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Open Access 01.12.2025 | Research

Effects of maternal positions in electronic fetal monitoring: a randomised controlled trial

verfasst von: Tuğba Yilmaz Esencan, Ayça Demir Yildirim, Ebru Sağiroğlu

Erschienen in: BMC Nursing | Ausgabe 1/2025

Abstract

Background

During electronic fetal monitoring, the positions provided to mothers by perinatal nurses and midwives are essential for ensuring maternal comfort, as well as maternal and fetal well-being. This study aimed to investigate the impact of various maternal positions during electronic fetal monitoring on maternal and fetal health.

Methods

This study was conducted in a randomized controlled trial design. The study included 240 pregnant women at 34–40 weeks of gestation. The data were collected via a descriptive form for pregnant women and a general comfort questionnaire.

Results

A statistically significant difference was found between cardiotocography monitoring positions in terms of cardiotocography duration, basal heart rate, and acceleration during cardiotocography (p < 0.05). The study indicated that the semi-Fowler position has a statistically significant effect on maternal comfort (t = 3.834, p < 0.05). It was also noted that the semi-Fowler position created a 0.911 rate of increase in general comfort.

Conclusions

The use of the semi sitting position as an alternative to the left lateral position in the clinic is worthy of recommendation, and in pregnant women with a high body mass index, the semi sitting position should be preferred during fetal monitoring. It is recommended that the semi-Fowler position be preferred for fetal monitoring in pregnant women with a high BMI, and further research should be conducted to make these positions standard in the clinic.

Clinical Study Registration

Since our research constituted a randomized controlled study, it was registered on the ClinicalTrials.gov website under ClinicalTrials ID No. NCT05863156||https://www.clinicaltrials.gov/) with the Clinical Trial Registry (30.12.2021/{1})

Trial registration

In addition, clinical trials were registered (NCT05863156||https://www.clinicaltrials.gov/) with the Clinical Trial Registry (30.12.2021/{1})).

This study was presented as an oral presentation at the 6th International Koru Pregnancy, Birth and Postpartum Congress on 27–30 April 2023.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background

Reducing maternal mortality and morbidity rates during pregnancy, as well as those of neonates, is achievable through antenatal monitoring [1]. Cardiotocography (CTG), also known as the nonstress test (NST), plays a crucial role in clinically monitoring fetal movements, assessing accelerations in the fetal heart rate (FHR), and predicting risks during pregnancy and labor [2]. CTG is an assessment tool that uses an electronic fetal monitor to record FHR data continuously for evaluating fetal health, typically starting from the 32nd week of gestation [3‐9]. This test has become almost routine in antenatal monitoring. Normal cardiotocographic parameters are recognized worldwide and have been validated. Electronic fetal monitoring (EFM) enables the assessment of fetal risk of intrauterine death or neonatal complications, facilitating close monitoring of high-risk pregnancies and the early detection of fetal hypoxia [4, 5].

CTG is widely employed globally in pregnancy and labor monitoring because of its noninvasive nature, accessibility, and user-friendliness.4 Short- or long-term changes in the fetal heart rate can be influenced by various maternal and fetal factors [4, 6]. These factors include the pregnant woman’s age, hunger state, uterine contractions, and position during CTG. Electronic fetal monitoring allows simultaneous assessment of FHR and uterine contractions, enabling early diagnosis of fetal asphyxia or ischemia and the implementation of risk mitigation measures [6]. This study focuses primarily on the effects of positioning the pregnant woman optimally during CTG.

It is recognized globally that only a limited number of positions, such as side-lying or semi sitting (semi-Fowler) positions, are commonly used during fetal monitoring [1, 8, 9]. In Turkey, pregnant women are typically placed in the left lateral position [6]. The few studies conducted in this area highlight the importance of examining different positions [1, 6, 7]. The supine position is discouraged during EFM because of reduced fetal oxygenation and an increased risk of maternal hypotension [1, 7‐9]. The recommended positions should ensure effective uterine perfusion and fetal heart rate optimization while preventing hypotension [7]. However, these recommended positions may restrict the patient’s movement and comfort [7, 8, 10]. Therefore, it is essential to explore various positions, including the right semi-Fowler, left semi-Fowler, and sitting positions, during electronic fetal monitoring to improve maternal comfort, provide choices to pregnant women, and enhance fetal well-being [10].

The American College of Obstetricians and Gynecologists (ACOG) states that electronic fetal monitoring can be conducted in the semi-Fowler position, where the individual lies on their back with their head elevated at a 30-degree angle, or in the sitting or lateral side-lying position [8, 9]. In its latest recommendation for EFM in 2015, The International Federation of Gynecology and Obstetrics (FIGO) recommends side-lying, semi-sitting and upright positions as preferable alternatives [11]. The woman’s position during EFM greatly influences the indication of fetal reactivity [4]. Few articles in the literature focus on less commonly used positions and assess the utilization and effects of right and left lateral positions, semi-Fowler positions, and sitting positions [1]. Emphasis has been placed on the need for investigations into different positions to ensure maternal comfort and maternal and fetal well-being [4, 10] Thus, this study was conducted to evaluate the impact of various positions on maternal comfort, maternal blood pressure, and fetal health during antenatal electronic fetal monitoring. In this study, the left lateral position, the position most recommended in clinical practice to optimise maternal-fetal circulation, was chosen for the control group. However, the semi-Fowler position, which is endorsed by authoritative guidelines such as ACOG and FIGO [9, 11], was also examined in the study and allowed the effects of alternative positions on maternal comfort and fetal welfare to be evaluated.

Research hypotheses

The semi-Fowler position during electronic fetal monitoring results in significantly greater maternal comfort than the left lateral and right lateral positions do.

