Rajiv Gandhi University of Health Sciences, Karnataka
Bangalore.
PROFORMA FOR REGISTRATION OF SUBJECTS FOR
DISSERTATION
1. / Name of the candidate andaddress / MOHAMMAD. HUSNA BHANU,
KRUPANIDHI COLLEGE OF NURSING,
CHIKKABELLANDUR,
CARMALARAM POST,VARTHUR HOBLI, BANGALORE – 560035.
2. / Name of the institution / Krupanidhi College Of Nursing
3. / Course of study and subject / M.Sc Nursing
Obstetrics and Gynaecological Nursing
4. / Date of admission to course / 01-06-2008
5. TITLE OF THE TOPIC:
A STUDY TO ASSESS THE EFFECTIVENESS OF WARM COMPRESS ON LUMBAR AND SACRAL REGION DURING FIRST STAGE OF LABOUR AMONG PRIMI MOTHERS IN LABOUR ROOM OF SELECTED MATERNITY HOSPITAL, AT BANGALORE.
6. BRIEF RESUME OF THE INTENDED WORK
6.1 NEED FOR THE STUDY:
Pain is a highly unpleasant and very personal sensation that can not be shared with others. No two people experience pain in exactly the same way.1 Among pains, the pain of child birth is a time honored and inevitable part of the human existence. Labour pain is a fluctuating cycle pain, appearing in waves, radiating and then subsiding inturn.2 The causes of labour pain are uterine contractions and dilatation of cervix which causes unbearable pain in mothers.3 The obstetricians and midwives are the health care providers who need to provide current maternity services to manage a women who is in labour.
A descriptive study was conducted on 100 low risk parturients who delivered vaginally in labour room. Three instruments, the numeric pain intensity scale, a pain assessment questionnaire and demographic questionnaire were used to assess labour experience and labour pain intensity levels. The results have shown that majority of parturients who did not receive pain relief measures reported pain intensity levels in I stage as >8 in Numeric Pain Intensity Scale (ranging from 0-10) and as 8.83 in second stage.4
Normally labour pain in primi mothers is unbearable, usually they cry out for help when the intensity increases. To relieve this pain there are many pharmacological and Non-pharmacological measures. But these pharmacological measures may cause some adverse effects. So, many women in labour would like to keep drug use to minimum level. A study was conducted to examine the relationship between epidural anesthesia and long term back ache after child birth among 11,701 women who delivered at maternity hospital, Birmingham. The results have shown that a significant association was found between back ache and epidural anaesthesia; nine hundred and three women out of four thousand seven hundred and sixty six women who had epidural anaesthesia reported backache compared with 731 of 6935 women who had not received epidural anaesthesia. This study concludes that the relation between backache and epidural anaesthesia is causal and back ache results from a combination of effective analgesia and stressed posture during labour.5
A randomized study was conducted among 50 women to evaluate the efficacy of spinal Clonidine combined with Ropivacaine and Sufentanil to reduce labour pain and its effects on maternal & fetal outcomes. The assessed factors were onset and duration of analgesia, pain, blood pressure, heart rate, incidence of nausea, pruiritis, umbilical artery pH, fetal heart rate abnormalities and Apgar score. The results revealed that intrathecal Clonidine with Ropivocaine and Sufentanil prolongs spinal analgesia, but it causes maternal hypertension.6
A prospective study was conducted over 700 women who gave birth at six maternity units in South England. The results showed that most women preferred to keep drug use to a minimum, though they expected labour to be quite or more painful. Women who preferred to avoid drugs were more satisfied with overall birth experiences than women who had drugs.7
Treating pain is important because coping of parturients with pain influences the birth experience as being perceived good or bad. Vaginal birth without analgesia or anaesthesia contributes to optimal health outcome for mother and babies.8 There are some non pharmacological measures to reduce labour pain such as TENS application, aromatherapy, acupressure, heat applications, hypnosis and breathing & relaxation techniques etc.Among these measures women prefer to have heat applications as it is considered as effective measure in relieving pain.2
A study was conducted to determine perineal outcomes and maternal comforts related to application of perineal warm pack in second stage of labour. The results have shown that women in warm pack group had significantly fewer III, IV degree tears and had lower perineal pain scores while giving birth and on first and second postnatal day when compared with control group. This study concludes that warm packs are simple, inexpensive practice and should be incorporated into second stage of labour.9 The heat brings more blood supply to the area where it is applied and reduces inflammation there by pain will be reduced.
A prospective study was carried out to assess the effect of warm tub bath during labour among 88 women. The results have shown that experimental group who bathed in warm tub bath for 30 minutes - 1 hour had cervical dilatation up to 2.5 cms/hr where as in control group it was 1.25 cms /hr. the study has concluded that warm tub bath during labour facilitates good cervical dilatation and reduces pain and discomfort.11
The investigator as a midwife has come across many women suffering from agonizing pain and discomfort during labour. On investigating women suffering in labour pain, the investigator found majority of women would like to receive Non – pharmacological pain relief strategies and avoid pharmacological measures probably due to their side effects. This prompted the researcher to carry out the study and if found effective, heat application can be recommended to adopt in the clinical practice to reduce labour pain.
6.2 REVIEW OF LITERATURE:
Pain is a universal unpleasant, sensory and emotional experience which is highly subjective in nature. Labour pain is a progressive and unbearable pain during child birth. In this study review of literature is categorized into three categories and they are
1) Labour pain perception
2) Heat application to relieve pain.
