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    • ARTICLE IN PRESS Midwifery (2009) 25, 286–294 www.elsevier.com/locate/midw A randomised controlled trial evaluating the effect of immersion bath on labour pain Flora Maria Barbosa da Silva, MsC, RN (Nurse Midwife)a,Ã, Sonia Maria Junqueira Vasconcellos de Oliveira, PhD, RN (Assistant Professor)b, Moacyr Roberto Cuce Nobre, MD, PhD (Assistant Professor)c a Sapopemba Birth Center, Rua Borges Lagoa no. 512 apto. 93-A, Vila Clementino, Sao Paulo, ˜ CEP 04038-000, Brazil b Department of Maternal-Child and Psychiatric Nursing, School of Nursing, University of Sao Paulo, Brazil, ˜ Avenida Dr. Eneas de Carvalho Aguiar, 419 CEP 05403-000, Sao Paulo, Brazil ˜ c Clinical Epidemiology Unit, Heart Institute (InCor) University of Sao Paulo, Medical School, ˜ Avenida Dr. Eneas de Carvalho Aguiar, 44 CEP 05403-904, Sao Paulo, Brazil ˜ ÃCorresponding author. E-mail addresses: flora010101@yahoo.com.br (F.M.B. da Silva), soniaju@usp.br (S.M.J.V. de Oliveira), mrcnobre@usp.br (M.R.C. Nobre). Received 10 August 2006; received in revised form 16 April 2007; accepted 24 April 2007 Abstract Objective: to evaluate the effect of an immersion bath on pain magnitude during the first stage of labour. Design: a randomised controlled trial comparing the pain scores of bathing and non-bathing nulliparous women during birth was employed. Setting: the study was conducted at the Normal Birth Center of Amparo Maternal, Sao Paulo, Brazil. ˜ Participants: 108 birthing women, with 54 women randomly assigned to each group. Interventions: when the birthing women presented at 6–7 cm of cervical dilation, they were placed in an immersion bath for 60 mins. Outcome measures: pain scores, using a behavioural pain scale and a numeric scale, were recorded at two evaluation time points: at 6–7 cm of cervical dilation and 1 h after the first pain score evaluation. Findings: at the first evaluation, on the behavioural scale, the means were 2.1 for both groups (p ¼ 0.914; 95% confidence intervals (CI) 1.9–2.3 for the control group and 2.0–2.2 for the experimental group). On the numeric scale, the means were 8.7 and 8.5 for the control and experimental groups, respectively (p ¼ 0.235; 95% CI 8.2–9.2 for the control group and 8.1–8.9 for the experimental group). At the second evaluation, the pain score means for both scales were statistically higher in the control group than in the experimental group. On the behavioural scale, the scores were 2.4 vs. 1.9, respectively, for the control and experimental groups (po0.001; 95% CI 2.2–2.6 for the control group and 1.7–2.1 for the experimental group). On the numeric scale, the scores were 9.3 vs. 8.5, respectively, for the control and experimental groups (po0.05; 95% CI 8.9–9.7 for the control group and 8.1–8.9 for the experimental group). Conclusions: mean labour pain scores in the control group were significantly higher than those in the experimental group. The present findings suggest that use of an immersion bath is a suitable alternative form of pain relief for women during labour. & 2007 Elsevier Ltd. All rights reserved. Keywords Immersion bath; Hydrotherapy; Pain; Labour; Randomised controlled trial 0266-6138/$ - see front matter & 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.midw.2007.04.006
    • ARTICLE IN PRESS A randomised controlled trial evaluating the effect of immersion bath on labour pain 287 Introduction Methods The use of immersion baths during labour has Participants become increasingly common among birth centres and hospitals worldwide. In Brazil, an approach The study was carried out from October 2002 which emphasises fewer interventions during through June 2003 at the Normal Birth Centre of labour and birth complements a trend in prenatal Amparo Maternal, a birth centre with an average of and labour care which began in the 1970s (Diniz, 1000 births each month, located in the city of Sao ˜ 2005). Newer birth centres have introduced bath Paulo, Brazil, which uses active labour manage- tubs as an alternative form of pain relief for ment. The inclusion criteria were: full-term nulli- labouring women. parous women with a live, cephalic presenting The relaxing effects of an immersion bath have singleton fetus; absence of clinical or obstetrical been attributed to the physiological responses complications; cervical dilation less than or equal produced by hot water immersion. Water immer- to 6 cm at the time of