A STUDY TO ASSESS THE EFFECT OF HOT APPLICATION ...

A STUDY TO ASSESS THE EFFECT OF HOT APPLICATION

VERSUS ICE APPLICATION DURING FIRST STAGE OF

LABOUR IN REDUCTION OF LABOUR PAIN AMONG

PRIMI MOTHERS IN SELECTED HOSPITALS

AT KANYAKUMARI DISTRICT

A DISSERTATION SUBMITTED TO THE TAMIL NADU

Dr. M.G.R. MEDICAL UNIVERSITY, CHENNAI, IN

PARTIAL FULFILLMENT OF REQUIREMENT

FOR THE DEGREE OF MASTER OF

SCIENCE IN NURSING

APRIL 2011






15-09-2009 APPROVED BY THE DISSSERTATION COMMITTEE ON

:

RESEARCH GUIDE : _______________________________________________ Prof. (MRS). SANTHI APPAVU, M.Sc(N), M.Phil(N). Principal & Head of the department of Medical & surgical nursing Christian college of nursing, Neyyoor. Kanya kumari district.

CLINICAL GUIDE : _______________________________________________ Mrs. ARZTA SOPHIA, M.Sc(N). Reader in obstetrics and gynaecology, Christian college of nursing, Neyyoor. Kanya kumari district.

MEDICAL GUIDE : _______________________________________________ DR. REENA RAJESH, M.D, D.G.O. Department of obstetrics and gynaecology, C.S.I. Kanyakumari Medical Mission Hospital,

Neyyoor.

A DISSERTATION SUBMITTED TO THE TAMIL NADU

Dr. M.G.R. MEDICAL UNIVERSITY, CHENNAI, IN

PARTIAL FULFILLMENT OF REQUIREMENT

FOR THE DEGREE OF MASTER OF

SCIENCE IN NURSING

APRIL 2011






Submitted in partial fulfillment of the requirement for the degree of

Master of Science in Nursing Tamil Nadu Dr. M.G.R. Medical university,

Chennai.

------------------------- ------------------------- Internal Examiner External Examiner

APRIL 2011

CERTIFICATE

Certified that the thesis titles “A study to Assess The Effect of Hot

Application Versus Ice Application during First Stage of Labour in Reduction

of Labour Pain among Primi mothers in selected Hospitals at Kanyakumari

District.” is a bonafide work by S. Jenila, II Year M.Sc., Nursing student of

Christian College of Nursing, Neyyoor submitted in partial fulfillment of

requirements of the Master of Science in Nursing under the Tamil Nadu Dr. M.G.R.

Medical University, Chennai, APRIL2011.

Date: Signature of Principal

DECLARATION

Investigator, II Year M.Sc., Nursing student of Christian College of Nursing,

Neyyoor do hereby declare that this thesis, “A study to Assess The Effect of Hot

Application Versus Ice Application during First Stage of Labour in Reduction

of Labour Pain among Primi mothers in selected Hospitals at Kanyakumari

District.” has not been submitted by me for the award of any Degree, Diploma Title

or recognition before.

Neyyoor, Investigator

ACKNOWLEDGEMENT ‘

Words are in adequate to express my heartfelt thanks to God

almighty for enabling me to undertake this study and for his blessings

bestowed on me throughout this study.

My hearty gratitude to the correspondent Adv.S.Sunder singh Bsc,

B.L correspondent Christian College of Nursing, Neyyoor for giving me

opportunity to study in this esteemed institution.

It is my pleasure duty to express my sincere gratitude and

heartfelt thanks to Prof. Mrs. Santhi Appavu Msc[N] M,Phil, Principal

and H.O.D of Medical Surgical Nursing Christian College of Nursing,

Neyyoor, for her tremendous effort and who has helped me in the midst of

her multifarious administrative responsibilities.

My deep sense of gratitude to our class co-ordinator

Mrs.Diana,M.sc[N] vice principal, Christian College of Nursing, Neyyoor,

for her encouragements and support given during this work.

I would like to express my sincere gratitude to my clinical guide

Mrs. Arzta Sophia, Msc[N] reader in Obstetrical and Gynaecological

Nursing in Christian College of Nursing,Neyyoor, for her excellent

guidance, valuable suggestions, enduring interest, constant help and

motivation. Special thanks for her affectionate support from the initial step

till the completion of the study.

I wish to express my thanks to my medical guide Dr. Christabel

Reena M.D,D.G.O, for her concern, keen interest, valuable suggestions

and constant encouragement during the course of this study.

I express my sincere thanks to Dr. Felsit Punitha, M.B.B.S,

D.G.O, P.P.K hospital Marthandam for giving permission to conduct study

in their hospital.

I express my deep sense of gratitude and thanks to Mrs.Suguna

Msc[N], Mrs.Anitta, Msc[N], Mrs.Henitta,Msc[N], Dr.Reena, Mrs.

Irine and Mrs.Majella Livingston,Msc[N] who devoted their valuable

time in solving my doubts and validate the tool.

I wish to express my sincere thanks to all the faculties of obstetrical

and gynaecological Nursing Department for their guidance and suggestions for

the completion of the study.

I thank prof. Mr. Arumugam, B.Sc., M.A., M.P.S., P.G.D.C.A., for

his meticulous effort in statistical analysis of the study.

I express my deep sense of gratitude to all faculties in Christian

college of nursing for their constant supportI thank the librarian

Mrs.Pramila.M.S.I.S.C, M.Phil and Mr.Gnanadhasan C.O.T, D.O.T for

the help rendered to me in collecting the literature.

I would like to express my sincere thanks to Mini Net Café,

Thingal Nagar for the excellent DTP work and untiring patience in

preparing this study.

I wish to express my thanks to the subjects, who participated &

provided the valuable data in this study on labour room of P.P.K Hospital,

Marthandam.

I wish to express my gratitude to the staff members in the labour

room of P.P.K Hospital, Marthandam, who were of immense help in

collecting the data.

A special bouquet of thanks to my father Mr.R Sathianesan, my

mother Mrs.J.Rosammal and my dearest sister Mrs.S.Benila for their

wonderful support, understanding, co-operation guidance and

encouragement throughout my study.

ABSTRACT

The study was undertaken to assess the effectiveness of hot application versus

ice application during first stage of labour in reduction of labour pain among

primi mothers in selected hospitals at kanyakumari district was conducted in

partial fulfillment of the requirement for the degree of Master of Science in

Nursing, Christian College of Nursing, Neyyoor, which is affiliated to

Dr. M.G.R. University, Chennai during the year 2009-2011.

THE OBJECTIVES OF THE STUDY WERE

To assess the level of labour pain among primi mothers before and

after administering hot application.

To assess the level of labour pain among primi mothers before and

after administering ice application.

To compare the effectiveness of hot application versus ice

application in reducing labour pain.

\To associate the level of labour pain before administering hot and

ice application with selected demographic variables such as age,

education, occupation, religion, type of family and family monthly

income.

A quantitative approach quasi experimental pre test post test design was

used for this study. The conceptual framework of this study was based on

Roy’s adaptation model. The samples were selected by convenience sampling.

The samples for the study was 60 primigravid mothers in the active stage of

labour. The mothers randomly assigned for group1 and group 2. For the group

1 hot application was given with the help of hot water bag on the lower back.

For the group 2 ice application was given in the LI 4 point with the help of ice

pieces. Post test was conducted after 20 minutes.

The tool used for the data collection comprised of 2 sections

Demographic variables

Visual analog scale

The content validity and pilot study was done to find out the feasibility of the

study. Data collection was done for 6 weeks. Based on the objectives and

hypotheses, the data collected were analyzed by using both descriptive and

inferential statistics.

MAJOR FINDINGS

In the present study the majority of the age group were between 25-29

among Group 1 and 20-24 years in Group 2. The Group 1 is 46.7%.

Group 2 is 60%.

This study denotes majority of samples education level is degree. The

Group1 is 46.7% the Group 2 is 40 %.

Majority of the mothers are home makers in both groups. Group 1 is

53.3%. the Group 2 is 73.3 %.

