Heliyon 9 (2023) e14785

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Heliyon
journal homepage: www.cell.com/heliyon

Review article

The effect of music-based interventions on short-term postpartum

episiotomy pain: A systematic review and meta-analysis
Azam Maleki a, Samaneh Youseflu b, *
a
Maternal and Child Health, Social Determinants of Health Research Center, Zanjan University of Medical Sciences, Zanjan, Iran
b
Candidate in Reproductive Health, Department of Midwifery and Reproductive Health, Isfahan University of Medical Sciences, Isfahan, Iran

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Episiotomy took over as the most common surgery in the field of midwifery that was
Postpartum pain performed in the second stage of labor to facilitate delivery, and reduce perineal damage. Music is
Episiotomy one of the methods used to combat pain. We applied a meta-analysis to investigate whether
Music-based interventions
music-based interventions can reduce short-term postpartum episiotomy pain. Four main English
Systematic review and meta-analysis
databases including Embase, PubMed, Web of Science, and Scopus were searched until July 2022.
All randomized controlled trials (RCTs) with at least two groups (control and intervention) that
aimed to measure the effect of music therapy on episiotomy pain were included in the present
review. The Cochrane risk of bias checklist was used to assess study quality. Study heterogeneity
was determined using the I2 statistic and publication bias using Begg’s and Egger’s tests. Results
of random effect analysis are presented as Standard Mean Difference (SMD) with 95% confidence
intervals (CI). Data were analyzed using the STATA software version 16. In total, seven articles
with 677 subjects were included in the meta-analysis. Overall, the pool estimates of the meta-
analysis demonstrated that music therapy has a positive impact on reducing short-term pain
derived from episiotomy in both primiparous and multiparous compared to the control group
(pooled SMD = − 1.60; CI = − 2.18, − 1.02, p-value<0.001). The heterogeneity was high among
including studies (I2 = 95.7%, p < 0.001). Our result showed that music-based interventions can
be considered a choice for the management of short-term postpartum episiotomy pain among
both primiparous and multiparous women. Future studies with large sample sizes and longer
follow-up periods will be required to draw better conclusions about the long-term effects on
postpartum pain.

1. Introduction

Episiotomy took over as the most common surgery in the field of midwifery that was performed in the second stage of labor to
facilitate delivery, and reduce perineal damage [1]. The benefits of episiotomy are still in doubt, which is why the World Health
Organization (WHO) recommends that episiotomy be reduced to less than 10% and limited to high-risk cases [2]. The prevalence of
episiotomy around the world is varied between 9.7 and 100% in Sweden, and Taiwan, respectively [3]. Like any surgical incision,
episiotomies can be complicated given hematoma, perineal pain, damage to the anal sphincters and mucosa, fever, rupture, redness,
swelling, and wound infection [4,5].

* Corresponding author.
E-mail addresses: s.yoseflu@yahoo.com, s.youseflu@zums.ac.ir (S. Youseflu).

https://doi.org/10.1016/j.heliyon.2023.e14785
Received 9 July 2022; Received in revised form 5 March 2023; Accepted 16 March 2023
Available online 23 March 2023
2405-8440/© 2023 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
A. Maleki and S. Youseflu Heliyon 9 (2023) e14785

