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The Journal of
Perinatal Education
Advancing Normal Birth
A Lamaze® International Publication
IN THIS ISSUE:
Choosing
Wisely for Birth
Doula Care
Using a Peanut Ball
With the Compliments of Springer Publishing Company, LLC
16 The Journal of Perinatal Education | Winter 2015, Volume 24, Number 1
Reducing Length of Labor and Cesarean
Surgery Rate Using a Peanut Ball for
Women Laboring With an Epidural
Christina Marie Tussey, MSN, RN, CNS
Emily Botsios, BSN, RN
Richard D. Gerkin, MD, MS
Lesly A. Kelly, PhD, RN
Juana Gamez, RN
Jennifer Mensik, PhD, RN, FAAN
ABSTRACT
One strategy for reducing the primary cesarean surgery rate and length of labor is using a peanut-shaped
exercise ball for women laboring under epidural analgesia. A randomized, controlled study was conducted
to determine whether use of a “peanut ball” decreased length of labor and increased the rate of vaginal birth.
Women who used the peanut ball (n 5 107) versus those who did not (n 5 91) demonstrated shorter first
stage labor by 29 min (p 5 .053) and second stage labor by 11 min (p , .001). The intervention was as-
sociated with a significantly lower incidence of cesarean surgery (OR 5 0.41, p 5 .04). The peanut ball is
potentially a successful nursing intervention to help progress labor and support vaginal birth for women
laboring under epidural analgesia.
The Journal of Perinatal Education, 24(1), 16–24, http://dx.doi.org/10.1891/1058-1243.24.1.16
Keywords: peanut ball, epidural, first stage labor, second stage labor, cesarean birth
begun assuming responsibility for limiting elective in-
ductions, recognizing that the best outcomes overall
for both the mother and the infant occur in facilities
with cesarean surgery rates in the 5%–10% range (Al-
thabe & Belizán, 2006). The Healthy People 2020 cesar-
ean surgery rate target is 23.9% for low-risk full-term
women with a singleton, vertex presentation (U.S.
Department of Health and Human Services, 2013).
As a result, efforts by the Association of Women’s
Cesarean surgery is often perceived as benign, but the
surgery can place the woman at an increased risk of
infection, hemorrhage, damage to abdominal and
urinary tract organs, longer recovery, and complica-
tions from anesthesia. In 2010, the U.S. cesarean rate
was at 32.8% (Martin, Hamilton, Ventura, Osterman,
& Matthews, 2013), a drastic increase from the initial
and ideal rate of 4.5% when it was first measured in
1965 (Taffel, Placek, & Liss, 1987). Organizations have
Copyright © Springer Publishing Company, LLC
Peanut Ball for Laboring Women | Tussey et al. 17
et al., 2011; Leighton & Halpern, 2002; Lieberman &
O’Donoghue, 2002). Other researchers found an in-
creased cesarean surgery rate, prolonged time in labor,
more instrumental births, and use of pharmacologic
agents to augment labor (American College of Obste-
tricians and Gynecologists, 2002; Anim-Somuah et al.,
2011; Eriksen et al., 2011). A meta-analysis concluded
that epidural use is associated with prolonging labor
40–90 min and with an increased risk of second stage
of labor that extended beyond 2 hr (American College
of Obstetricians and Gynecologists, 2002; Sharma,
McIntire, Wiley, & Leveno, 2004).
Prolonging Labor
Preventing the first cesarean surgery requires allow-
ing adequate time for first and second stages of labor,
as long as no maternal and fetal distress occurs. The
likelihood of vaginal birth is lower after elective labor
induction than after spontaneous labor, especially
when the induction is attempted on a nulliparous
woman with an unripened/unfavorable cervix or low
bishop score (Maslow & Sweeny, 2000; van Gemund,
Hardeman, Scherjon, & Kanhai, 2003). Induction of
labor reportedly increased from 9.5% of births in
1990 to 23.2% of births in 2011 (Martin et al., 2013).
The diagnosis of “failed induction” or “failure to prog-
ress” should be made only after an adequate attempt
(Spong, Berghella, Wenstrom, Mercer, & Saade, 2012).
