***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: & NA ; Forty‐five pregnant women in the first stage of labour presenting with lower back pain were r and omized into 2 groups . One group received intracutaneous injections of sterile water in the lumbosacral region , while the other group was given corresponding subcutaneous injections of isotonic saline , regarded as a placebo treatment . In the group that received intracutaneous sterile water injections  the mean VAS score was significantly more reduced compared to the placebo group at 10 min ( P < 0.001 ) , 45 min ( P < 0.02 ) , and at 90 min ( P < 0.05 ) after the treatment . The midwives ' blind estimation of the effectiveness of treatment was consistent with the VAS assessment . However , the requirement of pethidine ( meperidine ) was similar in the 2 groups . The analgesic method presented was found to be an effective treatment against lower back pain during the first stage of labour and it is speculated that the mode of action resembles acupuncture Background Anecdotal reports suggest that the addition of fentanyl ( an opioid ) to epidural analgesia for women during childbirth results in difficulty establishing breastfeeding . The aim of this paper is to determine any association between epidural analgesia and 1 ) breastfeeding in the first week postpartum and 2 ) breastfeeding cessation during the first 24 weeks postpartum . Methods A prospect i ve cohort study of 1280 women aged ≥ 16 years , who gave birth to a single live infant in the Australian Capital Territory in 1997 was conducted . Women completed question naires at weeks 1 , 8 , 16 and 24 postpartum . Breastfeeding information was collected in each of the four surveys and women were categorised as either fully breastfeeding , partially breastfeeding or not breastfeeding at all . Women who had stopped breastfeeding since the previous survey were asked when they stopped . Results In the first week postpartum , 93 % of women were either fully or partially breastfeeding their baby and 60 % were continuing to breastfeed at 24 weeks . Intrapartum analgesia and type of birth were associated with partial breastfeeding and breastfeeding difficulties in the first postpartum week ( p < 0.0001 ) . Analgesia , maternal age and education were associated with breastfeeding cessation in the first 24 weeks ( p < 0.0001 ) , with women who had epidurals being more likely to stop breastfeeding than women who used non-pharmacological methods of pain relief ( adjusted hazard ratio 2.02 , 95 % CI 1.53 , 2.67 ) . Conclusion Women in this cohort who had epidurals were less likely to fully breastfeed their infant in the few days after birth and more likely to stop breastfeeding in the first 24 weeks . Although this relationship may not be causal , it is important that women at higher risk of breastfeeding cessation are provided with adequate breastfeeding assistance and support Background The neural mechanisms underlying the modulation of pain perception by hypnosis remain obscure . In this study , we used positron emission tomography in 11 healthy volunteers to identify the brain areas in which hypnosis modulates cerebral responses to a noxious stimulus . Methods The protocol used a factorial design with two factors : state ( hypnotic state , resting state , mental imagery ) and stimulation ( warm non-noxious vs. hot noxious stimuli applied to right thenar eminence ) . Two cerebral blood flow scans were obtained with the 15O-water technique during each condition . After each scan , the subject was asked to rate pain sensation and unpleasantness . Statistical parametric mapping was used to determine the main effects of noxious stimulation and hypnotic state as well as state-by-stimulation interactions ( i.e. , brain areas that would be more or less activated in hypnosis than in control conditions , under noxious stimulation ) . Results Hypnosis decreased both pain sensation and the unpleasantness of noxious stimuli . Noxious stimulation caused an increase in regional cerebral blood flow in the thalamic nuclei and anterior cingulate and insular cortices . The hypnotic state induced a significant activation of a right-sided extrastriate area and the anterior cingulate cortex . The interaction analysis showed that the activity in the anterior (mid-)cingulate cortex was related to pain perception and unpleasantness differently in the hypnotic state than in control situations . Conclusions Both intensity and unpleasantness of the noxious stimuli are reduced during the hypnotic state . In addition , hypnotic modulation of pain is mediated by the anterior cingulate cortex The aim of this quasi‐experimental study was to examine the effects of maternal pethidine during labour on the developing breast feeding behaviour in infants in the first 2 h after birth compared with infants not exposed to pethidine . Forty‐four healthy infants were observed immediately after birth . They were placed skin‐to‐skin on their mothers ' chests . The development of mouth and sucking movements as well as rooting behaviour and state of sleep/wakefulness were noted . The observer was blind as to the pain relief the mother had received during labour . Of the 44 mothers 18 had received pethidine .  