CHAPTER – II

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A STUDY TO ASSESS THE EFFECTIVENESS OF MUSIC THERAPY ON PAIN PERCEPTION AND ANXIETY LEVEL OF PRIMIGRAVIDA

MOTHERS IN FIRST STAGE OF LABOUR IN A SELECTED HOSPITAL AT COIMBATORE

M.Sc (NURSING) DEGREE EXAMINATION BRANCH III– OBSTETRICS AND GYNAECOLOGY

R.V.S COLLEGE OF NURSING SULUR, COIMBATORE

THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY CHENNAI – 32.

MASTER OF SCIENCE IN NURSING (2008 -2010)

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A Study to Assess the Effectiveness of Music Therapy on Pain Perception and Anxiety Level of Primigravida Mothers in First Stage of Labour in a

Selected Hospital at Coimbatore

Examination : M.Sc (Nursing) Degree Examination Examination Month & Year :

Branch & Course : III- Obstetrics & Gynecological Nursing

Register Number : 30084623

Institution : RVS College of Nursing, Sulur, Coimbatore

Sd:______________________ Sd:______________________

( ) ( )

Internal Examiner External Examiner

Date:_________________ Date:_________________

The Tamilnadu Dr. M.G.R. Medical University Chennai – 32.

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ABSTRACT

“A study to assess the effectiveness of music therapy on pain perception and anxiety level on primigravida mothers in first stage of labor in a selected hospital at Coimbatore”.

The aim was to assess the pain and anxiety of primigravida mothers during labor and provide music therapy to reduce anxiety and improve pain perception and find the effectiveness of music therapy on them.

The conceptual framework used in this study was Callista Roy’s Adaptation Theory (1996). A quasi experimental post test design was used in the study. The data was collected from 30 primigravida mothers out of which 15 were taken as experimental and 15 as control group who were admitted in labor room with 3cm cervical dilatation in a selected hospital at Coimbatore.

The data was collected by interview method and observation checklist. The interview schedule consisted of demographic data, numeric pain scale, anxiety checklist, record for listing to music, views of mother regarding music therapy.

Demographic data contains seven item (age, religion, education, occupation, area of residence, type of family, like to music)

Pain was assessed using numeric pain scale. Hourly pain was checked starting from 3cm to end of first stage of labor. Record was maintained for listing to music, the starting time, type of music, removing time, total her heard and total her interrupted. For anxiety assessment 12 items (8 regarding anxiety of mothers and 4 regarding anxiety of baby) and they were asked to rate their view (strongly agree, agree, not sure, disagree, strongly disagree) at last the views of mothers was also collected for conclusion which included 5 questions. The data analysis includes descriptive and inferential statistics.

The mean pain score of the experimental group was 6.9 and that of control group was 7.33 with a mean difference of 0.43. Statistically there is a significant difference between mean pain score of the experimental and control group (t=3.09*, df=28,p<0.01). The overall anxiety of experimental group and control

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group was at moderate level in first phase, as the labor progress, the reduction of anxiety was seen more on the experimental group mothers than the control group mothers. However in the third phase a different pattern was observed, more mothers in control group showed mild anxiety.

The mean anxiety score of experimental group related to mother is 20.04 and control group 22.39 with a difference in the mean score of 2.35. Statistically there was a significant difference between the mean anxiety score of the two groups (anxiety related to mother t=3.45, df=28 p<0.01). Similarly in the mean score related to babies it was more in control group 8.7 compared to experimental groups 7.5 with a difference in mean score of 1.2. The mean anxiety score of control group was (31.2) higher than that of the experimental group (27.5).

Statistically there was a significant difference in the anxiety level between experimental and control group (t-3.2*, df-28, p<0.01).

Most of the mothers in experimental group (33%) had listened Karnatic instrumental and Western instrumental music. Four mothers listened to Western instrumental and four mothers listened to Karnatic vocal and Western instrumental music. A few mothers listened to all (Karnatic vocal, Karnatic instrumental, Western instrumental). Most of the mothers delivered within 7-8 hrs after listening to music for 1-2 hours. Correlation was examined between the duration of music listened and average anxiety by Karl Pearson Correlation Co-efficient. The relationship between duration of music listened and average anxiety showed no correlation (r = 0.09).

In the experimental group regarding the liking to music all the mothers (100%) expressed that they felt relaxed, secured, and less anxious and had increased more self control. Majority of the experimental group mothers (67%) expressed that music was enjoyable and helped in diversion from pain. Ten (67%) mothers liked music very much.

The study concludes that music therapy has its own effect in reducing anxiety level and improving pain perception in primigravida mothers.

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ACKNOWLEDGEMENT

First I would like to appreciate and thank the respondents for their participation and cooperation to conduct this study successfully.

It is my long desire to express my profound gratitude and exclusive thanks to Prof. Dr.Amamma Prabhakar, M.Sc (N), Ph.D, the visiting professor, RVS College of Nursing, Sulur. It is a matter of fact that without her esteemed suggestions, highly scholarly, touch and piercing insight from inception till completion of the study, this work could not have taken shape.

I would like to take this opportunity to convey my sincere and heartfelt thanks to Prof. Mrs. Mable Shivkar, M.Sc (N), my guide and Principal, RVS college of Nursing, Sulur, for her guidance and motivation which have been substantially responsible for my thesis.

I wish to express my thanks to Prof. Saramma Samuel, M.Sc (N), Vice Principal, RVS College of Nursing, Sulur, for her support.

I extent my gratitude to Mrs. Jessy Rani, M.Sc (N), Reader, RVS College of Nursing, for her guide, support and encouragement.

I express my heartfelt thanks to you. Mrs. Suja Santhosh, M.Sc (Statistics) B.Ed, for her expert opinion on statistical aspects and also for her guidance and encouragement.

I express my heartfelt thanks to Mrs. Suba, M.Phil (Food Science and Nutrition), for her expert opinion on statistical aspects and also her guidance and encouragement.

My deepest gratitude goes to Dr. Latha Prasanna, MBBS, DGO, her perseverance time for content validity. This has really proved valuable to me.

I express my sincere thanks to Dr. Bhanumathi, MBBS, DGO, HOD, of Obstetrics and Gynecology department GKNM hospital for her valuable information’s and guidance.

