Rajiv Gandhi University of Health Sciences Karnataka-Bangalore.

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 Name of the Candidate and

Address (In block Letters)

MISS.J.LEENA ANGELIN

1ST YEAR M.Sc.,(NURSING)

HARSHA COLLEGE OF

NURSING BANGALORE

2 Name of the Institution HARSHA COLLEGE OF

NURSING BANGALORE

3 Course of Study and Subject M.Sc., (NURSING)

OBSTERTRICS AND

GYNAECOLOGIAL NURSING

4 Date of Admission 06-08-2008

5

TITLE:

A STUDY TO EVALUATE THE EFFECT OF PACED

BREATHING ON LABOR PAIN PERCEPTION AMONG

PRIMI MOTHERS DURING LABOR IN HARSHA HOSPITAL

AT BANGALORE

6. BREIF RESUME OF THE INTENDED WORK

INTRODUCTION:

Pain in labor is a nearly universal experience. Pregnant women

commonly worry about the pain they will experience during labor and child birth. The

discomfort as experienced during labor has specific origins. During the first stage of

labor uterine contractions cause cervical dilatation, effacement and uterine ischemia

(decreased blood flow and therefore the local oxygen deficit) resulting from

contraction of the arteries to the myometrium. The discomfort from cervical changes

and uterine ischemia is visceral pain.

Pain thresholds cause the amount of pain experienced to be unique to

each individual. Anxiety and fear are commonly associated with increased pain

during labor. Mild anxiety is considered normal for a woman during labor and birth.

However excessive anxiety and fear cause more catecholamine secretions, which

increases the stimuli to the brain from the pelvis because of decreased blood flow

and increased muscle tension, which in turn magnifies the pain. Thus as fear and

anxiety heighten, muscle tension increases, the effectiveness of the uterine

contraction decreases, the experience of discomfort increases and a cycle of

increased fear and anxiety begins.

A wide variety of child birth preparation methods can provide a way to

help the women cope with the discomfort of labor and many numbers of non-

pharmacological strategies are being followed to reduce the labor pain.

The non-pharmacological strategies followed to encourage relaxation

and to relieve pain are firstly, cognitive strategies, such as child birth education,

breathing technique, music, imagery, use of focal points and hypnosis. Secondly,

cutaneous stimulation strategies such as counter pressure, massage (effleurage)

therapeutic touch, walking, rocking, changing position, application of heat or cold,

TENS, acupressure and water therapy.

Regular and reasonable exercise can help strengthen the muscles and prepare

the body for the stress of labor. Exercise can also increase the endurance, which will

come in handy if mother have a long labor.

The Lamaze technique is the most widely used method in the United States.

The Lamaze philosophy teaches that birth is a normal, natural, and healthy process

and those women should be empowered to approach it with confidence. Lamaze

classes educate women about the ways they can decrease their perception of pain,

such as through relaxation techniques, breathing exercises, distraction, or massage by

a supportive coach. Lamaze approach takes a neutral position toward pain medication,

encouraging women to make an informed decision about whether it's right for them.

The Bradley method (also called Husband-Coached Birth) emphasizes a

natural approach to birth and the active participation of the baby's father as birth

coach. A major goal of this method is the avoidance of medications unless absolutely

necessary. The Bradley method also focuses on good nutrition and exercise during

pregnancy and relaxation and deep-breathing techniques as a method of coping with

labor. Although the Bradley method advocates a medication-free birth experience, the

classes do prepare parents for unexpected complications or situations, like emergency

cesarean sections.

Some women choose to give birth using no medication at all, relying instead

on relaxation techniques and controlled breathing for pain.

Conscious relaxation involves progressive relaxation of muscle groups in the

entire body. Breathing pattern include deep abdominal respirations for most as labor

progresses, shallow breathing toward the end of the first stage, and until recently,

breath holding for pushing with contractions in the second stage of labor.

Teaching the mother to relax uninvolved muscles while her uterus contracts.

Lamaze teachers believe that chest breathing lifts the diaphragm off the contracting

uterus thus giving it more room to expand.

Breathing technique and relaxation techniques are being followed to reduce

the labor pain. Breathing technique such as relaxed breathing through the nose and out

through the mouth. This is during the beginning and the end of each contraction.

Relaxing techniques such as focusing (favorite, fixed or selected objectives will be

focused by the mother) imagery (the woman is encouraged to focus on a pleasant

scene, or picture, a place she feels relaxed or an activity she enjoys) feed back

relaxation (common feed back mechanism, the woman and her support person

verbalize the word “relax” at the on set of each contraction and throughout it as

needed) and music therapy.

