INTRODUCTION:

A human body can bear only up to 45DEL of pain. A mother feels up to 57 DEL of pain at time of giving birth which is equal to 20 bones getting fractured at a time.¹

Pain is an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.²

Most of the women wouldn’t attempt for normal delivery as labor pain is one of the most severe pain. So in order to have appropriate vision towards labor pain, positive parts must be increased and negative parts must be decreased.³

Pain management during labor should be women centered, not medically oriented. Midwives should use the pain relief model and the working with pain model. In the pain relief model, women are given various pain-relieving options. While in the working with pain model, women live with pain. And it’s up to the women to decide which model to use.⁴ Pain in labor is complex, and women should fully participate in the decision-making process before any one modality is selected.⁵

Most women are interested in non-pharmacological methods of pain relief during childbirth. The use of natural techniques reduces the intensity of labor pain.⁶ The most commonly selected techniques of labor pain relief by pregnant women were non-pharmacological (physical activity, use of amenities, water immersion) and pharmacological methods (nitrous oxide, epidural analgesia), respectively.⁷

The result shows that there is a significant relationship between the treatments of ice gel compress with labor pain [95% Confidence Interval (CI)]. And 86% of women in the intervention group experienced moderate pain while 86% of women in the control group experienced severe pain.⁸ The mean score of birth satisfaction in the intervention (ice pack application) group was slightly greater than the control group.⁹

NEED FOR STUDY:

Nonpharmacologic approaches, based on Gate Control (water immersion, massage, ambulation, positions) and Diffuse Noxious Inhibitory Control (acupressure, acupuncture, electrical stimulation, water injections), are associated with a reduction in epidural analgesia and a higher maternal satisfaction with childbirth. Non-pharmacologic approaches to relieve pain during labor, when used as a part of hospital pain relief strategies, provide significant benefits to women and their infants without causing additional harm.¹⁰

The pain score mean difference of hot application group was statistically highly significant. Also, the pain score mean difference of cold application group was statistically very highly significant. The difference between the mean reductions in pain intensity by both groups was not statistically significant. Both applications had equal effectiveness in reducing labour pain.¹¹

As labor pain can be distressful for some women and it may cause anxiety, affect further pregnancies, so labor pain must be managed accordingly. Also, negative experience of labor pain may increase the rate of cesarean section(C/S) as women may not cope with the labor pain and which will further increase the complications due to C/S. Thus, ice pack application can be used to decrease pain intensity of labor pain; it is also non-pharmacological, non-invasive and cheap method having no side effects on women and fetus.

STATEMENT OF PROBLEM:

Many of the women perceived childbirth pain as challenging, and they felt the need for effective support throughout childbirth. Feeling safe through the concept of continuous support was a key element of care to enhance the coping ability and avoid feelings of loneliness and fear. Pain during childbirth is universal despite the socio-economic, cultural and contextual differences. ¹²Women with severe fear of childbirth experienced significantly more labor pain than women without severe fear of childbirth.¹³ Pharmacological methods can reduce pain but have negative side-effects. Non-pharmacological methods may not reduce labor pain but can facilitate bonding with professionals and birth supporters.⁵

The mean score of labor pain intensity before and one hour after the ice pack application did not significantly differ from each other. But the mean score of labor pain intensity in the intervention group was significantly less than the control group at two, three, four, and five hours after the ice pack application. The mean score of the personal attributes subscale of birth satisfaction in the intervention group was significantly higher than the control group.⁹

Thus, labor pain should be managed in order to have positive birth experience and decrease fear of child birth. Ice pack application can be used a non-pharmacological method which may help the women to cope with labor pain and increase birth satisfaction although it may not eliminate labor pain completely.

OBJECTIVES:

Primary Objective:

To assess the effect of Ice pack application on pain intensity among women in the active phase of labor.

Secondary Objective:

To find out the association of pain intensity with selected variables.

HYPOTHESIS:

Research Hypothesis: There is a significant difference in effect of ice pack application on pain intensity among women in the active phase of labor between experimental and control group.

METHODOLOGY:

Type of study design:

An experimental study design was used.

Study Setting:

The study was conducted in 5 bedded Labor Room (LR) of B.P. Koirala Institute of Health Sciences (BPKIHS), Dharan. It is 830 bedded tertiary level hospital situated in eastern part of Nepal in province one. In an average 30-40 deliveries takes place daily.

