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DOI: 10.56732/pensarenf.v27i1.250
Review Article
How to cite this article: Coelho M, Tereso A. Virtual reality as a strategy for labour pain relief: scoping
review protocol. Pensar Enf [Internet]. 2023 Ago; 27(1):100-105. Available from:
Virtual reality as a strategy for labour pain relief:
scoping review protocol
During labour, pain can affect the health of the mother and the foetus, and its relief is a
right of the mother and a duty of the professionals. In the promotion of a positive
experience of labour, it is crucial that nurses specialised in maternal and obstetric health give
priority to pain assessment and the use of non-pharmacological methods for pain relief,
providing the necessary resources and empowering parturients to use them. Among said
methods, virtual reality stands out due to its ease of use and for allowing the reduction of
pain levels by diverting attention from the real world, using computers and other devices.
Since it is a new approach that is not yet implemented in delivery rooms in Portugal, it is
important to map the facilitating factors and barriers associated with its use, so that the
dissemination of existing knowledge and its transfer to skilled nursing care during the first
stage of labour can be planned.
To map the research evidence on the facilitating factors and barriers in the use of VR as a
non-pharmacological strategy for pain relief during labour in hospital settings.
This protocol follows the guidelines published by the Joanna Briggs Institute. The databases
MEDLINE, CINAHL, Cochrane Database of Systematic Reviews and MedicLatina
through the EBSCOhost platform, the Joanna Briggs Institute EBP Database, through the
Ovid platform are considered for the search and, the grey literature is also included. As
inclusion criteria, qualitative, quantitative and mixed studies that address virtual reality as a
pain relief strategy during labour in hospital settings (based on the mnemonic PCC -
Population, Concept and Context), published in Portuguese, French, Spanish or English
language between 2017 and 2022 are considered. The titles and abstracts of identified
references will be independently reviewed and assessed for eligibility by two reviewers. In
the event of a tie, a third reviewer will be used. Full text studies and data will be extracted
using a form. The data extraction table will show the mapped data in a descriptive way
answering the research questions.
The results will allow summarising the barriers and facilitating factors in the use of Virtual
Reality for pain relief during labour and thus contribute to decision making in planning the
dissemination of this strategy to pregnant women and health professionals and its
implementation in delivery rooms.
Systematic Review Record
Open Science Framework : osf.io/4b2sj
Virtual Reality; Pain in Labour; Obstetric Nursing; Parturient.
Marta Coelho1
Alexandra Tereso2
1 Master’s student. Nursing School of Lisbon, Lisbon.
Nursing Research, Innovation and Development
Centre of Lisbon (CIDNUR), Lisbon, Portugal.
2 PhD. Nursing School of Lisbon, Lisbon. Nursing
Research, Innovation and Development Centre of
Lisbon (CIDNUR), Lisbon, Portugal.
Corresponding author:
Alexandra Tereso
E-mail: alexandra.tereso@esel.pt
Received: 19.01.2023
Accepted: 25.05.2023
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DOI: 10.56732/pensarenf.v27i1.250
Review Article
Pain during labour is an individual experience.1 The way
pain is experienced by the parturient includes physiological
and psychosocial processes2 that depend on prepartum and
intrapartum factors.3 These include physical, psychological
(fear, anxiety, confidence), prenatal education, parity, the
position adopted by the woman, genetic and clinical factors,
the mother's level of education, socioeconomic and cultural
level, and the model of care during childbirth (e.g. presence
of a caregiver).4 Although pain during labour is a natural and
physiological condition, it can affect the well-being and
health of the woman and the foetus, the woman's emotional
relationship with the new-born, as well as her prospects for
future births.5
National and international guidelines on the positive birth
experience or respected motherhood advocate that pain
relief is crucial to the provision of quality care. The World
Health Organization6 states that pain relief should be based
on scientific evidence and made available in a timely manner,
according to the woman's choices, its culture and its needs.
