Original Article Application of Nonpharmacologic Methods to Relieve Pain during Labor: The Point of View of Primiparous Women Michele Edianez Gayeski, MSc,* Odal
ea Maria Br€ uggemann, PhD,† Marisa Monticelli, PhD,† and Evanguelia Kotzias Atherino dos Santos, PhD† ---

-

From the *University Hospital, Federal University of Santa Catarina, Trindade, Florian
opolis, Brazil; † Department of Nursing and Postgraduate Program, Federal University of Santa Catarina, University Campus, Trindade, Florian
opolis, Brazil. Address correspondence to Odal
ea Maria Br€ uggemann, PhD, Tocogynecology (Professor), Department of Nursing and Postgraduate Program, Federal University of Santa Catarina, University Campus, Trindade, Florian
opolis, Brazil 88040-970. E-mail: [email protected] Received February 15, 2011; Revised August 6, 2014; Accepted August 7, 2014. 1524-9042/$36.00 Ó 2015 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2014.08.006

ABSTRACT:

The aim of this study was to assess the application of nonpharmacologic methods to relieve pain during birthing from the point of view of primiparous women. To achieve this goal, a cross-sectional study was developed with 188 primiparous women interviewed using a standardized form on the day they were discharged from the hospital. Results indicated that the most-used nonpharmacologic method was emotional support provided by the woman’s companion (97.3%), followed by warm showers (91.5%); however, the highest degree of satisfaction derived from focused attention. In the assessment of the general degree of satisfaction with the methods studied, primiparous women experienced a high level of general satisfaction (88.3%). Significant associations between this result and changes in position (p ¼ .0340, odds ratio [OR] 3.29, confidence interval [CI] 95% 1.13-9.52) and focused attention (p ¼ .0326, OR 2.61, CI 95% 1.06-6.43) were observed. There was a significant association between the general score for satisfaction and the emotional support of an obstetrics nurse (p ¼ .0096, OR 3.78, CI 95% 1.49-9.55), of the obstetrician (p ¼ .0031, OR 3.74, CI 95% 1.5-9.33), and of the nurse’s aide (p ¼ .0303, OR 4.56, CI 95% 1.03-20.24). We concluded that in the obstetric center where the study was conducted, nearly all the nonpharmacologic methods available are being adopted by the members of the healthcare team, with the participation of a companion. However, those that generate the highest degree of satisfaction are not those most used. Ó 2015 by the American Society for Pain Management Nursing The pain that women may feel during childbirth is quite variable, as are the ways in which they respond to it. For this reason, the birthing environment and the support given by professionals and companions, as well the methods used to Pain Management Nursing, Vol 16, No 3 (June), 2015: pp 273-284

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relieve pain, are important because they can affect reactions during the birthing process (Enkin, Keirse, Renfrew, & Neilson, 1998) and play an important role in the development of symptoms of traumatic stress after childbirth (Garthus-Niegel, Knoph, Soest, Nielson, & Eberhard-Gran, 2014). The perception of acute pain of any type, as well as the pain of childbirth, is considered to have two dimensions—the sensory and the affective. However, the principal focus of research, and in practice, has always been the physical transmission of pain, giving little importance to emotional and affective components. Therefore, there is more evidence on the effectiveness of pharmacologic methods for pain relief and its adverse effects, although most nonpharmacologic methods are noninvasive and appear safe for mother and baby (Jones et al., 2012). Pain during labor, as well as methods for alleviating it, are of major concern to women of childbearing age and have major implications for intrabirthing progress, quality, and results (Caton, 2002). In some Brazilian hospitals, women may opt for the use of pharmacologic or nonpharmacologic methods (NPMs) for treating pain. Both have advantages. The most widely used pharmacologic method is epidural analgesia. On average, 30% of women who have low risk are subjected to this procedure (Leal et al., 2014). The principal difference is that pharmacologic methods, even though they produce evident results, can cause the mother and fetus or newborn to experience side effects. This possibility causes many women to prefer to avoid pharmaceuticals if other alternatives are available; avoidance may occur because of women’s desire to maintain a feeling of personal control during labor, as well as a desire to participate in a more effective manner. NPMs can be useful in the initial stages of labor, before pharmacologic options are indicated (Enkin et al., 1998). Studies on the transmission of pain and its modulation make possible important findings for understanding it, permitting the rebirth of traditional methods and the rise of new ones. Enkin et al. (1998) defined NPMs for the alleviation of pain as abilities developed with women for coping with stress and pain during labor, via physical and mental relaxation and various forms of concentration and distraction, in addition to controlled breathing patterns. Enkin et al. (1998) defined three categories of NPMs: (1) techniques that reduce painful stimulations, (2) techniques that activate peripheral sensory receptors, and (3) techniques that stimulate the descending inhibitory pathways. Using the definitions of Merhy and Onocko (1997), these methods can also be classified according