Episiotomy pain is one of the reasons for mothers’ fear of vaginal delivery and desire to have a cesarean section [6]. Negative
consequences of perineal pain include anxiety, fatigue, distress, lack of attention to health education provided by caregivers, feeling of
inability, reduced mother-infant bonding, and inappropriate breastfeeding positions [7–9]. Women need to rest immediately after
child birth for reasons such as fatigue, the effects of analgesics and local anesthesia, insomnia, and cultural issues; If this distance is
delayed due to episiotomy repair, it can be lead to a decrease in the mother infant bonding [10].
Various pharmacological (such as acetaminophen codeine, lidocaine gel, diclofenac sodium suppository, non-steroidal anti-in­
flammatory drugs) and non-pharmacological techniques (such as cold and heat therapy, acupressure, cooling gels, infrared radiation,
aromatherapy, herbal medicine, acupuncture, relaxation techniques, distraction and music therapy) are recommended to relieve
perineal pain after episiotomy [10–12].
Music is one of the methods used to combat pain [13]. This method has been used as a supplement to medication, along with other
forms of art therapy, psychotherapy and physiotherapy, which requires the close cooperation of therapists, physicians and psychol­
ogists [14]. Listening to favorite music causes muscle relaxation, a distraction from pain, reduction of pain intensity, reduction of
sending pain messages to the central nervous system, stabilizes vital signs, as well as reduces anxiety and analgesic consumption [15].
Moreover, music and sound stimulate the secretion of pain-relieving endorphins from the anterior pituitary gland and reduce the levels
of catecholamine and stress hormones [13,16,17]. Moreover, based on the gate control theory, the brain is as an active system that
filters, inhibits, excites, selects, and modulates inputs. Before pain messages are transmitted to the brain, they encounter “neural gates”
that control whether these signals are permitted to pass through to the brain. Transmission cells in the dorsal horn of the spinal cord
(neural gates) can both speed up the transmission of pain messages or minimize or even prevent from being transmitted to the brain at
all. It is suggested that music by affecting these gates can have an effect on the perception of pain experience [18].
Today, music is widely used in the field of obstetrics and gynecology. In one study on pregnant black women, musical auditory with
impact on the brain and autonomic nervous system can reduce the level of stress [19]. Many studies show a positive effect of
music-based interventions to reduce labor pain [20–22]. Results regarding the effect of music on pain related to episiotomy are
controversial. This study was conducted as a systematic review and meta-analysis to determine the effect of music-based interventions
on short-term postpartum episiotomy pain.

2. Materials and methods

2.1. Eligibility criteria

Included studies were required to meet all of the following criteria: 1) the study population is healthy women who had a vaginal
delivery, 2) randomized controlled trials (RCTs) with at least two groups (control and intervention) that aimed to measure the effect of
music on episiotomy pain, 3) full-text articles published up to July 2022, without imposing any language constraints.
Studies were excluded if they were at least one of the following criteria: 1) inaccessible full-text of articles 2) unexplained methods,
3) quasi-experimental study, systematic reviews and meta-analysis, animal experiment, cross-sectional, and observational study
design. 4) only assessed the caesarian postoperative pain.

2.2. Information sources

This systematic review and meta-analysis were performed based on the Preferred Reporting Items for Systematic reviews and Meta-
Analyses (PRISMA) statement. A comprehensive, and systematic search was performed in electronic databases including Medline,
Embase, Cochrane Database of Systematic Reviews (CDSR), PubMed, Web of Science, Scopus, CINAHL, Sid, IRANDOC, and Mag-Iran
for the period up to July 2022 using the following search strategies following the Mesh browser keywords and free-text words.

2.3. Search strategy

(“Postnatal Care"[Title/Abstract] OR “postpartum care"[Title/Abstract] OR “postnatal"[Title/Abstract] OR “postpartum"[Title/

Abstract]) AND “pain"[Title/Abstract] AND “music"[Title/Abstract]. (“postnatal pain"[Title/Abstract] OR “postpartum pain"[Title/
Abstract]) AND “music"[Title/Abstract]). (“pain"[Title/Abstract] AND “episiotomy"[Title/Abstract] AND “music"[Title/Abstract]).
Moreover, the manual approaches, in particular, hand-searching and perusing the bibliographies of retrieved articles were done to find
additional studies. For collecting unpublished data, various grey literature databases (such as Google Scholar, Open Grey SIGLE, Global
Index Medicus (GIM), NTIS, World Cat, UW Libraries Search), thesis and dissertations, as well as conference proceedings were scanned.

2.4. Selection process & data collection process

The current systematic review and meta-analysis were conducted based on the Preferred Reporting Items for Systematic reviews
and Meta-Analyses (PRISMA) statement. Using the Endnote program ver.X9 duplicate studies in different databases were eliminated.
The titles and abstracts of all articles were scanned. In the next step, we checked the full text of the studies to identify the articles that
met the selection criteria. Also, to reduce the potential risk of bias, two reviewers performed the literature review, data selection, and
quality assessment of data independently. Disagreements of the investigator were resolved through discussion between reviewers to
reach a consensus. The PRISMA flowchart (Fig. 1) is used for reporting the search result [23].