admission; intact amniotic sion during labour can reduce anxiety and catecho- membranes or membranes broken for not more lamine release, increase endorphin release, relax than 6 h prior to admission; and two or more muscles, and promote buoyancy in the water which uterine contractions every 10 mins (active labour). in turn decreases pressure on limbs and joints and allows freedom of movement (Cluett et al., 2007). Moreover, water immersion decreases blood pres- Sample size considerations sure via vasodilatation and blood flow redistribu- The number of births assisted by nurse–midwives at tion. This technique is considered safe; immersion the Normal Birth Center between June 1st and bath has not been associated with longer labours, August 7th 2001 was used as a reference to increases in surgical intervention, or poor neonatal estimate the sample size. During this period, 789 outcomes. However, to the author’s knowledge, no study to date has that systematically evaluated normal deliveries by nulliparous women took place at the centre. Cochran’s formula (1963) for negative outcomes following water immersion comparing the proportion of finite populations during labour. was employed to calculate the likely sample size Several studies have attempted to establish the (n ¼ 108 women), and represents a probabilistic effects of immersion bath on the mother–baby sample of the women who would use the maternity bionomy (Schorn et al., 1993; Cammu et al., 1994; service. The power to detect the differences Eckert et al., 2001). However, it is difficult to between the two groups’ means after the immer- compare findings across studies because most studies do not indicate the stage of labour in which sion bath was calculated using Open Epi software (2006), with statistical power of 96.1% for the the intervention was used. Moreover, in some numeric scale and 79.0% for the behavioural scale. cases, both nulliparous and multiparous women were included in the sample, and this distinction is an important factor in pain evaluation during Randomisation labour. The use of oxytocin should be reported as well, because it influences pain sensation. The women were allocated to the control or Previous studies have relied on various instru- experimental groups according to a computer- ments to measure the effects of immersion bath generated randomisation list. Each list number on labour pain, including visual analogue scales was covered by a tab, which hid the assigned group (Cammu et al., 1994; Benfield et al., 2001) and the of the next subject from the researcher. This tab use of peridural analgesia (Schorn et al., 1993; was removed only after signed consent was Eriksson et al., 1997; Eckert et al., 2001; Ohlsson obtained from each woman. The women were et al., 2001). However, the use of pharmacological included in the study in a pre-sorted sequence, in analgesia is an indirect measure of pain sensation which they had an equal chance of being assigned and does not reflect the woman’s subjective to either group. evaluation of the pain magnitude. Labour and The women were invited to participate in this vaginal birth involves a great deal of pain, and study after admission to the birth centre. Sao Paulo ˜ relatively few studies have evaluated the effects of city has approximately 12 million inhabitants; the water immersion on labour pain. Therefore, the majority of the female population choose to give present study evaluated the effect of an immersion birth in public health centres. The Normal Birth bath on pain magnitude during the first clinical Center admits birthing women from all districts of stage of labour. Sao Paulo and its surroundings. As discussed below, ˜
    • ARTICLE IN PRESS 288 F.M.B. da Silva et al. the prenatal care of these women was the capacity) equipped with a Cardalls heater. Fetal responsibility of the primary health-care units, heart rate was monitored intermittently during the which makes it difficult to recruit participants bath period using a Toitus sonar Doppler. The antenatally. Prior to inclusion in the study, each immersion bath lasted 60 mins and was timed using woman was given a detailed explanation of the a Sport Timers chronometer. An Incoterms ther- purpose and the methods of the study. A signed mometer was used to measure the water tempera- consent form was obtained from all voluntary ture, and body temperature was monitored using a participants, who were assured their right to Citizens