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Go Back       Himalayan Journal of Nursing and Midwifery | Volume:1 Issue:4 | July 30, 2022
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Evaluation of the Effect of Vedic Chants on Anxiety and Pain Score in Laboring Parturients with Ambulatory Epidural Labor Analgesia


Dr. Bharti Gupta1, Dr. Sapna Bharadwaj2, Dr. Shelly*3, and Dr. Amit Gupta4

1Dr. Bharti Gupta, Associate Professor, Department of Anaesthesiology, Dr. Rajendra Prasad Govt. Medical College, Kangra At Tanda, (H. P.), India

2Dr. Sapna Bharadwaj, Associate Professor, Department of Physiology, Dr. Rajendra Prasad Govt. Medical College, Kangra At Tanda, (H. P.), India

*3Dr. Shelly, Department of Anaesthesiology, Civil Hospital, Karsog, Mandi, (H. P.), India

4Dr. Amit Gupta, Associate Professor, Department of Gynaecology, Dr. Rajendra Prasad Govt. Medical College, Kangra At Tanda, (H. P.), India



*Corresponding Author

Dr. Shelly


Article History

Received: 10.07.2022

Accepted: 20.07.2022

Published: 30.07.2022


Abstract: Background: The present study was undertaken to evaluate the effect of Vedic chants on Anxiety and Pain Score in Laboring Parturients with Ambulatory Epidural Labor Analgesia. Material & Methods: A total of 38 patients with full term live cephalic singleton pregnancy in active labor with cervical dilatation 0-4cm with a request for ambulatory labor analgesia admitted in department of Obstetrics and Gynaecology at Dr. RPGMC Kangra at Tanda were participated in this study. We randomized the patients in two groups A and B. Both groups received epidural labor analgesia with 0.1% ropivacaine and 1.5ug/ml of fentanyl. Patients in group A were made to listen Vedic chants (Gayatri mantra) in 4 sessions of 30min each with 15mins break in between the sessions. In group B, patients received only ambulatory epidural labor analgesia without listening to Vedic chants. These two groups were observed for the various parameters till the delivery of the baby. Results: The two groups were comparable in terms of age, height, weight, BMI, occupation, parity, POG, mean cervical dilatation and contractions per 5minutes at the time of administration of labor analgesia and were statistically non-significant (p >0.05). We inferred that the mean anxiety score(AASPWL) was significantly lower in the group A (2.43±0.11), which received Vedic chants as music therapy along with epidural labor analgesia in comparison to the group B (3.44±0.13) who did not receive Vedic chants as music therapy. The difference between two groups was statistically highly significant (p <0.001).Parturients in both group A and B were supplemented with adequate epidural analgesia with 0.1% ropivacaine and 1.5 ug/ml fentanyl, resulting in pain scores (VAS-P) below 3 and difference was statistically non-significant (p >0.05). Conclusion: In our study, anxiety scores were drastically reduced by Vedicchants (Gayatri mantra) as music therapy, in comparison to control group.


Keywords: Evaluation, Vedicchants, Anxiety and Pain Score, Laboring Parturients, Ambulatory Epidural Labor Analgesia.


INTRODUCTION

Labor pain can be described as a paradoxical experience; one that is excruciating and yet desirable because of its positive outcome — the birth of a child.1,2 It is often described as the most challenging and intense pain experience a woman may go through, and yet enormous variations in women’s perceptions of this pain exist.2,3 Labor pain has been defined as an “excellent model of acute pain”, however unlike other acute pains that are usually associated with injury or pathology, labor pain is part of a normal physiological process.4


Anxiety is a physiological state characterized by fear and worry accompanied by physical changes such as palpitations, shortness of breath and a cognitive expectation of an impending danger. Anxiety is generally associated with increased pain during labor. Labor pain can be modified through psychological and physiological mechanisms. Fear of pain may be one component of labor-dependent anxiety and has a high correlation with pain levels reported during first-stage labor.2-4


Ropivacaine, a propyl homologue of bupivacaine (pure S-enantiomer), is levorotatory and possesses a relatively low potency, it has a greater safety profile. However, it appears that the drugs are not equipotent. The various epidural analgesic potency studies suggest a spectrum of relative potencies of 0.7:0.9:1.0 for ropivacaine:levobupivacaine:bupivacaine.5,6


