Original Article
Application of
From the *University Hospital,
Federal University of Santa Catarina,
Trindade, Florian
opolis, Brazil;
†
Department of Nursing and Post-
graduate Program, Federal
University of Santa Catarina,
University Campus, Trindade,
Florian
opolis, Brazil.
Address correspondence to Odal
ea
Maria Br€uggemann, PhD,
Tocogynecology (Professor),
Department of Nursing and Post-
graduate Program, Federal
University of Santa Catarina,
University Campus, Trindade,
Florian
opolis, Brazil 88040-970.
E-mail: odalea.ufsc@gmail.com
Received February 15, 2011;
Revised August 6, 2014;
Accepted August 7, 2014.
1524-9042/$36.00
Ó 2015 by the American Society for
Pain Management Nursing
http://dx.doi.org/10.1016/
j.pmn.2014.08.006
Nonpharmacologic
Methods to Relieve Pain
during Labor: The Point
of View of Primiparous
Women
Michele Edianez Gayeski, MSc,*
---
Odal
uggemann, PhD,† Marisa Monticelli, PhD,†
ea Maria Br€
and Evanguelia Kotzias Atherino dos Santos, PhD†
- ABSTRACT:
The aim of this study was to assess the application of nonpharmaco-
logic methods to relieve pain during birthing from the point of view of
primiparous women. To achieve this goal, a cross-sectional study was
developed with 188 primiparous women interviewed using a stan-
dardized form on the day they were discharged from the hospital.
Results indicated that the most-used nonpharmacologic method was
emotional support provided by the woman’s companion (97.3%),
followed by warm showers (91.5%); however, the highest degree of
satisfaction derived from focused attention. In the assessment of the
general degree of satisfaction with the methods studied, primiparous
women experienced a high level of general satisfaction (88.3%). Sig-
nificant associations between this result and changes in position
(p ¼ .0340, odds ratio [OR] 3.29, confidence interval [CI] 95% 1.13-9.52)
and focused attention (p ¼ .0326, OR 2.61, CI 95% 1.06-6.43) were
observed. There was a significant association between the general
score for satisfaction and the emotional support of an obstetrics nurse
(p ¼ .0096, OR 3.78, CI 95% 1.49-9.55), of the obstetrician (p ¼ .0031,
OR 3.74, CI 95% 1.5-9.33), and of the nurse’s aide (p ¼ .0303, OR 4.56, CI
95% 1.03-20.24). We concluded that in the obstetric center where the
study was conducted, nearly all the nonpharmacologic methods
available are being adopted by the members of the healthcare team,
with the participation of a companion. However, those that generate
the highest degree of satisfaction are not those most used.
Ó 2015 by the American Society for Pain Management Nursing
The pain that women may feel during childbirth is quite variable, as are the ways
in which they respond to it. For this reason, the birthing environment and the
support given by professionals and companions, as well the methods used to
Pain Management Nursing, Vol 16, No 3 (June), 2015: pp 273-284
274 Gayeski et al.
relieve pain, are important because they can affect re-
actions during the birthing process (Enkin, Keirse,
Renfrew, & Neilson, 1998) and play an important
role in the development of symptoms of traumatic
stress after childbirth (Garthus-Niegel, Knoph, Soest,
Nielson, & Eberhard-Gran, 2014).
The perception of acute pain of any type, as well
as the pain of childbirth, is considered to have two di-
mensions—the sensory and the affective. However,
the principal focus of research, and in practice, has al-
ways been the physical transmission of pain, giving
little importance to emotional and affective compo-
nents. Therefore, there is more evidence on the effec-
tiveness of pharmacologic methods for pain relief and
its adverse effects, although most nonpharmacologic
methods are noninvasive and appear safe for mother
and baby (Jones et al., 2012).
Pain during labor, as well as methods for allevi-
ating it, are of major concern to women of childbearing
age and have major implications for intrabirthing prog-
ress, quality, and results (Caton, 2002). In some
Brazilian hospitals, women may opt for the use of phar-
macologic or nonpharmacologic methods (NPMs) for
treating pain. Both have advantages. The most widely
used pharmacologic method is epidural analgesia. On
average, 30% of women who have low risk are sub-
jected to this procedure (Leal et al., 2014). The prin-
cipal difference is that pharmacologic methods, even
though they produce evident results, can cause the
mother and fetus or newborn to experience side ef-
fects. This possibility causes many women to prefer
to avoid pharmaceuticals if other alternatives are avail-
able; avoidance may occur because of women’s desire
to maintain a feeling of personal control during labor,
as well as a desire to participate in a more effective
manner. NPMs can be useful in the initial stages of la-
bor, before pharmacologic options are indicated
(Enkin et al., 1998).
Studies on the transmission of pain and its modu-
lation make possible important findings for under-
standing it, permitting the rebirth of traditional
methods and the rise of new ones. Enkin et al.
(1998) defined NPMs for the alleviation of pain as abil-
ities developed with women for coping with stress and
pain during labor, via physical and mental relaxation
and various forms of concentration and distraction,
in addition to controlled breathing patterns. Enkin
et al. (1998) defined three categories of NPMs: (1) tech-
niques that reduce painful stimulations, (2) techniques
that activate peripheral sensory receptors, and (3)
techniques that stimulate the descending inhibitory
pathways.
Using the definitions of Merhy and Onocko
(1997), these methods can also be classified according
to the degree of technology employed in their use.
Hard care technologies are represented by concrete
material such as apparatuses and permanent or dispos-
able furniture; light-hard care technologies, on the
other hand, are based on the structured knowledge
of health professionals, as well as of practice and epide-
miology, organizing its application for the labor pro-
cess; and light care technologies are related to the
knowledge people acquire—and make their own—
which influences the way they think and act in
response to health situations and is generated during
the very process that involves the interaction of health
workers and users. Using these definitions, NPMs used
to relieve pain during labor can be classified as hard
and light-hard care technologies, because all of them
require, at a minimum, structured knowledge for their
use, because they can interfere in maternal and
neonatal outcomes.
Many women appreciate these hard and light-hard
care technologies for alleviating pain during labor
because by using them, women gain a feeling of con-
trol, an ability to cope with the pain, and a greater
awareness of the support of their companions and
caregivers. The freedom to get up and to walk around,
to change position, and to push in a more effective
manner is also seen as a positive aspect of these tech-
niques (Simkim & O’Hara, 2002).
Enkin et al. (1998) describe several NPMs to
relieve pain during labor: movement and changes in
the position of the woman, counterpressure (the
continuous application of force on one spot of the lum-
bar region during contractions), superficial application
of hot and cold packs, immersion in water or warm
showers during labor and childbirth, stroking and mas-
sages, acupuncture, acupressure (compression or
deep massaging of traditional acupuncture spots),
transcutaneous electrical nervous stimulation (applica-
tion of a low-voltage current to the skin using surface
electrodes), sterile water injections (in four locations
in the lumbar region), aromatherapy, focused atten-
tion, and distraction (activities developed to keep the
person from thinking of the pain), hypnosis, and audio-
analgesia. Nonpharmacologic approaches to relieve
pain and continuous support during labor provide sig-
nificant benefits for women and their children and are
effective to reduce obstetric interventions (Chaillet
et al., 2014).
In Brazil, those options were not always offered to
women, because the obstetric model has always been
heavily focused on the medicalization of childbirth.
However, this began to change in 1980s, with the
completion of the Conference on Appropriate Tech-
nology for Birth, held in the city of Fortaleza in 1985,
organized by the World Health Organization (WHO),
 Nonpharmacologic Methods to Relieve Pain During Labor
the Pan-American Health Organization and the
Regional Office of the Americas (World Health
Organization, 1985). Moreover, the creation of the
ReHuNa—the Brazilian Network for the Humanization
of Childbirth, a civil society organization active since
1993, has played an important role structuring a move-
ment nowadays called ‘‘humanization of childbirth’’
(Rattner et al., 2010). This movement calls for assis-
tance and birth based on the recommendations of
the WHO and the results of scientific studies, which
supported a decrease in the use of unnecessarily inter-
ventionist techniques and the increase in respect for
women’s reproductive rights (McCallum & Reis, 2006).
Included among the suggestions were NPMs to
ease pain, described by the parturients. However, the
application of these methods began to be visible and
to be used in practice only in 1996, when a practical
guide on how to assist women during normal delivery
was widely publicized. This guide classified these prac-
tices as approaches to be used cautiously (World
Health Organization, 1996). The publication of this
new guide stimulated the production of knowledge
on this subject, leading to the development of several
