Received: 19 November 2018 Revised: 28 February 2019 Accepted: 25 March 2019

DOI: 10.1111/jjns.12272

ORIGINAL ARTICLE

The effect of sacral massage on labor pain and anxiety:

A randomized controlled trial

Semra Akköz Çevik​1 ​| Serap Karaduman​2

t using any medication and direct them to perceive the pain at
udy was conducted to determine the effect of sacral mas- sage
1​ y. ​Methods: ​This study was conducted as a randomized
Obstetric and Gyneacologic Nursing
Department, Gaziantep University of study at Ba​ ̆gc​ı​lar Hospital, Obstetrics and Gynecology
Faculty of Health Sciences, Gaziantep, nd October 2016. In all, 60 women, 30 of whom were in the
Turkey whom were in the experimental group, constituted the research
he experimental group were administered a massage to the
2​
Obstetric Department, Ba​ ̆gc​ı​lar Training
. The questionnaire form, birth action follow-up form,
and Research Hospital, Istanbul, Turkey
rm, visual analog scale (VAS) and state-trait anxiety inventory
Correspondence ​Semra Akköz Çevik, ta in the study. ​Results: T​ he latent phase VAS averages (3.57
Gaziantep University, Faculty of Health AS averages (7.03 ± 1.5) and transition phase VAS averages
Sciences, Obstetric and Gyneacologic Nursing erimental group were found to be statistically significantly
Department, Head of Midwifery Department, control group (​P < ​ .05). ​Conclusion: I​ t was concluded that
Gaziantep, Turkey. Email:
during labor reduced women​’​s labor pain, lowered the levels of
[email protected]
d to greater feel- ings of satisfaction among pregnant women in
Aim: ​Nonpharmacologic pain control methods, which are increasingly
y affected the perception of labor and had no fetal side effects.
widespread in coping with labor pain, are the methods that allow women to

