Effectiveness of Sacral Massage on Labor Pain and Satisfaction Among Antenatal Mothers in Active Phase of Labor

Background: Massage is a powerful old technique & non pharmacological pain control during 1 st stage. Satisfaction of mothers during birth is rather important in terms of women's health and positive family relations. Objective of the study is to assess the effectiveness of Sacral Massage on labour pain and satisfaction among antenatal mothers. Methodology: A quantitative research approach and true experimental research design was adopted; 60 antenatal mothers were selected by simple random sampling. Sacral massage was administered for 3 cycles each for 30 minutes at 5-10cm using superficial massage, deep friction & effleurage during active phase of labor and routine care was given to the control group. After intervention post test was conducted. Results: Study showed before Sacral massage the computed ‘t’ value (-0.36) was found to be statistically non-significant at 0.05 level of significance and after Sacral massage it was (-24.7) was statistically significant at <0.01 level of significance, there were significant difference in mean post test score of labor pain in both groups. Majority (86.6%) mothers were moderately satisfied, followed (13.3%) were highly satisfied with Sa-cral massage. Conclusion: Sacral massage was found effective to reduced pain and increase satisfaction.


INTRODUCTION
Pregnancy is a unique exciting time often in a women's life.It highlights the women's amazing, creative and nurturing power.When the women become pregnant most of them wonder about how to cope with the intensity of pain during labour and birth. 1 Pain in labour is nearly a universal experience for child bearing women.Child birth has been associated with pain and throughout history we find the measures to help to relieve it.Pain can vary during different times in the same labour and during different birth by the same woman. 2Pain is a highly unfriendly and personal feeling that cannot share with others.Progress of labor increases the intensity of labor pain which becomes unbearable and it need prompt treatment which is pharmacological or nonpharmacological. 3Massage is an old technique that is widely used during childbirth and can decrease the childbirth pain during labor.Massage is a costeffective nursing intervention that can decrease pain and anxiety during labor.The study performed by Semra Akkoz Cevik et.al. 2020 showed that sacral massage applied during labor reduced women's labor pain, lowered the levels of concern and anxiety.Massage also reduces the ischemia by amplification of local blood supply and stimulates the body to releases endorphins.This study showed that massage stimulates the body to releases endorphin when these endorphins attach to opiate receptor neurons, they reduce the intensity of pain in the human body and naturally block the pain signals which are produced by the nervous system. 4e wealth of the nation is its healthy population.The mother contribution in creating a healthy population is beyond explanation.So, mother should be kept physically, emotionally and socially healthy.Massage not only reduces pain and anxiety, but shortens labor and lowers new mothers' risk of experiencing postpartum depression.Scientific study conducted by Michel Tournaire et al. 2007 on complementary & alternative therapies to pain relief during labor showed that about 80 -90% of women who were massaged during labor pain have reduced or relieved their pain, made them feel psychologically supported and reduced their anxiety about labor and delivery. 5ssage decreases the severity of pain; loosen the spasms and delivers general relief in labor.An ideal labor pain relief method should meet the subsequent criteria, having the least possible side effects for the mother and fetus, having everlasting effects. 6Non pharmacological pain relief approaches have different compensations such as lack of side effects for mother and fetus and also being pleasing for both of them.Pain during labor include pressure on the bladder and bowel by the baby's head and enlarging of the birth canal and vagina so massage is a costeffective nursing practice that can reduction pain and anxiety during labor and partner's contribution in the massage can also positively inspiration the quali-ty of women's birth experience.In the literature massage was applied for 30 minutes, thus in this study the women in the experimental group were administered a sacral region under the supervision of a doctor for 30 min at every phase of labor. 7other study showed that lower back massage was effective to reduce labour pain during strong contraction.Massage was given by using hand very firmly over the base of the spine and over surrounding muscles. 8Since there were not much research studies on effect of sacral massage on reduction of labor pain and mother satisfaction in Himachal Pradesh.So, we decided to conduct this study to "assess the effectiveness of sacral massage on labor pain and satisfaction among antenatal mother in active phase of labor in Maharishi Markandeshwar Medical College and Hospital Solan, H.P.
The objectives of the study were to assess and evaluate pre-test and post test score of sacral massage on labour pain among antenatal mothers in both groups and satisfaction in experimental group, and also to find out association between post test score of labor pain among antenatal mothers with socio-demographic variables in both groups.

