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Table of Contents
Year : 2021  |  Volume : 22  |  Issue : 1  |  Page : 35-38

Effectiveness of four-square breathing exercise on after-labour pain among post-natal mothers

1 Clinical Instructor, Parul Institute of Nursing, Parul University, Vadodara, Gujarat, India
2 Assistant Professor, Department of Obstetrics and Gynaecology Nursing, Manikaka Topawala Institute of Nursing Charotar University of Science and Technology, Gujarat, India
3 Head, Department of Obstetrics and Gynaecology Nursing, Manikaka Topawala Institute of Nursing Charotar University of Science and Technology, Gujarat, India

Date of Submission14-Sep-2019
Date of Decision23-Apr-2020
Date of Acceptance24-Oct-2020
Date of Web Publication07-Jul-2021

Correspondence Address:
Ms. Jayshree Satishbhai Vasava
A.P. Thava, Ta. Netrang, Bharuch - 393 130, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJCN.IJCN_16_19

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Post-natal period is a joyous yet a challenging period for all mothers. Minor ailments which are physiologically rooted may cause some disruption in the normal routines of motherhood. After-labour pain is one such ailment which often goes unrecognised. The objectives of this study were to assess the level of after-labour pain in post-natal mothers and evaluate the effectiveness of four-square breathing exercise on reducing this pain. This study was conducted on 80 multiparous women recruited from four different maternity hospitals and randomly assigned to experimental and control groups. Experimental group mothers were taught and performed four-square breathing exercise and the control group had standard care. Pre assessment was done at baseline and post-assessment was done on each of the 2 days the exercise or standard care was provided in both control and experimental groups. A visual analogue numerical pain rating scale was used to measure pain. The findings of the study revealed that both control and experimental groups reported significant reduction in pain on post-assessment on 2nd day. The difference in median pain score between control and experimental groups was significant in the post-assessment on the 2nd day. It is concluded that after-labour pain reduces naturally overtime. However, four-square breathing exercise can help in reducing the pain further.

Keywords: Four-square breathing exercise, labour pain, mothers, post-natal period

How to cite this article:
Vasava JS, Patel SB, Tiwari A. Effectiveness of four-square breathing exercise on after-labour pain among post-natal mothers. Indian J Cont Nsg Edn 2021;22:35-8

How to cite this URL:
Vasava JS, Patel SB, Tiwari A. Effectiveness of four-square breathing exercise on after-labour pain among post-natal mothers. Indian J Cont Nsg Edn [serial online] 2021 [cited 2023 Feb 2];22:35-8. Available from: https://www.ijcne.org/text.asp?2021/22/1/35/320814

  Introduction Top

Motherhood is a precious and natural event for any woman. Women have specific needs and challenges in the antenatal, intranatal and post-natal phases during child bearing period.

During post-natal period, body of the woman experiences many physiological changes and many of the changes are present in uterus. Even after birth of the baby and delivery of placenta, uterus continues contracting to enhance constriction of maternal blood vessels on uterine wall at placental site. These persistent mild contractions are termed as after-labour pains or after-pains which create cramp like pain for varied period of time after delivery usually from a few days to 1 or 2 weeks. After-pain is usually spasmodic in nature and is felt in the lower abdomen as uterus contracts to return back to the pre-pregnancy size and place.[1] Furthermore, initiation of breastfeeding leads to synthesis of oxytocin which may produce more contraction in uterus.[2] After-labour pain affects the breastfeeding as it causes discomfort to mother to perform daily routine activity of caring for herself and the baby.[3] It also may act as a trigger in neuro-hormonal stress response which further leads to anxiety, insomnia and fatigue in post-natal women.[4]

In a study on post-partum pain, majority of women (96%) reported pain during breast feeding in three sites such as lower abdomen, low back and breast. This study also found that compared to primipara women multipara women experienced more intense pain which means after labour pain increased significantly with parity.[5] In India, the incidence of after-labour pain is reported as 67% in one of the study.[6] Many studies done on after labour pain had assessed the nature and characteristics of after-labour pain and non-pharmacological methods to minimise the after-labour pain. Non-pharmacological measures such as prone position, oil massage, kegel exercise, deep breathing exercise and application of Melissa Officinalis (Balm) have been found useful in reducing after-pains.[7],[8]

Few studies have included use of breathing exercise in pain management during labour.[9],[10] A study conducted in Egypt evaluated the effect of deep breathing exercise on after pain and reported that the breathing exercise minimised after pain.[11] In the present study, the investigator used four-square breathing exercise which is also known as Box Breathing exercise. It is relatively a new technique of breathing exercise. In Box Breathing exercise, the post-natal mother is asked to count four while breathing in, hold breath for 4 s, and slowly release the breath at the count of 4 and not to inhale for another 4 s. This cycle is repeated as instructed.