Recently, the role of cultural chants in reducing pain in labor has been reported. Chanting and deep breathing experiences as music therapy during the latent stage of labor may reduce pain perception and pain behaviors. Due to well-known limitations and serious side effects of painkillers, nowadays non-pharmacological methods such as music therapies are being broadly recommended. There are a few studies that analyze the effect of Vedic chants on anxiety and pain during labor. Listening to Vedic chants and Indian classical instrumental music has beneficial effects on alleviating anxiety levels induced by apprehension of invasive procedures and can be of therapeutic use.7-8


There is insufficient evidence to make a judgment about whether or not Vedic chants are effective for pain and anxiety relief in labor. In the present study, we aimed to evaluate the effect of Vedic chants on Anxiety and Pain Score in Laboring Parturients with Ambulatory Epidural Labor Analgesia.


AIM & OBJECTIVES:

To evaluate the effect of Vedic chants on Anxiety and Pain Score in Laboring Parturients with Ambulatory Epidural Labor Analgesia


MATERIALS & METHODS:

  • Study Site:

Departments of Anaesthesia, and Obstetrics & Gynaecology, Dr. RPGMC Kangraat Tanda (rural), Himachal Pradesh.


  • Study Design: Prospective randomized controlled study.


  • Study Duration:

The study was conducted over the period of 18 months including data collection, data organization, presentation, analysis, and interpretation.


  • Sample Size:

Sample size was calculated to a total of 80 patients (40 patients in each group). But due to COVID-19 pandemic limitations, only 38 patients (16 in Group A and 22 in Group B) were included in the study.


  • Inclusion Criteria:

Term live cephalic singleton pregnancy in active labor who were having contractions at least once in 5min with cervical dilation 0–4cm with a request for ambulatory labor analgesia were included in the study.


  • Exclusion Criteria:

  • Patient refusal for the procedure.

  • Local infection at site of epidural catheter placement.

  • Thrombocytopenia.

  • Coagulopathies.

  • HELLP syndrome.

  • Sepsis.

  • Deafness.

  • Spinal column deformities and spine surgery.

  • Patient having hypersensitivity to the study drug.

  • In case of Intrathecal catheter placement.

  • In case of accidental dural puncture.

  • Non-assuring fetal heart rate.

  • Prematurity and post-maturity.


  • Methodology:

After the intimation from obstetrician, the information regarding the epidural labor analgesia was explained to the laboring parturient and thereafter written consent for epidural labor analgesia was taken by the anaesthetist on duty. Before commencing the procedure, a case record form was filled for each patient. After that patient was taken to labor analgesia room in maternity complex. Patients were coloaded with 10ml/kg of ringer lactate over 15minutes, after securing intravenous line and all standard monitors like BP, SPO2, ECG attached, and vitals were recorded in case record sheet. Patient was positioned in the left lateral or sitting position and the procedure was carried out under all aseptic precaution. Skin was infiltrated with 2ml of 2% xylocaine at L2-3 or L3-4 intervertebral space. Epidural space was identified using a loss of resistance technique to normal saline with an 18G Tuohy’s needle and 20-gauge multi-orifice catheter was threaded through the cephalad directed tip of the epidural needle to a depth of 5 cm into the epidural space. The catheter was secured and the patient was placed in the supine position.


  • Drug Preparation for Epidural Activation:

Epidural drug was prepared by taking two, 10ml of syringes. In each syringe 5ml of 0.2% ropivacaine with 3.5ml of 0.9% normal saline and 1.5ml of fentanyl (10µg/ml) was added to it. Thus, a total of 20ml of drug was prepared with a final concentration of 0.1% ropivacaine and 1.5ug/ml of fentanyl in it for loading the epidural space.


  • Activation of Epidural Catheter for Labor Analgesia:

The prepared drug was given in increments of 3ml and each increment was considered as the test dose given after negative aspiration for blood and CSF and time was noted every time the increment given. The adequacy of analgesia was assessed 5 min after the increment of drug administered. Analgesia was considered adequate if pain score was<3.


