| 139

Pensar Enfermagem / v.27 n.01 / November 2023

DOI: 10.56732/pensarenf.v27i1.280

Quantitative Original Article

How to cite this article: Tereso A, Lopes F, Guterres R, Bértolo H, Carvalhal L, Curado A. Effectiveness

of therapeutic showering in pain relief during the first stage of labor. Pensar Enf [Internet]. 2023 Nov;

27(1):139-146. Available from: https://doi.org/10.56732/pensarenf.v27i1.280

Effectiveness of therapeutic showering in pain relief

during the first stage of labor

Abstract

Introduction

Pain prevention and effective control is emphasized as a priority for the obstetric unit’s

humanization. The therapeutic shower it’s an easy-to-deploy non-pharmacological

alternative whose effectiveness has not been recognized by nurses.

Objective

The aim of this study was to evaluate the effectiveness of therapeutic showering for pain

relief during the first stage of labor.

Methods

Quasi-experimental study with the following research question: Is the therapeutic shower

effective in relieving pain during the first stage of labor? Convenience sampling (n=81)

was used. Data were collected in the two maternity wards. Labor pain was assessed using

a Numeric Scale before water application as a comparative standard of pain level before

and after warm water application (immediately after, 10 and 20 minutes after). Data

analysis was performed using SPSS®, v.27.

Results

Repeated measurement ANOVA showed statistically significant results. Contrast analysis

between the first and second measurements revealed significant differences between the

mean level of pain immediately and 10 minutes after water application. However, post hoc

analysis revealed that after 20 minutes, the differences between the means were not

statistically significant.

Conclusion

Therapeutic showering is effective in pain reduction immediately and 10 minutes after

application.

Keywords

Hydrotherapy; Labor Pain; Pain Management; Pain Measurement.

Alexandra Tereso

orcid.org/0000-0002-4746-3649

Filipa Lopes

orcid.org/0000-0013-1676-9466

Rute Guterres

orcid.org/0000-0001-9999-9499

Helena Bértolo

orcid.org/0000-0002-6612-2700

Lucinda Carvalhal

orcid.org/0009-0009-8940-8304

Alice Curado

orcid.org/0000-0002-9942-7623

PhD. Maternal Health Department, Nursing School

of Lisbon (ESEL), Lisbon. Nursing Research,

Innovation and Development Centre of Lisbon

(CIDNUR), Lisbon, Portugal.

Master. Nursing School of Lisbon (ESEL), Lisbon.

Nursing Research, Innovation and Development

Centre of Lisbon (CIDNUR), Lisbon, Portugal.

Nursing degree. CHLO-Hospital de São Francisco

Xavier, Lisbon. Nursing School of Lisbon (ESEL),

Lisbon. Nursing Research, Innovation and

Development Centre of Lisbon (CIDNUR), Lisbon,

Portugal.

Master. Maternal Health Department, Nursing School

of Lisbon (ESEL), Lisbon. Nursing Research,

Innovation and Development Centre of Lisbon

(CIDNUR), Lisbon, Portugal.

Nursing degree. CHLO-Hospital de São Francisco

Xavier, Lisbon. Nursing School of Lisbon (ESEL),

Lisbon. Nursing Research, Innovation and

Development Centre of Lisbon (CIDNUR), Lisbon,

Portugal.

PhD. Nursing School of Lisbon (ESEL), Lisbon.

Nursing Research, Innovation and Development

Centre of Lisbon (CIDNUR), Lisbon, Portugal.

Corresponding author:

Alexandra Tereso

E-mail: alexandra.tereso@esel.pt

Received: 05.06.2023

Accepted: 14.10.2023

140 | Tereso, A.

Quantitative Original Article

Introduction

Pain can significantly influence the development of labor

and interfere with the decisions and satisfaction of women.

Anxiety and pain can be associated with longer labor, higher

levels of stress hormones, and greater use of

pharmacological analgesia.

