EFFECTIVENESS OF WARM COMPRESS IN SACRAL AREA ON LABOUR PAIN DURING 1
STSTAGE OF
LABOUR AMONG PRIMIPARTURIENTS AT SELECTED HOSPITAL, SALEM.
By
Ms. JAYANTHI. G Reg. No: 30109422
A DISSERTATION SUBMITTED TO
THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY, CHENNAI, IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE
DEGREE OF MASTER OF SCIENCE IN NURSING
(OBSTETRICS AND GYNAECOLOGICAL NURSING)
APRIL – 2012
CERTIFICATE
Certified that this is the bonafide work of Ms.JAYANTHI.G, final year M.Sc (Nursing) student of Sri Gokulam College of Nursing, Salem, submitted in partial fulfilment of the requirement for the Degree of Master of Science in Nursing to The Tamil Nadu Dr. M.G.R. Medical University, Chennai, under the Registration No.30109422.
College Seal:
Signature: ………
Prof.Dr. A. JAYASUDHA, Ph.D., (N).,
PRINCIPAL,
SRI GOKULAM COLLEGE OF NURSING, 3/836, PERIYAKALAM,
NEIKKARAPATTI, SALEM - 636 010.
EFFECTIVENESS OF WARM COMPRESS IN SACRAL AREA ON LABOUR PAIN DURING 1
STSTAGE OF
LABOUR AMONG PRIMIPARTURIENTS AT SELECTED HOSPITAL, SALEM.
Approved by the Dissertation Committee on: 21.12.2011
Signature of the Clinical Speciality Guide:………...
Mrs. K.AMUDHA, M.Sc(N), Associate Professor,
Department of Obstetrics & Gynaecology, Sri Gokulam College of Nursing,
Salem-636 010.
Signature of Medical Expert: ………..
Dr. P. CHELLAMMAL, M.D., DGO, Consultant Obstetrician and Gynaecologist, Sri Gokulam Hospital,
Salem-636 004.
______________________________ _________________________________
Signature of the Internal Examiner Signature of the External Examiner
with date with date
ACKNOWLEDGEMENT
“Gratitude makes of our past, brings peace for today, And creates a vision for tomorrow”
-John Fitzgerald Kenned I’m very grateful to Almighty God for his abundance of grace, mercy and blessing to successful completion of this study.
I wish to express my deep sense of gratitude and thanks to Dr.K.Arthanari,M.S., Managing Trustee, Sri Gokulam College of Nursing, for providing me an opportunity to undertake the course under Sri Gokulam Trust, Salem.
I express my sincere gratitude and endless thanks to Dr.P.Chellammal, M.D., DGO, Consultant Obstetrician and Gynaecologist, Sri Gokulam Hospital, for validating the tool, constant guidance and valuable suggestions.
I wish to express my deep sense of gratitude and Dr. A.Akila, M.S (O.G)., Consultant Obstetrician and Gynaecologist, Sri Gokulam Hospital, for validating the tool, constant guidance and valuable suggestions.
I express my sincere and whole hearted gratitude to Prof.Dr.A.Jayasudha,Ph.D(N)., Principal, Sri Gokulam College of Nursing, Salem, for her fondle care, patience, encouragement, abiding guidance and constant support given during the entire study. I consider this as a great honour and privilege to complete the study under her supervision.
I would like to put my heartfelt credit to Dr. K. Tamizharasi, Ph.D(N)., Vice Principal, Sri Gokulam College of Nursing, Salem, for her valuable suggestions and immense direction for completion of dissertation.
It is the most pleasant time to express my gratitude and exclusive thanks to my Guide Mrs. K.Amudha, M.Sc(N), Associate professor, Department of Obstetrics and Gynaecological Nursing, for her innovative, constructive and diligent effort to ensure the best quality of the study and her inspiring words will never be forgotten, which helped me to do my study in a wonderful and fruitful manner.
I’m very grateful to Mrs.R.Nalini, M.Sc(N), Mrs.R.Sheela Theras,M.Sc(N), Mrs.C.Radha, M.Sc(N), Mrs.J.Vijyalakshmi, M.Sc(N), Ms.P.Arthi, M.Sc(N), Lecturers, Department of Obstetrics and Gynaecological Nursing, for their help and support throughout my study.
I proudly convey my deep indebtedness to the class Co-ordinator Mrs.P.Lalitha Vijay, M.Sc.(N), Professor and Mrs.J.Devikanna M.Sc.(N), Lecturer, Sri Gokulam College of Nursing, for their timely help and guidance..
I broaden my honest recognition to all the Faculty Members of Sri Gokulam College of Nursing, for their hold during the course of this study.
I am obliged to the Medical and Nursing Experts for validating the tool and for the constructive comments.
I widen my genuine gratitude to the Dissertation Committee for offering constructive criticism and due sanction for carrying out this research work.
My sincere thanks to Mr.S.Sivakumar, M.Sc, M.Phil., (Ph.D.,) for his assistance in statistical analysis of this study.
I am delighted to convey my earnest gratefulness to the Mr.P.Jayaseelan, M.Sc., Librarian, Sri Gokulam College of Nursing and Special thanks to the librarians of The Tamilnadu Dr.M.G.R medical university and Apollo college of Nursing, Chennai, for extending necessary library facilities throughout the study.
My sincere thanks to the Managing Director, Salem Polyclinic, who granted permission to conduct the study and for the facilities she had provided in the institution which enabled me to do this study.
I thank all the Nursing and Non-nursing Faculty members of Salem Polyclinic, Salem for their guidance and timely help during data collection period.
My truthful praise to all the Samples who took part in this study, without their cooperation the study would not have been possible.
I wish to express my sincere gratitude to Sr.G.Sreeja, M.A., M.Phil., for her valuable editorial support.
I express my special thanks to Mr.V.Murugesan, Sri Krishna Computers, for his cooperation with me and untiring patience in typing this dissertation.
I express a heartfelt thanks to my Beloved Parents for their valuable support, blessings and prayers.
Last but not least, I express heart felt gratitude and thanks to My Friends who encouraged and supported to complete the study.
