ORIGINAL ARTICLE

The influence of cold pack on labour pain relief and birth

outcomes: a randomised controlled trial
Marjan Ahmad Shirvani and Jila Ganji

Aims and objectives. (1) To evaluate the influence of local cold on severity of labour pain and (2) to identify the effect of local
cold on maternal and neonatal outcomes.
Background. Fear of labour pain results in an increase in pain and duration of labour, maternal discontent and demand for
caesarean section. Regarding maternal and foetal complications of analgesic medications, the attention to application of
nonpharmacological methods including cold therapy is increased.
Design. Randomised controlled trial.
Methods. Sixty-four pregnant women, at initiation of active phase of labour, were allocated randomly to cold therapy and
control groups (n = 64). Null parity, term pregnancy, presence of single foetus, cephalic presentation and completing
informed consent were considered as inclusion criteria. Administration of analgesic and anaesthesia, foetal distress, skin
lesions in regions of cold therapy and high-risk pregnancy provided exclusion criteria. Cold pack was applied over abdomen
and back, for 10 minutes every 30 minutes during first phase of labour. Additionally, cold pack was placed over perineum,
for 5 minutes every 15 minutes during second phase. Pain severity was assessed based on the visual analogue scale.
Results. The two groups were not significantly different considering demographic data, gestational age, foetal weight, rup-
ture of membranes and primary severity of pain. Degree of pain was lower in cold therapy group during all parts of active
phase and second stage. Duration of all phases was shorter in cold therapy group in all phases. Foetal heart rate, perineal
laceration, type of birth, application of oxytocin and APGAR score were not significantly different between two groups.
Conclusion. Labour pain is probably reduced based on gate theory using cold. Pain control by cold maybe improves labour
progression without affecting mother and foetus adversely.
Relevance to clinical practice. Local cold therapy could be included in labour pain management.

Key words: cold, foetal, labour pain, maternal, outcome

Accepted for publication: 29 April 2013

and cultural factors; thus, it is difficult to predict the sever-

Introduction
Pain is an inevitable part of labour. The severity of pain is
reported to be mild, moderate, severe and intolerable in 15,
35, 30 and 20% of patients, respectively (Abushaikha
2005). The severity of pain is a reflection of different stim-
uli influenced by emotional, cognitive, motivational, social
ity of pain. Nevertheless, talking about labour pain causes
an imagination of severe pain in the mind (Green 1993,
Brownridge 1995, Lowe 2002). This results in preference of
caesarean section, despite all dangers and side effects, even
in patients without history of labour (Kolas et al. 2003,
Nerum et al. 2006). Fear of pain forms a vicious cycle, as

Authors: Marjan Ahmad Shirvani, MSc, Senior Lecturer, Depart- Correspondence: Jila Ganji, Senior Lecturer, Faculty of Nursing
ment of Midwifery, Mazandaran University of Medical Sciences, and Midwifery, Vesal st. Sari, Iran. Telephone: +01133367343.
Sari School of Nursing & Midwifery, Amir Mazandarani Boule- E-mail: zhila.ganji@yahoo.com
vard, Vesal St. Sari; Jila Ganji, MSc, Senior Lecturer, PhD Student
in Reproductive Health, Member of Student Research Committee,
Department of Midwifery, Mazandaran University of Medical
Sciences, Sari, Iran

