Effect of Stress Ball Use on Labor Pain and Birth Experience in Primiparous Women During Labor

INTRODUCTION Birth is a natural and unique process that creates significant emotional, social and psychological impacts in women's life cycles. It is emphasized that the pain experienced during this process is universal and is the most severe type of pain a woman can experience. This pain experienced during birth can vary depending on the stages of birth, obstetric care models, psychosocial, environmental, cultural and genetic factors. For this reason, while some women can successfully manage the pain of birth, some women cannot, and they may experience intense stress, lose control over their bodies and feel helpless. However, the World Health Organization (WHO) emphasizes that birth is not only a phenomenon that requires the mother and baby to survive, but also to reach their full potential in terms of health and holistic well-being, and that positive experiences related to birth should be developed.

This study aims to evaluate the effect of stress ball use during the of labor on labor pain and the childbirth experience among primiparous women. The findings obtained may contribute to the literature by demonstrating the effectiveness of stress balls as a non-invasive intervention that can be implemented by nurses and midwives during labor.

MATERIAL AND METHODS Study Design and Setting

This study will be conducted as a single-center, two-arm, parallel-group randomized controlled trial among primiparous women admitted to the Labour Ward of a public hospital in Türkiye. Women admitted during the latent phase of the first stage of labour, operationally defined in this study as cervical dilatation of 1-4 cm, will be screened for eligibility. Eligible women who agree to participate will provide written informed consent before randomization.

A total of 66 eligible primiparous women will be enrolled and randomly assigned in a 1:1 ratio to the stress-ball intervention group (n = 33) or the routine-care control group (n = 33).

Eligibility Criteria

Women will be eligible for participation if they are aged 18 years or older; are primiparous; have no high-risk pregnancy or chronic disease; have no condition that could interfere with communication or the provision of informed consent; have a term, singleton pregnancy with a healthy fetus in vertex presentation; are eligible for spontaneous vaginal birth at the time of enrolment; report the presence of intrapartum pain at enrolment, defined as a Visual Analog Scale (VAS) score of ≥1; and voluntarily agree to participate. The VAS ≥1 criterion will be used only to confirm the presence of labour pain and will not be considered a clinical threshold for pain severity.

Pre-randomization exclusion criteria will include the presence of a hand or arm condition that could interfere with stress-ball use and the use of another non-pharmacological method for labour pain management, such as a peanut ball or rebozo. Maternal or fetal complications occurring after randomization, a subsequent decision for cesarean delivery, or receipt of neuraxial labour analgesia will be considered post-randomization clinical events rather than pre-randomization eligibility criteria.

Randomization, Allocation Concealment, and Blinding

Eligible participants will be randomized during the latent phase of labour before initiation of the study intervention. Participants will be allocated in a 1:1 ratio using a computer-generated variable block randomization sequence with block sizes of 4 and 6. Allocation concealment will be maintained using sequentially numbered, identical, opaque, sealed envelopes prepared by an independent midwife who will not otherwise be involved in the study.

Because of the nature of the intervention, participants and the researcher responsible for administering the intervention will not be blinded to group allocation. VAS pain assessments will be performed by an independent outcome assessor who will not be involved in randomization or intervention delivery and will remain blinded to participants' group assignments.

Data Collection Instruments

Data will be collected using a researcher-developed Descriptive Information Form, the Visual Analog Scale (VAS), and the Childbirth Experience Questionnaire (CEQ).

The Descriptive Information Form will consist of three sections. The first section will assess participants' sociodemographic characteristics, and the second section will assess pregnancy- and childbirth-related characteristics. The third section will contain intervention-specific questions evaluating participants' views on and acceptability of stress-ball use. This section will be administered after childbirth only to women in the intervention group and will include questions regarding satisfaction with the stress ball, willingness to use it again, willingness to recommend it to other women, and whether any problems were experienced during its use.

Labour pain intensity will be assessed using the VAS, a 10-cm scale ranging from 0, indicating no pain, to 10, indicating unbearable pain. Higher scores will indicate greater perceived pain intensity. VAS assessments will be conducted during the predefined latent, active, and transition phases of the first stage of labour.

Childbirth experience will be evaluated after birth using the CEQ. The questionnaire consists of 22 items covering four dimensions of childbirth experience: birth process, professional support, perceived safety and memories, and agreement in decisions. Higher CEQ scores indicate a more positive childbirth experience.

Stress-Ball Intervention

Participants assigned to the intervention group will receive standardized instructions on stress-ball use. For study assessments, the first stage of labour will be operationally divided into three predefined phases: latent phase (1-4 cm cervical dilatation), active phase (5-7 cm), and transition phase (8-10 cm).

During contractions in each of these phases, participants in the intervention group will be instructed to squeeze the stress ball for 5 seconds and release it for 3 seconds, repeating this squeeze-release cycle throughout each contraction. The hand will be rested between contractions, and participants will alternate hands between successive contractions to minimize hand fatigue. Initial stress-ball use will be supervised by the researcher to ensure that participants understand and apply the technique consistently.

Control Group

Participants assigned to the control group will receive routine intrapartum care, including the standard monitoring, clinical care, and support routinely provided in the labour ward. Researcher contact required for study procedures and data collection will be maintained; however, women in the control group will not receive a stress ball or stress-ball-specific information or instructions while study outcomes are being assessed.

The control group will undergo the same phase-specific VAS assessment schedule as the intervention group. After completion of all outcome assessments, participants in the control group will be informed about the stress-ball technique and advised that they may consider its use during a future childbirth.

Data Collection Process

Following enrolment and randomization during the latent phase, baseline sociodemographic and obstetric information will be collected. Labour pain intensity will subsequently be assessed between contractions during each of the predefined latent, active, and transition phases using the VAS. The same outcome assessor will perform the VAS assessments in both groups and will remain blinded to group allocation.

Women assigned to the intervention group will use the stress ball during contractions according to the standardized intervention protocol, whereas women assigned to the control group will continue to receive routine intrapartum care without stress-ball use. Following childbirth and transfer to the postpartum ward, childbirth experience will be evaluated using the CEQ in both groups. Intervention-specific views and acceptability will additionally be assessed postpartum among women in the intervention group.

Primary and Secondary Outcomes

The primary outcome will be labour pain intensity measured using the VAS during the first stage of labour. Pain intensity will be assessed separately during the predefined latent, active, and transition phases. The sample size calculation will be based specifically on the planned between-group comparison of active-phase VAS scores.

The secondary outcomes will be the total and subdimension scores of the CEQ, which will be administered after childbirth. Participants' views regarding and acceptability of the stress-ball intervention will additionally be assessed descriptively in the intervention group and will not be considered primary or secondary effectiveness outcomes.

The inclusion criteria were: age ≥18 years; primiparity; absence of a high-risk pregnancy or chronic disease; no condition limiting communication or the provision of informed consent; a term, singleton pregnancy with a healthy fetus in vertex presentation; VAS ≥1 and voluntary agreement to participate in the study. The VAS ≥1 criterion was used solely to confirm that labour pain had begun and was not intended to represent a clinical pain threshold. The pre-randomization exclusion criteria were the presence of a hand or arm condition that could prevent stress ball use and the use of another non-pharmacological method for labour pain management (e.g., peanut ball or rebozo).