HCC Effects of Labor Dance & the Major Findings Analysis

Explore 16 (2020) 310 317Contents lists available at ScienceDirect
Explore
journal homepage: www.elsevier.com/locate/jsch
Research Letter
The effect of labor dance on perceived labor pain, birth satisfaction, and
neonatal outcomes
Bihter Akin, MW, Assist. Prof., PhDa,*, Birsen Karaca Saydam, RN, Assoc. Prof., PhDb
a
b
Selcuk University, Faculty of Health Sciences, Midwifery Department, Konya, Turkey
Ege University, Faculty of Health Sciences, Midwifery Department, Izmir, Turkey
A R T I C L E
I N F O
Keywords:
Dance
Birth (delivery)
Pain
Satisfaction
Neonatal results
A B S T R A C T
Objective: This research was conducted to determine the effects of labor dance on perceived birth pain, birth
satisfaction, and neonatal outcomes.
Design: This is an experimental study. Data were collected under three groups during the active phase of
labor: the dance practitioner midwife group (DPMG, comprising 40 pregnant women), the dance practitioner
spouse/partner group (DPSG, comprising 40 pregnant women) and the control group (CG, comprising 80
pregnant women).
Setting: This study was conducted between 1 April 2017 and 31 October 2017 in Turkey.
Participants: This study was administered on pregnant women volunteers with no risk during the active
phase of labor.
Interventions: During the active phase, pregnant women in DPMG danced with the midwife; pregnant
women in DPSG, on the other hand, danced with their spouses/partners throughout the active phase. When
vaginal dilatation reached 4 cm and 9 cm, labor pain was measured by employing the visual analog scale
(VAS). In the postpartum phase, newborn babies’ first, fifth, and tenth minute Apgar scores and oxygen saturation levels were measured and registered. In the first hour after delivery, the Mackey Birth Satisfaction
Scale was administered. CG, on the other hand, received only the routine procedures offered in the hospital.
Findings: The mean scores of VAS 1 and VAS 2 in DPSG and DPMG were lower than in CG. The fifth and tenth
minute Apgar scores and the first, fifth, and tenth minute oxygen saturation levels of the newborns in the
experimental groups, as well as the level of birth satisfaction, were significantly higher than in CG.
Key conclusions: The study showed a positive effect of labor dancing on the labor process.
© 2020 Elsevier Inc. All rights reserved.
1. Introduction
Labor is a significant process for both pregnant women and their
newborns. Pregnant women experience different feelings, such as
fear and pain, during labor. Not only does labor pain have negative
effects on pregnant women and fetuses, women’s psychological and
emotional states have a great effect on levels of perceived pain. 1-6
Therefore, midwives should closely monitor the medical statuses of
pregnant women and fetuses, check women’s physical and psychological states, and provide necessary assistance for coping with pain.7
Pharmacological and non-pharmacological methods are used to
cope with labor pain. 8-15 Regional and systemic analgesics are preferred
as pharmacological methods. 16-18 Of the non-pharmacological methods
used, massage, hot and cold therapies, therapeutic touch, breathing
techniques, hypnosis, and music are most commonly used.19,20 These
* Corresponding author.
E-mail addresses: bihterakin@yahoo.com (B. Akin),
birsenkaracasaydam@gmail.com (B.K. Saydam).
https://doi.org/10.1016/j.explore.2020.05.017
1550-8307/© 2020 Elsevier Inc. All rights reserved.
non-pharmacological methods, the analgesic effects of which are
explained by gate control and endorphin theory, are all comfortable
practices that are easy to use and reliable.21,22 The support provided by
people whose company is desired by pregnant women during the labor
process is the main factor that improves the effective use of non-pharmacological methods and provides feelings of self-control to pregnant
women during the process.20
Another non-pharmacological method that provides massage and
mobility with the support of the spouse/partner is the labor dance.23
The labor dance starts in the active labor phase of the first labor stage
and continues until the end of the first stage to reduce pregnant
women’s pain and provide emotional support. The pregnant women
can dance with someone they prefer (spouse/partner, mother, midwife, etc.) accompanied by light, calming music. The pregnant
woman puts her hands on the shoulders of her partner and sways
from left to right while the partner massages the pregnant woman’s
sacral area.24 The aim is to increase the effectiveness of the method
performed with the spouse/partner’s support, upright position, and
massage, apart from the music and body movements, and to provide
B. Akin and B.K. Saydam / Explore 16 (2020) 310 317
emotional support to the pregnant woman. 25-27 A labor dance that a
pregnant woman performs with her partner reduces perceived pain
and increases the woman’s satisfaction with birth.25 Yet, there is a
limited number of studies regarding labor dance.25 In this study, the
effects of labor dance with a midwife and spouse/partner are compared differently from previous studies. This study is important as it
is the first study comparing the effects of midwife and spouse/partner
support for women in the process of labor. This study was conducted
to determine the effects of labor dance on perceived labor pain, birth
satisfaction, and neonatal outcomes.
