Ciência & Saúde Coletiva

cienciaesaudecoletiva.com.br DOI: 10.1590/1413-81232024296.19032022

ISSN 1413-8123. v.29, n.6

Influence of non-pharmacological methods on duration of labor: 1

a systematic review

ARTICLE REVIEW
A influência de métodos não farmacológicos na duração do parto:
uma revisão sistemática

Thais Blaya Leite Gregolis (https://orcid.org/0000-0002-3799-4083) 1

Sabrina da Silva Santos (https://orcid.org/0000-0001-8327-3546) 1,2
Ilce Ferreira da Silva (https://orcid.org/0000-0002-7134-3030) 1,2
Andréa Ramos da Silva Bessa (https://orcid.org/0000-0002-9553-9310) 1

Abstract The article aims to verify the influen- Resumo O objetivo do artigo é verificar a influên-
ce of MNFs on the duration of the birth process. cia dos MNFs na duração do processo de parto. Rea-
A systematic review was carried out in the ME- lizou-se uma revisão sistemática nas bases de dados
DLINE, Web of Science and LILACS databases, MEDLINE, Web of Science e LILACS, por meio da
through a combination of terms that cover the combinação de termos que contemple a temática
topic addressed, from 1996 to 2021/April. The abordada, no período de 1996 a 2021/abril. Utili-
Excel spreadsheet was used to collect data to ex- zou-se para coleta de dados a planilha Excel para
tract information regarding each selected article, extração de informações referentes a cada artigo se-
in turn, data analysis included the evaluation and lecionado, por sua vez, a análise dos dados compre-
classification of quality, reliability and risk of bias, endeu a avaliação e classificação da qualidade, con-
thus, the following tools were used: Cochrane RoB fiabilidade e risco de viés, assim, utilizou-se como
2, Checklist and Newcastle-Ottawa Scale. Warm ferramentas: Cochrane RoB 2, Checklist e Escala de
bath, walking, exercises with a birthing ball, bre- Newcastle-Ottawa. Reduziram o tempo de trabalho
athing techniques, supine position, acupuncture, de parto banho morno, caminhada, exercícios com
acupressure and water birth reduced labor time. bola de parto, técnicas respiratórias, decúbito dorsal,
While spontaneous pushing, massage and immer- acupuntura, acupressão e parto na água. Enquan-
sion baths prolonged labor. Non-pharmacological to empurrões espontâneos, massagem e banho de
methods capable of reducing the duration of labor imersão prolongaram o trabalho de parto. Os mé-
were hot/warm shower, walking, birth ball exerci- todos não farmacológicos capazes de reduzir a du-
ses, breathing techniques, maternal mobility, dor- ração do trabalho de parto foram banho de chuveiro
1
Programa de Pós-
sal position, acupuncture, acupressure and water quente/morno, caminhada, exercícios com bola de
Graduação em Saúde
Coletiva, Universidade birth, as well. associated applied techniques such parto, técnicas de respiração, mobilidade materna,
Federal do Acre. Distrito as hot/warm bath, ball exercises and lumbosacral posição dorsal, acupuntura, acupressão e parto na
Industrial, Rio Branco-Ac.
massage, as well as immersion bath, ball exerci- água, também encurtaram o tempo de parto técni-
69920-900 Rio Branco
AC Brasil. ses, aromatherapy, vertical postures and mater- cas aplicadas associadas como banho quente/mor-
thaisgregolis@hotmail.com nal mobility with alternating vertical postures, no, exercícios com bola e massagem lombossacral,
2
Departamento de
shortened the birth time. assim como banho de imersão, exercícios com bola,
Epidemiologia e Métodos
Quantitativos em Saúde, Key words Methods, Parturition, Humanizing aromaterapia, posturas verticais e mobilidade ma-
Escola Nacional de Saúde delivery, Time terna com posturas verticais alternadas.
Pública Segio Arouca,
Palavras-chave Métodos, Parto, Parto humaniza-
Fundação Oswaldo Cruz.
Rio de Janeiro RJ Brasil. do, Tempo
Cien Saude Colet 2024; 29:e19032022
 2
Gregolis TBL et al.

