Chapter II

REVIEW OF RELATED LITERATURE AND STUDIES

The different articles gathered from related literatures below were published

from different countries. This contains information regarding Binaural Auditory

Beats, labor Pain and the factors associated with it, The Psychology of Pain, The

Second Phase of Labor, Pain and Anxiety Assessment, and Non-Pharmacological

Approaches to Manage Labor Pain and Anxiety.

Brainwave Entrainment: Binaural Auditory Beat Stimulation

Brainwave entrainment uses rhythmic stimuli to alter brainwave frequency

which leads to alteration in brain states. It has been investigated and used since

the late 1800s, yet many are still unaware that it exists. Those who listens to these

beats can benefit from even a single session of brainwave entrainment. (Huang

and Charyton, 2008).

The man who discovered binaural beats, Dove (1839), stated that when

the brain hears two tones of different frequencies in each ear simultaneously, it

causes the brain to perceive a new tone or beat.

It was not until 1973 though, that biophysicist Dr. Gerald Oster brought the

technology into mainstream awareness in a paper called Auditory Beats in the

Brain. According to Oster (1973), there is a possibility that physiological behavior

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changes that are hormonally induced may be made apparent by measuring the

binaural-beat spectrum. He stated that binaural beats involved different neural

pathways than conventional hearing, and they could trigger neural responses even

when both frequencies are below the human hearing threshold. This science

allows us to capture a specific frequency band and deliver it directly to our hearing

system, enabling us to experience brainwave entrainment. When beats of different

frequencies are introduced to the brain, the new perceived tone is the

mathematical difference between the two frequencies. For example, if a 200 Hz

sound frequency is sent to the left ear, and a 205 Hz is sent to the right ear, the

brain will process those two frequencies and perceive a new frequency at 5 Hz.

The brain follows along at the new frequency, which is 5 Hz, producing brainwaves

at the same rate of Hertz. The technical term for this process is Frequency

Following Response. Binaural Beats can entrain the brain to different states,

namely Alpha, Beta, Theta and Delta. The Delta brainwave state is a steady rate

of 0.1 to 4 Hz. The Theta brainwave state is a steady rate of 4 to 8 Hz. The Alpha

brainwave state is a steady rate of 8 to 14 hertz. The Beta brainwave state is a

steady rate of 14 to 30 hertz. And the Gamma brainwave state is a steady rate of

30 to 100 hertz.

Although the creation of Binaural Beats has only been made possible

through the technological advancements of this age, what most people don’t

realize is binaural beats dates back thousands of years. Ancient cultures were

aware of how the brain could be entrained through sound repetition well before

modern science was able to prove the process. They just did not refer to it as
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Binaural Beats. Scientist Melinda Maxfield, PhD (2001) conducted a research on

the drumbeats used during rituals of ancient cultures and discovered that they

generally beat at a steady rate of 4 ½ beats per second. This consistent beat

induced a trance-like state for the tribe, due to the brain shifting into a 4 ½ beats

per second brainwave frequency, which is a low Theta brainwave state.

There have been increasing reports and research efforts that are reporting

changes in mind processes associated with binaural beats. Binaural beating is an

audio phenomenon that is associated with relaxation, meditation, stress reduction,

pain management and improved sleep (Wilson 2000, Rhodes, 2003).

According to Argibay, Santed and Reales (2016) in a meta-analyses study

they conducted, three studies were found wherein the analgesic effects of binaural

beats were assessed. Dabu Bondoc (2010) and Kliempt, Ruta, Ogston, Landeck

and Martay (2000), measured the amount of anesthesia that were used on patients

on complex binaural beat therapy. Results showed a considerable smaller

analgesia requirement when subjects were exposed to binaural beats compared

to the control group that was not exposed to the said intervention.

Labor Pain and Factors Affecting Its Perception

According to the American Journal of Obstetrics and Gynecology (2002),

labor pain is a paradox in the magical world of childbirth. Due to the complex

physiological and psychosocial processes involved, the perception of pain varies

between each pregnancy.

