Peanut ball for decreasing length of labor: A systematic review and meta-analysis of randomized controlled trials

Full

length

article

Peanut

ball

for

decreasing

length

of

labor:

A

systematic

review

and

meta-analysis

of

randomized

controlled

trials

Jessica

M.

Grenvik

,

Emily

Rosenthal

,

Gabriele

Saccone

,

Luigi

Della

Corte

,

Johanna

Quist-Nelson

,

Richard

D.

Gerkin

,

Alexis

C.

Gimovsky

,

Mei

Kwan

,

Rebecca

Mercier

,

Vincenzo

Berghella

*

a

DivisionofMaternal-FetalMedicine,DepartmentofObstetricsandGynecology,SidneyKimmelMedicalCollegeofThomasJeffersonUniversity,Philadelphia, PA,USA

b

DepartmentofNeuroscience,ReproductiveSciencesandDentistry,SchoolofMedicine,UniversityofNaplesFedericoII,Naples,Italy

c

DivisionofMaternal-FetalMedicine,DepartmentofObstetricsandGynecology,TheGeorgeWashingtonUniversitySchoolofMedicineandHealthSciences, Washington,DC,USA

d

DepartmentofInternalMedicine,UniversityofArizonaCollegeofMedicinePhoenix,Phoenix,AZ,USA

e_{DepartmentofObstetricsandGynecology,KaiserPermanenteOrchardMedicalOffices,Downey,CA,USA}

ARTICLE INFO

Articlehistory: Received31July2019

Receivedinrevisedform18September2019 Accepted19September2019 Keywords: Peanutball Lengthoflabor Vaginaldelivery Cesareansection Laboranddelivery

ABSTRACT

Introduction: Prolonged length of labor is associated with increased maternal and neonatal

complications.Therefore,greatattentionhasbeengiventointerventionsaimedatreducingthelength

oflabor.Onesuchinterventionisthepeanutball,alargeelongatedexerciseballplacedbetweena

woman’slegsduringlabor.

Objective:Theaimofthissystematicreviewandmeta-analysisofrandomizedcontrolledtrials(RCTs)was

toassesstheeffectoftheuseofpeanutballinreducinglengthoflabor.

StudyDesign:Datasources:MEDLINE,EMBASE,WebofSciences,Scopus,ClinicalTrial.gov,OVIDand

CochraneLibraryweresearchedfrominceptionuntilJanuary2019.Selectioncriteria:Selectioncriteria

includedRCTsoflaboringwomenwithsingletongestationsincephalicpresentationatterm(37weeks)

whowererandomizedtoeitheruseofpeanutballorcontrolgroup(nopeanutball).DataCollectionand

Analysis:Fourtrialswith648nulliparousandmultiparouswomeninspontaneousorinducedlaborwere

identifiedandincluded.330womenwererandomizedtotheintervention(peanutballbetweenthe

kneesduringlabor)and318womentothecontrol.Summarymeasureswerereportedasmeandifference

(MD)with95%ofconfidenceinterval(CI)usingtherandomeffectsmodelofDerSimonianandLaird.The

primaryoutcomewastotallengthoflabor.PROSPERORegistrationNumber:CRD42018082438

Results:Totallengthoflaborwas79minshorterinthepeanutballgroup,butthiswasnotsignificant(MD

79.1min,95%CI 204.9,46.7).Peanutballuseshowedtrendstowardhigherincidenceofspontaneous

vaginaldeliveries(RR1.1,95%CI1.0, 1.2)andlowerincidenceofcesareandeliveries(RR0.8,95%CI0.6,1.0).

Conclusions:Peanutballusewasnotassociatedwithasignificantdecreaseintotallengthoflabor.Since

thereweretrendstowardreductionsinlengthoflabor,anincreasedincidenceinspontaneousvaginal

deliveries,andlowerincidenceofcesareandeliveries,moreresearchisneeded.

©2019ElsevierB.V.Allrightsreserved.