© 2013 John Wiley & Sons Ltd

Journal of Clinical Nursing, 23, 2473–2480, doi: 10.1111/jocn.12413 2473
M Ahmad Shirvani and J Ganji
fear exacerbates the pain and vice versa (Saisto et al. 2001,
Leeman et al. 2003, Cunningham et al. 2010). Fear and
anxiety stimulate sympathetic system and increase catechol-
amine that results in more pain, prolonged labour and
unsatisfactory experience of labour (Fuchs & Fuchs 1984,
Alehagen et al. 2001, Sercekus & Okumus 2007).
The nature of labour pain differs from other pains as it
results from uterus contractions–which are painful in con-
trast to muscular physiological spasms–not from real
trauma, tissue damage or abnormal procedure. Various
aetiologies are considered to be responsible for painful
myometrium contraction including hypoxaemia, pressure
on neuronal ganglions of cervix and lower parts of uterus,
distension of cervix and peritoneum covering fundus, in
addition to stretching of vagina and perineum and pressure
on pelvic floor muscles during the second phase of labour
(Leeman et al. 2003, Cunningham et al. 2010, El-Wahab
& Robinson 2011). As labour progression is dependent on
distension of vagina and perineum and uterus contractions,
it is not possible to remove the pain source and methods
should be applied for decreasing the pain. On the other
hand, most pregnant women request some kind of pain
relief during labour (Fridh & Gaston-Johansson 1990,
Kangas-Saarela & Kangas-K€arki 1994, Goldberg et al.
1999). Nowadays, using nonpharmacological methods is
preferred as drug administration during birth is limited
based on maternal and foetal complications, decreased par-
ticipation of mothers during labour, need for a specialist
and financial burden (Simkin & Bolding 2004, Cunningham
et al. 2010).
Background
It has been shown that application of severe cold–ice–exerts
strong and transient analgesic effect; consequently, its serial
application can be beneficial (Ernst & Fialka 1994). Local
application of cold is a nonpharmacological sensory
intervention applied in a wide range–superficial cold to ice
massage–on back, anus and perineum for attenuating deliv-
ery pain (Lieberman 1992, Simkin 1995, Simkin & Bolding
2004, Allaire 2007). Different instruments are used for this
purpose such as ice-filled glove, rolling pin and ice water–
dampened towel (Simkin & Bolding 2004).
In a study in 210 delivery units in Britain, it was demon-
strated that cold packs were applied in 44 (21%) centres
for pain control during the second phase of labour (Sanders
et al. 2005). In 9 maternity centres in USA, only 2
2% of
parturient women received local cold or heat; however, the
most probability of spontaneous vaginal birth was seen in
this group; the adjusted probability of spontaneous birth
2474
according to parity was 1
05 with CI 95%: 0
97–1
13 (The
CNM Data Group 1998). In a study performed on 46
women, 41 (91
1%) were trained to use cold/heat, but only
13 (28%) had applied the method (Brown et al. 2001).
Although cold therapy is being used as a conventional
method for peripartum women, to our knowledge, there is
no randomised controlled trial evaluating effect of cold in
decreasing labour pain. Most studies in this field have eval-
uated the effect of cold on reducing perineal pain (Ramler
& Roberts 1986, Leventhal et al. 2011, East et al. 2012) or
stimulating acupuncture points (Waters & Raisler 2003). In
the present study, we aimed to evaluate the effect of cold
on severity of pain and maternal and neonatal outcomes.
Methods
Design
This study was a randomised controlled trial with parallel
design that was performed in two hospitals in northern Iran
between September 2011–March 2012.
Study subjects
Sixty-four pregnant women admitted to labour unit were
randomly allocated to two groups as cold therapy (n = 32)
and control (n = 32). The head of research generated the
random allocation sequence by numbered cards. The groups
were matched based on the rupture of membranes and
body mass index (BMI). Inclusion criteria included the
following: null parity, age of 18–35, gestational age of
37–41 weeks, single pregnancy, cephalic presentation and
cervix dilatation of 3–4 cm. Patients with psychiatric disor-
ders, contracted pelvic, chronic systemic disorders, dermato-
logical problems in cold therapy region and complications of
pregnancy such as gestational hypertension, decrease in foetal
movement, foetus growth retardation, foetal death, abnormal
foetal heart rate and application of other pharmacological or
nonpharmacological analgesic methods were excluded.
Ethical considerations
The Ethical Committee of Mazandaran University of Medi-
cal Sciences approved the study’s protocol. The researcher
explained the study to all eligible parturient women who
were candidates for vaginal birth, when they were admitted
to the labour unit. Then, if they agree to participate, the
researcher would provide them information form and reply
to probably questions in the onset of active phase of
labour. They completed the informed consent form before