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A. Maleki and S. Youseflu Heliyon 9 (2023) e14785

2.5. Data items

After providing the full texts, articles information was extracted using a structured form including the author’s name, publication
date, location of study, setting, the sample size of each group, participant’s features, the comparison group, measurement instrument,
and results. The quantitative data were entered into STATA Software version 16.

2.6. Study risk of bias assessment

Two investigators (AM, and SY) independently assessed the risk of bias for each selected study through seven criteria that are
required by Cochrane guidelines for quality assessment of randomized controlled trials [23]. Each study was given a rating of high, low
or unclear in the following issues: random sequence generation (selection bias), allocation concealment (selection bias), blinding of the
participants and the personnel (performance bias), blinding of outcome assessors (detection bias), selective outcome reporting
(reporting bias), incomplete outcome data (attrition bias), and other risks of bias (bias due to problems not covered by 1–5).
In the event of insufficient details regarding the methodological quality of the article, the study authors were contacted; and if no
response was received after three attempts, the quality of the study was evaluated based on the available information. If there was any
disagreement in the risk of bias/quality appraisal assessments between investigators, it was resolved through joint discussion.

2.7. Heterogeneity of the included studies

The heterogeneity of the included studies was assessed using I2, Tau2, and χ2 statistics with associated significance values. The

Fig. 1. The PRISMA flowchart.

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 A. Maleki and S. Youseflu
Table 1
Characteristics of studies included in the systematic review.
Author. Year Location Type of music Recorded or live music Music therapist Sample Participants Intervention Tools Time of outcomes Result
Size measure

Gökduman Turkey watching nature scenery Recorder music None Inter = Primigravid Inter = classical VAS- Episiotomy repair time P<
2022 accompanied by classical 40 Mean age 21,2 Turkish music with P at immediately end of 0.05
Turkish music in Control ± 2,7 sterile virtual reality episiotomy repair, 1 h
acemaşiran tune with = 44 glasses later
sterile virtual reality Control = Routine Care
glasses
Kırca, 2020 Turkey Mother music preferences Recorder music No Inter1 Over20years, Inter1 = Music VAS- Vaginal delivery, P<
(15–20 min) = 50 Primiparous therapy, during P episiotomy pain at 0.05
Control episiotomy repair, hymen repair, skin
= 50 Turkish music, repair, immediately
15–20min end of episiotomy
Control = Routine Care repair, 1 h later
Anğın, 2020 Turkey classical music (n = 30), CD (90 min) no Inter1 23–40years Music Therapy, from VAS- Episiotomy pain at P>
Turkish pop music (n = = 30 Primiparous and stage 2 labor to end of P immediately end of 0.05
30) the first 30 songs most Inter2 Multiparous episiotomy repair episiotomy repair
frequently played in 3 = 30 Inter1 = Turkish
different national radio Control Classical Music
channels = 30 Inter2 = Turkish Pop
Music
Control = Routine Care
Buglione,2020 Italy Brick Cinema-relaxing Recorded music via no Inter = Mean Age 28.7 Inter = Music Therapy, VAS- Vaginal Delivery, P<
4

piano music with rhythm speakers (listening to 50 Year From Stage 1Labor To P episiotomy pain at 0.05
of 70 beats per minute music from the Control Primiparous Delivery 1.24.48 h
randomization until = 50 Control = Routine Care
the childbirth)
Chaichanalap, Thailand classical music, Turkish Recorded music via no Inter = Primiparous and Inter = Music Therapy, VAS- Vaginal Delivery, P<
2018 art music, Turkish folk- two-earphone device 50 Multiparous From Episiotomy P episiotomy pain at 2 0.05
music, Turkish classical (from first suturing Control Mean Age 25 RepairTo 6 H and 6 h
music and popular music until full 6 h = 50 Year Postpartum, A Yellow
based on mother postpartum) Brick Cinema-Relaxing
preferences Piano Music
Control = Routine Care
Simavli, 2014 Turkey self-selected music Recorded music via Based on music Inter = 18–35 Years, Inter = During Labor, VAS- Vaginal Delivery, P<
(classical music, light headphone therapy protocol in 71 Primiparous Turkish Six types of P postpartum pain at 1, 0.05
music, popular music, reducing pain (soft, Control music, 20-min break 4, 8, 16, 24 h
Turkish art music, Turkish relaxing, regular = 70 for every 2 h
folk music and Turkish rhythmic patterns control = routine care
Sufi music) without extreme
changes in dynamics)
Simavli, 2014 Turkey self-selected music Recorded music via Based on music Inter = 18–36 Years, Inter = During Labor, VAS- Vaginal Delivery, P<