Introduction

Prolongedlaborisassociatedwithincreasedmaternal compli-cationssuchaschorioamnionitis,perineallacerations,endometritis, postpartumhemorrhage,aswellasperinatalcomplicationssuchas

neonatalsepsis,lowerApgarscores,andincreasedadmissiontothe neonatalintensivecareunit(NICU)[1,2].

Prolonged labor and failure to progress are common

indications for cesarean delivery [3].Cesarean delivery may

subject the womanto a longer recovery timeand increased

risk of complications during the postpartum period and in

futurepregnancies.Therefore,greatattentionhasbeengiven tointerventionsaimedatreducingthelengthoflabor[4–15]. Midwivesandnursescommonlyusetraditionalbirthingballs (also knownas Swiss balls) to increase maternal comfort, and widenthepelvicoutlet[13–15].Analternativetothetraditional

* Correspondingauthorat:DivisionofMaternal-FetalMedicine,Departmentof ObstetricsandGynecology,ThomasJeffersonUniversity,833ChestnutStreet,First Floor,Philadelphia,PA,19107,USA.

E-mailaddress:vincenzo.berghella@jefferson.edu(V.Berghella).

https://doi.org/10.1016/j.ejogrb.2019.09.018

0301-2115/©2019ElsevierB.V.Allrightsreserved.

ContentslistsavailableatScienceDirect

European

Journal

of

Obstetrics

&

Gynecology

and

Reproductive

Biology

birthingballisthepeanutball,alargeelongatedplasticballshaped likeapeanutshellthatisplacedbetweenawoman’slegsduring laborwhilesheislyinginthelateralrecumbentposition[16–19]. Thispositionisthoughttomimictheuprightpositionandfacilitate wideningof thepelvisandfetaldescent[17].However,thereis limitedresearchavailabledetailingitsefficacyasalaboringtool andprovidingguidelinesforitsuse.

Objective

Thus, theaimofthissystematicreviewandmeta-analysisof randomizedcontrolledtrialswastoassesstheeffectoftheuseof peanutballinreducinglengthoflabor.

Methods Searchstrategy

Thismeta-analysiswasperformedaccordingtotheCochrane protocolrecommended for systematic review [20]. The review protocolwas designed a prioridefining methods for collecting, extractingandanalyzingdata.Theresearchwasconductedusing

MEDLINE, EMBASE, Web of Sciences, Scopus, ClinicalTrial.gov,

OVIDandCochraneLibraryaselectronicdatabases.Thetrialswere identified withthe use of a combination of the following text words:“peanut ball,”“peanutball”,“peanut laborball”, “peanut shapedball”fromtheinceptionofeachdatabasetoJanuary2019. Norestrictionsforlanguageorgeographiclocationwereapplied.In addition,thereferencelistsofallidentifiedarticleswereexamined toidentifystudiesnotcapturedbyelectronicsearches.

Studyselectionandriskofbias

Selection criteria included randomized controlled trials of laboringwomenwithsingletongestationswithcephalic presen-tationsatterm(>=37weeks)whowererandomizedtoeitheruse of peanut ball or control group (i.e. no peanut ball). Multiple gestationsandpretermbirthswereexcluded.

Theriskofbiasineachincludedstudywasassessedbyusingthe criteriaoutlinedintheCochraneHandbookforSystematicReviewsof Interventions [20]. Seven domains related to risk of bias were assessedineachincludedtrial,sincethereisevidencethatthese issuesareassociatedwithbiasedestimatesoftreatmenteffect:1)

random sequence generation; 2) allocation concealment; 3)

blindingof participantsand personnel; 4) blindingof outcome assessment;5)incompleteoutcomedata;6)selectivereporting; and7)otherbias.Reviewauthors’judgmentswerecategorizedas “lowrisk,”“highrisk”or“unclearrisk”ofbias.

Outcomes

Allanalysesweredoneusinganintention-to-treatapproach, evaluatingwomenaccordingtothetreatmentgrouptowhichthey wererandomlyallocatedintheoriginaltrials.