Population:

Those primiparous women in active stage of labor admitted in labor room in BPKIHS.

Sample:

Those primiparous women admitted in Labor Room in BPKIHS, meeting inclusion criteria.

Sample Size: 50

Sample calculation:

The sample size was calculated based on previous study conducted by Shivani M.A., and Ganji J.²⁴ Taking 10% sample mortality the sample size calculated was 25 in each group. The sample was taken in 1:1 ratio that was 25 as experimental and 25 as control group.

Sampling Technique:

Consecutive sampling technique was used to collect the data.

Eligibility Criteria:

Inclusion Criteria:

Primiparous women who had completed 37weeks of gestation the age group between 20 to 35years with cervical dilation from 4-6cm having adequate contraction and who were ready to participate in the study.

Exclusion Criteria:

Primiparous women who were given other measures of pain reduction.

Primiparous women who were indicated for cesarean section during the period of intervention.

Primiparous women who had clinical disorder (chronic pelvic pain, psychiatric disorders, previous spine surgery, eclampsia, meconium-stained liquor, fetal bradycardia).

Research Instrument:

The self-developed semi-structured questionnaire was prepared on socio-demographic data of the participants and the standardized numeric pain scale was used as research instrument. And the observation record was self-developed to record the pain intensity self-reported by women and categorized by using numeric pain scale.

The research instrument consisted of 2parts:

Part - I: Socio-demographic Information

Part-II: Observation record of indicators of pain intensity by self-reports of the women by using numeric pain scale

Description of the tool:

Part - I: Socio-demographic Information:

Age, education, occupation, religion, ethnicity, type of family, period of gestation.

Part-II: Observation record of indicators of pain intensity by self-reports of the women by using numeric pain scale

Pain intensity measured before ice pack application and immediately, 30minutes, 1hour and 2hours after ice pack application.

Numeric Rating Scale (NRS):

The NRS is a segmented numeric version of the visual analog scale (VAS) in which a respondent selects a whole number (0–10 integers) that best reflects the intensity of their pain. The common format is a horizontal bar or line. An 11-point numeric scale (NRS 11) with 0 representing one pain extreme (e.g., “no pain”) and 10 representing the other pain extreme (e.g., “pain as bad as you can imagine” and “worst pain imaginable”). The NRS can be administered verbally or graphically. The respondent is asked to indicate the numeric value on the segmented scale that best describes their pain intensity.²⁵ NRS is widely utilized as clinical and research pain assessment tools in the labor setting.²⁶High correlations were found between several pain scales such as Visual Analogue Scale, Box Numerical Scale and Verbal Rating Scale providing insights into the interchangeability between the scales in the obstetrical setting.²⁷

Scoring:

The number that the respondent indicates on the scale to rate their pain intensity was recorded. Scores range from 0–10.²⁵

Score interpretation:

Higher scores indicated greater pain intensity.²⁵^-²⁷

In this research, pain score was categorized as:

1-3 = mild pain

4-6 = moderate pain

7-10 = severe pain

Validity and Reliability:

The self-developed semi-structured questionnaire on socio-demographic data of the participants and observation record to record the pain intensity was prepared by researcher herself and content validity of the tool was established by consulting with guide, co guide and expertise of the subject matter.

The standardized Numeric pain scale which is already a valid and reliable tool was used to assess the intensity of pain.

Pre-testing of Tool:

Pre-testing was done on 10% of total participants (3 experimental group and 3 control group assigned by simple randomization) meeting the inclusion criteria in the similar setting i.e., Labor Room. Participants included in pretesting was excluded from the study.

Data Collection Procedure:

The data was collected by using self-developed semi-structured questionnaire regarding socio-demographic data of the participants and observation record for recording pain intensity self-reported by the women and categorized by using numeric pain scale. The data was collected by researcher herself. Women was informed about ice pack application. Orientation about ice pack application was given to the staff. Data was collected in a period of 4weeks (7^th August to 3^rd September’ 2022) from 7AM-6PM.

Simple Randomization was done to assign the sample in experimental and control group by using Microsoft (MS)-Excel 2007. A randomization list was used to produce two parallel groups (1:1 ratios) of the primiparous women with the help of a MS Excel 2007. A sequentially generated number with the experimental group (n=25) and control group (n= 25) was written in a selected envelope which was prepared by the researcher prior to the enrollment of the primiparous women.

