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doi:10.1111/jog.12345 J. Obstet. Gynaecol. Res. Vol. 40, No. 5: 1317–1323, May 2014

Transcutaneous electrical nerve stimulation for the relief

of post-partum uterine contraction pain during
breast-feeding: A randomized clinical trial

Ligia de Sousa1, Flávia A. Gomes-Sponholz2 and Ana Márcia S. Nakano2

1
Federal University of Alfenas – UNIFAL, Alfenas, Minas Gerais, and 2College of Nursing, University of São Paulo, Ribeirão
Preto, São Paulo, Brazil

Abstract
Aim: To evaluate transcutaneous electrical nerve stimulation (TENS) used to relieve uterine contraction pain
during breast-feeding in multiparous women.
Methods: A controlled and randomized clinical trial was performed with 32 post-partum multiparous women
who were breast-feeding. The participants were randomized into an experimental (EG, n = 16) and a control
group (CG, n = 16). Pain was assessed using the Numerical Rating Scale and the descriptors of the Present Pain
Intensity (PPI – McGill) during two sequential feeds. In the first assessment, the post-partum women in the EG
and CG were monitored while breast-feeding and questioned regarding the degree of uterine contraction pain.
In the second assessment, which was performed at the next feed, the EG used TENS while the CG was
monitored, with pain being reassessed following. In the EG, the TENS electrodes were placed between T10–L1
and S2–S4, with a frequency of 100 Hz, a pulse duration of 75 μs and amplitude adjusted to produce a strong
and tolerable sensation for 40 min. A descriptive analysis of the data and comparative intra- and intergroup
analyses were performed by means of a non-parametrical test, with a significance level P ≤ 0.05.
Results: The level of basal pain was 5.56 in the EG and 5.50 in the CG. In the intragroup analysis, the EG
(P < 0.0001) and CG (P = 0.04) presented significant pain reduction. In the intergroup analysis, the EG had
significant pain reduction (P < 0.01) in comparison to the CG. In the PPI analysis, a non-significant decrease in
pain intensity was observed in the EG.
Conclusion: TENS was found to be effective in reducing post-partum uterine contraction pain during
breast-feeding.
Key words: breast-feeding, pain, post-partum period, transcutaneous electrical nerve stimulation, uterine
contraction.

Introduction effectiveness.1 Characterized as a type of colic, uterine

contraction pain is acute2,3 and occurs due to the con-
The pain related to uterine contractions, experienced stant and rhythmic contractile activity of the uterus
by post-partum women, is a frequent complaint that following cord clamping.4 These contractions are
compromises the beginning of breast-feeding and its important to prevent post-partum hemorrhage and to

Received: June 25 2013.

Accepted: November 1 2013.
Reprint request to: Dr Ligia de Sousa, Curso de Fisioterapia, Universidade Federal de Alfenas, Unidade II – Av. Jovino Fernandes
Sales, 2600 Santa Clara, Alfenas, MG 37130-000, Brazil. Email: ligia.sousa@unifal-mg.edu.br
Scientific address where project was executed: College of Nursing, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.
Place where the study originated: College of Nursing, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.
Conflict of interest: None declared.

