MAEDICA – a Journal of Clinical Medicine

Mædica - a Journal of Clinical Medicine 2018; 13(4): 286-293

https://doi.org/10.26574/maedica.2018.13.4.286
O riginal paper

The Effect of Normal Physiologic

Childbirth on Labor Pain Relief:
an Interventional Study in
Mother-Friendly Hospitals
Somayeh MAKVANDIa, Khadigeh MIRZAIINAJMABADIb*, Najmeh TEHRANIANc,
Habibollah ESMILYd, Masoumeh MIRTEIMOORIe
School of Nursing and Midwifery, Mashhad University of Medical Sciences,
a

Mashhad, Iran
Department of Midwifery, School of Nursing and Midwifery,
b

Mashhad University of Medical Sciences, Mashhad, Iran

Tarbiat Modares University of Medical Sciences, Tehran, Iran
c

Social Determinants of Health Research Center,

d

Mashhad University of Medical Sciences, Mashhad, Iran

Department of Obstetrics and Gynecology, School of Medicine,
e

Mashhad University of Medical Sciences, Mashhad, Iran

ABSTRACT
Introduction: Normal physiologic childbirth program was implemented in mother-friendly hospitals of
Iran after 2008. In normal physiologic childbirth, non-pharmacological methods of labor pain relief were
applied. The aim of the present study is to assess the effect of the normal physiologic childbirth program in
a mother-friendly hospital on labor pain relief.
Methods: This study was a clinical trial that was conducted in Sina mother-friendly hospital in Ahvaz,
Iran, in 2016. The intervention group of 57 women was offered childbirth preparation classes during
pregnancy and a normal physiologic childbirth program during labor, while the control group of 57 women
received conventional care. The study outcome was the amount of labor pain measured between contractions
in various cervical dilatations until delivery.
Results: In the cervical dilatations of 6 cm, 8 cm and 10 cm, labor pain in the intervention group was
significantly lower than the control group. Furthermore, the mean of labor pain in the intervention group
was significantly lower than the control group (p<0.001)
Conclusion: Complete implementation of the normal physiologic childbirth program can reduce the
severity of labor pain.
Keywords: natural childbirth; prenatal education; labor pain; pain management;
non-pharmacologic approaches.

Address for correspondence:

Dr. Khadigeh Mirzaiinajmabadi, PhD
Department of Midwifery, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
Tel.: 0098 9123740580, Fax: 0098 51 38597313

Article received on the 18th of September and accepted for publication on the 28th of November 2018.

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Normal Physiologic Childbirth On Labor Pain Relief

INTRODUCTION freedom of action and independence, interven-

C
tions based on specific indications, and not rou-
hildbirth is as old as the man that tine (20).
brings unique experiences for wo­ In Iran, in the second half of 2002, the
men that will always be with them Mothers Health Department of the Ministry of
throughout their lives (1). Childbirth Health and Medical Education began designing
experience has been influenced by the content of mother-friendly hospital’s servi­
many factors such as knowledge about the labor ces. In this plan, the construction of new hospi-
process, quality of care and services, severity of tals is not considered, but modification of the
labor pain, method of labor pain management workflow and change in the content of services
and medical interventions. Medical interven- in the existing parts of maternities are consi­
tions that result from the advancement of medi- dered. In the design of a part of the mother-
cal science and seek to ensure the safety of friendly hospital’s program, a primary protocol
childbirth sometimes eliminate the concept of for standards of normal delivery using non-phar-
labor as a physiologic phenomenon and look to macological pain relief techniques (normal
it as a medical problem (2, 3). One of the main physiologic childbirth) has been developed. Af-
results of the medical treatment approach to ter careful and scientific review and final correc-
childbirth is the wasteful increase in cesarean tions, this protocol was performed in a few
section (C/S). According to the World Health Or- hospi­tals in Iran after 2008 (22, 23).
ganization, the C/S rate should not exceed According to the principles of mother-friendly
10-15% of all births in any part of the world (4), hospitals of Iran, in a comprehensive view, the
but published statistics in many countries, espe- normal physiologic childbirth program does not
cially in Iran, differed from this ratio and are very include only the labor and childbirth periods,
high (5). C/S is a major operation that has com- but it begins during pregnancy with the prepara-
plications such as maternal death (6), hemor- tion of the pregnant woman and her companion
rhage (7), infection (8), need for blood transfu- in the childbirth preparation classes. Preparation
sion (9), dense internal adhesions (10), classes start at the beginning of the 20th week of
thromboembolic (6), urinary retention (11), pregnancy and include eight sessions. The check-
bladder injury (12), and anesthetic complica- list of each meeting is based on the booklet of
tions (13, 14). Furthermore, a growth in the Ministry of Health, Medicine and Medical Edu-
C/S rate in a country may cause high costs to the cation. Some of these topics include teaching of
national health system (5). anatomy and physiology related to pregnancy,
Women’s fear of labor pain is known as one of risk symptoms, nutrition, personal and mental
the reasons for increasing the rate of C/S (15, 16). health, embryo development, supportive tech-
Labor pain is a physiologic phenomenon, but the niques, role of care givers, choice of delivery
psychosocial issues connected with it can harm method, mothers’ responsibilities for self-care,
women. It has consequences such as stress high-risk childbirth and mother’s participation,
symptoms, regret for the vaginal birth decision preparation of parents, visit to the maternity
and a request for C/S (17, 18). Management of ward and familiarity with health care providers.
labor pain is a serious aspect of obstetric care At the time of delivery, the absence of unne­
and a main goal of childbirth-related care (19). cessary medical interventions in the natural
In response to a wasteful increase in C/S rates, course of labor, individual support of women by
the Coalition for Improving Maternity Services in a reliable person, freedom of movement in labor,
the United States recorded its first agreement to non-supine positions, skin contact of the new-
improve vaginal delivery. In this way, the term born and mother quickly after delivery and
“mother-friendly hospital” was launched in 1996 breast feeding are recommended. In physiologic
(20). The objectives of mother-friendly hospitals childbirth, specific emphasis is put on the ma­
included improving the quality of normal child- nagement of labor using a variety of non-pharma-
birth care, reducing costs, and paying attention cological pain relief techniques such as aroma-
to the rights of mother and neonate (21). The therapy, heat therapy, acupressure, birthing ball,
principles of these hospitals include the natural water therapy, music therapy, reflexology, relaxa­
process of delivery, mother’s empowerment, tion, respiratory techniques, etc. As indicated by

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Normal Physiologic Childbirth On Labor Pain Relief

the suggestions of Iran’s Ministry of Health and acceleration of labor), induction of labor and use
treatment, a mix of non-pharmacological tech- of fundal pressure.
niques is usually used according to women’s will The intervention was a complete execution
and satisfaction (22, 23). of the physiologic delivery program, which in-
The present investigation evaluated the im- cluded holding antenatal preparation courses
pact of normal physiologic childbirth program in and physiologic childbirth utilizing a mix of non-
a mother-friendly hospital on labor pain relief. q pharmacological pain relief strategies.
Antenatal preparation courses, attended by
METHODS pregnant mothers and their female companions,
were started at the beginning of the 20th week of

T his was an interventional study with a proto-

col approved by the Ethics Committee of
Mashhad University of Medical Sciences,
pregnancy in eight sessions over a period of
ninety minutes per session, in a standard class-
room in the center. The teacher was a trained
Mashhad, Iran, and it was registered within the midwife with a valid certification of prenatal
Iranian registry of clinical trials (http://irct.ir) IRCT edu­cation approved by the Ministry of Health.
No. IRCT201508132204N4. The study was car- The educational content of every session was ac-
ried out at Sina mother-friendly hospital in cording to the standard booklet of Iran’s Ministry
Ahvaz, Iran, in 2016. A pilot study was conduc­ of Health and Treatment. At the end of the
ted to calculate the sample size, which recom- course, each person was given a certificate of at-
mended that a sample of 57 women within each tendance.
group would provide a power of 95% at 5% si­g­ In the normal physiologic childbirth program,
nificance. Subjects were selected from the pre- at the time of labor women were permitted to
natal clinic of our hospital after informing them eat liquid foods such as water, fresh fruit juices,
on the aim and course of the investigation and soups, porridges, and also dates. Routine medi-
after obtaining their written consent during the cal interventions such as amniotomy, labor in-
primary half visits of pregnancy. Selection of par- duction, serum therapy, and urinary catheteriza-
ticipants was purposive. It should be noted that tion were not performed. Complete bed rest was
the matching strategy was used to control exter- not required, and women were allowed to be in
nal factors; thus, for each subject in the interven- any agreeable position. A trained female com-
tion group, a single subject was selected for the panion was present alongside each woman until
control group for important external variables. delivery.
Women who were happy with their participation In the active phase of labor, a mix of non-
in the labor planning classes were included in medical pain relief techniques, including utili­
the intervention group, and those who did not zing a birthing ball, warm water Jet and aroma-
agree to attend classes and just got standard rou- therapy with lavender oil, were utilized. The
tine care were included in the control group. In- water Jet was filled with warm water with the
clusion criteria were as follows: consent to par- temperature of 36 to 39° C, so that the surface of
ticipate in the study, age of 18 to 35, low risk the water was on the abdomen and under the
pregnancy, single fetus, lack of contraindications client’s breasts. The participants were in a half-
for vaginal birth, estimation of fetal body weight sitting position. The water Jet was used from the
of 2.5 to 4 kg, participation in antenatal readi- start of the active phase of labor and at least one
ness courses for the subjects in the intervention hour was essential. Besides, during the active
group, 3 to 4 cm of cervical dilation at the begin- phase of labor, mothers were sitting on a birthing
ning of the study, and presence of a trained com- ball for 30 minutes and moving the pelvis right
panion in labor unit for the intervention group. and left or back and forward. Toward the start of
Exclusion criteria were as follows: presence of the active phase of labor until delivery, aroma-
risk factors at any time of the childbirth process, therapy was carried out using 15×15 cm nap-
such as severe vaginal bleeding, pathologic de- kins impregnated with 0.1 cc of 3% Lavender
celeration in the fetal heart rate, unnecessary essential oil combined with one cc of sterile wa-
and routine medical interventions such as use of ter, which were fitted on each woman’s neck-
some pharmacological agents (eg, atropine for line.

