Pain Perception During Labour

CHAPTER- II

REVIEW OF LITERATURE

The review of related literature is a essential aspects of scientific research. Its entails the systematic identification, reflection, critical analysis and reporting of existing information in relation to the problem of interest. The purpose of review of literature is to obtain comprehensive knowledge and in depth information about the effectiveness of ambulation on improve maternal comfort reduction of pain perception, outcome of labour during first stage of labour.

The purpose of review literature is to obtain comprehensive knowledge and in depth information about the effectiveness of ambulation on maternal comfort, pain perception &outcome of labour.

The literature gathered from exclusive review is depicted under the following heading.

• Section A: Literature related to pain perception during first stage of labour.
• Section B: Literature related to various maternal positions for maternal comfort, pain perception and outcome of labour during first stage of labour.
• Section C: Literature related to ambulation to improve maternal comfort, outcome of labour and reduce pain perception.
• Section D: Literature related to non pharmacological pain relief methods during first stage of labour for maternal comfort, pain perception and outcome of labour.

Section A: Literature related to pain perception during first stage of labour.

Campbell & Kurtz (2004) conducted a descriptive study characterized the labour pain at two stages of cervical dilatation with selected group 78 labouring mothers and compared the pain experienced at 2 stages of dilation(2-5 cm and of 6-10 cm) with women in Greenville. Stage’s of pain measured by Visual Analogue Scale, Present Pain Intensity, and the McGill Pain Questionnaire, and 1 observational measure, the nurse-rated Behavioural Index of Pain. The study results revealed that there was significant increase in pain with increased dilation occurred for all mothers both prim and multigravidas. He concluded that labour pain was equalin primi gravida than the multigravidas.

Lopez & Pires (2000) conducted the randomized control trail study was designed to evaluate the relationship between the parturients position and her abdominal and lumbar (continuous and contraction) pain during the first stage of labour. A homogeneous group of 100 parturients was selected in obstetric department of a general hospital, Argentina. Samples were randomly assigned to alternately assume the horizontal or the vertical position for 15-min periods. Positions were safely selected by the parturients. Thus, the mother adopted (a) a self-elected position, (b) recumbent (or erect), (c) a self-elected position, (d) erect (or recumbent), and so on. Pain intensity was measured by the Argentine Pain Questionnaire’s Present Pain Intensity and the Huskisson’s visual analogue scale. The findings revealed that a majority of parturients felt less abdominal and lumbar pain, either continuous or due to contractions, during recumbency. The effect was more remarkable when dilation exceeded five cm and less intense during the first half of the first stage of labour. He concluded that position may helpful to reduce the pain level during first stage of labour.

Mikolajczyk, Sundaram & Beaver Fraser (2010) conducted a survey study in aimed to examine labour patterns in a large population and to explore an alternative approach for diagnosing abnormal labour progression. The study were selected total of 26,838 parturient, who had a singleton term gestation, spontaneous onset of labour, vertex presentation, and a normal prenatal outcome in Maryland. An interval-censored regression method was used .The results revealed that Nulliparous women had longest and most gradual labour curve and start the active phase after 5 cm of cervical dilation and may not necessarily have a clear active phase and multiparous women of different parities had very similar curves. Researcher concluded that active phase of labour may not start until 5 cm of cervical dilation in multiparous and even later in nulliparous and after 6 cm dilatation only the progress in all pregnancy during labour .

Niven & Gijsbers (2004) conducted the exploratory study aimed to examine the nature, origin, and effectiveness of pain coping strategies used during childbirth with 51 British women was assessed around the time of birth. Pain was measured by visual analogue scales and the McGill Pain Questionnaire. Analysis of data obtained in an extended semi-structured interview. Subjects were found to use a range of strategies during labour, many of which they had previously used to cope with pain. In findings that the total number of strategies used in labour was negatively correlated with levels of labour pain.

