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. 2026 Apr 23;32(2):e70144. doi: 10.1111/ijn.70144

The Effect of Peanut Ball Use on the Labour Process and Maternal—Neonatal Outcomes in Parturient Women With High Maternal Body Mass Index: A Randomized Controlled Trial

Fulden Ozkececi 1,✉, Gulten Guvenc 2
PMCID: PMC13106928  PMID: 42026814

ABSTRACT

Aim

The aim of this study was to determine the effect of using a peanut ball in different positions on the labour process, maternal and neonatal outcomes for parturient women with high maternal body mass index.

Methods

This randomized controlled trial was conducted between March 2022 and August 2023 with 59 parturient women. The intervention group (n = 29) was positioned with a peanut ball for 30 min every hour until cervical dilatation reached 5–10 cm. No intervention was made for the control group (n = 30). Data collection tools included the Birth Satisfaction Scale and pain assessment using the visual analogue scale.

Results

The mean body mass index was 36.2 and 35.9 kg/m2 in the intervention and control group, respectively. There was no significant difference between the groups in terms of active phase duration (p = 0.522). Pain intensity at the end of the active phase was significantly lower in the intervention group (p = 0.001). Perineal trauma, Apgar score, and need for neonatal intensive care did not differ significantly between the groups (p = 0.706, p = 0.366 and p = 1.000, respectively); however, the Birth Satisfaction Scale score was significantly higher in the intervention group (p = 0.001).

Conclusion

Increasing use of peanut balls in parturient women with high maternal body mass index may decrease labour pain and improve satisfaction with the labour process.

Trial Registration

It was registered at ClinicalTrials.gov in March 2022 (NCT05276947). The trial protocol and statistical analysis plan can be accessed through the registry entry.

Keywords: childbirth, labour, obesity, obstetrics, pain, patient satisfaction, peanut ball

Summary

What Is Already Known About This Topic?

  • In the active management of labour, the use of positions appropriate to the stages of labour is one of the practices that contribute to the progress of labour.

What This Paper Adds:

  • Changing positions at frequent intervals (e.g., every 30 min) and starting the positions in the latent phase may increase the effectiveness of the intervention.

  • To increase women's acceptance of frequent position changes, it is recommended to teach positions and exercises with a peanut ball during the prenatal period.

  • No adverse effect on parturient women using the peanut ball was found.

The Implications of This Paper?

  • More randomized controlled trial results are needed to determine the effect of positioning used with a peanut ball on the duration of labour in parturient women with high maternal body mass index.

  • In order to use this ball effectively in delivery rooms, it is recommended that it be integrated into in‐service training plans, and that nurses and midwives receive training.

1. Introduction

A high body mass index (BMI) is one of the factors that predisposes individuals to dysfunctional labour (Maged et al. 2017; Cohen and Friedman 2020; Gimovsky 2021). In 2016, the World Health Organization (WHO) reported that 1.9 billion adults aged 18 years and older were overweight (40% women), and 650 million adults were obese (15% women) (WHO 2021). A report conducted in Turkey found that 29% of women were overweight and 30% were obese (Hacettepe University Population Studies Institute 2019). A high BMI poses a risk for critical conditions that need to be actively managed during labour, such as unsuccessful induction of labour, prolonged labour, and caesarean delivery (Nuthalapaty et al. 2004; Carlson and Lowe 2014; Ellekjaer et al. 2017). Prolonged labour is important because it is associated with increased maternal complications such as chorioamnionitis, endometritis, postpartum haemorrhage and neonatal complications such as neonatal sepsis, low Apgar score and increased admission to the neonatal intensive care unit (Pergialiotis et al. 2020; Infante‐Torres et al. 2020).

The WHO Intrapartum Care for a Positive Childbirth Experience guideline (2018) emphasizes the reduction of unnecessary medical interventions during labour, the promotion of woman‐centred care, and the active participation of respectful and supportive health professionals. In this context, nurses, midwives and physiotherapists play essential roles in addressing the physical and psychosocial needs of women during the birth process; they are considered important components of the multidisciplinary care team, especially in terms of pain management, supporting maternal mobility and improving the birth experience (WHO 2018; Bohren et al. 2017).

