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Explore
journal homepage: www.elsevier.com/locate/jsch

Massage and heat application on labor pain and comfort: A quasi-

randomized controlled experimental study
€ lya Tu
Hu € rkmena,*, Nazan Tuna Oranb
a
Department of Midwifery, Faculty of Health Sciences, Balıkesir University, Balıkesir, Turkey
b _
Department of Midwifery, Faculty of Health Sciences, Ege University, Izmir, Turkey

A R T I C L E I N F O A B S T R A C T

Article History: Aim: The aim of this study was to determine the effects of sacral massage and heat application on the percep-
Received 25 May 2020 tions of labor pain and comfort level in pregnant women.
Revised 4 August 2020 Methods: This was a quasi-randomized controlled experimental study. The data were collected under three
Accepted 9 August 2020
groups in 2016: the heat application group (HAG), the massage group (MG), and the control group (CG). Each
Available online xxx
group included 30 primiparous pregnant women (range of age: 17 35) whose cervix was dilated to 4 5 cm.
At 4 5 cm, 6 7 cm, and 8 9 cm cervical dilation, sacral massage was applied to MG, and sacral heat applica-
Keywords:
tion was applied to HAG. Each group received standard midwifery care during labor. The data were collected
Comfort during labor
Heat application
using the Childbirth Comfort Questionnaire (CCQ) and the Numerical Rating Scale (NRS). The data were ana-
Labor pain lyzed by using the Chi-square test, the Friedman test, Paired sample t-test, ANOVA, the Kruskal-Wallis test,
Massage and Wilcoxon signed-ranks test
Midwifery Results: The mean pain score in HAG (4.56§0.67) during 4 5 cm of cervical dilation was significantly lower
than those in MG (5.03§1.06) or CG (5.23§0.72) (p < 0.05). The mean pain scores in HAG (6.80§0.7) and MG
(7.30§0.8) during 6 7 cm of cervical dilation were significantly lower than that in CG (7.70§0.5) (p <
0.001). Moreover, a statistically significant difference was found between the mean CCQ total scores (HAG:
31.06§3.46, CG: 27.66§3.85, p < 0.05), mean CCQ physical comfort scores (HAG: 13.16§1.89, CG: 11.03§
1.80, p < 0.001), mean CCQ relief comfort level score (HAG: 11.23§1.43, CG: 10.00§2.01, p < 0.05) and mean
CCQ transcendence comfort level scores (HAG: 19.83§2.37, CG: 17.66§2.15, p < 0.05) and both HAG and CG
during 8 9 cm of cervical dilation.
Conclusions: Heat application and massage can be used as a safe and effective midwifery intervention to
reduce the perception of pain in pregnant women and provide comfort during labor.
© 2020 Elsevier Inc. All rights reserved.

Introduction of Obstetricians and Gynecologists have acknowledged that maternal

demand for pain relief is an adequate medical indication for treat-
Pain in the first stage of labor arises from cervical dilation and ment to relieve labor pain.3 Non-pharmacological methods to relieve
uterine contractions. Pain occurs in the back, sacrum, legs, and thighs labor pain address psycho-emotional factors and physical aspects of
as the fetal head descends into the pelvis creating pressure on the pain. A woman’s ability to control pain, emotions, and behavior dur-
lumbosacral plexus.1-3 Labor pain is a physiological sign of the pro- ing labor is an important aspect of a good childbirth experience.6-8
gression of labor. If not relieved, it can affect maternal and fetal Kolcaba9 created a holistic taxonomic structure for the concept of
health negatively.4,5 Excessive pain increases fear and anxiety in "comfort" consisting of three levels and four dimensions (physical,
pregnant women resulting in an increase in secretion of catechol- psychosocial, environmental, and sociocultural). Comfort during
amines. Catecholamine secretion leads to pelvic muscle strain result- childbirth and Kolcaba's9 comfort theory are compatible because nat-
ing in resistance against the repulsive force of the uterus and the ural childbirth is often desired. The concept of comfort is categorized
repulsive force exerted by pregnant women. Prolongation of this con- in three levels: ease, relief, and transcendence. If labor pain is man-
dition results in additional pain during the labor process.5 Therefore, aged successfully, pregnant women feel relieved. Pregnant women
the American Society of Anesthesiologists and the American College who can cope with labor pain and do not fear childbirth show tran-
scendence. Provision of comfort during labor is among midwifery
responsibilities. Midwives are responsible for the planning and
* Corresponding author.
€ rkmen),
E-mail addresses: [email protected] (H. Tu implementation of nonpharmacologic methods to reduce labor pain
[email protected] (N.T. Oran). in pregnant women and increase labor comfort levels.9-12