As far the religion is concerned Christians and Hindus are equal in

Group1.[46.7%]. Christians are dominating in Group 2[63.3 %].

Majority of samples from nuclear family [53.3%] in Group1. From

joint family in Group 2.

The pain score mean difference of Group1 is 2.2. The difference is

statistically highly significant [ t= 10.159, P< 0.001}

The pain score mean difference of group 2 is 2.6. The difference is

statistically very highly significant [t= 8.843, p<0.001}.

The mean reductions of both applications were 2.2±1.2 and 2.6 ± 1.6.

The difference between the mean reduction of both groups was not

statistically significant [t= 1.095, P> 0.05]. Both applications are equal

effectiveness in reducing labour pain.

The present study show that there was no significant association

between the pre test labour pain with selected demographic variables

such as age, education, occupation, religion, type of family and family

monthly income. The calculated value is less than the table value. The

P value is P> 0.05.

RECOMMENDATION

The previous reviews and the present study indicate both hot

application and ice application is the best option to reduce labour pain without

any side effects. So this study strongly recommended to use hot application

and ice application to reduce labour pain during labour.

A comparative study may be done between the hot and ice application

with other pharmacological methods.

Similar studies may be conducted in second stage of labour.

This study may be conducted in multi paras also.

A comparative study may be conducted among primi paras and

mltiparas.

Similar study may be conducted with a larger population.

CONCLUSION

As for this research this interventional study proved that there was a

significant reduction of pain after hot and ice application during first stage of

labour. The mean reduction of labour pain among hot application group primi

mothers was 2.2 ± 1.2 and the same to the ice application was 2.6 ± 1.6. The

differences were statistically very highly significant. Thus the reduction of

pain in both groups were due to the intervention of hot application and ice

application. The above two mean difference were not statistically differed [P >

0.05] Therefore hot versus ice application was very effective form of non

pharmacological intervention to relief pain during labour without any side

effects.

13

LIST OF CONTENTS

CHAPTER CONTENTS PAGE NO.

I INTRODUCTION 1-8

Need for the study 4

Statement of the problem 6

Objectives 6

Hypotheses 7

Operational Definitions 7

Assumption 8

Limitation 8

Projected outcome 9

II REVIEW OF LITERATURE 10-16

Studies related to ice massage 10

Studies related to hot application 14

CONCEPTUAL FRAME WORK 17

III METHODOLOGY 20-28

Research Approach 20

Research design 20

Variables under study 21

Setting of the study 21

Population 21

Sample 22

…Table continues

14

CHAPTER CONTENTS PAGE NO.

Sample size 22

Sampling Technique 22

Criteria for sample selection 23

• Inclusion criteria 23

• Exclusion criteria 23

Research tools 23

Description of the tool 23

Content validity of the tool 24

Pilot Study 24

method of data collection 25

Plan for data analysis 27

Protection of Human Rights 28

IV DATA ANALYSIS AND INTERPRETATION 29--33

V DISCUSSION 44-47

VI SUMMARY, CONCLUSION, IMPLICATION

AND RECOMMENDATION

48-54

REFERENCES 55-58

APPENDICES

i-viii

Table continued

15

LIST OF TABLES

TABLE

NO TITLE

PAGE

NO.

1. Frequency and percentage distribution of the demographic

profile in experimental group 1 and 2

30

2. Effectiveness of Hot and Ice application in reducing labour pain 39

3. Comparison of effectiveness of Hot and Ice application in

reducing labour pain

41

4. Association between level of labour pain before Hot and Ice

application with selected demographic variables

42

16

LIST OF FIGURES

FIGURES NO TITLE PAGE

NO.

1. Conceptual framework based on Callista Roy’s adaptation model

19

2. Age wise distribution of the mothers among the experimental group 1 and experimental group 2

33

3. Percentage distribution of educational status of the mothers among the experimental group 1 and experimental group 2

34

4. Occupation wise percentage distribution of mothers in the experimental group 1 and experimental group 2

35

5. Religion wise percentage distribution of mothers in the experimental group 1 and experimental group 2

36

6. Percentage distribution of type of family of mothers in the experimental group 1 and experimental group 2

37

7 Distribution of samples according to family monthly income 38

8. Comparison of pre test and post test pain score of experimental group 1 and experimental group 2

40

17

LIST OF APPENDICES

APPENDICES

NO TITLE PAGE NO.

A. Copy of letter seeking permission to conduct research study

i

B. Letter seeking experts opinion for the validity of tool ii

C List of experts for validation of the tool iii

D. Evaluation criteria check list for tool validation iv

E Tool (English) v-vi

F i Master sheet on pain score of primi mothers before vii

and after hot application

ii Master sheet on pain score of primi mothers before viii

and after Ice application

18

CHAPTER 1 INTRODUCTION

“One she who give birth to a baby rings the bells in the heaven”

Child birth is one of the most memorable and rewarding events of a couple's life.

No matter how often a woman gives birth, each experience is an intimate and

unique celebration of life, but labor and delivery are not without pain and some degree of

anxiety.

Child bearing is a natural physiological events however that creative process is a

challenge that places the body at risk [Zelling.E 1996]. All mothers are experiencing

severe pain associated with child birth.

Chapman describes, ‘labour pain as stimuli of receptive neurons arising from

contraction of uterine muscles, which is referred to as the visceral, pelvic and lumbar

sacral areas”

During labour, the woman experiences some degree of stress as her system

responds to the physical changes that prepare her to give birth. Nearly every woman in

labour experiences some degree of discomfort. Perception of pain is highly unique and

differs from one individual to another though the intensity of pain stimuli is same.

The basis of childbirth preparation is the belief that pain during childbirth is a

vicious cycle. As fear and anxiety heighten, muscle tension increases, inhibiting the

effectiveness of contractions, increasing discomfort and further heightening fear and

anxiety. Non-pharmacological and pharmacological pain management strategies provide

women with specific techniques they can use to cope with the discomfort of labour,

thereby increasing their feeling of control.

19

During the first stage of labor, women usually perceive the visceral pain of diffuse

abdominal cramping and uterine contractions. In the second stage of labor, there is a

sharper and more continuous somatic pain in the perineum. Pressure or nerve entrapment

caused by the fetus's head can cause severe back or leg pain. Nulliparous women generally

experience more sensory pain during early labor, while multiparous women may

experience more intense pain during the late first stage and the second stage of labor, as a

result of rapid fetal descent.(lowe).

The nature of labor pain is a complex process. The pain experience of childbirth is

extremely individual, and it also changes throughout the labor process. Pain is considered

to have at least three dimensions: sensory, affective, and cognitive components. The

sensory component passes signals from different stimuli all over the body to the brain in

an attempt to give information about the intensity, quality, and location of pain. The

affective component is associated with pleasant or unpleasant emotions. For labor, fear

and anxiety are important emotions that can enhance pain. The cognitive component is

associated with knowledge about mood, behavior, and thought patterns. Knowledge about

all these components helps in understanding an individual’s response to pain.

Today there are wide range of interventions available to help the laboring women

manage pain during labour such as analgesics, anaesthetics, transcutaneous electrical

nerve stimulation, entonox[50% oxygen and 50% nitrous oxide].

Non pharmacological methods are classified in to two, they are psychoprophylaxis

methods and psychological methods. Psychoprophylaxis methods are Lamaze techniques

deal and read method, support during labour, a dual relaxation, breathing techniques

positioning birthing balls, heat and cold application, ice immersion, aroma therapy,

acupuncture and acupressure.(Penny simkin 2007).

20

Many women are hesitant about using narcotics or epidural pain therapy due to

concern over whether their children will be adversely affected or about the way that they

will feel during delivery.

Ice application and hot application is convenient in early stage of labour.

Intensity of labour pain and memory of pain were both significantly reduced by

hot application and ice application. Heated packs or hot water bottles are placed on the

mothers back will reduce labour pain and promote comfort. Heat increases vaso dilation

and increases the blood flow, so transmission of pain to brain is reduced and it distracts

the mothers attention.(Brenda Lane 2009)..

When the skin in the lumbar area is stimulated with heat , a cutting type of pain

will be generated, thus creating a block to the slower signals from the uterine contractions.