2. Materials & Methods
2.1. Design
This experimental and prospective study aims to evaluate the
effects of labor dance, which is applied during the active phase of
labor, on perceived labor pain, birth satisfaction, and neonatal outcomes. This study was conducted at Urla State Hospital, Izmir, Turkey, which is affiliated with the Ministry of Health’s Public Hospitals
Administration. The study population was taken out of all the pregnant women who were admitted to the Urla State Hospital for labor
between April 2017 and October 2017.
2.2. Participants
The study sample included 160 pregnant women who had the following characteristics:
 Those who were admitted to the Ministry of Health Urla State
Hospital for labor
 Those whose cervical dilatation was between 4 and 8 cm
 Those who had received labor dance training by attending prenatal training with their spouses/partners in the perinatal period
(Only DPSG).
 Those who met the inclusion criteria (volunteering, term pregnancy (37-41 gestational weeks), single fetus, no pregnancy complications (oligohydramniosis and polihydramniosis, placenta
previa, pre-eclampsia, premature rupture of membrane, presentation anomalies, intrauterine growth retardation, intrauterine
death, macrosomic baby, fetal distress, etc.).
We excluded patients if
 They underwent cesarean section
 Labor was inducted
 Narcotic analgesics were used
The dance practitioner spouse/partner group (DPSG) included 40
pregnant women who signed the informed consent form, the dance
practitioner midwife group (DPMG) included 40 pregnant women and
midwives who had received labor dance training, and the control group
included 80 pregnant women who were subjected to routine treatment
without dance. The sample size was determined using power calculations G*Power 3, taking into account previous studies on labor dance for
satisfaction. Estimates of effects were derived from the findings of Abdolahian et al. (2014), who reported on the mean satisfaction of a experimental group (4.66 § 0.66) and a control group (4.13 § 1.04).25 We
aimed at detecting a similar difference. The number of samples in each
group (experimental and control) was 80. The power analysis showed
that the study sample size had 99% power with a = .05.
2.3. Data collection tools
A visual analog scale (VAS) was administered to determine pregnant women’s perceived labor pain when cervical dilatation was
311
4 cm, and the VAS was readministered when cervical dilatation was
9 cm. Electronic fetal monitoring was performed, and fetal heart rate
was examined and recorded on a partogram by a researcher every
thirty minutes. The Mackey Childbirth Satisfaction Rating Scale was
administered in the first hour after the delivery to determine pregnant women’s satisfaction levels. Newborns’ first minute, fifth minute, and tenth minute Apgar scores were evaluated and recorded.
Newborns’ first minute, fifth minute, and tenth minute oxygen saturation levels were measured on their right hands, and the results
were recorded. Only routine practices were performed with the control group, and data were recorded as in the experimental groups
(Figure 1).
2.4. Data collection procedures and labor dance
The pregnant women and their spouses/partners were trained in
labor dance during prenatal training (for DPSG). In order not to affect
the results the study, training was given about labor dance to women
and their spouses/partners without giving any information about the
aim of study and the effects of labor dance on labor pain. The pregnant women and their spouses/partners who wanted to perform the
practice were asked to inform the researcher when the labor started.
The researcher stayed with the pregnant women and their spouses
during the practice and labor process. The pregnant women started
to dance with their spouses during the active phase of the labor process, accompanied by meditation music in a dim, otherwise silent
environment. The spouse or partner massaged the pregnant women’s
sacral areas while dancing. During the active phase of labor, the pregnant women in DPMG danced with the midwives who were attendant in the delivery room and who were monitoring the pregnant
women’s statuses. Only routine practices were performed with the
control group (electronic fetal monitoring was performed, and fetal
heart rate was examined and recorded on a partogram by a
researcher every thirty minutes).
