Scheduled peanut birthing-ball positioning for labor in first-time mothers with an epidural

Inclusion Criteria:Inclusion Criteria:

To be eligible for participation, women must meet all the following criteria:

* Primiparous (first pregnancy resulting in a live birth or stillbirth after 20 weeks of gestation).
* Singleton at gestation.
* Gestational age of the term (37 weeks 0 days to 41 weeks 6 days).
* Admitted to the Labor and Delivery Unit at WWRC in active labor.
* Received epidural analgesia for labor pain management.
* Expected to have a vaginal delivery (e.g., no contraindications for vaginal birth identified at the time of recruitment).
* Able to understand and communicate in Arabic or English.
* Provide written informed consent.

Exclusion Criteria:The birthing ball should NOT be used in any of the following conditions:

1. Obstetric Contraindications (Maternal)

   * Any situation where vaginal birth is not appropriate (e.g., absolute indication for cesarean section)
   * Non-progress of labor requiring immediate intervention
   * Severe pre-eclampsia/eclampsia
   * Active vaginal bleeding of unknown cause
   * Placenta previa (major) or vasa previa
   * Placental abruption (suspected or confirmed)
   * Preterm labor with medical contraindication to ambulation or mobility
   * Ruptured membranes with unstable fetal head (high station) → Risk of cord prolapse
   * Severe maternal exhaustion requiring bed rest
   * Maternal hemodynamic instability
2. Fetal Contraindications

   * Non-reassuring fetal heart rate requiring continuous monitoring (Category II-III tracings)
   * Malpresentation requiring immediate obstetric intervention (e.g., transverse lie)
   * Suspected macrosomia with mechanical obstruction concerns (e.g., cephalopelvic disproportion)
   * Multiple gestation with instability or complications
3. Orthopedic / Musculoskeletal Contraindications

   * Any condition that prevents safe sitting, balancing, or weight-bearing, such as: Severe hips, leg, knee, or pelvic injuries
   * Significant arthritis of the lower limbs or pelvis
   * Recent joint surgery (hip/knee replacement, pelvic repair)
   * Neuromuscular disorders affecting balance (e.g., severe neuropathy)
   * Severe sciatica limiting mobility
   * Poor trunk control or inability to maintain safe seated posture
4. High-Risk Pregnancy Conditions

   * Use of birthing balls is contraindicated if pregnancy is classified as high-risk, including Uncontrolled gestational diabetes and Uncontrolled hypertension
   * Intrauterine growth restriction with required continuous monitoring
   * Polyhydramnios or severe oligohydramnios (risk of cord compression/instability)
   * Preterm premature rupture of membranes (PPROM)
   * History of preterm birth with current instability
   * Any condition requiring bed rest or reduced mobility
5. Safety / Environmental Contraindications

   * Patients are unable to follow instructions or unsteady balance
   * No trained staff available to supervise during labor use Unstable or improperly sized birthing ball