Use of whirlpool tubs for pain relief in active first stage labor: a descriptive study

This prospective, descriptive, exploratory study was undertaken to determine the effects of whirlpool tub use on women's perception of pain during active first stage labor. Other effects of tub use were also examined. The population was 85 women admitted to a birth center where deliveries were conducted by certified nurse-midwives. Pre- and posttub use pain measurements were taken on 46 women using a visual analogue scale. A postpartum questionnaire elicited benefits and problems of whirlpool tub use. Subjects were predominantly Caucasian, married, and high school educated. Mean age was 26 years. A statistically significant difference was found between pain scores before tub entry and 15 minutes after tub entry. Married women perceived significantly less pain than single women. No adverse effects of tub use were found. Progress of first stage labor was facilitated. Other benefits included relaxation and diversion. Research, educational, and clinical implications were discussed and recommendations made.

THE USE OF WHIRLPOOL TUBS FOR PAIN RELIEF IN ACTIVE FIRST STAGE LABOR: A DESCRIPTIVE STUDY by Kathleen J. Bell and Marianne Desmarais A dual thesis submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Master of Science College of Nursing The University of Utah June 1993 Copyright © Kathleen J. Bell and Marianne Desmarais 1993 All Rights Reserved THE UNIVERSITY OF UTAH GRADUATE SCHOOL SUPER\.TISORY CO~INIITTEE APPROVAL of a thesis submitted by Kathleen J. Bell and r~rianne Desmarais This thesis has been read by each member of the following supervisory committee and by majority vote has been found to be satisfactory. Di ane HelJbusch THE UNIVERSITY OF UTAH GRADUATE SCHOOL FINAL READING APPROVAL To the Graduate Council of the University of Utah: I have read the thesis of Kathleen J. Bell & Marianne Desmarais in its final form and have found that (1) its format, citations and bibliographic style are consistent and acceptable; (2) its illustrative materials including figures, tables and chans are in place; and (3) the final manuscript is satisfactory to the supervisory committee and is ready for submission to The Graduate School. Date~1 y t upervisory Committee Approved for the Major Department Linda K. Amos Chair/Dean Approved for the Graduate Council ABSTRACT This prospective, descriptive, exploratory study was undertaken to determine the effects of whirlpool tub use on women's perception of pain during active first stage labor. Other effects of tub use were also examined. The population was 85 women admitted to a birth center where deliveries were conducted by certified nurse-midwives. Pre- and posttub use pain measurements were taken on 46 women using a visual analogue scale. A postpartum questionnaire elicited benefits and problems of whirlpool tub use. Subjects were predominantly Caucasian, married, and high school educated. Mean age was 26 years. A statistically significant difference was found between pain scores before tub entry and 15 minutes after tub entry. Married women perceived significantly less pain than single women. No adverse effects of tub use were found. Progress of first stage labor was facilitated. Other benefits included relaxation and diversion. Research, educational, and clinical implications were discussed and recommendations made. TABLE OF CONTENTS ABSTRACT ..•...•••••••.•.•..••.•.••••••.••.•••.•...• .iv LIST OF TABLES ••.••••••••••••.••••••••••••••••• .vii ACKNOWLEDGMENTS ••••••••.••••.••••.••••••• . . . . . . . . . . . . . . .viii Chapter I. INTRODUCTION AND LITERATURE REVIEW •.•..••.•.••..•..•••.• 1 Introduction .....•. Literature Review .• Problem Statement. Research Questions. Hypotheses .•.••••.. • ••...• 1 • •• 2 • •• 18 .19 . .. 19 II. RESEARCH DESIGN AND METHODOLOGY •.•.................... 21 Study Design •.•••••••....• Clinical Setting .•..•..•••• orientation of Personnel. Sample •.•••.•••...••..••.. Instruments .••...•••..••.. Definitions of Operational Procedures ......•....... Ethical Considerations. Terms. .21 · .22 · .22 • .23 .24 • .25 • ••• 27 .29 III. RESULTS AND DISCUSSION .........•..................... 31 Data Analysis ..... Results ...••.•.••. Progress in Labor .. positions in Labor •. Use of Whirlpool Tub .. Pain Scores •••• Medication Use. Fetal Heart Tones. Status of Amniotic Membranes ••. APGAR Scores .............•. Postpartum Questionnaire •. Research Questions .•••.•. Results Related to Hypotheses .. Discussion •••........•........ ..31 •• 32 • .34 .39 .39 · .41 • .42 .44 • .46 .46 • •••• 47 • •. 49 • .52 · .55 IV. SUMMARY AND RECOMMENDATIONS ••..•.•••••••.•••••••••• 67 Appendices Summary ........................................ 67 Imp! ica tions •..•••..••••..•...•................ 68 Recommendations ••....••••..••••..•............. 69 A. HMO RISK SCORING SHEET ••.••••..•••.•••..•••..•..•.. 72 B. BIRTH SUITE EXCLUSION CRITERIA ••••.•.••.•••••.•..•• 75 C. INFORMED CONSENT •••••.•••••••...••••••.••..•.•..••. 79 D. FOLLOW-UP CONSENT •••..•••....•....•.......•........ 83 E. VISUAL ANALOGUE SCALE - PAIN ••....•................ 85 F. VISUAL ANALOGUE SCALE - EASE OF LABOR .............. 87 G. DATA COLLECTION SHEET ..••.•..•.•.•..••....•.•..•••. 89 H. POSTPARTUM QUESTIONNAIRE •.••..••••...••..••...•..•. 91 I. TUB WATER TEMPERATURE AND FHT .....•..........••••.. 93 J. APPROVAL LETTER FROM ASST. DEPT. HEAD, OB/GYN ...... 95 REFERENCES •••••••••••..•••••••••..•••••••••.••.••.••...•.• 97 LIST OF TABLES Table I. Age and Education ••..•••.•.••.•••••••••...••..••••• 33 I I. Race/Ethnici ty ••••.••.•...••..•••..••..••.••.••••• 34 I I I. Ma rita 1 S ta t us. • . . . • • . . • • • . . • • . . • . • . • . . . • • . • . • . . . • 35 IV. Parity and Prenatal Classes ••••.•.•..•••..••...... 36 V. Length of Labor and Time in Tub •.••..•.•.•.••••••• 38 VI. Tub water Temperature •••..•••..••...•••..••...••.. 40 VII. Pain Scale Scores compared with Tub Use ••.....•... 43 VIII. Visual Analogue Pain Scores •..•..••..••••.•••..•• 45 IX. Length of Time in Minutes from Rupture •...•.•....• 47 X. Length of Time in Minutes from Initial Tub •••..... 59 XI. comparison of Mean Length in Hours ................ 60 ACKNOWLEDGMENTS We wish to extend our gratitude and appreciation to the following people without whose assistance and support this research would not have been possible: 1. To the women who participated in the study - for their gracious cooperation during labor. 2. To the staff of the Birth Suite - for the excellent work of data collection and documentation. 3. To the administration and CNMs of FHP - for their cooperation and permission to conduct this research. 4. To our committee members: Diane Heubusch, CNM; Eileen Csontos, MD; and Joyce Foster, PhD, CNM - for their personal commitment to our educational process. 5. To Dr. Jim Reading - for his excellent statistical consultation. 6. To Joyce Rathbun - for her accurate and patient answers to our seemingly endless questions regarding the graduate education program. 7. To the staff of superb reference librarians at Eccles Library - for their expertise and availability. 8. To the International Childbirth Education Association - for grant funding to assist this research. 9. Most importantly, we thank our husbands and families - for their unlimited love, help, support, prayers, and patience as we undertook and completed this project. Their faith in our abilities kept us going through this process. We acknowledge and appreciate one another and are thankful for the friendship and partnership this work engendered. Kathleen J. Bell and Marianne Desmarais CHAPTER I INTRODUCTION AND LITERATURE REVIEW Introduction Pain is commonly experienced in childbirth. The management of pain in labor continues to be of major concern to both parturient and care providers. The effects of maternal pain and anxiety during labor have profound physical and psychological implications for both its ease and progress. Nursing and medical interventions for pain relief in labor involve a wide variety of therapeutic modalities. Water has been used in labor for centuries, and the use of warm water for pain relief and physical relaxation can be documented from ancient times. At present, the use of whirlpool tubs as a method of pain management in labor is clinically widespread. However, review of the literature reveals a scarcity of research documenting their effectiveness for this purpose. Therefore, this study was undertaken to determine the effectiveness of the whirlpool tub as a means to provide pain relief for women in active first stage labor. Literature Review During the latter part of this century childbirth pain has been the focus of research throughout the world. 2 Melzack (1984) found the pain of labor to be one of the most intense ever registered on the McGill Pain Questionnaire. The chapter in Williams Obstetrics that deals with analgesia and anesthesia opens with the following statement: "Labor may subject the nulliparous woman to the most pain she has ever experienced" (Pritchard & McDonald, 1985, p.327). Oxorn and Foote discuss six generally accepted hypotheses as to the physiologic causes of pain in labor: 1) hypoxia of the uterine musculature during contractions (ischemic pain); 2) cervical stretching and pressure on the nerve ganglia of the cervix; 3) traction on the fallopian tubes, ovaries, and peritoneum; 4) traction on and stretching of uterine ligaments; 5) pressure on the urethra, bladder, and rectum; 6) distention of the tissues of the pelvic floor and perineum (Oxorn-Foote, 1986). Bonica (1980) theorizes that high threshold pain receptors, called nociceptors, are repeatedly stimulated during contractions, which then lowers their threshold and results in stimuli becoming increasingly painful. Sensory receptors have been identified in the cervix, although none have been found within the body of the uterus itself (Greenhill & Friedman, 1974). Bonica also states another possible source of pain is cellular destruction that occurs with cervical dilatation and fetal expulsion, during which "pain-producing substances" are released. In addition to physiological factors that cause pain Bonica (1980) cites several physical factors that influence the character and degree of pain in the parturient: 1) intensity and duration of contractions; 2) degree of cervical dilatation, as well as the rate of dilatation per contraction; 3) perineal distention; 4) maternal age, condition (e.g. fatigue, malnutrition, physical stamina), and parity; 5) fetal size and position. 3 According the International Association for the study of Pain (IASP, 1979, p.1) "pain is a multidimensional sUbjective experience of discomfort composed of both sensory and affective components". The pain experience of childbirth is of significance and has been widely researched. In a longitudinal study of couples during pregnancy, childbirth, and postpartum, Doering and Entwisle (1980) discovered that 29% of parturients found childbirth to be more painful than expected, whereas 22% found it to be less painful. On the average, the first stage of labor was characterized as being moderately to severely painful, and the second stage as slightly to moderately painful. Transition (8-10 cm cervical dilatation) was labeled most painful by 38% of parturients, 4% said childbirth was painless, and a full 12% said the most significant pain they experienced was iatrogenically introduced by caregivers (i.e., interventions such as IV's, enemas, etc.). 