© 2013 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 2473–2480
Original article
enrolling in the study. Participants could leave the study
whenever they want. Also, they are not required to pay for
addition cares.
Intervention
In cold therapy group, a trained doula, who was a midwife,
applied a 25 9 15 cm ice bag filled with 500 gr ice covered
by a towel over back, abdomen and lower parts of the
abdomen for 10 minutes since initiation of active phase
and repeated 30 minutes later. Additionally, she applied a
15 9 10 cm cool pack filled with 200 gr ice over perineum
during the second phase of delivery for 5 minutes every
15 minutes. The intervals were selected based on the mini-
mum time for initiation of cold effect, 5–10 minutes, and
its long effect (Pasero & McCaffery 1999). To control the
supporter effect, the doula gave the same supportive cares
to mothers in the control group during the labour. Also,
the researcher had awarded. her about importance of simi-
larity in supportive cares and checked it during the study.
A bedside midwife did routine care in both groups, such as
control of foetal heart rate and uterine contractions, appli-
cation of oxytocin if it was necessary and perform delivery
and episiotomy. We did not apply additional interventions
except for routine care for control group. Vaginal examina-
tions were performed based on cervix situation and labour
progression, almost every 1 hour.
Data collection
Obstetric and demographic information of patients was col-
lected by interview and reviewing the record files. Pain
severity was assessed by visual analogue scale (VAS).
A trained midwife asked participants of the two groups to
demonstrate the severity of pain on VAS at the beginning
of the active phase (dilatation of 3–4 cm), acceleration
phase (dilatation of 5–6 cm), maximum of slope (dilatation
of 7–8 cm), deceleration (dilatation of 9–10 cm) and the
second phase of labour. She recorded the data about dura-
tion of all phases of delivery, obstetric interventions and
maternal, foetal and neonatal outcomes in sheets for both
groups. Patients’ satisfaction about labour experience was
evaluated at the end of delivery by a five-point Likert ques-
tionnaire.
Statistical analysis
We used mean, standard deviation and frequency for
description of variables, chi-squared test and t-test for
comparison of qualitative and quantitative variables,
© 2013 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 2473–2480
The influence of cold pack on labor pain
respectively, and repeated measurement for evaluating
course of changes in and between two groups. The statisti-
cal significance was considered as a p value less than 0
05.
Results
Eighty-two parturient women were assessed, and after
exclusion of some women due to existence of confounder
variables and decline to participate, finally 64 eligible
women were enrolled in two groups of cold pack and
control consisting of 32 women in each group (Fig 1). No
significant difference was observed for obstetric and
demographic characteristics between the two groups
(Table 1).
Pain severity comparison based on the VAS score during
different labour phases revealed no significant differences
between the two groups at the initiation of active phase
(6
81  1
9 in cold therapy group and 7
0  2
03 in the
control group), while the differences were significant during
other phases. The pain severity was 5
53  1
34 and
6
96  2
10 (p < 0
02) during acceleration phase,
6
09  1
55 and 7
93  1
41 (p = 0
0001) through maxi-
mum of slope, 6
21  1
47 and 8
84  1
32 (p = 0
0001)
in deceleration phase and 6
50  1
64 and 9
25  1
10
(p = 0
0001) during second stage of birth in cold therapy
and control groups, respectively. So degree of pain was sig-
nificantly lower in cold therapy group compared with con-
trol. Although pain increased during labour process in cold
therapy group, it was always less severe than the initial
pain, while in control group, pain rose to a level more than
that of the initial phase except for acceleration phase.
Repeated measurement test revealed a significant difference
between the two groups in pain severity by time; addition-
ally, a significant interaction was found between the degree
of pain and kind of intervention. Figure 1 demonstrates
sequence of change in pain severity by time between the
two groups.
Duration of first, second and third stages of labour and
application of oxytocin were significantly shorter in cold
therapy group, but no significant difference was observed
between the two groups considering foetal heart rate, 1st
and 5th minute’s APGAR score, type of delivery and peri-
neal injury (Table 2).
In the cold therapy group, 53
1% and 37
5% of patients,
respectively, were moderately and highly satisfied about the
process of labour. On the other hand, in the control group,
most patients were unsatisfied or poorly satisfied and only
1 woman (3
1%) was highly satisfied. The difference in sat-
isfaction rate between the groups was significant
(p = 0
0001) (Fig. 2).
2475
M Ahmad Shirvani and J Ganji