2.5. Analysis
Data analysis was conducted using the Statistical Package for Social
Science 11.0. Descriptive data regarding pregnant women were provided as numbers and percentage distributions. Chi-squared tests
were used for categorized/classified variables. The Shapiro-Wilk test
was employed to determine certain obstetrical traits of pregnant
women, the total sum of dance time, perceived level of pain and birth
satisfaction among mothers, and whether or not data revealed a normal distribution prior to comparing the Apgar and oxygen saturation
levels of the newborns. Based on these test results, the Kruskal-Wallis
test was administered to analyze abnormally distributed data. Median,
minimum-maximum, mean, and standard deviation values are as
demonstrated. A post-hoc test was performed for further analysis in
case of a difference between the groups after the Kruskal-Wallis test.
Data were evaluated at a p < 0.05 threshold for statistical significance. 2.6. Ethical considerations Ethical approval for this study was obtained from the Ege University Research Ethics Committee, reference 24.03.17/ 17-3/8. Clinical trials of the research were registered under the code NCT04196660. 3. Results The pregnant women’s mean ages were 26.32 § 4.76 years, 27.45 § 4.57 years, and 27.38 § 3.42 years in DPSG, DPMG, and CG, respectively. As shown in Table 1, DPSG, DMPG, and CG had no statistically significant differences in demographic features and were homogeneous. 312 B. Akin and B.K. Saydam / Explore 16 (2020) 310 317 Pregnant women that met research inclusion criteria and volunteered to take part in the research (N =187) Spouse/partner group practicing dance (n = 57) Midwife group practicing dance (n = 44) Excluded from the research (11 women that the researcher did not attend during delivery, 3 women giving birth in a different institute, 2 women who quit the research, 1 woman who underwent caesarean delivery) Excluded from the research (1 woman who did not deliver by dancing with the midwife, 3 women who underwent caesarean delivery) Excluded from the research (7) Having caesarean delivery (3) Women who quit the research (4) Assignment of women who met the inclusion criteria and received labor dance training by attending prenatal training in the dance practitioner spouse/partner group (DPSG) Assignment of women who met the inclusion criteria and agreed to perform labor dance with a midwife in the dance practitioner midwife group (DPMG) Assignment of women who met the inclusion criteria and did not want to perform a labor dance Control group (n = 87) VAS practice when cervical dilatation was 4 cm (for all groups) When cervical dilatation was 4 cm, labor dance started with women’s spouses/partners, with intermittent dance during the labor process When cervical dilatation was 4 cm, labor dance started with women’s midwives, with intermittent dance during the labor process Routine care was offered (cervical dilatation and fetal heart rate was examined and recorded) VAS practice when cervical dilatation was 9 cm (for all groups) In the postpartum phase, data were collected about the newborns by administering a birth satisfaction scale in the first hour after birth (for all groups). Analyzed (n = 40) Analyzed (n = 40) Figure 1. Practice Stages of the Research Analyzed (n = 80) B. Akin and B.K. Saydam / Explore 16 (2020) 310 317 313 Table 1 Distributions Based on Pregnant Women’s Age Groups and Educational Statuses Variables* GROUPS Age Group < 20 Years Old 20-24 Years Old 25-29 Years Old 30-34 Years Old > 35 Years Old
x2 = 1.228 p = 0.351
Educational Status
Literate/Primary School
Middle School
High School
University and above
x2 = 16.120 p = 0.013
Occupational Activity
Worker
Government Official
Self-employment
Housewife
x 2 = 6.425 p= 0.377
Smoking Status Before Pregnancy
Smoking
No smoking
x 2 = 3.295 p= 0.193
TOTAL
Dance Practitioner Spouse/Partner Group
Dance Practitioner Midwife Group
Control Group
Total
n
%
n
%
n
%
n
%
5
10
16
9
0
12.5
25
40
22.5
0
0
12
16
10
2
0
30
40
25
5
0
24
36
20
0
0
30
45
25
0
5
46
68
39
2
3.1
28.8
42.5
24.4
1.2
2
0
22
16
5
0
55
40
4
8
17
11
10
20
42.5
27.5
4
22
37
17
5
27.5
46.3
21.3
10
30
76
44
6.3
18.7
47.5
27.5
4
11
9
16
10
27.5
22.5
40
8
10
9
13
20
25
22.5
32.5
14
11
16
39
17.5
13.75
20
48.75
26
16.25
32
20
37
23.125
65 40.625
13
27
32.5
67.5
7
33
17.5
82.5
26
54
32.5
67.5
46
114
28.75
71.25
40
100.0
40
100.0
80
100.0
160
100.0
* Number and percentage distributions of the groups are presented. Chi-Squared (p-value) methods were used for categorized/classified data, respectively.
