Rajiv Gandhi University of Health Sciences, Karnataka

Bangalore.

PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

1. Name of the candidate and MOHAMMAD. HUSNA BHANU,

2. Name of the institution Krupanidhi College Of Nursing

3. Course of study and subject M.Sc Nursing

4. Date of admission to course 01-06-2008

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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

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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

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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

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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.

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 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

adolescents 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

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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

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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

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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 ( 50 0 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

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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

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 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:

To assess the level of pain and behavioral responses in primi mothers during

the first stage of labour.

To assess the effectiveness of warm compress on labour pain.

To determine the association between pain and behavioral response scores and

selected demographic variables.

6.5 HYPOTHESIS:

H1 - Post test pain score and behavioral responses will be lesser than pretest pain

score and behavioral responses at 0.05 level of significance.

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6.6 OPERATIONAL DEFINITIONS:

Effectiveness:

Effectiveness refers to the extent to which the warm compress has its

impact on reducing the labour pain experienced by primi mothers as measured by

Numerical pain scale and observational check list.

Warm compress:

Warm compress is the application of moist heat over lumbar and sacral region by

means of Turkish towel wrung out of hot water (temp 100 0-1010 F). Warm

compress will be applied for a period of 15 minutes at half an hour interval for four

hours in I stage of labour.

First stage of labour:

First stage of labour refers to the time interval from 3cms cervical dilatation

till full dilatation cervix.

Pain:

It refers to intense never felt subjective discomfort experienced by primi

mothers in first stage of labour reported on Numerical pain scale.

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6.7 ASSUMPTIONS:

1) Primi mothers in first stage of labour will have severe pain during uterine

contractions.

2) Warm compress as a non pharmacological measure will reduce the intensity of

labour pain.

6.8 DELIMITATIONS:

This study is limited to primi mothers who are in first stage of labour and admitted

in a labour room of selected hospital.

6.9 PROJECTED OUTCOME:

The findings of this study will reveal that after application of warm compress there

may be a noticeable reduction in the level of labour pain experienced by primi

mothers in labour room.

7. MATERIALS AND METHODS:

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 7.1 SOURCE OF DATA

7.1.1 Research design

Quasi experimental design will be used to conduct the study.

Pretest Treatment Post test

O1 X O2

7.1.2 Setting:

This study will be conducted in labour room setting of Yediur Maternity Hospital.

Yediur Maternity Hospital is located in Jaya Nagar, Bangalore. The hospital

consisted a labour room, a post natal ward, an operation theatre and OPD. The

monthly statistics of labour cases are about 140, among which the primi cases will

be 40-50 per month.

7.1.3 Population

The study population consist of primi mothers in first stage of labour admitted in

labour room.

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 7.2 METHOD OF DATA COLLECTION:

7.2.1 Sampling procedure:

Purposive sampling method will be used in the study to select the primi mothers

who meets the inclusion criteria.

7.2.2 Sample size:

Forty Primi mothers who are in first stage of labour.

7.2.3 Inclusion criteria: Primi mothers who are

1) in first stage of labour

2) with term pregnancy.

3) with singleton pregnancy.

4) willing to participate in the study.

7.2.4 Exclusion Criteria: Primi mothers

1) who are on analgesics and sedatives.

2) whose cervical dilatation > 6cms on admission.

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 7.2.5 Instruments used for the study :

1) Part 1 - Baseline proforma

2) Part 2 - Numerical Pain Scale

Numerical pain scale is a straight line which has points, ranging from 0 to

10. Point 0 indicates no pain and point 10 indicates worst possible pain. The

subjects in the study will be given the scale and will be asked to mark to the point

at which they feel pain17.

3) Part 3 - Observational Check List

a) Observation during contractions

b) Observation in between uterine contractions

c) Manifestations of participation

7.2.6 Data collection method:

After securing written permission from the respective authority and based on

criteria informed consent will be taken, pre test will be conducted among primi

mothers who meets the inclusion criteria using numerical pain scale to assess pain

scores and behavioral responses using Observational check list. Warm compress

will be administered for 15 minutes at half an hour interval for four hours in first

stage of labour. Post test pain scores and behavioral responses will be assessed

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using numerical pain scale and Observational check list.

7.2.7 Data analysis plan:

Descriptive and inferential statistics will be used to analyse data according

to objectives.