Onset of analgesia was defined as from time of test dose to time of achieving VAS <3. If analgesia would not be adequate within 10mins after the increment given, then another increment of 3ml was given in order to achieve the VAS <3.


Sensory block height was assessed by loss of sensation to pin prick (blunt head of a pin). Onset of analgesia was defined as duration from injection of first test dose to attainment of VAS <3.


Presence of motor block in lower extremities was assessed using a modified Bromage scale (MBS).


VAS for pain and MBS was assessed every 15min. Pain score (VAS), sensory and motor block characteristics and vital parameters (pulse, mean arterial blood pressure, heart rate, oxygen saturation) was recorded at 0 (before epidural), 5, 15 min and then every 15min till 1 h and then every 30min until the delivery. At any point of time during the study period hypotension was defined as systolic blood pressure of <90mmHg and was treated with bolus of 50mcg of phenylephrine. Bradycardia was defined as heart rate <60bpm and was treated with bolus doses of 0.5mg atropine sulfate. All parturients were evaluated to assess their ability to walk, by performing SLR.


Patient was instructed to pass the urine as and when required by her, accompanied by attendants.


  • Vedic Chanting Procedure:

Randomization was done by computer generated random sequence number method to randomly divide them in two groups A and B. In group A, 16 and in group B, 22 patients were taken due to covid-19 pandemic limitations.

  • Group A:

All the patients listened to an already downloaded Vedic chants (Gayatri mantra) in mobile phone [Moto G2 (which belong to primary investigator) by earphones or by playing it in the background depending upon the patient’s choice] in 4 sessions of 30minutes each with 15minutes break in between after established epidural labor analgesia and consent of the patients.


  • Group B:

All the patients got only epidural labor analgesia and did not listen to Vedic chants (Gayatri mantra).


Labor was managed according to Obstetric department’s standard protocol. Mode of delivery (normal/instrumental delivery/caesarean delivery) was noted. Total amount of the epidural dose until the delivery was noted. Fetal heart rate was monitored throughout the study by using a cardiotocograph and any evidence of fetal heart rate decelerations was recorded. Neonatal assessment was performed by assessing the Apgar score at 1 and 5min as well as NICU admissions was recorded. The epidural catheter was removed after normal or cesarean delivery.


  • Outcome Assessment:

The VAS-P (VAS for pain) indicated the pain intensity in which 0 means no pain or the least possible pain, 10 means severe pain or the worst possible pain. The patients required scoring their pain intensity at 0, 5min, 15min, and every 15min till one hour, and then 30 min until delivery.


Anxiety was assessed using Anxiety Assessment Scale for Pregnant Women in Labor (AASPWL)61 The scale form has 9 items, scored from 1-5 in which 1 = minimum and 5 = maximum score, which was asked from the patients after established labor analgesia in both groups. It was assessed again in group A, after completion of 4 sessions of Vedic chants (i. e., 3hrs) and in group B, after 3hrs without listening to Vedic chants.


  • Ethical Consideration:

The study was initiated following approval from Institutional Ethics Committee (IEC) at Dr. RPGMC Kangra at Tanda. Consent form was collected from each enrolled study subject.


STATISTICAL ANALYSIS:

The data was entered in Microsoft excel spreadsheet. Statistical analysis was done using Microsoft excel and exported into SPSSv21.0 and online ‘social science statistics’ software. The quantitative data was analyzed and expressed as mean±SD and percentages. Student’s t-test was used for comparing continuous variables between the two groups. Chi square and Fisher’s exact test was used for comparing the categorical data between the two groups.


OBSERVATIONS & RESULTS:

The present study compared the effect of ambulatory epidural labor analgesia with Vedic chants (EA+VC) and ambulatory epidural labor analgesia (EA) alone in parturients in reducing the pain and anxiety related to labor. A total of 38 patients were included in the study at Department of Anaesthesiology and Department of Obstetrics & Gynaecology, Dr. Rajendra Prasad Government Medical College, Kangra at Tanda. Results of the study have been presented below:


Image is available at PDF file


  • Treatment Arms:

Patients were randomly divided into two groups. The patients in group A were made to listen to Vedicchants (Gayatri mantra) after established epidural labor analgesia and patients in group B received only epidural labor analgesia.


