Effectiveness of breathing exercises, foot reflexology and back massage

By Dr. Kamilya Jamel Baljon

reflexology foot pain work pregnancy

Many primigravidae have reported experiencing various levels of pain during labour and high levels of anxiety about the labour process and its outcomes.1–3Anxiety escalating to fear is a common issue related to labour, especially among primigravidae.4 5 Other recorded negative perceptions and psychological effects influencing labour experiences include distress and feelings of powerlessness during labour for women and their families.5–7

When poorly managed, labour pain may lead to severe consequences for women, such as prolonged labour,5 8 which may increase the risk of fetal distress, head compression, intrauterine fetal death, low Apgar scores and physical injuries to neonates.5 9 Prolonged labour results in increased risk of caesarean section, induced labour and assisted delivery using vacuum and forceps.10 11 Studies have also reported negative mental impacts on women, sometimes even including postnatal post-traumatic stress disorder,12 13 and subsequently reduced quality of life.14 Feelings of anxiety often originate from possible birthing complications about which pregnant women have heard and read,4 5 15 16 and may even result in women refusing normal vaginal delivery and insisting on caesarean sections without medical indications.17 It is therefore important for healthcare professionals to assist and educate all expectant mothers on labour pain management.

Appropriate labour pain management and interventions are important aspects of obstetric care to ensure optimum outcomes for mothers and babies.18 Pharmacological interventions used in the management of labour pain include systemic sedatives, analgesics and regional anaesthesia.19 Examples of these analgesics are aerosol and epidural opioids, intramuscular pethidine (IMP) and intravenous sedatives.20 21 Some of these are expensive and may be associated with adverse effects on mothers, the labour process and neonates.22 In contrast, most non-pharmacological methods for labour pain management are simple and non-invasive, and are often cheaper and safer than pharmacological interventions.23–25 Studies have found that non-pharmacological approaches, particularly breathing exercises, have positive impacts on relief of labour pain,26–28 and anxiety in pregnant mothers.29–31 This is especially true for Lamaze breathing, deep breathing exercises,26–28 32 33 reflexology6 34 and massage.35 Non-pharmacological approaches have been linked to shorter labour duration,36 and improved newborn outcomes.37 Our systematic review found that massage is beneficial for relieving labour pain,38 and is associated with greater relaxation, higher alertness levels, improved mood and reduced stress hormone (cortisol) levels and anxiety symptoms.39

It is hypothesised that the non-pharmacological approach of labour pain management occurs via the alteration of nociceptive stimuli and modification of the processing of nociceptive input at the central level, resulting in an overall improved sense of comfort and well-being, ultimately leading to stronger coping capabilities by the mothers in labour.40

The physiological mechanism of breathing is a protective action as it is a fight-or-flight reflex triggered by the central nervous system. Physiologically, deep abdominal breathing stimulates the parasympathetic nervous system. As a result, the blood circulation in pregnant women will undergo oxygenation, which will trigger the release of endorphins associated with decrease in heart rate and increase in feelings of calmness. At the same time, endorphins can also suppress the sympathetic system, leading to a decrease in the release of stress hormones such as cortisol.41 42

As for reflexology, so far there has been no constructive explanation of the underlying mechanism in reducing labour pain.6 36 The reflexology therapist will apply pressure three times on specific points of the feet that are energetically connected to certain parts and organs of the body. As with skin-to-skin contact during massage, reflexology point pressure could trigger the release of endogenous endorphins and encephalins that help to reduce labour pain, stress, fatigue and anxiety.43–46 Pressure on the solar plexus at the border of the upper and middle one-third of the sole is believed to facilitate the functions of the body’s nervous system.47 Pressure on the lower part of the forefoot reflects the heart and lungs. While pressure on the bridge of the foot reflects the liver and kidney, the heel will reflect the lower back, legs, pelvic region uterus and intestines. The uterine point is believed to be located in the indented region between the inner ankles and the sole.48 Therefore, it is believed to be helpful during labour. The pressure on toe and heel stimulate the reflex points in the pelvis. It is effective by releasing the oxytocin hormone which start and regulate the uterine contractions and relax during contractions.49

However, there are several postulated theories for its mechanism of action. First, the autonomic–somatic integration theory suggests that the pressure applied to the feet during reflexology compresses the receptors in the cells, thus opening up the ionic channels in the plasma membrane and triggering a local action with the potential to convey messages to the spinal cord and/or brain.46 The application of alternating pressure to the feet may also produce predictable reflexive actions within the nervous system and activate the parasympathetic nervous system.50 Based on the energy theory that posits that energy moves towards the head from reflex points that stimulate the neural paths, improve blood flow, release the endorphins and relief pain.51 Another contemporary method explains that reflexology acts through ‘sympathetic resonance’, in which an energy wave flows between therapist and client, promoting homeostatic balance.52 This may occur through local enzymatic reactions on receptive fields or through an improved blood supply as a result of local skin temperature changes following the skin-to-skin contact.47 Reflexologists also believe that the application of deep pressure on certain reflex points of the sole and palm may break any calcium crystals and uric acid accumulated in nerve endings that may cause blockages and induce pain.53