Section B: Literature related to various maternal positions for maternal comfort, pain perception and outcome of labour during first stage of labour

Andrews CM & chrzanowski (1985) Conduct a randomized clinical trial to evaluate the maternal comfort by providing various upright positions in 40 labouring women’s randomly assigned to either upright recumbent position. During the phase of maximum slope of labour. When the cervical dilatation from 4cm to 9cm,Every hour during the phase of maximum slope. The investigator examined each sample vaginally to determine her cervical dilatation and assessed her level of comfort by using maternal comfort assessment tool the women in upright position group had significantly shorter phase of maximum slope of in labour and facilitating uterine contractions & increasing comfort to the mother.

Bauer et al (1987) Conducted a comparative study to assess the effects of standing position and supine position on spontaneous uterine contractions and other aspects of labour in twenty normal term mothers they were given by standing and supine position vice versa with the time duration of thirty minutes the investigator examined each sample every thirty minutes for cervical dilatation and pain perception. The investigator found that the intensity of contractions was significantly higher in fifteen out of twenty mothers in standing position frequency of contraction diminished and Reduced duration of labour .the investigator concluded that there is no adverse effects and complications in standing position during labour.

Carlson (1999) in an article a study by providing different maternal positions to evaluate the comfort status foetal out come &duet ion of labour. In eighty primigravida uncomplicated mothers. The positions chosen by mothers. The investigator found that the different positions improved maternal comfort & foetal out come. & reduce length of labour.

Chen shin-zon (2003) in an article stated that a study to assess the effectiveness of sitting position on labour pain during first stage of labour .the investigator found that in sitting position the increased resting pressure in the sitting position is of some importance in the supplementing the down ward delivery force and increasing bearing down pressure in the sitting position could help to significantly shorten the duration.

Gupta et al (2000) In an article stated study To evaluate the safe birth good maternal & foetal out come by providing upright positions at Birmingham women’s hospital Edgbaston, UK the positions adopted natively by women during birth has been described as early 1882 by Engel am. The investigator found that by providing various upright positions [like holding Rope , birthing chair , unfeeling, squatting]the mother will have safe birth decreased perinatal problems.

Liu (2003) conducted a descriptive study to evaluate the reduce duration of labour by providing up right positions in 68 primi gravida mothers between the age of 18 to 25 years were assigned to three groups . One group used a 30 degree upright position with no bearing down instructions and second group used a 30 upright position with bearing down instructions the investigator found that the upright position enhanced the descent head with shorter duration of labour in both first and second stage of labour.

May berry et al (2003) in an article stated descriptive study to evaluate the facilitating progress of labour by providing various upright positions. At New York university. The study sample is 74 labouring healthy women. Providing upright positions for all women. The investigator founded that facilitating progress of labour reduction of vaginal bleeding improve neonatal out come.

Miquelutti et al(2007) conducted a explanatory study to assess the effectiveness of upright position during first stage of labour during first stage of labour to improve obstetrical and perinatal outcome. The investigator allotted fifty four women for experimental group. They were given upright position and other fifty three women in control group they were given supine position .the difference between two groups were evaluated by using χ2 will coxon and fishers exact tests significance was p<0.05 risk ratio is 95%. The investigator concluded that the upright position during first stage of labour will reduce duration of labour.

Roberts et al (2005) stated that systematic review to reduce instrumental delivery by providing up right positions during labour .in centre for perinatal health in Sydney .the study participials were 281 primigravida mothers in that 166 experimental group provident up right positions & its control group in recumbent position each trail is analysed by using meta analytic techniques. The investigator concluded that the up right position during labour significant reduction of instrumental delivery & duration of labour perinatal trauma& haemorrhage.

Roberts & Malasonos (2003) conducted a randomized clinical trial by providing sitting in a chair and a side lying to evaluate the maternal comfort & uterine efficiency among 19 primigravida mothers alternated between these two positions at thirty minute interval for as long possible during labour siting position during early labour [cervical dilatation less than 6cm”]and lie on their side in late labour [cervical dilatation greater than 6cm”]. The investigator found the uterine efficacy less in the siting position than in side lying position and also siting position will improve maternal comfort.

Sandi (2001) conducted double blind study to evaluate the duration of labour by providing upright position in selected parturient at the Negress oriental provincial hospital the investigator provided 45 degree upright position the aestivator found that Reduce maximum length of labour in both first & second stage of labour and good new born out comes .