Figure 1 Flow chart of participants’ enrolment in the study.

Table 1 The personal and obstetric characteristics of cold pack and control groups

Obstetric factors Cold pack group Control group p-value

Age (year) M  SD *
28
53  5
41 28
56  5
4 NS†
BMI (Kg/m2) M  SD 26
55  7
71 25
12  3
87 NS
Education
Illiterate 1 (50
0%) 1 (50
0%)
Primary 8 (53
3%) 7 (46
7%) NS
High school 11 (50
0%) 11 (50
0%)
University 12 (48
0%) 13 (52
0%)
Gestational age (week) M  SD 39
09  0
85 39
03  0
86 NS
Neonatal weight (gr) M  SD 3387
5  247
24 3390
6  237
40 NS
PROM‡
Yes 15 (55
6%) 12 (44
4%) NS
No 17 (45
9%) 20 (54
1%)
Oxytocin application
Yes 16 (48
5%) 17 (51
5%) NS
No 16 (51
6%) 15 (48
8%)

*Mean  SD (Standard Deviation).

†
No significance (p > 0
05).
‡
Premature rupture of membrane.

in addition to perineum in the second phase. In the only

Discussion
Application of a safe and effective pain management
method during labour plays an important role in modern
maternity care. Although cold therapy is applied for this
purpose, to our knowledge, there is no randomised con-
trolled trial on this method (Lieberman 1992, Simkin 1995,
The CNM Data Group 1998, Brown et al. 2001, Simkin &
Bolding 2004, Sanders et al. 2005, Allaire 2007).
This study demonstrated significant reduction in labour
pain during the first and second phases after application of
local cold to the back, abdomen, lower parts of abdomen,
clinical study about cold effect on the pain of first stage of
labour, Waters and Raisler applied ice massage on Hoku
point (L14) (Waters & Raisler 2003). They reported ice
massage in right and left hands during the first phase of
birth, resulting in 28
22 and 11
93 mm decrease in mean
pain severity score based on the VAS, respectively. As Hoku
is an acupuncture point, it seems that reduction in labour
pain is based on the stimulation of this point not the cold
itself. Furthermore, in most studies, including systematic
review of Cochrane, outcome of cold on decreasing perineal
pain after birth was evaluated, which had positive results

© 2013 John Wiley & Sons Ltd

2476 Journal of Clinical Nursing, 23, 2473–2480
Original article The influence of cold pack on labor pain

Table 2 The comparison of delivery outcomes between cold pack and control groups

Delivery outcomes Cold pack group Control group p-value

First-stage duration (min)M  SD 190
44  60
90 273
91  108
13 0
000

Second-stage duration (min)M  SD 32
12  10
60 41
15  11
96 0
006
Third-stage duration (min)M  SD 5
25  2
30 10
78  4
89 0
000
Duration of oxytocin application (min) M  SD 148
75  43
79 187
5  57
44 0
040
Foetal heart rate M  SD 140
53  5
41 140
34  5
81 NS*
APGAR (1st minute) M  SD 8
75  0
56 8
71  0
58
APGAR (5th minute) M  SD 10 10 NS
Perineum
Episiotomy 27 (47
4%) 30 (52
6%) NS
Laceration (degree 1) 5 (71
4%) 2 (28
6%)
Instrumental delivery
Yes 0 (0%) 1 (3
1%) NS
No 32 (50
8%) 31 (49
2%)

*No significance (p > 0
05).

(Ramler & Roberts 1986, Leventhal et al. 2011, East et al. 10

2012). 9
Qualitative and quantitative studies have determined the 8

Pain severity based on vas

association of perineal stretch before birth with severe pain
7
(Niven & Gijsbers 1984, Lowe & Robers 1998, Salmon
6
1999, Anderson 2000). Lowe and Roberts determined the
5
second phase of labour as the most painful stage. The mean
pain severity was 33
11  13
5 in their study (Lowe & 4 Cold
Robers 1998). Additionally, Niven and Gijsbers reported 3
Control
the mean pain severity of the second phase as 30
4 based 2
on the McGill Pain Questionnaire (Niven & Gijsbers 1
1984). Current study showed significant decrease in degree
0
of pain in this phase in cold therapy group versus control.
t