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I express my thanks to Mrs. Annapoorni, M.Sc (N), and Miss. Marial, M.Sc (N), for this support and guidance for developing the tool.

Finally I would like to thank for the excellent support and cooperation I received from my classmates, family members for extending me the necessary support and guidance and also for putting up with my absence during the time I had to prepare this detailed report.

I express my sincere gratitude to Mr. Kannan, Mr.Mohan, Mrs.

Kalaivani, Mrs. Stella Librarian who helped me for reference throughout my study and for this cooperation.

I express my thanks to SRS for their help in typing and printing works of the thesis.

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CHAPTER – I

INTRODUCTION

“The principle underlying music therapy is that physical health result from a healthy mind. The right type of music helps a person relax by soothing the nerves”.

(Swami Ganpati Sachidananda) BACKGROUND OF THE STUDY

Literature suggests that primigravida reports more intense sensory pain during first stage of labor and more effective pain in all stages of childbirth even though they received more analgesia. Birth is a family affair. The reproductive health of the total family is the corner stone of a healthy society. Many women approach childbirth with a fear of pain. The process of labor and the forthcoming birth may produce normal anxiety that is no more than a healthy anticipation of the events to come.

Music stimulates the release of endorphins and reduces the need for analgesic drugs. It distracts from the perception of pain and relieves anxiety and depression.

Music is being heard, the signals sent to the brain are sensory as real signals sent to the brain when pain is felt. Sensory output comes from the limbic system, which is usually considered the site of emotional synthesis (Cooper 1999).

Research has shown that those women participating in a music therapy assisted childbirth programme experience significantly more positive perceptions of their childbirth experience than those not participating in such a programme (Clark, Mc Carkle, Williams).

1 Angel Rajkumari (2008) conducted a study on effectiveness of music therapy in terms of level of pain perception among primigravida mother in Southern Railway Hospital, Chennai. Based on non probability purposive sampling technique, 30 mothers were allotted for experimental and 30 mothers were allotted for control group, music therapy was given to assess the level of labor pain perception. The

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pre and post assessment level of pain was obtained using a modified combined Numerical categorical pain intensity scale. The findings of the study showed that comparison of pre and post assessment ‘t’ value in session 1 was 21.53 and in section II the ‘t’ value was 21.05 which were significant at p< 0.001 level. It reveals that the primigravida mother’s pain perception level was reduced after music therapy.

Lilly Podder(2005-2006) had done a study to evaluate the effects of music therapy on anxiety level, pain perception and labor outcome in primipara mothers during first stage of labor in a selected hospital at Kolkota. Pretest post test control group design was selected. Out of 60 samples 30 experimental group and 30 control group were taken. The tool used for the study were structured interview schedule for demographic data, structured record analysis proforma for labor assessment, Speil- Berger’s State anxiety scale for anxiety assessment, Numeric pain intensity scale for pain assessment and structured performa for fetal and maternal outcome.

The study reveals that those mothers who were exposed to music therapy experienced significantly less pain perception and reduction in anxiety level during labor than the control group mother.

Phumdoung, Good M.(1984) conducted a study to find the effect of music on sensation and distrust of pain in those primiparous women during the active phase of the labor. The Gate Control Theory of pain was the theoretical framework for the study. Randomization with a computerized minimization program was used to assign women to a music group (n=55) or a control group (n=55). Women in the intervention group listened to soft music without lyrics for 3 hours starting early in the active phase of labor. Dual visual analog scales were used to measure sensation and distress of pain before starting the study and at 3 hourly post tests. While controlling for post test scores, one way repeated measures analysis of covariance indicated that those in the music group had significantly less sensation and distress of pain than did the control group F(1,107)=18.69, P<.001, effect size=.15 and F(1,107)=14.87, (p<.001, effect size=.12), respectively. Sensation and distress significantly increased across the 3 hours in both groups (p<.001), except for distress in the music group during the first hour. Distress was significantly lower than

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sensation in both group (p<.05). In this controlled study, music at mild to moderate strength intervention constantly provided significant relief of severe pain across 3 hours of labor and delayed the increase of affective pain for I hour.

Clark (1986), Winslow (1981) found that music serves several functions in the natural childbirth process including attention focusing, distraction from pain, stimulating pleasure responses, focusing breathing and as a conditioned stimulus for relaxation. There were 20 subjects in this study. Thirteen experimental subjects received 6 prenatal music training sessions with a music therapist. Seven control group subjects did not receive the music therapy. After birth, the music therapist administered a childbirth experience questionnaire to each subject. Results indicated that the music group had higher success scores on 5 out of 7 indices of childbirth process. Overall, findings suggested that music therapy may successfully contribute to reducing anxiety during childbirth, as well as augment positive feelings of support throughout the childbirth experience.

Music therapy treatment for mother during childbirth is highly effective and it significantly decrease the levels of anxiety Winslow (1986).

Music can also be used to direct attention away from pain. While the subjective experience of pain is not reduced, sound stimulation can effectively distract the patient and provide a cognitive strategy for pain control and suppression of pain responses Clark et al (1981).

Relaxation during childbirth ensure adequate oxygenation to vital areas and minimize both physical and psychological fatigue. Most relaxation training exercise use a trigger stimulus for learned relaxation response and music has been shown to have excellent potential as a conditioned stimulus for relaxation M C Kinney (1990) The field of music therapy had grown and developed for the period of last 20 years. Clark, Mc Carkle, William found that music serves several functions in the natural childbirth process including attention focusing, distraction from pain, stimulating pleasure responses, focusing breathing, and a conditioned stimulus for relaxation.

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NEED FOR THE STUDY

Pain and anxiety has been identified as one of the most frustrating problem in primigravida mothers in labor room.

The mothers who were exposed to music therapy experienced significantly less pain perception during labor than the control group mothers MM Con Mullana, Ambala Henyana (2005-2006).

Livingston (1979) conducted a study in music therapy to enhance relaxation and facilitate controlled breathing and sensory stimulation in delivery.

During the clinical posting in the labor room, the investigator has seen that women admitted in the labor room, especially primigravida women were crying and shouting in the latent phase (or) first stage of labor and often asked many questions about the labor process and they requested the doctors to do Caesarean section because of poor pain perception. Even though mothers undergo counseling classes before delivery, the primigravida mothers will be having some anxiety. The investigator found that the pain perception of each mother is different and want to assess the effectiveness of music therapy to reduce pain during first stage of labour.

