Effectiveness of Virtual Reality and Stress-Ball Distraction for Pain During Episiotomy Repair: A Four-Arm Randomized Controlled Trial
Downloads
Objective: This study compared the effectiveness of virtual reality (VR), stress-ball distraction, their combination, and routine care in reducing pain during episiotomy repair.
Methods and Materials: A four-arm, parallel-group randomized controlled trial was conducted in two hospitals in Al-Muthanna Governorate, Iraq, between December 2025 and February 2026. The final analysis included 112 postpartum women allocated equally to VR, stress-ball distraction, combined VR and stress-ball distraction, or routine care (n = 28 per group). Pain intensity was assessed immediately after episiotomy repair using a 0–10 Visual Analogue Scale. Between-group differences were analyzed using one-way ANOVA followed by Tukey HSD comparisons in SPSS 26.
Findings: Mean pain scores were 3.82 ± 1.24 for VR, 5.46 ± 1.10 for stress-ball distraction, 3.48 ± 1.38 for combined treatment, and 7.39 ± 1.49 for routine care. The overall between-group difference was significant, F(3,108) = 52.18, p < .001, η² = .592. Compared with routine care, VR (MD = 3.57), stress-ball distraction (MD = 1.93), and combined treatment (MD = 3.91) significantly reduced pain (all p < .001). Both VR and combined treatment were superior to stress-ball distraction (p < .001). However, the difference between VR alone and combined treatment was nonsignificant (p = .768).
Conclusion: VR significantly reduced pain during episiotomy repair. Combining VR with stress-ball distraction provided no statistically significant additional benefit, while stress-ball distraction remained an effective, low-cost alternative.
Downloads
Abdelgalil, M. S., Amer, B. E., Eldesouky, E., Darwish, M. Y., Farag, E., Mohamed, A., et al. (2025). Network meta-analysis of episiotomy approaches: Comparing routine, restrictive, and non-episiotomy strategies and their effects on maternal and neonatal outcomes in primiparous patients. Reproductive Health, 22, 161. https://doi.org/10.1186/s12978-025-02132-9
Al-Shammary, S. E., & Al-Fayyadh, S. (2024). The effectiveness of non-pharmacological interventions on reducing intramuscular injection-related pain in adult patients: A randomized controlled trial. Iraqi National Journal of Nursing Specialties, 37(1), 36–49. https://doi.org/10.58897/d17ypv79
Alghadir, A. H., Anwer, S., Iqbal, A., & Iqbal, Z. A. (2018). Test-retest reliability, validity, and minimum detectable change of visual analog, numerical rating, and verbal rating scales for measurement of osteoarthritic knee pain. Journal of Pain Research, 11, 851–856. https://doi.org/10.2147/JPR.S158847
Azu, T. D., Abraham, S. A., Doe, P. F., Amoadu, M., & Owusu, G. (2024). Prevalence and predictors of episiotomy among puerperal women accessing postnatal care in the Kumasi Metropolis. BMC Pregnancy and Childbirth, 24, 750. https://doi.org/10.1186/s12884-024-06967-1
Bazaliński, D., Wójcik, A., Pytlak, K., Bryła, J., Kąkol, E., Majka, D., & Dzień, J. (2025). The use of virtual reality as a non-pharmacological approach for pain reduction during the debridement and dressing of hard-to-heal wounds. Journal of Clinical Medicine, 14(12), 4229. https://doi.org/10.3390/jcm14124229
Bergendahl, S., Jonsson, M., Hesselman, S., Ankarcrona, V., Leijonhufvud, Å., Wihlbäck, A.-C., et al. (2024). Lateral episiotomy or no episiotomy in vacuum-assisted delivery in nulliparous women (EVA): Multicentre, open-label, randomised controlled trial. BMJ, 385, e079014. https://doi.org/10.1136/bmj-2023-079014
Bonarska, M., Adasik, D., Szymczyk, S., Łocik, G., & Stanirowski, P. (2025). A systematic review of contemporary and emerging analgesia techniques for natural labor: Patient-centered approaches and technological advances. Journal of Clinical Medicine, 14(11), 3977. https://doi.org/10.3390/jcm14113977
Choudhari, R. G., Tayade, S. A., Venurkar, S. V., & Deshpande, V. P. (2022). A review of episiotomy and modalities for relief of episiotomy pain. Cureus, 14, e31620. https://doi.org/10.7759/cureus.31620
ClinicalTrials.gov. (2026). Comparison between virtual reality and stress ball intervention in managing pain during episiotomy repair (NCT07499011). U.S. National Library of Medicine. https://clinicaltrials.gov/study/NCT07499011
Fadhil, S. N., & Ali, R. M. (2019). Effect of non-pharmacological pain management methods on reducing the severity of labor pain in primigravida women. Indian Journal of Public Health Research & Development, 10(7), 680. https://doi.org/10.5958/0976-5506.2019.01653.X
Faruki, A., Nguyen, T., Proeschel, S., Levy, N., Yu, J., Ip, V., et al. (2019). Virtual reality as an adjunct to anesthesia in the operating room. Trials, 20, 782. https://doi.org/10.1186/s13063-019-3922-2