In the active management of labour, using positions appropriate for the stages of labour is one of the practices that contribute to the progression of labour (Bohren et al. 2017). The use of balls to support mobility and facilitate positioning is one of the therapeutic strategies in physiotherapy practice (de Sena Fraga et al. 2024; Delgado et al. 2024). A round birth ball (Swiss ball and pezzi ball) is used to facilitate vertical positions in labour (Perez 2000). Another form is the peanut ball, which is designed in the shape of a peanut. The peanut ball is designed to be placed between the knees in the supine or side‐lying position. Peanut balls of different sizes have also been designed to facilitate squatting and assist foetal descent (Grant and Clutter 2014). The fact that this ball is shaped like a peanut makes it easier for the body to remain balanced (Tussey et al. 2015). According to the results of randomized controlled trials, the peanut ball is a low‐cost, nonpharmacological tool that shortens the duration of the active phase, decreases caesarean section rates, increases maternal comfort and decreases perceived pain when used in the active phase of labour (Grenvik et al. 2019; Hickey and Savage 2019; de Sena Fraga et al. 2024).

When a parturient woman is immobile, the foetus' ability to enter the pelvis, reposition, and descend is reduced. Therefore, women should be encouraged to adopt maternal positions that increase pelvic mobility and improve labour progression, even if they have mobility limitations due to labour devices (Ahmed et al. 2022). According to a systematic review and meta‐analysis conducted by Delgado et al. (2022), the findings support the recommendation of using a peanut ball after epidural analgesia for parturient women. The study suggests that further research should evaluate the effectiveness of peanut ball application in parturient women with different characteristics who did not receive pharmacologic analgesia. In this context, the aim was to assess the impact of using peanut balls during labour for women with high BMI on the labour process and maternal‐neonatal outcomes. Study hypotheses were:

The use of a peanut ball during the active phase in parturient women with high maternal BMI would affect active phase duration compared with the control group.

The use of a peanut ball during the active phase in parturient women with high maternal BMI would affect labour pain level compared with the control group.

The use of a peanut ball during the active phase in parturient women with high maternal BMI would affect birth satisfaction score compared with the control group.

The use of a peanut ball during the active phase in parturient women with high maternal BMI would affect perineal trauma compared with the control group.

The use of a peanut ball during the active phase in parturient women with high maternal BMI would affect neonatal outcomes, including Apgar scores and the need for neonatal intensive care, compared with the control group.

2. Methods

2.1. Design and Setting

This study was designed as a prospective, parallel‐group, randomized controlled clinical trial with a 1:1 allocation ratio and a superiority framework. The study population consisted of parturient women admitted to a training and research hospital between March 2022 and August 2023. An average of 30–40 deliveries is performed monthly at the hospital. The labour process is monitored and managed by midwives, nurses and obstetricians. All vaginal deliveries are conducted by obstetrics and gynaecology residents under the supervision of attending specialists. According to the institutional protocol, the need for episiotomy is assessed based on the progression of labour and the risk of perineal injury, and it is frequently performed, especially in primiparous women.

2.2. Participants and Sampling

Women who were at gestational week 37 or later, had a singleton pregnancy, were expecting a vaginal delivery with cephalic presentation, had a maternal BMI of 30 kg/m2 or higher, had cervical dilatation of 4 cm or less upon admission, were over 18 years old, had no pregnancy complications (such as polyhydramnios, oligohydramnios, intrauterine growth retardation and pre‐eclampsia/eclampsia), did not receive pharmacologic analgesia, had no suspicion of foetal anomaly, and had no damage to the spine or hip joint were eligible to participate in the study.

