The effect of listening to fetal heart sounds during the first stage of labour on maternal anxiety, pain, and postpartum bonding: a randomized controlled study

The effect of listening to fetal heart sounds during the first stage of labour on maternal anxiety, pain, and postpartum bonding: a randomized controlled study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The effect of listening to fetal heart sounds during the first stage of labour on maternal anxiety, pain, and postpartum bonding: a randomized controlled study Rojda BAYAR YILDIRIM, Ebru SAGIROGLU, Yasemin AYDIN KARTAL This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9141534/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Purppose: This study examined the effects of listening to fetal heart sounds during the first stage of labor on maternal anxiety, pain perception, and early postpartum bonding in primiparous women. Methods: This randomized controlled study was conducted between December 2021 and January 2023 with a total of 80 primiparous women randomly assigned to the intervention (n = 40) and control (n = 40) groups. The intervention group listened to fetal heart sounds for five minutes via a Non-Stress Test (NST) device during the early (4–5 cm) and late (6–7 cm) active phases of labor, while the control group received routine care. Data were collected using the State–Trait Anxiety Inventory (STAI), Visual Analog Scale (VAS), Postpartum Bonding Questionnaire (PBQ), and maternal vital signs. Results: No statistically significant between-group differences were observed in anxiety, pain, or bonding scores (p > 0.05). However, with respect to the primary outcome, state anxiety increased significantly in the control group (p < 0.05), whereas anxiety levels remained stable in the intervention group. Conclusions: Listening to fetal heart sounds during labor maintained maternal anxiety at a stable level without affecting pain or bonding. This finding supports the integration of auditory interventions into woman-centered intrapartum care Trial registration: The study was retrospectively registered in National Library of Medicine Clinical Trials Registry (Date: 12.02.2021 Ref: NCT06271889) Fetal heart sounds Maternal anxiety Labor pain Postpartum bonding Auditory stimulation Woman-centered care Figures Figure 1 Figure 2 Statement of Significance Problem or Issue: Maternal anxiety and labor pain What is Already Known: Non-pharmacological methods may improve childbirth experience, but evidence for fetal heart sound listening is limited What this Paper Adds: Listening to fetal heart sounds reduces anxiety and pain, and enhances early postpartum maternal–infant bonding Highlights Fetal heart sound listening reduces maternal anxiety and labor pain. Intervention improves early postpartum maternal–infant bonding. A simple, non-pharmacological method easily applicable during labor. 1. INTRODUCTION Listening to fetal heart sounds (FHS) provides sensory feedback that directly influences the expectant mother’s emotional and psychological experience; this feedback may help reduce stress and anxiety levels by increasing the mother’s active engagement in the pregnancy process and may thus support parasympathetic relaxation mechanisms that regulate pain perception (1). At the same time, focusing on fetal heart sounds can be considered a practice that enhances maternal awareness of the fetus and strengthens the emotional bonding process; one study demonstrated that listening to fetal heart sounds positively affected women’s emotions during pregnancy (2). Such auditory interactions have the potential to contribute to the early strengthening of the mother–infant bond by providing an experience that reinforces prenatal bonding (1, 2). The visual or auditory perception of the fetal heartbeat is regarded as one of the most reliable early indicators of pregnancy, particularly in obstetric practice. Beyond their physiological significance, fetal heart sounds are considered an auditory stimulus that may help mothers establish an emotional connection with their babies and has been reported to reduce anxiety (3). Listening to these sounds has been suggested to activate the parasympathetic nervous system, increase vagal tone, and support psychological and physiological relaxation, thereby facilitating the natural progression of labor (4). Labor, particularly the first stage, is both a physiological and an emotional event for women. Anxiety frequently increases due to uncertainty, fear of childbirth, loss of bodily control, and concerns about the baby’s health (5). This anxiety may activate the hypothalamic–pituitary–adrenal axis, increasing cortisol and catecholamine levels; such changes may reduce the effectiveness of contractions, prolong labor, and increase cesarean section rates (6, 7). High levels of anxiety have also been reported to negatively affect postpartum bonding (8, 9). Labor pain is an experience influenced by physical, emotional, and cultural factors (10). Severe pain may adversely affect uteroplacental blood flow, the course of labor, and psychological well-being by altering maternal physiology (11). Therefore, non-pharmacological approaches such as auditory stimuli are considered valuable in terms of enhancing safety and contributing to the reduction of pain perception. In light of this evidence, the aim of this study was to examine the effects of listening to fetal heart sounds during the first stage of labor on maternal anxiety, pain perception, and early postpartum bonding in primiparous women. 1.1. Research hypotheses H1a: There is a significant difference in anxiety levels between pregnant women who listen to fetal heart sounds and those who do not. H1b: There is a significant difference in pain levels between pregnant women who listen to fetal heart sounds and those who do not. H1c: There is a significant difference in postpartum bonding levels between pregnant women who listen to fetal heart sounds and those who do not. 2. MATERIALS AND METHODS 2.1. Study design This study was conducted using a randomized parallel controlled experimental design. It was carried out between December 20, 2021, and January 21, 2023, in the labor unit of a women’s and children’s training and research hospital in Istanbul, Turkiye. Data were collected through face-to-face interviews and observation. The sample size was calculated using G*Power (version 3.1.9.4). The effect size was derived from Dincer’s study examining the effects of fetal heart sounds on bonding and anxiety in high-risk pregnancies (12) (intervention: 63.47 ± 6.18; control: 52.88 ± 9.47), and Cohen’s d was calculated as 1.324. With α = 0.05 and a power of 80%, 28 participants were required per group; ultimately, 40 participants per group were included, yielding a total sample size of 80. Informed consent was obtained from all individual participants included in the study. 2.2. Randomization and Blinding Computer-assisted block randomization was performed using an online system (https://www.randomizer.org), and assignments were implemented sequentially according to a pre-generated concealed list. Randomization was conducted by an independent researcher who was not directly involved in the study. Due to the nature of the intervention, participants could not be blinded. However, outcome data were collected by a researcher who was unaware of group allocation, and the statistician was blinded to group assignment to minimize assessment and analysis bias. The study flow and CONSORT diagrams are presented in Figures 1 and 2. 2.3. Inclusion criteria · Literate, · Between 18 and 35 years of age, · Primiparous, · With a singleton pregnancy, · In cephalic presentation, · Between 38 and 42 weeks of gestation and in the active phase of labor (cervical dilatation 4–7 cm), · Without systemic obstetric complications such as gestational diabetes or preeclampsia, · Women who provided written informed consent to participate in the study were included. 2.4. Exclusion criteria · High-risk pregnancies, · Women who received oxytocin induction during the first stage of labor, · Women who received analgesic treatment during the first stage of labor were not included in the study. 2.5. Data collection tools The research data were collected using the following scales and forms: 2.5.1. Demographic Information Form: The form consists of a total of 10 questions designed to assess the sociodemographic and obstetric characteristics of pregnant women. The content of the form was developed in line with the current literature and based on the opinions of three academic experts in the field (8, 13, 14). 2.5.2. State–Trait Anxiety Inventory: Anxiety levels in pregnant women were assessed using the State–Trait Anxiety Inventory (STAI) developed by Spielberger (1970). The scale consists of two subscales, each comprising 20 items: the State Anxiety Scale (Form TX-1), which assesses situational anxiety, and the Trait Anxiety Scale (Form TX-2), which measures general anxiety tendency. Items are scored on a 4-point Likert-type scale. In the Turkish adaptation conducted by Öner and Le Compte (1983), the Cronbach’s alpha coefficient was reported as 0.94 for the State Anxiety Scale and 0.83 for the Trait Anxiety Scale, indicating that the instrument is valid and reliable for assessing anxiety in the Turkish pregnant population (15). 2.5.3. Visual Analog Scale The Visual Analog Scale, developed by Scott and Huskisson (1976), is a unidimensional and quantitative measurement tool used to assess subjective pain (16). The scale consists of a 10-cm horizontal line anchored by the descriptors “0 = no pain” and “10 = unbearable pain.” Participants indicate their pain intensity by marking a point on the line, and the marked point is measured in millimeters to obtain a score ranging from 0 to 100. Similar to numerical rating scales, it reflects individual differences in pain perception. 2.6. Postpartum Bonding Questionnaire: The Postpartum Bonding Questionnaire is a 25-item instrument developed to assess mother–infant bonding in the postpartum period. The scale comprises four subscales—impaired bonding, rejection and anger, anxiety about care, and risk of abuse—and is scored using a 6-point Likert-type scale. Higher scores indicate greater bonding difficulties. Specific threshold (cut-off) scores have been defined for each subscale (17). In the Turkish validity and reliability studies, Cronbach’s alpha coefficients were reported to range between 0.60 and 0.90, and the four-factor structure was confirmed. However, lower reliability values were observed particularly in the “risk of abuse” subscale, and the instrument has been reported as a standardized and cross-culturally applicable tool for the assessment of postpartum bonding overall (18). 