Virtual Reality Experience During Labour (VIREL); a Qualitative Study

Virtual Reality Experience During Labour (VIREL); a Qualitative 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 Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Virtual Reality Experience During Labour (VIREL); a Qualitative Study Anne-Claire Musters, Ann-Sofie Vandevenne, Arie Franx, Martine MLH Wassen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1048092/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Apr, 2023 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted 9 You are reading this latest preprint version Abstract Background There is increasing evidence that virtual reality (VR) is effective in the reduction of labour pain. The implementation of alternative methods like VR to reduce labour pain can contribute to reduce the request of pharmacological pain management methods and associated side effects. The aim of this study is to examine women’s experiences, preferences and satisfaction in regard to the use of VR during labour. Methods A qualitative interview study conducted in a non-university teaching hospital in The Netherlands. Two VR applications, respectively a guided meditation (VR1) and an interactive game (VR2) were tested in eligible women with a singleton pregnancy, scheduled for induction of labour. For the primary outcome, patients’ VR experience and application preference were examined using a post-intervention questionnaire and a semi-structured interview. Labour pain before and directly after VR was evaluated using the NRS score. Results 24 women, of whom fourteen were nulliparous and ten multiparous, were included and 12 of these women participated in semi-structured interviews. Three themes were identified after data analysis: “The VR experience”, “Pain reduction”, and “Usability of the VR application”. All patients were highly satisfied with VR use during labour and reported pain reduction during VR. VR1 was preferred above VR 2 by 17 (71%) women. Both VR1 and VR2 caused a significant decrease in mean NRS scores comparing pain pre-VR use to pain during VR use, of respectively 1·81 (VR1) vs. 1·28 (VR2). Conclusion All women were highly satisfied with VR use during labour, preferred guided meditation and experienced less pain. These results can contribute to the development of a potential promising new non-pharmacological tool to reduce labour pain. Virtual reality labour pain analgesia obstetric care Figures Figure 1 Background Epidural Analgesia (EA) has been regarded as the most effective method of labour analgesia. 1 There is a wide variation internationally in the use of intrapartum pharmacological analgesia, varying from 22.3% in The Netherlands to 83.1% in Sweden in nulliparous women. 2 The rates of EA during labour in nulliparous women varies from 19.4% in England to 83.4% in Finland. 2 Pharmacological analgesia methods are known to have adverse side effects, such as nausea, vomiting and drowsiness in parental opioids (intramuscular and intravenous drugs like patient-controlled analgesia); pruritus, nausea, desaturation, respiratory depression and apnea in patient-controlled remifentanil analgesia; and maternal fever, maternal hypotension and urinary retention in EA. Furthermore, routine EA is likely resulting in more operative deliveries. 3 , 4 , 5 , 6 Considering these possible adverse effects, it is worth exploring alternative methods for labour pain relief. Virtual reality (VR) is increasingly used in healthcare, and makes use of the principle of distraction. 7 Pain perception is strongly affected by psychological factors. 8 , 9 The perception of pain is thought to be (partly) related to the amount of attention that is given to pain stimuli. 10 , 11 A systematic review and meta-analysis showed interactive VR to reduce acute pain during dressing changes in adults with burns or cut wounds. 12 The VRAIL pilot study, a preliminary randomized controlled trial of 27 women, showed a significant decrease in pain and anxiety during labour in the VR-group. 13 A recently published review including nine studies related to VR during pregnancy and delivery, discussed the potential of VR as an effective method for pain and anxiety. 14 VR is inexpensive and can be used as a safe, non-invasive, analgesic method, without risks of drug addiction and minimal side effects. 15 , 16 Therefore, VR has tremendous potential as a safe alternative to existing pharmacological analgesia during labour. However, implementation of VR in obstetric care requires insights in labouring women’s preferences and pain reduction perceived by women. This study aims to examine the experience, preference, and satisfaction of VR in women during labour. Methods Study design and participants The study was set up as a single centre, qualitative study in a non-university teaching hospital in The Netherlands. Women were included between July 2020 and January 2021. This study was approved by the Medical Review Ethics Committee and registered as a clinical trial trial (ClinicalTrials.gov Identifier: NCT04858984, date of registration: 26/04/2021). Inclusion criteria were women of 18 years or older, native Dutch speaker, pregnant of a singleton in cephalic position, intention to deliver vaginally, and scheduled for induction of labour. Exclusion criteria were woman with chronic pain (persistent or recurrent pain >3 months and not due to the pregnancy), chronical use of opioids, alcohol or drug abuse, known motion or cyber-sickness, epileptic insults in previous history, claustrophobia, blindness, and severe hearing or vision deficits. 16 , 17 , 18 When scheduled for induction of labour women were given oral and written information about the study. Informed consent was obtained at the day of induction. The required number of patients for the qualitative data was determined by saturation: new patients were included until no new information was obtained. All collected data were stored in an electronic case report form (eCRF). This article has been written according to the consolidated criteria for reporting qualitative research (COREQ). 19 Intervention Participants experienced an immersive guided meditation (VR1) and an interactive game (VR2) experience during labour. A portable, standalone VR headset called Oculus Go (Facebook Technologies, LLC. 1601 Willow Road, Menlo Park, CA 940250) with a head-mounted display with built in audio drivers was used. Disposable hygiene masks and a surgical cap were used as an underlay below the headset and headset was cleaned afterwards according to a standard hygiene protocol. VR1 consisted of a video of an exotic location guided by the sound of the waves and a calm English-speaking voice. VR2 required women to use the controller to throw snowballs in order to catch presents and reach the next level. Patients were allowed to stop using the VR at any moment during the intervention. When the participant was declared to be in labour, defined as having regular painful uterine contractions, cervical effacement and at least 3cm dilatation, VR1 was offered for ten minutes. 20 Before and immediately after VR1, the patient was asked to fill out a Numeric Rating Scale (NRS) score for pain. During the 30-minute intermission after VR1 the patient completed the post-intervention questionnaire regarding VR1. Subsequently, VR2 was offered for ten minutes. Before and immediately after VR2 the patient filled in the NRS score for pain, and the patient completed a post-intervention questionnaire regarding VR2. Additional use of VR was allowed by maternal request and noted in the eCRF. If a woman had a request for pharmacological analgesia this was offered according to the local protocol. Five days post-partum all participants who completed both VR interventions were contacted by telephone for an interview. Questionnaires and semi-structured interviews The NRS score indicates the degree of pain on a scale from 0 to 10, where 0 means no pain and 10 is the worst pain imaginable. 21 In the post-intervention questionnaire the experience of both VR interventions were asked. The audiotaped interviews were conducted by AM and AV and lasted approximately 20 minutes. The interviews were semi-structured as they were based on a topic list (Table 1 ), and used to gain information about the preferences and experience of the VR applications during labour. As the interviews proceed, questions are adapted depending on the answers given to gain more depth and to verify whether the opinions agree between the participants. Table 1 Topic list semi-structured interviews (= supporting information) Panel: Theme categories and clusters of semi-structured interviews 1. VR experience 1.1 General experience 1.2 VR1 experience 1.3 VR2 experience 1.4 Preference 1.5 Side effects 1.6 Reusing VR 1.7 Recommendation to other women 1.8 Improvements 2 Pain reduction 2.1 Pain intensity 2.2 Pain perception 2.3 Distraction 3 Usability VR application 3.1 VR application 3.2 Comfort of VR glasses Data analysis The baseline characteristics and the NRS score data were analysed using SPSS (version 27). The Wilcoxon signed ranks test was used to analyse the difference in NRS score pre- and post-VR intervention. All interviews were transcribed verbatim. The interview transcripts were analysed by AM and AV. ATLAS.ti (version 8) was used by the investigators to code, organize and manage the data to facilitate data interpretation. MW read and coded 20% of the transcripts again, as a validity check. Findings were compared and discussed by AM, AV, and MW until consensus on themes and subthemes was achieved. Quotes were translated from Dutch to English by AM and AV, AF translated the English quotes back into Dutch sentences to make sure that the translation was substantively correct. Results A total of 52 women were approached to participate and 36 women gave informed consent (Figure 1). Eight women (22%) were excluded: six requested immediately pharmacological analgesia and two participants encountered technical issues with the VR glasses. Of the 28 women who used VR, four (14,3%) stopped immediately after starting: three women because of cyber-sickness and one woman felt uncomfortable wearing the VR glasses. Both VR interventions were completed by 18 of 24 women (75%), eight (44.4%) were primiparous and ten (55%) multiparous. Eight (44.4%) of the 18 women who completed both VR interventions requested no additional pain medication during labour of which seven (87.5%) were multiparous. Six of 24 (25%) women completed only VR1 of which five (83.3%) requested pharmacological pain medication after VR1 and one participant had to stop because of a technical issue with the Oculus Go. Additional VR