Theprimaryoutcomeofthismeta-analysiswasthetotallength oflabor.Secondary outcomeswerelengthofthefirststageand secondstageoflabor,modeofdelivery,andneonataloutcomes, includingbirthweightandApgarscore.Outcomeswereassessed insubgroupanalysesbyparity.

Dataanalysis

The dataanalysiswas completed usingReviewManager 5.3

(Copenhagen:The NordicCochraneCentre,Cochrane

Collabora-tion,2014).Between-studyheterogeneitywasexploredusingthe I2 _{statistic, which represents the percentage of between-study}

variationthatisduetoheterogeneityratherthanchance.Avalueof 0%indicatesnoobservedheterogeneity,whereasI2valuesof50% indicateasubstantiallevelofheterogeneity.

Thesummarymeasureswerereportedassummaryrelativerisk (RR)orassummarymeandifference(MD)with95%ofconfidence interval(CI)usingtherandomeffectsmodelofDerSimonianand Laird.

All review stages were conducted independently by two

reviewers (JG, ER). The two authors independently assessed

electronicsearch,eligibilityofthestudies,inclusioncriteria,risk of bias, data extraction and data analysis. Disagreements were resolvedbydiscussionwithathirdreviewer(VB).

The meta-analysis was reported following the Preferred

Reporting Item for Systematic Reviews and Meta-analyses

(PRISMA)statement[21].Fig.1showstheflowdiagram(PRISMA template)ofinformationthroughthedifferentphasesofreview.

The meta-analysis was registered with the PROSPERO

International Prospective Register of Systematic Reviews. The registrationnumberisCRD42018082438.

Results

Studyselectionandstudycharacteristics

Fourtrialswereincludedinthemeta-analysis[16–19].Alltrials

included only women with singleton gestations with cephalic

presentationatorafter37weeksgestationwhochoseanepidural fortheirlaborpainmanagement.Atotalof648nulliparousand

multiparous women in spontaneous or induced labor were

included. Of the 648 women included, 330 (50.93%) were

randomized to the intervention group (peanut ball) and 318

(49.1%)wererandomizedtothecontrolgroup (nopeanut ball) (Table1).

The intervention group (peanut ball) involved the use of a peanutshapedexerciseballplacedbetweenthekneesusuallysoon after the epidural and until 10cm dilation. The control group receivedstandardcarewithnouseofthepeanutball(Table2).

Oxytocinuse was only reported in two of the four studies

[17,19].Inthestudiesthatreportedoxytocinuse, 115of150women (76.7%)inthepeanutballgroupreceivedoxytocinand108of137 women(78.8%)inthecontrolgroupreceivedoxytocin.Threeof fourstudiesreportedinductionoflabor[16,17,19].Inonestudy,all womeninbothgroupswereinduced[16].Intheothertwostudies, 54of150women(36%)inthepeanutballgroupwereinducedand

52 of 137 women (38.0%) in the control group were induced

(Table3).

Riskofbiasofincludedstudies

The quality of the RCTs included in our meta-analysis was

assessedbyusingthecriteriaoutlinedintheCochraneHandbook

forSystematicReviewsofInterventions.Alltheincludedstudies hadlow riskofbiasin“randomsequencegeneration”Adequate methods forallocationofwomenwereusedinalltheincluded studies(Fig.2).Testsforfunnelplotasymmetrywerecarriedout

only with an exploratory aim because the total number of

publicationsincludedforeachoutcomewaslessthanten. Synthesisofresults

Theprimaryoutcome,totallengthoflabor,wasonlyreported inoneoutofthefourtrials[16].Inthistrial,totallengthoflabor

was 79minshorter in the peanutball group compared tothe

controlgroup;however,thisdifferenceisnotsignificant(MD 79.1min,95%CI 204.9,46.7;1study;170participants;Fig.3). Whenanalyzedbyparity,therewasalsonosignificantdifference intotallengthoflaborbetweenpeanutballversusnopeanutball

groupsinnulliparouswomenonly(MD 94.6min,95%CI 298.5,

109.3;1study;62participants;Table6)ormultiparouswomen

only (MD 89.7 min, 95% CI 238.4, 59.0; 1 study; 108

participants;Table7).