This knowledge is useful to practitioners assisting women in labor, because many

techniques for labor support depend on the distraction from pain caused by the stimulation

of competing nerve fibers. Methods such as massage, counter-pressure, acupuncture, and

sterile water injection also having this same mechanism.

Ice application of energy meridian point of large intestine to reduce the labour

pain during contraction. Large intestine 4 is located on the medial mid point of first

metacarpal, with in 3-4 mm of web of skin between the thumb and fore finger, though

the exact meridian, or massage point is on the inside of the thumb, the skin may be fragile

and sensitive to cold. To facilitate pain reduction, and reduce the potential for skin

damage, massage was performed by snugly placing a bag on the web between the thumb

and forefinger, filled with crushed ice. The web space is thicker, and less prone to trauma.

The technique can easily be taught to family members. several studies had shown that ice

application on this point was very helpful in reducing discomfort during labour

(Raisler,2003).

21

The purpose of this study is to compare the effectiveness of hot application and

ice application in relation to labour pain.

NEED FOR THE STUDY

Labour pains are a major damper in the joy of having a baby. The thought of the

pain that women have such as pictures of pregnant women screaming in pain, that they

have seen in hundreds of films, flash through their mind during labour and makes them

ill.

Labour pains are a fact of life that cannot be avoided. But reduced to some extent

by the use of pharmacological or non pharmacological approach.

Systematic review of studies on women's experiences and expectations of pain

relief in labor found a gap between their expectations and their actual experiences of pain

in labour.

The management of labour pain is a major goal of intra partum care. There are

two general approaches: pharmacologic and non pharmacologic. Pharmacologic

approaches are directed at elimination of the physical sensation of labor pain, whereas non

pharmacologic approaches are largely directed toward prevention of suffering. Suffering

may be defined in terms of any of the following psychological elements: a perceived threat

to the body and/or psyche; helplessness and loss of control; distress; insufficient resources

for coping with the distressing situation; fear of death of the mother or baby. Although

pain and suffering often occur together, one may suffer without pain or have pain without

suffering.(Michel.C.Klein2008)

The non pharmacologic approach to pain management includes a wide variety of

techniques that address not only the physical sensations of pain, but also attempt to

22

prevent suffering by enhancing the psychoemotional and spiritual components of care.

Non pharmacologic techniques for management of labor pain can be combined or used

sequentially to increase their total effect.

Several pharmacological options are available for the management of labour pain .

Analgesia is usually used for blocking pain impulse to the brain by increasing fibre

transmission or by stimulating local release of endorphin. There are some complications

and side effects by the use of Analgesics and Anaesthesia.

Through the use of non invasive, non pharmacological pain relief measure like

acupressure, back massage, hot water application, ice massage will reduce labour pain

with out side effects.

Hot water and ice pieces are easily available in all ward settings and the application

of hot water bottle on the mothers back and ice application between thumb and index

finger is very easy.

This motivated the investigator to find out the effectiveness of applying non

pharmacological, non invasive measures to relief pain during labour. This study aims at

comparing the effect of hot application and ice application in reducing labour pain.

STATEMENT OF THE PROBLEM

A study to assess the effect of hot application versus ice application during first stage

of labour in reduction of labour pain among primi mothers in selected hospitals at

kanyakumari district.

OBJECTIVES

The objectives of the study were

23

To assess the level of labour pain among primi mothers before and after

administering hot application.


administering ice application.

To compare the effectiveness of hot application versus ice application in reducing

labour pain.

To associate the level of labour pain with selected demographic variables such as

age, education, occupation, religion, family type and family monthly income.

HYPOTHESES

There will be significant reduction in labour pain after hot application at 0.001

level of significance.

There will be significant reduction of labour pain after ice application at 0.001

level of significance.

There will be significant difference between level of labour pain among two

Groups after the intervention.

OPERATIONAL DEFINITIONS

Assess

To estimate the level of pain before and after the application of Hot and Ice

application.

Effect

The degree of labour pain reduction after the application of Hot water bag and

crushed ice pieces.

Hot application

24

Superficial application of 46º c of water in a rubber bag covered with a cloth on the

mothers back for 20 minutes during contractions.

Ice application

Superficial application of crushed ice pieces covered by a small towel placed

between the thumb and index finger for 20 minutes during contractions.

First stage of labour

It is the duration between the onset of pain to 4-8cm cervical dilatation, during

active phase of labour, after rupturing of membrane, and contractions every 3-5 minutes

lasting 30-45 seconds.

Labour pain

Discomfort felt by the mother during first stage of labour as measured by visual

analog scale.

Primi mothers

A women who is going to give birth to her first offspring.

ASSUMPTIONS

1. The level of labour pain tolerance will differ from individual to

individual.

2. Mother will experience less labour pain after hot and ice application

LIMITATIONS

The study is limited to

1. Primi mothers

2. Mothers who are willing to participate

3. Study is limited only for 6 weeks

25

PROJECTED OUTCOME

The effect of hot application and ice application will reduce labour pain, and it

help nurses to identify the most effective method for relieving labour pain

CHAPTER II

REVIEW OF LITERATURE

26

Review of literature is the key step in the research process. Review of

literature refers to an extensive, exhaustive and systematic examination of

publications relevant to the research project

Review of literature is a broad comprehensive in depth systematic and

critical review of scholarly publications, unpublished print materials, audio visual

aids and personal materials. This chapter present review related to effectiveness

of ice and hot application for labour pain

Literature relevant for this study has been organized in the following sequence.

1. Studies related to effectiveness of Ice massage in reduction of labour pain.

2. Studies related to effectiveness of Hot application in reduction of labour pain.

Studies related to effectiveness of Ice massage in reduction of labour pain

Naghshin et al (2008) conducted a study to determine the effect of

hoku point ice massage on labour pain. participants of this clinical trial study

were 60 pregnant women having the inclusion criteria. Participants were

randomly divided in to two groups of thirty, each (control group =only touch of

Hoku point, Case group= ice massage of Hoku point). This procedure was done for

thirty minutes. Labor pain of subjects was measured by visual analog scale before

and after the procedure. Results showed that reduction of labour pain by ice

massage of Hoku point was statistically significant.P<0.001)this method therefore

applicable in labour rooms.

27

Lee et al (2007) conducted a double blind RCT of ice massage on

acupressure compared to touch on Sp6 acupressure point for labour pain. 75

women in labour were matched for five characteristics of labour and randomly

assigned. There were significant differences between the groups in subjective

labour pain scores immediately after the intervention (p=0.012), 30 mins after

(p=0.021) and 60mins after (p=0.012). Anxiety was also significantly lower in

the ice massage on acupressure group compared to the control (p=0.03)..

Chung et al (2003) randomly assigned 127 parturient women to an

intervention group who received ice massage at acupressure point Li4 and BL67,

placebo group who received light skin stroking at these points and a control

group (conversation only). All groups showed a significant decrease in labour

pain during the active first phase of labour (p=0.041) and ice massage on

acupressure point was significantly more effective than control (p=0.017)

Waters and Raisler (2003) done a study to investigate the use of ice massage

of the acupressure energy meridian point large intestine 4 (LI4) to reduce labor

pain during contractions. LI4 is located on the medial midpoint of the first

metacarpal, within 3 to 4 mm of the web of skin between the thumb and forefinger.

A one-group, pretest, posttest design was chosen, which used 100-mm Visual

Analog Scales (VAS) and the McGill Pain Questionnaire (MPQ) ranked

numerically and verbally to measure pain levels; the pretest served as the control.

Study participants were Hispanic and white Medicaid recipients who received

prenatal care at a women's clinic staffed by certified nurse-midwives and

obstetricians. Participants noted a pain reduction mean on the VAS of 28.22 mm

on the left hand and 11.93 mm on the right hand. The post delivery ranked MPQ

28

dropped from number 3 (distressing) to number 2 (discomforting). The study

results suggest that ice massage is a safe, noninvasive, nonpharmacological method

of reducing labor pain.