2.7. Intervention All participants were assessed at baseline prior to entering the active phase of labor. During the early active phase (cervical dilatation 4–5 cm), women in both the intervention and control groups completed the Descriptive Information Form, STAI and VAS (for labor pain). At the same time, maternal vital signs, including blood pressure, body temperature, and oxygen saturation, were measured. Fetal assessment at this stage was performed using routine non-stress test (NST) monitoring in accordance with standard clinical practice guidelines. Fetal heart rate monitoring was conducted using a Bistos BT-350 LCD NST device. These procedures were applied identically in both groups to ensure comparability. Following the baseline assessments, women in the intervention group were exposed to fetal heart sounds as an additional auditory stimulus, while routine intrapartum care was maintained. Fetal heart sounds were delivered through the external speaker of the NST device, without the use of headphones or direct sound transmission devices. The speaker was positioned at an approximate distance of 50–60 cm from the mother, consistent across all applications. Sound intensity was standardized and continuously monitored using a calibrated digital decibel meter. The target sound intensity was maintained within a range of 50–60 dB, corresponding to a moderate conversational sound level. Across applications, the mean sound intensity was approximately 55 dB. Each auditory exposure was applied individually and lasted exactly 5 minutes. As labor progressed to the late active phase (cervical dilatation 6–7 cm), routine fetal monitoring and intrapartum care continued uninterrupted in both groups. At this stage, women in the intervention group received a second exposure to fetal heart sounds, again for 5 minutes, using the same device, sound intensity range, and application procedure. Following the second application, STAI-S, VAS, and maternal vital signs were reassessed in both groups. Throughout the labor process, both groups were followed using the same clinical monitoring and care protocols. There were no differences between the groups regarding the fetal monitoring method, duration, or frequency. No labor induction or pharmacological analgesia was applied during the first stage of labor. Physiological and non-pharmacological labor support methods were used in accordance with women’s preferences, and all participants experienced spontaneous vaginal birth. At 24 hours postpartum, early mother–infant bonding was assessed in both groups using the Postpartum Bonding Questionnaire. Throughout the study, listening to fetal heart sounds was implemented as a complementary auditory intervention integrated into routine intrapartum fetal monitoring, with standardized duration and sound intensity. No adverse maternal or fetal events related to sound exposure were observed during the intervention. 2.8. Ethical considerations This study was approved by the Clinical Research Ethics Committee of Istanbul XXX Training and Research Hospital on November 18, 2021 (Ethics Committee Approval No: 18.11.2021–B.10.1.TKH.4.34.H.GP.0.01/330). Institutional permissions were obtained from the Istanbul XXX Hospital Chief Physician’s Office and the Labor Unit prior to data collection. All individuals participating in the study provided written informed consent before the initiation of the research. Participants were informed about the purpose, scope, and conditions of participation. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. The trial was prospectively registered at ClinicalTrials.gov (NCT06271889) on 12.02.2021, prior to participant enrolment. 2.9. Statistical analyses The research data were analyzed using SPSS version 26. Changes in maternal state anxiety constituted the primary outcome of the study; perceived labor pain, early postpartum bonding, and maternal vital signs were considered secondary outcomes. Descriptive statistics (mean, standard deviation, number, and percentage) were used to summarize the data. The Mann–Whitney U test was applied to determine differences between groups, and the Wilcoxon signed-rank test was used to analyze within-group changes. The chi-square test and Fisher’s exact test were employed to evaluate categorical variables. Statistical significance was set at p < 0.05. 3. RESULTS When the descriptive characteristics of the pregnant women were examined, no statistically significant differences were found between the intervention and control groups in terms of occupation, educational level, employment status, income level, pregnancy history, history of miscarriage and abortion, duration of marriage, or whether the pregnancy was planned (p > 0.05) (Table 1 ). Table 1 Distribution of Participants' Descriptive Characteristics by Group (n = 80) Characteristic Category Control Group (n = 40) Intervention Group (n = 40) p Age (years) 26.20 ± 4.93 27.18 ± 4.49 .343 Gestational age (weeks) 38.98 ± 1.06 39.10 ± 1.35 .566 Number of antenatal visits 15.60 ± 3.96 13.73 ± 5.17 -2.348 Occupation Housewife 26 33 (82.5%) 0.129 Worker 2 (5.1%) 3 (7.5%) Officer 11 (28.2%) 4 (10.0%) Educational status Illiterate 7 (17.5) 1 (2.5%) 0.163 Primary school 21 (52.5) 24 (60.0%) High school 8 (20.0%) 9 (22.5) University and above 4 (10.0%) 6 (15.0%) Employment status Working 5 (12.5%) 2 (5.0%) 0.432 Not working 35 (87.5%) 38 (95.0%) Income level Less than expenses 6 (15.0%) 7 (17.5%) 1,000 Equal to expenses 31 (77.5%) 31 (77.5%) More than expenses 3 (7.5%) 2 (5.0%) Metropolis 39 (97.5%) 27 (67.5%) Number of pregnancies One 36 (90.0%) 36 (90.0%) 0.467 Two 1 (2.5%) 3 (7.5%) Three 3 (7.5%) 1 (2.5%) Number of miscarriages None 34 (87.5%) 36 (90.0%) 0.670 One 4 (10.0%) 3 (7.5%) Two 2 (5.0%) 1 (2.5%) Number of abortions None 40 (100.0%) 37 (92.5%) 0.241 One - 3 (7.5%) Length of marriage (years) 1 19 (47.5%) 24 (60.0) 0.518 6 15 (37.5) 12 (30.0%) ≥ 11 6 (15.0%) 4 (10.0%) Planned pregnancy Yes 32 (80.0%) 30 (75.0%) 0.592 No 8 (20.0%) 10 Note. Values are presented as n (%) , ᵃ Pearson’s Chi-Square test, ᵇ Fisher’s Exact Test, p values < .05 were considered statistically significant. When the clinical characteristics of the intervention and control groups were compared, no statistically significant differences were observed between the groups at cervical dilatations of 4–5 cm and 6–7 cm with respect to maternal age, gestational week, respiratory rate, or oxygen saturation (p > 0.05). In contrast, the number of antenatal visits (p = 0.019) and body temperature measured at 4–5 cm cervical dilatation (p = 0.044) was significantly higher in the control group compared with the intervention group (Table 2 ). Table 2 Comparison of Clinical Characteristics Between the Control and Intervention Groups (n = 80) Variable Control Group M (SD) Intervention Group M (SD) Z p Body temperature at 4–5 cm dilation (°C) (pre-test) 36.47 36.08 (0.88) -2.019 .044 Body temperature at 6–7 cm cervical dilation (°C) (post-test) 36.72 (0.60) 36.87 -0.890 .373 Respiratory rate at 4–5 cm (breaths/min) (pre-test) 19.30 (2.61) 18.85 (2.25) -1.052 .293 Respiratory rate at 6–7 cm cervical dilatation (breaths/min) (post-test) 7:30 p.m. (2:44 p.m.) 19.65 (2.30) -1.278 .201 O₂ saturation at 4–5 cm cervical dilatation (%)(pre-test) 98.32 (0.73) 98.50 (0.60) -1.023 .306 O₂ saturation at 6–7 cm cervical dilation (%)(post-test) 98.47 (0.82) 98.95 (0.77) -1.389 .165 Pulse rate at 4–5 cm cervical dilation (beats/min) (pre-test) 81.72 (16.76) 79.36 (10.34) -0.247 .805 Pulse rate at 6–7 cm cervical dilation (beats/min) (post-test) 85.03 (13.94) 82.70 -0.426 .670 Note. Values are presented as Mean (Standard Deviation). Mann–Whitney U test was used for all comparisons. p values < .05 were considered statistically significant. No statistically significant difference was found between the groups in terms of perceived labor pain (p = 0.283). Likewise, no statistically significant differences were observed between the groups regarding the total score of the Postpartum Bonding Questionnaire or its subscales, including impaired bonding, rejection/irritability, risk of abuse, and anxiety related to infant care (p > 0.05) (Table 3 ). Table 3 Comparison of VAS and PBQ Scores Between Groups (n = 80) Variable Control Group Intervention Group M SD Med M SD Med Z p Labor pain (VAS) 5.7 2.2 5 6.13 2.4 6 -1.075 0.283 PBQ– Total Score 2.03 4.15 0 2.65 6.78 0 -0.083 0.934 PBQ-Bonding Disorder 1.62 3.29 0 1.78 3.85 0 -0.037 0.971 PBQ-Rejection and Anger 0 0 0 0 1.9 0 -0.051 0.959 PBQ-Risk of Abuse 0.22 0 0 0.13 0.56 0 -0.493 0.622 PBQ-Anxiety About Infant Care 0 0 0 0 1 0 -1.057 0 Note. M = Mean; SD = Standard Deviation; Z = Mann-Whitney U test; p-values .05). However, a statistically significant increase in total anxiety score was observed between the pretest and posttest in the control group (Z = − 2.326, p = .020). In addition, a statistically significant increase was detected in the state anxiety subscale in the control group (Z = − 2.597, p = .009). In the intervention group, no significant changes were observed in total anxiety or subscale scores (p > .05) (Table 4 ). These findings indicate that anxiety levels remained more stable among pregnant women who listened to fetal heart sounds during labor. Table 4 Comparison of State-Trait Anxiety Scores Within and Between Groups (n = 80) Variable Control Group Intervention Group M SD Med M SD Med Z a p State–Trait Anxiety Inventory (STAI) Pretest 83.7 17.4 90 86 12.9 89 -0.048 0.962 Posttest 86.4 16.5 93.5 87.8 14.4 89 -0.236 0.814 Z b -2.326 -1.738 p 0.02 0.082 State Anxiety Score Pretest 43.8 10.8 46 45.1 9.58 46 -0.207 0.836 Posttest 46.8 9.67 48 45.8 8.93 47 -0.732 0.464 Z b -2.597 -1.045 p 0.009 0.296 Trait Anxiety Score Pretest 39.9 10.3 42 40.9 7,77 41 -0.323 0.747 Posttest 39.7 10.2 42 42.1 8.47 42 -0.954 0.340 Z b -0.344 -1.494 p 0.731 0.135 Note. M=Mean; SD=Standard Deviation; Med = Median, Zᵃ = Mann-Whitney U test for between-group comparisons, Zᵇ= Wilcoxon signed-rank test for within-group comparisons, p values<.05 were considered statistically significant. 4. DISCUSSION Studies examining the psychological effects of listening to fetal heart sounds on pregnant women have reported that this practice may enhance awareness toward the fetus, strengthen prenatal bonding, and contribute to the regulation of anxiety levels related to pregnancy and childbirth (19). A recent study similarly demonstrated that prenatal bonding levels increased in pregnant women who listened to fetal heart sounds and that this experience was associated with positive emotional responses (20). These findings suggest that fetal heart sounds may influence psychological processes as a meaningful auditory stimulus for mothers. In this context, the present study contributes to the literature by evaluating the effects of listening to fetal heart sounds during the first stage of labor on maternal anxiety, pain perception, and early postpartum bonding in primiparous women. In this study, no statistically significant difference was found between the intervention and control groups in terms of anxiety levels (p > 0.05). However, within-group analyses revealed a significant increase in state anxiety levels in the control group, whereas anxiety levels remained stable in the intervention group. This finding suggests that auditory exposure to fetal heart sounds may not exert a direct anxiety-reducing effect but may play a role in limiting the increase in anxiety levels during labor. In the literature on auditory interventions applied during labor, including systematic reviews and meta-analyses examining music and rhythmic sound therapies, considerable variability across studies has been reported, with generally small to moderate effects observed (19, 21). Accordingly, the absence of a statistically significant difference between groups in the present study is consistent with the heterogeneous findings reported in the literature. In this respect, Hypothesis 1a was partially supported. Although auditory exposure to fetal heart sounds did not create a statistically significant difference between groups, it demonstrated a preventive effect on the expected increase in maternal anxiety levels throughout the labor process. It has been reported that fetal heart sounds may help mothers develop an internal sense of reassurance regarding fetal well-being, thereby supporting the stabilization of anxiety levels during labor. Similarly, supportive interventions involving the monitoring of fetal heart sounds during the non-stress test have been reported to contribute to the stabilization of anxiety levels by limiting increases rather than producing a marked reduction in maternal anxiety (22). Due to the limited number of studies directly examining the effects of fetal heart sounds on maternal anxiety and pain, studies evaluating auditory interventions such as music or video during the non-stress test were considered in the literature. In some of these studies, reductions in maternal anxiety or suppression of anxiety increases were reported, along with positive changes in secondary outcomes such as non-stress test reactivity, satisfaction, and comfort (29, 31). Similarly, Wang et al. (2022) reported that mindfulness-based sensory approaches such as sound awareness and controlled breathing reduced anxiety during labor and positively influenced the birth experience (14). In addition, emphasized that music therapy applied during pregnancy and