https://doi.org/10.1016/j.explore.2020.08.002
1550-8307/© 2020 Elsevier Inc. All rights reserved.
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During the first stage of labor, various non-pharmacological tech- pregnant women who were taken to cesarean section due to failure
niques are used to reduce labor pain and provide comfort. Massage to progress in labor were excluded.
and heat application are among the most commonly used methods to Routine oxytocin infusion is applied to pregnant women in the
reduce labor pain. The mechanism of action for both massage and hospital where this study was conducted. To all pregnant women in
heat application are the same and are explained by the gate control each group, 10 IU / ml oxytocin infusion was applied with 4 drops /
theory. This theory states that massage or heat application triggers a min in 4 5 cm cervical dilation. Oxytocin infusion was increased by
spinal cord reflex that closes the gateway to which pain is delivered 4 drops every 20 min and a maximum of 40 drops / min were
and increases the pain threshold. Heat or massage during childbirth applied.
oxygenate the region to which it is applied and removes waste mate- Quasi-randomization allocation was determined for each preg-
rials from that region as a result of vasodilation in the peripheral nant woman according to the day of the week they arrived at the
blood vessels. Also heat or massage applications during labor increase hospital in labor. Quasi-randomization allocating was achieved by
levels of serotonin and dopamine and decrease norepinephrine and collecting data on Mondays, Wednesdays, and Fridays of each
cortisol. This results in decreased fatigue, relaxation of muscle week during the study period. The reason for applying this ran-
spasms, increased relief and comfort, increased physical activity, domization method was due to the presence of more than one
mental distraction from the pain, and decreased anxiety. Therefore, pregnant woman in a room. Applying massage to one pregnant
the laboring woman can better tolerate the pain.7,8,13-15,16 Heat can woman while applying heat to the other would not be appropri-
be applied easily with various inexpensive devices and methods, ate. Sacral massage was applied on Mondays, sacral heat applica-
such as thermoforming, and the use of wet compresses and thermal tion was applied on Wednesdays, and data from the control
belts. These methods have few side effects if used properly. Heat can group were collected on Fridays.
be applied to the sacrum, lower abdomen and perineum during Standard midwifery care was provided according to the recom-
labor.4,16-19 Massage can be applied to areas such as the sacrum, mendations of the World Health Organization. Standard midwifery
shoulders, back, head, lower abdomen, hands, and feet during monitoring of cervical dilation and effacement, contractions, fetal
labor.8,20-23 In some studies, massage or heat application were used heartbeat rate, and vital findings were performed for all pregnant
as effective methods to reduce labor pain during the first stage of women. Additionally, midwives informed all pregnant women about
labor.4,10,19,24-32 To our knowledge, there is only one study in the lit- breathing techniques during labor.33
erature examining the effect of massage on comfort during labor
with a questionnaire.10 However, there are no studies in the litera-
ture that examine the effects of heat application on comfort during Data collection tools
labor with a measurement questionnaire. Therefore, this study aims
to determine the effects of sacral massage and heat application on A 3-part survey was used for data collection. The questionnaires
the perception of pain and comfort level during the first stage of included a personal information form (PIF), a numerical rating scale
labor. (NRS) for measuring pain, and the Childbirth Comfort Questionnaire
(CCQ) for evaluating comfort.
Methods
Personal information form
Study type and location The PIF, an investigator developed tool, consisted of 20 questions
divided into 2 sections: 1) demographic characteristics and 2) preg-
This quasi-randomized controlled experimental study was carried nancy and obstetric history (Table 1).
out between June and December 2016 in the delivery room of Public
Hospital in Turkey.
Childbirth comfort questionnaire-CCQ
Study sample Comfort is the expression of the desired or needed things in phys-
ical, psychosocial, sociocultural, and environmental areas.10 Physical
Considering previous studies conducted on massage and heat comfort encompasses the physical perception of labor pain. Psycho-
application in labor, a sample size of 30 for each group was deter- spiritual comfort encompasses feelings of self-esteem, inner self-
mined using the G * Power 3 program. Power analysis demonstrated awareness, and perception of meaning in one’s life. Environmental
that this sample size had a power of a = 0.05 to 99%. Estimation of comfort includes the effects of external factors on pregnant women.
effects was based on the previous findings of Karami et al.22 who Sociocultural comfort consists of sociocultural relations including
reported that mean pain intensity measured by visual analogue scale family, financial support, education, and tradition.9-12 The CCQ scale
was 7.22 § 0.83 in the massage group and 7.94 § 1.02 in the control was used to determine the comfort level of pregnant women. The
group. We aimed to determine a similar difference. The observed CCQ scale was developed by Schuling et al. ,10 and a Turkish validity
reduction in pain during 6 7 cm cervical dilatation after intervention and reliability study of the scale was carried out by Potur et al.34 The
compared to the control group had an effect size of 1.37. CCQ is a 5-point Likert-type scale with nine items. Each item is scored
A total of 98 primiparous pregnant women were included in the between strongly disagree (1 point) to strongly agree (5 points). It is
study. However, 8 of them were excluded because of delivery by possible to score from 9 to 45 when all questions on the scale are
cesarean section. Three research groups were formed: massage appli- answered. A high score refers to high comfort. The CCQ consists of
cation group (MG), heat application group (HAG), and a control group physical, environmental, and psychospiritual subscales and a specific
(CG) (n = 30 for each group). Sacral massage or sacral heat were sense of relief and transcendence. Potur et al.34 showed that the
applied to the intervention groups. Only standard midwifery care sociocultural subscale had an item total score correlation coefficient
was given to the control group (Fig. 1). less than 0.30. The items showing ease level were extracted from the
_
Inclusion criteria were: primiparous pregnant women with vagi- scale. Potur et al.34 found the Cronbach’s alpha reliability value of the
nal delivery expectancy, term pregnancy, single healthy fetus, scale to be 0.75, which is similar to that observed in the present
cephalic presentation, active labor stage (4 5 cm dilation), and Oxy- study. In the present study, the CCQ was applied two times in total,
tocin infusion. Exclusion criteria were: pharmacological interventions one before the intervention during 4 5 cm cervical dilation and one
for labor pain, primiparous women who do not cooperate during immediately after the intervention during 8 9 cm cervical dilation.
labor, and eczema at the massage/heat application area. Eight The Cronbach alpha coefficient of the study was found to be 0.78.
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Assessed for eligibility and Randomized (n=98)

Allocated Experimental group (Heat Allocated Experimental group Allocated Control group (CG)
application Group)(HAG) (n=32) (Massage Group)(MG) (n=33) (n=33)

4-5 cm cervical dilatation of labor (Before intervention): applied PIF, NRS and CCQ

Heat application Group (HAG) Massage Group (MG) Control Group (CG)

Heat application was applied for Massage was applied for 10 min. NRS was applied when 4-5 cm,
20 min. (during 4-5 cm, 6-7 cm (during 4-5 cm, 6-7 cm and 8-9 6-7 cm and 8-9 cm cervical
and 8-9 cm cervical dilation of cm cervical dilation of labor). dilation of labor
labor). After every intervention, After every intervention, NRS
NRS was applied was applied

Lost to follow-up Lost to follow-up Lost to follow-up

(n=2)(Cesarean) (n=3)(Cesarean) (n=3)(Cesarean)

Experimental group: CCQ was applied 8-9 cm cervical dilation of Control group: CCQ was applied
labor (after interventions) 8-9 cm cervical dilation of labor

NRS was applied after the delivery

Analyzed (n=30) Analyzed (n=30) Analyzed (n=30)

Fig. 1. flowchart of the research.