thermometer. withdraw from the study at any time. Outcome assessment Ethical approval Pain magnitude was evaluated by the behavioural The research project was approved by the Research pain scale and the numeric scale. The behavioural and Ethics Committee of the School of Nursing of pain scale (Bonnel and Boureau, 1985) is a measure the University of Sao Paulo. ˜ that continually evaluates the behaviour of birthing women, and was applied by the researcher. Intervention Scoring manifestations of pain In the control group, the birthing women did not The following five-point behavioural scale was use the bath during labour. These women received employed to track each subject’s experience of routine care from the Normal Birth Center and pain: Intensity 0—Normal respiration, no gasping, remained in a room with other women. The routine no agitation. Intensity 1—The frequency or ampli- care consisted of ambulation, amniotomy and tude of respiratory rates is modified during con- oxytocin use when cervical dilation remained tractions. All manifestations are considered unchanged for 3 h. Cardiotocography is routine manifestations of pain, whether they are inten- following admission to the birth centre. It is not tional (i.e., in relation to the psychological train- used for continuous fetal monitoring when the ing) or purely reactional. Intensity 2—In addition to birthing woman receives augmentation, because the aforementioned manifestations, signs of ten- keeping the woman confined to the bed can affect sion appear during contractions; these include labour progression. Therefore, fetal heart monitor- grasping reactions, such as the grasping of the ing was intermittent, and if any change in heart sheet, the bed or the hand of another person within rate was noticed, a cardiotocography examination reach. These reactions cease between contrac- was performed. In the experimental group, the tions. Intensity 3—The manifestations defined in immersion bath was used during the active phase of level 2 persist between contractions, indicating an labour, when the birthing women had achieved absence of relaxation. Intensity 4—Signs of relaxa- 6–7 cm of cervical dilation, and when pain sensa- tion may arise during contractions and possibly tion had become more intense. between them. These signs include abrupt uncon- In a previous study by Eriksson and colleagues trolled movements such as startle reactions. (1999), the use of immersion bath was compared in In addition to the behavioural scale described two groups of women: one group received the bath at above, a numeric scale represented by a horizontal a cervical dilation of less then 5 cm and the other at line with numerical marks from zero to 10 was used greater than 5 cm. The early bath was associated by each woman to quantify her sensation of pain. The with prolonged labour, greater incidence of augmen- numeric scale for pain was shown to each birthing tation, and more frequent peridural analgesia re- woman, and it was explained that zero denoted no quests. These findings are consistent with the present pain and 10 denoted the worst imaginable pain. The author’s clinical experience, and represent the researcher asked each woman to point with her finger rationale behind offering the immersion bath to to the value that represented the pain she was women that have achieved a cervical dilation of at experiencing at that moment during her labour. The least 6 cm. Each labouring woman adjusted the water researcher then conducted a verbal confirmation of temperature to her preference and this temperature the designated value and recorded the datum. was measured. Bath temperature did not exceed 38 1C. No chemicals were added to the water. Data collection Each woman entered the tub and remained in the water up to the nipple line. The immersion bath The researcher remained at the Normal Birth equipment consisted of an Astras bath tub (194 L Center during each participant’s entire labour,