Leventhal, leventhal shacham easterling (1989) study showed that active

coping reduces reports of pain from child birth. Two studies were conducted in which

pain and negative moods during labor were examined in relation to independent

variables. Instructions to monitor labor contractions given to parturients on admission

to the labor service and attendance at Lamaze (child birth preparation) class. In study

1 (N=48) pain and negative moods showed a sharp decline at stage 2 (active labor) for

women told to monitor and those who had attended class there was no decline for the

control group. In study 2 (N=29) women attending Lamaze class reported a similar

decline in pain during active labor and were more energetic and less tired at

admission. It was concluded that directed coping provided the best account for the

decline in pain and distress during active labor and an accurate expectations, seemed

to account for the enhanced energy at the point of admission, in anticipation of birth.

Relaxation is a stage of low arousal in which such bodily response as muscle

tension, heart rate, breathing rate and metabolism diminish so as to bring these

function in to equilibrium (Shrok 1988)

Relaxation is a learned skill and practice is essential to successful skill

development. Deep relaxation focusing and complex breathing patterns are the

techniques used to decrease the perception of pain. The four major breathing

techniques commonly used in child birth prepared are slow paced breathing, modified

paced breathing, patterned paced breathing and expulsion breathing all techniques can

be individualized to promote optimum relaxation and oxygenation (Katharyn 1994)

Paced breathing has been used to reduce pain perception during labor. It also

reduces the negative feelings, such as fear and anxiety, it is a non-pharmacological

method with favorable effects in reducing the pain perception during the labor (Rose,

1988)

Slow paced breathing involved breathing at approximately half the normal

breathing rate, which can be done throughout the duration of a contraction, slow

paced breathing provides the best oxygenation, is calming and the least fatiguing of

the breathing technique.

Many of non-pharmacological pain relieving measures say that promotion of

relaxation of the muscles, which increases blood supply to the paining muscles,

promotes release of endogenous opiates (endorphin) and less stimulation of free nerve

endings which are closing the gate of pain perceptions.

Health education is an integral part of maternal child nursing care. During

pregnancy intrapartum and postpartum period, nurses educate mother about health

behaviors that enhance positive maternal infant outcome. So it was felt that educating

primi women about slow paced breathing would help to improve pain tolerance

during labor.

6.1. NEED FOR THE STUDY

Child birth is a natural biological process and therefore the pain associated

with it is also perceived as normal and natural. The nature of the pain experienced

during labor depends on the physical and emotional status of the women. The primi

para women experience more intense pain during labor compared to multi gravida

(Mclazack, Taenzer and Kinch 1981). The primi para mothers do not know which the

intense level of pain and how to manage with that because they do not have any past

experience.

The pain of labor and delivery is one of the things that worry you about having

a baby. This is certainly understandable, because labor is painful for most

women(Larissa Hirsch, MD, Feb 2008).It's possible to have labor with relatively little

pain, but it's wise to prepare yourself by planning some strategies for coping with

pain. Alleviating your anxiety about pain is one of the best ways to ensure that you'll

be able to deal with it when the time comes.

For centuries among western civilization, offering pain relief in labor was

thought to be a moral, because according to the biblical account, God commanded

Eve, “I will greatly multiply the sorrow and they conception in sorrow those shalt

bring forth children. (Gen 3:16) the prevailing concept was that the child birth should

be painful.

Both pharmacological and non-pharmacological methods are used to reduce

the pain perception during labor. Labor and delivery medications may pose risk for

the mother, such as hypertension and the fetus as brady cardia, so their use must

always be against the alternative risk to the mother.

Most of the methods advocated are based on three premises. The first is that

discomfort during labor can be minimized if the woman comes into labor informed

about what is happening and prepared with breathing exercises to use during

contractions. The second premises are that discomfort during labor can be minimized

if the woman’s abdomen is relaxed and the uterus is allowed to rise freely against the

abdominal wall with contractions. The third premise is that the pain perception can be

altered by distraction techniques by a “gate control” theory of pain perception.

If a midwife do not give proper support and care to the mother in labor, that

aggravate the anxiety level of the mother, which increases adrenaline production.

Stimulation of anxiety and less relaxation during labor will lead to perception of more

labor pain. If a midwife give adequate support and care to the mother in labor which

would reduce the women’s anxiety which in turn will decrease adrenaline production.