The main findings were that infants exposed to pethidine had delayed and depressed sucking and rooting behaviour . In addition , a smaller proportion of infants exposed to pethidine started to suckle the breast . Rooting movements which are expected to be vigorous at 30 min after birth were affected both by administration of pethidine and a longer second stage of labour . It is suggested that the differences found in sucking behaviour may be a central effect of pethidine . Depression of rooting movements in the pethidine group may be caused by exhaustion due to a longer second stage of labour and administration of pethidine . It is recommended that pethidine‐exposed mother‐infant couples stay together after birth long enough to enable the infant to make the choice to attach or not to attach to the nipple without the forceful helping h and of the health staff To estimate the effects of intramuscular meperidine analgesia on fetal heart rate ( FHR ) patterns compared with placebo . In a prospect i ve r and omized study , 150 healthy women with singleton term pregnancy requesting analgesia during active labor were planned to receive either intramuscular meperidin 50 mg ( meperidin group ) or normal saline ( control group ) when they requested analgesia . Fetal heart rate patterns occurring within 40 minutes of initiation of labor analgesia were retrospectively read by maternal fetal medicine specialist who was blind to type of labor analgesia . Meperidine , compared with placebo , was associated with statistically significantly less beat to beat variability ( absent or less than 5 beats per minute ) ( 28 % versus 5 % of fetuses , P<0.05 ) , lower proportion of accelerations ( 37.3 % versus 17.3 % P<0.05 ) and of the FHR . Also FHR deceleration was significantly more than control group ( 25.5 % versus 4 % , P<0.05 ) . Meperidine has deleterious effects on FHR Aim . To study possible detrimental maternal and neonatal effects of immersion in warm water during labor Background : Waterbirths were introduced in 1991 as part of a new birth concept which consisted of careful monitoring and birth management , restrictive use of invasive methods and free choice of different birth methods . Methods : After the introduction of this new birth concept a prospect i ve observational study was initiated . All parturients of the region give birth in our clinic without pre selection , ours being the only birth clinic of the region . 2 % of the parturients will be referred to a larger birth clinic ( university clinic ) mainly because of preterm births before the end of the 33rd week of pregnancy . Every one of the 7,508 births between November 1991 , and May 21 , 1997 , was analyzed . In this article the birth parameters of mother and child in the most often chosen spontaneous birth methods will be compared to assess the safety of alternative  birth methods in general and of waterbirths in particular . 2,014 of these 5,953 spontaneous births were waterbirths , 1,108 were Maia-birthing stool births and 2,362 bedbirths ( vacuum extraction s not included ) . Results : The parity and age of the mother as well as the newborn ’s birth weight are comparable in all 3 groups : waterbirth , Maia-birthing stool , and bedbirths . An episiotomy was performed in only 12.8 % of the births in water , in 27.7 % of the births on the Maia-birthing stool and in 35.4 % of the bedbirths . These differences are statistically significant . In spite of the highest episiotomy rates , the bedbirths also show the highest 3rd- and 4th-degree laceration rates ( 4.1 % ) , thus the difference between the rates for bedbirths and alternative births methods for severe lacerations is significant . The mothers ’ blood loss is the lowest in waterbirths . Fewer  painkillers  are used in waterbirths and the experience of birth itself is more satisfying after a birth in water . The average arterial blood pH of the umbilical cord as well as the Apgar scoring at 5 and 10 min are significantly higher after waterbirths . Infections of the neonate do not occur more often after waterbirths . No case of water aspiration or any other perinatal complication of the mother or child which might be water-related was reported . Conclusion : Waterbirths and other alternative forms of birthing such as Maia-birthing stool do not demonstrate higher birth risks for the mother or the child than bedbirths if the same medical criteria are used in the monitoring as well as in the management of birth OBJECTIVE : To estimate the efficacy of paracervical compared with intracervical administration of local anesthesia during first-trimester suction curettage . METHODS : A double-blind , r and omized controlled trial comparing paracervical with intracervical lidocaine was performed in women undergoing elective first-trimester suction curettage with conscious sedation .  Pain was assessed at baseline , with dilation , and with curettage using a 10-cm visual analog scale ( VAS ) . Assuming a minimal clinical ly important difference in pain score of 1.6 cm and a mean pain score ( ±st and ard deviation [ SD ] ) of 4.7 ( ±2.9 ) cm for paracervical block , 120 patients would provide 80 % power with an alpha of .05 . RESULTS : For the 132 women r and omly assigned , no significant differences in VAS scores ( mean±SD ) were observed between paracervical and intracervical blocks during dilation ( 2.6±2.3 compared with 2.8±2.2 , P=.72 ) or curettage ( 3.9±2.9 compared with 3.3±2.5 , P=.16 ) . CONCLUSION : For women undergoing first-trimester suction curettage  with conscious sedation , there was no clinical ly meaningful difference in pain relief between paracervical and intracervical lidocaine . Providers