During the intervention women having adequate uterine contraction after 4-6cm cervical dilatation received ice pack application covered with single layer of cotton cloth on the sacrum for 10mins in every 30mins interval for 1hr. And bandage prepared from cotton cloth was tied loosely over the sacrum and abdomen to support the ice pack if necessary.

Data Analysis Procedure:

The data was entered in Microsoft Excel 2007 and analyzed in Statistical Package for Social Science (SPSS) version 11.5.

Descriptive statistics (frequency, percentage, mean and standard deviation) was calculated along with tabular form which was used to describe the various socio-demographic variables. Data was summarized using frequency distribution tables.

Inferential statistics (Likelihood ratio and Pearson’s chi-square test) was used to find out the difference between two groups. Independent sample t-test was used to find out the mean difference in pain intensity in between both groups. One-way ANOVA (Analysis of Variance) was used to illustrate the association between the outcome variable with selected independent variables at 95% confidence interval and 5% level of significance.

Ethical Considerations:

The study was conducted after the formal approval from the Institutional Review Committee (IRC), BPKIHS (Ref. No. 180/078/078-IRC).

Written permission was taken from the concerned authorities (Head, Department of Obstetrics and Gynecology; Matron, Nursing Service Administration; and Nursing Incharge of the Labor room, BPKIHS, Dharan) to conduct the study.

Written informed consent was taken from each participant before starting the study and proper documentation was done.

Participant’s Privacy and confidentiality was maintained by not disclosing the information with other and using the information only for study purpose.

Participant’s dignity was maintained by giving right to reject or discontinue from the research study at any time.

RESULTS:

Most of respondents were in the 20-25years age group, where 88.8% were in the experimental group and 56% in the control group. The mean age was 22.84±2.897 in the experimental group and 24.96±4.550 in the control group. The study population in the experimental and control group were not homogenous in terms of age (p=0.035) of the respondents. Slightly more than half of respondents had higher secondary education in the experimental group (56%) and control group (52%). Majority of respondents in both the groups were homemaker i.e., 64%. Most of the respondents i.e., 72% in the experimental group and 80% in the control group were from Hindu religion. Slightly more than one third of the respondents i.e., 40% in the experimental group and 36% in the control group were from Brahmin/Chhetri ethnic group. Most of the respondents were from joint family i.e., 84% in the experimental group and 64% in the control group. The study population in the experimental and control group were homogenous in terms of educational status (p=0.219), occupation (p=1.000), religion (p=0.608), ethnicity (p=0.624), type of family (p=0.226) of the respondents.

Majority of the respondents were at 38-40 weeks of gestation i.e., 76% in the experimental group and 64% in the control group. The mean period of gestation was 39.44±1.193 in the experimental group and 39.64±1.254 in the control group. Regarding cervical dilatation, slightly more than half of the respondents i.e., 56% in the experimental group and 60% in the control group had 4cm cervical dilatation. Majority of the respondents i.e., 80% in the experimental group and 64% in the control group had moderate uterine contraction. The study population in the experimental and control group were not homogenous in term of strength of contraction (p=0.042). The study population in the experimental and control group were homogenous in terms of period of gestation (p=0.355), cervical dilatation (p=0.786).

Table 1: Pain Intensity among Experimental and Control group (n=50)

Descriptions	Pain Intensity		p-value
	Experimental Group	Control Group
	Mean±SD	Mean±SD
Before intervention	8.28±1.514	8.04±1.814	0.614^*
Immediately after intervention	7.72±1.595	7.12±1.922	0.236^*
30mins after intervention	6.92±1.631	7.16±1.864	0.630^*
1hr after intervention	6.60±1.871	7.92±1.730	0.013^*
2hrs after intervention	7.88±1.878	8.84±1.375	0.045^*

^*Independent sample t-test

Table 1 depicts that the mean pain intensity was 8.28±1.514 and 8.04±1.814 before intervention; 7.72±1.595 and 7.12±1.922 immediately after intervention; 6.92±1.631 and 7.16±1.864 30mins after intervention in experimental and control group respectively. There was no significant difference in both the groups regarding the mean pain score before intervention (p=0.614), immediately after intervention (p=0.236), 30mins after intervention (p=0.630).

