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Sterile water injections for back pain in labour.

Introduction:

Severe low back pain during labour is often associated with the fetus lying in a posterior position. It is estimated that posterior positions occur between 5.5% (Ponkey, Cohen, Heffner, & Lieberman, 2003) and 8% (Cheng, Shaffer, & Caughey, 2006) and can cause long and painful labours (Coates, 2003). One method that may assist in reducing persistent back pain associated with the posterior position is sterile water injections into the maternal lumbosacral region. The technique, known also as sterile water blocks (Trolle, Moller, Kronborg, & Thomsen, 1991) or papules (Ader, Hansson, & Wallin, 1990), to reduce pain during labour have been used by midwives for the past 25 years in Scandinavian countries (Peart, James, & Deocampo, 2006) and in the USA and Canada since the 1990s (Varney, Kriebs, & Gegor, 2004). A brief search of midwifery textbooks published during the last 10 years found only two that mention the use of sterile water injections (Lowdermilk & Perry, 2004; Varney et al., 2004).

It has been included in the Canadian National Guidelines for Family-Centred Maternity and Newborn Care (Health Canada, 2000) and it is mentioned by Enkin, Keirse, Neilson, et al. (2000) as a method for reducing labour pain.

This paper examines the research surrounding use of sterile water injections to reduce maternal low back pain during labour. It describes the various techniques used by the researchers, assesses the results and considers issues for practice.

Literature Review

Early studies describe how lumbosacral subcutaneous injections of local anaesthetic were first used around 1929 to relieve labour back pain but these were not effective (Ader et al., 1990). In 1975 Odent (1991) used injections of distilled water into an area just below the ribs of labouring women before he accidentally found that sterile water (used for washing hands in the operating theatres) was more effective. According to Trolle, Moller, Kronborg et al. (1991) sterile water injections have been used effectively for relieving renal colic pain during the early 1980s. In 1986 the principle was successfully applied to women with low back pain in labour. However, none of the studies contained a control group (Ader et al., 1990). This led Ader and her colleagues to investigate the effects of sterile water injections compared to a placebo (normal saline) in a randomised controlled trial. Their study consisted of 45 women who required pain relief for low back pain during labour. One group (treatment group) received four intracutaneous injections. Intracutaneous injections are those that are given within the layers of the skin. It is a term derived from Latin with 'curtis' meaning skin and 'intra' meaning within. It is interchangeable with the term intradermal which derived from 'derma' meaning skin in Greek (Harris, Nagy, & Vardaxis, 2006). Each injection contained sterile water 0.1ml injected into the area marked by the sacral dimples (Michaelis' rhomboid) during a contraction. The area known as the Michaelis' rhomboid is shown in Figure 1 as a broken line, while the area where the injections can be inserted is indicated by the four small diamonds.

[FIGURE 1 OMITTED]

The other group (placebo group) received 0.1 ml of normal saline subcutaneously into the same region. All injections were given by a midwife, not involved with the woman's care. The researchers found that, while the subcutaneous injections were almost painless, the intracutaneous injections of sterile water caused a sharp 20 second long pain. Injections were therefore given during a contraction to 'mask' this experience. Women were asked to rate their pain using a visual analogue scale (VAS) on four occasions: before they had the injection; 10 minutes, 45 minutes and 90 minutes after the injection. The VAS was graded from 0 to 10 with "0" (no pain) to "10" (pain as bad as it gets). Results indicated that women in both groups identified that they had less pain after the injections compared to before the injection. However VAS scores for the treatment (sterile water) group were significantly less for each time period after the injection compared to the control (normal saline) group. That is, this study showed that both the treatment and the placebo reduced the level of back pain during labour, although more women in the sterile water group achieved an analgesic effect than in the normal saline group. (p=<0.001 at 10 minutes, p=<0.02 at 45 minutes and p=<0.05 at 90 minutes). The researchers noted that there were no long lasting side effects, that the injections could be easily administered by midwives; however the women did complain that the injection caused a burning pain which lasted a few seconds. Unfortunately, this study used two different injection routes for the treatment and control groups which may have influenced the results. This was rectified in the following study.