Length of thefirst stage of laborwas 53minshorterin the peanut ballgroupversusthe controlgroup,and thisdifference

approached significance (MD 53.2min, 95% CI 110.8,4.3; 4

studies;648participants;I2_{=60%;Table4).Thisdatawasfurther}

analyzedbasedonparity.Innulliparouswomen,lengthofthefirst stageof laborwas 48minshorterin thepeanut ballversusno peanut ball group;however, this differencewas not significant (MD 48.4min,95%CI 110.7,13.7;4studies;429participants; I2_{=49%;Table6).Similarly,formultiparouswomen,thelengthof}

thefirststageoflaborwas65minshorterinthepeanutballgroup,

but the difference was not significant (MD 64.6 min, 95%

CI 132.2,2.9];2studies;198participants;I2_=0%;Table7).

There was alsonosignificantdifference in thelengthofthe secondstageoflaborinthepeanutballgroupversusnopeanutball

Table1 StudyCharacteristics. Location Intervention group(n) Control group(n)

Parity Exclusioncriteria

Roth201616

USA 89 81 Nulliparous and multiparous

Initially,therewerenoexclusioncriteriaotherthanthoseimpliedbyinclusioncriteria. ResearcherslaterdecidedtoexcludefromanalysisallwomenwhorequiredC-section becausemostdidnotreach10cmdilation.

Tussey201517 _{USA 107 94 Nulliparous}

and multiparous

Preeclampsiarequiringmagnesiumsulfate;intrauterineinfection;Category3fetalheart tracing

Evans201618

USA 91 100 Nulliparous Highriskpregnancies;musculoskeletaldisorders;pretermorpost-termgestation;diabetes; useofmagnesiumsulfate;plannedcesareandelivery

Mercier201819

USA 43 43 Nulliparous Multiparous,multiplegestation,under18yearsold,non-Englishspeakers,majorfetal congenitalanomalies

Table2

Interventionandcontrolgroups.

Howpeanutballwasused Whenenrolledinlabor Wheninlabor started

Wheninlabor ended

Controlgroup

Roth201616

Peanutballplacedbetweenknees.Additional lateralrotationofbodypositionevery30minutes.

Uponpresentingfor inductionoflabor

Within 30minutesof epidural.

At10cmdilation Nopeanutball,maximum onepillowbetween knees.

Tussey201517

Peanutballplacedbetweenknees.Additional changingofbodypositionevery1-2hoursafter epiduraladministration.

Afterreceivingepidural Immediately afterepidural.

At10cmdilation andafterpassive decentoffetus.

Nopeanutball

Evans201618

Peanutballplacedbetweenknees. Notreported Within 30minutesof epidural.

At10cmdilation Nopeanutball,receiving standardcareusing pillowsandwedges Mercier201819

Peanutballplacedbetweenkneesforatleast 15minutesperhouroflabor.

UponpresentingtoLabor andDeliveryforlaboror laborinduction

Uponreaching 6cmorgreater dilation

At10cmdilation Nopeanutball,maximum 2pillowsbetweenknees.

group (MD 11.7 min, 95% CI 33.6 to 10.2; 2 studies; 371 participants;I2=81%;Table4).Whenanalyzedbasedonparity, therewasnosignificantdifferencebetweengroupsinnulliparous women(MD 19.7,95%CI 45.7to6.4;2studies;152participants; I2=46%;Table6)orinmultiparouswomen(MD 5.5min,95% CI 11.6,0.7;2studies;198participants;I2_=0%;Table7).

Use ofthe peanut ball versus no peanut ball resulted in

trendsfor higher incidence of spontaneous vaginal delivery

(RR 1.1, 95% CI 1.0, 1.2; 4 studies; 648 participants; I2_=0%; Table4)andlowerincidenceofcesareandelivery(RR0.8,95% CI 0.6, 1.0; 4 studies; 648 participants; I2_{=0%; Table 4).}

Subgroupanalysesoftheseoutcomesinnulliparous(Table6)

andmultiparouswomen(Table7)concurredwiththeoverall

analysis(Figs.4and5).