Introduction es for the search included MEDLINE (Medical

Literature Analysis and Retrieval System Online
Labor involves movements of the fetus that guide – accessed via PubMed), Web of Science, and LI-
it along the birth canal, promoted by contractions LACS (Literatura Latino-Americana e do Caribe
of the uterus1. In this process, the first and longest em Ciências da Saúde – accessed via the Regional
stage is dilation, lasting 10-12 hours in primipa- da Biblioteca Virtual em Saúde - BVS portal). The
rous women and 6-8 hours in multiparas1-3. The search strings employed were built using terms
second, expulsion begins at full dilation and can registered in MeSH (Medical Subject Headings)
be divided into passive and active gain. The active – controlled vocabulary for indexing articles in
phase lasts up to 3 hours in primiparous women the scientific literature – combined according to
and up to 2 hours in multiparous women4. the search strategy chosen.
As it is possible that the stages of labor are The inclusion criteria were studies of any
long and exhausting, it is important, in addition design type, published between 1995 and April
to the humanized assistance recommended in the 2021, and in any language. Filters were applied
guidance for labor and birth, to include non-phar- to guide the search of studies for the review, ac-
macological methods (NPMs) that can reduce cording to the specific options available for each
the duration of labor and make the process more database or search site.
comfortable for fetus and mother2,3. Thus, for PubMed, the search was carried out
Thus, NPMs have been encouraged for over on April 6, with the initial retrieval of 2,089 pub-
25 years. It can confer benefits through relaxation lications, reduced to 1,431 records after applying
promoted by pain relief and also by promoting filters by year of publication (1995-2021), human
greater effectiveness of uterine contractions5,6. and female. For the Web of Science database, the
More active parturients, such as women who walk search took place on April 13, identifying 1,205
around during labor tend to have a shorter la- studies, of which 1,118 were selected for the ini-
bor7,8, as well as those who change position along tial analysis after applying the year of publication
with the movements, practice birth ball exercises filter (1995-2021). The search in the BVS was car-
and receive massages7. They are also more satisfied ried out on April 13, initially with 5,428 records,
with the duration of the first and second stages of this total was reduced to 153 publications after
labor8. Acupressure, Chinese medicine stimuli, restricting the results to studies carried out in the
also help to reduce the duration of labor9. How- LILACS database, involving humans and wom-
ever, the effectiveness and effects of MNPs are still en, and for the publication period (1995-2021).
unclear, so it is still unclear which MNP is most ef- Therefore, 2,700 publications were included in
fective in reducing the duration of labor and what the first stage of the review.
is the best frequency and stage of labor that should Searches retrieved studies published from
be applied10. 1996 to the date of the search (April 6-13, 2021).
In this context, seeking evidence on the effects The justification for the chosen period was based
of NPM on the duration of labor is important to on the fact that, in 1985, a meeting of specialists
help improve care for parturients. The aim of the from all over the world was held by the World
present study was to verify the influence of NPMs Health Organization (WHO), during which a
on the duration of the labor process. series of practical recommendations to be used
for the care in normal birth conditions were
made6. However, despite encouragement to use
Method evidence-based evidence, many of these practic-
es have not been implemented. Only in 1996 did
A systematic review was performed to map the the WHO publish a guide for safe motherhood,
effects of NPMs used in the labor process on the establishing what is and what is not indicated
duration of labor and delivery. This approach was during the care of mothers and babies in the nor-
chosen to provide a broader capture of the avail- mal delivery process6.
able evidence on the topic, allowing deeper in- The duration of labor, or its phases, is an out-
sights to be gained. come that deserves study, although it is not the
To determine the research question and search main outcome. Interventions evaluated vary, as
for evidence, the PICO strategy was used to facili- several different NFMs are used during labor that
tate the planning and execution of the study. can alter the duration of this process. Regarding
A bibliographic search was carried out be- the study population, although parturients were
tween April 6 and 13, 2021. The selected databas- the target population, studies with health profes-
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Ciência & Saúde Coletiva, 29(6):1-13, 2024