    • ARTICLE IN PRESS A randomised controlled trial evaluating the effect of immersion bath on labour pain 289 which lasted 12 h on average. The researcher the effect of the immersion bath on the labour of worked on alternate days of the week. All of the these women. There was no migration of birthing data collection was performed by one of the women between the groups and no subjects with- authors (F.M.B.S., a woman). There was no differ- drew from the study during the follow-up period. ence in the number or characteristics of birthing women attended on alternate days. The data were collected in the following se- Birthing women, newborn babies and labour quence: interview and randomisation; first evalua- characteristics tion carried out at 6–7 cm dilation, including pain evaluation according to the numeric and beha- All of the birthing women had full-term pregnan- vioural scales; and cervical dilation verification. cies, and the majority were white, primiparous and Body temperature and labour room temperature had partners. On average, they had 8 complete were verified, as well as the water bath tempera- years of education. The ages of the women ranged ture in the experimental group. The second from 15 to 31 years. The majority of women were evaluation was performed at the end of the aged 19 years or younger (51.0%), with 48% being immersion bath period, 1 h after the initial pre- 20–30 years old. bath assessment. Pain scores and cervical dilation Clinical data from the birth centre indicated were re-assessed during the second evaluation. that, historically, approximately 25% of the women All women, regardless of allocation, received treated were p19 years of age (Birth Center one-on-one care from the researcher. The birth was clinical data service, 2001). The results of a assisted by the nurse–midwives of the Normal Birth Brazilian study with nulliparous women reported a Center, but the researcher was at the side of the mean age of 18.6 years (Costa and Riesco, 2006), birthing women. whereas European and Australian studies have reported higher mean ages, e.g. 26.9 years (Downe et al., 2004), 31 years (Carfoot et al., 2004) and 27 Data analysis years (Shorten et al., 2002). The data in Tables 1 and 2 indicate that the two The Statistical Package for Social Sciences version groups did not differ in terms of any of the assessed 8.0 was used for analyses. First, a descriptive data independent variables, including race, number of analysis was performed in order to describe the gestations, marital status, membrane rupture women, their labours and newborn baby character- status, amniotic liquid appearance, oxytocin use, istics. In the qualitative variable analysis, w2, perineal condition, maternal age in years, scholar- Pearson’s and Fisher’s exact tests were used. For ship in years, gestational age in weeks, time from quantitative variables, Student’s t-tests and Man- rupture of the amniotic membranes until child- n–Whitney U-tests were performed. p-values less birth, cervical dilation at the time of oxytocin than 0.05 were considered statistically significant. administration, length of expulsive period in To analyse the relationship between the numeric minutes, room, bath or body temperature, new- and behavioural pain scales, Goodman and Krus- born baby weight, and Apgar scores at 1 and 5 mins kal’s Gamma tests were used. This test measures (for all comparisons, p40.05). The time from the association between ordinal variables, and is rupture of the amniotic membranes to childbirth represented by g. was calculated from the rupture up to the cephalic birth. Although this time was slightly higher in the Findings control group than in the experimental group, the small difference was not statistically significant Four women in the bath group were excluded from (p ¼ 0.082). If rupture of the amniotic membranes the study due to cardiotocographic symptoms occurred at the point of fetal childbirth, the time (n ¼ 2) or thick meconial liquid (n ¼ 2). Two between membrane rupture and childbirth was women in the non-bath group were administered recorded as 0 mins. No group differences emerged antihypertensive drugs and therefore required regarding cervical dilation at the time of oxytocin continuous blood pressure monitoring. All six of administration. these women received caesarean sections before In both groups, artificial membrane rupture their cervixes had dilated to 6 cm and before the was more common than spontaneous amniotic first pain score evaluation was recorded. None of rupture. The incidence of meconial amniotic fluid these six women were given the intervention was higher in the control group (six cases) than in (water immersion bath). It was not possible to the experimental group (one case), although this evaluate the pain scores (primary outcomes) and difference was not statistically significant. The