Compared with the left lateral and right lateral positions, the semi-Fowler position results in a significantly shorter duration of cardiotocography (CTG).

Compared with the left lateral and right lateral positions, the semi-Fowler position will produce statistically significant improvements in fetal health indicators, such as fetal heart rate acceleration and fetal movements, during CTG.

Maternal systolic and diastolic blood pressure will vary significantly on the basis of maternal position during CTG, with the semi-Fowler position providing a more stable blood pressure profile than the left lateral and right lateral positions do.

Methods

Study Design

This study was conducted at the pregnancy monitoring polyclinic of an obstetric hospital in Istanbul between December 2021 and January 2023. This study employed an experimental design as a randomized controlled trial with two intervention groups and one control group to evaluate the impact on maternal and fetal health on the basis of the position of the pregnant woman during electronic fetal monitoring. The study analysis followed the Consolidated Standards of Reporting Trials (CONSORT) reporting guidelines.

Study Population: The study population consisted of 12,000 individuals registered for electronic fetal monitoring at a hospital obstetrics polyclinic in the past year. The G*Power 3.1.9.4 program was used to calculate the study sample size. The calculations indicated an effect size of d:0.5 (medium) at a confidence interval (CI) of 95%. The sample size was initially set at 210 individuals but was increased by 15% to 240 to account for potential participation refusals.

The inclusion criteria for participants were as follows: were over the age of 18, were in the late third trimester (34th-40th gestational week), had fetal biometric measurements corresponding to the 34th-40th gestational week, had a single fetus, had no maternal or fetal risk factors affecting pregnancy, had normal vital signs before the procedure, were not fasted for more than 2 h before the procedure, and agreed to the suggested position. The reason for the selection of pregnant women between the 34th and 40th weeks of gestation was that routine CTG (cardiotocography) was recommended to be performed from the 34th week onwards to monitor fetal health in line with the prenatal care guidelines of the Ministry of Health in Turkey [12]. Pregnant women who did not meet the inclusion criteria were excluded from the study. Completion of the CTG procedure in less than 20 min and incomplete data entry were set as exclusion criteria.

Randomization: Participants were assigned to the intervention and control groups via a computer-generated random sequence from random.org (www.randomizer.org). Allocation concealment was maintained by an independent researcher who was not involved in the data collection process. A total of 240 participants were randomly allocated into three groups: 60 participants in the right lateral position (Intervention 1), 60 in the semi-Fowler position (Intervention 2), and 120 in the left lateral position (Control group).

Data collection tools

Information questionnaire

This questionnaire comprises 35 items covering pregnant women’s sociodemographics; obstetric data; and vital signs (blood pressure-BP, pulse, temperature, and oxygen saturation-SPO₂) before, during, and after CTG. Fetal monitoring findings were also assessed four times during the procedure (0–5 min, 6–10 min, 11–15 min, and 16–20 min), along with the position of the pregnant woman.

General comfort questionnaire-short form (GCQ-SF)

Developed by Kolcaba in 2006, this questionnaire measures comfort across the subdimensions of relief, ease, and transcendence. It contains both positive and negative items, with negative items scored in reverse. Scores are calculated by dividing the total score by the number of items, resulting in values between 1 (low comfort) and 6 (high comfort) [13‐15].

Procedure

Electronic fetal monitoring at the hospital was performed by midwives and nurses, with each session lasting 20 min. Pregnant women were assigned numbers upon arrival, and random assignment to groups was performed with the support of an independent clinic midwife and nurse, ensuring a single-blinded design. The same midwives and nurses conducted all the procedures throughout the study.

The intervention group, comprising 120 pregnant women, was further divided into two subgroups: 60 women were assigned to the right lateral position (Intervention 1), and 60 women were assigned to the semi-Fowler position (Intervention 2). The head of the bed was raised 45° in the semi-Fowler position. The positions were explained to the participants, and vital signs were monitored at regular intervals before, during, and after the CTG procedure.

The control group, which also consisted of 120 women, adhered to the clinic’s routine practice of the left lateral position. All women in this group were placed in the left lateral position, with the remainder of the procedures conducted in the same manner as those used for the intervention groups. Researchers supervised all monitoring and follow-up assessments (Fig. 1).

Statistical analysis

Data analysis was performed via the SPSS 24.0 (IBM Statistics, PASW Inc., Chicago, IL, USA) program. The distribution of the data was examined with the Kolmogorov‒Smirnov test. Descriptive statistics are presented as numbers, percentages, means, medians, standard deviations, and minimum and maximum values. Variables were analyzed via chi-square, ANOVA, and Kruskal‒Wallis tests on the basis of their distribution. The Kruskal‒Wallis hypothesis test was used to assess differences between groups in repeated measurements. Scale scores and relationships between positions were evaluated via simple linear regression analysis. The statistical significance threshold was set at p < 0.05.

Ethical approval and informed consent

This research received approval from the clinical research ethics board of the conducting hospital (Decision No. 123; Date: 18.12.2019). Written permission was obtained for the use of the scale In this study, informed consent forms were obtained from the participants in accordance with the Declaration of Helsinki, which is a guideline for all experiments conducted on humans and/or using human data in research, and the research was carried out in accordance with the regulations.

Results

The CTG was conducted with 60 participants in the right lateral position (Intervention 1), 60 in the semi-Fowler position (Intervention 2), and 120 participants in the left lateral position (control group). Table 1 presents the correlations between CTG positions and the sociodemographic and obstetric features of pregnant women. Among the sociodemographic features, a statistically significant relationship was observed between CTG positions and place of residence, number of miscarriages, and previous CTG positions.