to the degree of technology employed in their use. Hard care technologies are represented by concrete material such as apparatuses and permanent or disposable furniture; light-hard care technologies, on the other hand, are based on the structured knowledge of health professionals, as well as of practice and epidemiology, organizing its application for the labor process; and light care technologies are related to the knowledge people acquire—and make their own— which influences the way they think and act in response to health situations and is generated during the very process that involves the interaction of health workers and users. Using these definitions, NPMs used to relieve pain during labor can be classified as hard and light-hard care technologies, because all of them require, at a minimum, structured knowledge for their use, because they can interfere in maternal and neonatal outcomes. Many women appreciate these hard and light-hard care technologies for alleviating pain during labor because by using them, women gain a feeling of control, an ability to cope with the pain, and a greater awareness of the support of their companions and caregivers. The freedom to get up and to walk around, to change position, and to push in a more effective manner is also seen as a positive aspect of these techniques (Simkim & O’Hara, 2002). Enkin et al. (1998) describe several NPMs to relieve pain during labor: movement and changes in the position of the woman, counterpressure (the continuous application of force on one spot of the lumbar region during contractions), superficial application of hot and cold packs, immersion in water or warm showers during labor and childbirth, stroking and massages, acupuncture, acupressure (compression or deep massaging of traditional acupuncture spots), transcutaneous electrical nervous stimulation (application of a low-voltage current to the skin using surface electrodes), sterile water injections (in four locations in the lumbar region), aromatherapy, focused attention, and distraction (activities developed to keep the person from thinking of the pain), hypnosis, and audioanalgesia. Nonpharmacologic approaches to relieve pain and continuous support during labor provide significant benefits for women and their children and are effective to reduce obstetric interventions (Chaillet et al., 2014). In Brazil, those options were not always offered to women, because the obstetric model has always been heavily focused on the medicalization of childbirth. However, this began to change in 1980s, with the completion of the Conference on Appropriate Technology for Birth, held in the city of Fortaleza in 1985, organized by the World Health Organization (WHO),

Nonpharmacologic Methods to Relieve Pain During Labor

the Pan-American Health Organization and the Regional Office of the Americas (World Health Organization, 1985). Moreover, the creation of the ReHuNa—the Brazilian Network for the Humanization of Childbirth, a civil society organization active since 1993, has played an important role structuring a movement nowadays called ‘‘humanization of childbirth’’ (Rattner et al., 2010). This movement calls for assistance and birth based on the recommendations of the WHO and the results of scientific studies, which supported a decrease in the use of unnecessarily interventionist techniques and the increase in respect for women’s reproductive rights (McCallum & Reis, 2006). Included among the suggestions were NPMs to ease pain, described by the parturients. However, the application of these methods began to be visible and to be used in practice only in 1996, when a practical guide on how to assist women during normal delivery was widely publicized. This guide classified these practices as approaches to be used cautiously (World Health Organization, 1996). The publication of this new guide stimulated the production of knowledge on this subject, leading to the development of several research studies with the aim of providing the grounds for such practices. In the context of obstetric assistance in Brazil, the use of NPMs to relieve pain arises alongside a new way of viewing the birthing process, which seeks to reduce unnecessary interventions and to promote a complete and satisfactory experience for the woman and her companion. The implementation of obstetric practices, even those that are based on scientific evidence, requires assessment from the point of view of the woman. Therefore, the purpose of this study is to evaluate the application of NPMs to relieve pain during labor from the point of view of primiparous women, verifying which methods are used and which health professionals, students, and companions apply them and assessing the degree of satisfaction of primiparous women with these methods, as well as the obstetric results and the expectations of pain. It is believed that this knowledge, compiled from the evaluation of women who have undergone the birthing process, may provide support for promoting a wider use of NPMs to relieve pain during childbirth and to design strategies to encourage the participation of healthcare providers in their implementation.

METHODS Cross-Sectional Study Place of and Participants in the Study. The study was carried out between October 2008 and September

275

2009 at a maternity unit of a university hospital in southern Brazil. This maternity unit was inaugurated in 1995 and has 4 prelabor beds and 1 observation bed in the Obstetric Center, 22 beds in the maternity ward, and 16 beds in the neonatal intensive care unit; the institution performs approximately 1,400 deliveries per year and is part of the University Hospital, which is a medium-sized institution offering medium to highly complex services exclusively through the public health system (Santos & Siebert, 2001). Services to women and their companions are based on a philosophy of care with its principles grounded in humanization and interdisciplinarity, covering biological, social, and emotional aspects and also highlighting the importance of the family during the birthing process (Santos & Siebert, 2001). In most Brazilian maternity hospitals, women’s companions are the providers of support during labor and childbirth; however, there is a resistance by some health professionals to the presence of many people to accompany and support. Consequently, the presence of doulas in the maternity wards is restricted. This reality is different from the United States and other countries, in which the mother can also count on the support of a doula (Silva, Barros, Jorge, Melo, & Ferriera Jr., 2012). The obstetric practices adopted are congruent with the recommendations of the WHO for delivery and include the application of NPMs to relieve pain. Although the institution has a guide for routine procedures, the obstetric center has not adopted these protocols, and there are no established guidelines on how and when to use them or who should apply them. Nevertheless, some methods are prescribed by the nurse midwives during the first stage of labor. These include warm showers or immersion bath, breathing techniques, massages in the sacrum and cervical regions, use of the birth ball, sitting backward on a chair (Simkin, 2007), pelvic rocking exercises (rhythmic movement of the pelvis from side to side, round and round, or back and forth), and changes in position (genupectoral, squats, left side-lying). Focused attention and emotional support are also offered, although not prescribed. Thus, all these methods, classified as light-hard care technologies (Merhy & Onocko, 1997), have been evaluated in this study. The participants of the study were primiparous women. The criteria used for inclusion were $37 weeks’ gestation at admission, single gestation with cephalic presentation, vaginal or caesarean section, duration of labor $ 4 hours, and the presence of company during labor. The following were excluded from this study: women with multiple gestations, elected caesarean delivery, existence of obstetric pathologic

