Introduction

A new study was just released in the journal Anesthesia and Analgesia titled: 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 that examined the impact of virtual reality on laboring people’s self-reported pain levels and other stressors in labor.

One of the greatest worries that many pregnant people have will they be able to handle the pain of childbirth. Some people plan on laboring without pain medications. Others are hoping to birth without pharmacological help and still another group are keeping their options open. In the United States, approximately 60% of people giving birth do so with an epidural or combined spinal-epidural (CSE). Regardless of whether a person gave birth with or without an epidural or CSE, the vast majority of them use nonpharmacologic pain coping methods at some point in their labor. 

Immersive virtual reality distraction is a way to manage many sorts of pain and has been used since the mid-1980s. Virtual reality (VR) “is thought to offer potential therapeutic advantages in acute pain over other forms of distraction because of its ability to create a multisensory distraction while isolating a patient from the immediate clinical setting and replacing it with a more attractive virtual environment.”

In the past, some limitations to widespread usage of VR for pain management included the cost of the equipment and proprietary software, but the price has come down substantially and many affordable applications are now available. Researchers wanted to examine the effect of VR on labor pain.  They hypothesized that people birthing without pain medications would report less pain if they used a VR distraction to help them cope.  They also believed they would find additional benefits including the cognitive and affective components of pain, and a reduction in anxiety and nausea and improved patient satisfaction scores.

How was the study conducted

Eligible pregnant people were required to be at least 32 weeks pregnant with their first baby and in labor anticipating a vaginal delivery. Their pregnancy had to be low risk, and their labor was not concerning from a medical standpoint. Their BMI had to be under 40, they needed to be able to communicate without an interpreter, not have any hearing or vision deficits, psychiatric disorders, seizure history or a history of motion sickness.

At the time of labor, 28 laboring people met the inclusion criteria and chose to participate.  The laboring people were randomly assigned to receive unmedicated labor “without analgesics, alternative therapies, or systematic distraction” or with the addition of the VR program.

These people were between 19 to 38 years with 78% identifying as Caucasian and 67% having a bachelor’s degree or higher.

Participants in the VR group were provided an immersive and interactive VR system that was worn on the head and included a hand control and noise-reducing headphones. Once participants reported contraction pain of greater than 4 out of 10 on the pain scale, the study began and they were observed for 10 minutes or three contractions. The VR simulation was an ocean scene with marine mammals or something similar along with marine mammal calls and breathing underwater sounds. A stream of relaxing music was also included from a nighttime sleep program. The participants could control the direction of their view by moving their head and could simulate taking underwater pictures using the hand control. The non-VR participants did not use these VR methods or any other nonpharmacological coping methods.

What did the study results show 

27 out of 28 laboring people completed the study. The one participant withdrew to use the labor tub.

The participants self-reported their experience. The worst pain intensity reported was lower in the VR group. Anxiety was reported to be less in the VR group. 82% reported they “very much/completely enjoyed” using the VR tool in labor. 70% would want something developed specifically for labor and birth. No adverse events were reported. 15% of subjects who did not eventually require cesarean delivery ended up having an unmedicated vaginal birth.

What did the study conclude

The researchers stated that it was possible to use VR experiences to decrease pain and anxiety during labor using a low-cost consumer product. The researchers found effects similar to other VR testing on pain reduction in non-labor patients.

The researchers also acknowledged limitations to this study.  Participants self-selected to participate in this study.   The treatment was not blinded and pregnant people using the VR tools may have been impacted by the implications and underreported their pain and anxiety scores. (They suggested using a placebo VR experience to control for this.) There is no information on cervical measurements in this study as it was being applied to a low intervention clinical population. Finally, there has been little research into optimum conditions for VR use in labor. The 10 minute limit of use was selected to line up with previous research on VR pain reduction, but labor pain lasts significantly longer than that.

The researchers state that further focus should include “adaptability to variable patient positions (bed, chair, birth balls, tubs, and operating tables if requiring operative delivery), positive motivational biofeedback, goal-oriented tasks including position changes and mobility, and emotionally engaging content appealing to laboring women.”

Topics for discussion

I agree with the researchers, the study group was unusually small even though the results were significant. Prior research already tells us that many things help reduce the pain in labor – music, comforting touch, position changes, breathing patterns, rhythmic movement, water and more. It stands to reason that using VR would help too. It is important to note, very few laboring people use only one of these things at a time, but rather incorporate several techniques at once.

Three contractions or ten minutes is hardly enough time to see if anything works. As a doula supporting people in labor, I observe it often takes several contractions to find the new normal when a laboring person begins to try a new coping technique or position. They are often barely settled in the new routine in the span of ten minutes.

I would be curious to examine research on VR being used in addition to traditional coping methods and throughout labor. Are there fewer requests for pain medications? Are pain medications requested later in labor? Much more research needs to be done on the concept of virtual reality for pain management in labor, but I believe initial results warrant more research.

References

Frey, D. P., Bauer, M. E., Bell, C. L., Low, L. K., Hassett, A. L., Cassidy, R. B., Boyer, K.D. & Sharar, S. R. (2018). 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. Anesthesia and analgesia.

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