Upright and Squatting Positions During Labor: Effects on Birth Outcomes, Maternal Satisfaction, and Birth Trauma Perception in Multiparous Women

Upright and Squatting Positions During Labor: Effects on Birth Outcomes, Maternal Satisfaction, and Birth Trauma Perception in Multiparous Women | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Upright and Squatting Positions During Labor: Effects on Birth Outcomes, Maternal Satisfaction, and Birth Trauma Perception in Multiparous Women Aylin UCA, Nilgün AVCI This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8774633/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Maternal position during labor is a key non-pharmacological strategy that supports physiological birth and women’s active participation in the childbirth process. Although upright positions have been associated with favorable labor outcomes compared with supine positions, evidence directly comparing different upright positions—particularly in relation to maternal birth experience and perceived traumatic birth—remains limited. Objective This study aimed to compare the effects of standing and squatting positions during the first stage of labor on the birth process, birth comfort, pain intensity, and perceived traumatic birth experience among multiparous women. Methods This study was conducted using a comparative interventional design. A total of 82 multiparous women were included and allocated to either the standing group (n = 41) or the squatting group (n = 41) during labor. Data were collected using a personal information form, the Visual Analog Scale (VAS) for pain, the Labor Comfort Scale, and the Traumatic Birth Perception Scale. Outcomes were assessed during labor and within the first two hours postpartum. Statistical analyses included comparative and correlation analyses. Results No statistically significant differences were found between the standing and squatting groups in terms of labor duration, pain intensity, frequency of position preference, time spent in the position, birth comfort scores, or perceived traumatic birth levels (p > 0.05). However, in the squatting group, perceived traumatic birth was strongly and negatively correlated with overall birth comfort and all comfort subdimensions (p < 0.01), whereas no significant correlation was observed in the standing group. Conclusion Standing and squatting positions during the first stage of labor yield comparable physiological and clinical outcomes among multiparous women. Nevertheless, the strong association between birth comfort and perceived traumatic birth in the squatting group suggests that qualitative aspects of the birth experience may be influenced by the type of upright position adopted. These findings highlight the importance of offering women freedom of movement and individualized position choices during labor to support a positive childbirth experience. Trial registration: Retrospectively registered (NCT07383181) Address: Graduate Education Institute Midwifery Thesis Master’s Program Biruni University Istanbul Turkey Figures Figure 1 Introduction Position changes during labor are recognized as non-pharmacological relaxation methods that support women’s active participation in the childbirth process. Particularly during the first stage of labor, maternal position and mobility play a critical role in shaping both physiological birth outcomes and women’s subjective birth experiences. Adoption of upright positions during labor has been reported to result in more effective uterine contractions, reduced pain perception, shorter labor duration, fewer medical interventions, increased comfort, and enhanced progression of labor compared with horizontal positions, thereby contributing to higher maternal satisfaction and a more positive birth experience [ 1 – 8 ]. Upright positions include standing, squatting, kneeling, sitting, and hands-and-knees positions, and are distinguished from horizontal positions such as supine, lithotomy, and lateral postures [ 6 , 7 ]. Maternal satisfaction during childbirth is largely associated with women’s perceived comfort, the level of emotional support received, and the extent to which active participation in the birth process is facilitated. Midwifery support provided during labor enhances maternal comfort, satisfaction, and emotional well-being by helping women cope with pain, make informed decisions, and actively engage in the childbirth process [ 7 , 9 – 11 ]. High levels of birth satisfaction have been shown to positively affect maternal psychological well-being in the postpartum period, reduce stress levels, and decrease the risk of postpartum depression [ 12 , 13 ]. Another important dimension of the childbirth experience is the perception of postpartum birth trauma. Birth trauma is defined as an individualized experience arising from events and interactions related to childbirth that may lead to distressing emotional responses and result in short- or long-term negative effects on women’s physical and mental health [ 14 ]. Perceived birth trauma is influenced by factors such as intense pain during labor, feelings of loss of control, unmet expectations, and inadequate support, as well as individual, social, and cultural characteristics [ 15 – 20 ]. Respecting women’s birth preferences, supporting freedom of movement, and enabling women to choose comfortable positions during labor are emphasized as protective approaches against traumatic birth perceptions [ 17 , 20 ]. Although the beneficial effects of upright positions during the first stage of labor on physiological birth outcomes and maternal satisfaction are well documented, evidence examining their relationship with perceived birth trauma, particularly among multiparous women, remains limited. Moreover, most existing studies have compared upright positions with control groups or horizontal positions, whereas research directly comparing the effects of two different upright positions on the labor process and childbirth experience is scarce. Methods Study Design and Aim This randomized comparative interventional study was conducted to examine the effects of standing and squatting positions during labor on birth outcomes, maternal satisfaction, and perceived birth trauma among multiparous women. Setting and Period The study was carried out between June and November 2025 in the delivery unit of a public maternity hospital in Istanbul/Turkey with a high volume of vaginal births. The study population consisted of multiparous women admitted to the delivery unit during the study period. Population and Sample Sample size was calculated using G*Power 3.1, based on a previous interventional study reporting an effect size of 1.52 [ 8 ]. With a significance level of α = 0.05 and power of 95%, a minimum of 74 participants was required. Considering a potential 10% attrition rate, the final sample included 82 multiparous women, with 41 participants in each group. Inclusion and Exclusion Criteria Women were eligible if they were ≥ 18 years old, at 38–42 weeks of gestation, had a singleton pregnancy with cephalic presentation, cervical dilatation ≥ 4 cm, were multiparous, and agreed to participate. Women with multiple pregnancies, presentation anomalies, or high-risk conditions (e.g., preeclampsia, gestational diabetes, placenta-related complications, fetal distress, or fetal anomalies) were excluded. Research Hypotheses H1 Standing and squatting positions during labor differ in their effects on the birth process, maternal satisfaction, and perceived birth trauma among multiparous women. H1a Standing and squatting positions differ in terms of total labor and birth duration. H1b Standing and squatting positions differ in terms of maternal birth satisfaction. H1c Standing and squatting positions differ in terms of perceived birth trauma. Data Collection Instruments Data were collected using a Personal Information Form, the Childbirth Comfort Scale, and the Traumatic Birth Perception Scale. Personal Information Form : The form was developed by the researchers and included questions on women’s sociodemographic and obstetric characteristics , as well as labor-related information at admission , data on obstetric interventions , and pain intensity monitoring using