Heliyon 9 (2023) e14785

(classical music, light headphone therapy protocol. The 67 Primiparous Turkish Five types of P postpartum pain at 2 h 0.05
music, popular music, tempo of the music Control Music
Turkish art music, Turkish was selected between = 65 Control = Routine Care
folk music and Turkish 60 and 80 beats/min
Sufi music)
A. Maleki and S. Youseflu Heliyon 9 (2023) e14785

following classifications for the I2 statistic were used to identify the degree of heterogeneity: unimportant (0–40%), moderate het­
erogeneity (30–60%), substantial heterogeneity (50–90%), and notable heterogeneity (75–100%) [24]. Publication bias was assessed
using the funnel plot, and Egger’s and Begg’s tests.

2.8. Effect measures & synthesis methods

STATA software version 16 was used for analyses of data. Mean differences were used to find the effect of quantitative data. The
random effect was applied instead of the fixed effect due to the high level of heterogeneity. Subgroup analyses based on study quality
and time of outcomes measure were performed, due to the high level of heterogeneity.

3. Results

3.1. Study selection

We identified 142 articles by search in three major databases based on the search strategy from the following databases: Scopus
[24], web of science [7], PubMed [18], and other sources (93). After removing duplicated articles (21 articles), 108 articles in the title
and abstract review, and finally, 7 articles in the full-text review (due to 3 review articles, 3 articles related to caesarian postoperative
pain, and one article for the insufficient data) were excluded. In total, seven articles [25–31] with 677 subjects were included in the
meta-analysis. The process of the included articles is present in Fig. 1.

3.2. Study characteristics

All included articles except one article were published in the English language. The Description of the seven studies is summarized
in Table 1. Of these, 5 studies were conducted in Turkey, two remained articles were from Italy and Thailand. Regarding the time of
music, 4 studies were started during Labor, and 3 studies during episiotomy repair. Music in all studies was selected based on patient
preference for the local language. The time of postpartum pain measurement varies from episiotomy repair to 48 h after childbirth. In
all studies, the pain level was recorded using the visual analogue scale (VAS) for pain. In 5 studies participants were primiparous

Fig. 2. Forest plot of studies that investigated the influence of music therapy on episiotomy pain.

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A. Maleki and S. Youseflu Heliyon 9 (2023) e14785

women and the two remaining studies included both primiparous and multiparous women (Table 1).

3.3. Main result

In total, seven articles with 677 subjects were included in the meta-analysis. Overall, the pool estimates of the meta-analysis
demonstrated that music has a positive impact on reducing short-term pain derived from episiotomy in both primiparous and
multiparous (pooled SMD = − 1.60; CI = − 2.18, − 1.02, p-value<0.001). The heterogeneity was high among including studies (I2 =
95.7%, Tau-squared = 1.4371, p < 0.001). (Fig. 2).

3.4. Subgroup analysis

The subgroup analyses were conducted based on the quality of the study and time of outcome measure. The results of the subgroups
are reported in Figs. 3 and 4. The result of Fig. 3 shows that the quality of the study affects the pooled SMD and heterogeneity of studies.
The highest and lowest effect of music on reducing the pain was at two and 48 h after episiotomy repair respectively. The effect of
music on reducing the pain was statistically significant at 1 h, 2 h, and 3–24 h after episiotomy repair respectively. The 3–24 h follow-
up period has lower heterogeneity compared to the other periods (Fig. 3). The result of Fig. 4 shows that studies with high-quality
scores have more pooled SMD with low heterogeneity compared to low-quality studies (Fig. 4).

