ABSTRACT High maternal anxiety contributes to a prolonged latent phase and intrapartum complications. Reframing negative thoughts of women in labor to positive ones may reduce anxiety and the likelihood of subsequent complications. This international multicenter, randomized, controlled trial evaluated the likelihood that formalized nursing and midwifery intervention in hospital labor assessment units could increase the rate of spontaneous vaginal birth and improve other maternal and neonatal outcomes. A total of 5002 pregnant women >34-weeks gestation experiencing contractions, but not in active labor, were enrolled in the trial from 2003 to 2007 in 20 North American and UK hospitals. The participants were randomized to receive usual nursing care (n = 2501) or structured care (n = 2501). Structured care was a formalized approach to assessment of and interventions for maternal emotional state, pain, and fetal position. A small increase was found in rate of spontaneous vaginal birth among women in the structured care group (64.0%, n = 1597) compared with the usual care controls (61.3%, n = 1533); the odds ratio was 1.12, with a 95% confidence interval of 0.96 to 1.27. Fewer women in the structured care group (n = 403, 19.5%) rated the helpfulness of nurses or midwives in the labor assessment unit as less than very helpful compared with those who received usual care (n = 544, 26.4%); odds ratio 0.67, with a 98.75% confidence interval of 0.50 to 0.85. Similarly, fewer women receiving structured care (n = 233, 11.3%) reported disappointment with the amount of attention received from staff than those who received usual care (n = 407, 19.7%). No differences were found for indicators of maternal and fetal health during the hospital stay, intrapartum interventions, or other measured outcomes. These findings indicate that structured approach to care in hospital labor assessment units does not significantly increase the likelihood of spontaneous vaginal birth, but is associated with increased maternal satisfaction.