Jpn J Nurs Sci. 2​ 019;1​–​9. wileyonlinelibrary.com/journal/jjns © 2019 Japan Academy of Nursing Science ​1
KEYWORDS ​anxiety, labor pain, massage, surveys and questionnaires, visual
analog scale
 Non-pharmacological and supportive methods that are used to
ecrease pain are a part of midwifery/nursing practices.
Massage is the oldest tactile stimulation method that is used to
1 ​| ​INTRODUCTION elieve labor pain. Massage is a manual pro- cess performed on
he soft tissues of the body for systemic purposes to improve
ealth and well-being. Massage decreases the severity of pain,
Labor is regarded as one of the physiological behaviors in
oosens the spasms and pro- vides general relief during labor
humans that has existed since the beginning of humanity, the
Field, 2010).
formation cycle of which has remained unchanged (Gönenç &
Terzio ̆glu, 2012). Labor is a health state that most women
aspire to, at some point in their lives. The first thought that .1 ​| ​Aim
comes to the mind of an expecting woman
regarding her delivery is the pain of labor. The pain of labor ishis study was performed to determine the effect of sacral
the central and universal part of a woman's experience massage, of on labor pain and anxiety.
childbirth. Labor is a normal physiological process, which while
it should be an occasion for rejoicing, it also accom- panies with
it, lots of pain, agony, and discomfort and cer- tain risks. Thus​| ​MATERIALS AND METHODS
although being a joyful and empowering experience, it can end
with negative and tragic results, leav- ing the woman filled with.1 ​| ​Study design
fear and anxiety for future birth
(Labrecque, Nouwen, Bergeron, & Rancourt, 1999). The causes his was a randomized and controlled experimental study aimed
of labor pain can be either physical or psychological. Physicalo determine the effects of sacral massage on labor pain and
factors include uterine contractions, cervical dilata- tions,nxiety.
cervical effacements and so on. Psychological factors include 2.2 ​| ​Setting and samples
fear and anxiety, previous experiences, inadequate support,
inadequate knowledge. Pain perceived during labor may be The study was performed on volunteer pregnant women who
different for each woman (Sethi & Barnabas, 2017). The fear applied to Ba ̆gc​ı​lar Training and Research Hospital, Delivery
and anxiety that pregnant women experience during the labor Unit, to undergo their first labor between January 25 and
process leads to the stretching of pelvic muscles and creates October 25, 2016. This unit contains one delivery room (with
resistance against the repulsive force of the uterus and the two tables), two labor follow-up rooms (with five beds), one
repulsive force exerted by women during labor. The extension postpartum room (with five beds) and one nursing room.
of the anxiety-related tension in the pel- vic muscles causes According to hospital records, in all, 342 pregnant
general fatigue in pregnant women, increased pain and women who applied to Ba ̆gc​ı​lar Training and Research Hos-
decreased power to cope with the pain (Gönenç & Terzio ̆glu, pital, Delivery Unit to undergo their first labor between January
2012). Anxiety also reduces the self- confidence of an 25 and October 25, 2016, constituted the population of the
individual. As a result of this situation, pregnant women study. The following inclusion criteria were used to determine
perceive themselves as incompetent and unskilled. The anxiety participation in the study: (a) 19​–​40-year-old pri- miparous
experienced during labor directs women to caesarean section by pregnant women; (b) singleton pregnancies between 38​–​42
their own will (Fenwick, Staff, Gamble, Creedy, & Bayes, weeks; (c) pregnant women whose labor began spontaneously;
2010). The essence of mid- wifery can be with woman (d) pregnant women with a healthy fetus; (e) pregnant women
providing comfort in labor. Touch communicates caring and without any complications that may cause dystocia during labor;
reassurance. Manual healing methods used today during (f) pregnant women for whom analgesia and anesthesia were not
delivery include touch and massage therapy. Painful uterine used during the first phase of labor; (g) pregnant women who
contractions can be treated by applications of pressure with the volunteered to participate in the research and who could
hands to a woman's back, hips, thighs and sacrum. By massage establish verbal communication. In addition, pregnant women
therapy, pharmacological management during the first stage of with high-risk pregnancies, with caesarean section indication,
labor can be reduced, so fewer negative effects will be there on and pregnant women with a chronic illnesses were excluded.
the fetus and mother (Smith, Levett, Collins, & Jones, 2012). The sample size was calculated by the Medical Faculty
 Biostatistics Department using Minitab Program. The sam- ple
volume to represent the population was determined as minimum In this study, the questionnaire form, birth action follow-up
30 people for each group when considering com- parison resultsform, postpartum interview form, visual analog scale (VAS) and
state-trait anxiety inventory (STAI FORM TX-I) were used to
of mean scores in the study by Field, with a risk of ​α ​= .05, an
collect the data.
accuracy rate of 1​−α ​=.95 and a power ratio of B = 0.20, 1​−​B =
0.80 (Field, 2010).
The study was conducted with two groups, namely the1. Questionnaire form​: ​Questions that reflect the
experimental group, and control group. Thirty pregnant women sociodemographic characteristics of the patients (age,
were included in each group; therefore, the study was conductededucational status, social security, marital status), infor- mation
with a total of 60 pregnant women. The women who about pregnancy (drugs used, status of their will- ingness to
participated in the study were randomized as control (double) become pregnant, gestational week, status of
and experimental (single) groups according to the single or
double patient admission numbers.

2.3 ​| ​Measurements
2 ​AKKÖZ ÇEVIK ​AND ​KARADUMAN
attending examinations, status of collecting information about as used. The individual is required to indicate the feelings or
labor), the methods used to cope with the pain, and open-ended ehaviors that he/she has experienced in a specific sit- uation
questions that evaluate the previous use of massage. 2. Birth ccording to the degree of severity by marking one of the
action follow-up form: Questions that indicate the length of the ptions such as (a) Never, (b) Little, (c) Very and (d)
first phase, the interventions performed to shorten the first phase ompletely. The STAI requires the individual to describe how
of labor, the methods used by the patient to cope with the labor e/she feels at a certain moment and under certain conditions by
pain, the emotional behav- iors of the pregnant women during onsidering his/her feelings about a specific situation. While
labor, the length of the second phase, adjustment of the pregnant igh scores indicate high anxi- ety levels, low scores indicate
women, the presence of intervention in labor, the status of episi- w anxiety levels. The STAI consists of 20 statements. The
otomy, the total duration of labor and the baby's health. This core obtained from the scale may vary between 20 and 80.
form was applied to both groups during labor. 3. Postpartum While a high score represents a high anxiety level, a low score
interview form: Open and closed questions that indicate the pre- sents a low anxiety level. In the scoring performed in
pregnant women's thoughts about labor, the status of overall ccordance with the criteria directive, 0​–​19 points are regarded
satisfaction with labor and how the women feel were included ins ​“​none​”​, 20​–​39 points are regarded as ​“​mild
this form, which was pre- pared by a researcher in accordance anxiety​”​, 40​–​59 points are regarded as ​“​moderate anxi- ety​”​,
with the relevant lit- erature. This form was applied to both 60​–​79 points are regarded as ​“​heavy anxiety​” ​and 80 points
groups after giving birth. 4. VAS: This was used to measure the are regarded as ​“​severe anxiety​”​. In our study, the STAI
severity of labor pain. On this scale, numbers from 0 to 10 FORM TX-I was used in the active (5​–​7 cm) phase in the
appear on a horizontal line of 100 mm. The pain level is control group and in the active (5​–​7 cm) phase after the
expressed in figures that range from 0 to 10, as follows: the massage in the experimental group to evaluate the anxiety
absence of pain is indicated by ​“​0​”​, while the most severe pain is experienced by women during labor.
indicated by ​“​10​”​. In this method, it is explained to the
individual that there are two endpoints and that she is free to
mark any point that defines her pain. The VAS was applied to 2.4 ​| ​Data collection
the participants in the control group once in the latent (3​–​4 cm),
After approval and permission to conduct the study were
active (5​–​7 cm) and transition phases (8​–​10 cm) of labor. The
obtained from the ethics committee, the hospital's head nurse,
VAS was also applied to those in the experimental group once
delivery room charge nurse/midwife and other mid- wives and
after the massage in each phase. The diagnosis was made in
nurses were interviewed and informed about the purpose and
accordance with the subjective data including the patient's
scope of the study. Data were collected by one of the
verbal expression. 5. STAI FORM TX-I​: ​To determine state and
researchers. The researcher was aware of which patients were
trait anxiety levels of the participants, the STAI FORM TX-I
 assigned to each group. However, the researchers did not prolonged labor in mother and fetus are enormous and the
interfere in any way with the study results. When they massage for shortening of duration of labor is simple,
encountered women who met the inclu- sion criteria of the affordable, safe and more acceptable for pregnant women. In the
study, the purpose of the study was explained, and written literature massage was applied for 30 min, thus in this study the
consents were received from those who agreed to participate in women in the experimental group were administered a massage
the study. For the women who satisfied the criteria, participation
to the sacral region under the supervision of a doctor for 30 min
in the study was voluntary. Additionally, during the study, no at every phase of labor (Gallo et al., 2013; Haghighi, Masoumi,
women requested to with- draw and no women were excluded & Kazemi, 2016; Sethi & Barnabas, 2017).
from the study. Routine care and treatments for the women
continued during data collection.
2.5 ​| ​Procedure
Massage is an old technique that is widely used in child-
birth (Field, 2010) and can decrease the childbirth pain by Before the research data were collected, an informative meeting
reducing the adrenaline and noradrenaline secretion and regarding the purpose and scope of the study was held for the
increasing the endorphins and oxytocin release thus reducing the members of the healthcare team who worked in the obstetrics
childbirth duration by increasing uterine contractions (Alehagen,and gynecology clinic of the Turkish Republic Ministry of
Wijma, Lundberg, & Wijma, 2005; Cooke, Holzhauser, Jones, Health Public Hospitals Administration of
Davis, & Finucane, 2007). The complica- tions caused by
AKKÖZ ÇEVIK ​AND ​KARADUMAN ​3
4 ​AKKÖZ ÇEVIK A​ ND ​KARADUMAN
• ​TABLE 1 ​Comparison of the visual analog scale (VAS) values
One-on-one interviews were conducted with the pregnant ​of the experimental and control groups in the first phase of
women, and the voluntary disclosure forms, which ​labor (N = 60)
explained the purpose of the study, were completed.
• ​The prepared questionnaire form was applied.
• ​In addition to providing them with routine nursing/mid- ​Features
wifery care, the women in the experimental group were administered a massage to the sacral region under the
supervision of a doctor for 30 min using the effleurage (patting) (15 min) and vibration techniques (15 min) in the
latent (3​–​4 cm), active (5​–​7 cm) and transition (8​–​10 cm) phases of labor. To achieve this, the patients were placed
in the left lateral position in the latent (3​–​4 cm), active (5​–​7 cm) and transition (8​–​10 cm) phases of labor.
• ​The STAI FORM TX-I was applied and evaluated after the massage in the active (5​–​7 cm) phase.
• ​The VAS was evaluated after the massage in the latent (3​–​4 cm), active (5​–​7 cm) and transition (8​–​10 cm) phases.
• ​Birth action follow-up form and postpartum interview forms were applied.
For the pregnant women included in the control group:
• ​One-on-one interviews were conducted with the pregnant women, and the voluntary disclosure forms, which
explained the purpose of the study, were completed.
• ​The prepared questionnaire form was applied.
• ​Routine nursing/midwifery care was applied.
• ​The STAI FORM TX-I was applied and evaluated in the active (5​–​7 cm) phase.
• ​The VAS was evaluated in the latent (3​–​4 cm), active (5​–​7 cm) and transition (8​–​10 cm) phases.
• ​Birth action follow-up form and postpartum interview forms were applied.
One-on-one interviews were conducted with the women in both groups, and the voluntary disclosure forms, which
explained the purpose of the study, were completed. After ​Control group (​n ​= 30)
Experimental group (​n ​= 30) t​a ​P​**
VAS in the latent phase (3​–​4 cm)
4.67 ± 1.37 3.57 ± 1.43 0.03 .004
VAS in the active phase (5​–​7 cm)
8.43 ± 1.17 7.03 ± 1.5 4.04 .001
VAS in the transition phase (8​–​10 cm)
9.7 ± 0.53 8.83 ± 1.78 2.55 .013
 a​
Student's ​t t​ est. ​**​P ​< .05.
TABLE 2 ​Comparison of the state anxiety point averages of the experimental and control groups (N = 60)
Features
Control group (​n ​= 30)
Experimental group (​n ​= 30) t​a ​P​**
State anxiety scale point averages
39.57 ± 4.17 28.07 ± 2.96 9.18 .001
a​
​ P ​< .05.
Student's ​t t​ est. **​
Turkey, at the Istanbul Province Ba ̆gc​ı​lar Training and Research Hospital, where the study would be conducted.
In addition, cooperation was provided by the members of the healthcare team. For the correct application of the
massage, the researcher was trained by the physical therapist who worked at 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 hospital applications. The steps taken in this study are discussed below.
For the pregnant women included in the experimental group:
TABLE 3 ​Comparison of the thoughts about labor pain and labor of women in the control and experimental groups (N = 60)
Control group Experimental group ​χ​2a ​P​** Features
​ ​n (​ %) ​n ​(%)
Thoughts about labor pain
It was an unbearable pain 30 100.0 28 93.3 2.07 .151
It was less than I expected 0 0.0 2 6.7
Thoughts about labor
It was a difficult labor 24 80.0 8 26.7 17.14 .001**
It was a normal labor 6 20.0 22 73.3
a​
​ P ​< .05.
Chi-square test. **​
the prepared questionnaire form was applied to the women in
the experimental group, routine nursing/midwifery care was
provided.
 applied to the sacral region increases the
woman's satisfaction with the labor.
2.7 ​| ​Data analysis

In the evaluation of the data, in addition to descriptive statis-

tical methods (e.g., percentage, frequency, mean, and stan-

2.6 ​| ​Hypotheses of the study

1. Massage applied to the sacral region decreases the per-

ception of a woman's labor pain. 2. Massage applied
to the sacral region decreases the
woman's levels of concern and anxiety about labor. 3. Massage dard deviation), the Chi-square test and Student's ​t t​ est were
 used in the comparison of the qualitative data. The results were
averages of the pregnant women, the duration of the latent,
evaluated at a significance level of ​P ​< .05. active and transition phases of labor, and the anxiety level score.
The dependent variables of the study are the pain scoreThe independent variables of the study are the
AKKÖZ ÇEVIK ​AND ​KARADUMAN ​5

It has been assessed whether the pregnant women in the birth room conform to the inclusion
​ 342).
criteria in the survey (​n =

Pregnant women with high-risk pregnancies, with caesarean section indication, and Pregnant
women with a chronic illness were excluded (​n ​= 282).

Participants matching the selection criteria were assigned randomly by using simple
randomization (​n ​= 60)

Informed consent was obtained from the participants and the confirmation form was signed.
Questionaire form filled (​n ​= 60)
ied and evaluated in the active
.
​ 30)
Massage Group (experimental) (​n = nalogue Scale (VAS) was
Control Group (​n ​= 30) in the latent (3-4 cm), active (5-7
ion (8-10 cm) phases.
• The women in the experimental group were placed and vibration technique in the latent (3-4 cm),
in the left lateral position in the latent (3-4 cm), active (5-7 cm) and transition (8-10 cm)
active (5-7 cm) and transition (8-10 cm) phases of phases of labour.
labour during applying to massage.
• The state-trait anxiety inventory (STAI FORM
• The women in the experimental group were TX-I) was applied and evaluated after the
administered a massage to the sacral region under massage in the active (5-7 cm) phase.
the supervision of a doctor for 30 minutes using the
• The Visual Analogue Scale (VAS) was
effleurage (patting)
evaluated once after the massage in the latent
• Routine nursing/midwifery care was
(3-4 cm), active (5-7 cm) and transition (8-10
applied.
cm) phases.
• The state-trait anxiety inventory (STAI FORM

Birth action follow-up form and postpartum interview forms were applied

The data were analysed. The results were evaluated at a significance level of p <0.05.
pregnant women's ages, educational status, working status, ando become pregnant and the willingness to serve as controls
prenatal educational status, as well as the educational status ofefore labor.
the husbands of the pregnant women, the women​’​s willingness
 lower compared with those of the control group (​P < ​ .001)
(Table 1). The average of the VAS points given by women for
2.8 ​| ​Ethical consideration ​
pain perception in the transition phase (8​–​10 cm) was 9.7 (​SD =
0.53) in the control group and 8.83 (​SD = ​ 1.78) in the
Approval was received from the Ethics Committee for Clinical
experimental group. The VAS point averages of the experi-
Investigations of Ba ̆gc​ı​lar Training and Research Hospital to
mental group in the transition phase (8​–​10 cm) were found to be
conduct the study; the approval number is 2015/19/02. Written
statistically significantly lower compared with those of the
permission was received from the Chief Physician of Ba ̆gc​ı​lar
control group (​P <​ .05, Table 1).
Training and Research Hospital so that the study could be per-
formed. Verbal and written consents were received after the The comparison of the state anxiety point averages of
necessary explanations regarding the purpose of the study, the the experimental and control groups is presented in Table 2.
application method and the planned outcomes had been given to Accordingly, the state anxiety scale (STAI) point averages of
the patients included in the study. the control group and the experimental group were found to be
39.57 ± 4.17 and 28.07 ± 2.96, respectively. The state anxiety
scale (STAI) point averages of the experimental group were
3 ​| ​RESULTS found to be statistically significantly lower com- pared with
those of the control group (​P ​< .001, Table 2).
The average age of the pregnant women included in the study The comparison of the thoughts about labor pain and
was 23.5 ± 4.47 years. When the data on educational status were labor of the women in the control and experimental groups is
examined, 60% of the women in the experimen- tal group and presented in Table 3. While 100% of the women in the control
56.7% of the women in the control group were primary school group defined labor pain as ​“​an unbearable pain​”​, 93.3% of the
graduates, and 20% of the women in the experimental and women in the experimental group defined labor pain as ​“​an
control groups were high school graduates. Moreover, 100% of unbearable pain​”​. No statistically significant dif- ference was
the pregnant women stated that they intentionally became observed between the two groups in terms of the distributions of
pregnant. In all, 83.3% of the women in the control group and thoughts about labor pain (​P >
​ .05, Table 3). While 80% of the
96.7% of the women in the experi- mental group regularly went women in the control group stated that their labor was a difficult
for examinations throughout their pregnancy. In addition, 83.3% labor, 26.7% of the women in the experimental group stated that
of the women in the con- trol group and 93.33% of the women their labor was a difficult labor. The distributions of the finding
in the experimental group had received no information about that women in the experimental group accepted their labor as
labor. Furthermore, 66.7% of the women in the control group difficult were found to be statistically significantly lower
and 63.3% of the women in the experimental group were afraid compared with the control group (​P ​< .001, Table 3).
of the birth process. Finally, 93.3% of the women in the control The comparison of the post-natal feelings and overall
group and 96.7% of the women in the experimental group asked sat- isfaction with labor of the women in the control and experi-
one of their relatives to accompany them during labor. mental groups is presented in Table 4. Accordingly, the
The comparison of the VAS values of the experimental distributions of the answer of ​“​I'm fine​” ​given in response to the
and control groups in the first phase of labor is presented in question of ​“​How are you feeling now?​” ​were found to be
Table 1. Accordingly, the average of the VAS points given by statistically significantly higher in the experimental group than
women for pain perception in the latent phase (3​–​4 cm) was in the control group (​P ​< .05, Table 4). The distribu- tions of the
4.67 (​SD = ​ 1.37) in the control group and 3.57 (​SD ​= 1.43) in answer of ​“​Yes​” ​given in response to the ques- tion of ​“​Are you
the experimental group. The VAS point aver- ages of the generally satisfied with the labor process?​” ​by the experimental
experimental group in the latent phase (3​–​4 cm) were found to group were found to be statistically sig- nificantly higher
be statistically significantly lower than those of the control compared with the control group (​P ​< .05, Table 4).
group (​P < ​ .05) (Table 1). The average of the VAS points given
by women for pain perception in the active phase (5​–​7 cm) was
8.43 (​SD =​ 1.17) in the control group and 7.03 (​SD ​= 1.5) in the 4 ​| ​DISCUSSION
experimental group. The VAS point averages of the
experimental group in the active phase (5​–​7 cm) were found to Labor pain is a condition that is affected by many neuro-
be statistically significantly physiological, biochemical, psychogenic, ethnocultural, reli-
 gious, cognitive, psychological and environmental factors.and are gradually intensified so that labor can progress
Labor pains, unlike other pains, do not have a stable inten- sity
(Hosseini, Bagheri, & Honarparvaran, 2013). Moreover,
6 ​AKKÖZ ÇEVIK ​AND ​KARADUMAN
hase of labor decreases the per- ceived labor pain (Abbaspoor
Mohammadkhani, 2013; Mortazavi et al., 2012). Janssen et
. (2012) determined that massage application decreases the
atios of caesarean
sections that are elected due to the fear of labor and allows
mothers to have positive experiences during labor (Janssen et
al., 2012). Massage has an important place in modern nursing
practices. In addition, massage is now quite popular among
complementary initiatives as it is a low-cost, easy-to- apply and
effective method that does not require equipment and that does
not demand excessive amounts of time for the nurse. Massage is
used during labor to provide relaxation, to decrease pain and
suffering, to shorten the labor process and to increase the ability
60% of nulliparous women and 40% of multiparous women of the woman to cope with labor pain (Jones et al., 2012; Smith,
experience this severe condition as a result of the contraction of Collins, Cyna, & Crowther, 2006). The results of our study
the uterine muscles and the increased exacerbation of these support what is shown in the literature. In our study, the STAI
contractions as well as the interaction among the hor- mones point averages of the experimental group were found to be
produced by the mother and the baby and biochemi- cal and statistically signifi- cantly lower compared with those of the
immunological factors (Da ̆glar & Aydemir, 2011). The levels control group (​P ​< .001). This result confirms the hypothesis
of the pain perceived by pregnant women in the latent, active that ​“​mas- sage applied to the sacral region decreases the
and transition phases of the first phase of labor are different. woman's levels of concern and anxiety about labor​” ​that we put
Therefore, in our study, the VAS was evaluated in three phases forth at the beginning of the study. In the studies performed, it is
of labor, and the levels of the pain perceived by the pregnant emphasized that massage application is an effective method that
women were evaluated once after the mas- sage in the latent can decrease the anxiety level of pregnant women dur- ing the
(3​–​4 cm), active (5​–​7 cm) and transition (8​–​10 cm) phases in labor process (Lamadah & Nomani, 2016; Mortazavi et al.,
the experimental group. In our study, the latent phase (3​–​4 cm) 2012). Gönenç and Terzio ̆glu (2012) determined that the
VAS averages, the active phase (5​–​7 cm) VAS averages and the active phase state anxiety point average was lower in the group
transition phase (8​–​10 cm) VAS averages of the experimental that was administered a massage (Gönenç & Terzio​ ̆glu, 2012).
group were found to be statistically significantly lower than In our study, the total duration of labor was, on average,
those of the VAS aver- ages of the control group (​P ​< .05). 7.6 h (457.03min) in the control group and 7.12h (427.27 min)
These findings con- firmed the hypothesis that ​“​massage applied in the experimental group. No statistically sig- nificant
to the sacral region decreases the perception of women's labor difference was observed between the experimental and control
pain​”​, which we put forth at the beginning of the study. Gönenç groups with respect to the averages of the dura- tion of the first
and Terzio ̆glu (2012) concluded in their study that both mas- phase, second phase, and third phase of labor as well as the total
sage and acupressure applications in the transition phase of duration of labor (​P ​> .05). Similar to our findings, in a study
labor were effective in controlling the labor pain and that performed by Jannsen et al. in 2012, no significant difference
acupressure was more effective than massage alone after they was found between the first and second phases of labor in the
compared the use of massage alone and massage and groups with and without mas- sage application (Janssen et al.,
acupressure together (Gönenç & Terzio ̆glu, 2012). In some 2012). In contrast, in the
studies in the literature, it is stated that massage application at ABLE 4 ​Comparison of the post-natal
birth is effective in pain management and that it delays the use elings and overall satisfaction with the labor
of epidural analgesia (Gallo et al., 2013; Janssen, Shroff, & ocess of women in the control and
xperimental groups (N = 60)
Jaspar, 2012; Mortazavi, Khaki, Moradi, Heidari, & Vasegh
Control group Experimental
Rahimparvar, 2012). Similarly, in other studies in the literature,
it has been determined that massage application in the transition (%) ​n ​(%)
nt feelings
AKKÖZ ÇEVIK ​AND ​KARADUMAN ​7

I'm fine 15 50.0 26 86.7 9.73 .021

I'm tired 7 23.3 2 6.7

I have pain, I'm not comfortable 6 20.0 2 6.7

I am relieved 2 6.7 0 0.0

Overall satisfaction with the labor process

Yes 9 30.0 20 66.7 8.08 .004

No 21 70.0 10 33.3

Chi-square test. ​**​P

a​

< .05.
study by Haghighi et al. (2016), the durations of the first androup (Mortazavi et al., 2012). Similar results were shown in the
second phases of labor in the experimental group were shortertudy by Sethi and Barnabas (2017). In their study, it is stated
than that in the control group (Haghighi et al., 2016). Similarly,hat back mas- sage had a significant impact on pain and that
in the study by Lamadah and Nomani (2016), the durations ofack massage had a significant role in the reduction of pain and
the first and second stages of labor in the aro- matherapy grouphe improvement of the emotional experience of labor (Sethi &
were shorter than that of the control group (Lamadah & Barnabas, 2017).
Nomani, 2016).
In our study, while 100% of the women in the control
group and 93.3% of the women in the experimental group ​| ​CONCLUSION
defined labor pain as ​“​an unbearable pain​”​, 80% of the women in
the control group and 26.7% of the women in the experimental
n this study, which was performed to evaluate the effect of
group stated that their labor was difficult. The distributions of
acral massage on labor, it was concluded that sacral mas- sage
the finding that women in the experimental group viewed their
pplied during labor reduced the labor pain of women,
labor as difficult were statistically signifi- cantly lower
ecreased the levels of concern and anxiety, resulted in
compared with the control group (​P < ​ .001). Satisfaction with
ncreased satisfaction with the labor process among pregnant
the labor process and a feeling of well- being after labor in
women, positively affected the perception of labor and had no
women in the experimental group were statistically significantly
etal side effects.
higher compared with the control group (​P ​< .05). These
findings confirm the hypotheses that ​“​massage applied to the
sacral region has a positive effect on labor​” ​and ​“​massage
applied to the sacral region increases a woman's satisfactionUNDING
with labor,​” ​which we mentioned at the beginning of the
manuscript. In the study performed by Mor- tazavi et al. (2012), he authors declare that this study has received no financial
which included 120 primiparous women, the effect of massageupport.
therapy on pain, anxiety and satisfac- tion of women during CONFLICT OF INTEREST
labor was examined. They found that the satisfaction scores in
No conflict of interest has been declared by the authors.
the four phases of labor were sig- nificantly higher in the group
that was administered a mas- sage compared with the control
 anxiety levels of emergency nurses: Comparison between summer and
winter. ​Journal of Clinical Nursing​, 6(9), 1695​–​1703. Da​ ̆glar, G. &
Aydemir, N. (2011). Nonpharmacologic practices of mid- wife care to
AUTHOR CONTRIBUTIONS
reduce pain in vaginal delivery. ​Continuous Medical Education Journal,​
20, 1​–​6 (Original Work in TURKISH). Fenwick, F., Staff, L., Gamble, J.,
S.A.C. and S.K. contributed to the conception and design of this
Creedy, D. K. & Bayes, S. (2010). Why do women request caesarean
study; S.A.C. and S.K. carried out the statistical analysis of the
section in a normal, healthy first pregnancy? ​Original Research Article
data and drafted the manuscript; and S.A.C. made crit- ical Midwifery,​ 26(4), 394​–​400. Field, T. (2010). Pregnancy and labor massage.
revisions to the paper for important intellectual content. Expert Review of
Obstetrics & Gynecology​, 5(2), 177​–​181. Gallo, R. B. S.,
Santana, L. S., Ferreira, C. H. J., Marcolin, A. C., PoliNeto, O. B., Duarte,
ORCID G. ​et al​. (2013). Massage reduced severity of pain during labour: A
randomised trial. ​Journal of Physiother- apy,​ 59(2), 109​–​116.
Semra Akköz Çevik h​ ttps://orcid.org/0000-0001-5513- ̇
https://doi.org/10.1016/S1836-9553(13) 70163-2. Gönenç, M. ​ l. & Terzio
1372 ̆glu, F. (2012). The effect of massage and acu- pressure on pregnant
women anxiety level. ​Ankara Health Sciences journal,​ 1(3), 129​–​143
(Original Work in TURKISH). Haghighi, N., Masoumi, S. Z. & Kazemi, F.
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Lundberg, U. & Wijma, K. (2005). Fear, pain and stress hormones during Jaspar, P. (2012). Massage therapy and labor outcomes: A randomized
childbirth. ​Journal of Psychosomatic Obstetrics & Gynecology,​ 26(3),controlled trial. ​International Journal of Therapeutic Massage &
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(2007). The effect of aromatherapy massage with music on the stress and
8 ​AKKÖZ ÇEVIK ​AND ​KARADUMAN
Jones, L., Othman, M., Dowswell, T., Alfirevic, Z., Gates, S., Newburn, M. Ludhiana, Punjab, India. ​International Journal of Reproduction,
et al​. (2012). Pain management for women in labor: An overview of Contraception, Obstetrics and Gynecology,​ 6(1), 76​–​83. https://doi.
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Gynecology and Obstetrics​, 286(1), 19​–​23. Sethi, D. & Barnabas, S.
S. The effect of sacral massage on labor pain and
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AKKÖZ ÇEVIK ​AND ​KARADUMAN ​9

CRITICAL APPRAISAL ​Questions Answers Explanation

• The study was performed
1. Study design, survey or on volunteer pregnant
registration? women who applied to
Randomized controlled Bagcılar Training and
experimental study Research Hospital, Delivery
 Unit, to undergo their first
labor between January 25
and October 25, 2016
• The study was performed
on volunteer pregnant
women who applied to 2. Inductive or deductive
Bagcılar Training and reasoning?
Research Hospital, Delivery e reasoning Researcher collect all related
Unit, to undergo their first theory/literature → design
labor between January 25 material and
and October 25, 2016 method→collecting data →
• The study was performed analyze →conclusion
on volunteer pregnant
women who applied to 3 and 4 Type and scales of each
Bagcılar Training and variables in this study
Research Hospital, Delivery The dependent variables of the
Unit, to undergo their first
study:
labor between January 25
and October 25, 2016 • the pain score averages
of the pregnant women
• The women who
participated in the study
were randomized as control
• active and transition
phases of labor
• the anxiety level score The independent variables of the study
• Pregnant women's age
• educational status
• working status
• prenatal educational
status
• the women’s willingness to
become pregnant
• the willingness to serve as
controls before labor
Primary 5. Type of data, primary,
Data Resource the questionnaire form, birth secondary or tertiary
action follow-up form, resources?
postpartum interview form, visual analog scale (VAS) and state-trait anxiety inventory
(STAI FORM TX-I) were used to collect the data
6. Group or ungroup data? Group Data The study was conducted with
two groups, namely the experimental group, and control group
7. Ad hoc or routine data? Ad Hoc Data was collected for some period of time during
study.
8. Measures of Central
Tendency, Position and Dispersion
The effect of sacral massage on labor pain and anxiety
9. Tables that was used to
present results of this study
Comparative table 1. Comparison of VAS
values in the first phase of labor 2. Comparison of the state
anxiety point averages 3. Comparison of the
thoughts about labor pain and labor 4. Comparison of the post-
natal feelings and overall satisfaction with the labor process
10. Graph used in this paper No graph
11. Quality of research data High quality • The materials and
methods suit the purposes of this study
• There are a lot of variables collected in this study
• Methods of data
collection were done
12. Tables that was used
with valid measurement
to
• Comparisons
tive table 1. Comparison of VAS between
experimental and control
present results of this study
group were defined clearly
values in the first phase of
by tables
labor 2. Comparison of the
•state
Statistical analysis are
done according to the
anxiety point averages 3. Comparison of the
purpose of study
thoughts about labor pain
and labor 4. Comparison of
the post-
natal feelings and
overall satisfaction with
the labor process

13. Graph used in this paper No graph

 14. Quality of research data High quality • The materials and
methods suit the
purposes of this study
• There are a lot of
variables collected in this
study
• Methods of data collection
were done with valid
measurement
• Comparisons between
experimental and control
group were defined clearly
by tables
• Statistical analysis are
done according to the
purpose of study
15. Tables that was used values in the first phase of
to labor 2. Comparison of the
present results of this study state
Comparative table 1. Comparison of VAS anxiety point averages 3. Comparison of the
thoughts about labor pain
and labor 4. Comparison of
the post-
natal feelings and
overall satisfaction with
the labor process

16. 17 Graph used in this paper No graph

18. Quality of research data High quality • The materials and

methods suit the
purposes of this study
• There are a lot of
variables collected in this
study
• Methods of data collection
were done with valid
measurement
• Comparisons between
experimental and control
group were defined clearly
by tables
• Statistical analysis are
done according to the
purpose of study