© 2014 The Authors 1317

Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
L. Sousa et al.
maintain the homeostasis of the placental site, continu-
ing for 5–7 days after childbirth.2
In the nursing mother, uterine involution is faster
than in women who do not breast-feed, due to
the stimulation of the nipples and galactophorous
ducts. This stimulation results in uterine contractions,
mediated by the release of oxytocin, a nonapeptide
produced in the paraventricular and supraoptic hypo-
thalamic nuclei and secreted into the circulation during
labor and in response to suction during breast-
feeding.5–7 Because oxytocin stimulates uterine contrac-
tile activity during the suction of the newborn or in
response to nipple stimulation, this hormone exerts its
action on the uterine fibers, which explains the rela-
tionship between lactation and uterine contraction
pain.2,6,8
The use of non-pharmacological resources for pain
relief in different post-partum situations has been the
focus of several authors, including those who have
evaluated the effects of transcutaneous electrical nerve
stimulation (TENS).
Transcutaneous electrical nerve stimulation is a
simple, non-invasive, low-cost and easy-to-apply
resource.3 It may be defined as a physiotherapeutic
resource that utilizes small electrodes fixed onto the
skin and placed in specific regions to produce electrical
impulses, resulting in pain relief. According to Sluka
and Walsh9 and Walsh et al.,10 TENS promotes immedi-
ate pain relief through the generation of a depolarized
current, avoiding the formation of positive–negative
ionic concentrations under each electrode or within the
tissue. In addition, there are few adverse effects asso-
ciated with TENS.9,11,12
Although other studies have already demonstrated
the effectiveness of TENS in the relief of post-partum
uterine contraction pain,3,13 there are no reports in the
published work associating the use of TENS with
reduction of pain during breast-feeding. Hence, the
purpose of this study was to analyze the efficacy of
TENS in the relief of uterine contraction pain in mul-
tiparous women during breast-feeding, in the immedi-
ate post-partum period.
Methods
This was a controlled randomized clinical trial, devel-
oped in a maternity hospital in the state of São Paulo,
Brazil. The research proposal was approved by the
Research Ethics Committee of the University of São
Paulo at Ribeirão Preto College of Nursing, under pro-
tocol number 1095/2009.
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Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
Evaluated for eligibility
Excluded (n=6)
Did not meet inclusion
criteria (n=5)
Refused to participate in the
study (n=1)
Randomized (n=32)
Placed in EG (n=16) Placed in CG (n=16)
Subjects who received Subjects who not received
TENS (n=16) TENS (n=16)
Losses or interrupted Losses or interrupted
(n=0) (n=0)
Analyzed (n=16) Analyzed (n=16)
Figure 1 Trial design (CONSORT). CG, control group;
EG, experimental group; TENS, transcutaneous electri-
cal nerve stimulation.
Study participants were 32 multiparous women who
had undergone natural childbirth, aged over 18 years,
without post-partum complications, exclusively breast-
feeding, who experienced uterine contraction pain
while breast-feeding. The women were also literate
and able to understand the pain rating scales used.
Exclusion criteria were applied to post-partum women
who presented intolerance to the stimulus generated
by TENS and had complications requiring medical
intervention, such as hemorrhage and infection. The
volunteers were randomly divided, by means of a
computer-based randomization, into an experimental
group (EG) (n = 16), which received therapy with
TENS and a control group (CG) (n = 16), which did
not receive TENS. The study design is presented in
Figure 1, as per CONSORT.
Device and treatment with TENS
Transcutaneous electrical nerve stimulation was pro-
vided using a portable device (TENS KW Compact;
KW Indústria Nacional de Tecnologia e Eletrônica, São
Paulo, Brazil) that generated two-phase current and
asymmetrical waves, with controllable variation of fre-
quency and amplitude. Four silicon and carbon rubber
electrodes (5 cm × 3 cm) were used, with pH-neutral
conductive gel and hypoallergenic adhesive tape used
for fixation. Two electrodes were placed in parallel in
the T10–L1 region; the other two were placed in the
© 2014 The Authors