The triggers an increase in the levels of oxytocin (to stimulate labor and endorphin (to

reduce pain perception)

The job of the nurse in labor and delivery is not only to ensure a safe delivery

but also to create a positive and satisfying experience. Many simple, effective, low-

cost methods to relieve labor pain can be initiated by nurses, midwives, or physicians

with the potential benefits of improved labor progress, reduction use of riskier

medications, patient satisfaction, and lower costs.

The best analgesia for labor is relaxation. It is the foundation for all pain

management techniques in Lamaze prepared child birth. A variety of relaxation

techniques are taught, including progressive relaxation neuromuscular, dissociation

antogenic training, bio feed back, massage and acupressure, imagery, water therapy,

music and controlled breathing using paced breathing strategies.

All commonly used breathing techniques must be done in a way that maintains

adequate respiratory function without tiring the woman unnecessarily practicing

breathing techniques incorrectly can lead to hyperventilation, causing changes in

blood chemistry.

Relaxation techniques are designed to help the woman achieve a deep level of

relaxation of muscles not directly involved in the work of labor. Deliberate, controlled

learned breathing patterns are directly linked to optimum relaxation. Each breathing

pattern in used according to need, not according to a particular stage of labor.

Relaxation and breathing may contribute more to a woman’s ability to cope

with labor pain than to actually reduce that pain.

When using non pharmacologic techniques, a woman may prefer to close her

eyes or may want to concentrate on an external focal point. Classes emphasize that

keeping the eyes open on a focal point helps her concentrate on something out side

her body and thus away from the pain from concentration.

Breathing in the first stage of labor consist a various breathing techniques.

Paced breathing

The method begins with a very simple technique that is used as long as

possible when it is no longer effective breathing that requires more concentration is

added.

Cleansing breath:

Each concentration begins and ends with a deep inspiration and expiration

known as the cleansing breath. If helps the woman release tension. It provides oxygen

to help prevent myometrial hypoxia.

Slow-Paced Breathing

The first breathing is slow paced breathing. It refers to a slow rhythmic

repetitive breathing pattern used to reduce the level of labor pain through using focal

point.

Modified Paced-Breathing

When the woman finds that slow paced breathing is no longer effective. She

begins modified paced breathing. This chest breathing at a faster rate matches the

natural tendency to use more rapid breathing during stress or physical work such as

labor.

Pattern-Paced Breathing

Pattern paced breathing some times called pan blow or her too, health

involves focusing on a rhythmic pattern of breathing.

Jaya Sudha A (1996) conducted an evaluative study to determine the effect of

selected antenatal exercises on the outcome of labor in primi gravid women at

Dhakshina in Karnataka State. A quasi experimental non equivalent group with post-

test only design was only adopted for the study. The purposive sampling was

technique was used. The sample consisted of 60 primi gravid women, 30 in each

experimental and control group. The data collection tools were observation check

lists. Planned teaching strategy on selected antenatal exercises was prepared based on

the principle of Lamaze and Read’s method of exercise for child birth. Teaching was

given two phases first at the clinic and second at home. After the teaching

programme, the practices of exercises were monitored and their relevant knowledge

was assessed. The result showed that the experimental group had. Shorter duration of

labor, demonstrated significantly more positive behavioural responses (92. 59%)

during labor than the control group (14.29%)

It will be highly beneficial to implement this approach to women in labor. The

nurse who is working in the field of maternity nursing has an important role in

helping the women to use such non-pharmacological measures to cope with labor

pain. Since paced breathing is a non-pharmacological cost-effective method and easy

to practice by all, qualified nurses have a greater opportunity to teach paced breathing

to reduces the pain and anxiety level. Hence paced breathing has greater significance

in the present world of stressful era.

Number of researches said that breathing and relaxation therapy are effective

to reduce labor pain perception level. Considering the above factors the investigator

felt there is a need of preparing a STP on paced breathing which will be of importance

for educating antenatal women to modify their action towards paced breathing.

Improving the practice helps to prevent complications thus to lead safe delivery.

Today most health care providers recommend and offer child birth preparation

classes to expectant parents and relaxation of techniques and breathing techniques are

being followed on the mother in labor to increase her coping ability during labor. The

most common childbirth philosophies in the United States are Dick-read methods or

natural child birth, Lamaze method and Bradley method.