    • ARTICLE IN PRESS 290 F.M.B. da Silva et al. Table 1 Study subject characteristics. Variables Group p-valueà Control Experimental n % n % Race White 30 55.6 30 55.6 40.999 Not white 24 44.4 24 44.4 Number of gestations Primiparous 53 98.1 52 96.3 40.999 Second gestation 1 1.9 2 3.7 Marital status In a relationship 36 66.7 32 59.3 0.425 Not in a relationship 18 33.3 22 40.7 Rupture of amniotic membranes Spontaneous membrane rupture 18 33.3 12 22.2 0.197 Amniotomy 36 66.7 42 77.8 Amniotic liquid aspect Clear 48 88.9 53 98.1 0.072 Thin meconium 2 3.7 1 1.9 Moderate meconium 4 7.4 — — Oxytocin use Yes 23 42.6 19 35.2 0.430 No 31 57.4 35 64.8 Perineal condition Intact 11 20.4 13 24.1 0.708 First degree 11 20.4 7 13.0 Second degree 5 9.3 7 13.0 Episiotomy 27 50.0 27 50.0 Total 54 100 54 100 à w2 test and Fisher’s exact test for cell number less than five. presence of meconial fluid can be an indicator of with an average of 35 1C. Cammu et al. (1994) and fetal distress and is associated with fetal death, Eckert et al. (2001) used immersion bath tempera- neonatal death and neonatal morbidity. In the tures higher than 37 1C, whereas Eriksson et al. present study, the presence of meconial fluid was (1997) reported use of temperatures higher than not associated with increased newborn baby dis- 38 1C; neither study was associated with poor tress as assessed by Apgar scores (Table 2). maternal or neonatal outcomes. The highest bath In both groups, the majority of women (57.4% of water temperature (38 1C) used in this study was the control group and 64.8% of the experimental within the range than the authors consider safe for group) did not require oxytocin during labour. a 60-min treatment period. Among the women who were given oxytocin, five Geissbuehler et al. (2002), in a prospective study were administered the medication during the with 10,775 births, observed that birthing women expulsive period (three from the control group are able to thermoregulate; the birthing women and two from the experimental group); they were controlled the water temperature and bath time, not considered to have received oxytocin during so the core body and fetal temperatures remained labour, because the study parameters only consid- within the physiological range. Therefore, it is ered the interventions during active labour. probable that rigid guidelines regarding the dura- The bath water temperature, adjusted by the tion of the bath (60 mins in this study) and water birthing woman, was between 27.0 and 38.0 1C, temperature are unnecessary and can disrupt
    • ARTICLE IN PRESS A randomised controlled trial evaluating the effect of immersion bath on labour pain 291 Table 2 Study subject and newborn characteristics. Variable Group Mean SD Median Min Max p-value Age (years) Control 21.1 4.1 20.5 15.0 32.0 0.078 Experimental 19.7 3.6 19.0 14.0 30.0 Scholarship (years) Control 8.3 2.9 9.0 1.0 11.0 0.259 Experimental 8.0 2.6 8.5 1.0 14.0 Gestational age (years) Control 39.5 1.1 40.0 37.0 41.0 0.560 Experimental 39.5 0.9 39.5 37.0 41.0 Forewater rupture duration (mins) Control 249.4 195.6 179.0 15.0 870.0 0.082 Experimental 197.8 172.2 146.0 0 860.0 Dilation when using oxytocin (cm) Control 6.9 1.7 7.0 4.0 10.0 0.504Ã Experimental 6.6 2.1 7.0 4.0 10.0 Expulsive period length (mins) Control 31.8 19.1 27.0 5.0 106.0 0.194Ã Experimental 37.5 25.9 31.5 3.0 118.0 Setting temperature (1C) Control 23.6 3.7 24.0 15.0 30.0 0.484 Experimental 24.5 3.4 24.0 18.0.0 36.0 Temperature of birthing women (1C) Control 36.5 0.5 36.5 35.1 37.2 0.741 Experimental 36.3 1.6 36.5 35.0 37.7 Water temperature (1C) Experimental 35.1 2.0 35.0 27.0 38.0 — Newborn weight (g) Control 3316.8 367.4 3302.5 2760.0 4425.0 0.129Ã Experimental 3205.5 389.0 3205.0 2585.0 4045.0 Apgar score at 1 minute Control 8.8 0.5 9.0 7.0 9.0 0.289 Experimental 8.7 0.5 9.0 7.0 9.0 Apgar score at 5 minutes Control 9.5 0.5 9.5 8.0 10.0 0.399 Experimental 9.4 0.5 9.0 9.0 10.0 Ã Student’s t-test for normal distribution, Mann–Whitney U-test for non-parametric comparisons. normal thermoregulation. The Apgar scores indi- exhibited a lower overall score than the control cated good newborn baby health, although the group (1.9 vs. 2.4). Oxytocin administration did not present study was not designed to study neonatal influence the behavioural scale scores in either outcomes. group (Table 4). Interestingly, for the self-reported numeric scale scores of the control group, there was an increase Pain scores over the two evaluations, whereas in the