sionals who apply methods that can influence the risk of bias (good evidence quality), Some con-
duration of labor were also included, as defined cerns, or High risk of bias (low evidence quali-
in the PICO strategy. ty). The Checklist for quasi-experimental studies
The stages of selection and application of (non-randomized experimental studies) of the
the eligibility criteria were carried out by two Joanna Briggs Institute12 appraises the article in 9
researchers, aiming to respond to the study pro- domains (definition of cause and effect, inclusion
posal. Reference manager was not used in the ex- of participants in comparisons similar or groups,
ecution of this research. presence of control group, pre and post measure-
Criteria for exclusion were publications ments, follow-up, comparability, measurement of
studying a specific population (e.g. individuals outcomes and analysis).
presenting disease, such as multiple sclerosis, The Newcastle-Ottawa Scale (NOS)13 for
cancer, HIV, obesity; specific obstetric conditions cohort studies comprises 3 domains (selection,
such as pelvic or premature baby; women given comparability and results) giving a maximum
analgesics or an amniotomy), studies not ad- score of 9 points if all requirements are met, re-
dressing NPM associated with duration of labor flecting the quality of the evidence generated.
and/or one of its stages, that failed to specify the was employed to rate the quality of cross-sec-
strategies used, or analyzed the third stage of la- tional studies for. The NOS for case-control stud-
bor only (after birth). Literature reviews were also ies14, was used to assess the quality of both co-
excluded from the present work, reserving these hort and case-control studies assesses 3 domains
for discussion. The low methodological quality (selection, comparability and exposure), yielding
did not motivate exclusion of publications. 9 points if all items measuring methodologi-
Seven studies were classified as unavailable, cal quality are met. Also, the NOS adapted for
i.e. sought by accessing the CAPES Journals Site, cross-sectional studies15 comprises 3 domains,
Research Gate and Google Scholar, and by con- yielding a score of 0-9 points on the methodolog-
tacting the respective authors via e-mail, to no ical quality assessment.
avail. The findings of the analyses of study data and
The first step of selecting the retrieved pub- quality are given in tables and charts, grouped by
lications included reading the title and abstracts NPM studied. The stages of study selection and
of the identified studies, applying the eligibility analysis were performed as depicted in the flow
criteria. In the second stage, the full text of the diagram of the literature search and study selec-
studies selected in a new screening was read. This tion for review (Figure 1).
step produced the final list of studies for inclu-
sion in the analysis.
After that, the studies were all read in depth, Results
and the data extracted in forms (Google Forms)
and Excel spreadsheet (Microsoft Office). A total of 25 articles were included in the review
The data extraction form included fields that after identification during the steps of selection
collect study title, author(s), year of publication, and analysis of publications addressing effects of
journal, country, study location, study type, study NPMs on duration of labor. The methodological
objective, sample type, sample size, inclusion cri- characteristics of the studies selected are outlined
teria, exclusion criteria, study variables, inclusion in Chart 115.
of the control group, measurement instruments, The NPMs identified were hot/warm shower,
study duration, interventions, results found, sta- water immersion, walking, breathing techniques,
tistical treatment, coherence of conclusions, au- relaxation techniques, birth ball, massage, posi-
thors’ recommendations and classification of the tions adopted by mother, acupuncture, acupres-
quality level. sure, auriculotherapy, aromatherapy, water birth
Publications were assessed and classified for and pushing techniques during the expulsion
quality, reliability and risk of bias using appropri- stage. Some studies investigated a combination
ate instruments for each type of study design. of these different methods.
The revised Cochrane risk-of-bias tool for The methods identified were grouped accord-
randomized trials (RoB 2) was used for exper- ing to type of NPM or presented as a combination
imental studies11, comprises 5 domains of bias when applied in association with other methods.
(randomization, intervention, missing data, The influence of these NPMs on the duration of
measurement, and results reporting) and ex- labor, or its stages, for each study reviewed is de-
presses a result categorizing the study as Low scribed in Chart 2.
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Gregolis TBL et al.

Identification
Records identified (n=2,700): Removed prior to screening:
MEDLINE (n=1,431) Duplicate records removed (n=174)
Web of Science (n=1,118) Records removed for involving
LILACS (n=151) animals (n=457) and plants (n=2)

Records selected Records excluded

(n=2,067) (based on exclusion criteria)
Screening

(n=1,884)

Records selected for full Records excluded (n=158):

reading Records unavailable (n=7)
(n=183) Off-topic (n=151)
Included

Studies included in review

(n=25)

Figure 1. Flow diagram of literature search and study selection.

Source: Data from adapted study (The PRISMA 2020 statement: an updated guideline for reporting systematic reviews)15.