Table 1

Comparison of CGT positions in terms of sociodemographic and obstetric features

Variables		Right Lateral Side-Lying Position		Semi-Fowler Position		Left Lateral Side-Lying Position		Test Score	p
Variables		n	%	n	%	n	%	Test Score	p
Age (\(\:\stackrel{-}{X}\)±SD², 31.62 ± 4.46)	19–34	42	68.9	46	77.4	95	79.8	3.795**	0.391***
Age (\(\:\stackrel{-}{X}\)±SD², 31.62 ± 4.46)	35 and over	18	31.1	14	22.6	25	20.2	3.795**	0.391***
BMI³	18 and below (underweight)	-	-	-	-	-	-	1.104**	0.899*
	19–24 (normal)	15	26.2	20	32.3	31	26.1
	25–29 (overweight)	32	52.5	27	45.2	62	51.3
	30 and over (obese)	13	21.3	13	22.6	27	22.7
Civil Status	Officially Married, Partner in a Civil union	58	96.7	60	100	116	96.6	2.025**	0.375*
Civil Status	Partner in a Civil Union, Not Officially Married	2	3.3	0	0.0	4	3.4	2.025**	0.375*
Education	Primary School	12	20.0	7	11.3	22	18.6	0.310**	0.621*
	Middle School	9	15.0	15	24.2	22	18.6
	High school	19	30.0	18	30.6	37	30.5
	Associate Degree	6	10.0	7	11.3	12	9.3
	Bachelor’s Degree	11	18.3	12	21.0	26	22.0
	Graduate Degree	4	6.7	1	1.6	1	0.8
Employment	Employed	15	25.0	10	19.4	33	25.6	0.940**	0.628*
Employment	Unemployed	45	75.0	50	80.6	87	74.4	0.940**	0.628*
Place of Residence	Province	43	73.7	55	91.8	87	73.7	7.285**	0.004*
	District	17	26.3	5	8.2	33	24.6
	Village	0	0.0	0	0.0	2	1.7
Income Level	Income greater than expenditure	5	8.3	3	4.8	11	9.2	0.465**	0.269*
	Income equal to expenditure	34	56.7	33	56.5	65	54.6
	Income less than expenditure	21	35.0	24	38.7	44	36.1
Social Security	Yes	51	85.0	51	85.2	101	85.3	0.004**	0.998*
Social Security	No	9	15.0	9	14.8	19	14.7	0.004**	0.998*
Any medical problem	Yes	4	6.7	5	8.1	10	6.8	0.085**	0.438*
Any medical problem	No	56	93.3	55	91.9	110	93.2	0.085**	0.438*
Pregnancy	Planned	48	76.5	51	82.3	92	76.5	5.825**	0.054*
Pregnancy	Unplanned	12	23.5	11	17.7	28	23.5	5.825**	0.054*
Wanted Pregnancy	Yes	55	93.4	58	95.2	115	958	0.086**	0.446*
Wanted Pregnancy	No	5	6.6	2	4.8	5	42	0.086**	0.446*
Number of pregnancies	Primipara	13	20.3	25	37.5	42	33.3	4.536**	0.104
Number of pregnancies	Multipara	47	79.7	35	62.5	78	67.7	4.536**	0.104
Ending Week of Last Pregnancy	36th week or earlier	31	51.7	37	62.9	66	55.9	1.085**	0.167*
	37th-40th week	29	48.3	23	37.1	50	41.5
	41st week or later	0	0.0	0	0.0	4	2.5
Number of living children	None	17	28.8	25	39.3	46	39.3	0.025**	0.467*
	1–3	41	69.5	35	60.7	70	57.3
	4 or more	2	1.7	0	0.0	4	3.4
Number of Miscarriages	None	43	72.9	43	72.7	104	86.3	9.306**	0.002*
	1–2	15	25.4	12	18.2	16	13.7
	3 or more	2	1.7	5	9.1	0	0
Number of Wanted Miscarriages	None	51	86.2	48	82.1	109	91.5	3.142**	0.051*
	1–3	8	12.1	12	17.9	11	8.5
	4 or more	1	1.7	0	0.0	0	0.0
Mode of Delivery in Last Pregnancy	Vaginal delivery	30	45.5	19	32.7	35	28.8	5.440**	0.247*
	Cesarean	21	38.2	25	38.8	54	45.2
	No delivery	9	16.4	16	28.6	31	26.0
Position during previous CTG¹	Left Lateral Side-Lying Position	43	74.5	40	67.3	86	79.6	13.668**	0.006*
	Right Lateral Side-Lying Position	15	21.8	10	16.4	33	19.4
	Semi-Fowler Position	2	3.6	10	16.4	1	1.0

Cardiotocography, 2 x̄: mean, SD: Standard deviation, ³ Body Mass Index

*p < 0.05, p < 0.01 **Chi-square test, Cardiotocography

Various CTG parameters were monitored to assess maternal and fetal health. Table 2 presents the results, highlighting any differences in CTG parameters based on the positions of pregnant women. A statistically significant difference was found between CTG monitoring positions concerning CTG duration (group 1: 20.24 ± 1.99, group 2:18.46 ± 2.82 and group 3: 20.25 ± 3.07), basal heart rate maximum at 11–15 min (group 1:140.18 ± 9.82, group 2: 143.87 ± 8.88 and group 3: 138.16 ± 11.48), and the presence of accelerations during the CTG maximum at 11–15 min (group 1:1.39 ± 1.14, group 2: 1.74.87 ± 1.10 and group 3: 1.40 ± 1.08) (p < 0.05). Notably, the mean values for the semi-Fowler position (Intervention 2) were significantly different from those of the other positions. Additionally, significant differences were observed in fetal movements during the CTG based on position maximum at 16–20 min (p < 0.05), with the mean movement in the left lateral position (control group) being significantly different from that in the other positions. Decelerations during the CTG also exhibited statistically significant differences across various positions (p < 0.05), with the right lateral position (Intervention 1) differing significantly from the left lateral position.