The investigator conducted the study in a set up where no counseling or alternative methods were used.

During labor most of the women were unable to cope with the labor process because of profound anxiety regarding labor process. So many alternative methods are being used to reduce pain and anxiety during labor. Among them music therapy is one of the innovative method. Music diverts the concentration of mother from pain and subsequently anxiety also reduces.

STATEMENT OF THE PROBLEM

An experimental study to assess the effectiveness of music therapy in pain perception and anxiety level in first stage of labor among primigravida mothers in a selected hospital at Coimbatore.

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AIM OF THE STUDY

To assess the pain perception and anxiety level of primigravida mothers during labor, to provide music therapy and to find the effectiveness of music therapy in pain perception and anxiety level.

SPECIFIC OBJECTIVES

1. To assess and compare the level of pain in experimental and control group in first stage of labor.

2. To assess and compare the level of anxiety related to mothers in experimental and control group in three phases of first stage of labor.

3. To assess and compare the level of anxiety related to babies in experimental and control group in three phases of first stage of labor.

4. To assess and compare the overall anxiety of mothers in experimental and control group in three phases of first stage of labor.

5. To associate the duration of music listened and average anxiety of mothers in experimental group.

6. To identify the view of experimental group mothers regarding music therapy in experimental group.

HYPOTHESIS

H1 - There is a significant difference between pain perception of primigravida mothers of experimental and control group in first stage of labor.

H2 - There is a significant difference between overall pain perception of primigravida mothers of experimental and control group in first stage of labor.

H3 - There is a significant difference between the level of anxiety among primigravida mothers of experimental and control group related to mothers and babies in first stage of labor.

H4 - There is a significant difference between overall anxiety of primigravida mothers of experimental and control group in first stage of labor.

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OPERATIONAL DEFINITION Effectiveness

It refers to the outcome or result of the music therapy in primigravida mothers in tolerating pain and anxiety level during the first stage of labor.

Primigravida

The normal full term women who is admitted for first delivery.

First Stage of labor

The period of true labor pain with regular rhythmic contraction and cervical dilatation from 3cm to the full dilatation of cervix.

Anxiety

It refers to the generalized feeling of fear and uneasiness of the primigravida mother in first stage of labor.

Pain

An unpleasant bodily sensation produced due to contraction of uterus during labor.

Music therapy

Playing the music through earphone to the primigravida mothers as an intervention to tolerate pain and reduce anxiety during the first stage of labor.

ASSUMPTION

1. Music therapy can change pain perception of primigravida mothers after listening to music.

2. Music therapy can change anxiety level of primigravida mothers after listening to music.

3. Music therapy can improve the confidence level of primigravida mothers in first stage of labor.

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DELIMITATION The study is delimited to

¾ only primipara mothers

¾ mothers who like to hear music

SCOPE OF THE STUDY

The study highlights the effectiveness of music therapy in reducing anxiety and improving pain perception of primigravida mothers in first stage of labor. The study shows a difference in pain perception among experimental group and control group mothers. The level of anxiety is more in control group than experimental group. The study shows that music therapy can be used to reduce anxiety and improve pain perception in mothers during first stage of labor.

CONCEPTUAL FRAMEWORK

A conceptual model can be defined as a set of concepts and those assumptions that integrated them in to a meaningful configuration (Fewett, 1980).

Theoretical model for this study was derived from Callista Roy’s Adaptation Theory (1996). Roy employs a feedback cycle of input, through put and output.

Input is defined as stimuli, which can come from the environment or from within a person. Stimuli are classified as focal (immediately confronting the person), contextual (all other stimuli that are present), or residual (non specific such as cultural beliefs). Input also includes a person’s adaptation level (the range of the stimuli to which a person can adapt easily).

Throughput makes use of a person’s processes and effectors. “Processes’’

refers to the control mechanisms that a person uses an adaptive system. “Effectors’’

refers to the physiological function, self concept, and role function involved in adaption. The adaptive modes are the ways that a person adapts through physiological needs, self concepts and role function and inter dependant relation. In the adaptive system, system is defined as self parts connected to function as a whole for some purpose and it does by virtue of the inter dependence of its parts. Adaptive 7

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means that the human system has the capacity to adjust effectively to change environment. The adaptive system is regarded as a holistic system. This has two major internal control process called regulator and cognator sub system. These systems are viewed as innate or acquired copying mechanisms used by the adaptive system respond to change internal and external system. Innate copying mechanisms are generally determined and are generally viewed as automatic process. Acquired coping mechanisms are developed through process such as learning.

The regulator sub system responds automatically through neural, chemical and endocrine coping process. The cognator sub system responds to input from external and internal stimuli that involves physical, physiological, psychological and social factors including regular subsystem outputs. The regulator and cognator activity is manifested through the coping behavior in four adaptive modes that is through physiological needs, self concepts, and role function and interdependence relations.

Andrew and Roy (1991) explained that impacts from the person have been termed as stimuli and may come externally from the environment (external stimuli) and internally from the self (internal stimuli). The output from the adaptive system is effective and ineffective responses.

The modified model in this study explains the output as the focal stimuli (internal stimuli) namely pain perception and anxiety during labor. The contextual stimuli (contextual stimuli) are age, religion, occupation, area of residence, type of family. The coping mechanism of the cognator and regulator subsystem occurs through music therapy. The investigator has given music therapy to the experimental group during first stage of labor to primigravida mothers. The adaptive responses among the experimental group women are perception of less pain and anxiety. In control group the investigator has not done any intervention.

Figure 1 highlights the conceptual framework based on Roy’s Adaptation Model (1991).

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Figure-1 Roy’s Adaptation Model (1991) WITHOUT

Adaptation

Mal Adaptation WITH

INPUT

Experimental group

Control group

Decreased level of anxiety Decreased pain

perception

THROUGH PUT OUTPUT

MUSIC THERAPY

Effective Coping

Ineffective

Coping Increased Level of

anxiety Increased Pain

perception FOCAL STIMULI

Anxiety Pain perception CONTEXTUAL

STIMULI Age Type of Stimuli

Religion Education Family size Age of marriage

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0 2 4 6 8 10 12

1 2 3 4 5 6 7 8 9 10

Hours of labor

Mean pain score

Experimental Control

Figure-2 Pain perception for each hour in experimental and control group.

