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Measures
A patient data sheet was used for recording demographic and
clinical data from medical records. The nurse-rated present
behavioural intensity (PBI) (Bonnel & Boureau 1985) scale
was used as a measure of present manifestations of pain and
was translated into Chinese. The PBI is a five category
behavioural observation scale used to assess present beha-
Figure 1 Flow diagram of subject progress through the phases of vioural manifestations of pain: 0 – normal respiration, 1 – the
randomized trial. frequency or amplitude of respiration changes during con-
tractions, 2 – gasping reactions that cease during contraction
Procedure relaxation, 3 – gasping that persists between contractions,
After allocation, recruited subjects in the two groups were 4 – signs of agitation. Concurrent validity was supported by
told that pain and anxiety were to be compared through the Bonnel and Boureau (1985) with the self-reported present
three phases of labour. Subjects were approached by the pain intensity (PPI) scale, a measure of the overall pain
researcher who explained the purpose of the study and intensity on a scale of 0–5: 0 represents no pain, 1 mild, 2
described the data collection procedures. Informed consent discomforting, 3 distressing, 4 horrible, and 5 excruciating
was obtained. After the recruitment preliminaries had been pain. In the present study, the inter-rater reliability of PBI
carried out, subjects were asked to complete a form request- between the researcher, a clinical faculty member and a nurse
ing basic demographic information. In accordance with (n ¼ 3) was 100%. For three phases, concurrent validity
hospital policies for human experimentation, ethical approval correlations between the PBI and PPI were 0Æ45, 0Æ50 and
was obtained for the study. Permission to conduct the study 0Æ44.
and access the subjects was obtained from the director of The visual analogue scale for anxiety (VASA) consists of a
OBS-GYN and the head nurse of the unit. 10-cm horizontal line with the descriptors ‘no anxiety’ at the
Couples in the experimental group were given a detailed left and ‘worst possible anxiety’ at the right. Subjects were
description of the massage protocol. Following this, the asked to indicate how anxious they were feeling ‘right now’
primary researcher gave massage during uterine contractions by marking the appropriate place on the line. Higher values
in each phase and taught the method to the partner. In phase indicated increased levels of anxiety. The VASA is a reliable,
1 (latent phase, with the cervix dilated 3–4 cm) women were valid and sensitive self-reported measure for the study of
encouraged to close their eyes when uterine contractions subjective patient experiences including pain, nausea, fatigue
began and to take two deep breaths in order to concentrate and dyspnoea (Gift 1989).
on the massage. They received directional, reasonably firm Thirty minutes after childbirth, all subjects were asked to
and rhythmic massage lasting 30 minutes and comprising indicate subjective assessments of satisfaction with the child-
abdominal effleurage, sacral pressure and shoulder and back birth experience, support levels from their partner (‘How
kneading. Subjects were encouraged to select their favourite effectively did your partner help you deal with labour pain?’)
type and site for massage, depending on what felt most useful and assistance levels from nurses (‘How effectively did nurses
and comfortable at the time. The same 30-minute massage help you manage your labour pain?’) on 5-point scales. The
was repeated in phase 2 (active phase, 5–7 cm cervical partners were also asked to give their subjective assessments
dilation) and in phase 3 (transitional phase, 8–10 cm cervical of satisfaction with the childbirth attendance experience, and
dilation). After the 30-minute massage at each stage, pain and the level of support they had given to their wife (‘How
anxiety states were evaluated to assess the immediate effects effectively did you help your wife deal with labour pain?’) on
of the massage. The newly taught partners repeated the 5-point scales. Women in the experimental group were asked
massage at each phase of labour after the 30-minute massage to evaluate the helpfulness of massage on a 5-point scale, and
by the researcher. to answer an open-ended question about the advantages of
Subjects in the control group were not aware that they had massage. Nine experts examined the content validities of all
not received massage but nevertheless received standard instruments.
Descriptive statistics including the mean (SD), minimum effectively did your partner help you deal with labour pain?’
and maximum were calculated. Two-sample t-tests were used (d ¼ 0Æ57, 95% CI of d ¼ 0Æ09–1Æ04, P ¼ 0Æ019), and partners’
to test differences between the massage and control groups, assessments of ‘How effectively did you help your wife deal
and the mean differences between the control and massage with labour pain?’ (d ¼ 0Æ70, 95% CI of d ¼ 0Æ30–1Æ10,
groups for the PBI and VASA were produced with 95% P ¼ 0Æ001). The experimental group returned more positive
confidence intervals. evaluations, and 87% of the experimental group reported
that massage was of more than moderate helpfulness during
labour. On the other hand, subject satisfaction with the
Results
childbirth experience, their assessment of nursing assistance
Sixty primiparous women in labour were included in the levels and partner satisfaction with the childbirth attendance
study. The experimental group consisted of 30 women. experience were not significantly different. More than 90%
Subjects ranged between 21 and 35 years of age with a mean (55 of 60) of participants rated the nursing assistance as ‘very
age of 28 years, and had an average weight of 65Æ22 kg, helpful’ and ‘extremely helpful’ in both groups. In total, 73%
mean gestational age of 277Æ23 days, mean infant birth (44 of 60) of women and 82% (49 of 60) of partners felt
weight of 3196 g, and mean labour duration of 10Æ96 hours. ‘very’ and ‘extremely’ satisfied with the childbirth experience.
