Participants:
The researcher explained research objectives and methods for them, and provided a list of people who were willing to participate in the study and included in the study at the gestational age of 23–33 weeks. Inclusion criteria were: age 18–35 years; primiparous women; tendency to normal vaginal delivery; gestational age of 32–33 weeks; singleton pregnancy with head view; attending physiological delivery training courses during pregnancy at Atieh Hospital; having low risk pregnancy; and not using specific and invalid medications (alcohol and smoking) during pregnancy; normal placental and fetal status; lack of infertility and chronic diseases; and history of thyroid diseases; lack of familial history of depression; depression in pregnant women; and giving birth at Atieh Hospital, and explained the research goals and methods and prepared a list of people who had a willingness to participate in the study. Exclusion criteria included complications during pregnancy (preterm labor, preterm rupture of membranes, etc.), the absence in at least a counseling session, emergency cesarean section during labor due to fetal or maternal reasons (placental abruption, fetal distress), painless delivery or use of Entonox, and use of analgesics in labor.
Sampling Methods:
According to the data from Bolbol-haghighi et al.(2016), The sample size was 37 peoples based on the information below and following formula:
α = 0.05 Power = 0.80 M1 = 2.63 M2 = 3.55 Sd1 = Sd2 = 1.4
The sample size for each group was 45 persons with 20% loss in sampling (13).
Randomization procedure and Randomization allocation concealment:
Simple randomization method was used in this study with red and blue balls. Women were divided into intervention and control groups (Fig. 1).
Blinding:
Due to the content of counseling sessions, there was no possibility of blindness in this study.
Instrument tools:
1-demographic questionnaire: Includes questions about age, weight, height, marital status, job, education level, family income level.
2:Behavioral change assessment scale: This scale was completed by researcher. It has 5 degrees. This rating include:
Zero Degree: No pain with normal breathing, no restlessness
Grade one: Increased respiratory rate during contractions
Grade two: compressing surrounding tables such as beds, sheets, and other materials during uterine contractions
Grade Three: Includes symptoms defined in grade two, even between uterine contractions and no relaxation at all
Grade Four: Severe restlessness or perhaps between them, uncontrollable and sudden movements such as jumping
The reliability of this scale in the study by HeidarZadeh (2017) was confirmed by the Cronbach’s alpha 0.8 (14).
3- Visual Analogue Scale (VAS): The VAS using a 10-cm line represented the continuum of the pregnant women’s opinion of the degree of pain. One extremity of the line represented “too much pain and unbearable pain,” and the other extremity represented “absence of pain” The participants were asked to rate the degree of pain by making a mark on the line. The validity and reliability of this tool has been proven in previous studies (15). Demographic information was completed by two groups at the beginning of the study. And the next two scales for both groups were completed during childbirth.
Intervention:
Individuals in intervention group were contacted and informed about time and place of class to participate in four weekly counseling sessions in 5 to 7-individual groups at Atieh Hospital. Control group did not receive any intervention. And they participated in routine normal vaginal birth preparation classes. Consultation sessions were designed and conducted as follows.
During the first meeting, the members of the group got to know each other and explained the purpose of their consultative sessions. And their questions were answered. During the second session, people were helped to identify their wrong beliefs and irrational thoughts and hearings about labor pain and the stages of childbirth. The third session began with explanations that misconceptions about the pains of natural childbirth may be the source of exacerbation of these pains, as well as their unbearable and ultimately cesarean delivery. Participants were also briefed on positive mental imagerytechnique and its stages (Table1). In the fourth session, ways to deal with negative thoughts and perceptions were taught. And people were instructed to use the technique three times a day for 15 minutes each until the end of pregnancy.
After the completion of sessions, follow-up was conducted until the pregnant woman was hospitalized for delivery. In the active phase of labor with the onset of 3–4 cm dilatation, the researcher was present at the mother’s bedside and the training, which was presented before the birth, was reviewed. Positive mental imagerytechnique were again taught to each individual during the labor stages as well as the labor pains. The pain assessment was then performed using the visual analogue scale (VAS) and behavioral pain scale at 4–5 cm, 6–7 cm and 8–10 cm dilatations at the peak of contraction. The same stages without counseling was done in the control group. It should be noted that the researcher as accompanying midwife was present alongside all members of intervention. There was no other accompanying midwife in the mother’s bedside in the control group.
Data analyses:
The obtained data from above questionnaires was analyzed through SPSS 21 and analysis of covariance (ANCONA), independent t-test), and chi-square test. Significance level was considered less than 0.05.