Running head: DECREASING PAIN INTENSITY DURING ACTIVE LABOR 1

Decreasing Pain Intensity Utilizing Non-Pharmacological Interventions During the Active Phase

of Labor

Olivia Meitzner

University of South Florida

DECREASING PAIN INTENSITY DURING ACTIVE LABOR 2

Abstract

Clinical problem: Patients who choose to have a natural birth, without the use of medication, will

receive the standard nursing care when they go into labor. Examples of this care includes clinical

examinations of station, dilatation, and effacement completed every two hours, as well as fetal

heart rate monitoring evaluated every 30 minutes during the active phase of labor (Taavoni,

Sheikhan, Abdolahian, & Ghavi, 2016). However, without the implementation of additional

nursing interventions, pain intensity will increase. If nothing is done to help reduce pain, patient

satisfaction will ultimately decrease.

Objective: The objective of this synthesis is to discuss the utilization of non-pharmacological

interventions such as massage, birthing ball exercises, heat therapy, therapeutic showering, and

acupressure, to decrease pain intensity compared to the standards of care in patients during the

active phase of labor. PubMed and CINAHL were used to search for randomized control trials

(RCT) regarding this PICOT question. The key search terms were obstetric labor, nursing care,

labor pain, massage, non-pharmacological interventions, and pain management.

Results: In laboring women, there is statistically significant evidence that utilization of non-

pharmacological interventions reduces the severity of pain expressively better than usual care of

fetal heart rate monitoring and two-hour round the clock examinations. Gallo et al. (2013)

confirmed that the use of massage during the active phase of labor helps reduce pain intensity

perceived by the patient (95% Cl). Stark (2017) found that therapeutic showering helped

significantly decrease pain intensity during the active phase of labor (p<0.001). Mafetoni, &

Shimo (2016) created a study investigating whether or not acupressure has an effect on labor

pain. This study demonstrated that acupressure on the SP6 point is a complementary intervention

that is non-invasive, safe, and can lessen pain during the active phase of labor (p< 0.0001).
DECREASING PAIN INTENSITY DURING ACTIVE LABOR 3

Taavoni et al. (2016) found that were noteworthy variances between the pain scores of the

women in the birthing ball group after 30-minute, 60-minute, and 90-minute interventions (P =

0.001), when comparing pain scores of the participants receiving standards of care. Finally, a

study on dance labor found that the use of multiple non-pharmacological interventions, such as

standing in a pelvic tilt while receiving lumbar massage, could increase the effectiveness of pain

management(p=0.036) as well as increase satisfaction (p=0.021) with patients during active labor

(Abdolahian, Ghavi, Abdollahifard, & Sheikhan, 2014).

Conclusion: These studies examined cost-effective and easily implemented interventions that can

be applied in the clinical setting with laboring patients to decrease pain intensity. These methods

helped alleviate pain better than the standards of care, therefore, they should be presented to all

women in labor who want a natural birth or different options of pain management. More research

is necessary to understand why these methods are not practiced across all facilities, and which

interventions are most effective. There should also be research done with various races and

cultures to examine racial and cultural preferences. It would also be useful to create studies that

have larger and more diverse sample sizes to broaden and build on the knowledge already gained

from other studies.

DECREASING PAIN INTENSITY DURING ACTIVE LABOR 4

Decreasing Pain Intensity Utilizing Non-Pharmacological Interventions During the Active Phase

of Labor

Pain during childbirth is inevitable, however, despite this reality there are numerous

interventions that can be implemented to decrease pain intensity and increase the satisfaction

with the childbirth experience. Many women opt to have a natural childbirth, without the use of

pharmacological interventions to protect their infants from the adverse effects of medications

(Stark, M. A.,2017). Consequently, most facilities will carry on with the standards of care. For

example, clinical examinations will be done to review station, dilatation, and effacement

measurements as well as monitoring fetal heart rate (Taavoni et al., 2016). However, the pain felt

by the patient also needs to be addressed, even if the patient doesn’t want to receive medication

for the pain. Non-pharmacological pain relief measures can be implemented to help with the pain

that is inevitable and a reality in the birthing process. While there is an abundance of pain relief

techniques that can be used in the clinical setting, such as acupressure, therapeutic showering,

birthing ball exercises and massage, many facilities either don’t offer them or just don’t have the

resources available. Implementation of these simple, cost-effective, and safe non-

pharmacological interventions can lessen pain significantly compared to just providing the

standards of care given at most facilities. Providing patient centered care such as this will also

increase a patient’s satisfaction of their healthcare experience (Silva- Gallo, R. B., 2013;

Abdolahian et al., 2014). The question to address is why these resources aren’t widely available.