G*Power 3.1. was used to calculate the sample size. As a pilot standard deviation specific to the primary outcome was not available at the planning stage, an effect size‐based approach reported in the literature was used for sample size calculation. As this study included parturient women not receiving epidural analgesia, we accounted for this clinical difference when selecting the effect size, because epidural or other analgesia may alter labour dynamics and the response to the intervention. Accordingly, the most comparable reference study that provided the summary statistics required for the calculation was used to derive the effect size. In the study conducted by Farrag and Omar (2018), the effect size for the difference in the duration of the first stage of labour in the groups was calculated as 0.90. To achieve a power of over 95% in determining the study's power, the sample size was determined to be 56 (df = 54, t = 1.674), including 28 people in each group with a significance level of 5% and an effect size of 0.906. A caesarean section rate of 15% was reported in a previous study (Farrag and Omar 2018). Taking into account possible losses that may occur during the study such as emergency caesarean section decisions and participants wanting to leave the study, the sample size was increased by 25%. It was planned to include 35 participants in the intervention and control groups. The study was completed with 29 participants in the intervention group and 30 participants in the control group. This was due to four participants in the intervention group needing emergency caesarean sections, two participants wanting to leave the study and five participants in the control group requiring emergency caesarean sections. The study was reported following the Consolidated Standards for Reporting Trials (CONSORT) guidelines (Moher et al. 2010), and the participant flowchart is shown in Figure 1.

FIGURE 1.

FIGURE 1

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CONSORT flowchart of participant progress through the trial.

2.3. Randomization and Blinding

The study was conducted with two groups: an intervention group (n = 35) and a control group (n = 35). The randomization process was conducted by the researchers using ‘Random Allocation Software’ (Version 1.0). Participants were assigned to the relevant groups in order according to the random number sequence generated by the software. Because of the nature of the intervention, blinding of participants and the researcher was not feasible. Obstetric and neonatal data, such as cervical dilatation and Apgar scores, were obtained by clinical staff attending the labour, rather than by the researchers. The intervention was applied to participants following the same standard protocol (standard duration and intervals) and the evaluations were made with validated scales at the same time intervals. These precautions were aimed at minimizing possible subjective effects during the measurement process. Additionally, to reduce bias, the data were coded as groups 1 and 2 upon entry into the system and analysed by an independent statistical expert who was unaware of the group assignments. To prevent participants from influencing each other during the research, one participant was included in the study after the birth of the other participant was completed.

2.4. Intervention Group

A total of seven positions (side‐lying, tuck, semisitting, upright sitting, hands and knee fire hydrant, forward leaning as well as pushing) were identified for use in the intervention group. The implementation of each position was determined based on the participant's preference, the foetal head position and the level of descent. Consequently, not all positions were applied to every participant. Participants were shown visuals of the positions to ensure that they could easily and correctly assume them. The positions were held for 30 min every hour once cervical dilatation reached 5 cm, and the intervention ended at 10 cm dilatation.

The intervention was delivered by the researcher, who was certified through the ‘Peanut Ball Ambassador Program,’ which documents competence in the knowledge and safe use of the peanut ball during labour. During the intervention, the balls were covered with a clean cloth before use, and in the upright sitting position, an absorbent disposable pad was placed on the seating area. The inflation of each ball was checked prior to use. In accordance with the manufacturer's recommendations, overinflation was avoided by ensuring that the lines on the ball did not appear as a straight line and that the ball maintained its rounded shape; balls were inflated to a ‘firm but compressible’ level. To ensure safety during the intervention, the environment was checked and confirmed to be free of sharp objects. After each use, the balls were cleaned with disinfectant and disposable paper towels and then stored on a clean surface covered with cloth until the next usage.

2.5. Control Group

In the control group, participants received usual care including positioning support without the use of a peanut ball (e.g., semifowler and left lateral) and mobilization.

2.6. Outcome Measures

The primary outcomes were the active phase duration, defined as the time from 5 to 10 cm of cervical dilatation, and labour pain assessed using the visual analog scale (VAS). The secondary outcomes included maternal outcomes such as satisfaction, evaluated using the Birth Satisfaction Scale (BSS), and perineal trauma, as well as neonatal outcomes such as Apgar scores and need for intensive care.

2.7. Data Collection Tools

2.7.1. Sociodemographic and Health History Data Collection Form

The questionnaire created by the researcher consists of a total of 17 questions including sociodemographic, general health and obstetric characteristics such as age, height, weight at admission, educational status, family type, gestational week, parity and systemic disease (Hirshberg et al. 2014; Makvandi et al. 2015; Carpenter 2016; Carlson et al. 2017; Dammer et al. 2018; Grenvik et al. 2019; Hickey and Savage 2019; Carlhäll et al. 2020). BMI was calculated based on women's height and weight at the time of admission for labour (maternal BMI), with reference to previous studies on the relationship between maternal BMI and the labour process in the literature (Kominiarek et al. 2011; Wolfe et al. 2011; Maged et al. 2017). The BMI values obtained were classified according to WHO criteria (WHO 2021).