TABLE OF CONTENTS
CHAPTER CONTENT PAGE NO
I INTRODUCTION 1-11
• Need for the study 2
• Statement of the problem 4
• Objectives 4
• Operational definitions 4
• Assumptions 5
• Hypotheses 5
• Delimitations 6
• Projected Outcome 6
• Conceptual framework 6
II REVIEW OF LITERATURE 12-19
Literature related to
• Labour pain perception 12
• Complementary and alternative therapies used during childbirth.
• Effect of moist heat application during childbirth.
15 16
• Effectiveness of warm compress on level of
labour pain. 18
III METHODOLOGY 20-27
• Research Approach 20
• Research Design
• Population
20
• Description of Setting 22
• Sampling 22
• Variables 23
• Description of the Tools 24
• Validity and Reliability 25
• Pilot Study 25
• Method of Data Collection 26
• Plan for Data Analysis 26
IV DATA ANALYSIS AND INTERPRETATION 28-43
V DISCUSSION 44-46
VI SUMMARY, CONCLUSION, IMPLICATIONS AND RECOMMENDATIONS
47-50
BIBLIOGRAPHY 51-54
ANNEXURES i-xv
LIST OF TABLES
TABLE NO TITLE PAGE NO
3.1 Scoring procedure 24
4.1 Mean, SD and mean difference on level of labour pain among primiparturients in experimental and control group.
38
4.2 Mean, standard deviation and ‘t’ value on level of labour pain among primiparturients in experimental group.
39
4.3 Mean, SD and t-value on level of labour pain during first stage of labour among primiparturients in experimental group and control group.
40
4.4 Association on the level of labour pain among primiparturients in experimental and control group with their selected demographic variables.
41
LIST OF FIGURES
FIGURE NO. TITLE PAGE NO 1.1 Conceptual Framework based on Wall and
Malzack’s Gate control theory
10 3.1 Schematic Representation of Research Design. 21 4.1 Percentage distribution of primiparturients
according to their age in years.
30
4.2 Percentage distribution of primiparturients according to their educational status.
31
4.3 Percentage distribution of primiparturients according to their occupation.
32
4.4 Percentage distribution of primiparturients according to their work pattern.
33
4.5 Percentage distribution of primiparturients according to their weeks of gestation.
34
4.6
Percentage distribution of Primiparturients according to the pre and post-score on level of labour pain during first stage of labour in experimental group.
35
4.7 Percentage distribution of Primiparturients according to the pre and post-score on level of labour pain during first stage of labour in control group
37
LIST OF ANNEXURES
ANNEXURE TITLE PAGE NO
A. Letter seeking permission to conduct a research
study i
B. Letter granting permission to conduct a research
study ii
C. Letter requesting opinion and suggestions of experts
for content validity of the research tool iii
D. Tool for data collection iv
E. Certificate of validation xii
F. List of Experts for Content Validity xiii
G. Certificate of Editing xiv
H. Photos xv
ABSTRACT
A Study was conducted to Evaluate the Effectiveness of Warm Compress in sacral area on Labour Pain during 1st stage of Labour among Primiparturients at Selected Hospital, Salem.
A Quasi experimental, time series design was adopted. Non probability convenience sampling technique was used to select 60 samples, among which 30 were assigned to experimental group and 30 were assigned to control group. Structured interview schedule was used to collect the demographic variables and Numerical Pain Intensity Scale was used to assess the level of labour pain. Warm compress was given for 15 minutes duration for every 1 hour and level of pain was assessed before and after each intervention. The collected data were analyzed and findings revealed that, In experimental group 12(40%) of them were in the age group of 21-25 years. In control group 9(30%) of them were undergraduates. In experimental and control group 19(63.3%) of them were unemployed. In experimental group 25(83.3%) of them were moderate workers, where as in control group 21(70%) of them were moderate workers. In experimental group 16(53.3%) of them were in 40 weeks of gestation and in control group 17(56.7%) of them were in 39 weeks of gestation. The mean differences of warm compress on level of labour pain in experimental group were 2.03, 2.43, 2.26 and 1.86, where as in control group values were 0.13, 0.03, 0.06 and 0.07 respectively.
In experimental group, the calculated‘t’ value on level of labour pain before and after warm compress was 16.65, 15.52, 17.95, 12.47 which is significant at p<0.05 level. Hence H1 was retained. In experimental group, the pre and post-test mean score was 9.96 + 0.78 and 8.10+0.71 respectively, where as in control group, the pre and post-test mean score was 8.46 + 0.50 and 8.53 + 0.50 respectively and the calculated ‘t’ value of experimental group were 16.65, 15.52, 17.95, 12.47 where as in control group‘t’ values were 1.07, 0.57, 1.00, and 0.81.So there was a significant difference in the pre and post test mean score on level of labour pain in experimental and control group. Hence H2 was retained at p< 0.05 level. There was no significant association found between the level of labour pain among primiparturients with their selected demographic variables both in experimental and control group. Hence H3 was rejected. Warm compress is one of the alternative and complementary therapies, which is simple, safe and cost effective and found to be effective in reducing labour pain and also promotes psychological well being of the mother.
CHAPTER- I INTRODUCTION
“Child birth is more admirable than conquest, more amazing than Self-defence and courageous as either one”
-Gloria Steinem Motherhood is a gift for every woman. Pregnancy and birth are a unique experience. The physiological transaction from pregnancy to motherhood occurs in each woman physically and psychologically. During pregnancy, the women and fetus prepare for labour process. The labour process is an exciting and anxious time for woman. In a relatively short period, they experience one of the most profound changes in their lives. (Lowdermilk, 2004).
Pain in labour is universal and is accepted. Labour pain is viewed as a consequence of imbalance between two energy entities. Thus for a woman in labour, her labour experience may depend on how well her physical, psychological, and spiritual energies are balanced and harmonized.
Even though delivery is a natural phenomenon, it has been demonstrated that accompanying labour pain is severe and intolerable, which results in changes in the blood pressure, pulse, respiration, skin colour and diaphoresis. The labour pain may have bouts of nausea, vomiting, increased anxiety, gesturing and excessive muscular excitability throughout the body.
Michel Tournaire, et.al, (2008) reported that many complementary and alternative methods have been used to reduce pain during labour and delivery. These methods are popular because they emphasize the individual personality and the interaction between mind, body and environment. They are attractive to people who
want to be more involved in their own care. Midwives, nurses are required to assist patient with psychological methods and in fact use alternative approaches more often.
