Efficacy of Warm Showers on Labor Pain and Birth Experiences During the First Labor Stage

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RESEARCH

Efficacy of Warm Showers on Labor Pain and Birth Experiences During the First Labor Stage Shu-Ling Lee, Chieh-Yu Liu, Yu-Yin Lu, and Meei-Ling Gau

Correspondence Meei-Ling Gau, RN, CNM, IBCLC, PhD, Graduate Institute of Nurse-Midwifery, National Taipei University of Nursing and Health Sciences, No. 365, Ming-Te Road, Peitou, Taipei 112, Taiwan. [email protected] Keywords warm showers labor pain birth experience

ABSTRACT Objective: To determine the efficacy of warm showers on parturition pain and the birth experiences of women during the first stage of labor. Design: Randomized controlled trial (RCT). Setting/Participants: The study was conducted from July 10, 2010 to January 12, 2011 in the maternity ward of a Taipei City regional teaching hospital, site of approximately 220 to 250 births per month. Ninety-two expectant mothers were recruited (recruitment rate: 70.8%) and allocated by block randomization into the two arms of the study. In total, 80 women completed the trial: 41 in the control group and 39 in the experimental group. Methods: Participants in the experimental group received warm shower bath interventions. Each shower lasted 20 minutes. After a 5-minute full body or lower back shower, participants could spend 15 minutes directing shower water toward any body region that felt most comfortable. Facilities allowed participants to stand and sit as desired. Water was constantly monitored and maintained at a temperature of 37◦ C. Participants in the control group received standard childbirth care. Results: Labor pain and the birth experience were assessed using the Visual Analogue Scale for Pain (VASP) and the Labour Agentry Scale, respectively. After adjusting for demographic and obstetric data, experimental-group women who participated in warm showers reported significantly lower VASP scores at 4-cm and 7-cm cervical dilations, and higher birth experiences than the control group. Conclusion: Apart from the positive physical hygiene effects, warm showers are a cost-effective, convenient, easy-todeploy, nonpharmacological approach to pain reduction. This intervention helps women in labor to participate fully in the birthing process, earn continuous caregiver support, feel cared for and comforted, and have a more positive overall experience.

JOGNN, 42, 19-28; 2013. DOI: 10.1111/j.1552-6909.2012.01424.x Accepted August 2012

Shu-Ling Lee, RN, CNM, MS, is a registered nurse in the Department of Nursing, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan. Chieh-Yu Liu, PhD, is an associate professor in the Graduate Institute of Nurse-Midwifery, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan.

(Continued)

The authors report no conflict of interest or relevant financial relationships.

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lthough a happy and meaningful experience in a woman’s life, childbirth is also source of extreme physical pain and hardship (Simkin & Hull, 2011; Waldenstrom, 2003). The International Association for the Study of Pain (IASP) defined pain as a subjective and unpleasant sensory and emotional experience associated with actual or potential tissue damage (Merskey & Bogduk, 1994). Many studies point to labor pains as the most significant source of discomfort during childbirth, generating levels of pain that test or exceed physical endurance limits (Akerman & Dresner, 2009; Leeman, Fontaine, King, Klein, & Ratcliffe, 2003). Labor pains and loss of control, the two most frequently cited unpleasant experiences of childbirth, directly affect woman’s satis-

A

faction concerning birth care, which in turn adversely affects self-perceptions and self-esteem (Hauck, Fenwick, Downie, & Butt, 2007; Niven & Murphy-Black, 2000). Williams, Povey, and White (2008) stated that pain relief in the maternity ward should effectively relieve perceived pain in a manner that does not disrupt the birthing process and ensures fetal safety. Pharmacological and nonpharmacological methods are the two predominant approaches to clinical pain suppression and control. Although effective at relieving pain, parenteral pain medication and epidural interventions cause known side effects in the mother and fetus, consequently lengthening the labor duration (Cesario, 2008; Walker

 C 2012 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses

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RESEARCH

Warm Showers, Labor Pain, and Birth Experiences

Warm showers can relieve pain while also encouraging mothers to shift positions, thus facilitating the downward progression of the fetus through the birth canal.

warm showers to women who were experiencing the first active phase of labor. We assessed pain relief efficacy as well as its impact on the birth experience.