the Visual Analog Scale. Childbirth Comfort Scale : The scale was originally developed by Kerri Durnell Schuiling (2003) and its Turkish validity and reliability were established by Coskuner Potur et al. (2015) . The scale is a five-point Likert-type instrument consisting of nine items and includes three subdimensions: physical, environmental , and psychospiritual comfort. Items 5, 7, and 8 are reverse scored. Total scores range from 9 to 45 , with higher scores indicating a higher level of childbirth comfort . The Cronbach’s alpha coefficient of the scale was reported as 0.75 [ 10 ]. Traumatic Birth Perception Scale : The scale was developed by Yalnız et al. (2016) to assess women’s perceptions of childbirth-related trauma. The scale consists of 13 items , each rated on a scale from 0 (positive perception) to 10 (negative perception). Total scores range from 0 to 130 , with higher scores indicating a greater level of perceived traumatic birth experience . According to the scoring system, total scores of 0–26 indicate very low, 27–52 low, 53–78 moderate, 79–104 high, and 105–130 very high levels of perceived birth trauma. The scale demonstrated high internal consistency, with a Cronbach’s alpha coefficient of 0.89 [ 21 ]. Randomization and Intervention Participants were randomly assigned to either the standing group or the squatting group using an online randomization tool ( https://randomizer.org/ ). All participants received routine obstetric care according to institutional protocols following admission to the delivery unit. Eligible women who consented to participate were randomly assigned to either the standing group or the squatting group. In the standing group, women were encouraged to remain standing or walk during contraction-related pain episodes throughout labor. The frequency and duration of standing during contractions were recorded hourly by the researcher. Following each pain episode, women’s mobility and positioning weren’t restricted, and they were allowed to rest, walk, or remain standing according to their preference, while routine obstetric care was maintained. In the squatting group, in addition to routine mobilization, women were encouraged to assume the squatting position during contractions. Squatting was supported using a birthing ball or bed rails according to the woman’s preference. The frequency and duration of squatting during contractions were recorded hourly. After each pain episode, women were free to adopt any position of their choice as part of routine clinical care, without restriction. In both groups, pain intensity was assessed hourly using the VAS. Throughout the intervention period, standard obstetric monitoring, medical management, and midwifery care were continued in accordance with routine clinical practice. Postpartum outcomes, including total labor duration, birth duration, perineal trauma, and episiotomy requirement, were recorded. Maternal comfort and perceived birth trauma were assessed at the second postpartum hour. This timing ensured that data collection was completed before environmental changes associated with ward transfer, allowing women to report their childbirth-related perceptions in a stable and standardized setting following initial postpartum care. Outcome Measures Primary outcomes included total labor duration, total birth duration, perineal trauma, and episiotomy requirement. Secondary outcomes were maternal comfort and perceived birth trauma. Statistical Analysis Data were analyzed using Statistical Package for the Social Sciences version 22.0. Descriptive statistics were presented as numbers, percentages, means, and standard deviations. Normality was assessed using skewness and kurtosis values. Group comparisons were performed using Chi-square or Fisher’s exact tests for categorical variables and independent samples t-tests for continuous variables. Within-group comparisons were conducted using paired t-tests. Statistical significance was set at p < 0.05. Ethical Considerations Ethical approval was obtained from the Clinical Research Ethics Committee of X University (Protocol No: 25–26; Date: 08 April 2025). Institutional permission has been obtained from the relevant hospital. Written informed consent was obtained from all participants, and confidentiality was strictly maintained. Permission to use the measurement scales was obtained from the original authors. The study was conducted in accordance with the principles of the Declaration of Helsinki. Results A total of 82 multiparous women were included in the study, with 41 participants allocated to each of the standing and squatting groups. No statistically significant differences were observed between the groups in terms of age, educational level, marital status, obstetric history or clinical characteristics at admission to the delivery unit (p>0.05, Table 1). During labor, VAS pain scores measured at admission and throughout the follow-up period were comparable between the groups, with no statistically significant differences observed (p>0.05). VAS pain scores demonstrated a wide range in both groups throughout labor (min-max: 4–10). Similarly, no significant difference was found between the groups in terms of the number of positions preferred during pain episodes (p>0.05); the mean number of position preferences was 11.93±13.91 in the standing group and 8.46±7.29 in the squatting group. There was also no statistically significant difference between the groups regarding position duration (p > 0.05); the mean total time spent in the position was 409.83±457.06 seconds in the standing group and 299.34±250.25 seconds in the squatting group. Position durations showed a wide distribution in both groups (min–max: 30–2355 seconds). No statistically significant differences were observed between the standing and squatting groups in terms of total scores or categorical levels of the Traumatic Birth Perception Scale (p>0.05). Likewise, total scores and subscale scores (physical, environmental, and psychospiritual comfort) of the Childbirth Comfort Scale did not differ significantly between the groups (p>0.05, Table 2). Correlation analysis revealed strong and significant negative associations between perceived birth trauma and total childbirth comfort scores, as well as all comfort subscales, in the squatting group (p<0.01). In contrast, no statistically significant association was found between perceived birth trauma and childbirth comfort in the standing group. Discussion This study is among the limited number of investigations that directly compare the effects of two different upright positions—standing and squatting—during labor on the birth process, birth comfort, and perceived traumatic birth experience among multiparous women. The majority of previous studies examining maternal positions during the first stage of labor have focused on comparisons between upright and horizontal or supine positions, while largely overlooking differences among upright positions themselves [ 2 , 6 , 22 – 28 ]. In the present study, the absence of significant differences between standing and squatting positions in terms of labor progress, pain intensity, frequency of position preference, and duration of time spent in the preferred position suggests that these two upright positions may exert their effects through similar physiological mechanisms [ 6 , 23 , 25 , 26 ]. These findings indicate that neither standing nor squatting confers superiority over the other in reducing pain intensity and support the notion that pain perception during labor is not determined solely by maternal position, but rather shaped by multiple interacting factors, including contraction intensity, individual pain thresholds, and the physiological progression of labor [ 26 , 29 ]. Consistent with the literature, evidence directly comparing different upright positions remains limited, as most studies have focused on upright versus supine comparisons [ 22 – 26 ]. Despite similar physiological and clinical outcomes across groups, the strong association observed between perceived traumatic birth and birth comfort in the squatting group suggests that qualitative dimensions of the birth experience may be influenced by the nature of the position adopted. This