S2–S4 region,14 corresponding to the level of the spine
that receives nociceptive information from the uterus
and cervix.15 The TENS device was programmed to
generate a 100-Hz current and 75 msec pulse for
40 min. Any increase in intensity was decided by the
participants, after being instructed to keep a strong and
tolerable stimulation without muscle contraction. The
TENS device was calibrated before the beginning of
data collection using a digital oscilloscope.
Procedures
For the selection of the participants, the authors ini-
tially searched medical records of a rooming-in unit for
multiparous women who had given birth within the
past 48 h, who had not received pain medication for at
least 6 h prior to data collection and who had no order
for pain medication. The participants were informed
that they could ask for pain medication at any time
during the study without influencing the care received
at the maternity hospital, but that this would result in
their necessary exclusion from the study. The post-
partum women were invited to participate in the study
in the rooming-in unit of the maternity hospital, where
they received information regarding the study proce-
dures, and their signature on the Free and Informed
Consent Form was obtained, after they read, under-
stood and accepted it. Once the participant was
included in the study, she was assigned to one of the
groups, according to the randomization spreadsheet.
Initially, a data collection form was filled out regard-
ing sociodemographic, obstetric and breast-feeding-
related variables. The women in the EG and CG were
assessed during two sequential feeds, the first without
TENS and the second with the application of TENS in
the EG. During the assessments, the participants were
instructed to remain sitting up with their feet on the
ground, and to hold their newborn in their arms, so as
to standardize their body position while breast-
feeding. In the first assessment, the participants in the
two groups were monitored during breast-feeding
and, following, rated their pain using the pain rating
scale. The second assessment was performed during
the following feed. This time, the EG had the TENS
device applied, maintaining the standardized body
position; the CG was monitored during breast-feeding
and, following, the uterine contraction pain experi-
enced during feeding was assessed. In the EG, TENS
was applied during the whole breast-feeding from the
beginning to the end of the feed. After its removal, the
women were assessed again in terms of the uterine
© 2014 The Authors
Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
TENS for post-partum uterine pain
contraction pain experienced during the feed. They
also completed a questionnaire regarding their satisfac-
tion with the treatment.
Pain measurement
Uterine contraction pain was assessed by means of an
11-point Numerical Rating Scale (NRS), in which 0
means absence of pain and 10 represents extreme
pain.16 Once they were provided the data regarding the
scale, the participants were asked: ‘Which number
would you assign for the strongest colic-like pain you
felt while you were breast-feeding the baby?’
At the end of the study, the participants in the EG
answered a questionnaire about their satisfaction with
the treatment, comprising the following options: ‘very
satisfied’, ‘poorly satisfied’ or ‘dissatisfied’ with the
pain relief provided by TENS. The questionnaire also
assessed the use of the device in future post-partum
experiences for pain relief, requesting ‘yes’ or ‘no’
answers. The discomfort produced by the current
stimulation was analyzed in the EG by the TENS dis-
comfort questionnaire, a verbal scale of five options:
‘no discomfort’, ‘mild’, ‘moderate’, ‘severe’ and ‘worst
possible discomfort’.3
Data analysis
Sample size was calculated using a sample calculation
based on a pilot study developed with six post-partum
women, who received therapy with TENS. A clinically
relevant reduction in pain scores after intervention was
considered at 1.39 on the numerical rating scale;17 stan-
dard deviation ranged between 1.8 and 2.0 for the EG
and CG, respectively (α = 0.01 and power = 90%;
β = 0.1). Student’s t-test and the PASS 2008 (Power
Analyses and Simple Size) program were used to deter-
mine a sample size of 16 subjects per group.
Data were analyzed using the statistical SPSS (Statis-
tical Package for the Social Sciences) program. In the
statistical tests, a significance level of 5% was used
(P ≤ 0.05).
A descriptive analysis of sociodemographic and
obstetric data were performed by χ2-test and Student’s
t-test. The Mann–Whitney U-test was used for compari-
son of pain between the groups before and after appli-
cation of TENS, and the Wilcoxon rank sum test for
intragroup analysis.
Results
Characteristics of the participants
The study participants presented a mean age of
26.84 ± 5.14 years, with no statistical difference
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L. Sousa et al.

between the groups (P = 0.06). The variables regarding
education (P = 0.95), marital status (P = 0.65), occupa-
tion (P = 1.00) and race (P = 0.99) did not present any
statistical difference between the groups either, assur-
ing the homogeneity of the sample.
All women in the study breast-fed their babies on
demand; that is, there was no predetermined time
scheduled for breast-feeding, which was provided as
per the newborn’s signs/cues of hunger. However, all
newborns were breast-fed within 30 min after delivery.
The mean duration of the feed in the first assessment
of the studied women was 28.43 ± 11.65 and
25.31 ± 6.18 min in the EG and CG, respectively
(P = 0.35). In the second assessment, the mean feed-
ing time was 29.68 ± 10.24 min in the EG and
25.33 ± 7.89 min in the CG (P = 0.21).
Table 1 presents characteristics of the patients and
the main variables related to labor, childbirth and the
post-partum period.
Results related to pain
Numerical pain rating scale
None of the participants made use of medication for
pain relief 6 h before or during of the study.
The studied groups presented a similar score for
basal pain levels (considering the first feed assessed),
with 5.56 in the EG and 5.50 in the CG. Table 2 presents
the results obtained with TENS, comparing the studied
groups.
Questions regarding TENS
Regarding the satisfaction with the TENS treatment in
the EG, among the 16 participants in this group, 10
(62.5%) felt ‘very satisfied’ and six (37.5%) women
claimed to be ‘satisfied’ with the treatment. None of the
women felt ‘poorly satisfied’ or ‘dissatisfied’ after the
use of conventional TENS. As for the discomfort pro-
duced by the current of the device, all women (100%)

