ABSTRACT

A study on effect of birthing ball in reduction of labour pain among primigravida mothers during the first stage of labour in a selected hospital A Randomized control trial
Mrs Swapna Sukumaran RN, RM, MSc(N), Lecturer, Samaritan College of Nursing, Pazhanganad, Ernakulam, kerala. Email - swapnarajesh_2000@yahoo.co.in

Child birth is an exciting and meaningful experience in a womens life. From the origin of mankind, women are made to undergo labour pain which is one of the most painful condition. Reducing the labour pain and providing comfort to the mother is the most important challenge that midwives and physicians face from very beginning. Positioning strategies and movement between contractions are one among the alternative therapies which is found effective in reducing labour pain, adding to the comfort and improving the progress of labour. Many research studies have proved that ambulation in the first stage of labour has many benefits like improving comfort of the mother, helping for ease of labour by easy descen of babyunder gravity, but the pain of uterine contractions makes ambulation difficult for the women. When thinking out a solution for this, the researcher was encouraged hearing the uxe of birthing ball which can provide added benefits as of ambulation in a comfortable sitting position during labour. The "birthing ball" is a wonderful comfort tool for pregnancy and labour which is used in many of the birthing centres in foreign countries. It is the best feasible way to help the labouring mother adopt sitting, kneeling and upright positions comfortably which will help to reduce labour pain, provide comfort, and increase satisfaction. The active birthing ball is a large air filled ball that is easily inflated in minutes. It is made of extra tough non-slip burst proof PVC that is easily wiped clean. The ball is very strong and can take up to 300lbs in weight, which is 2-3 times the weight of a normal pregnant woman. Researches have proved that the birthing ball has many advantages. The ball can give comfort and support women who use upright positions. It also promotes comfort and can decrease pain by stimulating mechanoreceptors and joint receptors. Use of the ball demonstrates a significant improvement in core muscle stability, including: the muscles of the chest, abdomen, and pelvis which are instrumental in the labor process for deep breathing, pushing, and general movement. The ball provides soft, natural support easing back strain and encourages optimal fetal positioning. The birthing ball helps to keep the womans pelvis moving whilst supported and so reduces muscle spasms and intensity of labour. The ball can allow birth partners to assist in massaging the womans back and apply counter pressure. Sitting on the ball encourages a natural swaying or rotating motion of the pelvis and maximises gravity, helping the baby descend; it will exert an even pressure and so simulate dilatation. The upright position adopted when sitting on the birthing ball encourages widening of the pelvis and an improve head descent. Being free to move and change position and go with the flow of contractions can improve blood flow to the placenta and help to prevent fetal distress. By analysing the benefits of it, the researcher felt that, if a simple physiotherapy ball which is easy to use and can add to the benefit of the labouring mother and her fetus in a number of ways, why cant it be adopted in our birthing centres. So this motivated the investigator to select this study A study on effect of birthing ball in reduction of labour pain among primigravida mothers during the first stage of labour in a selected hospital at Mangalore. OBJECTIVES OF THE STUDY

To assess the level of labor pain in the control and experimental group of primigravida mothers To assess the effect of birthing ball on reduction of labor pain in the experimental group To compare the level of labor pain between experimental group and the control group of primigravida mothers after using birthing ball To find the association between labour pain and selected demographic and related factors variables.

OPERATIONAL DEFINITIONS Effect-. In this study effect refers to the extent to which the birthing ball has achieved the outcome of pain reduction of women in labour measured by visual analogue scale. Birthing ball- A Birthing Ball or Labour Ball is a large airfilled rubber ball (about 60 centimetres or 24 inch in diameter)made up of extra tough non-slip burst proof PVC that is easily wiped clean. It is available in different sizes from 60 cms to 95 cms in diameter as per height and size of the women. Labour pain- In this study, the term labour pain, refers to the stimuli of the receptor neurons arising from the contractions of uterine muscles which are referred to visceral, lumbar, pelvic and sacral areas. Reduction of labour pain- In this study, reduction of labour pain, refers to relieving labour pain by using birthing ball (by making the labouring women to sit on the ball and rock) and measured by visual analogue scale. 25 Primigravida mothers- In this study, primigravida mothers refers to primigravida women between age of 18-35 with gestational age of 37-40 weeks who are in first stage of labour with a cervical dilatation of 1-6 centimetres . ASSUMPTION The study assumes that: Mothers will experience reduction in labour pain and increased comfort while using birthing ball during labour. HYPOTHESIS H1 - There will be significant reduction of labour pain after the use of birthing ball H2 - There will be significant difference between the experimental and control group in the reduction of labour pain. H3 - There will be significant association between labour pain and the selected demographic variables such as age, education, occupation, religion, fear regarding impending labour, and awareness regarding child birth process.
CONCEPTUAL FRAME WORK This study aimed at determining the effect of birthing ball during the first stage of labour. Based on discussion with experts and extensive review of literature, the investigator felt that Dr Katherine Kathy Kolcabas Theory Of Comfort is the best suited model. The model postulates that the comfort is a patient outcome; the effects of which can be measurable METHODS

