INTRODUCTION:

Labour is a wondrous act of nature and unique to every childbearing woman. Woman and her family members experience tension, anxiety and fear combined with exhilaration and eagerness during the labour process. They may even cease from talking and smiling behavior. 80% of the laboring women perceived the pain as very severe to intolerable of which, 50% of the multiparous had pain scores of 8-10 even after treatment for pain during labour [1]. Thus, pain control is significant problem in a labour setting.

An acceptable and conducive environment created during labour by a nurse will enhance an optimistic experience for both the parturient and her family. This atmosphere empower woman to combat labour and also provide opportunity for monitoring a laboring woman, so as to detect abnormalities at the earliest.

As pain is subjective in nature, it is often misinterpreted by health care professionals. As a result, appropriate analgesics are not administered to the laboring women. Hence, it is suggested to incorporate certain nonpharmacological pain relieving measures [2]. Also, health care professionals need to develop an effective communication with the laboring woman to create a positive childbirth experience. The woman’s wishes and cultural background must be considered while selecting an approach to help her during labour. Most of the laboring women prefer non pharmacological measures to manage pain than pharmacological agents. A wide variety of the measures such as acupuncture, massage, reflexology, herbal medicines, homoeopathy, hypnosis and/or music are utilized to reduce labour pain. Use of such measures help to shift the laboring mothers concentration from pain and other negative perceptions of fear and anxiety. Moreover, these non pharmacological measures are found to be simple, safe and relatively inexpensive.

Complementary therapies are commonly used by the population in their day to day lives. In United Kingdom, 47% of state boards recommend use of complementary therapies during labour [3]. Use of relaxation techniques and massage is recommended for reduction of labour pain perception [4] [5]. Studies show that aromatherapy promotes comfort of labouring women by relieving pain, anxiety, nausea, vomiting and it also strengthens the uterine contractions. A study on the use of aromatherapy during labour found that more than 50% of the women felt that aromatherapy was helpful and only 14% perceived it as unhelpful. Out of the 100 mothers who used the aromatherapy, 61% used for relief of fear and anxiety, 7% for relief of pain, 6% used it to improve uterine contractions, 14% to reduce the feeling of nausea and vomiting [6].

Lavender oil used for aromatherapy is a very versatile essential oil that can be used throughout labour to promote relaxation. It provides a sedation effect to the central nervous system and relieves headache, nervous tension and balances mood swings. According to the American Pregnancy Association, lavender can help create a tranquil, relaxing atmosphere which can reduce pain and stimulate contraction of uterus [7].

The three stress hormones, cortisol, adrenaline and noradrenaline are increased significantly during labour [8]. Massage improves immune system functioning by decreasing the level of stress hormones, while increasing the level of endorphins and increasing the production of oxytocin [9] [10]. Hence, during and in between the contractions, relaxation can be enhanced by massage using an aroma oil or aroma lotion. Various beneficial measures exist for reducing labour pain such as continuous labour support, baths, intradermal water blocks, massage, maternal movement and positioning. It is suggested that although measures such as acupuncture, massage, transcutaneous electrical nerve stimulation, and hypnosis are promising, yet they require further study [11].

Moreover, studies using massage as a complementary therapy are available, but the combined effect of massage using lavender oil is under evaluated. To substantiate the research based evidence on these concepts, the investigator proposed to study the effect of lavender oil massage on lumbosacral region for reduction of labour pain and also to identify the effect it has on progress of labour among primiparturients.

The study objectives are:

1. Determine the effect of lavender oil massage on lumbosacral region for labour pain among primiparturients.

2. Assess the effect of lavender oil massage on lumbosacral region for labour progress among primiparturients.

3. Associate the labour pain and progress with selected background variables among primiparturients.

The hypothesis formulated for the study includes:

H1: There is a significant difference in labour pain among primiparturients in the study group who receive lavender oil massage on lumbosacral region than those primiparturients in the control group who do not.

H2: There is a significant difference in cervical dilatation among primiparturients in the study group who receive lavender oil massage on lumbosacral region than those primiparturients in the control group who do not.