Methods & O’Brien, 1999), augmenting risk of neonatal respiratory distress (Walker & O’Brien), and decreasing infant suckling ability (Bell, White-Traut, & Medoff-Cooper, 2010). With labor pain outside her control, a mother also faces increased risk of feeling fear, anxiety, helplessness, and loss of control of the overall birthing process (Hauck et al., 2007; Simkin & Hull, 2011; Waldenstrom, 2003). Coupled with the restrictions to movement imposed by continuous fetal heart monitors, intravenous drips, and oxytocin infusions, mothers may abandon the natural birthing process and request a cesarean (Romano & Lothian, 2008; Shilling, Romano, & DiFranco, 2007). Accordingly, many women consider using nonpharmacological methods to relieve and control childbirth pain (Fenwick, Hauck, Downie, & Butt, 2005; Williams et al.).

Yu-Yin Lu, RN, PhD, is an assistant professor in the Department of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan. Meei-Ling Gau, RN, CNM, IBCLC, PhD, is a professor in the Graduate Institute of Nurse-Midwifery, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan.

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In rehabilitation medicine and the treatment of arthritis and other pain symptoms, water therapy (baths and showers) has an extensive history (Benfield, Herman, Katz, Wilson, & Davis, 2001; Nichols, 1996). Water transmits a desired therapeutic temperature into target tissues, changing the state of irritant receptors and reducing perceived pain (Benfield et al., 2010; Nichols). The exact origins of hydrotherapy on childbirth pain relief are unknown. Laboring and birthing in water has increased in use since being promoted in Russia in the 1970s by Igor Charkovsky (Cluett & Burns, 2012). Michel Odent (1983) subsequently popularized water immersion in other European countries. Numerous clinical studies have since shown that immersion baths induce relaxation, relieve pain, and lower blood pressure (Benfield et al. 2010; da Silva, de Oliveira, Nobre, 2009) while affording mothers a greater role in decision making and a greater sense of control over childbirth (Eckert, Turnbull, & MacLennan, 2001). Warm showers also encourage mothers to shift positions, facilitating the downward progression of the fetus through the birth canal (Stark, Rudell, & Haus, 2008). Although most hospital maternity wards in Taiwan offer shower facilities, domestic research studies on the pain relief efficacy of warm showers during labor are lacking. In this study, we introduced

We used a randomized controlled trial design, assigning participants into the experimental and control groups.

Participants and Setting The study was conducted in the maternity ward of a Taipei City regional teaching hospital that averages 220 to 250 births monthly. The ward’s seven delivery rooms included two labor/delivery/recovery (LDR) rooms. All rooms were private with bathrooms. Standard patient care included intermittent fetal monitoring and pelvic examinations for cervical dilatation. Women were free to walk around for at least 20 minutes every hour. Recruited participants were laboring women who were anticipating an uncomplicated vaginal birth of a term singleton fetus, dilated to at least 4 cm at time of enrollment, accompanied by their spouses or other family members, and willing to participate. All participants who accepted epidurals or underwent cesareans were excluded. Random allocation computer software assigned participants to either the experimental or control group. Statistical power analysis calculated the required sample size. Assumptions were as follows: α = .05, power = .80, and effect size = .30. Based on the G∗ Power statistical package (Germany; version 3.1.1, Fual, Erdfelder, Lang, & Buchner, 2007), two-tailed tests, and an effect size value to detect changes in pain between groups, the necessary sample size was estimated as 41 participants per group. In taking into account a possible attrition rate of 10%, we set the target sample size at 45 participants per group.