Table 1
Sociodemographic and obstetric characteristics of pregnant women.

Characteristic Heat application group Massage group Control group X2p

n % n % n %

Age group
19 and under 3 9.4 2 6.1 2 6.1
20 29 years 26 81.2 27 81.8 25 75.7 1.423
30 and older 3 9.4 4 12.1 6 18.2 0.840
Age, Mean§SD 23.68§3.49 24.39§3.96 25.45§3.64
(Min.17; Max.32) (Min.19; Max.35) (Min.18; Max.32)
Educational status
Primary school Graduate 14 43.8 15 45.4 14 42.4 0.675
Highschool graduateUniversity graduate 117 34.421.8 126 36.418.2 145 42.415.2 0.954
Working status
Yes 5 15.6 10 30.3 11 33.3 2.977
No 27 84.4 23 69.7 22 66.7 0.226
Planned pregnancya
Yes 30 93.8 31 93.9 30 90.9
No 2 6.2 2 6.1 3 9.1
Antenatal control frequency
One to four follow-ups 6 18.8 3 9.1 3 9.1 1.871
Five and more follow-ups 26 81.2 30 90.9 30 90.9 0.392
Mean antenatal control 7.97§3.22 8.48§2.50 8.09§2.72
(Min.1; Max.15) (Min.4; Max.15) (Min.2; Max;14)
Total 32 100.0 33 100.0 33 100.0
a
Since more than 20% of the cells had the value of less than 5, they were not evaluated.
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Numerical rating scale (NRS) (number: 94,025,189 050.03 5764). The pregnant women who
agreed to participate in the study were informed about the study pur-
The NRS scale was used to evaluate pain levels.35 Subjects were pose and procedures. It was explained to the participants that the
asked to rate the level of their pain using numbers from 0 (no pain) interventions did not pose risks to pregnant women. Participants
to 10 (worst imaginable pain) on this scale. In the present study, NRS were also informed that all identifiable information would be kept
was applied five times in total, once before the intervention, three confidential. Participants could leave the study at any time. Written
times immediately after interventions (during 4 5, 6 7, and 8 9 cm consents and volunteer information forms were obtained from all
cervical dilations) and once after delivery. participants. The study was recorded in the Clinical Trial Database
(NCT04382833).
Data collection procedures
Data analysis
Each study participant was supplied with a descriptive informa-
tion form, Childbirth Comfort Questionnaire (CCQ) to determine com- A Chi-square test was used to determine differences between
fort level, and Numerical Rating Scale (NRS) to determine the level of groups in terms of sociodemographic and obstetric characteristics of
pain, during the active stage of labor (before intervention, 4 5 cm pregnant women. The Kolmogorov Simirnov test was used to assess
cervical dilation) by the first author. Each group received standard the normality of the data.
midwifery care in the first stage of labor (Fig. 1). Within groups, the Friedman test was used to determine changes
_
The Intervention groups were treated three times in total, during in the pain perception of pregnant women as labor progressed. Sig-
4 5, 6 7, and 8 9 cm cervical dilation. Massage and heat application nificant differences between pain level during 4 5 cm cervical dila-
were applied by the first author. Immediately after each intervention, tion and pain level during other labor stages were determined using
the NRS was recorded between contractions. The CCQ was recorded the Wilcoxon signed-rank test. A repeated-measures analysis of vari-
between contractions and before any intervention during 4 5 cm ance (ANOVA) was used to determine differences in comfort level
cervical dilation and after the last intervention made during 8 9 cm over time within each group. Differences in comfort level between 4
cervical dilation (Fig. 1). and 5 and 8 9 cm cervical dilation were assessed using a paired-
In CG, the NRS was recorded during 4 5, 6 7, and 8 9 cm cervi- sample t-test.
cal dilation, and the CCQ during 4 5 and 8 9 cm cervical dilation Within groups, the Kruskal Wallis test was used to determine
(Fig. 1). differences between pain level perception in pregnant women in the
The NRS was applied a final time in all three groups at 5 min after heat application, massage, and control groups. A one-way ANOVA
delivery (Fig. 1). and Bonferroni post-hoc test were used to determine whether a sig-
nificant relationship existed between comfort levels in the heat appli-
_
Intervention cation, massage, and control groups.