Brady et al (2001) administered ice massage to a convenience sample of 66

volunteers complaining of lower back pain. This was a single group pretest posttest

design. Pain and anxiety significantly decreased after treatment (p<0.001), which

did not change when demographic variables were controlled for. The absence of a

control group and use of a volunteer sample who paid for treatment limits the

validity of these results.

Darin indels [2000] done a study on 49 pregnant women between the ages of

16 and 38 years in early labor received ice massage on a specific acupuncture point

on the hand (called Large Intestine 4 or LI-4 in Traditional Chinese Medicine) at

the beginning of a contraction, continuing until the contraction stopped. This was

repeated on the other hand when the next contraction started. The massage was

carried out on each hand for 20 minutes or until after the fourth contraction,

whichever came first. Crushed ice in a small hand towel was used to administer the

massage, results shows significant reduction of labour pain after the treatment

Melzack et al (1992) did a pilot study using ice massage for reducing labour

pain. 20 womens were recruited to participate in this study on their admission to

the labour and delivery unit at Humana Hospital Dade City. Ice massage of the

energy meridian LI4 was performed during each contraction and was carried out

over a 30 minute period. Data from the visual analog scale showed a mean

reduction in pain of 25.15. The reduction of pain was statistically significant.

29

Melzack et al conducted a comparative study to find out the

effectiveness of ice massage and TENS for the relief of back pain. Patients

suffering chronic low back pain were treated with both ice massage and TENS.

The order of treatments was balanced, and changes in the intensity of pain were

measured with the McGill Pain Questionnaire (MPQ). The results show that both

methods are equally effective: based on the Pain Rating Index of the MPQ, 67-

69% of patients obtained pain relief greater than 33% with each method. The

results indicate that ice massage is an effective therapeutic tool, and appears to be

more effective than TES for some patients.

Studies related to effectiveness of Hot application in reduction of labour pain

Brenda lane[2009] suggested Placing a heat pack directly on mother's

back significantly reduces the pain during uterine contractions

Romia[2007] suggested the effectiveness of 13 non-pharmacologic

methods used to relieve pain and reduce suffering in labor.. Adequate evidence of

benefit in reducing pain exists for continuous labor support, baths, intradermal

water blocks, and maternal movement and positioning. Acupuncture, massage,

transcutaneous electrical nerve stimulation, and hypnosis are promising, but they

require further study. The effectiveness of childbirth education, relaxation and

breathing, heat and cold, acupressure, hypnosis, aromatherapy, music, and

audioanalgesia are reduces the labour pain during active stage.

Behmanesh et al(2007) done a study to find out the effect of heat

therapy on labor pain severity and delivery outcome in parturient women. In this

study 64 nulliparous women were randomly divided in to 2 groups (heat therapy

30

and routine care group ). The control group received routine care in obstetrics ward

but the heat therapy group used warm bag for the low back since the cervix dilated

about 3-4 cm to the end of the first stage of labor and for perinea at the second

stage as well as the routine cares. The severity of pain was determined on dilatation

of 3-4, 6-7 and 9-10 cm and at the end of the second stage of labor by Mc Gill pain

questionnaire. Comparison of the two groups showed a significant decrease in the

intensity (severity) of pain in the heat therapy group in the first stage, and on

dilatation of 6-7 cm and 9-10 cm, and in the second stage of labor. Also, in the heat

therapy group duration of the first and third stages of labor decreased but that of

the secondstage of labor showed no significant difference between the two groups.

Emiley cook [2006] had done a study to find out the effectiveness of

applying hot water bottle to relieve lower back pain among mothers. It is reported

that hot water application had a positive effect and no side effects was reported.

Penny simkan et al[2003] suggested Superficial applications of heat and/or

cold, in various forms, are popular with laboring women. They are easy to use, in

expensive, require no prior practice and have minimal negative side effects when

used properly. randomized trials on the use of heat or cold during labor shows

reduction of pain and promote comfort. Heat is typically applied to the woman's

back, lower abdomen, groin and/or perineum. Possible heat sources include a

warm water bottle, heated rice-filled sock, warm compress (wash clothes soaked in

warm water and wrung out), electric heating pad, or warm blanket. Heat

31

application during active stage of labour significantly reduces labour pain and

suffering.

Topozada et al [1983] done a study to find out the effect of local

application of heat on the lower back on uterine activity was evaluated in 15 full-

term multiparous women early in the first stage of labor. Cardiotocographic

monitoring showed that heat induces a significant increase in uterine activity

without causing any abnormal fetal heart changes. The stimulated contractions

return back to base line level following removal of heat. The application of heat on

the lower back of women in early labor appears to offer a new non-

pharmacological modality for the stimulation of uterine activity.

32

CONCEPTUAL FRAMEWORK

Conceptual framework is brief explanation of a theory or those portions of a theory

to be tested in a study (Grove, 2003).

The conceptual framework of this study is based on the Callista Roy Adaptation

Model (1984). According to Roy a system is a set of units so related or connected as a

form a unity or whole and characterized by inputs, outputs, control process and feedback

processes.

Input

A stimulus is “The degree of change or stimulus most immediately confronting the

person and the one to which the person must make an adaptive response, that is, the factor

that precipitates behavior”.

In this study input refers to selected demographic and clinical variables such as

age, education, occupation, religion, type of family and family monthly income.

Control process

Roy views that perception of the person links the regulator with cognator. In this

study control process refers to perception of labour pain among primi mothers admitted in

selected hospital Kanyakumari.

Effectors

Effectors are the ways of coping that manifest regulator and cognator activity.

In these study effectors refers to providing Hot application and ice application to

primi mothers.

33

Output

Adaptive responses are “responses that promote integrity of the person in terms of

the goals of survival, growth, reproduction and mastery”. Ineffective responses are

“responses that do not contribute to adaptive goals that is survival, growth, reproduction

and mastery”.

In this study output refers to greater pain reduction among the primi mothers..

CONCLUSION

The above conceptual framework based on Callista Roy adaptation model

conclude that the intervention in both group 1 and 2 has reduced labour pain.

34

FEED BACK

SELECTED DEMOGRAPHIC VARIABLES ♦Age ♦Education ♦Occupation ♦Religion ♦Type of family ♦Family monthly income

Perception of Labour pain among primi mothers

GROUP 1 Hot application

EFFECTIVE RESPONSE Greater reduction of labour pain

GROUP 2 Ice application

EFFECTIVE RESPONSE Greater reduction of labour pain

CONTROL PROCESS

EFFECTORS OUTPUT INPUT

35

CHAPTER II

METHODOLOGY Research methodology is designed to develop or define or refine methods of

obtaining, organizing or analyzing data [Polit, 2006]. It is the systematic way to solve

research problems [Kothari, 1990].

This phase of study deals with Research design, Variables, Description of

the settings, Population sample, Description of the sampling technique, Description

of the instruments designed for the study, Pilot study, Method of data collection

and data analysis

RESEARCH APPROACH

Quantitative approach is a powerful design for testing hypothesis of causal

relationship among variables (Basavantahappa, 2005).

To accomplish the objectives of the study researcher used quantitative approach

RESEARCH DESIGN

The research design is the plan of how, when and where data are to be

collected and analyzed (Parahoo, 2006).

In this study quasi experimental pre test post test design was used

The diagrammatic representation of this design is as follows:

O1 X O2

O3 X O4

O1 - labour pain before hot application

X - Intervention hot application

O2 - labour pain after hot application.

O3 - labour pain before ice application

36

X - Intervention ice application

O4 - labour pain after ice application

VARIABLES UNDER STUDY

Variables are the inherent characteristics of research subjects (Polit, 2008).

Independent variable - Hot application and Ice application

Dependent variable - Labour pain

SETTING OF THE STUDY

Setting is the physical location and condition in which data collection takes place

in the study (Polit, 2008).

The study was conducted in labour room of P.P.K Hospital marthandam. This

hospital has well equipped labour room recording more than 100 deliveries per month.

This hospital is well known for its medical and nursing care.To have a large sample this

hospital was selected

POPULATION

Population is the aggregate of cases about which the researcher would like to make

generalization (Polit, 1999).

