Student Projects

Quantitative

Research

Proposal

Maternal Positions during First Stage of Labor under Epidural Anesthesia

Jane Letushko
April, 2011

Abstract
The term "maternal birthing position" refers to the various physical postures the pregnant
mother may assume during the process of childbirth, with position, posture, and attitude,
as the arrangement of the body or its parts (Dictionary.com, 2010). All parturient women
assume a position, either by choice or by direction of care providers or support people.
There is no evidence that the standard, supine recumbent position used most often in the
hospital setting, is associated with any advantage for women or babies, although it may
be more convenient for staff (Lawrence, Lewis, Dowswell & Styles, 2009). However,
there are a number of deleterious effects to the supine recumbent position noted in the
literature, which include adverse effects on maternal hemodynamics and fetal status due
to supine hypotension syndrome, along with poor descent and engagement of the fetus,
leading to an increase in instrumental deliveries, episiotomies, and greater blood loss
(Blackburn, 2007). Upright positions and mobility are known to positively influence the
womans comfort level in labor, help her better cope with pain, and enhance her sense of
control (Albers, 2007). Data on the effect of upright positioning on labor duration and
maternal, fetal and neonatal outcomes is conflicting. There is underutilization of mobility
and upright positioning during labor, with a large national survey revealing 76 percent of
mothers reporting no mobility after onset of active labor, and 57 percent in back-lying
positions for delivery (Declereq, Sakala, Corry, & Applebaum, 2006), which may be
attributed to an increase in epidural anesthesia use. This correlating increase in epidural
use for pain relief, affects maternal positioning during the first stage of labor. This
inquiry proposes a quantitative observational study that will describe maternal
positioning during the first stage of labor in women undergoing epidural anesthesia for
pain relief. Word count: 295

Chapter 1: Statement and Significance of the Problem

Introduction
The term "maternal birthing position" refers to the various physical postures the
pregnant mother may assume during the process of childbirth, with position,
posture, and attitude, as the arrangement of the body or its parts

(Dictionary.com, 2010). The womans position during labor is dependent on

multiple factors, such as use of anesthesia/analgesia, maternal preference,
available support, phase of labor, and affects many if not all aspects of the
childbirth process. Additionally, one position is rarely maintained throughout
the entire length of labor. However, most women in the developed world who
labor in a hospital setting spend the majority of their labors in bed.
Maternal position influences the powers, the passage and the passenger (see
Table 1), assisting or hindering the work of each one. Position change and
ambulation during labor and birth are known to be natural responses to
physiologic cues, nevertheless remain greatly underutilized in the hospital
setting. A large national survey revealed that 76 percent of mothers reporting no
mobility after onset of active labor, and 57 percent in back-lying positions for
delivery (Declereq, Sakala, Corry, & Applebaum, 2006), which may be
attributed to an increase in epidural anesthesia use, convenience for hospital
staff,
and
lack
of
labor
support,
among
others.
Labor compromises those processes that result in the expulsion of the products
of conception by the mother (Varney, 2004 p. 737). The first stage of labor lasts
from the onset of true labor to full dilation of the cervix, and consists of two
phases latent and active (Oxorn, 1986). Position during labor has played a
vital role in the physiological, psychological, and cultural aspects of childbirth,
as the woman assumes a position either by choice or direction.
Labor positions can be categorized into two groups, which would include the
upright and recumbent positions. The recumbent position includes supine,
semi-recumbent, and lateral positions. Upright positions include walking,
sitting, standing, leaning, kneeling, squatting and all-fours. The choice of
position may be influenced by the birth environment, culture, available support,
characteristics of the labor, and fetal position. As long as there is no
contraindication to mobility and upright posture during the first stage of labor,
the woman should be allowed to assume any position that is comfortable for her
at the time (see Appendix E). However, currently in the hospital setting, the
majority of women typically spend most of the first stage of labor in bed in a
recumbent position.
Table 1: The Four Ps of Labor
The Four Ps of
Definition
Labor
Refers to uterine activity generated by uterine musculature to
Powers
deliver the passenger, or the fetus
Passenger
The fetus

Passage

Psyche
(Gabbe,
The

Consists of the maternal pelvis composed of the sacrum, ilium,

ischium, and pubis and the resistance provided by the soft tissue
Refers to the mothers psychological state and ability to cope with
the labor and includes any feelings that might impede or facilitate
the labor process, such as apprehension, fear, anxiety, excitement,
or sense of control
2007)
Evolution

