jogn1424

JOGNN R E S E A R C HEfficacy of Warm Showers on LaborPain and Birth Experiences Duringthe First Labor StageShu-Ling Lee, Chieh-Yu Liu, Yu-Yin Lu, and Meei-Ling Gau

CorrespondenceMeei-Ling Gau, RN, CNM,IBCLC, PhD, GraduateInstitute ofNurse-Midwifery, NationalTaipei University ofNursing and HealthSciences, No. 365, Ming-TeRoad, Peitou, Taipei 112,[email protected]

Keywordswarm showerslabor painbirth experience

ABSTRACTObjective: To determine the efficacy of warm showers on parturition pain and the birth experiences of women duringthe first stage of labor.Design: Randomized controlled trial (RCT).Setting/Participants: The study was conducted from July 10, 2010 to January 12, 2011 in the maternity ward of aTaipei City regional teaching hospital, site of approximately 220 to 250 births per month. Ninety-two expectant motherswere recruited (recruitment rate: 70.8%) and allocated by block randomization into the two arms of the study. In total,80 women completed the trial: 41 in the control group and 39 in the experimental group.Methods: Participants in the experimental group received warm shower bath interventions. Each shower lasted 20minutes. After a 5-minute full body or lower back shower, participants could spend 15 minutes directing shower watertoward any body region that felt most comfortable. Facilities allowed participants to stand and sit as desired. Waterwas constantly monitored and maintained at a temperature of 37C. Participants in the control group received standardchildbirth care.

Results: Labor pain and the birth experience were assessed using the Visual Analogue Scale for Pain (VASP) andthe Labour Agentry Scale, respectively. After adjusting for demographic and obstetric data, experimental-group womenwho participated in warm showers reported significantly lower VASP scores at 4-cm and 7-cm cervical dilations, andhigher birth experiences than the control group.Conclusion: Apart from the positive physical hygiene effects, warm showers are a cost-effective, convenient, easy-to-deploy, nonpharmacological approach to pain reduction. This intervention helps women in labor to participate fully inthe birthing process, earn continuous caregiver support, feel cared for and comforted, and have a more positive overallexperience.

JOGNN, 42, 19-28; 2013. DOI: 10.1111/j.1552-6909.2012.01424.xAccepted August 2012

Shu-Ling Lee, RN, CNM,MS, is a registered nurse inthe Department of Nursing,Taipei City Hospital,Heping Fuyou Branch,Taipei, Taiwan.

Chieh-Yu Liu, PhD, is anassociate professor in theGraduate Institute ofNurse-Midwifery, NationalTaipei University ofNursing and HealthSciences, Taipei, Taiwan.

(Continued)

Although a happy and meaningful experiencein a womans life, childbirth is also sourceof extreme physical pain and hardship (Simkin& Hull, 2011; Waldenstrom, 2003). The Interna-tional Association for the Study of Pain (IASP) de-fined pain as a subjective and unpleasant sen-sory and emotional experience associated withactual or potential tissue damage (Merskey &Bogduk, 1994). Many studies point to labor painsas the most significant source of discomfort dur-ing childbirth, generating levels of pain that testor exceed physical endurance limits (Akerman &Dresner, 2009; Leeman, Fontaine, King, Klein, &Ratcliffe, 2003). Labor pains and loss of control,the two most frequently cited unpleasant experi-ences of childbirth, directly affect womans satis-

faction concerning birth care, which in turn ad-versely affects self-perceptions and self-esteem(Hauck, Fenwick, Downie, & Butt, 2007; Niven &Murphy-Black, 2000).

Williams, Povey, and White (2008) stated that painrelief in the maternity ward should effectively re-lieve perceived pain in a manner that does not dis-rupt the birthing process and ensures fetal safety.Pharmacological and nonpharmacological meth-ods are the two predominant approaches to clini-cal pain suppression and control. Although effec-tive at relieving pain, parenteral pain medicationand epidural interventions cause known side ef-fects in the mother and fetus, consequently length-ening the labor duration (Cesario, 2008; Walker

The authors report no con-flict of interest or relevantfinancial relationships.

http://jognn.awhonn.org C 2012 AWHONN, the Association of Womens Health, Obstetric and Neonatal Nurses 19

R E S E A R C H Warm Showers, Labor Pain, and Birth Experiences

Warm showers can relieve pain while also encouraging mothersto shift positions, thus facilitating the downward progression of

the fetus through the birth canal.

