Comparison of the Efficacy of Virtual Reality Glasses versus Mint Gum for Pain and Anxiety Relief During Episiotomy Repair: A Randomized Clinical Trial

Abstract

Background:

Pain and discomfort associated with episiotomy, especially during its repair, are significant sources of fear among women and may contribute to increased rates of cesarean section. This study aimed to compare the effects of virtual reality (VR) glasses and mint gum on pain intensity and anxiety during episiotomy repair among primiparous women.

Materials and Methods:

In this single-blind randomized clinical trial, 108 eligible primiparous women were randomly assigned to three groups using block randomization: VR glasses (n = 36), mint gum (n = 36), and control (n = 36). Pain intensity was measured at four time points using the visual analoge scale, and anxiety was assessed using the Spielberger State Anxiety Inventory 1 h after the repair. Data analysis was performed using IBM SPSS Statistics version 27 via one-way analysis of variance, Tukey’s post hoc test, Kruskal–Wallis, and Chi-square tests, as appropriate.

Results:

No significant differences in pain or anxiety were observed between the groups before the intervention (p > 0.05). However, pain and anxiety scores were significantly lower in both intervention groups than in the control group (p < 0.05). No significant difference was observed between the VR and mint gum groups.

Conclusions:

Both VR glasses and mint gum were effective in reducing pain and anxiety during episiotomy repair. As low-cost, nonpharmacological interventions, they can be recommended for routine use in maternity care.

Introduction

Episiotomy is one of the most common surgical procedures performed during vaginal delivery, particularly among primiparous women. It is typically performed to widen the vaginal opening and facilitate the birth process.[1] However, this procedure can lead to various complications, including dyspareunia, depression, reduced maternal ability to care for the newborn, pain, hematoma, wound dehiscence, and infection.[2,3] Awareness of these potential outcomes can increase anxiety and fear in primiparous mothers, which can be shared with others and further raise concerns among expectant women. In turn, this psychological response may heighten the perception of pain.[4] A study in Nigeria found that over half of the women held a negative view of episiotomy and suggested that the procedure should be avoided entirely by relatives. Fear of pain associated with episiotomy has become a factor contributes to the increasing preference of women for cesarean sections over vaginal births.[5] In Iran, the rate of episiotomy among first-time mothers is alarmingly high, reaching up to 97%.[6] This high rate highlights the urgent need for safe, effective, and nonpharmacological interventions to lessen the fear, anxiety, and discomfort associated with the procedure. While pain relievers and narcotics are often used, their side effects, such as nausea, vomiting, low blood pressure, drowsiness, heart problems, and high costs, make them less desirable and practical.[7,8] Several nondrug methods have been used to manage fear and anxiety in women during labor. These include distraction techniques, aromatherapy, acupressure, breathing exercises, foot reflexology, and music therapy. Distraction techniques are simple yet effective approaches that help shift the focus away from uncomfortable emotional feelings. This approach is based on the idea that the human brain cannot simultaneously focus on two different thoughts. The perception of pain and stress can be greatly reduced by engaging the mind with an alternative focus, such as a neutral or positive stimulus.[9]

Two notable distraction methods applied in various medical settings are virtual reality (VR) and chewing gum.[10,11,12] VR is a system that simulates the real world, distracting individuals from the actual situation and reducing their perception of pain.[13] In a clinical trial conducted in Turkey by Kirca et al., the use of VR significantly reduced anxiety and pain in primiparous women undergoing episiotomy repair.[14] Orhan and Bülez found reduced pain and increased satisfaction among primiparous women using VR during the procedure.[15] Chewing gum is another method of sensory distraction. It modulates blood cortisol levels, which are associated with reductions in stress and anxiety.[16] Gum chewing is believed to decrease the sensory processing of external stressors and inhibit the transmission of stress-related signals to the brain.[10] In a study conducted by Topcu et al. in Turkey, a significant reduction in pain intensity was reported during intravenous cannulation in children following gum chewing. However, no significant change in anxiety levels was observed.[17] However, some trials, such as that by Tong Bet et al., have shown no significant benefit of chewing gum on postoperative abdominal pain.[18]

The aroma and taste of mint have long been recognized for their uplifting and calming effects. Mint has been used since ancient civilizations to enhance alertness and mood. Its aroma has been associated with reduced nausea, anxiety, and pain in medical settings.[19,20] Ebrahimian et al. found that both VR and mint gum reduced labor pain and anxiety during the first stage of labor, with no significant differences between the two methods.[12]

