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Introduction: Childbirth, while a natural physiological process, poses significant challenges due to intense labour pain caused by ischemic changes in the uterus, cervical stretching, and tissue damage in the perineum. Non-pharmacological methods, such as the use of birth balls and peanut balls, have emerged as effective tools to alleviate pain, reduce anxiety, and improve labour outcomes without the side effects associated with pharmacological interventions. This study aimed to evaluate the impact of these interventions on labour progress, pain relief, and delivery outcomes. Methodlogy: This randomized controlled trial was conducted at Adichunchanagiri Hospital and Research Centre over 18 months. Participants included primigravida and multigravida women with singleton pregnan- cies in cephalic presentation and gestational ages over 37 weeks. Using block randomization, 128 women were divided into two groups: a trial group utilizing birth and peanut balls and a control group receiving standard care. The trial group underwent training sessions to perform exercises such as pelvic rocking and squatting, designed to improve pelvic mobility and fetal alignment. Pain levels were assessed using the Visual Analog Scale (VAS), and outcomes were analyzed using SPSS software with a significance threshold of p < 0.05. Results: The trial group exhibited significantly better outcomes in labour progress and pain management compared to the control group. Cervical dilation rates were higher in the trial group (Bishop’s Score 6–8: 84.4% vs. 51.6%; p=0.00), and total labour duration was shorter (621.47 ± 158.414 minutes vs. 702 ± 149.603 minutes; p=0.022). Pain scores after exercise were significantly reduced in the trial group (VAS score: 5.75 ± 0.617 vs. 8.92 ± 0.27; p<0.001). Normal vaginal deliveries were more frequent in the trial group (84.3% vs. 65.6%; p=0.045), and cesarean section rates were lower (12.5% vs. 26.6%; p=0.045). Conclusion: Birth and peanut balls offer a gentle, non-invasive, and effective method for pain relief and improved labour outcomes. They present a valuable addition to routine obstetric care and should be in- corporated into clinical practice to enhance maternal and neonatal health. Future multi-center trials are recommended to validate these findings and explore their long-term impacts.
Keywords: Birth ball; Peanut ball; Labour pain; Non-pharmacological pain relief; Vaginal delivery; Maternal outcomes; Labour management; Pain reduction; Birthball; Peanutball; Labourpain; Non-pharmacologicalpainrelief; Vaginaldelivery; Labourmanagement; Painreduction
Childbirthisanormalphysiologicalprocess,yetitis oftenalife-changingandchallengingexperiencefor manywomen,markedbypainfuluterinecontractions. Labourpain,characterizedbysensory,emotional,and perceptivecomponents,iscausedbyischemicchanges intheuterus,stretchingofthecervix,andthelower uterinesegment. Itisconsideredoneofthemostintensepainsexperiencedbywomen,profoundlyaffectingthemphysicallyandemotionally. Improperhandlingofchildbirthmayleadtocomplicationssuchas prolongedlabourorlabourdystocia,increasingrisks forbothmaternalandneonataloutcomes .
Prolongedlabourisassociatedwithcomplications,includingneonatalinfections, lowApgarscores, NICU admissions, and cesarean deliveries. Cesarean sections often result in extended recovery periods and heightenedrisksofcomplicationsduringthepostpartumperiodandfuturepregnancies.Therefore,strategiestoaddressprolongedlabourandenhancematernalandneonataloutcomesarecritical. Labourprogressesthroughfourstages,withthefirststagebeing thelongest,lasting12–16hoursforprimiparaand6–8 hoursformultipara.Duringtheactivephase,marked byintenseandfrequentcontractions, womenoften experienceshakiness,nausea,andirritability. Effortstoreducelabourdurationandimprovebirth outcomeshavegarneredsignificantattention. The WorldHealthOrganization(WHO)recommendsfrequent positionchangesandmovementsduringlabourtopreventprolongedlabourandcesareansections. However,traditionalpracticesinmanyhospitals,suchas labourinduction,epiduralanesthesia,andcontinuous fetalmonitoring,maylimitmobility.Toaddressthese issues,toolslikethebirthballprovideanalternative forachievingfrequentpositionchangeswithoutdisruptingmedicalprocedures.