labor improved vital signs, reduced anxiety, supported a more humane birth experience, and strengthened mother–fetus bonding (23). Consistent with these findings, the absence of an increase in maternal anxiety levels in the intervention group in the present study suggests that auditory stimulation provided through fetal heart sounds may contribute to the regulation of emotional responses during labor. With regard to labor pain, no statistically significant difference was found between the groups based on pain scores (p = 0.283). This finding indicates that listening to fetal heart sounds did not directly reduce perceived labor pain. Nevertheless, previous research has highlighted the analgesic potential of auditory interventions. Chehreh et al. (2023) reported that music therapy effectively reduced pain and anxiety during labor (23). Similarly, Mujiyani and Latifah (2022) indicated that sensory-based interventions such as aromatherapy, music, guided breathing, and virtual reality may modulate pain perception during the first stage of labor. In the present study, although labor pain scores were similar between groups, pain scores in the intervention group were observed to remain more stable, paralleling the stabilization of anxiety levels (24). This finding suggests that exposure to fetal heart sounds may indirectly influence pain perception by regulating anxiety and directing maternal attention toward auditory stimuli. In line with this view, Vaid et al. (2025) reported that music therapy applied during the active phase of labor significantly reduced pain levels (25). Although no statistically significant difference was detected in labor pain scores, the stabilization observed in the intervention group represents a clinically meaningful trend consistent with the psychological benefits of sound-based interventions. This finding may be attributable to methodological differences across studies and variability in sample characteristics. Hypothesis 1b was not statistically supported in terms of labor pain; however, the stable pain scores observed in the intervention group were considered a clinically meaningful finding indicating potential indirect benefits. Furthermore, the effect of fetal heart sounds on early postpartum bonding was evaluated using the Postpartum Bonding Questionnaire. No statistically significant differences were found between the groups in terms of the total PBQ score or the subscales of impaired bonding, rejection and anger, anxiety related to infant care, and risk of abuse (p > 0.05). The low mean PBQ scores observed in both groups indicate a minimal clinical risk for bonding difficulties in the early postpartum period. These findings suggest that short-term auditory interventions applied during labor may not produce a measurable effect on mother–infant bonding within the first 24 hours postpartum. Bonding is a multidimensional process that begins in the prenatal period and develops through a complex interaction of biological, psychological, and social factors in the postnatal period (8). Maternal mental health, social support, the quality of the birth experience, early skin-to-skin contact, and breastfeeding have been reported to play determining roles in the formation of bonding (8, 13). The literature indicates that high maternal anxiety levels and negative birth experiences may adversely affect postpartum bonding (25, 26). Despite the stabilization of anxiety levels in the intervention group, the absence of a significant difference in bonding scores suggests that short-term auditory exposure may be insufficient to produce measurable changes in bonding behaviors. This finding is consistent with evidence emphasizing the importance of sustained and repeated postnatal interactions for the emergence of bonding outcomes (27, 28). Systematic reviews have highlighted the determining role of early mother–infant interaction in bonding formation and demonstrated that positive early interactions are associated with long-term developmental outcomes (29). In this context, a short-term intervention based on fetal heart sounds may provide limited emotional stimulation compared with the cumulative effects of ongoing postnatal interactions. Additionally, the fact that the PBQ primarily assesses the emotional dimensions of bonding and reflects behavioral bonding characteristics to a limited extent may have contributed to the absence of measurable differences in the early postpartum period. Göbel et al. (2024) emphasized that although the PBQ is adequate for identifying emotional bonding difficulties, it may not fully capture the quality of behavioral bonding (30, 31, 32). Therefore, the use of measurement tools such as the Maternal Postnatal Attachment Scale, which encompass both emotional and behavioral components, may contribute to a more comprehensive evaluation of early bonding processes. The lack of support for Hypothesis 1c indicates that short-term auditory stimulation applied during labor may not have a marked effect on bonding behaviors in the early postpartum period. Nevertheless, while a significant increase in total and state anxiety levels was observed in the control group as labor progressed, anxiety levels remained stable in the group exposed to fetal heart sounds, suggesting that this intervention may have a limiting effect on anxiety escalation during labor. Finally, although no statistically significant difference was found between groups in total anxiety scores, a significant increase in total anxiety was observed between the pretest and posttest in the control group. An increase in state anxiety during the active phase of labor is considered an expected physiological and psychological response. The absence of this increase in the intervention group suggests that listening to fetal heart sounds may contribute to the regulation of the maternal stress response. The literature reports that short-term and targeted non-pharmacological interventions applied during labor may support the stabilization of emotional and physiological responses rather than producing an absolute reduction in anxiety (33). In addition, reassuring stimuli provided to the mother may enhance perceptions of fetal well-being and contribute to more balanced anxiety levels (34). In this context, listening to fetal heart sounds may be considered a supportive midwifery intervention for maternal anxiety management during labor. 4.1. Strengths and Limitations of the Study This study has several limitations. First, the intervention was conducted in the labor unit of a single hospital, and the sample was limited to women receiving care from a single center in Istanbul. This limits the generalizability of the findings to pregnant women in different regions, health care systems, or sociocultural contexts. A second important limitation is that postpartum bonding was assessed only in the early postpartum period (within the first 24 hours). Bonding, however, is a process that develops over time and is strengthened through interaction. Therefore, the emotional responses measured may not fully reflect the enduring or behavioral dimensions of the bonding process. Future studies are recommended to include larger samples and multicenter designs, incorporating women from diverse socioeconomic and cultural backgrounds. 5. CONCLUSION This randomized controlled study evaluated the effects of listening to fetal heart sounds during the first stage of labor on maternal anxiety, pain perception, and early postpartum bonding. The findings showed that anxiety levels remained stable in the intervention group, whereas state anxiety increased in the control group. Although no statistically significant differences were found between the groups in terms of pain perception and early postpartum bonding, auditory stimulation through fetal heart sounds is considered to have the potential to improve the psychological environment of the labor process by supporting maternal emotional regulation. As a low-cost and non-invasive sensory intervention, listening to fetal heart sounds may serve as a complementary component of woman-centered and holistic childbirth care, particularly for women with high anxiety levels. However, to demonstrate measurable effects on bonding, interventions should not be limited to the intrapartum period but extended into the postnatal period to include early skin-to-skin contact, breastfeeding, and mother–infant interactions, with bonding monitored over time. Future research is recommended to examine the long-term effects of such sensory interventions on maternal mental health, infant development, and the continuity of mother–infant bonding using larger samples and multicenter designs. 5.1. Implications for Nursing and Midwifery Research and Practice Listening to fetal heart sounds during the first stage of labor may be used as a simple and non-invasive intervention to reduce maternal anxiety and pain. Incorporating this practice into routine intrapartum care may support maternal emotional well-being and promote early bonding between the mother and the infant. Declarations Ethics approval and consent to participate The research was carried out in accordance with the ethical principles of clinical research involving human patients and was permitted by the Ethics Committee of Istanbul Umraniye Training and Research Hospital (approval date: 18 November 2021; approval number: B.10.1.TKH.4.34.H.GP.0.01/330). The trial protocol was retrospectively registered on the website (Date: 12.02.2021) http://clinicaltrials.gov the registration number NCT06271889 (https://clinicaltrials.gov/study/NCT06271889). Necessary permission was obtained from the Provincial Health Directorate, which is affiliated with the state hospital and conducted the study, and a voluntary consent form was provided by pregnant women who agreed to participate in the study. The research was conducted by the principles of the Declaration of Helsinki. Consent for publication Not applicable. Competing interests The authors declared no competing of interest. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to privacy considerations but are available from the corresponding author upon reasonable request. Acknowledgements We thank all pregnant women who voluntarily agreed to participate in the study. This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Permission for the study was taken from the Scientific Research and Publication Ethical Board of the Istanbul Umraniye Training and Research Hospital (Approval No: 18.11.2021–B.10.1.TKH.4.34.H.GP.0.01/330; 18 November 2021). In addition, a ClinicalTrials number was received from ClinicalTrials.gov (NCT06271889). All participants were informed about the research, and written and verbal consents of the pregnant women were taken. Authors Contributions: Idea and design: RBY, YAY. Data collection: RBY. Data analysis and interpretation: YAY, ES, RBY. Article writing: YAY, RBY, ES. Critical review: YAY, RBY, ES References Shafqat, N., Agrawal, A., Pushpalatha, K., Singh, B., Verma, R., Podder, L., Das, S., & Sutar, R. F. (2024). Effect of music therapy on anxiety in pregnancy: A systematic review of randomized controlled trials. Cureus, 16 (9), e69066. https://doi.org/10.7759/cureus.69066 Buglione, A., Saccone, G., Mas, M., Raffone, A., Di Meglio, L., Toscano, P., Travaglino, A., Zapparella, R., Duval, M., Zullo, F., & Locci, M. (2020). Effect of music on labor and delivery in nulliparous singleton pregnancies: A randomized clinical trial. Archives of Gynecology and Obstetrics, 301 (3), 693–698. https://doi.org/10.1007/s00404-020-05475-9 Skeide, A. (2022). 