The target population in this study comprised of primi mothers who had

completed 37 weeks of gestation and the active stage of labour admitted in maternity

ward of P.P.K hospital, Marthandam

SAMPLE

Sample refers to the individuals who are included in data collection, who are

selected from the whole population (Somekh, 2005).

37

All primi mothers, who had admitted in the P.P.K Hospital, Marthandam with

the active phase of labour pain in the age group of 20- 35 years and met the

inclusion criteria were the samples.

SAMPLE SIZE

Sample size is the total number of study participants participating in a study (Polit,

2008).

Sixty primi mothers were taken as samples. Thirty in the Group 1 [Hot

application] and thirty in the Group 2 [Ice application].

SAMPLING TECHNIQUE

It is the process of selecting a portion of the population to represent the entire

population.

All primi mothers, who satisfied the inclusion criteria were selected using

convenience sampling technique.

CRITERIA FOR SAMPLE SELECTION

Inclusion criteria

• Primi mothers.

• Primi mothers who have completed 37 weeks of gestation.

• Primi mothers who is in the age group between 20 to 35 years.

• Primi mothers with ruptured membranes and cervical dilatation between 4-

8 cm as per vaginal examination.

Exclusion criteria

• Mothers with medical contraindications

38

• High risk mothers

• Multigravid mothers

RESEARCH TOOL

DESCRIPTION OF THE TOOL

The tool used for this study was divided in to two sections.

Section A [Demographic data of the mothers]

This dealt with the demographic data of the mothers. It included items such as

age, education, occupation, type of family, family monthly income.

Section B [Visual analogue pain assessment scale]

Visual analogue pain assessment scale to assess the intensity of pain. It consist of

10 cm base line at 1 cm interval from 0-10

Scoring procedure

No pain 0 0%

Mild pain 1-3 10-30%

Moderate pain 4-6 40-60%

Severe pain 7-10 70-100%

CONTENT VALIDITY OF THE TOOL

Validity is the degree to which the instrument measures what is intended to measure

(Polit, 2008).

The content of the tool was validated by 5 experts in the field of obstetrical and

gynaecological nursing 1 expert in the medical field of obstetrics and

gynaecology.

PILOT STUDY

39

A pilot study is a small scale version or trial run designed to test the methods to be

used in a larger, more rigorous study which is sometimes referred to as the present

study (Polit, 2008).

The pilot study was conducted in the labour room of the M.L hospital

nagercoil. The investigator obtained permission from the concerned authorities

prior to the study. The study was conducted on 6 primi mothers. Three in the

Group 1 and three in the Group 2. Group 1 received hot application on the lower

back. Group 2 received ice application in between the thumb and index fingers.

Pain level was assessed by using visual analog scale

Analysis of the data was done using descriptive and inferential statistics. The

tool and the instrument were found feasible and practicable. No further changes

were made in the tool after the pilot study. The investigator proceeded for the main

study

METHOD OF DATA COLLECTION

The data was collected within the given period of 6 weeks after obtaining a

written permission from the concerned authorities. The purpose and nature of the

study was explained and pre test was conducted before giving intervention. Level

of labour pain was assessed by using visual analogue scale. During the intervention

30 samples received hot application on the lower back with the help of hot water

bag for 20 minutes, and 30 samples received ice application in between thumb and

index finger with the help of crushed ice pieces covered by a small towel for 20

minutes. After the intervention post test was conducted and the level of pain was

assessed by using visual analogue scale.

40

DESCRIPTION OF THE PROCEDURE

Intervention 1

Hot water application was explained to the primi mothers. Applying hot water

bottle on the lower back relieve labour pain.

Steps of procedure

1. Wash hands

2. Take hot water in the jug, pour some water and empty it.

3. Fill 1/3 of the bottle with hot water

4. Place the bag in a fat surface and cork it tightly.

5. Dry the out side of the bag. put the cover and take it to the bedside

6. Apply hot water bag on the lower back for 20 minutes

7. Remove the hot water bag when the procedure is completed.

8. Ask the mother to mark her level of pain in the visual analog scale

Intervention 2{Ice application}

Ice application .was explained to the primi mothers. Applying ice pieces in the LI 4

point relieve labour pain.

Steps

1. Hand washing done and dried

2. Crushed ice pieces was prepared and it was covered in a small towel.

3. Procedure was explained.

41

4. Then the acupressure point Large Intestine 4 {web of the space in between

thumb and index finger}.was identified

5. Ice massage was for 20 minutes.

6. After the procedure the primi mothers marked their pain level I the visual

analog scale.

PLAN FOR DATA ANALYSIS

Both descriptive and inferential statistics were used to analyze the collected

data. Descriptive statistics were used to analyze the demographic varibles in terms

of frequeny and percentage.

The difference in the pain level of the mothers in the active phase of

labour during pre test and post test were analyzed using un paired’ t’ test

The difference in the pain level of the mothers in the active phase of labour

in the experimental group 1 and experimental group 2 were analyzed using

paired’ t’ test

PROTECTION OF HUMAN RIGHTS

The proposed study was conducted after the approval of the dissertation

committee of C.C.N Neyyoor. Permission was obtained from the director of P.P.K

hospital Marthandam. Oral consent was obtained from each sample subjects before

starting the data collection. Assurance was given to the study subjects regarding

the confidentiality of the data collected

42

CHAPTER - IV

ANALYSIS AND INTERPRETATION OF DATA

This chapter deals with description of the samples, analysis and interpretation of

data collected from the sample subjects to assess the effectiveness of hot application

versus ice application in reduction of labour pain among primi mothers in selected

hospitals at Kanyakumari District.

The data collected during the present study were analyzed based on the objectives

and hypothesis of the study.

43

The objectives of the study were

1. To assess the level of labour pain among primi mothers before and after

administering hot application.

2. To assess the level of labour pain among primi mothers before and after

administering ice application.

3. To compare the effectiveness of hot application versus ice application in reducing

labour pain.

4. To associate the level of labour pain before hot and ice application with selected

demographic variables.

SECTION – I

The primi para mothers were described according to their demographic

characteristic such as age, education, occupation, religion, type of family and family

monthly income.

TABLE – 1: FREQUENCY AND PERCENTAGE DISTRIBUTION OF THE

DEMOGRAPHIC PROFILE OF THE GROUP 1 AND GROUP 2.

N=60

Group 1 Group 2 S. No

Demographic variables Group f % f %

1. Age 20 – 24 13 43.3 18 60.0

25 – 29 14 46.7 10 33.3

30 – 34 3 10.0 2 6.7

2. Education High school 7 23.3 9 30.0

Higher secondary 7 23.3 9 30.0

44

Group 1 Group 2 S. No

Demographic variables Group f % f %

Diploma 2 6.7 - -

Degree 14 46.7 12 40.0

3 Occupation Labourer 2 6.7 5 16.7

Home maker 16 53.3 22 73.3

Service 5 16.7 1 3.3

Teacher 7 23.3 2 6.7

4 Religion Christian 14 46.7 19 63.3

Hindu 14 46.7 9 30.0

Muslim 2 6.6 2 6.7

5. Type of family Nuclear 16 53.3 13 43.3

Joint 14 46.7 17 56.7

6. <5000 12 40.0 15 50

Family monthly income

5000 and above

5000

18 60.0 15 50

The table 1 shows that the majority of the subjects out of 30, 14(647.7%) were

between 25-29 years, 13(43.3%) were between 20-24 and 3 out of 30(10%) were between

30-34 years in e group 1.

Similarly the age group of the subject 18 out of 30(60%) were between 20-24 years

10 out of 30(33.3%) were between 25-29 years 2 out of 30(6.7%) were between 30-34

years in group 2.

In education majority 14 out of 30(46.7%) were Degree, 23.3% were High School,

23.3% were higher secondary and 2 out of 30 were diploma in group 1.

45

The data illustrated majority 40% were Degree and 30% were High School and

30% were higher secondary in group 2.

In occupation majority 16(53.3%) mothers were home makers, 7(23.3%) were

teachers, 5(16.7%) were other services and 2 out of 30 were labourer, in group 1

In group 2 majority 73.3% were home makers, 5(16.7%) were labourer, out of 2

were teacher and only one 1(3.3%) were other services.