Adequate time for first and second stage labor is lon-
ger than traditionally estimated (Zhang et al., 2010).
Spong et al. (2012) defines second stage arrest as no
progress (descent or rotation) for more than 4 hr in a
nullipara with an epidural and more than 3 hr in mul-
tiparous women with an epidural. A major concern
with unanticipated prolonged labor is the potential
need for further medical intervention.
Additional Birth Interventions
In addition to prolonged labor, epidural use is as-
sociated with additional birth interventions, such
as a higher rate of operative instrumental births
(Anim-Somuah et al., 2011; Leighton & Halp-
ern, 2002; Lieberman & O’Donoghue, 2002). An
increased risk of instrumental births has been
Health, Obstetrics, and Neonatal Nursing Association
(AWHONN), the American College of Obstetrics and
Gynecology (ACOG), and March of Dimes discourage
pregnant women from requesting an elective induc-
tion when not medically indicated.
Labor that fails to progress is the most common
indication for primary cesarean surgery (Gifford
et al., 2000). In low-risk nulliparous women, the use
of epidural analgesia for labor pain was associated
with higher risks of emergency cesarean surgery and
vacuum-assisted birth (Eriksen, Nohr, & Kjærgaard,
2011). Epidural analgesia influences the course of
labor and birth, and there is an increase in instru-
mental birth (forceps or vacuum), fetal malposition,
a longer second stage labor, and fetal distress when
compared with women who receive intravenous
opiates (American College of Obstetricians and Gy-
necologists, 2002; Anim-Somuah, Smyth, & Jones,
2011; Lieberman & O’Donoghue, 2002).
Practitioners have reported in the literature that use
of an exercise ball at the bedside of laboring women
without an epidural can facilitate a more normal labor
progression (Gau, Chang, Tian, & Lin, 2011; Johnston,
1997; Zwelling, 2010). The ball promotes spinal flex-
ion, increasing the uterospinal angle, and increasing
the pelvic diameters to facilitate occiput posterior rota-
tion (Zwelling, 2010), which results in a widened pelvic
outlet. In general, exercise/birthing balls widen the pel-
vic inlet and outlet dimensions passively stretching the
adductor magnus muscles, resulting in the widening of
the intertuberous diameter (Shermer & Raines, 1997).
Using a peanut ball with women who have received
an epidural is gaining popularity with labor and birth
professionals, but there is limited evidence to support
its use. Therefore, a research study was designed, based
on pilot data, to explore the differences in labor time
and spontaneous vaginal birth between women labor-
ing with an epidural who use a peanut-shaped exercise
ball compared to those who do not use a ball.
REVIEW OF LITERATURE
In 2008, a study in 27 states showed that 61% of single-
ton births were to women who received an epidural or
spinal anesthesia during labor (Osterman & Martin,
2011). Although generally accepted as safe and a nor-
mal part of any birth, labor epidurals have a wide
range of potential complications. In three systematic
reviews and a prospective study, epidural analgesia was
associated with an increased requirement of oxytocin
augmentation, prolonged second stage, and instru-
mental births (Anim-Somuah et al., 2011; Caruselli
Association of Women’s Health, Obstetrics and Neonatal Nurses,
the American College of Obstetricians and Gynecologists, and the
March of Dimes discourage pregnant women from requesting an
elective induction when not medically indicated.
Copyright © Springer Publishing Company, LLC
18 The Journal of Perinatal Education | Winter 2015, Volume 24, Number 1
is smaller than the ends. To facilitate the desired
upright position for successful labor progression,
a peanut ball could be placed between a woman’s
legs while she is limited to staying in bed (Figure 1).
The ball is supported in place with a pillow behind
the woman’s hips to support the woman’s legs.
Based on previous knowledge of maternal position
changes, it was hypothesized that the simple placement
of the peanut ball between a laboring woman’s legs
could increase pelvic diameter and allow more room
for fetal descent. Although the peanut ball is currently
used in labor and birth units, little research exists to
support its effectiveness in improving labor outcomes.
In an effort to explore the effectiveness of using a
peanut ball for laboring women with an epidural, a
nurse-led study was designed to compare the length of
labor and mode of birth in a controlled, randomized
study with two groups: women who used a peanut ball
compared to those who did not use a peanut ball.