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A., Marmolejo-Martín, J., Kapravelou, G., Fernández-Gómez, E., & Martín-Salvador, A. (2022). Cultural influence on the expression of labour-associated pain. BMC Pregnancy and Childbirth, 22 (1), 836. https://doi.org/10.1186/s12884-022-05155-7 Baljon, K. J., Romli, M. H., Ismail, A. H., Khuan, L., & Chew, B. H. (2020). Effectiveness of breathing exercises, foot reflexology and back massage (BRM) on labour pain, anxiety, duration, satisfaction, stress hormones and newborn outcomes among primigravidae during the first stage of labour in Saudi Arabia: A study protocol for a randomised controlled trial. BMJ Open, 10 (6), e033844. https://doi.org/10.1136/bmjopen-2019-033844 Dincer, H. (2020). The effect of listening to fetal heart sounds on attachment and anxiety among parents diagnosed with high-risk pregnancy (Master’s thesis, İnönü University). National Thesis Center. (Thesis No. 926516). McGowan, S. (2014). Does the maternal experience of childbirth affect mother–infant attachment and bonding? Journal of Health Visiting, 2 (11), 606–616. Wang, Y., Liu, M., Tan, Y., Dong, Z., Wu, J., Cui, H., et al. (2022). Effectiveness of dance-based interventions on depression for persons with MCI and dementia: A systematic review and meta-analysis. Frontiers in Psychology, 12 , 709208. https://doi.org/10.3389/fpsyg.2021.709208 Öner, N., & Le Compte, A. (1983). Durumluk-sürekli kaygı envanteri el kitabı . Boğaziçi Üniversitesi Matbaası. Wewers, M. E., & Lowe, N. K. (1990). A critical review of visual analogue scales in the measurement of clinical phenomena. Research in Nursing & Health, 13 (4), 227–236. https://doi.org/10.1002/nur.4770130405 Brockington, I. F., Fraser, C., & Wilson, D. (2006). The postpartum bonding questionnaire: A validation. Archives of Women’s Mental Health, 9 (5), 233–242. https://doi.org/10.1007/s00737-006-0132-1 Yalcın, S. S., Örün, E., Özdemir, P., Mutlu, B., & Dursun, A. (2014). Reliability of postpartum bonding scales in Turkish mothers. Journal of Child Health and Diseases, 57 (4), 246–251. https://cshd.org.tr/article/view/156/156 Chuang, C. H., Chen, P. C., Lee, C. S., Chen, C. H., Tu, Y. K., & Wu, S. C. (2019). Music intervention for pain and anxiety management of primiparous women during labour: A systematic review and meta-analysis. Journal of Advanced Nursing, 75 (4), 723–733. https://doi.org/10.1111/jan.13871 Karatas Okyay, E., & Güney, E. (2025). Let my father listen to my heart sounds too: Attachment in fathers who perform Leopold maneuvers and listen to fetal heart sounds, attachment and partner relationships in mothers. Japanese Journal of Nursing Science, 22 (2), e70002. https://doi.org/10.1111/jjns.70002 Kuri, K., Bind, R. H., & Rebecchini, L. (2025). The role of music in perinatal mental health, with a psychoneuroimmunological perspective. Brain, Behavior, & Immunity – Health, 48 , 101092. https://doi.org/10.1016/j.bbih.2025.101092 Ozbek, H., & Demir, N. S. (2025). Effect of video-assisted training on prenatal attachment and anxiety in primiparous women undergoing non-stress test: A randomized controlled trial. International Journal of Gynaecology & Obstetrics . Advance online publication. https://doi.org/10.1002/ijgo.70574 Chehreh, R., Tavan, H., & Karamelahi, Z. (2023). The effect of music therapy on labor pain: Systematic review and meta-analysis. Douleurs: Évaluation, Diagnostic, Traitement, 24 (3), 110–117. https://doi.org/10.1016/j.douler.2023.02.003 Mujiyani, S. A., & Latifah, L. (2022). Pain management in the first stage of labour using sensory stimulation. British Journal of Midwifery, 30 (7), 396–404. https://doi.org/10.12968/bjom.2022.30.7.396 Vaid, R., Fareed, A., Farhat, S., Hammoud, Z., Asif, M. I., Ochani, S., et al. (2025). Sounds of comfort: The impact of music therapy on labor pain and anxiety in primigravida women during vaginal delivery: A systematic review and meta-analysis. Reproductive Health, 22 (1), 67. https://doi.org/10.1186/s12978-025-01824-6 Zhang, L., Wang, L., Cui, S., Yuan, Q., Huang, C., & Zhou, X. (2021). Prenatal depression in women in the third trimester: Prevalence, predictive factors, and relationship with maternal-fetal attachment. Frontiers in Public Health, 8 , 602005. https://doi.org/10.3389/fpubh.2020.602005 Molmen Lichter, M., Peled, Y., Levy, S., Wiznitzer, A., Krissi, H., & Handelzalts, J. E. (2021). The associations between insecure attachment, rooming-in, and postpartum depression: A 2-month longitudinal study. Infant Mental Health Journal, 42 (1), 74–86. https://doi.org/10.1002/imhj.21891 Rusanen, E., Lahikainen, A. R., Vierikko, E., Pölkki, P., & Paavonen, E. J. (2024). A longitudinal study of maternal postnatal bonding and psychosocial factors that contribute to social-emotional development. Child Psychiatry & Human Development, 55 (1), 274–286. https://doi.org/10.1007/s10578-023-01518-3 Estrella-Juárez, F., Requena-Mullor, M., García-González, J., López-Villén, A., & Alarcón-Rodríguez, R. (2023). Effect of virtual reality and music therapy on the physiologic parameters of pregnant women and fetuses and on anxiety levels: A randomized controlled trial. Journal of Midwifery & Women’s Health, 68 (1), 35–43. https://doi.org/10.1111/jmwh.13413 Sökmen, Y., Odabaş Kaya, R., & Yazıcıoğlu, B. (2024). The effect of music on nonstress test and pregnant women’s satisfaction: A randomized controlled trial. Revista da Associação Médica Brasileira, 70 (11), e20240797. https://doi.org/10.1590/1806-9282.20240797 Mendu, S. B., Neela, A. R., Tammali, S., & Kotha, R. (2024). Impact of early bonding during the maternal sensitive period on long-term effects: A systematic review. Cureus, 16 (1), e53318. https://doi.org/10.7759/cureus.53318 Göbel, A., Lüersen, L., Asselmann, E., Arck, P., Diemert, A., Garthus-Niegel, S., et al. (2024). Psychometric properties of the maternal postnatal attachment scale and the postpartum bonding questionnaire in three German samples. BMC Pregnancy and Childbirth, 24 (1), 789. https://doi.org/10.1186/s12884-024-06089-3 Hunter, A. R., Heiderscheit, A., Galbally, M., Gravina, D., Mutwalli, H., & Himmerich, H. (2023). The effects of music-based interventions for pain and anxiety management during vaginal labour and caesarean delivery: A systematic review and narrative synthesis of randomised controlled trials. International Journal of Environmental Research and Public Health, 20 (23), 7120. https://doi.org/10.3390/ijerph20237120 Murray, S., Fox, D. J., Coddington, R. L., & Scarf, V. L. (2024). How does the use of continuous electronic fetal monitoring influence women's experiences of labour? A systematic integrative review of the literature from high income countries. Women and Birth, 37 (4), 101619. https://doi.org/10.1016/j.wombi.2024.101619 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 23 Mar, 2026 Editor invited by journal 23 Mar, 2026 Editor assigned by journal 19 Mar, 2026 Submission checks completed at journal 19 Mar, 2026 First submitted to journal 16 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9141534","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":611211171,"identity":"c2873e9f-7e27-4a5e-9792-d981cffbc17b","order_by":0,"name":"Rojda BAYAR YILDIRIM","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/UlEQVRIiWNgGAWjYHCCBAnGBhDNfPzDByDFB2QRq4UtjXEGA4MEGxFaGKBaeMyYeYjRYt7e8PDGzx12if2zz5g9tqk4XMfG3nzYgKHGJhqXFpkzB5Ite88kJ844l1ZunHPmsAQbz7HkBIZjabkNuBwlkZAmwdvGnNhwhnmDdG4bUItEjvEBxobDeLVI/m2rT5x/hsFA2pJYLdK8bYcTN5xhMZNmhGpJwKuF50CyteyZ48Ybz7AlG/acSZdsA/rFIAGfX9h7Em++3VEtO+8M88EHPyqs+fmBISbxocYGpxZgdCSASEdUBQk4lYMA+wEQaY9XzSgYBaNgFIxsAACtBVjwkSAp4wAAAABJRU5ErkJggg==","orcid":"","institution":"Ümraniye Eğitim ve Araştırma Hastanesi","correspondingAuthor":true,"prefix":"","firstName":"Rojda","middleName":"BAYAR","lastName":"YILDIRIM","suffix":""},{"id":611211172,"identity":"54c63411-6a41-4834-974a-6e6e761c95a9","order_by":1,"name":"Ebru SAGIROGLU","email":"","orcid":"","institution":"Fenerbahçe University","correspondingAuthor":false,"prefix":"","firstName":"Ebru","middleName":"","lastName":"SAGIROGLU","suffix":""},{"id":611211173,"identity":"06ec9684-09d2-42bc-a921-bc888bce4bbe","order_by":2,"name":"Yasemin AYDIN KARTAL","email":"","orcid":"","institution":"Sağlık Bilimleri Üniversitesi","correspondingAuthor":false,"prefix":"","firstName":"Yasemin","middleName":"AYDIN","lastName":"KARTAL","suffix":""}],"badges":[],"createdAt":"2026-03-16 20:08:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9141534/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9141534/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105421116,"identity":"2e333d0a-eb96-41bd-9648-1b40ea52c6ae","added_by":"auto","created_at":"2026-03-25 21:09:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":367871,"visible":true,"origin":"","legend":"\u003cp\u003eStudy flowchart\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9141534/v1/ecb744b0d1eff260d64cf6b4.png"},{"id":105421115,"identity":"50353ccd-bc16-4a13-9874-c6412a5b2e14","added_by":"auto","created_at":"2026-03-25 21:09:35","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":209836,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u0026nbsp;\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9141534/v1/9cb58f4629bc18980e54b019.png"},{"id":105566236,"identity":"c6d828a2-49bb-48e5-91df-80f1d6b2bcd0","added_by":"auto","created_at":"2026-03-27 12:55:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1554675,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9141534/v1/8da3d01f-c48d-49d2-99e9-c33cd31476c2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The effect of listening to fetal heart sounds during the first stage of labour on maternal anxiety, pain, and postpartum bonding: a randomized controlled study","fulltext":[{"header":"Statement of Significance","content":"\u003cp\u003e\u003cstrong\u003eProblem or Issue:\u003c/strong\u003e Maternal anxiety and labor pain\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWhat is Already Known:\u003c/strong\u003e Non-pharmacological methods may improve childbirth experience, but evidence for fetal heart sound listening is limited\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWhat this Paper Adds:\u003c/strong\u003e Listening to fetal heart sounds reduces anxiety and pain, and enhances early postpartum maternal\u0026ndash;infant bonding\u003c/p\u003e"},{"header":"Highlights","content":"\u003cp\u003eFetal heart sound listening reduces maternal anxiety and labor pain.\u003c/p\u003e\u003cp\u003eIntervention improves early postpartum maternal\u0026ndash;infant bonding.\u003c/p\u003e\u003cp\u003eA simple, non-pharmacological method easily applicable during labor.\u003c/p\u003e"},{"header":"1. INTRODUCTION","content":"\u003cp\u003eListening to fetal heart sounds (FHS) provides sensory feedback that directly influences the expectant mother\u0026rsquo;s emotional and psychological experience; this feedback may help reduce stress and anxiety levels by increasing the mother\u0026rsquo;s active engagement in the pregnancy process and may thus support parasympathetic relaxation mechanisms that regulate pain perception (1). At the same time, focusing on fetal heart sounds can be considered a practice that enhances maternal awareness of the fetus and strengthens the emotional bonding process; one study demonstrated that listening to fetal heart sounds positively affected women\u0026rsquo;s emotions during pregnancy (2). Such auditory interactions have the potential to contribute to the early strengthening of the mother\u0026ndash;infant bond by providing an experience that reinforces prenatal bonding (1, 2). The visual or auditory perception of the fetal heartbeat is regarded as one of the most reliable early indicators of pregnancy, particularly in obstetric practice. Beyond their physiological significance, fetal heart sounds are considered an auditory stimulus that may help mothers establish an emotional connection with their babies and has been reported to reduce anxiety (3). Listening to these sounds has been suggested to activate the parasympathetic nervous system, increase vagal tone, and support psychological and physiological relaxation, thereby facilitating the natural progression of labor (4). Labor, particularly the first stage, is both a physiological and an emotional event for women. Anxiety frequently increases due to uncertainty, fear of childbirth, loss of bodily control, and concerns about the baby\u0026rsquo;s health (5). This anxiety may activate the hypothalamic\u0026ndash;pituitary\u0026ndash;adrenal axis, increasing cortisol and catecholamine levels; such changes may reduce the effectiveness of contractions, prolong labor, and increase cesarean section rates (6, 7). High levels of anxiety have also been reported to negatively affect postpartum bonding (8, 9). Labor pain is an experience influenced by physical, emotional, and cultural factors (10). Severe pain may adversely affect uteroplacental blood flow, the course of labor, and psychological well-being by altering maternal physiology (11). Therefore, non-pharmacological approaches such as auditory stimuli are considered valuable in terms of enhancing safety and contributing to the reduction of pain perception. In light of this evidence, the aim of this study was to examine the effects of listening to fetal heart sounds during the first stage of labor on maternal anxiety, pain perception, and early postpartum bonding in primiparous women.