  • To assess the level of after labour pain among post-natal women in experimental and control groups
  • To evaluate the effect of four-square breathing exercise on after-labour pain in post-natal women.

  Methods Top

An experimental study design was used in the study. Study participants were recruited from four hospitals in the central part of Gujarat. The sample size was estimated as 80 from the pilot study results with a power of 80 and 0.05 level of significance. Multiparous women who were between 18 and 30 years of age, delivered in the previous 24 h, who had delivered live single foetus at term by normal vaginal delivery without episiotomy were conveniently included and then randomly allocated to experimental and control groups (40 in each). Mothers who were under any sedation or using analgesia or who had post-natal complications and those who had respiratory condition like asthma were excluded from the study.

Ethical approval for the study was obtained by Institutional Ethics Committee-Human Research, and from the Institutional Review Board. Informed written consent of the participants was taken. If participants were illiterate, the consent was read out and impression of thumb was taken from participants in the presence of a family member.


To get the baseline data on socio-demographic variables and maternal variables, a structured questionnaire was used. To analyse the pain level researchers used Visual Analogue numerical pain rating scale which was developed by Hayes and Patterson in the year 1923.[12] The tool was sent to five specialists in the field of obstetrics and gynaecological nursing. The various experts were requested to provide their feedback regarding adequacy, and relevance of content. In the present study, reliability of tool was estimated as 0.95. It suggested that tool was reliable to collect data.

Data collection procedure

Informed written consent was obtained from all participants. Baseline assessment for after-labour pain was performed on all mothers on the 1st day after delivery before the intervention. Mothers were requested to rate their lower abdominal pain with the visual analogue numerical pain rating scale. Mothers in the experimental group were demonstrated four-square breathing exercise after 6 h of delivery by the investigator. They performed 20 rounds of four-square breathing exercise on 1st day morning in the presence of researcher [Figure 1]. Again the same participants did 20 rounds of four-square breathing exercise on 1st day evening in the presence of investigator. In evening, the post-test was taken. On 2nd day the same procedure was repeated by researcher in morning and evening and post-assessment was done. The mothers in the control group had the pre- and post-assessment for pain but had standard care given in the wards.
Figure 1: Four-square breathing

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  Results Top

Majority of mothers in both experimental (55%) and control groups (72.5%) were in the age group of 26–29 years. In the experimental group majority (65%) had primary education and in the control group 55% had primary education. In the experimental group, majority of the mothers (72.5%) were multiparous and had delivered more than three babies in the past [Table 1].
Table 1: Distribution of mothers as per their socio-demographic and maternal variables

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On the 1st day, majority (92.5%) of mothers in both groups had moderate pain at pre-assessment. On the 2nd day, all of them (100%) in experimental group and 70% in control group had mild pain [Table 2].
Table 2: Distribution of mothers according to level of pain in experimental and control groups before intervention on both days

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[Table 3] shows that on the 1st day, 87.5% in the experimental group had mild pain and 67.5% in control group had moderate pain at post-assessment. On the 2nd day, 20% of mothers continued to have moderate pain at post-assessment in control group compared to all who had only mild pain in the experimental group.
Table 3: Distribution of mothers according to level of pain in experimental and control groups in the post-assessment on both days

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There was a significant difference (P < 0.001) in the median pain scores between pre-assessment on day one and post-assessment on day 2 after 2 days of intervention in experimental group. Similar significant difference (P < 0.001) was also noted in the median pain scores between pre assessment on day one and post-assessment on day 2 in control group [Table 4].
Table 4: Effectiveness of four-square breathing exercise on after-labour pain

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There was no difference in the pain score at pre-assessment between control and experimental group. Pain score of day 2 evening (after intervention) between experimental group and control group was significantly different [Table 5] showing that four-square breathing was effective in augmenting the pain reduction by the second post-natal day.
Table 5: Comparison of four-square breathing exercise on after-labour pain among experimental group and control group