pe

e
se

ag
tio

tio
slo
On

st
While pain significantly increased during the second phase
ra

ra
of

nd
le

la
ce
ce

co
um

De
Ac

in the control group, it did not differed from other stages

Se
im
ax
M

in the cold therapy group and was even milder than in the
initiation of active phase.
Various mechanisms are thought to be involved in the
analgesic effects of cold therapy, including change in nerve
conduction velocity, attenuation or block of pain conduction
to central nervous system via gate control theory, mind devi-
ation from pain, improvement of energy flow in acupuncture
points and decreased muscle stretch, which all result in
increase in pain perception threshold (Ernst & Fialka 1994,
The CNM Data Group 1998, Simkin & Bolding 2004).
Gate control theory describes change of pain perception in
brain by other stimulant competitive sensory signals (Wall
1978). Also, Totonchi et al. reported a reduction in anxiety
by cold therapy. Then it seems that decrease in catechol-
amine and increase in endorphin are other mechanisms of
pain management via cold therapy (Tootoonchi et al. 1999).
Furthermore, duration of all stages was shorter in cold
therapy group. Severe pain increases fear and anxiety, so
stimulates sympathetic system and releases catecholamine
Labor phases
Figure 2 The changes in labour pain in cold pack and control
group.
that result in prolonged labour (Sercekus & Okumus 2007,
El-Wahab & Robinson 2011). It seems that effective uterus
contractions produced by cold therapy persisted after birth,
as the third stage was also significantly shorter in the
experiment group. Curkovic and Vitulic reported cold
application increases pain threshold after 10–30 minutes
(Curkovic & Vitulic 1993). Pasero et al. reported higher
and longer efficacy of cold therapy in pain reduction com-
pared with heat application (Pasero & McCaffery 1999).
Consequently, the effect of cold may last up to the third
stage of labour after eliminating the source. Decrease in
duration of birth contributes to lower maternal fatigue,
decreased postpartum bleeding and prevention of unneces-
sary interventions. It seems that reduction in pain and birth

© 2013 John Wiley & Sons Ltd

Journal of Clinical Nursing, 23, 2473–2480 2477
M Ahmad Shirvani and J Ganji

duration is independent of oxytocin consumption and rup-
ture of membranes, as they were similar in both groups.
Alehagen et al. showed that the amount of pain relief influ-
ences the correlation between fear and duration of the sec-
ond phase of labour (Alehagen et al. 2001). As no other
pain-relieving method was applied and a doula was present
in control group, to eliminate the effect of supporter factor,
it seems that the cold therapy was the major effective factor.
Evaluating maternal and foetal outcomes considering foe-
tal heart rate, APGAR score, instrumental delivery and per-
ineal laceration demonstrated no adverse effect due to use
of cold pack. As heat prevents perineal laceration by
stretching the perineum, it is expected that cold acts rever-
sely (Sanders et al. 2005); although the rate of perineal lac-
eration was higher in cold therapy group, it was not
significantly different from the control group. However,
certain conclusions about cold effect on perineal laceration
are not possible because routine episiotomy was performed
in most of the patients in both groups. It seems that a sig-
nificant decrease in duration of oxytocin application is due
to more effective uterine contractions.
Maternal satisfactory rate was higher in cold therapy
group, considering the shorter duration of labour and lesser
pain. In a study performed by Brown et al., none of the
patients assessed topical cold/heat application ineffective
(Brown et al. 2001). Nonpharmacological methods includ-
ing cold therapy increased maternal satisfaction by inducing
control and empowerment feelings (Mackey 1995, Walden-
strom et al. 1996, Brown et al. 2001).
Only 4 women declined to participate in this study.
Women’s interest to the subject of labour pain control and
researcher’s explanations at the time of admission about the
process of study may be the reasons of this low decline. Of
course, it was a limitation of the study that no placebo
group was compared with the experiment group.
Conclusion
According to this study, application of local cold to the
back, abdomen and lower part of abdomen in the first
phase of labour, in addition to perineum in the second
phase, causes significant reduction in labour pain. Further-
more, based on the results, it probably has a benefit effect
on labour phases without adverse effect on mother and foe-
tal outcomes. More investigation into blind placebo group
is suggested. For above reasons, cold therapy is said to be
associated with higher satisfaction of mother.
Relevance to clinical practice
Pain is an inevitable part of labour. Consideration to man-
agement of labour pain is important because it can affect
the progress of labour and mother’s experience of birth. It
seems that application of cold therapy is a safe, simple and
available method with no need of experts who significantly
relieve labour pain.
Disclosure
The authors have confirmed that all authors meet the
ICMJE criteria for authorship credit (www.icmje.org/
ethical_1author.html), as follows: (1) substantial contribu-
tions to conception and design of, or acquisition of data or
analysis and interpretation of data, (2) drafting the article
or revising it critically for important intellectual content,
and (3) final approval of the version to be published.
Conflict of Interest
The authors have no conflict of interests to disclose. The
registration number in IRCT (www.irct.ir) was 20110827
7422N1.
Acknowledgement
This study was approved by Research Deputy of Mazanda-
ran University of Medical Sciences (project no. H89-
26).The authors would like to acknowledge this respectable
duty for financial support. Also we thank Dr. Khalilian for
statistical advice.