Gökduman Keleş, M., & Altinkaya, S. Ö. (2025). The effect of virtual reality accompanied by music on women’s perceived pain and postpartum comfort during episiotomy repair: A randomized controlled trial. Pain Management Nursing, 26(4), e398–e404. https://doi.org/10.1016/j.pmn.2025.02.004
Gür, E. Y., & Apay, S. E. (2020). The effect of cognitive behavioral techniques using virtual reality on birth pain: A randomized controlled trial. Midwifery, 91, 102856. https://doi.org/10.1016/j.midw.2020.102856
Kjeldgaard Pedersen, L., Fisker, L. Y. V., Rölfing, J. D., Ahlburg, P., Veien, M., Vase, L., & Møller-Madsen, B. (2023). Virtual reality increases pressure pain threshold and lowers anxiety in children compared with control and non-immersive control: A randomized crossover trial. European Journal of Pain, 27(7), 805–815. https://doi.org/10.1002/ejp.2108
Kouijzer, M. M. T. E., Kip, H., Bouman, Y. H. A., & Kelders, S. M. (2023). Implementation of virtual reality in healthcare: A scoping review on the implementation process of virtual reality in various healthcare settings. Implementation Science Communications, 4, 67. https://doi.org/10.1186/s43058-023-00442-2
Mohammadi, H., Rasti, J., & Ebrahimi, E. (2023). Virtual reality, fear of pain and labor pain intensity: A randomized controlled trial. Anesthesiology and Pain Medicine, 13(1), e130387. https://doi.org/10.5812/aapm-130387
National Health Service. (2023). Episiotomy and perineal tears. https://www.nhs.uk/pregnancy/labour-and-birth/episiotomy-and-perineal-tears/
Orhan, M., & Bülez, A. (2023). The effect of virtual reality glasses applied during episiotomy on pain and satisfaction: A single-blind randomized controlled study. Journal of Pain Research, 16, 2227–2239. https://doi.org/10.2147/JPR.S412883
Rodriguez, S. T., Jimenez, R. T., Wang, E. Y., Zuniga-Hernandez, M., Titzler, J., Jackson, C., et al. (2025). Virtual reality improves pain threshold and recall in healthy adults: A randomized crossover study. Journal of Clinical Anesthesia, 103, 111816. https://doi.org/10.1016/j.jclinane.2025.111816
Seyed Alitabar, S. H. (2024). The future of healthcare: Navigating challenges and embracing technological advances. International Journal of Body, Mind and Culture, 11(2), 89–92. https://doi.org/10.22122/ijbmc.v11i2.695
Seyed Alitabar, S. H. (2025). The biopsychosocial model in modern healthcare: Overcoming barriers to holistic patient care. International Journal of Body, Mind and Culture, 12(2), 1–4. https://doi.org/10.61838/ijbmc.v12i2.950
Shawq, A. H. (2024). Effectiveness of deep breathing technique on pain level of school children during catheterization. Medical Journal of Babylon, 21(Suppl 1), S120–S125. https://doi.org/10.4103/mjbl.mjbl_258_23
Shawq, A. H., Al-Musawi, K. M., Kalel, M. J., & Mahmod, A. A. (2025). The effects of music interventions on children’s pain severity and anxiety during dressing changes in Iraq: A randomized controlled trial. Jurnal Keperawatan Soedirman, 20(1), 43. https://doi.org/10.20884/1.jks.2025.20.1.13100
Singh, S., Thakur, T., Chandhiok, N., & Dhillon, B. S. (2016). Pattern of episiotomy use and its immediate complications among vaginal deliveries in 18 tertiary care hospitals in India. Indian Journal of Medical Research, 143(4), 474–480. https://doi.org/10.4103/0971-5916.184304
Tanya, N. K., R., & N., R. (2023). A prospective, randomized, single-blind study comparing polyglactin-910 fast suture and chromic catgut suture in episiotomy repair. International Journal of Reproduction, Contraception, Obstetrics and Gynecology, 12(10), 3141–3148. https://doi.org/10.18203/2320-1770.ijrcog20232962
Tosun, B., Berşe, S., Dirgar, E., & Özen, N. (2025). Effect of stress ball use on cannulation-related invasive pain in hemodialysis patients: A randomized controlled, single-blind study. BMC Nephrology, 26, 140. https://doi.org/10.1186/s12882-025-04071-w
Watheeg Kharbot, S. H., & Mohammed, A. Q. (2025). The effect of virtual reality-based intervention technique on reducing pain in children with burns during dressing changes. International Journal of Body, Mind and Culture, 12(7), 71–80. https://doi.org/10.61838/ijbmc.v12i7.1021
Xu, B., Luo, Q., Wu, R., Lu, Y., Ying, H., Xu, Y., & Lu, Z. (2022). Perineal stress as a predictor of performing episiotomy in primiparous women: A prospective observational study. BMC Pregnancy and Childbirth, 22, 793. https://doi.org/10.1186/s12884-022-05075-2
Yuksel, S., Ustun, A., Kar, E., Ozcan, A., & Callioglu, N. (2025). The impact of different skin suture methods in episiotomy repair on healing and pain: A randomized clinical trial. Health Care for Women International, 46(9), 1015–1029. https://doi.org/10.1080/07399332.2025.2499498
Copyright (c) 2026 International Journal of Body, Mind and Culture
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
