also be used when neuraxial techniques are contraindicated, during the time interval between epidural placement and analgesic onset, or in the rare situation that neuraxial anesthesia fails.

Negative attitudes toward CAM techniques or birth philosophies may threaten our patients’ satisfaction with their childbirth experience. A systematic review of 137 reports of factors that influenced women’s evaluations of their child birth experiences (including RCTs and systematic reviews of intrapartum interventions) found that personal expectations, the amount of support from caregivers, the quality of the caregiver–patient relationship, and the patient’s involvement in decision making were so important that they surpassed the influences of demographic differences, childbirth preparation, their degree of experienced pain, medical interventions, their physical birth environment, and continuity of care (17). Therefore, for some patients, respecting and supporting an individual parturient’s decisions regarding her pain relief, keeping the parturient involved and in control of her analgesic decisions, and creating a positive caregiver–patient relationship may be more important for the anesthesiologist than eliminating pain with neuraxial analgesia.

Lamaze® is the most recognized childbirth philosophy in the United States. It was developed in the 1960s by Dr. Fernand Lamaze, a French obstetrician, as a technique of “psychoprophylaxis” in which breathing and relaxation techniques were employed by parturients in order to experience “childbirth without pain.” Since this time, Lamaze has developed from breathing and relaxation techniques into an entire philosophy of pregnancy, childbirth, and parenting (see Tables 6-1–6-4). The main tenet of this philosophy is that birth is “normal, natural, and healthy” and provides “a foundation and direction for women as they prepare to give birth and become mothers” (18). Lamaze educators no longer teach that the Lamaze techniques result in a pain-free birth experience. Lamaze educators are certified by Lamaze International and accredited by the National Organization of Competency Assurance (NOCA).

When Lamaze techniques were first introduced throughout the United States in the 1960s and 1970s, a woman’s birth experience was quite different from a typical birth experience in a United States hospital now. Introduction of the Lamaze philosophy created a movement of parturients who actively prepared themselves for childbirth, of fathers who participated in the preparation process, and of caregivers who empowered birthing women with information and choices. Such philosophies are now recommended and largely practiced by the obstetric medical community in the United States today. One of the early studies evaluating Lamaze assessed obstetric outcomes in 500 consecutive Lamaze-prepared patients and compared them to 500 controls with no childbirth preparation. The Lamaze-prepared patients had one-fourth the number of cesarean deliveries and one-fifth the amount of fetal distress (P < 0.005), one-third the incidence of postpartum infection (P < 0.005), and fewer perineal lacerations with those that occurred not as serious as those in the control patients (P < 0.005). The control patients had three times as many cases of preeclampsia (P < 0.005) and twice as many cases of prematurity (P < 0.05) (19). Although selection bias may exist in this study, it did indicate that childbirth preparation for women was likely not harmful and perhaps helpful.

A 1984 study found only a slight decrease in average pain score that was not statistically significant between women prepared with Lamaze versus a control group (20). However, a 1985 study measuring levels of plasma beta-endorphin levels (which have been found to be reduced in effective analgesic techniques such as epidural or intrathecal analgesia) found that in 26 patients who had Lamaze preparation compared to 28 patients who had no Lamaze classes, the Lamaze group had significantly lower plasma beta-endorphin immunoreactivity (37.2 vs. 68.5 pg/mL; p < 0.02) as well as shorter first stages of labor (8.28 hours vs. 9.86 hours; p < 0.02) (21). Lamaze childbirth preparation is well accepted by women. According to a 1990 publication by Mackey, 95% of Lamaze-prepared women who were interviewed stated that being informed through Lamaze education decreased their fear, increased their relaxation, reduced tension, and increased their chances of managing their labor well (22). Furthermore, the philosophy itself does not necessarily recommend against pharmacologic pain relief for women but instead empowers women to make their own choices throughout their birth experience. Many of the Lamaze techniques work well in conjunction with intravenous or neuraxial analgesia.

Dr. Robert Bradley, an obstetrician and natural childbirth proponent, published his book Husband-Coached Childbirth in 1965 (23). In the most recent version of this book he states, “New research brings new impetus and new justification for bringing babies into the world in an ideal state: babies who are breast-fed immediately and unhandicapped by the ill effects of drugs. It is a basic human right to be so born. What better endowment could we give a child?” (24).

