Elsevier

Midwifery

Volume 25, Issue 2, April 2009, Pages e39-e48
Midwifery

‘Soothing the ring of fire’: Australian women's and midwives’ experiences of using perineal warm packs in the second stage of labour

https://doi.org/10.1016/j.midw.2007.08.002Get rights and content

Abstract

Objective

to determine women's and midwives’ experiences of using perineal warm packs in the second stage of labour.

Design

as part of a randomised controlled trial (Warm Pack Trial), women and midwives were asked to complete questionnaires about the effects of the warm packs on pain, perineal trauma, comfort, feelings of control, satisfaction and intentions for use during future births.

Setting

two hospitals in Sydney, Australia.

Participants

a randomised controlled trial was undertaken. In the late second stage of labour, nulliparous women (n=717) giving birth were randomly allocated to having warm packs (n=360) applied to their perineum or standard care (n=357). Standard care was defined as any second stage practice carried out by midwives that did not include the application of warm packs to the perineum. Three hundred and two nulliparous women randomised to receive warm packs (84%) received the treatment. Questionnaires were completed by 266 (88%) women who received warm packs, and 270 (89%) midwives who applied warm packs to these women.

Intervention

warm, moist packs were applied to the perineum in the late second stage of labour.

Findings

warm packs were highly acceptable to both women and midwives as a means of relieving pain during the late second stage of labour. Almost the same number of women (79.7%) and midwives (80.4%) felt that the warm packs reduced perineal pain during the birth. Both midwives and women were positive about using warm packs in the future. The majority of women (85.7%) said that they would like to use perineal warm packs again for their next birth and would recommend them to friends (86.1%). Likewise, 91% of midwives were positive about using the warm packs, with 92.6% considering using them in the future as part of routine care in the second stage of labour.

Key conclusions

responses to questionnaires, eliciting experiences of women and midwives involved in the Warm Pack Trial, demonstrated that the practice of applying perineal warm packs in the late second stage of labour was highly acceptable and effective in helping to relieve perineal pain and increase comfort.

Implications for practice

perineal warm packs should be incorporated into second stage pain relief options available to women during childbirth.

Introduction

Perineal pain, such as that experienced with the birth of the baby's head, can be severe and unlike any other pain experienced during labour. Women's expression of this pain when giving birth has motivated midwives since ancient times to seek out methods that may comfort and ease this pain. In The Works of Aristotle, the ‘ring of fire’ that women often experience when giving birth is described as ‘if it [perineum] were scratched or pricked with pins’ (Aristotle, date unknown, pp. 253–254).1 Soranus of Ephesus (98–138 AD), in his book Gynaecology, was one of the earliest writers to describe the care of the perineum. He gave instructions that one should ‘drench warm pieces of cloth with warm, sweet olive oil and put them over the abdomen as well as the labia and keep them saturated with the warm oil for some time, and one must also place bladders filled with warm oil alongside’ (Temkin, 1956, p. 72).

Anderson (2000) argued that very little is known about women's experiences of the second stage of labour and what aspects of midwifery care help or hinder them in the process of giving birth. The second stage, in particular, is associated with the onset of new and frightening sensations that appear to follow a predictable pattern. A study by Anderson (2000) of the experiences of 16 women in the second stage of labour reported sensations such as bulging, cracking, splitting, opening and breaking. On feeling these overwhelming sensations, women have to overcome a barrier of fear that initially prevents them from pushing.

Perineal trauma following childbirth is associated with significant short- and long-term morbidity for women (Sleep and Grant, 1987; Klein et al., 1994; Glazener et al., 1995; Glazener, 1997; McCandlish et al., 1998; Albers et al., 1999; Barrett et al., 2000; Sultan and Thakar, 2002). The level of pain that women experience when actually giving birth and methods that might ease this pain are less well understood. The pain felt during the advancement of the fetal head and stretching of the perineum in the minutes before giving birth has been reported to be severe (Miller, 1994). Much of the research on pain in labour has focused on analgesia in the first stage. The pain associated with the actual birth has been largely overlooked (Sanders et al., 2005). For example, of the 68 randomised trials examining epidural analgesia in labour, only one included information on the effectiveness of perineal analgesia during birth (Hill, 1995). In a Cochrane review on birth position in the second stage of labour, only five of 19 trials included maternal pain during the birth as an outcome (Gupta et al., 2006).

Studies that have examined the degree of pain experienced in the different stages of labour reported that the most severe pain was experienced in the second stage (Niven and Gijsbers, 1984; Lowe and Roberts, 1998). The pain reported was significantly higher than pain scores given by patients suffering from cancer and arthritis (Melzack, 1975). Obviously marked differences exist, as the pain of the second stage of labour is physiologically normal and occurs for a relatively short time compared with pain experienced with illnesses such as cancer and arthritis. In an observational study of women in the second stage of labour (McKay et al., 1990), seven of the 20 women interviewed used negative terms such as painful, miserable or horrible. The authors of this study suggested that strategies are needed to help alleviate some of the intense sensations of the second stage.