Table 2

Comparison of CTG evaluation parameters according to CTG position

Variables	CTG Duration	Right Lateral Side-Lying Position (1)		Semi-Fowler Position (2)		Left Lateral Side-Lying Position (3)		Test Score	p	Bonferroni Group
Variables	CTG Duration	X̄²	SD³	X̄	SD	X̄	SD
Starting time of CTG		11.76	2.14	11.30	1.87	11.76	2.13	0.991**	0.373*
Ending time of CTG		13.86	13.83	11.61	1.84	12.09	2.14	1.635**	0.197*
CTG Duration		20.24	1.99	18.46	2.82	20.25	3.07	8.919**	0.000*	2 > 1, 2 > 3
Basal Heart Rate	In first 5 min	138.13	9.43	143.57	7.93	137.50	10.64	7.542**	0.001*	2 > 1, 2 > 3
	6th-10th minutes	139.54	9.63	143.69	8.09	138.16	11.48	5.321**	0.006	2 > 3
	11th-15th minutes	140.18	9.82	143.87	8.88	139.36	10.70	3.769**	0.025*	2 > 3
	16th-20th minutes	140.04	9.40	143.35	8.40	139.53	10.47	2.939**	0.055*
Fetal tachycardia	In first 5 min	168.33	10.40	168.75	7.50	175.	5.00	0.700**	0.528*
	6th-10th minutes	170.00	0.00	172.00	5.70	170.00	0.00	0.205**	0.820*
	11th-15th minutes	168.00	0.00	170.00	5.4	172.00	4.87	1.409**	0.543*
	16th-20th minutes	165.00	0.00	170.00	5.00	175.00	7.07	1.063**	0.448*
Bradycardia	At 5th minute	-	-	-	-	-	-	-	-
	6th-10th minutes	100.00	-	107.50	10.60	-	-	0.333	0.667*
	11th-15th minutes	-	-	-	-	-	-	-	-
	16th-20th minutes	-	-	-	-	-	-	-	-
Fetal Movement	In first 5 min	4.80	4.07	3.72	2.34	7.48	5.22	15.980**	0.000*	3 > 2, 3 > 1
	6th-10th minutes	4.54	3.98	3.55	2.71	6.58	5.55	9.100**	0.000*	3 > 2, 3 > 1
	11th-15th minutes	4.49	3.72	3.05	2.46	6.49	4.87	13.829**	0.000*	3 > 2, 3 > 1
	16th-20th minutes	4.39	3.95	3.05	2.21	6.52	4.33	16.720**	0.000*	3 > 2, 3 > 1
Number of Contractions	In first 5 min	2.96	3.14	2.74	2.53	2.95	2.88	0.442***	0.802
	6th-10th minutes	1.93	2.70	1.90	2.63	1.69	2.28	0.151***	0.927*
	11th-15th minutes	1.09	0.396	0.98	0.23	1.12	0.376	5.835***	0.054*
	16th-20th minutes	1.16	0.77	1.32	1.05	1.08	0.056	1.313***	0.519*
Intensity of Contraction	In first 5 min	26.31	24.34	20.23	22.86	25.06	24.23	1.011***	0.603
	6th-10th minutes	46.16	23.54	44.98	22.18	46.28	21.60	0.028***	0.986*
	11th-15th minutes	46.16	23.54	44.98	22.18	46.28	23.54	0.028***	0.986*
	16th-20th minutes	25.75	10.34	22.26	20.00	24.82	10.54	0.102	0.950*
Accelerations	In first 5 min	1.08	1.03	1.61	1.05	1.11	0.96	5.318**	0.006*	2 > 1, 2 > 3
	6th-10th minutes	1.18	1.08	1.51	1.11	1.18	1.08	2.015**	0.136*
	11th-15th minutes	1.39	1.14	1.74	1.10	1.40	1.08	1.953**	0.144*
	16th-20th minutes	1.32	1.22	1.70	1.50	1.45	1.12	1.347**	0.262*
Decelerations	In first 5 min	0.06	0.24	0.11	0.46	0.18	0.55	1.895***	0.388*
	6th-10th minutes	0.04	0.21	0.21	0.68	0.27	0.62	8.075**	0.018*	1 > 3
	11th-15th minutes	0.08	0.33	0.12	0.38	0.15	0.40	2.255***	0.324*
	16th-20th minutes	0.04	0.21	0.07	0.26	0.18	0.50	4.439***	0.109*

Cardiotocography, ² x̄: mean, ³ SD: Standard deviation

*p < 0.05, p < 0.01 ** ANOVA, ***Kruskal‒Wallis test

Table 3 presents the results of vital sign monitoring before, during, and after CTG, categorized by CTG position, revealing differences between the positions. Systolic blood pressure and body temperature were significantly different before, during, and after CTG in terms of position, time, and group-time results (p < 0.05). These differences were predominantly driven by the significant variations associated with the semi-Fowler position compared with other positions. In terms of time, significant differences were observed at the time of CTG compared with other times. Diastolic blood pressure and pulse rates also demonstrated statistically significant differences in values recorded before, during, and after CTG in relation to position and time (p < 0.05). Diastolic blood pressure measurements differed over time, with values before and after CTG significantly differing from those recorded at the time of CTG (p < 0.05). Compared with the mean values at other positions, the right lateral position had a statistically significant difference in pulse rate. In terms of pulse rate, the values recorded before CTG were different from the values recorded at other times.