Research Approach - A quantitative randomized control trial approach was adopted in this study. Research Design In order to accomplish the main objective of the study, the research design adopted was pre test - post test control group design. Setting It is the physical location and condition in which data collection takes place in a study44. The study is conducted in K.S Hedge charitable hospital Deralakatte. Population In the present study population refers to all patients who are admitted in antenatal/labour ward in the first stage of labour Sample In the present study the sample size consist of 40 patients, 20 patients each in control and experimental group. Sampling Technique Selection of hospital in Mangalore Convenient Sampling

1st Phase

2nd Phase

Selection of 40 subjects based on inclusion criteria

Purposive Sampling

3rd Phase

Assignment of samples 20 Control group 20 Experimental group

Random Allocation By Lotary Method

Fig 1: Schematic Representation Of Sampling Technique. SAMPLING CRITERIA Inclusion criteria Primigravida mothers in the first stage of labour who were Available during the period of data collection Willing to participate in the study Between 18- 35 years of age. Within the gestational age of 37-40 weeks in the selected hospital

In first stage of labor between cervical dilatation of 1-6 centimeters. In first stage with intact amniotic membranes. Not induced with cerviprime. Not administered with analgesics Not diagnosed as having HBsAg and HIV infection.

DATA COLLECTION INSTRUMENTS Data collection tools are the procedures or instruments used by the researcher to observe or measure the key variables in the research problem. The following instruments were used for collection of data: Tool 1: Demographic proforma. Section -1 Baseline Data - The background information about the client is included in this section which has about 5 five items. viz age, education, occupation, religion and monthly income. Section -2 Related Factors- Related factors includes five items which elicits the information about the patient regarding, the normal response to pain, awareness about child birth and coping strategies, emotional status regarding impending labour, awareness regarding non-pharmacological measures, and the clients readiness regarding pain management. Tool 2: Visual Analogue Scale To measure the pain intensity, a standard version of Johns Hopkins Visual analogue scale was used. A wooden frame marked from 0-10 encompassing 10 divisions at equal interval namely 0,1,2,3,4,5,6,7,8,9,10. The divisions zero to ten will portray the pain intensity in ascending order that is at 0 - lowest pain intensity and at 10- peak the subjects were asked to slide the plastic pointer as according to their pain level. Scoring system - Mild pain : 1 - < 4 Moderate pain : 4 - < 7 Severe pain : 7 - < 10 PROCEDURE FOR ADMINISTRATION OF BIRTHING BALL Instructions to the participants The researcher gave the following instructions to the clients who were participating in the study 1. Participants will be made to sit on the birthing ball as comfortable as they sit on a chair. 2. Depending up on the height of the patient, an appropriate sized ball will be given to the patient 3. Participants have to stand with legs apart with a wide base, and then has to sit on the ball. 4. The participants will be taken care of by the researcher when they are on the ball. (The subjects should never be allowed to use the ball unless her support person is with her). 5. The participants will be given a firm support in the front of her on to which they can hold while they are on the ball. (This can be accomplished by placing the ball at the side of the bed and raising the side rail for her to hold for stability, or the ball can be placed at the foot of the bed where she can hold on to the handles of the foot support or the squat bar) 6. When the uterine contractions occur the subjects have to rock, on the ball comfortably, along with the waves of contraction. 7. If the clients feel uncomfortable at any point of time, they are free to inform the researcher and if needed can quit the study.

Steps in administration of birthing ball. The participants will be selected on the basis of the inclusion criteria Subjects will be individually informed about the purpose of the study Subjects will be informed about the benefits of the birthing ball and how it eases and provides comfort during labour. The researcher will demonstrate how to sit on the ball A written consent from the participants will be taken to participate in the study. Two hours after the onset of true uterine contractions, the pretest labour pain score of the participant will be assessed. Select the appropriate size ball. Spread a sterile towel on to the top of the ball. Ask the patient to keep her legs apart and make the client to sit on the ball. The legs of the client should be firm on the floor while sitting. A firm support will be given to patient, on to which they can hold on while sitting. The participant is made comfortable on the ball. When the uterine contractions occur, she has to rock comfortably. The FHR and uterine contractions will be monitored continuously. After one hour of administration of birthing ball the post test pain scores will be assessed. Likewise, the birthing ball is administered for every one hour, at an interval of two hours and the pretest pain score and the post test pain scores at cervical dilatation of 1-2 cms, 3-4 cms, and 5-6 cms are assessed. Researcher will support the patient throughout the entire procedure and ensure that the client is not let alone on the ball.