METHODOLOGY
Study Design and Setting: This was a randomized controlled experimental study.A quantitative research approach and true experimental research design was adopted.The study was conducted in the months of March, 2023 to May, 2023 at First stage and labour room situated in 6 th floor at Maharishi Markandeshwar Medical College & Hospital Kumarhatti-Solan Himachal Pradesh.The study was performed in volunteer pregnant women.Data Collection: A structured questionnaire was pilot tested.The population of the research consisted of antenatal women who were admitted to the delivery room.When the power analysis was performed, the sample size was calculated with a 5% error level, bidirectional significance level, 95% confidence interval, and 80% ability to represent the universe.It was found that at least 30 participants for each group and 60 antenatal mothers in total were needed (30 participants for the massage group and 30 participants for the control group).The following inclusion criteria were used to determine participation in the study: (1) 18-30 years old antenatal mothers (2)  Singleton pregnancies between 37-40 weeks (3) Pregnant women whose labour began spontaneously (4) Pregnant women with a healthy foetus (5) Pregnant women without any complications that may cause dystocia during labour (6) Pregnant women for whom analgesia and anesthesia were not used during the first phase of labour (7) Pregnant women who volunteered to participate in the research and who could establish verbal communication.In addition, pregnant women with high-risk pregnancies, with caesarean section indication, and pregnant women with a chronic illness were excluded.
Sample for the study was selected after sample size estimation using the formula that is: Where, Z1-α/2: The level of significance for two trails, when researcher considers that intervention may have positive or negative effect on outcome variables.Otherwise, one tail effect is considered only in one direction (Z1α); Z1-β: The power researcher considers for detecting the difference, which is generally considered 80% or 90%.; Z0.90 = 1.28 from Gaussian table; σ1 is SD of the outcome variable in group-1; σ2 is SD of the outcome variable in group-2; m1 is mean of the outcome variable in group-1; and m2 is mean of the outcome variable in group-2 The sample volume to represent the population was determined as minimum 30 people for each group.
The women who participated in the study were randomized into either the control or the experimental group.Allocation to groups carried out by simple randomization method.Participants were chosen, one sealed envelope out of ten (5 Experimental group, 5 control group), offered by the researcher.This process was continued for all participants with inclusion criteria.ethics committee, the hospital's head nurse, delivery room charge nurse/midwife and other midwives and nurses were informed about the purpose and scope of the study.Data were collected by one of the researchers.The researcher was aware of which patients were assigned to each group.However, the researchers did not interfere in any way with the study results.When they encountered women who met the inclusion criteria of the study, the purpose of the study was explained, and written consents were received from those who agreed to participate in the study.For the women who satisfied the criteria, participation in the study was voluntary.Additionally, during the study, no women requested to withdraw and no women were excluded from the study.Routine care and treatments for the women continued during data collection.Intervention: Sacral Massage: Massage was administered to antenatal mothers to the sacral region under the supervision of midwife and obstetrician for 3 cycles each for 30 minutes at cervical dilatation 5-6cm, 7-8cm, 9-10cm using superficial massage (5 minutes), deep friction (5 minutes) and effleurage (5minutes) on each buttock during active phase (5-10cm) of labor.To attain this, patient was placed in left lateral position or position desired by mother in active phase (5-10cm) of labor.This technique was applied between T10 and S4 according to Fig. 2. For the correct application of the massage, we were trained by a certified Physiotherapist at MMMC& Hospital.
Procedure: The data was collected by the researchers through face-to-face interviews.Before data collection, an informative meeting regarding the purpose and scope of study was held for the members of healthcare team who worked in the unit, where study would be conducted.In addition, cooperation was provided by the members of the healthcare team.For the correct application of massage, the researcher was trained by the physiotherapist who worked at MMMC& Hospital.The massage was applied only to the pregnant women in the intervention group at every phase of labor.There was no intervention in the control group except for routine care.
Steps for data collection, in the experimental & Control group were as follows: In Experimental Group: Face to face interview was conducted with the antenatal mothers.The prepared socio-demographic variables, Visual analog scale (Wong & Waker Faces Pain Rating Scale) was applied.In addition to providing them with routine midwifery care the antenatal mother in the experimental group has been administered a massage to the sacral region under the supervision of midwife and obstetrician for 3 cycles.The Visual Analog Scale was applied and evaluated after the massage in the active phase.The Self Structured Satisfaction Likert Scale was applied and evaluated after delivery.Face to face interview was conducted with the antenatal mothers.The prepared socio-demographic variables, obstetrical variables, Visual analogue Scale was applied and routine midwifery care was given.The self-structured satisfaction Likert scale was applied and evaluated after delivery.
Data Analysis: Data were analysed on the basis of objectives of the study.Descriptive and inferential characteristics were used for analysis purpose.Cal-culation was carried out manually with the calculator and with help of MS EXCEL and also SPSS Version 22.