Thermoforming, a dry heat application method, was performed on Results

the sacral (S1 S4) vertebrae region of pregnant women in HAG while
they were in either a sitting or left-side lying position (during 4 5, Table 1 shows sociodemographic and obstetric characteristics of
6 7, and 8 9 cm cervical dilation).4 Thermoforming was applied by pregnant women in HAG, MG, and CG. Pregnant women in HAG, MG,
first wrapping the material with a towel to protect pregnant women and CG were found to be homogeneous in terms of age, education,
from the direct effect of its hot surface. According to previous studies, working status, and antenatal control frequency (p > 0.05).
the temperature of thermoforming should be between 38 and 40 ° The mean post-intervention pain score during 4 5 cm cervical
C.28,36,37 The mean water temperature used in thermoforming was dilation in labor was lower in HAG than in MG (p = 0.032) and CG
50 °C. The water temperature was measured using a liquid thermom- (p = 0.007). The mean post-intervention pain score during 6 7 cm
eter. When 50 °C water was used for thermoforming heat application, cervical dilation in labor was lower in HAG than in MG (p = 0.023)
the surface temperature reached around 40 °C. The heat application and CG (p < 0.001). Additionally, it was determined to be lower in
was carried out continuously for 20 min.38 Heat applications were MG than in CG (p = 0.036). As labor progressed, the mean pain score
applied by the first author. in all groups was observed to increase (p < 0.001) (Wilcoxon Signed-
In the present study, Linda Kimber's39 massage protocol was used. Ranks Test) (Table 2) (Fig. 2).
Massage using effleurage and friction techniques was applied to the Table 3 shows that the mean post-intervention total comfort score
4 5 cm right and left lateral parts of the midline on the sacral during 8 9 cm cervical dilation in labor was higher in HAG than in
(S1 S4) vertebrae region of participants in the massage application CG (p = 0.002) (Fig. 3).
group, while in a sitting or left-side lying position (during 4 5, 6 7, A post hoc Bonferroni test revealed that the decrease in the com-
and 8 9 cm cervical dilation). The massage application was carried fort level of pregnant women in the later stages of labor was less in
out continuously for only 10 min because it was thought to cause irri- the intervention groups than in CG (p < 0.001) (Table 3).
tation to the area where it was administered. Massage therapy was A post hoc Bonferroni test also revealed that the mean post-inter-
applied by the first author who trained in massage. vention physical comfort score during 8 9 cm cervical dilation in
labor was higher in HAG than in CG (p < 0.001). In addition, the
Outcome measures mean post-intervention relief and transcendence score during
8 9 cm cervical dilation in labor was higher in HAG than in CG
The primary outcome measures included 1) severity of labor pain (p = 0.021 and 0.002, respectively) (Table 3).
assessed by NRS, and 2) comfort level at labor. A secondary outcome A statistically significant difference occurred between the mean
measure was that of the responses of participants about effectiveness scores of comfort total, physical and psychospiritual comfort sub-
of massage and heat application. scale, relief and transcendence comfort level obtained by each group
during 4 5 and 8 9 cm cervical dilation in labor (p < 0.001). In CG,
Ethical considerations the mean environmental comfort score during 4 5 cm cervical dila-
tion in labor was higher than the mean post-intervention environ-
The study was approved by the Clinical Research Ethics Commit- mental comfort score during 8 9 cm cervical dilation in labor (p <
tee of Medicine in Turkey and the Public Hospitals Association 0.001) (Paired Sample t -test) (Table 3).
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Table 2
Pain levels perceived by pregnant women during labor process.

Pain (NRS) Heat application group (HAG) Massage group (MG) Control group (CG) pa Difference

n Mean§SD n Mean§SD n Mean§SD

(Min. Max) (Min. Max) (Min. Max)

Pre-intervention pain level in the first 32 5.06§0.78 33 4.90§0.80 33 5.00§0.87 0.716

stage (4 5 cm cervical dilation) (3 6) (3 6) (4 6)
Post-intervention pain level during 32 4.56§0.67 33 5.03§1.06 33 5.23§0.72 0.004 Heat application group < Massage group
4 5 cm cervical dilation (4 6) (3 7) (4 6) Heat application group <Control group
Post-intervention pain level during 30 6.80§0.71 31 7.30§0.83 32 7.70§0.59 < 0.001 Heat application group < Massage group
6 7 cm cervical dilation (5 8) (6 9) (7 9) Heat application group < Control group
Massage group < Control group
Post-intervention pain level during 30 9.20§0.61 30 9.46§0.50 30 9.43§0.67 0.177
8 9 cm cervical dilation (8 10) (9 10) (8 10)
Pain level after delivery 30 0.13§0.34 30 0.23§0.43 30 0.16§0.37 0.591
(0 1) (0 1) (0 1)
pb < 0.001 < 0.001 < 0.001
a
Kruskal-Wallis Test.
b
Friedman Test (Wilcoxon Signed-Ranks Test) Oxytocin infusion was applied to pregnant women in each group.

Fig. 2. Level of pain perceived by pregnant women in the heat application, massage, and control groups.

Discussion et al.,4 Behmanesh et al.,44 and Yazdkhasti et al.36 applied a minimum

of 60 80 min of heat application to pregnant women in the first
Pregnant women feel pain in the first stage of labor due to cervical phase of labor. We theorize that the ineffectiveness of heat appli-
dilation, uterine contractions, strain of the uterine lower segment, cation in 8 9 cm cervical dilation in this study was due to the
uterine hypoxia, ischemia due to metabolites accumulated in the duration of heat application. Taavoni et al.24,31 found that the
myometrium, and pressure on neighboring tissues. The pain felt in heat application performed on the sacral and perineal regions
the early stages of labor mostly occurs in the lower abdomen and was effective in relieving labor pain for 60 and 90 min after inter-
sacral region.1,5 In the present study, an increase in NRS scores of vention. Tarrat et al.37 and Tzeng and Su27 reported that labor
pregnant women occurred as the labor progressed. Similarly, previ- pain level decreased after sacral heat application compared to the
ous studies examining the effects of nonpharmacological methods on pre-intervention.
labor pain revealed that the labor pain scores of pregnant women Thermoforming, one of the dry heat application methods, was
increased as the labor progressed.27,40,41 used in the present study. Previous studies have examined the effects
The effect of heat application and massage on pain is explained by of wet heat application methods, such as a warm shower or heat
the gate control mechanism. Accordingly, sensory receptors in the water bath on labor pain. Similar to present study’s results, these
skin are stimulated through heat application and massage. The gate studies reported that heat application was effective in relieving labor
for pain conduction is closed because the conduction of sensory pain during the active stage of labor.45,46 Some studies have exam-
receptors is faster than the conduction of pain.42,43 The present study ined the effect of cold and heat applications in labor. Ghani41 and
demonstrated that HAG experienced a higher decrease in labor pain Ganji et al.28 reported that heat and cold applications on the lower
compared with the MG and CG during 4 5 and 6 7 cm cervical dila- abdomen and sacral regions reduced the pain perception of pregnant
tion in labor. However, the present study found that heat application women in the first stage of labor. Unlike the present study, these
was not effective in relieving labor pain during 8 9 cm cervical dila- studies reported relieving effects of heat and cold applications on
tion. Fahami et al.,4 Behmanesh et al.,44 Yazdkhasti et al.,36 and Kaur labor pain during 8 9 cm cervical dilation. This difference may be
et al.19 and reported that the heat application performed on the lower due to the cold application. Some studies examined the effects of
back region reduced labor pain during the first stage of labor. Fahami heat application on labor pain in the first and second stages of labor
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Table 3
Comparison of the mean score in total comfort, comfort subscale, and comfort level obtained by pregnant women in the heat application, massage, and control groups.