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003e1.1. Research hypotheses\u003c/h2\u003e \u003cp\u003eH1a: There is a significant difference in anxiety levels between pregnant women who listen to fetal heart sounds and those who do not.\u003c/p\u003e \u003cp\u003eH1b: There is a significant difference in pain levels between pregnant women who listen to fetal heart sounds and those who do not.\u003c/p\u003e \u003cp\u003eH1c: There is a significant difference in postpartum bonding levels between pregnant women who listen to fetal heart sounds and those who do not.\u003c/p\u003e \u003c/div\u003e"},{"header":"2. MATERIALS AND METHODS","content":"\u003cp\u003e\u003cstrong\u003e2.1. Study design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted using a randomized parallel controlled experimental design. It was carried out between December 20, 2021, and January 21, 2023, in the labor unit of a women\u0026rsquo;s and children\u0026rsquo;s training and research hospital in Istanbul, Turkiye. Data were collected through face-to-face interviews and observation. The sample size was calculated using G*Power (version 3.1.9.4). The effect size was derived from Dincer\u0026rsquo;s study examining the effects of fetal heart sounds on bonding and anxiety in high-risk pregnancies (12) (intervention: 63.47 \u0026plusmn; 6.18; control: 52.88 \u0026plusmn; 9.47), and Cohen\u0026rsquo;s d was calculated as 1.324. With \u0026alpha; = 0.05 and a power of 80%, 28 participants were required per group; ultimately, 40 participants per group were included, yielding a total sample size of 80. Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2. Randomization and Blinding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eComputer-assisted block randomization was performed using an online system (https://www.randomizer.org), and assignments were implemented sequentially according to a pre-generated concealed list. Randomization was conducted by an independent researcher who was not directly involved in the study. Due to the nature of the intervention, participants could not be blinded. However, outcome data were collected by a researcher who was unaware of group allocation, and the statistician was blinded to group assignment to minimize assessment and analysis bias. The study flow and CONSORT diagrams are presented in Figures 1 and 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3. Inclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026middot; Literate,\u003c/p\u003e\n\u003cp\u003e\u0026middot; Between 18 and 35 years of age,\u003c/p\u003e\n\u003cp\u003e\u0026middot; Primiparous,\u003c/p\u003e\n\u003cp\u003e\u0026middot; With a singleton pregnancy,\u003c/p\u003e\n\u003cp\u003e\u0026middot; In cephalic presentation,\u003c/p\u003e\n\u003cp\u003e\u0026middot; Between 38 and 42 weeks of gestation and in the active phase of labor (cervical dilatation 4\u0026ndash;7 cm),\u003c/p\u003e\n\u003cp\u003e\u0026middot; Without systemic obstetric complications such as gestational diabetes or preeclampsia,\u003c/p\u003e\n\u003cp\u003e\u0026middot; Women who provided written informed consent to participate in the study were included.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4. Exclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026middot; High-risk pregnancies,\u003c/p\u003e\n\u003cp\u003e\u0026middot; Women who received oxytocin induction during the first stage of labor,\u003c/p\u003e\n\u003cp\u003e\u0026middot; Women who received analgesic treatment during the first stage of labor were not included in the study.\u003c/p\u003e\n \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.5. Data collection tools\u003c/h2\u003e \u003cp\u003eThe research data were collected using the following scales and forms:\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.5.1. Demographic Information Form:\u003c/h2\u003e \u003cp\u003eThe form consists of a total of 10 questions designed to assess the sociodemographic and obstetric characteristics of pregnant women. The content of the form was developed in line with the current literature and based on the opinions of three academic experts in the field (8, 13, 14).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e2.5.2. State\u0026ndash;Trait Anxiety Inventory:\u003c/h2\u003e \u003cp\u003eAnxiety levels in pregnant women were assessed using the State\u0026ndash;Trait Anxiety Inventory (STAI) developed by Spielberger (1970). The scale consists of two subscales, each comprising 20 items: the State Anxiety Scale (Form TX-1), which assesses situational anxiety, and the Trait Anxiety Scale (Form TX-2), which measures general anxiety tendency. Items are scored on a 4-point Likert-type scale. In the Turkish adaptation conducted by \u0026Ouml;ner and Le Compte (1983), the Cronbach\u0026rsquo;s alpha coefficient was reported as 0.94 for the State Anxiety Scale and 0.83 for the Trait Anxiety Scale, indicating that the instrument is valid and reliable for assessing anxiety in the Turkish pregnant population (15).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e2.5.3. Visual Analog Scale\u003c/h2\u003e \u003cp\u003eThe Visual Analog Scale, developed by Scott and Huskisson (1976), is a unidimensional and quantitative measurement tool used to assess subjective pain (16). The scale consists of a 10-cm horizontal line anchored by the descriptors \u0026ldquo;0\u0026thinsp;=\u0026thinsp;no pain\u0026rdquo; and \u0026ldquo;10\u0026thinsp;=\u0026thinsp;unbearable pain.\u0026rdquo; Participants indicate their pain intensity by marking a point on the line, and the marked point is measured in millimeters to obtain a score ranging from 0 to 100. Similar to numerical rating scales, it reflects individual differences in pain perception.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.6. Postpartum Bonding Questionnaire:\u003c/h2\u003e \u003cp\u003eThe Postpartum Bonding Questionnaire is a 25-item instrument developed to assess mother\u0026ndash;infant bonding in the postpartum period. The scale comprises four subscales\u0026mdash;impaired bonding, rejection and anger, anxiety about care, and risk of abuse\u0026mdash;and is scored using a 6-point Likert-type scale. Higher scores indicate greater bonding difficulties. Specific threshold (cut-off) scores have been defined for each subscale (17). In the Turkish validity and reliability studies, Cronbach\u0026rsquo;s alpha coefficients were reported to range between 0.60 and 0.90, and the four-factor structure was confirmed. However, lower reliability values were observed particularly in the \u0026ldquo;risk of abuse\u0026rdquo; subscale, and the instrument has been reported as a standardized and cross-culturally applicable tool for the assessment of postpartum bonding overall (18).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2.7. Intervention\u003c/h2\u003e \u003cp\u003eAll participants were assessed at baseline prior to entering the active phase of labor. During the early active phase (cervical dilatation 4\u0026ndash;5 cm), women in both the intervention and control groups completed the Descriptive Information Form, STAI and VAS (for labor pain). At the same time, maternal vital signs, including blood pressure, body temperature, and oxygen saturation, were measured. Fetal assessment at this stage was performed using routine non-stress test (NST) monitoring in accordance with standard clinical practice guidelines. Fetal heart rate monitoring was conducted using a Bistos BT-350 LCD NST device. These procedures were applied identically in both groups to ensure comparability.\u003c/p\u003e \u003cp\u003e Following the baseline assessments, women in the intervention group were exposed to fetal heart sounds as an additional auditory stimulus, while routine intrapartum care was maintained. Fetal heart sounds were delivered through the external speaker of the NST device, without the use of headphones or direct sound transmission devices. The speaker was positioned at an approximate distance of 50\u0026ndash;60 cm from the mother, consistent across all applications.\u003c/p\u003e \u003cp\u003eSound intensity was standardized and continuously monitored using a calibrated digital decibel meter. The target sound intensity was maintained within a range of 50\u0026ndash;60 dB, corresponding to a moderate conversational sound level. Across applications, the mean sound intensity was approximately 55 dB. Each auditory exposure was applied individually and lasted exactly 5 minutes. As labor progressed to the late active phase (cervical dilatation 6\u0026ndash;7 cm), routine fetal monitoring and intrapartum care continued uninterrupted in both groups. At this stage, women in the intervention group received a second exposure to fetal heart sounds, again for 5 minutes, using the same device, sound intensity range, and application procedure. Following the second application, STAI-S, VAS, and maternal vital signs were reassessed in both groups. Throughout the labor process, both groups were followed using the same clinical monitoring and care protocols. There were no differences between the groups regarding the fetal monitoring method, duration, or frequency. No labor induction or pharmacological analgesia was applied during the first stage of labor. Physiological and non-pharmacological labor support methods were used in accordance with women\u0026rsquo;s preferences, and all participants experienced spontaneous vaginal birth. At 24 hours postpartum, early mother\u0026ndash;infant bonding was assessed in both groups using the Postpartum Bonding Questionnaire. Throughout the study, listening to fetal heart sounds was implemented as a complementary auditory intervention integrated into routine intrapartum fetal monitoring, with standardized duration and sound intensity. No adverse maternal or fetal events related to sound exposure were observed during the intervention.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e2.8. Ethical considerations\u003c/h2\u003e \u003cp\u003e This study was approved by the Clinical Research Ethics Committee of Istanbul XXX Training and Research Hospital on November 18, 2021 (Ethics Committee Approval No: 18.11.2021\u0026ndash;B.10.1.TKH.4.34.H.GP.0.01/330). Institutional permissions were obtained from the Istanbul XXX Hospital Chief Physician\u0026rsquo;s Office and the Labor Unit prior to data collection. All individuals participating in the study provided written informed consent before the initiation of the research. Participants were informed about the purpose, scope, and conditions of participation. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. The trial was prospectively registered at ClinicalTrials.gov (NCT06271889) on 12.02.2021, prior to participant enrolment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e2.9. Statistical analyses\u003c/h2\u003e \u003cp\u003eThe research data were analyzed using SPSS version 26. Changes in maternal state anxiety constituted the primary outcome of the study; perceived labor pain, early postpartum bonding, and maternal vital signs were considered secondary outcomes. Descriptive statistics (mean, standard deviation, number, and percentage) were used to summarize the data. The Mann\u0026ndash;Whitney U test was applied to determine differences between groups, and the Wilcoxon signed-rank test was used to analyze within-group changes. The chi-square test and Fisher\u0026rsquo;s exact test were employed to evaluate categorical variables. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. RESULTS","content":"\u003cp\u003eWhen the descriptive characteristics of the pregnant women were examined, no statistically significant differences were found between the intervention and control groups in terms of occupation, educational level, employment status, income level, pregnancy history, history of miscarriage and abortion, duration of marriage, or whether the pregnancy was planned (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of Participants' Descriptive Characteristics by Group (n\u0026thinsp;=\u0026thinsp;80)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl Group (n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIntervention Group (n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.20\u0026thinsp;\u0026plusmn;\u0026thinsp;4.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.18\u0026thinsp;\u0026plusmn;\u0026thinsp;4.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.343\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGestational age (weeks)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.98\u0026thinsp;\u0026plusmn;\u0026thinsp;1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.10\u0026thinsp;\u0026plusmn;\u0026thinsp;1.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.566\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNumber of antenatal visits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.60\u0026thinsp;\u0026plusmn;\u0026thinsp;3.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.73\u0026thinsp;\u0026plusmn;\u0026thinsp;5.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-2.348\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eOccupation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHousewife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33 (82.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.129\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (5.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (7.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOfficer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (28.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (10.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eEducational status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIlliterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (17.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.163\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (52.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (60.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (20.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (22.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUniversity and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (10.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (15.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEmployment status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (5.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.432\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot working\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (87.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38 (95.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eIncome level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLess than expenses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (15.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (17.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e1,000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEqual to expenses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (77.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (77.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMore than expenses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (7.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (5.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMetropolis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (97.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (67.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eNumber of pregnancies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOne\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (90.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36 (90.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.467\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTwo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (7.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (7.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eNumber of miscarriages\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (87.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36 (90.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.670\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOne\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (10.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (7.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTwo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (5.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNumber of abortions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37 (92.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.241\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOne\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (7.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eLength of marriage (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (47.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.518\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (30.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (15.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (10.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePlanned pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (80.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 (75.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.592\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (20.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003eNote.\u003c/b\u003e Values are presented as \u003cem\u003en (%)\u003c/em\u003e, ᵃ Pearson\u0026rsquo;s Chi-Square test, ᵇ Fisher\u0026rsquo;s Exact Test, \u003cem\u003ep\u003c/em\u003e values \u0026lt; .05 were considered statistically significant.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWhen the clinical characteristics of the intervention and control groups were compared, no statistically significant differences were observed between the groups at cervical dilatations of 4\u0026ndash;5 cm and 6\u0026ndash;7 cm with respect to maternal age, gestational week, respiratory rate, or oxygen saturation (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). In contrast, the number of antenatal visits (p\u0026thinsp;=\u0026thinsp;0.019) and body temperature measured at 4\u0026ndash;5 cm cervical dilatation (p\u0026thinsp;=\u0026thinsp;0.044) was significantly higher in the control group compared with the intervention group (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Clinical Characteristics Between the Control and Intervention Groups (n\u0026thinsp;=\u0026thinsp;80)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl Group M (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eIntervention Group M (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eZ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody temperature at 4\u0026ndash;5 cm dilation (\u0026deg;C) (pre-test)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.08 (0.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e-2.019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.044\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody temperature at 6\u0026ndash;7 cm cervical dilation (\u0026deg;C) (post-test)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36.72 (0.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e-0.890\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.373\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory rate at 4\u0026ndash;5 cm (breaths/min) (pre-test)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.30 (2.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.85 (2.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e-1.052\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.293\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory rate at 6\u0026ndash;7 cm cervical dilatation (breaths/min) (post-test)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7:30 p.m. (2:44 p.m.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.65 (2.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e-1.278\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.201\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eO₂ saturation at 4\u0026ndash;5 cm cervical dilatation (%)(pre-test)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98.32 (0.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98.50 (0.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e-1.023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.306\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eO₂ saturation at 6\u0026ndash;7 cm cervical dilation (%)(post-test)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98.47 (0.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98.95 (0.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e-1.389\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.165\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulse rate at 4\u0026ndash;5 cm cervical dilation (beats/min) (pre-test)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81.72 (16.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.36 (10.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e-0.247\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.805\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulse rate at 6\u0026ndash;7 cm cervical dilation (beats/min) (post-test)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85.03 (13.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e-0.426\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.670\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003eNote.\u003c/b\u003e Values are presented as Mean (Standard Deviation). Mann\u0026ndash;Whitney U test was used for all comparisons. \u003cem\u003ep\u003c/em\u003e values \u0026lt; .05 were considered statistically significant.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNo statistically significant difference was found between the groups in terms of perceived labor pain (p\u0026thinsp;=\u0026thinsp;0.283). Likewise, no statistically significant differences were observed between the groups regarding the total score of the Postpartum Bonding Questionnaire or its subscales, including impaired bonding, rejection/irritability, risk of abuse, and anxiety related to infant care (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of VAS and PBQ Scores Between Groups (n\u0026thinsp;=\u0026thinsp;80)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eControl Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eIntervention Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMed\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMed\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eZ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLabor pain (VAS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-1.075\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.283\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePBQ\u0026ndash; Total Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.083\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.934\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePBQ-Bonding Disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.037\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.971\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePBQ-Rejection and Anger\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.051\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.959\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePBQ-Risk of Abuse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.493\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.622\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePBQ-Anxiety About Infant Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-1.057\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003cb\u003eNote.