1-5

As privileged caregivers of

parturients, fetuses, and families, obstetric nurses can play

an essential role when considering pain as the fifth vital sign

and promoting the use of non-pharmacological strategies

for its relief.

Providing non-pharmacological alternatives that facilitate

women's autonomy and decision-making in pain

management during labor can minimize fear and anxiety and

facilitate the release of hormones that favor the birthing

process.

In the first stage of labor, several studies have

reported that conventional pharmacological approaches

may not be beneficial for the physiological evolution of

labor.

Obstetric nurses can use their skills and contribute

objectively to prevent the unwanted effects of

pharmacological strategies, improve physical sensations, and

mitigate the psychological and emotional perception of pain

in parturients.

Among existing non-pharmacological labor pain relief

alternatives, hydrotherapy (defined as the external

application of water for therapeutic purposes) has been

considered by several national and international institutions

as an option that can provide significant pain relief and

optimize the positive delivery experience of women, fetuses

and families.

6, 9-12

In Portugal, the Board of the Obstetric and Maternal Health

Nursing Specialty College of the Council of Nursing

has a

project called Maternity with Quality in which, one of the

indicators of the relevance of the project and measurement,

highlights the importance of promote and apply non-

pharmacological pain relief measures in labor and delivery.

The project maintains that the use of water during labor for

pain relief, in the first and second stages, promotes the well-

being of women and contributes to lowering the incidence

of episiotomies and cesarean deliveries. Two of the core

concepts of maternal health and obstetric nursing care are

woman-centered care and the promotion of normal

childbirth.

In this context, making therapeutic showers

available to women and supporting them in decisions

regarding labor pain management can contribute to the

recognition of the role of women in childbirth and its

depathologization.

The Portuguese Council of Nursing

states that the

therapeutic use of warm showers results in a statistically

significant reduction in the use of epidural analgesia during

the dilation period and does not present adverse effects with

implications for the duration of labor, the rate of surgical

births, and neonatal well-being. Providing hydrotherapy in

Portuguese hospitals, in this case in the form of showers

with warm water, means providing women with an

empowering environment and instituting adequate care

policies that include non-pharmacological strategies for pain

relief in obstetric units. In this context, and taking into

account its beneficial effects, it is essential to encourage the

use of therapeutic showers, given how easy they are to apply

and that they do not require large investments in resources.

Despite the contributions mentioned above, in practice, the

use of showers is not widespread. Stark and Miller

described some of the barriers to this implementation.

These authors consider it important to develop research on

such barriers, including strategies to overcome them.

Stark

tested the effectiveness of therapeutic showering

during labor in a study with 32 parturients in active labor, in

which water was applied for 30 minutes. The study found

that in relation to the control group, there was a statistically

significant reduction in pain, and that therapeutic showering

was effective in reducing pain, discomfort, anxiety, and

tension, while improving relaxation and supporting labor.

Despite this evidence, in Portuguese maternity hospitals, the

use of hydrotherapy is far from widespread and often

neglected in relation to pharmacological strategies. If on the

one hand, material resources (in the case of immersion baths

or showering) are essential, on the other hand, producing

research and disseminating results about the effectiveness of

the strategy can help motivate nurses and develop evidence-

based practices.

Stark

considered it important to distinguish therapeutic

showering from hygienic showering, which usually includes

active effort and movement to wash and cleanse.

Therapeutic showering is mainly passive, allowing the flow

of water to achieve the intended effect. Therapeutic reasons

for showering may include heating, cooling, humidifying,

relaxing, revitalizing, and massage, as well as pain relief.

obtain the desired benefit of showering, exposure to a warm

shower requires more time than what is needed for hygienic

showering.

Although there have been some studies that evaluate the

effectiveness of hydrotherapy, the available scientific

evidence focuses on hydrotherapy performed with

immersion baths. In some countries, warm showers during

labor are commonly used, but have not been subjected to

scientific study and are not discussed.

In this context, it is

necessary to assess its effectiveness to establish evidence-

based practice that promotes a healthier and more rewarding

childbirth experience.