research studies with the aim of providing the grounds
for such practices.
In the context of obstetric assistance in Brazil, the
use of NPMs to relieve pain arises alongside a new way
of viewing the birthing process, which seeks to reduce
unnecessary interventions and to promote a complete
and satisfactory experience for the woman and her
companion. The implementation of obstetric prac-
tices, even those that are based on scientific evidence,
requires assessment from the point of view of the
woman.
Therefore, the purpose of this study is to evaluate
the application of NPMs to relieve pain during labor
from the point of view of primiparous women, veri-
fying which methods are used and which health pro-
fessionals, students, and companions apply them and
assessing the degree of satisfaction of primiparous
women with these methods, as well as the obstetric re-
sults and the expectations of pain. It is believed that
this knowledge, compiled from the evaluation of
women who have undergone the birthing process,
may provide support for promoting a wider use of
NPMs to relieve pain during childbirth and to design
strategies to encourage the participation of healthcare
providers in their implementation.
METHODS
Cross-Sectional Study
Place of and Participants in the Study. The study
was carried out between October 2008 and September
275
2009 at a maternity unit of a university hospital in
southern Brazil. This maternity unit was inaugurated
in 1995 and has 4 prelabor beds and 1 observation
bed in the Obstetric Center, 22 beds in the maternity
ward, and 16 beds in the neonatal intensive care
unit; the institution performs approximately 1,400 de-
liveries per year and is part of the University Hospital,
which is a medium-sized institution offering medium to
highly complex services exclusively through the pub-
lic health system (Santos & Siebert, 2001).
Services to women and their companions are
based on a philosophy of care with its principles
grounded in humanization and interdisciplinarity,
covering biological, social, and emotional aspects and
also highlighting the importance of the family during
the birthing process (Santos & Siebert, 2001). In
most Brazilian maternity hospitals, women’s compan-
ions are the providers of support during labor and
childbirth; however, there is a resistance by some
health professionals to the presence of many people
to accompany and support. Consequently, the pres-
ence of doulas in the maternity wards is restricted.
This reality is different from the United States and
other countries, in which the mother can also count
on the support of a doula (Silva, Barros, Jorge, Melo,
& Ferriera Jr., 2012).
The obstetric practices adopted are congruent
with the recommendations of the WHO for delivery
and include the application of NPMs to relieve pain.
Although the institution has a guide for routine proce-
dures, the obstetric center has not adopted these pro-
tocols, and there are no established guidelines on how
and when to use them or who should apply them.
Nevertheless, some methods are prescribed by the
nurse midwives during the first stage of labor. These
include warm showers or immersion bath, breathing
techniques, massages in the sacrum and cervical re-
gions, use of the birth ball, sitting backward on a chair
(Simkin, 2007), pelvic rocking exercises (rhythmic
movement of the pelvis from side to side, round and
round, or back and forth), and changes in position
(genupectoral, squats, left side-lying). Focused atten-
tion and emotional support are also offered, although
not prescribed. Thus, all these methods, classified as
light-hard care technologies (Merhy & Onocko,
1997), have been evaluated in this study.
The participants of the study were primiparous
women. The criteria used for inclusion were $37
weeks’ gestation at admission, single gestation with ce-
phalic presentation, vaginal or caesarean section, dura-
tion of labor $ 4 hours, and the presence of company
during labor. The following were excluded from this
study: women with multiple gestations, elected
caesarean delivery, existence of obstetric pathologic
276 Gayeski et al.
conditions (preeclampsia, placenta previa, premature
separation of placenta, cardiopathies, gestational dia-
betes), fetal stress during the initial stages of labor,
use of forceps during delivery, and fetal death.
Calculation of the Sample Size. The type of the
sample was stratified proportionally and by conven-
tion. The sample size calculation was based on the
number of births (vaginal and caesarean) of primipa-
rous women at the maternity of the University Hospital
at the Federal University of Santa Catarina in 2007.
These data were obtained from the Perinatal Clinical
History Database (Hist
oria Cl
ınica Perinatal Base), a
tool developed by the Latin-American Perinatology
Center, and totaled 336 births, of which 61.1% were
normal births, 36.7% were cesarean section, and
2.2% were vaginal deliveries with the use of forceps.
Considering that the number of deliveries regis-
tered in 2007 in the Latin-American Perinatology Cen-
ter’s program was 1,213 and that the annual
statistical data of the Obstetric Center’s Nursing Ser-
vices indicated 1,482 deliveries in 2007, the estimated
number of primiparous women was increased by 10%,
and it was estimated that approximately 369 women
gave birth through normal birth or cesarean section de-
livery in that year. Therefore, in relation to the size of
the sample, the degree of satisfaction of the primipa-
rous women using NPMs to relieve pain was estimated
at 50%, with a confidence interval of 95% and margin
of error of 5%, which resulted in a sample size of at
least 188 primiparous women to be interviewed, of
whom 30% (57) underwent cesarean section and
70% (131) had normal birth.
The index used to calculate the number of cesar-
ean section in the sample was based on a historical se-
ries of the maternity of the University Hospital, which
found that between 1996 and 2005 the percentage was
approximately 30% on average (Br€ uggemann, Knobel,
Siebert, Boing, & Andrezzo, 2009). For the statistical
calculations, we used the Statistics Virtual Teaching-
Learning Computer Program (SEstatNet) (Nassar,
2008).
Ethical Considerations. All aspects involved in this
study comply with Resolution 196/96 issued by the Na-
tional Council for Health. The project was approved by
the Committee for Ethics in Research of the Federal
University of Santa Catarina on August 25, 2008 (Pro-
cess no. 225/08 FR-209528). All participants signed
the Terms of Free and Informed Consent.
Data Collection. The interviews were conducted by
the researchers on the day of discharge from the hospi-
tal. The information was registered on a form contain-
ing a questionnaire related to the primiparous
women’s sociodemographic and obstetric data, the
type of NPM used to relieve pain, information on the
members of the health professional team who applied
it (nurse-midwife, the nurse’s assistant or technician,
nursing student, obstetrician, and medical student),
and information about whether the woman’s compan-
ion (mother, partner, sister, baby’s father, and others)
applied any of the methods, and woman’s degree of
satisfaction with the practices. Data related to the la-
bor, the delivery, and the newborn were obtained
from the medical charts.
In order to ensure that the women’s answers were
as credible as possible, the interviewer provided an
explanation of each of the methods included in the
study. For example, the explanations given for the
focused attention method were based on Enkin et al.
(1998), who defined it as the development of activities
to keep the patient from thinking about pain through a
focus on visual, auditory, tactile, or other kinds of stim-
uli. Information on emotional support was provided
based on Hodnett, Gates, Hofmeyr, and Sakala
(2013), who defined it as the continuous presence of
an empathic person who offers counseling, reassur-
ance, praise, and information, among other tangible
forms to help the woman cope with the stress of labor.
The individuals who applied the method were
also interviewed in order to allow for their identifica-
tion. In relation to satisfaction, the interviewees identi-
fied one of five symbols showing facial expressions
that best represented their feelings toward each of
the methods used: very dissatisfied, dissatisfied, indif-
ferent, satisfied, very satisfied.
Statistical Analysis. The completed forms were
revised and encoded and the data fed into the Epi
Info Version 2005 program (Centers for Disease Con-
trol and Prevention, Atlanta, GA). SAS Version 8.2
(SAS Institute Inc., Cary, NC) was used for statistical an-
alyses. Quantitative variables were evaluated in rela-
tion to the mean and standard deviation, and the
qualitative variables were assessed in terms of their ab-
solute and relative frequencies.
For the calculation of the odds ratio (OR) and the
95% confidence interval (CI) of the degree of satisfac-
tion of the primiparous women (evaluated according
to how they felt about the application of NPMs to alle-
viate pain during labor: very dissatisfied, dissatisfied,
indifferent, well satisfied, or very satisfied), the re-
sponses ‘‘well satisfied’’ and ‘‘very satisfied’’ were
considered as indications of satisfaction (Brown &
Lumley, 1994). The general score of satisfaction of
the primiparous women was calculated using the Lik-
ert scale (Hulley, Cummings, Browner, Grady, &
Newman, 2008).
In order to evaluate the association between the
general score of satisfaction, the satisfaction with
each individual method, the obstetric results, and the
 Nonpharmacologic Methods to Relieve Pain During Labor 277