METHODS
Design and Setting
A two-group controlled, randomized study was
conducted to test the effectiveness of the peanut ball
intervention related to shorter labor time and im-
proved rates of spontaneous vaginal birth. The study
was given full review and approved by the hospital’s
institutional review board.
The study was conducted at a large, nonprofit, in-
ner-city teaching hospital in the Southwestern United
States from January 2009 to January 2010. The labor
and birth unit consisted of 20 labor and birth rooms
staffed by registered nurses that maintained a 2:1 or
less patient ratio. The unit’s standard of care for con-
tinuous electronic fetal monitoring laboring patients
with an epidural followed American College of Ob-
stetricians and Gynecologists and AWHONN guide-
reported in nulliparous women using epidural an-
algesia in comparison to other forms of pain relief
(Comparative Obstetric Mobile Epidural Trial Study
Group, 2001). The risk of vacuum birth was more
than doubled among the women who had epidural
analgesia (Anim-Somuah et al., 2011). Instrumental
vaginal births are associated with increased mater-
nal risks, such as vaginal and perineal trauma and
anal sphincter damage, resulting in urinary inconti-
nence, bowel and sexual problems, and dyspareunia
(Eason, Labrecque, Wells, & Feldman, 2000; Ekeus,
Nilsson, & Gottvall, 2008; Groutz et al., 2011). In ad-
dition, instrument-assisted vaginal births can be as-
sociated with adverse events in infants, such as caput
succedaneum or cephalhematoma, or skull fractures
with vacuum-assisted births (Simonson et al., 2007).
Widening the Pelvic Outlet
Gifford et al. (2000) reported that lack of progress in
labor was the reason for 68% of unplanned cesarean
surgeries for cephalic-presenting fetuses. Widening
the pelvic outlet is one method of supporting the
natural progression of birth. When a woman is lean-
ing forward while on her side, the contractions direct
the fetus toward the larger posterior half of the pelvic
inlet, where the fetus has more room to flex, rotate,
and descend (Biancuzzo, 1993; Fenwick & Simkin,
1987). Although many factors can contribute to the
protraction and arrest of labor, including weakened
contractions, fetal alignment, or maternal pelvic size
(Ehsanipoor & Satin, 2012), using position changes
to widen the pelvic outlet can be beneficial.
NURSE-DRIVEN PEANUT BALL
INTERVENTION
There are multiple benefits associated with mater-
nal position changes, including decreased pain, in-
creased maternal–fetal circulation, improved quality
of uterine contractions, decreased length of labor,
and facilitation of fetal descent (Zwelling, 2010). A
laboring woman with an epidural is limited in the
number of different positions she can try.
Midwives were the first to use a round exercise
ball as a nonpharmacological means to facilitate
progression of labor. The ball is believed to enhance
labor by optimally positioning the fetus in relation to
the pelvis (Johnston, 1997). A “peanut ball” is shaped
like a peanut shell, where the middle circumference
Figure 1. A nurse demonstrates a side-lying position with the
peanut ball placed between her legs.
A “peanut ball” is shaped like a peanut shell, where the middle
circumference is smaller than the ends.
Copyright © Springer Publishing Company, LLC
Peanut Ball for Laboring Women | Tussey et al. 19
lines, including an assessment of maternal uterine
and fetal status every 15-30 min and every time the
oxytocin was adjusted. The patient was assisted with
turning or changing their position and adjusting
the peanut ball every 1–2 hours after receiving the
epidural. All anesthesiologists in the study hospital
belong to the same physician practice group and use
a standard protocol for epidural dosing. Prior to the
study, the facility was experiencing a 67.9% epidural
rate and 32.5% cesarean surgery rate.
Participants
Laboring women were recruited if they met the in-
clusion criteria, which included being in active labor,
using an epidural for pain control, and with the fe-
tus in the cephalic presentation. Women who had an
indication for either elective induction or augmen-
tation of labor, such as mild preeclampsia, possible
macrosomia, or patient request, were eligible for
inclusion. Women younger than the age of 18 years
were included with parental consent. Women were
excluded if they required magnesium sulfate for pre-
eclampsia, had signs of an intrauterine infection, or
had a Category 3 fetal heart rate tracing, indicating
the fetus may be hypoxia or acidotic.