3.5. Sensitivity analysis

We explored the impact of one insignificant result by using a sensitivity analysis and excluding that study [25]. The pool estimates
of the sensitivity analysis demonstrated that pooled SMD was − 1.83 CI95% (− 2.38, − 1.28) I2 = 94.6%. p-value<0.001.

Fig. 3. Forest plot of subgroup analysis based on time of pain measure.

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Fig. 4. Subgroup analysis based on the quality of studies.

3.6. Publication bias

The results reported that no significant publication bias was observed according to the Begg’s (Kendall’s score = − 10.00, z =
− 0.45, p = 1.3495) and Eggerʼs tests (z = 1.01, p = 0.3137), respectively. In Fig. 3, the funnel plot showed symmetrical distribution
among studies (Fig. 5).

3.7. Quality of included the studies

We used the Cochrane Collaboration recommend tools for assessing the methodological quality of clinical trials. In our study, the

Fig. 5. Funnel plot of publication bias.

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quality of the three studies was high and four studies were low (Fig. 6).

4. Discussion

To our knowledge, this study is the first meta-analysis to assess the effect of music on short-term postpartum episiotomy pain. Our
findings show that music-based interventions can be reduced the 1.60-unit of episiotomy pain score in both primiparous and
multiparous than the control group. The highest and lowest effect of music on reducing the pain was at two and 48 h after episiotomy
repair respectively. The effect of music on reducing the pain was statistically significant from 1 h to 24 h after episiotomy repair. Music
can reduce pain by stimulating endorphin secretion, inhibiting peripheral sensory nerves, and reducing excitement and stress [17,32].
Of course, all this depends on the type of song, the lyrics of song, patient’s preferred song/style of music. Fast-paced music puts the
brain on alert while quiet music calms the mind and affects the automatic functioning of the nervous system, reducing breathing, heart
rate, and stress [32,33].
Few systematic reviews were done regarding the benefits of music in the psychological and physiological aspects of pregnancy,
childbirth, and postpartum-related issue. In this regard, in 2021 Shimada et al. conducted a systematic review of 23 interventional
studies (15 articles for prenatal period, 7 articles for childbirth, and one article for postpartum period) to evaluate the effectiveness of
the music intervention on pregnant women. Their study’s search period was from 2009 to 2019 with Portuguese, English, and Spanish
language limitations. They reported that music can provide benefits to the management of pregnancy-related anxiety, stress and
depression, labour pain, or improvement of fetal-maternal bond, and prenatal sleep quality [34]. In their study, only two studies were
regarding postpartum pain and no meta-analysis was done.
Similar to our study, Hakimi et al. conducted a systematic review and meta-analysis in 2022 on the effect of music therapy on
anxiety and pain during the postpartum period. Their results revealed a positive effect of music on the reduction of anxiety and pain
intensity from 0.5 to 8 h after delivery. In their meta-analysis for the analysis of pain severity after natural vaginal delivery (NVD) or
cesarean section (CS), only three studies were included, and the results are not focused on episiotomy pain. However, high hetero­
geneity was seen among the included studies, and no sensitivity analysis was performed. Moreover, the included studies in this meta-

Fig. 6. The results of Cochrane Risk of Bias Tool for the Evaluation of Clinical Trial Quality.

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analysis were not music therapy because they were not conducted by trained music therapist [35].
Also, in 2021 Hasanah et al. conducted a meta-analysis of 9 randomized control trials to evaluate the effectiveness of music therapy
on labor pain. Despite the high rate of heterogeneity, they showed that music can significantly reduce the first stage of labor pain in
parturient mothers. The quality of the included study has not been assessed [36]. An inconsistent result was reported by Chuang et al.,
2019. Their meta-analysis (5 studies on both randomized controlled or quasi-experimental trials) reveal not significantly impact of
music therapy on labor pain of primiparous women [37]. Overall, our results were consistent with the two mentioned studies and
demonstrate that music could be a simple and convenient option for reducing short-term postpartum pain similar to labor pain.
Analgesic effects of music can be explained by a combination of many mechanisms such as the release of endorphins, distraction or
attention focusing on stimulus, the orientation of pleasure, emotional modification, and relaxation [16,38]. The beneficial effects of
music therapy are not only limited to the health of the prospective mother, but also extend to the developing of the fetus [16]. Loewy
et al. study show that in premature infants, the live sound and parent-preferred lullabies applied by a music therapist improved cardiac
and respiratory function, sleep patterns, caloric intake, and sucking behaviors [39].
Due to insufficient data, our result cannot support which kind of music is more effective. Only one study was conducted a com­
parison between two types of music (classical music vs Turkish pop music) on reducing postpartum pain that their result was not
statistically significant [25]. Early evidence shows that music without lyrics could be effective in reducing pain [40]. Therefore, it can
be useful in designing a standardized music-based intervention.