DATA COLLECTION PROCESS Fourty samples selected were randomly and equally allocated into control and experimental group using lottery method,. The pre test labour pain scores were assessed, using Visual Analogue Scale, in the control and experimental group. The pain scores were assessed 2 hrs after the onset of true uterine contraction (at a cervical dilatation of 1-2 cms), and then subsequently at a cervical dilatation of 3-4 cms and 5-6 cms respectively. Birthing ball was administered to the experimental group as per the procedure for 1 hour after each pre test

pain score assessment, whereas the control group was not given any intervention. Then the pain score was reassessed in control and experimental group in each areas- Area 1, Area 2, and Area 3 respectively (ie. labour pain at cervical dilatation of 1-2 cms, at 3-4 cms and 5-6 cms respectively).and were compared. RESULTS Section 1 Distribution of sample characteristics Distribution of sample characteristics based on the age revealed that majority of the samples, 10 (50%) in experimental group and 9 ( 45%) in the control group, were under the age group of 21-25 years. The educational qualification reveals that majority of the samples,7 (35%) in the experimental group, and 9 (45%) in the control group have completed high school education. Distribution of subjects according to occupation revealed that majority of samples, 13 (65%) in the experimental and 11(55%) in the control group were house wives. Religion wise distribution of samples revealed that the majority of subjects in the experimental13(65%) and control group15 (75%) were Hindus. Monthly income wise distribution of samples reveals that the majority of subjects in the experimental and control group are having a monthly income in between the range 4001- 6000 rupees. The subjects belonging to this category are 8 (40%) in the experimental group and 12 (60%) in the control group. The distribution of samples based on the normal response to pain revealed that the samples, 9 (45%) in the experimental and 10 (50%) in the control group cries with moderate pain The distribution of sample based the awareness about child birth revealed that majority of the subjects, 17 (85%) in the experimental and 18 (90%) in the control group have got some awareness regarding child birth process and coping strategies from literature, family and peer group. The distribution of subjects based on the emotional status regarding impending labour reveals that, 17 (85%) subjects of experimental group and 14 (70%) subjects of the control group are having slight fear about delivery process, but having confidence on their ability to get along with labour pain if support is given. The distribution of subjects based on awareness regarding non-pharmacological labour pain management majority, ie 10 (50%) in experimental group and 11 (55%) control group, were not at all aware about non-pharmacological management for labour pain reduction. The distribution of subjects based on the readiness to co-operate with the pain management in labour reveals that majority of the subjects, ie 14(70%) in the experimental and 18 (90%) in the control group has positive attitude and willingness to co-operate with non-pharmacological management if well supported Section II Level of Labour pain of subjects in experimental and control group

The pretest and posttest pain score of primigravida mothers during the first stage of labour in areas 1,area 2, and area 3 (at cervical dilatation of 2-3 cms, 3-4 cms, and 5-6 cms)

respectively were assessed in the control and experimental group . The datas were analyzed in terms of frequency and percentage Table: 1 Distribution of Pretest and Posttest Scores of labour pain among subjects PRETEST SCORES Sl. no Intensity of labour pain POSTTEST SCORES

Control group Percentage Frequency

Experimental group Percentage Frequency

Control group Percentage Frequency

Experimental group Percentage 95% 05% 00% 35% 65% 00% 00% 85% 15% Frequency 19 01 00 07 13 00 00 17 03

Area 1 1 2 3 Mild (1-4) Moderate (4-7) Severe (7-10) Area 2 1 2 3 Mild (1-4) Moderate (4-7) Severe (7-10 Area 3 1 2 3 Mild (1-4) Moderate (4-7) Severe (7-10) 00 00 20 00% 100% 00% 00 00 20 00% 100% 00% 00 00 20 00% 00% 100% 00 20 00 00% 100% 00% 00 19 01 00% 95% 05% 00 19 01 00% 95% 05% 17 03 00 85% 15% 00% 19 01 00 95 % 05% 00% 16 04 00 80% 20% 00%

Section - III Effect Of Birthing Ball On Level Of Labor Pain In The Experimental Group. Effect of birthing ball on reduction of labour pain was assessed using Visual Analouge Scale. Analysis was done using paired t test. To test the statistical difference between the

pre test mean score and post test score of labour pain, the following hypothesis was formulated and was tested. H1- There will be significant reduction of labor pain after the use of birthing ball. Table 2 Mean, Mean difference , Standard Deviation, and paired t value of pre and post test labour pain scores of the experimental group. n = 20 Area Experimental group Pre test Post test Pre test Post test 3.65 Pre test Post test 5.75 7.65 -1.9 .718 11.83 Mean Mean Difference Std Deviation Calt value P value (LOS)