Hot/warm shower tive stage22. These studies, however, presented as

a limitation the absence of a measure of the mag-
With regard to the hot/warm shower meth- nitude of the effect of the studied method on the
od, applied alone, the sole publication identified duration of the labor stage.
showed a reduction in the duration of the active
stage of labor35 and had a low risk of bias on the Walking
methodological quality analysis11.
The results of the single study investigating
Immersion bath the effect of walking on duration of labor showed
that, for every 100 meters walked in the first hour,
For the immersion bath approach, mixed re- there was a 22-minute reduction in the length
sults were reported. Three studies found no differ- of the active stage; a 10-minute reduction for
ence in duration of labor among the women who the second hour, and 6-minute decrease in the
used this method17,20,27. On the quality analysis, third hour of labor23, the effects were evidenced
one of the publications was rated as having Low through logistic regression. This study was rated
risk of bias11, one as Some concerns12 and the oth- as having a low risk of bias12.
er as High risk of bias11. One of the studies found
no effects on the active stage of labor among nul- Breathing techniques
liparous and multiparous women or on the ex-
pulsion stage in multiparous women. The same Only one article addressed breathing tech-
study, rated as having good methodological quali- niques as a dedicated topic of investigation. The
ty13, observed increased duration of the expulsion study in question applied the Lamaze method, in-
stage in nulliparous women who used the tech- volving breathing techniques applied at different
nique38, however, it did not show the magnitude levels. The strategy promoted a statistically signif-
of the method’s effect on the duration of labor. icant reduction in the latent and active stages of
An increase in the expulsion stage after im- labor, analyzed by comparison of means32. How-
mersion bath was documented by two studies22,34 ever, the magnitude of the effect on the duration
of high methodological quality13, one of which of labor was not shown and the methodology of
also showed an increase in the duration of the ac- the study was rated as having some concerns12.
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Ciência & Saúde Coletiva, 29(6):1-13, 2024

Chart 1. Summarized characteristics of studies analyzing effects of NPMs on duration of labor.
Study Year Country Study design Method assessed
Bomfim-Hyppólito, 1994 Brazil (Fortaleza) Experimental Semi-sitting position (60º trunk
199816 inclination) during expulsion stage
Eckert et al., 200117 1995 Australia Experimental Immersion bath in first stage of labor.
Schröcksnadel et al., 1998 Austria Case-control Water birth.
200318
Almeida et al., 200519 2000 Brazil (Goiânia) Experimental Breathing techniques associated with
relaxation techniques.
Bio et al., 20067 2003 Brazil (São Paulo) Experimental Keep moving and switching to vertical
positions during labor and delivery.
Silva and Oliveira, 2002 Brazil (São Paulo) Experimental Immersion bath for 40-60 minutes.
200620
Gaudernack et al., 2003 Norway Experimental Acupuncture.
200621
Zanetti-Daellenbach 1998 Switzerland Cohort Water birth after immersion bath for time
et al., 200722 desired by parturient.
Mamede et al., 200723 2004 Brazil (São Paulo) Quasi- Walking during active stage of labor.
experimental
Gau et al., 201124 2008 Taiwan Experimental Birth ball exercise.
Cortes et al., 201125 2011 UK Population- Water birth.
based cohort
Gallo et al., 201326 2009 Brazil Experimental Massage during dilation period and uterine
(Ribeirão Preto) contractions for 30 mins.
Liu et al., 201427 2009 China Experimental Immersion bath in active stage of labor.
Mafetoni and Shimo, 2013 Brasil (Campinas) Experimental Acupressure at point BP6.
201528
Desseauve et al., 2015 France Cross- Dorsal decubitus during labor and delivery,
201629 sectional change in position during labor, dorsal
decubitus in expulsion stage.
Vaziri et al., 201630 2014 Iran Experimental Spontaneous pushing in lateral position.
Koyucu and Demirci, 2013 Turkey Experimental Spontaneous pushing.
201731
Cicek and Basar, 2016 Turkey Experimental Lamaze breathing technique.
201732
Makvandi et al., 2016 Iran Quasi- Combination of immersion bath, birth ball
201833 experimental exercise, aromatherapy with lavender.
Gallo et al., 20188 2011 Brazil (Ribeirão Experimental Pelvic movement exercises on Swiss ball,
Preto) 40-min massage, 40-min hot/warm shower.
Ulfsdottir et al., 2014 Sweden Cohort Water birth.
201834
Maddady et al., 2015 Iran Experimental Hot / warm shower.
201835
Mafetoni et al., 201836 2015 Brazil (Campinas) Experimental Auriculotherapy.
Cavalcanti et al., 2013 Brazil (São Paulo) Experimental Hot / warm shower and exercises with
201937 Swiss ball, alone and in combination.
Neiman et al., 202038 2016 USA Cohort Immersion bath and waterbirth.
Source: Authors.

Birth ball exercises stage of the labor process by using a Swiss ball24.
It was methodologically rated as having Some
One study involved birth ball exercises, concerns11, and it did not show the measure of
showing a reduction in duration of the active the effect of the method on the duration of labor.
 6
Gregolis TBL et al.