finding highlights the importance of evaluating upright positions not only in terms of effectiveness, but also in terms of how they shape women’s subjective birth experiences, thereby contributing original evidence to a limited body of literature [ 5 , 7 , 22 , 23 , 25 , 26 , 29 ]. In line with the World Health Organization framework for a positive childbirth experience, birth comfort and satisfaction are shaped by a sense of control, supportive care, freedom of movement, and women’s active participation in the birth process rather than by position alone [ 6 , 9 ]. From this perspective, squatting may have contributed to reduced traumatic perception and enhanced comfort by facilitating pelvic opening and promoting greater bodily engagement and perceived control during labor [ 2 , 7 , 22 ]. However, this effect appears to arise not as an absolute advantage over standing, but through an interaction with women’s momentary needs and subjective perceptions [ 23 ]. From a clinical standpoint, these findings underscore the importance of adopting a woman-centered approach in midwifery care that prioritizes mobility and freedom of position rather than prescribing a specific posture during labor. Offering upright positions such as standing and squatting as complementary and supportive options, tailored to women’s preferences and comfort, may represent a valuable clinical strategy to enhance birth comfort and mitigate traumatic birth perceptions [ 7 , 22 , 23 ]. Limitations and Strengths This study has several limitations. Its single-center design may limit the generalizability of the findings. In addition, the inclusion of only multiparous women restricts the applicability of the results to nulliparous populations. Nevertheless, the direct comparison of two upright positions during the first stage of labor represents an original contribution to the limited existing literature. The homogeneity of the groups in terms of sociodemographic and obstetric characteristics strengthened the internal validity of the study by enabling a more unbiased assessment of positional effects. Furthermore, the simultaneous evaluation of perceived traumatic birth and birth comfort, which are subjective yet clinically meaningful outcomes, constitutes an important strength by capturing the multidimensional nature of the childbirth experience. In this respect, the study emphasizes that upright positions during the first stage of labor should be considered not only through a “upright–supine” framework, but also by acknowledging the diversity among upright positions themselves. Abbreviations VAS Visual Analog Scale Declarations Ethics approval and consent to participate: Ethical approval for this study was obtained from the Clinical Research Ethics Committee of Istinye University (Protocol No: 25-26; Date: 08 April 2025). Institutional permission was obtained from the relevant hospital. Written informed consent was obtained from all participants prior to participation. The study was conducted in accordance with the principles of the Declaration of Helsinki.This randomized controlled trial was registered at ClinicalTrials.gov (Identifier: NCT07383181, Registration Date: 14 January 2026). Consent for publication: Not applicable. Availability of data and materials: The datasets generated and/or analyzed during the current study are not publicly available due to ethical and privacy considerations related to childbirth data but are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors' contributions: AU and NA were involved in the conception of the study. AU and NA contributed to the study design. Data collection and acquisition were performed by AU. Statistical analysis was conducted by AU and NA. NA contributed to revising the manuscript for intellectual content. All authors read and approved the final manuscript and agreed to be accountable for all aspects of the work. Acknowledgements: This study was conducted as part of a master’s thesis in midwifery. The authors sincerely thank all the pregnant women who voluntarily participated in this study, as well as the healthcare staff of the participating hospital for their support during data collection. References Jowitt M. Electronic fetal monitoring is more important than freedom of maternal position in labour: AGAINST: A biomechanical model of labour suggests that maternal freedom of movement is critical for a good birth. BJOG. 2018;125(7):894. 10.1111/1471-0528.15026 . Priddis HS, Keedle H, Dahlen H. The perfect storm of trauma: The experiences of women who have experienced birth trauma and subsequently accessed residential parenting services in Australia. Women Birth. 2018;31(1):17–24. 10.1016/j.wombi.2017.06.007 . Mirzakhani K, Karimi FZ, Mohamadzadeh Vatanchi A, Feroz Zaidi F, Mirzaei Najmabadi K. The effect of maternal position on maternal, fetal and neonatal outcomes: a systematic review. J Midwifery Reprod Health. 2020;8(1):1988–2004. 10.22038/jmrh.2019.38133.1423 . Fox D, Maude R, Coddington R, Woodworth R, Scarf V, Watson K, Foureur M. The use of continuous fetal monitoring technologies that enable mobility in labour for women with complex pregnancies: A survey of Australian and New Zealand hospitals. Midwifery. 2021;93:102887. 10.1016/j.midw.2020.102887 . Grenvik JM, Rosenthal E, Wey S, Saccone G, De Vivo V, De Prisco LCPA, Delgado García BE, Berghella V. Birthing ball for reducing labor pain: A systematic review and meta-analysis of randomized controlled trials. J Matern Fetal Neonatal Med. 2022;35(25):5184–93. 10.1080/14767058.2021.1875439 . Imaniar MS, Nurhikmah TS, Laksmining S, Rahmatul S. Effect of upright position on pain and duration of the active phase of the first stage of labor among women in labor in the work area of Tasikmalaya TPMB. Embrio J Kebidanan. 2023;15(1):21–7. 10.36456/embrio.v15i1.6758 . Rose Prasad I, Awasthi P. Effectiveness of squatting position on the duration of labor and maternal satisfaction among primi gravida mothers: A mixed method approach. Int J Nurs Res. 2023;9(2):57–62. 10.31690/ijnr.2023.v09i02.010 . Kaçar N. Evaluation of the effect of sling and swing positions to pregnant women in labour on the labour process and birth outcomes [doctoral dissertation]. Eskişehir: Eskişehir Osmangazi University, Institute of Health Sciences; 2024. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2013;7CD003766. 10.1002/14651858.CD003766.pub5 . Coskuner Potur D, Dogan Merih Y, Kulek H, Can Gurkan O. The validity and reliability of the Turkish version of the Childbirth Comfort Questionnaire. J Anatolia Nurs Health Sci. 2015;18(4):252–8. Fathi Najafi T, Latifnejad Roudsari R, Ebrahimipour H. The best encouraging persons in labor: A content analysis of Iranian mothers' experiences of labor support. PLoS ONE. 2017;12(7):e0179702. 10.1371/journal.pone.0179702 . Bossano CM, Townsend KM, Walton AC, Blomquist JL, Handa VL. The maternal childbirth experience more than a decade after delivery. Am J Obstet Gynecol. 2017;217(3):e3421–8. 10.1016/j.ajog.2017.04.027 . Balcik Colak M, Akin B, Kalkan SC, Uslu Yuvaci H. Effects of labor support on pregnant women's childbirth comfort, satisfaction and postpartum comfort levels: A randomized controlled trial. BMC Pregnancy Childbirth. 2025;25(1):789. 10.1186/s12884-025-07904-6 . Leinweber J, Fontein-Kuipers Y, Karlsdottir SI, Ekström-Bergström A, Nilsson C, Stramrood C, Thomson G. Developing a woman-centered, inclusive definition of positive childbirth experiences: A discussion paper. Birth. 2023;50(2):362–383. 10.1111/birt.12666 Elmir R, Schmied V, Wilkes L, Jackson D. Women’s perceptions and experiences of a traumatic birth: A meta-ethnography. J Adv Nurs. 2010;66(10):2142–53. 10.1111/j.1365-2648.2010.05391.x . Gokce Isbir G, Inci F. Traumatic childbirth and nursing approaches. J Womens Health Nurs (JOWHEN). 2016;1(1):29–40. Heim MA, Makuch MY. Pregnant women’s knowledge of non-pharmacological techniques for pain relief during childbirth. Eur J Midwifery. 2022;6:5. 10.18332/ejm/145235 . Heim MA, Makuch MY. Pregnant women's knowledge of non-pharmacological techniques for pain relief during childbirth. Eur J midwifery. 2022;6:5. https://doi.org/10.18332/ejm/145235 . Mucuk O, Ozkan H. Perception of traumatic childbirth of women and factors affecting. J Basic Clin Health Sci. 2022;6(2):608–16. 