Trolle et al. (1991) in a double blind randomised control trial assessed the degree of pain relief achieved in 272 women with low back pain in labour using the same injection route for all participants. The researchers used the same technique as Ader et al's (1990) study (0.1 mls of fluid into four points of the Michaelis' rhomboid) of sterile water or normal saline. Both injection mediums were provided in identical ampoules and randomly mixed and numbered so that the midwives were not aware of the fluid being used. All participants received intradermal injections into the lumbar-sacral area. Women were asked to rate their pain using VAS on three occasions: before they had the injection, one hour and two hours after the injection. The VAS was similar in design to the one described by Ader et al. Results from both groups indicated that women had less pain after the injections compared to before the injections. The researchers found a significant difference between the two groups post injection results. They found that 89% of women in the sterile water group experienced an analgesic effect compared with 45% of women in the normal saline group (p=<0.005) with the effect lasting one to two hours. The authors noted that intradermal injections using normal saline were painful but those using sterile water were more painful. Yet significantly more women from the sterile water group would request the same pain relief again than from the normal saline group (p=<0.005).

The findings from these two studies indicated that intradermal injections of sterile water provided effective analgesia but were initially very painful. This led Martensson & Wallin (1999) to examine the differences in analgesia achieved between intracutaneous and subcutaneous injections using a randomised controlled trail of 99 women in labour. Two groups were given sterile water injections: one group received 0.1 ml intracutaneously while the other group received 0.5ml subcutaneously. A placebo group were given a subcutaneous injection of 0.1 ml normal saline. Each woman received four injections, during a contraction, into the same area described previously except this time the researchers asked the women to breathe on a combination of oxygen and nitrous oxide to reduce the pain sensation created by the injections. Women were asked to complete a VAS (similar to that described previously) before the injections, then at 10, 45 and 90 minutes after the injection. Women were also asked if they would request the injections during a future labour. Results indicated that there was no significant difference in the VAS scores between the groups using intracutaneous or subcutaneous sterile water. There was however, a significant difference in the VAS scores between the two sterile water groups and the placebo (normal saline) group indicating that sterile water had a greater analgesic effect than normal saline for more than 45 minutes after the injections. Women in the two treatment groups experienced more pain during the injection than the women in the placebo group yet significantly more women in the experimental groups would use the method again compared to the placebo group. A limitation of the study was that the researchers were unable to determine which injection route was more painful.

To assess which injection route caused more pain for the women Martensson, Nyberg and Wallin, (2000) investigated, in a double blind study, two injection routes: intracutaneous or subcutaneous. The study involved 100 non pregnant women between the ages of 18-45, randomised into two groups. Both groups received the same treatment: two injections 10 minutes apart. One group were given 0.1 ml of sterile water intracutaneously into the left sacrum followed 10 minutes later by 0.5 ml sterile water subcutaneously into the right sacrum. The same method was used with the second group except they were given the subcutaneous injection first and the intracutaneous injection 10 minutes later. Women were asked to rate the pain they experienced 90 seconds after each injection on a VAS, similar to those described previously. A second trial was undertaken a week later with both groups receiving the same injections but in reverse order. The researchers found that women experienced significantly more pain with the intracutaneous injections than with the subcutaneous injections. These women however, were not pregnant and not in labour.

In an Australian study, Peart et al. (2006) evaluated the effect that sterile water intradermal injections had on low back pain of 60 women during labour from two different hospitals. Women were required to request this type of pain relief prior to labour to be eligible for the study. The researchers used a similar VAS to those studies described previously and injected the sterile water into the Michaelis' rhomboid region using four injections. To reduce the pain of the injections each pair of injections were given simultaneously by two staff. The injections were not given until women indicated a VAS pain score of seven or more. This was because the researchers had undertaken a preliminary evaluation which indicated that the pain of the injections was unacceptable to the women unless their VAS pain score was seven or more. VAS sores were collected prior to the injection, five minutes after the injection and then every 30 minutes for two hours. Results showed a significant difference in responses between the pre and post injection VAS scores indicating 90% of women were experiencing less pain after than before the injection. There was also a significant reduction in the VAS scores for a period of 90 minutes following the injection indicating the period of analgesic effect. Women were very satisfied with the technique and would use it again although 96% indicated that it was very painful. Unfortunately, the authors stated they administered between 0.1 and 0.5 mls of sterile water but no mention was made why there was a difference in the volumes injected or if this effected the period of analgesia.