Instruments A structured questionnaire collected participant demographic and obstetric information. Demographic data included age, height, weight, marital status, education, occupation, and medical history. Obstetric data included parity, weeks gestation, pharmaceutical use during labor, antenatal education, infant birth weight, method of rupture of membranes, number of pelvic examinations, and 1- and 5-minute Apgar scores.

JOGNN, 42, 19-28; 2013. DOI: 10.1111/j.1552-6909.2012.01424.x

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RESEARCH

Lee, S. L., Liu, C. Y., Lu, Y. Y., and Gau, M. L.

Visual Analogue Scale for Pain The Visual Analogue Scale for Pain (VASP) is a pain assessment tool previously used to assess a broad spectrum of pain including arthritis, burns, surgery, childbirth, and cancer (Bostrom, Sandh, Lundberg, & Fridlund, 2003; Gift, 1989; Harandi, Esfandani, & Shakibaei, 2004; Peng et al., 2010; Tamiya et al., 2002). The VASP is scored on a 10-cm horizontal line punctuated by 10 evenly spaced marks numbered from 0 to 10, with the first located to the extreme left and the 10th to the extreme right. Possible scores ranged from 0 (no pain) to 10 (extreme pain). Respondents assigned their scores based on subjective perceptions of current pain. Simple to use, the VASP is applicable for all types of physical pain and is the most widely used pain measurement scale during childbirth in Taiwan (Chung, Hung, Kuo, & Huang, 2003; Gau, Chang, Tian, & Lin, 2011; Liu, Chang, & Chen, 2010).

Labor Agentry Scale The self-administered Labor Agentry Scale developed by Hodnett and Simmons-Tropea (1987) measures a mother’s feelings of control during childbirth. Its 10-item inventory includes six positive and four negative descriptions of perceived degree of control experienced during childbirth. Scoring follows a 7-point Likert-type scale format, with 7 (all the time), 6 (most of the time), 5 (more than half the time), 4 (about half the time), 3 (nearly half the time), 2 (only occasionally), and 1 (almost never or never). Possible scores ranged from 10 to 70, with a higher number corresponding with a more positive experience. Previous studies reported Cronbach’s alphas for the LAS in the .91 to .98 range (Adewuya, Ologun, & Ibigbami, 2006; Goodman, Mackey, & Tavakoli, 2004; Hodnett & Simmons-Tropea). The LAS was translated into Chinese using Brislin’s (1986) two-stage process. A professional Chinese-to-English translator—who had not seen the original LAS—retranslated into English a firstversion Chinese copy of the LAS performed by a maternity professor. A second (native U.S.) translation professional compared the two English versions for content validity. We assessed items for cross-correlation and appropriateness using a three-point evaluation scale, with 3, 2, and 1, respectively, indicating appropriate, no need for revision, appropriate, minor revisions required, and not appropriate, major revisions required. Results for the Chinese LAS revealed a 1.0 content validity index.

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To confirm scale efficacy, Streiner and Norman (2003) and Beck, Bernal, and Froman (2003) recommended that translated scales be pilot tested on a population of potential users prior to formal use. Therefore, at a hospital in Southern Taiwan, we administered the Chinese version LAS on 12 qualified mothers who answered the questionnaire within 24 hours postpartum. The Cronbach’s alpha for the pilot test was .89.

Intervention Warm showers were the therapeutic intervention. We gave all potential participants an educational flier that explained the intervention and listed its requirements, including (a) participant allows preshower session checks of fetal heartbeat and cervix dilation, (b) all participants accompanied by spouse, family member, etc., (c) water temperature maintained at 37 degrees Celsius (C), and (d) sessions last 20 minutes. Prior to enrollment, we monitored the fetal heartbeat and cervical dilations of experimental group candidates for 30 minutes to confirm normal labor progression. We also helped administer the first 20-minute intervention session. After a 5-minute full-body or lower-back shower, participants were permitted to direct shower water anywhere that felt most comfortable. Nurses allowed participants to stand and sit as desired. After the first session, nurses monitored the fetal heartbeat and dilation status for at least 20 minutes every hour. Given continued normal labor progression, we allowed participants to take 20-minute accompanied warm showers as desired. During the intervention, participants could take an additional accompanied shower session as long as the fetal heartbeat and dilation status were normal and researcher consent was achieved. Water temperature was monitored every 5 minutes with a bath thermometer to confirm a constant 37◦ C. Participants could personally adjust the ambient temperature of the shower room to their own comfort.