10.30621/jbachs.1001319 . Nagle U, Naughton S, Ayers S, Cooley S, Duffy RM, Dikmen-Yildiz P. A survey of perceived traumatic birth experiences in an Irish maternity sample: prevalence, risk factors and follow up. Midwifery. 2022;113:103419. 10.1016/j.midw.2022.103419 . Aksu DF, Serçekuş P. Traumatic childbirth experiences, effects and coping: A qualitative study. Sex Reprod Healthc. 2023;37:100898. 10.1016/j.srhc.2023.100898 . Yalnız H, Canan F, Genç RE, Kuloğlu MM, Geçici Ö. Development of a scale of traumatic childbirth perception. Turk Med J. 2016;8(3):81–8. Souza JP, Miquelutti MA, Cecatti JG, Makuch MY. Maternal position during the first stage of labor: A systematic review. Reprod Health. 2006;3:10. 10.1186/1742-4755-3-10 . Lawrence A, Lewis L, Hofmeyr GJ, Styles C. Maternal positions and mobility during first stage labour. Cochrane Database Syst Rev. 2013;10CD003934. 10.1002/14651858.CD003934.pub4 . Akin B, Sogukpinar N, Akman L, Yavuzsen HT. Evaluation of the effects of maternal mobilization on mode of birth and newborn health status in the first phase of birth. Gumushane Univ J Health Sci. 2017;6(2):33–41. Emam AMM, Al-Zahrani AE. Upright versus recumbent position during first stage of labor among primipara women on labor outcomes. J Nurs Educ Pract. 2018;8(7):113. 10.5430/jnep.v8n7p113 . Ibrahim HAF, Said HII, Elgzar WTI. Effect of upright and ambulant positions versus supine during the active first stage of labor on birth outcomes among nulliparous women: Randomized controlled clinical trial. Front Nurs. 2020;7(3):239–48. 10.2478/fon-2020-0035 . Humphries A, Thompson JMD, Stone P, Mirjalili SA. The effect of positioning on maternal anatomy and hemodynamics during late pregnancy. Clin Anat. 2020;33(6):943–9. 10.1002/ca.23614 . Jani D, Clark A, Couper S, Thompson JMD, David AL, Melbourne A, Mirjalili A, Lydon AM, Stone PR. The effect of maternal position on placental blood flow and fetoplacental oxygenation in late gestation fetal growth restriction: A magnetic resonance imaging study. J Physiol. 2023;601(23):5391–411. 10.1113/JP284269 . Simpson M, Catling C. Understanding psychological traumatic birth experiences: A literature review. Women Birth. 2016;29(3):203–7. 10.1016/j.wombi.2015.10.009 . Tables Tables are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 10 Mar, 2026 Reviews received at journal 05 Mar, 2026 Reviewers agreed at journal 05 Mar, 2026 Reviews received at journal 03 Mar, 2026 Reviewers agreed at journal 02 Mar, 2026 Reviewers invited by journal 24 Feb, 2026 Editor invited by journal 09 Feb, 2026 Editor assigned by journal 05 Feb, 2026 Submission checks completed at journal 05 Feb, 2026 First submitted to journal 03 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8774633","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":596725722,"identity":"890cc90b-a41b-4e26-af25-d9b644b4cd5b","order_by":0,"name":"Aylin UCA","email":"","orcid":"","institution":"Biruni University","correspondingAuthor":false,"prefix":"","firstName":"Aylin","middleName":"","lastName":"UCA","suffix":""},{"id":596725724,"identity":"3bbd2ea8-02ee-43f0-9653-66298be42da7","order_by":1,"name":"Nilgün AVCI","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFUlEQVRIie3RMUvDQBTA8XcEkuWijgdK/QpPOpRSJV/ljoAugk7FsXLwpkLXOPgdHB0jN2QJde2YIriIELcOKXi1tiokcRW8/3QP8uPCPQCX6y/meaPPE7suJABfD34bYVuiUQJ+Ed5otgR8AYCbczPpBUy/hPdwiJmhq6KqDnoiTqEcGoj201rS14wGYQ5Hd7mimSLk/eRUsmRqgO/IWoKGUTckYDcJs2SEHGfn6IVkScOfbUi0IpeyWpGL0lu2E/1kiZoIRiD9j1vsM/5yC7slEU+40kJRl2P+jA/j6RnneQN5NKZ8peMTCrL526LqRJjF82IxHHSCcT2B9TrEt3lPQgptm7T7L3/Ou2nLxy6Xy/Ufewfq/VgF9nqxLQAAAABJRU5ErkJggg==","orcid":"","institution":"Istinye Unıversity","correspondingAuthor":true,"prefix":"","firstName":"Nilgün","middleName":"","lastName":"AVCI","suffix":""}],"badges":[],"createdAt":"2026-02-03 10:59:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8774633/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8774633/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103627831,"identity":"de830198-7888-41e6-8a29-72f6bf347afe","added_by":"auto","created_at":"2026-02-27 21:22:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":171527,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8774633/v1/8851fe0563e900d91e7d40fd.png"},{"id":105562596,"identity":"cd496bcd-3ca5-40b3-8c27-a7350a72a081","added_by":"auto","created_at":"2026-03-27 12:43:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1076796,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8774633/v1/c0730c00-67c6-46b2-959b-c51d19c6c552.pdf"},{"id":103627832,"identity":"9891e59d-1dc8-4117-84ca-7539301e6d91","added_by":"auto","created_at":"2026-02-27 21:22:47","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":18249,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-8774633/v1/5ae5e9eb32f5d9de9bcbd75f.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Upright and Squatting Positions During Labor: Effects on Birth Outcomes, Maternal Satisfaction, and Birth Trauma Perception in Multiparous Women","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePosition changes during labor are recognized as non-pharmacological relaxation methods that support women\u0026rsquo;s active participation in the childbirth process. Particularly during the first stage of labor, maternal position and mobility play a critical role in shaping both physiological birth outcomes and women\u0026rsquo;s subjective birth experiences. Adoption of upright positions during labor has been reported to result in more effective uterine contractions, reduced pain perception, shorter labor duration, fewer medical interventions, increased comfort, and enhanced progression of labor compared with horizontal positions, thereby contributing to higher maternal satisfaction and a more positive birth experience [\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Upright positions include standing, squatting, kneeling, sitting, and hands-and-knees positions, and are distinguished from horizontal positions such as supine, lithotomy, and lateral postures [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMaternal satisfaction during childbirth is largely associated with women\u0026rsquo;s perceived comfort, the level of emotional support received, and the extent to which active participation in the birth process is facilitated. Midwifery support provided during labor enhances maternal comfort, satisfaction, and emotional well-being by helping women cope with pain, make informed decisions, and actively engage in the childbirth process [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. High levels of birth satisfaction have been shown to positively affect maternal psychological well-being in the postpartum period, reduce stress levels, and decrease the risk of postpartum depression [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnother important dimension of the childbirth experience is the perception of postpartum birth trauma. Birth trauma is defined as an individualized experience arising from events and interactions related to childbirth that may lead to distressing emotional responses and result in short- or long-term negative effects on women\u0026rsquo;s physical and mental health [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Perceived birth trauma is influenced by factors such as intense pain during labor, feelings of loss of control, unmet expectations, and inadequate support, as well as individual, social, and cultural characteristics [\u003cspan additionalcitationids=\"CR16 CR17 CR18 CR19\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Respecting women\u0026rsquo;s birth preferences, supporting freedom of movement, and enabling women to choose comfortable positions during labor are emphasized as protective approaches against traumatic birth perceptions [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough the beneficial effects of upright positions during the first stage of labor on physiological birth outcomes and maternal satisfaction are well documented, evidence examining their relationship with perceived birth trauma, particularly among multiparous women, remains limited. Moreover, most existing studies have compared upright positions with control groups or horizontal positions, whereas research directly comparing the effects of two different upright positions on the labor process and childbirth experience is scarce.