experi- mental group, the pain scores remained relatively An initial evaluation of the pain scores was constant over the two evaluations (Table 3). The performed as soon as each woman arrived at the experimental group reported lower numeric scale labour ward and after her randomisation and pain scores than the control group (8.5 vs. 9.3), informed consent were conducted. In this first with a statistically significant difference for the evaluation, the mean behavioural scale results were second evaluation. Similar to the results with the 1.6 for the control group and 1.7 for the experi- behavioural scale, oxytocin use did not affect the mental group (p ¼ 0.591), and the numeric scale numeric scale scores for either group (Table 4). scores were 7.1 and 6.7 (p ¼ 0.405) in the control It was noted that the maximum level of pain in and experimental groups, respectively. A trend the behavioural scale was only recorded in the towards higher pain levels is expected as labour control group (one subject). By contrast, the progresses and the contractions intensify. For the maximum level was recorded on the subjective second evaluation, there was a statistically signifi- numeric scale by women in both groups (38 cant difference between the groups (po0.001). subjects in the control group and 19 subjects in On the behavioural scale, the experimental group the experimental group). Goodman and Kruskal’s
    • ARTICLE IN PRESS 292 F.M.B. da Silva et al. Gamma test yielded an association index of scores than the control group (49 vs. 64, on a visual g ¼ 0.85 (positive association) for the control group analogue scale), verified 30 mins after the begin- and g ¼ 0.95 (positive association) for the experi- ning of the intervention (Cluett et al., 2004). mental group, verifying that there was indeed a In the present study, the pain sensations of valid association between the numeric and beha- labour, which intensify as labour progresses, ap- vioural scales. This demonstrates that, in both peared to increase more gradually in women groups, the intensities of pain recorded by the exposed to the water immersion bath. This finding birthing women and by the researcher were is similar to the results of Cammu et al. (1994), who consistent. evaluated, with a visual analogue scale, the pain sensations of birthing women who did or did not use an immersion bath during labour. Although these Discussion researchers observed similar pain scores for women regardless of immersion bath use, a signi- This study evaluated both observer-scored (beha- ficantly more gradual increase in the pain sensa- vioural scale) and self-reported (numeric scale) tions in the immersion bath group was observed pain scores for women given a water immersion (Cammu et al., 1994). bath or no bath during active labour. Both pain Mackey (2001) reported that several studies have scores differed (po0.001 and po0.05) at the found that women who used the immersion bath second assessment (Table 3). These results are required less frequent use of analgesia and anaes- consistent with those obtained in a randomised thesia during childbirth, and these findings were clinical study, which evaluated the influence of confirmed by Cluett et al. (2007). These authors immersion bath on nulliparous women with dystocia concluded that the use of an immersion bath or cervical dilation of less than 1 cm/h. The during labour reduces reported maternal pain. experimental group exhibited significantly lower However, the use of analgesia, anaesthesia or pain Table 3 Behavioural scale and numerical scale scores for the first and second evaluations. Scale Evaluation Group Mean SD Median CI 95%a p-valueb Behavioural scale First Control 2.1 0.6 2.0 1.9–2.3 0.914 Experimental 2.1 0.5 2.0 2.0–2.2 Second Control 2.4 0.7 2.5 2.2–2.6 o0.001 Experimental 1.9 0.7 2.0 1.7–2.1 Numeric scale First Control 8.7 1.7 9.0 8.2–9.2 0.235 Experimental 8.5 1.4 9.0 8.1–8.9 Second Control 9.3 1.4 10.0 8.9–9.7 o0.05 Experimental 8.5 1.6 9.0 8.1–8.9 a z-test. b Mann–Whitney test. Table 4 Behavioural scale and numeric scale scores relative to oxytocin use. Scale Group Oxytocin use n Mean SD Median Min Max p-value Behavioural scale Control Yes 7 2.6 0.8 3.0 1 3.0 0.415 No 47 2.4 0.8 2.0 1 4.0 Experimental Yes 10 1.7 0.8 2.0 0 3.0 0.46 No 44 1.9 0.6 2.0 1 3.0 Numeric scale Control Yes 7 9.6 1.1 10 7 10 0.424 No 47 9.3 1.4 10 4 10 Experimental Yes 10 8.4 1.7 9 6 10 0.927 No 44 8.5 1.5 9 4 10 Mann–Whitney test.