4 Melzack (1984) corroborates the variability of pain experienced in childbirth in his study using the McGill Pain Questionnaire to measure pain in labor. Out of 87 primiparas, 9.2% rated childbirth pain as very mild, 29.5% as moderate, 37.9% as severe, and 23.4% as extremely severe. This distribution is very similar to the findings of a study by Nettelbladt, Fagerstrom, and Uddenberg (1976). Multiparas in Melzack's study (1984) had lower pain scores than primiparas, another commonly repeated finding. Melzack concluded that pain in labor is highly individualized, finding poor correlation between the pain a woman experienced and the stage of her labor. Also highly individual is where in the body a woman experiences pain. The location(s) change with both the stage and progress of labor. The pain of first stage labor is often perceived in the lower abdominal, groin, and lumbar areas, with the pain of second stage moving downward to include hips, buttocks, and legs (Bonica, 1980). Niven and Gijsbers (1984) used the McGill Pain Questionnaire to measure childbirth pain both in labor and 24-48 hours postpartum. Severe pain was recorded in the 29 subjects, again with highly variable results. In 1933, Dick-Read (1933) published his hypothesis that childbirth is not inherently painful. He proposed that the pain of labor was largely psychic in origin. He stated that fear (caused by social and cultural myths) causes excitation of the sympathetic nervous system and that this activates 5 contraction of the circular muscle fibers of the uterus, producing opposition between the upper and lower portions of the uterus. The tension that results from this obstructional process leads to pain. Dick-Read (1947) was also a proponent of the ischemic pain theory which justified his "fear-tension-pain" syndrome. He believed that ischemia arose from prolonged uterine tension, brought on by fear. Bonica (1980) describes the psychologic dimensions that can influence the degree of pain in childbirth as follows: 1) anxiety and emotional arousal, 2) motivation and affect, and 3) cognitive, conceptual, judgmental dimensions. It has been well documented that anxiety and arousal serve to increase muscular tension, thereby increasing nociceptor stimulation. Fear and anxiety can activate the sympathetic nervous system, which can cause ischemia through vasospasm. Thus Bonica's statements are, in essence, just what Dick­Read said 60 years ago. In 1965 Melzack and Wall (1965) proposed a theory claiming the perception of pain was under the control of a gating mechanism within the spinal cord. continued research has validated the concepts of this theory. The gate control theory may be used to explain the effectiveness of many pain relief techniques, including hydrotherapy. The theory states that pain stimuli can be modified as they travel through the spinal cord. Pain stimuli resulting from injury or noxious stimuli levels are transmitted along an ascending pathway via small diameter fibers. When the impulse reaches 6 the sUbstantiosa gelatinosa, a "highly specialized closed system of cells that extends through the spinal cord on both sides" (Bonica, 1979, p.101) a gating mechanism can be activated by sensation traveling via large diameter fibers. This modifies or inhibits the pain impulse before it reaches the transmission cells in the dorsal horn. Sensations of pressure, wetness, and heat (such as those encountered in hydrotherapy) are transmitted along large-diameter nerve fibers, activating this gate mechanism. Importantly, the proposed spinal cord gating mechanism is also thought to work via a descending pathway as well. The descending system appears to contribute information from the reticular formation and cortex of the brain, possibly accounting for the effectiveness of cognitive strategies (e.g., childbirth education, relaxation, breathing, music, visual imagery) and anxiety reduction (e.g., verbal and emotional support) on the pain experience. Another popular pain theory is the endogenous pain control theory. According to this theory, the body possesses a natural pain-suppression system functioning at the mid brain, medulla, and spinal cord (Brucker, 1984). Morphine-like SUbstances called endorphins are released from the pituitary gland (Wolf, 1980) and travel to opiate receptors, where they inhibit pain-transmission neurons. Endorphins have been classified as beta-endorphins and enkephalins (Jimenez, 1983). 7 Lederman, Lederman, Work, and McCann (1985) found that increased maternal anxiety in labor correlated significantly with increased levels of plasma epinephrine (a catecholemine used as a biochemical measure of anxiety). Significant correlations were also found with decreased uterine contractility and increased length of labor. In a review of the literature on stress, pain, and catecholemines in labor, Simpkin (1986) elaborates on the effects of excessive maternal catecholemines on the fetus, leading to fetal hypoxia and distress which continues into the neonatal period. Both the gate control theory and the endogenous pain control theory have been used to explain the modes of action for nonpharmaceutical pain relief methods, including hydrotherapy (Brucker, 1984). Hydrotherapy is the term used to refer to external application of water to the body for therapeutic effects (Brown, 1982). The use of heated water for pain relief and physical relaxation can be documented from ancient times, especially of natural hot springs worldwide (Church, 1989). To date, the American medical literature has devoted little to therapeutic uses of warm water immersion during labor and birth. Most of the experience acquired with this nonpharmaceutical pain relief measure has been in Europe. The first documented water birth occurred in 1805 in France. After 48 hours of labor an exhausted parturient climbed into a hot tub to relax, and delivered her infant shortly afterwards in the water (Embry, 1805)! In 1983 Dr. Michel Odent described 100 births that had taken place underwater at the French state hospital at Pithviers and observed that "water seems to help many parturients reach a certain state of consciousness where they become indifferent to what is going on around them" (Odent, 1983, p.1476). He concluded: 8 the use of warm water during labor requires further research, but we hope that other experience would confirm that immersion in warm water is an efficient, easy, economical way to reduce the use of drugs and the rate of intervention in parturition. (Odent, 1983, p. 1477) The biophysical principles underlying hydrotherapy, i.e. buoyancy, hydrostatic pressure, and specific heat, have been well discussed by Edlich (1979) and can be applied to laboring women in water. Archimedes' principle states that a body at rest, which is wholly or partially immersed in a fluid, experiences an upthrust that is equal to the weight of the fluid displaced (Brown, 1982). The increased body fat of pregnant women makes them more buoyant and gives them greater hydrodynamic lift, thereby imparting a "weightless" feeling when immersed. As a woman uses less energy to support her body during contractions, her muscles will become less tense. As she relaxes more completely she will experience less pain; and as pain decreases, anxiety decreases as well (Dick-Read, 1947). Decreasing anxiety reduces catecholemine levels, encouraging uninhibited flow of her natural oxytocins and endorphins. This leads to a 9 balance of pain/relaxation which facilitates normal progress of labor (Church, 1989). When a submerged body is at rest the pressure is the same in all directions, and equally distributed at any given depth beneath the surface of the liquid (Edlich, 1987). The water exerts hydrostatic pressure on the surface of the part of the body that is underwater equal to the density of water (Brown, 1982). Because of this hydrokinetic effect of equal pressure and support on all body surfaces, women often comment on the reduction in pain when their abdomens are submerged (Church, 1989). Women who are required to get out of the tub/pool for any reason usually feel increased pain (Kitzinger, 1991). This hydrostatic pressure is also theorized to be responsible for beneficial blood pressure changes among women who develop arterial hypertension either as a result of toxemia or in response to anxiety and pain in labor (Church, 1989; Doniec-Ulman, 1987; Goodlin, Engdahl Hoffman, Williams, & Buchan, 1984; Katz, 1990; Rosenthal, 1991). Water has the capability of absorbing and holding more heat per unit weight than any other substance, and therefore is an excellent distributor of heat (Brown, 1982). The literature is in agreement that the best water temperature for use in labor is dictated by the mother's comfort, which usually is slightly above blood temperature (Aderhold & Perry, 1991; Brown, 1982; Church, 1989; Kitzinger, 1991). Moore, Peterson, & Manwell (1964) recommend a range of 92-98 10 degrees Fahrenheit (34-38 degrees centigrade) for hydrotherapy, and many medical protocols recommend 37 degrees Centigrade for use in labor. The ideal temperature is warm enough to prevent loss of body heat by conduction (which can lead to chilling), yet is cool enough for the woman to accomplish the work of labor without becoming hyperthermic (which can lead to dehydration) (Church, 1989). In Western society, pregnant women have long resorted to the warm bath to ease both physical discomfort and psychological distress. Bathing with warm water produces numerous physiologic effects. The skin is richly supplied with sweat glands and capillaries that are controlled by the sympathetic nervous system. It has been well documented that the sympathetic nervous system responds to psychological changes to maintain physiologic homeostasis - the fight or flight response (Eyzaguirre & Fidone, 1975). When the skin is immersed in warm water both the water and the heat exert a soothing action on the cutaneous nerve endings in the skin, and affect all the organs with which the skin is in reflex connection (Finnerty & Corbitt, 1960). Turbine jets are used to increase the water circulation, thereby enhancing the mechanical effect of stimulating sensory input and proprioceptive feedback (Lindsey, 1990). The heat causes an increase in nerve conduction velocity and muscle relaxation, which in turn enhances psychological relaxation, causing a generalized relief of mental tension (Brown, 1982). According to Finnerty and Corbitt (1960), prolonged immersion baths were used over 100 years ago for relaxation and inducing sleep in nervous mental patients. Virtually all the literature surveyed mentioned enhanced relaxation as a benefit of warm water bathing in labor 11 (Aderhold & Perry, 1991; Brown, 1982; Church, 1989; Daniels, 1989; Gillot-de-Vries, Wesel, & Busine, 1987: Gordon, 1991: Kitzinger, 1991: Lenstrup, Schantz, Berget, Feder, Roseno, & Hertel, 1987; Milner, 1988; Odent, 1983,1984; Rosenthal, 1991; Sakala, 1988; Waldenstrom, 1992). Both Rosenthal (1991) and Odent (1983,1984) report that women appear so relaxed in the bath they can doze during labor, suggesting an altered mental status which may be attributable to enhanced endorphin production. A related phenomenon is the laboring woman's perception of decreased pain in the bath (Lenstrup, et al., 1987). This analgesic effect is due to the heat conduction qualities of water. It is known that pain and heat sensations travel along the same nerve fibers. Hydrotherapy is reportedly effective in treating unlocalized pain associated with visceral disorders, or with the sympathetic nervous system (Finnerty & Corbitt, 1960). It is theorized that pain in first stage labor stems largely from the cervix which is primarily innervated by the sympathetic nervous system. Midwives, physicians, and parturients who have used hydrotherapy in labor all testify to its ability to increase comfort (Brown, 1982; Church, 1989; Daniels, 1989; Ford, 1989; Gillot-de-Vries, et al., 1987; Kitzinger, 1991; 12 Milner, 1988; Odent, 1983; Rosenthal, 1991; Sakala, 1988; Waldenstrom, 1992). Women are familiar with the emotional and physical benefits of the bath, and therefore anticipate relief from its use. The technique of pouring or ladling water over a parturient's abdomen and/or sacrum during contractions has been called a "home birth epidural" (Sakala, 1988, p.1149). The more upright posture assumed during the bath also serves to reduce pain (Rosenthal, 1991). A recumbent posture decreases uterine perfusion, and can contribute to ischemic labor pain that resembles intermittent claudication, an experience that is almost unbearable for most women (Bienarz, 1968). Parturients who labor and deliver in an active, primarily upright position feel control over the birth that translates into an element of control over pain (Rosenthal, 1991). Over a 4 year period, Dr. Michael Rosenthal has assisted at approximately 500 water births, and reports that >90% of the mothers used no analgesic drugs during labor and delivery. "He further reports that they deliver their babies while awake, aware, and in control of the process of birth, an empowering experience that stays with them forever" (Daniels, 1989, p. 200) • Conflicting reports of the use of analgesics in combination with hydrotherapy during labor are found in the literature. Some authors state that their use has been virtually eliminated (Daniels, 1989; Gordon, 1991; Odent, 13 1983). Others report significantly less medication being used by women who labor in hydrotherapy tubs (Aderhold & Perry, 1991; Milner, 1988; Sakala, 1988). Two studies failed to demonstrate a significant difference in drug utilization between women who used the tub and those who did not (Lenstrup, et al., 1987; Rosenthal, 1991). controversy also exists in the literature regarding hydrotherapy's effects on labor progress. Odent implemented pools of warm water at Pithviers for use in labor "in hopes of conferring the benefits of pain relief and more rapid labor progress" (Odent, 1981, p.7). Some authors contend that cervical dilatation tends to be more rapid (Gordon, 1991; Gradert, Hertel, Lenstrup, Bach, Christensen, & Roseno, 1987; Hassid, 1978; Kitzinger, 1991; Odent, 1983). Others cite incidences of labor both accelerating and decelerating as a result of warm water immersion, with a key factor being how well labor is established before entry into the water (Church, 1989; Sakala, 1988). Many institutional protocols prohibit the use of baths until labor is well under way (4-5 cm cervical dilatation) because the profound relaxation effects on the uterus can stop contractions altogether. Three studies report no significant difference in duration of labor between women who use the tub and those who do not (Lenstrup, et al., 1987; Rosenthal, 1991; Schorn, 1991). Although obstetricians formerly advised women to discontinue tub bathing in the last 6 weeks of pregnancy to 14 prevent infective organisms from entering the vagina (Goodrich, 1950; Seigel, 1960), the modern opinion is that bathing at any time during pregnancy and the puerperium is safe (Pritchard & McDonald, 1985). Using water for pain relief or for delivery does not increase the infection risk to mother or baby, provided standard precautions are taken to cleanse the tub/pool before use. Two recent independent studies both demonstrated no significant difference in infection rates of chorioamnionitis or endometritis for women who used the tub, regardless of membrane status (Church, 1991; Schorn, 1991). Their findings are supported throughout the literature (Gordon, 1991; Odent, 1983; Rosenthal, 1991; Sakala, 1998). Maternal hyperthermia, such as could be induced by sauna bathing at temperatures of 175-194 degrees Fahrenheit (80-90 degrees Centigrade), has been implicated as a possible teratogen during the period of organogenesis in the first trimester of pregnancy (Clarren, Smith, and Harver, 1979). The warm water baths used in labor equalize the core temperature with that of the skin and subcutaneous tissues, but do not elevate maternal core body temperature (Brown, 1982). Even with maternal exposure to hyperthermia conditions during the latter half of pregnancy, no adverse fetal effects have been found (Smith, Clarren, and Harver, 1978). Dick-Read (1959) described the ideal obstetric anesthetic as one that must: 1) alleviate suffering, 2) not 15 interfere with the progress of labor, and 3) be safe for the baby. All the literature reviewed indicates the safety of hydrotherapy in labor and delivery for both mother and baby_ Odent (Odent, 1983, p.1477) states: "We have found no risk attached to either labor or birth under water." Rosenthal (Rosenthal, 1991, p.38) states that warm water immersion during labor is "an inexpensive, effective modality that has been virtually free of adverse outcomes. No other intervention can be said to be so free of risk." In her dissertation on the validation of a visual analogue scale for pain measurement in childbirth Giuffre states: It appears, then, that pain perception is more than simply a balance of inhibition and excitation at the spinal cord level, but results, rather, from elaborate interaction at multiple levels of many different types of information. The variety and scope of experiences that presumably are stored as information to affect pain perception are possibly infinite (e.g. culture, education, age, sex, experience, etc.) This may account for the varying, sometimes unpredictable, results encountered with pain interventions. Variance in pain perception will be seen not only between individuals but within individuals, depending upon their immediate physical, behavioral, psychological, and environmental states. (Giuffre, 1983, p. 21) Melzack's theoretical framework (Melzack, 1982) leads one to the understanding that relevant cognitive, psychological, and physical processes influence a person's PERCEPTION of pain, not his REACTION to it. McCaffery (McCaffery, 1972, p.8) states: "Pain is whatever the experiencing person says it is, and exists whenever he/she says it does." With this in mind, it becomes apparent that 16 the only way to adequately assess pain is to ask the person perceiving it. To this end Melzack (1975) published the McGill Pain Questionnaire in 1975. In order to avoid measuring pain as though it were a single phenomenon of sensation, this lengthy word evaluation tool was devised to supposedly measure the three proposed dimensions of pain perception (sensory, affective, and evaluative). This tool may take as long as 30 minutes to complete, making it highly impractical for use in labor. In an attempt to expedite measurement of acute pain of known origin (e.g., labor, dental, or surgical pain) the visual analogue scale (VAS) was developed and is being increasingly used to measure clinical pain. Visual analogue and graphic rating scales have been used and studied for a considerable time (Hayes & Patterson, 1921). The VAS is a straight line, usually 10 cm long, with the ends labeled according to the extremes of the phenomenon being measured. Graphic rating scales are similar lines with a few descriptive words or numbers placed along the line at intervals. The disadvantage of such a limited descriptive scale is that people are confined to rating their pain according to the word categories presented, which do not necessarily represent all possible degrees along the continuum from "no pain" to "pain as bad as it can be." Aitken (1969, p.989) claims that category scales such as graphic rating scales "fail to grasp the nuances of feeling." Stevens (1974) states that statistical analysis of visual analogue scales is superior to that of graphic rating scales, because they offer opportunity for ratio scaling that fixed categories cannot include. 17 In 1976 Scott and Huskisson described the results of a study in which six different graphic rating scales and visual analogue scales were compared for reliability and sensitivity. Of the six, scores on the VAS appeared to be the most uniformly distributed (a distribution predicted by the authors as most likely to represent sensitivity). The dissertation previously quoted (Giuffre, 1983) established the validity of the visual analogue scale for pain measurement in childbirth. Numerous researchers have used the visual analogue scale in studies of both real and analogued labor pain (Chaves & Barber, 1974; Connolly, 1978; Gaston-Johansson, Fridh, & Turner-Norvell, 1988; Geden, Beck, Hauge, & Pohlman, 1985; Park & Han, 1987; scott-Palmer & Skevington, 1981). Correlations ranging from .60 to .81 have been found between the visual analogue scale and verbal numerical rating scales (Downie, Leatham, Rhind, Wright, Branco, & Anderson, 1978; Ohnhaus & Adler, 1975: Scott & Huskisson, 1976). Experimenter effects are always of concern when conducting a research study. The visual analogue scale has three characteristics that decrease the potential risk of experimenter effects: 1) subjects score the tool themselves, 2) the tool is easily understood and does not need repeated (possibly differing) explanations, 3) the measurement procedure usually takes less than 30 seconds. 18 Melzack (1975) suggests that measuring pain with the visual analogue scale provides measurement along only a single continuum of sensory perception, and ignores the cognitive and emotional dimensions. The gate control theory, however, supports the intricate interaction of behavioral and anatomical dimensions of pain that, together, comprise a unitary perception. The investigators agree with Giuffre (1983, p.97) in her premise "that a unitary phenomenon of pain is most sensitively and validly measured with a unitary measure such as the visual analogue scale." Problem statement Review of the literature reveals a scarcity of research documenting the effectiveness of whirlpool tubs as a means to provide pain relief for laboring women. To illustrate the limited role hydrotherapy plays in contemporary biomedical practice, a MEDLINE search resulted in fewer than 10 articles describing the potential uses of water in childbirth. Whereas some innovations in medical care have been adopted by primary care providers only after lengthy scrutiny in academic centers and numerous reviews of research studies in peer-reviewed journals, by contrast, the use of whirlpool baths during labor has had a "grass-roots" origin. In the realm of prenatal care and birth we have witnessed the development of a consumer-driven market. 19 Economic pressures, better-informed consumers, and more discriminating payers are compelling us to provide care that is cost-effective and of an appropriate level. This atmosphere has given rise to a number of childbirth alternatives, including nurse-midwifery care, freestanding birth centers, and whirlpool baths. This investigative study provides quantitative data for measurement of the tub's use and effectiveness, data that are not contained at present in the existing literature. Research Questions The purpose of this descriptive exploratory study was to determine the effects of whirlpool tub use during active first stage labor at a freestanding birth center where deliveries are conducted by certified nurse-midwives. A pre- and posttub use evaluation of pain and maternal responses to a brief postpartum questionnaire addressed the following research questions: 1. What is the effect of whirlpool tub use during active first stage labor on women's perception of pain? 2. What are other benefits, if any, of whirlpool tub use during active first stage labor? Hypotheses 1. Scores on the VAS will increase as labor progresses. 2. Multigravidas will have lower scores on the VAS than primigravidas. 3. Women who use the whirlpool tub will have lower scores on the VAS than those who do not. 4. Pain scores on the VAS prior to tub entry will be the same or greater than the exit scores. 5. The average length of labor for women who use the tub will be less than the Friedman "norms." 6. Marital status will affect pain scores. 7. Childbirth education status will affect pain scores. 8. FHT's 15 minutes after tub entry will be higher than those prior to tub entry. 20 CHAPTER II RESEARCH DESIGN AND METHODOLOGY Study Design This study was designed to be a prospective, descriptive, exploratory study of whirlpool tub use for pain relief during active first stage labor in a freestanding birth center. A visual analogue scale (VAS) was used to measure pain during labor. Measurements were taken every 2 hours during labor, prior to tub entry, 15 minutes after tub entry, and prior to exit from the whirlpool tub whenever used. Pain perception during labor as measured by the score on the VAS is the dependent variable. Almost 100 independent variables were recorded in the study, the most salient of which include: mat~rnal age, parity, race, marital status, years of educatio~, attendance at prenatal classes, positions used in the active phase of labor, medications used, tub water temperature, time in the tub, length of active phase and first stage labor, contraction intervals, fetal heart tones (FHT), status of amniotic membranes, newborn APGAR scores, and responses to five postpartum questions. 22 Clinical setting The Birth suite is a free-standing birthing center contained within an ambulatory clinic building of a large health maintenance organization (HMO)in Salt Lake City, utah. Women delivering in the Birth suite are a) clients of the HMO, and b) clients of a nurse-midwifery faculty practice of the University of Utah. There are four birthing rooms. Two rooms are equipped with private whirlpool tubs, and one tub is shared between two rooms. They are available for use as desired. Approximately 40 births a month take place in this setting. The women who self-select to deliver at the Birth suite must meet obstetrical screening criteria for being low risk, as measured by a score of 3 or lower on the HMO risk-scoring sheet. See Appendices A and B. The Birth Suite is staffed by registered nurses (RN) and specially trained medical assistants (MA). All patients in labor are attended by an RN for labor support. In addition, certified nurse-midwives (CNM) are in attendance during active phase labor. Pharmacological methods of pain relief available include analgesia and local anesthesia. All deliveries during the study period were conducted by CNMs. Orientation of Personnel The researchers attended several staff meetings of the six staff RNs at the Birth suite to instruct them in the data collection methods. The consent form was reviewed and the procedures for enrolling subjects in the study defined. 23 Instruction in administration of the VAS during labor was provided, and postpartum data requirements reviewed. Data collection instruments and supplies were provided to the staff with appropriate explanation for their use and security. The researchers personally supervised the initial five study participants to assure correct application of all study procedures. During the study period data was retrieved two times a week by one of the researchers, and ongoing progress reports regarding the numbers of study subjects and completeness of data collection were given to the Birth suite staff. Sample Data were collected during the calendar period between September 29, 1992 and December 31, 1992. All women who were admitted to the Birth Suite during that time were asked to participate in the study. The RN assigned to a woman's care obtained written consent to participate during the woman's initial evaluation for admission, after providing her with an explanation of the study. See Appendices C and D. It should be noted that in a review of the existing literature on the VAS, including the validation study done by Giuffre (1983), data concerning the differences between repeated measurements of individual patient scores were not found. Consultation with a statistician revealed that because of the unavailability of this critical data, a power analysis to determine optimal sample size could not be conducted. Therefore, it was decided to use a convenience sample to be determined over a finite study period. Instruments 24 The visual analogue scale is widely used by researchers for general pain evaluation. Maureen Guiffre (1983) established its initial validity for use with women during labor. This study used a 10 cm vertical line printed on a 4 inch by 6 inch card. The bottom end of the line was labeled "no pain," and the top end was labeled "pain as bad as it can be." See Appendix E. The score is derived by placing a key over the card the patient has marked. The key has a 0 over the "no pain" end. From the 0 end the line is divided into 20 half-centimeter intervals. Scores possible are from o to 20. The most extreme top half centimeter and the top extreme border are given the same score of 20. A similar scale to evaluate ease of labor was used. The end descriptors on this scale were livery easy" and "harder than anything I've done." See Appendix F. The scale was scored in the same manner as the VAS, with a range of 0-20. Copies of the data collection sheet and postpartum questionnaire are found in Appendix G and H. Water temperatures in the tubs were measured using regulation pool thermometers. Fetal heart tones (FHT) were evaluated by means of electronic fetal monitoring (EFM) on admission, and subsequently during labor only as ordered by 25 the CNM. Intermittent monitoring during labor according to ACOG guidelines (via portable Doppler) is routine procedure at the Birth suite (ACOG, 1989). This made it possible to monitor FHTs whether the subject was in or out of the tub. See Appendix I. Definitions of Operational Terms Visual analogue scale (VAS) refers to an instrument used to measure pain (Scott and Huskisson, 1976). This instrument consists of a 10 cm vertical line with the bottom end labeled "no pain" and the top end labeled "pain as bad as it can be." Pain perception refers to the statement by Margo McCaffery that states: Pain is whatever the experiencing person says it is, and exists whenever he says it does. What the patient 'says' about his pain experience is not limited to his verbal and llocal re..