The Effect Of Sacral Massage On Labour Pain and Anxiety: A Randomized Controlled Trial
Phase: NA
Conditions: Labor Pain
Sponsor: Semra Çevik, phD

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The Effect Of Sacral Massage On Labour Pain and  Anxiety: A  Randomized Controlled Trial 
Objective: This study was conducted as a randomized, control experimental study to determine the effect of 
sacral massage, on labour pain and anxiety.  
Background 
         Labour is regarded as one of the physiological behaviours in humans that has existed since the 
beginning of humanity, the formation cycle of which has remained unchanged (Gönenç & Terzioğlu, 2012). 
Labour is a health state that most women aspire to, at some point in their lives. The first thought that comes 
to the mind of an expecting woman regarding her delivery is the pain of labour. The pain of the labour is the 
central and universal part of woman’s experience of childbirth. Labour is a normal physiological process, 
which while should be an occasion for rejoicing, it also accompanies with it, lots of pain, agony, and 
discomfort and certain risks. Thus although being a joyful and empowering experience it can end with 
negative and tragic results, leaving the woman filled with fear and anxiety for future birth (Labrecque, 
Nouwen, Bergeron, & Rancourt, 1999). The causes of labour pain can be either physical or psychological. 
Physical factors include uterine contractions, cervical dilatations, cervical effacements etc. Psychological 
factors include fear and anxiety, previous experiences, inadequate support, inadequate knowledge. Pain 
perceived during labour may be different for each woman (Sethi & Barnabas, 2017). The fear and anxiety 
that pregnant women experience during the labour process leads to the stretching of pelvic muscles and 
creates resistance against the repulsive force of the uterus and the repulsive force exerted by the women 
during labour. The extension of the anxiety-related tension in the pelvic muscles causes general fatigue in 
pregnant women, increased pain and decreased power to cope with the pain (Gönenç & Terzioğlu, 2012). 
Feelings of anxiety can cause pregnant women to inappropriately respond and lose their self-control. 
Anxiety also reduces the self-confidence of an individual. As a result of this situation, pregnant women 
perceive themselves as incompetent and unskilled. The anxiety experienced during labour directs women to 
caesarean section by their own will (Fenwick et al., 2010). The essence of midwifery can be with woman 
providing comfort in labour. Touch communicates caring and reassurance. Manual healing methods used 
today during delivery include touch and massage therapy. Painful uterine contractions can be treated by 
applications of pressure with the hands to woman’s back, hips, thighs and sacrum. By massage therapy, 
pharmacological management during the first stage of labour can be reduced. So less negative effects will be 

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there on foetus and mother (Smith, Levett, Collins,& Jones, 2012). Non-pharmacological and supportive 
methods that are used to decrease pain are a part of midwifery/nursing practices. Massage is the oldest tactile 
stimulation method that is used to relieve labour pain. Massage is a manual process performed on the soft 
tissues of the body for systemic purposes to improve health and well-being. Massage decreases the severity 
of pain, loosens the spasms and provides general relief during labour (Field, 2010). 
 METHODS 
Study design 
          This was a randomized and controlled experimental study aimed to determine the effects of sacral 
massage on labour pain and anxiety. 
Setting and samples 
          The study was performed in volunteer pregnant women who applied to xxx Training and Research 
Hospital, Delivery Unit, to undergo their first labour between January 25 and October 25, 2016. This unit 
contains 1 delivery room (with 2 tables), 2 labour follow-up rooms (with 5 beds), 1 postpartum room (with 5 
beds) and 1 nursing room.  
         According to hospital records, in all, 342 pregnant women who applied to xxx Training and Research 
Hospital, Delivery Unit to undergo their first labour between January 25 and October 25, 2016, constituted 
the population of the study. The following inclusion criteria were used to determine participation in the 
study: (1) 19-40-year-old primiparous pregnant women;(2) Singleton pregnancies between 38-42 weeks; (3) 
Pregnant women whose labour began spontaneously; (4) Pregnant women with a healthy foetus; (5) 
Pregnant women without any complications that may cause dystocia during labour; (6) Pregnant women for 
whom analgesia and anaesthesia were not used during the first phase of labour; (7) Pregnant women who 
volunteered to participate in the research and who could establish verbal communication. In addition, 
Pregnant women with high-risk pregnancies, with caesarean section indication, and Pregnant women with a 
chronic illness were excluded.  
          The sample size was calculated by Medical Faculty Biostatistics Department using Minitab Program. 
The sample volume to represent the population was determined as minimum 30 people for each group when 
considering comparison results of mean scores in the study of Field., with a risk of α= 0.05, an accuracy rate 
of 1-α =0.95 and a power ratio of B= 0.20, 1-B= 0.80 [3].    

