Effects of Breastfeeding, Virtual Reality, and Stress Ball on Pain, Anxiety, Cortisol Levels, and Comfort During Episiotomy Repair

Study Rationale and Background:

Episiotomy is a common surgical procedure performed during vaginal delivery to facilitate the baby's passage. In Turkey, episiotomy rates among primiparous women are reported to be as high as 89-95%. This procedure often leads to significant maternal pain and anxiety during the repair (stitching) phase. There is an increasing need for person-centered interventions that can be easily integrated into midwifery care to manage pain and stress.

Objective:

The primary objective of this randomized controlled experimental study is to evaluate the effects of three different interventions-Breastfeeding, Virtual Reality (VR) Goggles, and Stress Ball-on maternal pain, anxiety, saliva cortisol levels, and postpartum comfort during episiotomy repair.

Methodology and Interventions:

The study will be conducted with primiparous women who are randomly assigned to one of four groups:

Intervention Group 1 (Breastfeeding): Mothers will initiate breastfeeding their newborns during the episiotomy repair.

Intervention Group 2 (Virtual Reality): Mothers will wear VR goggles and watch relaxing, pre-selected content to provide a cognitive distraction during the procedure.

Intervention Group 3 (Stress Ball): Mothers will use a stress ball to redirect their focus and manage physical tension during the repair.

Control Group: Mothers will receive standard hospital care and routine midwifery support.

Measurements and Data Collection:

Data will be collected at multiple time points to assess the physiological and psychological impact of the interventions:

Pain Intensity: Measured using the Visual Analog Scale (VAS-P). Assessments will be performed twice: immediately before the start of the repair and immediately after completion.

Anxiety Levels: Evaluated using the State-Trait Anxiety Inventory (STAI-S). Scores will be recorded before and after the repair process.

Biochemical Stress Response: Saliva cortisol levels will be analyzed to provide an objective measure of the stress response. Samples will be collected pre-intervention and post-intervention.

Postpartum Comfort: Assessed using the Postpartum Comfort Scale between the 6th and 24th hour following the delivery.

Statistical Analysis Plan:

The data will be analyzed to compare the efficacy of the three interventions against the control group. Differences in pain, anxiety, cortisol, and comfort scores will be evaluated to determine which application (if any) significantly affects the maternal experience during the early postpartum period.

Inclusion criteria

• Pregnant women between 18 and 45 years of age.
• Primiparous women (first-time mothers).
• Gestational age between 37 and 42 weeks (term pregnancy).
• Singleton pregnancy with a vertex presentation.
• Spontaneous vaginal delivery requiring a mediolateral episiotomy.
• Newborn birth weight between 2500 and 4500 grams.
• Newborn Apgar scores of 7 or higher at the 1st and 5th minutes.
• Ability to read, understand, and speak Turkish fluently.
• Voluntary participation with signed informed consent.

Exclusion and Withdrawal Criteria:

• Requesting to withdraw from the research at any stage.
• Presence of any congenital anomalies in the newborn.
• Presence of maternal visual or hearing impairments.
• Occurrence of fetal mortality or morbidity.
• Occurrence of anal sphincter injury or 3rd/4th-degree lacerations in addition to the episiotomy.
• Performance of the episiotomy repair in an operating room.
• Use of assisted delivery methods (e.g., vacuum extraction).
• Administration of sedative drugs or extra anesthetic agents (excluding routine local perineal infiltration).
• Development of maternal complications (e.g., postpartum hemorrhage) preventing data collection.