The Effects of Breathing Exercises and Virtual Reality Applications During Pregnancy and Labor.
Condition: Labor Pain; Labor Onset; Patient Satisfaction; Virtual Reality; Breathing; Tic
MeSH terms: Respiratory Aspiration; Labor Pain
Study type: Interventional

Summary: 
      Aim and Objectives: The purpose of this study was to determine the effects of breathing
      exercises and virtual reality applications during pregnancy and labor on labor pain,
      duration, and birth satisfaction.

      Background: Conducted studies show that practices such as virtual reality have positive
      effects on labor. However, there is no study that compares the effects of breathing exercises
      with virtual reality applications on labor.

      Design: A randomized controlled experiment was conducted by the CONSORT guidelines.

      Methods: The study included 114 pregnant women (Breathing Exercise Group:39, Virtual Reality
      Group:37, Control Group:38). The research was carried out in two stages. In the first stage,
      for the experimental groups at the 36th-39th weeks of pregnancy, a 10-minute breathing
      exercise was performed 3 times a week using virtual reality glasses and a breathing exercise
      device. In the second stage of the study (when the cervical dilatation was 4 cm), the
      breathing exercise group was made breathing exercises again. The virtual reality group
      watched a 10-minute video with virtual reality glasses. Once the virtual reality glasses were
      removed from experimental groups Visual Analogue Scale was applied. Birth satisfaction was
      evaluated with the Birth Satisfaction Scale within the first 4 hours after the delivery was
      completed.
    

Detailed description: 
      1. INTRODUCTION Management of labor pain and increasing the birth satisfaction level of the
           expectant mother are the main goals of prenatal and postpartum care (Huntley, Coon, &
           Ernest, 2004). For this purpose, two kinds of methods, which are pharmacological and
           non-pharmacological are used (Vulkan, & Yıldız, 2016).

           One of the non-pharmacological applications is virtual reality technology (Dockx et al.,
           2016; Ebrahimian, & Bilandi, 2022).

           Another non-pharmacological application in pregnancy and labor is breathing exercises
           (Dikmen, & Sanlı, 2019).

        2. MATERIAL AND METHODS Study design The researchers carried out this study between October
           2020 and January 2022 in the pregnant outpatient clinic and in the delivery room, at the
           maternity hospital in southeastern Anatolia, Turkey.

      Study population The sample of the study consisted of all pregnant women who applied to the
      pregnancy polyclinic for normal delivery. The sample size of the study was calculated as 63
      pregnant women including 21 participants in each group using the G*Power Software version
      3.9.1 with the VAS mean scores in the study by Dutucu (2019) as 5.63 (SD = 1.07), and
      obtaining a rate of 80% in the power test, an alpha value of 0.05 with a 95% confidence level
      (Dutucu, 2019). However, we decided to include 40 pregnant women in each group in order to be
      able to generalize and strengthen the research results. The study reached 120 pregnant women.
      Five pregnant women did not meet the inclusion criteria and one pregnant woman withdraw from
      the study during the process and was excluded from the study. Eventually, the study sample
      was composed of 114 pregnant women based on the CONSORT 2010 flow diagram: 39 in the
      breathing exercise group, 37 participants in the virtual reality group, and 38 in the control
      group.

      Randomization Pregnant women were randomly selected via a drawing, and they were assigned to
      either the experimental or control group. For the drawing of lots; 120 small papers were
      prepared, and the words 'virtual', 'breathing', and 'control' were written on every 40
      papers, and they were folded and put into a bag. The inclusion of pregnant into groups was
      determined according to the papers pregnant drew from the bag. Pregnant women participating
      in the study did not know how many groups are available and which method will be applied to
      the group in which they are selected. We carried out this study with three groups, one
      control, and two experiments. The experimental group is divided into two groups, the
      breathing exercise group, and the virtual reality group.

      Data Collection Tools The data of the study were collected by using "Descriptive Information
      Form", "Labour Observation Form", "Visual Analog Scale ", and "Birth Satisfaction Scale".

      Collection of data The First Stage of The Research As mentioned before, this step was applied
      in the same way for both experimental groups. The descriptive information form was filled in
      by the pregnant women under the supervision of the researchers. At the 36th gestational week,
      the pregnant women were informed that they should not eat or drink anything 1 hour before the
      exercise. In addition, we gave the necessary information to the participants about virtual
      reality and breathing exercise devices together with how they would be applied and what video
      content they would watch. A 10-minute(5 minutes of breathing exercise and 5 minutes of
      relaxation exercise at the end of the exercise) breathing exercise video was shown to the
      participants using virtual reality glasses. At the same time, the participants were asked to
      do the breathing exercises shown in the video using the breathing exercise device. This
      application was performed 3 times a week from the 36th gestational week to the 40th
      gestational week, and 12 times in total until birth.