6.2. REVIEW OF LITERATURE

REVIEW OF LITERATURE

“A great literature is chiefly a product of inquiring minds in revolt against the

immovable certainties of nation”. -Mecken H.C

A review of literature is an extensive critical review of the extant literature on

the research topic. It is an essential first step in those methodologies that require

context to interpret and understand the research problem by locating it within the

body of knowledge on the research topic (Worrall and carelley 1997)

Literature review serves a number of important functions in the research

process. It helps the researcher to generate ideas or to focus on a research topic. It also

can be useful in pointing out the research design, methodology, meaning of tools and

type of statistical analysis, that might be productive in pursuing the research problem.

Review of literature in this study is organized under the following

headings.

a) Reviews related to pain assessment in general

b) Reviews related to pain perception of women in labor

c) Reviews related to effect of paced breathing on labor pain perception.

a). REVIEWS RELATED TO PAIN ASSESSMENT IN GENERAL

Randall et.al., (2004) conducted a study on comparison of the verbal rating

scale and the visual analog scale for pain assessment on 85 chronic pain patients by

survey method at the pain management service at Louisiana state university health

sciences center, Shreveport. A physician interviewed the patient and filled out survey

forms. Patients were asked to rate their pain with the VAS (verbal assessment scale)

and the VRS. The VAS consisted of a 10cm line anchored by two extremes of pain.

Patients were asked to make a mark on the line that represented their level of

perceived pain intensity. For VRS (verbal rating scale) Patients were asked to verbally

rate his or her level of perceived pain intensity on a numerical scale from 0 to 10, with

the zero representing one extreme and the 10 representing the other extreme. Data

were analyzed with correlation analysis and student’s test for paired data. Significance

was defined as P<0.05. Pearson correlation coefficient (r=0.906) and P value

(<0.0001) showed excellent correlation between the two, although VRS showed a

tend to be higher than VAS (P=0.068). The results revealed that the VRS provided a

useful alternative to the VAS scores in assessment of chronic pain.

Aubrun, et.al., (2003) conducted an observational study to assess the use of the

VAS and other pain scales by nurses in the post anaesthesia care unit at university

Pierre at Marie curie Paris. Among 600 patients included in the study, nurses used the

VAS in 531, the numerical rating scale in 30%, the verbal rating scale in 12% and the

behavioral scale in 5% in 43% of the assessments, nurse did not use the VAS, the

most frequently cited reason was related to their preference for other methods. In 54%

of the assessments, the reason for not using the VAS was related to the patients,

mainly when they were in too much pain to use it (22%) when the patients were in too

much pain, the numerical rating scale was chosen in 54% and the behavioral scale in

27%. There was no difference between young patients and elderly patients. The study

findings reveals that although the VAS is the standard methods to assess pain, the

nurse preferred using the numerical rating scale.

Polly,et.al., (2003) conducted a prospective cohort study on validation of a

verbally, administered numerical rating scale of acute pain among 108 adult patients

in urban emergency department, New York. The objective of the study was to assess

the comparability of the NRS and visual analog scale (VAS) as measured of acute

pain and to identify the minimum clinically significant difference in pain that could be

detected on the NRS. Convenience sampling technique was used. Patients verbally

rated pain intensity as an integar from 0 to 10 (0=No pain, 10= worst possible pain)

and marked a 10cm horizontal VAS bounded by these descriptors. VAS and NRS data

were obtained at presentation, 30 minutes later and 60 minutes later. At 30 and 60

minutes patients were asked whether their pain was “much less” “a little less”, “about

the same”, “a little more”, or “much more”. Difference between consecutive pairs of

measurements on the VAS and NRS obtained at 30 minutes intervals were calculated

for each of the five categories of pain descriptor. The association between VAS and

NRS scores was expressed as a correlation co-efficient. The VAS scores were

regressed on the NRS scores in order to assess the equivalence of the measures. The

mean changes associated with descriptors “a little less” were combined to define the

minimum clinically significant difference in pain measured on the VAS and NRS of

108 patients entered, 103 provided data at 30 minutes and 86 at 60 minutes. NRS

scores were strongly correlated to VAS scores at all time periods (r=0.94, 95%,

Cl=0.93 to 0.95).

The slope of the regression was 1.01 (95% Cl =0.97 to 1.06) and the Y

intercept was -0.34 (95% Cl = -0.67 to -0.01). The minimum clinically significant

difference in pain was 1.3 (95% Cl = 1.0 to1.5) on the NRS and 1.4 (95% Cl=1.1 to

1.7) on the Vas. Thus, the findings suggest that the verbally administered NRS can be

substituted for the VAS in acute pain measurement.

Choiniere.M and Amsel.R (2001) conducted a study on validity and utility of

tool known as visual analogue thermometer (VAT) in Boston University. The

researchers compared the VAT to other conventional instruments whose psychometric

qualities are scientifically recognized two studies were performed to meet the

subjective.