Theoretical Model:

The theoretical framework adapted for this study is based on Imogene King’s theory of goal attainment (1981) [12]. King considers human to be an open system in constant interaction with his / her environment. Based on the assumption that labouring mothers are open to three interacting systems which include: Personal system, Interpersonal system and Social system. Primiparturient experiences pain and the investigator monitors the pain through numerical pain scale and both the primiparturient and the investigator mutually set the goals to reduce labour pain perception, improve labour progress and thereby enhance coping with labour. The primiparturient gives her consent for undergoing massage with lavender oil in the lumbosacral region, a form of complementary therapy to attain the set goals. By implementing lavender oil massage, labouring process can be enhanced by reducing the labour pain perception and improving the cooperation.

MATERIALS AND METHODS:

A two group pretest – posttest experimental, time series research design was adopted. The study was conducted in labour room of Sri Ramachandra Hospital, a tertiary hospital located in the suburban region of city of Chennai. The intervention given to the participants in the study group included the application of gentle massage with 3-4 drops of lavender oil mixed with 2.5 ml of coconut oil as carrier oil, over the lumbar and sacral region of labouring mother. Massage given consisted of four steps, namely stroking the back, circular strokes, relaxing the pelvis, and stroking the lower back given for 15 minutes. The intervention was given twice at an interval of two hours. The mothers in the study group also received routine care along with the proposed intervention, whereas the participants in the control group received only routine care given by health care professionals in the labour room.

Sixty mothers who satisfied the inclusion criteria were selected by consecutive non probability sampling, of which 30 mothers were allocated to study group and 30 mothers to control group respectively. The inclusion criteria for selection of primiparturients were: facing labour for the first time, with cervical dilatation of 3-4 cm, speak and understand local language, and show willingness to participate in the study. Mothers positive for skin allergy sensitivity test and those who developed complication during first stage of labour or with high risk pregnancy such as hypertension, diabetes mellitus, pre eclampsia, cardiac diseases, etc. were excluded. Pilot study was done to confirm feasibility and practicability. No modifications were made in the tool and data collection procedure for the main study.

Data collection procedure:

Ethical permission for conduction of the study was obtained from the Students’ Ethics committee of Sri Ramachandra University. Prior to the collection of data, the investigator introduced self to the mothers and established rapport with them. Mothers were assured that no physical or emotional harm would be done in the course of study. The mothers who met the inclusion criteria were chosen. The intervention was explained to the mothers and a written consent was obtained prior to initiation of the intervention. The purpose of the study was explained to each subject in the language known to them (Tamil/ English). Adequate privacy was ensured throughout the study. To rule out hypersensitivity towards lavender oil, a check for skin allergy was conducted among the study group participants by applying two drops of lavender oil over the inner aspect of forearm and the area was observed for 5-10 minutes for any reaction.

Then the required materials for each massage was prepared and kept ready for use. Prior to the intervention, pain and cervical dilatation were assessed and after the lumbosacral massage intervention for the first time, pain was reassessed at the end of 15 minutes (posttest 1) and after two hours (posttest 2). Then, massage was administered second time, two hours after the first intervention in same fashion and posttest was reassessed 15 minutes (posttest 3) and after two hours (posttest 4) after intervention for the second time. Cervical dilatation was reassessed 4 hours after the first intervention.

The women in the control group received the routine care that included continuous fetal surveillance, 4^th hourly per vaginal examination and administration of analgesics. The pretest labour pain was assessed after assigning the participants to the control group and posttest was assessed after 15 minutes (posttest 1), and 2 hours (posttest 2) after routine care. Pain was reassessed again after 2 hours 15 minutes (posttest 3) and after 4 hours (posttest 4) of routine care. Cervical dilatation was assessed after 4 hours. The assessment system for pain at different time intervals was carried out for the control group mothers at similar time intervals as assessed for the study group women after two sittings of lumbosacral massage intervention. The duration of labour in all three stages of labour were calculated for the participants in both the groups.