The studies conducted and the review of various scientific databases reveal inconsistent findings regarding the effects of VR headsets and chewing gum on labor pain and anxiety. Despite the promising potential of both VR and chewing gum as nonpharmacological pain management techniques, a clear knowledge gap exists regarding their comparative efficacy and practical application during episiotomy repair. Although individual studies have explored these methods separately, direct head-to-head comparisons in the specific context of episiotomy are still lacking. Furthermore, the inconsistent findings across existing studies, particularly for chewing gum, create clinical uncertainty for healthcare providers, as some trials show significant benefits while others show none. This inconsistency may be due to variations in study populations, intervention protocols, or outcome measures. Therefore, a rigorous comparative study that directly evaluates both interventions against a control group within the same clinical setting and population is critical. Such evidence is essential to guide midwives and obstetric care providers in selecting the most effective, feasible, and patient-preferred method for reducing pain and anxiety during this common procedure. Therefore, this study aimed to compare the effects of VR and mint gum on pain and anxiety during episiotomy repair in primiparous women.

Materials and Methods

This study was a single-blind, randomized controlled trial (registration code: IRCT2024121664063N1). The study population comprised term primiparous women who met the inclusion criteria. Eligible participants were enrolled, provided written informed consent, and were randomly allocated to either the intervention or control group during the first stage of labor. The objective of this study was to compare the effects of VR and mint chewing gum on the intensity of pain and anxiety during episiotomy repair.

Participants included women in the active phase of labor who met the inclusion criteria. Eligible participants were low-risk Iranian women with singleton term pregnancies (37–42 weeks of gestation) who underwent a standard mediolateral episiotomy. Additional criteria included a neonatal birth weight between 2000 and 4000 g, a 5-min Apgar score of 8–10, the absence of fetal anomalies, and no known psychiatric disorders (e.g., depression, schizophrenia, substance use disorder). The participants also needed to have normal visual acuity to ensure adequate interaction with the VR device. Participants were excluded or withdrawn from the study after enrollment (and their data were not analyzed) if any of the following occurred: development of any obstetric complication or hemorrhage requiring immediate medical intervention; conversion to an instrumental delivery (forceps or vacuum); neonates born with Apgar scores <8 or with birth-related complications, administration of >5 mL of lidocaine; lack of lidocaine use during episiotomy repair due to emergency conditions; extensive episiotomy incisions; participant’s request to withdraw from the study at any point. Potential participants who, despite meeting the inclusion criteria, were not enrolled in the study included those: cases referred during crowning, since there was insufficient time to complete the enrollment procedure and ensure the safe application of the study protocol. The sample size was calculated using Cochran’s formula for comparing two independent means based on pain score data from Orhan and Bülez.[15] With α = 0.05, β = 0.10, σ₁ = 1.28, σ₂ = 1.62, μ₁ = 0.84, and μ₂ = 2.04, the initial sample size was 30 per group. The final sample size was determined as 36 participants for each of the three groups (VR, mint gum, and control), accounting for 20% dropout, totaling 108 participants. Ultimately, from among 280 primiparous women referred to the Maternity Hospital in 2025, 108 eligible women were enrolled in the study [Figure 1]. A total of 108 eligible primiparous women were recruited and randomly allocated into three equal groups (n = 36 each) using computer-generated block randomization with a block size of six. Randomization was stratified based on preintervention State Anxiety Inventory scores to control for the potential confounding effect of baseline anxiety. This ensured a balanced distribution of high-anxiety participants across all groups. Although participants could not be blinded due to the nature of the interventions, the outcome assessor and data analyst remained blinded to group assignment. The researcher explained the study’s objectives and procedures to all eligible participants. Once written informed consent was obtained, the participants were enrolled and monitored during the first stage of labor. The participants were then allocated to either the intervention or control groups, and the study procedures were implemented as described below.

Figure 1.