      All applications were carried out in a quiet, calm pregnant outpatient clinic in the
      hospital, and a cushion on which the pregnant woman could sit and a pillow that could support
      her back were used to ensure the comfort of the pregnant woman.

      The Second Stage of The Research After the first stage of the research was applied to the
      experimental groups, the second stage was carried out during the delivery at the 40th week of
      pregnancy. The second stage was applied in a different way for the Breathing Exercise Group
      and Virtual Reality Group. In the following sections, the second stage is explained for both
      groups.

      Breathing Exercise Group Participants after being admitted to the delivery room of Gaziantep
      Cengiz Gökçek Obstetrics and Pediatrics Hospital and taken to their beds, the labor
      evaluation section of the labor observation form was filled. Firstly the pregnant women were
      placed in the semi-fowler position and virtual reality glasses with a breathing exercise
      device were put on when the cervical dilatation was 4 cm (the beginning of the active phase).
      A 10-minute (5 minutes of breathing exercise and 5 minutes of relaxation exercise at the end
      of the exercise) breathing exercise video was shown to the participants using virtual reality
      glasses. At the same time, the participants were asked to do the breathing exercises shown in
      the video using the breathing exercise device. As soon as the virtual reality glasses and
      breathing exercise device were removed, VAS was applied. In order to evaluate the second and
      third stages of labor, the birth evaluation section of the labor observation form was filled
      out. Satisfaction with birth was evaluated with the ''Birth Satisfaction Scale'' within the
      first 4 hours after birth after the delivery was completed.

      Virtual Reality Group Participants after being admitted to the delivery room of Gaziantep
      Cengiz Gökçek Obstetrics and Pediatrics Hospital and taken to their beds, the labor
      evaluation section of the labor observation form was filled. Firstly the pregnant women were
      placed in the semi-fowler position and virtual reality glasses were put on when the cervical
      dilatation was 4 cm (the beginning of the active phase). Then, in virtual reality glasses, a
      10-minute relaxing video of the chirping of birds, calm sea, colorful birds, sunrise, sunset,
      colorful flowers, and trees was played accompanied by the background music called ''Dancing
      With Nature'' by Tim Janis. Once the virtual reality glasses were removed VAS was applied. In
      order to evaluate the second and third stages of labor, the birth evaluation part of the
      labor observation form was filled out. Birth satisfaction was evaluated with the ''Birth
      Satisfaction Scale'' within the first 4 hours after the delivery was completed.

      Control Group A descriptive information form was filled out at the 36th week of pregnancy in
      a quiet pregnant outpatient clinic in the hospital. After participants were admitted to the
      delivery room of Gaziantep Cengiz Gökçek Obstetrics and Pediatrics Hospital at the 40th week
      of pregnancy, and taken to their beds, in labor observation form, the labor section and the
      birth evaluation section which are used to evaluate the second and third stages of labor were
      filled out. Then, VAS was applied when cervical dilatation was 4 cm (the beginning of the
      active phase). Birth satisfaction was evaluated with the ''Birth Satisfaction Scale'' within
      the first 4 hours after birth after the delivery was completed.

      No application was made to pregnant women in this group, except for routine practices in the
      pregnant outpatient clinic at the hospital and in the delivery room.
    

Intervention name(s): Breathing Exercise; Virtual Reality
Intervention type(s): Other; Other
Intervention description(s): The research was carried out in two stages. In the first stage, for the experimental groups at the 36th-39th weeks of pregnancy, a 10-minute breathing exercise was performed 3 times a week using virtual reality glasses and a breathing exercise device. In the second stage of the study (when the cervical dilatation was 4 cm), the breathing exercise group was made breathing exercises again. As soon as the virtual reality glasses and breathing exercise device were removed, VAS was applied. In order to evaluate the second and third stages of labor, the birth evaluation section of the labor observation form was filled out. Satisfaction with birth was evaluated with the ''Birth Satisfaction Scale'' within the first 4 hours after birth after the delivery was completed.; The research was carried out in two stages. In the first stage, for the experimental groups at the 36th-39th weeks of pregnancy, a 10-minute breathing exercise was performed 3 times a week using virtual reality glasses and a breathing exercise device. In the second stage of the study (when the cervical dilatation was 4 cm) the virtual reality group watched a 10-minute video with virtual reality glasses. Once the virtual reality glasses were removed from experimental groups Visual Analogue Scale was applied. Birth satisfaction was evaluated with the Birth Satisfaction Scale within the first 4 hours after the delivery was completed.
Allocation: Randomized
Intervention model: Crossover Assignment
Masking: Single (Participant)
Primary purpose: Supportive Care
Keywords: breathing exercises; virtual reality; pain intensity; duration of labor; birth satisfaction