Shuttle Brown, (2011) in recent research revealed that the non- pharmacological approach prevents suffering by enhancing the psycho emotional and spiritual components of care. In this method, the primary goal is not to make the pain disappear. Instead, the women is educated and assisted by her caregivers, child birth educators and support people to play an active role in decision making and using self- comforting techniques and non-pharmacological methods to relieve pain and enhance labour progress.
Lanane K., (2007), in one of the non-pharmacological method to relieve labour pain is the heat application. Heat is typically applied to the woman’s back, lower abdomen, groin and/ or perineum. Heat sources include a hot water bottle, warm compress, warm bath or shower. In addition to being used for pain relief, heat reduce muscle spasm, decrease joint stiffness, used to relieve chills or trembling, and increase connective tissue extensibility and hence muscle relaxation.
Dahlen , et al., (2007) conducted a study on perineal outcomes and maternal comfort related to the application of perineal warm packs in the second stage of labour. The study findings revealed that the application of perineal warm packs in late second stage significantly reduces third degree lacerations, labour pain and urinary incontinence.
Need for the Study
Worldwide every year approximately 211 million women experience the joy of pregnancy based on WHO report in 2005, whereas in India approximately 30 million women experience pregnancy annually. (UNICEF, 2005)
The management of labour pain is a major goal of intrapartum care. There are two general approaches, pharmacological and non-pharmacological. Pharmacological approaches are directed at elimination of the physical sensation of labour pain, whereas non-pharmacological approaches are largely directed towards prevention of sufferings.
Reassurance, guidance, encouragement and unconditional acceptance of coping style are used along with this alternative complementary medicine. So women perceive that they coped successfully with the pain and stress of labour and state that they are able to transcend their pain and experience a sense of strength and spiritual comfort during labour. The majority of obstetricians (68%) and midwives (78%) had formally referred a patient for use of one of the complementary therapies. Over 70%
of obstetricians and midwives considered massage, acupuncture, yoga, warm and cold compress to be useful and safe to use during pregnancy. (Penny Simkin, 2004)
Benny.C, (2003) conducted a study in St.Clares hospital among 50 primiparturients to evaluate the effectiveness of alternative and complementary therapies used during labour. She examined that these five methods (labour support, bath, heat packs, touch and massage) were effective for back pain relief. Critical evaluation of controlled studies of these five methods suggested that all five may be effective in reducing labour pain and improving the obstetric outcomes and they are safe when used appropriately.
Brenda Lane, (2009) in his recent research at Delhi, showed that 68% of mothers, when applied heat to the areas of pain during labour, blocks the pain signal to the mother’s brain. Heat is an effective tool to reduce labour pain. When heat is applied to the skin it stimulates the pain receptors, so that the transmission of pain to the brain is reduced. In the same way the heat distracts the mother’s attention from
pain perception. Considering all these advantages of heat application in order to reduce labour pain during first stage of labour, the researcher felt there is need to conduct a study on effectiveness of warm compress on level of labour pain during the first stage of labour.
Statement of the Problem
A Study to Evaluate the Effectiveness of Warm Compress in sacral area on Labour Pain during 1st stage of Labour among Primiparturients at Selected Hospital, Salem.
Objectives
1. To assess the level of labour pain among primiparturients during 1st stage of labour in experimental and control group.
2. To evaluate the effectiveness of warm compress in sacral area on level of labour pain during 1st stage of labour among primiparturients in experimental group.
3. To associate the level of labour pain among primi-parturients with their selected demographic variables in experimental and control group.
Operational Definitions Evaluate:
It refers to the statistical measurement on the level of labour pain among primiparturients in experimental group after warm compress in sacral area.
Effectiveness:
It refers to the significant reduction in level of labour pain in response to warm compress as determined by the differences between pre-test and post-test scores.
Warm compress:
It is the compress given in the sacral area with cotton cloth dipped in the warm water of temperature between 103oF and 105oF for 15 minutes duration for every one hour interval during first stage of labour.
Labour pain:
It is a painful uterine contraction at regular intervals with increasing intensity and duration during 1st stage of labour, which is measured by Numerical Pain Intensity Scale.
1st stage of labour:
It refers to the active and transitional phase of labour, which starts from 4cm dilatation and ends with 10cm dilatation of the cervix.
Primiparturients:
The women who is undergoing labour for the first time.
Assumption
1. Women those who are in labour may experience pain and it differs with each women.
2. Warm compress in sacral area will have significant effect on the level of labour pain during 1st stage of labour.
3. Warmth helps in vasodilatation and helps in release of endorphin and also used to relieve muscle tension that reduces labour pain.
Hypotheses
H1: There will be a significant difference in the level of labour pain during 1st stage of labour among primiparturients before and after warm compress in experimental group at P<0.05 level.
H2: There will be a significant difference in the pre and post test scores on level of labour pain during 1st stage of labour among primiparturients in experimental and control group P<0.05 level.
H3: There will be a significant association on level of labour pain among primiparturients with their selected demographic variables in experimental and control group at p<0.05 level.
Delimitations
The study is delimited to,
1. 4 weeks of data collection 2. 60 samples only.
3. Assessment of level of labour pain was limited to 1st stage of labour.
Projected outcome
This study was conducted to evaluate the effectiveness of warm compress in sacral area on labour pain among primiparturients. Findings of this study will help the staff nurse to practice in hospital and community. It can be used by the multipurpose health worker to reduce the level of labour pain at the peripheral level .
Conceptual Framework
Polit and Hungler state that the conceptual framework is interrelated concepts on abstractions that are assembled together in some rational scheme by virtue of this relevance to a common scheme. It is a device that helps to stimulate research and the extension of knowledge by providing both direction and impetus. The present study was aimed at determining the effectiveness of warm compress in sacral area on the level of labour pain among primiparturients. The conceptual framework of this study was derived from Gate control theory.
Gate control theory of pain:
The gate control theory first postulated by Ronald Melzack and Patrick David Wall in 1965. This theory suggests that for pain to pass through the gate there must be unopposed passage for nociceptive information arriving at the synapses in the substantia gelatinosa. The pain impulses will be carried out by the small diameters, slow conducting A,α and C fibres. Impulses travelled through small diameter fibres will open the pain gate and the person feels pain. Pain gate is also receiving impulses produced by stimulation of thermo receptors or mechano receptors transmitted via large diameter myelinated A, β fibres inhibit and super impose the small diameter impulse. Many non- pharmacological procedures such as application of pressure, TENS stimulate the nerve endings connected with large diameter fibres which can produce a reduction of pain by closing the pain gate.