In another randomised control trial (Bahasadri, Ahmadi-Abhari, Dehghani-Nik, & Habibi, 2006) explored the effect of the subcutaneous route and one injection site rather that the four injections used by Ader et al.(1990); Trolle et al (1991); Martensson & Wallin (1999) and Peart et al. (2006). Bahasadri et al. investigated the effect of using subcutaneous injections of sterile water (treatment group) and normal saline (placebo group) on 100 women during labour. Both groups received one 0.5 ml of fluid injected into subcutaneous tissue in one area only. This area was the one women considered most painful in the sacral-lumbar region. Pain scores were calculated using a faces rating scale (FRS) prior to the injection and again 10 and 45 minutes after the injection. The FRS used was the Wong-Baker Faces Pain Rating Scale which has six faces with varying expressions from smiling (scored as "0" and labelled No hurt) to crying (scored as "5" and labelled Hurts worst) (Belville & Seupaul, 2005). Although the FRS was developed for paediatric use (Crisp & Taylor, 2005) it has been used across cultures and has been translated into a number of languages (McCaffery, 2002). It has also been validated reliably in adults against the visual analogue scale (Freeman, Smyth, Dallam, & Jackson, 2001; Ware, Epps, Herr, & Packard, 2006). Results indicated that there was a reduction in the FRS pain scores in both groups after the injections compared to before the injections. However, there was a significant difference (p <0.01) between the two groups at 10 and 45 minutes after the injections; indicating that sterile water had a greater analgesic effect compared to normal saline. The researchers found that women complained that the injection was painful and the pain lasted approximately two minutes.

A recent RCT (Martensson, Stener-Victorin, & Wallin, 2008) evaluated pain relief and relaxation achieved during labour in 128 women using 0.05ml of sterile water injections compared with acupuncture. Both interventions were administered by 40 midwives trained in the procedures and the interventions were repeated when required. In the sterile water group four to eight injections were administered subcutaneously during a contraction in the area indicated by the woman as being the most painful. The area was not restricted to the lower lumbar sacral region. The pain relief achieved was assessed by VAS prior to the intervention then at half hourly intervals after the intervention for three hours by the women and also assessed by another midwife. Results from women indicated those in the sterile water group reported significantly less pain (p<0.001) than the acupuncture group and had a higher degree of relaxation (p<0.001). The sterile water group continued to have significantly less pain (p =< 0.04) for 180 minutes after the interventions except for at the 150 minute point, which produced a non significant result. Midwives also assessed women in the sterile water group as having less pain (p<0.001) and greater relaxation (p<0.002) than those in the acupuncture group. There were no significant differences in birth outcomes however there was only a 7% caesarean section rate of the study. Interestingly, this study did not exclude women from the study if the location of their pain was other than low back pain. Earlier studies only included women with severe low back pain. Unfortunately, the authors did not report the most common areas where this pain occurred but is an interesting issue since the results support sterile water injections as an effective pain relief measure. Pain relief has been reported using this method in other anatomical areas (Trolle et al., 1991).

The evidence from these studies suggests that sterile water injections are an effective method to relieve low back pain in labour although the placebo (normal saline) also produced, to some degree, an analgesic effect. Table 1 provides a summary of the studies reviewed. Interestingly, when reported none of the studies identified any statistical differences between birth outcomes of the experimental or control groups except Trolle et al (1991) and Martensson et al.(2008). The former study was the largest and they found a significant difference in the caesarean section rates between the groups (p=<0.05) which the authors were unable to explain. Fewer women from the sterile water group (4.2%) required surgery compared with 11.4% from the normal saline group and both groups had similar rates of instrumental deliveries. It is possible that reduction in the back pain allowed women to relax sufficiently to permit contractions to rotate a malposition. In the later study (Martensson, Stener-Victorin et al., 2008) reported no differences in the birth outcomes between the two groups but their caesarean section rate for the study was very low (7%). It would have been of value to know the caesarean section rate for the population from which this study was drawn.