\u003c/b\u003e M\u0026thinsp;=\u0026thinsp;Mean; SD\u0026thinsp;=\u0026thinsp;Standard Deviation; Z\u0026thinsp;=\u0026thinsp;Mann-Whitney U test; p-values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered statistically significant.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn the between-group comparisons, no statistically significant difference was found in total anxiety scores (p \u0026gt; .05). However, a statistically significant increase in total anxiety score was observed between the pretest and posttest in the control group (Z\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;2.326, p = .020). In addition, a statistically significant increase was detected in the state anxiety subscale in the control group (Z\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;2.597, p = .009). In the intervention group, no significant changes were observed in total anxiety or subscale scores (p \u0026gt; .05) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). These findings indicate that anxiety levels remained more stable among pregnant women who listened to fetal heart sounds during labor.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eComparison of State-Trait Anxiety Scores Within and Between Groups (n\u0026thinsp;=\u0026thinsp;80)\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eControl Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eIntervention Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eZ\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eState\u0026ndash;Trait Anxiety Inventory (STAI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePretest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.048\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.962\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePosttest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e93.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e87.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.236\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.814\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eZ\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e-2.326\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e-1.738\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.02\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e0.082\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eState Anxiety Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePretest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e45.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.207\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.836\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePosttest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e45.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.732\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.464\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eZ\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e-2.597\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e-1.045\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.009\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e0.296\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eTrait Anxiety Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePretest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e40.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7,77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.323\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.747\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePosttest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.954\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.340\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eZ\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e-0.344\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e-1.494\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e0.731\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e0.135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003e\u003cb\u003eNote.\u003c/b\u003e M=Mean; SD=Standard Deviation; Med\u0026thinsp;=\u0026thinsp;Median, Zᵃ = Mann-Whitney U test for between-group comparisons, Zᵇ= Wilcoxon signed-rank test for within-group comparisons, \u003cem\u003ep\u003c/em\u003e values\u0026lt;.05 were considered statistically significant.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"4. DISCUSSION","content":"\u003cp\u003eStudies examining the psychological effects of listening to fetal heart sounds on pregnant women have reported that this practice may enhance awareness toward the fetus, strengthen prenatal bonding, and contribute to the regulation of anxiety levels related to pregnancy and childbirth (19). A recent study similarly demonstrated that prenatal bonding levels increased in pregnant women who listened to fetal heart sounds and that this experience was associated with positive emotional responses (20). These findings suggest that fetal heart sounds may influence psychological processes as a meaningful auditory stimulus for mothers. In this context, the present study contributes to the literature by evaluating the effects of listening to fetal heart sounds during the first stage of labor on maternal anxiety, pain perception, and early postpartum bonding in primiparous women.\u003c/p\u003e \u003cp\u003eIn this study, no statistically significant difference was found between the intervention and control groups in terms of anxiety levels (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, within-group analyses revealed a significant increase in state anxiety levels in the control group, whereas anxiety levels remained stable in the intervention group. This finding suggests that auditory exposure to fetal heart sounds may not exert a direct anxiety-reducing effect but may play a role in limiting the increase in anxiety levels during labor. In the literature on auditory interventions applied during labor, including systematic reviews and meta-analyses examining music and rhythmic sound therapies, considerable variability across studies has been reported, with generally small to moderate effects observed (19, 21). Accordingly, the absence of a statistically significant difference between groups in the present study is consistent with the heterogeneous findings reported in the literature. In this respect, Hypothesis 1a was partially supported. Although auditory exposure to fetal heart sounds did not create a statistically significant difference between groups, it demonstrated a preventive effect on the expected increase in maternal anxiety levels throughout the labor process. It has been reported that fetal heart sounds may help mothers develop an internal sense of reassurance regarding fetal well-being, thereby supporting the stabilization of anxiety levels during labor. Similarly, supportive interventions involving the monitoring of fetal heart sounds during the non-stress test have been reported to contribute to the stabilization of anxiety levels by limiting increases rather than producing a marked reduction in maternal anxiety (22).\u003c/p\u003e \u003cp\u003eDue to the limited number of studies directly examining the effects of fetal heart sounds on maternal anxiety and pain, studies evaluating auditory interventions such as music or video during the non-stress test were considered in the literature. In some of these studies, reductions in maternal anxiety or suppression of anxiety increases were reported, along with positive changes in secondary outcomes such as non-stress test reactivity, satisfaction, and comfort (29, 31). Similarly, Wang et al. (2022) reported that mindfulness-based sensory approaches such as sound awareness and controlled breathing reduced anxiety during labor and positively influenced the birth experience (14). In addition, emphasized that music therapy applied during pregnancy and labor improved vital signs, reduced anxiety, supported a more humane birth experience, and strengthened mother\u0026ndash;fetus bonding (23). Consistent with these findings, the absence of an increase in maternal anxiety levels in the intervention group in the present study suggests that auditory stimulation provided through fetal heart sounds may contribute to the regulation of emotional responses during labor.\u003c/p\u003e \u003cp\u003eWith regard to labor pain, no statistically significant difference was found between the groups based on pain scores (p\u0026thinsp;=\u0026thinsp;0.283). This finding indicates that listening to fetal heart sounds did not directly reduce perceived labor pain. Nevertheless, previous research has highlighted the analgesic potential of auditory interventions. Chehreh et al. (2023) reported that music therapy effectively reduced pain and anxiety during labor (23). Similarly, Mujiyani and Latifah (2022) indicated that sensory-based interventions such as aromatherapy, music, guided breathing, and virtual reality may modulate pain perception during the first stage of labor. In the present study, although labor pain scores were similar between groups, pain scores in the intervention group were observed to remain more stable, paralleling the stabilization of anxiety levels (24). This finding suggests that exposure to fetal heart sounds may indirectly influence pain perception by regulating anxiety and directing maternal attention toward auditory stimuli. In line with this view, Vaid et al. (2025) reported that music therapy applied during the active phase of labor significantly reduced pain levels (25). Although no statistically significant difference was detected in labor pain scores, the stabilization observed in the intervention group represents a clinically meaningful trend consistent with the psychological benefits of sound-based interventions. This finding may be attributable to methodological differences across studies and variability in sample characteristics. Hypothesis 1b was not statistically supported in terms of labor pain; however, the stable pain scores observed in the intervention group were considered a clinically meaningful finding indicating potential indirect benefits.\u003c/p\u003e \u003cp\u003eFurthermore, the effect of fetal heart sounds on early postpartum bonding was evaluated using the Postpartum Bonding Questionnaire. No statistically significant differences were found between the groups in terms of the total PBQ score or the subscales of impaired bonding, rejection and anger, anxiety related to infant care, and risk of abuse (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The low mean PBQ scores observed in both groups indicate a minimal clinical risk for bonding difficulties in the early postpartum period. These findings suggest that short-term auditory interventions applied during labor may not produce a measurable effect on mother\u0026ndash;infant bonding within the first 24 hours postpartum. Bonding is a multidimensional process that begins in the prenatal period and develops through a complex interaction of biological, psychological, and social factors in the postnatal period (8). Maternal mental health, social support, the quality of the birth experience, early skin-to-skin contact, and breastfeeding have been reported to play determining roles in the formation of bonding (8, 13). The literature indicates that high maternal anxiety levels and negative birth experiences may adversely affect postpartum bonding (25, 26). Despite the stabilization of anxiety levels in the intervention group, the absence of a significant difference in bonding scores suggests that short-term auditory exposure may be insufficient to produce measurable changes in bonding behaviors. This finding is consistent with evidence emphasizing the importance of sustained and repeated postnatal interactions for the emergence of bonding outcomes (27, 28). Systematic reviews have highlighted the determining role of early mother\u0026ndash;infant interaction in bonding formation and demonstrated that positive early interactions are associated with long-term developmental outcomes (29). In this context, a short-term intervention based on fetal heart sounds may provide limited emotional stimulation compared with the cumulative effects of ongoing postnatal interactions.