RESULTS
Frequency   This showed that there will be significant difference in mean post test score of labor pain in antenatal mothers of experimental group and control group.Hence H1 hypothesis is accepted.
Data in table 3 revels that majority (86.6%) of mothers were moderately satisfied with the sacral massage followed (13.3%) mothers are highly satisfied with sacral massage and (0%) mothers are less satisfied with sacral massage.

DISCUSSION
Labor pain is a public experience for all women during the delivery time.Therefore, a pain relief measure for mother during labor is vital.Massage is an old practice that is widely used in childbirth and can decline the childbirth pain during 1st stage.Massage is a cost-effective nursing intervention that can reduction of pain and anxiety during labor.Sacral massage refers to the massage given to antenatal mothers at sacral region to reduce the labor pain.
Present study revealed that majority (87%) mothers were moderately satisfied with sacral massage, & few (13%) mothers were highly satisfied with sacral massage.Similar studies were reported by Illknur (2020) who did study on effects of massage and acupressure on relieving labor pain, reducing labor time and increasing delivery satisfaction, which showed that in massage only group majority (96.8%) mothers are satisfied with sacral massage 19 , similarly by Maghalian (2022) 20 , Sundaram (2023) 21 .
Present study revealed that highest pain score of labor pain is not associated with socio demographic variables such as age (p=0.49NS ) , marital status , educational status of mother (p=0.61NS ) , educational status of father (p=0.75NS ), area of residence (p=0.12NS ), occupation of husband (p=0.77NS ), occupation of antenatal mothers (0.90 NS ), religion(p=0.85NS ) ,type of family(p= 0.55 NS ) ,family income (p=0.67NS ), family support (0.85 NS ), type of lifestyle (p=0.40NS ) and heard about sacral massage (p=0.69NS ).Chi square was not found statistically significant at 0.05 level of significance.Similar study was reported by Devi et.al who did study on effectiveness of Back Massage in First stage labour pain among pregnant women (2020) who did that post test score regarding back massage was not associated with demographic variables such as age, family income, education, occupation, religion, type of family, gravida, period of gestation, any history of abortion, chi square was not found statistically significant at 0.05 level of significance.Mwakawanga (2022) find effectiveness of Back Massage in First stage labour pain among pregnant women showed that no association with the demographic variables such as age, family income, education, occupation, religion, type of family. 22Chaillet (2014) uses nonpharmacologic approaches based on continuous support with sacral massage, were the most effective for reducing obstetric interventions during labor. 23

LIMITATIONS
One of the limitations of the current study is the small sample size.Thus, studies with larger sample size are recommended.

Table 1 :
Frequency and Percentage Distribution of Selected Demographic Variables of Antenatal Mothers in Active Phase of Labour in Experimental and Control Group (N=60) and Percentage Distribution of Selected Demographic Variables of Antenatal Mothers in Active Phase of Labour in Experimental and Control Group were shown in table 1.

Table 2 :
Mean, Mean Difference, Standard Deviation Difference, Standard Error of Mean Difference and 't' Value of Pre-Test and post-test Highest Pain Scores of Antenatal Mothers during Active Phase of Labor in Experimental Group and Control Group (N=60)

Table 2
revels that mean pretest pain score of antenatal mothers during active phase of labor in experimental group was 8.56 and in control group was 8.63.Mean difference 0.66, however the difference was non-significant at 0.05 level of significance.

Table 3 :
Frequency and Percentage Distribution of Antenatal Mothers in terms of Level of Satisfaction regarding Selected Stages of Post Interventions in experimental group (N=30)

Table 4 :
Chi square showing association of posttest of higher pain score with selected demographic variables of experimental group (N=30) *Significant(p≤0.05);NS= Not Significant (p≥0.05)