RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

| | |

|1.Name of the candidate and address |Mrs. Smitha liza varughese, |

| |M.Sc Nursing 1st year, |

| |Dr. Syamala Reddy College of Nursing, |

| |# 111/1 SGR Main Road, |

| |Munnekolala, |

| |Marathahalli, |

| |Bangalore -560037. |

|2.Name of the Institution |Dr.Syamala Reddy college of Nursing |

|3.Course of study and subject |M.Sc Nursing 1 Year. |

| |Obstetrics and Gynecological Nursing |

|4. Date of admission to course |June 2009 |

|5. Title of the study |A comparative study on effectiveness of breathing exercise and music |

| |therapy in pain relief among parturient mothers during the first stage|

| |of labor in a selected hospital at Bangalore. |

6. BRIEF RESUME OF INTENTED WORK

6.1INTRODUTION

"An hour of pain is as long as a day of pleasure"

--- GEORGE BERNARD SHAW

Pregnancy is a crucial period and childbirth represents the most painful event in most women's lifetime. Childbirth (also called labour, birth, partus or parturition) is the culmination of a human pregnancy or gestation period with birth of one or more newborn infants from a woman's uterus. The process of normal human childbirth is categorized in three stages of labour: the shortening and dilation of the cervix, descent and birth of the infant, and birth of the placenta. The erect posture causes the weight of the abdominal contents to thrust on the pelvic floor, a complex structure which must not only support this weight but allow three channels to pass through it: the urethra, the vagina and the cervix. 1

Pregnant women commonly worry about the pain they will experience during labour and childbirth. Pain during labor is caused primarily by uterine muscle contractions and somewhat by pressure on the cervix. This pain manifests itself as cramping in the abdomen, groin, and back, as well as a tired, achy feeling all over. Some women experience pain in their sides or thighs as well. Other causes of pain during labour include pressure on the bladder and bowels by the baby's head and the stretching of the birth canal and vagina.1

Although labor is often thought of as one of the more painful events in human experience, it ranges widely from woman to woman and even from pregnancy to pregnancy. Women experience labor pain differently, for some, it resembles menstrual cramps; for others, severe pressure; and for others, extremely strong waves that feel like diarrheal cramps. In addition, first-time mothers are more likely to give their pain a higher rating than women who've had babies before. 1

Contractions progress over time by getting longer, stronger and closer together. Mothers may notice some mild-moderate intensity during contractions; however, in between contractions she is able to converse and behaves normally. As labour progresses the pain increases, as contractions stays for a longer duration and becomes stronger.2

The first stage of labour includes early labour, active labour and transition. Early labor is defined by cervical dilation of 0-3cm, contractions in the range of 5-20 minutes and lasting for about 30-45 seconds. Active labor is defined by cervical dilation of 4-8cm, contractions 3-5 minutes apart and lasting about 60 seconds. Transition is defined by cervical dilation of 8-10cm; contractions are about 2-3 minutes apart and last for approximately 60-90 seconds.3

Read G.D a British Obstetrician states that primitive tribes had little or no pain in labour and calls that as a natural birth. He believed that the fear of childbirth is acquired and is culturally induced in women .As a result; he linked fear, tension and pain together and decided to break the vicious cycle by giving a simple explanation to women regarding birth process and their active participation during labour.4

Pregnant women commonly worry about the pain they will experience during labour and childbirth and how they will react and deal with that pain. It is important to alleviate pain, but commonly it is not the quantum of pain a women experiences, but whether she will meet her goals in coping with the pain that influences her perception of the birth experience as ' good or bad '.Although the pain thresh hold is remarkably similar in all persons regardless of sexual, social, ethnic or cultural differences, those differences play a definite role in the individuals perception of the pain experience.4

A woman who is fearful of pain will describe the sensations as much more intense and painful than a woman who is not fearful of the pain. It is not that the pain and pressures of childbirth do not exist for the confident woman; she simply interprets the sensations as more than just pain. If you approach labor as if it were something to "suffer through," or as if the labor process has no value, you increase the chances you will react to labor with fear and stress. This can send you into a cycle of increased pain, which increases your fear which again increases your pain. This is called the Fear Tension Pain Cycle. 4

The major factor contributing to a positive and favourable over all evaluation of childbirth is the women's perception of being able to maintain control during labour and delivery i.e., control of pain perception, control over emotion and actions and most frequently control in being an active participant.4

