Maternal Position Changes for Prolonged Labor

(CIRCUIT Trial)

Recruiting at 1 trial location

Overseen By Drew Hensel Maternal Fetal Medicine Fellow, MD

Age: Any Age

Sex: Female

Trial Phase: Academic

Sponsor: Washington University School of Medicine

Must be taking: Oxytocin

Must not be taking: Magnesium sulfate

Disqualifiers: Uterine infection, Major fetal anomalies, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Compensation: Varies

Number of Visits: 2

82 Participants Needed

Trial Summary

What is the purpose of this trial?

This pilot, randomized control trial will test whether or not a specific circuit of position changes improves maternal outcomes in cases of prolonged labor. Patient who have prolonged labor will be approached for consent and randomization to one of two study groups: circuit intervention against routine standard of care position changes. 82 patients will be enrolled in the study. Exclusion criteria will include: any uterine infection prior to randomization, magnesium sulfate treatment, major fetal anomalies, BMI ≥50, non-reassuring fetal status prior to randomization, or any maternal diagnosis that precludes safety or feasibility of the circuit of maternal position changes. The 3 aims of the study will include: the outcome that the circuit of position changes has on the duration of the first stage of labor, maternal and neonatal morbidity, and maternal satisfaction.

Will I have to stop taking my current medications?

The trial information does not specify whether you need to stop taking your current medications. However, if you are receiving magnesium sulfate treatment, you would be excluded from participating.

What data supports the effectiveness of the treatment Circuit of maternal position changes for prolonged labor?

Research shows that changing positions during labor can help progress labor and reduce complications like long labor and the need for cesarean sections. Studies have found that different positions can help the baby move into a better position for birth, making labor easier and more comfortable for the mother. ^{1 2 3 4 5}

Is it safe for mothers to change positions during labor?

Research suggests that changing positions during labor is generally safe and can be a valuable, noninvasive way to help labor progress. It is a common practice that women have used for comfort and is considered acceptable in promoting labor progress. ^{1 2 6 7 8}

How does the treatment of maternal position changes for prolonged labor differ from other treatments?

The treatment of maternal position changes for prolonged labor is unique because it involves non-invasive, natural movements and postures to facilitate labor progress, unlike other interventions like epidurals or inductions. This approach leverages the body's natural physiology to improve labor outcomes, such as reducing the risk of cesarean births and shortening labor duration, by enhancing uterine activity and fetal positioning. ^{1 2 5 9 10}

Eligibility Criteria

This trial is for English-speaking patients with a single baby in the correct head-down position, who are at least 34 weeks pregnant. They must be experiencing prolonged labor, defined as slow cervical dilation despite ruptured membranes and oxytocin use. Those with uterine infections, on magnesium sulfate treatment, having major fetal anomalies or extremely high BMI (≥50), non-reassuring fetal status before randomization, or any condition that makes the circuit unsafe cannot join.

Inclusion Criteria

I am English-speaking, over 34 weeks pregnant, in labor, and my labor is not progressing as expected.

Timeline

Screening

Participants are screened for eligibility to participate in the trial

Upon admission to labor and delivery or diagnosis of protracted labor

1 visit (in-person)

Randomization and Intervention

Participants are randomized to either the circuit intervention arm or the control arm. The intervention cohort undergoes the circuit of position changes every 2 hours, repeated up to 3 times or until the second stage of labor is achieved.

From randomization until delivery

Continuous monitoring during labor

Postpartum Follow-up

Participants are monitored for maternal and neonatal outcomes, and complete a maternal satisfaction survey regarding their labor experience.

From delivery until postpartum discharge

1 visit (in-person)

Treatment Details

Interventions

• Circuit of maternal position changes

Trial Overview The study compares a specific set of maternal position changes to routine care during prolonged labor. It aims to see if these movements can shorten the first stage of labor and improve outcomes and satisfaction for both mother and baby. Participants will be randomly assigned to one of two groups: those performing the circuit or receiving standard care.