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CHAPTER – II

REVIEW OF LITERATURE

A review of literature is an eventual aspect of scientific study. It involves the systematic identification, location, serving and summary of the written materials that contain information on a research problem. It broadens the views of the investigator regarding the problem under investigation, helps in focusing on the issues specially conserving the study.

This chapter deals with the information collected in relation to the present study.

The literatures have been organized as follows:

1. Literature related to pain and anxiety of primigravida mothers.

2. Literature related to effect of music on pain perception.

3. Literature related to effect of music on anxiety perception.

1. Literature related to pain and anxiety of primigravida mothers

Okayam Hisayo Japan (2005) conducted a study on anxiety of primigravida and multigravida mothers. The subjects were 188 primigravida and 142 multigravidas with no obstetric trouble or complications. A cross-sectional, anonymous, and self recording questionnaire was used for collecting data. As a result of the analysis, it was proved that “acceptance of pregnancy” and

“relationship with mother” in the early stage and “concern for well being of self and baby” and “acceptance of pregnancy” in the middle and last stages, are significant factors influencing their anxiety of primigravidas. On the other hand, for multigravida as the “relationship with husband” in the early stage, “concern for well being of self and baby” and “acceptance of pregnancy” in the middle stage, and

“concern for well being of self and baby”, “acceptance of pregnancy”, and

“preparation for labor” in the last stage are significant factors.

Jonansson F. G (2001) had done a study on progression of labor pain in primipara and multiparas. Primigravida reported more intense sensory pain during 9

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first stage of labor even though they received analgesia. The author noted that non pharmacologic methods of pain relief may be useful for reducing the affective component of pain, but that analgesia was more effective lowering sensory pain intensity.

Catherin (2000) reported that pain in the first stage of labor is mostly due to cervical stretching. With intense pain, sensations may also be felt above and below these areas, that is, in the upper thighs and the umbilical region.

Wing Cheung, Wan Yim (1981) had done a study on maternal anxiety and feelings of control during labor. An exploratory descriptive correlation design was adopted. Data were collected on three occasions, during latent phase of labor, active phase of labor and within 24-48 hours after delivery. Correlation co-efficient test indicated a significant negative relationship between the feelings of control and maternal anxiety during labor.

Ludingtone (1980) conducted a study by comparing different pain syndromes. He found that average labor pain syndromes and average labor pain scores were higher in both primi and multiparous women.

2. Literature related to effect of music on pain perception.

Angel Rajkumari (2008) conducted a study on effectiveness of music therapy in terms of level of pain perception among primigravida mother in Southern Railway Hospital, Chennai. Based on non probability purposive sampling technique, 30 mothers were allotted for experimental and 30 mothers were allotted for control group. Music therapy was given to assess the level of labor pain perception. The pre and post assessment of level of pain was obtained using a modified combined Numerical Categorical Pain Intensity Scale. The findings of the study showed that comparison of pre and post assessment ‘t’ value in session 1 was 21.53 and in session II , the ‘t ’value was 21.05 which were significant at p<0.01 level. It reveals that the primigravida mother’s pain perception level was reduced after music therapy.

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Lilly Podder (2005-2006) conducted an experimental study to evaluate the effects of music therapy on anxiety level, pain perception and labor outcome in primipara mothers during first stage of labor in a selected hospital at Kolkota.

Pretest post test control group design was selected. Out of 60 samples 30 were assigned to experimental and 30 were assigned to control group. The tool used for the study was a structured interview schedule for demographic data, structured record analysis proforma for labor assessment, Speil-Berger’s State Anxiety Scale for anxiety assessment, Numeric Pain Intensity Scale for pain assessment and structured proforma for fetal and maternal outcome. The study reveals that those mothers who were exposed to music therapy experienced significantly less pain perception and reduction in anxiety level during labor than the control group mothers.

In a study conducted by Brawing (2000) the planned use of music by mother and care giver enhanced prenatal preparation for birth, and was found to be an important adjunct to pain and anxiety management during labor and delivery.

According to Standing (1989) music coupled with relaxation techniques, such as progressive muscle relaxation, imaging, deep breathing and suggestion, has been effective in facilitative relaxation and reducing percieved pain.

Phumdoung, Good. M (1984) conducted a study to find the effect of music on sensation and distrust of pain in those primiparous women during the active phase of the labor. The gate control of pain was the theoretical framework for the study. Randomization with a computerized minimization program was used to assign women to a music group (n=55) or a control group (n=55). Women in the intervention group listened to soft music without lyrics for 3 hours starting early in the active phase of labor. Dual visual analog scales were used to measure sensation and distress of pain before starting the study and at 3 hardly post tests. While controlling for post test scores, one way repeated measures analysis of covariance indicated that those in the music group had significantly less sensation and distress of pain than did the control group F(1,107)=18.69, p<.001, effect size =.15, and F(1,107)=14.87, p<.001, effect size=12 respectively. Sensation and distress significantly increased across the 3 hours in both groups (p<.001), except for distress

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in the music group during the first hour. Distress was significantly lower than sensation in both group (p<.05). In this controlled study, music a mild to moderate strength intervention constantly provided significant relief of severe pain across 3 hours of labor and delayed the increase of affective pain for 1 hour.

Henser, Larson and Connell (1983) studied the use of music to enhance relaxation and decrease pain responses in mothers during child birth. The music therapist used music to cue rhythmic breathing, assist the mothers in relaxation, prompt positive associations, and help focus attention on the music as a diversion from pain and hospital sounds. A sample of 7 Lamaze trained mothers were used and subjects served as their own controls. Two individual music therapy sessions were conducted with the subjects prior to the birth experiences. During labor each mother experienced periods of music and non music were observed. One week after the delivery each mother was given a post delivery questionnaire and was asked how the music helped her concentrate, relax, and whether it helped it with rhythmic breathing. Results indicated that all the mothers had fewer pain responses in the music versus no music condition and that music aided concentration, relaxation, cued breathing, and diverted attention from pain.

Codding (1982) observed less perceived pain while. Win our (1984) noted greater relaxation, shorter labor, and the less pain medication with women for whom music was provided.