In this context, non-pharmacological pain relief strategies
that do not entail the risk of adverse effects of
pharmacological strategies such as increased duration of
labour and the need for instrumental deliveries, are
highlighted.1,7 These strategies have the potential to reduce
the side effects of epidural analgesia, increase the rate of
adherence to breastfeeding, increase shared decision-
making and control over labour, facilitate interaction with
professionals, and ultimately increase the satisfaction of the
parturient woman and its family. 8-9
Among the non-pharmacological strategies for pain relief
during childbirth, virtual reality (VR) stands out as a non-
invasive method, presenting several benefits (increased
satisfaction and decreased pain, duration of labour and
anxiety), being effective and easy to use.4,10-11 Musters et al.12
consider that there has been an increase in scientific
evidence that VR is effective in reducing pain during
childbirth, and that its use may contribute to reducing the
use of pharmacological pain control methods and,
concomitantly, the side effects associated with them.
VR is a new technology that uses computers and other
devices, which allows the parturient to experience a sense of
presence in an immersive three-dimensional and interactive
environment, which contributes to reducing the perception
of pain, diverting attention away from the real world.13 This
abstraction and sensory experience can also be used
simultaneously with other techniques, which is an advantage
that should be taken into consideration. 14
Pain perception is (in part) related to the attention paid to
painful stimuli15 and distraction techniques take the
attention away from a noxious stimulus, requiring limited
attention from the user. Although distraction through
watching movies, listening to music, and having non-clinical
conversations has become more common during medical
procedures, VR systems may provide a more effective
alternative. Distraction may be a very promising analgesia
technique that can be used safely and effectively for the
reduction of pain and discomfort during medical
procedures.16 In recent years, several researches have
explored the effectiveness of immersive VR distraction in
reducing pain related to different medical procedures and
also labour. 15
Some of the most recent distraction techniques use
advanced audio-visual technology, which combines visual
and auditory stimuli in two- or three-dimensional videos.
These techniques are called audiovisual VR systems, goggle
systems or simply audio visual distraction and do not use
kinetic stimuli. VR uses sophisticated equipment such as 3-
D monitors (Head Mounted Displays) placed on the head,
which have a large field of view, and motion detection
systems which allow users to interact with the virtual
environment. There is a multiplicity of features and
components that can be added to or removed from the
equipment, which translates into the costs involved for its
The use of VR as an analgesia technique offers more
immersive images due to occluding headsets that project the
images right in front of the user's eyes and, depending on
the model used, block real-world stimuli (visual, auditory or
both).16 McCaffery and Pasero17 have designated this
phenomenon as sensory shielding. In the latter, the user is
protected from pain by the distraction resulting from
immersion, which is particularly increased in VR through
the use of Head Mounted Displays that direct the focus of
attention to what is happening in the virtual world.16
In the first phase of labour, VR is of particular interest due
to its non-invasive nature, its contribution to pain relief and
the absence of significant side effects.11
In the studies conducted by Baradwan et al.4, Akin et al.1, and
Carus et al.18, the benefits of VR were highlighted as being:
the reduction in the perception of pain in parturients, the
decrease in anxiety levels, the increase in the satisfaction of
women and significant others, the absence of adverse
effects, as well as the decreased risk of complications for the
foetus and postpartum disorders for women. In this context,
it is also important to mention the qualitative study
conducted by Wong et al.19, in which the perceptions of
parturients during the use of virtual reality were analysed and
in which they concluded that women felt calmer and more
relaxed, with decreased levels of anxiety and more focused
on breathing. This study also showed significant
improvements in self-efficacy through the use of VR.