of

Birthing

Positions

Historically, women have labored in the upright position. Earliest records of maternal
birth positions show the parturient in an upright posture, usually squatting or kneeling
(Dundes, 1987). In early Egyptian civilizations, women birthed either on birthing stools
or while crouching over sizzling, hot stones (Johnson, Johnson & Gupta, 1991). The
position adopted naturally by women during birth has been described as early as 1882 by
Engelmann. He observed that primitive woman, not influenced by Western cultures,
would try to avoid the dorsal position and would change position whenever desired
(Gupta & Nikodem, 2000). Before modernizing birth, women were encouraged to
frequently change positions during labor to increase the effectiveness of uterine pains,
because it was believed that constant position in labor contributed to inertia (Johnson,
Johnson
&
Gupta,
1991).
The utilization of the horizontal birth positions has been a relatively new concept. This
position has been widely used in Western cultures only for the past two hundred years
(Dundes, 1987). The revolutionary change started in seventeenth century France, with the
advent of obstetric surgeons gradually taking over the midwifes role of birth attendants.
Francois Mauricaeu (1637-1709), an influential French obstetrician, has been credited
with implicating the first major obstetrical change in the position of the parturient
(Dunn, 1991). The standard use of upright positions during labor and birth was replaced
with the recumbent position to facilitate examinations and obstetric operations for the
obstetrician (1991) and to save the trouble of carrying the woman back to bed
afterwards
(Johnson,
Johnson
&
Gupta,
1991).
By the end of the nineteenth century, the recumbent position came to be preferred almost
exclusively. This was largely due to an increasing utilization of obstetrical interventions,
such as the forceps, which restricted the mother into a supine position during delivery.
With an increasing number of obstetricians attending births, the womens ability to
choose a position most comfortable for her was no longer an option. Immobility in labor,
and even restraint during birth became a common phenomenon, especially as the use of
drugs became more frequent during the first half of the twentieth century (Johnson,
Johnson & Gupta, 1991). Bedrest in labor has become the norm in developed countries
and has coincided with hospitalization for birth, physician dominance of intrapartum care,
and the liberal use of technology for childbirth (Albers, et al, 1997).
The

Debate

With an increased emphasis on evidence-based practice in the hospital setting, maternal

behavior in labor has been studied in order to improve outcomes for both the woman and
her child. Factors that contribute to maternal and fetal well-being are becoming an
increasingly common requirement both for maternity hospitals committed to the
humanization of childbirth and for women themselves (Miquelutti, 2009). Maternal
position change and ambulation can be a non-invasive and non-pharmacological method
of pain relief. Women, who were allowed to ambulate and move as desired during labor,
are known to cope with their pain more effectively and have an increase sense of control
(Albers, 2007). Labor without bed confinement has been utilized to promote the
empowerment of women (Souza, Miquelutti, Cecatti & Makuch, 2006). Mobility has
shown to provide laboring women with a self-regulated distraction from the challenge of
labor while increasing the mothers comfort level, leading to a decreased need for
analgesia (Lawrence, Lewis, Dowswell & Styles, 2009). From the physiological
standpoint, in contrast to upright positions, the supine position has been observed to be
associated with the compression of abdominal blood vessels and impairment of fetal
nutrition and oxygenation, leading to negative outcomes for not only the mother but the
fetus.
(Souza,
Miquelutti,
Cecatti
&
Makuch,
2006
).
However, there still remains some debate regarding the outcomes of labor positions on
labor progress and maternal, fetal and neonatal outcomes. Although various positions
adopted during labor and delivery have been studied over the past 40 years, controversy
still surrounds the results regarding obstetric variables, such as effect on labor duration.
(Miquelutti et al, 2009). Several earlier studies did not find any significant effects of
ambulation on labor progress or fetal outcomes, however other outcomes were positively
influenced by ambulation, such as decrease use in forceps, episiotomies and increase in
maternal satisfaction (Bloom et al, 1998). Although no harmful effects were ever
observed, previous research failed to demonstrate any difference in outcomes for mobile,
horizontal or upright maternal positioning during first stage of labor. A randomized trial
by McManus and Calder (1978), conducted with women undergoing an induction of
labor, observed no difference between mothers assigned to a recumbent position and
those assigned to an upright position in the length of labor, mode of delivery,
requirements of oxytocic and analgesic drugs, or fetal and neonatal condition. Despite the
positive effects of mobility in labor on pain perception and sense of control, earlier
studies are inconclusive regarding its role in decreasing labor duration, with some
research failing to show any difference in fetal and neonatal outcomes.
In addition, it is difficult to conduct research by assigning women to a certain position for
the entire duration of the first stage of labor. Women may feel the need to change
positions frequently, presenting a challenge to the research design causing an inability to
represent a strong control group. Small sample sizes in controlled studies have also
contributed to the lack of strong evidence regarding effects of maternal position. Albers
(2007) states that past reviews of research have identified flaws in early studies on
mobility and position change, such as small samples, selection bias, and confounding in
nonrandomized studies, and failures of randomization in attempted trials.
The use of technology for monitoring maternal and fetal status, along with an increased

use of epidural anesthesia have also greatly contributed to the maternal bed confinement
in the horizontal position. A woman semi-reclining or lying down on the side or back
during the first stage of labor may be more convenient for staff and can make it easier to
monitor progression and check the baby (Lawrence, Lewis, Dowswell & Styles, 2009).
The lack of low technological care measures in the hospital setting poses a challenge for
observing the effects of mobility and positioning in the first stage of labor. The actual
application of policy regarding upright maternal posture in labor poses additional
opposition staff and care providers, despite documented benefits and lack of negative
effects.
Scope

of

the

Problem

There are approximately 60 million women of reproductive age in the United States, and
over six million of these women become pregnant, with approximately four million
giving birth each year. (Center for Disease Control and Prevention [CDC], 2003).
Childbearing is a major life passage for over 4.3 million mothers, newborns, and
families annually (Sakala & Corry, 2008). In 2007, out of the millions of women giving
births, an overwhelming 99.1 percent of them delivered in hospitals (CDC, 2010). Within
the U.S. healthcare system, childbirth is the leading cause for hospitalization, with about
23 percent of individuals discharged being mothers or infants (Sakala & Corry, 2008).
Significance