Table 1: Treatment arms

Group

Description

Frequency

A

Epidural labor analgesia + Vedicchants

16

B

Epidural labor analgesia

22


Mean age of the patients in group A (25.1±4.8) was comparable to that in group B (25.6±3.3); p = 0.69. Mean height of the patients in group A was comparable to that in group B (156.9±3.5 vs. 157±3.2; p = 0.955). Mean weight of the patients in group A was comparable to that in group B (61.4±7.9vs. 62.6±6.5; p = 0.623). Mean BMI of the patients in group A was comparable to that in group B (22.5±4.4 vs. 21.1±4.2; p = 0.170). Mean POG of the patients in group A was comparable to that in group B (39.1±0.8 vs. 39.1±0.9; p = 0.914).


Table 2: Comparison of socio-clinical variables between two groups


Group A (n=16)

Group B (n=22)

p-value*

Age(years)

25.1±4.8

25.6±3.3

0.69

Height (In cm)

156.9±3.5

157±3.2

0.955

Weight (In Kg)

61.4±7.9

62.6±6.5

0.623

BMI

24.9±2.8

25.4±2.6

0.595

POG

39.1±0.8

39.1±0.9

0.914


In group A, 13 (81.2%) and in group B, 19 (86.4%) patients were home-makers. Occupation-wise both the groups were comparable (p = 0.669). Patients in both the groups had ASA grade II. Both the groups were comparable in terms of gravidity.


Table 3: Distribution of patients according to occupation, co-morbidity and Gravida



Group A (n=16)

Group B (n=22)

p-value*

Occupation

Home-maker

13 (81.2%)

19 (86.4%)

0.669

working

3 (18.8%)

3 (13.6%)

Comorbidity

Present

3 (19%)

6 (27%)

0.706

Absent

13 (81%)

16 (73%)

Gravidity

Primigravida(PGR)

14 (87%)

13 (59%)

0.078

Multigravida(MGR)

2 (13%)

9 (41%)


Mean Anxiety Assessment Scale for Pregnant Women in Labor (AASPWL) of the patients before music intervention and established epidural analgesia in group A was comparable to that in group B (3.56±0.13 vs. 3.55±0.12; p = 0.756). Mean AASPWL of the patients after listening to Vedic chants in group A and after 3 hours without Vedic chants in group B varied highly significantly (2.43±0.11 vs. 3.44±0.13; p <0.001).


Table 4: Comparison of mean AASPWL before and after music intervention between two groups


Group A (n=16)

Group B (n=22)

p-value*

Before music intervention AASPWL

3.56±0.13

3.55±0.12

0.756

AASPWL after music intervention

2.43±0.11

3.44±0.13

p<0.001


In Group A, there was a highly significant (p <0.001) decrease in AASPWL after listening to Vedic chants in laboring parturients. In Group B, there was also a decrease in AASPWL after 3 hours of initial activation of epidural labor analgesia but it was not statistically significant.


Visual analog scale of pain (VAS-P) was achieved below 3 for all the patients in two groups. Modified Bromage scale score was achieved 6 in all the patients in two groups.


DISCUSSION:

Several studies have shown that music therapy can inhibit stress, reducing anxiety and neuro-hormonal responses to psychological stress as well as preoperative anxiety and postoperative pain9-10.Some authors have allowed patients to select the type of music, whereas other prefer to use classical music11.However, the results of these studies were not strictly comparable as different methods of investigation have been used and the most suitable type of music is still a matter of debate. So, we used Vedic chants (Gayatri mantra), as music therapy in our study, as most of the patients are familiar with it.


In the present study the difference in the mean age, height, weight, body mass index, occupation, comorbidity, gravidity and period of gestation (POG) among these two groups were statistically non-significant (P value >0.05), hence these two groups were comparable with respect to mean age, height, weight, Body mass index, occupation, comorbidity, gravidity and period of gestation (POG).