The Hindu, Christian and Muslim religious mothers were 14(46.7%), 14(46.7%)

and 2(6.6%) respectively, in group 1.

In religion, the data is shown that majority 19(63.3%) were Christians, 9(30.0%)

were Hindu, out of 2(6.7%) were Muslims in group 2.

The data denotes 16(53.3%) were Nuclear family and 14(46.7%) were joint family

in group 1.

The data shown 17(56.7%) were joint family and 13(43.3%) were nuclear family

in group 2.

The data portrays majority of subjects 18(60%) were have monthly income above

5000 and 12(40%) were have monthly income below 5000 in group 1.

Regarding family monthly income 15(50%) were getting salary below 5000 and

15(50%) were getting salary above 5000 in group 2.

46

FIG-2: AGE WISE DISTRIBUTION OF THE MOTHERS AMONG THE

GROUP 1 AND GROUP 2

47

0

10

20

30

40

50

60

20-24 25-29 30-34

4346.7

10

60

33.3

6.7

perc

enta

ge

FIG-3: PERCENTAGE DISTRIBUTION OF EDUCATIONAL STATUS OF THE

MOTHERS AMONG THE GROUP 1 AND GROUP 2

48

0

5

10

15

20

25

30

35

40

45

50

High school Higher secondary

Diploma Degree

23.3 23.3

6.7

46.7

30 30

0

40Pe

rcen

tage

Education

Group 1

Group 2

FIG-4: OCCUPATION WISE PERCENTAGE DISTRIBUTION OF MOTHERS

IN THE GROUP 1 AND L GROUP 2

49

6.70%

53.30%

16.70%23.30%

16.70%

73.30%

3.30%6.70%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

Labourer Home maker service Teacher

perc

enta

ge

occupation

Group 1

Group 2

FIG-5: RELIGION WISE PERCENTAGE DISTRIBUTION OF MOTHERS IN

THE GROUP 1 AND GROUP 2

50

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

Hindhu christian Muslim

46.70% 46.70%

6.60%

63.30%

30%

6.70%

percentage

Religion

Group 1

Group 2

FIG-6: PERCENTAGE DISTRIBUTION OF TYPE OF FAMILY OF MOTHERS

IN THE GROUP 1 AND GROUP 2

51

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

Nuclear Joint

53.30%

46.70%43.30%

56.70%

percentage

Type of family

Group 1

Group 2

FIG-7-: DISTRIBUTION OF SAMPLES ACCORDING TO FAMILY MONTHLY

INCOME

52

0%

10%

20%

30%

40%

50%

60%

< 5000 >5000

40%

60%

50% 50%

perc

enta

ge

family monthly income

Group 1

Group 2

SECTION – II

TABLE – 2: EFFECTIVENESS OF HOT AND ICE APPLICATION IN

REDUCING LABOUR PAIN

53

Pre test Post test Reduction Application

Mean S.D Mean S.D Mean SDMDt d.f Signifi-

cance

Hot 6.7 1.0 4.5 1.0 2.2 1.2 10.159 29 P<0.001

Ice 6.6 1.1 4 1.1 2.6 1.6 8.843 29 P<0.001

The above table 1 shows that the mean pain level before hot application was 6.7 ±

1.0 after hot application 4.5 ± 1.0. The hot application significantly reduced the labour

pain (P<0.0001). The mean labour pain before ice application was 6.6 ± 1.1 after the ice

application was 4.0 ± 1.1. Both applications had reduced the labour pain significantly.

The mean difference of both applications were 2.2 ± 1.2 and 2.6 ± 1.6.

FIG-8 COMPARISON OF PRE TEST AND POST TEST PAIN SCORE OF

GROUP 1 AND GROUP 2

54

0

1

2

3

4

5

6

7

Group 1 Group 2

6.7 6.6

4.54

Mean pain score

pre test

post test

TABLE – 3: COMPARISON OF EFFECTIVENESS OF HOT AND ICE

APPLICATION IN REDUCING LABOUR PAIN.

S.No Group M.D SDMD t d.f Significance

1. Hot 2.2 1.2

2. Ice 2.6 1.6 1.095 58 P>0.05

55

Table 3 shows that, the mean reductions of both applications were 2.2 ± 1.2 and

2.6 ± 1.6. The difference between the mean reductions of both groups was not statistically

significant (t=1.095, d.f=58, and P>0.05). Both applications had equal effectiveness.

SECTION –3

TABLE – 4: ASSOCIATION BETWEEN LEVEL OF LABOUR PAIN BEFORE

HOT AND ICE APPLICATION WITH SELECTED DEMOGRAPHIC

VARIABLES.

The labour pain before hot and ice application was associated with the

demographic profile of primi para mothers as follows.

56

Mothers of hot application Mothers of ice applicationS. No

Demographic variables χ2 d.f Significance χ2 d.f Significance

1. Age 0.76 2 P>0.05 3.333 2 P>0.05

2. Education 6.237 3 P>0.05 4.074 3 P>0.05

3. Occupation 5.724 3 P>0.05 3.750 3 P>0.05

4. Religion 0.779 2 P>0.05 1.698 2 P>0.05

5. Type of family 0.741 1 P>0.05 0.362 1 P>0.05

6. Family

monthly income 1.531 1 P>0.05 0.556 1 P>0.05

The above table shows that there was no significant association between the pain

before Hot and Ice application with their age .P > 0.05

There is .no significant association between the pain before Hot and Ice application

with their educational status. P> 0.05

There is no significant association between the pre test labour pain with the

occupation of primi mothers. P> 0.05

There is no significant association between the pre test labour pain with the

religion of primi mothers. P> 0.05

There is .no significant association between the pain before Hot and Ice application

with their type of family.. P> 0.05

There is no significant association between the pre test labour pain with the family

monthly income of primi mothers. P> 0.05

57

CHAPTER V DISCUSSION

The present study has undertaken to assess the effectiveness of hot application

versus ice application in reduction of labour pain among primi mothers in selected

hospitals at kanyakumari district. Totally 60 primimothers during active stage of labour

with labour pain were selected by convenience sampling method. Among sixty, thiry

samples were assigned to Group1 and 30 were assigned to Group 2. Pretest was conducted

by using visual analog scale. Group 1 received hot application with the help of hot water

bag on the lower back for 20 minutes, and Group 2 received ice application with the help

of crushed ice pieces in between thumb and index finger for 20 minutes. Post test was

conducted by using visual analog scale.

OBJECTIVES The objectives of the study were

58

1. To assess the level of labour pain among primimothers before and after hot

application.

2. To assess the level of labour pain among primimothers before and after ice

application.

3. To compare the effectiveness of hot application versus ice application in reducing

labour pain.

4. To associate the level of labour pain before hot and ice application with selected

demographic variables such as age, education, occupation, religion, type of family

and family monthly income.

SAMPLE CHARACTERISTICS

In the present study the majority of the age group were between 25-29 among

Group 1 and 20-24 years in Group 2.The Group 1 is 46.7%. Group 2 is 60%.

This study denotes majority of samples education level is degree. The Group1

is 46.7% the Group 2 is 40 %.

Majority of the mothers are home makers in both groups. Group 1 is 53.3%. the

Group 2 is 73.3 %.

As far the religion is concerned Christians and Hindus are equal in Group

1[46.7%]. Christians are dominating in Group 2[63.3 %].

Majority of samples from nuclear family [53.3%] in Group1 from joint family

in Group 2.