The aim of this study was to evaluate the effectiveness of

therapeutic showering for pain relief during the first stage of

labor in Portuguese hospitals.

Methods

The methodological options chosen based on the nature of

the research problem and objectives are foundational to

ensuring the reliability and quality of research results. This

was a quasi-experimental study which investigated a

specific population, in this case, women who reported pain

in the first phase of labor, with the following research

question: Is the therapeutic shower effective in relieving

pain during the first stage of labor?

The evolution of pain levels was evaluated before applying

water vs. three times after water application (immediately

after, 10 minutes after, and 20 minutes after), in the pelvic

area, in the lower back, or in more than one location. Data

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analysis was performed using the repeated measures

ANOVA. The assumptions were analyzed using the

Kolmogorov-Smirnov and Mauchly's tests

which analyze

the normality of distributions and the sphericity of the

matrix of variances-covariances, respectively. The variable

"pain level" presented normal distribution in the first two

assessments after application, immediately after application

and 10 minutes after application, with p>0.05. The variable

"pain level", in the third application did not present normal

distribution, homogeneous variances, or zero covariances

(W=0.974; X2(2)=1.933; p=0.380), indicating sphericity.

Multiple comparisons were made using contrasts with the

first measurement (immediately after water application) as

a reference and conducting the Fisher's LSD post-hoc test.

The data were analyzed using IBM SPSS®, v. 27 (IBM

Corp., Armonk, N. Y., USA).

Participants

Sampling was non-random, accidental, casual or

convenient

and included 81 observations (n=81).

Participants included all women in labor who met the

inclusion criteria: parturients in the first stage of labor who

verbalized pain; were 18 years old or older; had a low-risk

pregnancy, were at full term pregnancy, and had a single

fetus; and expressed an interest in participating. The study

established clinical criteria that guaranteed the safety of the

intervention and its evaluation. Ethical and legal

requirements for studies with human subjects were

followed, and participants signed free and informed

consent forms. Women who were submitted to other

pharmacological or non-pharmacological pain relief

strategies were excluded.

The study was conducted in two Portuguese maternity

wards (one in a public hospital and the other in a private

hospital) in Lisbon, between June 2018 and December

2021. It is worth emphasizing that the data collection

period was extended because of the restrictions imposed by

the SARS-CoV-2 pandemic in Portugal.

Risks/Benefits for participants

The intervention (therapeutic showering) did not imply

predictable risks for the parturients or fetuses. According

to the American College of Nurse-Midwives

, high-quality

research validates the use of hydrotherapy for pain relief

during labor, which does not increase risks for healthy

women during childbirth or neonates when evidence-based

clinical guidelines are followed. Obstetric nurses who were

caring for the parturients were responsible for verifying

their clinical conditions to ensure their safety. The use of

this strategy involved reorganizing spaces and equipment

to provide the necessary physical resources for access to

and application of therapeutic showers, to preserve the

privacy and intimacy of the participants, and to ensure

safety during the procedure, especially by preventing

sudden changes in water temperature and preventing falls.

The benefits for participants in this study were related to

pain relief as a result of the proposed intervention.

Data collection instrument

A two-part questionnaire was created for this study. The

first part gathered sociodemographic and obstetric

information about the participants and included the

following items: age, level of education, nationality,

obstetric index, location of prenatal care,

preparation/negotiation of a birth plan, attendance at

childbirth and parenthood preparation course, and whether

therapeutic showering was included in this course. The

second part included questions about the location of pain

(pelvis, lower back or more than one location), duration

and location of therapeutic shower application, and

assessment of pain level at four times (before the

intervention, immediately after, 10 minutes after, and 20

minutes after). An 11-point numerical scale was used to

assess pain. This scale consists of a ruler divided into eleven

equal parts, numbered sequentially from 0 (which

corresponds to no pain) to 10 (which corresponds to

maximum pain).