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          The study was conducted with two groups, namely Massage Group (experimental), and Control 
Group. 30 pregnant women were included in each group; therefore, the study was conducted with a total of 
60 pregnant women. The women who participated in the study were randomized randomly as control 
(double) and experimental (single) groups according to the single or double patient admission numbers.  The 
women who participated in the study were randomized into either the control (double) or the experimental 
(single) group according to single or double patient admission numbers. 
Measurements 
          In this study, the Questionnaire form, Birth action follow-up form,  postpartum interview form ,Visual 
analogue scale (VAS) and State-trait anxiety inventory (STAI FORM TX-I) were used to collect the data. 
1. Questionnaire Form: Questions that reflect the sociodemographic characteristics of the patients (age, 
educational status, social security, marital status), information about pregnancy (drugs used, status of their 
willingness to become pregnant, gestational week, status of attending examinations, status of collecting 
information about labour), the methods used to cope with the pain, and open-ended questions that evaluate 
the previous use of massage. 
2. Birth Action Follow-Up Form:  The questions that indicate the length of the first phase, the 
interventions performed to shorten the first phase of labour, the methods used by the patient to cope with the 
labour pain, the emotional behaviours of the pregnant women during labour, the length of the second phase, 
adjustment of the pregnant women, the presence of intervention in labour, the status of episiotomy, the total 
duration of labour and the baby's health. 
3. Postpartum Interview Form:  Open and closed questions that indicate the pregnant women’s thoughts 
about labour, the status of overall satisfaction with labour and how the women feel were included in this 
form, which was prepared by a researcher in accordance with the relevant literature. 
 4. Visual Analogue Scale (VAS): The Visual Analogue Scale (VAS) was used to measure the severity of 
labour pain. On this scale, numbers from 0 to 10 appear on a horizontal line of 100 mm. The pain level is 
expressed in figures that range from 0 to 10, as follows: the absence of pain is indicated by "0", while the 
most severe pain is indicated by "10". In this method, it is explained to the individual that there are two 
endpoints and that he/she is free to mark any point that defines his/her pain.  

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         The VAS was applied to the participants in the control group once in the latent (3-4 cm), active (5-7 
cm) and transition phases (8-10 cm) of labour. The VAS was also applied to those in the experimental group 
once after the massage in each phase. The diagnosis was made in accordance with the subjective data 
including the patient's verbal expression.  
  5. State-Trait Anxiety Inventory (STAI FORM TX-I): To determine state and trait anxiety levels of the 
participants, the state-trait anxiety inventory (STAI FORM TX -I) was used. The individual is required to 
indicate the feelings or behaviours that he/she has experienced in a specific situation according to the degree 
of severity by marking one of the options such as (1) Never, (2) Little, (3) Very and (4) Completely. The 
state-trait anxiety inventory requires the individual to describe how he/she feels at a certain moment and 
under certain conditions by considering his/her feelings about a specific situation. While high scores indicate 
high anxiety levels, low scores indicate low anxiety levels. The state-trait anxiety inventory consists of  20 
statements. The score obtained from the scale may vary between 20 and 80. While a high score represents a 
high anxiety level, a low score represents a low anxiety level. In the scoring performed in accordance with 
the criteria directive, 0-19 points are regarded as "none", 20-39 points are regarded as "mild anxiety", 40-59 
points are regarded as "moderate anxiety", 60-79 points are regarded as "heavy anxiety" and 80 points are 
regarded as “severe anxiety”. In our study, the STAI FORM TX-I was used in the active (5-7 cm) phase in 
the control group and in the active (5-7 cm) phase after the massage in the experimental group to evaluate 
the anxiety experienced by women during labour. 
Data Collection  
         After approval and permission to conduct the study were obtained from the ethics committee, the 
hospital’s head nurse, delivery room charge nurse/midwife and other midwives and nurses were interviewed 
and informed about the purpose and scope of the study. Data were collected by one of the researchers. The 
researcher was aware of which patients were assigned to each group. However, the researchers did not 
interfere in any way with the study results. When they encountered women who met the inclusion criteria of 
the study, the purpose of the study was explained, and written consents were received from those who agreed 
to participate in the study. For the women who satisfied the criteria, participation in the study was voluntary. 
Additionally, during the study, no women requested to withdraw and no women were excluded from the 
study. Routine care and treatments for the women continued during data collection. 