2.7.2. Birth Follow‐Up Form

The form is divided into three sections. The first section gathers information on admission to the delivery room including the time of admission, reason for admission, vital signs on admission, and whether an enema was administered. The second section includes the initial evaluation findings of labour such as cervical effacement and foetal head level, as well as hourly monitoring of cervical dilatation, details on induction/augmentation, amniotomy and bladder catheterization once cervical dilatation reaches 5 cm. The third section includes details on the time and mode of delivery as well as maternal information such as whether an episiotomy was performed and if any perineal trauma occurred.

2.7.3. Visual Analog Scale of Pain Intensity

The VAS is a unidimensional instrument that has been validated as a measure of pain intensity (Price et al. 1983). The scale consists of a 10‐cm horizontal line anchored by ‘no pain’ at one end and ‘the worst pain imaginable’ at the other. Individuals are asked to mark the point on the line that corresponds to their level of pain. The distance between the ‘no pain’ anchor and the individual's mark is then measured to obtain a numerical value (Yesilyurt and Faydali 2020).

2.7.4. Data Collection Form on the Newborn

This form was designed by the researchers to record the foetal head position at delivery, Apgar score (at the 1st and 5th minute), need for intensive care and birth weight.

2.7.5. Birth Satisfaction Scale

The BSS, developed by Hollins Martin and Fleming in 20, is utilized to assess mothers' perceptions of birth satisfaction. The BSS is a 30‐item instrument rated on a 5‐point Likert scale; higher scores indicate higher levels of birth satisfaction. In the Turkish validity and reliability study of the BSS, the Cronbach's α coefficient was reported as 0.62 (Cetin et al. 2015). In the present study, the Cronbach's α value for the BSS was found to be 0.87.

2.7.6. Peanut Ball Intervention and Satisfaction Evaluation Form

The form consists of two sections. The first section records information about the positions (position names, time, and duration of practice). The second section, completed in the first hour after birth, is designed to assess the participants' experiences with the peanut ball (whether they found it useful, the most comfortable position, etc.). This form was created by the researchers through a literature review (Grant and Clutter 2014; Tussey et al. 2015).

2.8. Data Collection Procedures

Data were collected during labour, at birth, and within the first hour postpartum (Figure 2). Sociodemographic and health history data, information peanut ball intervention and satisfaction, as well as VAS and BSS scores, were collected verbally from the participants by the researcher and recorded on paper forms. Birth follow‐up data and newborn information were obtained from health records.

FIGURE 2.

FIGURE 2

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Timing of data collection.

2.9. Data Analysis

The data obtained from the study were analysed using IBM SPSS Version 26.0 (IBM Corporation, Armonk, NY, USA) with a statistical significance level accepted as p < 0.05. Continuous variables were expressed as mean ± standard deviation and/or median (min–max), while categorical data were presented as numbers and percentages. Normality analysis of continuous variables was conducted using the Kolmogorov–Smirnov test. For data that followed a normal distribution two‐group analyses were carried out using Student's t‐test; three or more group were performed using a one‐way analysis of variance (post hoc: Bonferroni). In cases where the data did not adhere to a normal distribution, the Mann–Whitney U test was utilized for analyses between two groups. The linear relationship between continuous variables was assessed through Pearson correlation analysis, while the relationship between categorical and/or discrete variables was evaluated using the chi‐square test or Fisher's exact test. Effect sizes were interpreted using Cohen's conventional thresholds, where d = 0.2 is considered small, d = 0.5 medium and d = 0.8 large (Cohen 1988). Participants with missing outcome data were excluded from the analyses.

2.10. Ethical Considerations

Ethics approval for this study was obtained from the Clinical Research Ethics Committee of the University of Health Sciences, Gülhane Faculty of Medicine (Decision No: 2021/16). Institutional permission was also obtained from the institution where the study was carried out prior to data collection. Written informed consent was obtained from all participants after they were informed about the study procedures. The study was registered at ClinicalTrials.gov in March 2022 (NCT05276947).