to

Womens

Health

Women delivering in the hospital setting are more exposed to medical interventions
associated with perinatal morbidity. These interventions include the use of narcotic and
epidural analgesia, augmentation and induction of labor, assisted vaginal births, and
increased cesarean sections (American College of Nurse-Midwives [ACNM], 2010).
The current style of maternity care is procedure-intensive, and six of the fifteen most
commonly performed hospital procedures in the entire population are associated with
childbirth
(Sakala
&
Corry,
2008).
The increasing cesarean section rate in this country has been of great concern, and
reduction a primary goal. Cesarean section is currently the most common operating
room procedure in the country (Sakala & Corry, 2008). The cesarean rate rose by 53
percent from 1996 to 2007, reaching 32 percent, the highest rate ever reported in the
United States (CDC, 2010). In addition, slightly more than four percent of infants were
delivered by either forceps or vacuum extraction (CDC, 2010). A mid-course review of
the national Healthy People 2010 objectives for the country found that there has been
movement away from targets for many of the maternity objectives (Sakala & Corry,
2008), including an increase in maternal mortality rates due to a rise in surgical
interventions and postoperative complications ( The Joint Commission, 2010). In 2004,
the total percent of women choosing primary elective cesarean sections for delivery was
20.5 percent, or approximately 1.2 million mothers (CDC, 2006). Elective cesarean
delivery accounts for over half of all cesarean sections done each year (CDC, 2006), and
therefore these women are excluded from this inquiry due to the fact that they do not
experience labor. Mobility and upright positioning in labor may help decrease the

cesarean section rate due to their effect on maternal and fetal outcomes.
Even though most childbearing women in the U.S. are healthy and at low risk for
complications, national surveys reveal that almost all mothers who give birth in hospitals
experience high rates of interventions with risk of adverse effects (Sakala & Corry, 2008).
Women are denied the ability to ambulate and follow their instinctive drive to change the
positioning of their bodies in order to facilitate birth. Active labor, or the onset of regular
uterine contractions and dilation of cervix of about four centimeters and effacement
greater than 80 percent (Gabbe, 2007), poses unique physical and emotional demands on
the mother due to increasing intensity of sensations. In 2005, a national survey of women
who gave birth in the U.S. called Listening to Mothers II gathered data on the use of
obstetrical interventions in a primarily healthy population. Among restrictions
experienced in the hospital setting, 76 percent of mothers reported to have no mobility
after the onset of active labor, with 57 percent reporting back-lying positions while giving
birth (Declereq, Sakala, Corry, & Applebaum, 2006). Practices associated with the
birthing process are, therefore, important to the woman's health and well-being as well as
the
successful
outcome
of
her
pregnancy
(Dundes,
1987).
A small but vocal segment of pregnant women are becoming more aware of the natural
process of childbirth and chose to birth in an environment that does not interrupt its
course, such as in their home or at a birth center. Most women have the potential to have
a physiologic labor and birth: one that starts and proceeds on its own, without routine use
of interventions or drugs (Albers, 2007). The attitudes and expectations of healthcare
staff, women and their partners have shifted with regard to pain, pain relief and
appropriate behavior during labor and childbirth, allowing women options and supporting
their decisions and choices (Lawrence, Lewis, Dowswell & Styles, 2009).
Families seek a more comforting birthing environment and the ability to have available
support of partners and family for the birthing woman. Most birthing facilities in this
nation allow women to have supportive others in the labor room at all times. Hospitals
and birth centers provide women with objects such as rocking chairs and birthing balls
that allow for positioning and help women cope with labor. Therefore, the availability of
data on mobility during the labor process can affect care providers management during
the intrapartal period. It can also make women more comfortable with their choices to
follow their bodys natural rhythm of birth. With utilizing evidence-based care in
practice, the best-evaluated treatments and interventions available to women can improve
their health and reduce the potential of harm (Albers, 2007). In addition, encouragement
of mobility in labor is a low-cost intervention that influences the womans comfort level
and
ability
to
cope.
Significance

to

Midwifery

Midwives have been supporting women during childbirth since early human civilization,
with mention of midwifery in the literature being in the Book of Genesis. Fulfilling its
meaning of with women, midwifery has survived through the centuries as birth, the
renewal of life, continues through the ages (Varney, 2004, p. 3). The midwifery model of