Data Collection Process We recruited study participants from the birth unit of one regional hospital in northern Taiwan. Recruitment began in July 2010 after the hospital Institutional Review Board and nursing and maternity departments granted approval. Potential participants and those meeting the study criteria were approached individually. The study purpose and procedures were carefully explained, with questions clarified prior to written consent. To

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Warm Showers, Labor Pain, and Birth Experiences

Warm showers decreased labor pain and improved the childbirth experience.

maintain data confidentiality, all data related to patient identity was excised, and a code system was assigned to participants. Participants were informed of their right to withdraw from the study at any point without affecting subsequent care. Qualified participants were randomly assigned to experimental and control groups, both of which received standard maternity nursing care, with the former undergoing intervention. The research assistant (RA) explained the study purpose to both parents upon hospital admission, offering them an informational document, and obtaining written informed consent. The RA personally handled all first shower bath sessions, pre- and postintervention pain assessments, and data collection. Control group participants provided demographic data after receiving standard hospital care, responded to the VASP at 10 and 20 minutes after 4-cm and 7-cm dilation, and filled out the LAS within 24 hours of delivery. After receiving standard nursing care and providing demographic data, experimental group participants took their first 20-minute warm showers at 4-cm dilation assisted by the RA. Experimental group participants responded to the VASP prior to taking warm showers at 4-cm and 7-cm dilation and at 10 and 20 minutes afterward. Lastly, they completed the LAS.

Data Analysis The SPSS version 18.0 was used for the analyses. Descriptive data analysis identified the demographic and obstetrics characteristics of participants. The Kolmogorov–Smirnov goodnessof-fit test and normality plot investigated the distributional characteristics of study-dependent variables. The results indicated that the values for the target variables were normally distributed among the population. Chi-squared or independent t tests evaluated differences in demographic and obstetric variables between groups. The generalized estimating equations (GEE) model controlled the effects of study covariates and analyzed the independent effect of warm showers. The GEE approach considered within-person variability and accounted for correlated data resulting from repeated measurements

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across different time points and multiple observations of the same individual (Zeger & Liang, 1986). The GEE approach has been proposed as a nonparametric and appropriate method to conduct repeated measurement analysis. The level of significance was set at .05, two-tailed.

Results A total of 130 women were assessed for eligibility; 38 were excluded due to planned cesarean (n = 17), refusal (n = 3), and no time to collect data due to the simultaneous admission of two subjects (n = 18). Ninety-two participants met the inclusion criteria and were enrolled in the study: 46 participants were randomized to the warm showers group, and 46 to the control group. Nonetheless, some participants (n = 12) were removed from the study for various reasons including: emergency cesarean (n = 6), epidural anaesthesia (n = 3), and rapid delivery (n = 3) (Figure 1). From the original participant sample, seven participants were removed from the experimental group and five participants from the control group, yielding an attrition rate of 13.04%. As a result, the study included 39 participants in the experimental group and 41 in the control (Figure 1). Table 1 provides a description of the 80 participants relative to demographic and obstetrical characteristics. The mean reported age was 31.64 years. They were predominately university graduates (65%), nulliparous (53.8%), experienced the natural rupture of membranes (75%), without induction (81.3%), and lacked antenatal class attendance (62.5%). The average prepregnancy weight, prepregnancy body mass index (BMI), and total pregnancy weight gain were 53.11 kg, 20.88 kg, and 13.57 kg, respectively. The average received pelvic examinations in total and between 4 cm to 7 cm dilatation were 6.30 and 2.92, respectively. The groups demonstrated no statistical differences in demographic and obstetrical variables (p > .05). We found that warm showers improved the childbirth experience and decreased labor pain (Table 2). The mean LAS score of the intervention group was 54.15 (SD = 6.38) and 46.58 (SD = 8.61) of the control group (t = 4.45, p < .001). In terms of pain scores, at baseline, the mean pain scores for the intervention group were 6.84 (4 cm) and 8.74 (7 cm) compared to 5.15 (4 cm) and 8.22 (7 cm) for the control group. At 10- and 20-minutes postintervention, mean pain scores for the experimental group dropped