The primary potential harm associated with the intervention was fall risk. Participants were informed about the risk of falling prior to the procedure and safety precautions (seeking assistance when changing positions, avoiding sudden movements) were explained. Although adverse events such as falls or near‐falls were not monitored using a formal checklist, participants were closely supervised by the researcher throughout the intervention.

3. Results

3.1. Participant Characteristics

The mean age was 26.1 ± 3.9 and 25.7 ± 4.2 years, and the mean BMI was 36.2 ± 4.9 and 35.9 ± 4.1 kg/m2 in the intervention and control groups respectively. The highest percentage 55.2% and 46.7% were educated at the high school level, 69% and 76.7% were unemployed, and 96.6% and 93.3% had a nuclear family type in the intervention and control groups, respectively. There was no significant difference between the groups in terms of all socio‐demographic and health history data (p > 0.05).

When the cervical dilatation was 5 cm, the mean cervical effacement, assessed on a 0%–100% scale during vaginal examination was 59.6% ± 9.0% and 59.7% ± 9.3%, and the mean foetal head descent level was −2.2 ± 0.9 and −2.3 ± 0.9 in the intervention and control groups, respectively. No statistically significant difference was found between the groups in terms of obstetric findings at the first evaluation (p > 0.05) (Table 1). Though not shown in the table, there was no statistically significant difference between the groups in terms of enema, induction/augmentation, amniotomy, and bladder catheterization rates (p > 0.05).

TABLE 1.

Descriptive characteristics of groups.

Intervention group (n = 29) Control group (n = 30) t p
x̄ ±SS x̄ ±SS
Age 26.1 ± 3.9 25.7 ± 4.2 0.411 0.683 a
Gestation week 39.3 ± 0.8 38.9 ± 1.2 1.607 0.113 a
Year since last birth 4.1 ± 2.3 3.9 ± 1.1 0.238 0.815 a
BMI 36.2 ± 4.9 35.9 ± 4.1 0.285 0.776 a
BMI classes n (%) n (%) χ 2 p
Class I 15 (51.7) 15 (53.6) 0.916 0.633 b
Class II 9 (31.0) 6 (21.4)
Class III 5 (17.2) 7 (25.0)
Education level
Elementary 6 (20.7) 11 (36.7) 1.921 0.383 b
High school 16 (55.2) 14 (46.7)
University and higher 7 (24.1) 5 (16.7)
Employment
Employed 9 (31.0) 7 (23.3) 0.442 0.506 b
Not employed 20 (69.0) 23 (76.7)
Income level
Less than expenses 3 (10.3) 5 (16.7) 0.471 0.471 b
Equals expenses 23 (79.3) 24 (80.0)
Exceeds expenses 3 (10.3) 1 (3.3)
Family type
Nuclear 28 (96.6) 28 (93.3) 0.316 0.574 b
Large 1 (3.4) 2 (6.7)
Prenatal care
4 and more 29 (100.0) 28 (93.3) 2.001 0.492 c
Less than 4 0 (0.0) 2 (6.7)
Smoking
Yes 3 (10.3) 6 (20.0) 1.063 0.472 c
No 26 (89.7) 24 (80.0)
Exercise
Regular 1 (3.4) 1 (3.3) 0.517 0.772 b
İrregular 7 (24.1) 5 (16.7)
Never 21 (72.4) 24 (80.0)
Parity
Nullipar 19 (65.5) 20 (66.7) 0.926 0.926 b
Multipar 10 (34.5) 10 (33.3)
Reason for admission
Spontaneous membrane rupture 12 (41.4) 11 (36.7) 4.876 0.181 b
Labour induction 10 (34.5) 12 (40.0)
Cervical dilatation over 4 cm 5 (17.2) 1 (3.3)
Regular uterine contraction 2 (6.9) 6 (20.0)
Chronic diseases
No 22 (75.9) 22 (73.3) 0.824 0.824 b
Yes 7 (24.1) 8 (26.7)
Obstetric findings x̄ ±SS x̄ ±SS t p
Cervical dilatation (cm) 5.0 ± 0.2 5.0 ± 0.0 1.017 0.313 a
Cervical effacement (%) 59.6 ± 9.0 59.7 ± 9.3 −0.005 0.996 a
Foetal head station (−, +) −2.2 ± 0.9 −2.3 ± 0.9 0.107 0.915 a
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a

Student's t‐test.

b

Chi‐square test.

c

Fisher's exact test.