care is comprised of beliefs that include the facilitation of the natural processes and
nonintervention in these normal processes unless indicated (p. 4). Midwives believe that
every individual has the right to safe, satisfying health care with respect to human dignity
and cultural variations (ACNM, 2004). Midwives protect the natural birth process, by
honoring the normalcy of womens life cycle events. In addition to the important tasks of
patient education and counseling, midwives also provide safe, effective care, as well as
support and advice for the woman and her family during pregnancy, childbirth and
postpartum
(International
Confederation
of
Midwives,
2005).
All these responsibilities play an important role especially during the labor process, with
the midwife as the primary advocate for the patient and her family. Because of the high
proportion of healthy gravidas in the total childbearing population, and the ethical
responsibility of clinicians to first, do no harm, intrapartum care strategies that help
labor remain normal warrant priority status in maternity care (Albers, 2007). Mobility
during the first stage of labor has been discouraged and often forbidden in many of the
hospital settings, primarily due to careproviders preferences and the use of interventions
such as continuous fetal monitoring, intravenous infusions and epidural anesthesia.
Healthcare professionals attending women in labor and during delivery have ceased to
utilize mobility and upright positions due to inconvenience and lack of knowledge
regarding their impact. No harmful effects have ever been observed, and the inclination
some women have to move about appears related to options available in the birth
environment
and
encouragement
from
caregivers
(Albers,
2007).
Midwives are responsible for staying informed about the outcomes of maternal mobility
in labor and the effect of positions in which a woman chooses to labor. Consumer choices
in maternity care are partially determined by clinician preference, by what is available in
the birth setting, and by lack of full informed consent for common forms of care (Albers,
2007). Women cannot be expected to seek care measures that are not being practiced and
are unfamiliar to their care providers. British researchers have recently argued that
achieving a higher rate of normal vaginal birth is associated with clinicians belief in birth
as a physiologic process, evidence-based practice and one-to-one care, and team work
involving a shared philosophy with colleagues (Johanson, Newburn, & MacFarlane,
2002).
High quality health care involves practices that are consistent with the best known
evidence. Midwives in the twenty-first century must use evidence-based care in an
environment that reveres technology and is mistrusting traditional noninterventional
approaches to care (Varney, 2004 p. 794). With the majority of midwives currently
working in a hospital setting, care rendered to laboring women must incorporate the best
evidence-based practices. Depending on type of care received, the laboring womans
confidence in her ability to labor and give birth may either be enhanced or diminished.
The common use of interventions and treatments during labor and the resulting low
proportion of spontaneous vaginal births argue for modifications in the current priorities
in hospital based care (Albers, 2007). Midwives in the United States can argue forcefully
for evidence-based care, which fully supports the midwifery model of care (2007).
Therefore, as natural as the wave-like contractions which move the passenger down the

passage, the womans natural response to mobilize and adapt to the rhythm of labor still
remains in need of good evidence in order to penetrate through the intervention-driven
approach to maternity care.

Chapter 2: Review of Literature & Conceptual

Framework
Maternal mobility and upright positioning during the first stage of
labor is greatly underutilized in the hospital setting among developed nations.
With modernization of birth care practices and an increasing use of
interventions, such as continuous fetal monitoring and epidural anesthesia,
supine recumbent positions became the norm for the majority of parturient
women. The rising rate of cesarean sections in this country is of great concern,
with an increasing amount of research targeted to identify modalities that
prevent negative outcomes and surgical interventions. The study and use of
mobility and upright positioning have been neglected in literature as well as in
practice, despite their well-documented use by women as far back as early
human civilization. A shift away from the normal labor approach, infused with
high-tech interventions has failed to produce improved outcomes. With a
renewed interest in natural birth and increase in the use of evidence-based
practices in the healthcare setting, mobility and maternal positioning have
regained the interest of researchers and healthcare providers alike.
Conceptual

Framework

Theoretical and conceptual frameworks play several interrelated roles in

progress of science by making research findings meaningful and generalized
(Pilot & Beck, 2008). Theories allow researchers to bind together observations
and facts in an orderly scheme, especially while drawing together accumulated
facts from separate and isolated investigations. By linking findings into one
coherent structure, the accumulated evidence is made more accessible, and
consequently, more useful (Polit & Beck, 2008). Therefore, conceptual
frameworks can act like maps that give logic to the experimental inquiry.
Theories are an important resource for the development of interventions used in
practice that are evidence-based. Along with summarizing, theories and
models can guide a researchers understanding of not only the what of natural
phenomena but also the why of their occurrences (Polit & Beck, 2008 p.145).
Theories often provide the basis for predicting the occurrences of phenomena,
which in turn, have implications for the control of these events. As a result,
theories and conceptual frameworks guide advances in practice by

accumulating knowledge and evidence of the phenomena studied.

Labor is a physiologically and psychologically stressful time for both the
mother and fetus. The maternal anatomy and physiology is capable of adjusting
to the stressors presented by parturition and does so in many different ways. By
doing this, the chances of better outcomes for both the woman and neonate are
increased. Maternal positioning affects many aspects of the anatomy and
physiology adaptations needed to influence all aspects of labor including
powers, passage, passenger and psyche. Positioning during labor influences the
characteristics and effectiveness of uterine contractions, fetal well-being,
maternal comfort, and course of labor (Blackburn, 2007 p. 142). The
conceptual framework guiding this study is based on both maternal
anatomy/physiology and biomechanical principles of positioning, along with
maternal/fetal stress response in labor influenced by pain and the overall ability
to
cope.
Labor and delivery are not passive processes in which uterine contractions
push a rigid object through a fixed aperture (Gabbe, 2007 p. 305). The ability
of the fetus to be born vaginally is dependent on the complex interaction of
uterine activity, the fetus, and maternal pelvis, also known as the four Ps powers, passenger, passage and psyche. Parturition is a multifactorial
physiologic process that involves multiple interconnected positive feed forward
and negative feedback loops (Blackburn, 2007 p. 131). When labor occurs
normally, both maternal and fetal processes are involved. Major events in
parturition during the first stage include myometrial contractility, cervical
dilation, and possibly fetal membrane rupture (Varney, 2004).
The powers refer to the forces generated by the uterine musculature. Significant
hemodynamic changes can be attributed to the pain and anxiety associated with
labor and delivery, due to release of catecholamines and the increased vascular
tone (Blackburn, 2007). Much of the increasing maternal cardiac output is
distributed to the uteroplacental circuit. The decline in uterine vascular
resistance allows blood flow to the uterus to increase. Supine positioning
results in lower cardiac output, increased heart rate, and decreased stroke
volume (Blackburn, 2007). In a supine position, maternal blood pools in
dependent vessels, which reduces venous return and decreases cardiac output
and blood pressure with increasing orthostatic stress (2007). The gravid uterus
is also associated with a significant amount of caval blood flow obstruction in
the supine position (Blackburn, 2007, p. 274). After the first trimester, the
supine position is associated with a nine percent decrease in cardiac output
(Wang & Apgar, 1998). In this maternal position the aorta may also be
compressed, which can alter arterial blood pressure, but can be reversed in the