There was not a signi_ficant difference in rate of operative

vaginal delivery in peanut ball versus no peanut ball group

(Table4)overall,orinsubgroupanalysesofnulliparous(Table6) andmultiparouswomen(Table7).Therewasalsonosignificant differencefoundinneonataloutcomessuchasApgarscoreand birthweight(Table5).

Discussion Mainfindings

Thismeta-analysisincludedfourtrialswith648participants andaimedtoevaluatelengthof labor,and potentialharmsand benefits of peanuts ball in singleton gestations with cephalic

presentation at term with epidural anesthesia. This study

demonstratedthatuseofthepeanutballduringlaborresultsin a non-significant reduction intotal lengthoflaborbyoverone hour.Similarly,atrendtowardreductionoffirstandsecondstage oflaborwasalsofoundinthepeanutballgroupversusthecontrol group,thoughthistrendwasnotsignificant.Therewasalsoaslight increasedincidenceofspontaneousvaginaldeliveryanddecreased incidenceofcesareandelivery,andthesedataapproachedbutdid notreachstatisticalsignificance.Thesefindingssuggestthatwhile thereisnosignificantbenefit associatedwithuseofthepeanut ball,theremaybepossiblereductioninthelengthoflaborand possibleincreasedincidenceofspontaneousvaginaldelivery,with moreresearchanddataneeded.

Table3

Labormanagement.

Oxytocin Induction

Roth201616 _{Notreported Allwomenwereinduced}

PB:78/78(100%)NoPB:71/71(100%) Tussey201517

PB:Oxytocinusedin85/107(79.3%)NoPB:Oxytocinusedin74/94(79.8%) PB:30/107(28.0%)wereinduced NoPB:29/94(31.5%)wereinduced Evans201618

Notreported Notreported

Mercier201819

PB:Oxytocinusedin30/43(70%)NoPB:Oxytocinusedin34/43(79%) PB:24/43(55%)NoPB:23/43(53%) PB,peanutball.

Fig.2. Assessmentofriskofbias.(A)Summaryofriskofbiasforeachtrial;Plussign:lowriskofbias;minussign:highriskofbias;questionmark:unclearriskofbias.(B)Risk ofbiasgraphabouteachriskofbiasitempresentedaspercentagesacrossallincludedstudies.

Strengths,limitations,andcomparisonwithexistingliterature Thismeta-analysishasseveralstrengths.All randomized con-trolledtrialspublishedonthistopicwereincludedinthisanalysis.To ourknowledge,thisisthefirstmeta-analysisexaminingwhetheruse ofthepeanutballreducesthelengthoflabor.

Limitationsofthisanalysisareinherenttothelimitationsofthe includedRCTs.Onlyfourtrialswereincluded,andonlyonestudy

reporteddataontheprimaryoutcome.Defininglengthoflaboris

challenging since it often depends onwhen a woman initially

presentsforlaboriflaborisspontaneous.Iflaborisinduced,itis stillchallengingbecausetechniquesusedforcervicalripeningcan varybetweenpatientsand providers.However,thefact thatall studiesinthisanalysisarerandomizedshouldmitigatesomeof this variability. Additionally, subgroup analyses in RCTs are consideredtobeprovisional;therefore,anysubgroupanalysisin

Fig.2.(Continued)

Fig.3. Forestplotfortotallengthoflabor.

Table4

Obstetricoutcomes.