4.1. Strengths, and limitations

This study is the first meta-analysis regarding the effect of music on reducing episiotomy pain. The current systematic review and
meta-analysis were conducted based on the standard procedure based on the Preferred Reporting Items for Systematic reviews and
Meta-Analyses (PRISMA) statement, and only clinical trials were included. Despite the study’s strengths, the results have inherent
limitations. The heterogeneity of included studies was high and a meta-analysis of only seven articles was too small to prove our
hypothesis. Therefore, our findings should be interpreted cautiously. Moreover, the majority of included study was conducted in Italy,
Turkey, and Thailand. There was no study in low income country. There is some evidence that emphasized there are residency, and
racial inequality (measured by the total effect of ethnicity/skin color) in obstetric good practices and interventions in labor and birth
care [41,42]. Therefore, it is recommended to conduct more research in different cultures with different socio-economic status.

5. Conclusion

Our result showed that music can be considered a choice for the management of short-term postpartum episiotomy pain among
both primiparous and multiparous women. Future studies with large sample sizes and longer follow-up periods will be required to
draw better conclusions about the long-term effects of music on postpartum pain.

Declarations

Author contribution statement

All authors listed have significantly contributed to the development and the writing of this article.

Funding statement

Azam Maleki was supported by Zanjan University of Medical Sciences [A-11-344-27] IR.ZUMS.REC.1400.511.

Data availability statement

The data used to support the findings of this study are available upon request.

Declaration of interest’s statement

The authors confirm that this paper has been read and approved and that there are no other persons who satisfied the criteria for
authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all authors.

Acknowledgments

We would like to thank the Clinical Research Development Center of Ayatollah Mousavi Hospital, Zanjan University of Medical
Sciences for their collaboration.