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There is a sense of individuality regarding the experience of pain which

means that not all women go through it the same way. As stated by Whitburn,

Jones, Davey and Small (2017), one of the determinants of pain perception during

labor is the meaning she attributes to it. If a woman perceives pain as a positive

experience, then the outcome also connects to positive emotions and cognition.

On the other hand, if a woman views childbirth as threatening then the outcome

would connect to feelings of negativity, worsening the pain she is experiencing.

Hence, one of the major factors in determining a woman’s ability to cope with pain

is her social environment.

The experience of labor pain is a highly individualized reflection of a

variable stimuli uniquely received and interpreted through an individual’s

emotional, motivational, cognitive, social and cultural circumstances. Choosing

one among a variety of methods of pain-related care is desirable. (Lowe, 2002)

The Psychology of Pain: On Anxiety

Pain varies from person to person, culture to culture. According to the book

The Challenge of Pain by Melzack and Wall (1982), the amount and quality of pain

a woman feels is also determined by their previous experiences and how well they

remember them. It is also determined by their ability to understand the origin of

their pain and comprehend its consequences. Even the culture in which they have

been brought up plays an important role on how they would react and feel pain.
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Simkin (2011) states that psychological pain can be manifested in fear,

anxiety and panic attacks and can be the outcome of lack of preparation,

knowledge, and understanding of the birthing process.

If a person’s attention is focused solely on a potentially painful experience,

he will tend to perceive pain more intensely than he normally would. In a study

conducted by Hall and Stride (2000), even a simple appearance of the word ‘pain’

in a set of instructions made test subjects reported a level of electric shock as

painful when they did not regard that as painful when the word ‘pain’ was absent

from the series of instructions. Hence, the mere anticipation of pain can intensify

the perception of pain.

Distraction of attention away from pain is also well-known. A study of the

effects of music and white noise on pain shows that people quickly use those

auditory sources to reduce their pain. In an experiment made by Melzack, Weisz,

and Spraque (2000), the subjects had their hand immersed in ice-water which

elicited a deep, aching, severe pain that few people can tolerate for only a few

minutes. Later on, the subjects were given an opportunity to listen to music and

white noise. But they did not just sit back and listened passively to it, instead, they

tapped their feet, turned the volume louder and sang along with it in an attempt to

distract themselves from the pain. Distraction of attention is useful to laboring

women because it only works if the pain rises slowly in intensity. They often find

that the pain actually decreases before it reaches the anticipated intolerable level.
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First Stage of Labor

The first stage of labor is when contractions slowly opens up the cervix. It

has 3 stages: early labor, active labor and the transitional phase. During the first

stage, your cervix needs to ripen and open to prepare for the delivery of the baby.

By the end of this stage, the cervix will be fully dilated at about ten (10) centimeters

in diameter (McCormick, 2009)

According to Zwelling, Johnson, and Allen (2006), during the first stage of

labor, the woman only experiences discomfort during contractions and is

essentially pain-free in between contractions. Although, there are some women

who experiences persistent low back pain even during in-between contractions.

These are those women whose fetus is in a posterior position. As labor progresses

and the cervix continues to dilate, the woman becomes more tired and has a lot

more difficulty in coping with the pain.

Active Phase of Labor

The second phase of labor is termed the Active phase. It is considered to

begin at the time the woman’s cervix begins dilating at 3cm continuing to 7cm.

Contractions during this phase will last for about 45 to 60 seconds with 3 to 5-

minute intervals (Satin, 2018).

According to Angeby et al (2018), in the study they conducted in a mid-

sized hospital in western Sweden that consisted of 1343 birth records of women

who intended vaginal births and who has spontaneous onset of labor, a prolonged
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Active phase of labor was more common among nulliparous than multiparous

women. The study also stated that Amniotomy increases the chance to have

prolonged Active phase of labor for both nulliparous and multiparous women.

Women who experienced prolonged Active phase were more likely to receive

obstetric intervention, assisted vaginal birth for nulliparous and emergency

cesarean section for both nulliparous and multiparous women.

Pain and Anxiety Assessment

According to Yazbek (2016), the key for labor pain management is pain

assessment. A standardized pain assessment instrument can help with the correct

measurement and management of labor pain.