expectation of pain, the OR with a 95% CI was calcu-

lated and, for values expected to be less than 5, the TABLE 1.
chi-squared or Fisher’s exact test was used. The level Nonpharmacologic Methods used during Labor
of significance was established at 5%. (n ¼ 188)
A multivariate logistic regression analysis was per-
Methods n %
formed using stepwise selection criteria to order to
select the principal risk factors. For this, general satis- Support of companion
faction was considered the dependent variable (well Yes 183 97.3
satisfied and very satisfied versus indifferent, dissatis- No 5 2.7
Warm showers
fied and very dissatisfied), and the NPMs used were
Yes 172 91.5
the independent variables (including emotional sup- No 16 8.5
port, the obstetric data, and the primiparous women’ Breathing techniques
expectation of pain). Yes 165 87.8
No 23 12.2
Changes of position
RESULTS Yes 165 87.8
No 23 12.2
The average age of the 188 primiparous women who Birth ball
participated in the study was 23.3 years (5.5 standard Yes 150 79.8
deviations [SD]); most of them had a stable relationship No 38 20.2
Support from the nurse-midwife
(76.2%), had finished high school (54.5%), worked at
Yes 148 78.7
home (57.7%), had had six or more prenatal exams No 40 21.3
(70.9%), and had not participated in group programs Focused attention
for pregnant women (68.8%). Yes 131 69.7
In relation to the data concerning labor, the No 57 30.3
Support from obstetrician
average time was 16.9 hours (SD ¼ 12.1) and the me-
Yes 128 68.1
dian was 12.5 hours; most women did not use epidural No 60 39.1
analgesia (84.1%) or other pharmaceutical drugs Manual massage
(78.8%) for pain relief, did not present alterations in Yes 105 55.9
the fetal heart rate (90.5%) nor have meconium in No 83 44.1
Sitting backward on a chair
the amniotic fluid (90.9%), and made use of oxytocin
Yes 56 29.8
(61.4%). In relation to the type of delivery, 30.2% No 132 70.2
were caesarean and 69.8% were normal, most of these Support from a nurse’s assistant
in the vertical position (66.1%). Yes 54 28.7
The NPMs used most commonly for pain relief No 134 71.3
Massage with equipment
during labor were the companion’s emotional support
Yes 39 20.7
(97.3%) and the warm showers (91.5%), followed by No 149 79.3
breathing techniques and changes in position Music
(87.8%), the birth ball (79.8%), emotional support Yes 20 10.6
from the nurse-midwife (78.7%), focused attention No 168 89.4
Support from nursing student
(69.7%), and manual massages (55.9%). Among the
Yes 37 19.1
methods least used were music (10.6%), massage using No 152 80.9
equipment (20.7%), and sitting backward on a chair Support from medical student
(29.8%) (Table 1). Yes 36 19.1
Regarding the members of the healthcare team No 152 80.9
applying the NPMs, primiparous women indicated
that most NPMs were applied by the nurse-midwife,
highlighting the warm showers (47.3%), changes in po- (9.1%) and the birth ball (6.9%). Students, from both
sition (38.8%), the birth ball (36.2%), and breathing the nursing and medical fields, were recognized by a
techniques (34.6%). Physician’s participation was small number of the participants. The nursing students
greater in the application of breathing techniques participated more in the warm showers (2.6%) and in
(28.1%) and changes in position (21.3%). Among breathing techniques (2.6%) and the medical students
healthcare professionals, the nurse assistants and tech- in breathing techniques (2.1%) and changes in position
nicians were the least identified by the primiparous (2.1%). Companions participated in the application of
women; the highest percentages related to baths practically all methods, particularly manual massage
278 Gayeski et al.