Instruments:

The instrument used had four sections. Section A - Demographic variables that included age in years, educational status, occupation, type of work, monthly family income, type of family and past surgical history; Section B - Obstetrical variables that included gravida, abortion and gestational age of the primiparturients; Section C - Numerical pain scale which was numbered in linear fashion from 0 to 10; Section D- Labour progress chart that included cervical dilatation and duration of labour.

Statistical Analysis:

Descriptive statistics (frequency, percentage, mean, standard deviation) and inferential statistics (paired t test, independent t test and Repeated measures ANOVA) were used to investigate the data and to test the study hypotheses. In all the tests, p values less than .05 were interpreted as statistically significant.

RESULTS:

The background variables of the participants indicated that 46.7% of the primiparturients were in the age group of 21-25 years in the study group and 53.3% were in the same age group range in the control group. 40% and 43.3% of the mothers had secondary education in the study and control group respectively. 73.3% of the primiparturients were homemakers and 26.7% were employed in both the groups.

In the study group, 60% were moderate type of workers, 30% were sedentary workers whereas in the control group 56.7% were moderate workers and 30% were sedentary workers.

96.7% were not subjected to any surgery and 3.3% had previous history of hernioplasty and septoplasty in study group whereas in the control group 93.3% were not subjected to any surgery and 6.7% had a history of appendectomy and hernioplasty. 56.7% and 53.3% were primigravidae in the study and control group respectively. Moreover, 56.7% and 36.7% of them had no history of abortion in the study and the control group.

In the study group, 53.3% and 46.7% of the primiparturients were in between 39-40 and 37-38 weeks respectively, whereas in the control group, 70% and 23.3% of them were in between 39-40 and 37-38 weeks respectively.

Table 1 reveals that in both the groups, as per the physiology, labour pain increases with progress of labour. Repeated measures ANOVA in the study and control group across time intervals shows a statistical significance at p<0.001. There is a significant difference in labour pain perception across the different time intervals between the groups at p<0.001. This indicates that the primiparturients in the study group had better reduction in labour pain than primiparturients in the control group.

Table 1. Repeated measures ANOVA of labour pain among primiparturients within and between the study and control groups (N=60)

Labour pain	Pretest		Posttest 1		Posttest 2		Posttest 3		Posttest 4		F, df and p value across time intervals within groups
Labour pain	M	SD	M	SD	M	SD	M	SD	M	SD	F, df and p value across time intervals within groups
Study group (n=30)	2.67	0.60	2.23	0.85	4.93	0.94	4.03	0.71	6.63	0.92	177.777 29 0.000 ***
Control group (n=30)	2.53	0.57	2.70	0.59	4.77	0.85	5.97	0.71	7.80	0.71	409.983 29 0.000 ***
F, df and p value across time interval between groups	516.866 58 0.000***

M= Mean, SD = Standard deviation, *** p<0.001

Table 2. Mean, standard deviation, paired t and independent t value of cervical dilatation among primiparturients in the study and control group (N=60).

Cervical dilatation	Pretest	Posttest	Mean Difference (SD)	Paired t value
Cervical dilatation	Mean (SD)	Mean (SD)	Mean Difference (SD)	Paired t value
Study group	3.27 (0.45)	8.30 (0.75)	5.03 (0.80)	34.08 0.000***
Control group	3.43 (0.50)	8.50 (0.86)	5.06 (1.01)	27.34 0.000***
Independent t value	1.35 0.182(NS)	0.95 0.341(NS)

*** p<0.001, NS – Non significant

Table 3. Mean, standard deviation and independent t value of duration of labour among primiparturients in the study and control group (N=60).