exposure during labour was requested by ten (41.7%) women. Data saturation concerning experience, preference and satisfaction of VR use was reached after 12 semi-structured interviews. Baseline characteristics of the study group were reported in Table 2 and of the interviewees in Table 3 . As expected, multiparous women were significantly older than nulliparous women. All women were Caucasian. By one woman out of 28, induction was started by artificial rupture of membranes, all other inductions were started by using a foley catheter. Table 2 Baseline characteristics of participants. All women n = 28 Primiparous women n = 16 Multiparous women n = 12 P-value (α = 0·05) Age, mean ± SD, years 30·82 ± 3·86 28·88 ± 3·78 33·42 ± 2·07 0·001 BMI before pregnancy, mean ± SD, kg/m2 26·93 ± 5·90 27·03 ± 5·37 26·78 ± 6·79 0·915 Gestational age, mean ± SD, weeks 39·21 ± 1·50 39·18 ± 1·63 39·25 ± 1·36 0·907 Table 3 Data of interviewees. Parity Age, years Gestational age, weeks + days Profession Repeated use of VR Additional pharmacological analgesia after VR VR-preference VIREL-1 Multiparous 35 41+2 Nurse VR1 No VR1 VIREL-2 Multiparous 33 39+0 Doctor No Yes, EA VR1 VIREL-7 Primiparous 29 41+4 Social worker No Yes, remifentanil VR1 VIREL-10 Multiparous 36 38+1 Disability support worker VR1 No VR1 VIREL-12 Multiparous 33 38+2 Administrative assistant VR1 +VR2 No VR1 + VR2 VIREL-14 Primiparous 32 39+0 Childcare worker VR1 Yes, remifentanil VR1 VIREL-16 Multiparous 31 38+0 Childcare worker No No VR2 VIREL-19 Primiparous 33 38+6 Nurse No Yes, EA VR1 VIREL-20 Multiparous 35 38+1 Housewife, completed general secondary school VR1 Yes, remifentanil VR1 VIREL-23 Primiparous 25 38+1 Nurse No Yes, EA VR2 VIREL-25 Primiparous 28 38+1 Estate agent No Yes, EA VR1 VIREL-27 Multiparous 30 40+1 Entrepreneur No No VR2 Three themes emerged from analysis of the semi-structured interviews: (1) the VR experience, (2) the pain reduction, and (3) the usability of the VR-application. Theme 1: The VR experience General experience Overall, all interviewees experienced positive effects when using VR. “Yes, it surely was a positive experience... A good way to detach myself from labour pain… I think VR is especially useful to relax in between the contraction” (VIREL-20) “It was great. I think I had a dilation of four centimetres when I used the VR for the first time and stopped using VR at eight centimetres.” (VIREL-1) Additionally, women lost perception of the external environment while using the guided meditation VR. “I prefer the guided meditation for several reasons: the relaxing sound of the waves, the voice guidance, and the perception of being in a pleasant environment instead of being in a hospital.” (VIREL-25) All women describe VR as a good distraction method during labour. “You mentioned talking to my partner and your telephone ringing while I was using VR, but I did not remember hearing any of it.” (VIREL-2) “I was so distracted by the beach environment and the meditation voice, that I was less aware of the pain I was in.” (VIREL-20) VR1 experience Four women reported that the guided meditation VR helped them with their breathing technique. “It helped me to control my breathing during a contraction” (VIREL-25) The guided meditation VR provides a continuous support, which was mentioned as positive by multiple women. It enhanced their self confidence in bearing the labour pain. “The continuous support of the VR voice was pleasant” (VIREL-2) The beautiful wide view and tranquillity was highlighted by women regarding the VR images, but a preference for less voice guidance was also expressed. “It is important that the environment is interesting and has a wide view.” (VIREL-2) “I liked the voice guidance at some moments, but not the entire time. More moments of just music and nature sounds would be nice.” (VIREL-23) VR2 experience All women reported the importance of relaxation during labour and stated that an interactive game was not suitable, because during the game they continuously tightened their muscles. “I could not relax during the game which caused no reduction in pain.” (VIREL-7) At some point during labour the experienced degree of pain was too high to focus on playing a game, which seems to make the interactive game less suitable during labour. “The game could be really fun, but from my perspective it is not suitable during labour. I could not focus on the game.” (VIREL-1) “I would prefer playing a game when I am in less pain, because now I could not concentrate on it.” (VIREL-2) Preference Eight women preferred VR1, three women liked both VR interventions, and one woman reported no additional value of VR. She preferred her partner to help her cope with labour pain. 11 Women described VR as helpful for coping with labour pain during the first stages of dilation, but when contractions became too severe and they felt lots of pressure, or the urge to push, they were unable to handle VR glasses any longer. Six out of the seven women who used no additional pain medication stopped using VR just before the second stage of labour. “… but when the contraction and the labour pain got really intense, the beach was not comforting me anymore.” (VIREL-10) “When I felt like pushing the VR glasses were not comfortable anymore.” (VIREL-1) Nine women stated that they preferred their own native language during the guided meditation instead of a non-native language. “Listening to a non-native language requires more energy.” (VIREL-10) Multiple women mentioned the passive way of distraction as an advantage of VR1. Whereas the VR2 was too much afford during labour. “The advantage of the guided meditation is that you do not need to actively participate in experience.” (VIREL-2) Side effects None of the women who completed both VR interventions reported side-effects. Reusing VR Except VIREL-16 all interviewees would use VR during a subsequent labour. “I would definitely use the VR glasses again during a next delivery. I would like to use the VR glasses even longer to pass the time.” (VIREL-12) Recommendation to other women All women would recommend using VR during labour to cope with their contractions. “I surely would, if it is not working for you, you can immediately stop using VR.” (VIREL-10) “It is worth trying… Everyone has to experience it for themselves.” (VIREL-27) Improvements In this study, the intervention lasted ten minutes. Seven women, however reported that a prolonged VR session without any intermission could have a better effect on long lasting pain reduction during labour. Time seemed to be going faster while using VR. “Ten minutes is very short; I think using VR for 30 minutes or maybe an hour without intermission would be better.” (VIREL-2) Regarding to the intention of longer VR use women would prefer different nature environments or at least a more entertaining environment to keep their attention. “Although I love the beach, a change in different relaxing environments during a longer period of VR use would be nice.” (VIREL-14) The importance of support of midwifes, nurses, and the partner to make VR successful was also mentioned by two women. “If the midwife would have put more effort into convincing me to try VR again, I might have used VR another time… The support and persuasiveness of the caregivers regarding VR partly determines the success of VR.” (VIREL-2) It seems to be important that the guided meditation is specifically developed for use during labour and that the voice guidance helps women cope with their contractions. Women reported they needed positive vocal support especially during the most painful contractions. “When the labour pain got worse, I needed a more coaching guidance and lots of positive mental support.” (VIREL-25) “When experiencing severe labour pain, I needed a voice to help me cope with the contraction. Unfortunately, it was not possible with this application.” (VIREL-1) Overall, partners were not bothered by their wife using VR. Although some partners stated they would like it to see what she is experiencing on an iPad. Theme 2: Pain reduction Pain intensity All women reported a reduction in labour pain. One woman felt no pain at all when using VR. “At the beginning I did not feel my contractions at all when using the guided meditation, after taking off the VR glasses I could not tell how many contractions I had in the last ten minutes.” (VIREL-1) 11 women describe their contractions as less intense and less painful when using VR. “It reduced the pain to a level that makes it bearable.” (VIREL-25) “ … the contractions felt shorter and less intense” (VIREL-19) Women described VR as an effective method to reduce pain, especially during the first stage of the active labour phase VR. “At the end, my contractions were too painful to concentrate on the VR environment and could I not experience the relaxed feeling I experienced before.” (VIREL-25) Pain perception Women described VR1 as a relaxing experience; they were more focused on the nature environment, the soothing voice and their breathing. This caused enough distraction to reduce the degree of experienced pain. 11 participants experienced positive effects regarding to their pain perception and the tension in their body. “Without VR I felt strong contractions and a lot of pelvic pressure, but when using VR, the perception of the contractions was less.” (VIREL-10) Distraction The distractive component of VR reduces the amount of experienced pain. “Because of the distractive component of the VR I was not focused on my pain, but I still felt it.” (VIREL-27) “The contractions were less intense because I was distracted by hearing the soothing voice.” (VIREL-14) In the first stages of experiencing labour pain, a change in environment seemed to be important to keep a woman’s attention. In the later, more severe, stages of labour pain a change in environment was less important, at that point the vocal support during a contraction was more meaningful. “The first time I got bored after a couple of minutes seeing the same beach environment… The second time using the meditation VR, I did not pay much attention to the surrounding, so the change of environment was less important.” (VIREL-1) Theme 3: The usability of the VR-application All women mentioned that it is important to keep the VR application as simple as possible regarding to the usability. All women were positive about the comfort of the VR glasses. Three women noted that it would be nice to use the VR glasses at least once before experiencing labour pain. “It would be nice to try the VR glasses before being in labour, so you feel more comfortable using them when in pain...” (VIREL-16) Verification of the qualitative data was done by