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References

[1] L. Ghulmiyyah, S. Sinno, F. Mirza, E. Finianos, A. Nassar, Episiotomy: history, present and future–a review, J. Matern. Fetal Neonatal Med. 35 (7) (2022)
1386–1391.
[2] I. Melo, L. Katz, I. Coutinho, M.M. Amorim, Selective episiotomy vs. implementation of a non episiotomy protocol: a randomized clinical trial, Reprod. Health 11
(1) (2014) 1–6.
[3] I.D. Graham, G. Carroli, C. Davies, J.M. Medves, Episiotomy rates around the world: an update, Birth 32 (3) (2005) 219–223.
[4] Z.F. Deyaso, T.T. Chekole, R.G. Bedada, W. Molla, E.B. Uddo, T.T. Mamo, Prevalence of episiotomy practice and factors associated with it in Ethiopia, systematic
review and meta-analysis, Women’s Health 18 (2022), 17455057221091659.
[5] J. Ye, Y. Chen, H. Yang, Q. Chen, Y. Huang, J. Zhao, et al., A nationwide cross-sectional survey of episiotomy practice in China, Lancet Reg. Health-West. Pacific
19 (2022), 100345.
[6] K. Demšar, M. Svetina, I. Verdenik, N. Tul, I. Blickstein, V.G. Velikonja, Tokophobia (fear of childbirth): prevalence and risk factors, J. Perinat. Med. 46 (2)
(2018) 151–154.
[7] A.Ş. Kırca, D.K. Gül, The effect of music and skin contact with the newborn on pain and anxiety during episiotomy repair in primiparous women: a double-blind
randomized controlled study, Explore 18 (2) (2022) 210–216.
[8] N.J. Shoorab, M. Mirteimouri, A. Taghipour, R.L. Roudsari, Women’s experiences of emotional recovery from childbirth-related perineal trauma: a qualitative
content analysis, Int. J. Commun. Based Nurs. Midwifery 7 (3) (2019) 181.
[9] C.Y. Lai, H.W. Cheung, T.T. Hsi Lao, T.K. Lau, T.Y. Leung, Is the policy of restrictive episiotomy generalisable? A prospective observational study, J. Matern.
Fetal Neonatal Med. 22 (12) (2009) 1116–1121.
[10] Z. Karaçam, K. Eroğlu, Effects of episiotomy on bonding and mothers’ health, J. Adv. Nurs. 43 (4) (2003) 384–394.
[11] R.G. Choudhari, S.A. Tayade, S.V. Venurkar, V.P. Deshpande, A review of episiotomy and modalities for relief of episiotomy pain, Cureus 14 (11) (2022).
[12] K. Laine, B.M. Yli, V. Cole, C. Schwarz, A. Kwee, D. Ayres-de-Campos, et al., European guidelines on perinatal care-Peripartum care Episiotomy, J. Matern. Fetal
Neonatal Med. (2021) 1–6.
[13] B. Ramesh, A. Srinivasan, Impact of music therapy of the extracellular status of endocrine markers in pregnant women-a review, Music Med. 14 (4) (2022)
245–260.
[14] E. Dobrzynska, H. Cesarz, J. Rymaszewska, A. Kiejna, Music therapy–History, definitions and application, Arch. Psychiatr. Psychother. 8 (1) (2006) 47–52.
[15] L. Mitchell, R.A. MacDonald, Music and pain: evidence from experimental perspectives, Music, Health Wellbeing (2012) 230–238.
[16] P.N. Parmar, Music therapy and music medicine during antenatal period: mechanisms and evidence of effects on maternal and fetal health, Indian J. Integr.
Med. (2019) 1–7.
[17] H.-H. Lin, Y.-C. Chang, H.-H. Chou, C.-P. Chang, M.-Y. Huang, S.-J. Liu, et al., Effect of music interventions on anxiety during labor: a systematic review and
meta-analysis of randomized controlled trials, PeerJ 7 (2019) e6945.
[18] J. Loewy, Underlying music mechanisms influencing the neurology of pain: an integrative model, Brain Sci. 12 (10) (2022) 1317.
[19] J.V. Loewy, E. Corwin, D. Jones, Integrative research for understanding intersectional stress among pregnant Black women: postulates for music therapy and
biological assessments, Music Med. 14 (2) (2022) 102–107.
[20] M. Gökduman Keleş, The Effect of Virtual Reality Glasses Used with Music during Episiotomy Repair on Women’s Perceived Pain, Vital Signs and Postpartum
Comfort, Aydın Adnan Menderes Üniversitesi, Sağlık Bilimleri Enstitüsü: Aydın, Turkey, 2022 dissertation.
[21] H. Guo, M. Que, J. Shen, Q. Nie, Y. Chen, Q. Huang, et al., Effect of music therapy combined with free position delivery on labor pain and birth outcomes, Appl.
Bionics Biomech. (2022) 2022.
[22] Ş. Çatalgöl, E. Ceber Turfan, The effects of music therapy applied to pregnant women on maternal, fetal, and neonatal results: a randomized controlled study,
Health Care Women Int. 43 (5) (2022) 448–464.