The first study was carried out with a group of 65 acute pain patients (cardiac,

orthopedic, abdominal, renal operations) who provided pain intensity ratings using the

VAT, a standard Vas, and the MC gill pain questionnaire. A second set of measures

were obtained from a group of 243 acute pain patients (cardiac, orthopedic,

abdominal, renal operations) who qualified the intensity of a set of descriptive pain

terms with the VAT, a numerical scale (NRS) and a VAS. The results of both studies

support the concurrent validity of the VAT as a pain measure when assessing changes

in pain levels. The VAT was able to distinguish between different pain intensities.

Confirming the construct validity of the instrument no major differences emerged in

the relative sensitivity of VAT compared to the standard VAS, both scales yielding

comparable pain estimates. No major problem was noticed in subjects understanding

or using either the VAT or VAS.

Paul S.Myles,MBBS,MPH, MD, Department of Anesthesia and pain

management, Alfred Hospital, conducted a study. The visual analog scale (VAS) is a

tool widely used to measure pain, yet controversy surrounds whether the VAS score is

ratio or ordinal data. We studied 52 post operative patients and measured their pain

intensity using the VAS. We then asked them to consider different amounts of pain

(conceptually twice as much and then half as much) and asked them to repeat their

VAS rating after each consideration (VAS2 and VAS3, respectively). Patients with

unrelieved pain had their pain treated with IV fentanyl and were then asked to rate

their pain intensity when they considered they had half as much pain. We compared

the baseline VAS (VAS1) with VAS2 and VAS3. The mean (95% confidence interval)

for VAS2 was 2.12 (1.81 – 2.43) and VAS3 was 0.45 (0.38-0.52) we conclude that the

VAS is linear for mild to moderate pain and the VAS score can be treated as ratio

data.

A change in the visual analog scale score represents a relative change in the

magnitude of pain sensation. Use of the VAS in comparative analgesic trials can now

meaning fully qualify differences in potency and efficacy.

b) REVIEWS RELATED TO PAIN PERCEPTION OF WOMEN IN LABOR

Wijma et.al., (2001) conducted a comparative study on the labor pain among

primi para and multipara women during 1st stage of labor. 35 primi parous and 39

multi parous women were selected for the study by using random selection method.

Verbal rating scale was used to collect the data. The data was analyzed by mean, SD

and t test. The result of the study shows the primi para women reported higher level of

pain than the multiparaous women (t=0.735; p=0.01). The challenge for staff of a

delivery ward is to support the women in labor in a way that decreases fear, which in

turn might reduce the women’s need of pain relief.

Cambell and Kurtz (2000) conducted a descriptive study to evaluate the

intensity of the labor pain at the two stages of cervical dilatation, (cervical dilation of

2-5cm and 6-10cm) at east cardina university, school of nursing, Greeille, 78 women

in labor were selected through convenient sampling technique. Using 3 self-reported

measures such as VAS, present pain intensity scale and MC Gill pain questionnaire

carried out the pain assessment. These were the one observational measure to rate

behavioral index of pain. The data were analyzed by descriptive and inferential

statistics. The result of the study shows that when the cervical dilation increased, there

was significant increase in self-report pain and observed pain on all the cited

measures (t=15.72, P=0.01). Pain was characterized as discomforting during early

dilation and distressing horrible and excruciating as dilatation progressed.

May AE and Elton CD (1999) conducted a prospective descriptive study on

the labor pain at Leicester Royal university. Study was conducted over a period of 2

months. 100 the primi para mothers who had been admitted in hospital for delivery

were selected by convenience sampling technique pain assessment was carried out by

direct questioning method using a 4-point verbal rating scale of none, mild, moderate

and severe in labor room during first stage and second stage. Data was analyzed by

descriptive and inferential statistics. The results of the study shows that the labor is a

painful event for every women, 95% of the primi para mothers experienced

progressively increasing pain during first stage from mild to severe which is

spasmodic and radiating in nature.