Area 1 (Pain at cervical dilatation of 1-2 cm) Area 2 (Pain at cervical dilatation of 3-4 cms) Area 3 (Pain at cervical dilatation of 5-6 cms)

2.70 1.70 - 1.0 .562 7.958 df = 19 0.000 P <0.05 - 1.55 .510 13.58 HS

5.20

The results shown in the above table 2, depicts that mean post test pain scores of the mothers were significantly lower than their mean pre test pain scores in all the areas. The calculated t value in Area -1 (7.958), Area -2 (13.581) , and Area -3 (11.831) at 0.05 level of significance is greater than the table value i.e. the t tab (19) = 2.093. Hence research hypothesis was accepted indicating that there was significant reduction of labor pain after the use of birthing ball. Section IV Compare The Level Of Labour Pain Between Experimental And Control Group The difference in labour pain of control and experimental group were statistically analyzed using independent sample t-test. To test and compare the scores statistically, the following hypothesis was formulated. H2 - There will be significant difference between the experimental and control group in the reduction of labor pain. Table 3 Independent sample t test of experimental & control group pain score n = 40

Area

Post test pain Mean scores

Mean Difference

Std Deviation

Calt value

P value (LOS) .000 P <0.05 HS

Area 1 Control group (Pain at cervical dilatation of Experimental group (1-2 cm) Area (Pain cervical dilatation (3-4 cm) Area (Pain cervical dilatation (5-6 cm) 2 Control group at Experimental of group 3 Control group at of Experimental group

.35

-.65

.489

3.901

-1.00 .45 -1.35 .45 -1.75 -1.30

.562 .510 .933 .605 1.164 HS - Highly Significant 4.432 .000 P <0.05 HS .001 P<0.05 HS

-.900

3.784

t (tab)38 = 2.021

The above table:3 depicts that the mean difference and the standard deviation of experimental group and control group in Area -1, Area -2, and Area 3. The calculated t value in each areas were 3.901, 3.784, and 4.432 respectively which was greater than the t table value. So the research hypothesis H2 was accepted which denoted that there was significant difference between the experimental and control group in the reduction of labor pain. Section V Association between labour pain and selected demographic variables In order to find out the association between labour pain and selected demographic variables, the following hypothesis was formulated. H3: There will be significant association between labour pain and selected variables like age, education, occupation, religion, awareness regarding childbirth and coping strategies, and fear regarding child birth. To find the association between labour pain and selected variables like age, education, occupation, and religion, chi square test was used. To find the association between labour pain and selected variables like awareness regarding childbirth and coping strategies, and fear regarding child birth, Fischers exact test was used. There was no significant association between the level of pain and selected demographic variables like age, education, occupation, and religion (2cal=0.292, 0.641, 0.329, 0.888, 0.154, 0.262 respectively which is p>0.05) at 0.05 level of significance. So the research hypothesis was rejected and null hypothesis was accepted. INTERPRETATION AND CONCLUSION

Majority of the samples in the experimental group (50%) and in the control group( 45%) were under the age group of 21-25 years. In this study birthing ball was found to be effective in reduction of labour pain among primigravida mothers in the first stage of labour. The mean post interventional pain score in experimental group was less than that of the mean pre interventional pain scores. There was no significant association between labour pain and selected demographic variables. So from the study It was concluded that birthing ball was found to be effective in reduction of labour pain among primigravida mothers during the first stage of labour.
NURSING IMPLICATIONS: The findings of the study have implications in the various areas of nursing that is nursing education, nursing practice, nursing administration, and nursing research. Nursing Practise- From this study it was found that birthing balls were very effective in providing labour pain reduction, reduction of back pain, and providing comfort to all the mothers. The mothers sitting on birthing ball subjectively expressed that they are comfortable on the ball than lying down. Most of the mothers verbalized that, its easy and good to sit on the ball and rock rather than walking when uterine contractions were there.So it can be used widely in birthing centers as a simple and cost effective intervention to provide positioning and movement strategies (like upright sitting position, semisquatting position, leaning forward position etc and rocking and swaying movement ) as per patient comfort Nursing Research - There is lack of literature and research done on the effect of birthing ball. Some literature and studies in foreign countries state that birthing ball has many advantages and uses in antenatal, intranatal and postnatal periods, Use of birthing balls have various advantages being observed, increased placental circulation, increased comfort for the mother to change positions, even cervical dilatation, decrease duration of first stage of labour, decreased number of instrumental deliveries and caesarean section, decreased evidence of perineal tears, easy for the mothers to sit, reduced back ache, decreased effort to push than in supine position, facilitates pelvis for easy fitting of fetal head and engagement. So researchers have to be motivated to conduct more researches on the topics

KEY WORDS Birthing Ball, Labour Pain, Primigravida Mothers, Visual Analogue Scale