should feel confident that both techniques provide equally effective and acceptable analgesia . CLINICAL TRIAL REGISTRATION : Clinical Trials.gov , www . clinical trials.gov , NCT00816751 LEVEL OF EVIDENCE : OBJECTIVE To study the effectiveness of intracutaneous injections of sterile water in relieving  low back pain during labor in Thai women . STUDY DESIGN R and omized controlled trial . SETTING Department of Obstetrics and Gynecology , Taksin Hospital , Bangkok . MATERIAL AND METHOD Fifty pregnant women at term , requiring pain relief for severe low back pain during the first stage of labor . The women were r and omized to receive either 4 intracutaneous injections of 0.1 mL sterile water ( n = 25 ) or isotonic saline as placebo ( n = 25 ) . MAIN OUTCOME MEASURES Pain scores measured by visual analogue scale . RESULTS Mean pain scores were significantly lower among the treatment group compared to the placebo group at 30 minutes , 1 and 2 hours after injections ( p = 0.018 , 0.046 , and 0.027 respectively ) . Mean pain reduction were significantly greater in the treatment group compared to the placebo group at 30 minutes , 1 and 2 hours after injections ( p < 0.001 ) . There was no difference between the two groups with regard to time to delivery and rate of instrumental and cesarean delivery . CONCLUSION The intracutaneous injections of sterile water was found to be an effective treatment against lower back pain during the first stage of labor Pain control during labor is a primary objective of antalgic therapy . The use of the peridural as an elective procedure for labor analgesia is now corroborated by the international scientific community . Sometimes a combined spinal-peridural procedure is used together with the intrathecal administration of opioids to also cover the first stage of labor . Unfortunately , patients and /or gynecologists often request analgesia in a late stage of labor . The aim of our study was to evaluate the possibility of using a subarachnoid block alone for labor analgesia when this is requested at a late stage , that is , in advanced labor with cervical dilation greater than 7 cm . After approval by our ethics committee and the written and informed consent of the patients , 111 women were enrolled in this study and r and omly divided into two groups . The first group ( Group S : 55 patients ) received a subarachnoid block with 2.5 mg hyperbaric bupivacaine + 25 mug fentanyl + 1 mL 10 % glucose . A pudendal nerve block with 7 mL 2 % mepivacaine in each side was administered to the second group ( Group P : 56 patients ) . In both groups , careful maternal-fetal monitoring was conducted , and pain was scored on a numerical scale from 0 to 
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Based on these three comparisons , we have categorised interventions into : " What works " , " What may work " , and " Insufficient evidence to make a judgement".WHAT WORKS Evidence suggests that epidural , combined spinal epidural ( CSE ) and inhaled analgesia effectively manage pain in labour , but may give rise to adverse effects .
Epidural , and inhaled analgesia effectively relieve pain when compared with placebo or a different type of intervention ( epidural versus opioids ) .
Combined-spinal epidurals relieve pain more quickly than traditional or low dose epidurals .
Women receiving inhaled analgesia were more likely to experience vomiting , nausea and dizziness .
When compared with placebo or opioids , women receiving epidural analgesia had more  instrumental vaginal births  and  caesarean sections for fetal distress , although there was no difference in the rates of caesarean section overall .
Women receiving epidural analgesia were more likely to experience hypotension , motor blockade , fever or urinary retention .
Less urinary retention was observed in women receiving CSE than in women receiving traditional epidurals .
More women receiving CSE than low-dose epidural experienced pruritus .
WHAT MAY WORKThere is some evidence to suggest that immersion in water , relaxation , acupuncture , massage and local anaesthetic nerve blocks or non-opioid drugs may improve management of labour pain , with few adverse effects .
These interventions relieved pain and improved satisfaction with pain relief ( immersion , relaxation , acupuncture , local anaesthetic nerve blocks , non-opioids ) and childbirth experience ( immersion , relaxation , non-opioids ) when compared with placebo or st and ard care .
Relaxation was associated with fewer assisted vaginal births and acupuncture was associated with fewer assisted vaginal births and caesarean sections .
INSUFFICIENT EVIDENCE There is insufficient evidence to make judgements on whether or not hypnosis , biofeedback , sterile water injection , aromatherapy , TENS , or parenteral opioids are more effective than placebo or other interventions for pain management in labour .
In comparison with other opioids more women receiving pethidine experienced adverse effects including drowsiness and nausea .
AUTHORS ' CONCLUSIONS Most methods of non-pharmacological pain management are non-invasive and appear to be safe for mother and baby , however , their efficacy is unclear , due to limited high quality evidence .
There is more evidence to support the efficacy of pharmacological methods , but these have more adverse effects .
Thus , epidural analgesia provides effective pain relief but at the cost of increased instrumental vaginal birth .