CONSORT diagram of the study

Following standard perineal preparation and draping, the participants in the VR group placed the SHINECON SC-G15E VR headset over their eyes before episiotomy repair. A local injection of 2 mL of 2% lidocaine solution was administered for analgesia. The headset displayed soothing 360° video content with accompanying music to promote relaxation and reduce anxiety during the repair procedure. The content included natural scenery, such as forests, oceans, galaxies, skies, and underwater environments. Each participant was allowed to select their preferred visual theme. Video playback continued throughout the duration of the episiotomy repair. Participants inserted a memory card containing preloaded video content into the smartphone to use the VR headset. The Deo or VARS mobile applications were installed to support 3D and 360° video playback. The video content was sourced from www.taktab.net included calming music and immersive 3D visuals tailored to individual user preferences. This multimedia experience was designed to distract participants and promote relaxation during the episiotomy repair. The participants in the mint gum group were given a1.5-g piece of sugar-free mint gum immediately before episiotomy repair. A 5-mL injection of 2% lidocaine was administered as a local anesthetic. Participants were instructed to chew the gum continuously throughout the repair procedure.

The control group received routine postpartum care, including a 5-mL injection of 2% lidocaine for local anesthesia and standard skin-to-skin contact with their newborn immediately after birth. All episiotomy repairs were performed by a single skilled midwife to ensure consistency and minimize confounding variables. In addition, immediate skin-to-skin contact with the newborn was implemented for all participants across the three groups immediately after delivery and maintained throughout the episiotomy repair procedure. procedure.

Data collection was performed by the researcher. First, maternal demographic information (age, BMI, education, occupation) and neonatal characteristics (gender, birth weight, length, and Apgar scores at 1 and 5 min) were recorded. Pain intensity was then assessed using the visual analog scale (VAS), a standardized 10-cm horizontal line anchored from 0 (“no pain”) to 10 (“unbearable pain”). The VAS has well-established validity and reliability, including in Iranian populations.[21] Assessments were conducted at four critical time points to evaluate the dynamic effect of the interventions: (T1) before the intervention (baseline); (T2) during the repair of the vaginal mucosa; (T3) during the repair of the perineal skin; and (T4) immediately after the completion of the repair. The T4 measurement was essential for assessing the immediate residual pain and the carry-over effect of the interventions once the primary mechanical stimulus (suturing) had ceased. Anxiety level was assessed using the Spielberger State-Trait Anxiety Inventory (STAI). This instrument consists of 40 items: 20 items measure state anxiety and 20 items assess trait anxiety. Only the state anxiety (STAI-S) subscale was used in this study. Each item is scored on a 4-point Likert scale ranging from “not at all” to “very much,” with total scores ranging from 20 to 80. A higher score indicates a higher level of anxiety. The Persian version of the STAI was standardized by Behrooz Mahram,[22] and its reliability was confirmed by Salari et al. using Cronbach’s alpha coefficient (α = 0.88).[23] The STAI-S was administered at two time points: preintervention: to establish baseline anxiety levels and ensure comparability among the groups, postintervention (within 1 h after repair): to evaluate the effects of the interventions following episiotomy repair. All data were collected by the primary investigator, who systematically recorded the responses to the VAS and STAI-S, ensuring consistent and accurate data collection.

Data analysis was performed using SPSS version 16 (SPSS Inc., Chicago, IL, USA) via one-way analysis of variance (ANOVA), Tukey’s post hoc test, Kruskal-Wallis, and Chi-square tests, as appropriate. Quantitative variables were reported as mean (standard deviation), and qualitative variables were reported as frequency and percentage. The Shapiro–Wilk test was used to assess the normality of quantitative variables, and Levene’s test was applied to evaluate the homogeneity of variances. To compare normally distributed quantitative variables between the three groups, one-way ANOVA followed by Tukey’s post hoc test was used. For non-normally distributed variables, the Kruskal–Wallis test was applied. The Chi-square test or Fisher’s exact test was used to compare categorical variables, where appropriate. To compare the mean pain scores across the study groups, two-way ANOVA was employed to evaluate the main effects of group and time, as well as their interaction. A p < 0.05 was considered statistically significant.

Ethical consideration

Necessary administrative permission was obtained to access the maternity ward where the study was conducted. Following ethical approval (IR.RUMS.REC.1403.128), written informed consent was obtained from all eligible participants after providing comprehensive explanations of the study’s objectives and procedures. The participants were assured of the confidentiality and anonymity of their information. The participants were informed of their right to withdraw from the study at any stage without incurring any consequences. No financial cost was imposed on the participants. Principles of honesty, confidentiality, and academic integrity were observed throughout the study. The study findings will be communicated to relevant stakeholders upon completion.