Table 1 Distribution of the frequency (n) and percentage (%) of the characteristics and variables related to labor, childbirth
and the post-partum period
Variable EG, n % CG, n % Total, n % P
Body mass index
Underweight 6 37.5 1 6.25 7 21.875
Appropriate 7 43.75 10 62.5 17 53.125 0.99
Overweight 3 18.75 5 31.25 8 25
Previous pregnancies
1–3 14 87.5 9 56.25 23 71.875 0.99
4–6 2 12.5 5 30.25 7 21.875
≥7 — — 2 12.5 2 6.25
Correct latch
Correct 16 100 15 93.75 31 96.875 0.30
Incorrect — — 1 6.25 1 3.125
Correct position of the newborn
Correct 16 100 14 87.5 30 93.75 0.46
Incorrect — — 2 12.5 2 6.25
Use of analgesia for labor
Yes 10 62.5 14 87.5 24 75 0.22
No 6 37.5 2 12.5 8 25
Oxytocin – labor
Yes 12 75 12 75 24 75 1.00
No 4 25 4 25 8 25
Perineum
Intact 6 37.5 9 56.25 15 46.875
RMLE 6 37.5 2 12.5 8 25 0.65
First degree laceration 4 25 5 31.25 9 28.125
Oxytocin – post-partum
Yes 14 87.5 13 81.25 27 84.375 0.62
No 2 12.5 3 18.75 5 15.625
Skin-to-skin contact
Yes 7 43.75 8 50 15 46.875 0.72
No 9 56.25 8 50 17 53.125
CG, control group; EG, experimental group; RMLE, right mediolateral episiotomy.

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Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
 TENS for post-partum uterine pain

Table 2 Analysis of the mean difference of the NRS scores in the first and second
assessments
NRS Mean ± standard deviation
EG CG P
1st assessment – 1st feed 5.56 ± 1.99 5.50 ± 2.25 0.89
2nd assessment – 2nd feed 3.56 ± 1.78 4.81 ± 2.37 0.12
Dif. 1st – 2nd 2.00 ± 0.96 0.69 ± 1.25 <0.01
P-value <0.0001 0.04
CG, control group; Dif. 1st – 2nd, difference between first and the second assessment; EG,
experimental group; NRS, Numerical Rating Scale. Columns present the intragroup analysis,
whereas rows present the intergroup analysis. Intragroup analysis, Wilcoxon rank sum test.
Intergroup analysis, Mann–Whitney U-test.

reported absence of discomfort with the use of conven-
tional TENS. When questioned regarding the use of
conventional TENS for the relief of uterine contraction
pain following future births, all women in the experi-
mental group (100%) stated they would use the tech-
nique again.
Discussion
There is a lack of studies in the published work regard-
ing the use of non-pharmacological resources, such as
TENS, for the relief of uterine contraction pain after
childbirth, especially during breast-feeding, and the
studies found approaching uterine contraction after
childbirth fail to mention breast-feeding.3 Neverthe-
less, published studies have discussed the use of TENS
for pain relief during uterine contractions in labor and
childbirth.15,16,18–21
In this study, the effectiveness of TENS was assessed
in terms of the relief of uterine contraction pain during
breast-feeding after natural childbirth in multiparous
women. The criterion to include multiparous women is
justified by the fact that multiparity contributes to an
increase in the duration and frequency of uterine con-
tractions, although the mechanism is still uncertain.2
The pain in multiparous women may be related to a
central sensitization of the organism in the long term,
in response to the intense tissue damage of the uterus
and other pelvic structures during each childbirth,
changing the process of information relayed along the
spine and supraspinal structures and intensifying the
uterine contractions.5
In the assessment of breast-feeding effectiveness,
there was no significant difference between the studied
groups during the two periods of data collection, with
the observation of the feeding indicators of correct
position and latch of the newborn, which are determi-
nant factors for ineffective breast-feeding, interfering
in the breast–uterus connection and in the effectiveness
of uterine contractions during breast-feeding.22
Regarding the application of TENS, the use of two
pairs of electrodes fixed between T10–L1 and S2–S4
adopted in this study seems to be the position that
provides the best results, because it corresponds to the
sensitivity level of the afferent fibers of the uterus, and
has already been shown to be effective in the relief of
labor pain.15,16,23 The studies of Ólsen et al.3 and
Navarro-Nuñes and Pacheco-Carrasco24 evaluated the
use of TENS in the relief of uterine contraction pain
after childbirth, with electrodes fixed in the lower
abdominal region above the uterus, and also observed
positive results.
The parameters of stimulation are determinant for
TENS therapy to be successful.25 For Wang et al.,11 the
frequency, amplitude and time of treatment caused
diverging results. The parameters of stimulation used
in this study have already been used in previous
studies and are considered ideal for the treatment of
this type of pain, which is characterized as acute.18,19,25,26
In this study, the women in EG were instructed to
increase the amplitude of the device whenever the
perception of stimulation weakened, so that they
experienced a strong and tolerable tingling sensation.
For Bjordal et al.,26 an effective amplitude for pain
relief with TENS must be greater than 15 mA. Accord-
ing to Platon et al.,27 applying low-amplitude TENS
does not result in effective pain relief and requires the
additional consumption of pharmacological pain
relief medications. These authors obtained good
results with TENS for pain relief after surgical abor-
tion using 20–60 mA of intensity. In the present study,
the amplitude was not assessed, because the device
did not allow such measurement. However, the
researcher continuously instructed the participants to
increase the amplitude as soon as the tingling sensa-
tion diminished, so as to adapt the current and avoid