If nociceptive information is allowed through the gate then this traffic will continue up the lateral spino-thalamic tract of the spinal cord to the thalamus, and from here to the cerebral cortex. As this stimulus passes through the brain stem it may cause an interaction between the grey matter and the mid brain, hence transmitting the pain.
Suppression system and their descending neurons can release an endogeneous opiate substance in to substantia gelatinosa at spinal cord level. The chemical nature of this endogeneous opiate, which may be endorphin or encephalin is such as to cause inhibition of transmission in the nociceptive circuit synapses. This is achieved by blocking the release of the chemical transmitter (substance P) in the pain circuit.
Cutaneous stimulus of a noxious type is applied such as application of warm compress and then the release of endorphin or encephalin could reduce pain at a spinal level.
Based on the principles of gate control theory, the following conceptual framework was developed. Methods used to reduce the labour pain are influenced by selected variables such as age, education, occupation, type of work and weeks of gestation.
Labour pain:
Labour pain is caused by uterine contractions which lead to cervical dilatation, effacement and uterine ischemia due to contractions of the arteries of myometrium.
Intervention:
Warm compress was given for 15 minutes duration in the interval of 1 hour for 4 times in experimental group.
Stimulation of pain receptors:
Contraction of the uterus stimulates the pain receptors in lower abdomen and the lumbar and sacral area of the back. In the control group more stimulation of pain receptors in these areas due to close contact between the contracting uterus and abdominal and lower back structures. In case of experimental group less stimulation of free nerve endings due to relaxation caused by warm compress. Here warm compress in the sacral area reduces muscle spasm and cause muscle relaxation.
Travelling of pain impulses:
Normally pain impulses are travelling through small short conducting A, α and C fibres. Impulses from stimulation such as warm compress, massage and TENS etc., will be quickly conducted by large myelinated A, β fibres. In the control group pain impulses will be conducted straight away by A, α and C fibres which reach the gate of pain and open the gate. In experimental group where the primi parturients
receive the warm compress, impulses will be conducted by fast conducting A, β large fibres which reaches the gate of pain very quickly.
Gating mechanism:
Pain impulses during the first stage of labour is transmitted through spinal nerve segment of T11-12 and accessory lower thoracic and upper lumbar sympathetic nerve which are travelled through (A, α and C ) small diameter and slow conducting myelinated fibres and reach the pain gate and open the gate, thus mother perceives pain. Impulses from warm compress travel through fast conducting myelinated A, β fibres which superimpose small fibres and closes the pain gate and 13 endorphin which is released from the inter neuron at spinal cord level which also closes the gate of pain. Thus mother perceives less pain in the lower lumbar and sacral region.
Figure – 1.1: Conceptual Framework based on Wall & Malzack’s Gate Control Theory Intervention Stimulation on
pain perception
Travelling of impulses
Gating mechanism Labour Pain
Demographic variables
• Age
• Education
• Occupation
• Type of work
• Weeks of gestation
Experimental group
Contracting uterus
Control group
Gate is opened
No intervention given.
warm compress was given.
Less stimulation of nerve ending Gate is
closed
Reduction in level of labour
pain
More pain Nerve stimulation of
free nerve ending
Gate is opened continuously
Large diameter fibres (A, β)
Small fibres impulses, endorphin release from intervention Gate is
opened
Small diameter fibre (A, δ,C)
C)
10
Summary
This chapter dealt with need for study, statement of the problem, objectives, assumptions, operational definition, hypotheses and conceptual framework.
CHAPTER – II
REVIEW OF LITERATURE
A literature review involves the systematic identification, location, scrutiny and summary of written materials that contain information on a research problem.
(Polit and Hungler, 2008)
The researcher has divided the review of literature under the following categories as,
Literature related to
1. Literature related to labour pain perception
2. Literature related to complementary and alternative therapies used during child birth.
3. Literature related to effect of moist heat application during childbirth.
4. Literature related to effectiveness of warm compress on level of labour pain.
1. Literature related to Labour Pain Perception
Meharunnisa khashkeli, (2008) conducted a descriptive study on pain perception during labour among labouring women at liagut university hospital, Hyderabad. 400 labouring women were selected by convenience sampling technique.
Two questionnaires were used to collect the data. Data was analysed on simple percentage basis. The study findings revealed among labouring women 136(34%) cases had acceptable birth experience, while 264(66%) patients found it as an exhausting painful experience and 87.5% had a positive attitude for future child bearing.
Neykon D., et.al. (2008) conducted a study to assess the level of knowledge, attitude on labour pain relief methods among women attending antenatal clinic in Nairobi. The researcher reported that 90% indicated that they would intend to have
some form of labour pain relief at their next delivery.18% had been offered some form of pain relief at their last delivery among those 82% of them had effective pain relief. The level of knowledge on labour analgesia was still inadequate even when most of the participants were literate.
Brown and Campbell, (2007) conducted a descriptive study to evaluate the intensity of the labour pain at 2 stages of cervical dilatation, (cervical dilatation of 2 to 5 cm and 6 to 10 cm.) at California university, Green Ville. 78 women in labour were selected through convenience sampling technique. The intensity of pain were assessed by three self-report measures such as Visual Analogue Scale(VAS), Present pain intensity Scale (PPI), McGill pain questionnaire, and one observational measure that is nurse rated behavioural index of pain. The data were analysed by descriptive and inferential statistics. The result of the study shows that Pain was characterised as discomfort during early dilatation with a mean score of 5.43 + 0.16. As the dilatation progressed, the pain was characterised as horrible and agony for both multigravida and primi gravid women with mean score of 8.63 + 0.84 and calculated ‘t’ value is 15.72 at p<0.05 level. The study shows that as the cervical dilatation increases there was a significant increase in the intensity of labour pain .
Bauer Roach and Dawson, (2006) investigated the perception of labour pain among parturient mothers at Megban university, Washington. 32 parturient mothers were selected by random sampling technique. M.C. Gill pain questionnaire and present pain intensity scale (PPI) was used to assess the level of labour pain. Data was analyzed and the findings revealed that when the pain level is mild to moderate, the observed mean score was 3.32+0.04 and a higher mean score of 8.46+1.32 was observed when the pain level is severe. The result of the study showed that, as the labour progress, the intensity of the labour pain is severe.