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conditions (preeclampsia, placenta previa, premature separation of placenta, cardiopathies, gestational diabetes), fetal stress during the initial stages of labor, use of forceps during delivery, and fetal death. Calculation of the Sample Size. The type of the sample was stratified proportionally and by convention. The sample size calculation was based on the number of births (vaginal and caesarean) of primiparous women at the maternity of the University Hospital at the Federal University of Santa Catarina in 2007. These data were obtained from the Perinatal Clinical History Database (Hist
oria Cl
ınica Perinatal Base), a tool developed by the Latin-American Perinatology Center, and totaled 336 births, of which 61.1% were normal births, 36.7% were cesarean section, and 2.2% were vaginal deliveries with the use of forceps. Considering that the number of deliveries registered in 2007 in the Latin-American Perinatology Center’s program was 1,213 and that the annual statistical data of the Obstetric Center’s Nursing Services indicated 1,482 deliveries in 2007, the estimated number of primiparous women was increased by 10%, and it was estimated that approximately 369 women gave birth through normal birth or cesarean section delivery in that year. Therefore, in relation to the size of the sample, the degree of satisfaction of the primiparous women using NPMs to relieve pain was estimated at 50%, with a confidence interval of 95% and margin of error of 5%, which resulted in a sample size of at least 188 primiparous women to be interviewed, of whom 30% (57) underwent cesarean section and 70% (131) had normal birth. The index used to calculate the number of cesarean section in the sample was based on a historical series of the maternity of the University Hospital, which found that between 1996 and 2005 the percentage was approximately 30% on average (Br€ uggemann, Knobel, Siebert, Boing, & Andrezzo, 2009). For the statistical calculations, we used the Statistics Virtual TeachingLearning Computer Program (SEstatNet) (Nassar, 2008). Ethical Considerations. All aspects involved in this study comply with Resolution 196/96 issued by the National Council for Health. The project was approved by the Committee for Ethics in Research of the Federal University of Santa Catarina on August 25, 2008 (Process no. 225/08 FR-209528). All participants signed the Terms of Free and Informed Consent. Data Collection. The interviews were conducted by the researchers on the day of discharge from the hospital. The information was registered on a form containing a questionnaire related to the primiparous women’s sociodemographic and obstetric data, the type of NPM used to relieve pain, information on the

members of the health professional team who applied it (nurse-midwife, the nurse’s assistant or technician, nursing student, obstetrician, and medical student), and information about whether the woman’s companion (mother, partner, sister, baby’s father, and others) applied any of the methods, and woman’s degree of satisfaction with the practices. Data related to the labor, the delivery, and the newborn were obtained from the medical charts. In order to ensure that the women’s answers were as credible as possible, the interviewer provided an explanation of each of the methods included in the study. For example, the explanations given for the focused attention method were based on Enkin et al. (1998), who defined it as the development of activities to keep the patient from thinking about pain through a focus on visual, auditory, tactile, or other kinds of stimuli. Information on emotional support was provided based on Hodnett, Gates, Hofmeyr, and Sakala (2013), who defined it as the continuous presence of an empathic person who offers counseling, reassurance, praise, and information, among other tangible forms to help the woman cope with the stress of labor. The individuals who applied the method were also interviewed in order to allow for their identification. In relation to satisfaction, the interviewees identified one of five symbols showing facial expressions that best represented their feelings toward each of the methods used: very dissatisfied, dissatisfied, indifferent, satisfied, very satisfied. Statistical Analysis. The completed forms were revised and encoded and the data fed into the Epi Info Version 2005 program (Centers for Disease Control and Prevention, Atlanta, GA). SAS Version 8.2 (SAS Institute Inc., Cary, NC) was used for statistical analyses. Quantitative variables were evaluated in relation to the mean and standard deviation, and the qualitative variables were assessed in terms of their absolute and relative frequencies. For the calculation of the odds ratio (OR) and the 95% confidence interval (CI) of the degree of satisfaction of the primiparous women (evaluated according to how they felt about the application of NPMs to alleviate pain during labor: very dissatisfied, dissatisfied, indifferent, well satisfied, or very satisfied), the responses ‘‘well satisfied’’ and ‘‘very satisfied’’ were considered as indications of satisfaction (Brown & Lumley, 1994). The general score of satisfaction of the primiparous women was calculated using the Likert scale (Hulley, Cummings, Browner, Grady, & Newman, 2008). In order to evaluate the association between the general score of satisfaction, the satisfaction with each individual method, the obstetric results, and the