A synthesis of the literature will discuss the impact of various non-pharmacological interventions

on women during the active phase of labor in addition to comparing the effects of these

interventions with the of the standards of care given in hospitals around the world.
DECREASING PAIN INTENSITY DURING ACTIVE LABOR 5

Literature Search

PubMed and CINAHL were utilized to find multiple randomized controlled trials

(RCT) pertaining to the PICOT question: In pregnant women, how does utilizing non-

pharmacological interventions compared to standards of care, impact pain intensity during the

active phase of labor? Key terms included in the search were obstetric labor, nursing care, labor

pain, massage, non-pharmacological interventions, and pain management.

Literature Review

Five RCTs were applied to this synthesis to measure the effectiveness of utilizing non-

pharmacological nursing interventions compared to standards of care on the intensity of pain

during the active phase of labor. There are many options of non-pharmacological interventions

that can be presented to women in labor to help decrease labor pain. Stark (2017) demonstrated

that the simple action of taking a shower during labor can help decrease pain, discomfort, anxiety

and tension, while increasing relaxation. Thirty-one women participated in a RCT to compare

differences in pain, discomfort, anxiety, relaxation and coping when using therapeutic showering

for 30 minutes during active labor with those participants who received usual labor care without

therapeutic showering. The experimental group contained 17 women and the control group

contained 14 women. Women in the experimental group were brought to a bathroom with a

shower attached. They remained in the shower for 30 minutes and then evaluation of pain,

discomfort, anxiety, tension, coping, and relaxation using a numerical rating scale were evaluated

at 15 minutes and then again at 30 minutes. The numerical rating scale used was the visual

analog scale which ranged from 0, which is none at all, to 10, being the most possible. Women in

the control group were given the usual unit standards of care. They were not allowed to shower
DECREASING PAIN INTENSITY DURING ACTIVE LABOR 6

or receive an epidural, otherwise they would have been excluded from the study. The control

group was also assessed for pain, discomfort, anxiety, tension, coping, and relaxation two times

in a 30-minute interval. Pain went down significantly in the shower treatment group (p< 0.001),

compared to the control group. Discomfort, anxiety, relaxation and tension all showed significant

improvements (p< 0.001). There wasn’t any significance when comparing coping between the

groups. Strengths of this study included random assignment of the intervention and control

groups, as well as rationale provided to explain why one of the women couldn’t complete the

study. Other strengths included the fact that follow-up assessments were conducted long enough

to adequately study the effects of the intervention and participants were examined in the groups

that they were randomly assigned to in the beginning of the experiment. In addition, the VAS

was used to measure pain, anxiety, tension, relaxation and coping, which is proven to be valid

and reliable for experiments. All participants had like demographics with the exception of age.

The control group was significantly older; however, researchers don’t believe this had a major

impact on the variables being studied. Additional areas of weakness included the fact that

random assignment was not concealed from the individuals who conducted the experiment, and

the control group wasn’t appropriate because the showering intervention was not the only

difference between the groups. The control group was allowed to use a tub, as well as sit and

walk as they pleased which could have skewed the results.

Mafetoni & Shimo (2016) created a RCT with 156 pregnant women to analyze the results

of acupressure on the sanyinjiao point (SP6) for laboring women. The SP6 point is believed to

control some aspects of the reproductive organs and have an effect on lengthy and difficult

childbirth. Participants were dispersed into three groups: acupressure (SP6) (n=52), touch group

(TG) (n=52) /placebo and the control group (CG)(n=52). Pain intensity was measured using the
DECREASING PAIN INTENSITY DURING ACTIVE LABOR 7

Visual Analogue Scale (VAS). The SP6 group received a deep pressure with fast decompression

therapy. The TG group received low intensity superficial touch. The CG received standards of

care including clinical examinations of station, dilatation, and effacement measurements

completed every two hours, and fetal heart rate monitoring done every 30 minutes. The results

concluded that there was a significant pain reduction in the experimental group that received

acupressure at the SP6 point compared with the TG and CG groups (p <0.0001). SP6 point is an

intervention that is non-invasive, safe, and can ease pain during the active phase of labor. This is

a practice that can, without much difficulty, be integrated into the clinical setting to provide

women with non-pharmacological interventions. Strengths of this study included randomization

of women into the different groups, single-blinding between the SP6 group and the TG, and in

addition, everyone was analyzed in their original groups. All participants completed the study

and had similar demographics. The pain score was evaluated during the treatment as well as 60

minutes afterwards which was adequate time to see the full effects of the intervention. The VAS

instrument to measure pain was valid and reliable. A weakness of the study was that the

researchers were not blinded to the group allocation. Another weakness of this study was that the

control group was allowed to use other non-pharmacological interventions during their labor like

take a shower, receive massages and move at their own liberty, so the intervention of acupressure

was not the only difference between the groups.