Participant Groups

Group I: Circuit Intervention Arm Experimental Treatment 1 Intervention

The intervention cohort will undergo the circuit of position changes every 2 hours. The circuit will be repeated up to 3 times or until the second stage of labor is achieved, delivery occurs, or labor arrest diagnosis is made. Participants will be considered as adherent to intervention arm if they undergo one complete circuit of maneuvers. Nurses will keep patients on continuous fetal monitoring during the circuit of position changes. Any persistent non-reassuring fetal status in one position of the circuit will prompt progression to the next position in the circuit. The planned circuit of maneuvers will be: 10-minutes of side-lying release on one side 10-minutes of side-lying release on other side 10-minutes of open-knee chest 10-minutes of shaking apples 20-minutes of flying cowgirl on one side 20-minutes of flying cowgirl on opposite side as position 5 20-minutes of running man on same side as position 5 20-minutes of running man on opposite side as position 5

Group II: Control Arm Active Control 1 Intervention

Patients randomized to the control arm will have their labor courses managed per current best practice recommendations. This will include nurse or patient facilitated position changes per the discretion of the patient's clinical care team. Routine position changes allowed in this control group will include walking, sitting, squatting, thrones, supine, hands and knees, and lateral decubitus with or without peanut ball. No positions in the circuit intervention group will be permitted to be used in the control group. Any circuit positions used in the control group will be tracked and documented.

Who Is Running the Clinical Trial?

Washington University School of Medicine

Lead Sponsor

Trials

2,027

Recruited

2,353,000+

Barnes-Jewish Hospital

Collaborator

Trials

36

Recruited

10,300+

The Foundation for Barnes-Jewish Hospital

Collaborator

Trials

43

Recruited

6,600+

Findings from Research

Maternal movement and position changes during labor are crucial for facilitating progress, but modern interventions like epidurals and fetal monitoring have made these changes less common, potentially leading to complications like dystocia.

The article reviews historical research and presents six physiological principles to guide effective maternal positioning strategies, especially before and after receiving epidural anesthesia, to improve labor outcomes.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Overcoming the challenges: maternal movement and positioning to facilitate labor progress. Zwelling, E.[2022]

Maternal positioning during labor is a valuable, noninvasive intervention that can enhance comfort and promote labor progress, as women often instinctively change positions for relief.

The review identifies six mechanisms by which changing maternal positions can help prevent or correct dystocia, highlighting the importance of mobility in the birthing process.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Maternal positioning to prevent or alleviate dystocia in labor. Fenwick, L., Simkin, P.[2019]

Upright positions during labor offer several benefits, including improved physiological and psychosocial outcomes, as discussed in the context of historical practices and modern obstetric influences.

The paper provides recommendations for healthcare providers to facilitate the use of upright positions during labor, highlighting the importance of integrating these practices into current labor and delivery protocols.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Positioning during the second stage of labor: moving back to basics. Shermer, RH., Raines, DA.[2019]

A randomized clinical trial is currently evaluating the effectiveness of maternal positioning techniques in managing occipito-posterior (OP) fetal head positions during labor, involving 438 women at a major maternity unit in Switzerland.

If successful, these techniques could significantly reduce complications associated with persistent OP positions, such as prolonged labor and the need for emergency cesarean sections, while being well-accepted by women and easy to implement.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Maternal positioning to correct occipito-posterior fetal position in labour: a randomised controlled trial. Guittier, MJ., Othenin-Girard, V., Irion, O., et al.[2021]

A study involving 100 healthy pregnant women showed that specific maternal postures can effectively rotate a fetus from a posterior or transverse position to an optimal anterior position, with significant results (p < 0.000).

All four tested postures were similarly effective, and the Sims posture was particularly successful in maintaining the anterior position when performed correctly.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Nursing, maternal postures, and fetal position. Andrews, CM., Andrews, EC.[2013]

In a study of 58 women during cervical dilatation from 6 to 8 centimeters, adopting a sitting position significantly reduced labor pain intensity compared to a supine position, particularly for lower back pain.