3.2. Birth Process Outcomes

There were no significant differences between the groups in the duration of the active phase (intervention 202.9 ± 59.5 vs. control 213.6 ± 67.5 min; p = 0.522) or the second stage (23.8 ± 15.0 vs. 23.4 ± 11.8 min; p = 0.903).

The cervical dilatation rate was 1.6 ± 0.5 cm/h in the intervention group and 1.5 ± 0.4 cm/h in the control group. There was no statistically significant difference between the intervention and the control groups in the hourly cervical dilatation rate (p = 0.516) (Table 2).

TABLE 2.

Labour duration, cervical dilation rate, VAS score and BSS score of the groups.

Intervention group (n = 29) Control group (n = 30)
x̄ ±SS x̄ ±SS t p Effect size
The active phase (min.) 202.9 ± 59.5 213.6 ± 67.5 −0.645 0.522 a
The second stage (min.) 23.8 ± 15.0 23.4 ± 11.8 0.122 0.903 a
Cervical dilatation (cm/h) 1.6 ± 0.5 1.5 ± 0.4 0.654 0.516 a
VAS‐Latent phase (4 cm) 5.6 ± 1.4 5.6 ± 2.2 −0.026 0.979 a
VAS‐Active phase end (10 cm) 9.6 ± 0.6 10.0 ± 0.0 −3.342 0.001 a 0.867
Total birth satisfaction 105.6 ± 10.3 95.7 ± 10.2 3.600 0.001 a 0.938
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a

Student's t‐test.

3.3. Maternal Outcomes

In both groups, all participants (N = 59) had noninstrumental vaginal deliveries, and an episiotomy was performed in each case. Perineal trauma occurred in 13.8% of the intervention group and 10% of the control group (p = 0.706). All perineal traumas were classified as first‐ or second‐degree lacerations; no severe (third‐ or fourth‐degree) lacerations were observed (Table 4).

TABLE 4.

Maternal and neonatal outcomes.

Maternal outcomes Intervention group (n = 29) Control group (n = 30)
n (%) n (%) χ 2 p
Delivery mode
Noninstrumental vaginal delivery 29 (100.0) 30 (100) — —
Episiotomy
Yes 29 (100.0) 30 (100.0) — —
Perineal trauma
Yes 4 (13.8) 3 (10.0) 0.203 0.706 a
No 25 (86.2) 27 (90.0)
Neonatal outcomes Intervention group (n = 29) Control group (n = 30)
x̄ ±SS x̄ ±SS t p
Birth weight (g) 3249.6 ± 336.3 3243.0 ± 315.4 0.078 0.938 b
Apgar score Median (min–max) Median (min–max) z p
1st min 7 (6–8) 7 (3–9) −0.905 0.366 b
5th min 9 (8–10) 9 (7–10) −1.738 0.082 b
n (%) n (%) χ 2 p
Head position
Anterior 29 (100.0) 30 (100.0) — —
Neonatal intensive care
Yes 1 (3.4) 1 (3.3) 0,001 1000 a
No 28 (96.6) 29 (96.7)
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a

Fisher's exact test.

b

Student's t‐test.

There was no statistically significant difference between the groups in the latent phase‐VAS score (p = 0.979), whereas the end of active phase‐VAS score was significantly lower in the intervention group than in the control group (p = 0.001), with a large effect size (Cohen's d = 0.86).

The mean VAS pain score was 7.9 ± 1.2 immediately before participants were moved to the upright sitting position (before positioning), and 6.5 ± 1.6 while they were in the upright sitting position (postpositioning), indicating a statistically significant difference (p < 0.001) with a small effect size (Cohen's d = 0.36) (Table 3). Additionally, 72.4% of the participants in the intervention group stated feeling comfortable in the upright sitting position, while 24.1% stated that no position provided comfort.

TABLE 3.

VAS score by positions in the intervention group.