3) Heat application in labour
1) Labour pain perception:
A descriptive study was conducted to describe the quality and intensity of adolescent’s pain during the progression of labour. The Gaston-Johansson Pain-O-Meter was administered to 33 adolescents during the three labor phases (2-4 cm, 5-7 cm, and 8-10 cm) following a contraction. The most frequently selected sensory words were cramping in Phase I and pressing in Phases II and III. Miserable and killing were the most commonly chosen affective words during the three labour phases. The results showed that total pain intensity scores were highest during Phase III of labour and delivery. A t-test of independent samples found that quality and intensity pain scores for primiparous and multiparous adolescent participants were not significantly different during the progression of labour.10
A descriptive study was conducted to assess labour pain experience and intensity among 100 low risk Jordanian parturients who delivered vaginally in labour room of a major hospital in the city of Amman. Three instruments, the numeric pain scale, a pain assessment questionnaire and demographic questionnaire were used to assess labour experiences and labour pain intensity levels. The results have shown that majority of parturients ( 81% ) who did not receive pain relief measures reported painful labour experiences and pain intensity levels as >8 in I stage and 8.83 in II stage of labour on numerical pain intensity scale (ranging from zero – ten) . The study concluded that role of supporters and educators among maternity nurses and midwifes need to improve considerably.4
A study was conducted on perception of labour pain among mothers and their attending midwives in The Queen Elizabeth Hospital, South Australia. The study used Short Form Mc Gill Pain Questionnaire to assess labour pain for every 15 min during I stage of labour. The results have shown that both midwives and mothers pain scores were similar at mild and moderate pain levels, but have shown significant difference at severe pain levels at 0.05 level of significance. The study concluded that experience and perception of pain are subjective and thus remains difficult for an observer to estimate.12
2) Heat application to relieve pain :
A randomized placebo and active controlled study was conducted to assess the effectiveness of continuous low level topical heat application in the treatment of dysmenorrhoea. The study used an abdominal patch (heated and unheated) for approximately 12 consecutive hours per day and oral medications (Ibuprofen 400mg) three times daily, approximately 6hrs apart for 2 consecutive days. Pain relief and pain intensity were recorded at 17 time points. The results have shown that eighty four patients were enrolled and eighty one completed the study protocol. Over two days of treatment, the heated patch plus placebo tablet group ( mean 3.27, P< 0.001), the unheated patch plus Ibuprofen group (mean 3.07, P< 0.001 ) , and a combination of heated patch plus Ibuprofen group ( mean 3.55 P< 0.001) had significantly greater pain relief than the unheated patch and placebo group. The study concluded that continuous low level heat therapy was as effective as ibuprofen for the treatment of dysmenorrhoea.13
Nine randomized and non randomized controlled trials were conducted among 1117 participants to examine the effect of superficial heat therapy to reduce low back pain. In two trials 258 participants were provided heat wrap therapy and control group was on oral placebo treatment. The results have shown that experimental group have significantly reduced pain after 5 days at 0.05 level of significance. In one trial of 90 participants, it was found that a heated blanket significantly decreased back pain at 0.05 level of significance and in one more trial of 100 participants the additional effect of exercise to heat wrap was examined and with this back pain was reduced after 7 days. The study has concluded that heat therapy has good effect to reduce back pain.14
A study was conducted to assess the effect of heat on amplitude of myoelectronic activity in back muscle by using frequency standardized surface Electro Myogram recording on healthy volunteers . The results have shown that there was a significant reduction of amplitude after applying mudpacks ( 500 c) in wilcoxon matched pair signed ranks test at 0.05 level of significance where as the control group showed no alteration in amplitude even after a period of 20 minutes rest.15
3 ) Heat application in labour :
A randomized controlled trial was conducted on women's experience and midwives opinion on use of perineal warm packs in second stage of labour. warm packs. Out of Seven hundred and seventeen primi women, 360 women were applied warm packs on perineum and 375 women received standard care. The findings stated that warm packs were highly acceptable to both women and midwives as a mean of relieving pain during the last second stage of labour. Almost the same number of women (79.7%) and midwives (80.4%) felt that warm packs will reduce pain during the birth. Both women and midwives were positive about using warm packs in the future. Majority of the women (85.7%) said that they would like to use perineal warm packs again for their next birth and about 86.6% of women would like to recommended for their friends. Like wise 91% of midwives were positive about using them in the future as a part of routine maternity care in second stage of labour. The study concluded that warm packs on perineum in second stage of labour was highly acceptable and effective in helping to relieve perineal pain and increases comfort.9
A prospective study was undertaken where 88 women had warm tub bath for 30 minutes - 2 hours during first stage of labour after a strict normal pregnancy. A control consisted of seventy two women during pregnancy and labour, but did not want to take a warm tub bath during labour. Apart from the bath, the two groups followed the usual obstetric procedures of the department. The results have shown that cervical dilatation in Bath group was 2.5 cms compared with 1.25 cms in control group. Mean pain score in bath group was higher before the bath and they experienced pain relief during and after bath which was not observed in control group.11
A quasi experimental study (pre test post test control group) was conducted on effectiveness of warm compress on labour pain. The sample consisted 60, second and third gravid women in labour who met inclusion criteria were randomly assigned to group 1, group 2 and group 3. All the three groups had usual care and support from health care professionals. Data was collected by using visual analogue scale and structured observational check list. The study revealed the experimental group had reduction in pain and experienced comfort than the control group at 0.05 level of significance. The study concluded that warm compress is one of the simple, effective, non invasive and cost effective method having no side effects on mother and infant.16
6.3 STATEMENT OF THE PROBLEM:
A study to assess the effectiveness of warm compress on lumbar and sacral region during first stage of labour among primi mothers in labour room of selected Maternity hospital, at Bangalore.
6.4 OBJECTIVES OF THE STUDY:
à To assess the level of pain and behavioral responses in primi mothers during the first stage of labour.