TABLE 2.
Member of Health Care Team and Companion who Applied the Nonpharmacologic Method (n ¼ 188)
Member of Healthcare Team and Companion

NM NA OB NS MS C DK NR
Method n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Warm showers 89 (47.3) 17 (9.1) 16 (8.5) 5 (2.6) 3 (1.6) 2 (1.1) 40 (21.3) 16 (8.5)
Massage with equipment 4 (2.1) — 1 (.5) 2 (1.1) — 32 (17) — 149 (79.3)
Manual massage 26 (13.9) 5 (2.7) 7 (3.7) 2 (1.1) — 60 (31.9) 4 (2.1) 84 (44.6)
Breathing techniques 65 (34.6) 6 (3.2) 53 (28.1) 5 (2.7) 4 (2.1) 11 (5.9) 20 (10.6) 24 (12.8)
Changes of position 73 (38.8) 7 (3.7) 40 (21.3) 2 (1.1) 4 (2.1) 5 (2.6) 33 (17.6) 24 (12.8)
Birth ball 68 (36.2) 13 (6.9) 22 (11.7) 3 (1.6) 1 (.5) 8 (4.3) 35 (18.6) 38 (20.2)
Sitting backward on a chair 17 (9) 2 (1.1) 7 (3.7) — — 10 (5.3) 20 (10.6) 132 (70.3)
Music 7 (3.7) — 2 (1.1) 2 (1.1) — — 8 (4.3) 169 (89.9)
Focused attention 33 (17.6) 4 (2.1) 33 (17.6) 4 (2.1) 2 (1.1) 47 (25.0) 7 (3.7) 58 (30.8)
C ¼ companion (partner/baby’s father, mother, sister, others); DK ¼ does not know; NA ¼ nurse assistant; NM ¼ nurse-midwife; NR ¼ not received; NS ¼
nursing student; MS ¼ medical student; OB ¼ obstetrician.

(31.9%) and focused attention (25%). Many of the pri- Regarding the obstetric results and the expecta-
miparous women did not identify who applied the tion of pain, there were no significant associations be-
methods, notably the bath (21.3%), the birth ball tween the general score of satisfaction with the
(18.6%), and changes in position (17.6%) (Table 2). application of NPMs for pain relief (Table 6). In the
The evaluation of the general score of satisfaction multivariate logistic regression analysis (multiple OR),
with the application of nonpharmacologic methods us- considering as independent variables all the NPMs
ing the Likert scale indicated that the participants had a (Table 1), emotional support (Table 5), obstetric re-
high level of general satisfaction (88.3%) and only a sults of labor, and expectation of pain (Table 6), the
small number experienced dissatisfaction (11.7%). In ones that actually present a significant association
relation to each method, the highest degree of satisfac- with the level of general satisfaction are changes in po-
tion was accorded to focused attention (77.9%), fol- sition (OR 3.21, CI 95% 1.02-10.10), the emotional sup-
lowed by the warm showers (76.9%) and the birth port provided by the nurse-midwife (OR 3.82, CI 95%
ball (60.3%) (Table 3). 1.43-10.20), and the emotional support given by the
Significant associations were observed between doctor (OR 3.82, CI 95% 1.30-8.70).
the general score of satisfaction with changes in posi-
tion (p ¼ .0340, OR 3.29, CI 95% 1.13-9.52) and focused
attention (p ¼ .0326, OR 2.61, CI 95% 1.06-6.43) TABLE 3.
(Table 4). Evaluation of the Degree of Primiparous
In Table 5 it is possible to observe that the results Women’s Satisfaction with Each
of the general score of satisfaction regarding the pres- Nonpharmacologic Method Received (n ¼ 188)
ence of emotional support during labor indicates a
Degree of Satisfaction
high degree of satisfaction with the emotional support
provided by the woman’s companion of choice Satisfied Dissatisfied
(98.2%), and among the members of the healthcare
team, the highest percentages relate to the participa- Method n % n %
tion of the nurse-midwife (81.9%) and the obstetrician
(72.1%). In relation to the participation of the various Focused attention 102 77.9 29 22.1
Warm showers 133 76.9 40 23.1
members of the healthcare team, significant associa- Birth ball 91 60.3 60 39.7
tion was found between the general score of satisfac- Breathing techniques 96 58.2 69 41.8
tion with the methods and the emotional support Manual massage 61 58.1 44 41.9
provided by the nurse (p ¼ .0096, OR 3.78, CI 95% Changes of position 95 57.9 69 42.0
1.49-9.55), the doctor (p ¼ .0031, OR 3.74, CI 95% Music 10 50.0 10 50.0
Massage with equipment 16 41.0 23 59.0
1.5-9.33), and the nurse’s assistant or technician Sitting backward on a chair 19 33.9 37 66.1
(p ¼ .0303, OR 4.56, CI 95% 1.03-20.24).
 Nonpharmacologic Methods to Relieve Pain During Labor 279

TABLE 4.
Evaluation of the General Score of Primiparous Women’s Satisfaction in Relation to Each
Nonpharmacologic Method (n ¼ 188)
General Degree of Satisfaction

Satisfied Dissatisfied

Method n % n % OR (CI 95%) p Value

Warm showers
Yes 152 91.6 20 90.9 1.09 (.23-5.23) 1.0000
No 14 8.4 2 9.1
Massage with equipment
Yes 33 19.9 6 27.3 .66 (.24-1.82) .4100
No 133 80.1 16 72.7
Manual massage
Yes 97 58.4 8 36.4 2.46 (.98-6.18) .0501*
No 69 41.6 14 63.6
Breathing techniques
Yes 148 89.2 17 77.3 2.42 (.80-7.34) .1564
No 18 10.8 5 22.7
Changes of position
Yes 149 89.8 16 72.7 3.29 (1.13-9.52) .0340
No 17 10.2 6 27.3
Birth ball
Yes 134 80.7 16 72.7 1.57 (.57-4.33) .3998
No 32 19.3 6 27.3
Sitting backward on a chair
Yes 51 30.7 5 22.7 1.51 (.53-4.13) .4410*
No 115 69.3 17 77.3
Music
Yes 20 12.0 — — 6.30 (.37-07.81) .1364
No 146 88.0 22 100
Focused attention
Yes 120 72.3 11 50 2.61 (1.06-6.43) .0326*
No 46 27.7 11 50
CI ¼ confidence interval; Fisher’s exact text; OR ¼ odds ratio.
The bold values indicate a significant association of p < 0.05.
*Chi-squared test.