All groups were found to be similar in number of pregnancies,
week of pregnancy, cervical dilatation at the time of hospitalization,
and the duration of the active phase (Table 2).
The median total labor dance durations were 48 and 56 minutes
in DPSG and DPMG, respectively. These two groups were similar in
terms of total dance durations (p = 0.873). The median resting times
were 113 and 132 minutes in DPSG and DPMG, respectively, and
these two groups were similar in terms of resting times (p = 0.376)
(Table 3).
The mean scores of perceived pain between groups were evaluated twice, when cervical dilatation was 4 cm and when cervical dilatation was 9 cm (Table 4). The difference in the pain scores when
cervical dilatation was 4 cm was found to be significant (p = 0.043).
When cervical dilatation was 9 cm, the difference was measured
with respect to perceived labor pain level between groups
(p = 0.014). In further analyses (by post hoc Tukey test) this difference
was attributed to the significant lowness of DPSG and DPMG pain levels in contrast to CG (p = 0.01). The median first minute Apgar score
was found to be 9 in DPSG, DPMG, and CG, and there was no
statistically significant difference between the groups (p = 0.91). The
median fifth minute Apgar score was found to be 10 in DPSG, 9 in
DPMG, and 8 in CG, and this difference was statistically significant (p
< 0.01). Further analysis (by post hoc Tukey test) found that this difference arose from the significantly higher Apgar scores of DPSG compared to those of DPMG and CG. The median tenth minute Apgar score was found to be 10 in DPSG, DPMG, and CG (p = 0.06). Newborns’ first minute oxygen saturation levels were 89 in the experimental groups (DPSG, DPMG) and 88 in the control group, and there was a statistically significant difference between the groups (p = 0.05). The fifth minute oxygen saturation levels were 99 in the experimental groups and 94 in the control group, and the tenth minute oxygen saturation levels were 99 in the experimental groups and the control group. There was a statistically significant difference in the fifth minute and tenth minute oxygen saturation levels between the groups (p < 0.01) (Table 5). In order to analyze the birth satisfaction of the mothers, the Mackey Birth Satisfaction Scale was administered to compare the total mean scores and subdimensions of the scale. Among DPSG, Table 2 Pregnant Women’s Distributions Based on the Number of Pregnancies, Week of Pregnancy, Cervical Dilatation at the Time of Hospitalization, and the Duration of the Active Phase Variables* GROUPS Dance Practitioner Spouse/Partner Group n = 40 Dance Practitioner Midwife Group n = 40 Median (Min-Max) Mean§SD Median (Min-Max) Mean§SD Median (Min-Max) Mean§SD Number of Pregnancies 1 (1-2) 1.47§0.50 1 (1-4) 1.52§0.71 1 (1-4) 1.46§0.65 Week of Pregnancy x2 = 6.001 p = 0.050 Cervical Dilatation at Hospitalization (cm) x2 = 2.759 p = 0.252 Duration of Active Phase (hours) 40.0 (38-41) 39.52§0.87 39.6 (38-41) 39.57§0.71 39.0 (37-41) 39.23§0.78 2 (1-3) 2.32§0.61 3 (1-4) 2.55§0.84 2 (1-4) 2.36§0.71 5.5 (3-12) 6.77§2.64 6.0 (3-12) 6.35§2.20 6.0 (3-20) 6.72§2.34 x2 = 0.403 p = 0.817 x2 = 0.905 p = 0.636 Control Group n = 80 * The Kruskal-Wallis H (x2 value) method was used and is shown as the median value with minimum and maximum values in parentheses and mean, standard deviation. 314 B. Akin and B.K. Saydam / Explore 16 (2020) 310 317 Table 3 Findings Regarding the Total Dance and Resting Durations of the Pregnant Women in the Experimental Groups Variables* GROUPS Total Dance Duration (minutes) z = -.159 p = 0.873 Total Rest Duration (minutes)** Dance Practitioner Spouse/Partner Group n = 40 Dance Practitioner Midwife Group n = 40 Median (Min-Max) 48 (43-124) Mean§SD 63.30§24.33 Median (Min-Max) 56 (36-95) Mean§SD 60.68§20.22 113 (58-216) 140.96§57.52 132 (67-216) 143.01§22.44 z = -.886 p = 0.376 * The Mann-Whitney U Test (Z value) was performed. ** Resting time included activities such as sitting in bed, lying, sleeping, eating, and showering, which the pregnant women performed when they were not dancing. Table 4 Pregnant Women’s Distributions of Perceived Pain Scores When Cervical Dilatation Was 4 cm. and When Cervical Dilatation Was 9 cm. Variables GROUPS When cervical dilatation was 4 cm (mm.)* When cervical dilatation was 9 cm(mm.)