The sitting position resulted in clinically meaningful reductions in pain scores, with the most notable relief observed in lumbar pain during contractions, indicating it could be an effective strategy for pain management in labor.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

The relationship between the parturient's positions and perceptions of labor pain intensity. Adachi, K., Shimada, M., Usui, A.[2019]

In a study of 264 women during labor, the incidence of severe perineal trauma was very low at 0.75%, with cases occurring only in younger nulliparous women, indicating that severe trauma is rare in this population.

The maternal position during the second stage of labor did not significantly affect the risk of perineal trauma, but being white or a first-time mother (nulliparous) increased the likelihood of experiencing perineal tears by 3.90 and 2.90 times, respectively.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Perineal Trauma in a Low-risk Maternity with High Prevalence of Upright Position during the Second Stage of Labor. Peppe, MV., Stefanello, J., Infante, BF., et al.[2022]

A survey of 206 pregnant women revealed that while 76% were aware of fetal malposition during labor, only 28% knew that maternal posture could help correct it, indicating a need for increased awareness and education on this topic.

Although 86% of women expressed interest in participating in labor research, only 37% were willing to join a randomized controlled trial, with comfort concerns and the need for partner consultation being significant barriers to participation.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Pregnant women's views on the acceptability, enablers, and barriers of participation in a randomized controlled trial of maternal posture for fetal malposition in labor. Barrowclough, J., Kool, B., Crowther, CA.[2022]

In a study analyzing 116 intrauterine pressure records, the sitting position during labor was found to significantly elevate resting and bearing down pressures compared to the supine position, particularly benefiting nulliparous women during the second stage of labor.

The sitting position not only increased bearing down pressure but also led to a shorter duration of the second stage of labor for nulliparas and the dilation period for multiparas, suggesting that maternal position can influence labor efficiency without affecting uterine contractility.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Effects of sitting position on uterine activity during labor. Chen, SZ., Aisaka, K., Mori, H., et al.[2009]

The traditional dorsal position for labor and birth may have disadvantages, as alternative positions like lateral and upright can enhance uterine contractions.

Upright positions not only improve contraction quality but also lead to shorter and more comfortable labors, highlighting the need for educating women about these benefits and supporting them in adopting these positions during childbirth.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Maternal position during labor and birth: a reassessment. McKay, SR.[2019]

References

1. United States pubmed.ncbi.nlm.nih.gov

Overcoming the challenges: maternal movement and positioning to facilitate labor progress. [2022]

2. United States pubmed.ncbi.nlm.nih.gov

Maternal positioning to prevent or alleviate dystocia in labor. [2019]

3. United States pubmed.ncbi.nlm.nih.gov

Positioning during the second stage of labor: moving back to basics. [2019]

4. England pubmed.ncbi.nlm.nih.gov

Maternal positioning to correct occipito-posterior fetal position in labour: a randomised controlled trial. [2021]

5. United States pubmed.ncbi.nlm.nih.gov

Nursing, maternal postures, and fetal position. [2013]

6. United States pubmed.ncbi.nlm.nih.gov

The relationship between the parturient's positions and perceptions of labor pain intensity. [2019]

7. Brazil pubmed.ncbi.nlm.nih.gov

Perineal Trauma in a Low-risk Maternity with High Prevalence of Upright Position during the Second Stage of Labor. [2022]

8. Greece pubmed.ncbi.nlm.nih.gov

Pregnant women's views on the acceptability, enablers, and barriers of participation in a randomized controlled trial of maternal posture for fetal malposition in labor. [2022]

9. United States pubmed.ncbi.nlm.nih.gov

Effects of sitting position on uterine activity during labor. [2009]

10. United States pubmed.ncbi.nlm.nih.gov

Maternal position during labor and birth: a reassessment. [2019]