Effect of Squatting Position in the Second Stage of Labor on Birth Outcomes

October 31, 2026 updated by: Meryem ÖZDEMİR, Ege University

Effect of Squatting Position on Birth Outcomes in the Second Stage of Labor in Nulliparous Women: A Randomized Controlled Trial/ Nullipar Kadınlarda Doğumun İkinci Evresinde Çömelme Pozisyonu Uygulamasının Doğum Sonuçlarına Etkisi: Randomize Kontrollü Çalışma

The second stage of labor is a crucial phase during which the fetus progresses through the birth canal, a process significantly influenced by maternal positions. While adopting specific birthing positions during the second stage offers potential benefits for maternal and neonatal health, inappropriate positions can lead to negative short- and long-term consequences. These include severe perineal lacerations, postpartum hemorrhage, an increased risk of neonatal complications, and postpartum urinary incontinence.

Birthing positions are considered non-medical interventions because they alter physiological and anatomical adaptations during labor. These adaptations, related to pelvic dimensions, intrauterine pressure, and the progression of the fetal head through the birth canal, directly influence maternal and fetal outcomes. Studies have reported that horizontal positioning during labor increases the likelihood of cesarean delivery, assisted vaginal delivery, episiotomy, and abnormal fetal heart rates.

Conversely, upright positions offer several advantages during labor. They facilitate fetal descent by utilizing gravity, strengthen uterine contractions, reduce the risk of aortocaval compression, increase pelvic dimensions, and help maintain fetal flexion in the narrowest parts of the birth canal. In the squatting position, maternal hip flexion significantly alters the pelvic axis angles through which the fetal head progresses, facilitating spontaneous vaginal delivery. Furthermore, uterine contractions are stronger and more effective in achieving effacement and dilation in the squatting position, thereby significantly contributing to the progression of labor.

The World Health Organization (2018) Intrapartum Care Management Guidelines recommend supporting upright positions in the second stage of labor for a more positive birth experience. However, data remains limited regarding the optimal upright position for women during this stage. Accordingly, this randomized controlled experimental study was designed to examine the effects of the squatting position during the second stage of labor on obstetric, maternal, and neonatal outcomes in nulliparous women with low-risk pregnancies planning a vaginal delivery.

Study Overview

Status

Status

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Recruiting

Conditions

Conditions

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Intervention / Treatment

Intervention / Treatment

A process or action that is the focus of a clinical study. Interventions include drugs, medical devices, procedures, vaccines, and other products that are either investigational or already available. Interventions can also include noninvasive approaches, such as education or modifying diet and exercise.

Detailed Description

It has been reported that upright positions during the second stage of labor are more beneficial than horizontal positions in improving maternal and neonatal birth outcomes and reducing certain obstetric complications. Upright positions are those in which the woman's third and fifth lumbar vertebrae are aligned vertically rather than horizontally, a practice recommended by numerous international organizations.

Upright and horizontal positions are defined based on the angle formed between the horizontal plane and the line connecting the midpoints of the maternal third and fifth lumbar vertebrae. Accordingly, an upright position is defined when the spine is vertical and this angle exceeds 45°, whereas an angle of less than 45° is considered horizontal. Despite the proven advantages of upright birthing positions during the second stage of labor, the majority of women today still commonly give birth in the supine lithotomy position. The lithotomy position is considered a risk factor for a prolonged second stage of labor due to its negative impact on uterine function and its limitation of the effects of gravity. A prolonged second stage is significantly associated with adverse maternal and neonatal outcomes, such as postpartum hemorrhage, assisted delivery, cesarean section, third- and fourth-degree perineal lacerations, and low Apgar scores. These negative outcomes can lead women to perceive their birthing experience negatively, making them more likely to develop birth anxiety in future pregnancies, prefer cesarean delivery, or avoid future childbirth altogether.

Although evidence definitively evaluating the absolute benefits and risks of various upright positions remains limited, studies suggest that positions that do not restrict sacral flexibility during labor have the potential to support superior maternal and neonatal outcomes. Upright positions that maintain sacral flexibility are considered more favorable for promoting natural childbirth because they allow for pelvic outlet expansion. Based on this literature, an ideal birthing position should positively contribute to delivery outcomes by preserving sacral flexibility, allowing full mobility of the bony pelvis to expand pelvic dimensions, and maximizing the utilization of gravity. Accordingly, the squatting position, which falls into both the upright and flexible sacrum categories, may uniquely contribute to improving outcomes in spontaneous vaginal deliveries. However, further structured research is emphasized to better define and comprehensively evaluate the specific clinical effects of the squatting position during delivery.