The control group consisted of 30 women between 20 and
39 years of age, with a mean age of 27Æ9 years, average
Discussion
maternal weight of 67Æ07 kg, mean gestational age of
276Æ53 days, mean infant birth weight of 3106 g, and mean Although massage is believed to be a simple, effective and
labour duration of 9Æ61 hours. Demographic and obstetric safe method of support and relief for women during child-
data for the experimental and control groups were compared. birth, few scientifically rigorous assessments exist to substan-
No significant differences (P > 0Æ05) were found between tiate this belief. Chen and Chang (2000) commented that in
the two groups in terms of age, maternal weight, gestational the high-tech medical environment the use of touch therapy
age, infant birth weight and mean duration of labour such as effleurage, stroking, sacral pressure and patting or
(Table 1). handholding could help women to remain a sense of body
Pain and anxiety intensity scores reached a peak during the boundary intactness and facilitate their ability to cope with
third phase of labour (Table 2). Mean scores, SD, mean labour. This study sheds some light on the effects of massage
differences and assessments of pain and anxiety intensity on women in childbirth. Data from different phases (latent,
scores during the three phases for the two groups are shown active and transition) all suggested that massage reduced pain
in Table 2. PBI and VASA levels showed a relatively steady behaviour observations during the three phases and also
increase in both groups as labour progressed. Trend analysis helped to reduce anxiety levels during the latent phase.
showed that these were significant, linear trends. Significantly Behavioural observational measurement demonstrated less
lower PBI scores in the massage group (0Æ73, 1Æ73 and 2Æ17) agitation following massage at all three phases. Field et al.
were observed than among the controls (1Æ30, 2Æ17 and 2Æ87) (1997) found significant effects only from massage at 3–5 cm
at phase 1, 2 and 3 of labour, respectively. Differences cervical dilation. This is the first controlled study to provide
between the VASA means were also compared, with only evidence that massage provides psychosocial support for
phase 1 showing a significant difference (massage group women during all three phases of labour. Appropriate touch
37Æ20, control group 53Æ47). at appropriate times may help the woman to feel in control of
A sense of satisfaction from massage was noted by her body and maintain a sense of body boundary integrity. In
participants, as was the value of massage to the couple’s keeping with earlier work (Chen et al. 2001), comforting
experience of labour. From Table 2, two significant differ- touch was found to be significant and important. This finding
ences were found in the assessments by women of ‘How differed from that in a study in Hong Kong (Holroyd et al.
Table 2 Mean (SD), estimated difference (95% CI) and P-values for pain and anxiety intensity scores during the three phases of labour in two
groups
PBI
Phase 1 0Æ73 (0Æ52) 1Æ30 (0Æ53) ÿ0Æ57 (ÿ 0Æ84, ÿ0Æ29) 0Æ000
Phase 2 1Æ73 (0Æ45) 2Æ17 (0Æ59) ÿ0Æ43 (ÿ 0Æ71, ÿ0Æ16) 0Æ002
Phase 3 2Æ17 (0Æ53) 2Æ87 (0Æ78) ÿ0Æ70 (ÿ 1Æ04, ÿ0Æ36) 0Æ000
VASA
Phase 1 37Æ20 (20Æ30) 53Æ47 (22Æ18) ÿ16Æ27 (ÿ 27Æ25, ÿ5Æ28) 0Æ040
Phase 2 64Æ93 (24Æ07) 73Æ87 (22Æ64) ÿ8Æ93 (ÿ 21Æ01, 3Æ14) 0Æ144
Phase 3 80Æ67 (19Æ11) 85Æ17 (18Æ29) ÿ4Æ50 (ÿ 14Æ17, 5Æ17) 0Æ355
1997), which reported that Chinese people use distance to Lower levels of self-reported pain and anxiety were
regulate their privacy and level of intimacy in encounters. The described in Field’s study of massage when women were at
results of our study suggest that, although cultural, ethnic, approximately 3–5 cm cervical dilation (Field et al. 1997).
and religious differences exist between Eastern and Western The physical and psychological influences of massage on
societies, the perception of nursing behaviours by Taiwanese couples’ experiences of labour were very positive (Kimber
women is similar to that of Western women. 1998). Of the nonpharmacological methods, massage is an
The Gate Control Theory proposes a gating mechanism at effective, noninvasive technique for promoting relaxation and
the spinal cord and may explain the effects of massage seen improving communication with women in labour. As mas-
in this study. The gate is thought to open when increased sage requires a supportive personal presence, it is possible
activity from small diameter nerve fibres transmit pain that the favourable effects are, in part, because of continuous
impulses to the spinal cord and brain. Massage or pressure emotional support (McCaffery & Beebe 1989, Anonymous
activity that activates large diameter fibres can close the 1998). In order to find an effect over and above the presence
gate, thereby inhibiting the transmission of pain (Melzack & of a supportive person, the control group was to some extent
Wall 1965). Another possibility is that massage may placebo controlled, in that the person doing and teaching
increase the level of endorphins (endogenous opioids) massage was present and made conversation with control
thereby reducing pain (McCaffery & Beebe 1989). Based couples but did not actively intervene.
on the subjective assessments of women in this study, the
effects of massage can be categorized as pain relieving
Conclusion
(‘Although pain was still there, massage promoted my
comfort’) and psychologically supportive (‘Massage made Caregivers’ physical touch influenced the woman’s reaction
me feel that someone was sharing my suffering’). The tactile to pain, made her feel safer and calmer, and improved her
stimulation may also increase vagal activity, which in turn well-being during labour. Consequently, massage has the
lowers physiological arousal and stress hormone (cortisol) potential to improve the relationship between nurses/mid-
levels. Additionally, feelings associated with a caring and wives and women in labour, as well as between the couple.
empathic forms of massage may affect higher brain centres, Touch and massage can convey concern, security, closeness
further influencing perceptions of pain (Melzack & Wall and encouragement, and at the same time serve as a
1965, Field 1998). psychosocial intervention.