59

THE FIRST OBJECTIVE OF THE STUDY WAS TO ASSESS THE LEVEL

OF LABOUR PAIN AMONG PRIMI MOTHERS BEFORE AND AFTER

ADMINISTERING HOT APPLICATION

Based on the first objective the evaluator assessed the level of labour pain before

and after administering Hot application. The mean pain level before Hot

application was 6.7 ±1.0 and the same after Hot application was 4.5 ± 1.0. The

mean reduction after Hot application is 2.2±1.2. The Hot application significantly

reduced the labour pain [ t = 10.159, d.f = 29, P < 0.001]

THE SECOND OBJECTIVE OF THE STUDY WAS TO ASSESS THE

LEVEL OF LABOUR PAIN AMONG PRIMI MOTHERS BEFORE AND

AFTER ADMINISTERING ICE APPLICATION

Based on the first objective the evaluator assessed the level of labour pain

before and after administering Ice application. The mean pain level before Ice

application was 6.6 ± 1.1 and the same after Ice application was 4.0 ± 1.1. The

mean reduction after Ice application is 2.6 ± 1.6. The Ice application significantly

reduced the labour pain [ t = 8.843, d.f =29, P<0.001]

THE THIRD OBJECTIVE OF THE STUDY WAS TO ASSESS THE

EFFECTIVENESS OF HOT APPLICATION VERSUS ICE APPLICATION

IN REDUCING LABOUR PAIN

Based on the third objective the evaluator assessed the effectiveness of hot

application versus ice application in reduction of labour pain. The mean reduction

of both applications were 2.2 ± 1.2 and 2.6 ± 1.6. The difference between the mean

reductions of both groups was not statistically significant .[t = 1.095, d.f =58, and

P > 0.05]. Both group had equal effectiveness in reducing labour pain.

60

THE FOURTH OBJECTIVE OF THE STUDY WAS TO ASSOCIATE THE

LEVEL OF LABOUR PAIN BEFORE HOT AND ICE APPLICATION

WITH SELECTED DEMOGRAPHIC VARIABLES

There is no significant association between pre test labour pain in both group 1

and 2 with selected demographic variables such as age, education, occupation,

religion , family type and family monthly income.

HYPOTHESES

From the analysis and arguments the research hypotheses {H1] “The hot

application significantly reduced the first stage labour pain among the primi para

mothers was accepted. The H2 “ The ice application significantly reduced the first stage

labour pain among primi para mothers” was accepted. The H3 “ The effectiveness

of hot and ice application in reduction of labour pain was significantly differed was

rejected, Both applications were equal in reduction of first stage labour pain

LIMITATION

The study was conducted in limited area and the sample size was small. Therefore

the study findings cannot be generalized in large population.

CHAPTER -VI

SUMMARY, CONCLUSION, IMPLICATION AND

RECOMMENDATION

This chapter deals with the summary of the study, its findings, conclusion and

61

implication for different areas like nursing practice, nursing education, nursing

administrations, nursing research, limitations and recommendations for further nursing

research

SUMMARY OF THE STUDY

The present study is “ To assess the effectiveness of hot application versus ice

application during first stage of labour in reduction of labour pain among primi mothers

in selected hospitals at kanyakumari district

A Quantitative approach quasi experimental pre test post test design was used for

this study. The conceptual framework of this study was based on Roy’s adaptation model.

The samples were selected by conveniece sampling. The samples for the study was 60

primigravid mothers in the active stage of labour. The mothers randomly assigned for

group1 and group 2. For the group 1 hot application was given with the help of hot water

bag on the lower back. For the group 2 ice application was given in the LI 4 point with the

help of ice pieces. Post test was conducted after 20 minutes.

The tool used for the data collection comprised of 2 sections

• Demographic variables

• Visual analog scale

The content validity and pilot study was done to find out the feasibility of the study.

Data collection was done for 6 weeks. Based on the objectives and hypothesis, the data

collected was analyzed by using both descriptive and inferential statistics

THE OBJECTIVES OF THE STUDY WERE

62


administering hot application


administering ice application

To compare the effectiveness of hot application versus ice application in

reducing labour pain

To associate the level of labour pain before administering hot and ice

application with selected demographic variables such as age, education,

occupation, religion, type of family and family monthly income.

MAJOR FINDINGS

In the present study the majority of the age group were between 25-29 among

Group 1 and 20-24 years in Group 2.The Group 1 is 46.7%. Group 2 is 60%.

This study denotes majority of samples education level is degree. The Group1 is

46.7% the Group 2 is 40 %.

Majority of the mothers are home makers in both groups. Group 1 is 53.3%. the

Group 2 is 73.3 %.

As far the religion is concerned Christians and Hindus are equal in Group

1[46.7%]. Christians are dominating in Group 2[63.3 %].

Majority of samples from nuclear family [53.3%] in Group1 from joint family in

Group 2.

63

The pain score mean difference of Group1 is 2.2. The difference is statistically

highly significant [ t= 10.159, P< 0.001}

The pain score mean difference of group 2 is 2.6. The difference is statistically

very highly significant [t= 8.843, p<0.001}.

The mean reductions of both applications were 2.2±1.2 and 2.6 ± 1.6. the

difference between the mean reduction of both groups was not statistically

significant [t= 1.095, P> 0.05]. Both applications are equal effectiveness in

reducing labour pain.

The present study show that there was no significant association between the pre

test labour pain with selected demographic variables such as age, education,

occupation, religion, type of family and family monthly income. The calculated

value is less than the table value. The P value is P> 0.05.

IMPLICATIONS OF THE STUDY

The study has implications in various areas such as nursing practice, nursing

education, nursing administration and nursing research

The study suggest that hot application and ice application can be extremely

useful in helping to manage the labour pain and it can be utilized as pain relief measure

during labour

NURSING PRACTICE

Based on the findings hot and ice application can be incorporated in maternity wards

and the midwives can use hot and ice application as pain relief measure during labour

64

Hot and Ice application can be taught to the midwifes one who conduct delivery

Hot and Ice application can be administered in institutional level since it has no side

effects

It is expected to practice in the field of midwifery

NURSING EDUCATION

Nursing curriculum lays emphasis on pharmacological approach and gives very

little attention to non pharmacological measure which scope for independent practice,

So, more emphasis can be given to these aspects,

The findings of the present study would help the nursing students to give impartance in

the application of hot and ice as a nursing intervention in the management of labour

pain.

To educate the nursing students to practice hot and ice application as a pain relief

measure during labour.

It can be also included in the nursing curriculum as a non pharmacological measure to

relieve pain during labour

NURSING ADMINISTRATION

In service education can be conducted to the nursing personnel regarding non

pharmacological measure to reduce the labour pain.

In administrative level periodic conferences, symposium, seminars can be arranged to

update the knowledge, skill and practice of the nurses.

65

NURSING RESEARCH

There is in need for extensive and intensive research in this area,

The study can be done with large sample for the generalization of the findings.

The study findings will motivate to do further research in this area especially on non

pharmacological methods.

The same study can be done in different settings.

RECOMMENDATIONS

The previous reviews and the present study indicate both hot application and ice

application is the best option to reduce labour pain without any side effects. So this

study strongly recommended to use hot application and ice application to reduce labour

pain during labour

A comparative study may be done between the hot and ice application with other

pharmacological methods

Similar studies may be conducted in second stage of labour

This study may be conducted in mulit paras also

A comparative study may be conducted among primi paras and multiparas

Similar study may be conducted with a larger population

SUGGESTIONS

Additional knowledge may be imparted to the midwives regarding non

pharmacological methods of pain relief, who is attending the labouring mother

66

The knowledge of using Hot application and Ice application to be explained to the

midwives so that they can explain it to the mothers to adopt the appropriate pain relief

technique

The knowledge can be imparted for all the parturient mothers that hot application and

ice application has no side effects and it is non invasive

CONCLUSION

As for this research this interventional study proved that there was a significant

reduction of pain after hot and ice application during first stage of labour. The mean

reduction of labour pain among hot application group primi mothers was 2.2 ± 1.2 and the

same to the ice application was 2.6 ± 1.6. The differences were statistically very highly

significant. Thus the reduction of pain in both groups were due to the intervention of hot

application and ice application. The above two mean difference were not statistically

differed [P > 0.05] Therefore hot versus ice application was very effective form of non

pharmacological intervention to relief pain during labour without any side effects.

67

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• Basavanthappa. B.T. (1998). Nursing research. (1st ed).Mumbai. Jaypee

Brothers Medical Publishers. 49.

• Bennett. RV. Brown, Lk. (2001).Myles, Text book for midwives, (13th

edition). London: Churchill Livingston.192-195.

• Dutta ,DC.(1997), Text book of Gynaecology, (3rd edition). New central

book agency..393.