left lateral position (Blackburn, 2007). Any other position, other than supine,
can affect blood flow by decreasing pressure on the great vessels by the gravid
uterus. Mobility can further increase perfusion and affect the mother and fetus.
In addition to a decrease in pressure from the enlarged uterus, mobility results
in hemodynamic changes that maximize cardiac output and optimize blood
flow to the placenta and the developing fetus (Wang & Apgar, 1998). Prolonged
motionlessness is associated with a decrease in cardiac output of up to 18
percent
(1998).
With the onset of labor, there is an increased demand for oxygen. The increase
in oxygen consumption is largely due to uterine muscle activity. When there is
insufficient time for uterine relaxation and restabilization after a contraction,
oxygen content is lower and myometrial hypoxia as well as metabolic acidosis
may occur near the next contraction (Blackburn, 2007). Over time this can lead
to inadequate oxygenation, which increases the severity of the labor pain
perception and prolonged labor. Myometrial lactic acidosis and a small
decrease in oxygen saturation may be contributing factors to dysfunctional
labor (Quenby, et al, 2004). Subjective interpretation of labor and the pain
experience can trigger maternal hyperventilation and alter fetal homeostasis
(Blackburn, 2007) affecting neonatal outcomes, in addition to negative
maternal
outcomes.
During pregnancy, hormonal changes are thought to induce a greater laxity in
joints, assisting in the softening of the pubic symphysis to accommodate
delivery (Wang & Apgar, 1998). Relaxin and progesterone affect the cartilage
and connective tissue of the sacroiliac joints and the symphysis pubis and
increase ligamentous laxity (Blackburn, 2007). Widening and increased
mobility of the sacroiliac synchondroses and symphysis pubis begins by ten to
twelve weeks gestation, with the symphysis pubis widening up to ten
millimeters (2007). With the help of the normal physiologic adaptations
occurring in pregnancy, maternal movement and positioning are also believed
to alter the dimensions of the pelvis. It has been demonstrated that there is a
significant increase in interspinous diameter in the last trimester of pregnancy
and after childbirth, which is depended on maternal positioning (Michel, et al,
2002, al Ahwani, et al, 1991). A decrease in mobility and use of horizontal
positions during the intrapartum period deprives the mother of the advantages
of gravity. Gravity aids other biomechanical maternal principals in guiding the
fetus into a desirable alignment and adapting to the maternal pelvis in a way
that is more accommodating for a normal, vaginal birth. Malpresentations and
malpositions which often occur with epidural use, such as the occiput posterior
position, are largely due to a decrease in maternal mobility and horizontal

posture as a result of this form of anesthesia (Sizer & Nirmal, 2000).

The process of labor involves significant pain and stress for most women. Pain
during the first stage of labor results from a combination of uterine contractions
and cervical dilation (Gabbe, 2007 p. 396). Painful sensations travel from the
uterus through visceral afferent or sympathetic nerves that enter the spinal cord
through the posterior segments of thoracic spinal nerves (2007). Since maternal
and fetal stress response to pain of labor is more difficult to assess, most
researchers describe and quantify stress in terms of the release of
adrenocorticotropic hormones, cortisol, catecholamines, and beta-endorphins.
Early labor is accompanied by continual elevations in plasma
adrenocorticotropic hormone and cortisol levels, followed by increase in
epinephrine, norepinephrine, and beta-endorphins throughout labor (Blackburn,
2007). Stress has been known to negatively affect labor progress due to a
uterine relaxant effect of beta-adrenergic agents, along an increase in
epinephrine which is associated with anxiety and prolonged labor (Gabbe,
2007). Both epinephrine and norepinephrine decrease uterine blood flow
affecting fetal status. Maternal psychological stress, which increases
catecholamine levels, affects uterine blood flow and fetal acid-base status, as
demonstrated in animal studies (Gabbe, 2007). Maternal physical and
psychological comfort in labor is crucial for preventing additional stress. This
can further be accomplished by allowing the mother to move freely and follow
her bodys signals to mobilize and change position during labor.
Definitions