Dexter. F (1981) conducted a study on the effects of listening to music as a non invasive nursing method of pain control. The effects of soothing and stimulating music on pain and tactile thresholds, heart rate and blood pressure were determined on healthy female volunteers (N=10) in laboratory settings. Data were analyzed by ANOVA for repeated measures and post comparison tests. Soothing music significantly elevated pain thresholds, but not tactile thresholds. Stimulating music significantly elevated pain thresholds as well as tactile thresholds. Neither stimulating nor soothing music had a significant effect on autonomic activity. Based on the results of this laboratory study and studies, the effects of listening to music on people in pain warrants further examination.

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Locsin (1981) used music with postoperative obstetric and gynecological patients and observed a decrease in overt pain reactions during the first 48 hours following surgery. In addition, they found that those patients who used music required less post operative pain medications than these who did not.

3. Literature related to effect of music on anxiety during labor.

Lucy Newmark Sammours (2004) conducted a study to determine factors affecting the use of music by women during childbirth and to compare the frequency of actual music use during childbirth and during prenatal labor. Results demonstrated that music provides an adjunct to childbirth that is highly desirable for some women, while unappealing or inconvenient for others.

Jaisankar (2003) conducted a study to investigate the effects of music therapy on women’s physiologic measures, level of anxiety, and satisfaction during cesarean delivery. Sixty four women who were planning to have a cesarean delivery were randomly divided into an experimental and a control group. The experimental group received routine care and music therapy, whereas the control group received routine care only. Results indicated that, compared to the control group the experimental group had significantly lower anxiety and a higher level of satisfaction regarding the cesarean experience.

Leibman (1989) observed significantly reduced state of anxiety in adolescents who received music assisted relaxation to curing during the third trimester. In addition, muscle relaxation was used to treat anxiety and increase compliance with treatment in hospitalized high-risk mothers.

Clark (1986) and Winslow (1981) found that music serves several functions in the natural childbirth process including attention focusing, distraction from pain ,stimulating pleasure responses, focusing breathing, and as a conditioned stimulus for relaxation. There were 20 subjects in this study. Thirteen experimental subjects received 6 pre natal music training sessions with a music therapist. Seven control group subjects did not receive the music therapy. After birth, the music therapist administered a childbirth experience questionnaire to each subject. Results indicated that the music group had higher success scores on 5 out of 7 indices of childbirth 13

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process. Overall, findings suggested that music therapy may successfully contribute to reducing anxiety during childbirth, as well as augment positive feelings of support throughout the childbirth experience.

The above mentioned studies have explored to reveal some effect of music therapy on pain perception and anxiety level of mothers during labor. Through these findings the researcher concludes that music therapy improves pain perception and reduces anxiety of mothers during labor.

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CHAPTER – III

METHODOLOGY

This chapter explains the methodology adopted by the researcher to assess pain perception and anxiety level during the first stage of labor followed by music therapy. It deals with the research design, variables under study, setting of the study, population, sample size, sampling technique, criteria for selection of the sample, development of the tool, pilot study, data collection procedure and statistical analysis.

RESEARCH DESIGN

The research design is a platform from which the investigator explores new knowledge in an effort to better describe and understand the phenomena, clarify possible explanation and identify potential causative factors (Polit FD, Beck TC 2008).

This study adopted is a quasi experimental pre test and post test approach.

A quasi experimental design is selected to gain more information about effect of music therapy on labor pain and anxiety in first stage of labor. The purpose of the study was to find out the effectiveness of music therapy on labor pain and anxiety level. Hence a quasi experimental approach was considered most appropriately.

Experimental group

O1---- X----O2 ----X----O3 Control group

O1---O2---O3

O1 Pain and anxiety assessment of experimental group on admission.

O2 Pain and anxiety assessment of experimental group after four hours.

O3 Pain and anxiety assessment of experimental group at the end of first stage of labor.

X Music Therapy.

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VARIABLES OF THE STUDY Independant variable

Music therapy Dependant variable

Pain perception and level of anxiety SETTINGS OF THE STUDY

Settings refer to the area where the study was conducted. The investigator conducted a study in a selected hospital at Coimbatore. It is a Multi Specialty Hospital with all facilities. It has well equipped labor room and has separate room for three stages of labor with adequate staff and equipments. In the labor room no relatives were allowed, no alternative methods were used for treatment. Around 300 deliveries were conducted per month.

POPULATION

The population of the study consisted of primigravida mothers who were admitted in hospital for delivery at the time of study.

SAMPLE SIZE

The sample consisted of 30 primigrivada mothers who fulfilled the criteria for sample selection and were admitted at the selected hospital for delivery.

SAMPLING TECHNIQUE

Non probability convenience sampling technique was adopted for selection of the sample. The samples were randomly assigned to the experimental and control group.

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SAMPLE CRITERIA Inclusion criteria

1. Primigravida mothers who were admitted in the active phase of first stage of labor with 3cm of cervical dilation.

2. Women who were willing to hear music in first stage of labor.

Exclusion criteria

1. Other than primigravida mothers 2. Women with high risk pregnancies 3. Women with preterm labor.

DESCRIPTION OF THE TOOL

The instrument used for the study was an interview schedule consisting of four parts. (Refer Appendix – vi)

Part-I consisted of demographic variables which included age, religion, education, occupation, area of residence, type of family.

Part-II consisted of assessment of pain using Numerical Pain Scale. Mothers were asked to point out the pain score every starting from 3cm cervical dilatation.

Per vaginal examination is done every 4 hourly.

Part-III consisted of record for listening to music in that time of putting the earphone, removing the earphone, type of music, total hours heard, total hours interrupted were recorded.

Part –IV consisted of assessment of anxiety checklist which consisted of 12 items. Out of 12 items 8 items were regarding anxiety of mother and 4 items were regarding anxiety of baby. Anxiety is checked thrice (on admission, after 4hrs, after delivery).

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DEVELOPMENT OF THE TOOL

The tool was developed based on the objectives of the study, review of literature, discussion with experts. For assessing pain the Numerical Pain Intensity Scale was used. For assessing anxiety a checklist containing twelve items (8 items regarding anxiety of mother and 4 items regarding anxiety of baby) were made.

Record for listening to music and views of mother regarding music therapy in childbirth was also made after discussion with experts and from literature review.