Hip flexion during squatting significantly alters the pelvic axis, cervical, and pelvic floor angles along which the fetal head progresses. This mechanical advantage creates additional space for the fetal rotations required during descent through the birth canal. Furthermore, it allows the fetus to benefit maximally from gravity, facilitating a faster and smoother descent while stretching the perineum gradually. By relaxing the woman's diaphragm and chest cavity, the squatting position also optimizes respiration and generates better intra-abdominal pressure. This enables more effective use of maternal abdominal muscles with less physical effort, thereby contributing to improved delivery outcomes, fewer medical interventions, and a reduced rate of intrapartum emergency cesarean sections.

In Turkey, the Ministry of Health actively promotes the expansion of "Mother-Friendly Hospital" practices. However, although the modern birthing beds used in single-patient delivery rooms within these frameworks offer women the opportunity to assume diverse positions, standard deliveries routinely continue to be performed in the conventional lithotomy position, mirroring the limitations of previously used gynecological exam tables. Consequently, research on the effects of the squatting position on the anatomy and physiology of labor, and how it alters intrapartum dynamics, is critical for guiding clinical practices in childbirth. Therefore, this study, entitled "The Effect of Squatting Position Application in the Second Stage of Labor on Birth Outcomes in Nulliparous Women: A Randomized Controlled Trial," aims to examine the effects of the squatting position during the second stage of labor in nulliparous women with low-risk pregnancies, comparing it to the widely used lithotomy position on modern birthing beds in Mother-Friendly Hospitals, on obstetric, maternal, and fetal-neonatal delivery outcomes.

Study Type

Study Type

Describes the nature of a clinical study. Study types include interventional studies (also called clinical trials), observational studies (including patient registries), and expanded access.
Interventional

Enrollment (Estimated)

Enrollment

The number of participants in a clinical study. The "anticipated" enrollment is the target number of participants that the researchers need for the study.
60

Phase

Phase

The stage of a clinical trial studying a drug or biological product, based on definitions developed by the U.S. Food and Drug Administration (FDA). The phase is based on the study's objective, the number of participants, and other characteristics. There are five phases: Early Phase 1 (formerly listed as Phase 0), Phase 1, Phase 2, Phase 3, and Phase 4. Not Applicable is used to describe trials without FDA-defined phases, including trials of devices or behavioral interventions.
  • Not Applicable

Contacts and Locations

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Study Contact

Study Contact

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Study Locations

Participation Criteria

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Eligibility Criteria

Eligibility Criteria

The key requirements that people who want to participate in a clinical study must meet or the characteristics they must have. Eligibility criteria consist of both inclusion criteria (which are required for a person to participate in the study) and exclusion criteria (which prevent a person from participating). Types of eligibility criteria include whether a study accepts healthy volunteers, has age or age group requirements, or is limited by sex.

Ages Eligible for Study

18 years to 45 years (Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

Female

Description

Inclusion Criteria:

  • Pregnant women who have read, understood, and voluntarily accepted the informed consent form both verbally and in writing,
  • Individuals aged 18 years and older,
  • Nulliparous pregnant women who will give birth for the first time,
  • Gestational age between 37+0 and 41+6 weeks,
  • Having a singleton, live fetus in vertex presentation,
  • Pregnant women with intact membranes upon hospital admission (no observed amniotic fluid leakage).

Exclusion Criteria:

  • Having a diagnosis of high-risk pregnancy either previously or during hospital admission for normal delivery,
  • Having a body mass index (BMI) of 30 kg/m² or above,
  • Having a fetus with a detected congenital anomaly,
  • Having any chronic disease (such as hypertension or diabetes),
  • Having a mental or cognitive illness,
  • Having any type of disability (such as orthopedic, hearing, visual, or speech impairment),
  • Detection of pelvic contraction findings during the vaginal examination upon admission (such as reaching the promontory or palpating the ischial spines during vaginal examination),
  • Estimated fetal weight of 4000 grams or above based on ultrasonography measurements,
  • Estimated fetal weight of 2500 grams or below based on ultrasonography measurements,
  • Term infants diagnosed with intrauterine growth restriction (IUGR)
  • Unfollowed pregnancies without routine ultrasonography measurements and screening tests.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Other
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm

Participant Group / Arm

A group or subgroup of participants in a clinical trial that receives a specific intervention/treatment, or no intervention, according to the trial's protocol.
Intervention / Treatment

Intervention / Treatment

A process or action that is the focus of a clinical study. Interventions include drugs, medical devices, procedures, vaccines, and other products that are either investigational or already available. Interventions can also include noninvasive approaches, such as education or modifying diet and exercise.
Active Comparator: Routine Care