Basker, Ferguson, Roach and Dawson (2001) investigated the perceptions of

labor pain by mothers and their attending midwives. The aim of the current study was

to examine the perception of pain by laboring women and their attendant midwife,

from the onset of labor to delivery. Accurate measurement and appropriate

management of pain is a significant problem for attendant medical and nursing

personal. Both the experience and perception of pain are regarded as subjective and

are therefore difficult to measure objectively. Indeed, much of the literature reports

that pain is often under-or over- estimated by nursing staff who as a consequence

consistently fail to administer adequate analgesia. Few studies have specifically

examined the ability of midwives to assess the pain of laboring women. The short

form MC Gill pain questionnaire (SF-MPQ) routinely used to assess pain in obstetric

environments was used to determine pain the perception. Thirteen laboring women

and mine midwives completed the SF-MPQ. Every 15 minutes beginning at the time

of admittance to the delivery suite. Peak pain ratings for the preceding 15 minutes

were obtained without reference to prior ratings are each other’s scores. Further,

midwives in the maternity unit of the Queen Elizabeth hospital (TQEH). Adelaide

south Australia completed a survey investigating the cues they use to assess pain

during labor. The results of the study were on each measure of pain on the SF-MPQ,

the midwives scores correlated with the mother’s scores across the entire the pain

range. Further analyses showed that mother’s and midwives pain scores were similar

at mid moderate pain levels, but midwives significantly under estimated pain intensity

at levels that mothers described as severe. The survey responses indicated that

midwives rely on both verbal and non verbal cues to assess pain levels. The cues used

by midwives to differentiate pain intensities and qualities are similar to those used in

other clinical settings, but may have limited discriminatory value as pain levels

become severe.

c) REVIEWS RELATED TO EFFECT OF PACED BREATHING ON LABOR

PAIN PERCEPTION

Fourth September 1998 joint data collection by nine nurse midwifery practices

in the united states permitted a description of pain management practices with

Intrapartum patients. Observational data are reported for 4,171 healthy gravidas at

term. A wide variety of techniques for pain management including both

pharmacologic and non pharmacologic methods were used. High prevalence

modalities were paced breathing (used by 55.2% of this clinical sample). Activity and

position change (42.4%) Narcotics (30%) and epidurals 18.7%. Paced breathing plus

narcotics was the most common combination. Variations are reported for sub groups

of women according to age, parity race / ethnicity, education, insurance, marital

status, activity in labor and type of delivery.

Kathylyn Hesson P.hd., 8th December 1997. This study examined the breathing

patterns of a small sample of women (n=21) during labor. The study also examined

the different thoughts or cognitions the women experienced, during their early

contraction and assessed whether these cognition, when classified as associative or

dissociative in orientation, were related to breathing styles and length of labor.

Respiration rate and tidal volume were monitored during and between contractions.

The breathing results indicated considerable variation among women in individual

respiration rate and tidal volume both between and during contractions. In addition

marked variability was found in both the direction and degree of change in breathing

frequency and tidal volume in response to contractions.

Pugh million, Gray and Strickland 1998 conducted a study on first stage labor

management, an examination of patterned breathing and fatigue. A secondary analysis

was conducted on a subset of a prospective longitudinal study of fatigue during the

Intrapartum period. The sample comprised 56 primi parous women in labor whose

fatigue was measured every 2hrs and 6 hrs after admission at each data point, the

investigatory evaluated the method of breathing that participants used. The results

show that during the latent phase of labor, women using patterned breathing exhibited

significantly more fatigue.

In the active phase, differences between groups were not significant,

controlling for age, education and marital status of participants did not change the

results. It was concluded that it is appropriate for nurses, midwives, physician and

doulas to encourage the use of patterned breathing as an intervention in active labor,

however, patterned breathing may increase, the mother’s fatigue, level if begun too

early.

Kanji (2000) conducted a study on management of pain through antigenic

training of faculty of health studies, Buckinghamshire Chilterns University College,

Chalfont stgiles, and Buckinghamshire, UK. Physical and emotional pain is an in

evitable part of human existence and are without natural antidotes. In view of this, and

in the light of increasing professional reluctance to depend on analgesics, this study

proposes the wide spread application of autogenic training, a relaxation technique

which has been seen to confront pain very effectively. And also to reduce

substantially drugs dependency. It analyses autogenic training in respect of some of

the more common pain – allied disorders such as child birth, head aches and

migraines back pain, cancer and palliative care, and cardiology.