Different approaches to childbirth preparation stress a number of varying techniques for using them as a 'tool' to help the women maintain control through contractions. It is found that a sense of control during delivery was related to positive perceptions of birth experience. 4

Numerous life stressors during pregnancy, such as concerns for the baby, self, medical care, childbirth, and finances, can contribute to elevated levels of anxiety. This anxiety can be further intensified by hospitalization for high-risk complications. It has been suggested that high anxiety or psychological stress in the mother can result in a higher number of fetal abnormalities and maternal obstetrical complications. Due to poor coping with pain, it may lead to prolonged labour which may also cause fetal death. 5

Relaxation is thought to increase pain tolerance through a number of mechanisms, including the reduction of anxiety, decreased catecholamine response, increased uterine blood flow, and decreased muscle tension .6

Relaxation is most effective as a pain management strategy when learned and practiced in advance of the labor experience. Relaxation, breathing techniques, positioning/movement, massage, hydrotherapy, hot/cold therapy, music, guided imagery, acupressure, and aromatherapy are some self-help comfort measures women may initiate during labor to achieve an effective coping level for their labor experience. Lamaze childbirth preparation classes teach the majority of these techniques .7

The Fear Tension Pain theory of pain management, the fear (or stress) a woman experiences during labor causes her body to react in ways that increase the pain. The originator of this theory, Dr. Dick-Read, hypothesized labor was not inherently painful. He believed the pain in labor was largely due to the fear of labor prevalent in the culture. He taught the birth canal could be obstructed by this fear. As the labor becomes dysfunctional, the pain increases and the mother's fear of what is happening increases and so increases the tension she feels and increases the pain which then cycles back to increase her fear.4

According to the Fear Tension Pain theory of childbirth, the pain of labor can be lessened by stopping the cycle at any point. To stop the cycle at the fear point, experts recommend preparing for labor through education, birth planning and mental/emotional work.4

Avoiding tension in labor is generally accomplished through a variety of relaxation techniques. Some, such as the progressive relaxation, keep the mother's mind relaxed and prevent fear.

Relaxation techniques help to keep the mother's body tension free to avoid excessive pain and discomfort. Relaxation techniques must be practiced before labor to be effective during labour. There are different relaxation techniques such as hypnosis, yoga, meditation, walking, massage or counter pressure, changing position, taking a bath or shower, music therapy, distracting yourself by counting or performing an activity that keeps your mind otherwise occupied .8

Music can be a powerful distraction, turning the patient's attention away from pain and promoting relaxation. It can be used in conjunction with pharmacological interventions and offer additional help to the patient in pain. Letting the patient choose the type of music they prefer is also important, giving them choices in their quest for pain relief. Most relaxation training exercises use a trigger stimulus for the learned relaxation response, and music has been shown to have excellent potential as a conditioned stimulus for relaxation.8

In a randomized controlled trial, 110 primiparous women, during the active phase of labor, were assigned to a soft music group for 3 h (n = 55) or a control group (n = 55). Dual VAS was used to measure the sensation of pain before starting the study and every three hours. The results indicate that in the music group women had significantly less sensation of pain. 9

Deep breathing also helps to release the endorphins into the body. The endorphins are the body’s natural painkillers and are extremely useful in relieving overall physical pains and aches. In addition it also helps in easing problems regarding sleeplessness. Breathing deeply helps in relaxing the muscles, which is a leading cause of aches and pains related to the neck, back and stomach. Another important feature that deep breathing offers is the trigger that it evokes in the parasympathetic nervous system bringing about the relaxation response.

An experimental study was conducted on breathing exercises regarding effect of pain during labour.The study was conducted on women during first stage of labour. They advocates slow deep breathing exercises and determined their effect on pain. Results shows that, pain intensity is less in mothers doing breathing exercise when compared to mothers having no intervention. They recommended deep breathing exercise in mother as it causes no harm for both mother and fetus10.

Brain function physically changes in response to music. The rhythm can guide the body into breathing in slower, deeper patterns that have a calming effect. Heart rate and blood pressure are also responsive to the types of music that are listened to. The speed of the heartbeat tends to speed or slow depending on the volume and speed of the auditory stimulus. Louder and faster noises tend to raise both heart rate and blood pressure; slower, softer, and more regular tones produce the opposite result.

The importance of labour support through measures like music therapy and breathing exercises cannot be underestimated since it is proved through experiments and experience of many mother that childbirth is not only a memorable event and also brings happiness to her life as well as the family. The supporting such as music therapy and breathing exercises can be implemented to meet the needs of mother during labour.