Chart 2. Non-pharmacological methods (NPMs) analyzed and effects on mean duration of labor or labor stage.
Study Intervention Sample Effect Duration (minutes) Statistics Quality
With Without With NPMs Without NPMs
NPMs NPMs
Hot/warm shower
Maddady Hot / warm 50 49 Reduction Active stage: Active stage: Mean Differ- Low risk
et al., shower 221.2 312.6 ence -110.7; of bias12
201835 95%CI:
169.5; -51.8
Immersion bath
Silva and Immersion bath 54 54 No effect 6-10 cm dilation: 6-10 cm dilation: p=0.89 Low risk
Oliveira, for 40 to 60 min- 250.9 260.4 of bias12
200620 utes
Neiman Immersion bath 61 111 Nulliparous Nulliparous Nulliparous Nulliparous Good
et al., No effect Active stage: Active stage: p=0.13 quality14
202038 Increase 764.7 757.8 p=0.03
Multiparous Expulsion stage: Expulsion stage: Multiparous
No effect 88.4 79.7 p=0.59
No effect Multiparous Multiparous p=0.08
Active stage: Active stage:
469.3 401.9
Expulsion stage: Expulsion stage:
20.6 16.8
Liu et al., Immersion bath 33 47 No effect Active stage: Active stage: p=0.43 Some
201427 in first stage of No effect 596.55 552.30 p=0.72 con-
labor Expulsion stage: Expulsion stage: cerns13
58.79 56.04
Eckert Immersion bath 137 137 No effect Active stage: Active stage: p=0.89 High
et al., in first stage of No effect 404.23 407.21 p=0.65 risk of
200117 labor Expulsion stage: Expulsion stage: bias12
64.94 68.80
Walking
Mamede Walking 75 - Reduction Active stage: 22; 10 and 6 minutes Linear re- Low risk
et al., shorter for every 100 meters walked gression of bias13
200723 at 1st, 2nd or 3rd hour, respectively
Breathing techniques
Cicek Lamaze breathing 35 35 Reduction Latent stage: Latent stage: p<0.001 Some
and technique Reduction 403.71 658.71 p=0.01 con-
Basar, No effect Active stage: Active stage: p=0.28 cerns12
201732 No effect 174.00 264.57 p=0.14
Transition stage: Transition stage:
110.71 101.42
Expulsion stage: Expulsion stage:
19.11 24.48
Ball exercises
Gau Birth ball exer- 48 39 Reduction Active stage: 380 Active stage: p=0.04 Some
et al., cises No effect Expulsion stage: 485.4 p=0.59 con-
201124 38.48 Expulsion stage: cerns12
41.3
Massage
Gallo 30-min massage 23 23 Increase Labor: 408 Labor: 342 Mean dif- Low risk
et al., ference 1.1 of bias12
201326 hour;
95%CI: 0.2;
2.0
it continues
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Ciência & Saúde Coletiva, 29(6):1-13, 2024

Chart 2. Non-pharmacological methods (NPMs) analyzed and effects on mean duration of labor or labor stage.
Study Intervention Sample Effect Duration (minutes) Statistics Quality
With Without With NPMs Without NPMs
NPMs NPMs
Positions adopted by mother
Des- Dorsal decubitus 431 120 Reduction Labor classified as ≥120 or <120 OR=2.2 Good
seauve during labor minutes 95%CI: 1.2; quality15
et al., 4.2
201629 Dorsal decubitus 303 144 Increase Labor classified as ≥120 or <120 OR=0.1
during expulsion minutes 95%CI: 0.0;
0.4
Bom- Semi-sitting 127 121 No effect Expulsion stage: Expulsion stage: p=0.06 High
fim-Hyp- position (60º) in 21.7 25.1 risk of
póli- expulsion stage bias12
to,199816
Maternal mobility
Des- Switching posi- 411 140 Increase Labor classified as ≥120 or <120 OR=0.2 Good
seauve tion during labor minutes 95%CI: 0.1; quality15
et al., 0.3
201629
Acupuncture/Acupressure/Auriculotherapy
Gaud- Acupuncture 43 48 Reduction Active stage: 264 Active stage: 366 Mean Dif- Low risk
ernack ference 1.7 of bias12
et al., hour;
200621 95%CI: 0.2;
3.1
Mafeto- Acupressure at 38 30 Reduction 628.10 913.10 p=0.004 Low risk
ni and point BP6 of bias12
Shimo,
201528
Mafetoni Auriculotherapy 25 27 No effect 607.8 694.7 p=0.08 Low risk
et al., of bias12
201836
Water birth
Schröck- Water birth in 47 265 Reduction Expulsion stage: Expulsion stage: p=0.02 Good
snadel District Hospital 15 20 quali-
et al., Water birth at 218 265 No effect Expulsion stage: Expulsion stage: Non-signif- ty14
200318 University Hos- 23 20 icant
pital
Zanet- Water birth after 89 146 No effect Active stage: Active stage: Non-signif- Good
ti-Dael- immersion bath Reduction 330.5 352.8 icant quality14
lenbach Expulsion stage: Expulsion stage: p<0.001
et al., 35.3 49.1
200722
Cortes Water birth 78 48 Reduction Expulsion stage: Expulsion stage: p=0.01 Good
et al., 43 57 quality14
201125
Ulfsdot- Water birth 306 306 Reduction Expulsion stage: Expulsion stage: p=0.01 Good
tir et al., 21.6 26.8 quality14
201834
Neiman Water birth 58 111 Nulliparous Nulliparous Nulliparous Nulliparous Good
et al., Reduction Expulsion stage: Expulsion stage: p=0.03 quality14
202038 Multiparous 23.2 79.7 Multiparous
No effect Multiparous Multiparous p=0.08
Expulsion stage: Expulsion stage:
9.5 16.8
it continues
 8
Gregolis TBL et al.