Power Analysis
To determine the number of participants needed in
each group, data from an internal pilot study were used
to calculate power. A small group of nonrandomized la-
boring women with an epidural who used a peanut ball
(n 5 30) were compared to those who did not (n 5 22).
Lengths of first and second stage labor were recorded.
Results demonstrated a 46-min reduction in first stage
labor and an 11-min reduction in second stage labor
with women who used the peanut ball. It was deter-
mined that 90 subjects in each group would provide a
power of .80 at an alpha of .05. To account for dropouts,
a sample size of 100 subjects per group was planned.
Subject Recruitment
Potential study participants were identified and ap-
proached after they received an epidural. The prin-
cipal researcher or research assistant recruited and
obtained written informed consent using the par-
ticipant’s primary language (English or Spanish).
Participants were randomly assigned to either the
intervention or control group in a 1:1 ratio using
randomized blocks of varying sizes from an online
randomization plan generator. Participant assign-
ments were placed in sealed, sequentially numbered
opaque envelopes by a person not involved with the
study. Each allocation was revealed once an eligible
participant completed the informed consent process.
Intervention
There were peanut balls on the unit and available to
be used for the study in each labor and birth room.
Each peanut ball was made of durable, nonlatex
material and was covered with a large plastic bag. A
patient gown was tied around the ball to prevent dis-
comfort from the plastic resting against the woman’s
legs. The balls were thoroughly cleaned using anti-
septic techniques between each patient use.
Registered nurses were educated by the investi-
gators on the study protocol, and standard care was
given to both the intervention and control groups.
Standard care involved turning patients from side to
side or placing the woman in semi- or high-Fowler
position every 1–2 hr. No other restrictions were
placed on the patient as part of the study protocol.
The peanut ball was placed between the legs of a
woman in the intervention group immediately after
she received her epidural and consented to participate
in the study. The ball was removed when the cervix
of the woman became completely effaced and dilated,
passive descent had occurred, and she was ready to
actively push. Demographic data were collected orally
from all participants by the investigators in their pre-
ferred language of English or Spanish. Women were
asked their age, gravidity, parity, ethnicity, estimated
date of birth, and whether or not they had been diag-
nosed with diabetes. The cervical dilation, effacement,
and station were recorded from their vaginal exam
(usually 30–60 min prior) before epidural placement.
After birth, nuchal cord occurrence, Apgar scores,
and fetal weight were recorded. In addition, data on
whether the participant was induced, received oxy-
tocin augmentation, had forceps or vacuum inter-
vention, gave birth vaginally or via cesarean, and the
length of first and second stages of labor was collected.
The main outcome measures of the study were
length of labor and mode of birth (spontaneous
vaginal or cesarean surgery). The length of first stage
labor time was recorded from placement of the pea-
nut ball to full effacement, station, dilation, and birth
(length of first stage of labor is from placement of the
peanut ball to 100% effacement and 10 cm dilation).
The length of second stage labor time was recorded
from complete cervical dilation to expulsion of the
fetus (Cunningham et al., 2010). The mode of birth
was recorded as spontaneous vaginal or cesarean
surgery. The use of any interventional devices,
Copyright © Springer Publishing Company, LLC
20 The Journal of Perinatal Education | Winter 2015, Volume 24, Number 1
(n 5 107) or control group (n 5 94). Most partici-
pant demographics were statistically similar between
the groups (Table 1); however, it was noted that the
women’s parity and cervical dilation were signifi-
cantly different between the two groups, and further
post hoc analysis was completed to statistically con-
trol for the difference. No complications were re-
ported from the use of the peanut ball intervention
and no differences in Apgar scores occurred in either
group during the study. In addition, no neonatal or
maternal deaths occurred in either group.
Significant unadjusted differences were found
in comparing length of labor and mode of birth
between the two groups (Table 2). Women in the
peanut ball group had a significantly shorter first
stage labor time than those in the control group
(p , .01). Second stage labor was also significantly
such as vacuum or forceps, or pharmacological
interventions, such as oxytocin, was documented.