Duration of labour	Study group (n=30)		Control group (n=30)		Independent t and
	M	SD	M	SD	p value
First stage (Hrs. mins)	10.35	1.09	12.24	1.29	5.79 0.000***
Second stage (Mins)	30.33	7.42	28.17	8.55	1.04 0.299(NS)
Third stage (Mins)	16.00	5.42	14.23	4.49	1.67 0.099(NS)
Total (Hrs. mins)	11.21	1.22	13.16	1.42	6.67 0.000***

*** p<0.001, NS – Non Significant

Table 2 reveals that the mean difference of cervical dilatation in the study group was 5.03 between pretest and posttest with SD of 0.80, with a statistical significance at p<0.001. Similarly, the mean difference of cervical dilatation in the control group was 5.06 with SD of 1.01, which was also statistically significant at p<0.001. But there was no statistical significance noted for cervical dilatation between the study and control group both in the pretest and in the posttest done after four hours of intervention.

Table 3 reveals that there was a statistically significant difference in the duration of first stage of labour between the study and control group. No statistical significance was found in the duration of second and third stage of labour between the groups. The difference in first stage duration has contributed to the statistically significant difference between groups in the total duration of labour.

DISCUSSION:

Nurses are accountable for providing care to the labouring women with a goal to protect the well being of the mother, newborn and her family. It has been pointed out that application of pressure to the woman’s back, abdomen, hips, thighs, sacrum and perineum with the hands of the investigator or partner reduces the painful contractions of the uterus. Positive or negative perception of the massage depends upon the person who is administering the massage[2]. So by providing lavender oil massage over the lumbosacral region, a significant difference in the repeated ANOVA measures of labour pain across different intervals of time between the groups was observed. The study group showed better reduction in pain compared to the control group.

Moreover, in the current study, the labour pain score difference among the primiparturients in the study group indicated that the pain reduction was better in posttest 1, 15 minutes after the intervention than after 2 hours of intervention (Posttest 2). Similar differences were noted in the second sitting also. This indicated that lavender oil massage had a very good effect for a shorter period. Studies have also suggested that during labour, massage is the cost-effective intervention for decreasing pain and anxiety as well the partners' participation in performing massage can influence the women's birth experiences positively [4]. Hence for this study the stated hypothesis 1 was accepted.

According to Friedman curve, the beginning of latent phase will be with soft, with uneven uterine contractions that has a softening and shortening effect on the cervix. As the labour progresses there will be more regular and stronger contractions preceded with the active phase of labour that result in rapid cervical dilation and descent of the presenting part [13]. This study denoted that cervical dilatation improved among primiparturients in the study group and the control group with labour progress. But the lavender oil massage did not show statistical significance between the study and control group. Hence, hypothesis 2 was rejected.

Regarding the duration of labour among primiparturients in the study group, the mean difference in total duration of labour was 11.21 with the SD of 1.22 whereas in the control group, the mean difference was 13.16 with a SD of 1.42. The independent t and p value of total duration of labour between the groups was found to be statistically significant at p<0.001. Hence the stated hypothesis (H₃) for this study was accepted.

The study results depicted that there was no significant association between selected background variables and labour pain among primiparturients in the study group and in the control group. There was no significant association between background variables and cervical dilatation among primiparturients in the study group and control group. Also, no significant association between background variables and duration of labour was found except for age and type of work at p<0.05 among primiparturients in the study group and for educational status at p<0.05 among primiparturients in the control group.

Some of the limitations of this study include that the data obtained regarding labour pain were subjective. Massage intervention was limited to two sittings only. Extraneous variables like environment, pain tolerance, attitude of other health workers towards the subject were not taken into consideration. Further studies are recommended to test the effect of lavender oil massage with objective measures of pain and also further reinstate the duration of effect the message has on labour pain.

CONCLUSION:

Generally primiparturients have higher level of pain perception and poor pain tolerance during childbirth due to lack of childbirth experience. Through a good positive, philosophy of care and able practice policies to control labour pain, pain perception can be decreased to a great extent. This study has showed that first stage lumbosacral massage reduces the perception of labour pain and thereby enhances the normal progress of labour among primiparturients.

REFERENCES:

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Received on 06.10.2014 Modified on 10.11.2014

Int. J. Adv. Nur. Management 3(1):Jan. - Mar., 2015; Page 37-41

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