of

key

concepts

and

relationships

The term "maternal birthing position" refers to the various physical postures the
pregnant mother may assume during the process of childbirth, with position,
posture, and attitude, as the arrangement of the body or its parts
(Dictionary.com, 2010). Labor positions can be categorized into two groups,
either the upright or recumbent positions. The recumbent position includes
supine, semi-recumbent, and lateral positions. Upright positions include
walking, sitting, standing, leaning, kneeling, squatting and all-fours.
Consequently, the position a laboring woman assumes affects her anatomy and
physiology. Maternal anatomy includes adaptations of the womans body to the
various positions during the first stage of labor that affect all bodily structures.
Physiology refers to mechanical, physical and biochemical functions that are
affected by maternal mobility and positioning during labor. The alterations in
the maternal anatomical structures and physiological functions impact the
interaction between all mechanisms of labor including powers, passenger,
passage, and psyche. Outcomes affected by mobility and upright positioning
are categorized as maternal, fetal or neonatal. Maternal outcomes include labor

duration, decrease in pain perception or ability to cope and mode of delivery.

Fetal and neonatal outcomes include fetal heart rate during the intrapartum
period and Apgar scores after delivery. This inquiry focuses on how maternal
mobility and positioning affect the anatomy and physiology of the mother, by
affecting the four Ps of labor and consequently maternal, fetal and neonatal
outcomes. (Refer to Table 1).
Table 2: Maternal Labor Positions
Upright Positions
Recumbent Positions
Walking
Supine
Sitting
Semi-recumbent
Standing
Lateral (left or right)
Leaning
Kneeling
Squatting
All-fours/hands-and-knees
Figure 1: The Interaction of Maternal Anatomy and Physiology and their effect on
the Four Ps of Labor

Please open file for Figure 1 and conceptual map

Conceptual

Map

A conceptual map is a schematic representation of a theory or conceptual model

that graphically represents key concepts and linkages among them (Polit &
Beck, 2008 p. 749). The conceptual map or diagram which reflects the key
concepts for this inquiry is illustrated on the attached document. See attached
document

Literature
Search

(conceptual

map).

Review
Strategy

A systematic literature review was conducted to gather information on maternal

mobility and positioning during the first stage of labor and outcomes for both
the mother and baby. Articles selected for this review only addressed labor
positions and mobility during the first stage of labor, and those pertaining to
second stage were excluded. Studies were retrieved through the Google Scholar
search engine, American College of Nurse Midwives (ACNM) websites
journal search, as well as Philadelphia Universitys multiple electronic
databases. Research studies from international journals were also reviewed to
incorporate a diverse outlook on labor management and practices and the effect
on
outcomes
for
women
and
neonates.
The

Powers

One of the earliest studies to measure the effects of ambulation in labor using
continuous monitoring by radiotelemetry was done in England and has been
published in the British Medical Journal. While studying the effect of
ambulation on labor, Flynn, Kelly, Hollens and Lunch (1978), determined that
mobility has human benefits for both the mother and fetus. A randomized
prospective study conducted in England included 68 women. Randomized
controlled trials are considered by many a gold standard for yielding reliable
evidence about cause and effects, and can achieve greater confidence in casual
relationships because they are observed under controlled conditions (Polit &
Beck,
2008).
Thirty-four women were assigned to each group (either ambulant or recumbent
position in active labor), including 17 primigravidas and 17 multigravidas in
each group. All participants were between 37 and 42 weeks gestation, and were
between 16 and 38 years of age. The fetal presentation was cephalic in 33
participants and 1 breech in each group. A fetal electrode was applied to the
presenting part and an intrauterine pressure catheter inserted when the cervix
was at least two centimeters dilated and the woman was in spontaneous labor.
An amniotomy was performed if the mothers membranes were still intact in
order to apply the monitors. The participants in the ambulating group were
encouraged to move around as long as she wished with the continuous
monitoring of uterine contractions and fetal heart rate via a telemetry monitor.
Patients in the recumbent group were assigned to remain in the lateral position
throughout all stages of labor, with conventional bedside monitoring of the fetal
heart and intrauterine pressure. Cervical dilation and descent of the presenting
part were initially assessed at the start of monitoring and then every two hours
during labor. Analgesia was administered when the midwife thought the patient
was becoming distressed with pain (Flynn, Kelly, Hollens & Lunch, 1978).
Anelgesia medications included promethazine, promazine, and bupivacaine.

Augmentation with oxytocin or prostaglandin was given when indicated by

delay in labor. When intravenous treatment was necessary in the ambulant
group, the patient was returned to bed, unless oral prostaglandin was
administered after which the mother could remain ambulatory. The MannWhitney U Test was used to analyze the data gathered in this trial. HewlettPackard 78100A radiotelemetry was used to record contraction pattern and fetal
heart
rate.
The results of the study revealed that ambulation had several benefits. First,
uterine action was shown to be significantly better in the ambulant group. The
first stage of labor for the ambulant group was shorter, an average of 4.1 hours,
than those in bed who labored an average of 6.7 hours (p< 0.001). Contraction
amplitude resulted in an average of 55.53 mmHg in the ambulant group and
46.54 mmHg in the women who remained in bed (p<0.005). More women who
remained in the recumbent position needed augmentation. The number of
women who ambulated and still needed oxytocin was six, compared to twelve
women who remained recumbent. There was no significant difference in the
mean dilatation of the cervix between the ambulant compared with recumbent
group. Mode of delivery appeared to be effected by ambulation also (see Table
4). The majority of the women in the ambulant group had normal vaginal
births, and no one required a cesarean section. Also, Apgar scores were higher
for women in the ambulant group, showing a beneficial effect of ambulation on
the fetus and newborn as well (see Table 5).
Table 4: Mode of Delivery for Women who Remained Ambulant vs. those in Bed
Significance
Mode of Delivery
Ambulant (n=34) Bed (n=34)
difference
Normal
31
22
Assisted breech
1
1
nd
Forceps (for delay of 2
2
10
p<0.01
stage)
Cesarean section (for fetal
distress and failure to 0
progress
(Flynn, Kelly, Hollens & Lunch, 1978)