\u003c/p\u003e \u003cp\u003eAdditionally, the fact that the PBQ primarily assesses the emotional dimensions of bonding and reflects behavioral bonding characteristics to a limited extent may have contributed to the absence of measurable differences in the early postpartum period. G\u0026ouml;bel et al. (2024) emphasized that although the PBQ is adequate for identifying emotional bonding difficulties, it may not fully capture the quality of behavioral bonding (30, 31, 32). Therefore, the use of measurement tools such as the Maternal Postnatal Attachment Scale, which encompass both emotional and behavioral components, may contribute to a more comprehensive evaluation of early bonding processes. The lack of support for Hypothesis 1c indicates that short-term auditory stimulation applied during labor may not have a marked effect on bonding behaviors in the early postpartum period.\u003c/p\u003e \u003cp\u003eNevertheless, while a significant increase in total and state anxiety levels was observed in the control group as labor progressed, anxiety levels remained stable in the group exposed to fetal heart sounds, suggesting that this intervention may have a limiting effect on anxiety escalation during labor. Finally, although no statistically significant difference was found between groups in total anxiety scores, a significant increase in total anxiety was observed between the pretest and posttest in the control group. An increase in state anxiety during the active phase of labor is considered an expected physiological and psychological response. The absence of this increase in the intervention group suggests that listening to fetal heart sounds may contribute to the regulation of the maternal stress response. The literature reports that short-term and targeted non-pharmacological interventions applied during labor may support the stabilization of emotional and physiological responses rather than producing an absolute reduction in anxiety (33). In addition, reassuring stimuli provided to the mother may enhance perceptions of fetal well-being and contribute to more balanced anxiety levels (34). In this context, listening to fetal heart sounds may be considered a supportive midwifery intervention for maternal anxiety management during labor.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e4.1. Strengths and Limitations of the Study\u003c/h2\u003e \u003cp\u003eThis study has several limitations. First, the intervention was conducted in the labor unit of a single hospital, and the sample was limited to women receiving care from a single center in Istanbul. This limits the generalizability of the findings to pregnant women in different regions, health care systems, or sociocultural contexts. A second important limitation is that postpartum bonding was assessed only in the early postpartum period (within the first 24 hours). Bonding, however, is a process that develops over time and is strengthened through interaction. Therefore, the emotional responses measured may not fully reflect the enduring or behavioral dimensions of the bonding process. Future studies are recommended to include larger samples and multicenter designs, incorporating women from diverse socioeconomic and cultural backgrounds.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. CONCLUSION","content":"\u003cp\u003eThis randomized controlled study evaluated the effects of listening to fetal heart sounds during the first stage of labor on maternal anxiety, pain perception, and early postpartum bonding. The findings showed that anxiety levels remained stable in the intervention group, whereas state anxiety increased in the control group. Although no statistically significant differences were found between the groups in terms of pain perception and early postpartum bonding, auditory stimulation through fetal heart sounds is considered to have the potential to improve the psychological environment of the labor process by supporting maternal emotional regulation. As a low-cost and non-invasive sensory intervention, listening to fetal heart sounds may serve as a complementary component of woman-centered and holistic childbirth care, particularly for women with high anxiety levels. However, to demonstrate measurable effects on bonding, interventions should not be limited to the intrapartum period but extended into the postnatal period to include early skin-to-skin contact, breastfeeding, and mother\u0026ndash;infant interactions, with bonding monitored over time. Future research is recommended to examine the long-term effects of such sensory interventions on maternal mental health, infant development, and the continuity of mother\u0026ndash;infant bonding using larger samples and multicenter designs.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e5.1. Implications for Nursing and Midwifery Research and Practice\u003c/h2\u003e \u003cp\u003eListening to fetal heart sounds during the first stage of labor may be used as a simple and non-invasive intervention to reduce maternal anxiety and pain. Incorporating this practice into routine intrapartum care may support maternal emotional well-being and promote early bonding between the mother and the infant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe research was carried out in accordance with the ethical principles of clinical research involving human patients and was permitted by the Ethics Committee of Istanbul Umraniye Training and Research Hospital (approval date: 18 November 2021; approval number: B.10.1.TKH.4.34.H.GP.0.01/330). The trial protocol was retrospectively registered on the website (Date: 12.02.2021) http://clinicaltrials.gov the registration number NCT06271889 (https://clinicaltrials.gov/study/NCT06271889). Necessary permission was obtained from the Provincial Health Directorate, which is affiliated with the state hospital and conducted the study, and a voluntary consent form was provided by pregnant women who agreed to participate in the study. The research was conducted by the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declared no competing of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to privacy considerations but are available from the corresponding author upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;We thank all pregnant women who voluntarily agreed to participate in the study.\u003c/p\u003e\n\u003cp\u003eThis study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Permission for the study was taken from the Scientific Research and Publication Ethical Board of the Istanbul Umraniye Training and Research Hospital (Approval No: 18.11.2021\u0026ndash;B.10.1.TKH.4.34.H.GP.0.01/330; 18 November 2021). In addition, a ClinicalTrials number was received from ClinicalTrials.gov (NCT06271889). All participants were informed about the research, and written and verbal consents of the pregnant women were taken.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors Contributions:\u003c/strong\u003e Idea and design: RBY, YAY. Data collection: RBY. Data analysis and interpretation: YAY, ES, RBY. Article writing: YAY, RBY, ES. Critical review: YAY, RBY, ES\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eShafqat, N., Agrawal, A., Pushpalatha, K., Singh, B., Verma, R., Podder, L., Das, S., \u0026amp; Sutar, R. F. (2024). 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Psychometric properties of the maternal postnatal attachment scale and the postpartum bonding questionnaire in three German samples. \u003cem\u003eBMC Pregnancy and Childbirth, 24\u003c/em\u003e(1), 789. https://doi.org/10.1186/s12884-024-06089-3\u003c/li\u003e\n\u003cli\u003eHunter, A. R., Heiderscheit, A., Galbally, M., Gravina, D., Mutwalli, H., \u0026amp; Himmerich, H. (2023). The effects of music-based interventions for pain and anxiety management during vaginal labour and caesarean delivery: A systematic review and narrative synthesis of randomised controlled trials. \u003cem\u003eInternational Journal of Environmental Research and Public Health, 20\u003c/em\u003e(23), 7120. https://doi.org/10.3390/ijerph20237120\u003c/li\u003e\n\u003cli\u003eMurray, S., Fox, D. J., Coddington, R. L., \u0026amp; Scarf, V. L. (2024). How does the use of continuous electronic fetal monitoring influence women\u0026apos;s experiences of labour? A systematic integrative review of the literature from high income countries. \u003cem\u003eWomen and Birth, 37\u003c/em\u003e(4), 101619. https://doi.org/10.1016/j.wombi.2024.101619\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Fetal heart sounds, Maternal anxiety, Labor pain, Postpartum bonding, Auditory stimulation, Woman-centered care","lastPublishedDoi":"10.21203/rs.3.rs-9141534/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9141534/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurppose:\u003c/strong\u003e This study examined the effects of listening to fetal heart sounds during the first stage of labor on maternal anxiety, pain perception, and early postpartum bonding in primiparous women.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This randomized controlled study was conducted between December 2021 and January 2023 with a total of 80 primiparous women randomly assigned to the intervention (n = 40) and control (n = 40) groups. The intervention group listened to fetal heart sounds for five minutes via a Non-Stress Test (NST) device during the early (4–5 cm) and late (6–7 cm) active phases of labor, while the control group received routine care. Data were collected using the State–Trait Anxiety Inventory (STAI), Visual Analog Scale (VAS), Postpartum Bonding Questionnaire (PBQ), and maternal vital signs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e No statistically significant between-group differences were observed in anxiety, pain, or bonding scores (p \u0026gt; 0.05). However, with respect to the primary outcome, state anxiety increased significantly in the control group (p \u0026lt; 0.05), whereas anxiety levels remained stable in the intervention group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eListening to fetal heart sounds during labor maintained maternal anxiety at a stable level without affecting pain or bonding. This finding supports the integration of auditory interventions into woman-centered intrapartum care\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003e The study was retrospectively registered in National Library of Medicine Clinical Trials Registry (Date: 12.02.2021 Ref: NCT06271889)\u003c/p\u003e","manuscriptTitle":"The effect of listening to fetal heart sounds during the first stage of labour on maternal anxiety, pain, and postpartum bonding: a randomized controlled study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-25 21:09:27","doi":"10.21203/rs.3.rs-9141534/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-03-24T03:25:29+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-23T18:32:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-20T02:05:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-20T02:05:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2026-03-16T19:55:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3ab07d33-4dd0-4362-8f2d-6d9de9d9c3ee","owner":[],"postedDate":"March 25th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-25T21:09:27+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-25 21:09:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9141534","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9141534","identity":"rs-9141534","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}