Chart 2. Non-pharmacological methods (NPMs) analyzed and effects on mean duration of labor or labor stage.
Study Intervention Sample Effect Duration (minutes) Statistics Quality
With Without With NPMs Without NPMs
NPMs NPMs
Pushing techniques in expulsion stage
Koyucu Spontaneous 40 40 Increase Expulsion stage: Expulsion stage: p<0.001 Low risk
and pushing 63.2 46.6 of bias12
Demirci,
201731
Vaziri Spontaneous 35 34 Increase Expulsion stage: Expulsion stage: p<0.001 Some
et al., pushing in lateral 76.32 64.56 con-
201630 position cerns12
Techniques used in association
Almeida Breathing plus 19 17 Increase Latent stage: Latent stage: p=0.01 Some
et al., relaxation tech- No effect 145.26 84.70 p=0.54 con-
200519 niques No effect Active stage: Active stage: p=0.16 cerns12
173.68 151.76
Transition stage: Transition stage:
126.31 103.23
Cavalca- Hot / warm show- 39 44 No effect From combined Hot shower to p=0.10 Low risk
nti et al., er plus birth ball intervention to birth: of bias12
201937 exercises birth: 216.85 255.05
45 From birth ball p=0.10
exercises to birth:
288.41
Gallo et Ball exercises, 40 40 No effect Active stage: 373 Active stage: 445 95%CI: Low risk
al., 20188 lumbosacral mas- Reduction Expulsion stage: Expulsion stage: 148; 5 of bias12
sage plus warm/ 19 37 95%CI: 30;
hot shower -5
Makvan- Immersion bath, 77 77 Reduction Active stage: Active stage: p<0.001 Low risk
di et al., birth ball exercise, No effect 210.02 269.54 p=0.08 of bias13
201833 aromatherapy Expulsion stage: Expulsion stage:
with lavender and 36.61 43.08
vertical positions
during second
stage of labor
Bio et al., Mobility and al- 50 50 Reduction Active stage: 316 Active stage: 508 p<0.001 Some
20067 ternating vertical con-
postures cerns12
Source: Authors.

Massage ting position had no effect on duration of labor16,

however without presenting the magnitude of the
Only one article addressed massage alone, effect of the method over time.
whose results showed that the technique promot-
ed an increase in duration of labor26. The trial in Maternal mobility
question was rated as having Low risk of bias11.
Changes in the position of the mother during
Maternal positions adopted labor were associated with longer labor times29 in
a study of High methodological quality14.
In one publication, the use of dorsal decubi-
tus in the active stage was associated with short- Acupuncture/Acupressure/Auriculotherapy
er labor time29, where the study in question had
Good methodological quality14. In another study, In a study with low risk of bias11, acupuncture
rated as having High risk of bias11, the semi-sit- was shown to reduce the length of time elapsed
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Ciência & Saúde Coletiva, 29(6):1-13, 2024

