Early Diagnosis and Intervention for Fetal Malposition in Active Labor and Its Impact on Mode of Delivery

Early Diagnosis and Intervention for Fetal Malposition in Active Labor and Its Impact on Mode of Delivery

Early Diagnosis and Intervention for Fetal Malposition in Active Labor and Its Impact on Mode of Delivery: A Randomized Controlled Trial

The goal of this randomized trial is to test if changing a person's position in labor can increase the chances of delivering their baby vaginally. Specifically, it aims to answer the questions: In fetuses who are facing upwards (occiput posterior, OP) or sideways (occiput transverse, OT) during labor, does changing the patient's position during active labor to a side-lying posture with a peanut ball increase the chances of them having a successful, spontaneous vaginal delivery? Does changing the patient's position in active labor affect the position of the baby at the time of delivery? Do intentional position changes in labor impact patient-perceived autonomy during their labor and delivery experience? Participants will: Receive an ultrasound during labor to determine the position of their baby Be asked to adopt a specific position in labor (side-lying with peanut ball) if they are randomized to the study group Receive additional ultrasounds during labor to assess their baby's position Fill out a questionnaire about their labor experience following the delivery of their baby

In this randomized trial, the investigators aim to evaluate the effects of early ultrasound diagnosis and active management of fetal malposition during the first stage of labor. Specifically, the investigators will compare the modified Sims (side-lying) position ipsilateral to fetal spine with the addition of a peanut ball versus free maternal position choice in occiput posterior (OP) or occiput transverse (OT) fetuses diagnosed by ultrasound during active labor, defined as greater than 6cm cervical dilation. The primary outcome will be operative delivery rates, defined as either cesarean delivery or instrumental vaginal delivery with vacuum or forceps. The investigators will also assess rates of spontaneous rotation to occiput anterior (OA) position at complete dilation and at delivery, as well as the impact of the position changes on the patient's labor experience and their perceived autonomy.

Intervention group (side-lying position with peanut ball) versus control group (free position choice, no peanut ball)

Participants randomized to this group will be asked to adopt a side-lying, lateral position on the ipsilateral side of the fetal spine. A peanut ball will be positioned between the participant's legs while in this position. They will be asked to maintain this position for 60 minutes.

Participants randomized to this group will be able to adopt any position of their choosing during the 60-minute study period. They will not be able to use a peanut ball during this time.

Participants will be assisted into a position lying on their side, specifically the same side as the fetal spine diagnosed by ultrasound. An inflated peanut ball will be positioned between the legs to open the pelvis. They will be asked to maintain the position for 60 minutes.

Participants will be asked to adopt any position of their choosing and to maintain it for 60 minutes. They will be asked to not use a peanut ball during the 60 minute study period.

The percent of fetuses that rotate to facing downwards (occiput anterior) at the time of complete cervical dilation (10cm) in each study group

The percent of fetuses that rotate to facing downwards (occiput anterior, OA) at the time of delivery in each study group

The mean amount of time spent pushing during the second stage of labor in each group (measured in minutes)

The percent of each degree of vaginal laceration (first, second, third, fourth) sustained during vaginal delivery in each study group

The mean score on the validated Labor Agentry Scale (LAS) in each study group, which measures the degree that the participant felt in control during their labor process. Possible total scores for the Labor Agentry Scale range from 10 (rarely felt in control) to 70 (almost always felt in control).

Inclusion Criteria: Maternal age >18 Term gestation (>37 weeks) Singleton pregnancy Spontaneous or induced active labor (cervical dilation 6-9cm) Epidural anesthesia Cephalic fetal presentation, OP/OT position diagnosed by bedside ultrasound Continuous external fetal monitoring Ability to consent Exclusion Criteria: Multiple gestations Unanesthetized labor Known fetal anomalies Known intrauterine fetal demise Inability to consent