Totallengthoflabor(min) 1st

stage(min) 2nd

stage(min) SVD OVD CD

Roth201616 _423.8(353.6) vs502.9(469.0) 370.1(341.5)vs 449.3(456.1) 53.7(47.6)vs 53.6(54.0) 73/86(84.9%)vs 70/84(83.3%) 4/86(4.7%)vs4/ 84(4.8%) 9/86(10.5%)vs 10/84(11.9%) Tussey201517 Notreported 250.9(185.9)vs 343.0(214.3) 21.5(25.0)vs 43.8(52.1) 87/107(81.3%)vs 64/94(68.1%) 9/107(8.4%)vs 11/94(11.7%) 11/107(10.3%)vs 19/94(21.1%) Evans201618 Notreported 331.3(187.1)vs 322.7(174) Notreported 70/91(76.9%)vs 69/100(69.0%) 0/91vs0/100 21/91(23.1%)vs 31/100(31.0%) Mercier201819 Notreported 315(176)vs387 (227) Notreported 29/43(67.4%)vs 28/43(65.1%) 0/43vs0/43 14/43(32.6%)vs 15/43(34.9%) Total 424vs503 317vs376 38vs49 259/327(79.2%) vs231/321 (72.0%) 13/327(4.0%)vs 15/321(4.7%) 55/327(16.8%)vs 75/321(23.4%) I2 N/A 60% 81% 0% 0% 0% RRorMD (95%CI) 79.1[ 204.9 to46.7] 53.2[ 110.8to 4.3] 11.7[ 33.6to 10.2] 1.1[1.0to1.2] 0.8[0.4to1.6] 0.8[0.6to1.0]

Datapresentedasnumbers(percentage)orasmean(standarddeviation)intheintervention(peanutball)vscontrol(nopeanutball)group.

RR,relativerisk;MD,meandifference;CI,confidenceinterval;SVD,spontaneousvaginaldelivery;OVD,operativevaginaldelivery;CD,cesareandelivery.

Fig.5. Forestplotforcesareandeliveryinnulliparouswomen.

Table5

Neonataloutcomes.

Birthweight(grams) Apgarscoreat1min Apgarscoreat10min Roth201616

Notreported Notreported Notreported

Tussey201517 _{3,456(452)vs3393(609) 8.2(1.2)vs8.2(1.5) 8.8(1.2)vs8.8(1.0)}

Evans201618 _{Notreported Notreported Notreported}

Mercier201819

3,254(466)vs3281(509) Notreported Notreported

Total 3,355vs3,337 8.2vs8.2 8.8vs8.8

I2

0% Notapplicable Notapplicable

MD(95%CI) 28.8[ 98.4to156.0] 0.0[ 0.4to0.4] 0.0[ 0.3to0.3] Datapresentedasnumbers(percentage)orasmean(standarddeviation)intheintervention(peanutball)vscontrol(nopeanutball)group.

MD,meandifference;CI,confidenceinterval.

Table6

Obstetricsoutcomesinsubgroupanalysesofnulliparouswomen.

Totallengthoflabor(min) 1st_{stage(min) 2}nd_{stage(min) SVD OVD CD}

Roth201616 605.6(403.9)vs 700.2(410.6) 502.9(412.7)vs 596.7(408.5) 102.8(49.9)vs 103.5(69.7) 22/34(64.7%)vs 16/28(57.1%) 4/34 (11.8%)vs3/28 (10.7%) 8/34 (23.5%)vs9/28 (10.7%) Tussey201517 _{Notreported 303.8(230.7)vs}

401.1(197.1) 33.7(27.5)vs62.7 (60.1) 36/51(70.6%)vs 29/55(44.6%) 4/51(7.8%)vs 8/55(14.5%) 11/51(21.6%)vs 18/55(32.7%) Evans201618 Notreported 331.3(187.1)vs 322.7(174) Notreported 70/91(76.9%)vs 69/100(69.0%) 0/91vs0/100 21/91(23.1%)vs 31/100(31.0%) Mercier201819 Notreported 315(176)vs387 (227) Notreported 29/43(67.4%)vs 28/43(65.1%) 0/43vs0/43 14/43(32.6%)vs 15/43(34.9%) Total 606vs700 363vs376 68vs83 157/219(71.7%) vs142/226 (62.8%) 8/219(3.7%)vs11/ 226(4.9%) 54/219(24.7%)vs 73/226(32.3%) I2 Notapplicable 49% 46% 0% 0% 0% RRorMD(95% CI) 94.6[ 298.5to109.3] 48.5[ 110.7to 13.7] 19.7[ 45.7to 6.4] 1.1[1.0to1.3] 0.7[0.3to1.7] 0.8[0.6to1.0]

Datapresentedasnumbers(percentage)orasmean(standarddeviation)intheintervention(peanutball)vscontrol(nopeanutball)group.