JOGNN, 42, 19-28; 2013. DOI: 10.1111/j.1552-6909.2012.01424.x

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Lee, S. L., Liu, C. Y., Lu, Y. Y., and Gau, M. L.

Figure 1. CONSORT diagram. Passage of participants through each trial stage.

significantly while increasing significantly for the control group (Table 2 and Figure 2). GEE analysis evaluated these differences after adjusting for several variables with potential effects on labor pain. Table 3 shows that changes to mean pain scores were significantly lower among the intervention group (β = −1.48, 4 cm and β = −1.65, 7 cm) than the control. Time-dependent changes also indicate that posttest pain values rose an average 0.15∼0.71 points over pretest results, implying a growth trend. However, the interaction effect (group difference and time) revealed that the intervention group achieved a significantly greater drop in pain values compared to their control group peers over time (β = −2.28∼−2.79, p < .001).

Discussion The VASP scores for the experimental group were lower than control group scores at all measured

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periods. All differences achieved statistical significance. Average pain was less at 10 minutes than 20 minutes postshower, echoing Huang (2010), whose research on the efficacy of heat therapy in reducing labor pains during the three phases of the first stage of labor found that initial applications reduced pain more significantly than midperiod and late-period applications. Study participants had higher VASP scores at 7-cm dilations than 4-cm, indicating that pain level increased as mothers progressed through the initial stages of labor. This finding confirms with those of Gau et al. (2011), Chung et al. (2003), as well as Simkin and Ancheta (2011). Our data clearly demonstrate the effectiveness of warm showers in reducing labor pain while reinforcing the results of similar studies (Benfield et al., 2001; Benfield et al., 2010; Nichols, 1996). Melzack and Wall’s gate control theory of pain (as cited in Montes-Sandoval, 1999; Warren,

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Table 1: Participant Backgrounds and Obstetrical Information Overall

Control group

Intervention

(N = 80)

(n = 41)

group (n = 39)

N Age (M, SD)

% 31.64

n 4.24

% 31.83

n 4.62

Statistics

% 31.44

3.85

Education Junior college and below

28

35.0

15

36.6

13

33.3

University and above

52

65.0

26

63.4

26

66.7

Height (cm, M, SD)

p

−0.35b

.681

0.10a

.329

159.40

5.47

158.59

5.89

160.25

5.27

−0.85b

.174

53.11

7.80

53.09

7.98

53.13

7.71

0.61b

.978

9.02

b

.879

b

.653

b

Weight (Kg, M, SD) Prepregnancy Current weight Total weight gain Prepregnancy body mass