There have been three systematic reviews of RCT's covering complementary and alternative medicine (CAM) in obstetrics which have included the technique of sterile water injections for the relief of pain in labour. Simpkin & O'Hara (2002) evaluated five non pharmacological methods including continuous labour support; touch and massage; baths; movement and positioning; and sterile water injections. They found that although all methods reduced labour pain temporarily, sterile water injections had the most consistent results. Huntley, Thompson Coon & Ernst (2004) found 12 RCTs which included acupuncture, hypnosis, massage, biofeedback, respiratory autogenic training and sterile water injections in their systematic review of CAM used to treat labour pain. They concluded that only those trials using sterile water injections provided significant evidence of effectiveness. A later review by Anderson and Johnson (2005) examined CAM used in health promotion and for obstetric treatments during the prenatal, intrapartum and postpartum periods. In the intrapartum period they identified four interventions used to treat the pain of labour: acupuncture; massage; acupressure and sterile water injections. These authors also found that the only intervention that was effective was sterile water injections.

Considerations for Practice

The literature raises some interesting issues that require consideration. The following section discusses these in relationship to midwifery practice within the context of New Zealand and includes points related to performing the techniques; guidance and informed consent.

a) Techniques

Firstly, the technique for inserting subcutaneous injections is easier than intradermal (intracutaneous) injections and has fewer problems. Figure 2 provides a diagram of the layers of the skin and the angles used of each type of injection.

[FIGURE 2 OMITTED]

Subcutaneous injections are inserted into the connective tissue under the dermal layer of the skin however the depth of subcutaneous tissue is determined by body weight. Both the needle angle and needle length are determined by the woman's body weight. For example, the angle is determined by the amount of tissue that can be grasped or pinched. If you can grasp about 2.5 cms of skin, the needle is inserted at a 45 degree angle (Figure 2) using a 17 mm 25G needle. You can then continue to pinch the skin fold as you insert the needle quickly or you can stretch the skin and then insert the needle. It is easier to penetrate and it is less painful when the skin is pulled tightly. In both situations release the skin before injecting the sterile water slowly. It may however, be difficult to give a subcutaneous injection to very thin women who have little connective tissue. If 5cms of skin is grasped however, then the needle is injected at a 90 degree angle using a 25G needle with a length that is approximately half the length of the skin fold. Inject the sterile water slowly while you continue to maintain a grasp of the skin fold as obese women have a layer of fat above the subcutaneous layer. (Crisp & Taylor, 2005). An intradermal injection is typically used for vaccine or serum screening (ibid) or to apply a local anaesthetic (Johnson & Taylor, 2006). Fluid is injected under the dermis at a 5-15 degree angle (as shown in Figure 2) so that a blister, papule or bleb is formed (Figure 3). During the procedure the skin should be stretched and a 25 G needle inserted into the skin until resistance is felt. The needle is then advanced for about 3mm so the bevel of the needle is still visible under the skin. Further resistance should be felt as the sterile water is injected slowly. A blister should be visible however if it does not form, it means the injection has been placed lower into the subcutaneous tissue. Also, if no resistance is felt the fluid is probably being injected into the lower subcutaneous level (Crisp & Taylor, 2005). As pain relief is achieved by both routes this is probably not so important for midwifery. This is supported by Martensson & Wallin (1999) who found that 89% of women having had intracutaneous injections in their study would be willing to use the technique again compared to 81% in the subcutaneous group.