& OBrien, 1999), augmenting risk of neonatalrespiratory distress (Walker & OBrien), and de-creasing infant suckling ability (Bell, White-Traut,& Medoff-Cooper, 2010). With labor pain outsideher control, a mother also faces increased riskof feeling fear, anxiety, helplessness, and lossof control of the overall birthing process (Haucket al., 2007; Simkin & Hull, 2011; Waldenstrom,2003). Coupled with the restrictions to movementimposed by continuous fetal heart monitors, in-travenous drips, and oxytocin infusions, mothersmay abandon the natural birthing process andrequest a cesarean (Romano & Lothian, 2008;Shilling, Romano, & DiFranco, 2007). Accordingly,many women consider using nonpharmacologi-cal methods to relieve and control childbirth pain(Fenwick, Hauck, Downie, & Butt, 2005; Williamset al.).

In rehabilitation medicine and the treatment ofarthritis and other pain symptoms, water ther-apy (baths and showers) has an extensive history(Benfield, Herman, Katz, Wilson, & Davis, 2001;Nichols, 1996). Water transmits a desired thera-peutic temperature into target tissues, changingthe state of irritant receptors and reducing per-ceived pain (Benfield et al., 2010; Nichols). Theexact origins of hydrotherapy on childbirth painrelief are unknown. Laboring and birthing in wa-ter has increased in use since being promoted inRussia in the 1970s by Igor Charkovsky (Cluett &Burns, 2012). Michel Odent (1983) subsequentlypopularized water immersion in other Europeancountries. Numerous clinical studies have sinceshown that immersion baths induce relaxation, re-lieve pain, and lower blood pressure (Benfieldet al. 2010; da Silva, de Oliveira, Nobre, 2009)while affording mothers a greater role in decisionmaking and a greater sense of control over child-birth (Eckert, Turnbull, & MacLennan, 2001). Warmshowers also encourage mothers to shift positions,facilitating the downward progression of the fe-tus through the birth canal (Stark, Rudell, & Haus,2008).

Yu-Yin Lu, RN, PhD, is anassistant professor in theDepartment of Nursing,National Taipei Universityof Nursing and HealthSciences, Taipei, Taiwan.

Meei-Ling Gau, RN, CNM,IBCLC, PhD, is a professorin the Graduate Institute ofNurse-Midwifery, NationalTaipei University ofNursing and HealthSciences, Taipei, Taiwan.

Although most hospital maternity wards in Taiwanoffer shower facilities, domestic research studieson the pain relief efficacy of warm showers dur-ing labor are lacking. In this study, we introduced

warm showers to women who were experiencingthe first active phase of labor. We assessed painrelief efficacy as well as its impact on the birthexperience.

MethodsWe used a randomized controlled trial design,assigning participants into the experimental andcontrol groups.

Participants and SettingThe study was conducted in the maternityward of a Taipei City regional teaching hospi-tal that averages 220 to 250 births monthly. Thewards seven delivery rooms included two la-bor/delivery/recovery (LDR) rooms. All rooms wereprivate with bathrooms. Standard patient care in-cluded intermittent fetal monitoring and pelvic ex-aminations for cervical dilatation. Women werefree to walk around for at least 20 minutes everyhour.

Recruited participants were laboring women whowere anticipating an uncomplicated vaginal birthof a term singleton fetus, dilated to at least4 cm at time of enrollment, accompanied bytheir spouses or other family members, andwilling to participate. All participants who ac-cepted epidurals or underwent cesareans wereexcluded.

Random allocation computer software assignedparticipants to either the experimental or controlgroup. Statistical power analysis calculated the re-quired sample size. Assumptions were as follows: = .05, power = .80, and effect size = .30. Basedon the GPower statistical package (Germany;version 3.1.1, Fual, Erdfelder, Lang, & Buchner,2007), two-tailed tests, and an effect size value todetect changes in pain between groups, the nec-essary sample size was estimated as 41 partici-pants per group. In taking into account a possibleattrition rate of 10%, we set the target sample sizeat 45 participants per group.

InstrumentsA structured questionnaire collected participantdemographic and obstetric information. Demo-graphic data included age, height, weight, maritalstatus, education, occupation, and medical his-tory. Obstetric data included parity, weeks ges-tation, pharmaceutical use during labor, antenataleducation, infant birth weight, method of rupture ofmembranes, number of pelvic examinations, and1- and 5-minute Apgar scores.

20 JOGNN, 42, 19-28; 2013. DOI: 10.1111/j.1552-6909.2012.01424.x http://jognn.awhonn.org

Lee, S. L., Liu, C. Y., Lu, Y. Y., and Gau, M. L. R E S E A R C H

Visual Analogue Scale for PainThe Visual Analogue Scale for Pain (VASP) is apain assessment tool previously used to assess abroad spectrum of pain including arthritis, burns,surgery, childbirth, and cancer (Bostrom, Sandh,Lundberg, & Fridlund, 2003; Gift, 1989; Harandi,Esfandani, & Shakibaei, 2004; Peng et al., 2010;Tamiya et al., 2002). The VASP is scored on a10-cm horizontal line punctuated by 10 evenlyspaced marks numbered from 0 to 10, with thefirst located to the extreme left and the 10th tothe extreme right. Possible scores ranged from 0(no pain) to 10 (extreme pain). Respondents as-signed their scores based on subjective percep-tions of current pain. Simple to use, the VASP isapplicable for all types of physical pain and is themost widely used pain measurement scale duringchildbirth in Taiwan (Chung, Hung, Kuo, & Huang,2003; Gau, Chang, Tian, & Lin, 2011; Liu, Chang,& Chen, 2010).

Labor Agentry ScaleThe self-administered Labor Agentry Scale de-veloped by Hodnett and Simmons-Tropea (1987)measures a mothers feelings of control duringchildbirth. Its 10-item inventory includes six pos-itive and four negative descriptions of perceiveddegree of control experienced during childbirth.Scoring follows a 7-point Likert-type scale format,with 7 (all the time), 6 (most of the time), 5 (morethan half the time), 4 (about half the time), 3 (nearlyhalf the time), 2 (only occasionally), and 1 (almostnever or never). Possible scores ranged from 10to 70, with a higher number corresponding witha more positive experience. Previous studies re-ported Cronbachs alphas for the LAS in the .91 to.98 range (Adewuya, Ologun, & Ibigbami, 2006;Goodman, Mackey, & Tavakoli, 2004; Hodnett &Simmons-Tropea).

The LAS was translated into Chinese using Bris-lins (1986) two-stage process. A professionalChinese-to-English translatorwho had not seenthe original LASretranslated into English a first-version Chinese copy of the LAS performed bya maternity professor. A second (native U.S.)translation professional compared the two Englishversions for content validity. We assessed itemsfor cross-correlation and appropriateness using athree-point evaluation scale, with 3, 2, and 1, re-spectively, indicating appropriate, no need for re-vision, appropriate, minor revisions required, andnot appropriate, major revisions required. Resultsfor the Chinese LAS revealed a 1.0 content validityindex.

To confirm scale efficacy, Streiner and Norman(2003) and Beck, Bernal, and Froman (2003) rec-ommended that translated scales be pilot testedon a population of potential users prior to formaluse. Therefore, at a hospital in Southern Taiwan,we administered the Chinese version LAS on 12qualified mothers who answered the questionnairewithin 24 hours postpartum. The Cronbachs alphafor the pilot test was .89.

InterventionWarm showers were the therapeutic intervention.We gave all potential participants an educationalflier that explained the intervention and listedits requirements, including (a) participant allowspreshower session checks of fetal heartbeat andcervix dilation, (b) all participants accompaniedby spouse, family member, etc., (c) water tem-perature maintained at 37 degrees Celsius (C),and (d) sessions last 20 minutes. Prior to enroll-ment, we monitored the fetal heartbeat and cervi-cal dilations of experimental group candidates for30 minutes to confirm normal labor progression.We also helped administer the first 20-minute in-tervention session. After a 5-minute full-body orlower-back shower, participants were permitted todirect shower water anywhere that felt most com-fortable. Nurses allowed participants to stand andsit as desired. After the first session, nurses mon-itored the fetal heartbeat and dilation status for atleast 20 minutes every hour. Given continued nor-mal labor progression, we allowed participants totake 20-minute accompanied warm showers asdesired.

During the intervention, participants could take anadditional accompanied shower session as longas the fetal heartbeat and dilation status were nor-mal and researcher consent was achieved. Wa-ter temperature was monitored every 5 minuteswith a bath thermometer to confirm a constant37C. Participants could personally adjust the am-bient temperature of the shower room to their owncomfort.

Data Collection ProcessWe recruited study participants from the birth unitof one regional hospital in northern Taiwan. Re-cruitment began in July 2010 after the hospitalInstitutional Review Board and nursing and ma-ternity departments granted approval. Potentialparticipants and those meeting the study crite-ria were approached individually. The study pur-pose and procedures were carefully explained,with questions clarified prior to written consent. To

JOGNN 2013; Vol. 42, Issue 1 21


Warm showers decreased labor pain and improved thechildbirth experience.

maintain data confidentiality, all data related topatient identity was excised, and a code systemwas assigned to participants. Participants wereinformed of their right to withdraw from the studyat any point without affecting subsequent care.Qualified participants were randomly assigned toexperimental and control groups, both of which re-ceived standard maternity nursing care, with theformer undergoing intervention.

The research assistant (RA) explained the studypurpose to both parents upon hospital admis-sion, offering them an informational document,and obtaining written informed consent. The RApersonally handled all first shower bath sessions,pre- and postintervention pain assessments, anddata collection. Control group participants pro-vided demographic data after receiving standardhospital care, responded to the VASP at 10 and20 minutes after 4-cm and 7-cm dilation, and filledout the LAS within 24 hours of delivery.

After receiving standard nursing care and provid-ing demographic data, experimental group par-ticipants took their first 20-minute warm showersat 4-cm dilation assisted by the RA. Experimentalgroup participants responded to the VASP prior totaking warm showers at 4-cm and 7-cm dilationand at 10 and 20 minutes afterward. Lastly, theycompleted the LAS.

Data AnalysisThe SPSS version 18.0 was used for the anal-yses. Descriptive data analysis identified thedemographic and obstetrics characteristics ofparticipants. The KolmogorovSmirnov goodness-of-fit test and normality plot investigated the distri-butional characteristics of study-dependent vari-ables. The results indicated that the values for thetarget variables were normally distributed amongthe population. Chi-squared or independent t testsevaluated differences in demographic and obstet-ric variables between groups.

The generalized estimating equations (GEE)model controlled the effects of study covari-ates and analyzed the independent effect ofwarm showers. The GEE approach consideredwithin-person variability and accounted for corre-lated data resulting from repeated measurements

across different time points and multiple observa-tions of the same individual (Zeger & Liang, 1986).The GEE approach has been proposed as a non-parametric and appropriate method to conduct re-peated measurement analysis. The level of signif-icance was set at .05, two-tailed.

ResultsA total of 130 women were assessed for eligibil-ity; 38 were excluded due to planned cesarean(n= 17), refusal (n= 3), and no time to collect datadue to the simultaneous admission of two subjects(n = 18). Ninety-two participants met the inclusioncriteria and were enrolled in the study: 46 par-ticipants were randomized to the warm showersgroup, and 46 to the control group. Nonetheless,some participants (n = 12) were removed from thestudy for various reasons including: emergencycesarean (n = 6), epidural anaesthesia (n = 3),and rapid delivery (n= 3) (Figure 1). From the orig-inal participant sample, seven participants wereremoved from the experimental group and five par-ticipants from the control group, yielding an attri-tion rate of 13.04%. As a result, the study included39 participants in the experimental group and 41in the control (Figure 1).