May AE, and Elton CD, (2005) conducted a descriptive study on labour pain at Leicester Royal University, London. Primiparturients who have been admitted in hospital for delivery were selected by convenience sampling technique. Pain assessment was carried out by direct questioning method using a 4- point verbal rating scale during first and second stage of labour. Data was analysed by descriptive and inferential statistics. The results of the study showed that 95% of the primipara mothers experienced progressively increasing pain during 1st stage from mild to severe which is spasmodic and radiating in nature (t=0.810,p<0.01). The study shows that labour is a painful event and the pain increases as the labour progress.
Baker, A., Ferguson, Roach et.al., (2002) conducted a study at Queen Elizabeth hospital, Australia, to examine the perception of pain among 13 labouring women and their attending midwives from the onset of labour to delivery. McGill pain questionnaire and Visual analogue scale was used to collect the data. The data was analysed and the findings revealed that there is a significant correlation between mothers and midwives pain score were similar at mild to moderate pain levels with a mean score of t(60)= 0.910 NS, and r= 0.75 at p<0.05 level and there is a significant difference in the level of pain with a mean score of t(25)= 2.301 at p< 0.05 level , when the pain level is severe. The study reveals that the mother and midwives pain score were similar at mild to moderate pain. But midwives significantly underestimated the pain intensity at levels that mothers described as severe.
Wijma, (2001) conducted a comparative study on labour pain among primi Para and multi Para women during first stage of labour.35primi parous and 39 multiparous women were selected for the study by using simple random sampling technique. verbal rating scale was used to collect the data. The data was analysed by
14
mean SD and ‘t’ test (t=0.735;p=0.001). The result of the study shows that primi Para women reported higher level of pain than the multiparaous women.
2. Literature related to Complementary and alternative therapy used during child birth
Jayabharathi, (2010) conducted a true experimental design on selected complementary therapies on labour pain among primi mothers at selected hospital, Chennai. Simple random sampling technique was used to select 60 primi mothers in which 30 were assigned to experimental and 30 in control group. Structured questionnaire, visual analogue scale and categorical numerical pain assessment scale was used to collect the data. The data were analysed and the findings revealed that the pretest mean score on labour pain was 5.66+2.33 and unpaired‘t’ value is 0.158. and the posttest mean score on labour pain was 3.33+1.86 and unpaired‘t’ value is 4.384 at p<0.001 level. Selected complementary therapies such as massage, breathing exercises, position change and heat application was effective in reducing labour pain.
Smith C.A, (2006) conducted a randomised controlled trial to investigate the effectiveness of complementary and alternative therapies on labour pain among women in labour. 1488 women were included in the study and the samples were distributed to acupuncture (n=496), audio-analgesia (n=24), acupressure (n=172), aromatherapy (n=22), hypnosis(n=729), massage (n=60) and relaxation technique (n=34). Data analysis was done and the findings revealed that the mother who received acupressure and hypnosis had effective pain relief relative risk of 0.70, 95%
of C.I and RR of 0.53, 95% of C.I respectively. The study finding reveals that acupuncture and hypnosis were effective in reducing labour pain.
Sylvia,T., Brown., Lee Ann., (2004) conducted a retrospective descriptive study to evaluate the effectiveness of non-pharmacological pain relief methods on
pain during intrapartum among parturient mothers at NewZealand. 46 samples among which 37 were primiparas and 9 were multiparas. Data was collected using 2 questionnaire, data was analyzed on simple percentage basis. The study findings revealed that 91.3% used breathing exercise, 87.0% used relaxation techniques, 50%
used acupressure, 56.5% used position change, 54.3% used massage, 28% used hot and cold therapy, 31.1% used guided therapy, 13% used music therapy and 10.9%
used aroma therapy. The study reveals that among the nonpharmacological methods used breathing exercise, relaxation technique, accupressure and massage were found to be most effective.
The CNM Data Group, (2003) conducted a survey to evaluate the method raised by nurse midwives in the birth centres to manage pain in labour. 4171 Women were selected by convenience sampling technique. Data was collected using structured questionnaire and analyzed using simple percentage basis. The results showed that the majority (84%) used non-pharmacological methods, while about (16%) used pharmacological method. Among non-pharmacological methods used, 55.2% of midwives adopted paced breathing, 42.4% adopted position change, 2.4%
used heat therapy and 30% of the midwives used narcotic analgesia as a pharmacological pain relief measure in labour.
3. Literature Related To Effect of Moist Heat Application During Child Birth Lenstrup C, et.al., (2008) conducted a study to assess the effectiveness of warm tub bath during delivery among primiparturients at selected hospital, Newyork.
80 women participated in experimental group and 80 in control group. The study findings showed a significantly faster cervical dilatation in the bathing group of (2.5 cm / hour) than the control group (1.26 cm/hour) and a decreased use of oxytocin. The mean pain scores in the bath group were higher (8.63+1.05) as the start of the study before the bath. They experienced a pain relief during bath (mean score =4.32+0.06,
t=5.234 at p<0.05 level) which was not observed in the control group. The study results showed that the need for oxytocin and meperidine was approximately twice as high in the control group and also 90% of women in experimental group had a desire for bath in their next labour.
Groelzka.M, et,al, (2006) conducted a comparative study on water birth Vs normal vaginal delivery on psychosomatic reactions among women in labour at selected maternity centre ,New York. Sample size was 90. Experimental group of 45 women bathed during 1st stage of normal labour and delivery was compared with a group of 45 women who gave birth in any other way. Analysis was done on simple percentage basis. After entering the pool, 69% of cases had reduced labour pain and.
In 58% of cases the time of delivery was advanced. The women described appeasement (78%), relaxation (67%), better opportunity to mid spasm rest (67%).
This study revealed that warm water bath decreases labour pain and advances delivery.
Wiley, (2005) conducted a study to evaluate the effectiveness of hydro therapy on psycho physiological symptoms during labour. A randomised pre-test, post-test group design was used. 18 samples were selected using convenience sampling technique. Visual analogue scale was used to assess the level of labour pain. The study results showed that in experimental group anxiety and pain scores were decreased compared to non-bathers (t= 3.654 at p<0.01 level). The study findings offer support for the therapeutic effect of warm water bathing in labour for acute, short term anxiety and pain reduction.