Table 3

Intergroup comparisons of vital signs during CTG

		Right Lateral Side-Lying Position (1) X̄ ± SD²	Semi-Fowler Position (2) X̄ ± SD	Left Lateral Side-Lying Position (3) X̄ ± SD	Test Score**	p	Bonferroni Group	Bonferroni Time
Blood Pressure (Systolic)	Before CTG (1)	113.67 ± 10.06	108.16 ± 10.56	112.80 ± 11.21	\(\:{F}_{Group}\)=7.964	0.000*	2 > 3, 2 > 1	1 > 3, 1 > 2
	At the moment of CTG (2)	110.37 ± 9.41	107.00 ± 8.57	108.89 ± 11.00	\(\:{F}_{Time}\)= 13.014 \(\:{F}_{GroupxTime}\)= 2.649	0.000* 0.000*
	After CTG (3)	115.91 ± 10.76	100.08 ± 8.15	113.56 ± 12.28	\(\:{F}_{Time}\)= 13.014 \(\:{F}_{GroupxTime}\)= 2.649	0.000* 0.000*
Blood Pressure (Diastolic)	Before CTG (1)	71.00 ± 9.06	66.83 ± 6.83	69.20 ± 9.90	\(\:{F}_{Group}\)=6.829 \(\:{F}_{Time}\)= 9.940 \(\:{F}_{GroupxTime}\)= 2.049	0.000* 0.000* 0.090*	1 > 3, 1 > 2	2 = 3 > 1
	At the moment of CTG (2)	67.00 ± 9.60	64.29 ± 7.26	66.56 ± 11.70
	After CTG (3)	70.41 ± 10.18	64.64 ± 7.29	71.10 ± 11.36
Pulse	Before CTG (1)	94.70 ± 10.84	97.77 ± 11.03	93.37 ± 12.28	\(\:{F}_{Group}\)=5.461 \(\:{F}_{Time}\)= 10.315 \(\:{F}_{GroupxTime}\)= 0.822	0.005* 0.000* 0.512*	2 > 1, 2 > 3	3 > 2, 2 > 1
	At the moment of CTG (2)	92.24 ± 10.60	95.88 ± 10.51	89.84 ± 11.29
	After CTG (3)	92.06 ± 10.53	96.20 ± 9.31	91.77 ± 10.23
Body Temperature	Before CTG (1)	36.32 ± 0.46	36.29 ± 0.15	36.49 ± 0.49	\(\:{F}_{Group}\)=11.776 \(\:{F}_{Time}\)= 3.975 \(\:{F}_{GroupxTime}\)= 3.232	0.000* 0.023* 0.015*	3 > 2, 3 > 1	1 > 2 > 3
	At the moment of CTG (2)	36.40 ± 0.50	36.26 ± 0.17	36.60 ± 0.51
	After CTG (3)	36.41 ± 0.49	36.24 ± 0.14	36.58 ± 0.51

Cardiotocography, ² x̄: mean SD: Standard deviation

p < 0.05, p < 0.01 **Kruskal‒Wallis Hypothesis Test

Table 4 provides an analysis of the impact of BMI on vital signs when CTG was performed in different positions. Systolic blood pressure (semi-fowler position: 107.08 ± 8.15), diastolic blood pressure (semi-fowler position: 64.64 ± 7.29), and body temperature (semi-fowler position: 36.24 ± 0.14), were significantly different between the groups (p < 0.05). However, BMI and BMI by position did not appear to affect vital signs (p > 0.05).

Table 4

Comparison of the effects of body mass index on CTG position and vital signs

	Group		\(\:\stackrel{-}{\varvec{X}}\)²	SD³	F	p	Bonferroni
Systolic Blood Pressure	Right Lateral Side-Lying Position (1)		115.91	10.76	26.785**	0.002*	2 > 3, 1 > 3
	Semi-Fowler Position (2)		107.08	8.15
	Left Lateral Side-Lying Position (3)		113.56	12.28
BMI					2.734**	0.157
Group*BMI⁴					0.323**	0.862
Diastolic Blood Pressure		Right Lateral Side-Lying Position (1)	70.41	10.18	14.054**	0.010*	2 > 3, 2 > 1
		Semi-Fowler Position (2)	64.64	7.29
		Left Lateral Side-Lying Position (3)	71.10	11.36
BMI					2.193**	0.214
Group*BMI					0.518**	0.722
Pulse		Right Lateral Side-Lying Position (1)	92.06	10.53	6.002**	0.053	-
		Semi-Fowler Position (2)	96.20	9.31
		Left Lateral Side-Lying Position (3)	91.77	10.23
BMI					0.461**	0.658
Group*BMI					0.733**	0.570
Body Temperature		Right Lateral Side-Lying Position (1)	36.41	0.49	88.070**	0.000*	2 > 3
		Semi-Fowler Position (2)	36.24	0.14
		Left Lateral Side-Lying Position (3)	36.58	0.51
BMI					3.572**	0.072
Group*BMI					0.076**	0.989

Cardiotocography, ² x̄: mean, ³ SD: Standard deviation

*p < 0.05, p < 0.01** ANOVA, ¹BMI: Body mass index

The regression analysis results, presented in Table 5, indicate the significance level corresponding to the F value in the general comfort scale mean score across positions. Notably, only the semi-Fowler position exhibited statistical significance (F = 17.366; p < 0.05). The beta coefficient of the independent variable, the t value, and the significance level showed that the semi-Fowler position had a statistically significant effect on comfort (t = 3.834, p < 0.05). This result explained 5.8% of the change in general comfort (adjusted R2 = 0.058). Specifically, the semi-Fowler position led to a 0.911 increase in general comfort (β = 0.911).