Childbirth Comfort Questionnaire (CCQ) Heat application Massage Control pa Difference

group (HAG) group (MG) group (CG)
Mean§SD Mean§SD Mean§SD

Comfort total score

Pre-intervention comfort during 4 5 cm cervical dilation 34.03§3.47 33.06§3.92 33.45§4.32 0.607
Post-intervention comfort during 8 9 cm cervical dilation 31.06§3.46 29.76§3.74 27.66§3.85 0.002 Heat application group > Control groupb
pc < 0.001 < 0.000 < 0.000
Difference between comfort during 4 5 cm and 8 9 cm cervical 2.86§2.01 3.23§1.92 5.60§1.52 < 0.001 Heat application group < Control groupb
dilation Massage group < Control groupb

Comfort subscale
Physical Comfort
Pre-intervention physical comfort during 4 5 cm cervical dilation 14.75§2.09 14.00§2.79 13.93§1.95 0.296
Post-intervention physical comfort during 8 9 cm cervical 13.16§1.89 12.20§2.17 11.03§1.80 < 0.001 Heat application group > Control groupb
dilation
pc < 0.001 < 0.001 < 0.001
Psychospiritual Comfort
Pre-intervention psychospiritual comfort during 4 5 cm cervical 6.93§1.68 6.33§1.96 6.72§2.42 0.485
dilation
Post-intervention psychospiritual comfort during 8 9 cm cervical 5.46§1.30 5.13§2.19 5.00§2.11 0.625
dilation
pc < 0.001 < 0.001 < 0.001
Environmental Comfort
Pre-intervention environmental comfort during 4 5 cm cervical 12.34 § 1.53 12.72§1.66 12.78§1.49 0.469
dilation
Post-intervention environmental comfort during 8 9 cm cervical 12.43§1.59 12.43§1.52 11.63§1.65 0.085
dilation
pc 0.455 0.305 < 0.001
Comfort level
Relief
Pre-intervention relief during 4 5 cm cervical dilation 12.03§1.67 11.72§1.48 11.42§1.95 0.366
Post-intervention relief during 8 9 cm cervical dilation 11.23§1.43 10.63§1.51 10.00§2.01 0.021 Heat application group > Control groupb
pc 0.001 < 0.001 < 0.001
Transcendence
Pre-intervention transcendence during 4 5 cm cervical dilation 22.00§2.21 21.33§2.95 22.03§2.66 0.482
Post-intervention transcendence during 8 9 cm cervical dilation 19.83§2.37 19.13§2.59 17.66§2.15 0.002 Heat application group > Control groupb
pc < 0.001 < 0.001 < 0.001
a
One-way ANOVA.
b
Post Hoc Bonferroni Test.
c
The repeated-measures analysis of variance (Paired Sample t test).

and found that heat application on the perineal region decreased per- The present study found that heat application and massage were
ineal pain in the second stage of labor. Hence, it was concluded that not effective in relieving labor pain during 8 9 cm cervical dilation.
heat application relieved pain in the region where it was applied.15- As labor progresses, the pressure of the fetal head on the lumbosacral
17,47
Reduction of labor pain in the first stage of labor can contribute plexus increases sacral pain and also causes pain in the back, legs,
to a positive delivery experience and natural birth. In addition, the and hips. In addition, as cervical dilation increases, the severity of
results of this study indicate that sacral heat application at labor can pain also increases.1,2 Therefore, it is considered that interventions
be applied as a midwifery intervention. on the sacral region are not quite effective in relieving pain in the
Massage increases circulation in the affected area and reduces the later stages of labor. Chang et al.25 and Kamalifard et al.48 also
accumulation of irritating substances, such as lactic acid, in the reported that massage application had no effect on relieving labor
region. Thus, the pain perception is reduced.42,43 The present study pain during 8 10 cm cervical dilation.
found that massage application reduced labor pain during 6 7 cm Comfort provides the senses of relief, ease, security, prosperity,
cervical dilation. A study examining the effects of nonpharmacologi- hope, and expectation.10 Nonpharmacological methods used during
cal pain relief methods on labor pain found that massage applied to labor cause a decrease in both pain sensation and anxiety of pregnant
the sacral region reduced labor pain in 65.3% of pregnant women.8 women, and also lead to an increase in their self-esteem. The effect of
Ranjbaran et al.,29 Hu et al.,30 and Çevik and Karaduman32 reported nonpharmacological methods on comfort during childbirth can be
that massage application relieved labor pain during first stage of significant.49 The present study demonstrated that the decrease in
labor. In the present study, only the sacral region was massaged. Pre- the comfort level of pregnant women in the later stages of labor was
vious studies reported that massage applied to the head, shoulders, less in the intervention groups than in the control group. These
back, lower abdomen, hands, feet, and sacral regions reduced pain in results indicate that heat application and massage are effective in
the first stage of labor. However, the present study found that mas- providing comfort during the labor process. It is known that massage
sage was not effective in relieving labor pain during 4 5 and 8 9 cm provides physical and emotional relief. Massage is mostly used for
cervical dilation. The difference between these studies might be stress reduction and relaxation during the labor process. Schuiling
because of the differences in massage duration and regions.8,20-23 et al.10 found that massage was effective in providing comfort during
Similar to the present study, Chang et al.,25 Mortazavi et al.26 and childbirth. Simkin and Bolding49 observed that massage application
Kamalifard et al.48 found that massage application relieved labor pain during labor increased the feeling of relief in pregnant women. Hu
during 5 7 cm cervical dilation, but was not effective during 8 9 cm et al.30 and Çevik And Karaduman32 reported that massage therapy
cervical dilation. reduced the participants’ anxiety levels. Yildirim and Sahin23 found
 ARTICLE IN PRESS
€ rkmen and N.T. Oran / Explore 00 (2020) 1 8
H. Tu 7