** Dance Practitioner Spouse/ Partner Group n = 40 Dance Practitioner Midwife Group n = 40 Control Group n = 80 Median (Min-Max) Median (Min- Max) Mean§SD 5.00 (3-7) a 9.00 (7-10) a Mean§SD b Statistical Value Median (Min-Max) c 5.02§1.14 5.00 (2-8) 5.35§1.87 5.00 (3-8) 8.60§1.03 9 (7-10)b 8.82§1.15 9.00 (8-10)c Mean§SD P Value 5.61§1.34 0.043ac * A Kruskal-Wallis Test was administered since the data distribution was not normal. ** Post hoc Tukey tes applied in previous studies, which included interventions for reducing labor pain, had no negative effects on newborns’ Apgar scores. Regarding the implementation of the practice, no difference in the Apgar scores was present between the infants of the different groups of pregnant women.22,29 Lawrence et al. (2013) investigated twelve studies in a meta-analysis to examine the effects of maternal mobilization on labor and found only one study that demonstrated that newborns’ fifth minute Apgar scores in the experimental groups were higher than in the control group.9 Support, mobility, and nonpharmacological methods provided to women during labor reduced the anxiety of the pregnant women, shortened the labor duration because of the pressure on the cervix, and positively affected the newborns.9,10,22 Newborns in the experimental groups had higher first minute, fifth minute, and tenth minute oxygen saturation levels than did the control group. Previous studies that examined the effects on newborns of non-pharmacological methods used in the management of labor pain have evaluated their mean Apgar scores and statuses regarding hospitalization in the intensive care unit.9,10,22 The first and fifth minute oxygen saturation levels in this study agree with those of previous studies. Not only did the labor dance have a positive effect on newborns’ fifth and tenth minute oxygen saturation levels, but it also ensured a greater effect when the practice was performed with a spouse. Findings obtained in this study also reveal that labor dance renders positive effects not only on newborn babies but also on women giving birth (Table 6). One of the most crucial components of labor dance is the physical and emotional support offered during labor. Previous studies that have examined support during pregnancy, labor, or the postpartum period state that pregnant women or women who recently gave birth always need social support, yet the support of the spouse or partner is particularly significant. Another study stated that back massage applied to pregnant women during labor increased mothers’ birth satisfaction.30 Abdolahian et al. (2014) found the birth satisfaction of pregnant women who danced with their spouses to be significantly higher than those who did not dance.25 These study results are compatible with the literature. Labor dances performed with spouses helped women to be satisfied with the labor experience. Ferrer (2016) compared the effects of humanistic and medical care models on women’s birth satisfaction during the intrapartum period. In a humanistic care model, women are allowed to be overseen by their partners and/or another person in the phases of labor, birth, and after birth. At the same time, it is recommended to avoid redundant interventions (constant monitorization, intravenous infusion, amniotomy, etc.). The study found that women who were attended to under the humanistic care model had significantly higher levels of satisfaction with their health professionals, their babies, and their spouses than those who were attended to under the biomedical care model.31 The humanistic care model displays similarities to mother-friendly hospital practices. All pregnant women were provided care using mother-friendly hospital practices. Satisfaction subscales, except for satisfaction with the physician and the total scale score of the experimental groups, were higher than those of the control group. Mother-friendly hospital practices have positive effects on mothers’ satisfaction; furthermore, labor dance enhances this positive effect. Similarly, another study stated that pregnant women who underwent the labor process with the support of health professionals or relatives in a specially prepared room were more satisfied than were pregnant women who had routine care.32 Smith stated that aromatherapy, music, and massage did not affect women’s birth satisfaction; however, hypnosis positively affected their satisfaction.10 Sandall et al. (2016) examined 15 studies of 17,674 pregnant women, comparing their care with