comparison with the NRS scores. The mean NRS scores before starting respectively VR1 and VR2 were 6·71 (SD1·65) and 6·89 (SD1·88) respectively (Table 4 ). The mean NRS scores after VR1 and after VR2 were 4·96 (SD2·01) and 5·61 (SD2·23) respectively (Table 4 ). The reported decrease in NRS score was 1·8 after VR1 and 1·2 after VR2 (Table 4 ). Table 4 NRS scores before and after VR intervention. NRS before VR ( mean ± SD) NRS after VR ( mean ± SD) p-value ( α = 0 · 05) VR1, n = 24 Primiparous, n = 14 Multiparous, n = 10 6·71 ± 1·65 7·29 ± 1·27 5·90 ± 1·85 4·96 ± 2·01 5·64 ± 1·60 4·00 ± 2·21 0·000 0·002 0·010 VR2, n = 18 Primiparous, n = 8 Multiparous, n = 10 6·89 ± 1·88 7·50 ± 1·51 6·40 ± 2·07 5·61 ± 2·23 6·25 ± 1·98 5·10 ± 2·38 0·001 0·026 0·017 Discussion Summary of findings All women were highly satisfied with VR use during labour and experienced less pain. Women preferred the guided meditation. In particular, multiparous women benefited from VR use. The significant difference in NRS score before and after the use of VR supports the potential effectiveness of this innovative technique during labour. When evaluating all participants, the guided meditation seems to be preferred during labour in comparison to the interactive game. This is supported by the qualitative and quantitative data of this study. We evaluated suggestions for improvement made by the interviewees during the early and late dilatation stage of labour. During the latent phase and the early dilatation stage of labour (defined as regular painful contractions and a cervical dilatation of 3-5cm) women preferred more distraction such as different nature environments, a more realistic image of the surrounding, and a meditative voice guidance. During the late dilatation stage (defined as a cervical dilatation 6-10cm), when contractions are more painful, women preferred coaching, less distraction, and calm music or soothing nature sounds in between the contractions. Emotional support such as praising for endurance, positive words and psychical support like breathing techniques helped women to cope with labour pain. 22 Coaching and emotional support will be incorporated in the development of a future VR labour application. Strengths and limitations The strength of this study is that this is the first qualitative evidence of the satisfaction and preference of the use of VR during labour. These results can contribute to develop a new VR tool and innovative technique to reduce labour pain. A limitation of this study was that all interviewees were contacted by telephone, as the Covid-19 lockdown did not allow face-to-face interviews. Because of this, we may have missed nonverbal cues. However, each time an interviewee gave feedback, we summarized and repeated the feedback to verify that we understood the message correctly. Six interviews were not conducted because the patient could not be reached by telephone. Another limitation is that we only included women who were scheduled for an induction of labour. Literature suggests the active phase of labour in primiparous women is longer in induced labour than in spontaneous onset, this will lead to more exhaustion and a higher request for pharmacological analgesia. 23 Therefore, we suspect that VR may be more effective in women who have a spontaneous onset of labour. Interpretation The guided meditation provides the experience of continuous support during labour without causing side effects. There were no statistically significant differences in pain measured by NRS scores between primiparous and multiparous women. However, multiparous women requested pharmacological analgesia less often. This is possibly related to a shorter duration of the active stage of labour in multiparous women. 23 Therefore, multiparous women stayed motivated to use VR. Previous studies have demonstrated that VR is an effective tool to manage pain and distress in several medical procedures, such as wound care, dental procedures and dialysis. 24 The effect of VR on this short acute pain moments cannot be compared with long term pain management during labour. A RCT with 40 nulliparous women, of whom 21 received 30 minutes VR during labour, showed a significant reduction of pain in the VR group. 25 The interviewees reported the importance of support by midwives, nurses and the partner to make VR a successful alternative to pharmacological analgesia. It is possible that the positive effect of VR can be partly explained by offering continuous support. Continuous support during childbirth by a midwife, partner or doula is highly appreciated by women in labour and results in better birth experiences and a decrease in analgesia use, shorter duration of labour, increase in spontaneous vaginal birth and improved five-minute Apgar score. 22 , 26 , 27 Conclusion This study demonstrates, VR to be a potentially, valuable non-pharmacological tool to reduce labour pain. The interviewees in this study were highly satisfied with VR, and reported improvements such as using VR for a longer period of time, and a VR application specially aimed for women in labour. These suggestions can contribute to developing a specific labour VR application and improve the effectiveness. Randomised controlled trials have to be performed to assess the effect of VR on the request for pharmacological analgesia by women in labour before VR can be implemented as routine standard care. List of abbreviations VR: virtual reality; EA: Epidural analgesia; eCRF: electronic case report form; NRS: Numeric Rating Scale Declarations Conflict of interest All authors declare no conflict of interest. Completed disclosure of interests forms are available to view online as supporting information. Details of ethics Approval This study was approved by the Medical Review Ethics Committee and the scientific research bureau (BWO) from the Zuyderland Medical Centre on 08 June 2020 (METCZ20200096) and registered as a clinical trial (ClinicalTrials.gov Identifier: NCT04858984). Contribution to Authorship MW conceived the idea and supervised the study. MW and AM contributed to the study concept and design. Literature search was performed by MW and AM. AM managed and coordinated the research activities and planning. AM and AV were responsible for the recruitment of participants and conducted all the interviews. MW, AM, AV, and AF contributed to the analysis and interpretation of the data. MW and AM developed the first draft of the manuscript, AV and AF revised all manuscript drafts. All authors read and approved the final manuscript. Funding This research received no grant from any funding agency in the public, commercial, or non-profit sectors. Acknowledgements The authors would like to thank all the women and their partners who participated in the study. Data availability statement: The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Ethics and consent All methods were carried out in accordance with relevant guidelines and regulations. Consent to participate Informed Consent was obtained from the participants in the study. Consent for publication Not applicable. References Anim-Somuah M, Smyth RM, Cyna AM, Cuthbert A. Epidural versus non-epidural or no analgesia for pain management in labour. Cochrane Database Syst Rev. 2018;5:CD000331. 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Cite Share Download PDF Status: Published Journal Publication published 24 Apr, 2023 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Major revision 07 Mar, 2022 Reviews received at journal 06 Mar, 2022 Reviewers agreed at journal 22 Feb, 2022 Reviewers agreed at journal 21 Feb, 2022 Reviewers invited by journal 16 Feb, 2022 Editor assigned by journal 10 Feb, 2022 Editor invited by journal 03 Feb, 2022 Submission checks completed at journal 03 Feb, 2022 First submitted to journal 03 Nov, 2021 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. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies 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-1048092","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":81254181,"identity":"2d0df199-52d0-4129-b5fa-796c15894227","order_by":0,"name":"Anne-Claire Musters","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/UlEQVRIiWNgGAWjYFAD9gYgwcbAwAekJBgYLAgoTwBingMQLWwQLRJEaJFIIFILfwN3muTPHzb58jOfP5PmKbPJZ2M/e/AG4w7cWiQO8G6T5klIs9xwOyFNmudcmmUbT16yBeMZPA4DaWFIOGxgIJ1wTJq37bABG0OOmQRjG24t8kAtkj8S/hvIzzzYBtTy34CN/w1+LQZALRI8CQcMGG4wswG1HDBgkyBgi+Fh3s3WPGnJBgZn0pgt55xLBmp5Y2yRiEeL3PHejTd/2NgZyLcff3jjTZmdAT9/juGNj202uL3PjMRm4oGxEnBrQAWMP4hVOQpGwSgYBSMKAACGdkcmrPz5fgAAAABJRU5ErkJggg==","orcid":"","institution":"Zuyderland Medisch Centrum","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Anne-Claire","middleName":"","lastName":"Musters","suffix":""},{"id":81254183,"identity":"aec0ce67-baab-4559-bd09-1bcfb130dfed","order_by":1,"name":"Ann-Sofie Vandevenne","email":"","orcid":"","institution":"Maastricht University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ann-Sofie","middleName":"","lastName":"Vandevenne","suffix":""},{"id":81254184,"identity":"36a34cfb-5771-4034-b7ac-2552d4ac8e5d","order_by":2,"name":"Arie Franx","email":"","orcid":"","institution":"Erasmus MC","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Arie","middleName":"","lastName":"Franx","suffix":""},{"id":81254185,"identity":"6af281cb-6b7d-431c-bfd7-fdfc4f0b27db","order_by":3,"name":"Martine MLH Wassen","email":"","orcid":"","institution":"Zuyderland Medisch Centrum","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Martine","middleName":"MLH","lastName":"Wassen","suffix":""}],"badges":[],"createdAt":"2021-11-03 19:59:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1048092/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1048092/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12884-023-05432-9","type":"published","date":"2023-04-24T20:38:41+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":17994562,"identity":"00ef5d05-7deb-4c32-9dc2-5e6c290b76a2","added_by":"auto","created_at":"2022-02-07 15:20:36","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":131830,"visible":true,"origin":"","legend":"\u003cp\u003eStudy algorithm and sample characteristics.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1048092/v1/c02d267a7f81e1d78a9c6905.jpg"},{"id":44727023,"identity":"a7a7d2c4-98bf-4ddc-b122-90fb6eddff99","added_by":"auto","created_at":"2023-10-16 20:51:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":501790,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1048092/v1/3fef82e8-61e5-4827-9598-ff64aa086c67.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eVirtual Reality Experience During Labour (VIREL); a Qualitative Study\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eEpidural Analgesia (EA) has been regarded as the most effective method of labour analgesia.