Non-pharmacologicalmethods,includingtheuseof birthballs,havegainedpopularityduetotheadverse effectsandhighcostsassociatedwithpharmacologicalanalgesia. Suchmethodspromotecomfort,wellbeing,andasenseofcontrol,makinglabouramore positiveexperience.Non-pharmacologicaltechniques includemassage,hypnosis,transcutaneouselectrical nervestimulation(TENS),acupuncture,icemassage, hydrotherapy, aromatherapy, herbaltherapy, music therapy,andbirthballexercises.
Thebirthball,alsoknownasafitballorSwissball,typicallyhasadiameterof55–65cm.Initiallyusedbyphysiotherapistsforbackpainrelief,itwasintroducedasa childbirthtoolinthe1980s.Itallowswomentositor leanagainstitwhileperformingexercisesthatrelieve painandanxiety,shortenlabourduration,andfacilitatefetalrotationanddescent.Exercisesincludepelvic tilts, circular hip movements, gentle bouncing, and leaningforward.Theseexercisesenhancepelvicmobil- 12–13 ityandalignment,promotingnaturallabourprogress. Anothervariationisthepeanutball,aplasticballshaped likeapeanut,usedduringlabourtopositionthefetus optimallyinthepelvis.Itsdesignsupportsvariouspostures,includingside-lyingpositions,helpingtoexpand thepelvisandaligntheinfantforeasierdelivery.The peanutballisparticularlyusefulforwomenunableto ambulateduetomedicalcircumstances,promotinga C-curvespinalalignmentthatfacilitatesfetalpassage 14–15 throughthepelvis.
Boththebirthballandpeanutballarelow-cost,noninvasivetoolsthatcanbereusedandsterilized.They areeffectiveinenhancinglabouroutcomes,especially insettingswherematernalmortalityremainshighdue tocomplicationsduringlabouranddelivery.Despite theirbenefits,somehealthcareprovidersrestrictmo- 2–3 bilityduringlabour,limitingthepotentialadvantages ofsuchtools. Theintroductionofthepeanutballas acomplementary,non-pharmacologicalintervention isgainingtractioninreducinglabourdiscomfortand 16–18 duration. Whilethepeanutballisincreasinglyused inlabourandbirthunits, researchonitsefficacyremainslimited.Thisstudyaimstoevaluatetheimpact 5–7 ofthebirthballandpeanutballonlabourprogress, pain relief, and birth outcomes, contributing to the bodyofevidencesupportingtheiruse.
ThestudywasconductedintheDepartmentofObstetricsandGynecologyatAdichunchanagiriHospitaland ResearchCentre,BGNagar,asatwo-armrandomized controlstudywithblockrandomization.Theduration ofthestudywas18months,spanningfromSeptember 2022 to May 2024. Allocation concealment was achievedusingsequentiallynumberedopaquesealed envelopescontaininggroupassignmentsdetermined bycomputer-generatedrandomsequences.Theseenvelopeswerehandedoverbytheprincipalinvestigatortothehealthcareworkerresponsibleforcarrying out the intervention. The study was single-blinded, withdatacollectorsunawareoftheinterventionassignments.
9–11 Participantsincludedinthestudywereprimigravida andmultigravidawomenwithsingletonpregnanciesin cephalicpresentationsforvaginalbirth,agestational ageofmorethan37weeks,andanuncomplicatedobstetrichistory.Womenwithnormalextremitieswere alsoincluded. Exclusioncriteriaweresetforwomen withpsychiatricdisorders,hypertension,cephalopelvic disproportion,malpresentation,unwillingnesstoparticipate,complicatedpregnanciesrequiringclosemonitoringorrestrictedmobility,andabnormalplacental sitessuchasplacentapreviaorabruptioplacentae. Samplesizewascalculatedconsideringtheformula:
VisualAnalogueScore(VAS)forpain , Alpha = 0.05 Power = 80% UsingGPowersoftware,itwasdeterminedthat64participants per group were required, makingthe total samplesize128.