For this group, following the hospital's routine clinical practices and standard intrapartum care, the upper section (head section) of the birthing bed is elevated to an angle of less than 45 degrees during delivery. The pregnant woman is placed in the lithotomy position by positioning her legs on the foot supports attached to the right and left sides of the birthing bed. The deliveries of the pregnant women included in this control group will be conducted in the lithotomy position by the researcher.
Other: Routin Care (Lithotomy Position)

Nulliparous pregnant women included in this control group will receive routine clinical care, and no experimental intervention will be performed until the crowning stage (when the fetal scalp becomes visible at the perineum). For this group, following standard intrapartum protocols, the upper section (head section) of the birthing bed is elevated to an angle of less than 45 degrees during delivery. The pregnant woman is placed in the conventional lithotomy position by positioning her legs on the foot supports attached to the right and left sides of the birthing bed. The deliveries of the pregnant women included in this control group will be conducted in the lithotomy position by the researcher, Expert Midwife Meryem Ozdemir.

Other Names:
  • second stage of labor
  • maternal position
  • birth position
  • nulliparous women
  • lithotomy position
Experimental: Squatting Position

After the fetal head crowns from the perineum, the upper section (head section) of the birthing bed will be elevated to an angle between 45 and 60 degrees. The pregnant woman will lean against the backrest of the birthing bed and position her buttocks on the seating area. She will be assisted to place her legs in flexion at the knees, with the soles of her feet pressing firmly onto the edges of the seating area. While the pregnant woman is maintained in this position, the delivery of the fetus will be conducted by the researcher.
Other: Experimental (Squatting Position)

Until the second stage of labor (until cervical dilation reaches 10 cm), routine clinical care will continue to be provided.

During the second stage of labor, in the active phase when the pregnant woman begins to feel spontaneous urges to push, she will be supported to assume a squatting position on the birthing bed. The woman will adopt the squatting position during uterine contractions and will be allowed to rest in any position she desires on the bed between contractions.

Delivery Phase: After the fetal head crowns, the upper section (head section) of the birthing bed will be elevated to an angle between 45 and 60 degrees. The pregnant woman will lean against the backrest, position her buttocks on the seating area, and place her legs in flexion at the knees, pressing her feet onto the edges of the bed. While the pregnant woman is held in this position, the delivery of the fetus will be performed by Meryem Özdemir, a specialist midwife who is part of the research team.

Other Names:
  • second stage of labor
  • maternal position
  • birth position
  • squatting position
  • nulliparous women

What is the study measuring?

Primary Outcome Measures

Primary Outcome Measures

In a clinical study's protocol, the planned outcome measure that is the most important for evaluating the effect of an intervention/treatment. Most clinical studies have one primary outcome measure, but some have more than one.
Outcome Measure
Measure Description
Time Frame
Duration of the second stage of labor
Time Frame: From the exact moment of full cervical dilation (10 cm) until the complete delivery of the fetus (measured in minutes)

The time elapsed from the completion of cervical dilation (full dilation - 10 cm) to the birth of the baby will be recorded.
From the exact moment of full cervical dilation (10 cm) until the complete delivery of the fetus (measured in minutes)
Need for operative or obstetric interventions during delivery
Time Frame: From the onset of labor (and after the crowning of the fetal head) until the complete delivery of the infant's entire body (measured in minutes).

The occurrence of any obstetric or operative interventions (such as episiotomy incision, vacuum extraction/Kiwi device use, or fundal pressure/Kristeller maneuver) will be recorded as a binary outcome (yes or no).
From the onset of labor (and after the crowning of the fetal head) until the complete delivery of the infant's entire body (measured in minutes).

Secondary Outcome Measures

Secondary Outcome Measures

In a clinical study's protocol, a planned outcome measure that is not as important as the primary outcome measure for evaluating the effect of an intervention but is still of interest. Most clinical studies have more than one secondary outcome measure.
Outcome Measure
Measure Description
Time Frame
Perineal Laceration Degree and Episiotomy Status
Time Frame: Immediately following the delivery of the placenta.