References
Abushaikha L (2005) Labor pain experience:
a Jordanian perspective. International
Journal of Nursing Practice 8, 33–38.
Alehagen S, Wijma K & Wijma B (2001) Fear
during labor. Acta Obstetricia et Gyne-
cologica Scandinavica 80, 315–320.
Allaire AD (2007) Complementary and
alternative medicine in the labor and
delivery suite. Clinical Obstetrics and
Gynecology 44, 681–691.
Anderson T (2000) Feeling safe enough to let
go the relationship between a woman
and her midwife during the second stage
of labour. In The midwife-mother rela-
tionship (Kirkham M ed), Macmillan
Press Ltd, London, pp. 92–119.
Brown ST, Douglas C & Flood LAP (2001)
Women’s evaluation of intra partum
non pharmacological pain relief meth-
ods used during labor. The Journal of
Perinatal Education 10, 1–8.
Brownridge P (1995) The nature and con-
sequences of childbirth pain. European
Journal of Obstetrics, Gynecology,

© 2013 John Wiley & Sons Ltd

2478 Journal of Clinical Nursing, 23, 2473–2480
Original article
and Reproductive Biology 59,
S9–S15.
Cunningham FG, Leveno KJ, Bloom SL,
Hauth JC, Rouse DJ & Spong CY
(2010) Williams Obstetrics (21 ed.). Mc
Graw Hill Medical, New York, NY.
Curkovic B & Vitulic V (1993) The influence
of heat and cold on the pain threshold
in rheumatoid arthritis. Zeitschriftf€ ur
Rheumatologie 52, 289–291.
East CE, Begg L, Henshall NE, Marchant P
& Wallace K (2012) Local cooling for
relieving pain from perineal trauma sus-
tained during childbirth (review). Coch-
rane Database of Systematic Review.
Available at: http://mrw.interscience.
wiley.com/cochrane/clsysrev/articles/
CD006304/frfra.html (accessed 10
November 2012).
El-Wahab N & Robinson N (2011) Anal-
gesia and anesthesia in labor. Obstet-
rics Gynecology and Reproductive
Medicine 21, 137–141.
Ernst E & Fialka V (1994) Ice freezes
pain? A review of the clinical effec-
tiveness of analgesic cold therapy.
Journal of Pain and Symptom Man-
agement 9, 56–59.
Fridh G & Gaston-Johansson F (1990) Do
primiparas and multiparas have realis-
tic expectations of labor. Acta Journal
of Obstetrics and Gynecology Scandi-
navia 69, 103–109.
Fuchs AR & Fuchs F (1984) Endocrinol-
ogy of human parturition: a review.
British Journal of Obstetrics and
Gynecology 4, 948–967.
Goldberg AB, Cohen A & Lieberman E
(1999) Nulliparas’ preferences for epi-
dural analgesia: their effects on actual
use in labor. Birth 26, 139–143.
Green JM (1993) Expectations and experi-
ences of pain in labor findings from a
large prospective study. Birth 20, 65–72.
Kangas-Saarela T & Kangas-K€arki K (1994)
Pain and pain relief in labour: parturi-
ents’ experiences. International Journal
of Obsterics Anesthesia 3, 67–74.
© 2013 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 2473–2480
Kolas T, Hofoss D & Daltveirt AK (2003)
Indications for caesarean deliveries in
Norway. American Journal of Obstet-
rics and Gynecology 188, 864–870.
Leeman L, Fontaine P, King V, Klein MC
& Ratcliffe S (2003) The nature and
management of labor pain: part I.
nonpharmacologic pain relief. Ameri-
can Family Physician 68, 1109–1112.
Leventhal LC, de Oliveira SM, Nobre MR
& da Silva FM (2011) Perineal analge-
sia with an ice pack after spontaneous
vaginal birth: a randomized controlled
trial. Journal of Midwifery and
Women’s Health 56, 141–146.
Lieberman AB (1992) Easing Labor Pain:
The Complete Guide to a More Com-
fortable and Rewarding Birth, revised
edition. Harvard Common Press, Bos-
ton, MA, pp. 114–115.
Lowe N (2002) The nature of labor pain.
American Journal of Obstetrics and
Gynecology 186, S16–S24.
Lowe NK & Robers J (1998) The conver-
gence between in labor report and
postpartum recall of parturition pain.
Research in Nursing and Health 11,
11–21.
Mackey MC (1995) Women’s evaluation of
