Transcutaneus Electricity Nerve
Stimulation (TENS) to relief pain during
Labour :
A systematic Review of
Endang
Koni Suryaningsih1, Meei-Ling
Gau CNM., R.N., PhD2.
1
Student of
International Nurse-Midwifery Master of Science Program, National Taipei University
of Nursing and Health Sciences
2
Lecturer of Department of Nurse-Midwifery Master of Science Program,
National Taipei University of Nursing
and Health Sciences
1. Asses the Patient
A pregnant women 37 weeks, 27 years old, come
to the “Midwifery’s private clinic to consult her pregnant. This is her first pregnant. The result of her
examination, there is no problem on her pregnant, no risk factors was findings,
so the Midwife judge that she can deliver her baby with normal. But She was fear of childbirth. according to her neighbor, there is any
method, something like tools or equipment that can make pain will relief. It
was something like electrode and applied on our back, with electricity voltage.
She want to know which one can relief pain, with TENS or not.
Anatomy
of a good clinical question :eding
occur? Is there any change on her
reproductive system?
v Problem
: labour, pain
v Intervention
: Transcutaneus Electricity Nervous Stimulate (TENS)
v Comparison
: with standar care
v Outcome
: relief pain labour
2. Ask the question
For
our patient, the clinical question is :
In
the first stage labor, is TENS more effectively to relief pain rather than
without treatment or other treatment?
It
is a therapy question and the best evidence would be a randomized
controlled trial (RCT).
3. Acquire evidence
The
PubMed, and CINAhL database were searched for articles using by keywords : “TENS”,
“Labor Pain”. Of the 90 articles initially identified in the database search, 5 articles were selected for careful
evaluation, 85 of these were excluded after analyzing. See figure 1 (adopt from
(F.D. Mello) ).
Five full texts were
evaluated for eligibility. The eligible articles are :
A.
Transcutaneous
nerve stimulation (TENS) during the first stage labor : a
Randomized
Abstract
Our
objective was to study the efficacy of transcutaneous electrical nerve
stimulation (TENS ) in reducing pain during the first stage of labour. Using a
prospective randomized placebo-controlled, double blinding critical trial, a
patient-controlled analgesia system was used to measured difference in outcome.
Trial took place is labor unit at the St. Antonius Hospital Nieuwegein, The
Netherlands, during a period of 18 months. Forty- six patient, during the first
stage of labour, were treat with TENS, and 48 with a placebo apparatus. Main outcomes measures were pain relief,
among of administrated analgesics, obstetrical and neonatal outcomes, and side
effects. No significant differences
occurred between groups in the number of request pethidin/ promethazine. The fetal outcome in both group was the
same. TENS and placebo was considered equally effective both patients and
staff. In conclusion, TENS was not more
effective than placebo apparatus in relieving pain during the first stage of
labour. No adverse side- effects occurred.
B.
Pain
relief by applying transcutaneous electrical nerve stimulation (TENS) on
acupuncture points during the first stage of labor : A randomized double-blind
placebo-
Abstract
Transcutaneous
electrical nerve stimulation (TENS) is one of the non-pharmacological means of
pain relief for labor and delivery. We aimed to investigate the efficacy and safety of TENS specific
acupuncture points for reducing pain in the first stage of labor. In this double-blind, placebo-controlled
trial, we randomly assigned healthy full-term parturients in active phase of first-stage labor either
TENS on four acupuncture points (Hegu [L1 4]
and Sanyinjao [Sp 6]) (n=52) or the TENS placebo (n=53). Visual
Analogue Scale (VAS) score was used to asses pain before at 30 and 60 minutes
after treatment. The primary outcome was the rate of Visual Analogue Scale
(VAS) score decrease ≥3 in each group. A questionnaire was given at 24 hour
post-partum to evaluate the satisfaction of pain relieving method and
willingness to have the same treatment again. Mode of delivery and neonatal
effect was measured as secondary outcome. One hundred women were eligible for
analysis. TENS group experience VAS
score reduction ≥ 3 significantly more
common then the TENS placebo group (31/50 [ 62%]) vs. (7/50 [14%], P<
0.001 ). Willingness of using the some
analgesic method for a future childbirth was also significantly different
(TENS ; 48/50 [96%] vs. TENS placebo ; 33/50 [66%], P< 0.001 ). Operative delivery was increased in the
TENS group (12/50 [24%] vs. 4/50 [8%], P< 0.05 ), but he neonatal outcome
were not different. The application
of TENS on specific acupuncture points could be a non-invasive adjunct for pain
relief in the first stage labor.