Streamer et al (2005) conducted that Randomized control trial of evaluate the rotation of foetal head by providing Hands & Knee positions for occipito posterior position to occipita anterior during labour. In 13 labour units in university attillated hospital study participates were 147 labouring women with a occipito posterior position in that 70 were hands keep position at least 30 min over per 1hour the experimental group and 77 were control group. (No hands knee positioning) The investigator used ultra sonography to find out foetal head rotation. Head rotation following one hour. The investigator conclude that the experimental group had significant reduction in persistent back pain, changing of foetal head to occipito posterior to occipito anterior position and other outcomes like decreased operative delivery and decreased perennial trauma and also good foetal out come. And the control group have the relative risk of operative delivery.

wine kiln watchers (2003) stated that case control study to evaluate the maternal and neonatal out come by providing various positions. At department of obstetrics & gynaecology of the university hospital viema between 1997 -2002 total study participants were 714 labouring women. 307 women were control group providing supine position & 307 were experimental group providing upright positions (squatting & other alternative birth positions. The analysis was restricted to 37 weeks normal sized foetus & cephalic persecution with out any medical (or) obstetrical risk the investigator found that upright position associated with beneficial effects such as a lower rate of episiotomy, and reduced use of medical analgesia & oxytocin.

Section C: Literature related to ambulation to improve maternal comfort, outcome of labour and reduce pain perception:

Hemmiki et al (1985) conducted a pilot study to evaluate the maternal comfort & length of labour by providing ambulation vs. oxytocin administration. The investigator selected fifty seven mothers randomly assigned control group & experimental group .the investigator used as randomized control trial for this study. the investigator provided ambulation for experimental group & oxytocin for control group. In experimental group 60% of the women in the ambulation delivered their babies with out oxytocin. The mean length of first and second stage of labour was reduced and also they had positive outcomes on the other hand the control group .they are experienced stronger contractions before pushing and also suffering from strong contractions. The investigator finds that ambulation will improve maternal comfort, out come of labour& decreasing length of labour.

Lawrence et al (2009) conducted a randomized clinical trial to evaluate maternal comfort & decrease length of labour by providing walking and upright positions at Townsville hospital Queensland Australia with the sample of 3706 pregnant primigravida mothers they were using random and quasi random sampling for comfort and experimental group in experimental group who are different upright position and walking the investigator concluded that the first stage of labour approximately one hour shorter than in a recumbent positions and other outcomes labour it will increase well being of mothers & foetus

Lupe et al (1986) in an article stated that assess the effect of ambulation during first stage of labour to reduce length of labour .and also it will speeds the progress of labour.ambulation will improve maternal satisfaction, and also it will improve maternal and foetal out come. The investigator reported the ambulation reported the ambulation during labour will improve greater maternal comfort and ability to tolerate labour and ability to tolerate labour pain, decrease use of anaesthesia and analgesia.

Read ja mitter et al (1981) conducted a comparative study to assess the effectiveness of ambulation versus oxytocin administration on improve labour progress. The investigator selected fourteen mothers (who failed augmentation in active phase of labour) assigned eight mothers in experimental group ,they were given ambulation and six mothers in control group ,they were given oxytocin infusion .the investigator used telemetry to monitor maternal and foetal condition in foetus heart rate and activity in mother station of the head , cervical dilatation, uterine activity contraction ,frequency and efficacy. The results included labour progress significantly better in ambulatory group the investigator concluded that ambulation is effective than oxytocin.

Souja et al (2006) in an article a study to evaluate to reduce the length of the first stage of labour by providing ambulation and upright positions at Brazil the investigator used Randomised control trials carried to assess the effect of ambulation the investigator found that the ambulation in the first stage of labour will improve maternal comfort & reduce the length of labour.

Stewart & caldera (1984) conducted a study meta analysis to assess the effectiveness of maternal posture on the progress of labour. The investigator selected 275 labour women are randomly assigned as control group and experimental group, control group were not given any specific position and experimental group were given ambulation. Radio telemetry was used to identify foetal heart rate the results included in ambulatory group shorter phase of labour and had maternal satisfaction, relived from pain. The investigator concluded that there were significantly shorter labour phase of labour phase in ambulation group.