The severity of perineal lacerations will be evaluated based on clinical definitions: first-degree (injury to the perineal skin and/or vaginal mucosa); second-degree (injury to the perineal muscles); third-degree (injury to the anal sphincter complex and anorectal mucosa); and fourth-degree (obstetric anal sphincter injuries involving anatomical and physiological damage to the anal sphincter). If no laceration occurs, the perineum will be recorded as intact. Additionally, whether an episiotomy incision was performed by the researcher during delivery, and if so, its severity/degree will be evaluated and recorded in accordance with the clinical definitions specified above.
Immediately following the delivery of the placenta.
Maternal Pain Level at the Onset of the Second Stage of Labor
Time Frame: Immediately after the procedure/intervention (During the interval between uterine contractions following the onset of the second stage)

Maternal pain levels during uterine contractions will be assessed at the exact onset of the second stage of labor (full cervical dilation) using the Visual Analog Scale (VAS), where scores range from 1 (least pain) to 10 (most severe pain). Measurements will be obtained by asking the pregnant woman during the resting period between contractions.
Immediately after the procedure/intervention (During the interval between uterine contractions following the onset of the second stage)
Maternal Pain Level at the Crowning Stage of the Fetal Head
Time Frame: At crowning of the fetal head, during the second stage of labor

Maternal pain levels during uterine contractions will be assessed at the crowning stage of the fetal head using the Visual Analog Scale (VAS), where scores range from 1 (least pain) to 10 (most severe pain). Measurements will be obtained by asking the pregnant woman during the resting period between contractions.
At crowning of the fetal head, during the second stage of labor
Maternal Fatigue Level at the Onset of the Second Stage of Labor
Time Frame: At the onset of the second stage of labor (full cervical dilation)

Maternal fatigue levels will be assessed at the exact onset of the second stage of labor (full cervical dilation) using the Visual Analog Scale (VAS), where scores range from 1 (least fatigue) to 10 (most severe fatigue). Measurements will be obtained by asking the pregnant woman during the resting period between contractions.
At the onset of the second stage of labor (full cervical dilation)
Maternal Fatigue Level at the Crowning Stage of the Fetal Head
Time Frame: At crowning of the fetal head, during the second stage of labor

Maternal fatigue levels will be assessed at the crowning stage of the fetal head using the Visual Analog Scale (VAS), where scores range from 1 (least fatigue) to 10 (most severe fatigue). Measurements will be obtained by asking the pregnant woman during the resting period between contractions.
At crowning of the fetal head, during the second stage of labor
Maternal Childbirth Experience
Time Frame: Within the first 24 hours postpartum, prior to hospital discharge

Maternal childbirth experience will be evaluated using the Childbirth Experience Questionnaire (CEQ). Participants in both the intervention and control groups will be asked to complete the questionnaire postpartum, specifically after they have breastfed their babies and achieved adequate rest, prior to hospital discharge. The total score obtained from the scale will be evaluated. Higher scores on the questionnaire indicate a more positive and better childbirth experience. There is no specific cut-off score for this scale.
Within the first 24 hours postpartum, prior to hospital discharge
Newborn 1st Minute APGAR Score
Time Frame: At 1 minute after birth

The newborn's health status and transition to extrauterine life will be evaluated at the 1st minute after birth using the standard APGAR scoring system. The score ranges from 0 to 10, with higher scores indicating a better clinical condition of the newborn.
At 1 minute after birth
Newborn 5th Minute APGAR Score
Time Frame: At 5 minutes after birth

The newborn's health status and adaptation to extrauterine life will be evaluated at 5 minutes after delivery using the standard APGAR scoring system. The score ranges from 0 to 10, with higher scores indicating a better clinical condition of the newborn.
At 5 minutes after birth
Umbilical Cord Blood Gas Parameters
Time Frame: Immediately after the delivery of the baby and prior to placental separation

Umbilical cord blood gas analysis will be performed to evaluate the oxygenation and acid-base status of the newborn. Immediately after the complete delivery of the baby and prior to placental separation, a blood sample will be collected from the maternal side of the umbilical cord using a blood gas syringe by the researcher. The clinical parameters to be evaluated from the hospital's laboratory computer system include: umbilical artery pH, partial pressure of carbon dioxide (pCO2, measured in mmHg), partial pressure of oxygen (pO2, measured in mmHg), and base excess (BE, measured in mEq/L)
Immediately after the delivery of the baby and prior to placental separation
Requirement for Neonatal Resuscitation
Time Frame: During the immediate stabilization period within the first minutes after birth

Whether the newborn requires any level of neonatal resuscitation (such as positive pressure ventilation, endotracheal intubation, or administration of medications) during the immediate stabilization period in the delivery room will be recorded as a binary outcome (yes or no).
During the immediate stabilization period within the first minutes after birth
Status of Being Placed in Maternal Skin-to-Skin Contact Without Intervention
Time Frame: Immediately following the delivery of the baby

Whether the newborn can be placed directly in skin-to-skin contact with the mother or routine healthy newborn care can be provided without requiring any special medical interventions or admission to the neonatal intensive care unit (NICU) will be recorded as a binary outcome (yes or no).
Immediately following the delivery of the baby
Newborn Clinical Status and Physical Examination Findings
Time Frame: Within the first hour after birth