~ponses; it encompasses all of his behavioral responses to his pain experfence. (McCaffery, 1972,p.8) Active phase labor refers to cervical dilatation of four centimeters or greater (up to 10 cm), as assessed by a vaginal exam performed by the registered nurse or the certified nurse-midwife. Latent phase labor refers to the amount of time it takes to achieve 4 cm cervical dilatation, recorded from the subjective maternal report of onset of labor (as measured by regularly occurring uterine contractions). First stage labor refers to the amount of time it takes to accomplish complete cervical dilatation (0-10 em). Warm water immersion or tub bath refers to the total immersion of the pregnant woman's abdomen in a warm tub of water, regardless of the extent of use of the hydrotherapy jets. Nullipara refers to a woman who has not carried a pregnancy to the point of viability. Primipara refers to a woman who has had one pregnancy in which the fetus or fetuses reached the point of viability. 26 Multipara refers to a woman who has had two or more pregnancies in which the fetus or fetuses reached the point of viability. Parity refers to the number of viable infants a woman has delivered. contraction interval is the time between the onset of one uterine contraction and the onset of the next, as recorded in minutes. FHT refers to the fetal heart tones as recorded by portable Doppler or on the electronic fetal monitor. Pain scale score refers to the mark that the mother makes on the visual analogue scale, as measured in .5 cm increments from numbers 1 to 20, which is then recorded by the R.N. Water temperature refers to the water temperature of the whirlpool tub while in use, as recorded with a Fahrenheit thermometer. 27 Entry refers to the time the mother entered the whirlpool tub. Exit refers to the time she left the tub, and duration is the total amount of time the mother spent in the whirlpool tub. Procedures The initial evaluation of subjects, which is routine for all Birth suite patients, included a vaginal examination to determine cervical dilatation and a 20 minute EFM strip to evaluate fetal well-being and contraction pattern. On admission to the Birth suite selected demographic information was recorded on the data collection sheet. If the woman was too advanced in labor to participate in the study, only data regarding the initial evaluation were obtained. The same data were recorded on women who refused to participate in the study. If the woman agreed to participate, she was given the consent form to read and sign. All patient data were numbered sequentially from the start of the study. To protect patient confidentiality, there were no names or patient identification numbers used. Use of the pain analogue scale commenced with active phase labor. The RNs explained and administered the visual analogue scale to all participants. The visual analogue scale was scored after a contraction and timed to the nearest quarter hour noted. Subsequent scoring at 2 hour intervals (+/-15 minutes) was done until complete dilation was achieved. 28 For tub nonusers data recorded postdelivery from patient records included: (1) positions used during labor, (2) medications (if any), (3) length of labor, (4) newborn 1 and 5 minute APGAR scores, (5) and any untoward events (such as complications, transfers, etc.). For tub users the data recorded included: (1) time of entry, exit, and duration in the tub for each tub use; (2) VAS pain scale score after contraction prior to tub entry, 15 minutes after tub entry, and after contraction prior to exit from tub; (3) FHR and water temperature while in tUb; (4) positions used in labor, (5) medications (if any), (6) length of labor, (7) newborn one and five minute APGAR scores, (8) and any untoward events (as above). The researchers obtained pertinent demographic data from the labor and delivery record. This information included prenatal classes, marital status, age, race, parity, etc. Data concerning variables that progress throughout the course of labor were taken from the labor and delivery record for recording ongoing information. This data included onset of labor, status of membranes, positions used during labor, vaginal exams, incidence of meconium, etc. All subjects answered a few brief questions within 2 hours postpartum. Tub users answered the following questions: 1. Have you ever used a warm water tub or Jacuzzi for pain or discomfort during any pregnancy or any previous labor? 2. Would you elect to use the Jacuzzi during another labor? 3. Please list any benefits (other than pain relief) that you experienced during your use of the Jacuzzi during this labor? 4. Please list any problems which you experienced in the use of the Jacuzzi during this labor. 5. Ease of labor scale. Tub non-users answered questions #1, 2, and 5. Procedure for Administration of the VAS 29 Immediately following a uterine contraction the parturient was asked to consider the most recent contraction. The RN handed the parturient a clip board on which was fastened a card containing the visual analogue scale. The RN then read the visual analogue scale end descriptors aloud, handed the women a pencil, and asked her to mark the position along the continuum that best represented the pain she experienced with her last contraction. This same procedure was used for the test score prior to tub entry, 15 minutes after tub entry, and the score recorded prior to tub exit. Ethical Considerations Approval for conduct of this study at the Birth suite was granted by the CNM who was the Associate Department Head of OB/GYN at the HMO. See Appendix J. The study had been previously approved as a minimal risk study by the 30 University of Utah Institutional Review Board for the Protection of Human Subjects. The use of whirlpool tubs for pain relief in labor is a method of pain management already in routine use at the Birth suite. The tubs there have been safely used by patients in labor for more than 7 years. Subjects' confidentiality was strictly protected in the study by use of a sequential numbering system as identification for data. at the Birth suite only. was done. Use of patient records took place No photocopying of patient records CHAPTER III RESULTS AND DISCUSSION Data Analysis Data collected at the Birth suite were brought to the university of Utah, coded, and entered into a Macintosh computer. The STAT80 software program was used to complete statistical analyses. Interval and ratio level data were summarized by using measures of central tendency, e.g., means, ranges, and standard deviations. Nominal data were summarized by frequency counts and percentages. The study was initially designed to explore and measure the differences between two groups of laboring women: tub users and tub nonusers. However, upon beginning analysis of the study data, it became apparent that these two groups were too disparate in size (44:2) to allow valid investigation of their difference~. Therefore, the statistical analyses completed were as follows: 1. Paired and independent t-tests between groups 3. wilcoxon rank-sum tests between groups disparately sized 32 Results During the study period there were 94 births to women admitted to the Birth suite. Thirty-six women were too advanced in labor upon admission to participate in the study, and 3 women refused to participate. Data were not collected on 9 women due to staff error. Forty-six women were enrolled in the study, including 4 who were later transferred out of the Birth suite for delivery secondary to complications. Two of these women were transferred in second stage labor; 1 with a face presentation, the other for arrest of descent. The remaining 2 women were transferred at 7 and 8 cm dilation, respectively, both for failure to progress in labor. Demographic statistics for the study population were computed using data from 85 subjects who were admitted to the Birth suite during the study period (46 enrolled in tub study, plus 3 who refused, plus 36 too advanced in labor to participate). The parturients ranged in age from 14 to 42 years, with a mean of 26 years. The educational level of the 85 women ranged from 5 to 20 years of schooling, with a mean of 12 years. Twenty percent had less than a high school education, 34% were high school graduates, 43% had completed 1 to 4 years of college, and 3% had pursued graduate study. See Table I. Table I Aqe and Education N = 85 33 Aqe Years of Education Mean 26 yrs. 12 Standard Deviation ± 5.6 ± 2.4 Ranqe 14 - 42 yrs. 5 - 20 The population in Salt Lake City, Utah, is predominantly Caucasian, and the demographics reflect this with 92% of the women being Caucasian, 3% American Indian, 4% Hispanic, and 1% Asian. (Note: These racial/ethnic classifications are as listed on the American College of Nurse-Midwives' Gravidata, a database used at the Birth Suite.) See Table II. Seventy two percent of the women were married, 14% were single, 9% lived with a partner, and 5% were either separated or divorced. See Table III. Forty-four percent of the parturients had taken prenatal education classes with the current pregnancy. Fifty-eight percent of the multiparas had also taken prenatal classes with a previous pregnancy. Only 14% of the 34 women had no prenatal education at all before this delivery. See Table IV. Progress in Labor Upon admission to the Birth suite cervical dilation of the 85 parturients ranged from 3 to 10 cm, with most subjects (75%) admitted between 4 to 6 cm dilation, and the rest admitted at >6 cm dilation. The study criteria define active labor as beginning at 4 cm cervical dilation. It is important to note that none of the 85 parturients were admitted in latent phase labor. Contraction intervals ranged between 1 to 6 minutes, with a mean interval of every 3 minutes. The length of active phase labor varied from 38 minutes to 625 minutes (10 hours, 20 minutes), with a standard deviation of 140 minutes. Lengths of active phase labor were evenly distributed within this range among the sUbjects. The mean length of active phase labor for primiparas was 264 minutes (4 hours, 24 minutes), with a standard deviation of 117 minutes. For multiparas the mean length of active phase labor was 224 minutes (3 hours, 24 minutes), with a standard deviation of 154 minutes. Table V contains a graphic interpretation of the differences found in progress of labor between primiparas and multiparas. The total length of first stage labor ranged from 87 to 1407 minutes (23 hours, 27 minutes), with an even distribution recorded among all subjects. The overall mean length of first stage labor was 508 minutes: 8 hours, 28 minutes. Caucasian American Indian Hispanic Asian Totals Table II Race/Ethnicity :N = 85 :N 78 3 3 1 85 35 Percent 92 ~ 0 3% 3% 1% 100% Married single Living with partner Divorced Separated Totals Table III Marital status II = 85 II 61 12 8 3 1 85 36 Percent 72% 14% 9% 4% 1% 100% Primiparas Multiparas Prenatal Classes Durinq Current Preqnancy Yes No Prenatal Classes Durinq Previous Preqnancy Yes No N/A Table IV parity and Prenatal Classes N = 85 N 25 60 37 48 49 11 24* * primiqravida Missinq Data 1 37 Percent 30% 70% 44% 56% 58% 13% 28% * 1% Admission Time to Delivery Primip Multip Overall N=17 N=25 N=421 Mean 289 202 237 Standard ±222 ± 136 ± 179 Deviation Range 21·1013 46~40 21-1013 Table V Lenqth of Labor and Time in Tub: Total Times in Minutes N = 46 Total Length of 1.B Stage Labor Total Length of Active Phase Labor Primip Multip Overall Primip Multip Overall N =18 N=26 N=442 N=18 N=26 N=442 640 415 508 264 224 240 ±342 ±263 ±315 ± 117 ± 154 ± 140 120·1407 87-1065 87-1407 79465 38~25 38~25 1. 4 women transferred out of Birth suite are not included. 2. 