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Nonpharmacologic Methods to Relieve Pain During Labor

expectation of pain, the OR with a 95% CI was calculated and, for values expected to be less than 5, the chi-squared or Fisher’s exact test was used. The level of significance was established at 5%. A multivariate logistic regression analysis was performed using stepwise selection criteria to order to select the principal risk factors. For this, general satisfaction was considered the dependent variable (well satisfied and very satisfied versus indifferent, dissatisfied and very dissatisfied), and the NPMs used were the independent variables (including emotional support, the obstetric data, and the primiparous women’ expectation of pain).

RESULTS The average age of the 188 primiparous women who participated in the study was 23.3 years (5.5 standard deviations [SD]); most of them had a stable relationship (76.2%), had finished high school (54.5%), worked at home (57.7%), had had six or more prenatal exams (70.9%), and had not participated in group programs for pregnant women (68.8%). In relation to the data concerning labor, the average time was 16.9 hours (SD ¼ 12.1) and the median was 12.5 hours; most women did not use epidural analgesia (84.1%) or other pharmaceutical drugs (78.8%) for pain relief, did not present alterations in the fetal heart rate (90.5%) nor have meconium in the amniotic fluid (90.9%), and made use of oxytocin (61.4%). In relation to the type of delivery, 30.2% were caesarean and 69.8% were normal, most of these in the vertical position (66.1%). The NPMs used most commonly for pain relief during labor were the companion’s emotional support (97.3%) and the warm showers (91.5%), followed by breathing techniques and changes in position (87.8%), the birth ball (79.8%), emotional support from the nurse-midwife (78.7%), focused attention (69.7%), and manual massages (55.9%). Among the methods least used were music (10.6%), massage using equipment (20.7%), and sitting backward on a chair (29.8%) (Table 1). Regarding the members of the healthcare team applying the NPMs, primiparous women indicated that most NPMs were applied by the nurse-midwife, highlighting the warm showers (47.3%), changes in position (38.8%), the birth ball (36.2%), and breathing techniques (34.6%). Physician’s participation was greater in the application of breathing techniques (28.1%) and changes in position (21.3%). Among healthcare professionals, the nurse assistants and technicians were the least identified by the primiparous women; the highest percentages related to baths

TABLE 1. Nonpharmacologic Methods used during Labor (n ¼ 188) Methods Support of companion Yes No Warm showers Yes No Breathing techniques Yes No Changes of position Yes No Birth ball Yes No Support from the nurse-midwife Yes No Focused attention Yes No Support from obstetrician Yes No Manual massage Yes No Sitting backward on a chair Yes No Support from a nurse’s assistant Yes No Massage with equipment Yes No Music Yes No Support from nursing student Yes No Support from medical student Yes No

n

%

183 5

97.3 2.7

172 16

91.5 8.5

165 23

87.8 12.2

165 23

87.8 12.2

150 38

79.8 20.2

148 40

78.7 21.3

131 57

69.7 30.3

128 60

68.1 39.1

105 83

55.9 44.1

56 132

29.8 70.2

54 134

28.7 71.3

39 149

20.7 79.3

20 168

10.6 89.4

37 152

19.1 80.9

36 152

19.1 80.9

(9.1%) and the birth ball (6.9%). Students, from both the nursing and medical fields, were recognized by a small number of the participants. The nursing students participated more in the warm showers (2.6%) and in breathing techniques (2.6%) and the medical students in breathing techniques (2.1%) and changes in position (2.1%). Companions participated in the application of practically all methods, particularly manual massage

278

Gayeski et al.

TABLE 2. Member of Health Care Team and Companion who Applied the Nonpharmacologic Method (n ¼ 188) Member of Healthcare Team and Companion Method

NM n (%)

NA n (%)

OB n (%)

NS n (%)

MS n (%)

C n (%)

DK n (%)

NR n (%)

Warm showers Massage with equipment Manual massage Breathing techniques Changes of position Birth ball Sitting backward on a chair Music Focused attention

89 (47.3) 4 (2.1) 26 (13.9) 65 (34.6) 73 (38.8) 68 (36.2) 17 (9) 7 (3.7) 33 (17.6)

17 (9.1) — 5 (2.7) 6 (3.2) 7 (3.7) 13 (6.9) 2 (1.1) — 4 (2.1)