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e There is a wide variation internationally in the use of intrapartum pharmacological analgesia, varying from 22.3% in The Netherlands to 83.1% in Sweden in nulliparous women.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e The rates of EA during labour in nulliparous women varies from 19.4% in England to 83.4% in Finland.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Pharmacological analgesia methods are known to have adverse side effects, such as nausea, vomiting and drowsiness in parental opioids (intramuscular and intravenous drugs like patient-controlled analgesia); pruritus, nausea, desaturation, respiratory depression and apnea in patient-controlled remifentanil analgesia; and maternal fever, maternal hypotension and urinary retention in EA. Furthermore, routine EA is likely resulting in more operative deliveries.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Considering these possible adverse effects, it is worth exploring alternative methods for labour pain relief.\u003c/p\u003e \u003cp\u003eVirtual reality (VR) is increasingly used in healthcare, and makes use of the principle of distraction.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Pain perception is strongly affected by psychological factors.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e The perception of pain is thought to be (partly) related to the amount of attention that is given to pain stimuli.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e A systematic review and meta-analysis showed interactive VR to reduce acute pain during dressing changes in adults with burns or cut wounds.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e The VRAIL pilot study, a preliminary randomized controlled trial of 27 women, showed a significant decrease in pain and anxiety during labour in the VR-group.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e A recently published review including nine studies related to VR during pregnancy and delivery, discussed the potential of VR as an effective method for pain and anxiety.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eVR is inexpensive and can be used as a safe, non-invasive, analgesic method, without risks of drug addiction and minimal side effects.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Therefore, VR has tremendous potential as a safe alternative to existing pharmacological analgesia during labour. However, implementation of VR in obstetric care requires insights in labouring women\u0026rsquo;s preferences and pain reduction perceived by women. This study aims to examine the experience, preference, and satisfaction of VR in women during labour.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003ch2\u003eStudy design and participants\u003c/h2\u003e\n\u003cp\u003eThe study was set up as a single centre, qualitative study in a non-university teaching hospital in The Netherlands. Women were included between July 2020 and January 2021. This study was approved by the Medical Review Ethics Committee and registered as a clinical trial trial (ClinicalTrials.gov Identifier: NCT04858984, date of registration: 26/04/2021).\u003c/p\u003e\n\u003cp\u003eInclusion criteria were women of 18 years or older, native Dutch speaker, pregnant of a singleton in cephalic position, intention to deliver vaginally, and scheduled for induction of labour. Exclusion criteria were woman with chronic pain (persistent or recurrent pain \u0026gt;3 months and not due to the pregnancy), chronical use of opioids, alcohol or drug abuse, known motion or cyber-sickness, epileptic insults in previous history, claustrophobia, blindness, and severe hearing or vision deficits.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eWhen scheduled for induction of labour women were given oral and written information about the study. Informed consent was obtained at the day of induction. The required number of patients for the qualitative data was determined by saturation: new patients were included until no new information was obtained. All collected data were stored in an electronic case report form (eCRF). This article has been written according to the consolidated criteria for reporting qualitative research (COREQ).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003ch2\u003eIntervention\u003c/h2\u003e\n\u003cp\u003eParticipants experienced an immersive guided meditation (VR1) and an interactive game (VR2) experience during labour. A portable, standalone VR headset called Oculus Go (Facebook Technologies, LLC. 1601 Willow Road, Menlo Park, CA 940250) with a head-mounted display with built in audio drivers was used. Disposable hygiene masks and a surgical cap were used as an underlay below the headset and headset was cleaned afterwards according to a standard hygiene protocol.\u003c/p\u003e\n\u003cp\u003eVR1 consisted of a video of an exotic location guided by the sound of the waves and a calm English-speaking voice. VR2 required women to use the controller to throw snowballs in order to catch presents and reach the next level. Patients were allowed to stop using the VR at any moment during the intervention.\u003c/p\u003e\n\u003cp\u003eWhen the participant was declared to be in labour, defined as having regular painful uterine contractions, cervical effacement and at least 3cm dilatation, VR1 was offered for ten minutes.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Before and immediately after VR1, the patient was asked to fill out a Numeric Rating Scale (NRS) score for pain.\u003c/p\u003e\n\u003cp\u003eDuring the 30-minute intermission after VR1 the patient completed the post-intervention questionnaire regarding VR1. Subsequently, VR2 was offered for ten minutes. Before and immediately after VR2 the patient filled in the NRS score for pain, and the patient completed a post-intervention questionnaire regarding VR2. Additional use of VR was allowed by maternal request and noted in the eCRF. If a woman had a request for pharmacological analgesia this was offered according to the local protocol. Five days post-partum all participants who completed both VR interventions were contacted by telephone for an interview.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n\u003ch2\u003eQuestionnaires and semi-structured interviews\u003c/h2\u003e\n\u003cp\u003eThe NRS score indicates the degree of pain on a scale from 0 to 10, where 0 means no pain and 10 is the worst pain imaginable.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e In the post-intervention questionnaire the experience of both VR interventions were asked.\u003c/p\u003e\n\u003cp\u003eThe audiotaped interviews were conducted by AM and AV and lasted approximately 20 minutes. The interviews were semi-structured as they were based on a topic list (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e), and used to gain information about the preferences and experience of the VR applications during labour. As the interviews proceed, questions are adapted depending on the answers given to gain more depth and to verify whether the opinions agree between the participants.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eTopic list semi-structured interviews (= supporting information)\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePanel: Theme categories and clusters of semi-structured interviews\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1. VR experience\u003c/p\u003e\n\u003cp\u003e1.1 General experience\u003c/p\u003e\n\u003cp\u003e1.2 VR1 experience\u003c/p\u003e\n\u003cp\u003e1.3 VR2 experience\u003c/p\u003e\n\u003cp\u003e1.4 Preference\u003c/p\u003e\n\u003cp\u003e1.5 Side effects\u003c/p\u003e\n\u003cp\u003e1.6 Reusing VR\u003c/p\u003e\n\u003cp\u003e1.7 Recommendation to other women\u003c/p\u003e\n\u003cp\u003e1.8 Improvements\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 Pain reduction\u003c/p\u003e\n\u003cp\u003e2.1 Pain intensity\u003c/p\u003e\n\u003cp\u003e2.2 Pain perception\u003c/p\u003e\n\u003cp\u003e2.3 Distraction\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 Usability VR application\u003c/p\u003e\n\u003cp\u003e3.1 VR application\u003c/p\u003e\n\u003cp\u003e3.2 Comfort of VR glasses\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n\u003ch2\u003eData analysis\u003c/h2\u003e\n\u003cp\u003eThe baseline characteristics and the NRS score data were analysed using SPSS (version 27). The Wilcoxon signed ranks test was used to analyse the difference in NRS score pre- and post-VR intervention.\u003c/p\u003e\n\u003cp\u003eAll interviews were transcribed verbatim. The interview transcripts were analysed by AM and AV. ATLAS.ti (version 8) was used by the investigators to code, organize and manage the data to facilitate data interpretation. MW read and coded 20% of the transcripts again, as a validity check. Findings were compared and discussed by AM, AV, and MW until consensus on themes and subthemes was achieved.\u003c/p\u003e\n\u003cp\u003eQuotes were translated from Dutch to English by AM and AV, AF translated the English quotes back into Dutch sentences to make sure that the translation was substantively correct.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 52 women were approached to participate and 36 women gave informed consent (Figure 1). Eight women (22%) were excluded: six requested immediately pharmacological analgesia and two participants encountered technical issues with the VR glasses. Of the 28 women who used VR, four (14,3%) stopped immediately after starting: three women because of cyber-sickness and one woman felt uncomfortable wearing the VR glasses.\u003c/p\u003e\n\u003cp\u003eBoth VR interventions were completed by 18 of 24 women (75%), eight (44.4%) were primiparous and ten (55%) multiparous. Eight (44.4%) of the 18 women who completed both VR interventions requested no additional pain medication during labour of which seven (87.5%) were multiparous. Six of 24 (25%) women completed only VR1 of which five (83.3%) requested pharmacological pain medication after VR1 and one participant had to stop because of a technical issue with the Oculus Go. Additional VR exposure during labour was requested by ten (41.7%) women.\u003c/p\u003e\n\u003cp\u003eData saturation concerning experience, preference and satisfaction of VR use was reached after 12 semi-structured interviews.\u003c/p\u003e\n\u003cp\u003eBaseline characteristics of the study group were reported in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e and of the interviewees in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e. As expected, multiparous women were significantly older than nulliparous women. All women were Caucasian. By one woman out of 28, induction was started by artificial rupture of membranes, all other inductions were started by using a foley catheter.