DISCUSSION and birthing experience (Br€ uggemann, Parpinelli,

In general, all the NPMs available at the maternity unit
of the University Hospital are being used as a result of
the philosophy of patient care the institution has adop-
ted since its inauguration, based on the recommenda-
tions of the WHO (1996). The most-used NPM,
according to the primiparous women, is the support
of the woman’s companion (Table 1). Continuous sup-
port has proven to be truly beneficial during labor
because it reduces the need for interventions such as
epidural analgesia, caesarean section, or use of instru-
ments (forceps or vacuum). It also decreases the wom-
an’s level of dissatisfaction with the birthing
experience (Hodnett et al., 2013). A randomized clin-
ical trial reported that the presence of support pro-
vided by the woman’s companion of choice is a
strong predictor of global satisfaction with the labor
Osis, Cecatti, & Neto, 2007).
It is interesting to note that the second most
commonly used method was the warm showers
(Table 1). This is a proven method for reducing the
pain of laboring women in the active phase of labor
(Davim et al., 2008; Santana, Gallo, Ferreira, Quintana,
& Marcolin, 2013). The first scientific article on the
use of water during labor was published in 1973 in
France and describes the first 100 births in water
(Odent, 1983). After the 1990s, when the WHO
included the immersion bath as an NPM to be used dur-
ing labor, there was increased interest in generating suf-
ficient evidence to support this practice. During the last
two decades, most of randomized clinical trials have
evaluated immersion baths (Cluett, Pickering, Getliffe,
& James, 2004; Ohlsson et al., 2001; Rush et al., 1996;
280 Gayeski et al.

TABLE 5.
Evaluation of the General Score of Primiparous Women’s Satisfaction with the Emotional Support
Received from Each Member of the Healthcare Team and Companion (n ¼ 188)
General Satisfaction

Satisfied Dissatisfied

Emotional Support n % n % OR (CI 95%) p Value

Companion
Yes 163 98.2 20 90.9 5.43 (.86-34.50) .1053
No 3 1.8 2 9.1
Nurse-midwife
Yes 136 81.9 12 54.5 3.78 (1.49-9.55) .0096
No 30 18.1 10 45.5
Doctor
Yes 119 72.1 9 40.9 3.74 (1.50-9.33) .0031*
No 46 27.9 13 59.1
Nurse assistant
Yes 52 31.3 2 9.1 4.56 (1.03-20.24) .0303*
No 114 68.7 20 90.9
Nursing student
Yes 33 19.9 4 18.2 1.12 (.35-3.52) 1.0000
No 133 80.1 18 81.8
Medical student
Yes 30 18.1 6 27.3 .59 (.21-1.63) .3845
No 136 81.9 16 72.7
CI ¼ confidence interval; Fisher’s exact test; OR ¼ odds ratio.
The bold values indicate a significant association of p < 0.05.
*Chi-squared test.

Silva, Oliveira, & Nobre, 2009) and some controlled
clinical trial of therapeutic intervention type rated
aspersion showers (Davim et al., 2008; Santana et al.,
2013), pointing to several benefits, among which are
higher levels of satisfaction with the labor experience
and pain relief, as long as certain conditions, such as a
minimum dilation of 3 centimeters, are met before
initiating its application.
Although warm showers followed by breathing
techniques and changes in position were the most
commonly used NPMs (Table 1), having generated
high levels of satisfaction, the method that actually pro-
duced the highest degree of satisfaction was focused
attention, followed by the birth ball (Table 3). It is
worth noting that of the most commonly used
methods, only the warm showers is among those that
lead to very high degrees of satisfaction. On the other
hand, focused attention and the birth ball were pointed
out in this study as the women’s favorites, although
they are not among the most commonly used
(Tables 2 and 3). A randomized clinical trial reported
that the combination of warm showers and perineal
exercises with a Swiss ball during labor significantly
decreased the perception of pain (Barbieri, Henrique,
Chors, Maia, & Gabrielloni, 2013).
Satisfaction during the first stage of labor was not
assessed in the clinical trials on immersion baths,
analyzed in the Cochrane review (Cluett & Burns,
2009). However, some authors (Cluett et al., 2004)
included the evaluation of satisfaction with immersion
baths in their 2004 study, and the nulliparas of the
experimental group reported higher degrees of satis-
faction with the birthing experience than the control
group, although without statistical significance.
Among the methods assessed, changes of position
and focused attention were the only ones that pro-
duced a statistically significant association with the
general score of satisfaction, even though they were
not among the most used (Table 4). Randomized
studies that evaluated the change in position reported
a reduction in pain scores and an increase in comfort
and satisfaction of mothers who have adopted the up-
right position (Adachi, Shimada, & Usui, 2003;
Miquelutti, Cecatti, Morais, & Makuch, 2009).
It is interesting to observe that focused attention
and distraction are activities that can be developed by
caregivers to help the woman in labor not to think
about pain. This can be done through verbal con-
ditioning (Abushaikha & Oweis, 2005; Enkin et al.,
1998), a simple method that can contribute to break
 Nonpharmacologic Methods to Relieve Pain During Labor 281

TABLE 6.
Obstetric Results and Primiparous Women’s Expectation of Pain, According to the Degree of General
Satisfaction with the Methods (n ¼ 188)
General Satisfaction

Satisfied Dissatisfied

n % n % OR (CI 95%) p Value

Obstetric Data
Oxytocin
Labor 102 61.4 13 59.1 .9044*
No 46 27.7 7 31.8 .84 (.31-2.24)
During pushing 18 10.8 2 9.1 1.15 (.24-5.52)
Misoprostol .7585
Labor 26 15.7 4 18.2 .84 (.26-2.67)
No 140 84.3 18 81.8
Labor time
#8 hours 34 20.5 2 9.1
>8 hours 132 79.5 20 90.9 .39 (.09-1.74) .3804
Type of delivery/position
Caesarean 47 28.3 9 40.9 .55 (.22-4.40)
Normal vertical 113 68.1 12 54.5
Normal horizontal 5 3.0 1 4.5 .53 (.06-4.93) .3799
Normal genupectoral 1 .6 — — .33 (.01-8.55)
Use of pharmaceutical drugs
No 6 3.6 3 13.6 .0735
Yes 160 96.4 19 86.4 4.21 (.97-18.23)
Epidural analgesia
Yes 26 15.7 4 18.2 .84 (.26-2.67) .7585
No 140 84.3 18 81.8
Heartbeat of fetus
Without alteration 152 91.6 18 81.8 .2362
With alteration 14 8.4 4 18.2 .41 (.12-1.40)
Amniotic fluid meconium
No 151 91.0 18 81.8 2.58 (.76-8.77) .1231
Yes 13 7.8 4 18.2
Expectation of Pain
Did not have one 13 7.8 — — 4.32 (.25-75.90)
Expected to feel what she felt 16 9.6 1 4.5 2.50 (.31-20.06) .6195
Expected to feel less pain 115 69.3 18 81.8
Expected to feel more pain 21 12.7 3 13.6 1.10 (.30-4.05)
CI ¼ confidence interval; OR ¼ odds ratio.
*Chi-squared test. Fisher’s exact test.