ApprovalforthestudywasobtainedfromtheInstitutionalEthicsCommitteeofSriAdichunchanagiriHospitalandResearchCentre.Writteninformedconsent wascollectedfromallparticipantswhomettheinclusioncriteria.Thestudy’sobjectives,procedures,and expectedoutcomeswereexplainedtoeachparticipant indetailbeforeenrollment.Participantswererandomizedintoeithertheinterventionorcontrolarmusing computer-generatedrandomsequences, withblock randomization(blocksizeof5)ensuringequaldistributionacrossbothgroups.
Intheinterventionarm,participantsattendedtraining sessionsstartingat38weeksofpregnancy,lastingone hourdaily,andwereaskedtopracticeathome.These sessions were continued during the latent phase of labour.Birthballsofvaryingsizes(55cm,65cm,and 75cm)wereprovided,andparticipantswereguided toselecttheappropriatesize.Theyweretaughtfour typesofpositionswitheightexercises,includingpelvic rocking,hula-hoopmovements,andleaningforward. The exercises also included standing, kneeling, and squattingpositionstoenhancepelvicmobility,fetal descent,andalignment.
Theyalsoperformedexercisesusingthepeanutball, includingsquatting, bouncing, side-lying, andsemisittingpositions.Exercisessuchasthetuckposition, asymmetricallunge,andkneelingwithforwardleaning wereperformedfor20–30minutestoensurebilateral pelvic opening. The exercises were designed to enhancematernalcomfortandtheeffectivenessofthe technique.
Patientswhodidnotparticipateinanyexercisesare takenasthecontrolgroup;theyareaskedtorestin theircomfortablepositionsandgivenstandardobstetriccare.Allparticipantsansweredquestionnairesduringlabourattwopoints:whencervicaldilationreached 4cmandwhenitreached7–8cm.Standardcarewas providedforbothgroups.Investigationsincludedblood groupandRhfactor,completebloodcount(CBC),randombloodsugar(RBS),venerealdiseaseresearchlaboratory(VDRL)test,HIV,HepatitisBantigen(HBsAg), urineroutineandmicroscopy,obstetricscans,andnonstresstests(NST).Theprimaryoutcomesofthestudy includedcervicaldilation,totallabourdurationafter usingthebirthball,theoverallchildbirthexperience, and the mode of delivery. Secondary outcomes focusedontherequirementforassistedvaginaldelivery = 0.25 orcesareansection,neonatalintensivecareunit(NICU) admissions,andvariationsinneonatalAPGARscores.
ThedatawascollectedandcompiledinMSExcel.Descriptivestatisticshavebeenusedtopresentthedata. Toanalysethedata,SPSS(Version26.0)wasused.Significancelevelwasfixedas5%(α = 0.05).Qualitative variablesareexpressedasfrequencyandpercentages, andquantitativevariablesareexpressedasmeanand standard deviation. To compare the proportion betweengroups,chi-squaretestwasapplied,andtocomparethemeanvaluesbetweengroups,student t-test wasused.
Thesocio-demographicanalysis(Table1)showedthat theagedistributionamongparticipantswassimilar acrossthetrialandcontrolgroups,withthemajority aged between 21–30 years and no significant differencesnoted(p = 0.188). Primigravidawomencomprised60.9%ofthetrialgroupand67.2%ofthecontrol group,whilemultigravidawomenaccountedfor39.1% and32.8%,respectively,alsoshowingnosignificant difference(p = 0.461).Thegestationalagedistribution indicatedahigherpercentageofparticipantsinthe39– 40weekscategoryinthetrialgroup(57.8%)compared tothecontrolgroup(39.1%),butthiswasnotstatisticallysignificant(p = 0.105). Vitalparameters(Table 1)suchaspulserate,systolicbloodpressure(BP),and diastolicBPwerecomparablebetweenthegroups.The trialgrouphadameanpulserateof 80.17 ± 5.403 bpm comparedto 77.64 ± 6.121 bpminthecontrolgroup (p = 0.342).SystolicBPwas 116.91 ± 7.928 mmHgin thetrialgroupand 115.97±8.526 mmHginthecontrol group(p = 0.874),whilediastolicBPwas 75.44±6.042 mmHgand 71.06±6.91 mmHgintherespectivegroups (p = 0.423).
