J. Psychosom. Obstet. Gynecol. 18 (1997) 286-291

Labor pain is reduced by massage therapy

?: Field', M . Hernandez-Rkf, S. Taylor', 0. Quintino' and I. Bumran2

'Touch Research Institute, University of Miami School of Medicine and *Educating Hands School of Massage Therapy, Miami, Florida, USA

Key words: LABOR PAIN. ASSAG AGE

ABSTRACT Twenty-eight women were recruited from prenatal classes and randomly assigned to receive massage in addition to coaching in breathing from theirpartners during labor, or to receive coaching in breathing alone (a technique learned during prenatal classes). 'The massaged mothers reported a decrease in depressed mood, anxiety and pain, and showed less agitated activity and anxiety and more positive affect

following thejrst massage during labor: In addition, the massaged mothers had sign$cantly shorter labors, a shorter hospital stay and less postpartum depression.

INTRODUCTION

Touch and massage have been used during labor in nearly every culture for hundreds of years'. Only recently has physical support been available to Western women during delivery2. In the past, massage and support during labor were used to improve or correct the position of the fetus, to stimulate uterine contractions, to prevent the fetus from rising back up in the abdomen and to emrt mechanical pressure to aid in the expulsion of the child3. However, today the focus tends to center more on relaxation to reduce anxiety and alleviate pain'.

A strong association between m a t e d anxiety (typically measured by self-report questionnaires) and labor discomfort has been reported. Labor discomfort is thought to arise fiom fear of the

unknown, which leads to sympathetic arousal pro- ducing tension in the circular fibers of the uterus and rigidity at the opening of the cervix'. This force acts against the expulsive muscle fibers in labor, producing tension within the uterine cavity which is interpreted by the laboring mother as pain. Pro- longed uterine muscle tension can produce ischemia (local and temporary anemia due to poor blood flow), resulting in pain. Maternal anxiety can cause increased catecholamines, resulting in a decrease in uterine contractility and blood flow, and therefore pain and maternal complications during delivery2.

henatal classes often include instructions on visualization and imagery, with the expectation that women will be more relaxed and in control of pain during labor. A recent study on the effectiveness of imagery, however, failed to find differences between women who participated in visual imagery training sessions and a control group with regard to self-reports on anxiety and pain levels during labo9. However, when intense visual imagery training sessions were used in the management of labor pain and other chronic pain conditionsa, the results were more favorable. Thus, visual imagery techniques may be effective for reducing pain associated with labor, although at the cost of extensive training.

Being .touched in general during labor and delivery is perceived by mothers as a positive experience9. For example, abdominal massage used

Correspondence to: T. Field, Touch h r c h I n ~ t i t u ~ . University of Miami School of Mdicine. PO Box 016820. Mimi. FL 33101. USA

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Field et al. Massage and labor

in some Lamaze childbirth educational classes has been suggested for easing discomfort of tired or cramping muscles and facilitating control and relaxation during labor'". The presence and involvement of partners who touch the women during labor have been significantly correlated with less need for drugs, shorter labors, fewer perinatal problems and more optimal maternal interactions".

Studies involving doulas (labor support people), who have already experienced a labor of their own and remain at the patient's bedside from time of admission to the end of birth, show a positive impact on labor'. Studies involving male partners, such as the husband, have also reported positive effects'*. In a study comparing doulas and male partners, doulas touched the laboring women more and were present for more time during labor than male partnersI2. A pilot study by Kennel1 and colleague^'^ reported inconclusive results when examining male partner behavior during labor and delivery, with some partners providing excellent support while others did not.

These reports combined suggest that persons providing more touch have been more favorably viewed by women in labor. The touching seems to reduce maternal anxiety and facilitate labor and delivery. However, it is still unclear whether the reduced anxiety and pain derive from the supportive presence of another person, such as the doula, or whether active touch such as massage therapy could further reduce those problems. The present study compared partners massaging women in labor versus the partners being present and simply doing what came naturally during labor (typically the coaching in breathing exercises they had learned in prenatal classes). We expected that massage coupled with the breathing exercises would have more positive effects than the breathing exercises alone on anxiety and pain, as well as length of labor.

METHODS

Sample

The sample comprised 28 middle socioeconomic status women (mean age=29.7) who were recruited from Lamaze classes during their last trimester (mean = 37 weeks gestation). The sample size was predetermined by a power analysis based on a medium size effect, an alpha of 0.05 and power > 0.80 in previous massage study data. The women

were most frequently married (91%) and distributed 34% White, 9% Black and 57% Hispanic. Other sample characteristics were (1) 74% had worked through the seventh month of pregnancy; (2) 75% had more than 12 prenatal visits; (3) 60% had attended from one to six childbirth classes, 63% had learned the breathing technique and 60% reported using the breathing technique during delivery; and (4) 67% reported having had a massage previously The women were randomly assigned (based on a table of numbers) to massage therapy or a control group. The groups did not differ on any of the above baseline variables. The groups also did not differ on the relationship with labor partner (88% were husbands, 9% parents and 3% relatives).