the cycle of tension-fear-pain. However, it is rarely
recognized and valued by professionals as a NPM
and, in the institution that was the object of this study,
it is not included in the nurses’ prescription guide.
The primiparas participating in this research indicated
that these practices are more often conducted by
their companions, but all the members of the health-
care team were cited as a reference at least once, in
particular the nurse-midwife and the obstetrician
(Table 2).
Neither focused attention nor the use of the birth
ball (both producing a high degree of satisfaction) was
included in the latest systematic reviews of NPMs for alle-
viating pain (Cluett & Burns, 2009; Simkin & Bolding,
2004; Simkim & O’Hara, 2002; Smith, Collins, Cyna, &
Crowther, 2006), a fact that may explain the difficulty
in locating published materials on these methods.
In relation to the healthcare professional who
applied the methods, the nurse-midwife stands out in
most of them, although the obstetricians were also
involved in the application of all the methods cited.
Another study using a qualitative approach, conducted
at a Brazilian obstetric center, points to the difficulty of
using alternative resources, such as the birth ball, mas-
sages, and showers, because doctors see them as of lit-
tle scientific value or as inappropriate. However, when
282 Gayeski et al.
the benefits were described, they changed their opin-
ions (Dias & Domingues, 2005).
This finding is also relevant if we consider that
most randomized clinical trials on NPMs to alleviate
pain during labor, published in the last few decades,
were conducted and applied by nurse-midwives
(Chang, Chen, & Huang, 2006; Cluett et al., 2004;
Field, Hernandez-Reif, Taylor, Quintino, & Burman,
1997; Rush et al., 1996; Silva et al., 2009). Regarding
the nurses’ assistants and nursing and medical
students, only a small number were pointed out by
the women as a reference for the application of these
methods. However, a high number of primiparas were
not able to identify which member of the healthcare
team applied the method, which might be due to the
fact that some of them may not have identified
themselves before offering the service (Table 2).
It is relevant to point out that both nursing and
medical students also involved themselves more in
the application of the methods most used by the ob-
stetric nurses (warm showers) and obstetricians
(breathing techniques), which indicates that, as ser-
vices are offered in the institution that was the object
of this study, the first principle of the philosophy
related to the assistance to mothers is taught first
(Santos & Siebert, 2001) (Table 2).
The participation of the woman’s companion
(who did not receive any training) in the application
of manual massages was outstanding (Table 4).
Although this method did not increase the level of satis-
faction of the primiparas, it may have contributed to
their satisfaction (98.2% of them) with the emotional
support received from the companion (Table 5),
because massages promote a sense of proximity,
involvement, and empathy, which are the basic ele-
ments of support (Hodnett et al., 2013). Several ran-
domized clinical trials have included the companion
to provide massages (Chang et al., 2006; Chang,
Wang, & Chen, 2002; Field et al., 1997; Kimber,
McNabb, McCourt, Haines, & Brocklehurst, 2008),
and in one of them the companion was trained. In this
case, the women in the experimental group
experienced decreased levels of depression and pain
(p < .005) and of stress levels and anxiety (p < .001)
(Field et al., 1997). These findings suggest that prenatal
training and the presence of a companion applying the
method may generate higher degrees of satisfaction.
The results related to the emotional support provided
by a companion are congruent with the study conduct-
ed by Br€ uggemann et al. (2007), in which a strong asso-
ciation between the companion’s support and global
satisfaction with the birthing experience was found.
It was reported in the present study that, among
the members of the healthcare team identified by the
primiparas, there was a statistically significant associa-
tion between the emotional support provided by the
nurse-midwife, the obstetrician, and the nurses’ assis-
tants and the general degree of satisfaction with the
methods (Table 5). Thus, it is possible to infer that the
odds of the mother experiencing satisfaction with
NPMs to relieve pain are associated with the participa-
tion of these professionals in the procedures, as long
as this participation is also genuine and empathic in
the same way that focused attention was perceived
(Table 4). Davim, Torres, and Dantas (2009) underline
the importance of being aware of verbal and nonverbal
behaviors on the part of the healthcare team involved in
providing services because these factors have a major
influence on the context in which the woman finds her-
self. The reason is that the behavior of health profes-
sionals in the face of pain interferes directly in their
relationship with the user of the services. These aspects
are valued by women because they wanted personal-
ized service that focuses on their needs and also they
want health professionals who combine their knowl-
edge and clinical skills with competence in interper-
sonal relationships (Renfrew et al., 2014).
These results may be due to the context of care-
giving in which this study was conducted—that is, an
obstetric center that embraces humanistic principles
and attempts to incorporate the recommendations of
the WHO in assisting labor. This attitude may be
consolidating a service model that promotes a less
interventionist professional. Therefore, it was not sur-
prising that the primiparas participating in this study
identified the doctors (a small percentage in some
cases) as having applied all the methods including
emotional support (Table 2), although a doctor is
widely seen as an interventionist, more concerned
with eliminating physical pain than suffering, having
been trained in depth to deal with gestational compli-
cations and the intensive use of technologies (Lowe,
2002; Riesco & Tsunechiro, 2002).
In Brazil, the current model is predominantly bio-
logic, and breaking away from it is viewed as a slow
process, requiring behavioral changes by healthcare