Theanalysisofobstetriccharacteristics(Table2)highlightedsignificantdifferencesbetweenthetrialand controlgroupsintermsofBishop’sScoreandPVdilatation. Ahigherpercentageofparticipantsinthetrial grouphadaBishop’sScoreof6–8(84.4%)compared tothecontrolgroup(51.6%),whilethecontrolgroup showedahigherproportionofparticipantswithascore of3–5(48.4%vs.15.6%inthetrialgroup),withastatisticallysignificantdifference(p = 0.00).PVdilatation of > 3 cmwasobservedin70.3%ofthetrialgroup comparedto64.1%inthecontrolgroup,whereas < 3 cmdilationwasmorecommoninthecontrolgroup (35.9%) than in the trial group (29.7%) (p = 0.018). Painperceptionduringexerciserevealedmarkeddifferences,withallparticipantsexperiencingseverepain withoutexerciseinbothgroups(p = 1.000).However, thetrialgroupreportedmilderpainlevelswithexercise, includingmild(46.9%)andmoderatepain(53.1%),in contrasttothecontrolgroup,whereallparticipants reportedseverepainwithexercise(p < 0.001)(Table2, Figure1).TheVisualAnalogScale(VAS)scoresbefore exerciseweresimilaracrossgroups(p = 0.873),but post-exercisescoresweresignificantlylowerinthetrial group(5.75 ± 0.617 vs. 8.92 ± 0.27; p < 0.001)(Table 2,Figure2).
Labourcharacteristics(Table3)showedcomparable ratesoflabourinduction,with48.4%ofthetrialgroup and 43.8% of the control group requiring induction (p = 0.122). Spontaneous labour was also similar, with39.1%inthetrialgroupand29.7%inthecontrol group. Thedurationfrom4cmtofullcervicaldilatationwasshorterinthetrialgroup(511.02 ± 248.362 minutes) compared to the control group (624.14 ± 194.256 minutes). Second-stagelabourwasalsosignificantlyshorterinthetrialgroup(28.68 ± 4.407 minutesvs. 34.69 ± 7.323 minutes, p = 0.050).Thetotal labourdurationwasmarkedlylowerinthetrialgroup (621.47 ± 158.414 minutes)comparedtothecontrol group(702 ± 149.603 minutes, p = 0.022).Regarding themodeofdelivery,normalvaginaldeliverieswere morefrequentinthetrialgroup(84.3%)thaninthe controlgroup(65.6%),whiletherateofcesareansectionswashigherinthecontrolgroup(26.6%vs.12.5% inthetrialgroup, p = 0.045).Instrumentaldeliveries werelesscommoninbothgroups,withratesof3.13% inthetrialgroupand7.8%inthecontrolgroup(Table 3).Indicationsforcesareansections,includingfailure toprogressandfetaldistress,weresimilarbetween groups,withnosignificantdifferencesnoted. Thematernalandperinataloutcomes(Figure3)indicatedexcellentresultsinbothgroups,with100%good outcomesformothersandneonatesinboththetrial and control groups. The interventions were associatedwithimprovedmaternalcomfortandenhanced neonatalwell-being,asreflectedbythecomparable andfavourableoutcomesinbothgroups.