The horizontal version of the ruler was

use. The pain intensity was always that reported by the

participants, and it was recorded by the obstetric nurses at

the different assessment times. All parturients received an

explanation about the scale using simple and accessible

language and confirmed that they had correctly understood

its meaning and how to use it.

Ethical aspects

This study was approved by the Health Ethics Committees

of the institutions involved (RNEC: 20170700050).

Informed consent forms were signed by all the participants,

who were told that they could withdraw their participation

at any time without any consequences and without having

to explain their reasons. The participants were also

informed that the data collected would be confidential,

coded and entered into a database for statistical analysis,

and would only be used for the purpose of this study.

Secrecy and anonymity were guaranteed, as well as privacy

and intimacy during the intervention. All procedures were

carried out in accordance with Declaration of Helsinki and

relevant guidelines and regulations.

Intervention

Therapeutic showering was the intervention. All potential

participants were informed about the intervention by the

obstetric nurses and asked about their availability to

participate in the study. In all situations, the evolution of

labor was assessed, and auscultation of the fetal heart

rate was performed before and after the intervention.

The participants were free to choose where to apply water,

and the nurses recorded where the water touched their

bodies. The duration of water application was recorded in

time intervals: less than 10 minutes, between 10 and 20

minutes, and more than 20 minutes. Warm water was made

available, and each parturient adjusted the temperature to

best suit their well-being and comfort.

142 | Tereso, A.

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Results

The parturients who participated in this study were

between 18 and 45 years old, with a mean age of 30 years

(M=29.96) and a standard deviation of 6 (SD=5.54).

Regarding country of origin, 77% were Portuguese, 11%

Brazilian, 5% Cape Verdean, 4% Angolan, and the

remaining 3% were Australian, Italian, and Russian (1%

each). In terms of level of education, 50% had a higher

education degree (undergraduate degree 3%, graduate

degree 47%), 35% had studied up to year 10 and 12 of

secondary school, and the remaining participants, up to

year 4 of elementary school.

Of the participants, 69% were primiparous (first-time

parturients) and had not attended a childbirth preparation

course. The remaining 31% had attended a preparation

course, and 26% reported that the course had covered

hydrotherapy.

Pain was assessed before the intervention, to establish a

comparative level of pain before water application, and

after application (immediately after application, 10 minutes

after, and 20 minutes after) (Figure 1).

Figure 1 - Pain level distribution by location of pain [Mean+-2 Standard Error (SE)]

To analyze the mean pain levels at the different times after

water application, the mean value of pain before its

application was used as a baseline (Mean=6.85, SE=0.22).

Figure 2 shows that the average pain level decreased

immediately regardless of time after water application, with

a progressive increase at 10 and 20 minutes. However, the

water application time in minutes shows a greater

dispersion of data when it is less than 10 minutes and more

than 20 minutes, compared to the intermediate time

between 10 and 20 minutes.

Figure 2 - Distribution of pain level according to time after water application

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The data for the three pain assessment times were also

analyzed in terms of location of water application (pelvis,

lower back, or more than one place).

As shown in Figure 1, increased pain levels (pelvic, lower

back, and in more than one location) occurred immediately

after the application of water, and at 10 and 20 minutes

post-intervention, although with greater data dispersion

when the pain was in the lower back.

The repeated measures ANOVA showed that the results

were statistically significant [F(2.10)=23.12; p<0.001;

η2p=0.236 and π = 0.878]. The contrast analysis between

the first measurement (before the water application) and

the other measurements showed no statistically significant

differences, with the exception of contrast analysis between

the first and second measurements that revealed significant

differences between mean level of pain assessed

immediately after water application and 10 minutes after

application [(F(1.5)=15.324, p<0.001, η2p= 0.170 and

π=0.972]. However, the post-hoc analysis revealed that

after 20 minutes, the differences between the means were

not significant (p>0.05).

Discussion

In most studies of the therapeutic application of water, a

large number of authors, are used as references or used in

the discussion of their results, have only investigated the

effect of hydrotherapy applied through immersion baths,

such as in Benfield et al.