Taavoni et al. (2016) designed a RCT to examine the effects of using birthing ball

exercises and heat therapy on pain reduction during active labor. The heat therapy group had

n=30 participants, the birthing ball group had n=30 participants and the control group had n=30

participants. Pain was logged using the visual analog scale (VAS). Pain scores were documented

before the intervention was done and subsequently documented every 30 minutes until cervical
DECREASING PAIN INTENSITY DURING ACTIVE LABOR 8

dilation was approximately eight centimeters. In the heat therapy group, the women sat in a

reclining position while the researcher placed warm packs to the participants' sacral and perineal

area for 30 minutes. Women in the birthing ball group were coached to sit on the ball and rock

their hips for a minimum of 30 minutes. Women in the control group remained in a lying position

without the use of any other intervention, such as ambulating. These women only received the

standards of care. After 30 minutes, 60 minutes, and 90 minutes, pain scores showed a significant

decrease in the birthing ball group when compared to the control group (p = 0.001). In addition,

the average pain severity score in the heat therapy group was lower than the control group, 60

and 90 minutes after the intervention (p<0.05). This study showed that non-pharmacological

nursing interventions like applying heat to the source of pain and providing and teaching birthing

ball exercises can be integrated into the clinical setting to improve patient satisfaction resulting

from decreased pain levels during labor. Strengths of this experiment include random assignment

of the intervention and control groups. In addition, the individual accountable for data analysis

was unaware of the study purposes to reduce bias. Two participants were omitted from the study

because they needed a cesarean section. Pain assessments were conducted using the VAS which

is dependable and accurate, and pain was assessed three different times which allowed the

intervention to be analyzed adequately. All women were observed in the respected assigned

group, and all women had similar demographics. In this study, the control group was fitting

because the intervention was the only difference between the groups. A weakness of this study

was that the random assignment was not kept secret from the researchers conducting the

experiment except the data analyzer. Another weakness was that participants were informed that

heat therapy and birthing balls would be used in the study to compare their effects on labor pain
DECREASING PAIN INTENSITY DURING ACTIVE LABOR 9

and whether it provides a satisfactory child birthing experience. Explanation of the study could

have created certain expectations in the women’s mind about what results were expected.

Abdolahian et al. (2014) created a RCT to study the effectiveness of a combination of

non-pharmacological treatments termed dance labor on the reduction of pain intensity and the

consequence it has on satisfaction during childbirth. 60 women were randomly assigned, 30 in

the dance labor experimental group and 30 women in the control group. The dance labor group

was instructed to stand upright in a pelvic tilt and rock their hips back and forth and or around in

a circle while the partner who was with them during labor massaged their back and sacrum for

30 minutes minimum. Dance labor encourages music because it contributes to a calm rhythm

promoting a very tranquil environment. Participants in the control group received the standards

of care during labor and were not allowed to ambulate or use any interventions for pain

reduction. Pain scores were measured by the VAS. Pain results were recorded before labor in

both groups, and then taken every 30 minutes until cervical dilation reached approximately ten

centimeters. After 30 minutes(p=0.012) and after 60 minutes(p=0.036), there were noteworthy

changes between the pain scores of the dance labor group compared to the pain scores of the

control group. There was also a significant difference in the average satisfaction score between

the two groups (p=0.021). Using multiple pain management techniques can enhance the overall

effect of different non-pharmacological interventions as well as allow women to feel in control

of the childbirth process. Strengths of this study included that the researchers used a table of

random numbers to randomize the experimental and control groups. All women had similar

demographics, completed the study, and were examined in the group they were originally

assigned to in the beginning of the experiment. Pain and satisfactory calculations were

implemented after 30 minutes and 60 minutes which was a suitable amount of time to measure
DECREASING PAIN INTENSITY DURING ACTIVE LABOR 10

the effectiveness of the intervention. The VAS is a well-recognized tool that is reliable and valid

for this study. The control group was suitable for this experiment because they only received the

standards of care including usual clinical examination of dilation, effacement, and station as well

as monitoring of fetal heart rate. The control group was not allowed to use any other form of pain

management or they would be excluded from the study. Another strength of the study was that

the researcher in control of data analysis was not told the purpose of the study to lower an

possible any bias that might arise. A weakness of this study included that random assignment was

not hidden from the researchers or participants completing the study with the exception of the

data analyzer. In addition, the researchers described the aim of the study before obtaining consent

which could have an effect on the responses from the participants.