(Appendix-vii, Page No:78)

SCORING AND SCORE INTERPRETATION

Scoring for pain: Numeric pain intensity scale is used. Scoring is done from 0 to 10 0 – no pain

1-2 – mild pain 3-4 – moderate pain 5-6 – severe pain 7-8 – very severe pain 9-10 – worst possible pain

Scoring for anxiety: Score for anxiety was given under 5 point scale (strongly agree, agree, non significant, disagree, strongly disagree). According to the positive question scoring was from 5,4,3,2,1 and for negative question, scoring range was 1,2,3,4,5.

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S. No Area Score Score Interpretation 1. Anxiety related to mother 8-18 Mild anxiety

19-29 Moderate anxiety

30-40 Severe anxiety

2. Anxiety related to baby 04-09 Mild anxiety

16-20 Severe anxiety 3. Total anxiety 12-28 Mild anxiety

45-60 Severe anxiety

CONTENT VALIDITY

The tool along with the teaching plan and objectives were submitted to three nursing and one medical expert. The medical expert was DGO from RVS Hospital of more than 10 years experience, one nursing expert is the Principal, M.Sc (N) more than 20 years experience of RVS College of Nursing, Sulur, the other nursing expert is the Principal, M.Sc (N) more than 10 years experience from RVS College of Nursing, Kannampalayam and the other nursing expert was the Nursing Superintendent, M.Sc (N) with 20 years experience, from Ramakrishna Hospital, Coimbatore. They accepted the tool and there was no modification.

RELIABILITY

The reliability of the tool was established as follows:

Internal consistency of the questionnaire was checked by split half method.

The tool was administered to the experimental group mothers. The reliability was calculated by Guttmann chaffiest of correlation. The obtained of value was 0.76.

The tool appeared to have sufficient reliability.

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PILOT STUDY

A pilot study was conducted in the selected hospital at Coimbatore, in order to test the practicability and feasibility of the study from 25-7-09 to 29-7-09.

Initially a written permission was obtained from the Administrative Officer of the selected hospital for the data collection. Based on the inclusion criteria, primigravida mothers who were admitted in the labor room with 3cm cervical dilatation were selected by convenient sampling technique. The mothers were explained about the study, willingness were obtained by interview method and data was collected.

Privacy was maintained and confidentiality assured. It took six days to collect the data. After conducting the pilot study, the feasibility of the study was confirmed.

There was good cooperation from the concerned authority and the samples. The interview schedule was found relevant and the time was convenient.

DATA COLLECTION METHOD

Permission for the study was obtained from the hospital at Coimbatore. The study was done from 1/07/09 – 31/07/09. The data was collected when the women came for delivery. First, the investigator developed rapport with the mother, met all the basic needs and provided comfortable bed and the demographic data were collected from the mother. Case record was checked and per vaginal examination was done. According to the convenient sampling technique and inclusion criteria the subjects were selected, fifteen mothers in control group and fifteen mothers in experimental groups. The investigator gave explanation regarding music therapy to the mother and got verbal consent from her. For the experimental group and control group pain were assessed every hourly. Anxiety was assessed on admission, after 4 hours and at the end of first stage of labor. Pain was assessed using numerical pain scale and anxiety was assessed using anxiety checklist. Then from 3 cm cervical dilatation onwards music therapy given as long as the mother wishes to hear. The intensity of pain, cervical dilatation, time was recorded.

In observation record for listening to music, (record for putting on earphone, removing the earphone, type of music heard total hours heard, total hours interrupted) were also recorded. The mother’s demographic data was collected 20

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before treatment and views of mothers regarding music therapy and childbirth were also collected. For the control group no music was given. All other observations were done similar to the experimental group. The investigator was able to get two or three samples per day.

PLAN FOR DATA ANALYSIS

The data analysis was done by using descriptive and inferential statistics.

1. Descriptive statistics

1. Frequency and percentage distribution were used to analyze demographic variable to assess the degree of pain every hourly in first stage of labor, to assess the level of anxiety on admission, after 4 hours, at the and of first stage of labor and at different stages of cervical dilatation and regarding the views of mother in experimental group and type of music listened.

2. Mean score and standard deviation were used to determine the difference in degree of pain at different stages of cervical dilation and difference in anxiety level in experimental and control group.

2. Inferential statistics

1. ‘t’ test was used to determine the significant difference in degree of pain at different stages of cervical dilation.

2. ‘t’ test was used to determine the significant difference in the level of anxiety at different phases in first stage of labor.

3. Karl Pearson Correlation Coefficient was used to check association between the music listened and level of anxiety.

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CHAPTER IV

ANALYSIS AND INTERPRETATION

Analysis as “categorizing, ordering, manipulating and summarizing of data to reduce to intelligible and interpretable form so that the research problem can be studied and tested including the relationship between variables” Kerlinger (1976).

Abdullah and Levin (1979) have stated that interpretation of tabulated data can bring to light the real meaning of the findings of a study.

This chapter deals with the analysis and interpretation of data collected from 30 primigravida mothers (15 in experimental and 15 in control group). The data have been analyzed and presented under the following headings.

1. Demographic characteristics of the sample

This section deals with the demographic profile of the primigravida mothers in relation to age, religion, education, occupation, area of residence in frequency and percentage.

2. Analysis of pain of the primigravida mothers

Pain has been analyzed hourly in experimental and control group by mean score and its significance by statistical test, also the overall pain for experimental and control group during the first stage of labor and its significance by statistical test.

3. Analysis of anxiety the primigravida mothers

Anxiety has been analyzed in three levels (mild, moderate and severe) for the experimental and control group in relation to the mother and baby and overall anxiety during the first stage of labor in frequency and percentage, and also on three point scale in frequency and percentage. Comparison of level of anxiety in experimental and control group has been done by mean score and its significance by statistical test.

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4. Assessment for listening to music

Music has been analyzed in experimental group according to the type of music listened, duration of hearing music in frequency and percentage distribution and views of mother regarding music.

5. Correlation of variables

Correlation has been done between duration of music listened and level of anxiety also the duration of labor and duration of music listened in experimental group and its significance by statistical test.

6. Assessment on views of mothers

Mothers views has been checked at the end of the study.