William et al (1980) conducted a clinical trial to assess the effectiveness of ambulation during first stage of labour on improve maternal and foetal outcome. The investigator selected 48 parturient mothers as experimental group they were given ambulation and another 55mothers are control group they were not given any ambulation. The results include the experimental group (who are given ambulation) shows improve maternal comfort, reduce pain and improve maternal and foetal outcome. The investigator concluded that the ambulation in first stage of labour will improve maternal and foetal out come.

Wilson mi et al (2009) conducted a comparitive study to evaluate the maternal comfort & reduce instrumental delivery at Royal Hallam shire hospital U.K on 1052 primigravida mothers. The investigator divided in to two groups. Ambulation for experimental group epidural anaesthesia for control group the investigator found that there is difference in experimental group than control group ambulation will improve maternal comfort& Reduce length of labour.

Section D: Literature related to non pharmacological pain relief methods during first stage of labour for maternal comfort, pain perception and outcome of labour.

Labreque & Novmen (2000) conducted a randomized study to assess the effectiveness of non pharmacologic approaches to relief the low back pain. The investigation selected a sample of thirty four women by using three non pharmacological approaches line intracutaneous saline water injections , trans cutaneous electrical nerve stimulations , standard care including back massage, whirl pool bath and liberal mobilisation . The investigator randomly assigned 1 of 3 treatments. The investigator used visual analogue scale .The women’s were self evaluated both intensity and effective. The investigator used to evaluate satisfaction by using labour a gentry scale and delivery satisfaction index. The results included. The women received intracutaneous sterile water injections group. Unpleasantness of pain lower than standard care group. While the teens group (P= 0.01 and P= .003) similar results were observed for intensity P= .01 and unpleasantness P=.03 pain assessed just before delivery .The investigator found that there is no significant difference between all 3 group but first group has received back pain during labour.

Lee & chang hang (2000) conducted a quantitative study to assess the effectiveness sp6 acupressure on labour pain and delivery time in labour the investigator selected randomised clinical trial at university attached hospital with the sample size of 75 labour women randomly assigned n=36 were experimental group n=39 were control group according to parity ,cervical dilatation ,rupture of membranes and labour stage . the investigator include thirty minutes acupressure on sp6 acupoint was performed labour pain was measured four times using structured questionnaire and visual analogue scale . immediately after intervention and 30-60minutes after intervention there were significantly difference between the group in subjective labour pain scores at all time points immediately after interventions (p=0.012) 30 minutes after intervention (p=0.021) and 60 minutes after intervention(p=0.012) the total labour was significantly shorter in experimental group. The investigator concluded that sp6 acupressure was effective in decreasing labour pain

Simkin & Ohra (2004) Conducted a qualitative study to assess the effectiveness of non pharmacological methods on labour pain relief maternal satisfaction other obstetric labour. By giving non pharmacologic pain relief methods. At North America in selected hospitals. The investigation used five non pharmacological methods. Those are continuos labour support, touch, bath massage, maternal movement and postings. And intra dermal water blocks for back pain relief. The investigation found that all methods are effective to reduce labour pain .Increase, maternal comfort and out come of labour.

Toumarie & Theauyomeau (1982) In an article on acupressure on labour pain relief .the investigator used randomized control trial for study to apply acupressure over lumbosacral area during first stage of labour the investigator found that the acupressure will relief from labour pain during first stage of labour decease use of analgesics.

Water & Raiser (2002) Conducted a study to assess the effectiveness of ice massage on labour pain the investigator selected Hispanic and white pre labour women as a study sample. The investigator used ice massage of the acupressure energy meridian point large intestine and (L 14) to reduce labour pain during contractions (L 14) is located at medial mid point of skin between thumb and fore finger. The investigator chosen pre & post test design and which used 100 mm visual analogue scale and MC Gill pain questionnaire ranked numerically, verbally to measure pain levels. Participants noted a pain reduction mean on the VAS of 28.22 on the left hand & 11.93 mm on the right hand. The investigator concluded that ice massage is a safe, effective, non invasive method of reducing labour pain.