Florido, oltrasal, Fajardo, Gonzalez – Escanuela, Villaverde and Gonzalez –

Gomez (1997) investigated a study on plasma concentrations of beta- endorphin and

adrenocorticotropic hormone in women with and without child birth preparation at

department of obstetrics and Genecology, university of Granada, spain. They studied

plasma concentrations of beta-endorphin (beta-EP) and adrenocorticotropic hormone

(ACTH) during dilation, expulsion and immediate puerperium in 47 primiparous

women with an un eventful pregnancy and spontaneous vaginal delivery twenty-five

women had received child birth preparation with the Lamaze method, and 22 had

received no preparation. Mean concentrations of beta-EP from the beginning of labor

until. Puerperium was higher in women who had received preparation, but there was

no significant difference between the two groups. When behavior during labor was

evaluated regardless of which group the patient was assigned to, women whose

behavior was unsatisfactory has significantly higher concentrations of ACTH at all

times during child birth. They discuss the role of child birth preparation as a way to

enhance beta-EP secretion. Levels of ACTH on the other hand, appear to be more

closely related with behavior during labor regardless of whether the mother received

preparation.

6.3 PROBLEM STATEMENT

A STUDY TO EVALUATE THE EFFECT OF PACED BREATHING ON

LABOR PAIN PERCEPTION AMONG PRIMI MOTHERS DURING LABOR IN

HARSHA HOSPITAL BANGALORE

6.4 OBJECTIVES

1. To assess the level of pain perception after paced breathing among primi

mothers in labor in the choosen experimental group.

2. To assess the level of pain perception among primi mothers in labor in the

choosen control group.

3. To find out the difference between both choosen experimental and control

groups in terms of reduction of pain perception

4. To find out the association between the level of pain perception and selected

demographic variables of primi mothers in labor such as age, education,

occupation and regularity of antenatal checkup.

6.4.1. HYPOTHESIS

H1 The mean post-pain perception score of the experimental group will be

significantly lower than the mean post-pain perception score of the control group

as measured by visual analog pain perception scale.

H2 There will be significant association between the level of pain perception and

the selected demographic variables of women in labor such as age, education,

occupation and regularity of antenatal checkup.

6.5. OPERATIONAL DEFINITIONS

EFFECT

Refers to an result or action in terms of significant reduction in the level of

pain perception of women in labor as measured by the visual analog pain perception

scale.

PACED BREATHING

Refers to a slow, rhythmic, repetitive breathing pattern used to reduce the level

of labor pain perception of women, it is an act of inhaling and exhaling air.

PRIMI MOTHERS IN LABOR

Refers to the mother with full term first pregnancy {who completed 37

weeks}term in labour, who are admitted in the labor room in active phase of labor.

6.6. ASSUMPTIONS:

The perception of labor pain differs from mother to mother

Relaxation is a learned skill of deep breathing form of relaxation

Paced breathing has no adverse effect on mothers with labor pain.

6.7. DELIMITATIONS

The study is limited to primi gravida women above 37 weeks of gestation

Assessment of the level of pain perception is limited to first stage of labor

(5cm to 7 cm of cervical dilation)after monitoring their breathing exercise

Data collection as measured by visual analogue.

Sample size is limited to 60 patients.

Study limited for 4 weeks

7. MATERIAL AND METHODS.

7.1.SOURCES OF DATA

Primi mothers with true labour pain and admitted in Harsha hospital at Bangalore

7.1.1. RESEARCH DESIGN AND APPORACH

A quasi-experimental with post test control group design. Diagrammatic

representation of the design is given below.

Group Intervention Post-Test

E X Op2

C - Op2

E - Experimental group

C - Control group

X - Intervention paced breathing

Qp2 - Post test of labor pain perception in experimental group

Qp2 - Post test of labor pain perception in control group

EXPERIMENTAL GROUP

Select the mother in early labor (3cm dilation maximum)

Giving an instructions regarding paced breathing

Advice her to empty the bladder within 30 minutes before observing her

Observe and check with the mother whether if she is following the

instructions.

Instructing regarding visual analog scale (differentiate from color)

Vaginal examination performed (5to7cm) observe uterine contraction &

duration

Check the intensity of pain according to numbering from visual analog pain

perception scale

CONTROL GROUP

No paced breathing teaching

Teaching regarding visual analog scale

Select the mother, Vaginal examination done (5 to 7 cm)

Observe contraction, duration, intensity of pain according to visual analog

pain, perception scale

7.1.2. SETTING

The study will be conducted in Maternity ward in Harsha Hospital at

Bangalore.

7.1.3. POPULATION

The target of this study was primi term in labor, above 37 weeks of gestation

who were admitted in labor room with true labor pain.

7.2. METHOD OF DATA COLLECTION

7.2.1. SAMPLING PROCEDURE

Purposive sampling technique

7.2.2. SAMPLE SIZE

The sample consists of 60 primigravid women above 37 weeks of gestation

who were admitted in labor room with true labor pain.

