Optimising Labour Outcomes: The Impact of the Semi-Fowler’s Position on Labour Duration and Maternal-Neonatal Outcomes in Primigravida Mothers

INTRODUCTION

Labour is a natural process, yet it is intricate, involving numerous physiological and psychological variables. The care provided during childbirth can significantly impact women both physically and emotionally.^[1]

The childbirth experience is an intensely dynamic, physical, and emotional event with lifelong implications. Women who are provided with continuously available support during labour have improved outcomes compared with women who do not have one‐to‐one, continuously available support.^[2] Effective management of labour is crucial, as it is one of the most common medical challenges for healthcare providers. Proper management is closely linked to the normal progression of labour. Mismanagement can result in prolonged or obstructed labour, leading to issues such as maternal exhaustion, uterine rupture, postpartum bleeding, and infection. Therefore, early detection and prevention of deviations from normal labour are essential to reduce the incidence of complications.^[2,3]

Maternity care provider clinicians have been aware for many decades that the maternal supine position and pregnancy are not a good mix. This is probably because when the woman lies on her back, the gravid uterus is known to compress the inferior vena cava.^[4] This can result in a range of negative sequelae, such as maternal hypotension and reduced blood flow to the foetus.^[5] The supine position may be disadvantageous for foetal wellbeing and in compromised pregnancies may be a sufficient stressor to contribute to foetal demise.’ This fits well with the triple risk model for stillbirth; these results certainly support the findings from earlier epidemiological studies, that supine sleep in pregnancy increases the risk of stillbirth, particularly in the growth‐restricted foetus.^[6]

In the context of childbirth, the semi-Fowler’s position is a beneficial posture where a woman’s back is inclined at a 45° angle from the horizontal plane, resembling a modified sitting position. This positioning is advantageous as it enhances the expulsive force, directing it towards the pelvis and leveraging the effect of gravity. Additionally, this posture is conducive to modern obstetric care, providing comfort and ease of access for healthcare providers.^[7]

Conversely, the lithotomy position, despite its widespread use among care providers, has been associated with several risks. Research suggests that this position not only increases the likelihood of perineal lacerations but also elevates the risk of lumbosacral spine and lower extremity nerve injuries. These findings underscore the importance of considering alternative positions, like the semi-Fowler’s, to mitigate such risks and improve overall birthing experiences.^[7]

Semi Fowler’s position during labour and birth can increase the available space within the pelvis by 28-30%, giving more room to the baby for rotation & descent. There is also a 54% decreased incidence of foetal heart rate abnormalities when the mother is upright.^[6] Semi Fowler’s position decreases the need for epidural analgesia and reduces the risk for emergency caesarean section by 29%.^[8]

The body of evidence supporting the benefits of the semi-Fowler’s position during labour is substantial. In light of this evidence, the present study was conducted to assess the effectiveness of the semi-Fowler’s position on selected maternal and neonatal outcomes among Primigravida mothers and to find out the association between selected demographic variables with labour outcomes in the semi-Fowler’s group. From shortening the duration of labour to enhancing foetal well-being and reducing the likelihood of surgical interventions, the semi-Fowler’s position offers multiple advantages that contribute to improved outcomes for both mother and child. As maternity care practices continue to advance, the integration of evidence-based positioning strategies such as the semi-Fowler’s position should be prioritised by healthcare providers aiming to enhance the birthing experience.

MATERIAL AND METHODS

The study employed a quantitative research approach, specifically utilising a quasi-experimental design. This design was chosen to evaluate the effects of the semi-Fowler’s position on labour outcomes among primigravida mothers. The target population for this study comprised primigravida mothers recruited from four hospitals within the Kheda-Anand district of Gujarat. These hospitals were selected through convenience sampling based on their geographical proximity and feasibility for data collection. The sample size was determined using power analysis to achieve 80% power with a significance level (alpha) of 0.05. Based on the calculation, 91 participants were required. To account for an expected dropout rate of 10%, the study included a total of 100 participants. Participants were selected using an enumerative sampling technique to ensure unbiased and representative samples. The study was carried out over a period from December 2021 to November 2022.

Inclusion criteria for the study were as follows: 1) primigravida mothers (first pregnancy); 2) single foetus with cephalic presentation; 3) gestational age between 35 to 40 weeks; 4) cervical dilation between 3 to 5 cm; 5) no known pregnancy complications or risk factors; 6) willingness to adopt the semi-Fowler’s position during the first stage of labour; and 7) Undergoing spontaneous vaginal delivery at term. Exclusion criteria included: 1) multiparous mothers; 2) multiple gestations; 3) high-risk conditions such as preeclampsia, gestational diabetes, precipitate labour, placenta previa, or known fetal anomalies; 4) induced or augmented labour; 5) caesarean deliveries (elective or emergency); 6) any condition limiting the ability to maintain the Semi-Fowler’s position; and 7) non-consent or withdrawal from the study. In the semi-Fowler’s group, participants received positioning interventions after informed consent and collection of personal data, which occurred before full cervical dilation. The intervention began when the mother reached 3-5 cm of cervical dilation, with the semi-Fowler’s position introduced at the initiation of the first stage of labour till the full cervical dilation (10 cm).