Comprehensive newborn physical examination and clinical status findings will be evaluated and recorded by a neonatologist to ensure safety and monitor neonatal adaptation within the first hour following delivery. The evaluated parameters will include: cardiovascular findings (heart rate, preductal SpO2, and perfusion index); respiratory findings (respiratory rate, presence of chest retractions, and nasal flaring); gastrointestinal findings (presence of meconium); integumentary/skeletal findings (normal condition of the clavicle); and neurological findings (muscle tone and brachial plexus status). Any deviations from normal clinical values will be recorded.
Within the first hour after birth

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Sponsor

The organization or person who initiates the study and who has authority and control over the study.
Ege University

Collaborators

Collaborators

An organization other than the sponsor that provides support for a clinical study. This support may include activities related to funding, design, implementation, data analysis, or reporting.
Cigli Regional Training Hospital

Investigators

Investigators

A researcher involved in a clinical study. Related terms include site principal investigator, site sub-investigator, study chair, study director, and study principal investigator.
  • Study Director: İbrahim Karaca, Prof., Çiğli Training and Research Hospital
  • Study Chair: Esin Ceber Turfan, Prof., Ege University

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

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Study Major Dates

Study Start (Actual)

Study Start

The actual date on which the first participant was enrolled in a clinical study. The "anticipated" study start date is the date that the researchers think will be the study start date.
February 27, 2026

Primary Completion (Estimated)

Primary Completion

The date on which the last participant in a clinical study was examined or received an intervention to collect final data for the primary outcome measure. Whether the clinical study ended according to the protocol or was terminated does not affect this date. For clinical studies with more than one primary outcome measure with different completion dates, this term refers to the date on which data collection is completed for all the primary outcome measures. The "anticipated" primary completion date is the date that the researchers think will be the primary completion date for the study.
December 31, 2026

Study Completion (Estimated)

Study Completion

The date on which the last participant in a clinical study was examined or received an intervention/treatment to collect final data for the primary outcome measures, secondary outcome measures, and adverse events (that is, the last participant's last visit). The "anticipated" study completion date is the date that the researchers think will be the study completion date.
January 31, 2027

Study Registration Dates

First Submitted

First Submitted

The date on which the study sponsor or investigator first submitted a study record to ClinicalTrials.gov. There is typically a delay of a few days between the first submitted date and the record's availability on ClinicalTrials.gov (the first posted date).
May 27, 2026

First Submitted That Met QC Criteria

First Submitted That Met QC Criteria

The date on which the study sponsor or investigator first submits a study record that is consistent with National Library of Medicine (NLM) quality control (QC) review criteria. The sponsor or investigator may need to revise and submit a study record one or more times before NLM's QC review criteria are met. It is the responsibility of the sponsor or investigator to ensure that the study record is consistent with the NLM QC review criteria.
October 31, 2026

First Posted (Actual)

First Posted

The date on which the study record was first available on ClinicalTrials.gov after National Library of Medicine (NLM) quality control (QC) review has concluded. There is typically a delay of a few days between the date the study sponsor or investigator submitted the study record and the first posted date.
November 5, 2026

Study Record Updates

Last Update Posted (Actual)

Last Update Posted

The most recent date on which changes to a study record were made available on ClinicalTrials.gov. There may be a delay between when the changes were submitted to ClinicalTrials.gov by the study's sponsor or investigator (the last update submitted date) and the last update posted date.
November 5, 2026

Last Update Submitted That Met QC Criteria

Last Update Submitted That Met QC Criteria

The most recent date on which the study sponsor or investigator submitted changes to a study record that are consistent with National Library of Medicine (NLM) quality control (QC) review criteria. It is the responsibility of the sponsor or investigator to ensure that the study record is consistent with the NLM QC review criteria.
October 31, 2026

Last Verified

Last Verified

The most recent date on which the study sponsor or investigator confirmed the information about a clinical study on ClinicalTrials.gov as accurate and current. If a study with a recruitment status of recruiting; not yet recruiting; or active, not recruiting has not been confirmed within the past 2 years, the study's recruitment status is shown as unknown.
May 1, 2026

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

Other Study ID Numbers

Identifiers or ID numbers other than the NCT number that are assigned to a clinical study by the study's sponsor, funders, or others. These numbers may include unique identifiers from other trial registries and National Institutes of Health grant numbers.
  • 25-AKD-354
  • 25-AKD-354 (Other Identifier: Turkish Medicines and Medical Devices Agency)

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

NO

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

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