Reflexology also results in body relaxation and stimulation of any blocked nerve endings, which may propel any sluggish glands or organs to regain their normal functioning.54 Ambiguity remains regarding the theories and mechanism of action of foot reflexology for labour pain, as compared with that for general pain.6 35 36 Nonetheless, it is plausible to believe that reflexology techniques would have similar physiological effects for labour pain that bring about a sense of well-being, analgesia and subsequently the perception of pain relief.37

Safe and efficient pain management is important for pregnant women and their families,18 and different types of CAM have been shown to be beneficial to reduce or alleviate labour pain. However, evidence is scarce regarding the effects of combined therapies.87 Therefore, we designed this trial to study the effects of BRM on labour pain and other psychological and physiological impacts among primigravidae. The study protocol for the RCT is to determine the combined effect of BRM on the intensity of pain and level of anxiety in primigravidae during the first stage of labour. Additional outcomes that will be assessed include stress hormones, maternal V/S, FHR, duration labour, neonatal Apgar score and maternal satisfaction.

In this study, the intervention will be applied only once and only during the first stage of labour even though the first stage of labour among primigravidae takes approximately 8–12 hours. By timing the intervention after cervical dilation of 6 cm, the effect of the combined BRM could exert its greatest influences (if any) on the labour experience of the primigravidae and neonatal outcome, because this period is believed to accompany the highest levels of labour pain.88 89

We will assess the outcomes using a mixture of subjective and objective tools. For example, pain intensity and anxiety levels are subjective measurements, based on the personal feelings and judgments of the respondents. Duration of labour, neonatal Apgar score and maternal stress hormones level of ACTH, cortisol and oxytocin are objective measurements that will indicate the stress response to the BRM intervention conducted on the primigravidae. This is one of the strengths of our study.

VAS is one of several ways of measuring the effectiveness of BRM, and is a commonly used graphic rating method.70 78However, VAS might not be the gold standard to measure labour pain, given the inconsistency of its results and its ceiling effect.78 90Recognising this inadequacy, we will ensure that the participants understand the VAS scoring at admission to the delivery room before they are asked to indicate their pain level later. Labour pain outcome will also be measured via pain intensity assessment using the PBI,74 which will be rated by outcome assessors. Multiple measurements will be taken during and after contraction, and before and after the intervention. There will also be other outcomes, related to maternal response to pain, namely anxiety level and maternal stress hormones.91

This study has several other limitations. First, the intervention will be performed for 1 hour, during which it may be interrupted by routine medical care such as regular vaginal examinations, V/S measurements and FHR monitoring. However, we believe that this will not reduce the effect of the BRM intervention, because we can start the BRM before or after the labour care routine. Second, the process of labour and birthing is unpredictable even if the participants are at low risk. In certain instances, the process of the intervention might not go well as planned and this may reduce the sample size. Some patients may end up needing a caesarean section, and some may suffer from other obstetric complications during delivery. As a result, we have inflated the sample size accordingly. Third, the results from this study will not be generalisable to multigravidae as we include only primigravidae. Nevertheless, we believe that primigravidae will benefit the most from the intervention as they are likely to experience a higher level of labour pain and a longer duration of labour compared with multigravidae. Fourth, placebo effects can influence patient outcomes after (CAM), resulting in high rates of good outcomes, which may be wrongly attributed to specific treatment effects.92

We recognise that the expertise and experience level of the reflexologist is an important factor in the quality of treatment provided and this may affect the outcomes of the BRM. The massage therapists and the outcome assessors will be given the appropriate training on the BRM for 1 week by the principal investigator who attended a professional training and was certified. After the training, they will be tested in a pilot study to ensure their competency in performing the BRM. Additional quality control measures for the outcome assessors are planned, as they will be assigned to the control delivery room or the intervention delivery room on the same day. All of the completed assessment forms will be reviewed and kept by the research coordinator in a safe location in the delivery room. Any issues on the form such as blank spaces and extreme values will be immediately clarified and resolved.

In addition to labour pain, this study will assess the anxiety level of pregnant mothers. Unlike labour pain, anxiety level can be affected by individual characteristics, previous life experiences and other environmental causes.93 However, we believe that these factors will not play a significant role after effective randomisation.

Apart from the actual labour experience, there are a few other external factors that may affect maternal satisfaction, such as the delivery room services, the health of the baby, the gender of the child, family support and other psychosocial factors. As satisfaction is a multidimensional and complex feeling, it is difficult to measure with a single tool and to narrow it down to only the first stage of labour.

It is understood that a birthing process is a natural event, especially for low-risk women. Thus, the management of labour should be conducted in a supportive manner with minimal or no interferences. This study will provide high-quality evidence about the effects of the combined BRM for labour pain management. These findings will be important for hospitals offerings for expectant mothers in providing a rationale for their decisions about which alternative treatments to offer, to primigravidae and their family members during decision-making about labour pain management.