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Aim\u003c/h2\u003e \u003cp\u003eThis randomized comparative interventional study was conducted to examine the effects of standing and squatting positions during labor on birth outcomes, maternal satisfaction, and perceived birth trauma among multiparous women.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSetting and Period\u003c/h3\u003e\n\u003cp\u003eThe study was carried out between June and November 2025 in the delivery unit of a public maternity hospital in Istanbul/Turkey with a high volume of vaginal births. The study population consisted of multiparous women admitted to the delivery unit during the study period.\u003c/p\u003e\n\u003ch3\u003ePopulation and Sample\u003c/h3\u003e\n\u003cp\u003eSample size was calculated using G*Power 3.1, based on a previous interventional study reporting an effect size of 1.52 [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. With a significance level of α\u0026thinsp;=\u0026thinsp;0.05 and power of 95%, a minimum of 74 participants was required. Considering a potential 10% attrition rate, the final sample included 82 multiparous women, with 41 participants in each group.\u003c/p\u003e\n\u003ch3\u003eInclusion and Exclusion Criteria\u003c/h3\u003e\n\u003cp\u003eWomen were eligible if they were \u0026ge;\u0026thinsp;18 years old, at 38\u0026ndash;42 weeks of gestation, had a singleton pregnancy with cephalic presentation, cervical dilatation\u0026thinsp;\u0026ge;\u0026thinsp;4 cm, were multiparous, and agreed to participate. Women with multiple pregnancies, presentation anomalies, or high-risk conditions (e.g., preeclampsia, gestational diabetes, placenta-related complications, fetal distress, or fetal anomalies) were excluded.\u003c/p\u003e\n\u003ch3\u003eResearch Hypotheses\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eH1\u003c/strong\u003e \u003cp\u003eStanding and squatting positions during labor differ in their effects on the birth process, maternal satisfaction, and perceived birth trauma among multiparous women.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eH1a\u003c/strong\u003e \u003cp\u003eStanding and squatting positions differ in terms of total labor and birth duration.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eH1b\u003c/strong\u003e \u003cp\u003eStanding and squatting positions differ in terms of maternal birth satisfaction.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eH1c\u003c/strong\u003e \u003cp\u003eStanding and squatting positions differ in terms of perceived birth trauma.\u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Collection Instruments\u003c/h2\u003e \u003cp\u003eData were collected using a Personal Information Form, the Childbirth Comfort Scale, and the Traumatic Birth Perception Scale.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePersonal Information Form\u003c/b\u003e: The form was developed by the researchers and included questions on women\u0026rsquo;s \u003cb\u003esociodemographic and obstetric characteristics\u003c/b\u003e, as well as \u003cb\u003elabor-related information at admission\u003c/b\u003e, data on \u003cb\u003eobstetric interventions\u003c/b\u003e, and \u003cb\u003epain intensity monitoring using the Visual Analog Scale.\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eChildbirth Comfort Scale\u003c/b\u003e: The scale was originally developed by \u003cb\u003eKerri Durnell Schuiling (2003)\u003c/b\u003e and its Turkish validity and reliability were established by Coskuner Potur \u003cb\u003eet al. (2015)\u003c/b\u003e. The scale is a \u003cb\u003efive-point Likert-type instrument\u003c/b\u003e consisting of \u003cb\u003enine items\u003c/b\u003e and includes three subdimensions: \u003cb\u003ephysical, environmental\u003c/b\u003e, and \u003cb\u003epsychospiritual\u003c/b\u003e comfort. Items \u003cb\u003e5, 7, and 8\u003c/b\u003e are reverse scored. Total scores range from \u003cb\u003e9 to 45\u003c/b\u003e, with higher scores indicating a \u003cb\u003ehigher level of childbirth comfort\u003c/b\u003e. The Cronbach\u0026rsquo;s alpha coefficient of the scale was reported as \u003cb\u003e0.75\u003c/b\u003e [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eTraumatic Birth Perception Scale\u003c/b\u003e: The scale was developed by \u003cb\u003eYalnız et al. (2016)\u003c/b\u003e to assess women\u0026rsquo;s perceptions of childbirth-related trauma. The scale consists of \u003cb\u003e13 items\u003c/b\u003e, each rated on a scale from \u003cb\u003e0 (positive perception)\u003c/b\u003e to \u003cb\u003e10 (negative perception).\u003c/b\u003e Total scores range from \u003cb\u003e0 to 130\u003c/b\u003e, with higher scores indicating a \u003cb\u003egreater level of perceived traumatic birth experience\u003c/b\u003e. According to the scoring system, total scores of \u003cb\u003e0\u0026ndash;26\u003c/b\u003e indicate very low, \u003cb\u003e27\u0026ndash;52\u003c/b\u003e low, \u003cb\u003e53\u0026ndash;78\u003c/b\u003e moderate, \u003cb\u003e79\u0026ndash;104\u003c/b\u003e high, and \u003cb\u003e105\u0026ndash;130\u003c/b\u003e very high levels of perceived birth trauma. The scale demonstrated high internal consistency, with a Cronbach\u0026rsquo;s alpha coefficient of \u003cb\u003e0.89\u003c/b\u003e [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRandomization and Intervention\u003c/h3\u003e\n\u003cp\u003eParticipants were randomly assigned to either the standing group or the squatting group using an online randomization tool (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://randomizer.org/\u003c/span\u003e\u003cspan address=\"https://randomizer.org/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). All participants received routine obstetric care according to institutional protocols following admission to the delivery unit. Eligible women who consented to participate were randomly assigned to either the standing group or the squatting group.\u003c/p\u003e \u003cp\u003eIn the standing group, women were encouraged to remain standing or walk during contraction-related pain episodes throughout labor. The frequency and duration of standing during contractions were recorded hourly by the researcher. Following each pain episode, women\u0026rsquo;s mobility and positioning weren\u0026rsquo;t restricted, and they were allowed to rest, walk, or remain standing according to their preference, while routine obstetric care was maintained.\u003c/p\u003e \u003cp\u003eIn the squatting group, in addition to routine mobilization, women were encouraged to assume the squatting position during contractions. Squatting was supported using a birthing ball or bed rails according to the woman\u0026rsquo;s preference. The frequency and duration of squatting during contractions were recorded hourly. After each pain episode, women were free to adopt any position of their choice as part of routine clinical care, without restriction.\u003c/p\u003e \u003cp\u003eIn both groups, pain intensity was assessed hourly using the VAS. Throughout the intervention period, standard obstetric monitoring, medical management, and midwifery care were continued in accordance with routine clinical practice. Postpartum outcomes, including total labor duration, birth duration, perineal trauma, and episiotomy requirement, were recorded. Maternal comfort and perceived birth trauma were assessed at the second postpartum hour. This timing ensured that data collection was completed before environmental changes associated with ward transfer, allowing women to report their childbirth-related perceptions in a stable and standardized setting following initial postpartum care.\u003c/p\u003e\n\u003ch3\u003eOutcome Measures\u003c/h3\u003e\n\u003cp\u003ePrimary outcomes included total labor duration, total birth duration, perineal trauma, and episiotomy requirement. Secondary outcomes were maternal comfort and perceived birth trauma.