C.
Transcutaneous
Electrical Nerve Stimulation on Acupoints Relieves Labor Pain : A Non-
randomized Controlled Study
Abstract
Objective
: To investigate the efficacy of
transcutaneous electrical nerve stimulation (TENS) on four specific acupuncture
points Hegu (LI4), Neiguan (PC6), Danshu (BL19) and Weishu (BL21) for
reducing pain in labor. Methods: A total of 160 voluntary nulliparous women who
were willing to receive TENS for analgesia were assigned to the treatment group
after cervical dilation of more than 2 cm. Another 145 nullipara were recruited
as the control group. Visual analogue scale (VAS) was used to assess the pain before
and 0.5 h after the application of TENS.
Then, VAS was assessed every one hour until delivery. Percentage of VAS
score decreased by > 25% was the primary outcome, the delivery mode and
neonatal outcome were measured as secondary outcomes. Adverse reactions were
also recorded during TENS. Results: The : The
percentage of VAS score decreased by > 25% was 68.6% in the TENS treatment
group. Maternal delivery mode and
neonatal outcomes were not significantly different between the two group.
In addition, the incidence of postpartum
hemorrhage in the TENS treatment group was less than the control group ( P
<0.05). There was no adverse
reaction recorded with TENS on acupoints. Conclusion: As a novel and
non-invasive approach, TENS on specific
acupoints including Hegu (LI4), Neiguan (PC6), Danshu (BL19) and Weishu (BL21)
was an effective method for analgesia in labor.
D. Transcutaneous electrical nerve
stimulation TENS for adjuvant pain-relief during labor and delivery
Abstract
Objecti
®e: We examined the efficacy of transcutaneous electrical nerve stimulation TENS
in general and the new Ž. Freemom TENS device LifeCare, Israel in particular,
for pain relief during labor and delivery. Methods: The study Ž . Ž . group
consisted of 104 women. Forty-six nulliparas 44.2% and 58 multiparas 55.8% ,
all of whom used the TENS device for pain relief during labor. All participants
completed a questionnaire on the degree of pain relief afforded them by TENS
during the delivery and related questions. The objective evaluation was based
on the documented Žlabor and delivery parameters including medical
interventions during delivery. Results: The majority of subjects 72% . of the
nulliparas and 69% of the multiparas considered TENS effective for the relief
of pain during labor. Most of Ž. them 67% of the nulliparas and 60% of the
multiparas responded positively to the use of TENS in future deliveries.
Sixty-five percent of the multiparas considered TENS at least as effective as
the other pain relief methods they had used before. TENS significantly reduced
the duration of the first stage of labor P-0.001 for nulliparas, P-0.005 for
multiparas and it significantly decreased the amount of analgesics administered
to individual patients. No significant difference was found in fetal heart rate
tracings, Apgar scores and cord blood pH between the study group and an equal
number of matched controls who used other forms of pain management.
Conclusions: TENS is an effective non-pharmacological, non-invasive adjuvant
pain relief modality for use in labor and delivery. TENS application reduced
the duration of the first stage of labor and the amount of analgesic drug
administered. There were no adverse effects on mothers or newborns. Q 1998
International Federation of Gynecology and Obstetrics
E.