In a RCT conducted by Silva- Gallo (2013), 46 women pregnant participated in a study to

ascertain if using a massage intervention helps relieve pain in the active phase of labor.

Experimental massage group was (n = 23), and the control group was (n = 23). Pain scores were

measured on a 100 mm visual analogue scale (VAS). The experimental group received the

massage intervention from a professional at the start of the active phase of labor as well as

during uterine contractions for 30 minutes. The control group was provided with the routine

standards of care in the maternity unit. The same investigator that was present for the

experimental group accompanied the control group for 30 minutes during active labor, as was

done for the massage group, but strictly for observing and answering questions. After completing

the massage intervention, women gave their perceived pain level; the score was recorded as 52

mm in the experimental group and 72 mm in control group, with a mean difference of 20 mm

(95% Cl). These results suggest that utilizing massage as an intervention during the active phase

of labor helps reduce pain intensity perceived by the patient and could be done in the clinical
DECREASING PAIN INTENSITY DURING ACTIVE LABOR 11

setting to improve patient satisfaction. Strengths of this study included randomly assigning

experimental and control groups, as well as employing concealed allocation and assessor

blinding. A second researcher was blinded to group allocation and wasn’t in the room when the

experimental or control interventions were being implemented. Pain severity was measured with

the VAS; this is known to be a reliable and valid instrument. No one was asked to leave the

study and none of them used analgesic medication during the study allowing the data to be

analyzed without the confounding effect of analgesic medication. All participants had similar

demographics and were analyzed in the specific groups that they were randomly assigned to at

the start of the experiment. A weakness of this study would be an inappropriate control group

since the intervention of massage was not the only difference between the groups as the control

group still had the presence of a researcher in the room which could have provided a sense of

comfort for the patient. It should be noted that there would be more accurate results if the control

group only received the standards of care and were then asked to rate their pain severity. Another

weakness was that pain severity was only measured immediately after the intervention was

implemented which is not adequate time to fully analyze the effects of the intervention.

Synthesis

Massage, acupressure, therapeutic showering, birthing ball exercises, heat therapy and the

combination of interventions termed dance therapy, all decreased pain intensity during the active

phase of labor (Silva-Gallo et al., 2013; Stark, 2017; Mafetoni & Shimo, 2016; Abdolahian et al.,

2014; Taavoni et al., 2016). Most variables of interest in the RCT that studied the efficacy of

therapeutic showering during labor changed in the anticipated path with pain, tension, anxiety,

and discomfort decreasing over time while relaxation improved (Stark, 2017). These results

show that the simple intervention of showering can positively impact a patient’s experience
DECREASING PAIN INTENSITY DURING ACTIVE LABOR 12

during labor. In the heat therapy experimental group, the mean pain score was significantly less

than that of the control group at 60 and 90 minutes after the intervention (p<0.05). There were

also significant differences between the pain scores in the birthing ball group at 30, 60 and 90

minutes after the intervention when comparing them with the control group (p=0.001) (Taavoni

et al., 2016). These outcomes show that the interventions of applying heat as well as performing

birthing ball exercises will effectively decrease the pain of labor for those who wish to use non-

pharmacological interventions. After receiving deep acupressure with fast decompression at the

Sanyinjiao point for 20 minutes and then again for 60 minutes, the pain score went down

significantly in the acupressure group when compared with the control group (p<0.0001)

(Mafetoni & Shimo, 2016). Pain scores in the dance labor groups went down significantly at 30

minutes (p=0.012) and 60 minutes after the intervention (p= 0.036) when compared to the

control group (Abdolahian et al., 2014). Use of these simple, inexpensive, non-pharmacological

interventions can be combined to enhance the overall effect and help patients feel more in control

during childbirth (Abdolahian et al., 2014). Pain severity in the massage group improved by a

mean of 17mm from baseline score, while the control group displayed an increase in pain

intensity of 3 mm. This showed an estimated 20 mm difference and a 95% confidence interval 10

to 31 on the VAS scale (Silva-Gallo, 2013). The combined effects of massage and the presence of

a support person can greatly increase patient satisfaction while also decreasing pain during the

childbirth process.