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  Discussion Top

The present study looked at after-labour pain in post-natal multiparous mothers and found that majority in both experimental and control group reported moderate level of after-labour pain. This is congruent to the literature which has reported after-labour pain as common ailment in post-natal women.[3],[4] On the 1st day majority in the experimental group (87.5%) experienced mild pain after the intervention compared to only 32.5% in the control group. The difference in the proportion who moved from reporting moderate to mild pain was higher in the experimental group revealing that the four-square breathing was helpful in reducing after-labour pain. The difference in pain scores were also different between experimental and control group at post-assessment on the 2nd day. This also denotes the effectiveness of four-square breathing in relieving after-labour pain. The study findings are similar to the study done in Egypt which also showed the effectiveness of breathing exercises in reducing after-labour pain.[11]

The present study result shows significant difference in the pain level of experimental group before and after the manipulation. Furthermore, it also shows significant difference between the pain score of control group before and after the manipulation as Wilcoxon test value is 5.623 and P < 0.001. From this result, it is understood that after-labour pain reduces naturally over time. Although this results may indicate an intervention as unnecessary, the difference in pain between experimental and control group mothers on 2nd day post-assessment shows that the pain reduction was more in experimental group and therefore a simple breathing exercise may help further reduce the pain intensity experiences. Pain is an uncomfortable feeling which may hinder mothers to happily perform their mothering role and therefore any intervention that reduces pain may be beneficial to them.

  Conclusion Top

From this study, it can be concluded that mothers experience after-labour pain. Although after-labour pain is rarely addressed it is evident that simple breathing exercises may be helpful in reducing pain and distress. Nurses need to remember to address this minor ailment in post-natal mothers and should be able to assist in alleviating this pain and promote comfort and ease.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Lowdermilk D, Perry S. Maternity Nursing. New York: Elsevier; 2008. p. 455-56.  Back to cited text no. 1
Lothian JA. The birth of a breastfeeding baby and mother. J Perinat Educ 2005;14:42-5.  Back to cited text no. 2
American College of Obstetricians and Gynaecologists. Postpartum Pain Management Number. 2018. Available from: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/07/postpartum-pain-management. [Last accessed on 2020 Dec 20].  Back to cited text no. 3
Tafazoli M, Ahmadabadi KM. Assessment of factors affecting afterpain in multiparous women delivered in Mashhad 17-Shahrivar Hospital, Mashhad, Iran. J Mid Repr Health 2014;2:60-5.  Back to cited text no. 4
Holdcroft A, Snidvongs S, Cason A, Doré CJ, Berkley KJ. Pain and uterine contractions during breast feeding in the immediate post-partum period increase with parity. Pain 2003;104:589-96.  Back to cited text no. 5
Raj S, Rajan R, Suvi KJ. Incidence of minor ailments of puerperium and related knowledge among postnatal mothers. Asian J Pharm Clin Res 2018;11:261-3.  Back to cited text no. 6
Ramasamy P, Suzan HL. Effectiveness of selected nursing measures on level of after birth pain among primipara mothers. J Obstet Gynecol 2014;2:100-5.  Back to cited text no. 7
Jose A. A Quasi Experimental Study to Assess Effect of Prone Position on Reduction of after Labour Pain among Postnatal Mother Who had Normal Vaginal Delivery. Bangalore, India: Rajiv Gandhi University of Health and Science Website; 2011. Available from: https://www.rguhs.ac.in/cdc/onlinecdc/uploads/05_N293_28653.do. [Last accessed on 2020 Dec 20].  Back to cited text no. 8
Yuksel H, Cayir Y, Kosan Z, Tastan K. Effectiveness of breathing exercises during the second stage of labor on labor pain and duration: A randomized controlled trial. J Integr Med 2017;15:456-61.  Back to cited text no. 9
Dengsangluri JA, Salunkhe JA. Effect of breathing exercise in reduction of pain during first stage of labour among primigravidas. Int J Health Sci Res 2015;5:390-8.  Back to cited text no. 10
Basyouni NR, Gohar IE. Effect of breathing exercise on after pains among Postpartum Women. J Nurs Health Sci 2017;6:88-96.  Back to cited text no. 11
Freyd M. The graphic rating scale. J Educ Psychol 1923;43:83-102.  Back to cited text no. 12


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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