, Simkin and Bolding

, Eckert et

al.

, Cluett et al.

, Silva et al.

and Gallo et al.

Of these,

Eckert et al.

stands out because, unlike the others, it

concluded that immersion in warm water does not confer

any clear benefits to parturients and that when the water

temperature is above 37 °C, it can be harmful to the fetus.

When considering hydrotherapy for pain relief during

labor, it is important to highlight that therapeutic

showering has characteristics and contributions that differ

from those of immersion baths. Johnson et al.

asserted

that women usually shower in upright positions, including

standing, rocking, swaying, squatting or sitting, and that

they can change their position in the shower to direct water

wherever it is needed to provide pain relief or a soothing

effect. Therefore, showering provides numerous benefits

during labor that are provided by movement as pain relief,

increased sense of self-efficacy, calming and comfort, and

perception of control over the environment and the

birthing experience.

Stark

also stated that therapeutic showering promotes and

facilitates physiological labor: the rhythmic impact of warm

water can provide a pleasant sensory distraction, the

shower allows freedom of movement, and showering

involves ambulation because of the necessary walking to

get into and out of the shower.

Gayeski et al.

assessed the application of non-

pharmacologic methods to relieve pain during labor, from

the point of view of the primiparous women (n=188), on

the day they were discharged from the hospital. They found

that warm showers were the second-most-used non-

pharmacologic method (91.5%) (emotional support

provided by the parturients companion was the first

[97.3%]). In this context, it is also important to mention

that some authors consider that there is a shortage of

scientific evidence to support warm showers as a

therapeutic intervention. Of these, emphasis goes to

Simkin and O'hara

, and Stark

, who contend that while

showering is considered an effective coping strategy during

labor, research about it is lacking and its effectiveness has

not been tested.

Of the studies that assessed the effect of therapeutic

showering for pain relief during the first phase of labor, we

highlight the work of Davim et al.

who observed

significant pain relief in parturients after the application of

water from a shower at room temperature, and a study

conducted by Barbieri et al.

in which a warm shower with

water at 37ºC was used on the lower back region for 30

minutes, showing no significant difference in the pain score

evaluated before the intervention and 1 hour after. As

concluded by Barbieri et al.

, Stark in his study published

in 2013

, highlighted that therapeutic showering did not

significantly reduce the perception of pain in participants.

In that study, the direction of the flow of the water and the

temperature of the water could be adjusted by the

parturients and, for safety reasons, they remained seated

during the procedure.

Pain measurements were carried

out 10 minutes after the intervention. The author noted

that if pain had been measured before leaving the shower,

there might have been a more evident reduction and the

results could have been different.

A study by Santana et al.

presented different results,

pointing to the benefits of therapeutic showering, and

concluding that, in the active phase of labor, a 20-minute

shower between 37 ºC and 39 ºC was effective in reducing

intensity of pain. Similarly, a 2017 study by Stark

highlighted that after 30 minutes of therapeutic showering

(this length of time was selected based on research

conducted by Benfield et al.

, whose findings with

immersion baths showed significant changes after 15

minutes), the intervention group presented statistically

significant decreases in pain, discomfort, anxiety and

tension, and a significant increase in relaxation, and they

concluded that therapeutic showering was effective in

reducing pain.

Lee et al.

found that average pain was less at 10 minutes

post-shower than at 20 minutes post-shower. Although

they did not evaluate pain immediately after water

application and did not record the location of pain or of

water application, they presented results similar to those

found in this study that pointed to the effectiveness of

therapeutic showering, at least at two times after

application. However, at the third time (20 minutes after

application), there was a decrease in its effectiveness. Lee et

al.

, who defined 37°C as the appropriate temperature for

the intervention for 20 minutes, affirmed that the

parturients in the intervention group, who were submitted

to warm showers, reported significantly lower scores on the

Visual Analog Scale for pain at 4cm and 7cm cervical

dilation, and better birth experiences than the control

144 | Tereso, A.