Childs, Piva, and Fritz (2005) stated that the Numeric Pain Rating Scale

(NPRS) is a unidimensional tool for measuring pain intensity in adults.

The Numeric Pain Rating Scale is a valid and reliable scale to measure

pain intensity. Also, one strength of this measure is the simplicity of scoring

(Hawker, 2011).

Besides the Numeric Pain Rating Scale, Likert Scales can also be used to

assess pain. According to Polit and Beck (2014), Likert Scale remains one of the

oldest methods for pain assessment and is also the most widely used scale for

pain measurement.

For the measurement of anxiety, the Hospital Anxiety and Depression

Scale will be used. This test only takes 2 to 5 minutes to complete. It was designed
 17

to provide a simple, yet reliable, tool for use in medical practice. The term ‘hospital’

in its title suggests that it is only valid in such settings, but many studies conducted

throughout the world have confirmed that it is valid when used in community

settings and primary care medical practices. (Snaith, 2003)

HADS was found to perform well in assessing the symptoms and

severity of anxiety disorders and depression in both somatic, psychiatric and

primary care patients and in the general population (Bjelland, Dahl, Haug and

Neckelmann 2002)

Non-Pharmacological Approaches to Manage Labor Pain and Anxiety

The management of labor pain is a major goal of intrapartum care. There

are two general approaches—pharmacologic and non-pharmacologic. The first

one is directed at reducing or eliminating the physical sensation of pain, whereas

non-pharmacologic approaches are directed at the prevention of suffering.

Suffering may be defined as a perceived threat to the body or psyche,

helplessness and feeling of losing control. Pain and suffering are often occurring

at the same time, but one may suffer without pain or may have pain without

suffering (Belaid, 2000)

According to Hamidzadeh, Shahpourian and Orak (2012) complementary

and alternative medicines have been used to decrease labor pain for many years.

In the study they conducted, they concluded that one of the non-pharmacological

interventions for pain which is the L14 acupressure was effective not only in
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decreasing labor pain, but also in shortening the duration of labor. Their

participants were satisfied, and no adverse effects were noted.

The Journal of Midwifery on Women’s Health (2004) stated that control of

labor pain is one of the major concerns of clinicians and their patients. Suffering,

which has an entirely different concept than pain, is not an outcome that is usually

monitored after childbirth. There are no adequate studies to determine the

effectiveness of relaxation techniques and deep-breathing exercises, heat and

cold compress, acupressure, hypnosis, aromatherapy and music therapy. And

even if there are research studies dedicated on this topic, findings are still too

varied to draw conclusions on its effectiveness. Though this may be the situation,

widespread satisfaction was reported among the majority of the users of these

non-pharmacological management techniques.

Synthesis

Zampi (2016) conducted a study entitled “Efficacy of Theta Binaural Beats

for the Treatment of Chronic Pain”. The similarity between both studies is that both

researchers are studying Binaural Beats as a management for Pain. The difference

between the two studies is that in the study mentioned above, Binaural Beats in

the Theta frequency was specifically studied. Another difference is the above

research focused on chronic pain, while the current research will be focusing on

labor pain. Zampi utilized the Haven-Yale Multidimensional Pain Inventory with

thirty-six (n=36) respondents with various types of chronic pain with the age
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ranging from twenty-six (26) to sixty-nine (69) years old. On the other hand, the

researchers will use the Numeric Pain Scale and Likert Scale as their research

instrument and will utilize pure-toned binaural beats. For the sample size, the

researchers will be asking a total of six (6) pregnant Filipino women with the age

ranging from twenty (20) to forty (40) years old to join the study.

Another dissimilarity is the research locale. Zampi conducted his research

at Richmond, Virginia, USA with participants recruited from the financial sector,

while the current study will be conducted at private lying-in clinics in Marikina,

Philippines.

This study is unique due to the utilization of a pure-toned binaural auditory

beat. There are currently too few studies on the effects of binaural beats in pain

management. Also, the researchers aim to prove this certain non-pharmacological

approach is an effective method in managing pain experienced by women in labor.