Results

This study analyzed data from 108 participants equally distributed between the VR, mint gum, and control groups. Maternal and neonatal characteristics were comparable across all groups. Pain intensity was assessed at four time points during the procedure, while anxiety levels were measured before and after the intervent. Baseline characteristics were similar comparable across all groups [Table 1], with no significant differences in maternal age, education, occupation, BMI, gestational age, or any neonatal parameters (all p > 0.05). According to Table 2, no significant difference in pain scores was observed between the groups before the intervention (p = 0.899). However, during vaginal mucosa repair, skin repair, and immediately after episiotomy repair, significant differences emerged among groups (p < 0.001). Post hoc analysis showed that the control group reported significantly higher pain scores than both the VR and mint gum groups (p < 0.001), while no significant difference was found between the VR and mint gum groups at any measurement point (p > 0.05) According to the results of the two-way repeated measures ANOVA [Table 3], the main effects of group, time, and their interaction, were statistically significant (p < 0.001). The overall mean pain score differed significantly among the groups, with the control group reporting higher scores than the VR headset and mint gum groups. Across all groups, pain scores decreased over time. The significant group-by-time interaction indicated that the rate of pain reduction was greater in the intervention groups than in the control group. The eta-squared analysis demonstrated that 57% of the variance in pain scores was attributable to time and 22.6% to the group-by-time interaction. According to the results presented in Table 4, Levene’s test indicated that the variances of state and trait anxiety scores, as well as their changes before and after the intervention, were homogeneous across the study groups.

Table 1.

Maternal and neonatal characteristics by study group

Group Variable	n=36			Test Statistic	D.F	p
	VR	Mint Gum	Control
Maternal age (years), mean (SD)	21.61 (5.06)	21.56 (4.49)	21.47 (4.63)	F=0.01	105,2	0.992*
Education level, (n, %)
Primary school	13 (36.10)	11 (30.60)	15 (41.70)	χ²=6.14	-	0.409†
Middle school	7 (19.40)	7 (19.40)	11 (30.60)
High school	10 (27.80)	15 (41.70)	7 (19.40)
Bachelor’s degree	6 (16.70)	3 (8.30)	3 (8.30)
Maternal occupation, (n, %)
Housewife	30 (83.30)	33 (91.70)	35 (97.2)	χ²=3.91	-	0.151†
Employed	6 (16.70)	3 (8.30)	1 (2.80)
Body mass index (kg/m2)	(18.13–20.88)	(18.00–21.47)	(19.00–20.83)	H=0.58	2	0.750‡
Gestational age (weeks)	(38.05–40.08)	(38.00–39.90)	(38.40–40.00)	H=2.26	2	0.324‡
Neonatal gender
Female	21 (58.30)	20 (55.60)	23 (63.90)	χ²=0.54	2	0.765†
Male	15 (41.70)	16(44.40)	13 (36.10)
Apgar sc
9–10	35 (97.20)	34 (94.40)	35 (97.20)	χ²=0.69	-	0.999‡
8–10	1 (2.80)	2 (5.60)	1 (2.80)
Neonatal weight (g)	2826.25 (382.77)	2789.72 (320.75)	2929.44 (315.58)	F=1.63	105, 2	0.202*
Neonatal length (cm)	50.74 (2.18)	51.11 (2.47)	51.19 (2.23)	F=0.41	105, 2	0.667*

SD=Standard deviation. Data are presented as: *Mean (SD), ^†median (first quartile–third quartile), or ^‡n (%). Group Comparisons were performed using: One-way ANOVA, ^†The Kruskal–Wallis test, or ^‡The Chi-square or Fisher’s exact test, as appropriate

Table 2.

Comparison of pain scores at different measurement phases of study

Group Variable	n=36, Mean (SD)			Test Statistic	D.F	p
	VR Group	Mint Gum	Control Group
Before intervention	4.83 (2.01)	4.94 (1.90)	4.72 (2.21)	F=0.11	105, 2	0.899
During vaginal mucosa repair	3.19 (1.55)	2.69 (1.37)	5.31 (1.41)	F=33.17	105, 2	<0.001
During skin repair	2.53 (1.40)	1.94 (1.35)	5.39 (1.15)	F=71.60	105, 2	<0.001
Immediately after the episiotomy repair	0.92 (1/00)	0.64 (0.90)	2.56 (1.03)	F=40.56	105, 2	<0.001

SD=Standard deviation

Table 3.

Mean and standard deviation of pain scores at different measurement times stage by study groups, with intra- and intergroup effects

Group Measurement Stage	n=36, Mean (SD)			p
	VR	Mint gum	Control	Group Effect	Time Effect	Group × Time Intervention
Before intervention	4.83 (2.01)	4.94 (1.90)	4.72 (2.21)	F=38.446	F=138.98	F=15.36
During vaginal mucosa repair	3.19 (1.55)	2.69 (1.37)	5.31 (1.41)	DF=105,2	DF=315,3	DF=315,6
During skin repair	2.53 (1.40)	1.94 (1.35)	5.39 (1.15)	p<0.001	p<0.001	P<0.001
Immediately after the episiotomy repair	0.92 (1.00)	0.64 (0.90)	2.56 (1.03)	ƞ²=0.42	ƞ²=0.57	ƞ²=0.22

SD=Standard deviation

Table 4.

Comparison of variance in state and trait anxiety scores before intervention and within the first hour postepisiotomy among the study groups

Anxiety Scale Stage	F-statistic (F)	D.F	p
State anxiety before intervention	0.02	105, 2	0.977
Trait anxiety before the intervention	1.14	105, 2	0.322
State anxiety within the first hour postepisiotomy repair	0.19	105, 2	0.831
Trait anxiety within the first hour postepisiotomy repair	0.88	105, 2	0.420
Change in state anxiety before and after intervention	0.05	105, 2	0.947
Change in trait anxiety before and after the intervention	2.22	105, 2	0.114

Table 5 shows no significant differences in state or trait anxiety scores between the groups before the intervention (p > 0.05). However, significant between-group differences emerged in state anxiety scores within the first hour postepisiotomy (p < 0.001). Post hoc analysis confirmed that the control group reported significantly higher state anxiety than both the VR and mint gum groups (p < 0.001), while no significant difference was observed between the two intervention groups. Similarly, the reduction in state anxiety was significantly greater in the intervention groups than in the control group (p < 0.001). No significant differences were found in postintervention trait anxiety scores or in the changes in trait anxiety scores (p > 0.05).

Table 5.

Comparison of mean state and trait anxiety scores and their changes before and after the intervention among the study groups

Groups Anxiety Scale-stages	n=36, Mean (SD)			Test-Statistic	(D.F)	P
	VR	Mint Gum	Control
State anxiety before intervention	53.08 (4.98)	52.33 (5.45)	52.22 (5.36)	F=0.28	105, 2	0.753
Trait anxiety before intervention	30.69 (4.19)	29.17 (5.53)	28.33 (3.76)	F=2.49	105, 2	0.088
State anxiety within the first-hour postepisiotomy repair	29.83 (4.13)	27.31 (4.19)	34.92 (4.86)	F=27.88	105, 2	<0.001
Trait anxiety within the first-hour postepisiotomy repair	29.47 (4.22)	28.33 (4.88)	27.53 (3.39)	F=1.94	105, 2	0.149
Change in state anxiety before and after intervention	23.25 (5.88)	25.03 (6.30)	17.31 (5.72)	F=16.51	105, 2	<0.001
Change in trait anxiety before and after intervention	1.22 (2.09)	0.83 (1.95)	0.81 (1.22)	F=0.61	105, 2	0.546

SD=Standard deviation

Discussion

This RCT provides robust evidence that nonpharmacological interventions can effectively manage pain and anxiety during episiotomy repair, offering practical alternatives to traditional pharmacotherapy. This study aimed to compare the effects of VR and mint gum on pain intensity and anxiety during episiotomy repair in primiparous women. The findings of our study demonstrated that both VR and chewing mint gum resulted in a statistically significant reduction in pain and anxiety scores during episiotomy repair compared with the control group. However, no significant difference was observed between the VR and chewing mint gum groups, indicating that both interventions were similarly effective in alleviating pain and anxiety. The comparable effectiveness of both interventions may be explained by their shared foundation in distraction theory. VR creates an immersive audiovisual environment that engages multiple sensory pathways and effectively competes with nociceptive signals for neural attention. Similarly, chewing mint gum provides multisensory distraction through gustatory stimulation, olfactory input from menthol, and rhythmic motor activity of mastication, all of which may interfere with pain perception through the gate control mechanism.