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tab3\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eBaseline characteristics of participants.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAll women\u003c/p\u003e\n \u003cp\u003en = 28\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePrimiparous women\u003c/p\u003e\n \u003cp\u003en = 16\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMultiparous women\u003c/p\u003e\n \u003cp\u003en = 12\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003cp\u003e(\u0026alpha;\u0026thinsp;=\u0026thinsp;0\u0026middot;05)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge, mean \u0026plusmn; SD, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30\u0026middot;82 \u0026plusmn; 3\u0026middot;86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e28\u0026middot;88 \u0026plusmn; 3\u0026middot;78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e33\u0026middot;42 \u0026plusmn; 2\u0026middot;07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u0026middot;001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBMI before pregnancy, mean \u0026plusmn; SD, kg/m2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26\u0026middot;93 \u0026plusmn; 5\u0026middot;90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e27\u0026middot;03 \u0026plusmn; 5\u0026middot;37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26\u0026middot;78 \u0026plusmn; 6\u0026middot;79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u0026middot;915\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGestational age, mean \u0026plusmn; SD, weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e39\u0026middot;21 \u0026plusmn; 1\u0026middot;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e39\u0026middot;18 \u0026plusmn; 1\u0026middot;63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e39\u0026middot;25 \u0026plusmn; 1\u0026middot;36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u0026middot;907\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003ctable border=\"1\" width=\"0\"\u003e\n \u003ccaption\u003e\n \u003cp\u003eTable 3\u003c/p\u003e\n \u003cp\u003eData of interviewees.\u0026nbsp;\u003c/p\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85\"\u003e\n \u003cp\u003e\u003cstrong\u003eParity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge, years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85\"\u003e\n \u003cp\u003e\u003cstrong\u003eGestational age, weeks + days\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"113\"\u003e\n \u003cp\u003e\u003cstrong\u003eProfession\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003e\u003cstrong\u003eRepeated use of VR\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"113\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdditional\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003epharmacological analgesia after VR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003e\u003cstrong\u003eVR-preference\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVIREL-1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85\"\u003e\n \u003cp\u003eMultiparous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85\"\u003e\n \u003cp\u003e41+2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"113\"\u003e\n \u003cp\u003eNurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVR1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"113\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVR1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVIREL-2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85\"\u003e\n \u003cp\u003eMultiparous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85\"\u003e\n \u003cp\u003e39+0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"113\"\u003e\n \u003cp\u003eDoctor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"113\"\u003e\n \u003cp\u003eYes, EA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVR1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVIREL-7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85\"\u003e\n \u003cp\u003ePrimiparous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85\"\u003e\n \u003cp\u003e41+4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"113\"\u003e\n \u003cp\u003eSocial worker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"113\"\u003e\n \u003cp\u003eYes, remifentanil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVR1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVIREL-10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85\"\u003e\n \u003cp\u003eMultiparous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85\"\u003e\n \u003cp\u003e38+1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"113\"\u003e\n \u003cp\u003eDisability support worker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVR1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"113\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVR1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVIREL-12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85\"\u003e\n \u003cp\u003eMultiparous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85\"\u003e\n \u003cp\u003e38+2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"113\"\u003e\n \u003cp\u003eAdministrative assistant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVR1 +VR2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"113\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVR1 + VR2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVIREL-14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85\"\u003e\n \u003cp\u003ePrimiparous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85\"\u003e\n \u003cp\u003e39+0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"113\"\u003e\n \u003cp\u003eChildcare worker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVR1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"113\"\u003e\n \u003cp\u003eYes, remifentanil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVR1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVIREL-16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85\"\u003e\n \u003cp\u003eMultiparous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85\"\u003e\n \u003cp\u003e38+0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"113\"\u003e\n \u003cp\u003eChildcare worker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"113\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVR2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVIREL-19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85\"\u003e\n \u003cp\u003ePrimiparous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85\"\u003e\n \u003cp\u003e38+6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"113\"\u003e\n \u003cp\u003eNurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"113\"\u003e\n \u003cp\u003eYes, EA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVR1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVIREL-20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85\"\u003e\n \u003cp\u003eMultiparous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85\"\u003e\n \u003cp\u003e38+1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"113\"\u003e\n \u003cp\u003eHousewife, completed general secondary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVR1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"113\"\u003e\n \u003cp\u003eYes, remifentanil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVR1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVIREL-23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85\"\u003e\n \u003cp\u003ePrimiparous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85\"\u003e\n \u003cp\u003e38+1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"113\"\u003e\n \u003cp\u003eNurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"113\"\u003e\n \u003cp\u003eYes, EA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVR2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVIREL-25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85\"\u003e\n \u003cp\u003ePrimiparous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85\"\u003e\n \u003cp\u003e38+1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"113\"\u003e\n \u003cp\u003eEstate agent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"113\"\u003e\n \u003cp\u003eYes, EA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVR1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVIREL-27\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85\"\u003e\n \u003cp\u003eMultiparous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85\"\u003e\n \u003cp\u003e40+1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"113\"\u003e\n \u003cp\u003eEntrepreneur\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"113\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76\"\u003e\n \u003cp\u003eVR2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eThree themes emerged from analysis of the semi-structured interviews: (1) the VR experience, (2) the pain reduction, and (3) the usability of the VR-application.\u003c/p\u003e\n\u003cdiv class=\"Section2\" id=\"Sec9\"\u003e\n \u003ch2\u003eTheme 1: The VR experience\u003c/h2\u003e\n \u003cdiv class=\"Section3\" id=\"Sec10\"\u003e\n \u003ch2\u003eGeneral experience\u003c/h2\u003e\n \u003cp\u003eOverall, all interviewees experienced positive effects when using VR.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;Yes, it surely was a positive experience... A good way to detach myself from labour pain\u0026hellip; I think VR is especially useful to relax in between the contraction\u0026rdquo; (VIREL-20)\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;It was great. I think I had a dilation of four centimetres when I used the VR for the first time and stopped using VR at eight centimetres.\u0026rdquo; (VIREL-1)\u003c/p\u003e\n \u003cp\u003eAdditionally, women lost perception of the external environment while using the guided meditation VR.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;I prefer the guided meditation for several reasons: the relaxing sound of the waves, the voice guidance, and the perception of being in a pleasant environment instead of being in a hospital.\u0026rdquo; (VIREL-25)\u003c/p\u003e\n \u003cp\u003eAll women describe VR as a good distraction method during labour.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;You mentioned talking to my partner and your telephone ringing while I was using VR, but I did not remember hearing any of it.