The degree to which pain during birth influences maternal satisfaction is controversial. It has become increasingly apparent that adequate analgesia is not the central factor in maximising maternal satisfaction with care. There are multiple factors involved, such as attitudes and behaviours of health providers during childbirth (Green and Baston, 2003). A Cochrane review on epidural analgesia showed that while epidural analgesia offered better pain relief than non-epidural analgesia, maternal satisfaction with pain relief was not significantly different (Anim-Somuah et al., 2005). Descriptive studies have also demonstrated that a woman's expectations and confidence in her ability to cope with pain are key to explaining the individual variation in pain experienced during labour and birth (Lowe, 1991).

Midwives and other accouchers use a variety of techniques in the second stage of labour to reduce genital tract trauma and pain (Renfrew et al., 1998). A postal survey of 210 maternity units in the UK (Sanders et al., 2005) found that midwives were using a variety of non-pharmacological analgesic methods to control pain at the end of the second stage of labour, including: hot packs (33%); cold packs (21%); perineal massage (52%); and injectable local anaesthetics (62%). Perineal warm packs are used in the belief that they reduce perineal trauma and increase comfort during the second stage of labour (Schrag, 1979; Balaskas, 1983; Kitzinger and Simkin, 1984; Albers et al., 1996; Hobbs, 2001; Sanders et al., 2005). The potential physiological beneficial effects of warm packs include the dilation of blood vessels and increased blood flow, both of which influence the transmission of pain and increase collagen extensibility (Porth, 1990; Fritz, 1995; Hayes, 2000). Randomised trials into the efficacy of perineal warm packs have limited generalisability because of their small sample sizes, mixed methods or lack of data about the effects on women's pain (Musgrove, 1999; Albers et al., 2005). Other approaches have also been tested. A recent randomised controlled trial into the effect of lidocaine spray to the perineum during birth found no effect on perineal pain (Sanders et al., 2006). A randomised trial into the effect of intrapartum perineal massage on perineal outcomes showed no significant reduction in perineal trauma, although there was no evaluation of perineal pain associated with the actual procedure (Stamp et al., 2001). A large UK trial compared a ‘hands-on’ technique with a ‘hands-poised’ technique for birth, and found greater perineal pain reported by women in the ‘hands-poised’ group at 10 days (McCandlish et al., 1998). However, the study did not evaluate pain felt during the actual birth.

This variation in practice, and evidence to support practice, was the impetus for this study. The trial was designed to test the efficacy of perineal warm packs and to examine the experiences of women who received them and midwives who applied them.

This paper reports the experiences of women and midwives involved in using perineal warm packs. The clinical outcomes of the trial itself are reported elsewhere (Dahlen et al., 2007b).

Section snippets

Methods

The trial was conducted from November 1997 to July 2004 at two maternity hospitals in Australia. Nulliparous women were approached to participate in the trial after they reached 36 weeks of gestation. Eligibility criteria included: a singleton pregnancy; cephalic presentation; anticipating a normal birth; not having performed perineal massage or intending to perform perineal massage antenatally; and being over 16 years of age. Ethical approval was obtained from the university and hospital's

Findings

In total, 1047 women were approached and consented to participate in the trial, and 717 were randomised: 360 to the warm pack group and 357 to the standard care group. The main reasons why 330 consenting women were not randomised were: staff too busy to carry out the randomisation process; caesarean section occurred prior to second stage; and women refused to take part in the trial (Fig. 1).

In total, 599 women completed the study protocol as allocated: 302 in the warm pack group and 297 in the

Discussion

The application of perineal warm packs is widely advocated by midwives (Sanders et al., 2005) to reduce perineal trauma and improve comfort during the birth. This is the largest randomised trial to date to evaluate the use of the procedure during the late second stage of labour and to examine both women's and midwives’ experiences.

This study had several limitations. Some of the 36 women and 32 midwives who did not complete the questionnaires may have been less positive about the effect of the

Conclusion

The practice of applying perineal warm packs in the late second stage of labour was highly acceptable to mothers and midwives in helping to relieve perineal pain and increase comfort, and should be incorporated into pain relief options available to women during childbirth. The reported experiences of women and midwives of using perineal warm packs were similar, especially the associated reduction in pain. This was supported by pain scores of women when giving birth (Dahlen et al., 2007b). Any

Acknowledgements

The authors are very grateful to the women who participated in the warm pack trial. They are also extremely grateful to the midwives at Royal Prince Alfred and The Canterbury Hospital for their enthusiastic support and participation, for without them, this trial would never have been completed.

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