Our results are consistent with the growing body of evidence supporting the use of nonpharmacological interventions for procedural pain management. For example, Orhan and Bülez examined the impact of VR on pain intensity and patient satisfaction during episiotomy repair and reported a significant reduction in pain and improved satisfaction in the intervention group.[15] Although their findings support our results, they acknowledged that a difference in educational levels between groups might have influenced outcomes, as education can affect how individuals perceive and respond to interventions. Another study conducted in 2016 aimed to evaluate the effect of VR on anxiety levels during episiotomy among primiparous women.[21] The findings revealed that VR significantly reduced anxiety. However, one notable limitation of this study was the lack of assessment of individual differences and baseline anxiety levels before the intervention. In contrast, in this study, anxiety levels were measured using a standardized questionnaire before the participants were assigned to different groups. Based on these results, participants were allocated to ensure homogeneity in baseline anxiety across groups. This approach strengthened the study’s internal validity by allowing for a more precise evaluation of the effects of the interventions on both anxiety and pain.

A study by Keleş and Altinkaya titled “The effect of VR with accompanying music on perceived pain in primiparous women during episiotomy” was conducted in Turkey and demonstrated a significant reduction in pain among participants in the intervention group.[22] However, in that study, multiple midwives performed the episiotomy repair procedures, and the music content was standardized for all participants without offering individual choice. These factors may have acted as confounding variables because they were not evenly distributed across the groups. In contrast, in the present study, all episiotomy repairs were performed by the same experienced midwife across all three work shifts, and the participants were given the freedom to select their preferred video content. Despite methodological differences, both studies support the use of VR glasses as an effective nonpharmacological strategy for pain reduction during episiotomy repair.

A study conducted in 2025 titled “The effect of chewing gum on the management of pain intensity and anxiety during labor in primiparous women” showed that chewing gum significantly reduced pain and anxiety levels in women.[23] These findings align with the results of this study, where chewing gum was also found to significantly reduce pain and anxiety. Chewing gum was used as a simple and accessible nonpharmacological intervention in both studies, leading to a meaningful reduction in both pain and anxiety. Furthermore, both studies involved primiparous women, which strengthens the consistency of the results.

In 2020, a study conducted in Turkey investigated the effect of chewing gum on pain and anxiety during venipuncture in children.[17] The results showed a significant reduction in pain but no significant difference in anxiety levels. In contrast, this study demonstrated a significant reduction in both pain and anxiety. This discrepancy may be attributed to the calming properties of mint in the gum used in this study. Mint contains compounds such as menthol, which act on the central nervous system to reduce the secretion of cortisol from the adrenal glands, thereby alleviating tension and anxiety.

A study conducted in 2022 in Gonabad aimed to compare the effects of VR and PMG on labor pain and anxiety. Both interventions significantly reduced the intensity of pain and anxiety, with no significant difference between them, indicating similar effectiveness. The methodological rigor of this trial is supported by several key strengths, including the use of blinded outcome assessors, randomization stratified by baseline anxiety to ensure group homogeneity, and having all procedures performed by a single experienced midwife to minimize operator-related variability. Furthermore, allowing participants to choose their preferred VR content enhanced the intervention’s ecological validity.

While pleasantness induction is a hypothesized mechanism, our study did not empirically measure it—a key limitation. Further limitations include the lack of participant blinding, the single-center design, and the absence of long-term follow-up. Notwithstanding these constraints, methodological strengths—such as blinded outcome assessment, anxiety-stratified randomization, procedural standardization by a single midwife, and participant-selected VR content—substantially strengthen the validity of our results. This trial robustly demonstrates that both VR and mint gum are similarly effective, nonpharmacological alternatives for acute pain and anxiety management during episiotomy repair. Future research should focus on multicenter trials with long-term follow-up, cost-effectiveness analyses, and direct quantification of proposed mechanisms like pleasantness induction.

Conclusion

This study demonstrated that both VR and chewing gum are effective nonpharmacological interventions for reducing pain and anxiety during episiotomy repair in primiparous women. Given their simplicity, low cost, and acceptability, these methods may serve as practical strategies to enhance maternal comfort and improve the quality of intrapartum care. The study interventions were well-tolerated with no reported harms.

Conflicts of interest

Nothing to declare.

Funding Statement

Rafsanjan School of Nursing and Midwifery