\u0026rdquo; (VIREL-2)\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;I was so distracted by the beach environment and the meditation voice, that I was less aware of the pain I was in.\u0026rdquo; (VIREL-20)\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec11\"\u003e\n \u003ch2\u003eVR1 experience\u003c/h2\u003e\n \u003cp\u003eFour women reported that the guided meditation VR helped them with their breathing technique.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;It helped me to control my breathing during a contraction\u0026rdquo; (VIREL-25)\u003c/p\u003e\n \u003cp\u003eThe guided meditation VR provides a continuous support, which was mentioned as positive by multiple women. It enhanced their self confidence in bearing the labour pain.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;The continuous support of the VR voice was pleasant\u0026rdquo; (VIREL-2)\u003c/p\u003e\n \u003cp\u003eThe beautiful wide view and tranquillity was highlighted by women regarding the VR images, but a preference for less voice guidance was also expressed.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;It is important that the environment is interesting and has a wide view.\u0026rdquo; (VIREL-2)\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;I liked the voice guidance at some moments, but not the entire time. More moments of just music and nature sounds would be nice.\u0026rdquo; (VIREL-23)\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec12\"\u003e\n \u003ch2\u003eVR2 experience\u003c/h2\u003e\n \u003cp\u003eAll women reported the importance of relaxation during labour and stated that an interactive game was not suitable, because during the game they continuously tightened their muscles.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;I could not relax during the game which caused no reduction in pain.\u0026rdquo; (VIREL-7)\u003c/p\u003e\n \u003cp\u003eAt some point during labour the experienced degree of pain was too high to focus on playing a game, which seems to make the interactive game less suitable during labour.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;The game could be really fun, but from my perspective it is not suitable during labour. I could not focus on the game.\u0026rdquo; (VIREL-1)\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;I would prefer playing a game when I am in less pain, because now I could not concentrate on it.\u0026rdquo; (VIREL-2)\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec13\"\u003e\n \u003ch2\u003ePreference\u003c/h2\u003e\n \u003cp\u003eEight women preferred VR1, three women liked both VR interventions, and one woman reported no additional value of VR. She preferred her partner to help her cope with labour pain.\u003c/p\u003e\n \u003cp\u003e11 Women described VR as helpful for coping with labour pain during the first stages of dilation, but when contractions became too severe and they felt lots of pressure, or the urge to push, they were unable to handle VR glasses any longer. Six out of the seven women who used no additional pain medication stopped using VR just before the second stage of labour.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;\u0026hellip; but when the contraction and the labour pain got really intense, the beach was not comforting me anymore.\u0026rdquo; (VIREL-10)\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;When I felt like pushing the VR glasses were not comfortable anymore.\u0026rdquo; (VIREL-1)\u003c/p\u003e\n \u003cp\u003eNine women stated that they preferred their own native language during the guided meditation instead of a non-native language.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;Listening to a non-native language requires more energy.\u0026rdquo; (VIREL-10)\u003c/p\u003e\n \u003cp\u003eMultiple women mentioned the passive way of distraction as an advantage of VR1. Whereas the VR2 was too much afford during labour.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;The advantage of the guided meditation is that you do not need to actively participate in experience.\u0026rdquo; (VIREL-2)\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec14\"\u003e\n \u003ch2\u003eSide effects\u003c/h2\u003e\n \u003cp\u003eNone of the women who completed both VR interventions reported side-effects.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec15\"\u003e\n \u003ch2\u003eReusing VR\u003c/h2\u003e\n \u003cp\u003eExcept VIREL-16 all interviewees would use VR during a subsequent labour.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;I would definitely use the VR glasses again during a next delivery. I would like to use the VR glasses even longer to pass the time.\u0026rdquo; (VIREL-12)\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec16\"\u003e\n \u003ch2\u003eRecommendation to other women\u003c/h2\u003e\n \u003cp\u003eAll women would recommend using VR during labour to cope with their contractions.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;I surely would, if it is not working for you, you can immediately stop using VR.\u0026rdquo; (VIREL-10)\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;It is worth trying\u0026hellip; Everyone has to experience it for themselves.\u0026rdquo; (VIREL-27)\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec17\"\u003e\n \u003ch2\u003eImprovements\u003c/h2\u003e\n \u003cp\u003eIn this study, the intervention lasted ten minutes. Seven women, however reported that a prolonged VR session without any intermission could have a better effect on long lasting pain reduction during labour. Time seemed to be going faster while using VR.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;Ten minutes is very short; I think using VR for 30 minutes or maybe an hour without intermission would be better.\u0026rdquo; (VIREL-2)\u003c/p\u003e\n \u003cp\u003eRegarding to the intention of longer VR use women would prefer different nature environments or at least a more entertaining environment to keep their attention.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;Although I love the beach, a change in different relaxing environments during a longer period of VR use would be nice.\u0026rdquo; (VIREL-14)\u003c/p\u003e\n \u003cp\u003eThe importance of support of midwifes, nurses, and the partner to make VR successful was also mentioned by two women.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;If the midwife would have put more effort into convincing me to try VR again, I might have used VR another time\u0026hellip; The support and persuasiveness of the caregivers regarding VR partly determines the success of VR.\u0026rdquo; (VIREL-2)\u003c/p\u003e\n \u003cp\u003eIt seems to be important that the guided meditation is specifically developed for use during labour and that the voice guidance helps women cope with their contractions. Women reported they needed positive vocal support especially during the most painful contractions.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;When the labour pain got worse, I needed a more coaching guidance and lots of positive mental support.\u0026rdquo; (VIREL-25)\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;When experiencing severe labour pain, I needed a voice to help me cope with the contraction. Unfortunately, it was not possible with this application.\u0026rdquo; (VIREL-1)\u003c/p\u003e\n \u003cp\u003eOverall, partners were not bothered by their wife using VR. Although some partners stated they would like it to see what she is experiencing on an iPad.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec18\"\u003e\n \u003ch2\u003eTheme 2: Pain reduction\u003c/h2\u003e\n \u003cdiv class=\"Section3\" id=\"Sec19\"\u003e\n \u003ch2\u003ePain intensity\u003c/h2\u003e\n \u003cp\u003eAll women reported a reduction in labour pain.\u003c/p\u003e\n \u003cp\u003eOne woman felt no pain at all when using VR.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;At the beginning I did not feel my contractions at all when using the guided meditation, after taking off the VR glasses I could not tell how many contractions I had in the last ten minutes.\u0026rdquo; (VIREL-1)\u003c/p\u003e\n \u003cp\u003e11 women describe their contractions as less intense and less painful when using VR.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;It reduced the pain to a level that makes it bearable.\u0026rdquo; (VIREL-25)\u003c/p\u003e\n \u003cp\u003e\u0026ldquo; \u0026hellip; the contractions felt shorter and less intense\u0026rdquo; (VIREL-19)\u003c/p\u003e\n \u003cp\u003eWomen described VR as an effective method to reduce pain, especially during the first stage of the active labour phase VR.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;At the end, my contractions were too painful to concentrate on the VR environment and could I not experience the relaxed feeling I experienced before.\u0026rdquo; (VIREL-25)\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec20\"\u003e\n \u003ch2\u003ePain perception\u003c/h2\u003e\n \u003cp\u003eWomen described VR1 as a relaxing experience; they were more focused on the nature environment, the soothing voice and their breathing. This caused enough distraction to reduce the degree of experienced pain. 11 participants experienced positive effects regarding to their pain perception and the tension in their body.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;Without VR I felt strong contractions and a lot of pelvic pressure, but when using VR, the perception of the contractions was less.\u0026rdquo; (VIREL-10)\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec21\"\u003e\n \u003ch2\u003eDistraction\u003c/h2\u003e\n \u003cp\u003eThe distractive component of VR reduces the amount of experienced pain.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;Because of the distractive component of the VR I was not focused on my pain, but I still felt it.\u0026rdquo; (VIREL-27)\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;The contractions were less intense because I was distracted by hearing the soothing voice.\u0026rdquo; (VIREL-14)\u003c/p\u003e\n \u003cp\u003eIn the first stages of experiencing labour pain, a change in environment seemed to be important to keep a woman\u0026rsquo;s attention. In the later, more severe, stages of labour pain a change in environment was less important, at that point the vocal support during a contraction was more meaningful.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;The first time I got bored after a couple of minutes seeing the same beach environment\u0026hellip; The second time using the meditation VR, I did not pay much attention to the surrounding, so the change of environment was less important.