Procedures

Massage condition

Following the admissions interview, the massage was taught to the partner for a mean of.10 min by a massage therapist. At approximately 3 -5cm cervical dilation, the subjects then received 20 min of head, shoulder/back, hand and foot massage, respectively The massage entailed moderate pressure and smooth movements specifically adapted to relax the strained and stressed areas of the laboring body The 20-min sequence consisted of smooth timed clockwise circular stroking movements for 5-min consecutive periods in each of the four regions while the mother was laying on her side: (1) around the head, down the temple to the (2) neck and shoulder, across and down the back; (3) to the hand and (4) then down to the foot. The same 20-min massage was repeated by the partner every hour for 5 h. The massage therapist was present only until the partner felt comfortable giving the massage on hidher own. None of the partners refused to give the massage and none of them reported being uncomfortable delivering the massage. Immediately after the first massage the research associate, who was blind to group assignment, was allowed into the labor room to record measures on the immediate effects of the massage.

Attention control condition

The control subjects and their partners were simply asked to engage in whatever activities they had been taught, for example the breathing coaching, or

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whatever came naturally during labor. Their activities were observed by a research associate, who served not only as a control for the subject receiving extra attention but also to record whether anyone in the control group was receiving massage. None of the control group mothers requested or received massage from their partners, even thwgh 60% had been previously exposed to massage. The same baseline and follow-up assessments were con- ducted at the same time as those of the massage group (a pre-/post-2O-min interval).

Self-report measures

Labor w a s considered that time period from the onset of hospitalization until the patient was taken to the delivery room at full cervical dilation. As soon as the subject was admitted to the hospital, a demographic interview was conducted to ensure comparability of the two groups.

Demographic information

This included maternal age, ethnicity, marital status, socioeconomic status, prenatal care, atten- dance at childbirth classes, self-report measures on importance of touch and previous experience being massaged.

Pre -post-massage measures

The Profile 0fMood States Depmion Scale

This 14-item, Likert-type self-report questionnaire of adjectives describing current depressed mood was completed by the mothers before and after the massage session.

( P O M S ) ~ ~

Feeling Good Thermometer

This is a visual analog scale that was used to assess in a less cognitive way the mothers feeling of well- being.

Stress level and labor pains

The mothers rated their stress levels and labor pains before and afier the massage on a 5-point Likert scale.

Partners mpott mearum

The partners rated the mothers stress level and labor progression on 5-point Likert scales before and after the massage.

The Behavior Observation Scak (BOS)i5 Before and after the massage session, the mothers behavior was rated by an observer blind to the mothers group status on a 3-point continuum on four scales including activity, anxiety, and positive facial expressions.

Post-labor measures

The Centerfor Epidemiological Studies Scalefor Depression (CES-D)16

This is a 20-item scale containing questions relating to depressed mood and psychophysiological indicators of depression. Respondents were asked to rate how frequently each symptom was experienced during the past week on a 4-point scale. The ratings form a summary score ranging from 0 to 60. A score greater than 16 indicates a high level of depression symptoms. This cutpoint corresponded to the 80th percentile of scores in community samples. Both the reliability and validity of the CES-D have been supported across demographically diverse subsarnples of the general population16.

The Touch Switivity Scale

This was uxd to document the mothers sensitivity to tactile stimulation. This scale includes 22 items on reactions to different types of touch, including whether the individual finds being accidentally touched. aversive.

Labor and neonatal measures

The hospital records were then examined by a research assistant who was blind to the mothers group assignment. The following data were recorded hours of labor, days hospitalization, the infants gestational age, birthweight, length, head circumference, Ponderal Index, and perinatal data on the Obstetric and Postnatal Complications Scales*.

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RESULTS

A repeated measures MANOVA on self-report and partner report measures with pre- and post-sessions as the repeated measure revealed a group by repeated measures interaction effect. Post hoc comparisons suggested the following for the self- report measures (see Table 1): (1) the massaged group mothers versus the control group mothers reported less depressed mood (on the POMS), feeling better (on the visual analog thermometer), lower stress levels and decreased labor pains; and (2) the control group mothers reported increased labor pains across the same period of time. The massage versus control group partners reported lower maternal stress levels and greater labor progression.