During the intervention, primigravida mothers were encouraged to maintain the semi-sitting position for 20 minutes, followed by a 10-minute rest in the left lateral position. This cycle was repeated six times until full cervical dilation was achieved. Once full dilation was confirmed, the mother was shifted to the labour bed. Uterine contractions were assessed using abdominal palpation by evaluating the hardness of the fundal area during contractions. Additionally, the intensity was assessed based on the mother’s subjective experience of pain and pressure. Both findings were systematically recorded using the WHO Partograph. Labor progression was monitored using observation methods, and cervical dilation was evaluated by the obstetrician through per vaginal (PV) examinations every 6 hours. The status of the rupture of membranes, whether spontaneous or artificial, was also observed and recorded. All findings were documented using a modified WHO Partograph. For neonatal outcomes, the Apgar score was checked at 1 minute and 5 minutes after birth in collaboration with the paediatrician and staff nurse. Additionally, the newborn’s weight was recorded, and any need for assistance, such as NICU admission, was evaluated. Post-test evaluations were conducted during the labour process and after delivery to measure both maternal and neonatal outcomes. The maternal outcomes assessed were duration of all three stages of labour, cervical dilation, intensity of uterine contractions, and rupture of membranes; while neonatal outcomes included APGAR score, birth weight, and the need for resuscitation or NICU admission. The findings demonstrated that the semi-Fowler’s position was effective in significantly improving maternal outcomes, with a marked reduction in labour duration across all stages (1.27 hours in the first, 1.88 hours in the second, and 2.05 hours in the third), along with enhanced cervical dilation and stronger uterine contractions. Although a few preterm deliveries were observed in late 36 weeks, all neonatal outcomes remained within healthy parameters, with no adverse effects, further supporting the safety and benefit of the semi-Fowler’s position during labour.

RESULTS

DISCUSSION

The findings demonstrated a significant impact of this position in shortening the duration of the first, second, and third stages of labour. Several studies have corroborated these results, indicating that the semi-Fowler’s position is associated with a reduced duration of labour in the second and third stages.^[9,10] Additionally, the study findings revealed that the semi-Fowler’s position significantly improved labour outcomes, with shorter second-stage duration (t=13.03, p<0.05), stronger and longer uterine contractions, and higher mean fetal heart rates at multiple observation points compared to the control group.^[11] Most women (73.3%) had 2–4 contractions within 10 minutes, and the majority (93.3%) achieved normal vaginal delivery with 10episiotomy. Neonatal outcomes remained optimal, with all foetal heart rate (FHR) values within the normal range.^[12] These findings align with earlier research showing that supported semi-sitting positions enhance labour efficiency and maternal comfort. For instance, one study reported a higher rate of spontaneous vaginal delivery (83.3% vs. 46.7%, p=0.001), less pain (p=0.004), and shorter second-stage duration in the semi-sitting group^[13]. Another trial demonstrated significantly shorter second-stage labour (t=5.87, p<0.001) and higher neonatal APGAR scores in the intervention group. Together, the evidence reinforces the semi-Fowler’s position as a safe, effective, and well-tolerated posture for optimising maternal and neonatal outcomes.^[14]

The present study found that the semi-Fowler’s position significantly improved labour outcomes, reducing the mean durations of the first, second, third, and total stages of labour (1.27, 1.88, 2.05, and 1.48 hours, respectively; p < 0.0001). It also increased the rate of cervical dilation (2.01 cm/hour) and the intensity of uterine contractions and positively influenced membrane rupture timing and mode of delivery (all p < 0.0001). Neonatal outcomes were favorable, with APGAR scores >7, normal birth weights, and no NICU admissions, even in 9 preterm deliveries (∼36 weeks). These results highlight the semi-Fowler’s position as a safe, simple, and effective intervention yet impactful modification to routine labour management that shortens labour, enhances maternal comfort, and supports positive birth outcomes.

Limitations of this study include several factors that may affect the interpretation of the results. The intervention was primarily carried out by one researcher with the assistance of other nurses, potentially introducing variability and affecting the consistency of the results. Participants also assumed the semi-Fowler’s position based on individual comfort levels and required rest periods between contractions, which may have influenced the uniformity of the intervention. Additionally, the study was confined to hospitals within the Kheda-Anand district of Gujarat, India, limiting the generalisability of the findings to other regions or populations. Finally, the sample size was restricted to 100 participants, which may impact the statistical power and robustness of the study’s outcomes. The intervention was not compared with a standard procedure, which affects the ability to evaluate its relative efficacy.

CONCLUSION

Positioning primigravida women in the semi-Fowler’s position has demonstrated significant benefits, including shorter labour duration, improved cervical dilation, and stronger uterine contractions, thereby enhancing maternal comfort and satisfaction. Incorporating this position into routine nursing care can optimise labour outcomes and reduce complications, making it a valuable alternative to the traditional supine position. Overall, the semi-Fowler’s position holds strong potential as a standard practice in maternity care, warranting continued research and promotion to further improve maternal and neonatal well-being.