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eData were analyzed using Statistical Package for the Social Sciences version 22.0. Descriptive statistics were presented as numbers, percentages, means, and standard deviations. Normality was assessed using skewness and kurtosis values. Group comparisons were performed using Chi-square or Fisher\u0026rsquo;s exact tests for categorical variables and independent samples t-tests for continuous variables. Within-group comparisons were conducted using paired t-tests. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003ewas obtained from the Clinical Research Ethics Committee of X University (Protocol No: 25\u0026ndash;26; Date: 08 April 2025). Institutional permission has been obtained from the relevant hospital. Written informed consent was obtained from all participants, and confidentiality was strictly maintained. Permission to use the measurement scales was obtained from the original authors. The study was conducted in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 82 multiparous women were included in the study, with 41 participants allocated to each of the standing and squatting groups. No statistically significant differences were observed between the groups in terms of age, educational level, marital status, obstetric history or clinical characteristics at admission to the delivery unit (p\u0026gt;0.05, Table 1).\u003c/p\u003e\n\u003cp\u003eDuring labor, VAS pain scores measured at admission and throughout the follow-up period were comparable between the groups, with no statistically significant differences observed (p\u0026gt;0.05). VAS pain scores demonstrated a wide range in both groups throughout labor (min-max: 4–10). Similarly, no significant difference was found between the groups in terms of the number of positions preferred during pain episodes (p\u0026gt;0.05); the mean number of position preferences was 11.93±13.91 in the standing group and 8.46±7.29 in the squatting group. There was also no statistically significant difference between the groups regarding position duration (p \u0026gt; 0.05); the mean total time spent in the position was 409.83±457.06 seconds in the standing group and 299.34±250.25 seconds in the squatting group. Position durations showed a wide distribution in both groups (min–max: 30–2355 seconds).\u003c/p\u003e\n\u003cp\u003eNo statistically significant differences were observed between the standing and squatting groups in terms of total scores or categorical levels of the Traumatic Birth Perception Scale (p\u0026gt;0.05). Likewise, total scores and subscale scores (physical, environmental, and psychospiritual comfort) of the Childbirth Comfort Scale did not differ significantly between the groups (p\u0026gt;0.05, Table 2).\u003c/p\u003e\n\u003cp\u003eCorrelation analysis revealed strong and significant negative associations between perceived birth trauma and total childbirth comfort scores, as well as all comfort subscales, in the squatting group (p\u0026lt;0.01). In contrast, no statistically significant association was found between perceived birth trauma and childbirth comfort in the standing group.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study is among the limited number of investigations that directly compare the effects of two different upright positions\u0026mdash;standing and squatting\u0026mdash;during labor on the birth process, birth comfort, and perceived traumatic birth experience among multiparous women. The majority of previous studies examining maternal positions during the first stage of labor have focused on comparisons between upright and horizontal or supine positions, while largely overlooking differences among upright positions themselves [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23 CR24 CR25 CR26 CR27\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the present study, the absence of significant differences between standing and squatting positions in terms of labor progress, pain intensity, frequency of position preference, and duration of time spent in the preferred position suggests that these two upright positions may exert their effects through similar physiological mechanisms [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. These findings indicate that neither standing nor squatting confers superiority over the other in reducing pain intensity and support the notion that pain perception during labor is not determined solely by maternal position, but rather shaped by multiple interacting factors, including contraction intensity, individual pain thresholds, and the physiological progression of labor [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Consistent with the literature, evidence directly comparing different upright positions remains limited, as most studies have focused on upright versus supine comparisons [\u003cspan additionalcitationids=\"CR23 CR24 CR25\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite similar physiological and clinical outcomes across groups, the strong association observed between perceived traumatic birth and birth comfort in the squatting group suggests that qualitative dimensions of the birth experience may be influenced by the nature of the position adopted. This finding highlights the importance of evaluating upright positions not only in terms of effectiveness, but also in terms of how they shape women\u0026rsquo;s subjective birth experiences, thereby contributing original evidence to a limited body of literature [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In line with the World Health Organization framework for a positive childbirth experience, birth comfort and satisfaction are shaped by a sense of control, supportive care, freedom of movement, and women\u0026rsquo;s active participation in the birth process rather than by position alone [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. From this perspective, squatting may have contributed to reduced traumatic perception and enhanced comfort by facilitating pelvic opening and promoting greater bodily engagement and perceived control during labor [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. However, this effect appears to arise not as an absolute advantage over standing, but through an interaction with women\u0026rsquo;s momentary needs and subjective perceptions [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFrom a clinical standpoint, these findings underscore the importance of adopting a woman-centered approach in midwifery care that prioritizes mobility and freedom of position rather than prescribing a specific posture during labor. Offering upright positions such as standing and squatting as complementary and supportive options, tailored to women\u0026rsquo;s preferences and comfort, may represent a valuable clinical strategy to enhance birth comfort and mitigate traumatic birth perceptions [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and Strengths\u003c/h2\u003e \u003cp\u003eThis study has several limitations. Its single-center design may limit the generalizability of the findings. In addition, the inclusion of only multiparous women restricts the applicability of the results to nulliparous populations. Nevertheless, the direct comparison of two upright positions during the first stage of labor represents an original contribution to the limited existing literature. The homogeneity of the groups in terms of sociodemographic and obstetric characteristics strengthened the internal validity of the study by enabling a more unbiased assessment of positional effects. Furthermore, the simultaneous evaluation of perceived traumatic birth and birth comfort, which are subjective yet clinically meaningful outcomes, constitutes an important strength by capturing the multidimensional nature of the childbirth experience. In this respect, the study emphasizes that upright positions during the first stage of labor should be considered not only through a \u0026ldquo;upright\u0026ndash;supine\u0026rdquo; framework, but also by acknowledging the diversity among upright positions themselves.