Table 1 provides a description of the 80 par-ticipants relative to demographic and obstetricalcharacteristics. The mean reported age was 31.64years. They were predominately university gradu-ates (65%), nulliparous (53.8%), experienced thenatural rupture of membranes (75%), without in-duction (81.3%), and lacked antenatal class at-tendance (62.5%). The average prepregnancyweight, prepregnancy body mass index (BMI),and total pregnancy weight gain were 53.11 kg,20.88 kg, and 13.57 kg, respectively. The aver-age received pelvic examinations in total and be-tween 4 cm to 7 cm dilatation were 6.30 and 2.92,respectively. The groups demonstrated no statis-tical differences in demographic and obstetricalvariables (p > .05).

We found that warm showers improved thechildbirth experience and decreased labor pain(Table 2). The mean LAS score of the interven-tion group was 54.15 (SD = 6.38) and 46.58(SD = 8.61) of the control group (t = 4.45,p < .001). In terms of pain scores, at baseline,the mean pain scores for the intervention groupwere 6.84 (4 cm) and 8.74 (7 cm) compared to5.15 (4 cm) and 8.22 (7 cm) for the control group.At 10- and 20-minutes postintervention, meanpain scores for the experimental group dropped



Figure 1. CONSORT diagram. Passage of participants through each trial stage.

significantly while increasing significantly for thecontrol group (Table 2 and Figure 2). GEE analy-sis evaluated these differences after adjusting forseveral variables with potential effects on laborpain. Table 3 shows that changes to mean painscores were significantly lower among the inter-vention group ( = 1.48, 4 cm and = 1.65,7 cm) than the control. Time-dependent changesalso indicate that posttest pain values rose anaverage 0.150.71 points over pretest results,implying a growth trend. However, the interac-tion effect (group difference and time) revealedthat the intervention group achieved a significantlygreater drop in pain values compared to their con-trol group peers over time ( = 2.282.79,p < .001).

DiscussionThe VASP scores for the experimental group werelower than control group scores at all measured

periods. All differences achieved statistical signif-icance. Average pain was less at 10 minutes than20 minutes postshower, echoing Huang (2010),whose research on the efficacy of heat therapyin reducing labor pains during the three phasesof the first stage of labor found that initial appli-cations reduced pain more significantly than mid-period and late-period applications. Study partici-pants had higher VASP scores at 7-cm dilationsthan 4-cm, indicating that pain level increasedas mothers progressed through the initial stagesof labor. This finding confirms with those of Gauet al. (2011), Chung et al. (2003), as well as Simkinand Ancheta (2011).

Our data clearly demonstrate the effective-ness of warm showers in reducing labor painwhile reinforcing the results of similar studies(Benfield et al., 2001; Benfield et al., 2010; Nichols,1996). Melzack and Walls gate control theory ofpain (as cited in Montes-Sandoval, 1999; Warren,

JOGNN 2013; Vol. 42, Issue 1 23


Table 1: Participant Backgrounds and Obstetrical Information

Overall Control group Intervention Statistics p

(N = 80) (n = 41) group (n = 39)

N % n % n %

Age (M, SD) 31.64 4.24 31.83 4.62 31.44 3.85 0.35b .681Education 0.10a .329

Junior college and below 28 35.0 15 36.6 13 33.3

University and above 52 65.0 26 63.4 26 66.7

Height (cm, M, SD) 159.40 5.47 158.59 5.89 160.25 5.27 0.85b .174Weight (Kg, M, SD)

Prepregnancy 53.11 7.80 53.09 7.98 53.13 7.71 0.61b .978

Current weight 66.68 9.20 66.83 9.48 66.52 9.02 0.67b .879

Total weight gain 13.57 3.58 13.75 3.40 13.38 3.80 0.45b .653

Prepregnancy body mass

index (M, SD)

