The effectiveness of breathing exercise, foot reflexology, and back massage (BRM) during the first stage of labor on labor pain, duration, anxiety, satisfaction, stress hormones, and newborn outcomes in women in Saudi Arabia who are pregnant for the first time

INTERVENTION: The intervention consists of three components in sequence: breathing exercises, foot reflexology and the back massage on top of standard nursing care in the delivery room. The intervention will last for 1 hour. The breathing exercises will take 5 min, reflexology 20 min and 35 min for lower limb and back massage. The intervention group will receive 5 minutes breathing exercise followed by foot reflexology for 10 minutes in each sole and 35 minutes lower limbs and back massage continuously on top of the standard usual midwifery care. The breathing exercises involve asking the woman to slowly and deeply breathe in through the nose during contractions for 2 s and consciously release air during breathing out for 2 s. The foot reflexology involves pressure on a special area on the sole of the foot to stimulate the nerves, with each step repeated five times: 1. Pressing the palms on the Achilles tendon and kneading the ankle 2. Kneading the thumb pads on the centre of the sole and bottom of the heel 3. Following the CIUW‐shape and MST‐shape on the foot lateral, intermediate, & combined on the foot 4. Pressing with a stick on the toes, ball, central foot and heel The back massage involves each step repeated three times: 1. Effleurage from the sacrum to the shoulder and deltoids 2. Applying thumb kneading and lateral pressure at the lumbar spine 3. Applying fist knuckling motion and thumb kneading on the lower back at one side then the other 4. Follow the upper back by applying the thumb kneading on the side of the erector spinae, then draining between the ribs towards the armpit area 5. Applying finger kneading on the trapezius muscle, following fist scooping 6. Pressing on the neck and shoulder area on each side. T CONDITION: Labor ; Pregnancy and Childbirth INCLUSION CRITERIA: 1. Primigravida women without any previous pregnancies such as miscarriages 2. Aged 20 to 35 years 3. At 37 to 41 weeks gestation when in labor 4. Having regular contractions with cervical dilatation of at least 6 cm 5. Regularly attended antenatal clinic from 26 to 34 weeks 6. Singleton pregnancy 7. Cephalic presentation in labor PRIMARY OUTCOME: ; 1. Assessor‐rated pain intensity measured using a present behavioral intensity (PBI) scale during a contraction and when there is absence of contraction at baseline, during intervention and post‐intervention immediately after the intervention and twice‐hourly thereafter during the first stage of labor. During the intervention, the pain intensity will be measured after breathing exercise and foot reflexology therapy (after 25 minutes from the start of the intervention). Similarly, the third pain intensity will be assessed halfway through the massage therapy (after 45 minutes) during and after contraction. The pain measurements for the control group will be taken in a similar manner before and after contraction beginning when the cervix is 6 cm dilated, during the intervention, and two times after intervention in the first stage.; 2. Patient‐reported pain intensity recorded using a visual analog scale (VAS) during a contraction and when there is absence of contraction at baseline, during intervention and post‐intervention immediately after the intervention and twice‐hourly thereafter during the first stage of labor. During the intervention, the pain intensity will be measured after breathing exercise and foot reflexology therapy (after 25 minutes from the start of the intervention). Similarly, the third pain intensity will be assessed halfway through the massage therapy (after 45 minutes) during and after contraction. The pain measurements for the control group will be taken in a similar manner before and after contraction beginning when the cervix is 6 cm dilated, during the intervention, and two times after intervention in the first stage.; 3. Anxiety during labor assessed using the Anxiety Assessment Scale for Pregnant Women in Labor (AASPWL) . There are nine questions with two sub‐dimensions: six questions on the birth process and three questions on motherhood constellation (grouping). The anxiety level will be measured at 6 cm dilation, after the completion of the interventions, and twice every hour during the first stage of labor.; SECONDARY OUTCOME: ; 1. Duration of labor measured from 3 cm cervical dilation and 6 cm dilation to the end of the first stage of labor using a partograph; 2. Maternal satisfaction assessed using Six Simple Questions (SSQ), a short questionnaire to assess maternal satisfaction during labor and delivery, measured once after delivery of the baby before the transfer of the mother to postnatal wards; 3. Levels of maternal adrenocorticotrophic hormone (ACTH) and cortisol in the blood. Samples were taken on admission and 90 min after 6 cm dilatation.; 4. Levels of maternal oxytocin in the blood. Samples were taken on admission and 90 min after 6 cm dilatation.; 5. Maternal vital signs measured by usual monitoring pre‐ and post‐intervention; 6. Fetal heart rate measured by cardiotocography pre‐ and post‐intervention; 7. Post‐delivery health of the newborn assessed using Apgar scores taken at 1 and 5 min after birth;