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Procudure  
         Before the research data were collected, an informative meeting regarding the purpose and scope of the 
study was held for the members of the healthcare team who worked in the obstetrics and gynaecology clinic 
of the Turkish Republic Ministry of Health Public Hospitals Administration of Turkey, at the Istanbul 
Province xxx 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 work at hospital. The massage was applied only to the 
pregnant women in the intervention group at every phase of labour. 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: 
● 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. 
● In addition to providing them with routine nursing/midwifery care, the women in the experimental 
group were administered a massage to the sacral region under the supervision of a doctor for 30 
minutes using the effleurage (patting) ( 15 minutes) and vibration technique ( 15 minutes)  in the 
latent (3-4 cm), active (5-7 cm) and transition (8-10 cm) phases of labour. 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 labour. 
● The state-trait anxiety inventory (STAI FORM TX-I) was applied and evaluated after the massage in 
the active (5-7 cm) phase. 
● The Visual Analogue Scale (VAS) was evaluated once 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. 

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● Routine nursing/midwifery care was applied. 
● The state-trait anxiety inventory (STAI FORM TX-I) was applied and evaluated in the active (5-7 
cm) phase.  
● The Visual Analogue Scale (VAS) was evaluated once 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 the prepared questionnaire form was 
applied to the women in the experimental group, routine nursing/midwifery care was provided.   
Hypotheses of the Study 
1. Massage applied to the sacral region decreases the perception of a woman's labour pain. 
2. Massage applied to the sacral region decreases the woman's levels of concern and anxiety about labour. 
3. Massage applied to the sacral region increases the woman's satisfaction with the labour. 
REFERENCES  
 Fenwick, F., Staff, L., Gamble, J., Creedy, D.K., Bayes, S. (2010). Why do women request caesarean 
section in a normal, healthy first pregnancy? Original Research Article Midwifery, 26( 4):394-400. 
 Field, T. (2010). Pregnancy and labor massage. Expert Review of Obstetrics & Gynecology, 5(2):177–181. 
 Gönenç, M.İ., & Terzioğlu, F. (2012). The Effect of Massage and Acupressure on Pregnant Women Anxiety 
Level. Ankara Health Sciences journal, 1(3):129-143. (Original Work in TURKISH) 
 Labrecque, M., Nouwen, A., Bergeron, M., Rancourt, J.F. (1999). A randomized controlled trial of 
nonpharmacologic approaches for relief of low back pain during labor. J FamPract, 48(4): 259-263. 
 Mortazavi, S.H, Khaki, S., Moradi, R., Heidari, K., Vasegh Rahimparvar, S.F. (2012). Effects of massage 
therapy and presence of attendant on pain, anxiety and satisfaction during labour. Arch Gynecol Obstetic, 
286(1):19-23. 
 Sethi, D.,  Barnabas, S. (2017). A pre-experimental study to evaluate the effectiveness of back massage 
among pregnant women in first stage of labour pains admitted in labour room of a selected hospital, 

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Ludhiana, 
Punjab, 
India. 
 
Int 
J 
Reprod 
Contracept 
Obstet 
Gynecol, 
6(1):76-83. 
DOI: 
http://dx.doi.org/10.18203/2320-1770.ijrcog20164636 
  Smith, C.A., Levett, K.M., Collins, C.T., Jones, L. (2012). Massage, reflexology and other manual methods 
for pain management in labour (review). The Cochrane Collaboration, 2: 1-27. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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