Background
Pain after caesarean sections (CS) can affect the well-being of the mother and her interaction with her baby. To manage pain relief during this period, most women receive analgesic drugs. However, these medications can potentially cause side effects in the mother and her baby. Complementary and alternative therapies (CAM) may be a safe way of reducing pain after a CS without adverse effects.
What is the question?
What are the effects of CAM in the treatment of post-caesarean pain?
Why is this important?
The findings of this review will be useful to help inform women, midwives and doctors about the potential benefits and disadvantages of CAM for pain relief after CS.
What evidence did we find?
We searched the literature in September 2019 and found 37 studies that evaluated eight different types of CAM. The certainty of the evidence from the studies ranged from low to very low, which means that we cannot be confident in the findings. The key reasons for this were that results were not always completely or clearly reported, the studies had serious limitations, and the results lacked precision.
Acupuncture or acupressure
We are uncertain if acupuncture or acupressure (versus no treatment) or acupuncture or acupressure plus analgesia (versus placebo plus analgesia) has any effect on pain because the quality of evidence is very low. Acupuncture or acupressure plus analgesia (versus analgesia) may reduce pain at 12 hours and 24 hours.
It is uncertain whether acupuncture or acupressure (versus no treatment) or acupuncture or acupressure plus analgesia (versus analgesia) has any effect on the risk of adverse effects because the quality of evidence is very low.
Aromatherapy
Aromatherapy may reduce pain at 12 and 24 hours when compared with placebo plus analgesia. It is uncertain if aromatherapy compared with placebo plus analgesia has any effect on adverse effects (anxiety).
Electromagnetic therapy
Electromagnetic therapy may reduce pain at 12 and 24 hours and may reduce rescue analgesic requirement compared with placebo plus analgesia.
Massage therapy
We are uncertain if hand and foot massage plus analgesia, compared with analgesia, has any effect on pain, adverse effects (anxiety) heart rate and respiratory rate because the quality of evidence is very low.
Music therapy
Music plus analgesia, compared with placebo plus analgesia, may reduce pain at one hour and 24 hours. It is uncertain if music plus analgesia, compared with placebo plus analgesia, has any effect on the risk of adverse effects (anxiety) or on heart rate.
Music plus analgesia compared with analgesia may reduce pain at one hour and 24 hours.
Reiki
It is uncertain if Reiki, compared with analgesia has any effect on pain at either one hour or 24 hours, adverse effects (anxiety) or vital signs because the quality of evidence is very low.
Relaxation
It is uncertain if relaxation, compared with standard care, has any effect on pain at 12 hours but it may reduce pain at 24 hours after the intervention.
Transcutaneous electrical nerve stimulation (TENS)
TENS may reduce pain at one hour after the intervention, compared with no treatment.
TENS plus analgesia, compared with placebo plus analgesia, may reduce pain, heart rate and respiratory rate.
It is uncertain if TENS plus analgesia, compared with analgesia, has any effect on pain at six or 24 hours after the intervention or on vital signs or on rescue analgesic requirement.
What does this mean?
There may be some benefit of acupuncture or acupressure, aromatherapy, electromagnetic therapy, massage, music therapy, relaxation, and TENS in the management of pain in women undergoing CS. From these trials, the evidence on harmful effects of CAM are lacking or are very uncertain.
Since pain control is the most relevant outcome for post-CS women and their clinicians, it is important that future studies of CAM for post-CS pain measure pain, preferably as the proportion of participants with at least moderate (30%) or substantial (50%) pain relief. Future trials also need to have be large enough to detect effects on clinical outcomes; measure other important outcomes as listed lin this review, and use validated scales.
Some CAM therapies may help reduce post-CS pain for up to 24 hours. The evidence on adverse events is too uncertain to make any judgements on safety and we have no evidence about the longer-term effects on pain.
Since pain control is the most relevant outcome for post-CS women and their clinicians, it is important that future studies of CAM for post-CS pain measure pain as a primary outcome, preferably as the proportion of participants with at least moderate (30%) or substantial (50%) pain relief. Measuring pain as a dichotomous variable would improve the certainty of evidence and it is easy to understand for non-specialists. Future trials also need to be large enough to detect effects on clinical outcomes; measure other important outcomes as listed lin this review, and use validated scales.
Pain after caesarean sections (CS) can affect the well-being of the mother and her ability with her newborn. Conventional pain-relieving strategies are often underused because of concerns about the adverse maternal and neonatal effects. Complementary alternative therapies (CAM) may offer an alternative for post-CS pain.
To assess the effects of CAM for post-caesarean pain.
We searched Cochrane Pregnancy and Childbirth’s Trials Register, LILACS, PEDro, CAMbase, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (6 September 2019), and checked the reference lists of retrieved articles.
Randomised controlled trials (RCTs), including quasi-RCTs and cluster-RCTs, comparing CAM, alone or associated with other forms of pain relief, versus other treatments or placebo or no treatment, for the treatment of post-CS pain.