Lee man. L, et,al., (2004) reported in a survey, that warm water baths are increasingly available in hospital and birth centres. A recent report of first national United States survey of women’s child bearing experience found that 6% of women
used warm water baths during labour and of that 45% of found it very helpful for pain relief.
4. Literature related to effectiveness of warm compress on level of labour pain:
Moogambiga, (2010) conducted a study to evaluate the effectiveness of warm compress on labour pain among primiparturients at selected hospitals, Coimbatore.
Non probability convenience sampling technique was used to select 60 primiparturients among which 30 were assigned to experimental group and 30 in control group. Data was collected using structured interview schedule and numerical pain intensity scale. Data was analysed and the finding revealed that the pretest mean score was 6.90+ 0.88, and post test mean score was 3.43 + 0.56 and the The calculated paired ‘t’ value of experimental group was 6.55 at p<0.05 level. The study findings revealed that warm compress was most effective in reducing muscle spasm during labour pain, and it also improved maternal wellbeing.
Kalpana, (2008) conducted a study to compare the effectiveness of moist heat application versus massage on labour pain among primiparturients at selected hospitals, Salem. Quasi experimental design was employed for this study.
convenience sampling technique was used to select the samples. Sample size was 60.
Visual analogue scale was used to assess the level of labour pain. Data was analysed and the finding revealed that the pre test mean score was 5.77+ 1.02 and 5.30+1.02 and the post test mean score was 3.67+ 0.55 and 3.33+ 0.99 and the calculated paired
‘t’ value was 4.68 at p < 0.05 level. The study finding revealed that both moist heat application and massage therapy were effective in reducing labour pain and it improved psychological wellbeing of the mother.
Gowri, (2007) conducted a study to evaluate the effectiveness of moist heat application during 1st stage of labour among primiparturients at selected hospitals, Salem. A quasi experimental research time series design was used. The samples were
selected using non-probability convenience sampling technique. Sample size was 60.
Among them 30 primiparturients were in control group and 30 in experimental group.
Structured interview schedule was used to collect demographic variables and Visual Analogue Scale was used to assess the level of labour pain. Data was analysed and the calculated pre test mean and S.D were was 6.45+ 1.02 and the post test mean and S.D were was 4.42+ 0.72 . The calculated paired ‘t’ value in experimental group was16.65 which is significant at p<0.05 level. The research findings revealed that warm compress helps not only to reduce the labour pain, but also improves the psychological well-being and reduces anxiety.
CHAPTER III METHODOLOGY
The methodology of research indicates the general pattern of organizing the procedure for the gathering valid and reliable data for the purpose of investigation.
(Polit, D.F, and Hungler, 2003) Research Approach
Quantitative evaluative research approach was adopted for this study.
Research Design
Quasi experimental design involves the manipulation of an independent variable that is an intervention. Quasi experimental design lacks randomization to treatment groups. (Polit. and Beck 2004)
Quasi experimental design, in which time series with multiple institution of treatment design.
E = O1X1O2 O3X2 O4 O5X3 O6 O7X4O8
C = O1 -O2 O3 - O4 O5 -O6 O7 - O8
E : Experimental group.
C : Control group.
X1, X2, X3, X4 : Warm compress
O1, O3, O5, O7 : Pain assessment before intervention O2’O4, O6, O8 : Pain assessment after intervention
Figure-3.1: Schematic Representation of Research Design.
Research Design Quasi experimental design
Population
Primiparturients in first stage of labour
Sample
Primiparturients who are in active and transitional phase of first stage of labour
Experimental group n = 30
Control group n = 30
Tool
Structured interview schedule Numerical Pain Intensity Scale
Data Collection Procedure
Experimental Group Pre-test
Control Group Pre-test Intervention (warm compress) No intervention
Post-test Post-test
Demographic variables 1. Age
2. Education 3. Occupation 4. Type of work 5. Weeks of gestation
Data analysis
(Descriptive and inferential statistics) Setting
Salem polyclinic, Salem
Non probability convenience sampling technique
Population
Population may be classified into two types, 1. Accessible population
2. Target population Target population
In this research the target population is the primiparturients.
Accessible population
Refers to the aggregate of cases which confirm to the designed criteria, as which is accessible to the researcher as the pool of the subjects or objects. In this research, the accessible population were the primiparturients who are in the active phase of first stage of the labour in Salem Polyclinic, Salem.
Description of settings
Setting is the general location and condition in which data collection takes place for the study. (Polit, D.F., and Hungler, 2003).
The study was conducted in Salem Polyclinic, Salem. It is located at TVS Bus stop, Four Roads, Salem. It is 1km from New Bus stand. The selection for this area was on the basis of,
1. Geographical proximity 2. Availability of subjects
3. Economy of time and money access
4. Feasibility in terms of cooperation extended by the health team members in Salem Polyclinic, and the researchers familiarity with the setting in terms of professional experiences.
Sampling
• Sample
The sample of the study comprises of primiparturients who are in the active phase of first stage of labour.
• Sample size
The sample size was 60 primiparturients, 30 in experimental group and 30 in control group from Salem Polyclinic, Salem.
• Sampling technique
Sampling refers to the process of selecting the portion of population to represent the entire population. (Polit, D.F, and Hungler, 2003)
Non-probability convenience sampling technique was adopted for selecting the samples for the study.
• Criteria for sample selection Inclusion criteria
1. Primiparturients who are in active phase of 1st stage of labour.
2. Singleton fetus.
3. 37-40 completed weeks of pregnancy.
4. Those who can understand Tamil or English language.
Exclusion criteria
1. High risk Pregnancy.
2. Women who receives analgesia and anaesthesia.
3. Women who are not willing to participate.
Variables
Independent variable: Warm compress.
Dependent variable: Level of labour pain.
Demographic variables: Age, education, type of work, occupation, weeks of gestation.
Development of the Tool
The tool is a written device that a researcher uses to collect the data. After a careful review of literature, the researcher used the numerical pain intensity scale to asses the level of pain. However, the demographic variables were identified by the structured interview schedule.