professionals (Leal et al., 2014). The results of this
study, however, indicate that the medical team is
already beginning to embrace this new model. In gen-
eral, it is possible to infer that emotional support is a
practice that can be incorporated in the daily routine
of an obstetric center, although Br€ uggemann, Ebsen,
Oliveira, Gorayeb, and Ebele (2014) describe the diffi-
culties of implementing it in the birthing environment
because it is busier, not very suitable, and the health
professionals often carry preconceived negative ideas
regarding the companion’s presence in the birth
setting.
 Nonpharmacologic Methods to Relieve Pain During Labor
It is important to highlight that the obstetric re-
sults as well as the primiparas’ expectation of pain
did not influence their general satisfaction with the
use of NPMs even when submitted to interventions
such as the use of oxytocin and misoprostol or experi-
encing labor pains for more than 8 hours. It is also
worth pointing out that no significant associations
were found between the use of epidural analgesia or
pharmaceutical drugs to alleviate pain and the degree
of satisfaction of the primiparas. These findings are
controversial because some randomized clinical trials
have reported an association between the reduction
in the use of epidural analgesia and oxytocin and a
high degree of satisfaction (Cluett et al., 2004) and
others have not (Kimber et al., 2008). Therefore, it is
possible to infer that the degree of satisfaction is
independent of the intervention when NPMs are
applied.
CONCLUSIONS
The results of this study indicate that in the maternity
unit of the University Hospital at the Federal University
of Santa Catarina, all available NPMs are, in general, be-
ing used by the healthcare team. However, those that
generate the highest degrees of satisfaction for the pop-
ulation of this study are not the most commonly used.
The support of the companion stands out as the most
commonly used NPM, followed by the warm showers.
The nurse-midwife is the professional who applies
REFERENCES
Abushaikha, L., & Oweis, A. (2005). Labour pain experi-
ence and intensity: A Jordain perspective. International
Journal of Nursing Practice, 11, 33–38.
Adachi, K., Shimada, M., & Usui, A. (2003). The relation-
ship between the parturient’s positions and perceptions of
labor pain intensity. Nursing Research, 52, 47–51.
Barbieri, M., Henrique, A. J., Chors, F. M., Maia, N. L., &
Gabrielloni, M. C. (2013). Warm shower aspersion, perineal
exercises with Swiss ball and pain in labor. Acta Paulista de
Enfermagem, 26(5), 478–484.
Brown, S., & Lumley, J. (1994). Satisfaction with care in labor
and birth: A survey of 790 Australian women. Birth, 21, 4–13.
Br€
uggemann, O. M., Knobel, R., Siebert, E. R., Boing, A. F.,
& Andrezzo, H. F. (2009). Vertical-position births at a uni-
versity hospital: A time-series study, 1996 to 2005. Brazilian
Journal of Mother and Child Health, 9, 189–196.
Br€
uggemann, O. M., Parpinelli, M. A., Osis, M. J.,
Cecatti, J. G., & Neto, A. S. (2007). Support to
woman by a companion of her choice during childbirth:
A randomized controlled trial. Reproductive Health
Journal, 4, 1–7.
Br€
uggemann, O. M., Ebsen, E. S., Oliveira, M. E.,
Gorayeb, M. K., & Ebele, R. R. (2014). Reasons which lead
the health services not to allow the presence of the birth
283
these methods the most, and the companion partici-
pates in almost all of them. The satisfaction of primip-
aras, when evaluated for each method individually, is
higher with focused attention and the warm showers.
However, focused attention and changes of position
are statistically associated with the general score of
satisfaction of primiparas with the methods.
Based on the results of logistic regression, it is
possible to conclude that the emotional support of
the nurse-midwife and the obstetrician, along with
changes in position, are the methods most associated
with the general satisfaction of the primiparas. These
are easy to implement in any obstetric environment
and do not depend on physical structures or material
resources.
Although this research has been developed in a
specific scenario in southern Brazil, the results and
conclusions can be discussed at the international level
because nonpharmacologic methods of pain relief dur-
ing labor are part of the strategies of the international
agenda of policies regarding women during pregnancy
and childbirth.
The results could be used for comparison pur-
poses between different realities, seeking similarities
and differences in the use of these methods, but also
as inspiration for the services that implement those
practices. As the research has indicated, the benefits,
according to mothers, besides helping to relieve
pain, include contributing to increased satisfaction
with hospital maternity services.
companion: Nurses’ discourses. Texto Contexto Enferma-
gem, 23(2), 270–277, Retrieved August 5, 2014 from. http://
www.scielo.br/scielo.php?script¼sci_arttext&pid¼S0104-
07072014000200270&lng¼pt.
Caton, D. (2002). The nature and management of labor
pain: Executive summary. American Journal of Obstetrics
and Gynecology, 186, 1–15.
Chaillet, N., Belaid, L., Crochetiere, C., Roy, L.,
Gagn
e, G. P., Moutquin, J. M., Rossignol, M., Dugas, M.,
Wassef, M., & Bonapace, J. (2014). Nonpharmacologic ap-
proaches for pain management during labor compared with
usual care: A meta-analysis. Birth, 2(41), 122–137.
Chang, M., Wang, S., & Chen, C. (2002). Effects of massage
on pain and anxiety during labour: A randomized controlled
trial in Taiwan. Journal of Advanced Nursing, 38, 68–73.
Chang, M. Y., Chen, C. H., & Huang, K. F. (2006). A com-
parison of massage effects on labor pain using the McGill pain
questionnaire. Journal of Nursing Research, 14, 191–196.
Cluett, E. R., & Burns, E. (2009). Immersion in water in
labour and birth. Cochrane Database of Systematic Re-
views(2), CD000111.
Cluett, E. R., Pickering, R. M., Getliffe, K., & James, N. J.
(2004). Randomised controlled trial of labouring in water
compared with standard of augmentation for management of
284 Gayeski et al.
dystocia in first stage of labour. British Medical Journal,
328, 314–320.
Davim, R. M., Torres, G. V., Dantas, J. C., Melo, E. S.,
Paiva, C. P., Vieira, D., & Costa, I. K. F. (2008). Showering as a
nonpharmacological strategy to relief the parturients pain.