Health professionals, with their knowledge and skills,
remain the most important factor in promoting a labour that
meets women's expectations20, ensuring a safe environment,
designing, implementing and assessing interventions for
pain prevention and control.21-22 During pregnancy and
childbirth, pain relief stands out in the professional practice
of obstetric nurses and is based not only on medical reasons,
but also on human reasons.23
The sharing of knowledge for the innovation of nursing
care, strategies and interventions is essential, as well as the
acquisition of resources and the training of professionals to
provide safe, accessible and effective alternatives24 for the
relief of pain in parturients.25 The implementation of VR in
the first stage of labour requires obtaining information on
the preferences of parturients and how they perceive pain.12
In prenatal care, these aspects can be clarified and the
102 | Tereso, A.
Review Article
development of the birth plan can be a good opportunity to
do so.
Despite its effectiveness in pain relief and the safety that its
application allows,26 VR is still not used in delivery rooms in
Portugal. In this context, it is essential to identify the
facilitating factors and barriers to the dissemination of the
available know-how, in order to promote its dissemination
during pregnancy in childbirth preparation courses and its
accessibility to parturients.
A search of MEDLINE (EBSCOhost), the Cochrane
Database of Systematic Reviews (EBSCOhost), and the
Joanna Briggs Institute EBP (Ovid) was performed and no
scoping reviews or systematic reviews on the topic were
Objectives and Research Questions
The aim of this scoping review (ScR) is to map the evidence
on the facilitating factors and barriers in the use of VR as a
non-pharmacological pain relief strategy during labour in
hospital settings.
The research questions are:
What are the barriers to using virtual reality as a pain relief
strategy during labour?
What are the facilitating factors in the use of virtual reality
as a strategy for pain relief during labour?
Following the methodology proposed by JBI, this scoping
protocol is presented according to the guidelines for
systematic review protocols provided by the Preferred
Reporting Items for Systematic review and Meta-Analysis
Protocols (PRISMA-P) checklist (Appendix 1).28 The
planned review will be presented according to the PRISMA
Extension for Scoping Reviews (PRISMA-ScR) Checklist
(Appendix 2).28
This protocol will be conducted to include all studies that
address virtual reality as a non-pharmacological strategy for
pain relief during labour. Ensuring a systematic and
replicable work, the structure of this ScR protocol, will
follow the following steps: define and align the objective
with the questions for the review, develop and align the
inclusion criteria with the objectives/questions; describe the
planned approach for the search, selection, data extraction
and presentation of evidence; search and select the evidence;
extract and analyse the evidence; present the results and
summarise the evidence in relation to the review objective,
reach conclusions and note any implications of the results.29
This protocol has been registered in the Open Science
Framework (registration no. osf.io/4b2sj )
Eligibility Criteria
Participants: this ScR protocol includes studies on the use
of virtual reality for pain relief during labour.
Concept: the phenomenon of interest defined for this ScR
concerns the facilitating factors and barriers to the use of
virtual reality as a non-pharmacological strategy for pain
relief during labour. The identification of these aspects will
make it possible to prevent the impact of barriers and
promote the successful implementation of this strategy in
birth units in Portugal.
Background: hospital (Delivery Rooms).
Types of Studies
This protocol includes primary (quantitative, qualitative and
mixed) or secondary (systematic literature reviews and ScR)
studies and grey literature. Studies published in Portuguese,
French, Spanish and English will be considered, since they
are the languages of the researchers. The timeline
considered will include the last 5 years of publication,
starting in 2017.29
Information sources
To identify potentially relevant documents for the ScR two
types of information sources will be used.
Electronic databases through the EBSCOhost platform:
CINAHL Complete, MEDLINE Complete, MedicLatina
and Cochrane Database of Systematic Reviews, and through
the OVID platform: JBI EBP.
Other documents from sources such as the Open Access
Scientific Repository of Portugal and from organisations
issuing guidelines on health care during childbirth.
Research strategy
The research strategy defined for this ScR will involve three
An initial search in relevant databases: MEDLINE,
CINAHL. Through this search, the most commonly used
descriptors (natural and indexed language) in the titles and
abstracts of the searched articles and the indexing terms
used to identify the articles related to the facilitating factors
and barriers in the use of virtual reality as a non-
pharmacological strategy for pain relief during labour are
The natural language search expression to be used in the
MEDLINE database includes truncation and wild cards and
will be: (Parturient OR Pregnan* OR Wom?n in Labo?r)
AND (Virtual Reality OR User-Computer Interface) AND
(Pain Management OR Pain Measuring OR Pain Relief OR
Labo?r Pain) AND (Hospital OR Obstetric Units).