Description of the Tool
The study consists of two sections, Section – 1: Demographic variables
It consists of 5 items related to personal and health variables. Verbal responses were obtained from the primiparturients regarding age, education, occupation, type of work, and weeks of gestation.
Section – 2: Numerical Pain Intensity Scale
A numerical pain intensity scale ranging from 0 to 10 are used to assess the level of labour pain among primiparturients.
Scoring Procedure
Table -3.1: Scoring Procedure Score Level of pain
0 No pain
1 – 3 Mild pain
4 – 6 Moderate pain
7 – 9 Severe pain
10 Worst possible pain
Level of pain was assessed before and after the interventions. The pregnant women were placed a score between 0 to10, after the verbalizations of women about her level of labour pain.
Validity and Reliability of the Tool Validity:
Polit, (1998) says that validity refers to the degree to which an instrument measures what it is supposed to be measured. The entire tool was validated by 7 experts, including 2 gynaecologists, 5 nursing experts. Experts were requested to judge the tool for its clarity, relatedness, sequence, meaningfulness, and content.
Suggestions were given by the experts and modified. The tool which was developed in English was translated into Tamil.
Reliability:
Reliability of an instrument is the degree of consistency measures that attribute it is supposed to be measured. (Polit and Hungler 1998 )
The reliability of the tool was done by inter rater method r = 0.98.
Pilot Study
Formal written permission was obtained from the managing director, Salem polyclinic, Salem, to conduct the pilot study from 27-6-11 to 3-7-11. Non-probability convenience sampling technique was used to select 6 primi parturients, among which 3 were assigned to experimental group and 3 were assigned to control group. After obtaining verbal consent from the primi parturients, demographic details were collected using structured interview schedule. The numerical pain intensity scale was used to assess the level of labour pain. Warm compress was given to the experimental group. Before and after intervention the level of pain was assessed in both groups.
The data was collected and interpreted. The researcher did not find any difficulty during pilot study. Hence it was continued in the main study.
Method for Data Collection Ethical consideration:
Prior to collection of data written permission was obtained from the Managing Director of Salem Polyclinic, Salem.
Informed consent was obtained from primi parturients.
Data collection procedure:
The data was collected after obtaining prior permission from 13.07.11 to 07.08.11 from the concerned authority to conduct the study. The data was collected for a period of 4 weeks. The researcher visited the labour room and the samples who fulfilled the inclusive criteria was selected by Non probability convenience sampling technique. Informed consent was obtained from the primiparturients. Structured interview schedule was used to collect the demographic details. The level of pain was assessed for the control group from 13.7.11 to 22.7.11 without any intervention.
For experimental group, warm compress was given in the sacral area with cotton cloth dipped in the warm water of temperature between 103oF and 105oF for 15 minutes duration for every one hour interval during first stage of labour for 4 times.
The level of labour pain was assessed before and after the intervention using numerical pain intensity scale consecutively.
Plan for Data Analysis
A master sheet was prepared with responses given by the samples and the data was analysed using descriptive and inferential analysis.
Summary
This chapter dealt with methodology. It consist of research approach, research design, population, setting, sampling, variables, description of tool, validity and reliability, method of data collection, pilot study and plan for data analysis.
CHAPTER – IV
DATA ANALYSIS AND INTERPRETATION
Analysis is a process of organizing and synthesizing data in such a way that research question can be answered and tested. (Polit and Hungler, 2003)
The term analysis refers to the computation of certain resources along with searching for patterns of relations that exists among data groups. Analysis of data in a general way involves a number of closely related operations, which are performed with the purpose of summarizing the collected data, organizing them in such a manner that they answer the research questions. (Kothari C.R, 1990)
This chapter present the Quasi experimental study attempted to evaluate the effectiveness of warm compress on labour pain among primiparturients at selected hospital, Salem.
Data was collected and analysed by the following sections, Section-A:
Distribution of primi-parturients according to their selected demographic variables in experimental and control group.
Section- B:
a. Distribution of primi-parturients according to the pre and post-test score on level of labour pain during first stage of labour in experimental group.
b. Distribution of primi-parturients according to the pre and post-test score on level of labour pain during first stage of labour in control group.
Section-C:
a. Mean, standard deviation, mean difference on level of labour pain among primiparturients in experimental and control group.
Section-D: Hypotheses testing
a. Mean, SD and t-value on level of labour pain during first stage of labour among primiparturients before and after warm compress in experimental group
b. Effectiveness of warm compress on level of labour pain among primiparturients in experimental and control group.
c. Association on level of labour pain among primiparturients with their selected demographic variables in experimental and control group.
Section-A
Distribution of primi-parturients according to their selected demographic variables in experimental and control group.
26.7%
33.33%
40%
26.7%
30%
40%
3.3%
0 10 20 30 40 50 60 70
Percentage of Primiparturients
18 – 20 yrs 21 – 25 yrs 26 – 30 yrs 31 – 35 yrs AGE IN YEARS
Experimental group Control group
Figure-4.1: Bar diagram shows percentage distribution of primiparturients according to their age in years.
The above figure represents that in experimental group 12(40%) of them belongs to the age group of 21-25 yrs, whereas in control group 12(40%) were belongs to the age group of 26-30 years.
6.7%6.7%
30%
23.3%
10%
23.3%
30%30%
23.3%
16.7%
0 10 20 30 40 50 60
Percentage of Primiparturients
Primary education
Higher secondary
Postgraduate
EDUCATIONAL STATUS
Experimental group Control group
Figure-4.2: Bar diagram shows percentage distribution of primiparturients according to their educational status.
The above figure shows that in experimental group 9(30%) of them were undergraduates and in control group 9(30%) of them were undergraduates.
36.7% 40%
63.3%
60%
0 10 20 30 40 50 60 70 80
Percentage of Primiparturients
Employed Unemployed OCCUPATION
Experimental group Control group
Figure-4.3: Bar diagram shows percentage distribution of primiparturients according to their occupation.
The above diagram shows that in experimental group 19(63.3%) of them were unemployed and in control group 18(60%) of them were unemployed.
16.7%
30%
83.3%
70%
0 10 20 30 40 50 60 70 80 90 100
Percentage of primiparturients
Sedentary work Moderate work WORK PATTERN
Experimental group Control group
Figure-4.4: Bar diagram shows percentage distribution of primiparturients according to their work pattern.