Data Analysis
Data were analyzed using SPSS Version 17.0. De-
scriptive statistics of the two groups were analyzed
and compared. Outcome measures were compared
between the groups using independent t tests and
Fisher exact tests, as appropriate. Linear and logis-
tic regression modeling was conducted to determine
the effect of the peanut ball on first and second stage
labor time and spontaneous birth, controlling for
independent significant predictors.
RESULTS
Between January 2009 and January 2010, 200 women
were randomly assigned to either the peanut ball
TABLE 1
Maternal Demographic Characteristics in Control and Intervention Groups
Characteristic Peanut Ball Group (n 5 107) Control Group (n 5 94)
Age, M (SD ) 27.5 (6.7) 27.3 (6.2)
Average gravidity, median 2.0 2.0
Parity,a median 1.0 0.0
Nulliparity,a % 47.7 59.6
White ethnicity, % 43.9 35.5
Hispanic ethnicity,% 43.0 46.2
Estimated date of birth in weeks, M (SD) 38.9 (2.4) 39.1 (2.5)
Diabetic, % 4.8 4.4
Cervical dilationa (in centimeters) at enrollment, median 4.5 4.0
Effacement at enrollment, % 84.2 77.7
Station at enrollment, median 21.0 21.0
Note. Gravidity defined as number of pregnancies; parity defined as number of births; nulliparity defined as never given birth.
aSignificant p , .05.
TABLE 2
Labor and Birth Outcomes
Outcome Peanut Ball Group (n 5 107) Control Group (n 5 94) Statistic p Value
Length of first stage labora (min) 268.8 (228.1–309.6) 356.2 (308.8–403.6) t test .006
Length of second stage labora (min) 21.3 (16.3–26.3) 43.5 (32.3–54.8) t test ,.001
Cesarean surgeryb11 (10.3) 19 (21.1) x2.011
Inductionb30 (28.0) 29 (31.5) x2.592
Oxytocin usedb85 (79.3) 74 (79.8) x2.925
Forceps usedb2 (1.9) 2 (2.2) x2.895
Vacuum usedb7 (6.7) 9 (9.7) x2.438
Nuchal cord presentb18 (17.5) 19 (21.1) x2.522
Apgar score at 1 minc9 (8–9) 9 (8–9) Wilcoxon test .926
Apgar score at 10 minc9 (9–9) 9 (9–9) Wilcoxon test .529
Fetal weight in gramsa3,456 (3,369–3,544) 3,393 (3,264–3,521) Wilcoxon test .337
aReported as M, (95% CI).
bReported as n, (%).
cReported as median, (25th–75th interquartile range).
Copyright © Springer Publishing Company, LLC
Peanut Ball for Laboring Women | Tussey et al. 21
TABLE 3
Univariate Analysis of Predictors of Outcomes
Variable p
First stage labor
Age .027
Gravidity .047
Parity .001
Oxytocin .062
Nulliparity ,.001
Cervical dilation ,.001
Effacement ,.001
Peanut ball .001
Second stage labor
Gravidity ,.001
Parity ,.001
Nulliparity ,.001
Peanut ball ,.001
Cesarean surgery
Gravidity .009
Parity ,.001
Nulliparity ,.001
Dilation ,.001
Peanut ball .011
Note. Gravidity 5 defined as number of pregnancies; parity 5 defined
as number of births; nulliparity 5 defined as never given birth.
TABLE 4
Regression Models for Length of First and Second Stage
Labor and Cesarean Surgery
First Stage Labor Coefficient p
Maternal age (for each year increase) 5.83 .011
Cervical dilation (for each cm increase) 230.80 ,.001
Nulliparous (yes vs. no) 58.20 ,.001
Use of peanut ball (yes vs. no) 228.60 .053
Second Stage Labor (min) Coefficient p
Use of peanut ball (yes vs. no) 211.10 ,.001
Cesarean Surgery Odds Ratio p
Nulliparous (yes vs. no) 8.00 ,.001
Use of peanut ball (yes vs. no) 0.41 .035
shorter in the peanut ball group than in the control
group (p , .001). The percentage of labors that re-
sulted in cesarean surgery was statistically higher in
the control group. Twenty-one percent (n 5 19) of
women assigned to the control group had cesarean
surgery compared to 10% (n 5 11) of the inter-
vention group (p , .05). No significant differences
were found between the groups in the use of phar-
macological intervention (induction or augmenta-
tion by oxytocin use) and instrumental intervention
(forceps or vacuum use).