2 of the 4 women were transferred prior to complete dilatation. Total Time in Tub Primip Multip Overall N=20 N=24 N=442 53 54 53 ±46 ±30 ±37 15·220 30-145 15-220 w (X) The total length of first stage labor was computed using a subjective estimate by each woman of the time when she was first aware of regularly occurring contractions as a beginning time, and an endpoint of the time of full dilatation as assessed by vaginal examination. positions in Labor 39 Parturients were encouraged by the care providers to stay active and mobile during labor. positions used in labor by the 46 women included: ambulatory (74%), sitting up (81%), hands and knees (61%), squatting (17%), reclining in bed (84%), and other positions not specified on the data collection sheets (48%). A number of the above positions were used by each woman. Seven women (15%) used all 6 different positions during active labor, and 14 women (30%) used 5 out of the 6 listed positional options. The remainder (76%) used between one and four positions during their labor. Use of Whirlpool Tub The following data refer to the 46 women enrolled in the tub study. Twenty primiparas and 26 multiparas were included. Participants were free to use the whirlpool tub at will during the course of their labors, under the supervision of the Birth suite staff. An overwhelming 97% of the women chose to be.in the whirlpool tub at some time during the active phase of their labor. Total time in the tub ranged from 15 minutes to 220 minutes. The mean time in 40 the tub was 53 minutes, with a standard deviation of 37 minutes, and no significant difference recorded between primiparas and multiparas. This mean value was computed to be 20% of the mean length of active phase labor for primiparas and 24% of the mean length of active phase labor for multiparas. See Table V. water temperature was selected by the subject according to her comfort, then measured and recorded. See Table VI. The range measured from 96-102 degrees Fahrenheit. Most women (85%) preferred the water temperature between 98-100 degrees Fahrenheit. These data are in agreement with other studies citing this range as the most therapeutic for hydrotherapy. Mean Standard Deviation Range Table VI Tub water Temperature in degrees Fahrenheit 99° ± 1.4 96° - 102° 41 Pain Scores Pain scores on the visual analogue scale (VAS), scored o to 20, ranged from 3 to 20 for all 46 women before entry into the whirlpool tUb. The mean VAS score before tub entry was 14 for both primiparas and multiparas, with a standard deviation of 4.6 for primiparas, and 4.1 for multiparas. This is the same value as the mean overall rating on the VAS for pain during labor, again with no difference recorded between primiparas and multiparas, and a reported range of 3 to 20. There were no significant differences in pain scores recorded 15 minutes after tub entry between the two parity groups, with a mean for primiparas of 12, for multiparas of 12.5, and overall, 12.2. A wilcoxon rank-sum test obtained on the VAS scores prior to tub entry and 15 minutes after tub entry indicated a statisticially significant decrease in pain (n = .02). Active phase labor is a period of time when decreasing amounts of pain as time progresses would be most unlikely. Giuffre's (1983) work shows a strong correlation between increasing scores on the VAS and progress of labor. Therefore, it is reasonable to assume that warm water immersion effected the reported decrease in the pain scores. No statistically significant difference was found between the scores 15 minutes after tub entry and those prior to tub exit, suggesting that the pain relief benefits of the whirlpool tub are evident within the first 15 minutes of use. The VAS score range recorded at 15 minutes after 42 tub entry was 3 to 19, with a standard deviation 5.5 for primiparas and 4.3 for multiparas. Pain scores prior to tub exit ranged from 3 to 20, with the mean for primiparas at 11.45, for multiparas at 13.7, and overall, 12.6. See Table VII. It is important to note the discrepancy in sample sizes for each of these measurement times. Often labor was progressing so rapidly it was not possible to obtain the pain measurement prior to tub exit. T-tests indicated a nonsignificant difference in pain scores between women who attended childbirth education classes during the current pregnancy and those who did not. There were too few cases to compare pain scores with childbirth education classes during a previous pregnancy. T-test comparison of pain prior to tub entry with marital status indicated a significantly higher pain score for single women (R =.05) These findings corroborate the work of Giuffre (1983) and others who document that labor is perceived as being more painful by single women than by married women. Medication Use No medications were used during active labor by 32 out of 46 women (70%). Fourteen subjects used narcotics, primarily IV Fentanyl, for pain relief. Two subjects received antiemetics, 2 received tranquilizers, and 1 was Table VII Pain Scale Scores compared with Tub Use N = 44* Prior to Tub 15 Min After P Prior to Tub Entry Tub Entry Value Exit N = 44 N = 381 N = 231 Primip Multip primip Multip primip Multip N = 20 N = 24 N = 18 N = 20 N = 11 N = 12 Mean 14 13.9 12 12 .02 2 11.4 13.7 Standard ± 4.6 ± 4.1 ± 5.5 ± 4.3 ± 6.1 ± 6.0 Deviation Ranqe 4 - 19 3 -20 3 -19 5 - 19 3 - 20 3 - 20 * Women who used tUb. 1. Missing data. 2. wilcoxon rank-sum test/ paired t-test. ~ w given an enema to aid progress in labor. No sedatives or medicinal herbs were used in this sample of women. 44 No statistically significant differences were found in any of the VAS pain scores between the women who used narcotics and those who did not. See Table VIII. These measurements included pain prior to tub entry, 15 minutes after entry into the tub, and prior to tub exit. It is interesting to note that the pain scores in the laboring women who used narcotic medications were found to be higher at all the times measured than in those who did not use medication. These findings may be partially explained by the theory of endorphin production in labor. If the receptor sites for endorphins within the body are "occupied" by the presence of narcotics, the effectiveness of these endogenous opiates is hampered. It can also be hypothesized that women with lower pain thresholds requested narcotics. Logically, these women would score higher on the VAS. Fetal Heart Tones Fetal heart tone (FHT) baselines remained within the range of normal (120-170) throughout the study. Prior to tub entry the range was 120-170, with a mean of 137, and a standard deviation of 10. FHTs 15 minutes after tub entry ranged from 112-160, with a mean of 139, and a standard deviation of 12. If immersion in the warm water of the tubs had caused maternal hyperthermia, fetal tachycardia should have been recorded. Conversely, if immersion had caused Prior to Tub Entry N = 44* 15 Min After Tub Entry N = 38* Prior to Tub Exit N = 23* * Missing data. Table VIII Visual Analoque Pain Scores compared with Narcotic Use N = 46 Narcotics Used No N = 14 Mean standard Mean Deviation 15 ±3.7 13 13 ±5.2 12 14 ±5.3 11 ~-test nonsignificant 45 Narcotics N = 32 Standard Deviation ±4.5 ±4.7 ±6.7 46 significant maternal vasodilatation, fetal bradycardia would have been expected. These results suggest maternal capability to safely adapt both thermoregulatory and hemodynamic functions while laboring in a warm water bath, with no adverse fetal effects. status of Amniotic Membranes Whereas 26% of the parturients experienced spontaneous rupture of the membranes (SROM), 74% had membranes artificially ruptured (AROM). Table IX reports the data collected on time from rupture of the membranes (ROM) to delivery. without corresponding data on cervical dilation at the time of ROM no comments can be made as to the effectiveness of AROM as a technique to speed progress of labor. However, the data illustrate that AROM occurred closer to the time of delivery than SROM. A four-class system was used to report the color and character of the amniotic fluid: 1) clear; 2) light/yellow meconium; 3) moderate/green meconium; 4) dark/thick particulate meconium. Thirty-six subjects had clear fluid, 10 had light to moderate green meconium. No cases of dark, thick, particulate meconium were encountered. APGAR Scores Infant outcomes were exceptionally good, with all APGAR scores at 1 minute between 7 and 9, and between 8 and 10 at 5 minutes. Importantly, there were no APGAR scores below 8 at 5 minutes. Table IX Lenqth of Time in Minutes from Rupture of Membranes to Delivery N = 42 * SROM AROM N = 10 N = 32 Mean 418 113 Standard Deviation ± 278 ± 99 Ranqe 63 - 910 3 - 445 * 4 women transferred prior to delivery are not included Postpartum Questionnaire 47 Qut of the 46 women in the tub study, 40 completed the postpartum questionnaire. There are missing postpartum data for 6 women, 4 of whom delivered outside the Birth suite and were unavailable for postpartum follow-up. Qnly 15 of the 42 tub study women who delivered in the Birth suite were asked by the care providers to complete the ease of labor scale (scored 0-20). This may be due to the fact that the scale had been printed on the back of the questionnaire and was overlooked. Scores on these data were not compared with the other study variables. However, it is interesting to note that the 15 ease of labor scores obtained ranged throughout a continuum of 6 to 20, with a mean of 15. These values are not far different from the overall range of 48 scores on the VAS for pain in labor, with a range from 3 to 20, and a mean of 14. This suggests a correlation between a woman's perception of pain in labor and her overall assessment of its difficulty. Only 8 of the 40 postpartum respondents had previously used a whirlpool tub for pain relief in labor. Most of the women were quite pleased with their labor experiences using the tubs, and an overwhelming majority of them (95%) said they would use the tub again in subsequent labors. Two women said they would not use the tub again. Although 18 women listed some problems with their use of the whirlpool tub, twice as many listed other benefits, in addition to pain relief, of using the tub during labor. Most of the problems enumerated had to do with the tubs' jets: in the wrong places; hard to operate/adjust; too strong and painful, especially during contractions; irritating/distracting due to the noise and bubbles. Others ranged from the one woman who felt the tub made her contractions "space out," to another whose labor went "too quickly" in the tub, making it difficult for her to "stay focused." Inability to get comfortable in the tub, lack of space to move around and/or change positions, and, most especially, difficulty getting out of the tub were also cited as problems with tub use. A greatly increased ability to relax in labor was cited by 65% of the women as an additional benefit of tub use. A few were able to relax so completely that they could sleep 49 between contractions. Warmth, soothing, calm, and a feeling of comfort, especially relief of back pain, were also common themes the women listed. Some liked the "change of pace" getting in the tub provided as a distraction and as a way to make the "time go by faster." A few thought it made their labor actually progress faster, one of whom went from 5 to 8 cm dilatation in less than an hour in the tUb. An increased sense of control and mastery of the birth experience were expressed by these verbatim comments: "It helped me keep my cool and stay calm"; "The contractions could work without me fighting against them"; "It helped with my imagery, and I was more focused." One eloquent woman wrote, " .•. it felt great to be surrounded by water, as you are in mother's womb .... II Research Questions 1. What is the effect of whirlpool tub use during active first stage labor on women's perception of pain? As stated above, within 15 minutes of tub entry VAS pain scores dropped from a mean of 14 to 12, and did not deviate much from that point regardless of how long the woman stayed in the tub. Paired t-test and wilcoxon comparisons indicated this is a statistically significant change (R =.02). study data show that pain scores actually decreased after tub use during active labor, and that they stayed constant while women remained in the tub. See Table VII. Subjects in Giuffre's (1983) study demonstrated 50 increasing scores on the VAS as labor progressed, as one would expect. Data in this study on women who used the whirpool tub in active labor showed no such change. In fact, the opposite was found. Women who used the tub perceived less pain both initially after entry and throughout the period of time they remained in the tub, even as labor advanced. 2. What are other benefits, if any, of whirlpool tub use during active first stage labor? There appear to be many very significant benefits, other than perceived pain relief, of using warm water baths in labor. Eighty-two percent of the women who used the tub during labor listed benefits other than pain relief. Most frequently listed was the effect of increased relaxation in the water, both during and between contractions. Virtually all accepted childbirth preparation methods stress the utmost importance of relaxation in a woman's ability to tolerate and work with the intense feelings of labor. Almost unanimously (95%), the women stated they would use the tub again in a subsequent labor. Many listed the increased comfort of being in the warm water. This effect is felt soon after getting into the bath. The ability to relax and even sleep in the tub suggests the "altered mental status" of laboring women noted by Drs. Odent (1984) and Rosenthal (1991) in their hundreds of observations of labor and delivery using warm water immersion. They hypothesize that this state may be due to alpha brain waves, enhanced 51 endorphin production, decreased anxiety, and lowered catecholemine levels. It is known that endorphins do not block sensation of pain, as do analgesia and anesthesia, but function to increase the body's ability to tolerate pain (Cahill, 1989). This may account for the rather paradoxical results this study obtained of women's relatively high scores on the VAS coupled with an overwhelmingly positive evaluation of the tubs' helpfulness to them during labor, and their willingness to use this method of pain management in labor again. Women in this study were asked to recall the pain of the most recent contraction for VAS scoring purposes. Cahill's (1989)study of the role of beta-endorphins during labor also measured pain levels between contractions, with interesting results. Close examination of the "pain patterns" obtained in her study indicated that pain perceived by the women between contractions increased at a greater rate than pain during contractions. The patterns also suggested that intermittent or acute pain is more effectively modulated by beta-endorphins than continuous pain. Many of the women in the tub study commented on their increased ability to relax between contractions while in the tub. This finding may be of great importance in explaining the tub's effectiveness for increased comfort levels in labor. If warm water immersion can produce an effective degree of continuous pain relief between contractions, and if the naturally occurring endogenous opiates modulate acute 52 pain during contractions, then it is reasonable to anticipate that labor will be better tolerated while in the tUb. The little change in pain scores over time in the tub may be partially explained by the theory of habituation. According to the gate control theory, temperature sensation travels via the same large nerve fibers as pain. Upon first entering the tub sensations of warmth and the feeling of the water as it runs over the skin would stimulate the large nerve fibers, thus "closing the gate" to the pain message. After about 15 minutes, as the large nerve fibers stop registering the new input of the warmth and the feel of the water, the pain messages are allowed to come "through the gate" once again. It is also necessary to consider the usual increase in pain experienced as labor advances. Results Related to Hypotheses 1. Scores on the VAS will increase as labor progresses. The study design intended that serial data regarding cervical dilation and VAS pain scores would be obtained in addition to pain scores related to tub use. However, the frequency with which cervical examinations were carried out and VAS scales were completed varied widely among the subjects. Some women progressed so rapidly through the active phase of labor that only one or two observations were possible. In order to test this hypothesis a correlation coefficient that summarizes the strength of the relationship 53 between two variables, the change in the VAS score and the change in cervical dilation, would need to be computed using bivariate correlation analysis. The procedure would involve pairing of these two variables at a number of different points in time, deriving the correlations and summarizing them. The researchers consulted with two statisticians and concluded that it was beyond the available data of this study to address this hypothesis. 2. Multigravidas will have lower scores on the VAS than primigravidas. Study data showed no statistically significant differences between these two groups at any and all points of measurement. Thus, this hypothesis cannot be supported. 3. Women who use the whirlpool tub will have lower pain scores on the visual analogue scale than those who do not. Because of the great disparity in group size between women who used the tub in labor and those who did not (44:2) it was impossible to do a valid statistical analysis to test this hypothesis. The researchers had expected more equality between these two groups. When designing this study, after much deliberation, we decided against a randomized, controlled study using one group of women allowed in the tub and another group who were forbidden its use. Since the tubs are a major feature of the care available at the Birth Suite, it was believed to be unethical to deny their use to laboring women who had few other alternatives for pain relief in that particular setting. There was also a 54 question of both Institutional Review Board approval for the study and of staff and provider's willingness to participate if it had been so constructed. 4. Pain scores on the VAS prior to tub entry will be the same or greater than the exit score. The mean pain score prior to tub entry was 14, the mean prior to tub exit was 12. This hypothesis is supported by the study data. Paired T-test comparisons could not be done on this data due to the disparity in sample sizes for each of these measurements. See Table VII. 5. The average length of labor for women who use the whirlpool tub will be less than the Friedman "norms". The mean length of first stage labor for primiparas was 10 hours, 23 minutes; for multiparas it was 6 hours, 54 minutes. Friedman data lists the mean for first stage labor to be 13 hours for primiparas; and 7 hours, 45 minutes for multiparas. The study data support this hypothesis. Friedman norms, data from the National Birth center Study, and whirlpool tub study data are compared in Table XI. 6. Marital status will affect pain scores. The mean VAS score was 13 for married women, and 16 for single women. Due to the disparate size of these two groups (61:16) the Wilcoxon rank-sum test was used, which yielded a R-value of .05. This denotes significant statistical difference between these two groups of women. The study data support this hypothesis. 7. Childbirth education status will affect pain scores. No statistically significant difference in mean VAS scores was reported between women who took childbirth education classes and those who did not (14:14), thus the study data do not support this hypothesis. 55 8. FHTs 15 minutes after tub entry will be higher than those prior to tub entry. No statistically significant difference was found between the means of these two variables (139:137), thus study data do not support this hypothesis. Discussion A review of the demographic data indicates several patterns. The study population was primarily Caucasian, married, at least high school educated, and in the prime of their childbearing years. They were all clients of a large HMO or a faculty nurse-midwifery practice, with prenatal and obstetrical care provided by well-qualified certified nurse­midwives. The combination of these factors may have strongly influenced the study results in the direction of the good outcomes reported. A convenience sample of all women admitted to the Birth suite during the study period was chosen by the researchers when developing the study design. It is important to note that a selection bias exists in this population of obstetrically low-risk women who both self-selected to deliver in the Birth suite, and self-selected to use the 56 whirlpool tub during labor. Women who come to the Birth suite do so prepared to labor and deliver in a non­institutional setting, and most of them prefer as little "medical" intervention during labor/delivery as possible. The ready availability of the whirlpool tubs is a strong incentive for these clients, many of whom anticipate a non­medicated birth experience. Although not many of the subjects had previous experience using the tubs during labor, it could be said that this sample of women were predisposed to their use and believed they would be effective as a tool to manage pain in labor. A previous study conducted in Salt Lake city profiled the differences between women who chose to deliver with/without epidural anesthesia. It found that women who chose not to have an epidural had higher levels of self-determination and internal locus of control, as measured by scales of the Utah Test for the Childbearing Year (Poore & Foster, 1985). The present study sample was open to nurse-midwifery management of the natural process of labor and delivery, a belief which may make a difference in their willingness to use the tub for pain management in labor. Because of the special nature of the sample population, it is not possible to generalize the study's findings beyond similar populations. Further research is necessary in a number of different clinical settings, using a more widely varied population. 57 The length of active phase labor provides an interesting commentary on nurse-midwifery management of labor in the Birth suite. It is important to note that no women were admitted in latent phase labor. This is accepted practice at the Birth suite, following the recommendations of Rosen: The average cervical dilatation for a patient to be ready to enter the labor and delivery room is near 4 cm. Too early patient admissions should be avoided. Early labor may be better tolerated at home and require less medication. (Rosen, 1990, p.24) The curves shown in Figure I represent progress in active phase labor only. An additional benefit of tub use by laboring women at the Birth suite appears to be an increase in the progress of first stage labor. See Tables X and XI. The study data for progress in first stage labor can be compared with the widely accepted Friedman graphs of progress in normal labor for both primiparas and multiparas. It should be noted that Friedman's studies and later studies of normal labor progress were all conducted in a hospital environment. It is apparent that the tub study subjects fall below the expected "normal" curves, with a mean for primiparas at 11 hours and for multiparas at 7 hours. Means for active phase labor are lower, as well, with 4 hours, 24 minutes recorded for primiparas in the tub study, and 3 hours, 42 minutes for multiparas. 58 Progress of Labor 1 hr 2 hr 3 hr 4 hr hr 6 hr 10 em - 9 em - 8 em - 7 em - 6 em - 5 em - 4 em - 3 em - 2 em - 1 em - 0 VEl VE2 VE3 VE4 VE5 VE6 N = 46 N = 46 N = 45 N = 31 N = 21 N = 10 primiparas (N = 20) Multiparas (N = 26) -------- Figure I Table X Lenqth of Time in Minutes from Initial Tub Entry to complete Dilation N = 42* primip Multip N = 18 N = 24 Mean 182 122 Standard Deviation ± 134 ± 85 Ranqe 25 - 621 20 - 315 . . . * 4 women transferred pr10r to de11very not 1ncluded At Pithviers, where he installed pools of warm water to help facilitate what he calls "physiologic" labor, Dr. 59 Odent observed that labor allowed to proceed without medical intervention in an atmosphere of privacy, support, and safety averaged about 4 hours (Personal communication, Oct. 1992). He theorizes this is the result of a physiologic hormonal balance achieved during labor. He states: privacy, intimacy, calm, freedom to labor in any position, and the helpful presence of midwives are crucial to a spontaneous first-stage labor. The harsh lighting, sudden noises, cold machines, and masked intruders typical of modern hospital environments, along with the absence of midwives, the denial or ignorance of their importance, and the confinement of women in labor to restricted positions -- all inhibit labor. (Odent, 1984, p.45) The National Birth Center study (NBCS) published in 1992 summarized data on 11,814 women who delivered in birth 60 centers. Their data compare more closely than the Friedman curves with the data recorded in this study. The NBCS listed the mean length of first stage labor for nulliparas as 11.8 hours, and for multiparas a range of 7-6 hours, which decreased with increasing parity. The mean length of first stage labor recorded in the tub study is slightly lower for primiparas, and falls exactly within the range of the NBCS for multiparas. Only 22% of the total NBCS sample took tub baths, in striking contrast to this study's 97% tub use rate. Consequently, it may be hypothesized that use of the tubs in the Birth suite had an effect of shortening the length of first stage labor, especially in primiparas. See Table XI. Table XI comparison of Mean Length in Hours of First stage Labor in Three Studies Friedman NBCS * Whirlpool norms Study primipara 13 11.8 10.6 Multipara 7.8 6 to 7 6.9 (~ with t parity) * National Birth Center Study data Tub 61 The initial purpose of this study was to explore the effects of whirlpool tub use on a laboring woman's perception of pain. However, in interpreting these results other issues must be considered. If pain in labor is not "relieved" by tub baths in a linear and reciprocal fashion, as it is with analgesic/anesthetic drugs (e.g., more analgesic leads to less pain), then how does using the tub influence the comfort level of a woman in labor? Does immersion work by influencing endorphin or catecholemine production, by altering neural transmissions, by affecting psychological/emotional status, or, most probably, by a combination of all of these factors? More importantly, is pain or pain relief really the main issue in caring for the laboring woman? Women in this study recorded high scores on the VAS. Yet most of them preferred using the tubs to medications, and would do the same again in a subsequent labor. This suggests a degree of satisfaction with their experience of birth, an important variable not addressed in this study. Humenick questions the prevailing norm among health care providers that the critical element involved in a "good birth experience" is the reduction of pain. Instead she proposes a model of mastery, in which the woman's perception of her experience is the key to satisfaction (Humenick, 1981). Several studies examine enjoyment and satisfaction in childbirth. One study with 249 subjects found women experience enjoyment primarily at birth (Norr, 1977). High levels of pain may interfere with enjoyment, but enjoyment and pain can certainly coexist. Norr's (1977) study found that women with low levels of pain do not necessarily have higher levels of enjoyment. In Doering and Entwisle's 62 (1980) study of the overall perception 120 women had of their birth experience, 14% said they were "ecstatic" at the moment of birth. The amount of enjoyment/pleasure/satisfaction a woman experiences during birth seems to be related to her ability to remain in control of and/or influence what happens to her. This relationship is supported by several studies (Davenport-Slack & Boylan, 1974; Willmuth, 1975). In the Birth suite women have many options for labor and delivery, including remaining upright and active, assuming any position that suits them for labor and birth, and using a warm bath. Such an approach gives the woman control over her birth process that may translate into an element of control over pain. This sense of control may be an important reason for the low narcotic utilization rate recorded by subjects in the study, compared to those who used a warm bath during labor. When viewed as a whole, it may be concluded that satisfaction with the birth experience may not be closely related to the efficacy of pain relief. This raises an important issue: Perhaps a major goal of health care providers for women in labor should be to enhance the parturients' sense of control or feelings of mastery and accomplishment. 63 Another issue to be considered is the traditional primary goal of childbirth preparation (prenatal) classes, the prevention or reduction of pain. In the early years of childbirth education the promise was "painless childbirth." The major proponents of prepared childbirth - Dick-Read, Velvovsky, and Lamaze (all males) - agreed on one thing: physiologic childbirth should not hurt. For most women the reality of childbirth does not live up to this premise. consequently, in many classes pain reduction is the central goal of preparation for childbirth. Class participants are taught to anticipate pain and to use prescribed relaxation and breathing techniques to control/cope with it. Using the McGill Pain Questionnaire to measure the quality and intensity of labor pain in a hospital setting, Melzack et ale (1981) found that conventional childbirth education provided very modest benefit, and that 81% of those women who had received it requested epidural anesthesia. In an extensive review of the literature on pain during labor, Roberts (1983) concludes that the reasons why pain in labor is more distressing for some women than others cannot be explained, because there is no direct relationship between aversive stimuli and the perception of pain. Furthermore, she finds that the distress of labor may be exacerbated by feelings of helplessness and lack of control. Relaxation and breathing may not relieve pain as much as they relieve the distress that accompanies pain. Roberts 64 (1983) reports that a number of studies have shown that the perception of intensity of pain is not the same perception as that of the unpleasantness of the pain. It is the suffering of pain that women want to avoid, and it is this aspect of suffering that childbirth education can most affect. This distinction is poorly understood by expectant parents, health providers, and researchers alike. It is appreciated by the postpartum women whose comments are quoted in this study. In essence, they say, "Yes, I knew the pain was there, but I was able to master it." Perhaps the focus of childbirth education should move away from specific techniques to reduce pain toward maintaining harmony with the physiologic process of labor and birth. Classes that provide instruction in a variety of active coping strategies, including the use of warm water immersion, might be more effective. Technique might better be deemphasized, and replaced with attempts to give women realistic expectations about pain in labor which is neither harmful nor dangerous, but normally associated with the birth experience. The model of mastery as the key to childbirth satisfaction may be more closely related to influencing the suffering aspect of pain. Hence, adopting mastery as the central goal of childbirth education may be more helpful in preparation for birth. The final questions raised by this study ask: Is there a place in modern obstetrics for the use of warm water immersion? What is it about the use of warm water that is 65 attractive and soothing to women in labor? Pregnant women understand the value of a warm bath. It is familiar, maternal, and a part of women's culture. They know the emotional and physical benefits of the bath, and therefore anticipate relief from its use. When taken on tours of the Birth Suite, almost without exception, pregnant women smile when they first glimpse the oversized, jetted tubs. The same smiles are not seen on their faces when they are shown the hospital delivery room. By contrast, when physicians tour the Birth suite and first view the tubs, puzzlement is seen in their faces. This difference in reactions parallels the current divergence in the attitudes of many physicians and pregnant women on how birth should be. Pregnant women rarely ask why one would use a bath in labor, physicians usually do. In the realm of prenatal care and birth we have witnessed the development of a consumer-driven market. This has given rise to a number of childbirth alternatives, including warm water immersion, nurse-midwifery care, and freestanding birth centers. Moving birth out of the hospital and into a freestanding birth center has a profound effect on most women, their families, and birth attendants. The birth environment is perceived as less threatening, the care is less ritualized. There is more touch than technology. In this environment more control is restored to laboring women and their families. with this recovery of freedom comes the pleasure of being able to labor and give birth in a more natural, physiologically normal way. 66 CHAPTER IV SUMMARY AND RECOMMENDATIONS summary Analysis of the data from this study provides support for the use of warm water immersion during labor. No adverse effects were found. It was shown to be a safe and positive intervention, one which facilitated rather than interfered with the normal process of labor. Data from the study show that the use of warm water in whirlpool or standard tubs produced rapid results to provide pain relief and to increase the laboring woman's sense of comfort. These effects encouraged relaxation, usually aiding her ability to focus on the process, and facilitating the progress of labor. Study data suggest that independent variables identified by previous researcher~ as key factors in the perception of pain are highly correlated with other variables. These extremely complicated intercorrelations pose weighty problems for investigators in search of the precise effects on the outcome measurement of pain attributable to each independent variable. In fact, such knowledge may be unattainable, because these variable do not occur independently in reality. Furthermore, such a pursuit may not actually be necessary to establish the safety and efficacy of interventions that will assuage pain. Implications Implications for nursing research and practice are listed as follows: 1. The study supports the practice of warm water immersion in tubs or pools as safe and beneficial for pain relief in laboring women. 2. The study provides data for comparison and further research regarding position changes, tub/shower use, and heat/cold applications as methods of pain management in labor. As research-based information becomes available on the effectiveness of nonpharmacologic pain management techniques, further research needs to be performed on how these can best be taught to childbearing women and their companions. 68 3. The study provides data for comparison and further research regarding progress of labor both inside and outside the hospital setting, and regarding the use of warm water immersion during active first stage labor. 4. The study adds to the growing body of data confirming the safety of care in birth centers. 5. The study addresses the need for methodologically sound studies to examine the childbirth experience of women who do and do not attend prenatal classes. The information gathered about birth might focus on variables such as 69 enjoyment, happiness, mastery, and satisfaction with the birth experience, as well as on factors such as pain, which have been more widely researched. 6. More studies need to be conducted on populations who are not predominantly white, middle-class women, e.g., adolescents, the indigent, and high-risk women. Recommendations The researchers recommend: 1. The continued use of warm water immersion as a pain management technique for labor, to be used at the parturient's discretion under appropriate supervision of her health care providers. Due to habituation, repeated entries into the tub at different times in labor may be more beneficial than continuous use. 2. A randomized, controlled study using two groups of women, water immersion and those not using water immersion, to examine the effects of tub use on both pain perception and progress of labor. 3. A prospective, randomized, controlled study investigating medications vs tub use in labor, to be done in a hospital setting where a more equitable and comprehensive scope of pain management techniques is available for use by the study sUbjects. 4. A study to compare progress of labor in out-of-hospital versus hospital settings. 70 5. A study to replicate Giuffre's results of increasing pain scale scores as labor progresses to help determine the usual amount pain increases as labor progresses. 6. More specific research into the causes of pain in childbirth and its prevention, as well as the short-term and long-term effects of pain during the birth experience on both mother and baby. A clearer understanding of the difference between intensity of pain and the unpleasantness of pain (suffering) is needed. Proposed research questions include: A. What is the relative effect of the factors that influence the childbirth experience? B. What are the predictors of pain in childbirth? c. What are the short-term and long-term effects of childbirth pain on both the woman and her baby? 7. Replication of this study using a larger sample size, and a wider demographic variety within the subject population. S. A study of the use of warm water pools instead of bathtubs for use in labor and birth. Most of the problems encountered with tub use might be remedied if pools were used instead of tubs. APPENDIX A HMO RISK SCORING SHEET 72 Standards (7 Procedures SubjeCT: POLICY: !\evision No. Procedure No. r.---~--~~----__ ~,~~~----~--J Supersedes Pt91=!'dure'" Dore bowed I ,.) I- t'J, ; . lasr issue dore Page 1 1 ItISK CRITERIA A birth 'center is not a hospital, and for this reason the following risk index will be utilized by the FHP OB/GYN Department. 1. Women who score 0-3 may be cared for at the FHP Birth Center with delivery anticipated at the birth center. Will be considered low risk. 2. Women who score 4 will be: a) Co-managed by the CNM and OB/GYN physician when appropriate. 'b) Referred to the OB/GYN physician for ,management·. Wome;'l scori.ngwithin. this category will be told . that delivery will occur in the FHP designated hospital unless the risk factors resolve. . 3. Women who score 5 or greater will be referred to the OB/GYN High Risk Clinic for obstetrical management. Women scoring withi~ this ,category will be told that delivery will occur in the FHP designated hospital. PHTStc;.L ElCNi lISt IHOEX me I ____ -------------------------1 IIIIX I 'ATI~T ,ROFILl I J ______ I __ ---------------------------~------------------------1 I z IACii: " 17 DIl AGE ,. 39 I I 3 ICRUC ASUS! em ADO lCTtY!: B£lfAVIO% I I Z ISERGi: DRIHKI!lCi (5 DRI~S SESSIOH) 1 I 1 I$OCI.Al DRlHJ::lRCi (2 DR(HXS DAT) I I' ISWXINCi ,. 1PAC; OAT (2) ,. 2 PACX' OAT (1) 1 I 1 IEDUc:.\TIOH " 9T1f SAOE J I 1 1000ClJDED LIVING CDHOrTlOHS 1 I 1 ILC'J SOCIa ECC!lOMIC STATUS (IE ADe, W!.FARE) I I 1 IOVElM:IGlfT se \o1:IGHT ClWtT III BOTTCH CF PI-Gi: I I 1 IUNDElUIEIGHT RIGifT JAHO SIDE I I 1 ISMALL STATUR;E (" 5') I I. IOTKEl.· (Si'EClFT), I I------l----------------------------~--------------:----------1 I I 'Rea.'!T PR!GlWICl' . 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AarTE pmCJfEPK""TIS X1) I , IMETABOUC • r "1CII I SID tAlETES MELLITUS • IJlSUl.IH I "11 I 1 I D1AlEr"cS MELLITUS· JIQH IHMIlf J 5'011 I. 2 J CTHB D.QCCUNE PROSLet$ (SCI:IRe-·OHLT· If SIal'S) I 5'1· I 2 J DES IXPCSUlE I 5'2" f INEUROPSYCHIATRIC I 5'3" I 1 I EMCTICHAL OK PSYCHIATRIC PRCSlEH$ f 5'''· I 1 r seIZURE DISCRDEIl . r 5'5" I IINFECTIOUS DIS-cASE I 5"" I· I I. &PArtTIS . J 5'f" 1 . IOTHER (SPECIFY' ASSIG2I lIS5) I . 5'a" 1··-·--[_ .. ·---------------------------··------------·-----------1 5'9· f I ,AMILY KISTDlY I 5'10" I---~-·I-------.. -----------------------·------------··----------I 5'1'· I 1 IDIAlElcS (PAmITS OR. SIBS) . I 6'0- J • 1 f INHERITABLE DE:FECT '. I I IcrrJfS . (SP!Ct" , ASSIIiI lIsr) I 1---1------:----. . ..... _. ..... - J I I . PHYSICAL EXAM (ASSt'GII IUD: 0-5) J :--I-----~ .. _-_ .. ···~----·--·····---I I- . laTHER Cs;:etIJlTl J 1---J----.. - .. - .. ..;..-----:o-----..;:.------( J , PlLvtHEl'lY . J ,·-----I-------~-------... ------------------· ····· .... f -f~r-:~. PELVIS f .__ I f TorAL IrSTClT AND J I PHYSICAL EXAM SCDlE , f WIGHT (lbs .. ) 1CC 103 tC9 111 116 121 125 131 133 1~1 '~9 87 89 92 95 104 1ea 112 1" 119 123 126 131 DES lIE) WJG"dT c:.\JJ 3 LIS 1~ nlHESia • 3 3 LIS MC 12-36 lIa • 18 1 LI WI: 36Tl1 WI: .' i'EiH. " 118 121 US 156 161 1~ 171 175 tao 25' lbs. APPENDIX B BIRTH SUITE EXCLUSION CRITERIA SubjeCT: Purpose: Policy: Utah P.egion Nursing Policies & Procedures Re"islon No. Procedur£' No. XJpeorcedes Pro Dor£' Issv£'d RevISIon Dore Pege of EXCLUSION CRITERIA To provide safe and appropriate care for all maternal clients seeking to deliver at the Birth suite/Center and identifying those risk factors that may interfere with that process. Birth suite/Center maternal. clients shall be limited to women initially determined to be at low maternity risk and evaluated regularly throughout pregnancy to ensure they remain at low risk for a poor pregnancy outcome. The Birth Suite/Center shail use the established OB/GYN Clinic Risk Assessment tool to assess the individual risk for each maternal client at term. In order to receive care as a Birth Suite/center client, maternal clients shall exhibit no evidence of the following: 1. Severe anemia or blood dyscrasia 2. Insulin dependent diabetes mellitus 3. Symptomatic cardiovascular disease, including active thrombophlebitis 4. Compromised renal function 5. Substance abuse 6. Pregnancy-induced hypertension to include moderate to sever hypertension, preeclampsia and toxemia 7. Known or suspected active herpes genital is 8. Viral infections during pregnancy know to adversely affect fetal well-being 9. Previous caesarean section, major uterine wall surgery or obstetrical complications likely to recur 10. Multiple gestation 11. Pre-term labor « 37 weeks), or post­term gestation (= to or > 43 weeks) 12. Prolonged rupture of membranes 13. IUGR or macrosomia 14. Suspected serious congenital anomaly 15. Petal presentation other than vertex 1 76 Subjeo: Urah P.egion Nursing Policies {:, Procedures ReviSIon No Procedure No. Supercedes Pro. Dore b.sued Revision Dore Page 16. Oligohydramnios, polyhydramnios or chorioamnionitis 17. Abruptio placenta or placenta previa 18. Fetal distress which will be likely to adversely affect the infant in labor or at birth, including moderate to heavy meconium stained amniotic fluid 19. Need for anesthesia or analgesia other than those used in a setting where anesthesia and analgesia are limited in accordance with the facility's written protocols 20. Desire for transfer from Birth Suite/Center care. 21. Any condition identified intrapartum or postpartum which will be likely to adversely affect the health of the maternal client or infant and will require management in a general acute hospital. PROCEDURE KEY POINTS/RATIONALE 1. Upon arrival or notification of imminent arrival of a candidate for Birth Suite/Center care, the staff shall obtain and review the prenatal record. 2 2. Accurate, correct information is necessary for appropriate care planning. Copies of prenatal records and FFS clients shall be maintained at the Birth Suite/Center, and be the responsibility of those facilities to send to ~ Birth Suite/Center. 77 1 I ! of Utah I'egion Nursing Policies 6 Procedures Subject: RevISIon No. Procedure No. 14fO.15 2. 3. After assessinq the information available in the prenatal records and evaluatinq the client, the staff shall report to the HCP, who shall' then make the decision about Birth Suite/Center admission or discharqe to other facility. In situations yhere birth is immipent and in the judqement of the HCP the client will be better served to remain in the Birth Suite/Center than to risk birth durinq transfer, birth will be conducted in the Birth Suite/Center. 2. 3. Svpercedes Pro. Dale Issued ReVISIon Oale Page of Accurate, leqible and timely information is essential for appropriate care planninq. Birth in a controlled environment, with available emerqency back-up is usually safer than durinq transfer to another facility. If emerqency transfer is necessary, it should be ordered by the HCP throuqh the most expeditious channel. (see appropriate transfer policy) Approved bY:. ~ &fte&b ~ '0 - Qi\n'\ Reviewed Reviewed Reviewed Reviewed Reviewed Oriqinated 1986 ("Memo") 3 FHP Birth suite Director/ OB/GYN Assoc ate Department Hea 78 APPENDIX C INFORMED CONSENT Pain and Jacuzzi Use During Active First stage Labor co-investigators: Marianne Desmarais B.S. R.N. and Kathleen Bell B.S. R.N. BACKGROUND: 80 The purpose of this research study is to measure the level of pain experienced by women during active first stage labor using a visual written scale called a pain visual analogue scale. STUDY PROCEDURE: Once every two hours you will be asked to mark a position along a vertical line in relation to how much pain you experienced during a just completed contraction. The scale is reproduced below: Pain as Bad as it can be No Pain In addition, if you choose to use the Jacuzzi tub you will mark the pain scale after the contraction just before you enter the tub, 15 minutes later, and again after the contraction just before you exit the tUb. You will do this each time you use the tub. It does not matter in this study that some women will choose to use the tub and other women will not want to use the tub during their labor. You will also be asked to answer 3 to 5 brief questions within two hours after you give birth. The Registered Nurse who will be . caring for you in labor will give you the written pain scale to mark during labor and the questions after delivery. ALTERNATIVE PROCEDURES: You may choose at any time during this study to use or not use medications as authorized by your health care provider or other methods of pain relief that are routinely available in the birth suite. RISKS: There are no risks except the possible discomfort of taking a few seconds to place a mark on the card after a contraction and to answer several questions after childbirth. In the media recently it has been reported about the risks of hot tub use during the first trimester of pregnancy. Our jacuzzi's are kept at a temperature of 98 to 100', considerably lower than hot tub temperatures, and are used exclusively during the third trimester of pregnancy. The jacuzzi's used in this manner are not harmful to a fully formed, term fetus or to the mother. BENEFITS: There are no direct benefits for participation in this research. The information gained may help future women in labor. NEW SIGNIFICANT INFORMATION TO THE SUBJECT: New information that develops during the course of the research which may relate to your willingness to continue participation will be given to you. CLINICAL RESEARCH PRODUCT DEVELOPMENT: One of the major reasons for this 'study is to be able to conduct clinical research into areas that may produce significant benefits in treating patients and in furthering' scientific knowledge through the development of products that can be safely manufactured and commercially distributed to those persons who would be aided by their use. The professionals involved in this research will not derive any financial reward from this study. CONFIDENTIALITY: The written information about each woman in the study will have no identifying number or name that would associate you with the information. Weare just numbering the information sequenti.ally as women come into the study. The Registered Nurse will fill in some information on the data sheet from your written records, such as age, length of labor, etc., which will not identify you in any way or be disclosed to other persons. Your record will not be photocopied. ' COMPENSATION: No compensation of any kind will be provided by FHP, Inc. or the investigator(s) for your participation in or for any injury or complications you may have as a result of your participation in this study. However, you will receive all appropriate 'medical care from FHP, Inc. PERSON TO CONTACT: If you have any questions regardin9 the research or related matters, you may contact Marianne Desmarais, 364-7882 (home) or 488-7001 (digital beeper). INSTITUTIONAL REVIEW BOARP: If you have questions regarding your rights as a research subject, or if problems arise which you do not feel you can discuss wi th the investigator, please contact the Institutional Review Board Office at (801) 581~3655. 81 82 VOLUNTARY PARTICIPATION: Participation in this study is purely voluntary. You are free to withdraw your consent and to discontinue participation in the study at any time without prejudice to the care you are entitled to. ADDITIONAL INFORMATION FOR FHP SUBSCRIBERS: Your participation in this study will not change the health care that would be provided to you if you had not been involved in this study. Your contract with FHP will not be changed as a result of participation in this study. Medical services will be offered at the usual charge, even if you develop a complication from participation in this study. Further information concerning policies in this regard of information about the conduct of this study, or the rights of. research subjects,· or your relationship with FHP may be obtained from Dr. Richard Frame at 561-2231. CONSENT: I agree to participate in the study and I have received a copy of the consent document. I have had an opportunity to ask questions and they have been answered to my satisfaction. Patient signature Date "Witness Date APPENDIX D FOLLOW-UP CONSENT Date: ______________________ _ I.D. No. ______________________ _ We thank you for your participation in this study. We hope the data gained will be useful for the ease and comfort of future women in their labors. If you would like to receive a copy of our findings please check the box below and we will mail you our completed report in the spring of 1993. Marianne Desmarais, RN, BSN, SNM Kathleen Bell, RN, BSN, SNM c=J Yes, please send study results. 84 APPENDIX E VISUAL ANALOGUE SCALE - PAIN Pain.as bad - ..... -as it can be - .... -No Pain 86 APPENDIX F VISUAL ANALOGUE SCALE - EASE OF LABOR Ease of labor Harder than anything I've done Very easy 88 APPENDIX G DATA COLLECTION SHEET 90 JACUZZI AND PAIN IN LABOR STUDY Subject Id ____ -... ADMISSION INFORMATION: (Fill out this section ror all admissions) Date, ______ Time (24 hI clock), ______ Note: Give patient the consent form to read and answer any questions while you do the admission strip Disposition: _Too advanced in labor to panicipate_Refused to participate_Will participate_Consent Signed DEMOGRAPHIC and LABOR INFORMATION: (Complete this section for all admissions) Age_ Yrs of Education_Parity (4 digit system) Full Tenn __ Premature __ Abonions_Living Children_ Prenatal Classes: This Pregnancy Yes __ No__ Any Previous Pregnancy Yes__ No __ Race/Ethnicity: __ White __ Black __ American Indian __ Hispanic __ Asian __ Other Marital Sraws: __ Married __ Living with Partner in Committed Relationship __ Separated __ Divorced __ Widowed __ Single Labor: Admission Dilatation __ Contraction Interval (from EFM if available) __ FHT Baseline (to nearest centimeter) .' , ' STUDY PARTICIPANT DATA: (Complete this section for women consenting to participate) Rupture of Membranes: Time (24 hI clock) __ _ SROM __ AROM __ Fluid Type:_Cleaf_Light, yellow-green. thin, watery _Mod. green, no paniculate_Dark green,thick,panic. Vaginal Exams During First Stage Labor: Time Dilatation,"-___ _ Time __ Dilatation~____ TIme __ Dilatation'-_____ _ Time _ Dilatation_ ____ Time_ _ Dilatation_____ Time_ _ Dilatation~ ______ Active Phase Labor Positions: (Check all that apply) _Ambulatory _Sitting up in bed or chair _Hands and Knees _Squatting _Lying down/reclining in bed ' _Bathwb/Jacuzzi/Shower _Other Time Completely Dilated (24 hI clock) __ _ Active Phase Labor Medications: (Check all that apply: _None _ Analgesics (Narcotic) _ Anesthesia (paracervicaI) _ Antiefnetics· H Vistaril or Phenergan given for _Tranquilizers· nausea only. check antiemetics. if _ Sedatives given for relaxation only, check tranquilizer. if for both. check both _ Medicinal Herbs _Other Length of Total FJJ'St Stage Labor: HOUlS __ Minutes __ Length of Active Phase Labor: HOUI'S __ Minutes __ (4 em to completely dilated) Date of Delivery___ Time of Delivery (24 hr clock) __ _ Apgar Score: __ 1 minute __ 5 minutes __ 10 minutes (if below 7 at 5 minutes) Untoward Events of Labor or Delivery: __ None OR Comment: _____________ _ (use reveISe side if necessary) APPENDIX H POSTPARTUM QUESTIONNAIRE JACUZZI , PAIN IN LllBOR STUDY IF YOO USED 'lliE 'lUB IJJRIN:; I.AB:R PI.EASE ANSWER AIL (JJESTIONS m::J:.ClW. IF YOO DID ~ USE '!HE 'lUB, PIEASE ANSWER CNI.N 0JE,STIa5 1 & 2. Post:.partum Questions 1) Have you ever used a warm. water tub or jacuzzi for pain or discomfort during any pregnancy or previous labor ? Y N 2) Would you elect to use the jacuzzi during another labor? Y 3) Please list any problems which you experienced in the use of the jacuzzi during this labor. N 4) Please list any benefits (other than pain relief) that you experienced during your use of the jacuzzi in this labor. 92 APPENDIX I TUB WATER TEMPERATURE AND FHT Date: ______________________ _ Time: ----------------------- Situation q 2hrs before tub entry 15 min after tub entry Prior to tub exit IoD. No. ____________ _ tub water temperature ----- 94 APPENDIX J APPROVAL LETTER FROM ASST. DEPT. HEAD, OB/GYN ADMINISTMTION 1801; 055·;:::;:;'; FAA CC01: 501·90;:::' MARKETING (a01; J55·0.,io ~6011 J55·?68C ;}5 wm Or..OA[)WAY ~T l..Ar.E CITY. UlAn tl410 i REDWOOD CENTER 1525 'WE~T 2tOO SOUTH SALT LAKE ellY. 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