16 (8.5) 1 (.5) 7 (3.7) 53 (28.1) 40 (21.3) 22 (11.7) 7 (3.7) 2 (1.1) 33 (17.6)

5 (2.6) 2 (1.1) 2 (1.1) 5 (2.7) 2 (1.1) 3 (1.6) — 2 (1.1) 4 (2.1)

3 (1.6) — — 4 (2.1) 4 (2.1) 1 (.5) — — 2 (1.1)

2 (1.1) 32 (17) 60 (31.9) 11 (5.9) 5 (2.6) 8 (4.3) 10 (5.3) — 47 (25.0)

40 (21.3) — 4 (2.1) 20 (10.6) 33 (17.6) 35 (18.6) 20 (10.6) 8 (4.3) 7 (3.7)

16 (8.5) 149 (79.3) 84 (44.6) 24 (12.8) 24 (12.8) 38 (20.2) 132 (70.3) 169 (89.9) 58 (30.8)

C ¼ companion (partner/baby’s father, mother, sister, others); DK ¼ does not know; NA ¼ nurse assistant; NM ¼ nurse-midwife; NR ¼ not received; NS ¼ nursing student; MS ¼ medical student; OB ¼ obstetrician.

(31.9%) and focused attention (25%). Many of the primiparous women did not identify who applied the methods, notably the bath (21.3%), the birth ball (18.6%), and changes in position (17.6%) (Table 2). The evaluation of the general score of satisfaction with the application of nonpharmacologic methods using the Likert scale indicated that the participants had a high level of general satisfaction (88.3%) and only a small number experienced dissatisfaction (11.7%). In relation to each method, the highest degree of satisfaction was accorded to focused attention (77.9%), followed by the warm showers (76.9%) and the birth ball (60.3%) (Table 3). Significant associations were observed between the general score of satisfaction with changes in position (p ¼ .0340, OR 3.29, CI 95% 1.13-9.52) and focused attention (p ¼ .0326, OR 2.61, CI 95% 1.06-6.43) (Table 4). In Table 5 it is possible to observe that the results of the general score of satisfaction regarding the presence of emotional support during labor indicates a high degree of satisfaction with the emotional support provided by the woman’s companion of choice (98.2%), and among the members of the healthcare team, the highest percentages relate to the participation of the nurse-midwife (81.9%) and the obstetrician (72.1%). In relation to the participation of the various members of the healthcare team, significant association was found between the general score of satisfaction with the methods and the emotional support provided by the nurse (p ¼ .0096, OR 3.78, CI 95% 1.49-9.55), the doctor (p ¼ .0031, OR 3.74, CI 95% 1.5-9.33), and the nurse’s assistant or technician (p ¼ .0303, OR 4.56, CI 95% 1.03-20.24).

Regarding the obstetric results and the expectation of pain, there were no significant associations between the general score of satisfaction with the application of NPMs for pain relief (Table 6). In the multivariate logistic regression analysis (multiple OR), considering as independent variables all the NPMs (Table 1), emotional support (Table 5), obstetric results of labor, and expectation of pain (Table 6), the ones that actually present a significant association with the level of general satisfaction are changes in position (OR 3.21, CI 95% 1.02-10.10), the emotional support provided by the nurse-midwife (OR 3.82, CI 95% 1.43-10.20), and the emotional support given by the doctor (OR 3.82, CI 95% 1.30-8.70).

TABLE 3. Evaluation of the Degree of Primiparous Women’s Satisfaction with Each Nonpharmacologic Method Received (n ¼ 188) Degree of Satisfaction Satisfied

Dissatisfied

Method

n

%

n

%

Focused attention Warm showers Birth ball Breathing techniques Manual massage Changes of position Music Massage with equipment Sitting backward on a chair

102 133 91 96 61 95 10 16 19

77.9 76.9 60.3 58.2 58.1 57.9 50.0 41.0 33.9

29 40 60 69 44 69 10 23 37

22.1 23.1 39.7 41.8 41.9 42.0 50.0 59.0 66.1

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Nonpharmacologic Methods to Relieve Pain During Labor

TABLE 4. Evaluation of the General Score of Primiparous Women’s Satisfaction in Relation to Each Nonpharmacologic Method (n ¼ 188) General Degree of Satisfaction Satisfied Method Warm showers Yes No Massage with equipment Yes No Manual massage Yes No Breathing techniques Yes No Changes of position Yes No Birth ball Yes No Sitting backward on a chair Yes No Music Yes No Focused attention Yes No

Dissatisfied

n

%

n

%

OR (CI 95%)

p Value

152 14

91.6 8.4

20 2

90.9 9.1

1.09 (.23-5.23)

1.0000

33 133

19.9 80.1

6 16

27.3 72.7

.66 (.24-1.82)

.4100

97 69

58.4 41.6

8 14

36.4 63.6

2.46 (.98-6.18)

.0501*

148 18

89.2 10.8

17 5

77.3 22.7

2.42 (.80-7.34)

.1564

149 17

89.8 10.2

16 6

72.7 27.3

3.29 (1.13-9.52)

.0340

134 32

80.7 19.3

16 6

72.7 27.3

1.57 (.57-4.33)

.3998

51 115

30.7 69.3

5 17

22.7 77.3

1.51 (.53-4.13)

.4410*

20 146

12.0 88.0

— 22

— 100

6.30 (.37-07.81)

.1364

120 46

72.3 27.7

11 11

50 50

2.61 (1.06-6.43)

.0326*

CI ¼ confidence interval; Fisher’s exact text; OR ¼ odds ratio. The bold values indicate a significant association of p < 0.05. *Chi-squared test.