between rupture of membranes and birth21. Ap- In one study, rated as having Low risk of
plication of acupressure at specific points also re- bias12, immersion bath was combined with ball
duced mean labor time in the intervention group, exercises, aromatherapy using essential oil of
with the effect reaching statistical significance28, lavender, and adoption of the vertical position
but the magnitude of the effect on the duration in the expulsion stage. The association of NPMs
of labor was not shown. The study was rated as was shown to reduce the active stage of labor but
having Low risk of bias11. In another study, also had no effect on the expulsion stage33, however, it
classified as having Low risk of bias11, the auric- is important to emphasize that the study did not
ulotherapy technique had no effect on average present the magnitude of the effect on the dura-
labor time36. tion of labor.
Lastly, one of the studies reviewed, in which
Water birth mothers kept moving position, switching vertical
postures during labor, had shorter labor times7.
Immersion during the expulsion stage short- This study was rated as having Some concerns
ened length of labor in 3 studies22,25,34. This also methodologically11, and the magnitude of the ef-
held true for nulliparous women, whose labor fect on the duration of labor was not shown, only
process was shortened by use of the technique38. the comparison of means.
However, in a study conducted at two different
hospitals, a reduction in the expulsion stage was
seen at one site, while no effect was found for the Discussion
other hospital18. These articles did not show the
magnitude of effect on delivery time but were Delivery within a hospital setting is characterized
classified as having good methodological quality13. by the use of a host of different technologies and
procedure intended to ensure the safety of both
Pushing techniques in expulsion stage mother and newborn. However, modern obstet-
rics does not treat the pregnancy period, labor or
Passive descent (delayed pushing) and spon- birth as natural expressions of health39.
taneous pushing were associated with longer Under this model, mothers and newborns are
expulsion times in 2 articles included in the re- exposed to major interventions which should be
view30,31. The 2 studies were rated as having Some used in a more controlled rational manner only
concerns and Low risk of bias, respectively11, but when necessary, yet are adopted as part of rou-
they did not show the measure of the effect of the tine practice. This overuse of interventions, such
method on the time of delivery. as the oxytocin, episiotomy, cesarean section,
nasopharyngeal aspiration, among others, disre-
Techniques used in association gard emotional, human and cultural aspects in-
volved in the process of childbirth39.
Some of the studies reviewed explored the In 2004, the Ministry of Health launched
influence of the application of more than one the National Policy for Humanization (PNH),
NPM, used in association, on duration of labor. tackling overly interventionist practices, with
The application of breathing techniques in asso- guidance for professional conduct to respect the
ciation with relaxation methods led to a longer physiological aspects of labor. These guidelines
latent stage of labor in the experimental group19, acknowledge social and cultural aspects, seek
however, it did not measure the magnitude of the to promote health, and provide the mother and
effect on delivery time and was classified with family with emotional support, ensuring success-
some methodological concerns11. ful labor and childbirth40.
In another study, rated as having Low risk of Although the PNH is valued in theory, good
bias11, the hot/warm shower technique was com- practices in labor assistance are not always ap-
bined with birth ball exercises, revealing no effect plied. According to data from the “Nascer no
on duration of labor37. Brasil” survey, only 5.6% of normal deliveries are
One study investigating the use of ball ex- performed without some type of intervention,
ercises, together with lumbosacral massage and where practices considered inappropriate and
hot/warm shower, showed a reduction in length even those that should be abolished, such as the
of the expulsion stage, but had no effect on the Kristeller maneuver, continue to be applied41.
active stage9. The study in question had Low risk It is important to emphasize that these inter-
of bias11. ventions are not restricted to normal delivery, but
 10
Gregolis TBL et al.