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1. DEMOGRAPHIC CHARACTERISTIC OF THE SAMPLES TABLE – I

FREQUENCY AND PERCENTAGE DISTRIBUTION OF EXPERIMENTAL AND CONTROL GROUP ACCORDING TO DEMOGRAPHIC VARIABLES N=30

24 Experimental group

N = 15

Control group N = 15 Sl.

No Characteristics

F % F %

1. Age a) 20 – 25 b) 26 – 30 c) 31 – 35 d) above 36

08 06 01 00

53.00 40.00 7.00

00

8 06 00 01

53.00 40.00 00 7.00 2 Religion

a) Hindu b) Christian

14 01

93.00 7.00

14 01

93.00 7.00 3 Education

a) Primary b) Elementary c) Secondary

d) Higher Education

00 00 03 12

00 00 20.00 80.00

01 02 03 09

7.00 13.00 20.00 60.00 4 Occupation

a) Employed b) Unemployed

07 08

47.00 53.00

03 12

20.00 80.00 5 Area of residence

a) Urban b) Rural

15 00

100 00

12 03

80.00 20.00 6 Type of family

a) Joint b) Nuclear

12 03

80.00 20.00

13 02

87.00 13.00 Table 1 presents the frequency and percentage distribution of primigravida mothers.

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25 Age : Age of the sample ranged from 20 years to above 36 years. In both the groups most of the mothers (53%) were aged 20-25 years and (40%) were aged between 26 – 30 years of age.

Religion: Fourteen primigravida mothers (93%) in experimental and control group were Hindus.

Education: Twelve primigravida mothers (80%) in experimental group and 9 primigravida mothers (60%) in control group had higher education.

Occupation: In experimental group 8 primigravida mothers (53%) and in control group 12 primigravida mothers (80%) were unemployed.

Area of residence: In experimental group 15 primigravida mothers (100%) and in control group 12 primigravida mothers (80%) were from urban area.

Type of family: In experimental group 12 primigravida mothers (80%) and in control group 13 primigravida mothers (87%) were from joint family.

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27 2. ANALYSIS OF PAIN OF THE PRIMIGRAVIDA MOTHERS

TABLE – II

HOURLY MEAN PAIN SCORE OF EXPERIMENTAL AND CONTROL GROUP IN FIRST STAGE OF LABOR AND LEVEL OF SIGNIFICANCE

N=30 No. of mothers Experimental

N = 15

Control N = 15 Labor process

(hourly)

Experi

mental Control Mean score SD Mean score SD

Mean difference

Unpaired ‘t’

value df = 28 p < 0.01

1^st hour 15 15 4.4 2.1 4.7 2.25 0.3 0.38 NS

2^nd hour 15 15 5.2 2.3 5.6 2.4 0.4 0.47 NS

3^rd hour 15 15 6 2.53 5.9 2.52 0.1 0.11 NS

4^thhour 15 15 6.6 2.67 6.7 2.68 0.1 0.163 NS

5^th hour 15 15 7.7 2.87 7.4 2.81 0.3 0.29 NS

6^thhour 14 15 7.7 2.77 8.2 2.97 0.5 2.87 *

7^th hour 14 14 9.5 3.08 9.1 3.11 0.4 2.42 *

8^th hour 06 14 06 2.07 9.7 3.11 3.7 2.85 *

9th hour 00 04 00 00 10 1.67 00 -

10^th hour 00 02 00 00 10 1.19 00 -

* Significant NS- Not significant df- degree of freedom Table value= 2.05 Table II shows the hourly mean pain score and significance of the two groups in first stage of labor.

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Both the experimental and control group shows an increase in mean pain score from first hour to end of first stage of labor .The mean score of pain in the first 5hours in the experimental group is less in some hours (1^st, 2^nd, 4^th ) compared to the control group and in the control group the mean score of pain is less during the third and 5^th hour. Statistically there is no significant difference between the mean pain score of experimental and control group from first hour to 5^th hour of first stage of labor .On 6^th and 8^th the mean score of pain of the control group is higher (8.2-9.7) compared to experimental group 7.7 where in the 7^th hour the mean pain score of experimental group is 9.5 and that of control group is 9.1. Statistically there is a significant difference between the pain score of experimental and control group from 6^th to 8^th hour of first stage of labor.

Figure 2 shows mean pain score of experimental and control group in the first stage of labor.

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TABLE III

OVERALL MEAN PAIN SCORE AND STANDARD DEVIATION OF THE EXPERIMENTAL AND CONTROL GROUP DURING FIRST STAGE OF

LABOR AND LEVEL OF SIGNIFICANCE

N=30

Sl.

No Group Mean

score SD Mean difference

Un paired ‘t’

value P < 0.01

df – 28

1 Experimental 6.9 0.417

2 Control 7.33 0.337

0.43 3.09*

* Significant NS- Not significant df- degree of freedom Table value = 2.34 Table III presents the overall mean pain score and standard deviation of the experimental and control group during first stage of labor.

The mean pain score of the experimental group was 6.9 and that of control group mean score was 7.33 with a mean difference of 0.43. Statistically there is a significant difference between mean pain score of the experimental and control group ( t=3.09*, df=28, p<0.01).

Therefore the H₁ “There is a significant difference between pain perception of primigravida mothers in experimental and control group in first stage of labor” is accepted.

Figure 3 shows overall mean pain score of the experimental and control group during first stage of labor.

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3. ANALYSIS OF ANXIETY OF PRIMIGRAVIDA MOTHERS IN EXPERIMENTAL AND CONTROL GROUP

TABLE IV

FREQUENCY AND PERCENTAGE OF EXPERIMENTAL AND CONTROL GROUP IN THREE LEVEL OF ANXIETY RELATED TO MOTHER IN

THREE PHASES OF FIRST STAGE OF LABOR

N=30 First stage of labor

On admission (firstphase)

After 4 hours (2^nd phase )

End of first stage (third phase) Exp

N=15

Cont N=15

Exp N=15

Cont N=15

Exp N=15

Cont N=15 Level of

anxiety

F % F % F % F % F % F %

Mild

(8 – 18) 0 0 0 00 5.0 33.33 0 00 7 46.66 0 00

Moderate

(19 -29) 15 100.0 15 100.0 10.0 66.66 15 100.0 8 53.33 15 100.0

Severe

(30 – 40) 0 00 0 00 0 00 0 00 0 00 0 00

Table IV presents the frequency and percentage of experimental and control group in three level of anxiety related to mother in the three phases of the first stage of labor (on admission, after 4hours, at the end of first stage).