Pain
relief in labour using Transcutaneus Electical Nervous Stimulation (TENS). A
TENS/TENS Placebo Controll in two parity groups
{Robert
F. Harison, #198}
Abstract
The
analgesic of Transcutaneus Electrical Nerve Stimulation in labour and effect on
outcome were investigated in double blind TENS/ TENS Placebo controlled Trial
in 100 primigravidae and 50 women in their third labour. There were no
differences between the TENS and the TENS Placebo user in term of pain concepts
or relief, and only 12 and 13% primigravida and 48 and 39% of the para 2 women
completed labour without requiring other analgesia in their respective group.
The primigravidae who used either TENS or TENS Placebo alone had shorter labour
than whose required further analgesia . although the outcome of labour for
mother and infant were similar in two groups, there was a higher operative
delivery rate in woman who also had epidural analgesia. There were highly
significant differences between the TENS and the TENS Placebo user in terms and
favourable comment.
4.
Five
Journals summary
|
No
|
Title
|
Research Method
|
|
1.
|
Transcutaneous
nerve stimulation (TENS) during the first stage labor : a
Randomized
|
Women scored their opinion about the
effectiveness of the treatment on a VAS. The TENS group scored 5.8 and the
placebo group 6.0 (not significant). In the TENS group 61% would ask for TENS
again during their next labour, 117. would refuse, and 2870 were ambiguous.
In the pla- cebo group these numbers were 56910,21Toand 23V0,re- spectively.
The mean intensity of the stimulation during contrac- tions was 2.3 (range
1–5) in the TENS group and 2.7 (range 1–6) in the placebo group. In between
contractions the stimulation was also lower in the TENS group (2.3) than in
the placebo group (2.6), both not being significantly different. No patients
experienced difficulties in handling the TENS apparatus.
Comparable to a previous study
(Bundsen et al. 1981) 75% of women were found to suffer from low back pain
and 50% experienced pain in the lower abdomen. Again, there were no
significant differences between TENS and placebo groups. The attending nurse
gave her/his opinion about TENS on a VAS. The outcome was 5.5 for the TENS
group and 4.4 for the placebo group, again not significant. The TENS signal
disturbed the foetal heart tracing sig- nal in 18 (3970)patients of the TENS
group. This occurred in two patients of the placebo group.
|
|
2.
|
Pain
relief by applying transcutaneous electrical nerve stimulation (TENS) on
acupuncture points during the first stage of labor : A randomized
double-blind placebo-
|
After
the assigned treatment, the median VAS scores in first stage of labor at 30
and 60 minute after the TENS showed significant lower in the TENS Group than
Placebo group (30 minute, TENS vs. TENS Placebo group : 4.5 [1-10] vs 7
[2-210], P,0.001; 60 min ; 6 [3-9] vs. 7.5 [4-10], P<0.001). the
difference VAS between before and after application in TENS group was significant (P<0.001) but
insignificant in TEN S Placebo (P=35). The rates of VAS score decrease ≥3 of
the two groups (TENS vs TENS Placebo)
were significantly different (62% [31/50] vs. 14% [7/50], P<0.001. based
on ITT analysis with those five participants having precipitous labour
counted as failure to achieve VAS decrease ≥3, the difference between the two
groups remained significan (60% [31/52] vs. 13% [ 7/53], P<0.001. of the
31 women with VAS score decrease ≥ 3
of the TENS group, 19 (61.3%)
needed only one application for the entire first stage of labor.
Regarding
the pain outcomes according to parity, the median VAS score in first stage of
labour at 30 min was significant in both primiparous and multiparous groups
(primiparous, TENS vs. TENS Placebo : 5 [3-10] vs. 7 [4-10], P< 0.001;
multiparous , TENS vs. Placebo ; 4 [1-7] vs 6[2-10], P< 0.001). the rates
of VAS scores decrease ≥ 3 were also significantly different in both
primiparous and multiparous groups (primiparous, 60% [18/30] vs. 11.4%
[4/35], P<0.001; multiparous, 65% [13/20] vs 20% [3/15], P=0.02.
|
|
3.