also to the routine use of various practices during Maternal mobility was also associated with
labor that need to be reviewed in order to restore a decrease in labor46, when combined with al-
women’s autonomy and well-being42,43, because ternating vertical postures, it was presented as a
when a labor of delivery is accelerated can have method for reducing the active phase of labor7.
consequences for the parturient. The freedom to choose the position, however,
Also, the extension of the stages of labor can has had conflicting results, as it means that the
lead to the indication of a cesarean section, due mother can choose the position she is most com-
to the risk of complications. The delay in the fortable in at any time during labor, be it vertical,
expulsive phase tends to occur due to maternal horizontal or a combination of the two.
exhaustion, inertia or hypoactivity of the uter- Also suggesting that a vertical or horizontal
us, and due to the inability to properly contract decubitus influences progression of labor, a lit-
the abdominal muscles. Thus, when performing erature review found most studies reported that
a cesarean section, there is a risk of infection, non-horizontal positions used during expulsion
hemorrhage, pulmonary embolism and disor- reduced the duration of birth, while almost half
ders during anesthesia and even the consequent showed that adopting the vertical position short-
maternal death2. ened the process. In the review, the best evidence
In addition, complications associated with suggested that positions that exploited gravity
the long period of labor may include postpartum shortened the process of giving birth, directing
hemorrhage due to uterine atony. Therefore, the the fetus to the birth canal47.
use of NFMs during this process tends to pro- In contrast to what this review found, the
mote satisfactory results, reducing the use of application of a progressive stretching meth-
medication and making parturients calmer and od called obstetric psychoprophylaxis normally
more relaxed, through specific techniques aimed reduces the duration, ensuring to shorten the
at comfort and reduction of the duration of la- dilation and expulsion phases, thus shortening
bor44. the delivery process as a whole46. The prescribed
Thus, the present study investigated, through Lamaze method, when associated with nursing
a systematic review, the effect of MNFs used intervention, also promotes shorter labor times48.
alone and/or in conjunction with other methods In addition, acupuncture and acupressure
to reduce the duration of labor and/or some stage at specific points can reduce the duration of la-
of labor. bor21,28, shortening the active stage by an average
The bath was the method more commonly of 1.21 hours and the second stage by 5.81 min-
found in studies applying it in conjunction with utes9, specifically attributed to the first method.
other techniques, such as birth ball exercises37. According to Chinese medicine, there are neces-
A literature review concluded that the benefits sary balances for the initiation and progression
of hot/warm showers on duration of labor were of the delivery process, where vital energy and
greater when the method was combined with the blood functions are essential; thus, these meth-
use of the birth ball45. ods are recommended to help balance the physi-
For the immersion bath approach, mixed cal components of the body49.
results were reported17,20,27,38, this association of Finally, water birth is another method that
this method with others helps to delay the use of reduces the expulsive time18,22,25,34,38, however,
pharmacological agents, allowing a more active the scientific literature states that its effects are
participation of the parturient woman and her still inconclusive50. Similarly, delayed expulsive
companion20. efforts or spontaneous pushing were associated
These techniques are considered safe, with with a longer second step of almost an hour51.
no adverse effects on obstetric outcomes, and are The diversity of analyzed methods and the
also associated with greater satisfaction with the heterogeneity of the studies constituted a limita-
duration of the process of labor and expulsion8. tion of the present study, making comparisons
However, the scientific literature points out and clarity impossible in relation to each MNP
that the exercise of the birthing ball confers bene- investigated.
fits to the woman, in the act of standing, contrib-
uting to the reduction of the time of parturition,
with shortening of the active phase24. In this way, Conclusions
walking also proved to be effective in the present
study for reducing the duration of both the dila- The MNFs presented in this study are strategies
tion and expulsion phases25. used for better management, with a view to good
 11

Ciência & Saúde Coletiva, 29(6):1-13, 2024

practices in labor and birth care that enable a bining breathing with relaxation techniques also
care model to be implemented by managers and promoted longer labor.
health professionals, in the elimination of unnec- It is noteworthy that this diversity of analyzed
essary interventions for parturients. methods and the heterogeneity of the selected
Among the methods presented in this study, articles in the present study verified a limitation,
showering, walking, exercises with the birth ball, making it impossible to make detailed compar-
breathing techniques, maternal mobility, acu- isons in relation to each identified NFM and
puncture and acupressure, aromatherapy, supine the analysis of the magnitude of the effect of the
position, immersion bath and water birth re- strategies on the duration of labor.
duced the duration of labor and/or delivery when However, it should be noted that this over-
applied alone. Also, the association of methods, view of the use of these methods can contribute
such as immersion bath, ball exercises, aroma- to reflection on the practice of health profes-
therapy, vertical postures and maternal mobility sionals in relation to the assistance provided to
with alternate vertical postures, shortened the women in labor, with the proposition of indica-
time of delivery or any of its phases. tors that allow the use of this practice; despite the
On the other hand, auriculotherapy, hot/ scientific literature pointing out the incipience of
warm bath associated with ball exercises did not investigations that address the difficulties of im-
affect the duration of labor, while immersion plementation and the necessary advances for its
bath during labor, massage and spontaneous execution as recommended.
pushing increased the duration of labor. Com-

Collaborations

TBL Gregolis performed the acquisition, analysis

and interpretation of data, as well as the elabora-
tion of the work. SS Santos, IF Silva and ARS Bes-
sa developed the study design, also participating
in the acquisition, analysis, interpretation of data
and elaboration of the work, in addition to its re-
view. All authors have read the manuscript, in-
terpreted the results, agreed on the final version
and agreed to be responsible for all aspects of the
work.
 12
Gregolis TBL et al.

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