Labouristheactivephaseofdeliveringthefetus,as the mother experiences painful and regular uterine contractions. This pain is associated with ischemic changesoftheuterus,whichareobservedduringthe alternatingphaseofcontractions,aswellasdilatation ofthecervixandloweruterinesegmentleadingtotissuedamageoftheperineum. Non-pharmacological managementtechniquesincludepositioning,massage, hypnosis,acupuncture,transcutaneouselectricalnerve stimulation,waterimmersion,musictherapy,hydrotherapy,aromatherapy,herbalremedies,birthingball,and others,usedtoreducepainandmakethepatientcomfortableduringlabourwithoutanyharmorsideeffects tobothmotherandfetus.Inourstudy,themajorityof participantswereaged21–25years.Thisisconsistent withfindingsbyTussey,Delgado,andStulz,whereparticipants’agesrangedfrom18to35years,indicating thatyoungermaternalagegroupsarecommonlyinvolvedintheseinterventions. Tusseyetal. included women aged 18–35 years, similar to our study, emphasizingtherelevanceofpeanutballinterventions acrossyoungmaternalpopulations. Delgadoetal. alsoreportedthattheuseofpeanutballswasbeneficialacrossthisagegroup,aligningwithourstudy’s demographic. Stulz et al. found similar age ranges, reinforcingthebroadapplicabilityofbirthballinterventions.
Ourstudyincludedamixofprimigravidaandmultigravidawomen,with60.9%beingfirst-timemothers. Delgadoetal. includedbothprimiparousandmultiparouswomen, reflectingthebroadapplicabilityof peanutballsacrossdifferentobstetrichistories.This findingalignswithourinclusionoffirst-timeandexperiencedmothers,indicatingthatbothgroupsbenefit fromtheuseofpeanutballs.TheBMCPregnancyand Childbirthstudyalsoconsideredtheparityofwomen andfoundthatbirthballexerciseswereeffectivefor bothfirst-timeandexperiencedmothers,similartoour findings.
In our study, the duration from 4 cm to full cervical dilatationwassignificantlyshorterinthetrialgroup usingpeanutballs. Delgadoetal. reportedthatthe useofpeanutballsreducedthefirststageoflaborby anaverageof87minutesandthesecondstageby22 minutes.Thisreductionisconsistentwithourfindings ofshorterlabordurationsinthetrialgroup.Rothetal. alsofoundthatusingpeanutballsduringlaborresulted inshorterlabordurations,whichsupportsourstudy’s outcomes.Tusseyetal.reportedthatusingapeanut ballsignificantlydecreasedthelengthofthefirststage oflabor,corroboratingourfindingsofreducedlabor durations.
Ourstudyfoundthatthetrialgrouphadahigherrate of normal vaginal deliveries and a lower rate of cesareansectionscomparedtothecontrolgroup. Bell etal. showedthatincorporatingbirthballexercises into a labor support protocol reduced the cesarean deliveryrateandincreasedthelikelihoodofvaginal delivery,aligningwithourfindingsofimprovedlabor outcomesinthetrialgroup. Delgadoetal.notedthat whilethereductionincesareanriskwithpeanutball usewasnotstatisticallysignificant,therewasatrend towardshighervaginaldeliveryrates,whichsupports ourobservations.Stulzetal.reportedimprovedlabor outcomeswithbirthballuse,includingincreasedrates ofspontaneousvaginaldeliveriesandreducedneed forcesareansections,similartoourfindings.
Ourstudyshowedsignificantpainreductioninthetrial groupusingbirthballs,withmanyparticipantsreportingmildtomoderatepainlevels.TheCochraneSystematicReviewfoundsignificantpainreliefandhighersatisfactionlevelsinwomenusingbirthballscomparedto thosereceivingstandardcare,aligningwithourresults of effective pain management using birth balls duringlabor. TheBMCPregnancyandChildbirthstudy demonstratedthatbirthballexercisessignificantlyreducedlaborpainandimprovedmaternalsatisfaction, consistentwithourfindingsofreducedpainlevelsand positivelaborexperiencesinthetrialgroup. Inthe meta-analysisreportbyAlexandreandassociatesin 2019,thereisevidenceofusingthepeanutballinthe first stage of labour, which helped in reducing pain within20–90minutesofusingit.