Heat applicaon group Massage group Control group

34.03 33.06 33.45

31.06 29.76
27.66

Comfort total score during 4-5 cm cervical Comfort total score during 8-9 cm cervical
dilaon dilaon

Fig. 3. Mean total comfort scores in groups.

that reactions such as crying, changes in facial expressions, expres- perception in pregnant women and provide them with comfort in
sions of fear, sensitivity, and uneasiness, were lower in pregnant the labor process. Additional studies are needed to evaluate the
women when massage and breathing techniques were applied dur- effects of massage and heat application in the first stage of labor, the
ing labor. In addition, pregnant women treated with massage and reduction in the perception of labor pain, and the increase in the level
breathing techniques remembered postpartum labor pain and the of comfort.
delivery room positively.
Heat application has a positive effect in relieving muscle. To our Author contributions
knowledge, there is no study in the literature that investigates the
effects of sacral heat application on comfort, when applied during the H.T. undertook the data collection, data analysis, and prepared the
first stage of labor with a measurement questionnaire. Previous stud- manuscript; N.T.O. prepared the manuscript. Both authors read and
ies have reported that perineal warm application in the second phase approved the final manuscript.
of labor positively affects maternal comfort by decreasing labor pain.
Previous studies have also suggested that heat application reduces Sources of funding
pain level in the treated region and provides patient
satisfaction.15,16,19,37,47,49 The American College of Nurse-Midwives None
reported that hydrotherapy, a wet heat application method used dur-
ing labor, provided comfort in pregnant women.50 These nonpharma-
Declaration of Competing Interest
cological methods used during labor reduce anxiety in pregnant
women.49 The literature shows that these nonpharmacological meth-
The authors report no conflicts of interest. No funding was
ods have positive effects on comfort level by providing relief in preg-
received for this study.
nant women.12 Therefore, it can be concluded that the decrease in
the comfort level of pregnant women that occurs as labor progresses
is lower. Therefore, individual midwifery care for pregnant women is Acknowledgements
significantly important.
The authors express thanks to the pregnant women for participa-
Limitations tion in the study.
Place or institution where the work was developed, city and coun-
try: Balıkesir Atatu€ rk City Hospital in Turkey.
This present study has limitations in that all pregnant women
received an oxytocin infusion in early labor compared to other mas-
sage or heat application studies where pregnant women were Supplementary materials
required to have a spontaneous onset of labor. They oxytocin infusion
may have affected the results of the present study. This is the first Supplementary material associated with this article can be found
study conducted to determine the effect of heat application on labor in the online version at doi:10.1016/j.explore.2020.08.002.
comfort. Therefore, it was not possible to compare the results with
those of a previous study. These findings may not be generalizable to References
different populations.
1. Davim RMB, Torres GV, Melo ES. Non-Pharmacological strategies on pain relief
during labor: pre-testing of an instrument. Rev Latino-am Enfermagem. 2007;15
Conclusions (6):1150–1156. http://www.scielo.br/pdf/rlae/v15n6/14.pdf.
2. El-Wahab N, Robinson N. Analgesia and anaesthesia in labor. Obstet Gynaecol
Heat application was found to reduce labor pain perception dur- Reprod Med. 2014;24(4):97–102. https://doi.org/10.1016/j.ogrm.2011.02.006.
3. ACOG. Practice Bulletin No. 209: obstetric Analgesia and Anesthesia. Obstet Gyne-
ing 4 5 and 6 7 cm cervical dilation, whereas massage application
col. 2019;133(3):e208–e225. https://doi.org/10.1097/AOG.0000000000003132.
was found to reduce labor pain perception during 6 7 cm cervical 4. Fahami F, Behmanesh F, Valiani M, Ashouri E. Effect of heat therapy on pain sever-
dilation. As labor progressed, the mean comfort score of pregnant ity in primigravida women. Iran J Nurs Midwifery Res. 2011;16(1):113–116.. PMID:
women decreased. This decrease was greater in CG than in HAG and 2203938; https://www.ncbi.nlm.nih.gov/pubmed/22039388.
5. Kulkarni S, Sia ST. Hazards of labor pain and the role of non-neuraxial labor analge-
MG. These results indicate that heat application and massage can be sia. Curr Anaesth Crit Care. 2014;4:109–114. https://doi.org/10.1016/j.
safely and effectively used as midwifery intervention to reduce pain tacc.2014.04.009.
 ARTICLE IN PRESS
8 € rkmen and N.T. Oran / Explore 00 (2020) 1 8
H. Tu