The search expression in indexed language to be used in the
same database will be: (MH "Labour, Obstetric" OR
"Pregnancy") AND (MH "Virtual Reality" OR MH "User-
Computer Interface") AND (MH "Pain Management" OR
MH "Pain Measurement" OR MH "Analgesia, Obstetrical"
OR MH "Labor Pain") AND MH "Hospital Units".
As limiting factors, the date of publication (from 2017 to
2023) and language (English, French, and Portuguese) will
be used.
Secondly, a search will be conducted by adapting the terms
described in the previous section for each of the sources
mentioned. The search strategy will be based on the
mnemonic "PCC" according to the JBI recommendations.
The Participants were the parturient women; the Concept
was virtual reality as a non-pharmacological strategy for pain
relief and the Context was the hospital (delivery rooms).30
The reading of the titles and abstracts by both reviewers
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Review Article
independently (using previously established questions) will
allow them to select those that meet the eligibility criteria
and that will be chosen to be read in full.
For refinement, the bibliographic references of all identified
articles and studies will be reviewed to include additional
Data mapping process
After the search, all selected studies will be sent to the
Mendeley reference management program and duplicates
will be removed. Subsequently, a detailed assessment of the
studies will be performed, and their selection will be based
on the inclusion criteria and the guiding questions of the
review. Two reviewers independent of each other will be
used for identification, selection, eligibility and inclusion
criteria. In case of doubt, divergent issues will be discussed,
and a third reviewer will be contacted for clarification.
Selected articles will be downloaded into the Covidence
programme, which, in partnership with Cochrane, allows
interaction between reviewers and optimises the systematic
review process, based on JBI recommendations. The
extracted data will include specific details on population,
concept and context, study methods and key findings
relevant to the study question.
Summary of Results
The results will be presented in the PRISMA flowchart
(Annex 3). The data extraction table will show it in an
organized and descriptive way, considering the review
questions. Thus, it is essential to identify the facilitating
factors and barriers in the use of VR in pain relief during
labour. These results will be presented in a descriptive and
analytical way, in a table where the characteristics of the
studies and documents considered in the ScR will be
VR is a non-pharmacological alternative for pain relief31 and
mapping the facilitating factors and barriers to its use during
labour allows planning interventions for the dissemination
and transfer of the knowledge produced involving nurses,
physicians and women/companions so as to promote the
use of this strategy by enhancing the facilitating factors and
minimising the barriers.
Authors’ contributions
Coelho, M: Rationale for the protocol, methodological
options and writing the manuscript.
Tereso, A: Rationale for the protocol, methodological
options and writing the manuscript.
Conflicts of interest
The authors declare that there is no conflict of interest.
No financial support was received for this research.
1. Akin B, Kocak MY, Küçükaydın Z, Güzel K. The effect
of showing images of the foetus with the virtual reality glass
during labour process on labour pain, birth perception and
anxiety. J Clin Nurs [Internet]. 2021 [cited 2022 dec 23]; 30
(1516): 23018. Disponível em:
2. Koyyalamudi V, Sidhu G, Cornett EM, Nguyen V,
Labrie-Brown C, Fox CJ, et al. New labor pain treatment
options. Curr Pain Headache Rep [Internet]. 2016 [cited
2022 dec 18]; 20 (2): 19. Disponível em:
3. Jahanishoorab N, Zagami SE, 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 [Internet]. 2015
[cited 2022 nov 23]; 40 (3): 21924. Disponível em:
4. Baradwan S, Khadawardi K, Badghish E, Alkhamis WH,
Dahi AA, Abdallah KM, et al. The impact of virtual reality
on pain management during normal labor: a systematic
review and meta-analysis of randomized controlled trials.