An interesting finding is that all of the studies involve the use of either direct contact by

another person or the presence of another person, which provided emotional support for the

laboring women and could have had an impact on the participants pain perception (Silva-Gallo et

al., 2013; Stark, 2017; Mafetoni & Shimo, 2016; Abdolahian et al., 2014; Taavoni et al., 2016 ).
DECREASING PAIN INTENSITY DURING ACTIVE LABOR 13

Three of the five RCT allowed their control groups to use other pain relief interventions during

active labor which could have had an impact on these participants pain levels (Silva-Gallo et al.,

2013; Stark, 2017; Mafetoni & Shimo, 2016). To obtain the most reliable data, the control group

should not be allowed to use any other intervention during the study. Unfortunately, there is an

ethical dilemma with allowing participants to go through the painful experience of labor without

any pain relief measures. However, two of the studies, one conducted by Abdolahian et al., 2014,

and the other by Taavoni et al., 2016, didn’t allow any pain management intervention, producing

the most accurate results, but also the most controversial results.

There is much needed room for growth in researching effectiveness of non-

pharmacological pain management for pregnant women in labor. For example, determining a

women’s expectation of labor pain before the study begins will help in the evaluation of overall

satisfaction of the birthing process. This is because one’s expectation is a major determining

factor of satisfaction (Abdolahian et al., 2014). Various cultures can impact factors such as pain

relief measures, expectations, and preference, thus further studies need to be conducted to

compare the success of non-pharmacological treatments among different cultures. Another gap in

research is the impact of educating patients of the different non-pharmacological interventions

well before their due date so they can prepare mentally for their labor.

Clinical Recommendations

Given the clinical data gathered in this synthesis regarding the utilization non-

pharmacological interventions to reduce pain during labor, there is evidence of a need for

change. Firstly, educating patients well before birth about the various non-pharmacological pain

management interventions can prepare them cognitively for childbirth and encourages patients to

be in control of their birth plan. It is the duty of healthcare providers to individualize patient care
DECREASING PAIN INTENSITY DURING ACTIVE LABOR 14

plans and this includes teaching them all of the pain relief options available. Unfortunately, it’s

not enough to merely educate patients on their different options; medical facilities and nurses

need to consistently provide and offer multiple non-pharmacological therapies for laboring

women who need pain reduction. Many of the interventions researched are inexpensive and

easily executed, therefore nurses can be easily trained to perform these therapies. Implementing

these strategies into the standards of care given to every patient during labor will reduce pain

caused by labor and ultimately lead to higher patient satisfaction.

DECREASING PAIN INTENSITY DURING ACTIVE LABOR 15

References

Abdolahian, S., Ghavi, F., Abdollahifard, S., & Sheikhan, F. (2014). Effect of dance labor on the

management of active phase labor pain & clients’ satisfaction: a randomized controlled

trial study. Global journal of health science, 6(3), 219.

Silva- Gallo, R. B., Santana, L. S., Jorge- Ferreira, C. H., Marcolin, A. C., Polineto, O. B.,

Duarte, G., & Quintana, S. M. (2013). Massage reduced severity of pain during labor: a

randomized trial. Journal of Physiotherapy), 59(2), 109–116. https://doi-

org.ezproxy.hsc.usf.edu/10.1016/S1836-9553(13)70163-2

Stark, M. A. (2017). Testing the Effectiveness of Therapeutic Showering in Labor. Journal of

Perinatal & Neonatal Nursing, 31(2), 109–117. https://doi-

org.ezproxy.hsc.usf.edu/10.1097/JPN.0000000000000243

Roque Mafetoni, R., & Kakuda Shimo, A. K. (2016). The effects of acupressure on labor pains

during childbirth: randomized clinical trial. Revista Latino-Americana de Enfermagem

(RLAE), 24, 1–8. https://doi-org.ezproxy.hsc.usf.edu/10.1590/1518-8345.0739.2738

Taavoni, S., Sheikhan, F., Abdolahian, S., & Ghavi, F. (2016). Birth ball or heat therapy? A

randomized controlled trial to compare the effectiveness of birth ball usage with sacrum-

perineal heat therapy in labor pain management. Complementary therapies in clinical

practice, 24, 99-102.