\u0026rdquo; (VIREL-1)\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec22\"\u003e\n \u003ch2\u003eTheme 3: The usability of the VR-application\u003c/h2\u003e\n \u003cp\u003eAll women mentioned that it is important to keep the VR application as simple as possible regarding to the usability. All women were positive about the comfort of the VR glasses. Three women noted that it would be nice to use the VR glasses at least once before experiencing labour pain.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;It would be nice to try the VR glasses before being in labour, so you feel more comfortable using them when in pain...\u0026rdquo; (VIREL-16)\u003c/p\u003e\n \u003cp\u003eVerification of the qualitative data was done by comparison with the NRS scores.\u003c/p\u003e\n \u003cp\u003eThe mean NRS scores before starting respectively VR1 and VR2 were 6\u0026middot;71 (SD1\u0026middot;65) and 6\u0026middot;89 (SD1\u0026middot;88) respectively (Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). The mean NRS scores after VR1 and after VR2 were 4\u0026middot;96 (SD2\u0026middot;01) and 5\u0026middot;61 (SD2\u0026middot;23) respectively (Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eThe reported decrease in NRS score was 1\u0026middot;8 after VR1 and 1\u0026middot;2 after VR2 (Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n \u003ctable border=\"1\" width=\"0\"\u003e\n \u003ccaption\u003e\n \u003cp\u003eTable 4\u003c/p\u003e\n \u003cp\u003eNRS scores before and after VR intervention.\u003c/p\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"151\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"170\"\u003e\n \u003cp\u003e\u003cstrong\u003eNRS before VR\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(\u003c/strong\u003e\u003cstrong\u003emean\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026plusmn;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"161\"\u003e\n \u003cp\u003e\u003cstrong\u003eNRS after VR\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(\u003c/strong\u003e\u003cstrong\u003emean\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026plusmn;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"124\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(\u003c/strong\u003e\u003cstrong\u003e\u0026alpha;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;= 0\u003c/strong\u003e\u003cstrong\u003e\u0026middot;\u003c/strong\u003e\u003cstrong\u003e05)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"151\"\u003e\n \u003cp\u003eVR1, n = 24\u003c/p\u003e\n \u003cp\u003ePrimiparous, n = 14\u003c/p\u003e\n \u003cp\u003eMultiparous, n = 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"170\"\u003e\n \u003cp\u003e6\u0026middot;71 \u0026plusmn; 1\u0026middot;65\u003c/p\u003e\n \u003cp\u003e7\u0026middot;29 \u0026plusmn; 1\u0026middot;27\u003c/p\u003e\n \u003cp\u003e5\u0026middot;90 \u0026plusmn; 1\u0026middot;85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"161\"\u003e\n \u003cp\u003e4\u0026middot;96 \u0026plusmn; 2\u0026middot;01\u003c/p\u003e\n \u003cp\u003e5\u0026middot;64 \u0026plusmn; 1\u0026middot;60\u003c/p\u003e\n \u003cp\u003e4\u0026middot;00 \u0026plusmn; 2\u0026middot;21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"124\"\u003e\n \u003cp\u003e0\u0026middot;000\u003c/p\u003e\n \u003cp\u003e0\u0026middot;002\u003c/p\u003e\n \u003cp\u003e0\u0026middot;010\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"151\"\u003e\n \u003cp\u003eVR2, n = 18\u003c/p\u003e\n \u003cp\u003ePrimiparous, n = 8\u003c/p\u003e\n \u003cp\u003eMultiparous, n = 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"170\"\u003e\n \u003cp\u003e6\u0026middot;89 \u0026plusmn; 1\u0026middot;88\u003c/p\u003e\n \u003cp\u003e7\u0026middot;50 \u0026plusmn; 1\u0026middot;51\u003c/p\u003e\n \u003cp\u003e6\u0026middot;40 \u0026plusmn; 2\u0026middot;07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"161\"\u003e\n \u003cp\u003e5\u0026middot;61 \u0026plusmn; 2\u0026middot;23\u003c/p\u003e\n \u003cp\u003e6\u0026middot;25 \u0026plusmn; 1\u0026middot;98\u003c/p\u003e\n \u003cp\u003e5\u0026middot;10 \u0026plusmn; 2\u0026middot;38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"124\"\u003e\n \u003cp\u003e0\u0026middot;001\u003c/p\u003e\n \u003cp\u003e0\u0026middot;026\u003c/p\u003e\n \u003cp\u003e0\u0026middot;017\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eSummary of findings\u003c/h2\u003e \u003cp\u003eAll women were highly satisfied with VR use during labour and experienced less pain. Women preferred the guided meditation. In particular, multiparous women benefited from VR use. The significant difference in NRS score before and after the use of VR supports the potential effectiveness of this innovative technique during labour.\u003c/p\u003e \u003cp\u003eWhen evaluating all participants, the guided meditation seems to be preferred during labour in comparison to the interactive game. This is supported by the qualitative and quantitative data of this study.\u003c/p\u003e \u003cp\u003eWe evaluated suggestions for improvement made by the interviewees during the early and late dilatation stage of labour. During the latent phase and the early dilatation stage of labour (defined as regular painful contractions and a cervical dilatation of 3-5cm) women preferred more distraction such as different nature environments, a more realistic image of the surrounding, and a meditative voice guidance. During the late dilatation stage (defined as a cervical dilatation 6-10cm), when contractions are more painful, women preferred coaching, less distraction, and calm music or soothing nature sounds in between the contractions. Emotional support such as praising for endurance, positive words and psychical support like breathing techniques helped women to cope with labour pain.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Coaching and emotional support will be incorporated in the development of a future VR labour application.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThe strength of this study is that this is the first qualitative evidence of the satisfaction and preference of the use of VR during labour. These results can contribute to develop a new VR tool and innovative technique to reduce labour pain.\u003c/p\u003e \u003cp\u003eA limitation of this study was that all interviewees were contacted by telephone, as the Covid-19 lockdown did not allow face-to-face interviews. Because of this, we may have missed nonverbal cues. However, each time an interviewee gave feedback, we summarized and repeated the feedback to verify that we understood the message correctly. Six interviews were not conducted because the patient could not be reached by telephone. Another limitation is that we only included women who were scheduled for an induction of labour. Literature suggests the active phase of labour in primiparous women is longer in induced labour than in spontaneous onset, this will lead to more exhaustion and a higher request for pharmacological analgesia.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Therefore, we suspect that VR may be more effective in women who have a spontaneous onset of labour.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003eInterpretation\u003c/h2\u003e \u003cp\u003eThe guided meditation provides the experience of continuous support during labour without causing side effects.\u003c/p\u003e \u003cp\u003eThere were no statistically significant differences in pain measured by NRS scores between primiparous and multiparous women. However, multiparous women requested pharmacological analgesia less often. This is possibly related to a shorter duration of the active stage of labour in multiparous women.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Therefore, multiparous women stayed motivated to use VR.\u003c/p\u003e \u003cp\u003ePrevious studies have demonstrated that VR is an effective tool to manage pain and distress in several medical procedures, such as wound care, dental procedures and dialysis.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e The effect of VR on this short acute pain moments cannot be compared with long term pain management during labour. A RCT with 40 nulliparous women, of whom 21 received 30 minutes VR during labour, showed a significant reduction of pain in the VR group.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe interviewees reported the importance of support by midwives, nurses and the partner to make VR a successful alternative to pharmacological analgesia. It is possible that the positive effect of VR can be partly explained by offering continuous support. Continuous support during childbirth by a midwife, partner or doula is highly appreciated by women in labour and results in better birth experiences and a decrease in analgesia use, shorter duration of labour, increase in spontaneous vaginal birth and improved five-minute Apgar score. \u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrates, VR to be a potentially, valuable non-pharmacological tool to reduce labour pain. The interviewees in this study were highly satisfied with VR, and reported improvements such as using VR for a longer period of time, and a VR application specially aimed for women in labour. These suggestions can contribute to developing a specific labour VR application and improve the effectiveness.\u003c/p\u003e \u003cp\u003eRandomised controlled trials have to be performed to assess the effect of VR on the request for pharmacological analgesia by women in labour before VR can be implemented as routine standard care.\u003c/p\u003e"},{"header":"List of abbreviations ","content":"\u003cp\u003eVR: virtual reality; EA: Epidural analgesia; eCRF: electronic case report form; NRS: Numeric Rating Scale\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare no conflict of interest. Completed disclosure of interests forms are available to view online as supporting information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDetails of ethics Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Medical Review Ethics Committee and the scientific research bureau (BWO) from the Zuyderland Medical Centre on 08 June 2020 (METCZ20200096) and registered as a clinical trial (ClinicalTrials.gov Identifier: NCT04858984).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContribution to Authorship\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMW conceived the idea and supervised the study. MW and AM contributed to the study concept and design. Literature search was performed by MW and AM. AM managed and coordinated the research activities and planning. AM and AV were responsible for the recruitment of participants and conducted all the interviews. MW, AM, AV, and AF contributed to the analysis and interpretation of the data. MW and AM developed the first draft of the manuscript, AV and AF revised all manuscript drafts. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no grant from any funding agency in the public, commercial, or non-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all the women and their partners who participated in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics and consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll methods were carried out in accordance with relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed Consent was obtained from the participants in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAnim-Somuah M, Smyth RM, Cyna AM, Cuthbert A. Epidural versus non-epidural or no analgesia for pain management in labour. Cochrane Database Syst Rev. 2018;5:CD000331.\u003c/li\u003e\n \u003cli\u003eSeijmonsbergen-Schermers A, Akker T, Rydahl E, Beeckman K, Bogaerts A, Binfa L, et al. Variations in use of childbirth interventions in 13 high-income countries: A multinational cross-sectional study. PLOS Medicine. 2020;17:e1003103.\u003c/li\u003e\n \u003cli\u003eJones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, et al. Pain management for women in labour: an overview of systematic reviews. Cochrane Database Syst Rev. 2012(3):CD009234.\u003c/li\u003e\n \u003cli\u003eWassen MM, Zuijlen J, Roumen FJ, Smits LJ, Marcus MA, Nijhuis JG. Early versus late epidural analgesia and risk of instrumental delivery in nulliparous women: a systematic review. BJOG. 2011;118(6):655-61.\u003c/li\u003e\n \u003cli\u003eSmith LA, Burns E, Cuthbert A. Parenteral opioids for maternal pain management in labour. Cochrane Database Syst Rev. 2018;6:CD007396.\u003c/li\u003e\n \u003cli\u003eVan de Velde M. Patient-controlled intravenous analgesia remifentanil for labor analgesia: time to stop, think and reconsider. Curr Opin Anaesthesiol. 2015;28(3):237-9.\u003c/li\u003e\n \u003cli\u003eIndovina P, Barone D, Gallo L, Chirico A, De Pietro G, Giordano A. Virtual Reality as a Distraction Intervention to Relieve Pain and Distress During Medical Procedures: A Comprehensive Literature Review. Clin J Pain. 2018;34(9):858-77.\u003c/li\u003e\n \u003cli\u003eMcCaul KD, Malott JM. Distraction and coping with pain. Psychol Bull. 1984;95(3):516-33.\u003c/li\u003e\n \u003cli\u003eKatz J, Rosenbloom BN. The golden anniversary of Melzack and Wall\u0026apos;s gate control theory of pain: Celebrating 50 years of pain research and management. Pain Res Manag. 2015;20(6):285-6.\u003c/li\u003e\n \u003cli\u003eBotella C PA, Banos R, Quero S, Breton-Lopez J. Virtual reality in the treatment of pain. J Cyber Ther Rehabil. 2008;1(1):93-100.\u003c/li\u003e\n \u003cli\u003eGu\u0026eacute;tin S, Brun L, M\u0026eacute;riadec C, Camus E, Deniaud M, Thayer J, et al. A Smartphone-Based Music Intervention to Reduce Pain and Anxiety in Women before or during Labor. European Journal of Integrative Medicine. 2018;in press.\u003c/li\u003e\n \u003cli\u003eMallari B, Spaeth EK, Goh H, Boyd BS. Virtual reality as an analgesic for acute and chronic pain in adults: a systematic review and meta-analysis. J Pain Res. 2019;12:2053-85.\u003c/li\u003e\n \u003cli\u003eFrey DP, Bauer ME, Bell CL, Low LK, Hassett AL, Cassidy RB, et al. Virtual Reality Analgesia in Labor: The VRAIL Pilot Study-A Preliminary Randomized Controlled Trial Suggesting Benefit of Immersive Virtual Reality Analgesia in Unmedicated Laboring Women. Anesth Analg. 2019;128(6):e93-e6. https:// doi: 10.1213/ANE.0000000000003649\u003c/li\u003e\n \u003cli\u003eHajesmaeel-Gohari S, Sarpourian F, Shafiei E. Virtual reality applications to assist pregant women: a scoping review. BMC pregnancy and childbirth. 2021;21(1):249. \u003ca href=\"https://doi.org/10.1186/s12884-021-03725-5\"\u003ehttps://doi.org/10.1186/s12884-021-03725-5\u003c/a\u003e\u003c/li\u003e\n \u003cli\u003eJahaniShoorab N, Ebrahimzadeh Zagami S, Nahvi A, Mazluom SR, Golmakani N, Talebi M, et al. The Effect of Virtual Reality on Pain in Primiparity Women during Episiotomy Repair: A Randomize Clinical Trial. Iran J Med Sci. 2015;40(3):219-24.\u003c/li\u003e\n \u003cli\u003eLi A, Montano Z, Chen VJ, Gold JI. Virtual reality and pain management: current trends and future directions. Pain Manag. 2011;1(2):147-57.\u003c/li\u003e\n \u003cli\u003eTreede RD, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, et al. A classification of chronic pain for ICD-11. Pain. 2015;156(6):1003-7.\u003c/li\u003e\n \u003cli\u003eLaViola, Jr. A discussion of cybersickness in virtual environments. ACM SIGCHI Bulletin. 2000;32:47-56.\u003c/li\u003e\n \u003cli\u003eTong A, Sainsbury P, Craig J. Consolidated Criteria for Reporting Qualitative Research (COREQ): A 32-Item Checklist for Interviews and Focus Groups. International journal for quality in health care : journal of the International Society for Quality in Health Care / ISQua. 2008;19:349-57.\u003c/li\u003e\n \u003cli\u003eHanley G, Munro S, Greyson D, Gross M, Hundley V, Spiby H, et al. Diagnosing onset of labor: A systematic review of definitions in the research literature. BMC Pregnancy and Childbirth. 2016;16.\u003c/li\u003e\n \u003cli\u003eBijur PE, Latimer CT, Gallagher EJ. Validation of a verbally administered numerical rating scale of acute pain for use in the emergency department. Acad Emerg Med. 2003;10(4):390-2.\u003c/li\u003e\n \u003cli\u003eBeigi NM, Broumandfar K, Bahadoran P, Abedi HA. Women\u0026apos;s experience of pain during childbirth. Iran J Nurs Midwifery Res. 2010;15(2):77-82.\u003c/li\u003e\n \u003cli\u003eOstborg TB, Romundstad PR, Eggebo TM. Duration of the active phase of labor in spontaneous and induced labors. Acta Obstet Gynecol Scand. 2017;96(1):120-7.\u003c/li\u003e\n \u003cli\u003eWiederhold MD, Gao K, Wiederhold BK. Clinical use of virtual reality distraction system to reduce anxiety and pain in dental procedures. Cyberpsychol Behav Soc Netw. 2014;17(6):359-65.\u003c/li\u003e\n \u003cli\u003eWong MS, Spiegel BMR, Gregory KD. Virtual Reality Reduces Pain in Laboring Women: A Randomized Controlled Trial. Am J Perinatol. 2020. \u003ca href=\"https://doi.org/10.1016/j.ajog.2019.11.055\"\u003ehttps://doi.org/10.1016/j.ajog.2019.11.055\u003c/a\u003e\u003c/li\u003e\n \u003cli\u003eLunda P, Minnie CS, Benade P. Women\u0026apos;s experiences of continuous support during childbirth: a meta-synthesis. BMC Pregnancy Childbirth. 2018;18(1):167.\u003c/li\u003e\n \u003cli\u003eBohren MA, Hofmeyr GJ, Sakala C, Fukuzawa RK, Cuthbert A. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2017;7:CD003766.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"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":"Virtual reality, labour, pain, analgesia, obstetric care","lastPublishedDoi":"10.21203/rs.3.rs-1048092/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1048092/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e There is increasing evidence that virtual reality (VR) is effective in the reduction of labour pain. The implementation of alternative methods like VR to reduce labour pain can contribute to reduce the request of pharmacological pain management methods and associated side effects. The aim of this study is to examine women’s experiences, preferences and satisfaction in regard to the use of VR during labour. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods \u003c/strong\u003eA qualitative interview study conducted in a non-university teaching hospital in The Netherlands. Two VR applications, respectively a guided meditation (VR1) and an interactive game (VR2) were tested in eligible women with a singleton pregnancy, scheduled for induction of labour. For the primary outcome, patients’ VR experience and application preference were examined using a post-intervention questionnaire and a semi-structured interview. Labour pain before and directly after VR was evaluated using the NRS score.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults \u003c/strong\u003e24 women, of whom fourteen were nulliparous and ten multiparous, were included and 12 of these women participated in semi-structured interviews. Three themes were identified after data analysis: “The VR experience”, “Pain reduction”, and “Usability of the VR application”.\u0026nbsp;All patients were highly satisfied with VR use during labour and reported pain reduction during VR. VR1 was preferred above VR 2 by 17 (71%) women. Both VR1 and VR2 caused a significant decrease in mean NRS scores comparing pain pre-VR use to pain during VR use, of respectively 1·81 (VR1) vs. 1·28 (VR2).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion \u003c/strong\u003eAll\u003cstrong\u003e \u003c/strong\u003ewomen were highly satisfied with VR use during labour, preferred guided meditation and experienced less pain. These results can contribute to the development of a potential promising new non-pharmacological tool to reduce labour pain.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Virtual Reality Experience During Labour (VIREL); a Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-02-07 15:20:34","doi":"10.21203/rs.3.rs-1048092/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-03-07T13:14:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-03-06T23:31:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"58ff4a76-18ca-4e26-99da-a5b92397bc05","date":"2022-02-22T22:28:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"58f6cc1f-3ff7-446d-9b7a-9b77005adc06","date":"2022-02-21T23:16:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-02-16T15:01:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-02-10T14:28:30+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-02-03T13:41:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-02-03T13:37:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2021-11-03T19:48:43+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":"207703eb-4442-4aa0-be47-f67b083ae1e0","owner":[],"postedDate":"February 7th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T20:44:00+00:00","versionOfRecord":{"articleIdentity":"rs-1048092","link":"https://doi.org/10.1186/s12884-023-05432-9","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2023-04-24 20:38:41","publishedOnDateReadable":"April 24th, 2023"},"versionCreatedAt":"2022-02-07 15:20:34","video":"","vorDoi":"10.1186/s12884-023-05432-9","vorDoiUrl":"https://doi.org/10.1186/s12884-023-05432-9","workflowStages":[]},"version":"v1","identity":"rs-1048092","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1048092","identity":"rs-1048092","version":["v1"]},"buildId":"oE6Zbj460LM0Up2FdVbMZ","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}