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVisual Analog Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eEthical approval for this study was obtained from the Clinical Research Ethics Committee of Istinye University (Protocol No: 25-26; Date: 08 April 2025). Institutional permission was obtained from the relevant hospital. Written informed consent was obtained from all participants prior to participation. The study was conducted in accordance with the principles of the Declaration of Helsinki.This randomized controlled trial was registered at ClinicalTrials.gov (Identifier: NCT07383181, Registration Date:\u0026nbsp;14 January 2026).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The datasets generated and/or analyzed during the current study are not publicly available due to ethical and privacy considerations related to childbirth data but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions:\u003c/strong\u003e AU and NA were involved in the conception of the study. AU and NA contributed to the study design. Data collection and acquisition were performed by AU. Statistical analysis was conducted by AU and NA. NA contributed to revising the manuscript for intellectual content. All authors read and approved the final manuscript and agreed to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e This study was conducted as part of a master’s thesis in midwifery. The authors sincerely thank all the pregnant women who voluntarily participated in this study, as well as the healthcare staff of the participating hospital for their support during data collection.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJowitt M. Electronic fetal monitoring is more important than freedom of maternal position in labour: AGAINST: A biomechanical model of labour suggests that maternal freedom of movement is critical for a good birth. BJOG. 2018;125(7):894. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/1471-0528.15026\u003c/span\u003e\u003cspan address=\"10.1111/1471-0528.15026\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePriddis HS, Keedle H, Dahlen H. The perfect storm of trauma: The experiences of women who have experienced birth trauma and subsequently accessed residential parenting services in Australia. Women Birth. 2018;31(1):17\u0026ndash;24. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.wombi.2017.06.007\u003c/span\u003e\u003cspan address=\"10.1016/j.wombi.2017.06.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMirzakhani K, Karimi FZ, Mohamadzadeh Vatanchi A, Feroz Zaidi F, Mirzaei Najmabadi K. The effect of maternal position on maternal, fetal and neonatal outcomes: a systematic review. J Midwifery Reprod Health. 2020;8(1):1988\u0026ndash;2004. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.22038/jmrh.2019.38133.1423\u003c/span\u003e\u003cspan address=\"10.22038/jmrh.2019.38133.1423\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFox D, Maude R, Coddington R, Woodworth R, Scarf V, Watson K, Foureur M. The use of continuous fetal monitoring technologies that enable mobility in labour for women with complex pregnancies: A survey of Australian and New Zealand hospitals. Midwifery. 2021;93:102887. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.midw.2020.102887\u003c/span\u003e\u003cspan address=\"10.1016/j.midw.2020.102887\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrenvik JM, Rosenthal E, Wey S, Saccone G, De Vivo V, De Prisco LCPA, Delgado Garc\u0026iacute;a BE, Berghella V. Birthing ball for reducing labor pain: A systematic review and meta-analysis of randomized controlled trials. J Matern Fetal Neonatal Med. 2022;35(25):5184\u0026ndash;93. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/14767058.2021.1875439\u003c/span\u003e\u003cspan address=\"10.1080/14767058.2021.1875439\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eImaniar MS, Nurhikmah TS, Laksmining S, Rahmatul S. Effect of upright position on pain and duration of the active phase of the first stage of labor among women in labor in the work area of Tasikmalaya TPMB. Embrio J Kebidanan. 2023;15(1):21\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.36456/embrio.v15i1.6758\u003c/span\u003e\u003cspan address=\"10.36456/embrio.v15i1.6758\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRose Prasad I, Awasthi P. Effectiveness of squatting position on the duration of labor and maternal satisfaction among primi gravida mothers: A mixed method approach. Int J Nurs Res. 2023;9(2):57\u0026ndash;62. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.31690/ijnr.2023.v09i02.010\u003c/span\u003e\u003cspan address=\"10.31690/ijnr.2023.v09i02.010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKa\u0026ccedil;ar N. \u003cem\u003eEvaluation of the effect of sling and swing positions to pregnant women in labour on the labour process and birth outcomes\u003c/em\u003e [doctoral dissertation]. Eskişehir: Eskişehir Osmangazi University, Institute of Health Sciences; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2013;7CD003766. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/14651858.CD003766.pub5\u003c/span\u003e\u003cspan address=\"10.1002/14651858.CD003766.pub5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoskuner Potur D, Dogan Merih Y, Kulek H, Can Gurkan O. The validity and reliability of the Turkish version of the Childbirth Comfort Questionnaire. J Anatolia Nurs Health Sci. 2015;18(4):252\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFathi Najafi T, Latifnejad Roudsari R, Ebrahimipour H. The best encouraging persons in labor: A content analysis of Iranian mothers' experiences of labor support. PLoS ONE. 2017;12(7):e0179702. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0179702\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0179702\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBossano CM, Townsend KM, Walton AC, Blomquist JL, Handa VL. The maternal childbirth experience more than a decade after delivery. Am J Obstet Gynecol. 2017;217(3):e3421\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ajog.2017.04.027\u003c/span\u003e\u003cspan address=\"10.1016/j.ajog.2017.04.027\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBalcik Colak M, Akin B, Kalkan SC, Uslu Yuvaci H. Effects of labor support on pregnant women's childbirth comfort, satisfaction and postpartum comfort levels: A randomized controlled trial. BMC Pregnancy Childbirth. 2025;25(1):789. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12884-025-07904-6\u003c/span\u003e\u003cspan address=\"10.1186/s12884-025-07904-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeinweber J, Fontein-Kuipers Y, Karlsdottir SI, Ekstr\u0026ouml;m-Bergstr\u0026ouml;m A, Nilsson C, Stramrood C, Thomson G. Developing a woman-centered, inclusive definition of positive childbirth experiences: A discussion paper. Birth. 2023;50(2):362\u0026ndash;383. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/birt.12666\u003c/span\u003e\u003cspan address=\"10.1111/birt.12666\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElmir R, Schmied V, Wilkes L, Jackson D. Women\u0026rsquo;s perceptions and experiences of a traumatic birth: A meta-ethnography. J Adv Nurs. 2010;66(10):2142\u0026ndash;53. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1365-2648.2010.05391.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1365-2648.2010.05391.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGokce Isbir G, Inci F. Traumatic childbirth and nursing approaches. J Womens Health Nurs (JOWHEN). 2016;1(1):29\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeim MA, Makuch MY. Pregnant women\u0026rsquo;s knowledge of non-pharmacological techniques for pain relief during childbirth. Eur J Midwifery. 2022;6:5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.18332/ejm/145235\u003c/span\u003e\u003cspan address=\"10.18332/ejm/145235\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeim MA, Makuch MY. Pregnant women's knowledge of non-pharmacological techniques for pain relief during childbirth. Eur J midwifery. 2022;6:5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.18332/ejm/145235\u003c/span\u003e\u003cspan address=\"10.18332/ejm/145235\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMucuk O, Ozkan H. Perception of traumatic childbirth of women and factors affecting. J Basic Clin Health Sci. 2022;6(2):608\u0026ndash;16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.30621/jbachs.1001319\u003c/span\u003e\u003cspan address=\"10.30621/jbachs.1001319\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNagle U, Naughton S, Ayers S, Cooley S, Duffy RM, Dikmen-Yildiz P. A survey of perceived traumatic birth experiences in an Irish maternity sample: prevalence, risk factors and follow up. Midwifery. 