7.2.3. INCLUSION CRITERIA

1. Primi term in labor who were above 37 weeks of gestation with true labor

pain.

2. Who were in the active phase of first stage of labor. (5 to 7cm of cervical

dilatation)

3. Who were in the age group of 20-35 years

4. Who were not having any Obstetric and medical complications

5. Who were willing to participate in the study

6. Who can understand and speak kannada.

7.2.4. EXCLUSION CRITERIA

1. Primi term in labor who are associated with the medical field.

2. Pre-term labor initiates before completing 37 weeks

3. Mothers who are chronically ill

4. High risk mothers eg. severe, PIH, GDM

7.2.5. INSTRUMENT USED

The instrument used in this study was a structured teaching method which

consisted of the following sections.

Section A : Demographic Data

Section B : Visual Analog pain perception scale

Section C : Observation check list on paced breathing procedure.

Section -Aa. Demographic Data : It includes age, religion, educational, occupation,

monthly income, area of residence, type of family.

b. Clinical Variables : It is usual pain tolerance level, regularity of antenatal

check up, Gestational age in weeks, last menstrual period, time of true

labor pain started cervical dilation, nature of uterine contraction,

administration of labor enhancing procedure 1 drug.

Section – B

Visual analog pain perception scale it is a standard method which

consist of ten points. It is used to assess the pain perception of term

mother in labor. The term primi mother who are in true labor were asked

to choose the appropriate pain perception level in the ten points. Visual

analog scales are performing PV and find out from 5-7 cm (2hrs) during

this period the data collected from the scale after each uterine contraction.

The scale was categorized as follows:

‘0’ denotes - No pain

‘1’ denotes - Slight pain

‘2-6’ denotes - moderate pain

‘7-9’ denotes - extreme pain

‘10’ denotes - excruciating pain

Section-C

Observation checklist on paced breathing procedure :

It was used to assess the skill. The checklist included two requisites

and steps of paced breathing as given in appendix. If the women

performed the steps accurately, a tick mark () was placed in column

“not performed”. Based on the women’s performance re teaching was

done.

7.2.6. DATA COLLECTION PROCEDURE

The data collection was done for four weeks in Harsha Hospital,

Bangalore. Every day on average 2-3 subjects were selected by purposive

sampling for experimental and control group. The teaching on paced

breathing was conducted for the experimental group after starting the true

labor pain for 10 minutes. After that women were asked to practice it

during every contraction under supervision. Post assessment of pain

perception was done for 2 hours.

In this data collection the first two weeks were dedicated to the

control group participants and the following next two weeks were for the

experimental group.

7.2.7. PLAN FOR ANALYSIS

The collected data will be planned and analyzed in the form of

descriptive inferential statistics. The analyzed data will be presented in

the form of tables and figures by using mean, percentage, standard

deviation and chi-square.

7.3. Does the study require any investigation or interview to be conducted

on patients or other humans or animals? If so please describe briefly.

No

7.4. ETHICAL CLEARANCE

The permission will be obtained from head of the intuition and consent

will be obtained from the participants during data collection.

REFERENCES

BOOK REFERENCE

1) Artal [Mittelmark], R., and R.A. Wiswell. 1986. Exercise in pregnancy.

Baltimore: Williams & Wilkins.

2) Bell, R., and M. O'Neill. 1994. Exercise and pregnancy: a review.

Birth. 21: 85-95.

3) Bing, E.D. 1975. Moving through pregnancy: the complete exercise

guide for today's woman. New York: Bantam Books.

4) Clapp 3rd, J.F., 1994. A clinical approach to exercise during

pregnancy. Clinics in Sports Medicine. 13: 443-458.

5) ACOG (2002) Exercise during pregnancy and the postpartum period:

Committee Opinion Obstetric Gynecology99; 171-173

6) Arena B,Maffulli N(2002)Exercise in pregnancy10(1):15-22

7) Hefferman AE (2004) exercise and pregnancy in primary care nurse

practitioner 25(3):42,49,53-56

JOURNAL REFERENCES

1. Birrer, R.B. 1990. Exercise during pregnancy. Journal of Family

Practice. 30: 717.

2. Brown W(2002)The benefits of physical exercise during pregnancy J

Sci Med Sport 5(1):37-45

3. Artal R,white S(2003) guidelines of the American college obstetricians

and gynecologists for exercises during pregnancy Br J Sports Med

37:6-12.

INTERNET REFERENCE

www.google.com

www.pubmed.com

www.msn.com.

www.midwifeinfo.com

www.wikipedia.org