6. Pang D, O’Sullivan G. Analgesia and anaesthesia in labor. Obstet Gynaecol Reprod 29. Ranjbaran M, Khorsandi M, Matourypour P, Shamsi M. Effect of Massage Therapy
Med. 2008;18(4):87–92. on Labor Pain Reduction in Primiparous Women: a Systematic Review and Meta-
7. Smith CA, Collins CT, Cyna AM, Crowther CA. Complementary and alternative ther- analysis of Randomized Controlled Clinical Trials in Iran. Iran J Nurs Midwifery Res.
apies for pain management in labor. Cochrane Database Systematic Rev. 2010;4. 2017;22(4):257 261. https://doi.org/10.4103/ijnmr.IJNMR_109_16.
https://doi.org/10.1002/14651858.CD003521.Pub2. Art. No.: CD003521. PMID: 30. Hu J, Brettle A, Jiang ZY, Zeng YC. A systematic review and meta-analysis of the
17054175. effect of massage therapy in pain relief during labor. J Nurs. 2017;6(4):1–14.
8. Erdogan SU, Yanıkkerem E, Goker A. Effects of low back massage on perceived https://doi.org/10.18686/jn.v6i4.130.
birth pain and satisfaction. Complement Ther Clin Pract. 2017;28:169–175. https:// 31. Taavoni S, Sheikhan F, Abdolahian S, Ghavi F. Birth ball or heat therapy? A random-
doi.org/10.1016/j.ctcp.2017.05.016. PMID: 28779925. ized controlled trial to compare the effectiveness of birth ball usage with sacrum-
9. Kolcaba KY. Holistic Comfort: operationalizing the construct as a nurse-sensitive perineal heat therapy in labor pain management. Complement Ther Clin Pract.
outcome. Adv Nurs Sci. 1992;15(1):1–10.. PMID: 1519906; https://www.ncbi.nlm. 2016;24:99 102. https://doi.org/10.1016/j.ctcp.2016.04.001.
nih.gov/pubmed/1519906. 32. Çevik SA, Karaduman S. The effect of sacral massage on labor pain and anxiety: a
10. Schuiling KD, Sampselle C, Kolcaba K. Exploring the presence of comfort within the randomized controlled trial. Jpn J Nurs Sci. 2020;17:1–9. https://doi.org/10.1111/
context of childbirth. Theory Midwifery Practice. Sec. Ed.. 2011:197–212. jjns.12272.
11. Koehn ML. Alternative and complementary therapies for labor and birth: an applica- 33. World Health Organization. WHO recommendations: Intrapartum Care For a Positive
tion of Kolcaba's Theory of Holistic Comfort. Holist Nurs Pract. 2000;15(1):66–77. ISSN: Childbirth Experience. Geneva: World Health Organization; 2018. Licence: CC BY-
08879311. PMID: 12119621; https://www.ncbi.nlm.nih.gov/pubmed/12119621. NC-SA 3.0 IGO. ISBN 978-92-4-155021-5.
12. Chuntharapat S, Petpichetchian W, Hatthakit U. Yoga during pregnancy: effects on 34. Potur DC, Merih YD, Ku € lek H, Gu € The Validity and Reliability of the Turkish
€ rkan OC.
maternal comfort, labor pain and birth outcomes. Complement Ther Clin Pract. Version of the Childbirth Comfort Questionnaire. J Anatolia Nurs Health Sci.
2008;14:105–115. https://doi.org/10.1016/j.ctcp.2007.12.007. 2015;18(4):252–258. http://dergipark.gov.tr/ataunihem/article/34841.
13. Lane E, Latham T. Managing pain using heat and cold therapy. Pediatr Nurs. 35. Hartrick CT, Kovan JP, Shapiro S. The Numeric Rating Scale for Clinical Pain Mea-
2009;21:14–18. https://doi.org/10.7748/paed2009.07.21.6.14.c7146. PMID: surement: a Ratio Measure? Pain Practice. 2003;3(4):310–316. https://doi.org/
19623797. 10.1111/j.1530-7085.2003.03034.x. PMID: 17166126.
14. Bolbol- Haghighi N, Masoumi SZ, Kazemi F. Effect of massage therapy on duration 36. Yazdkhasti M, Hanjani SM, Tourzani ZM. The effect of localized heat and cold ther-
of labor: a randomized controlled trial. J Clin Diagn Res. 2016;10(4):12–15. https:// apy on pain intensity, duration of phases of labor, and birth outcomes among pri-
doi.org/10.7860/JCDR/2016/17447.7688. PMID: 27190898. miparous females: a randomized, controlled trial. Shiraz E-Medical J. 2018;19(8):
15. Dahlen HG, Homer CSE, Cooke M, Upton AM, Nunn RA, Brodrick BS. Soothing the e65501. https://doi.org/10.5812/semj.65501. In Press2018.
ring of fire: australian women’s and midwives experiences of using perineal warm 37. Tarrats L, Paez I, Navarri I, Cabrera S, Puig M, Alonso S, et al. Heat Application on
packs in the second stage of labor. Midwifery. 2009;25(2):39–48. https://doi.org/ Lumbar and Suprapubic Pain During the Onset of Labour Using a New Abdominal
10.1016/j.midw.2007.08.002. PMID: 18031878. Two-Pocket Belt: a Randomized and Controlled Trial. Gynecol Obstet (Sunnyvale).
16. Tu€ rkmen H, Çetinkaya S, Apay E, Karamu € ftu
€ og
lu D, Kılıç H. The Effect of Perineal 2019;9:511. https://doi.org/10.35248/2161-10932.19.9.511.
Warm Application on Perineal Pain, Perineal Integrity, and Postpartum Comfort in 38. Use of Heat and Cold for Pain Relief, University of Missouri Health Care[document
the Second Stage of Labor: randomized Clinical Trial. Complement Med Res. on the Internet]. Available from:http://medicine.missouri.edu/ortho/uploads/
2020:1–8. https://doi.org/10.1159/000507605. Heat&Cold.pdf. (Date of access: 12.04.2016).
17. Akbarzadeh M, Nematollahi A, Farahmand M, Amooe S. The Effect of Two-Staged 39. Kimber L. 1999. Massage techniques for childbirth. Date of access: 05.05.2016,
Warm Compress on the Pain Duration of First and Second Labor Stages and Apgar http://www.positivehealth.com/article/childbirth/massage-techniques-forchild
Score in Prim Gravida Women: a Randomized Clinical Trial. J Caring Sci. 2018;7 birth.