2022;113:103419. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.midw.2022.103419\u003c/span\u003e\u003cspan address=\"10.1016/j.midw.2022.103419\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAksu DF, Ser\u0026ccedil;ekuş P. Traumatic childbirth experiences, effects and coping: A qualitative study. Sex Reprod Healthc. 2023;37:100898. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.srhc.2023.100898\u003c/span\u003e\u003cspan address=\"10.1016/j.srhc.2023.100898\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYalnız H, Canan F, Gen\u0026ccedil; RE, Kuloğlu MM, Ge\u0026ccedil;ici \u0026Ouml;. Development of a scale of traumatic childbirth perception. Turk Med J. 2016;8(3):81\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSouza JP, Miquelutti MA, Cecatti JG, Makuch MY. Maternal position during the first stage of labor: A systematic review. Reprod Health. 2006;3:10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1742-4755-3-10\u003c/span\u003e\u003cspan address=\"10.1186/1742-4755-3-10\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLawrence A, Lewis L, Hofmeyr GJ, Styles C. Maternal positions and mobility during first stage labour. Cochrane Database Syst Rev. 2013;10CD003934. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/14651858.CD003934.pub4\u003c/span\u003e\u003cspan address=\"10.1002/14651858.CD003934.pub4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAkin B, Sogukpinar N, Akman L, Yavuzsen HT. Evaluation of the effects of maternal mobilization on mode of birth and newborn health status in the first phase of birth. Gumushane Univ J Health Sci. 2017;6(2):33\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEmam AMM, Al-Zahrani AE. Upright versus recumbent position during first stage of labor among primipara women on labor outcomes. J Nurs Educ Pract. 2018;8(7):113. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5430/jnep.v8n7p113\u003c/span\u003e\u003cspan address=\"10.5430/jnep.v8n7p113\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIbrahim HAF, Said HII, Elgzar WTI. Effect of upright and ambulant positions versus supine during the active first stage of labor on birth outcomes among nulliparous women: Randomized controlled clinical trial. Front Nurs. 2020;7(3):239\u0026ndash;48. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2478/fon-2020-0035\u003c/span\u003e\u003cspan address=\"10.2478/fon-2020-0035\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHumphries A, Thompson JMD, Stone P, Mirjalili SA. The effect of positioning on maternal anatomy and hemodynamics during late pregnancy. Clin Anat. 2020;33(6):943\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/ca.23614\u003c/span\u003e\u003cspan address=\"10.1002/ca.23614\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJani D, Clark A, Couper S, Thompson JMD, David AL, Melbourne A, Mirjalili A, Lydon AM, Stone PR. The effect of maternal position on placental blood flow and fetoplacental oxygenation in late gestation fetal growth restriction: A magnetic resonance imaging study. J Physiol. 2023;601(23):5391\u0026ndash;411. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1113/JP284269\u003c/span\u003e\u003cspan address=\"10.1113/JP284269\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSimpson M, Catling C. Understanding psychological traumatic birth experiences: A literature review. Women Birth. 2016;29(3):203\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.wombi.2015.10.009\u003c/span\u003e\u003cspan address=\"10.1016/j.wombi.2015.10.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Address: Graduate Education Institute, Midwifery Thesis Master’s Program, Biruni University, Istanbul, Turkey","lastPublishedDoi":"10.21203/rs.3.rs-8774633/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8774633/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMaternal position during labor is a key non-pharmacological strategy that supports physiological birth and women\u0026rsquo;s active participation in the childbirth process. Although upright positions have been associated with favorable labor outcomes compared with supine positions, evidence directly comparing different upright positions\u0026mdash;particularly in relation to maternal birth experience and perceived traumatic birth\u0026mdash;remains limited.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis study aimed to compare the effects of standing and squatting positions during the first stage of labor on the birth process, birth comfort, pain intensity, and perceived traumatic birth experience among multiparous women.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study was conducted using a comparative interventional design. A total of 82 multiparous women were included and allocated to either the standing group (n\u0026thinsp;=\u0026thinsp;41) or the squatting group (n\u0026thinsp;=\u0026thinsp;41) during labor. Data were collected using a personal information form, the Visual Analog Scale (VAS) for pain, the Labor Comfort Scale, and the Traumatic Birth Perception Scale. Outcomes were assessed during labor and within the first two hours postpartum. Statistical analyses included comparative and correlation analyses.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eNo statistically significant differences were found between the standing and squatting groups in terms of labor duration, pain intensity, frequency of position preference, time spent in the position, birth comfort scores, or perceived traumatic birth levels (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, in the squatting group, perceived traumatic birth was strongly and negatively correlated with overall birth comfort and all comfort subdimensions (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), whereas no significant correlation was observed in the standing group.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eStanding and squatting positions during the first stage of labor yield comparable physiological and clinical outcomes among multiparous women. Nevertheless, the strong association between birth comfort and perceived traumatic birth in the squatting group suggests that qualitative aspects of the birth experience may be influenced by the type of upright position adopted. These findings highlight the importance of offering women freedom of movement and individualized position choices during labor to support a positive childbirth experience.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e \u003cp\u003eRetrospectively registered (NCT07383181)\u003c/p\u003e","manuscriptTitle":"Upright and Squatting Positions During Labor: Effects on Birth Outcomes, Maternal Satisfaction, and Birth Trauma Perception in Multiparous Women","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-27 21:22:43","doi":"10.21203/rs.3.rs-8774633/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-10T06:28:28+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-05T21:01:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"60879102105981325594507100873251430637","date":"2026-03-05T20:24:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-03T16:34:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"130104796239815651842872565490183856383","date":"2026-03-02T18:10:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-24T19:18:56+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-09T08:24:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-05T06:14:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-05T06:10:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2026-02-03T09:50:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"81e8d490-6812-4c3c-84fe-bdddbede4f3f","owner":[],"postedDate":"February 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-18T20:23:14+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-27 21:22:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8774633","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8774633","identity":"rs-8774633","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}