A repeated measures by group interaction effect and post hoc comparisons for the behavior observation measures suggested the following (see Table 2): (1) the massage group showed lower activity and anxiety levels and more positive facial expressions after the massage; and (2) the control group showed more positive facial expressions following a similar time period.

A MANOVA on the post-labor variables yielded a significant interaction effect. Post hoc comparisons suggested the following effects favoring the massage group (see Table 3): (1) less touch sensitivity; (2) lower levels of perinatal depression; (3) fewer hours in labor; and (4) a shorter hospital stay.

A MANOVA yielded no group differences on the following neonatal measures: (1) gestational age (mean = 39.0 weeks); (2) birthweight (mean = 3304g); (3) length (mean = 48.4cm); (4) head

Table 1 Means for self-report and partner's measures for pre-post-labor massage/control sessions (control means in parentheses)

Ptr Post

SeFreport measures Depressed mood (POMS) 14.0 (14.4) 6.9 (14.9) Feeling Good Thermometer' 5.6 (6.5) 6.8' (6.6) Stress level' 3.3 (3.4) 5.2- (3.5) Labor pains 5.0 (4.3) 3.5' (5.0)'

Partners' report measura Mother's stress level' 3.4 (3.3) 5.4' (3.6) Labor progression' 3.7 (4.1) 4.1' (3.7)' 'High values arc optimal. Superscripts denote group diffcrcnm c p < 0.05. "p < 0.001)

Table 2 Means for observer measures pre-post-labor musagelcontrol sessions (control means in parentheses) Bahavior observation measures PR Post

Activity' 1.7 (1.9) 2.5- (2.0) Anxiety' 1.9 (1.8) 2.4" (1.8) Positive facial expressions' 1.9 (2.0) 2.3' (2.6)-

~~ ~ ~ ~ ~~ ~

'High values arc optimal. Superscripts denote group differences (p < 0.05. "p < 0.01, "p < 0.001)

Table 3 Means for post-labor measures Group

Post-labor measures Massage Control

Postpartum depression (CES-D) 15.4 19.8' Touch sensitivity 27.9 11.1' No. of hours in labor 8.5 11.3' No. days hospital stay 1.3 2.2' Superscripts denotes group differences ('p < 0.05)

circumference (mean = 33.5cm); (5) Ponderal Index (mean = 1.6); (6) Obstetric Complications Scale Scores (mean = 116); and (7) Postnatal Complications Scale Scores (mean = 128).

DISCUSSION

Data from three different sources (the mother, partner and observer) converged to suggest that massage therapy reduces stress and pain during labor. The pregnant women themselves reported less depressed mood state, feeling better, having less stress and fewer labor pains following massage. In contrast, labor pains increased in those women who were not massaged. The mothers' partners (most frequently their husbands) also evaluated the massaged women as being less stressed and labor progressing better following the massage sessions. Behavioral observations by an observer who w a s blind to the women's goup assignment rated the women as having lower activity and anxiety levels. The only similarity between the groups was an increase in positive facial expressions.

Lower levels of self-reported stress and less depressed mood state and decreased behavioral anxiety have been reported following massage therapy in several st~dies'~J0. These lower anxiety/stress levels have typically been asseated with lower stress hormone (cortisol) levels. Lower pain levels have also resulted fiom massage therapy given to adults with pain syndromes such as fibromyalgia*'. The underlying mechanism for

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reduced stress hormones are unclear, although we have speculated elsewhere that reduced anxiety and stress hormones may be mediated by increasing parasympathetic activity accompanying massage. The mechanism underlying reduced pain is also unclear. Some investigators speculate that pressure. stimulation from massage pre-empts the processing of pain stimulation because pressure fibers arc longer and more myelinated and thus can relay the signal to the ' brain faster than pain fibersP. That these immediate effects of massage therapy translated into longer term effects including shorter labor, shorter hospital stay less touch sensitivity and less postpartum depression was more surprising.

These findings are tempered by the fact that the women's self-report might have been influenced by their wish to please their partners following the massage, and by the partners who provided the massage also providing their assessment on at least

two measures. In addition, the sample was small, suggesting the need for studies on larger samples and more comprehensive labor outcome measures. Having a larger sample size might reveal effects on neonatal outcome. Nonetheless, these data highlight the cost-effectiveness of significant others providing massage during labor. Further research is needed on the underlying mechanisms, and whether neonatal outcome can be enhanced by providing massage therapy during pregnancy long before the onset of labor.

ACKNOWLEDGEMENTS

This research was supported by an NIMH Research Scientist Award (#MH00331) and an NIMH Research Grant (#MH46586) to Tiffany Field and a grant from Johnson &Johnson to the Touch Research Institute.

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