other care models under the leadership of midwives. Services such as evaluating low-risk pregnant women’s needs during the antepartum, intrapartum, and postpartum periods; care planning; and referring patients to relevant specialists were provided under the leadership of midwives. This kind of care was provided by health professionals such as obstetricians, family physicians, and obstetrician nurses in other care models. The satisfaction status of women who received care under the leadership of midwives was found to be high compared to the women in other groups.33 The concerns of the pregnant women and their partners and spouses increased when the midwives left them alone during the labor process. The midwives constantly provided personal care, which pleased the pregnant women. This satisfaction helped them to perceive the clinical environment and all employees positively and to enhance psychological and physiological healing.34 It is highlighted that pregnant women in the experimental groups were never left on their own during the labor process in this research, and the non-presence of constant monitoring by the spouse or midwife affected women’s birth satisfaction in a positive way. Labor dance is a novel method that helps pregnant women, families, and midwives cooperate during labor and contributes to pregnant women’s spouses/partners being able to manage pain experiences during the first phase of labor. Since labor dance is practiced with one’s spouse/partner and midwives, this study was conducted in a mother-friendly hospital that allows spouses to be in the delivery room. In order to popularize labor dance and help pregnant women’s families contribute to intrapartum care, it is suggested to conduct dance practices in a wider sampling with other attendants a pregnant women would ask for (mother, sister, or friend) and in institutions that are not mother-friendly. 316 B. Akin and B.K. Saydam / Explore 16 (2020) 310 317 5. Conclusion The results of this study demonstrated that labor dance positively affected labor pain, birth satisfaction, and neonatal results. The labor dance was important; however, whether dancing occurred with a spouse/partner or midwife did not affect the study results. The pregnant women wanted their midwives’ company as much as they needed their families’ presence during labor, which is one of the most special moments of their lives. This study supports the “Midwives, Mothers, and Families: Partners for Life” theme of the 2017 International Confederation of Midwives (ICM). 9. 10. 11. 12. 13. Author Contributions B. A. and B. K. S. designed the study, analyzed the data, and drafted the manuscript; B. A. conducted the data collection and drafted the manuscript, as well as conducted the study and data collection. All the authors read and approved the final manuscript. 14. 15. 16. Ethical Approval All participants gave written consent to participate. Ethical approval was obtained from the Ege University Research Ethics Committee reference (24.03.17/ 17-3/8). All participants gave written consent to anonymised quotes being used in publications. Funding Sources: There is no funding in the study Clinical Trial Registry and Registration number: NCT04196660 17. 18. 19. 20. 21. Declaration of Competing Interest 22. The authors declare that there is no conflict of interest. 23. Acknowledgement This article was derived from a doctoral thesis. This paper was presented as an oral presentation at the 47th Global Nursing and Healthcare Conference in London between 1 and 3 March 2018. 24 25. 26. Supplementary materials 27. Supplementary material associated with this article can be found in the online version at doi:10.1016/j.explore.2020.05.017. References 1. Eisenach JC.The pain of childbirth and its effect on the mother and the fetus. Obstetric anesthesia: principles and practice. Philadelphia: Elsevier-Mosby2004: 288-301. € Birth pain and nursing approach. Journal of Ataturk University 2. Ertem G, Sevil U. School of Nursing. 2005;8:117–123. 3. 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Prof Birsen karaca Saydam, _ who was borned in Karşıyaka, Izmir. Her professions are reproductive health, infertility, obstetrics and gynecologic nursing, gynecological oncology nursing, gender equality in society and health education. Currently she has been conducting the Assos. Prof. Position in Ege University Faculty of Health Science Midwifery Department.