66.68 13.57

9.20

66.83

3.58

13.75

9.48 3.40

66.52 13.38

3.80

0.67 0.45

20.88

2.78

21.09

3.02

20.66

2.51

0.70

.484

39.06

1.16

39.19

1.05

38.91

1.26

0.12b

.283

0.00a

.987

1.20a

.273

index (M, SD) Gestational weeks (week, M, SD) Parity Nulliparous

43

53.8

22

53.7

21

53.8

Multiparous

37

46.2

19

46.3

18

46.2

Antenatal class attendance Yes

30

37.5

13

31.7

17

43.6

No

50

62.5

28

68.3

22

56.4

3094.9

280.8

3068.0

279.7

3106.2

302.2

0.59b

.560

Yes

15

18.7

9

22.0

6

15.4

0.56a

.455

No

65

81.3

32

78.0

33

84.6 3.75a

.053

Newborn weight (g, M, SD) Induction

AROM Yes

20

25.0

14

34.1

6

15.4

No

60

75.0

27

65.9

33

84.6

Pelvic examination (M, SD) (in

6.30

1.75

6.24

1.64

6.36

1.87

−0.29b

.770

2.92

0.67

2.95

0.74

2.90

0.60

0.36b

.722

total) Pelvic examination (M, SD) (within cervical dilatation 4–7 cm) Note. AROM = artificial rupture of membranes. a Chi-squared test. b Independent t test.

2010) described how nerves dispatch pain signals through the spinal cord to the brain. Pain stimuli cross the open spinal gate to receptors in the brain, where the appropriate pain response

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is directed. Interference with this transmission vector can yield effective pain relief (Warren). Signals generated by warm-water stimulation of epidermis thermoreceptors reach the brain faster

JOGNN, 42, 19-28; 2013. DOI: 10.1111/j.1552-6909.2012.01424.x

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RESEARCH

Lee, S. L., Liu, C. Y., Lu, Y. Y., and Gau, M. L.

than those sent by pain receptors, effectively blocking transmission of the latter and reducing perceived pain (Huang, 2010; Lane & Latham, 2009). Heat-enhanced blood circulation also relieves stress-induced muscle cramps. Focusing warmth on specific tissues further improves tissue metabolism and elasticity, raising the effective pain threshold (Benfield et al., 2001, 2010). The practical requirements of warm shower bath interventions further increases patient movements and activity, encouraging regular positional changes that help relieve pain (Stark et al., 2008). Many studies highlight the significant role of parturition pain on the mother’s perception of the childbirth experience (Gungor & Beji, 2007; Li et al., 2009). The negative correlation between pain and self-control implies that a mother’s sense of selfcontrol over the childbirth process increases with better pain control. Effective labor pain control is thus critical to making childbirth a more positive, rewarding experience. The two most important factors influencing client satisfaction with the childbirth experience are level of participation in decision making and degree of self-control over the process (Goodman et al., 2004; McCrea & Wright, 1999; Remer, 2008). Researchers have demonstrated that efficacy of water therapy on enhancing parturient mothers’ sense of self-control (Benfield et al., 2010; Eckert et al., 2001). In addition to enhanced support from caregivers, the

Table 2: Differences in Labor Pain and Labor Experience between the Two Groups (N = 80) Variable

Experimental Control group

group

mean (SD)

mean (SD)

t

3.91 <.001

Baseline

6.84 (1.93)

5.15 (1.96)

10 minutes

4.21 (1.51)

5.29 (1.98) −2.76

.007

20 minutes

5.13 (1.45)

5.85 (2.02) −1.84

.07

Baseline

8.74 (1.09)

8.22 (1.41)

.067

10 minutes

6.33 (1.92)

8.37 (1.32) −5.49 <.001

20 minutes

7.10 (1.92)

8.85 (1.22) −4.85 <.001

Pain (7 cm) 1.86

54.15 (6.38)

46.58 (8.61)

4.45 <.001

Nulliparous

51.71 (5.42)

45.77 (9.06)

2.59

Multiparious

57.00 (6.37)

47.52 (8.21)

3.80 <.001

Note. LAS = Labor Agentry Scale.

