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Efcacy of Warm Showers on Labor Pain and Birth Experiences During the First Labor Stage
Shu-Ling Lee, Chieh-Yu Liu, Yu-Yin Lu, and Meei-Ling Gau
Correspondence Meei-Ling Gau, RN, CNM, IBCLC, PhD, Graduate Institute of Nurse-Midwifery, National Taipei University of Nursing and Health Sciences, No. 365, Ming-Te Road, Peitou, Taipei 112, Taiwan. meeiling@ntunhs.edu.tw Keywords warm showers labor pain birth experience

ABSTRACT
Objective: To determine the efcacy of warm showers on parturition pain and the birth experiences of women during the rst stage of labor. Design: Randomized controlled trial (RCT). Setting/Participants: The study was conducted from July 10, 2010 to January 12, 2011 in the maternity ward of a Taipei City regional teaching hospital, site of approximately 220 to 250 births per month. Ninety-two expectant mothers were recruited (recruitment rate: 70.8%) and allocated by block randomization into the two arms of the study. In total, 80 women completed the trial: 41 in the control group and 39 in the experimental group. Methods: Participants in the experimental group received warm shower bath interventions. Each shower lasted 20 minutes. After a 5-minute full body or lower back shower, participants could spend 15 minutes directing shower water toward any body region that felt most comfortable. Facilities allowed participants to stand and sit as desired. Water was constantly monitored and maintained at a temperature of 37 C. Participants in the control group received standard childbirth care. Results: Labor pain and the birth experience were assessed using the Visual Analogue Scale for Pain (VASP) and the Labour Agentry Scale, respectively. After adjusting for demographic and obstetric data, experimental-group women who participated in warm showers reported signicantly lower VASP scores at 4-cm and 7-cm cervical dilations, and higher birth experiences than the control group. Conclusion: Apart from the positive physical hygiene effects, warm showers are a cost-effective, convenient, easy-todeploy, nonpharmacological approach to pain reduction. This intervention helps women in labor to participate fully in the birthing process, earn continuous caregiver support, feel cared for and comforted, and have a more positive overall experience.

JOGNN, 42, 19-28; 2013. DOI: 10.1111/j.1552-6909.2012.01424.x

Accepted August 2012

Shu-Ling Lee, RN, CNM, MS, is a registered nurse in the Department of Nursing, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan. Chieh-Yu Liu, PhD, is an associate professor in the Graduate Institute of Nurse-Midwifery, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan.

(Continued)

The authors report no conict of interest or relevant nancial relationships.

lthough a happy and meaningful experience in a womans life, childbirth is also source of extreme physical pain and hardship (Simkin & Hull, 2011; Waldenstrom, 2003). The International Association for the Study of Pain (IASP) dened pain as a subjective and unpleasant sensory and emotional experience associated with actual or potential tissue damage (Merskey & Bogduk, 1994). Many studies point to labor pains as the most signicant source of discomfort during childbirth, generating levels of pain that test or exceed physical endurance limits (Akerman & Dresner, 2009; Leeman, Fontaine, King, Klein, & Ratcliffe, 2003). Labor pains and loss of control, the two most frequently cited unpleasant experiences of childbirth, directly affect womans satis-

faction concerning birth care, which in turn adversely affects self-perceptions and self-esteem (Hauck, Fenwick, Downie, & Butt, 2007; Niven & Murphy-Black, 2000). Williams, Povey, and White (2008) stated that pain relief in the maternity ward should effectively relieve perceived pain in a manner that does not disrupt the birthing process and ensures fetal safety. Pharmacological and nonpharmacological methods are the two predominant approaches to clinical pain suppression and control. Although effective at relieving pain, parenteral pain medication and epidural interventions cause known side effects in the mother and fetus, consequently lengthening the labor duration (Cesario, 2008; Walker

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2012 AWHONN, the Association of Womens Health, Obstetric and Neonatal Nurses

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Warm showers can relieve pain while also encouraging mothers to shift positions, thus facilitating the downward progression of the fetus through the birth canal.

warm showers to women who were experiencing the rst active phase of labor. We assessed pain relief efcacy as well as its impact on the birth experience.

Methods
& OBrien, 1999), augmenting risk of neonatal respiratory distress (Walker & OBrien), and decreasing infant suckling ability (Bell, White-Traut, & Medoff-Cooper, 2010). With labor pain outside her control, a mother also faces increased risk of feeling fear, anxiety, helplessness, and loss of control of the overall birthing process (Hauck et al., 2007; Simkin & Hull, 2011; Waldenstrom, 2003). Coupled with the restrictions to movement imposed by continuous fetal heart monitors, intravenous drips, and oxytocin infusions, mothers may abandon the natural birthing process and request a cesarean (Romano & Lothian, 2008; Shilling, Romano, & DiFranco, 2007). Accordingly, many women consider using nonpharmacological methods to relieve and control childbirth pain (Fenwick, Hauck, Downie, & Butt, 2005; Williams et al.). In rehabilitation medicine and the treatment of arthritis and other pain symptoms, water therapy (baths and showers) has an extensive history (Beneld, Herman, Katz, Wilson, & Davis, 2001; Nichols, 1996). Water transmits a desired therapeutic temperature into target tissues, changing the state of irritant receptors and reducing perceived pain (Beneld et al., 2010; Nichols). The exact origins of hydrotherapy on childbirth pain relief are unknown. Laboring and birthing in water has increased in use since being promoted in Russia in the 1970s by Igor Charkovsky (Cluett & Burns, 2012). Michel Odent (1983) subsequently popularized water immersion in other European countries. Numerous clinical studies have since shown that immersion baths induce relaxation, relieve pain, and lower blood pressure (Beneld et al. 2010; da Silva, de Oliveira, Nobre, 2009) while affording mothers a greater role in decision making and a greater sense of control over childbirth (Eckert, Turnbull, & MacLennan, 2001). Warm showers also encourage mothers to shift positions, facilitating the downward progression of the fetus through the birth canal (Stark, Rudell, & Haus, 2008). Although most hospital maternity wards in Taiwan offer shower facilities, domestic research studies on the pain relief efcacy of warm showers during labor are lacking. In this study, we introduced We used a randomized controlled trial design, assigning participants into the experimental and control groups.

Participants and Setting

The study was conducted in the maternity ward of a Taipei City regional teaching hospital that averages 220 to 250 births monthly. The wards seven delivery rooms included two labor/delivery/recovery (LDR) rooms. All rooms were private with bathrooms. Standard patient care included intermittent fetal monitoring and pelvic examinations for cervical dilatation. Women were free to walk around for at least 20 minutes every hour. Recruited participants were laboring women who were anticipating an uncomplicated vaginal birth of a term singleton fetus, dilated to at least 4 cm at time of enrollment, accompanied by their spouses or other family members, and willing to participate. All participants who accepted epidurals or underwent cesareans were excluded. Random allocation computer software assigned participants to either the experimental or control group. Statistical power analysis calculated the required sample size. Assumptions were as follows: = .05, power = .80, and effect size = .30. Based on the G Power statistical package (Germany; version 3.1.1, Fual, Erdfelder, Lang, & Buchner, 2007), two-tailed tests, and an effect size value to detect changes in pain between groups, the necessary sample size was estimated as 41 participants per group. In taking into account a possible attrition rate of 10%, we set the target sample size at 45 participants per group.

Yu-Yin Lu, RN, PhD, is an assistant professor in the Department of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan. Meei-Ling Gau, RN, CNM, IBCLC, PhD, is a professor in the Graduate Institute of Nurse-Midwifery, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan.

Instruments
A structured questionnaire collected participant demographic and obstetric information. Demographic data included age, height, weight, marital status, education, occupation, and medical history. Obstetric data included parity, weeks gestation, pharmaceutical use during labor, antenatal education, infant birth weight, method of rupture of membranes, number of pelvic examinations, and 1- and 5-minute Apgar scores.

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Visual Analogue Scale for Pain

The Visual Analogue Scale for Pain (VASP) is a pain assessment tool previously used to assess a broad spectrum of pain including arthritis, burns, surgery, childbirth, and cancer (Bostrom, Sandh, Lundberg, & Fridlund, 2003; Gift, 1989; Harandi, Esfandani, & Shakibaei, 2004; Peng et al., 2010; Tamiya et al., 2002). The VASP is scored on a 10-cm horizontal line punctuated by 10 evenly spaced marks numbered from 0 to 10, with the rst located to the extreme left and the 10th to the extreme right. Possible scores ranged from 0 (no pain) to 10 (extreme pain). Respondents assigned their scores based on subjective perceptions of current pain. Simple to use, the VASP is applicable for all types of physical pain and is the most widely used pain measurement scale during childbirth in Taiwan (Chung, Hung, Kuo, & Huang, 2003; Gau, Chang, Tian, & Lin, 2011; Liu, Chang, & Chen, 2010).

To conrm scale efcacy, Streiner and Norman (2003) and Beck, Bernal, and Froman (2003) recommended that translated scales be pilot tested on a population of potential users prior to formal use. Therefore, at a hospital in Southern Taiwan, we administered the Chinese version LAS on 12 qualied mothers who answered the questionnaire within 24 hours postpartum. The Cronbachs alpha for the pilot test was .89.

Intervention
Warm showers were the therapeutic intervention. We gave all potential participants an educational ier that explained the intervention and listed its requirements, including (a) participant allows preshower session checks of fetal heartbeat and cervix dilation, (b) all participants accompanied by spouse, family member, etc., (c) water temperature maintained at 37 degrees Celsius (C), and (d) sessions last 20 minutes. Prior to enrollment, we monitored the fetal heartbeat and cervical dilations of experimental group candidates for 30 minutes to conrm normal labor progression. We also helped administer the rst 20-minute intervention session. After a 5-minute full-body or lower-back shower, participants were permitted to direct shower water anywhere that felt most comfortable. Nurses allowed participants to stand and sit as desired. After the rst session, nurses monitored the fetal heartbeat and dilation status for at least 20 minutes every hour. Given continued normal labor progression, we allowed participants to take 20-minute accompanied warm showers as desired. During the intervention, participants could take an additional accompanied shower session as long as the fetal heartbeat and dilation status were normal and researcher consent was achieved. Water temperature was monitored every 5 minutes with a bath thermometer to conrm a constant 37 C. Participants could personally adjust the ambient temperature of the shower room to their own comfort.

Labor Agentry Scale

The self-administered Labor Agentry Scale developed by Hodnett and Simmons-Tropea (1987) measures a mothers feelings of control during childbirth. Its 10-item inventory includes six positive and four negative descriptions of perceived degree of control experienced during childbirth. Scoring follows a 7-point Likert-type scale format, with 7 (all the time), 6 (most of the time), 5 (more than half the time), 4 (about half the time), 3 (nearly half the time), 2 (only occasionally), and 1 (almost never or never). Possible scores ranged from 10 to 70, with a higher number corresponding with a more positive experience. Previous studies reported Cronbachs alphas for the LAS in the .91 to .98 range (Adewuya, Ologun, & Ibigbami, 2006; Goodman, Mackey, & Tavakoli, 2004; Hodnett & Simmons-Tropea). The LAS was translated into Chinese using Brislins (1986) two-stage process. A professional Chinese-to-English translatorwho had not seen the original LASretranslated into English a rstversion Chinese copy of the LAS performed by a maternity professor. A second (native U.S.) translation professional compared the two English versions for content validity. We assessed items for cross-correlation and appropriateness using a three-point evaluation scale, with 3, 2, and 1, respectively, indicating appropriate, no need for revision, appropriate, minor revisions required, and not appropriate, major revisions required. Results for the Chinese LAS revealed a 1.0 content validity index.

Data Collection Process

We recruited study participants from the birth unit of one regional hospital in northern Taiwan. Recruitment began in July 2010 after the hospital Institutional Review Board and nursing and maternity departments granted approval. Potential participants and those meeting the study criteria were approached individually. The study purpose and procedures were carefully explained, with questions claried prior to written consent. To

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Warm Showers, Labor Pain, and Birth Experiences

Warm showers decreased labor pain and improved the childbirth experience.

maintain data condentiality, all data related to patient identity was excised, and a code system was assigned to participants. Participants were informed of their right to withdraw from the study at any point without affecting subsequent care. Qualied participants were randomly assigned to experimental and control groups, both of which received standard maternity nursing care, with the former undergoing intervention. The research assistant (RA) explained the study purpose to both parents upon hospital admission, offering them an informational document, and obtaining written informed consent. The RA personally handled all rst shower bath sessions, pre- and postintervention pain assessments, and data collection. Control group participants provided demographic data after receiving standard hospital care, responded to the VASP at 10 and 20 minutes after 4-cm and 7-cm dilation, and lled out the LAS within 24 hours of delivery. After receiving standard nursing care and providing demographic data, experimental group participants took their rst 20-minute warm showers at 4-cm dilation assisted by the RA. Experimental group participants responded to the VASP prior to taking warm showers at 4-cm and 7-cm dilation and at 10 and 20 minutes afterward. Lastly, they completed the LAS.

across different time points and multiple observations of the same individual (Zeger & Liang, 1986). The GEE approach has been proposed as a nonparametric and appropriate method to conduct repeated measurement analysis. The level of significance was set at .05, two-tailed.

Results
A total of 130 women were assessed for eligibility; 38 were excluded due to planned cesarean (n = 17), refusal (n = 3), and no time to collect data due to the simultaneous admission of two subjects (n = 18). Ninety-two participants met the inclusion criteria and were enrolled in the study: 46 participants were randomized to the warm showers group, and 46 to the control group. Nonetheless, some participants (n = 12) were removed from the study for various reasons including: emergency cesarean (n = 6), epidural anaesthesia (n = 3), and rapid delivery (n = 3) (Figure 1). From the original participant sample, seven participants were removed from the experimental group and ve participants from the control group, yielding an attrition rate of 13.04%. As a result, the study included 39 participants in the experimental group and 41 in the control (Figure 1). Table 1 provides a description of the 80 participants relative to demographic and obstetrical characteristics. The mean reported age was 31.64 years. They were predominately university graduates (65%), nulliparous (53.8%), experienced the natural rupture of membranes (75%), without induction (81.3%), and lacked antenatal class attendance (62.5%). The average prepregnancy weight, prepregnancy body mass index (BMI), and total pregnancy weight gain were 53.11 kg, 20.88 kg, and 13.57 kg, respectively. The average received pelvic examinations in total and between 4 cm to 7 cm dilatation were 6.30 and 2.92, respectively. The groups demonstrated no statistical differences in demographic and obstetrical variables (p > .05). We found that warm showers improved the childbirth experience and decreased labor pain (Table 2). The mean LAS score of the intervention group was 54.15 (SD = 6.38) and 46.58 (SD = 8.61) of the control group (t = 4.45, p < .001). In terms of pain scores, at baseline, the mean pain scores for the intervention group were 6.84 (4 cm) and 8.74 (7 cm) compared to 5.15 (4 cm) and 8.22 (7 cm) for the control group. At 10- and 20-minutes postintervention, mean pain scores for the experimental group dropped

Data Analysis
The SPSS version 18.0 was used for the analyses. Descriptive data analysis identied the demographic and obstetrics characteristics of participants. The KolmogorovSmirnov goodnessof-t test and normality plot investigated the distributional characteristics of study-dependent variables. The results indicated that the values for the target variables were normally distributed among the population. Chi-squared or independent t tests evaluated differences in demographic and obstetric variables between groups. The generalized estimating equations (GEE) model controlled the effects of study covariates and analyzed the independent effect of warm showers. The GEE approach considered within-person variability and accounted for correlated data resulting from repeated measurements

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Figure 1. CONSORT diagram. Passage of participants through each trial stage.

signicantly while increasing signicantly for the control group (Table 2 and Figure 2). GEE analysis evaluated these differences after adjusting for several variables with potential effects on labor pain. Table 3 shows that changes to mean pain scores were signicantly lower among the intervention group ( = 1.48, 4 cm and = 1.65, 7 cm) than the control. Time-dependent changes also indicate that posttest pain values rose an average 0.150.71 points over pretest results, implying a growth trend. However, the interaction effect (group difference and time) revealed that the intervention group achieved a signicantly greater drop in pain values compared to their control group peers over time ( = 2.282.79, p < .001).

periods. All differences achieved statistical significance. Average pain was less at 10 minutes than 20 minutes postshower, echoing Huang (2010), whose research on the efcacy of heat therapy in reducing labor pains during the three phases of the rst stage of labor found that initial applications reduced pain more signicantly than midperiod and late-period applications. Study participants had higher VASP scores at 7-cm dilations than 4-cm, indicating that pain level increased as mothers progressed through the initial stages of labor. This nding conrms with those of Gau et al. (2011), Chung et al. (2003), as well as Simkin and Ancheta (2011). Our data clearly demonstrate the effectiveness of warm showers in reducing labor pain while reinforcing the results of similar studies (Beneld et al., 2001; Beneld et al., 2010; Nichols, 1996). Melzack and Walls gate control theory of pain (as cited in Montes-Sandoval, 1999; Warren,

Discussion
The VASP scores for the experimental group were lower than control group scores at all measured

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Table 1: Participant Backgrounds and Obstetrical Information

Overall (N = 80) Control group (n = 41) Intervention group (n = 39) Statistics p

N Age (M, SD) Education Junior college and below University and above Height (cm, M, SD) Weight (Kg, M, SD) Prepregnancy Current weight Total weight gain Prepregnancy body mass index (M, SD) Gestational weeks (week, M, SD) Parity Nulliparous Multiparous Antenatal class attendance Yes No Newborn weight (g, M, SD) Induction Yes No AROM Yes No Pelvic examination (M, SD) (in total) Pelvic examination (M, SD) (within cervical dilatation 47 cm)
Note. AROM = articial rupture of membranes. a Chi-squared test. b Independent t test.

% 31.64 4.24

n 31.83

% 4.62

n 31.44

% 3.85 0.35b 0.10a .681 .329

28 52 159.40

35.0 65.0 5.47

15 26 158.59

36.6 63.4 5.89

13 26 160.25

33.3 66.7 5.27 0.85b .174

53.11 66.68 13.57 20.88

7.80 9.20 3.58 2.78

53.09 66.83 13.75 21.09

7.98 9.48 3.40 3.02

53.13 66.52 13.38 20.66

7.71 9.02 3.80 2.51

0.61b 0.67 0.45

b b b

.978 .879 .653 .484

0.70

39.06

1.16

39.19

1.05

38.91

1.26

0.12b

.283

0.00a 43 37 53.8 46.2 22 19 53.7 46.3 21 18 53.8 46.2 1.20a 30 50 3094.9 37.5 62.5 280.8 13 28 3068.0 31.7 68.3 279.7 17 22 3106.2 43.6 56.4 302.2 0.59b

.987

.273

.560

15 65

18.7 81.3

9 32

22.0 78.0

6 33

15.4 84.6

0.56a

.455

3.75a 20 60 6.30 25.0 75.0 1.75 14 27 6.24 34.1 65.9 1.64 6 33 6.36 15.4 84.6 1.87 0.29b

.053

.770

2.92

0.67

2.95

0.74

2.90

0.60

0.36b

.722

2010) described how nerves dispatch pain signals through the spinal cord to the brain. Pain stimuli cross the open spinal gate to receptors in the brain, where the appropriate pain response

is directed. Interference with this transmission vector can yield effective pain relief (Warren). Signals generated by warm-water stimulation of epidermis thermoreceptors reach the brain faster

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than those sent by pain receptors, effectively blocking transmission of the latter and reducing perceived pain (Huang, 2010; Lane & Latham, 2009). Heat-enhanced blood circulation also relieves stress-induced muscle cramps. Focusing warmth on specic tissues further improves tissue metabolism and elasticity, raising the effective pain threshold (Beneld et al., 2001, 2010). The practical requirements of warm shower bath interventions further increases patient movements and activity, encouraging regular positional changes that help relieve pain (Stark et al., 2008). Many studies highlight the signicant role of parturition pain on the mothers perception of the childbirth experience (Gungor & Beji, 2007; Li et al., 2009). The negative correlation between pain and self-control implies that a mothers sense of selfcontrol over the childbirth process increases with better pain control. Effective labor pain control is thus critical to making childbirth a more positive, rewarding experience. The two most important factors inuencing client satisfaction with the childbirth experience are level of participation in decision making and degree of self-control over the process (Goodman et al., 2004; McCrea & Wright, 1999; Remer, 2008). Researchers have demonstrated that efcacy of water therapy on enhancing parturient mothers sense of self-control (Beneld et al., 2010; Eckert et al., 2001). In addition to enhanced support from caregivers, the

Routine provision of warm shower intervention is recommended for laboring women because it is cost-effective, noninvasive, and easily applicable.

mothers perceived improved care, greater participation in the childbirth process, greater selfcontrol, and enhanced satisfaction with the childbirth experience (Gungor & Beji; Li et al.). In this study, the experimental group achieved higher average LAS scores than their control group counterparts. The nonpharmacological nursing care measures helped enhance the experimental group participants feelings of acceptance, making their childbirth experience more positive. This nding reinforces that of Austin (1989) who found that women in labor who showered had a generally more positive and satisfactory childbirth experience than those who did not. The core concepts of midwifery care are woman-centered care and the drive to normalize birthing (Simkin & Ancheta, 2011). Cluett and Burns (2012) indicated that warm showers facilitate this paradigm shift, from professional centered to women centered, from pathology dominated to normality expected. Thus, Odent (1983) stated that water implies relaxation, warmth, nature, and femininity. It offers caregivers (midwives, nurses, and/or partner) an opportunity to develop the skills required to provide woman-centered care, form therapeutic rapport with women, empower their decision making and participation, and control over their bodies (Cluett & Burns; Odent; Simkin & Ancheta). We advocate 37 C as the ideal warm shower bath temperature. Anecdotal studies have indicated that water at different temperatures achieves different therapeutic effects (Moore, Peterson, & Manwell, 1964). Water at 3438 C is comfortable against the skin, and at 3740 C is best for controlling pain when used properly and applied in sessions of 2030 minutes in length (Hecox, Weisberg, Andemicael-Mehreteab, & Sanko, 2005). However, Eckert et al. (2001) found water temperatures greater than 37 C may adversely affect the fetus. This study was conducted during the winter, a season of high air temperature variability that may adversely inuence participant willingness to shower. In fact, most participants requested that water temperatures be set higher than 37 C. To prevent partners or relatives from setting water temperatures greater than 37 C and to mitigate seasonal factors,

Table 2: Differences in Labor Pain and Labor Experience between the Two Groups (N = 80)
Variable Experimental Control group mean (SD) Pain (4 cm) Baseline 10 minutes 20 minutes Pain (7 cm) Baseline 10 minutes 20 minutes LAS Nulliparous Multiparious 8.74 (1.09) 6.33 (1.92) 7.10 (1.92) 54.15 (6.38) 51.71 (5.42) 57.00 (6.37) 8.22 (1.41) 1.86 .067 6.84 (1.93) 4.21 (1.51) 5.13 (1.45) 5.15 (1.96) 3.91 <.001 .007 .07 group mean (SD) t p

5.29 (1.98) 2.76 5.85 (2.02) 1.84

8.37 (1.32) 5.49 <.001 8.85 (1.22) 4.85 <.001 46.58 (8.61) 45.77 (9.06) 47.52 (8.21) 4.45 <.001 2.59 .013

3.80 <.001

Note. LAS = Labor Agentry Scale.

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Figure 2. Changes in labor pain scores (4 cm and 7 cm) at baseline and posttests.

researchers adjusted ambient air temperatures in the shower room to each participants preference prior to showering sessions. In addition, when participants focused warm water on their lower torso only, researchers provided warm towels for participants to drape over their shoulders to maintain upper body warmth. These facts highlight the need for maintaining adequate room and water temperatures in intervention sessions,

as well as the need for educating participants and their partners regarding water temperature control.

Conclusion
Our results demonstrate the efcacy of a warm shower in relieving labor pain and fostering

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stetrics & Gynaecology, 113(3), 284288. doi:10.1111/j.1471-

Table 3: Generalized Estimating Equations Modela on the Effect of Outcome Variables for Warm Showers (N = 80)
Variables Pain (4 cm) Group (Experimental vs. control) Time Baseline 10 min 20 min Group Time Group Baseline Group 10 min Group 20 min Pain (7 cm) Group (Experimental vs. control) Time Baseline 10 min 20 min Group Time Group Baseline Group 10 min Group 20 min Reference 2.56 .27 <.001 2.28 .32 <.001 Reference 0.15 .12 .072 1.65 .66 <.001 Reference 2.79 .31 <.001 2.43 .33 <.001 Reference 0.15 .14 .072 1.48 .40 <.001 SE p

0528.2006.00861.x Akerman, N., & Dresner, M. (2009). The management of breakthrough pain during labour. CNS Drugs, 23(8), 669679. Austin, K. A. (1989). Showering in labor: An effective pain management alternative (Master of Science in Nursing). Kirkhof School of Nursing, Grand Valley State University, Allendale, Grand Rapids, MI. Beck, C., Bernal, H., & Froman, R. (2003). Methods to document semantic equivalence of a translated scale. Research in Nursing and Health, 26 (1), 6473. doi:10.1002/nur.10066 Bell, A. F., White-Traut, R., & Medoff-Cooper, B. (2010). Neonatal neurobehavioral organization after exposure to maternal epidural analgesia in labor. Journal of Obstetric, Gynecologic & Neonatal Nursing, 39 (2), 178190. doi:10.1111/j.15526909.2010.01100.x Beneld, R. D., Herman, J., Katz, V. L., Wilson, S. P., & Davis, J. M. (2001). Hydrotherapy in labor. Research in Nursing & Health, 24 (1), 5767. doi:10.1002/1098-240X(200102) Beneld, R. D., Hortobagyi, T., Tanner, C. J., Swanson, M., Heitkemper, M. M., & Newton, E. R. (2010). The effects of hydrotherapy on anxiety, pain, neuroendocrine responses, and contraction dynamics during labor. Biological Research for Nursing, 12 (1), 2836. doi:10.1177/1099800410361535 Bostrom, B., Sandh, M., Lundberg, D., & Fridlund, B. (2003). A comparison of pain and health-related quality of life between two groups of cancer patients with differing average levels of pain. Journal of Clinical Nursing, 12 (5), 726735. doi:10.1046/j.13652702.2003.00777.x Brislin, R. W. (1986). The wording and translation of research instruments. In W. L. Lonner & J. W. Berry (Eds.), Field methods in cross-cultural research (pp. 137164). Newbury Park, CA: Sage. Cesario, S. K. (2008). Re-evaluation of Friedmans labor graph phase II: Determining the normal length of labor of women receiving epidural anesthesia. Journal of Obstetric, Gynecologic & Neonatal Nursing, 33(6), 713722. doi:10.1177/0884217504270596 Chung, U., Hung, L., Kuo, S., & Huang, C. (2003). Effects of LI4 and BL 67 acupressure on labor pain and uterine contractions in the rst stage of labor. Journal of Nursing Research, 11(4), 251 260. Cluett, E. R., & Burns, E. (2012). Immersion in water in labour and birth (Review). The Cochrane Library, 174. Retrieved from http://yhhiec.org.uk/wp-content/uploads/2012/01/immersion-in-

0.71 .08 <.001

0.63 .08 <.001

Note. a All models have been adjusted for age, education, parity, antenatal education attendance, prepregnancy body mass index, gestational weeks, induction, articial rupture of membranes, and pelvic examinations.

positive feelings toward the labor process during the rst stage of labor. This nonpharmacological alternative to pain relief is economical, easy to arrange, and does not require preintervention training. The warm showers require only that participants familiarize themselves with techniques and principles immediately beforehand and that a health professional facilitate the initial session. Continuing education for nurses/midwives should emphasize water therapy as a nonpharmacological alternative to pain relief in clinical practice, enhancing a nurses familiarity with such concepts and techniques in order to provide laboring women more pain control options.

water-cochrane-review.pdf da Silva, F. M. B., de Oliveira, S. M. J. V., & Nobre, M. R. C. (2009). A randomized controlled trial evaluating the effect of immersion bath on labour pain. Midwifery, 25(3), 286294. doi:10.1016/j.midw.2007.04.006 Eckert, K., Turnbull, D., & MacLennan, A. (2001). Immersion in water in the rst stage of labor: A randomized controlled trial. Birth: Issues in Perinatal Care, 28(2), 8493. doi:10.1046/j.1523536X.2001.00084.x Fenwick, J., Hauck, Y., Downie, J., & Butt, J. (2005). The childbirth Western expectations Australian of a self-selected Midwifery, cohort of women. 21(1), 2335.

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