Multiple regression analysis was used to deter-
mine independent predictors of first stage length of
labor, second stage length of labor, and spontaneous
vaginal birth. Univariate analysis was conducted on
each outcome with all predictors. Predictors with a
p , .10 were selected to be entered into regression
models (Table 3). Because significant differences
were found in nulliparity and cervical dilation be-
tween the groups, both predictors were entered into
each regression model and a stepwise method was
used to determine the final models. The final models
contained only those predictors that remained in the
model with a p , .05.
Linear regression models were used to determine
significant predictors, including use of the peanut
ball, on the length of first and second stage labor, and
logistic regression modeling was conducted for the
cesarean surgery outcome (Table 4). Linear regression
models revealed that time of the first stage of labor
was significantly independently predicted by maternal
age, nulliparity, and cervical dilation. In this model,
when controlling for these significant predictors of
length of first stage labor, the peanut ball approached
significance (p 5 .053). Use of the peanut ball would
decrease the first stage of labor by 29 min, which
could be considered a clinically significant result. In
a model assessing second stage labor, use of the pea-
nut ball was the only significant predictor, decreasing
labor time by 11 min (p , .001). In a model assess-
ing mode of birth, adjusting for nulliparity, women
in the peanut ball group were less than half as likely
(OR 5 0.41, p 5 .04) to undergo cesarean surgery.
DISCUSSION
The purpose of this study was to compare labor
times and mode of birth between laboring women
with an epidural who used a peanut ball and those
who did not. Results showed that women using the
peanut ball during labor had a significantly shorter
length of second stage labor. In addition, the cesar-
ean rate for those that used the peanut ball was sta-
tistically lower than those women who did not use
the peanut ball. Pharmacologic (induction and aug-
mentation) and instrument (forceps and vacuum)
intervention were lower in the peanut ball interven-
tion group, but the difference was not statistically
significant. Although randomization resulted in dif-
ferences in the parity and cervical dilation between
the two groups, additional analyses showed that the
peanut ball is still a significant predictor for nullipa-
rous women for length of second stage of labor and
Copyright © Springer Publishing Company, LLC
22 The Journal of Perinatal Education | Winter 2015, Volume 24, Number 1
ball intervention controlling for their effects. As an
exploratory study into the effectiveness of the pea-
nut ball, it is evident that future research should
assess the many more potential confounders for
failure of labor to progress. For example, recent re-
search on obesity and birth outcomes has demon-
strated that obese nulliparous women undergoing
labor induction were at increased risk for increased
labor time and cesarean surgery (Green & Shaker,
2011; Nuthalapaty, Rouse, & Owen, 2004). Stud-
ies assessing the use of the peanut ball in a high-
risk group would be useful in determining its
effectiveness.
The peanut ball was well received by patients, who
expressed satisfaction with a noninvasive, nonphar-
macologic intervention that did not cause discom-
fort and could potentially prevent complications.
After completion of the study, a practice change was
implemented to offer all laboring women with an
epidural the use of a peanut ball, and providers and
staff readily adopted the change.
Limitations
The study was limited to a single facility in the
Southwest. Although the study measured specific
labor outcomes, it did not control for all factors
that could potentially influence these outcomes.
Practice variation with physicians and nurses was
not tightly controlled; that is, patients and practi-
tioners were still given the option of when to ac-
tively push based on patient’s desire, fetal heart rate
tracing, and physician’s order. Additional analysis
was needed to control for differences between the
groups. The study did not monitor the total length
of time a woman sat in an upright position (head
of bed up greater than 45°) versus women in a re-
cumbent position; however, there is insufficient
data on which position for practitioners to recom-
mend for second stage labor for women with an
epidural (Kemp, Kingswood, Kibuka, & Thornton,
2013). In future studies, cervical dilation at time of
placement of the epidural and multiparity should
be controlled/randomly assigned to the interven-
tion and control groups.