In the present study, Mean AASPWL of the patients after activation of epidural analgesia in both groups was comparable (group A-3.56±0.13 vs group B-3.55±0.12; p = 0.756) and difference between the two was non-significant. Mean AASPWL of the patients after listening to Vedic chants sessions in group A (2.43±0.11) and after 3 hours without listening to Vedic chants in group B (3.44±0.13). The difference between two was statistically highly significant (p <0.001). When AASPWL was compared within the same group, we found that in group A there was very highly significant (p <0.001) decrease in AASPWL after listening to Vedic chants in parturients. Although, in Group B there was also a decrease in AASPWL after 3hours of activation of epidural labor analgesia but it was not statistically significant. So we concluded that in our study Vedicchants (Gayatri mantra) as music therapy was sufficient in relieving the anxiety of the laboring parturients.


Our results were supported by Simavli S et al.,12 in their study, 156 primiparous women who expected vaginal delivery were recruited and randomly assigned to a music group (n = 77) or a control group (n = 79). Women in the music group listened to self-chosen soft, relaxing, rhythmic music during labor. Pain intensity and anxiety level were measured using a visual analogue scale (0–10 cm). The two groups were compared in terms of pain severity, anxiety level, maternal hemodynamics, fetal-neonatal parameters and postpartum analgesic requirement. They concluded that before the music was played, the mean anxiety of the music and control groups were measured and found to be similar to each other (p >0.05). On the other hand, during the first (all phases) and second stage of labor, the mean anxiety score of the music group was found to be lower compared to the control group (all p < 0.001) which was statistically significant.


Liu YH et al.,13 in their study, sixty primiparas were randomly assigned to either the experimental group (n = 30) or the control group (n = 30). The experimental group received routine care and music therapy, whereas the control group received routine care only. The type of musicwomen chose were classical music, light music, popular music, crystal children’s music and Chinese religious music. Anxiety was measured with a visual analogue scale for anxiety and finger temperature by biofeedback system with DT-002 thermometer. Anxiety between groups were compared during the latent phase (2–4cm cervical dilation) and active phase (5–7cm) separately. They found that music was able to reduce the anxiety of the women in the experimental group during the latent phase of labor.


In our study we observed that all the patients of both group had VAS-P below 3 and the difference between two was non-significant (p >0.05), when adequate epidural analgesia was supplemented in both the groups. The reason behind this might be that in our study patients of both groups received ambulatory epidural labor analgesia with 0.1% ropivacaine and 1.5ug/ml of fentanyl, which was sufficient enough to reduce the labor pain.


Simavli S et al.,12 in their study concluded that before the music was played, mean pain scores of the music and control groups were measured and found to be similar to each other (p >0.05). On the other hand, during the first (all phases) and second stage of labor, the mean pain scores of the music group was found to be lower compared to the control group (all p <0.001) and was statistically significant.


Liu YH et al.,13 in their study, a self-report visual analogue scale for pain and a nurse-rated present behavioral intensity were used to measure labor pain. They concluded that the experimental group had significantly lower pain during the latent phase of labor. However, no significant differences were found between the two groups on all outcome measures during the active phase.


In a study, Phumdoung S et al.,14 assigned women to a music group and a control group. Women in music group listened to soft music without lyrics for 3hours in early active phase of labor. They observed that music group had significantly less sensation and distress of pain than did the control group (70.95±15.68 versus 64.73±15.87); (65.00±18.24 versus 52.91± 19.86) respectively.


CONCLUSION:

Labor epidurals are sufficient to allay the labor pains, but anxiety is generally associated with increased pain during labor, so needs to be taken care of. In our study, anxiety scores were drastically reduced by Vedic chants (Gayatri mantra) as music therapy, in comparison to control group. Anxiety is one of the most important parameter for overall assessment of satisfaction scores during hospital stay of the laboring parturients and ironically it’s the most neglected part of management. We highly recommend that patient's familiar music to be used whenever feasible. We used Vedic chants (Gayatri mantra) in our study as it was familiar to our patients. So the need of hour for improving overall satisfaction of laboring parturients is to utilize the gold standard technique of ambulatory epidural labor analgesia along with music therapy.


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