DISCUSSION In general, all the NPMs available at the maternity unit of the University Hospital are being used as a result of the philosophy of patient care the institution has adopted since its inauguration, based on the recommendations of the WHO (1996). The most-used NPM, according to the primiparous women, is the support of the woman’s companion (Table 1). Continuous support has proven to be truly beneficial during labor because it reduces the need for interventions such as epidural analgesia, caesarean section, or use of instruments (forceps or vacuum). It also decreases the woman’s level of dissatisfaction with the birthing experience (Hodnett et al., 2013). A randomized clinical trial reported that the presence of support provided by the woman’s companion of choice is a strong predictor of global satisfaction with the labor

and birthing experience (Br€ uggemann, Parpinelli, Osis, Cecatti, & Neto, 2007). It is interesting to note that the second most commonly used method was the warm showers (Table 1). This is a proven method for reducing the pain of laboring women in the active phase of labor (Davim et al., 2008; Santana, Gallo, Ferreira, Quintana, & Marcolin, 2013). The first scientific article on the use of water during labor was published in 1973 in France and describes the first 100 births in water (Odent, 1983). After the 1990s, when the WHO included the immersion bath as an NPM to be used during labor, there was increased interest in generating sufficient evidence to support this practice. During the last two decades, most of randomized clinical trials have evaluated immersion baths (Cluett, Pickering, Getliffe, & James, 2004; Ohlsson et al., 2001; Rush et al., 1996;

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Gayeski et al.

TABLE 5. Evaluation of the General Score of Primiparous Women’s Satisfaction with the Emotional Support Received from Each Member of the Healthcare Team and Companion (n ¼ 188) General Satisfaction Satisfied Emotional Support Companion Yes No Nurse-midwife Yes No Doctor Yes No Nurse assistant Yes No Nursing student Yes No Medical student Yes No

Dissatisfied

n

%

n

%

OR (CI 95%)

p Value

163 3

98.2 1.8

20 2

90.9 9.1

5.43 (.86-34.50)

.1053

136 30

81.9 18.1

12 10

54.5 45.5

3.78 (1.49-9.55)

.0096

119 46

72.1 27.9

9 13

40.9 59.1

3.74 (1.50-9.33)

.0031*

52 114

31.3 68.7

2 20

9.1 90.9

4.56 (1.03-20.24)

.0303*

33 133

19.9 80.1

4 18

18.2 81.8

1.12 (.35-3.52)

1.0000

30 136

18.1 81.9

6 16

27.3 72.7

.59 (.21-1.63)

.3845

CI ¼ confidence interval; Fisher’s exact test; OR ¼ odds ratio. The bold values indicate a significant association of p < 0.05. *Chi-squared test.

Silva, Oliveira, & Nobre, 2009) and some controlled clinical trial of therapeutic intervention type rated aspersion showers (Davim et al., 2008; Santana et al., 2013), pointing to several benefits, among which are higher levels of satisfaction with the labor experience and pain relief, as long as certain conditions, such as a minimum dilation of 3 centimeters, are met before initiating its application. Although warm showers followed by breathing techniques and changes in position were the most commonly used NPMs (Table 1), having generated high levels of satisfaction, the method that actually produced the highest degree of satisfaction was focused attention, followed by the birth ball (Table 3). It is worth noting that of the most commonly used methods, only the warm showers is among those that lead to very high degrees of satisfaction. On the other hand, focused attention and the birth ball were pointed out in this study as the women’s favorites, although they are not among the most commonly used (Tables 2 and 3). A randomized clinical trial reported that the combination of warm showers and perineal exercises with a Swiss ball during labor significantly decreased the perception of pain (Barbieri, Henrique, Chors, Maia, & Gabrielloni, 2013).