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Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
L. Sousa et al.
the effect of accommodation,27,28 can be seen as a limi-
tation of the study.
Ólsen et al.3 fixed a parameter of high amplitude
(50 mA) for the application of high-frequency TENS in
the relief of uterine contraction pain after childbirth
and compared it with a group using low intensity (10–
15 mA) TENS. These authors found positive results for
the two groups undergoing treatment; however, the
high-intensity group reported great discomfort with
the application of this technique.
Regarding the numerical pain rating scale, the pain
intensity of the uterine contraction pain during breast-
feeding in the EG was 2.00 and 0.69 in the CG. In both
groups, the reduction of the intragroup pain was sig-
nificant, as well as the intergroup reduction. However,
the assessment of the reduction of pain in the EG
showed clinically relevant pain relief, which was not
obtained in the CG. In addition, although the CG
showed a significant reduction of pain, it was not clini-
cally significant, with no significant clinical benefits for
the mothers in this group. The reason for this finding,
according to the published work, is that a clinically
relevant value for pain reduction is 13 mm for the
analog visual scale, corresponding to 1.3 in the
NRS.29–31 Also, the presence of the researcher accompa-
nying the control group may have influenced the
response of participants and limited the study.
In the study developed by Ólsen et al.,3 a significant
reduction in uterine contraction pain was observed, as
evidenced by the pain scores evaluated through the
analog visual scale in the groups that used high- and
low-intensity TENS. However, the women who used
high-amplitude TENS presented a greater reduction in
pain compared to those who used low-amplitude
TENS (49 mm and 21 mm, respectively), according to
the analog visual scale. The reduction obtained with
TENS in this study, which used high frequency with a
comfortably adjusted amplitude, may be compared to
the reduction obtained by Ólsen et al.3 when using high
frequency with low amplitude of stimulation, both
with clinically relevant pain reduction.
Regarding satisfaction with the use of TENS, the par-
ticipants reported that their pain was treated satisfacto-
rily. Similar results were found in a study on the use of
TENS to relieve incisional pain after cesarean section32
and perineal pain after childbirth with episiotomy.33 In
this study, none of the participants reported discomfort
with the use of TENS. According to Wang et al.,11 TENS
generates a massage that provides additional comfort
in addition to the relief of pain. In a study developed by
Ólsen et al.,3 TENS with high amplitude, used to relieve
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Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
uterine contraction pain, generated discomfort and
sensory discomfort during TENS application for most
of the participants, whereas the low amplitude appli-
cation did not cause discomfort.
The opinion of the women towards the use of TENS
in the post-partum period, both for the relief of pain
after cesarean section32 and for perineal pain after
childbirth with episiotomy,33 agree with the results pre-
sented, showing good acceptance of the method.
In clinical practice, it is common to find women dis-
couraged with the process of breast-feeding by the
presence of pain of uterine contraction. Thus, TENS can
be used to improve pain symptoms and to stimulate
the lactation, especially because its easy application
and portability (the woman herself can control the
timing and intensity of use of the device), which can be
used in all lactations that cause pain, especially in the
first seven days post-partum.2 The results of this study,
added to those found in the international published
work, indicate that TENS is a source for pain relief that
may present distinct advantages, such as the reduction
in the use of medications and a consequent decrease in
adverse effects caused by them.3,24
The authors conclude that the data obtained in this
study support the use of TENS in reducing uterine
contraction pain during breast-feeding in multiparous
women following natural childbirth.
Acknowledgment
The authors thank the Brazilian Federal Agency for
Support and Evaluation of Graduate Education.
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