|
Transcutaneous
Electrical Nerve Stimulation on Acupoints Relieves Labor Pain : A Non-
randomized Controlled Study
|
The durations of active phase of the
first stage, the second stage and the third stage of labor, the oxytocin
usage, incidence of instrumental and caesarean delivery, were not
significantly different between the two groups ( P >0.05). Although the
latent phase in TENS group was significantly longer than that in the control
group (287.6± 144.3 vs . 213.8±116.7 min, P <0.05). The postpartum blood
loss in TENS group was significantly lesser than that in the control group
(135.7±43.5 mL vs . 166.1± 54.5 mL, P <0.05)
VAS scores declined as a result of the
application of TENS. Compared with the pain level of the zero-time point
before TENS treatment, the scores declined prominently during the first 0.5
after TENS therapy ( P <0.01).
The mean VAS score decreased from
initial 8.76±1.32 scores to 6.78 ±1.72 scores ( P <0.05). The mean time to
show effective analgesia was 12.05±7.21 min. It took 56.55±48.0 min (range:
9-105 min) for VAS scores to decrease from the initial level (8.76±1.32) to
the lowest (5.39±1.88). Thereafter, the VAS scores rose slowly, but still
lower than the initial value until the fifth hour ( P <0.01). After 5 h,
the VAS scores increased dramatically. And 68% of pregnant women receiving
TENS treatment felt marked pain relief, only two of them (0.6%) felt
effective, and 31.4% of them responded ineffective.
|
|
4.
|
Transcutaneous
electrical nerve stimulation TENS for adjuvant pain-relief during labor and
delivery
|
Data were gathered for nulliparas and
multiparas separately. TENS was considered efficacious i.e. it reduced the
level of pain by 4 points or more on a scale of 1 -10 by 72% of the nulliparas
33/46 and 69% of the multiparas 40/58 . Most of the participants in both
sub-groups who favored TENS 67% of the nulliparas, . 60% of the multiparas
stated that they would use TENS again for their next labor.
Compared to the group of match controls,
the use of TENS significantly reduced the
duration of the first stage of labor, nulliparas, 720"235 minute
in the study group, 856"255 minute in the control group; for multiparas,
520"163 min and 612"184 min, respectively.
Of the TENS users, 67% of the
nulliparas and 60% of the multiparas asked for additional analgesia
meperidine or epidural block .
However, all these requests were made at a significantly higher degree of
cervical dilatation compared to the
controlled group nulliparas, 5.2 "1.1 cm and 2.5"0.5 cm;
multiparas, 7.1"2.1 .cm and 4.0 "1.5 cm, respectively . Rates of
pathological FHR tracings, as well as 1 and 5 min Apgar scores and cord blood
pH, were similar in the TENS participants and the control
|
|
5.
|
Pain
relief in labour using Transcutaneus Electical Nervous Stimulation (TENS). A
TENS/TENS Placebo Controll in two parity groups
|
Primigravida who complete labour
without requiring further analgesia were only 12 and 14% in the TENS and TENS
placebo in the para 2 women the respective percentages rose to 48 and 39%.
There were no significant differences between any sub groups regarding number
requiring further analgesia or when it was first given in relation to
duration of labour or cervical dilatation.
The duration of labor was shorter in the primigravidae who used either
TENS and TENS Placebo alone than in those needing further analgesia. Two ways
analysis of variance of these patient using factor TENS /TENS Placebo and
whether or not patients had further analgesia showed that patient who did not
require further analgesia had significantly shorter labour (P=<0.005).
Outcomes of Labour
There were no real differences in the
occurrence of normal and operative deliveries between TENS and TENS Placebo
user either in the primigravidae or
the para 2 patients. The 38 primigravidae who also choose an epidural only
three of the 13 TENS users and eight of the 25 TENS Placebo user had non
operative delivery. Theer were no
significant difference of APGAR Scores between the groups at 1 or 5 minute.
|
5.