[FIGURE 3 OMITTED]

The second consideration around the technique is the number of injections and the anatomical location. All the studies on labouring women used four injections except Bahasadri et al. (2006) who used one and Martensson et al.(2008) who used up to eight. Again all except for Martensson et al.(2008) used the lumbosacral region. Therefore, the number of injections used and the anatomical location may depend on the situation: where the woman feels the pain; where the woman is labouring; the number of health professionals available; and the midwives' skills. If the woman is experiencing generalised pain over the lower sacral area then the four injection technique may be the method of choice however if the woman can localise her pain to one particular spot then one injection may be appropriate.

Varney et al. (2004) stated that the injections are more effective if women identify their own points of pain. This is supported by Martensson et al. (2008) and Bahasadri et al. (2006) studies. However, if the location is in the lower back, Varney et al. (2004) suggest that the woman leans forward while standing, kneeling or sitting during the procedure. This permits the sacral dimples to be observed more easily if the four injections technique is to be used. Peart et al. (2006) noted that having an assistant to help administer the injections simultaneously decreased the pain sensation experienced by the women. Women are also more willing to have the procedure repeated in another labour if simultaneous injections are given (Martensson & Wallin, 1999).

Varney et al also suggest (using the one subcutaneous injection technique) that once the woman has identified the area that is painful with her finger, that it is marked by the midwife or an assistant (Figure 4). Marking a circle around the woman's finger allows the injection to be placed correctly. It also permits the midwife to monitor the position for further injections if pain returns although one author noted that it is not necessary to be exact in the placement of the injection site (Reynolds, 1998). The subcutaneous injection can then be inserted (Figure 5).

With the exception of Peart et al. (2006), all researchers used 0.1 ml of sterile water when the route was intradermal and 0.5 ml of sterile water used when the route was subcutaneous. Therefore these volumes should guide practice. Sterile water injections are easy to administer and have no side effects except that the initial injection can cause pain described as a bee or wasp sting lasting 30 to 90 seconds (Varney et al., 2004). The relief of pain is fast (Martensson et al., 2000) lasts two to three hours, and the injections can be repeated although these should be limited to three as local irritation may occur (Varney et al., 2004).

[FIGURE 4 OMITTED]

[FIGURE 5 OMITTED]

b) Guidance

This is a technique that is not well known. For example, although it has been identified as being used since 1990 in the USA, a survey of 107 midwives knowledge and attitudes in that country (Martensson, McSwiggin, & Mercer, 2008) found that 32% of the midwives used the technique while 46% of midwives had no knowledge of it. From personal discussions with a number of midwives across the North Island not one identified that they had heard of the technique. Furthermore, a personal enquiry to four of the education institutions offering Bachelor of Midwifery programmes found that none included the technique as a midwifery skill and in addition did not include intradermal injections in their curriculum. Therefore, midwives from these programmes, as well as other midwives, may need additional education and theoretical practise in the technique in order to gain competence.

A number of authors have provided advice regarding undertaking the different techniques. For example, when withdrawing the needle after insertion of an intradermal injection do not massage the site with a swab as this may cause the fluid to escape (Crisp & Taylor, 2005). Likewise, don't recommence any therapeutic massage over the injection site as it may dislodge the fluid and shorten the effect (Reynolds, 1998). Larger blebs have been suggested as resulting in longer periods of effective relief (Martensson, McSwiggin et al., 2008) however this requires further research. Other issues would also need consideration. For example, observing the site for the injections and making sure they are free of skin infections or damage such as bruising. Likewise, in the hours and days after the injections the area should be observed for signs of infection.

Most of the studies recommended that the injections be given during a contraction to minimise discomfort. However, the midwives who used this technique in the USA could not agree that this was an appropriate recommendation although they gave no reasons (Martensson, McSwiggin et al., 2008). It could be argued that it would be easier to administer the injections between contractions when a woman might reduce her bodily movements. However, this is an area that has not been researched. Providing women with nitrous oxide and oxygen to breath during the administration may help to diminish the pain of the injection (Martensson & Wallin, 1999).