of

Table 5: Fetal Heart Rate and Apgar Score Results

Accelerations
contractions
Decelerations

with

Ambulant (n=34) Bed (n=34)

Significance
difference

10

p<0.01

p<0.005

with 2

of

contractions:
Early
2
Variable
0
Late
Apgar
score
8*8
1-minute
9*9 (9-10)
5-minute
(Flynn, Kelly, Hollens & Lunch, 1978)

6
4
(7-10)

p<0.01
p<0.05

This research supports the theory that mobility benefits the laboring mother as
well as the fetus in many different ways. However, this study does have several
limitations. The author states that analgesia was administered upon the
midwifes assessment of patient status, but does not state that it was given per
patient request. It also does not identify how long the ambulant participants
who received analgesia remained recumbent. In addition, the continuous use of
technology, along with the discomfort of an intrauterine and fetal electrodes
placed internally in a woman may have caused significant discomfort and
therefore affected labor progression and fetal outcome. These variables studied
were not addressed by the author in the discussion. A strength of this study was
that continuous monitoring of fetal heart rate pattern and uterine contractions
presented solid evidence of the effect of walking on labor and the fetus. The use
of automated equipment reduces the chance of error (Polit &Beck, 2008), and
particularly in this study, clearly shows the benefits of ambulation on
contraction intensity and fetal heart rate variations. Overall, this limited
research does in fact outline many of the benefits of ambulation for maternal
and
neonatal
outcomes.
It is a well-known fact that the supine position in late pregnancy is associated
with decreased blood flow due to pressure exerted by the gravid uterus on
major maternal blood vessels. A decrease in blood flow affects the ability of the
uterus to contract adequately during labor. Kerr, Scott and Samuel (1964),
studied the effect of the supine position on the inferior vena cava during late
pregnancy. Inferior vena caval pressures were recorded in a total of twelve
women. An earlier observation was conducted with four patients known to have
an abnormal fetus and in whom pregnancy was to be terminated (two cases of
anencephaly; one cervical meningocele; one encephalocele). The other group of
women studied included eight patients between 38 and 40 weeks gestation, two
of which had abnormal fetuses at 32 weeks with gross hydramnios. In every
patient in this series, the fundus of the uterus was within 2 in. (5 cm.) of the
xiphisternum (Kerr, Scott & Samuel, 1964). X-ray filming was performed just
prior to the delivery, via elective cesarean section for various obstetric
reasons now out of vogue (Kerr, Scott & Samuel, 1964).

Simultaneous catheterization of both femoral veins was performed, and both

were passed along the femoral vein as far as the junction of the internal and
external iliac veins. After placement, just prior to filming, a urografin
solution was injected (Kerr, Scott & Samuel, 1964). This procedure was carried
out under anesthesia, and immediately after the first film has been taken, the
cesarean section was carried out with catheters left in place. Catheters were
perfused with saline to prevent clotting. After the delivery of the fetus, prior to
the closure of the abdomen, the uterus was lifted forward, a second bolus of dye
injected and another film taken. No adverse reactions were noted during the
procedure. This technique allowed the inferior vena cava to be visualized in the
absence of any compression by the gravid uterus (Kerr, Scott & Samuel, 1964).
Results showed that in the cases with abnormal fetuses, where the radiation
hazard was not thought to be of importance, films were also taken in the
lateral position in order to shift the uterine weight forward. These films
demonstrated the passage of dye up the inferior vena cava, although there still
appeared to be some degree of compression of the vein by the gravid uterus
even in the lateral position. It was found that in 10 out of the 12 cases
examined, complete obstruction to the passage of medium occurred at the level
of
the
bifurcation
of
the
inferior
vena
cava. In other words, the vein is not occluded at a single point near its origin,
but evenly throughout its course as high as the fundus reaches (Kerr, Scott &
Samuel, 1964). The study established that in the supine position in late
pregnancy, it is normal for the inferior vena cava to be virtually completely
occluded in supine positions by the gravid uterus. In addition, the renal veins
drain into the inferior vena cava and have no alternative drainage. Therefore,
obstruction to the inferior vena cava at the level of entry of the renal veins
implies increased renal venous pressure. Finally, the researchers concluded that
posture has profound effects on the circulation in late pregnancy and in the
lateral position obstruction is least partially relieved (Kerr, Scott & Samuel,
1964).
Despite the numerous limitations of this study, including a very limited number
of participants, lack of disclosure regarding informed consent, and several
ethical considerations, the research does clearly outline the physiologic
consequences of supine positioning. Being that this study was carried out over
four decades ago, it is obvious that it lacks strong design measures and has
considerable ethical faults, such as exposure of fetuses to x-rays despite having
known abnormalities. The number of women studied was also small. However,
for this type of research it is difficult to recruit a large number of participants
due its complicated research design and method of investigation. In addition,