7.3 DOES THE STUDY REQUIRES ANY INVESTIGATION OR

INVESTIGATION TO BE CONDUCTED ON PATIENT OR OTHER

HUMAN OR ANIMALS?

No

7.4 HAS ETHICAL CLEARANCE OBTAINED FROM YOUR

INSTITUTION ?

No invasive intervention will be used. Prior permission from the respective

authority and individual consent will be taken.

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8. LIST OF REFERENCE:

1) Barbara Kozier, Glenora Erb, Andrey Jean Bermann, Karen Burke.

Funsdamentals of Nursing. 7th ed. New Delhi: Dorking Kindersly Pvt.Ltd; 2007.

p.1081.

2) Lowne NK. The pain and discomfort during labour and birth. JOGNN 1996

Jan; 25(1): 82-92.

3) Ruth Bennet, Linda Brown. Myles text book for Midwives. 12th ed. Churchill

Livingston: 1993. p. 186-97.

4) Lubna Abushaikha, Arwa Oweis. Labour Pain experience and Intensity - A

Jourdin perspective. Journal of Transcultural Nursing 2007 Jan; 18(1): 35-40.

5) C.Mac Artur, M Lowis, EG Knox, JS Grawford. Epidural Anaesthesia and Long

term Bachache after Child birth. British Medical Journal 1990 Jul; 301(6742): 9-

12.

6) David H, Rosen M. Perinatal morbidity after analgesia. British Medical Journal

1996 Oct; 31(8): 105459.

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7) H. Homer, Brodrick. Expectations and experiences of pain in labour. Journal of

Obstetrics and Gynaecology 2001 Jun; 29(7): 53-57.

8) Francis Nichols, Elaine Zwellin. Maternal Newborn Nursing theory and

Practice. 1 st ed. Philadelphia: W.B Saunder; 1997. p. 832-39.

9) Hannah G.Dahlon, Carolie SE.Homer, Margaret cooke, Alexis M. Upton.

Australian women's and midwives experience of using perineal warm packs in II

stage of labour. Journal of Birth and Management 2007 Apr; 34(3): 132-35.

10) Diane Brage Hudson. Christie Campbell Grossman. Adolescents pain during

the progression of labour. Journal of Nursing Clinical research 1998 Jul; 7(1) :

82-93

11) Carsten Lenstrup, Anne Schantz, Arne Berget, Elisabeth Feder, Helle sper Yer.

Warm tub bath during delivery. Journal of Acta Obstetricia et Gynaecologia

Scandinavia 1987 Mar; 66(8): 707-12.

12) Angela Bakar, Sally A. Ferguson, Gregory. Perception of labour pain by

mothers and midwives. Issues and Innovations in Nursing 2001; 35(2).

13) Mark D.Akin, Kurt Weingand, David a. Hengehold, Mary Beth, Robert

T.Hinkle. Continuous low level topical heat in treatment of Dysmenorrhoea.

Journal of Ostetrics and Gynaecology 2001 Apr; 97(8): 343-49.

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14) French SD, Cameron M, Walker BF, Esterman AJ. Superficial heat and cold for

back pain. Cochrane Database for Systematic reviews 2006 Jan; 26 (1): 1002-13.

15) Magyarosy, Krause, Resch K.L, Guggemose. Surface EMG response to heat

and cold application on back muscle. European journal of Physical Medicine and

Rehabilitation !996 Jun; 6(33): 39-42.

16) Shirley Joseph. Effectiveness of warm compress on sacral area to women in

labour pain during first stage in a selected hospital at Bangalore. (Unpublished

master of Science Nursing dessertation submitted to Rajiv Gandhi University of

Health Sciences, Bangalore.)

17) Hartrick CT, Kovan JP, Shapiro S. The numeric rating scale for clinical pain

measurement:2003; 3 (4): available from: URLhttp://www.pain assessment

scales.org doi:10.1111/j.1530-7085.2003.03034.x.PMID17166126. Accessed

December 2005.

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Signature of candidate

Remarks of the guide

Name & Designation

11.1 Guide MRS.MARIA PREETHI MIRANDA

11.2 Signature

11.3 Co-Guide MISS.HEPSI BEULAH

11.4 Signature

11.5 Head of Department MRS. MARIA PREETHI MIRANDA

11.6 Signature

12.1 Remarks of the principal

12.2 Signature

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