The mean pain intensity was 6.60±1.871 and 7.92±1.730 1hr after intervention; 7.88±1.878 and 8.84±1.375 2hrs after intervention in experimental and control group respectively. There was significant difference in between the groups regarding the mean pain score 1hr after intervention (p=0.013), 2hrs after intervention (p=0.045) which shows the effectiveness of ice pack application in reducing pain.

Before intervention, pain intensity was significantly associated with education (p=0.008) in the experimental group. Immediately after intervention, pain intensity was significantly associated with occupation (0.046) in the experimental group and with age (0.020), religion (0.035) in the control group. After 30mins of intervention, pain intensity was significantly associated with educational status (0.015) in the experimental group and with age (0.011), religion (0.010) in the control group. After 1hr of intervention, pain intensity was significantly associated with education (0.004) in the experimental group and with age (0.009), religion (0.008) in the control group. After 2hrs of intervention, pain intensity was significantly associated with occupation (0.039) in the experimental group and with age (0.009), religion (0.006), ethnicity (0.042) in the control group.

DISCUSSION:

The findings of the study is in contrary of a study conducted in Indonesia by Mardliyana et al. which depicted that most of the respondents in the intervention (ice pack application) group experienced moderate pain intensity while in support of the same study findings that showed most of the respondents in the control group experienced severe pain.⁸

Again, it is in favor of the result of a study conducted in Egypt by Al-Battawi et al. which manifested that before intervention most of the respondents experienced severe pain in both the study (ice pack application) and control groups. While 60 minutes after intervention most of the respondents experienced moderate pain intensity in study group and severe pain intensity in control group. And it is contrasting to the same study result which revealed that most of the respondents in the study group experienced moderate pain intensity and severe pain intensity in control group immediately after intervention, 30minutes after intervention.¹⁴

Similarly, the study showed that immediately (p=0.236) and 30mins (p=0.630) after the intervention, the groups did not significantly differ from each other respecting the mean score of labor pain intensity. However, at 1hr (p=0.013) and 2hrs (p=0.045) after the intervention, the groups significantly differ from each other respecting the mean score of labor pain intensity.

The above findings were supported by a study conducted in Iran by Rahimi-Kian et al in which it showed that at 2, 3, 4 and 5hrs after intervention onset, the mean pain score of labor pain intensity in the intervention group was significantly less than the control group (p<0.001). And it is contradictory to the same study findings which showed that 1hr after intervention onset the groups did not significantly differ from each other (p=0.056)⁹.

Similarly, the findings of this study was supported by a Egyptian study by Al-Battawi et al. in which it showed that there was a statistically significant difference among study group in relation to their labor pain intensity after 60mins of ice application (p=0.0001). And it showed contradictory findings to the same study which depicted statistically significant difference among study group in relation to their labor pain intensity immediately, after 30mins of ice application (p=0.0001)¹⁴.

This study showed significant reduction in pain intensity in the experimental group than the control group which was similar to the findings of a study conducted by Yazdkhasti et al.¹⁷, Mardliyana et al.⁸, Sayed at al.²⁸, Shirvani et al.²⁴, Hanjani et al.²⁹, Lavanya et al.³⁰, Shirvani et al.³¹, Devi et al.³².

RECOMMENDATION:

Based on the study following recommendations can be made:

Ice pack application can be done routinely during the active stage of labor.

Orientation and In-service education for ice pack application can be provided to the nurses who provide care to the women in labor room.

Similar study can be conducted in multiparous women.

There is a need for further multicenter randomized control trial, comparing ice pack application with other methods of pain reduction in terms of efficacy and safety. After the large-scale multicenter studies, the standard guidelines for ice pack application can be set up in the labor room.

CONCLUSION:

The findings of the study showed the effectiveness of ice pack application in reducing pain among women during active stage of labor. There was significant difference in between the groups regarding the mean pain score 1hr after intervention, 2hrs after intervention which shows the effectiveness of ice pack application in reducing pain.

ACKNOWLEDGEMENT:

This research conducted for partial fulfillment of the requirement for the degree of Master of Science in Maternal Health Nursing.

REFERENCES:

1. A human body can bear only up to 45DEL of pain. A mother feels up to 57 DEL of pain at time of giving birth which is equal to 20 bones getting fractured at a time. - Bing [Internet]. [cited 2021 Sep 30].