    • ARTICLE IN PRESS A randomised controlled trial evaluating the effect of immersion bath on labour pain 293 medication is not a reliable measure of the and reported by the women were consistent. effectiveness of the bath in the relief of labour However, it is difficult for a healthy, nulliparous pain, because it does not measure the pain directly woman to imagine what she would consider ‘the (Simkim and O’Hara, 2002). worst imaginable pain’, given that this estimate is There are some limitations to the present study. linked to previous experiences of pain. It is important to consider the reasons for inviting It would be interesting to report the puerperal women to participate in the study although they infection rates among the women in this study. were in active labour. As publicly insured women do However, such a measure was not possible because not have a choice where they will give birth, it is the research locale does not offer a follow-up not possible to obtain informed consent prior to service for postpartum women. The study was not their admittance to the birth centre. Once these designed to evaluate the effects of the immersion women arrived at the centre, the researcher bath on neonatal outcomes, although it was noted explained the purpose of the study and that she that it had no adverse effects on the immediate would remain with the woman for the remainder of health (Apgar) scores of the babies. her labour. This practice is not part of routine care Due to the nature of water immersion, it was not in maternity services in Brazil, and may have possible to blind the birthing women or caregivers contributed to the consent of the women who to the intervention. In fact, the gold standard participated in the study. design for assessing an intervention is believed to Pain intensity can be evaluated either by be the double-blind randomised trial. However, in subjective reports of pain experience, or by general, blinding is impossible when the interven- evaluation by an observer. However, as pain is a tion is a highly visible component of care (Downe complex phenomenon, it should be assessed by two et al., 2004). As Cluett et al. (2007) suggests, not or more methods, or in a qualitative study. In the all participants or caregivers will have the same present study, the association analysis revealed opinion about the immersion bath, which can in that pain measurements taken by the researcher turn positively or negatively influence outcomes Assessed for eligibility in the first stage of labour (n = 114) Enrolment Randomised Bath group Non-bath group Assigned to intervention group in the first Assigned to control group in the second stage stage of labour (n = 58) of labour (n = 56) Received allocated intervention (n = 54) Received allocated intervention (n = 54) Allocation Did not receive allocated intervention (n = 4) Did not receive allocated intervention (n = 2) Reasons: four women had caesarean section Reasons: two women had hypertension and before the intervention they had caesarean section before the intervention Analysed (n = 54) Analysis Analysed (n = 54) Excluded from analysis (n = 0) Excluded from analysis (n = 0) Figure 1 Flow diagram of trial participants: initial and final inclusion.