their childbirth performance. Maternal
Child Nursing Journal 23, 57–72.
Nerum H, Halvorsen L & Sorlie T (2006)
Maternal request for caesarean section
due to fear of birth: can it be changed
through crisis-oriented counseling?
Birth 33, 221–228.
Niven C & Gijsbers K (1984) A study of
labor pain using the McGill Pain
Questionnaire. Social Science and
Medicine 19, 1347–1351.
Pasero C & McCaffery M (1999) Superfi-
cial cooling for pain relief. The Am
Journal of Nursing 99, 24.
Ramler D & Roberts J (1986) A compari-
son of cold and warm sitz bath for
relief of post partum perineal pain.
Journal of Obstetrics, Gynecology and
Neonatal Nursing 15, 471–474.
The influence of cold pack on labor pain
Saisto T, Kaaja R, Ylikorkala O & Hal-
mesmaki E (2001) Reduced pain toler-
ance during and after pregnancy in
women suffering from fear of labor.
Pain 93, 123–127.
Salmon D (1999) A feminist analysis of
women’s experiences of perineal
trauma in the immediate post-delivery
period. Midwifery 15, 247–256.
Sanders J, Peters T & Campbell R (2005)
Techniques to reduce perineal pain
during spontaneous vaginal delivery
and perineal suturing: a UK survey of
midwifery practice. Midwifery 21,
154–160.
Sercekus, P & Okumus H (2007) Fears
associated with child birthing among
nulliparous women in Turkey. Mid-
wifery 25, 155–162.
Simkin P (1995) Reducing pain and enhanc-
ing progress in labor: a guide to non
pharmacologic methods for maternity
caregivers. Birth 22, 161–170.
Simkin P & Bolding A (2004) Update on
non pharmacologic approaches to
relieve labor pain and prevent suffer-
ing. Journal of Midwifery and
Women’s Health 49, 489–504.
The CNM Data Group (1998) Midwifery
management of pain in labor. Journal
of Nurse Midwifery 43, 77–82.
Tootoonchi M, Aein F, Hasanpour M &
Yadegarfar G (1999) The effect of local
cold therapy and destruction on chil-
dren’s pain intensity of intramuscular
injection. Zahedan Journal of Research
in Medical Sciences 4, 73–77 (Abstract).
Waldenstrom U, Borg IM, Olsson B, Skold
M & Wall S (1996) The childbirth
experience: a study of 295 mothers.
Birth 23, 144–153.
Wall PD (1978) The gate control theory of
pain mechanisms: a re-examination
and re-statement. Brain 101, 1–18.
Waters L & Raisler J (2003) Ice massage
for reduction of labor pain. Journal of
Midwifery and Women’s Health 48,
317–321.
2479
M Ahmad Shirvani and J Ganji

The Journal of Clinical Nursing (JCN) is an international, peer reviewed journal that aims to promote a high standard of
clinically related scholarship which supports the practice and discipline of nursing.

For further information and full author guidelines, please visit JCN on the Wiley Online Library website: http://
wileyonlinelibrary.com/journal/jocn

Reasons to submit your paper to JCN:

High-impact forum: one of the world’s most cited nursing journals, with an impact factor of 1
316 – ranked 21/101
(Nursing (Social Science)) and 25/103 Nursing (Science) in the 2012 Journal Citation Reportsâ (Thomson Reuters, 2012).
One of the most read nursing journals in the world: over 1
9 million full text accesses in 2011 and accessible in over
8000 libraries worldwide (including over 3500 in developing countries with free or low cost access).
Early View: fully citable online publication ahead of inclusion in an issue.
Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jcnur.
Positive publishing experience: rapid double-blind peer review with constructive feedback.
Online Open: the option to make your article freely and openly accessible to non-subscribers upon publication in Wiley
Online Library, as well as the option to deposit the article in your preferred archive.

© 2013 John Wiley & Sons Ltd

2480 Journal of Clinical Nursing, 23, 2473–2480