RR,relativerisk;MD,meandifference;CI,confidenceinterval;SVD,spontaneousvaginaldelivery;OVD,operativevaginaldelivery;CD,cesareandelivery.

Table7

Obstetricsoutcomesinsubgroupanalysesofmultiparouswomen. Totallengthoflabor(min) 1st

stage(min) 2nd

stage(min) SVD OVD CD

Roth201616 _{336.6(292.8)vs} 426.3(471.5) 306.4(284.7)vs 392.1(464.7) 30.2(21.4)vs34.2 (29.7) 51/52(98.1%)vs 54/56(96.4%) 0/52vs1/56 (1.8%) 1/52(1.9%)vs1/ 56(1.8%) Tussey201517 _{Notreported 208.0(126.3)vs}

267.1(214.8) 11.6(17.5)vs18.0 (20.0) 56/56(100.0%)vs 31/38(81.6%) 0/56(0.0%)vs3/ 38(7.9%) 0/56(0.0%)vs4/ 38(10.5%) Evans201618 * – – – – – – Mercier201819 * – – – – – – Total 336vs426 257vs330 21vs26 107/108(99.1%) vs85/94(90.4%) 0/108vs4/94 (4.3%) 1/108(0.9%)vs5/ 94(5.3%) I2 _{N/A 0% 0% 88% 0% 44%} RRorMD(95%CI) 89.7[ 238.4to59.0] 64.6[ 132.2to 2.9] 5.5[ 11.6to 0.7] 1.1[0.9to1.4] 0.2[0.0to1.5] 0.3[0.0to4.3]

Datapresentedasnumbers(percentage)orasmean(standarddeviation)intheintervention(peanutball)vscontrol(nopeanutball)group.

RR,relativerisk;MD,meandifference;CI,confidenceinterval;SVD,spontaneousvaginaldelivery;OVD,operativevaginaldelivery;CD,cesareandelivery.

*

thismeta-analysiscannotbeconsideredasdefinitiveasanalysisof therandomizedgroup.

Conclusionsandimplications

Maternalpositioningduringlaborcanbemodifiedtofacilitate fetaldescentandprogressionoflabor.IntheUnitedStates,women mostcommonlylaborin ahorizontalpositionlikely duetothe popularity of epidural anesthesia for pain management [11]. Womenremaininbedafterplacementofepiduralanesthesiadue torisk of postural hypotensionand decreased lowerextremity mobility[11].However,thishorizontalpositionmaybe detrimen-taltotheprogressionoflabor.Thepressureofthebedcausesthe sacrumandcoccyxtobepushedanteriorly,hinderingthenatural wideningofthepelvicoutletand interferingwithfetaldescent [13].Therefore,laboringinanuprightpositionisfavoredinorder towiden the pelvic outlet and facilitate fetal descent. Upright positioning has also been associated with decreased operative vaginaldelivery,decreasedlengthoffirstandsecondstageoflabor, anddecreasedincidenceofperineallacerations[13].Someupright positionscommonlyused includestanding, squattingorsitting, includingsittingonabirthingball[11].

While ourresults arenot statisticallysignificant, use of the peanutballduringlabormayresultinareductionintotallengthof labor,firststageoflabor,andsecondstageoflabor,aswellastrends for higher rate of vaginal delivery and lower ratefor cesarean delivery.MoredatafromadditionalRCTsareneededtodetermine ifthesetrendsarevalid.

Disclosure

Theauthorsreportnoconflictofinterest. Financialsupport

No_financialsupportwasreceivedforthisstudy.

Theauthorsdeclarethefollowingfinancialinterests/personal

relationshipswhich may beconsidered as potential competing

interests:None

DeclarationofCompetingInterest

The authors declare that they have no known competing

financial interests or personal relationships that could have

appearedtoinfluencetheworkreportedinthispaper. References

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