288 Maedica A Journal of Clinical Medicine, Volume 13, No. 4, 2018

Normal Physiologic Childbirth On Labor Pain Relief

Vaginal examinations were done every two fetus. Immediately after expulsion of the fetus,
hours, and fetal heart rates were estimated each 20 units of oxytocin were infused intravenously,
half-hour in the active phase. In the second stage and the neonate was placed under a radiant
of labor, vaginal examinations were done every heater.
half-hour, and the fetal heart rates were estima­ It ought to be noted that to prevent bias,
ted at regular intervals. The progress of labor of every intervention was done by midwives with a
all women was plotted on the partogragh form. 5-10 years history of working at maternity. They
Upon completion of cervical dilation, a cou- attended in both physiologic and conventional
ple of minutes before delivery, subjects were delivery wards of the hospital.
transmitted to the specific bed of normal physi- The data-collection instrument was a self-
ologic childbirth and were set in an upright posi- made questionnaire that was validated through
tion and simultaneously with uterine contrac- content validity, and its reliability has been af-
tions and a feeling of defecation, encouraged to firmed with r=0.92. This form comprised two
pushing. Episiotomy was not routine. Immedi- sections: the first one related to the demographic
ately after the expulsion of the fetus, ten units of characteristics of the samples, and the second
intramuscular oxytocin were injected to the one related to pregnancy and labor information.
mother. Immediately after delivery, skin contact The study outcome was the amount of labor
of the mother and the neonate and breast fee­ pain measured by the investigator between con-
ding were performed with the help of the res­ tractions in various cervical dilations until deli­
ponsible neonatal staff. After two hours of birth, very. The Visual Analog Scale was used to esti-
mothers were transmitted to the postpartum mate labor pain which was a 100 mm line with
ward. It should be noted that all women who 90°angles at each end. Bipolar anchors (painless
had a risk factor requiring medical intervention and pain in the worst possible way) are placed at
at any time of the study were excluded from the each end of the line (24). Participants were asked
study. to display a mark along the length of the line to
Subjects of the control group received rou- show their pain intensity. Then, the distance be-
tine standard care. Mothers’ companions were tween the left end of the line (painless anchor)
not allowed to enter the labor room. Complete and the markings given by the participants was
bed rest was a part of the routine. Vaginal exa­ measured using a ruler. This amount indicates
mination and fetal heart auscultations were simi- the severity of the pain.
lar to those carried out in the intervention group. Data analysis was performed in SPSS Ver. 11.0
At the time of delivery, mothers were set in li- at a confidence interval of 95%. The
thotomy position. At this stage, using the Valsalva Kolmogorov–Smirnov test, descriptive statistics,
maneuver, the mothers were asked to push. The independent t-test, repeated measures test,
modified Ritgen maneuver was used to exit the Bonferoni post hoc test, and chi-square were
used. q

RESULTS

P articipants’ flow through the study is shown in

Figure 1. Table 1 shows basic data of both
study groups including demographic data and
qualitative features of pregnancy and labor.
There was no significant difference in quantita-
tive features of pregnancy and childbirth be-
tween the intervention and control groups
(Table 2).
There was no significant difference between
study groups in pain score at the beginning of the
study. Independent t-test showed that in the cer-
vical dilatations of 6 cm, 8 cm and 10 cm, the
FIGURE 1. The flow of participants through the study labor pain score in the control group was signifi-