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JOURNALS

• Behmanesh, F.(2009) "The Effect of Heat Therapy on Labor Pain Severity

and Delivery Outcome on Parturient Women" Iranian Red Crescent Medical

Journal.,

• Bons, S.(2008) "Warm Perineal Compresses May Reduce Third- And

Fourth-Degree Lacerations, Pain During Birth and Postpartum Urinary

Incontinence." Journal of Midwifery and Women's Health, May.

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Journal of obstetrics and Gynaecology .

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• Chung, UL, Hung, LC, Kuo, SC, Huang, CL(2003). “Effects of LI4 and BL 67

acupressure on labor pain and uterine contractions in the first stage of labor.”

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• Enjezab B, Khoushbin A, Bokaei M, Naghshin N, Effect of Ice Massage

on Hoku point for Reduction of Labour Pain,Journal of Shahid Sadoughi

University Of Medical Sciences and Health Services, Winter 2008; 69-74.

• Y. Khamis S. Shaal H. Damaraw A. Romia and M. Toppozada(1983)”

Effect of Heat on uterine contraction during labour”International Journal of

Gynaecology and Obstetrics, volume 21, issue 6

• Habananda T.(2004) Non pharmacological pain relief in labour. Journal of

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186:

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of midwifery and womens health. Oct 2003. 317-321.

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ELECTRONIC VERSION

• Bolding, ”non pharmacological approach to relieve pain and

suffering”http://www.pubmed.com

• Cook.E “hot water bottle really does ease pains” http://www.daily

mail.com

• Klein C “”non pharmacological approach for labour pain”

http://www.utdol.com

• Lane “Heat and compresses benefit mothers during child

birth”http://www.options suite 101.com

• Simkin “comfort during labour” http://www.childbirthconnection.org

• Taghineijad H,Delpisheh.A, Suhrabi.Z “massage and hot application to

relieve the severity of labour pain”http://www.pubmed.com

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APPENDIX – A LETTER SEEKING PERMISSION TO CONDUCT

RESEARCH STUDY

To

The Director, PPK Hospital, Marthandam, Kanyakumari District.

Respected Madam, Sub : Requisition for getting permission to do research study to assess the

effectiveness of hot application versus Ice applicationduring first stage of labour in reduction of labour pain among primi mothers in selected hospitals at Kanyakumari district.”

This is to introduce Ms..S. Jenila II year M.Sc. Nursing student of this College. She is to conduct a research project which is to be submitted to the Tamil Nadu Dr. M.G.R. Medical University, Chennai in partial fulfillment of University requirements for the award of M.Sc. degree in Nursing. Topic: .” to assess the effectiveness of hot application versus Ice applicationduring first stage of labour in reduction of labour pain among primi mothers in selected hospitals at Kanyakumari district.”

This student is in need of your esteemed help and co-operation as she is interested in conducting her research study in your well esteemed institution. This is to request you to kindly extend necessary facilities to her work on her proposed study during the month of May and June 2010.

74/M.Sc.(N)/2

72

Thanking you

APPENDIX-B

LETTER SEEKING EXPERTS OPINION FOR VALIDITY OF TOOLS From S.Jenila Msc [N] II year, Christian college of nursing, neyyoor. To Respected madam/sir

Sub : Requisition for expert opinion on suggestion for content validity

I am doing II year Msc [N] in Christian college of nursing,

Neyyoor, under Tamilnadu Dr.M.G.R medical university Chennai. As a

partial fulfillment of the course, I have chosen a topic of my interest “ A

study to assess the effectiveness of Hot application versus Ice

application iduring first stage of labour in reduction of labour pain

among primi mothers in selected hospitals at kanyakumari district.”

I have prepared demographic data and pain assessment scale. I here

kindly request you to evaluate the tool based on the evaluation criteria.

Your opinion and suggestion will help me to modify and restructure the

tool for successful completion of my study.

Thanking you

73

Yours truly

S.Jenila

APPENDIX -C

EVALUATION CRITERIA CHECK LIST FOR TOOL VALIDATION

Instruction The expert is requested to go through the following criteria for evaluation of questionnaire. Three columns are given for response and a column for remarks. Kindly place a tick mark in the appropriate column and give remarks. Interpretation of columns Column I - Meets the Criteria Column II - Partly meets the Criteria Column III - Does not meet the criteria S.No Criteria I II III Remarks 1. Scoring • Adequacy • Clarity • Simplicity 2 Content • Logical sequence • Adequacy • Relevance 3 Language • Appropriate • Clarity • Simplicity 4 Practicability • It is easy to score • Does it precisely

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• Utility Any other suggestions ------------------------------------------------------------------- Signature : Name : Designation : Address :

APPENDIX -D LIST OF EXPERTS WHO HAVE VALIDATED THE TOOL

1. Dr.Christabel Reena, M.D.D.GO

Obstetrics and gynaecologist

,C.S.I Medical Mission Hospital

Neyyoor.

2. Mrs.Henita,Msc(N0

Asst,Prof in obstetrics and gynaecoloical nursing

C.S.I.Somervell college of nursing,

Karaakonam

3. Mrs.Suguna,Msc(N0,Ph.D,

Vice principal,

Nehru nursing college,

Vallioor.

4. Mrs.Anita Mary Leena,Msc(N0,

Asst,Prof in obstetrics and gynaecoloical nursing

St.Xaviers catholic college of nursing,

Chunkankadai.

5. Mrs.Irine Praveen,

Vice principal,

Vengateshwara nursing college,Chennai.

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6. Mrs.Majella Livingston,Msc(N)

Reader,

St.Xaviers catholic college of nursing,

Chunkankadai

APPENDIX-E

RESEARCH TOOL SECTION 1 DEMOGRAPHIC DATA

1. Age

a. 20-24 years

b. 25-29 years

c. 30-34 years

2. Education

a. High school

b. Higher secondary

c. Diploma

d. Degree

3. Occupation a. Labourer

b. Home maker

c. Service

d. Teacher

4. Religion

a. Hindhu

b. Christian

c. Muslim

5. Family type

a. Nuclear family

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b. Joint family

6. Family monthly income per month

a. < 5000

b. >5000

SECTION II Visual analog scale

Visual analog scale is a self report tool. It consist of 10cm baseline

at 1 cm interval from 0-10. If 0 means no pain and 10 means the worst

pain the mother can ever imagine

scoring procedure

no pain 0 0%

mild pain 1-3 10-30%

moderate pain 4-6 40-60%

severe pain 7-10 70-100%

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APPENDIX-F i

MASTER SHEET ON PAIN SCORE OF PRIMI MOTHERS

BEFORE AND AFTER HOT APPLICATION

Sample No Pre-test Post-test Sample

No Pre-test Post-test

1. 7 6 16. 7 3

2. 8 4 17. 7 5

3. 6 5 18. 5 3

4. 6 4 19. 6 4

5. 8 3 20. 7 3

6. 8 5 21. 8 6

7. 7 5 22. 7 5

8. 7 6 23. 5 4

9. 8 4 24. 5 4

10. 5 4 25. 7 5

11. 6 5 26. 6 4

12. 8 5 27. 5 4

13. 7 3 28. 8 5

14. 7 6 29. 7 6

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15. 6 4 30. 7 5

APPENDIX-F ii

MASTER SHEET ON PAIN SCORE OF PRIMI MOTHERS

BEFORE AND AFTER ICEAPPLICATION

Sample No Pre-test Post-test Sample

No Pre-test Post-test

1. 7 4 16. 8 5

2. 8 5 17. 7 4

3. 7 6 18. 5 2

4. 7 4 19. 8 6

5. 7 4 20. 7 5

6. 8 5 21. 6 3

7. 7 3 22. 7 3

8. 8 4 23. 6 3

9. 5 4 24. 7 5

10. 6 3 25. 6 4

11. 5 3 26. 5 3

12. 5 4 27. 6 3

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13. 6 4 28. 7 4

14. 7 6 29. 8 5

15. 5 2 30. 8 4

A STUDY TO ASSESS THE EFFECT OF HOT APPLICATION ...

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