Before positioning Postpositoning
x̄ ±SS x̄ ±SS t p Effect size
VAS‐Upright sitting (n = 27) 7.9 ± 1.2 6.5 ± 1.6 6.911 < 0.001 a 0.362
VAS‐Semisitting (right) (n = 19) 7.6 ± 1.6 7.4 ± 1.8 1.714 0.104 a
VAS‐Semisitting (left) (n = 14) 8.0 ± 0.8 7.8 ± 0.9 1.472 0.165 a
VAS‐Side lying (left) (n = 28) 9.1 ± 0.9 9.1 ± 0.9 —
VAS‐Forward leaning (n = 4) 9.0 ± 1.7 8.3 ± 2.9 1.000 0.423 a
VAS‐Tuck position (n = 8) 9.2 ± 0.7 9.2 ± 0.7 —
VAS‐Pushing (n = 1) 10.0 ± 0.0 10.0 ± 0.0 —
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a

Paired sample t‐test.

Birth satisfaction (the BSS score) was significantly higher in the intervention group compared with the control group (p = 0.001), with a large effect size (Cohen's d = 0.93) (Table 2). Though not shown in the table, all participants in the intervention group stated that they found the practice useful and indicated that they would prefer the peanut ball positioning in their next delivery. Regarding the aspects perceived as beneficial, 48.2% of the participants reported that the practice facilitated the progression of labour and 37.9% stated that it helped reduce pain.

3.4. Neonatal Outcomes

There were no statistical differences between the groups in terms of birth weight (p = 0.938) and foetal head position at birth. The median Apgar scores at the first and fifth minute were 7 (6–8) and 7 (3–9), respectively, for the intervention group; and 9 (8–10) and 9 (7–10), respectively, for the control group, with no statistical difference (p = 0.366; p = 0.082, respectively). The rate of neonatal intensive care requirement was 3.4% in the intervention group and 3.3% in the control group, also with no statistical difference (p = 1.000) (Table 4).

4. Discussion

The use of peanut balls during labour was not found to have an effect on the duration of the active phase and the second stage in parturient women with high BMI. However, it was found that the positions used with the peanut ball reduced the perceived pain during labour and increased the level of birth satisfaction.

4.1. Birth Process Outcomes

The findings of this study are consistent with some previous research indicating that the use of the peanut ball does not have a significant effect on the duration of labour (Grenvik et al. 2019; Ahmadpour et al. 2021; Alan Dikmen et al. 2025). However, other studies have shown that using the peanut ball can lead to shorter labour duration (Ahmed et al. 2022; Delgado et al. 2022; de Sena Fraga et al. 2024; Cankaya et al. 2025). These conflicting results may be related to methodological differences, such as variations in position protocols, the timing of initiation, the frequency or duration of peanut ball use and the actual duration measured.

Observations during the study indicated that in several cases, the time required to reach the active phase of labour was prolonged, induction was unsuccessful, and caesarean delivery was performed before the onset of active labour. This raises the question of whether initiating peanut ball positioning earlier, prior to the active phase, could facilitate cervical dilatation in women with high maternal BMI; this should be addressed in future research.

4.2. Maternal Outcomes

In the present study, all births were conducted as noninstrumental vaginal deliveries. Tussey et al. (2015) and Evans and Cremering (2016) observed numerically lower operative vaginal delivery (forceps/vacuum) rates with peanut ball use, although differences were not statistically significant. These differences may be related to variations in labour duration reported across studies.

When assessing perineal trauma, in contrast to the findings of the present study, Ahmed et al. (2022) demonstrated that the use of peanut ball intervention was associated with a reduced incidence of genital injury. Similarly, Evans and Cremering (2016) observed lower rates of third‐ and fourth‐degree lacerations and operative vaginal delivery in the intervention group, although these differences were not statistically significant. This discrepancy may be attributable to differences in outcome definitions (genital injury vs. perineal trauma), sample size (and statistical power), as well as variations in labour duration and intrapartum management practices in the relevant studies.

The results of the current study parallel the findings of studies indicating that the use of peanut ball can reduce labour pain (Jayasudha et al. 2021; Sonmez and Ejder Apay 2023; Alan Dikmen et al. 2025). Additionally, previous studies suggest that upright positions during labour, compared to lying on the back, can reduce labour pain (Taavoni et al. 2011; Lawrence et al. 2013). In this study, the use of a large‐sized peanut ball in a straddling upright position was found to be particularly effective in managing labour pain. Although the exact mechanism underlying the analgesic effect of this position remains unclear, possible mechanisms include a decrease in mechanical pressure on the nerves around the sacroiliac joint (Taavoni et al. 2011) and inhibition of nociceptive signals through the gate control theory (Delgado et al. 2022).