Sex Reprod Healthc [Internet]. 2022 [cited 2023 jan 5]; 32:
1-7. Disponível em:
5. Ebrahimian A, Bilandi RR, Bilandī MRR, Sabzeh Z.
Comparison of the effectiveness of virtual reality and
chewing mint gum on labor pain and anxiety: a randomized
controlled trial. BMC Pregnancy Childbirth. [Internet].
2022 [cited 2023 jan 5]; 22 (49): 19.
6. World Health Organization. WHO recommendations:
intrapartum care for a positive childbirth experience.
Transforming care of women and babies for improved
health and well-being [Internet]. Geneva: WHO; 2018
[cited 2022 nov 29]. 18. Disponível em:
7. Massov L, Robinson B, Rodriguez-Ramirez E, Maude R.
Virtual reality is beneficial in decreasing pain in labouring
women: a preliminary study. Aust N Z J Obstet Gynaecol
[Internet]. 2022 [cited 2023 jan 5]; (63) 193197.
Disponível em:
8. Frey 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 [Internet].
2019 [cited 2022 dec 20];128 (6) E936. Disponível em:
9. Thomson G, Feeley C, Moran VH, Downe S, Oladapo
OT. Women’s experiences of pharmacological and non-
104 | Tereso, A.
Review Article
pharmacological pain relief methods for labour and
childbirth: a qualitative systematic review. Reprod Health
[Internet]. 2019 [cited 2022 dec 20]; 16 (71) 1-20.
Disponível em: https://doi.org/10.1186/s12978-019-
10. Pourmand A, Davis S, Marchak A, Whiteside T, Sikka
N. Virtual reality as a clinical tool for pain management.
Curr Pain Headache Rep [Internet]. 2018 [cited 2022 dec
17]; 22 (53) 17. Disponível
em: https://doi.org/10.1007/s11916-018-0708-2
11. Pratiw IG, Husin F, Ganiem AR, Susiarno H, Arifin A,
Wirahkusuma, F. The effect of virtual reality on pain in
primiparity women. Int J Nurs Heal Sci [Internet]. 2017
[cited 2022 dec 17]; 4 (4): 4650. Disponível em:
12. Musters A, Vandevenne AS, Franx A, Wassen MMLH.
Virtual reality experience during labour (virel); a qualitative
study. BMC Pregnancy Childbirth [Internet]. 2023 [cited
2023 jan 19]; 23 (1): 283. Disponível em:
13. Wiederhold BK, Gao K, Sulea C, Wiederhold MD.
Virtual reality as a distraction technique in chronic pain
patients. Cyberpsychol Behav Soc Netw [Internet]. 2014
[cited 2022 nov 29];17 (6): 34652. Disponível em:
14. O’Connor S, Mayne A, Hood B. Virtual reality-based
mindfulness for chronic pain management: a scoping
review. Pain Manag Nurs [Internet]. 2022 [cited 2023 jan
5]; 3(3):35969. Disponível em:
15. Botella C, Palacios AG, Baños R, Quero S, Breton-
Lopez J. Virtual reality in the treatment of pain. Journal of
Cybertherapy & Rehabilitation [Internet]. 2008 [cited 2022
dec 17]; 1 (1) 93-100. Disponível em:
16. Wismeijer AAJ, Vingerhoets JJM,. The use of virtual
reality and audiovisual eyeglass systems as adjunct analgesic
techniques: A review of the literature. Ann. Behav. Med
[Internet]. 2005 [cited 2022 dec 7]; 30 (3): 268278.
Disponível em:
17. McCaffery M, Pasero C. Pain: Clinical manual 2nd ed.
St. Louis: Mosby:1999. 795 p.
18. Carus EG, Albayrak N, Bildirici HM, Ozmen SG.
Immersive virtual reality on childbirth experience for
women: a randomized controlled trial. BMC Pregnancy
Childbirth [Internet]. 2022 [cited 2023 jan 3]; 22 (354): 18.