6.2 NEED FOR THE STUDY

In most labour room it is a common sight that the mothers shout, keep their bodies rigid and start pushing before the cervix is fully dilated, this leads to early rupture of membrane as well as prolonged and complicated labour which affect the condition of the infant at birth. During labour when the women are instructed they are able to follow instructions because they experience pain .Hence the women must be prepared during labour.2

Pain thrush hold's cause the amount of pain experienced to be unique to each individual. Pain is a subjective symptom. No one, but the women herself can describe or know the extent of her pain. Pain may cause anxiety, which may increase the intensity of pain. Insufficient input or monotonous stimuli may cause pain to worsen. If pain increases it may be due to advancing labour. Pain can create other problems for the labouring women that can negatively affect the childbirth experience and, if not resolved, can also contribute to increase .2

Complementary therapies have been a part of nursing practice for centuries and are supported today as a part of nursing practice by many state boards of nursing. Some of these modalities can be used by nurses as a part of their comprehensive plan of labor support for women during the childbirth experience. This article describes five complementary therapies (aromatherapy, massage, use of birth balls, music therapy, and hydrotherapy, breathing exercises), and how one large Midwestern hospital system implemented an educational program for nurses that helped them integrate complementary therapies into their nursing care for laboring women.

Various studies have demonstrated the effectiveness of background music in inducing relaxation under stress, and report on the extremely relaxing effect of music on women experiencing labour.

In a study, an individualized music therapy programme was developed for each participant, including music selections based on the mother's preferences and on observations of the pace or tempo of her breathing, as well as training in progressive relaxation with the music serving as stimulus. Over 70% of participants felt that the music aided relaxation and an overwhelming 100% displayed fewer pain responses during labour while music was playing than when it was not.12

Research regarding the use of music to reduce labor pain has also demonstrated some success: music may be used to promote relaxation during the early stages of labor and as a stimulant to promote movement during later stages, when physical exertion is required .20

Relaxation is "a state of low arousal in which such bodily response as muscle tension, heart rate, breathing rate and metabolism diminish so as to bring these functions in to equilibrium". Relaxation is a learned skill and practice, is essential to successful skill development .Deep relaxation, focusing and complex breathing patterns are the techniques used to decrease the perception of pain. All techniques can be individualized to promote optimum relaxation and oxygenation.8

Beginning in the late 1950s, many specific methods for non – medication pain reduction were developed. These included the Lamaze, Dick- Read, and Bradley methods. Childbirth education has been moving away from the method approach. Most of the methods advocated are based on three premises.9

The first is that discomfort during labour can be minimized if the woman comes into labour informed about what is happening and prepared with breathing exercises to use during contractions. The second premise is that discomfort during labour can be minimized if the women's abdomen is relaxed and the uterus is allowed to rise freely against the abdominal wall with contractions.9

The third premise is that the pain perception be altered by distraction techniques by a "gate control" theory of pain perception. Relaxation is most effective as a pain management strategy when learned and practiced in advance of the labor experience. Commonly used techniques include a focus on specific relaxation and deep breathing exercises as a distraction from the discomforts of labor .8

A study was conducted with the use of music to enhance relaxation and decrease pain responses in mothers during childbirth. The music therapists used music to cue rhythmic breathing, assist the mothers in relaxation, prompt positive associations, and help focus attention on the music as a diversion from pain and hospital sounds. A small sample of seven Lamaze-trained mothers was used and subjects served as their own controls. Two individual music therapy sessions were conducted with the subjects prior to the birth experiences.  In the first session the music therapist established rapport and determined the musical preferences of the mother.  Prior to the second session the music therapist developed an individualized music program for each mom.  During the second session the mothers were familiarized with their music programs and instructed in relaxation and breathing techniques.

The music therapists attended the births and monitored music during the experience.   During labor each mother experienced periods of music and non-music and were observed under both conditions.  Observations of tension and relaxation in various parts of the body were made and recorded.  Two other relaxation behaviors, breathing and verbalization were observed and recorded as positive, negative, or neutral.  During the delivery phase the music therapists played music that was specially selected by each mother and her coach. Results indicated that all of the mothers had fewer pain responses in the music vs. no-music condition, and that music aided concentration, relaxation, cued breathing, and diverted attention from pain.9

The investigator has come across different experience in the labour ward, in providing so many techniques to reduce the pain of women's during labour. Many studies have shown the effectiveness of music therapy as well as breathing exercises during the labour process has considerable control over pain. The investigator felt the need to see which among music therapy and breathing exercises is more effective in controlling the pain during the labour.

6.3 REVIEW OF LITERATURE

The review of literature is organized in the following sequence.

1) Studies related to effectiveness of music therapy on reducing pain during the first stage of labour.

2) Studies related to effectiveness of deep breathing exercises on reducing pain during the first stage of labour.

3) Studies related to combination of both music and breathing exercises on pain reduction during first stage of labour.

An experimental study was conducted on the effectiveness of music therapy in terms of level of pain perception among primi gravida mothers in the labour ward of Railway hospital, Perambur, Chennai. Based on non- probability purposive sampling technique, 30 mothers were allotted for experimental and 30 mothers were allotted for control group. The pre and post assessment level of pain was obtained using a modified combined numerical categorical pain intensity scale. The findings of the study showed that the primi gravida mothers' pain perception level was reduced after music therapy. 13

An experimental study was conducted on mothers who require less pharmaceutical pain relief during labor. Using music that is familiar and associated with positive imagery is the most helpful. Maternal movement is helpful to get the baby into a proper birthing position and dilate the cervix. Enjoying some "music to move by" can encourage the mother to stay active for as long as possible during labor. The rhythmic auditory stimulation may also prompt the body to release endorphins, which are a natural form of pain relief. Many women select different styles of music for each stage of labor, with a more intense or faster piece feeling like a natural accompaniment to the more difficult parts of labor. Instrumental music is often preferred. The studies reveled that music is more effective for mothers during labour. 14

A randomized controlled trial which examined the effects of music on sensation and distress of pain in Thai primiparous women during the active phase of labor. The gate control theory of pain was the theoretical framework for this study. Randomization with a computerized minimization program was used to assign women to a music group (n = 55) or a control group (n = 55). Women in the intervention group listened to soft music without lyrics for 3 hours starting early in the active phase of labor. Dual visual analog scales were used to measure sensation and distress of pain before starting the study and at three hourly posttests. While controlling for pretest scores, one-way repeated measures analysis of covariance indicated that those in the music group had significantly less sensation and distress of pain than did the control group. Sensation and distress significantly increased across the 3 hours in both groups except for distress in the music group during the first hour. Distress was significantly lower than sensation in both groups. In this controlled study, music—a mild to moderate strength intervention consistently provided significant relief of severe pain across 3 hours of labor and delayed the increase of affective pain for 1 hour. Nurses can provide soft music to laboring women for greater pain relief during the active phase when contractions are strong and women suffer. 15

A quasi experimental study was conducted to determine the effect of music therapy and positioning in the first stage of labour on labour pain, anxiety, stage of labour, and childbirth experience in primi parous labouring women in Ramathibodi hospital, Bangkok, and equally divided into an experimental and a control group. The instruments used in this study were the Visual Analog Scale for assessing pain and the State-Trait Anxiety Inventory for assessing anxiety. The stage of labour was assessed from the time of onset of true labour pain until the time of cervix dilatation at 10cms, whereas the childbirth experience was assessed by Perception of Birth Experience Questionnaire. The results revealed that the primiparous labouring women in the experimental group had the lower mean score of labour pain in the active phase and transitional phase. For anxiety during childbirth, they had a lower mean score and for perception of childbirth experience, they had higher scores than the control group with statistical significance. The stage of labour in the experimental group was shorter than the control group, with statistical insignificance. These results clearly indicate that listening to music therapy and positioning during the first stage of labour could reduce labour pain and anxiety, and also positively impact on the childbirth experience. 16.

An experimental study of the effectiveness of music for pain relief during labor and delivery. They found that music serves several functions in the natural childbirth process including attention focusing, distraction from pain, stimulating pleasure responses, focusing breathing, and as a conditioned stimulus for relaxation. There were 20 subjects in this study.  Thirteen experimental subjects received 6 pre-natal music training sessions with a music therapist.  Seven control group subjects did not receive the music treatment.  The treatment sessions were focused on selecting appropriate music and learning/practicing music-assisted relaxation techniques.  The experimental group patients each received a stereo cassette tape for home practice in order to become familiar with the relaxation techniques.  The Music Therapist was notified when each subject went to the hospital and assisted the patients in labor and delivery.  The therapist played the music continually and relied on it more than verbal contact when the woman was in labor.  During the pushing phase, the tempo, intensity, and energy of the music were increased to give the mothers energy to push.  Special music, which was chosen by the parents, was played at the time of the delivery and the music concluded when the patient left the delivery room .Results indicated that the music group had higher success scores on 5 out of 7 indices of the childbirth process.  Overall, findings suggested that music therapy may successfully contribute to reducing anxiety and pain during childbirth, as well as augment positive feelings of support throughout the childbirth experience. 17.

An experimental study was conducted on duration and outcomes of labour on 40 women by giving breathing exercises to one group containing 20 and other group was left without giving intervention. The study found out the computed 't' value indicated a significant difference in the duration of first stage of labour in primi gravida mothers where as in primi Para mothers , there was no significant difference in the duration of first stage of labour and had reduced pain during labour . 18

A study conducted to evaluate the effectiveness of back massage and breathing exercises on pain relief in primi gravida mothers during the first stage of labour in selected government hospital of Delhi .The samples comprised of 26 experimental and 26 control group primi mothers who were selected by purposive sampling. A standardized pain assessment tool (0-10 numerical pain intensity scale) was used to collect the data. Data were analysed using descriptive and inferential statistics .The conclusion of the study based on the basis of findings was back massage and breathing exercise were found to be an effective non–pharmacological measure for significantly reducing the intensity of labour pain in primi mothers. 19

Retrospective, descriptive survey design study examined which nonpharmacologic pain-relief techniques laboring women use most often and the effectiveness of the chosen techniques. Of the 10 nonpharmacological strategies rated by the sample (N = 46), breathing techniques, relaxation, acupressure, and massage were found to be the most effective. However, no specific technique or techniques were helpful for all participants. The results shown that the participants reported breathing techniques as the most effective pain relieving technique used during labor, followed by relaxation, acupressure, and massage..19

A study was conducted to evaluate the effect of relaxation technique on maternal and fetal outcome in a selected group of antenatal primi Para mothers in selected hospitals in west Bengal. Simple random sampling was used to obtain the sample of 67 primi gravida mothers, 32 in experimental group and 35 in control group. Experimental group mothers were taught the Lamaze method of relaxation technique and breathing exercises. The findings showed that behaviour score of mothers for experimental group was higher and duration of labour was higher in control group , frequency of normal vaginal delivery was significantly higher in experimental group and frequency of occurrence of maternal complications was significantly lower in experimental group than that of control group .Frequency of use of pain relieving drugs was found to be significantly higher in control group as compared to experimental group mothers .Mean apgar score at birth in the new born of the experimental group was found to be significantly higher than those of control group , frequency of occurrence of birth injury was not found to be statistically significant in the new borns of mother in both experimental and control groups.20

6.4 STATEMENT OF THE PROBLEM

A comparative study on effectiveness of breathing exercise and music therapy in pain relief among parturient mothers during the first stage of labor in a selected hospital at Bangalore.

6.5 OBJECTIVES

1. To assess the pain level of the parturient mothers before the intervention

2. To monitor the pain level after breathing exercise and music therapy

3. To identify the effectiveness between breathing exercise and music therapy

4. To determine the association between level of pain and the demographic variables

6.6 OPERATIONAL DEFINITION

Effectiveness: improvement of music and breathing exercise in terms of significant reduction in the level of pain perception of women in labour as measured by the numerical pain intensity scale.

Breathing exercises: is a technique of complementary medicine where deep breathing exercise will help parturient mothers to overcome pain and pain perception experienced during first stage of labour.

Music therapy: is a technique of complementary medicine where combination of soft music will help parturient mothers to overcome pain and pain perception experienced during first stage of labour.

Pain relief: The reduction in the level of pain experienced by the women after music therapy and breathing exercise during first stage of labour and measured in terms of numerical rating scale.

Parturient mothers: The mothers undergoing labour process

First stage of labour: starts from true pain till the complete dilatation of the cervix.

6.7 HYPOTHESIS

H1: There is a significant difference between music therapy and breathing exercises in reducing the pain level among parturient mothers.

H2: There is a significant relation between the level of pain and demographic variables.

6.8 ASSUMPTIONS

1. The perception of labour pain differs with each women in labour

2. Music therapy and deep breathing exercise has no adverse effect on women on outcome of labour.

3. Music therapy and deep breathing exercise reduces the pain level among the parturient mothers.

7. MATERIALS AND METHODS

7.1 SOURCES OF DATA

The parturient mothers in labour ward with the gestational age between 38-42 weeks, in a selected hospital, Bangalore.

7.2 METHODS OF DATA COLLECTION PROCEDURE

RESEARCH APPROACH:

True Experimental study

RESEARCH DESIGN:

A crossover design by using a standard numerical pain rating scale to determine the level pain after music and breathing exercise in parturient mothers during the first stage of labour.

SAMPLING TECHNIQUE:

The sample of 40 Primi gravida mothers within the gestational age of 38-42 weeks will be selected using non probability convenience sampling technique. Data will be collected using antenatal records. The verbal consent will be taken from the samples prior to the study.

SAMPLE AND SAMPLE SIZE

The sample of 40 primi gravida mothers within the gestational age of 38-42 weeks at a selected hospital in Bangalore.

SETTING OF THE STUDY

The true experimental study will be conducted in HAL Hospital Bangalore.

7.2.1 SAMPLING CRITERIA

Inclusive Criteria

➢ Parturient mothers who have pain in active and transient phase of first stage of labour.

➢ Parturient mothers who are between 38-42 weeks of gestation

➢ Primi parturient mothers

➢ Parturient mothers who are willing to participate in the study

Exclusive Criteria

➢ Parturient mothers with high risk cases.

7.2.2 DATA COLLECTION TOOL:

A structured interview will be used to collect the socio demographic data such as age, education, area of residence, type of family and gestational age.

A standard numerical pain rating scale will be used to assess the pain level of the parturient mothers after music therapy and breathing exercise.

7.2.3 VALIDITY

A standard numerical pain rating scale is used to assess the pain level of the parturient mothers.

The validity of the tool will be ascertained in consultation with guide and other experts from various fields like nursing, obstetricians and statistician.

7.2.4 DATA ANALYSIS METHODS

The data analysis will be done using descriptive statistics such as frequency distribution, percentage, mean and standard deviation and inferential statistical such as't' test and chi square.

7.3 Does the study require any investigation or interventions to be conducted on patients or other human or animal?

Yes, music therapy and breathing exercise will be given to the 40 parturient mothers during the first stage of labour.

7.4 Has Ethical clearance been obtained?

Yes, formal permission will be obtained from chief medical officer of HAL hospital .The mothers will be clearly explained about the study purpose and will take a verbal consent. Assurance will be given to the mothers that anonymity of all information will be maintained.

8. LIST OF REFERENCES

1. childbirth_pain.html

2. healiohealth.library

3. http/childbirth-labour-delivery

4.

5. Music Therapy in Childbirth and Neonatal Care, CAMT, Wilfred Laurier University.

6. Lowe N. K. The pain and discomfort of labor and birth. Journal of Obstetric, Gynecologic and Neonatal Nursing. 1996; 25(1):82–89.

7. Nichols F. H, Humenick S. S. 2000. Childbirth education: Practice, research, and theory, 2nd edition, Philadelphia: W.B. Saunders Company.

8. Olds S. B, London M. L, Ladewig P. W. 1996. Maternal newborn nursing—A family centered approach. Menlo Park, CA: Addison Wesley.

9. Complementary Therapies for Laboring Women, MCN, the American Journal of Maternal/Child Nursing, November/December 2006.

10. Sharma R, Suneja A, Jaswal R, et al Journal of Obstetric, Gynecologic, and Neonatal Nursing. November 2002

11. CNM Data Group. Midwifery management of pain in labor. Journal of Nurse-Midwifery. 1998;43(2):77–82.

12. Hanser, S., Larson, S.C. & O’Connell, A.S. (1983).  The effect of music on relaxation of expectant mothers during labor.  Journal of Music Therapy, 20 (2), 50-58.

13. Angel Rajakumari .G, Dr Mrs.A.Judie., Nightingale Nursing Times, November 2008: 48-50.

14. Judith Turner, Complementary Therapies for Laboring Women, MCN, the American Journal of Maternal/Child Nursing,2006

15. Sasitorn Phumdoung, Marion Good, Obstetric Gynecological Nursing and Midwifery Department, Prince of Songkla University, Faculty of Nursing, Hatyai, Songkhla, Thailand, June 2003.

16. Durham L, Collins M. The effect of music as a conditioning aid in prepared childbirth education. Journal of Obstetric, Gynecologic and Neonatal Nursing. 1986; 15:268–270.

17. Clark, McCorkle, and Williams (1981), Music assisted labor and delivery. Journal of Music Therapy, Vol.18(2),88-100.

18. alert.

19. Sylvia T. Brown, Carol Douglas, and LeeAnn Plaster Flood, CNM .Journal of Prenatal Education 2001

20. prodevce

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