The above bar diagram shows that in experimental group 25(83.3%) of them were moderate workers and in control group 21(70%) of them were moderate workers.
10%
3.3%
36.7%
56.7%
53.3%
40%
0 10 20 30 40 50 60 70
Percentage of primiparturients
38 weeks 39 week s 40 weeks
WEEKS OF GESTATION
Experimental group Control group
Figure-4.5: Bar diagram shows percentage distribution of primiparturients according to their weeks of gestation.
The above diagram shows that in experimental group 16(53.3%) of them were in 40 weeks of gestation and in control group 17(56.7%) of them were in 39 weeks of gestation.
Section - B
a) Distribution of primi-parturients according to the pre and post-test score on level of labour pain during first stage of labour in experimental group
60 100
40
3.3
96.7
60 96.7
3.3
100
40
3.3
96.7 96.7
3.3
0 10 20 30 40 50 60 70 80 90 100
O1 O2 O3 O4 O5 O6 O7 O8
LEVEL OF LABOUR PAIN
Percentage of primiparturients
Worst Possible Pain Severe Pain Moderate Pain Mild Pain
Figure-4.6: Bar diagram shows percentage distribution primi-parturients according to the pre and post-test score on level of labour pain during first stage of labour in experimental group.
O1,O3,O5,O7 - Pretest O2,O4,O6,O8 - Posttest
The above figure shows that in experimental group the pre-test scores on the level of labour pain (O1, O3,O5, O7) were 30(100%) of them had moderate pain, and 29(96.7%) of them had severe pain, 30(100%) of them had severe pain and 29(96.7%) of them had worst possible pain respectively.
In post-test scores on level of labour pain (O2, O4, O6,O8) were 18(60%) had mild pain, 29(96.7%) had moderate pain, 18(60%) had moderate pain and 29(96.7%) had severe pain respectively.
b) Distribution of primi-parturients according to the pre and post-test score on level of labour pain during first stage of labour in control group
73.3
6.70 26.7
93.30
96.7 96.7
13.3
3.3 3.3
86.7
100 100
73.3 26.7
0 10 20 30 40 50 60 70 80 90 100
O1 O2 O3 O4 O5 O6 O7 O8
LEVEL OF LABOUR PAIN
Percentage of primiparturients
Worst Possible Pain Severe Pain Moderate Pain Mild Pain
Figure-4.7: Bar diagram shows percentage Distribution of primi-parturients according to the pre and post-test score on level of labour pain during first stage of labour in control group
O1,O3,O5,O7 - Pretest O2,O4,O6,O8 - Posttest
The above figure shows that in control group the pre-test scores on the level of labour pain (O1, O3, O5,O7 ) were 22(73%) had mild pain, and 29(96.7%) had moderate pain and 26(86.7%) had severe pain and 30(100%) had severe pain respectively.
Whereas in post-test scores on the level of labour pain (O2, O4, O6,O8) were 28(93.3%) had moderate pain, 29(96.7%) had moderate pain and 30(100%) had severe pain and 22(73.3%) had worst possible pain respectively.
This finding reveals that the level of labour pain is reduced in experimental group than control group among primiparturients.
38
Section - C
a) Mean, standard deviation, mean difference on level of labour pain during first stage of labour among primiparturients in experimental and control group.
Table-4.2:
Mean, SD and mean difference on level of labour pain in experimental and control group.
n=60 Series of
observation
Experimental group (n=30) Control group (n=30)
Mean SD Mean
difference
Mean SD Mean
difference
O1 5.46 0.57
2.03 3.30 0.53
0.13
O2 3.43 0.56 3.43 0.50
O3 7.43 0.56
2.43 5.13 0.57
0.03
O4 5.00 0.52 5.16 0.59
O5 8.60 0.49
2.26 6.90 0.40
0.06
O6 6.33 0.71 6.96 0.49
O7 9.96 0.18
1.86 8.46 0.50
0.07
O8 8.10 0.71 8.53 0.50
O1,O3,O5,O7 – Pretest O2,O4,O6,O8 - Posttest
The above table shows that the mean difference of experimental group values are 2.03, 2.43, 2.26, and 1.86 respectively, where as in control group values are 0.13, 0.03, 0.06 and 0.76 respectively.
39
Section-D Hypotheses testing
a) Mean, SD and t-value on level of labour pain during first stage of labour among primiparturients before and after warm compress in experimental group
Table-4.3 : Mean, standard deviation and ‘t’ value on level of labour pain in experimental group
n=30
Series of observation
Experimental group
Mean SD ‘t’ value
O1 5.46 0.57 16.65*
O2 3.43 0.56
O3 7.43 0.56 15.52*
O4 5.00 0.52
O5 8.60 0.49 17.95*
O6 6.33 0.71
O7 9.96 0.78 12.47*
O8 8.10 0.71
* significant at P<0.05 level; table value – 1.961; df - 58 O1,O3,O5,O7 – Pretest
O2,O4,O6,O8 - Posttest
The table shows that ‘t’ value of experimental group are 16.65, 15.52, 17.95 and 12.47 respectively. Hence H1 is retained.
40
b) Effectiveness of warm compress on level of labour pain among primiparturients in experimental and control group.
Table-4.3:
Mean, SD and t-value on level of labour pain during first stage of labour among primiparturients in experimental group and control group
n=60 Series of
observation
Experimental group (n=30) Control group (n=30) Mean SD ‘t’ value Mean SD ‘t’ value
O1 5.46 0.57
16.65*
3.30 0.53 1.07
O2 3.43 0.56 3.43 0.50
O3 7.43 0.56
15.52*
5.13 0.57 0.57
O4 5.00 0.52 5.16 0.59
O5 8.60 0.49
17.95*
6.90 0.40 1.00
O6 6.33 0.71 6.96 0.49
O7 9.96 0.78
12.47*
8.46 0.50 0.81
O8 8.10 0.71 8.53 0.50
* significant at P<0.05 level; table value – 1.961; df - 59 O1,O3,O5,O7 – Pretest
O2,O4,O6,O8 - Posttest
The table shows that ‘t’ value of experimental group are 16.65, 15.52, 17.95 and 12.47 whereas in control group ‘t’ values are 1.07, 0.57, 1.00 and 0.81 respectively.
So, it is proved that warm compress is effective in reducing labour pain. Hence H2 is retained.