The mechanism by which a birth ball might reduce labourpainis not established. The birthballworks bysupportingtheperineum,reducingthepressureon pelvicfloormuscles,andprovidingcomforttothepatientbyreducingthepain.Theballblockspainbyactingonthesensorydiscriminativecomponentofpain (PainGateTheory).Thesetoolsarebeneficialacross variousagegroupsandobstetrichistories,significantly reducing labor duration, managing pain effectively, andincreasingthelikelihoodofnormalvaginaldeliveries.
Thestudydemonstratedthatbirthballandpeanutball exerciseseffectivelyalleviatedpain,reducedanxiety, andresultedinfewercesareansectionswithmorenormal vaginal deliveries. These non-pharmacological methodsofferaside-effect-free,resource-efficientalternativetopharmacologicaltherapiesformanaging labourpain.
Thestudy’slimitationsincludearelativelysmallsamplesize,restrictinggeneralizability,anditssingle-center design,whichmaynotreflectbroaderclinicalsettings. Selectionbiasduetonon-randomizedparticipantselection and reliance on subjective pain assessment throughtheVisualAnalogScale(VAS)furtherlimitthe robustnessofthefindings.
Incorporatingbirthballandpeanutballexercisesas routine practice in labour wards can reduce labour pain, decrease cesarean delivery rates, and shorten labourdurationwithoutdrug-relatedsideeffects.Educatingpatientsandensuringtheavailabilityofthese cost-effectivetools,eveninlow-resourcesettings,is essentialforimprovingmaternaloutcomes.
Futurestudiesshouldaddresstheselimitationsthrough larger,multi-centerrandomizedcontrolledtrialswith stratifiedsamplingtoreducebiasandimprovegeneralizability. Combiningobjectiveandsubjectivemeasuresoflabouroutcomesandexploringthelong-term maternalandneonatalhealthimpacts,aswellascosteffectiveness,wouldprovidestrongerevidenceforin- 24 tegratingtheseinterventionsintoclinicalpractice.
Ahumanbodycantypicallyendureupto45delsofpain, yetduringchildbirth,womenexperiencepainreaching upto57dels.Thishighlightstheextremediscomfort mothersfaceduringlabour,ajourneythattransforms boththeirlivesandtheiridentityasamother.Itiscrucialtoprioritizethecomfortandsupportofwomen duringthe10to12hoursofintenselabourpain.Modernmothersincreasinglyoptforcesareansectionsor pharmacologicalmethodsforpainlessdeliveries,leadingtoariseincesareanratesanddeliverycosts. To mitigatethecomplicationsassociatedwiththesemethods,non-pharmacologicalapproachesliketheuseof birthballsandpeanutballsoffereffectivealternatives. Thesemethodshelpalleviatepainandanxiety,reduce cesareansectionrates,andcanbeimplementedeven inlow-resourcesettings.
Birthballsprovideasimpleyetpowerfulsolutionfor reducinglabourpain.Theyareassociatedwithshorter labourdurations,lowerpainlevels,andhigherrates ofnormalvaginaldeliveries.Beyondbeinganexercise tool, thebirthballservesasasupportivepartnerin painrelief,enhancingthecomfortofexpectantmothersduringpregnancyandlabour.Incorporatingthese exercises,alongwithpassiveworkoutsathomeduring termgestation,shouldberecommendedinallhealthcare institutions to improve maternal and fetal outcomes. Whilethisstudyunderscoresthebenefitsof birthballsandpeanutballs,furtherresearchisneeded toconfirmthesefindingsacrossdiversepopulations andsettings.Byaddressingthelimitationsandexpandingonthecurrentresults,futurestudiescanstrengthen theevidenceforclinicaluse,ultimatelyenhancingmaternalandneonatalcare.Birthballsemergeasagentle yetprofoundtoolforpainrelief,makinglabouramore bearableandpositiveexperienceformothers.