The birth satisfaction result of this study is consistent with previous findings suggesting that the use of the peanut ball enhances satisfaction during labour (Payton 2015; Tussey et al. 2015; Sonmez and Ejder Apay 2023; de Sena Fraga et al. 2024; Kamath et al. 2024; Makvandi et al. 2025). This positive effect may be attributed to the supportive and ergonomic nature of the positioning provided by the peanut ball.

4.3. Neonatal Outcomes

In terms of Apgar scores and the need for neonatal intensive care, the findings of the present study are consistent with previous studies (Ahmed et al. 2022; Grenvik et al. 2023; de Sena Fraga et al. 2024). However, in the study conducted by Cankaya et al. (2025), the 1st‐ and 5th‐minute Apgar scores were reported to be higher in the peanut ball group compared to the control group. This difference may be attributed to variations in intrapartum management practices.

4.4. Strengths and Limitations

One of the limitations of the study is the small sample size and the single‐centre design, which restrict the generalizability of the results. Results may vary across institutions with different obstetric care protocols, staffing conditions or resources. Similarly, sociodemographic or cultural differences may influence women's presentation to hospital in labour, their perception of pain and satisfaction as well as the effectiveness of peanut ball intervention. Therefore, multicenter studies with larger, more diverse populations are necessary for the generalizability of these results.

Cervical dilatation measurements were made by clinicians following routine practice, which may have resulted in minimal differences between measurements. Additionally, the fact that the data belonging to the scale were collected by the researcher who carried out the intervention is also seen as a limitation of the study. Factors such as foetal position, induction method, and other potentially influential variables were not analyzed and should be addressed in future research. The lack of triangulation between subjective scale data and objective indicators (e.g., mobility level or vital signs) may have limited the depth of interpretation. Lastly, practical challenges encountered during data collection, such as cases ending in caesarean section before the onset of active labour and participant loss due to the researcher's absence from the ward, also affected the completion of the sample.

The sample size calculation was informed by a reference study using a time‐duration endpoint that was not fully aligned with the primary outcome of this study, which may have limited the study power to detect differences in the primary time‐duration outcome.

Despite these limitations, the study's practical approach offers valuable insights that can inform clinical practices to improve labour experiences and outcomes in this specific group. Furthermore, suggesting the use of peanut ball in this specific group could potentially reduce labour pain has laid the groundwork for further research to be conducted on cohorts with similar profiles.

5. Conclusions

This study demonstrated that using peanut ball in women with high BMI did not affect labour duration or maternal and neonatal outcomes, but significantly reduced labour pain and increased birth satisfaction. These findings demonstrate the value of peanut balls as a supportive, nonpharmacological method of labour, particularly in upright sitting (straddling) position. From a policy perspective, integrating such cost‐effective and safe interventions into maternity services could contribute to women‐centred obstetric practice. From an educational perspective, the importance of training healthcare professionals in evidence‐based comfort practices during labour is emphasized. Further research is needed to assess the effect on labour duration with larger sample sizes and multicenter designs, to determine the applicability of peanut ball use in different populations, and to clarify its role in standard clinical guidelines.

Authors Contributions

Study design: Fulden Ozkececi and Gulten Guvenc. Data collection: Fulden Ozkececi. Analysis: Fulden Ozkececi and Gulten Guvenc. Manuscript preparation: Fulden Ozkececi and Gulten Guvenc. All listed authors meet the authorship criteria, and all authors are in agreement with the content of the manuscript.

Funding

The authors have nothing to report.

Ethics Statements

Ethics approval for this study was obtained from the Clinical Research Ethics Committee of the University of Health Sciences, Gülhane Faculty of Medicine (Decision No: 2021/16). Institutional permission was also obtained from the institution where the study was carried out prior to data collection. Written informed consent was obtained from all participants after they were informed about the study procedures. The study was registered at ClinicalTrials.gov in March 2022 (NCT05276947).

Conflicts of Interest

The authors declare no conflicts of interest.

Acknowledgements

The authors thank all the patient's voluntary participation.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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