    • ARTICLE IN PRESS 294 F.M.B. da Silva et al. such as pain perception, analgesia use and mater- Carfoot, S., Williamson, P.R., Dickson, R., 2004. The value of a nal satisfaction. A final limitation of this study is pilot study in breast feeding research. Midwifery 20, the fact that the women given an immersion bath 188–193. Cluett, E.R., Nikodem, V.C., McCandlish, R.E., Burns, E.E., 2007. were removed from the routine labour setting, Immersion in water in pregnancy, labour and birth (Cochrane where they would have been with other labouring Review). In: The Cochrane Library, Issue 1, 2007. Update women. This may have had a relaxing influence, by Software, Oxford. providing privacy and tranquility. Cluett, E.R., Pickering, R.M., Getliffe, K., James, N.S.G.S., 2004. Randomised controlled trial of labouring in water compared with standard of augmentation for management of dystocia in first stage of labour. British Medical Journal 328, Conclusion 314–320. Cochran, W.G., 1963. Sampling techniques, 2nd edn. Wiley, New York. The present study explored the effects of water Costa, A.S.C., Riesco, M.L.G., 2006. A comparison of ‘‘hands off’’ immersion bath on labour pain. The pain index versus ‘‘hands on’’ techniques for decreasing perineal scores among women who used the immersion bath lacerations during birth. Journal of Midwifery & Women’s were significantly lower than those of non-bathing Health 51, 106–111. women. The advantages of this non-pharmacologi- -˜ Diniz, C.S.G., 2005. Humanizacao da assistencia ao parto no ˆ Brasil: os muitos sentidos de um movimento. Ciencia & saude ˆ ´ cal method may include a reduction and/or delay in coletiva 10, 627–637. the use of drugs for pain control, allowing the Downe, S., Gerrett, D., Renfrew, M.J., 2004. A prospective labouring women to play a more active role in the randomized trial on the effect of position in the passive labour process (Fig. 1). second stage of labour on birth outcome in nulliparous women using epidural analgesia. Midwifery 20, 157–168. Eckert, K., Tumbull, D., MacLennan, A., 2001. Immersion in water in the first stage of labour: a randomized controlled Acknowledgements trial. Birth 728, 84–93. Eriksson, M., Mattsson, L.-A., Ladfors, L., 1997. Early or late bath during the first stage of labour: a randomized study of This work was supported by the Research Group 200 women. Midwifery 13, 146–148. ‘‘Nurse-Midwifery and Childbirth: care models, Geissbuehler, V., Eberhard, J., Lebrecht, A., 2002. Waterbirth: agents, and practices’’ of the School of Nursing at water temperature and bathing time—mother knows best! the University of Sao Paulo. ˜ Perinatal Medicine 30, 371–378. Special thanks to the birthing women who shared Mackey, M.M., 2001. Use of water in labour and birth. Clinical Obstetrics and Gynecology 44, 733–749. with us their labour experience and the Amparo Ohlsson, G., Buchhave, P., Leandersson, U., Nordstrom, L.,¨ Maternal nursing and midwifery staff. Rydhstrom, Sjolin, I., 2001. Warm tub bathing during labour: ¨ ¨ maternal and neonatal effects. Acta Obstetricia et Gyneco- logica Scandinavica 80, 311–314. Open Epi available in: /http://www.openepi.com/Menu/ References OpenEpiMenu.htmS. Schorn, M.N., McAllister, J.L., Blanco, J.D., 1993. Water Benfield, R.D., Herman, J., Katz, V.L., Wilson, S.P., Davis, J.M., immersion and the effect on labour. Journal of Nurse 2001. Hydrotherapy in labour. Research in Nursing & Health Midwifery 38, 336–342. 24, 57–67. Shorten, A., Donsante, J., Shorten, B., 2002. Birth position, Bonnel, A.M., Boureau, F., 1985. Labour pain assessment: accoucheur, and perineal outcomes: informing women about validity of a behavioral index. Pain 22, 81–90. choices for vaginal birth. Birth 29, 18–27. Cammu, H., Clasen, K., Van Wettere, L., Derde, M., 1994. To Simkim, P.P., O’Hara, M., 2002. Nonpharmacologic relief of pain bathe or not to bathe during the first stage of labour. Acta during labour: systematic reviews of five methods. American Obstetricia et Gynecologica Scandinavica 73, 468–472. Journal of Obstetrics and Gynecology 186 (Suppl), S131–S159.