Table 5

Effect of the CTG position on the general comfort questionnaire score

Dependent Variable	Independent Variable	β	Standard Error	Beta	t	p	F**	Model (p)	R2
General Comfort Questionnaire Score	(Constant)	3.398	0.168	-	20.168	0.000*	3.034	0.083	0.012
	Right Lateral Side-Lying Position	− 0.163	0.094	− 0.112	-1.742	0.083	3.034	0.083	0.012
	(Constant)	2.506	0.163	-	15.335	0.000*
	Semi-Fowler Position	0.349	0.911	0.240	3.834	0.000*	14.700	0.000*	0.058
	(Constant)	3.329	0.129	-	25.786	0.000*	3.090	0.080	0.013
	Left Lateral Side-Lying Position	-0.143	0.081	-0.113	-1.758	0.080	3.090	0.080	0.013

Cardiotocography

CTG process taking less than 20 min

*p < 0.05, p < 0.01 ** Simple linear regression

Discussion

The recommended maternal positions during cardiotocography (CTG) include left lateral, semi-Fowler, left lateral semi-Fowler, and sitting positions. These positions have been shown in previous studies to optimize uterine perfusion and fetal heart rate while preventing maternal hypotension [16‐18].

In this study, a statistically significant relationship was found between CTG positions and sociodemographic characteristics, especially place of residence, number of miscarriages and previous CTG positions. The significant difference observed for the ‘place of residence’ variable in CTG position preferences may be interpreted as the potential influence of socio-cultural factors and regional health practices on these preferences. These relationships may result from differences in cultural norms and practices in different residential areas, the influence of previous obstetric experiences such as miscarriage on maternal comfort and preferences, and familiarity with certain CTG positions based on previous experience. The statistical difference observed in the variable ‘Position during previous CTG’ underscores the importance of prior experiences in shaping maternal preferences, suggesting that familiarity and comfort with previously used positions may influence current choices, which has implications for personalized care and improving maternal satisfaction during CTG monitoring.

In our study, we found that the semi-Fowler position (Intervention 2) led to a shorter CTG duration, optimized basal heart rate, and increased number of accelerations, resulting in significant differences between groups (p < 0.05). Another randomized controlled trial reported that the semi-Fowler position was effective in achieving a faster CTG result than the left lateral position [1]. Considering the high number of pregnant women seeking antenatal care from perinatal nurses and midwives, the utilization of the semi-Fowler position may expedite CTG results.

Our study revealed that the left lateral position (control group) during CTG led to an increase in the number of fetal movements and caused significant differences between groups (p < 0.05). However, the presence of decelerations in the CTG was more pronounced in the right lateral position (Intervention 1). These findings contrast with some studies that reported no significant difference in the basal heart rate related to different maternal positions during CTG [4]. Other studies reported increased CTG reactivity in the left lateral semi-Fowler position but not significantly different from that in the semi-Fowler or left lateral positions [1]. Kaur et al. [19] reported no significant difference between the left lateral and sitting positions in terms of CTG reactivity. Our study, similar to the results of Ibrahim et al. [18], indicated that the semi-Fowler position led to higher fetal heart rates than the supine and left lateral positions did. A study examining the position and fetal health in pregnancies between 36 and 40 weeks found that umbilical artery flow increased when transitioning from the left lateral to the supine position (p < 0.001), indicating that vascular resistance in the umbilical-placental circulation increases in the supine position, opposing forward flow [20]. This variation in findings underscores the need for further exploration of maternal positions during CTG.

With respect to maternal vital signs, our study revealed that the semi-Fowler position exhibited significant differences in maternal blood pressure and body temperature during CTG. Additionally, the right lateral position was associated with an increase in the maternal pulse rate [21]. Unlike other studies, our research indicated that not only maternal blood pressure but also parameters such as body temperature and pulse rate were affected by maternal position during CTG. Although statistical significance was obtained for body temperature and pulse rate were affected by maternal position during, this difference is not clinically relevant. This difference was thought to be more of a reflection of maternal comfort. Previous studies reported that maternal blood pressure was within normal limits in all three positions, but the respiratory rate increased in the left lateral and semi-Fowler positions [17, 22]. In contrast, maternal hypotension was noted in the supine position in other studies, which was attributed to pressure on the inferior vena cava [23, 24]. Our findings suggest that the right lateral position could be considered an alternative to the supine position.

Our study also highlighted the impact of BMI on maternal systolic blood pressure, diastolic blood pressure, and body temperature at different CTG positions. Previous studies have rarely explored the relationship between maternal position and fetal monitoring with respect to BMI. Our data suggest that pregnant women with a high BMI may benefit from the semi-Fowler position during fetal monitoring. In a randomized controlled trial evaluating external fetal electrocardiogram monitoring systems, wireless CTG application resulted in more interpretable data in subjects with a body mass index (BMI) ≥ 30 kg/m² [25]. It was suggested that, alongside the position, the device used during CTG could also have an impact.

Finally, when examining the relationship between maternal comfort and position during fetal monitoring, our study revealed that the semi-Fowler position provided the highest level of comfort. Maternal comfort is known to influence the accuracy of fetal monitoring results [1, 17, 22, 26, 27]. However, some studies reported that the left lateral position contributed more to comfort than the semi-Fowler and supine positions did [19]. The present study suggests that the semi-Fowler position can be a comfortable alternative to the left lateral position for pregnant women.