Disponível em: https://doi.org/10.1186/s12884-022-
19. Wong MS, Gregory KD, Spiegel BMR, Khalil C. Patient
perceptions of virtual reality for pain relief in labor: A
qualitative study. Front. Pain Res [Internet].2022 [cited
2023 jan 3]; (3): 16.
20. Ayres-De-Campos D. Intrapartum fetal surveillance.
Best Pract Res Clin Obstet Gynaecol [Internet]. 2016 [cited
2022 dec 20]; (30):12 Disponível em:
21. Ordem dos Enfermeiros. Regulamento nº 391/2019.
Regulamento das competências específicas do enfermeiro
especialista em enfermagem de saúde materna e obstétrica.
Diário da República, II Série (N.º 85 de 03-05-2019):
13560-13565. Disponível em:
22. Wyatt J. Essential competencies. People & Strategy
[Internet]. 2009 [cited 2022 dec 7]; 32 (2):13. Disponível
23. Crowther SA, Hall J, Balabanoff D, Baranowska B, Kay
L, Menage D, et al. Spirituality and childbirth: An
international virtual cooperative inquiry. Women and
Birth [Internet]. 2021 [cited 2022 dec 15]; 34 (2): e13545.
Disponível em:
24. Costa AP, Sánchez-Gómez MC, Cilleros MVM,
organizadores. A prática na investigação qualitativa:
exemplos de estudos [E-book na Internet].Oliveira de
Azeméis: Ludomedia; 2017 [cited 2022 dec 15]. 165 p.
Disponível em: https://www.webqda.net/wp-
25. Jylhä V, Oikarainen A, Perälä M-L, Holopainen A.
Facilitating evidence-based practice in nursing and
midwifery in the WHO European Region. [Internet].
Copenhagen WHO; 2017 [cited 2022 nov 28]. 44 p.
Disponível em:
26. Xu N, Chen S, Liu Y, Jing Y, Gu P. the effects of virtual
reality in maternal delivery: systematic review and meta-
analysis. JMIR Serious Games [Internet]. 2022 [cited 2023
jan 5]; 10 (4): 1-13. Disponível em:
27. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A,
Petticrew M, et al. Preferred reporting items for systematic
review and meta-analysis protocols (PRISMA-P) 2015
statement. Syst Rev [Internet]. 2015 [cited 2022 nov 28]; 4
(1): 1-9. Disponível em: https://doi.org/10.1186/2046-
28. Tricco, AC, Lillie, E, Zarin, W, O’Brien, KK,
Colquhoun, H, Levac, D, Moher, D, Peters, MD, Horsley,
T, Weeks, L, Hempel S et al. PRISMA Extension for
scoping reviews (PRISMA-ScR): Checklist and explanation.
Ann Intern Med [Internet] 2018 [cited 2022 nov 28]; 169
(7) 467-473. Disponível em:
Pensar Enfermagem / v.27 n.01 / August 2023 | 105
DOI: 10.56732/pensarenf.v27i1.250
Review Article
29. Peters MDJ, Godfrey C, McInerney P, Munn Z, Tricco
AC, Khalil, H. Scoping reviews. In: Aromataris E, Munn Z,
editors. JBI Manual for Evidence Synthesis [Internet], JBI
2020 [cited 2022 nov 16]. Capítulo 11. Disponível em:
30. Salmond S, Bennett MJ. Systematic review of qualitative
evidence.In: Holly C, Salmond S, Saimbert M.
Comprehensive systematic review for advanced practice
nursing 3rd. New York : Springer; 2021. p. 295349
31. Wong MS, Spiegel BMR, Gregory KD. Virtual reality
reduces pain in laboring women: a randomized controlled
trial [Internet]. Am J Perinatol 2021[cited 2022 nov 16]; 38
(S01): 167-172. Disponível em: