http://doi.org/10.33698/NRF0151–  Kirandeep Kaur,  Avinash Kaur Rana, Shalini Gainder

Abstract : Childbirth is a painful process. Various complementary methods are used to relieve pain. Quasi experimental study was conducted to assess the effect of video on breathing exercises during labour on pain perception and duration of labour among the primigravida mothers admitted in tertiary care hospital, India. Forty mothers, purposely selected, were randomly allocated 20 each into experimental and control group. The experimental group participants were shown a video on ‘breathing exercises during labour’, before onset of labour and performance of exercises during labour was assessed through the checklist. The pain score during first stage of labour was recorded as per numeric pain rating scale. Duration of first and second stage of labour was measured by developed tool. The assessment of pain perception at the latent, early and late active phases of first stage of labour showed statistical significant difference among experimental and control group (p<0.01). Statistical significant difference(p<0.01) was also observed in the duration of first stage of labour with mean duration(8 hours 48 minutes) in experimental group as compared to control group (9 hours 48 minutes). The mean duration of second stage of labour was also significantly less (p<0.01) i.e. 24 minutes in experimental group as compared to 32 minutes in control group. The study concluded that the practice of breathing exercises during labour help to reduce pain perception & duration of first and second stage of labour.

Key words:

Pain perception, Duration of labour, Video

 

Correspondance at

 Dr. Kirandeep Kaur

Add. Professor, Depar tment of Obstetrics and Gynecology, PGIMER, Chandigarh.

Email address: deepkirangill@gmail.com

Introduction

Labour pain is a complex, personal, subjective, multi-factorial phenomenon which is influenced by psychological, biological, socio-cultural and economic factors. Although labour is often thought of as one of the most painful events in human experience, it ranges widely from woman to woman and even from pregnancy to pregnancy. First-time mothers are more likely to give their pain a higher rating than woman who’ve had babies before.1,2

The unique aspect of childbirth is the association of this physiologic practice pain and discomfort. However, the experience of pain during laboiur is not a simple reflection of the physiologic processes of parturition. Instead, labour pain is the result of a complex and subjective interaction of multiple physiologic and psychological factors on a woman’s individual interpretation of labour stimuli. An understanding of labour pain in a multidimensional framework provides the basis for a woman-centered approach to labour pain management that includes a broad range of pharmacologic and non- pharmacologic intervention strategies.3

Mother can soothe herself with attention-focusing devices such as relaxation, slowed breathing and music; and can supply herself with calming sights to look at and special companions to comfort her. Perhaps mother choose to concentrate on so-called left-brain (rational) activities-counting to herself, pacing or patterning her breathing, focusing on a particular picture, or listening to her par tner count time on a watch. Practicing lots of strategies and being flexible about changing strategies midstream can help her get through the painful contractions and prevent her from tensing up in anticipation of future pain.4,5

Nonpharmacologic pain-relief techniques were used on laboring women to assess which was most effective technique. Of the ten nonpharmacological strategies rated by the forty six mothers, breathing techniques were repor ted as the most effective pain relieving technique used during labor, followed by relaxation, acupressure, and massage. The results provide directions for childbir th educators in designing and implementing an effective childbirth education curriculum that assists women to have empowered birth experiences.6,7

The antenatal women require education in preparation for childbirth and pain reduction strategies. The first time mothers out of unawareness, fear, anxiety results in an uncooperative attitude and a stressful childbirth experience. So need was felt to teach mothers an alternative therapy to cope with labour. Among various methods of teaching like still pictures, booklets, flip books, models, posters, motion picture had an advantage above all. Learning through video have a long lasting impression as it compels and holds the attention of the viewer. The individual watching the video imitates the behaviour and try to be competent in performing it. This is based on principle of learning by doing which is congruent with the Chinese proverb ‘what I hear I forget, what I see I remember, what I do I know’. Films are inevitable as practically the best teaching method. They show settings and situations that no amount of discussion can convey. Video, as an educational intervention, is useful because the technology provides multi-media multi-sensory information about complex behavior. A computer search of the electronic databases of Medline and CINHAL between 1990 and 1999 by Krouse in 2008 reviewed 18 research studies involving video modelling which identified three major uses i.e. assisting decision making regarding treatment options, reducing pre-procedural anxiety and improving coping skills and teaching self-care practices.7 So the concept assessing the impact of video, on ‘breathing exercises during labour’, on pain perception and duration of labour among primigravida mothers an alternative therapy to cope with labour was channelized.

Objective

To assess the effect of video on breathing exercises during labour on pain perception and duration of labour among primigravida mothers.

Materials and Methods

The study was carried out in labour room of Nehru hospital, PGIMER, Chandigarh. The study protocol was a video film of Hindi version (duration- 10 minutes) which was developed with the storyline on breathing exercises during first stage of labour (slow breathing, fast breathing, pant-pant blow) and for second stage of labour (breathing exercises during childbirth). The video was developed in two phases. First phase was preliminary preparation which included review of literature, generation of pool of data, preparation of preliminary video. In the second phase content and face validity of the video was assessed by showing the video among the panelist and then feasibility of using the video was checked through pilot study and the necessary modifications were introduced into the video. The video was again shown to the panelist for validation and the video was finalized.

The other tools included in the study were sociodemographic performa, observation checklist for assessing the practice of breathing exercises by the mothers in experimental group, modified 1-10 numeric pain rating scale, assessment proforma for duration of labour. The tools in the study were prepared based on extensive review of literature and researcher’s clinical experience. Validation was obtained by the experts in the field of nursing, public health, community medicine, obstetrics and gynecology. Forty primigravida mothers who were admitted in labour room in the month of October and November were selected by purposive sampling technique. Those mothers who were willing to participate in the study and had minimal qualification up to matric were enrolled in the study. Mothers with respiratory diseases such as asthma, tuberculosis abdominal/ uterine surgery were excluded from the study. Randomization was done by lottery method into experimental and control group.

The study proposal was approved by the Ethical Committee of PGIMER, Chandigarh and the Head of Department of Obstetrics and Gynecology. Socio-demographic profile of the subjects in both the groups were filled. The subjects in the experimental group were shown the ‘video film’ prior to the onset of labour and re-demonstrations of the breathing exercises were obtained whereas control group received no intervention. The performance of the exercises was rated on the ‘observation checklist during the labour. Then pain perception at the latent phase, early active phase and late active phase was verbalized by the mothers in both the groups on ‘modified numeric pain rating scale’. The duration of first and second stage of labour was noted on the assessment performa for duration of labour. The data was analyzed with the help of SPSS Program. The various statistical measures such as measures of central tendency, measures of dispersion, percentage, parametric tests i.e. unpaired t test and non-parametric tests i.e. chi square test were used to interpret the results.

Results

Socio Demographic profile of the subjects in experimental and Control Groups:

It is evident from table 1 that the subjects in experimental group were in the age range of 19-28 years with the mean age 24.3±2.1 years whereas control group subjects were in the age range of 20-27 years with the mean age 23.8±2.1 years. Among the subjects of both groups, 65 % of subjects in the age group of 23-26 years. Taking in consideration qualification, 50% of the subjects in control group and 45 % in experimental group were undergraduates and equal proportion were graduate and above in former in comparison to 55% in the latter. For occupation more than half were not working in both the groups. The maximum mothers had less than 2 years of married life in both the groups with the range in experimental group was 10 months to 3 years with Mean 1.04 ±0.76 years, and the years of married life of control group ranges between 10 months and 3 and half years with mean 1.01±0.7 years. Both the groups were found to be homogeneous in nature as per chi square test (p>0.05).

 

Table 1: Socio Demographic Data

Variable Experimental

GROUP(n=20)n (%)

Control GROUP

(n=20)n (%)

X2

P value

Age in years*

19-22

23-26

27-30

 

05(25)

13(65)

02(10)

 

06(30)

13(65)

01(5)

 

2.297

2

0.317NS

Qualification Under graduation Graduation

and above

 

9(45)

11(55)

 

10(50)

10(50)

 

0.159

2

0.924NS

Occupation Not working Workinng  

12(60)

08(40)

 

11(55)

9(45)

 

0.688

3

0.876NS

Years of married life

<2 years

>2 years

 

16(80)

4(20)

 

17(85)

3(15)

 

0.035

1

0.852NS

Obstetrical data in experimental and control groups

Table 2 describes the subjects with respect to Period of Gestation and Obstetrical or Medical problem. Mean POG of Experimental group was 37.8±1.2 weeks with range of 35 weeks 3 days to 40 weeks whereas Mean POG of Control group was 37.5±1.2 weeks with range of 35 weeks 4 days-39 weeks 4 days. The table also depicts the obstetrical or medical problem among the subjects of both the groups. 55% of the subjects in experimental group and 65% in control group had no obstetrical or medical problem. Both the groups were found to be statistically homogeneous in nature as per chi square test.(p >0.05).

Table 2: Obstetric Data

VARIABLE EXPERIMENTAL GROUP (n=20)      n (%) CONTROL GROUP (n=20)n (%) X2

df, P value

POG**

35-37+6 weeks

38-40+6 weeks

 

11(55)

9(45)

 

11(55)

9(45)

 

5.969

3

0.113NS

Obstetrical/ Medical problem No obstetrical or medical problem

Obstetrical or medical problem

 

 

11(55)

 

9(45)

 

 

13(65)

 

7(35)

 

 

2.700

4

0.609NS

Figure 1 : Performance of breathing exercises by mothers in labour*

n = 20

satisfactory             average

10%

*Period of Gestation

Performance of breathing exercises by mothers in experimental group

 

90%

Figure 1 reveals the performance of the breathing exercises during labour by experimental group subjects to whom breathing exercises were taught using a video. Majority of the mothers (90%) performed the exercises rated as satisfactory and only 10 % performed average.

Pain perception in the first stage of labour Figure 2 illustrates the comparison of pain perception in latent phase, early active phase and late active phase in both groups (experimental and control) in the first stage of labour. The mean score of pain in latent phase was 3.1 ± 0.5 with range of 2 to 4 in experimental group whereas in control group it was 4.05 ± 0.7 with range of 3 to 5. The mean score of pain in early active phase for experimental group was 5.9 ± 0.8 with range of 4 to 7 whereas it was 7.05 ± 0.9 with range of 5 to 8 in control group. The mean score of pain in late active phase in experimental group was 8.5 ± 0.7 with range of 7 to 10 whereas it was depicted 9.3 ± 0.7 with range of 8 to 10 in control group. The unpaired t test depicts the significant difference in the pain scores in latent, early active and late active phase of first stage of labour among both groups (p value<0.01)

Duration of first and second stage of labour in experimental and control groups Table 3 compares the Duration of first and second stage of labour in both groups (experimental and control). More than half of the subjects (60%) in experimental group as compared to only 1/4 th subjects in control group had less than equal to nine hours duration of first stage of labour. 40% of the subjects in experimental group had more than nine hours duration of first stage of labour in comparison to ¾th of the subjects in control group . The mean value and standard deviation was 8.8 ± 0.9 hours with range of 7.45 to 11.20 hours in experimental group whereas that in control group was 9.8 ± 1.1 hours with range of 8.25 – 12.10 hours. Taking into consideration the Duration of Second Stage of labour in experimental and control group, 45% of the subjects in experimental group had duration of 2nd stage of labour less than 20 minutes as compared to only 5 % in control group. More than half (60%) of the control group subjects had 20 minutes to 35 minutes duration of second stage of labour in comparison to 45% of experimental group. Only 10% of subjects in experimental group as compared to 35% in control group had more than 35 minutes duration of second stage of labour. The mean value of duration of 2nd stage of labour for experimental group was 24 ± 6.4 minutes with range of 15 to 40 minutes. The value of mean duration of 2nd stage of labour for control group was 32.1 ± 8.5 minutes with range of 20 to 50 minutes. The unpaired t test depicts the statistically highly significant difference in the duration of first and second stage of labour  among both groups (p value<0.01).

 Table 3: Comparison of Duration of First and Second stage of labour in experimental and control groups      N=40

 

Duration of labour Experimental group n=20(n%) Control goup n=20(n%) t, df,

p value

First stage of labour (hours)

<9 hours

>9 hours

 

12(60)

8(40)

 

5(25)

15(75)

 

-3.103

38

0.004

Second stage of labour

(minutes)

<20

20-35

>35

 

9(45)

9(45)

2(10)

 

1(5)

12(60)

7(35)

 

-3.405

38

0.002

 

Discussion

Most women experience labour pain as severe or unbearable during childbirth. So it is valuable to offer complementary pain relief methods to women in childbir th. Most childbirth education classes and most books on childbirth present relaxation techniques, along with a variety of rhythmic breathing patterns intended to complement and promote relaxation or to provide distraction from labor pain. They are also used to enhance a woman’s sense of control. 1,8,9

Practicing the breathing techniques becomes an automatic response to pain. A mother more relaxed will respond in a positive manner to pain. Breathing techniques determine the wellbeing status and become a measure of control. The present study included breathing exercises as a complementary pain relief therapy in labour.

This is also consistent with earlier research reporting breathing and relaxation as the predominant techniques employed for pain relief in labour.6,10 For teaching the breathing exercises to the mothers before labour various methods were taken into consideration which can help the mothers to learn, understand and practice the desired behaviour in labour.

Audio visual education in the modern sense of the expression is a movement of recent growth. The film is the most potent medium of learning. On the same ground the present study developed a Hindi version video on ‘breathing exercises during labour’ with duration of 10 minutes. The video developed during the study was very helpful in teaching the breathing exercises and was able to motivate the mothers to practice these exercises during labour. This was evident from the scores of the ‘observation checklist for practice of breathing exercises during labour’ as majority of the mothers performed the exercises rated as satisfactory. The results were consistent with the computer search of the electronic databases by Helene J. Krouse in 2008 which found that the use of video as a teaching aid has potential benefits for clinical practice in facilitating knowledge acquisition, reducing preparatory anxiety, and improving self-care.7

The assessment of pain perception at the latent phase, early and late active phases of first stage of labour showed statistically significant difference among experimental and control group. The pain scores reported by the subjects of both the groups were minimum in latent phase and maximum in late active phase. The study results were in agreement with those of Jaya Bharathi who found statistical highly significant difference in the post-assessment level of labour pain perception of primi mothers in experimental and control groups.11

Breathing exercises secure more oxygen in order to have strength and energy for mother and child and brings a purpose for each contraction, making them more productive. In the same context the present study depicted the significant reduction in the duration of first stage of labour among the subjects of experimental group. The findings in the current study are consistent with the work of Ciobanu and Anca who found that labor parameters were upgraded for the group which practiced breathing and relaxation and depicted significant reduction in duration of first stage of labour.12

The study results had also shown the significant reduction in the duration of second stage of labour in the group which practiced breathing exercises. The results were in agreement with the previous research findings in which the duration of second stage of labour was 21 minutes in group which practiced breathing exercises in comparison to 39 minutes which did not. Thus reflecting the reduction in duration of second stage of labour.12

The present study hence concluded that the use of video on breathing exercise during labour was effective during childbirth to reduce pain perception and duration of labour. It is recommended that the obstetric nursing personnel should focus on teaching breathing exercises as complementary therapy with multimedia aids and encouraging the mothers during labour to practice them to make childbir th a less painful and stressful experience.

References

  1. Lieberman A. Easing Labor Pain: the complete guide to a more comfortable and rewarding birth [online] 2008 [cited 2010 Dec 26] Available from: URL:http:// child development institute.htm
  2. Cunningham G. Leveno J.K. Williams Obstetrics, labour and delivery. Twenty second ed. Mc-Graw hills companies.2007;17:4.
  3. Bonica Textbook of Pain. Edinburgh: Churchill-Livingstone,1994. In P.Wall & R. Melzack (Eds.).
  4. Michel and Anne. Complementary and Alternative Approaches to Pain Relief During Labor. Ecam 2007[cited December 29, 2010]:10.1093:1-9. Available from: URL: http://www.ecam.oxfordjournals.org //
  5. Nettlebladt The significance of repor ted childbir th pain. Journal of Psychosomatic Research.1976.[Cited 2010 December14]; 20, 215. Available from: URL: http://docsgoogle.com
  6. Brown Women’s Evaluation of Intrapartum Nonpharmacological Pain Relief Methods Used during Labor . Journal of perinatal education advancing Normal birth. 2001. [Cited 2010December 29];10(3): 1-8. Available from: URL: http:/

/www.ncbi.nlm.nih.gov/pmc//

  1. Krouse Video modelling to educate patients. Journal of Advanced Nursing,2001. [cited 2010 December29]; 33: 748-757. Available from : URL:http:// www.sciencedirect.com//
  2. Hofbauer Cor tical representation of the sensory dimension of pain. J Neurophysiology [abstract] .2001.[cited 2010 December 29]; 86: 402- 11.Available from: URL: http:// www.Sciencedirect.com//
  3. n Culture and Childbearing. In A. Clark (Ed.). Culture and Childbearing. Philadelphia: F.A. Davis.1978.[cited 2010 December13] Available from: URL: http:// www.bir thingnaturally.net/research/ pain.html
  4. Davenpor t   S,   Boylan Psychological correlates of childbirth pain.Psychosomatic Medicine. 1974. [cited 2010 December 14]; 36, 215. Available from: URL: http:// www.psychosomaticmedicine.org//
  5. Bharathi J Effective Nursing Interventions on Pain during Labour among Primi Mothers. The Nursing Journal of India. 2010[Cited 2011 December 29]; 6. Available from: URL: http:// www.tnaionline.org//
  6. Ciobanu DD, Anca LI. Comparative study regarding the influence of pain management on labor deployment . Ovidius university annals, series physical education and sport / science, movement and health. 2010. [Cited 2012 March 22]; 2; 881-89. Available from : URL: http:// sciencedirect.com//