This quote encompasses the birth philosophy that has become known as the Bradley method. Bradley method instructors are certified by the American Academy of Husband-Coached Childbirth (AAHCC). The method teaches the husband or partner to coach the laboring woman in her breathing and to keep the labor environment free of distractions. The philosophy emphasizes education, preparation, the participation of a supportive, loving coach, and the importance of keeping women healthy and low-risk to avoid complications which could lead to medical intervention. The goal of the Bradley method is achieving a “natural childbirth”—a birth without surgery, medication, or medical intervention. Therefore, the Bradley method does not support the use of intravenous or neuraxial analgesia for laboring parturients.

The Bradley method students are taught techniques of deep abdominal breathing and concentrated awareness to work through the pain. The Bradley method works to give couples an understanding of the labor and delivery process prior to childbirth. However, it has also been thought by some to foster a sense of suspicion of health care providers because of its emphasis on “consumerism” which they define as patients/parents taking responsibility for their safety and the safety of the baby. No RCTs have been done evaluating the Bradley method.

Other less well-known birth philosophies also exist. Grantly, Dick-Read introduced a philosophy of “natural childbirth” in 1933 in which the pain of childbirth was thought to be a pathologic response by women because they were fearful and tense (25). Through teaching the facts of childbirth and instructing them in relaxation techniques, Dick-Read believed that the pain of childbirth could be diminished.

Frederic Leboyer published a book in 1974 entitled Birth Without Violence which established his philosophy inspired by Indian yoga in which an environment of tranquility is established (26). The mother, father, and professionals are all to remain quiet and calm. The mother is to keep her attention focused on the baby throughout the process to increase her pain threshold. The room is to have little noise and light and the baby is to be given a warm bath upon birth. Although neither Dick-Read’s nor Leboyer’s philosophies have been well studied, some of their general principles are incorporated into modern natural childbirth teachings.

The use of birthing pools, tubs, or whirlpools during labor is becoming more popular in many hospitals and birthing centers in the United States. (Fig. 6-1). Immersion in warm water appears to provide comfort to many women in labor.
The mechanism of the analgesia is unknown—possibly the buoyancy as well as the warmth and soothing atmosphere are helpful. In addition, the warmth and flotation may influence nociceptive input with resultant analgesic effects.

Restrictions as to which patients can use hydrotherapy during labor vary from hospital to hospital. For most hospitals, contraindications to hydrotherapy in labor may include premature labor, multiple gestation, patients undergoing a trial of labor after cesarean (TOLAC), induced labor, active genital herpes or other infections, ruptured membranes and/or the presence of meconium-stained amniotic fluid, or vaginal bleeding. Some institutions allow a parturient to only labor but not birth in the tub; others allow both labor and birth. Most hospitals also have guidelines for water temperature and length of immersion. A study by Geissbuehler et al. does not support such guidelines and reports no significant thermal risks to mother or baby when mothers choose their own temperature and duration of immersion (27). New monitors allow continuous fetal heart rate monitoring even while the parturient is submerged in water. In general, anesthesiologists agree that a laboring patient with an epidural is not allowed to use a tub or shower.

A 1983 observational study suggested that women who labor in water have faster labors, less perineal tears, and less requirement for other analgesics (28). Other studies have also suggested decreased rates of tears, episiotomies, blood loss (29), or obstetrical intervention such as augmentation, amniotomy, episiotomy, or operative delivery (30). A randomized trial involving 108 parturients in Brazil supported the analgesic benefits of laboring in water (31). Studies have also found less frequent use of conventional analgesic medications or techniques (such as neuraxial or intravenous analgesia) during hydrotherapy (30,32,33). It is interesting to note that hydrotherapy may offer greater benefit during early labor and lesser benefit at the time of birth (30). Some studies suggest that labor pain with hydrotherapy seems to escalate more slowly; however, the pain experienced in the end of the birthing process is similar to that experienced by women undergoing conventional birth (31,34). A Cochrane review including 11 trials (n = 3,146) found that there was significant reduction in the epidural, spinal, or paracervical analgesia rate amongst women randomized to water immersion compared to controls (odds ratio 0.82, 95% confidence interval 0.70 to 0.98). There were no differences in rates of assisted vaginal deliveries, cesarean deliveries, perineal trauma, or maternal infection (35).