Satisfaction during the first stage of labor was not assessed in the clinical trials on immersion baths, analyzed in the Cochrane review (Cluett & Burns, 2009). However, some authors (Cluett et al., 2004) included the evaluation of satisfaction with immersion baths in their 2004 study, and the nulliparas of the experimental group reported higher degrees of satisfaction with the birthing experience than the control group, although without statistical significance. Among the methods assessed, changes of position and focused attention were the only ones that produced a statistically significant association with the general score of satisfaction, even though they were not among the most used (Table 4). Randomized studies that evaluated the change in position reported a reduction in pain scores and an increase in comfort and satisfaction of mothers who have adopted the upright position (Adachi, Shimada, & Usui, 2003; Miquelutti, Cecatti, Morais, & Makuch, 2009). It is interesting to observe that focused attention and distraction are activities that can be developed by caregivers to help the woman in labor not to think about pain. This can be done through verbal conditioning (Abushaikha & Oweis, 2005; Enkin et al., 1998), a simple method that can contribute to break

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Nonpharmacologic Methods to Relieve Pain During Labor

TABLE 6. Obstetric Results and Primiparous Women’s Expectation of Pain, According to the Degree of General Satisfaction with the Methods (n ¼ 188) General Satisfaction Satisfied

Obstetric Data Oxytocin Labor No During pushing Misoprostol Labor No Labor time #8 hours >8 hours Type of delivery/position Caesarean Normal vertical Normal horizontal Normal genupectoral Use of pharmaceutical drugs No Yes Epidural analgesia Yes No Heartbeat of fetus Without alteration With alteration Amniotic fluid meconium No Yes Expectation of Pain Did not have one Expected to feel what she felt Expected to feel less pain Expected to feel more pain

Dissatisfied p Value

n

%

n

%

OR (CI 95%)

102 46 18

61.4 27.7 10.8

13 7 2

59.1 31.8 9.1

.84 (.31-2.24) 1.15 (.24-5.52)

26 140

15.7 84.3

4 18

18.2 81.8

34 132

20.5 79.5

2 20

9.1 90.9

47 113 5 1

28.3 68.1 3.0 .6

9 12 1 —

40.9 54.5 4.5 —

.53 (.06-4.93) .33 (.01-8.55)

6 160

3.6 96.4

3 19

13.6 86.4

4.21 (.97-18.23)

26 140

15.7 84.3

4 18

18.2 81.8

152 14

91.6 8.4

18 4

81.8 18.2

151 13

91.0 7.8

18 4

81.8 18.2

2.58 (.76-8.77)

.1231

13 16 115 21

7.8 9.6 69.3 12.7

— 1 18 3

— 4.5 81.8 13.6

4.32 (.25-75.90) 2.50 (.31-20.06)

.6195

.9044* .7585 .84 (.26-2.67)

.39 (.09-1.74)

.3804

.55 (.22-4.40) .3799 .0735 .84 (.26-2.67)

.7585 .2362

.41 (.12-1.40)

1.10 (.30-4.05)

CI ¼ confidence interval; OR ¼ odds ratio. *Chi-squared test. Fisher’s exact test.

the cycle of tension-fear-pain. However, it is rarely recognized and valued by professionals as a NPM and, in the institution that was the object of this study, it is not included in the nurses’ prescription guide. The primiparas participating in this research indicated that these practices are more often conducted by their companions, but all the members of the healthcare team were cited as a reference at least once, in particular the nurse-midwife and the obstetrician (Table 2). Neither focused attention nor the use of the birth ball (both producing a high degree of satisfaction) was included in the latest systematic reviews of NPMs for alle-

viating pain (Cluett & Burns, 2009; Simkin & Bolding, 2004; Simkim & O’Hara, 2002; Smith, Collins, Cyna, & Crowther, 2006), a fact that may explain the difficulty in locating published materials on these methods. In relation to the healthcare professional who applied the methods, the nurse-midwife stands out in most of them, although the obstetricians were also involved in the application of all the methods cited. Another study using a qualitative approach, conducted at a Brazilian obstetric center, points to the difficulty of using alternative resources, such as the birth ball, massages, and showers, because doctors see them as of little scientific value or as inappropriate. However, when

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Gayeski et al.

the benefits were described, they changed their opinions (Dias & Domingues, 2005). This finding is also relevant if we consider that most randomized clinical trials on NPMs to alleviate pain during labor, published in the last few decades, were conducted and applied by nurse-midwives (Chang, Chen, & Huang, 2006; Cluett et al., 2004; Field, Hernandez-Reif, Taylor, Quintino, & Burman, 1997; Rush et al., 1996; Silva et al., 2009). Regarding the nurses’ assistants and nursing and medical students, only a small number were pointed out by the women as a reference for the application of these methods. However, a high number of primiparas were not able to identify which member of the healthcare team applied the method, which might be due to the fact that some of them may not have identified themselves before offering the service (Table 2). It is relevant to point out that both nursing and medical students also involved themselves more in the application of the methods most used by the obstetric nurses (warm showers) and obstetricians (breathing techniques), which indicates that, as services are offered in the institution that was the object of this study, the first principle of the philosophy related to the assistance to mothers is taught first (Santos & Siebert, 2001) (Table 2). The participation of the woman’s companion (who did not receive any training) in the application of manual massages was outstanding (Table 4). Although this method did not increase the level of satisfaction of the primiparas, it may have contributed to their satisfaction (98.2% of them) with the emotional support received from the companion (Table 5), because massages promote a sense of proximity, involvement, and empathy, which are the basic elements of support (Hodnett et al., 2013). Several randomized clinical trials have included the companion to provide massages (Chang et al., 2006; Chang, Wang, & Chen, 2002; Field et al., 1997; Kimber, McNabb, McCourt, Haines, & Brocklehurst, 2008), and in one of them the companion was trained. In this case, the women in the experimental group experienced decreased levels of depression and pain (p < .005) and of stress levels and anxiety (p < .001) (Field et al., 1997). These findings suggest that prenatal training and the presence of a companion applying the method may generate higher degrees of satisfaction. The results related to the emotional support provided by a companion are congruent with the study conducted by Br€ uggemann et al. (2007), in which a strong association between the companion’s support and global satisfaction with the birthing experience was found. It was reported in the present study that, among the members of the healthcare team identified by the