Sterile water injections provide midwives with another option to offer women as they work with the pain of labour. It has been reported that between 70%-90% of women experience pain relief for at least 60 minutes after the injection (Reynolds, 2000) although this relief can last up to two hours (Martensson, Stener-Victorin et al., 2008) and the injections can be repeated (Varney et al., 2004). It may be ideal for women who require pain relief prior to transfer from a rural area or for women waiting for an epidural. It may also be an option for women who do not want to use narcotics or to have an epidural.

c) Consent

Sterile water injections are another option for women to consider particular if they are keen to use only non pharmacological methods of working with pain. Women should be offered concise information about this technique during their pregnancy once midwives are competent to offer it. The information should include advantages and disadvantages of using the techniques; an explanation of the different techniques; when the method may be used; and a scientific explanation of how the technique works.

The advantages of this method of pain relief is that it is relatively quick to administer in any situation, is cheap and can be used in homebirths, birthing units or major hospitals. It may be used as a main pain relief measure or used as an interim measure if the woman is being transferred to secondary care for an epidural. Therefore it may be idea tool for midwives working in rural areas to include in their skill repertoire as studies suggest that 90% of women were satisfied with the degree of pain relief achieved (Peart et al., 2006).

The major disadvantage of the technique is the initial severe burning pain that can last up to 90 seconds and has been described as a bee or wasp sting although research indicates that the pain sensation can be reduced using the subcutaneous method (Martensson et al., 2000). This information needs to be carefully explained to the woman together with the fact that, like other pain relief measures, it may not be 100% effective or last for hours but it can be repeated.

Conclusion

The evidence from these studies suggests that sterile water injections are an effective method to relieve low back pain in labour. They are simple to undertake and may provide women with an alternative method to narcotics and epidurals. The severe transitory pain experienced by the women immediately after the injection appears to be the only side effect. The number of injections and the route to be used will depend on the woman, her place of labour, and the midwife's skills. However, a single subcutaneous injection, into the area identified by the woman as being the most painful, appears to be effective and cause the least pain. This would be an ideal topic to be included in the Technical Skills Workshops. An evaluation of the technique in a New Zealand based population is also required.

Accepted for publication March 2008

Duff, M. (2008) Sterile Water Injections for Back Pain in Labour

New Zealand College of Midwives Journal 39, 33-38

References

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Author:

Margaret (Margie) Duff

PhD, BN, RM, RCompN, Certificate in Tertiary Teaching,

Senior Midwifery Researcher

University of Western Sydney, Australia.

Correspondence to: margieduff@gmail.com
Table 1: A Summary of the Studies Reviewed.

Note: VAS--Visual analogue scale; FRS--Faces rating scale. Note--For
ease of comparison the term intradermal has been used throughout this
summary in place of intracutaneous used by some authors.

Authors (Year)        Participants

Ader et al (1990)     45 women with low back
                      pain in labour >37 wks

Trope et al. (1991)   272 women with severe
                      low back pain in labour
                      > 39 wks

Martensson &          99 women with severe
Wallin (1999)         low back pain in labour.
                      Term pregnancies

Martensson et al      100 non pregnant
(2000)                women between 18 and
                      45 years

Pert et al. (2006)    Women in early labour
                      with VAS> 7

Bahasadri et al.      100 women in labour
(2006)                with low back pain.

Martensson et al.     128 women in
(2008)                spontaneous labour at
                      term

Authors (Year)        Intervention

Ader et al (1990)     4 intradermal sterile
                      water injections

Trope et al. (1991)   4 intradermal sterile
                      water injections into
                      lower lumbar sacral area

Martensson &          Group 1
Wallin (1999)
                      4 intradermal sterile
                      water injections into
                      lower lumbar sacral area

                      Group 2

                      4 subcutaneous sterile
                      water injections into
                      lower lumbar sacral area

Martensson et al      Group 1
(2000)
                      Intradermal sterile
                      water into left sacrum
                      followed 10 minutes
                      later by subcutaneously
                      sterile water into right
                      sacrum.

                      Group 2

                      Subcutaneous sterile
                      water into right sacrum
                      followed 10 minutes
                      later by intradermaly
                      sterile water into left
                      sacrum.