Appraisal
the evidence
|
No
|
Author
|
Were patients
randomized?
|
Was group
allocation concealed?
|
Were patients in
the study groups similar with respect to known prognostic variables?
|
To what extent was
the study blinded?
|
Was follow-up
complete?
|
Were patients
analyzed in the groups to which they were first allocated?
|
Aside the experimental intervention, were the group treat equally?
|
|
1
|
Transcutaneous
nerve stimulation (TENS) during the first stage labor : a Randomized
|
Yes
|
No mention
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
|
2
|
Pain
relief by applying transcutaneous electrical nerve stimulation (TENS) on
acupuncture points during the first stage of labor : A randomized
double-blind placebo-
|
Yes
|
No describe
|
No Mention
|
Yes
|
Yes
|
Yes
|
Yes
|
|
3
|
Transcutaneous
Electrical Nerve Stimulation on Acupoints Relieves Labor Pain : A Non-
randomized Controlled Study
|
Yes
|
No describe
|
No describe
|
Inadequate.
|
No
|
Not mentioned.
|
Yes
|
|
No
|
Author
|
Were patients
randomized?
|
Was group
allocation concealed?
|
Were patients in
the study groups similar with respect to known prognostic variables?
|
To what extent was
the study blinded?
|
Was follow-up
complete?
|
Were patients
analyzed in the groups to which they were first allocated?
|
Aside the experimental intervention, were the group treat equally?
|
|
4
|
Transcutaneous
electrical nerve stimulation TENS for adjuvant pain-relief during labor and
delivery
|
No describe,
only mention control and study group
|
No describe
|
Yes
|
No Describe
|
Yes
|
Yes
|
Yes
|
|
5
|
Pain
relief in labour using Transcutaneus Electical Nervous Stimulation (TENS). A
TENS/TENS Placebo Controll in two parity groups
|
Yes
|
.Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
|
|
Question
|
Answer
|
|
1.
|
Were the study
patients similar to my population of interest?
|
In general, the respondents have the same characteristics
in Indonesian’s population. Race and demographic are different. Mostly,
Indonesia society, are feeling close minded regarding something new,
especially in medical field, because they concerned about safety that could
be harm to their health. In this case, the patients need role model who give the example , if it is work, they
would be to try.
|
|
2.
|
Does your population
match the study inclusion criteria?
If
not, are there compelling reasons why the results should not apply to your
population?
|
No at all. Acupuncture has significant effective to relief labour
pain than TENS, and if TENS used in the specific points. TENS has
significantly effect to relief labor pain rather than other method,. In
Indonesia, using an cupuncture as a method to reduce pain in labour never had
been before, so it is not common (for this time). Moreover, to obtain this
skill, someone need to present specialist training. Regarding TENS, it could
be and possible to apply in Indonesia.
|
|
3.
|
Were all clinically
important outcomes considered?
What were the primary and secondary endpoints studied? |
From
those literature review, primary outcome of research was the rate of VAS
score decrease, and the secondary were the mode of delivery.
|
|
4.
|
Are the likely treatment benefits worth the
potential harm and costs?
|
TENS are likely treatment benefits and no
potential harm. But maybe likely potential cost should be considered to
provide TENS devices in the hospital or other healthcare facilities. To
operate this device, require certain skill, so this device is only be
provided in the hospital or other health facilities and also should be under control
health provider. Skin irritated due to application of electrode device has
been reported but the consequently is not negligible compare with the
outcomes.
|
|
5.
|
Will the results help in caring
for my patient?
|
Yes, TENS help in caring for my patients. This device
could become an option method to reduce pain labor during first stage.
|
6. Conclusion
:
Ø There was inconsistent result, whether TENS can be
used effectively to reduce pain labor (without acupuncture points). It due to
those 5 journals have different method
about frequency and duration to apply
TENS. Consistency result to apply TENS during first stage of labour, on
acupuncture points and the duration minimum 30 minutes intermittent with
voltage 100-150Hz.
Ø The use of TENS at home in early labour has not been
evaluated. TENS is widely available in hospital settings and under control
health provider
Ø Need
information and counseling about TENS since antenatal class
Reference
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