primiparas, there was a statistically significant association between the emotional support provided by the nurse-midwife, the obstetrician, and the nurses’ assistants and the general degree of satisfaction with the methods (Table 5). Thus, it is possible to infer that the odds of the mother experiencing satisfaction with NPMs to relieve pain are associated with the participation of these professionals in the procedures, as long as this participation is also genuine and empathic in the same way that focused attention was perceived (Table 4). Davim, Torres, and Dantas (2009) underline the importance of being aware of verbal and nonverbal behaviors on the part of the healthcare team involved in providing services because these factors have a major influence on the context in which the woman finds herself. The reason is that the behavior of health professionals in the face of pain interferes directly in their relationship with the user of the services. These aspects are valued by women because they wanted personalized service that focuses on their needs and also they want health professionals who combine their knowledge and clinical skills with competence in interpersonal relationships (Renfrew et al., 2014). These results may be due to the context of caregiving in which this study was conducted—that is, an obstetric center that embraces humanistic principles and attempts to incorporate the recommendations of the WHO in assisting labor. This attitude may be consolidating a service model that promotes a less interventionist professional. Therefore, it was not surprising that the primiparas participating in this study identified the doctors (a small percentage in some cases) as having applied all the methods including emotional support (Table 2), although a doctor is widely seen as an interventionist, more concerned with eliminating physical pain than suffering, having been trained in depth to deal with gestational complications and the intensive use of technologies (Lowe, 2002; Riesco & Tsunechiro, 2002). In Brazil, the current model is predominantly biologic, and breaking away from it is viewed as a slow process, requiring behavioral changes by healthcare professionals (Leal et al., 2014). The results of this study, however, indicate that the medical team is already beginning to embrace this new model. In general, it is possible to infer that emotional support is a practice that can be incorporated in the daily routine of an obstetric center, although Br€ uggemann, Ebsen, Oliveira, Gorayeb, and Ebele (2014) describe the difficulties of implementing it in the birthing environment because it is busier, not very suitable, and the health professionals often carry preconceived negative ideas regarding the companion’s presence in the birth setting.

Nonpharmacologic Methods to Relieve Pain During Labor

It is important to highlight that the obstetric results as well as the primiparas’ expectation of pain did not influence their general satisfaction with the use of NPMs even when submitted to interventions such as the use of oxytocin and misoprostol or experiencing labor pains for more than 8 hours. It is also worth pointing out that no significant associations were found between the use of epidural analgesia or pharmaceutical drugs to alleviate pain and the degree of satisfaction of the primiparas. These findings are controversial because some randomized clinical trials have reported an association between the reduction in the use of epidural analgesia and oxytocin and a high degree of satisfaction (Cluett et al., 2004) and others have not (Kimber et al., 2008). Therefore, it is possible to infer that the degree of satisfaction is independent of the intervention when NPMs are applied.

CONCLUSIONS The results of this study indicate that in the maternity unit of the University Hospital at the Federal University of Santa Catarina, all available NPMs are, in general, being used by the healthcare team. However, those that generate the highest degrees of satisfaction for the population of this study are not the most commonly used. The support of the companion stands out as the most commonly used NPM, followed by the warm showers. The nurse-midwife is the professional who applies

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these methods the most, and the companion participates in almost all of them. The satisfaction of primiparas, when evaluated for each method individually, is higher with focused attention and the warm showers. However, focused attention and changes of position are statistically associated with the general score of satisfaction of primiparas with the methods. Based on the results of logistic regression, it is possible to conclude that the emotional support of the nurse-midwife and the obstetrician, along with changes in position, are the methods most associated with the general satisfaction of the primiparas. These are easy to implement in any obstetric environment and do not depend on physical structures or material resources. Although this research has been developed in a specific scenario in southern Brazil, the results and conclusions can be discussed at the international level because nonpharmacologic methods of pain relief during labor are part of the strategies of the international agenda of policies regarding women during pregnancy and childbirth. The results could be used for comparison purposes between different realities, seeking similarities and differences in the use of these methods, but also as inspiration for the services that implement those practices. As the research has indicated, the benefits, according to mothers, besides helping to relieve pain, include contributing to increased satisfaction with hospital maternity services.

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