[23] J.P. Peters, L. Hooft, W. Grolman, I. Stegeman, Reporting quality of systematic reviews and meta-analyses of otorhinolaryngologic articles based on the PRISMA
statement, PLoS One 10 (8) (2015), e0136540.
[24] C. Lefebvre, E. Manheimer, J. Glanville, J. Higgins, S. Green, Cochrane Handbook for Systematic Reviews of Interventions, The Cochrane Collaboration,
Oxfordshire, UK, 2011.
[25] A.D. Anğin, M.A. Oruç, A. Öktem, T. Gürsu, Y. Alan, O. Sakin, et al., The effect of music on pain and anxiety in episiotomy, J. Ankara Med. J. 20 (3) (2020)
541–552.
[26] A. Buglione, G. Saccone, M. Mas, A. Raffone, L. Di Meglio, L. di Meglio, et al., Effect of music on labor and delivery in nulliparous singleton pregnancies: a
randomized clinical trial, Arch. Gynecol. Obstet. 301 (3) (2020) 693–698.
[27] A.Ş. Kırca, D.K.J.E. Gül, The effect of music and skin contact with the newborn on pain and anxiety during episiotomy repair in primiparous women: a double-
blind randomized controlled study, J. Explore (2020).
[28] R. Chaichanalap, W. Laosooksathit, K. Kongsomboon, T. Hanprasertpong, Efficacy of music therapy on immediate postpartum episiotomy pain: a randomized
controlled trial, Thai J. Obstet. Gynaecol. (2018) 158–165.
[29] S. Simavli, I. Gumus, I. Kaygusuz, M. Yildirim, B. Usluogullari, H. Kafali, Effect of music on labor pain relief, anxiety level and postpartum analgesic
requirement: a randomized controlled clinical trial, Gynecol. Obstet. Invest. 78 (4) (2014) 244–250.
[30] S. Simavli, I. Kaygusuz, I. Gumus, B. Usluogullari, M. Yildirim, H. Kafali, Effect of music therapy during vaginal delivery on postpartum pain relief and mental
health, J. Affect. Disord. 156 (2014) 194–199.
[31] M. Gökduman Keleş, Müzik eşliğinde izletilen sanal gerçeklik gözlüğünün epizyotomi onarımı sırasında kadınların algıladığı ağrıya, yaşam bulgularına ve
doğum sonu konforuna etkisi, 2022.
[32] R. Finnerty, Music Therapy as an Intervention for Pain Perception, Anglia Ruskin University, Cambridge, England, 2006 dissertation.
[33] L.M. Bailey, Music therapy in pain management, J. Pain Symptom Manag. 1 (1) (1986) 25–28.
[34] B.M.O. Shimada, M.A. Cabral, V.O. Silva, G.C. Vagetti, Interventions among pregnant women in the field of music therapy: a systematic review, Revista
Brasileira de Ginecologia e Obstetrícia/RBGO Gynecol. Obstet. 43 (5) (2021) 403–413.
[35] S. Hakimi, K. Hajizadeh, R. Hasanzade, M. Ranjbar, A systematic review and meta-analysis of the effects of music therapy on postpartum anxiety and pain levels,
J. Caring Sci. 10 (4) (2021) 230.
[36] U. Hasanah, B. Murti, H. Prasetya, The effectiveness of aromatherapy and music therapy to reduce pain during stage-1 of birth delivery: a meta-analysis,
J. Matern. Child Health 6 (3) (2021) 295–306.
[37] C.H. Chuang, P.C. Chen, C.S. Lee, C.H. Chen, Y.K. Tu, S.C. Wu, Music intervention for pain and anxiety management of the primiparous women during labour: a
systematic review and meta-analysis, J. Adv. Nurs. 75 (4) (2019) 723–733.
[38] R.I. Dunbar, K. Kaskatis, I. MacDonald, V. Barra, Performance of music elevates pain threshold and positive affect: implications for the evolutionary function of
music, Evol. Psychol. 10 (4) (2012), 147470491201000403.
[39] J. Loewy, K. Stewart, A.-M. Dassler, A. Telsey, P. Homel, The effects of music therapy on vital signs, feeding, and sleep in premature infants, Pediatrics 131 (5)
(2013) 902–918.
[40] J.S. Martin-Saavedra, L.D. Vergara-Mendez, I. Pradilla, A. Velez-van-Meerbeke, C. Talero-Gutierrez, Standardizing music characteristics for the management of
pain: a systematic review and meta-analysis of clinical trials, Compl. Ther. Med. 41 (2018) 81–89.
[41] M. Steenkamp, A. Rumbold, L. Barclay, S. Kildea, A population-based investigation into inequalities amongst Indigenous mothers and newborns by place of
residence in the Northern territory, Australia, BMC Pregnancy Childbirth 12 (1) (2012) 44.
[42] M.T. Alves, DCd Chagas, AMd Santos, V.M.F. Simões, BVdS. Ayres, GLd Santos, et al., Racial inequality in obstetric good practices and interventions in labor and
birth care in Rede Cegonha, Ciência Saúde Coletiva 26 (2021) 837–846.

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