Quantitative Original Article

group. Regarding water application sites, after a 5 minute

full-body or lower-back shower, participants were

permitted to direct shower water anywhere that felt most

comfortable, although they did not record location of pain

or of water application after 5 minutes.

Despite the studies that mention only the beneficial effects

of therapeutic showering, it is also important to mention

research that does not corroborate these findings. Henrique

et al.

and Cavalcanti et al.

found an increase in pain scores

and a shorter labor duration in the group of participants

submitted to the intervention.

In terms of research developed to evaluate specific aspects

of therapeutic showering, namely temperature, duration of

application, and location of application, Hecox et al.

argued that the effect of water for pain relief was greater

when the temperature varied between 37 °C and 40 °C and

was applied in 20-30minute sessions, and Lee et al.

maintained that 37 °C was the ideal water temperature.

In the present study, the results showed that time after

application in minutes impacted level of pain. Although the

pattern for the three times was similar in the interval

between 10 and 20 minutes, there was a decrease in the level

of pain that was more pronounced immediately after water

application, and the results also seemed more consistent

because there was lower data dispersion.

Conclusions

Therapeutic showering is a non-pharmacological strategy

that, in the first stage of labor, contributes to safe but

temporary pain relief, with pain levels that are lower at the

time of application (pelvis, lower back and in more than

one place) and that increase over time at 10 and 20 minutes,

although with greater data dispersion when the pain was

located in the lower back region.

It is essential that the benefits of this strategy become

accessible to parturients as one of the dimensions of

humanized childbirth, and obstetric nurses should promote

the exercise of women's right to self-determination, which

includes free and informed decisions about non-

pharmacological pain relief strategies during the first stage

of labor.

This pain relief strategy does not require previous training

of women or a need for specific physical resources, since

most Portuguese maternity hospitals have warm water

showers available in the bathrooms that are accessible to

parturients. Nevertheless, it may have some impact on the

allocation of human resources, because it implies the

availability of nurses to accompany women during the

procedure, and there may be some limitations related to

personnel restrictions in the context of the SARS-CoV-2.

More research is needed about therapeutic showering that

allows it to be evaluated, not only in terms of its effect on

pain relief, but also on the evolution of labor and the

satisfaction of women and families. Producing and

disseminating such knowledge will increase the visibility of

therapeutic showering in obstetric nursing practice

guidelines, parenting preparation courses, and the

standardization of non-pharmacological pain relief

methods available in labor and delivery units in Portugal.

Considering that the results show an increase of pain over

time, and taking into account other studies that have

observed higher levels of pain when measurements were

not taken immediately post-intervention, it would be

interesting to always assess pain immediately after the

intervention and at shorter time intervals, namely 5 and 10

minutes.

Study limitations

Limitations of this study include the sample size, the type

of sampling, restrictions due to the SARS-CoV-2

pandemic, and lack of evaluation of shower water

temperature, since each participant regulated the

temperature based on their preferences.

Authors’ contributions

AT: Conception and design of the study; data collection;

data analysis and interpretation; statistical analysis; drafting

the manuscript; critical review of the manuscript.

FL: Conception ad design of the study; data collection.

RG: Conception ad design of the study; data collection.

HB: Conception ad design of the study; drafting the

manuscript; critical review of the manuscript.

LC: Conception ad design of the study; data collection.

AC: Conception and design of the study; data collection;

data analysis and interpretation; statistical analysis; drafting

the manuscript; critical review of the manuscript.

Conflicts of interest and Funding

The authors declare that they have no conflicts of interest

with respect to the authorship or publication of this article.

The authors state that the opinions expressed in this article

are their own and not from an official position of the

institutions or financial agent.

Acknowledgments

The authors thank the parturient women, who voluntarily

made themselves available to participate in this study, and

the nurses who made up the data collection team.

Sources of support / Financing

The authors declare there’s no funding.

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