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Normal Physiologic Childbirth On Labor Pain Relief

p value
Parameter Baseline Peak CM CM washout
(ANOVA)
<20 years 9 (15.78) 7 (12.28)
20-24 years 15 (26.31) 22 (38.59)
Age 0.56
25-30 years 21 (36.84) 17 (29.82)
>30 years 12 (21.05) 11 (19.29)
Primary school 33 (57.89) 30 (52.63)
Education level High school 15 (26.31) 19 (33.33) 0.87
College degree 9 (15.78) 8 (14.03)
E/A ratio Housekeeper 52 (91.22) 52 (91.22)
E/A ratio Beautifier 4 (7.01) 5 (8.77) 1.0
E/A ratio Photographer 1 (1.75) 0 (0)
E/A ratio Primiparous 37 (64.91) 35 (61.40)
0.42
E/A ratio Multiparous 20 (35.08) 22 (38.59)
<18.5 10 (17.54) 7 (12.28)
E/A ratio
E/A ratio 18.5-24.9 28 (49.12) 34 (59.64)
0.39
E/A ratio 25-29.9 9 (15.78) 11 (19.29)
E/A ratio
>30 10 (17.54) 5 (8.77)
Intact 35 (61.40) 37 (64.91)
Fetal membranes at admission 0.69
Rupture 22 (38.59) 20 (35.08)
3 14 (24.56) 15 (26.31)
Numbers in
4 23 (40.35) 26 (45.61) 0.71
Uterine contractions at the 10 min
5 20 (35.08) 16 (28.07)
beginning of the study
Moderate 35 (61.40) 33 (57.89)
Severity 0.70
Severe 22 (38.59) 24 (42.11)
Vaginal delivery 52 (91.23) 51(89.47)
Delivery mode 0.66
C/S 5 (8.77) 6 (10.53)
Female 30 (57.69) 27 (52.94)
Sex of neonate 0.62
Male 22 (42.31) 24 (47.05)
7 2 (3.84) 1 (1.96)
First min APGAR 8 8 (15.38) 7 (13.72) 0.81
10 48 (92.31) 50 (98.94)
9 4 (7.69) 1 (1.96)
5 min APGAR 0.18
10.10 ± 3.58 9.70 ± 2.80
*Data are shown as numbers (percent)

TABLE 1. Demographic data and qualitative characteristics related to pregnancy and labor of the
two study groups*

cantly higher than the intervention group post hoc test demonstrated that there is a signifi-
(Table 3). cant difference between all of the pairs to
Based on the repeated measures test, the pairs. q
mean of labor pain in frequent measurements
showed a significant difference (p=0.008). As DISCUSSION

T
well, the mean labor pain in the intervention he aim of this study was to evaluate the im-
group was significantly lower than the control pacts of the normal physiologic childbirth
(p<0.001) (Table 4). Comparison of the pair to program on labor pain. The results demonstrated
pair of the mean of labor pain using Bonferoni a statistically significant decrease in labor pain

290 Maedica A Journal of Clinical Medicine, Volume 13, No. 4, 2018

Normal Physiologic Childbirth On Labor Pain Relief

Intervention group Control group

P value
(n=57) (n=57)
Gestational age (days) 275.61±8.06 272.88±9.03 0.09
Weight gain in pregnancy (kg) 11.82±4.53 13.40±4.81 0.07
Uterine contraction duration at beginning of study (sec) 45.52±8.32 43.77±7.27 0.23
BISHOP score 6.47±1.33 6.12±1.15 0.13
Baseline cervical dilatation (cm) 4.07±0.77 3.92±0.70 0.31
Baseline cervical effacement (%) 51.57±12.78 47.36±14.45 0.10
Neonate’s weight (gr) 3346.01±441.85 3274.49±394.38 0.39
Neonate’s head circumference (cm) 34.24±1.23 34.34±0.92 0.63
First min APGAR 8.78±0.51 8.82±0.43 0.56
5 min APGAR 9.92±0.26 9.98±0.14 0.17
*Data are shown as the mean ± standard deviation
TABLE 2. Quantitative characteristics related to pregnancy and labor of the two study groups*