Limitations of this study

This study has several limitations that should be considered when the findings are interpreted. First, the research was conducted in a single healthcare facility, which may restrict the generalizability of the results to other settings or populations. Second, only maternal comfort and fetal well-being during a 20-minute session of electronic fetal monitoring were assessed, and long-term outcomes were not evaluated. In addition, the Intervention group experienced a drop-out rate of approximately 20 per cent. This was due to the CTG process taking less than 20 min and incomplete data entry. Future research should address these limitations by employing multicenter designs, extending monitoring durations, and considering additional maternal and fetal factors.

Conclusions

In conclusion, this study provides important insights into the effects of maternal positioning during antenatal electronic fetal monitoring. Compared with other positions, the semi-Fowler position was associated with higher baseline fetal heart rates, increased fetal movements, and greater fetal accelerations. These findings suggest that maternal position can significantly influence fetal heart rate patterns. Additionally, maternal blood pressure exhibited notable differences in the semi-Fowler position during repeated measurements, highlighting the potential impact of this position on maternal cardiovascular status, which is of particular relevance to perinatal nursing and midwifery practice.

Furthermore, the right lateral position was associated with an increase in maternal heart rate, emphasizing the importance of monitoring maternal hemodynamics during fetal monitoring in this position. Compared with other positions, the semi-Fowler position also appeared to offer greater maternal comfort, whereas the left lateral position emerged as a suitable alternative, promoting maternal well-being. Notably, pregnant women with higher BMIs may benefit from the semi-Fowler position during fetal monitoring, a finding that underscores its practical implications in perinatal care.

The findings of this study highlight the critical importance of selecting an appropriate maternal position during cardiotocography to ensure accurate assessment and to optimize both maternal and fetal outcomes. The development of standardized protocols for antenatal electronic fetal monitoring is essential to guide clinical practice, as incorrect positioning may lead to inaccurate results. Therefore, implementing such guidelines is crucial for enhancing the quality of care in perinatal settings.

Acknowledgements

We would like to express our gratitude to all the pregnant women who opened their doors for research.

Declarations

Ethics committee approval was obtained from the Ethics Committee of Istanbul Zeynep Kamil Women’s and Children’s Diseases Training and Research Hospital where this research was conducted. (Decision No. 123; Date: 18.12.2019). Written permission for the use of the scale was obtained. Written informed consent was obtained from the study participants. The participants entered the study on a voluntary basis.

Not applicable.

Competing interests

The authors declare no competing interests.

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

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Kıratlı D, Yavan T, Karaşahin KE, Yenen MC. The Effect of different maternal positions on reactivity of the Nonstress Test, maternal blood pressure and heart rate. J Dr Behcet Uz Children’s Hosp. 2018;8(156):101–8. https://doi.org/10.5222/buchd.2018.101.CrossRef

Umana OD, Siccardi MA. Prenatal Nonstress Test. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537123/

Thayer SM, Faramarzi P, Krauss M, et al. Heterogeneity in management of category II fetal tracings: data from a multihospital healthcare system. Am J Obstet Gynecol. 2022;226(1):623–4. https://doi.org/10.1016/j.ajog.2021.11.1026.CrossRef

Zeng R, Lu Y, Long S, Wang C, Bai J. Cardiotocography signal abnormality classification using time-frequency features and ensemble cost-sensitive SVM classifier. Comput Biol Med. 2021;130:104–218. https://doi.org/10.1016/j.compbiomed.2021.104218.CrossRef

Sharma J, Goyal M. Cardiotocography and diabetic pregnancy. The Journal of the Pakistan medical association. 2016;66(9 Suppl 1):30–33. Available from: https://www.researchgate.net/publication/326491954_Cardiotocography_and_diabetic_pregnancy

Aktaş S, Osmanağaoğlu MA. Intrapartum Electronic Fetal Monitoring and Responsibilities of Health Professionals. E-J New World Sci Acad. 2017;12(1):14–29. https://doi.org/10.12739/nwsa.2017.12.1.4b0009.CrossRef

Patel R, Smitha MV, Jena SK, Jacob J, John J. Do different positions during a nonstress test affect the maternofetal physiological parameters and comfort in pregnant women? J EdU Health Promot. 2022;11:386. Available from: https://www.jehp.net//text.asp?2022/11/1/386/361942

Sekhavat L, Tabatabaei A, The Effect of Different Maternal Position on Nonstress Test (NST). World Appl Sci J. 2014;32(5):853–6. https://doi.org/10.5829/idosi.wasj.2014.32.05.83246.CrossRef

Antepartum fetal surveillance. Practice Bulletin 145. American College of Obstetricians and gynecologists. Obstet Gynecol. 2014;124:182–92. https://doi.org/10.1097/01.AOG.0000451759.90082.7b.CrossRef

10.

Ryu D, Kim, DH, Price JT, et al. Comprehensive pregnancy monitoring with a network of wireless, soft, and flexible sensors in high- and low-resource health settings. PNAS. 2021;118(20):e2100466118. https://doi.org/10.1073/pnas.2100466118.

11.

Ayres-de-Campos D, Spong CY, Chandraharan E, FIGO Intrapartum Fetal Monitoring Expert Consensus Panel. & (2015). FIGO consensus guidelines on intrapartum fetal monitoring: Cardiotocography. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2015; 131(1), 13–24. https://doi.org/10.1016/j.ijgo.2015.06.020

12.

Republic of Turkey Ministry of Health, Public Health Institution of Turkey, Department of Women and Reproductive Health. Risky Pregnancies Management Guide. No:926, 2014. Available at: https://dosyamerkez.saglik.gov.tr/Eklenti/21958

13.

Kolcaba K, Schirm V, Steiner R. Effects of hand massage on comfort of nursing home residents. Geriatr Nurs. 2006;27(2):85–91. https://doi.org/10.1016/j.gerinurse.2006.02.006.CrossRefPubMed

14.