(1):21–26. https://doi.org/10.15171/jcs.2018.004. 40. Chang MY, Wang SY, Chen CH. Effects of massage on pain and anxiety during
18. Tarrats-Velasco L, Cabrera-Jaime S, Gonzalo-de Liria CR, Marti-Ras N, Puig-Domi- labor: a randomized controlled trial in Taiwan. J Adv Nurs. 2002;38(1):68–73..
ngo M. An Elastic Two-Pocket Pelvic Belt For the Application of Local Lumbo-Pelvic PMID: 11895532; https://www.ncbi.nlm.nih.gov/pubmed/11895532.
Heat in Labour. Gynecol Obstet (Sunnyvale). 2019;9:515. https://doi.org/10.35248/ 41. Ghani RMA. Effect of heat and cold therapy during the first stage of labor on
2161-10932.19.9.51. women perception of birth experience: a randomized controlled trial. J Biol Agric
19. Kaur J, Sheoran P, Kaur S, Sarin J. Effectiveness of Warm Compression on Lumbo- Healthc. 2014;4(26):66–72. https://www.iiste.org/Journals/index.php/JBAH/arti-
Sacral Region in Terms of Labour Pain Intensity and Labour Outcomes among Nul- cle/view/17411.
liparous: an Interventional Study. J Caring Sci. 2020;9(1):9 12. https://doi.org/ 42. Chaillet N, Belaid L, Crocheti C, Roy L, Gagn GP, Moutquin JM. et al. Nonpharmaco-
10.34172/jcs.2020.002. logic approaches for pain management during labor compared with usual care: a
20. Taghinejad H, Delpisheh A, Suhrabi Z. Comparison between massage and music meta-analysis. BIRTH. Issues Prenat Care. 2014;41(2):122–137. https://doi.org/
therapies to relieve the severity of labor pain. J Women's Health. 2010;6(3):377– 10.1111/birt.12103. PMID: 24761801.
381. https://doi.org/10.2217/whe.10.15. PMID: 20426604. 43. Field T. Pregnancy and labor massage. Expert Rev Obstet & Gynecol. 2010;5(2):177–
21. Smith CA, Levett KM, Collins CT, Jones L. Massage, reflexology and other manuel 181. https://doi.org/10.1586/eog.10.12. PMID: 20479957.
methods for pain managment in labor (review). Cochrane Libr. 2012;2:1–43. 44. Behmanesh F, Pasha H, Zeinalzadeh M. The effect of heat therapy on labor pain
https://doi.org/10.1002/14651858.CD009290.pub2. PMID: 22336862. severity and delivery outcome in parturient women. Iran Red Crescent Med J.
22. Karami NK, Safarzadeh A, Fathizadeh N. Effect of massage therapy on severity of 2009;11(2):188–192.
pain and outcome of labor in primipara. Iranian J Nursing Midwifery Res. 2007;12 45. Lee SL, Liu CY, Lu YY, Gau ML. Efficacy of warm showers on labor pain and birth
(1):6–9. https://www.researchgate.net/publication/228770678_Effect_of_ experiences during the first labor stage. J Obst Gny Neo. 2013;42:19–28. https://
Massage_Therapy_on_Severity_of_Pain_and_Outcome_of_Labor_in_Primipara. doi.org/10.1111/j.1552-6909.2012.01424.x. PMID: 23167574.
23. Yildirim G, Sahin NH. The effect of breathing and skin stimulation techniques on 46. Liu Y, Liu Y, Huang X, Du C, Peng J, Huang P. et.al. Comparison of maternal and neo-
labor pain perception of Turkish women. Pain Res Manage. 2004;9(4):183–187. natal outcomes between water immersion during labor and conventional labor
PMID: 15605131; https://www.ncbi.nlm.nih.gov/pubmed/15605131. and delivery. BMC Pregnancy Childbirth. 2014;14(160):1–7.. PMID: 24886438;
24. Taavoni S, Abdolahian S, Haghani H. Effect of sacrum-perineum heat therapy on active https://doi.org/10.1186/1471-2393-14-160.
phase labor pain and client satisfaction: a randomized, controlled trial study. Pain Med. 47. Essa RM, Ismail NIAA. Effect of second stage perineal warm compresses on perineal
2013;14:1301–1306. https://doi.org/10.1111/pme.12161. PMID: 23746110. pain and outcome among primiparae. J Nurs Educ Pract. 2016;6(4):48–58. https://
25. Chang MY, Chen CH, Huang KF. A comparison of massage effects on labor pain using doi.org/10.5430/jnep.v6n4p48.
the McGill Pain Questionnaire. J Nurs Res. 2006;14:190–197. PMID: 16967401. 48. Kamalifard M, Shahnazi M, Melli MS, Allahverdizadeh S, Toraby S, Ghahvechi A.
26. Mortazavi SH, Khaki S, Moradi R, Heidari K, Rahimparvar SFV. Effects of massage The efficacy of massage therapy and breathing techniques on pain intensity and
therapy and presence of attendant on pain, anxiety and satisfaction during labor. physiological responses to labor pain. J Caring Sci. 2012;1(2):73–78. https://doi.
Arch Gynecol Obstet. 2012;286:19–23. https://doi.org/10.1007/s00404-012-2227- org/10.5681/jcs.2012.011. PMID: 25276679.
4. PMID: 22271239. 49. Simkin P, Bolding A. Update on nonpharmacologic approaches to relieve labor pain
27. Tzeng YL, Su T. Low back pain during labor and related factors. J Nurs Res. 2008;16 and prevent suffering. J Midwifery Womens Health. 2004;49(6):489–504. https://
(3):231–240. PMID: 18792893; https://www.ncbi.nlm.nih.gov/pubmed/ doi.org/10.1016/j.jmwh.2004.07.007. PMID: 15544978.
18792893. 50. American College of Nurse-Midwives. Hydrotherapy During Labor and Birth. Divi-
28. Ganji Z, Sahirvani MA, Rezaei-Abhari F, Danesh M. The effect of intermittent local sion of Standards and Practice; 2014. Clinical Documents Section(Date of
heat and cold on labor pain and child birth outcome. Iran J Nurs Midwifery Res. access:13.06.2017); http://www.midwife.org/acnm/files/ccLibraryFiles/Filename/
2013;18(4):298–303. https://www.ncbi.nlm.nih.gov/pubmed/24403926. 000000004048/Hydrotherapy-During-Labor-and-Birth-April-2014.pdf.