20.88 2.78 21.09 3.02 20.66 2.51 0.70b .484

Gestational weeks (week, M,

SD)

39.06 1.16 39.19 1.05 38.91 1.26 0.12b .283

Parity 0.00a .987

Nulliparous 43 53.8 22 53.7 21 53.8

Multiparous 37 46.2 19 46.3 18 46.2

Antenatal class attendance 1.20a .273

Yes 30 37.5 13 31.7 17 43.6

No 50 62.5 28 68.3 22 56.4

Newborn weight (g, M, SD) 3094.9 280.8 3068.0 279.7 3106.2 302.2 0.59b .560

Induction

Yes 15 18.7 9 22.0 6 15.4 0.56a .455

No 65 81.3 32 78.0 33 84.6

AROM 3.75a .053

Yes 20 25.0 14 34.1 6 15.4

No 60 75.0 27 65.9 33 84.6

Pelvic examination (M, SD) (in

total)

6.30 1.75 6.24 1.64 6.36 1.87 0.29b .770

Pelvic examination (M, SD)

(within cervical dilatation

47 cm)

2.92 0.67 2.95 0.74 2.90 0.60 0.36b .722

Note. AROM = artificial rupture of membranes.aChi-squared test.bIndependent t test.

2010) described how nerves dispatch pain sig-nals through the spinal cord to the brain. Painstimuli cross the open spinal gate to receptors inthe brain, where the appropriate pain response

is directed. Interference with this transmissionvector can yield effective pain relief (Warren).Signals generated by warm-water stimulation ofepidermis thermoreceptors reach the brain faster



than those sent by pain receptors, effectivelyblocking transmission of the latter and reducingperceived pain (Huang, 2010; Lane & Latham,2009). Heat-enhanced blood circulation also re-lieves stress-induced muscle cramps. Focusingwarmth on specific tissues further improves tis-sue metabolism and elasticity, raising the effectivepain threshold (Benfield et al., 2001, 2010). Thepractical requirements of warm shower bath inter-ventions further increases patient movements andactivity, encouraging regular positional changesthat help relieve pain (Stark et al., 2008).

Many studies highlight the significant role of partu-rition pain on the mothers perception of the child-birth experience (Gungor & Beji, 2007; Li et al.,2009). The negative correlation between pain andself-control implies that a mothers sense of self-control over the childbirth process increases withbetter pain control. Effective labor pain controlis thus critical to making childbirth a more posi-tive, rewarding experience. The two most impor-tant factors influencing client satisfaction with thechildbirth experience are level of participation indecision making and degree of self-control overthe process (Goodman et al., 2004; McCrea &Wright, 1999; Remer, 2008). Researchers havedemonstrated that efficacy of water therapy on en-hancing parturient mothers sense of self-control(Benfield et al., 2010; Eckert et al., 2001). In ad-dition to enhanced support from caregivers, the

Table 2: Differences in Labor Pain and LaborExperience between the Two Groups (N= 80)Variable Experimental Control t p

group group

mean (SD) mean (SD)

Pain (4 cm)

Baseline 6.84 (1.93) 5.15 (1.96) 3.91


Figure 2. Changes in labor pain scores (4 cm and 7 cm) at baseline and posttests.

researchers adjusted ambient air temperaturesin the shower room to each participants pref-erence prior to showering sessions. In addition,when participants focused warm water on theirlower torso only, researchers provided warm tow-els for participants to drape over their shoul-ders to maintain upper body warmth. These factshighlight the need for maintaining adequate roomand water temperatures in intervention sessions,

as well as the need for educating participantsand their partners regarding water temperaturecontrol.

ConclusionOur results demonstrate the efficacy of a warmshower in relieving labor pain and fostering



Table 3: Generalized Estimating EquationsModela on the Effect of Outcome Variablesfor Warm Showers (N = 80)Variables SE p

Pain (4 cm)

Group (Experimental vs. control) 1.48 .40


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