Kolcaba K, Tilton C, Drouin C. Comfort theory: A unifying framework to enhance the practice environment. Journal of Nursing Administration. 2006;36(11):538–44. Available from: https://www.researchgate.net/profile/Katharine-Kolcaba/publication/6698936_Comfort_Theory_a_unifying_framework_to_enhance_the_practice_environment/links/551575960cf2f7d80a32eafd/Comfort-Theory-a-unifying-framework-to-enhance-the-practice-environment.pdf

15.

Çıtlık SC, Çevik S, Özden G. Turkish validity and reliability study of the General Comfort Scale Short Form. Journal of the Nursing Forum in Diabetes, Obesity and Hypertension. 2018;10(2),16–22. Available from: https://toad.halileksi.net/olcek/genel-konfor-olcegi-kisa-formu/

16.

McKinney ES, James SR, Murray SS, Nelson K, Ashwill J. Maternal-child nursing E-Book. Fifth Edition. Volume 12. Elsevier; 2018. p. 281. https://books.google.com.tr/books?isbn=0323478344.

17.

Essa R, Hafez SK. Effect of different positions of pregnant women on their comfort and fetal cardiotocographic patterns during non stress test. Int J Res Health Sci Nurs. 2018;2(4):2–24. https://doi.org/10.53555/hsn.v4i2.257.CrossRef

18.

Ibrahim HA, Elgzar WT, Saied EAR. The effect of different positions during nonstress test on maternal hemodynamic parameters, satisfaction, and fetal cardiotocographic patterns. Afr J Reprod Health. 2021;25(1):81–9. https://doi.org/10.29063/ajrh2021/v25i1.10.CrossRefPubMed

19.

Kaur VS, Saha PK. A comparative study to assess the effect of different maternal position on reactivity and time consumption for non stress test. Nurs Midwifery Res J. 2015;11(4):145–52. https://doi.org/10.33698/NRF0193.CrossRef

20.

Kember AJ, Anderson JL, House SC, Reuter DG, Goergen CJ, Hobson SR. Impact of maternal posture on fetal physiology in human pregnancy: a narrative review. Front Physiol. 2024;15:1394707. https://doi.org/10.3389/fphys.2024.1394707.CrossRefPubMedPubMedCentral

21.

Mucuk S, Bülbül T. Effects of position on nonstress test results and maternal satisfaction. Adv Clin Experimental Medicine: Official Organ Wroclaw Med Univ. 2021;30(11):1127–32. https://doi.org/10.17219/acem/140196.CrossRef

22.

Sayed EL, Mohamady HA. Effects of different maternal positions during Non-stress Test on Maternofetal physiological parameters. Tanta Sci Nurs J. 2016;10(1):116–31. https://doi.org/10.21608/TSNJ.2016.71197.CrossRef

23.

Stone PR, Burgess W, McIntyre JP, Thompson JM, et al. Effect of maternal position on fetal behavioral state and heart rate variability in healthy late gestation pregnancy. J Physiol. 2017;595(4):1213–21. https://doi.org/10.1113/JP273201.CrossRefPubMed

24.

Esin S. Factors that increase reactivity during fetal non stress testing. Curr Opin Obstet Gynecol. 2014;26(2):61–6. https://doi.org/10.1097/GCO.0000000000000050.CrossRefPubMed

25.

Monson M, Heuser C, Einerson BD, et al. Evaluation of an external fetal electrocardiogram monitoring system: a randomized controlled trial. Am J Obstet Gynecol. 2020;223:244. https://doi.org/10.1016/j.ajog.2020.02.012.CrossRefPubMedCentral

26.

Humphries A, Mirjalili SA, Tarr GP, Thompson JMD, Stone P. The effect of supine positioning on maternal hemodynamics during late pregnancy. J Matern Fetal Neonatal Med. 2019;32(23):3923–30. https://doi.org/10.1080/14767058.2018.1478958.CrossRefPubMed

27.

Lucchini M, Wapner RJ, Chia-Ling NC, et al. Effects of maternal sleep position on fetal and maternal heart rate patterns using overnight home fetal ECG recordings. Int J Gynecol Obstet. 2020;149(1):82–7. https://doi.org/10.1002/ijgo.13096.CrossRef

Titel: Effects of maternal positions in electronic fetal monitoring: a randomised controlled trial
verfasst von: Tuğba Yilmaz Esencan
Ayça Demir Yildirim
Ebru Sağiroğlu
Publikationsdatum: 01.12.2025
Verlag: BioMed Central
Erschienen in: BMC Nursing / Ausgabe 1/2025
Elektronische ISSN: 1472-6955
DOI: https://doi.org/10.1186/s12912-024-02654-w

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Springerpflege

Effects of maternal positions in electronic fetal monitoring: a randomised controlled trial

Abstract

Background

Methods

Results

Conclusions

Clinical Study Registration

Trial registration

Publisher’s note

Background

Research hypotheses

Methods

Data collection tools

Information questionnaire

General comfort questionnaire-short form (GCQ-SF)

Procedure

Statistical analysis

Ethical approval and informed consent

Results

Discussion

Limitations of this study

Conclusions

Acknowledgements

Declarations

Competing interests

Publisher’s note

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Trial registration

Publisher’s note

Background

Research hypotheses

Methods

Data collection tools

Information questionnaire

General comfort questionnaire-short form (GCQ-SF)

Procedure

Statistical analysis

Ethical approval and informed consent

Results

Discussion

Limitations of this study

Conclusions

Acknowledgements

Declarations

Ethics approval and consent to participate

Consent for publication

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