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mothers perceived improved care, greater participation in the childbirth process, greater selfcontrol, and enhanced satisfaction with the childbirth experience (Gungor & Beji; Li et al.). In this study, the experimental group achieved higher average LAS scores than their control group counterparts. The nonpharmacological nursing care measures helped enhance the experimental group participants’ feelings of acceptance, making their childbirth experience more positive. This finding reinforces that of Austin (1989) who found that women in labor who showered had a generally more positive and satisfactory childbirth experience than those who did not. The core concepts of midwifery care are woman-centered care and the drive to normalize birthing (Simkin & Ancheta, 2011). Cluett and Burns (2012) indicated that warm showers facilitate this paradigm shift, from professional centered to women centered, from pathology dominated to normality expected. Thus, Odent (1983) stated that water implies relaxation, warmth, nature, and femininity. It offers caregivers (midwives, nurses, and/or partner) an opportunity to develop the skills required to provide woman-centered care, form therapeutic rapport with women, empower their decision making and participation, and control over their bodies (Cluett & Burns; Odent; Simkin & Ancheta).

p

Pain (4 cm)

LAS

Routine provision of warm shower intervention is recommended for laboring women because it is cost-effective, noninvasive, and easily applicable.

.013

We advocate 37◦ C as the ideal warm shower bath temperature. Anecdotal studies have indicated that water at different temperatures achieves different therapeutic effects (Moore, Peterson, & Manwell, 1964). Water at 34∼38◦ C is comfortable against the skin, and at 37∼40◦ C is best for controlling pain when used properly and applied in sessions of 20∼30 minutes in length (Hecox, Weisberg, Andemicael-Mehreteab, & Sanko, 2005). However, Eckert et al. (2001) found water temperatures greater than 37◦ C may adversely affect the fetus. This study was conducted during the winter, a season of high air temperature variability that may adversely influence participant willingness to shower. In fact, most participants requested that water temperatures be set higher than 37◦ C. To prevent partners or relatives from setting water temperatures greater than 37◦ C and to mitigate seasonal factors,

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Warm Showers, Labor Pain, and Birth Experiences

Figure 2. Changes in labor pain scores (4 cm and 7 cm) at baseline and posttests.

researchers adjusted ambient air temperatures in the shower room to each participant’s preference prior to showering sessions. In addition, when participants focused warm water on their lower torso only, researchers provided warm towels for participants to drape over their shoulders to maintain upper body warmth. These facts highlight the need for maintaining adequate room and water temperatures in intervention sessions,

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as well as the need for educating participants and their partners regarding water temperature control.

Conclusion Our results demonstrate the efficacy of a warm shower in relieving labor pain and fostering

JOGNN, 42, 19-28; 2013. DOI: 10.1111/j.1552-6909.2012.01424.x

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RESEARCH

Lee, S. L., Liu, C. Y., Lu, Y. Y., and Gau, M. L.

stetrics & Gynaecology, 113(3), 284–288. doi:10.1111/j.1471-

Table 3: Generalized Estimating Equations Modela on the Effect of Outcome Variables for Warm Showers (N = 80)

0528.2006.00861.x Akerman, N., & Dresner, M. (2009). The management of breakthrough pain during labour. CNS Drugs, 23(8), 669–679. Austin, K. A. (1989). Showering in labor: An effective pain manage-

Variables

β

SE

ment alternative (Master of Science in Nursing). Kirkhof School of

p

Nursing, Grand Valley State University, Allendale, Grand Rapids,

Pain (4 cm) Group (Experimental vs. control)

MI.

−1.48 .40 <.001

mantic equivalence of a translated scale. Research in Nursing

Time Baseline

and Health, 26 (1), 64–73. doi:10.1002/nur.10066 Bell, A. F., White-Traut, R., & Medoff-Cooper, B. (2010). Neona-

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−2.28 .32 <.001

Note. a All models have been adjusted for age, education, parity, antenatal education attendance, prepregnancy body mass index, gestational weeks, induction, artificial rupture of membranes, and pelvic examinations.

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positive feelings toward the labor process during the first stage of labor. This nonpharmacological alternative to pain relief is economical, easy to arrange, and does not require preintervention training. The warm showers require only that participants familiarize themselves with techniques and principles immediately beforehand and that a health professional facilitate the initial session. Continuing education for nurses/midwives should emphasize water therapy as a nonpharmacological alternative to pain relief in clinical practice, enhancing a nurse’s familiarity with such concepts and techniques in order to provide laboring women more pain control options.

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