Intervention group Control group

P value
(n=57) (n=57)
At beginning of the study 6.70±1.73 7.31±2.11 0.09
At cervical dilatation of 6cm 8.29±1.74 9.27±1.13 0.001
At cervical dilatation of 8cm 9.14±1.05 9.67±0.87 0.005
At cervical dilatation of 10cm 9.73±0.62 9.96±0.28 0.019
*Data are shown as the mean ± standard deviation

TABLE 3. Comparison of the mean of labor pain in different cervical dilatations in two study groups*

f df P value

Greenhouse-Geisser 1.96 4.54 0.01

Huynh-Feldt 2.30 4.54 0.008
Group 1 14.82 <0.001
TABLE 4. Comparison of the mean of labor pain in two study groups using repeated measures test

when the normal physiologic childbirth program Fear of vaginal delivery, anxiety, tension, and
was completely executed. unfamiliarity with the environment bring senti-
In mother-friendly hospitals of Iran, the initial ments of profound insecurity for women during
segment of the physiologic childbirth program is labor, recognizing a solid connection among la-
holding labor readiness classes for expectant bor pain and anxiety in laboring women (26-28).
women. In the present investigation, because of It seems that each of the non-pharmacologi-
participation in these classes and visit to the ma- cal approaches of labor pain relief that were ap-
ternity ward amid pregnancy, the members of plied in the present investigation could relieve
the intervention group were rationally arranged labor pain, and when these combined with each
for confronting the phenomenon of childbirth. other, the analgesic effects were intensified too.
Antenatal training is in a powerful position to en- Rush’s study showed that using a Jacuzzi in
hance normal delivery. A review by Ferguson et labor had positive effects on analgesia require-
al. has shown some positive emotional impacts ments (29). A Cochrane review revealed that im-
of antenatal training on labor and delivery. One mersion in water during the primary stage of la-
of these impacts is a decrement in maternal ten- bor decreases the utilization of epidural or spinal
sion (25). analgesia (30). It seems that a relative condition

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Normal Physiologic Childbirth On Labor Pain Relief

of weightlessness in water enables the laboring non-pharmacological strategies of labor pain re-
women to take different positions that are lief may be associated to distraction from the
soo­thing and agreeable. Furthermore, immersing feeling of pain (41).
in warm water can create a calming impact One of the limitations of this study was that
which can relieve anxiety. Also, water immersion randomization of subjects was not possible. The
can reduce the secretion of stress-related hor- normal physiologic childbirth was an emerging
mones such as catecholamines (31, 32). phenomenon in Iran and was moderately ob-
A recent meta-analysis suggested that the scure to pregnant women. Since one of the stan-
clinical use of a birthing ball exercises could be dards of the normal physiologic childbirth pro-
an useful tool for parturient women to decrease gram is to give decision-making power to females,
pain (33). The basic mechanism of a birth ball we cannot compel pregnant women to have a
remains unknown but according to the gate con- normal physiologic delivery or conventional de-
trol theory, using non-painful massages to a pain- livery. In other words, in mother-friendly hospi-
ful area can reduce pain (34). Furthermore, the tals, the majority of clients were recommended
birth ball may provide a perineal support without to participate in childbirth preparation classes
imposing huge pressure (35). and deliver physiologically; however, the deci-
Also, some investigations showed that free- sion was entirely made by participants. So, we
dom of movement and upright positions during needed to use purposeful sampling. But the uti-
labor helped the natural power of gravity to im- lization of matching strategy controlled the exter-
prove the presenting part descent, enhancing the nal factors. q
quality and adequacy of uterine contractions
and reducing the labor pain (36, 37). CONCLUSION
A recent meta-analysis by Makvandi et al.
demonstrated a decrease in labor pain with La­
vender aromatherapy via both massage and in- T he results of this investigation demonstrated
that completion of the physiologic childbirth
program could decrease the severity of labor
halation (38). It seems that there is a close con-
nection among maternal anxiety and severity of pain. Therefore, it supports the usefulness of
labor pain, Lavender oil as a basic oil, is con- poli­cies that enable all pregnant women to par-
sumed via breathing and can decrease cortisol ticipate in this program and benefit from it. q
secretion or increase serotonin secretion. Conflicts of interest: none declared.
Mirzaei’s study showed that aromatherapy with Financial support: none declared.
Lavender oil decreased the rate of maternal anxi­ Acknowledgments: This investigation was
ety, cortisol release, and improved serotonin dis- part of SM’s PhD thesis and was supported by a
charge during labor (39, 40). grant from the vice-chancellor of research,
In addition to the above mentioned study, the Mashhad University of Medical Sciences,
reduction in labor pain that happens with Mashhad, Iran.

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