A potential benefit was found in using this non-
pharmacologic intervention to improve the like-
lihood of a woman having progression of labor, a
vaginal birth, and reducing complications during
childbirth. However, any intervention to prog-
ress labor should be used with caution for women
who require Group B streptococcal prophylaxis
because antibiotic infusion is recommended to be
vaginal birth and approached significance for first
stage labor length.
Because limited research is available on the use
of exercise or peanut balls with women with an epi-
dural, the research question was generated from a
growing trend in hospital labor and birth units to use
such balls. Epidural analgesia relaxes the pelvic floor
muscles, which may delay the rotation of the fetal
head, engender a weakened desire to push because of
diminution of the bearing down reflex, and reduce
uterine activity (Mayberry et al., 1999). Lieberman
& O’Donoghue (2002) found that epidural analgesia
was associated with persistent occiput posterior po-
sition at birth, which plays a role with increasing risk
of operative birth. The duration of the active phase
of labor before 6 cm dilation is longer in women
undergoing induction (Zhang, Troendle, & Yancey,
2002). Most inductions are performed on patients
before 6 cm, and in this study, 4 cm was the median
exam at the time the epidural was received. In ad-
dition, upright positioning in combination with the
peanut ball can potentially optimize gravity and pel-
vic widening; when the woman leans forward in a
“C-curve” position, the sacrum and coccyx are free
to move back, thus increasing the anterior-posterior
diameter of the pelvis (Zwelling, 2010).
Although the sample size was small and not all
potential confounders were measured, findings sug-
gest that the peanut ball can be an effective clinical
intervention in saving time pushing and reducing
the cesarean surgery rate, particularly in women
who have not previously had children. In both the
peanut ball and control group, the primary reason
for cesarean surgery in the study included diagno-
sis of failure to progress or fetal intolerance to labor.
Because 90% of cesarean surgeries result in sub-
sequent repeat cesareans for future births (Spong
et al., 2012), the peanut ball can be particularly use-
ful in helping nulliparous women avoid a primary
cesarean.
Despite randomization, some demographic
characteristics were unequally distributed and in-
fluential in the length of labor or outcome, and ad-
ditional analysis was needed to assess the peanut
The peanut ball was well received by patients, who expressed
satisfaction with a noninvasive, nonpharmacologic intervention
that did not cause discomfort and could potentially prevent
complications.
Copyright © Springer Publishing Company, LLC
Peanut Ball for Laboring Women | Tussey et al. 23
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Implications for Practice and Recommendations
for Future Research
The findings from this study demonstrate the poten-
tial of the peanut ball to reduce length of labor and
promote spontaneous vaginal birth. Future research
should address the effectiveness of the peanut ball
with a larger sample controlling for more potential
confounders. However, as a low-risk, low-cost nurs-
ing intervention, the peanut ball can be introduced
to women to promote positive labor outcomes. In-
tegration of the use of a peanut ball can begin with
childbirth educators demonstrating the peanut ball
to participants of childbirth classes; nurses in labor
and birth units can include the peanut ball use in ba-
sic labor management classes in nursing orientation.
The peanut ball has the potential to help decrease
the length of second stage labor and provide a suc-
cessful vaginal birth. Of U.S. women who require a
primary cesarean surgery, more than 90% will have
a subsequent repeat cesarean. The peanut ball pro-
vides an option for reducing the risks associated
the primary cesarean surgery and implications for
subsequent pregnancies.
CONCLUSION
This study provides evidence that laboring women
with an epidural who use a peanut-shaped exercise
ball, compared to women who did not, had signifi-
cantly shorter length of labor and a higher likelihood
of spontaneous vaginal birth. In addition, no harm-
ful effects were identified to the mother or the fetus/
newborn. The researchers think that these changes
are likely attributed to the potential opening of the
pelvic outlet; however, more research is needed on
the peanut ball as a nonpharmacologic intervention.
The study hospital, which is part of a larger
health system, implemented the use of the peanut
ball to all laboring women with an epidural after
the study was completed. In conjunction with other
efforts, the hospital’s outcomes resulted in system-
wide implementation of the peanut ball in all labor
and birth units.
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