Focusing on Maryam's Flower at Labor
Condition: Labor Pain; Satisfaction
MeSH terms: Labor Pain
Study type: Interventional

Summary: 
      Objective: To determine the effect that focusing attention on the plant, Maryam's Flower, has
      on pregnant women's perception of pain, level of comfort and labor satisfaction during the
      first phase of labor.

      Method: This randomized controlled experimental study was conducted with an intervention
      group (n=61) and control group (n=63) involving primipara pregnant women who were at 1 cm
      cervical dilatation. The pregnant women in the intervention group were asked to focus their
      attention on Maryam's flower opening its leaf buds and imagine the labor's progress during
      the course of their labor. The control group only received standard midwifery care. Each
      group was administered the VAS at specific times (at 4-5 cm, 6-7 cm, and 8-9 cm cervical
      dilatation) to determine their level of labor pain. The Childbirth Comfort Questionnaire
      (CCQ) was also administered when the women were at 4-5 cm and 8-9 cm cervical dilatation to
      determine their level of birth comfort. The duration of labor was monitored using a
      partograph form. Finally, the Birth Satisfaction Scale was applied to determine the women's
      satisfaction with the labor in the 2nd hour of the postpartum period.
    

Detailed description: 
      Design and Settings This randomized controlled experimental study was conducted in the
      delivery room of the Atatürk City Hospital in Balıkesir, Turkey between the dates of May 2019
      and January 2020.

      Participants The sample size was determined using G * Power 3 power calculations, taking into
      consideration previous studies on the effect of positive mental imagination during labor.
      Impact predictions were obtained from the findings derived from Yavari et al., which
      specified the pain intensity during 6-7 cm cervical dilatation to be 6.73 ± 1.34 in the
      positive mental imagination group, and 7.63 ± 1.64 in the control group (18). This study
      expected to detect differences similar to those reported by Yavari et al. The sample size was
      determined to be 61 for each group. Maryam's flower group included 61 pregnant women, while
      the control group included 63 pregnant women. In the Maryam's flower group, 6 pregnant women
      and in the control group, 2 pregnant women underwent cesarean sections, therefore, the study
      was completed with 55 pregnant women from the Maryam's flower group and 61 pregnant women
      from the control group (The pregnant women underwent cesarean sections after 6-7 cm cervical
      dilatation). The power analysis indicated that the sample size of the study had a power of
      94% with α = 0.05. The decrease observed in labor pain for the Maryam's flower group at 6-7
      cm cervical dilatation had an effect size of 0.59 when compared to the control group.

      Study inclusion criteria included pregnant women who expected vaginal delivery and a single
      healthy fetus, who were primipara and in the first phase of the labor, and who were at 1 cm
      cervical dilatation. Pregnant women who were multipara, had a risky pregnancy, a child with
      complications, multiple pregnancies, or a premature delivery and those who delivered after 1
      cm cervical dilatation were excluded from the study.

      Single-blind block randomization was performed with closed opaque envelopes, where 61 of the
      124 envelopes include pieces of paper on which were written "intervention" and 63 on which
      were written "control". The randomization sequence was determined by a statistician through a
      computerized research randomizer. The intervention group focused on Maryam's flower
      throughout the delivery, while the control group was provided standard midwifery care.

      Data Collection The participating pregnant women who were in the first phase of labor and at
      1 cm cervical dilatation were administered an introductory information form. In the
      intervention group, Maryam's flower was placed in a bowl of water once the women were at 1 cm
      cervical dilatation, and the pregnant women were asked to focus on the plant. Each group,
      that is, the intervention group and the control group, were administered the Visual Analog
      Scale (VAS-1) when they were at 4-5 cm cervical dilatation and the Childbirth Comfort
      Questionnaire, to detect their levels of birth comfort, and the VAS-2 when they were at 6-7
      cm cervical dilatation. Once the women reached 8-10 cm cervical dilation, they were asked to
      respond to the VAS-3 and Childbirth Comfort Questionnaire. The Birth Satisfaction Scale was
      used to determine the level of postnatal satisfaction.

      Measures The study data were collected through the Pregnant Information Form, the VAS, the
      Partograph form, the Childbirth Comfort Questionnaire, and the Birth Satisfaction Scale.

      The Pregnant Information Form (PIF): This form included questions on the sociodemographic,
      gynecological, and obstetric characteristics of the pregnant women.

      Visual Analog Scale (VAS): This scale was used to determine the level of labor pain. The
      scale features a 10-cm long vertical line, with 0 at the bottom end and 10 at the top end.
      The VAS was administered when the women were at 4-5 cm, 6-7 cm, and 8-10 cm cervical
      dilatation, and the women completed the scale themselves Partograph Form: This form was used
      to determine the duration of the first phase of the labor process (active phase and
      transition phase).

      Childbirth Comfort Questionnaire (CCQ): This questionnaire was developed by Kerri Durnell
      Schuling and Carolyn Sampselle in 2003 (7). The Turkish reliability and validity study of the
      questionnaire was conducted by Potur et al. (2015) (11), who reported that the CCQ included
      physical, environmental, and psychospiritual subscales and relief and transcendence levels.
      The questionnaire features 9 items, each of which are evaluated based on a 5-point
      Likert-type scale, where 1 represented strongly disagree and 5 represented strongly agree.
      The minimum and maximum scores possible on the scale are 9 and 45, respectively, with higher
      scores representing higher levels of comfort and lower scores representing lower levels.
      Potur et al. found Cronbach's alpha reliability coefficient to be 0.75. The CCQ was
      administered twice in this study, once at 4-5 cm cervical dilatation and once at 8-9 cm
      cervical dilatation.

      The Birth Satisfaction Scale (BSS): The Turkish reliability and validity study of this scale
      developed by Hollins Martin and Fleming was conducted by Çoşar et al. (2015). The scale is a
      Likert-type scale comprised of 30 questions. The minimum and maximum scores possible on the
      scale are 30 and 150, respectively. Higher scores indicate higher birth satisfaction. An
      analysis conducted to determine the internal consistency of the BSS found the Cronbach's
      alpha value to be 0.62. The BSS was administered at the 2nd hour of the postnatal period.

      Intervention Maryam's flower was placed in a bowl of water and left in the room of the
      pregnant women who were at 1 cm cervical dilatation and in the first phase of the labor. It
      was explained to the pregnant women that the leaves of the plant would open up in the water,
      and they were asked to imagine that the birth canal would simultaneously open up. In effect,
      they were told to focus on the opening of these leaves during the course of the labor
      (Pictures 1 and 2). All the pregnant women, those in the control group and in intervention
      group, were provided with standard midwifery care. As part of the standard midwifery care
      given to the pregnant women, follow-up of cervical dilatation and effacement, contraction,
      fetal heart rate, and vital signs were monitored. The pregnant women were given information
      on breathing and pushing techniques. Moreover, induction was performed on all the pregnant
      women. in labor.
    

Intervention name(s): Foccusing on Maryam's Flower
Intervention type(s): Other
Intervention description(s): Effect of Focusing on Maryam's Flower During the First Phase of the labor
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Participant)
Primary purpose: Supportive Care
Keywords: comfort at labor; labor pain; Maryam's flower; focused attention; birth satisfaction