2. IASP Announces Revised Definition of Pain - International Association for the Study of Pain (IASP) [Internet]. [cited 2022 Sep 8].

3. NM B, K B, P B, HA A. Women’s experience of pain during childbirth. Iran J Nurs Midwifery Res [Internet]. 2010 Jan 1 [cited 2021 Sep 30];15(2):77–82.

4. Marshall J, Raynor M. Myles Textbook for Midwives. 16th ed. China: Elsevier; 2015. p. 55–80

5. Thomson G, Feeley C, Moran VH, Downe S, Oladapo OT. Women’s experiences of pharmacological and non-pharmacological pain relief methods for labour and childbirth: A qualitative systematic review. Reprod Health [Internet]. 2019 [cited 2023 Jan 10];16(1): 1-20

6. Pilewska-Kozak et al. Non-Pharmacological Methods of Pain Relief in Labor in the Opinion of Puerperae. Annals of Women's Health [Internet]. 2017 Sep 21 [cited 2023 Jan 10]; 1 (1): 1-4.

7. Pietrzak J, M˛ Edrzycka-D ˛ Abrowska W, Tomaszek L, Grzybowska ME. A Cross-Sectional Survey of Labor Pain Control and Women’s Satisfaction. Res Public Heal [Internet]. 2022 [cited 2023 Jan 9];19 (6):17-41.

8. Mardliyana NE, Raden A, EN UH. Effect of ice gel compress towards labor pain during Active Phase Stage I at private midwivery clinics in Surabaya City area. Maj Obstet Ginekol [Internet]. 2018 [cited 2021 Sep 30];25(1):21-25.

9. Rahimi-Kian F, Shahbazi S, Mohammadi S, Haghani S, Rahimikian F, Shahbazi S, et al. The effects of ice pack application on pain intensity in the active phase of labor and on birth satisfaction among primiparous women. Nurs Pract Today [Internet]. 2018 [cited 2021 Sep 30];5(3):355–362.

10. N V der G, K L. Women’s experiences of coping with pain during childbirth: a critical review of qualitative research. Midwifery [Internet]. 2015 Mar 1 [cited 2021 Oct 5];31(3):349–358.

11. Junge C, von Soest T, Weidner K, Seidler A, Eberhard-Gran M, Garthus-Niegel S. Labor pain in women with and without severe fear of childbirth: A population-based, longitudinal study. Birth [Internet]. 2018;45(4):469–477.

12. Chaillet N, Belaid L, Crochetière C, Roy L, Gagné GP, Moutquin JM, et al. Nonpharmacologic Approaches for Pain Management During Labor Compared with Usual Care: A Meta-Analysis. Birth [Internet]. 2014 Jun 1 [cited 2021 Oct 5];41(2):122–137.

13. Jenila S. A Study to Assess the Effect of Hot Application Versus Ice Application during First Stage of Labour in Reduction of Labour Pain among Primi Mothers in Selected Hospitals at Kanyakumari District. 2011 [cited 2021 Sep 30].

14. Al-Battawi JI, Mahmoud NM, Essa RM. Effect of ice pack application on pain intensity during active phase of the first stage of labor among primiparaous. J Nurs Educ Pract [Internet]. 2017 [cited 2021 Sep 30];8(2):35-39.

15. Sugandary M, Dash M, Chitra AF. Effectiveness of intermittent heat and cold application on labour pain and duration of labour among the intranatal mothers. J. Public Health Dis. [Internet]. 2018 [cited 2021 Sep 30];1(2):49–55.

16. Mahmoud R, Ghani A. Effect of Heat and Cold Therapy during the First Stage of Labor on Women Perception of Birth Experience: A Randomized Controlled Trial. Journal of Biology, Agriculture and Healthcare [Internet]. 2014 [cited 2021 Nov 16]; 4 (26): 66-90.

17. Yazdkhasti M, Hanjani SM, Tourzani ZM. The effect of localized heat and cold therapy on pain intensity, duration of phases of labor, and birth outcomes among primiparous females: A randomized, controlled trial. Shiraz E Med J [Internet]. 2018 [cited 2021 Sep 30];19(8): 1-8.

18. Didevar M, Navvabi-Rigi SD, Dadkhah S. The effectiveness of heat therapy and cold therapy in labor pain intensity in primiparous women: A randomized controlled trial. Nurs Midwifery Stud [Internet]. 2022 [cited 2023 Jan 10];11(3):171–176.

19. Yildirim E. The effect of cold application to the sacral area on labor pain and labor process : A randomized controlled trial. ADYÜ Sağlık Bilimleri Derg [Internet]. 2022 [cited 2023 Jan 10];8(2):96–105.

20. Nehbandani S, Koochakzaei M, Keikhaie F, Jahantigh F. Comparison of the Effect of Hot and Cold Massage at Spleen 6 on Pain Relief During Active Labor Phase: A Clinical Trial. Med - Surg Nurs J [Internet] [cited 2023 Jan 10]. 2019;8(3):3–9.

21. Royhanaty Isy, Lestari Sri Puji, Nurlaeli J. Comparison of the Effectiveness of Warm Belt and. J Ilmu dan Teknol Kesehat STIKES Widya Husada [Internet]. 2022 [cited 2023 Jan 10];13(1):1–6.

22. Sahaya MA, KalaBarathi S. Effectiveness of Cold Pack Application on Reduction of Pain Perception during Active Phase of Labour among Parturient Mothers. Cardiometry [Internet]. 2022 [cited 2023 Jan 10];(23):161–166.

23. Hidayatin N, Dwi A A, Prawitasari E. The Effect of a Cold Compress on Pain During the First Stage of Childbirth at BPM. J Ners [Internet]. 2020 [cited 2023 Jan 10];15(1Sp):473–475.

24. Shirvani MA, Ganji Z. The influence of cold pack on labour pain relief and birth outcomes: A randomised controlled trial. J Clin Nurs [Internet]. 2014 [cited 2021 Sep 30];23(17–18):73–80.

25. Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken) [Internet]. 2011 Nov 1 [cited 2021 Nov 9];63(S11):240–252.

26. Carvalho B, Cohen SE. Measuring the labor pain experience: Delivery still far off. Int J Obstet Anesth [Internet]. 2013 [cited 2021 Sep 30];22(1):6–9.

27. Wei CK, Leng CY, Siew Lin SK. The use of the Visual Analogue Scale for the assessment of labour pain: a systematic review. JBI Libr Syst Rev [Internet]. 2010 [cited 2021 Sep 30];8(24):972–1015.

28. Abdallah S H EL, Abd A A A N. Effect of Localized Warm versus Cold Compresses on Pain Severity during First Stage of Labor among Primiparous. IOSR-JNHS [Internet]. May-June 2019 [cited 2022 Jun 25];8 (3):14–24.

29. Hanjani SM, Tourzani ZM, Tajvidi M, Baheri B, Asl MPL. Effect of localized cold treatment modality on pain intensity during labor in primiparous women. Iran J Obstet Gynecol Infertil [Internet]. 2018 Jul 1 [cited 2021 Sep 30];21(5):14–21.

30. Lavanya S. Effectiveness of Icepack Application on Reduction of Labour Pain Among Primi Gravid Women During First Stage of Labour Admitted in MGMCRI. Int J Obstet Perinat Neonatal Nurs [Internet]. 2017 Sep 13 [cited 2022 Jun 25];3(2):1–5.

31. Dinmohammadi M, Jalali A, Peyrovi H. Comparison of Separate and Intermittent Heat and Cold Therapy in Labour Pain Management. Nurs Pract Today [Internet]. 2016 [cited 2021 Sep 30];3(1):31–9.

32. Crabbe PJ. To assess the Effectiveness of Ice Pack Massage on Labour Pain Perception during First Stage of Labour among Primi Gravid Mothers admitted at Labour Ward, Government Rajaji Hospital, Madurai. Apr 2012 [cited 2021 Sep 30].

33. Nadu T. A Study to assess the Effect of Hot Application during First Stage of Labor Pain among Primi Mothers in Slelected Hospitals at anyakumari District. Apr 2011 [cited 2023 Apr 15].

Received on 19.08.2024 Revised on 11.10.2024

Accepted on 18.11.2024 Published on 12.12.2024

Available online on December 30, 2024

Asian J. Nursing Education and Research. 2024;14(4):299-305.

DOI: 10.52711/2349-2996.2024.00058