On admission all the mothers (100% ) in the experimental group and control group had moderate anxiety. After 4hours in the first stage of labor 5 mothers (33.33%) in the experimental group had mild anxiety and 10 mothers (66.66%) had moderate anxiety and no mothers had severe anxiety. In the control group all the mothers (100%) had moderate anxiety in second phase. At the end of first stage in 30

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experimental group 7 mothers (46.66%) had mild anxiety and 8 mothers (53.33%) had moderate anxiety. In the control group all the mothers (100%) had moderate anxiety.

Though all the mothers in both the groups have moderate anxiety in first phase, as the labor progresses the number of mothers with moderate anxiety is reduced and the number of mothers with mild anxiety is increased in the experimental group. Where as in the control group all the mothers with moderate anxiety in first phase continue to be in the same level of anxiety till the third phase in the first stage of labor.

The table concludes that the reduction of anxiety in the experimental group could be due to the effect of listening to music.

Figure 4 shows percentage of experimental and control group in three levels of anxiety related to mother in three phases of first stage of labor.

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TABLE V

FREQUENCY AND PERCENTAGE OF EXPERIMENTAL AND CONTROL GROUP IN THREE LEVELS OF ANXIETY RELATED TO BABY IN

THREE PHASES OF FIRST STAGE OF LABOR

On admission (firstphase)

After 4 hours (2^nd phase)

End of first stage (third phase) Exp

N=15

Cont N=15

Exp N=15

Cont N=15

Exp N=15

anxiety

F % F % F % F % F % F %

Mild

(4 – 9) 11 73.33 9 60.00 15 100 11 73.33 13 86.66 14 93.33 Moderate

(10 – 15) 4 26.66 6 40.00 0 00 4 26.66 2 13.33 1 6.00 Severe

(16 – 20) 0 00 0 00 0 00 0 00 0 00 0 00

Table V presents the level of anxiety in experimental group and control group related to baby in 3 phases of first stage of labor.

On admission 11 mothers (73.33%) in the experimental group had mild anxiety and 4 mothers (26.66%) had moderate anxiety. In the control group 9 mothers (60%) had moderate anxiety and 6 mothers (40%) had moderate anxiety in first phase.

In the second phase while all the mothers in experimental group had mild anxiety and in the control group 11 mothers (73.33%) had mild anxiety and 4 mothers (26.66%) with moderate anxiety.

In the third phase of first stage of labor 13 mothers (86.66%) in the experimental group and 14 mothers (93.33%) control group had mild anxiety.

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Most of the mothers in both group had mild anxiety in first phase, as the labor progresses the number of mothers with moderate anxiety is reduced and the number of mothers with mild anxiety is increased in experimental group. However in the third phase an equal number of mothers of both the groups have shown only mild anxiety.

The table concludes that reduction of anxiety in the experimental group could be due to the effect of listening to music .But the reduction of anxiety seen in the control group throughout the labor is rather difficult to explain.

Figure 5 shows percentage of experimental and control group in three levels of anxiety related to baby in three phases of first stage of labor.

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TABLE VI

FREQUENCY AND PERCENTAGE DISTRIBUTION OF EXPERIMENT AND CONTROL GROUP IN THREE LEVELS OF OVERALL ANXIETY

IN THE THREE PHASES OF FIRST STAGE OF LABOR

On admission After 4 hours End of first stage Exp

N=15

Cont N=15

Exp N=15

Cont N=15

Exp N=15

anxiety

F % F % F % F % F % F %

Mild

(12 – 28) 1 6.60 1 6.60 9 60.00 3 20.00 10 66.6 7 46.60 Moderate

(29 – 44) 14 93.3 14 93.3 6 40.00 12 80.00 5 33.3 8 53.30 Severe

(45 – 60) 0 00 0 00 0 00 0 00 0 00 0 00

Table VI presents frequency and percentage distribution of experimental and control group in three levels of overall anxiety in 3 phases of first stage of labor.

In the first phase majority of the mothers (93.33%) in both groups experienced same level of moderate anxiety.

In the second phase 9 mothers (60%) in the experimental group had mild anxiety where as in control group, only 3 mothers (20%) showed mild anxiety.

In the third phase of first stage of labor while the number of mothers in experimental group remained almost same with mild anxiety in the control there was an increase of 4 mothers (20.6%) with mild anxiety.

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The table shows that the overall anxiety of experimental group and control group was at moderate level in first phase, as the labor progress, the reduction of anxiety is seen more on the experimental group mothers than the control group mothers. However in the third phase a different pattern is observed, more mothers in control group showed mild anxiety.

Figure 6 shows percentage of experimental and control group in three levels of overall anxiety in three phases of first stage of labor.

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TABLE VII

MEAN ANXIETY SCORE OF EXPERIMENTAL AND CONTROL GROUP RELATED TO MOTHER AND BABY AND LEVEL OF SIGNIFICANCE

N=30

Sl.

No Items Max score

Mean score SD

Mean score

%

Mean difference

Unpaired

‘t’ test df=28 p=0.01 1 Related to

mother Experimental Control

40 40

20.04 22.39

2.4 1.04

50.10

55.90 2.35 3.45*

2 Related to baby Experimental Control

20 20

7.5 8.7

1.8 0.83

37.50

43.50 1.2 2.31*

* Significant NS- Not significant df- degree of freedom Table value = 2.05*

Table VII presents the mean anxiety score related to mother and baby of experimental and control group and level of significance.

The mean anxiety score of experimental group related to mother is 20.04 and control group 22.39 with a difference of mean score 2.35. Statistically there is a significant difference between the mean anxiety of the two groups (anxiety related to mother t=3.45, df=28, p<0.01). Similarly in the mean score related to baby is more in control group 8.7 compared to experimental group 7.5 with a difference of mean score 1.2.

The H2 “There is a significant difference in the anxiety level of primigravida mothers related to mother and baby between experimental and control group” is accepted.

The table concludes that level of anxiety related to mother and baby in the control group is more than the anxiety of the experimental group.

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CHAPTER – II

TABLE OF CONTENTS

CHAPTER – I

CHAPTER – II

CHAPTER – III