Two review authors independently performed study selection, extracted data, assessed risk of bias and assessed the certainty of evidence using GRADE.
We included 37 studies (3076 women) which investigated eight different CAM therapies for post-CS pain relief. There is substantial heterogeneity among the trials. We downgraded the certainty of evidence due to small numbers of women participating in the trials and to risk of bias related to lack of blinding and inadequate reporting of randomisation processes. None of the trials reported pain at six weeks after discharge.
Primary outcomes were pain and adverse effects, reported per intervention below. Secondary outcomes included vital signs, rescue analgesic requirement at six weeks after discharge; all of which were poorly reported, not reported, or we are uncertain as to the effect
Acupuncture or acupressure
We are very uncertain if acupuncture or acupressure (versus no treatment) or acupuncture or acupressure plus analgesia (versus placebo plus analgesia) has any effect on pain because the quality of evidence is very low. Acupuncture or acupressure plus analgesia (versus analgesia) may reduce pain at 12 hours (standardised mean difference (SMD) -0.28, 95% confidence interval (CI) -0.64 to 0.07; 2 studies; 130 women; low-certainty evidence) and 24 hours (SMD -0.63, 95% CI -0.99 to -0.26; 2 studies; 130 women; low-certainty evidence).
It is uncertain whether acupuncture or acupressure (versus no treatment) or acupuncture or acupressure plus analgesia (versus analgesia) has any effect on the risk of adverse effects because the quality of evidence is very low.
Aromatherapy
Aromatherapy plus analgesia may reduce pain when compared with placebo plus analgesia at 12 hours (mean difference (MD) -2.63 visual analogue scale (VAS), 95% CI -3.48 to -1.77; 3 studies; 360 women; low-certainty evidence) and 24 hours (MD -3.38 VAS, 95% CI -3.85 to -2.91; 1 study; 200 women; low-certainty evidence). We are uncertain if aromatherapy plus analgesia has any effect on adverse effects (anxiety) compared with placebo plus analgesia.
Electromagnetic therapy
Electromagnetic therapy may reduce pain compared with placebo plus analgesia at 12 hours (MD -8.00, 95% CI -11.65 to -4.35; 1 study; 72 women; low-certainty evidence) and 24 hours (MD -13.00 VAS, 95% CI -17.13 to -8.87; 1 study; 72 women; low-certainty evidence).
Massage
We identified six studies (651 women), five of which were quasi-RCTs, comparing massage (foot and hand) plus analgesia versus analgesia. All the evidence relating to pain, adverse effects (anxiety), vital signs and rescue analgesic requirement was very low-certainty.
Music
Music plus analgesia may reduce pain when compared with placebo plus analgesia at one hour (SMD -0.84, 95% CI -1.23 to -0.46; 2 studies; 115 women; low-certainty evidence), 24 hours (MD -1.79, 95% CI -2.67 to -0.91; 1 study; 38 women; low-certainty evidence), and also when compared with analgesia at one hour (MD -2.11, 95% CI -3.11 to -1.10; 1 study; 38 women; low-certainty evidence) and at 24 hours (MD -2.69, 95% CI -3.67 to -1.70; 1 study; 38 women; low-certainty evidence). It is uncertain whether music plus analgesia has any effect on adverse effects (anxiety), when compared with placebo plus analgesia because the quality of evidence is very low.
Reiki
We are uncertain if Reiki plus analgesia compared with analgesia alone has any effect on pain, adverse effects, vital signs or rescue analgesic requirement because the quality of evidence is very low (one study, 90 women).
Relaxation
Relaxation may reduce pain compared with standard care at 24 hours (MD -0.53 VAS, 95% CI -1.05 to -0.01; 1 study; 60 women; low-certainty evidence).
Transcutaneous electrical nerve stimulation
TENS (versus no treatment) may reduce pain at one hour (MD -2.26, 95% CI -3.35 to -1.17; 1 study; 40 women; low-certainty evidence). TENS plus analgesia (versus placebo plus analgesia) may reduce pain at one hour (SMD -1.10 VAS, 95% CI -1.37 to -0.82; 3 studies; 238 women; low-certainty evidence) and at 24 hours (MD -0.70 VAS, 95% CI -0.87 to -0.53; 1 study; 108 women; low-certainty evidence).
TENS plus analgesia (versus placebo plus analgesia) may reduce heart rate (MD -7.00 bpm, 95% CI -7.63 to -6.37; 108 women; 1 study; low-certainty evidence) and respiratory rate (MD -1.10 brpm, 95% CI -1.26 to -0.94; 108 women; 1 study; low-certainty evidence).
We are uncertain if TENS plus analgesia (versus analgesia) has any effect on pain at six hours or 24 hours, or vital signs because the quality of evidence is very low (two studies, 92 women).