Pert et al. (2006)    4 intradermal sterile
                      water injections into
                      lower lumbar sacral area
                      given simultaneously by
                      two staff

Bahasadri et al.      1 subcutaneous sterile
(2006)                water injection into the
                      lower lumbar area

Martensson et al.     All women treated
(2008)                by acupuncture at
                      GV20, L14, and
                      SPG and at another
                      4-7 acupuncture sites
                      selected from BL23-24;
                      BL54; EX19; GB25-29.
                      Needles inserted, and
                      stimulated every 10
                      mins for 40 mins.

Authors (Year)        Control

Ader et al (1990)     4 subcutaneous isotonic
                      saline injections

Trope et al. (1991)   4 intradermal saline
                      injections into lower
                      lumbar sacral area

Martensson &          Group 3
Wallin (1999)
                      4 subcutaneous isotonic
                      saline injections into
                      lower lumbar sacral area

Martensson et al      One week later the two
(2000)                groups received the
                      intervention again but in
                      reverse order

Pert et al. (2006)

Bahasadri et al.      1 subcutaneous nomal
(2006)                saline injection into the
                      lower lumbar area

Martensson et al.     Four to eight
(2008)                subcutaneous injections
                      sterile water in the area
                      indicated by the woman
                      as being the most painful.

Authors (Year)        Outcomes measured

Ader et al (1990)     VAS scores before
                      treatment and at 10, 45
                      and 90 minutes after
                      treatment.

Trope et al. (1991)   VAS scores before
                      treatment and at 60
                      and 120 minutes after
                      treatment

Martensson &          VAS scores prior to
Wallin (1999)         treatment and at 10, 45
                      and 90 minutes after
                      treatment

Martensson et al      Pain intensity of the
(2000)                injections measured by
                      VAS scores 90 seconds
                      after injections

Pert et al. (2006)    VAS scores prior to
                      treatment and at 5, 30,
                      G0, 90, 150 and 180
                      minutes after treatment.
                      Satisfaction survey

Bahasadri et al.      FRS score prior to
(2006)                treatment and at 10
                      and 45 minutes afer
                      treatment.

Martensson et al.     VAS scores prior to
(2008)                treatment and after the
                      last treatment at 30, G0,
                      90, 120, 150 and 180
                      minutes by the woman
                      and another midwife.

Authors (Year)        Main results

Ader et al (1990)     Mean VAS scores reduced
                      in the intervention group

                      * 10 minutes p=<0.001

                      * 45 minutes p=<0.02

                      * 90 minutes p=<0.05

Trope et al. (1991)   More women (89%) in
                      the intervention group
                      reported an analgesic
                      effect (p = <0.0005). Less
                      C/S in intervention group
                      (p = <0.05).

Martensson &          No difference in the VAS
Wallin (1999)         scores between the two
                      sterile water groups.
                      Less pain in sterile water
                      groups and the isotonic
                      saline group at 10 minutes
                      (p = <0.002) and 45 minutes
                      (p = <0.006). <0.001)

Martensson et al      Intradermal injections
(2000)                were significantly more
                      painful than subcutaneous
                      injections (p = <0.001)

Pert et al. (2006)    VAS scores decreased
                      significantly from pre
                      treatment to 90 minutes
                      post treatment (p<0.000)

                      * 90% satisfied with the
                      pain relief

                      * 96% stated the worst
                      aspect was the pain of the
                      injection

Bahasadri et al.      Sterile water group had
(2006)                a significantly lower
                      pain score at 10 and 45
                      minutes compared with
                      the normal saline group

Martensson et al.     Women in the sterile
(2008)                water group reported
                      significantly less pain than
                      the acupuncture group
                      (p = <0.001) and greater
                      relaxation (p = <0.001).
                      Womenweresignificantly
                      older in the acupuncture
                      group compared to
                      the sterile water group
                      (p = <0.018). More women
                      (71%) in the sterile water
                      group would use the
                      treatment again compared
                      to 59% in the acupuncture
                      group (non significant)
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Title Annotation:PRACTICE ISSUE
Author:Duff, Margaret "Margie"
Publication:New Zealand College of Midwives Journal
Date:Oct 1, 2008
Words:6125
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