Revista Eletronica de Enfermagem, 10(3), 600–609,
Retrieved August 5, 2014 from. http://www.fen.ufg.br/
revista/v10/n3/v10n3a06.htm.
Davim, R. M. B., Torres, G. V., & Dantas, J. C. (2009).
Effectiveness of non-pharmacological strategies in relieving
labor pain. Revista da Escola de Enfermagem da Universi-
dade Federal de S~ ao Paulo, 43, 438–445.
Dias, M. A. B., & Domingues, R. M. S. M. (2005). Challenges
for the implementation of a humanization policy in hospital
care for childbirth. Ci^encia & Sa
ude Coletiva, 10, 669–705.
Enkin, M., Keirse, M. J. N. C., Renfrew, M., & Neilson, J.
(1998). Control of pain in labor. In M. Enkin,
M. J. N. C. Keirse, M. Renfrew, & J. Neilson (Eds.), A guide to
effective care in pregnancy & childbirth (pp. 247–261).
New York: Oxford University Press.
Field, T., Hernandez-Reif, M., Taylor, S., Quintino, O., &
Burman, I. (1997). Labor pain is reduced by massage therapy.
Journal of Psychosomatic Obstetrics and Gynecology, 18,
286–291.
Garthus-Niegel, S., Knoph, C., Soest, T., Nielsen, C. S., &
Eberhard-Gran, M. (2014). The role of labor pain and overall
birth experience in the development of posttraumatic stress
symptoms: A longitudinal cohort study. Birth, 41(1), 108–115.
Hodnett, E. D., Gates, S., Hofmeyr, G. J., & Sakala, C.
(2013). Continuous support for women during childbirth.
Cochrane Database of Systematic Reviews CD003766.
Hulley, S. B., Cummings, S. R., Browner, W. S., Grady, D. G.,
& Newman, T. B. (2008). Designing clinical research. Phil-
adelphia: Lippincott Williams & Wilkins.
Jones, L., Othman, M., Dowswell, T., Alfirevic, Z., Gates, S.,
Newburn, M., Jordan, S., Lavender, T., & Neilson, J. P. (2012).
Pain management for women in labour: An overview of sys-
tematic reviews. Cochrane Database of Systematic Reviews
CD009234.
Kimber, L., McNabb, M., McCourt, C., Haines, A., &
Brocklehurst, P. (2008). Massage or music for pain relief in
labour: A pilot randomized placebo controlled trial. Euro-
pean Journal of Pain, 12, 961–969.
Leal, M. C., Pereira, A. P. E., Domingues, R. M. S. M., Theme
Filha, M. M., Dias, M. A. B., Nakamura-Pereira, M.,
Bastos, M. H., & Gama, S. G. N. (2014). Obstetric interven-
tions during labor and childbirth in Brazilian low-risk
women. Cadernos de Sa
ude P
ublica, 30, S17–S32.
Lowe, N. (2002). The nature of labor pain. American
Journal of Obstetrics and Gynecology, 186, 16–24.
McCallum, C., & Reis, A. (2006). Re-signifying pain,
overcoming loneliness: Childbirth experiences among
working-class adolescents in a public maternity hospital
in Salvador, Bahia, Brazil. Cadernos de Sa
ude P
ublica, 22,
1483–1491.
Merhy, E. E., & Onocko, R. (1997). Agir em sa
ude: um
desafio para o p
ublico. S~ao Paulo: Editora Hucitec.
Miquelutti, M. A., Cecatti, J. G., Morais, S. S., &
Makuch, M. Y. (2009). The vertical position during labor:
Pain and satisfaction. Revista Brasileira de Sa
ude
Materno-Infantil [serial on the Internet], 9(4), 393–398,
Retrieved August 4, 2014 from. http://www.scielo.br/
scielo.php?script¼sci_arttext&pid¼S1519382920090004
00002&lng¼en.
Nassar, S. M. (2008). SestatNet: Sistema Especialista para
o Ensino de Estat
ıstica na Web. Florian
opolis, SC, Brazil.
Retrieved June 10, 2008 from http://www.sestatnet.ufsc.br/.
Odent, M. (1983). Birth under water. Lancet, 2, 1476–
1777.
Ohlsson, G., Buchhave, P., Leandersson, U., Nordstrom, L.,
Rydhstrom, H., & Sjolin, I. (2001). Warm tub bathing during
labour: Maternal and neonatal effects. Acta Obstetricia et
Gynecologica Scandinavica, 80, 311–314.
Rattner, D., Santos, M. L., Lessa, H., & Diniz, S. D. (2010).
ReHuNa—the Brazilian network for the humanization of
childbirth. Revista Tempus Actas Sa
ude Coletiva, 4, 215–228.
Renfrew, M. J., McFadden, A., Bastos, M. H., Campbell, J.,
Channon, A. A., Cheung, N. F., Silva, D. R., Downe, S.,
Kennedy, H. P., Malata, A., McCormick, F., Wick, L., &
Declercq, E. (2014). Midwifery and quality care: Findings
from a new evidence informed framework for maternal and
newborn care. The Lancet Midwifery: An Executive Sum-
mary, 384(9948), 1129–1145.
Riesco, M. L. G., & Tsunechiro, M. A. (2002). Midwifery
and nurse-midwifery: Old problems or new possibilities?
Revista Estudos Feministas, 10, 449–459.
Rush, J., Burlock, S., Lambert, K., Loosley-Millman, M.,
Hutchison, B., & Enkin, M. (1996). The effects of whirlpool
baths in labor: A randomized controlled trial. Birth, 23,
136–143.
Santana, L. S., Gallo, R. B. S., Ferreira, C. H. J.,
Quintana, S. M., & Marcolin, A. C. (2013). Effect of shower
bath on pain relief of parturients in active labor stage. Re-
vista Dor [serial on the Internet], 14(2), 111–113, Retrieved
August 4, 2014 from. http://www.scielo.br/scielo.php?pid¼
S180600132013000200007&script¼sci_arttext&tlng¼en.
Santos, O. M. B., & Siebert, E. R. C. (2001). The humani-
zation of birth experience at the University of Santa Catarina
maternity hospital. International Journal of Gynecology &
Obstetrics, 75(Suppl.), S73–S79.
Silva, F. M., Oliveira, S. M., & Nobre, M. R. (2009). A
randomised controlled trial evaluating the effect of immer-
sion bath on labour pain. Midwifery, 25, 286–294.
Silva, R. M., Barros, N. F., Jorge, H. M. F., Melo, L. P. T. M., &
Ferreira A. R. Jr. (2012). Qualitative evidence of monitoring
by doulas during labor and childbirth. Ci^encia & Sa
ude Co-
letiva, 17, 2783–2794.
Simkin, P. (2007). Comfort in labor: How you can help
yourself to a normal satisfying childbirth. Retrieved June 17,
2010 from http://www.childbirthconnection.org/pdfs/
comfort-in-labor-simkin.pdf.
Simkin, P., & Bolding, A. (2004). Update on non-
pharmacologic approaches to relieve labor pain and prevent
suffering. Journal of Midwifery & Women’s Health, 49, 489–
504.
Simkim, P. P., & O’Hara, M. (2002). Nonpharmacologic
relief of pain during labour: Systematic reviews of five
methods. American Journal of Obstetrics and Gynecology,
186(Suppl), 131–159.
Smith, C. A., Collins, C. T., Cyna, A. M., & Crowther, C. A.
(2006). Complementary and alternative therapies for pain
management in labour. Cochrane Database of Systematic
Reviews(4), CD003521.
World Health Organization. (1985). Appropriate technol-
ogy for birth. Fortaleza, Brazil: World Health Organization.
World Health Organization. (1996). Normal delivery
assistance: A practical guide. Geneva: World Health
Organization.