performing a femoral catheterization during an already risky abdominal surgery

with the injection of radiographic dye, places the patient at an increased risk for
complications. There was no mention of informed consent given by any of the
participants, as well as no disclosure of approval by any type of ethics
committee for this research. These limitations would make this type of research
extremely difficult to repeat, especially if a larger group was considered for
future
study.
Nevertheless, this study clearly shows the advantage of upright positioning on
the maternal hemodynamics during late pregnancy. With the uterus in a forward
position, the obstructed blood flow is minimized, further implying that
ambulation and upright posture has positive effect on maternal and fetal wellbeing. The authors urge careproviders and researchers to consider this concept
when caring for or studying women who are late gestational age. Reduced
pressure on maternal blood vessels promotes venous return and cardiac output,
thus increasing uterine perfusion and fetal oxygenation (Blackburn, 2007).
Bodner-Adler et al (2003) studied 307 women who delivered in an upright
position in a large University Hospital of Vienna, Austria, between 1997 and
2002. This case-controlled study was aimed at comparing maternal, perineal
and neonatal outcomes of upright and supine birth positions in low-risk women.
The participants selected had uncomplicated pregnancies, an uncomplicated
first and second stage of labor, were over 37 weeks gestation, had a normal size
fetus, and a pregnancy with a cephalic presentation. During the study period,
614 women where studied and 307 women were assigned randomly to upright
positioning and 307 women to supine positioning. Eighty five primiparas and
222 multiparas were randomly selected for the upright positioning, and any
women with medical or obstetric factors were excluded. Patients undergoing
epidural analgesia during delivery were excluded from the study. Chi-square
tests were used to compare the frequency distributions of binary outcomes
between the two subject groupings. Continuous variables were compared using
a t-test. P-values smaller than 0.05 were considered statistically significant. The
SPSS
system
was
used
for
the
calculations.
Information on all the events occurring during the labor and delivery was
recorded on a pre-coded form by an experienced physician. The information
included:
1.
2.
3.
4.

duration
of
occurrence
presence

the

first
of
or

and
second
obstetric
absence

parity
stages
of
labor
laceration
of
episiotomy

5.
use
of
oxytocin
6.
use
of
homeopathy
7.
use
of
medical
analgesia
(Nubain,
Alodan,
and
Tramal)
8. severe postpartum hemorrhage (maternal blood loss > 500 ml)
9. neonatal parameters determined by APGAR score at 1 and 5 minutes (cut off point 7 as
the
minimal
acceptable
score)
10. cord pH
The results of this study showed a benefit of using upright positions because they seemed
to be associated with a decrease of medical analgesia (31/307 vs. 64/307; p=0.001) and
oxytocin use (32/307 vs. 64/307: p= 0.001). There was also a significant decrease of
episiotomy observed in women choosing an upright position (p = 0.0001). Perineal
lacerations occurred more often when the patient was upright, but the difference did not
reach statistical significance (88/307 vs. 68/307; p=0.078). The researchers observed no
significant difference in the amount of blood loss between the two groups. As far as
neonatal outcomes, there was no difference found in neonatal outcomes determined by
the
Apgar
score
and
cord
pH.
This study further supports the fact that upright labor positioning appears to benefit
maternal and neonatal outcomes. The strengths of this study included a large sample size
and the ability to randomize participants into two groups. Although having multiple study
sites is advantageous in terms of enhancing the generalizability of the study findings
(Polit & Beck, 2008), this trial provided consistency by being carried out in a single
institution in addition to only including women who were low-risk. The population
studied may vary in several ways when compared with the general population in this
country. First, there may be significant differences in the overall health between this
studys population and that of those in our nation. Diet, overall activity level, childbirth
beliefs and expectations, and the culture of the healthcare facility may greatly vary
between the Austrians and Americans. Overall, the findings support the use of upright
positioning during labor in order to enhance maternal and fetal physiologic function and
improve
outcomes
for
both.
The aim of the study by Frenea, et al (2004), was to investigate two primary maternal
outcomes - duration of labor and pain scores, by comparing ambulation versus
recumbence in women with uncomplicated term pregnancies receiving epidural
analgesia. After approval by the institutions ethics committee and an obtained informed
consent, nulliparous and multiparous mothers were randomly assigned to be recumbent
(Group 1) or ambulant (Group 2) using sealed, numbered envelopes after participants had
received the first dose of epidural analgesia. Overall, 64 women were studied over a
period of one year, however only 61 or the participants were included in the results since
three of the women were excluded due to adverse effects of the epidural infusion. Women
between 37 and 42 weeks gestation, with a fixed, cephalic, uncomplicated pregnancy
were chosen for this study. The mothers also had to be 3 to 5 centimeters dilated at the
insertion of the epidural, and could be either in spontaneous labor or induced. According
to Polit & Beck (2008), screening criteria and the randomization allows for the two
groups to be similar, making the results more valid. In Group 1, patients were confined to

bed in dorsal or lateral recumbence. In Group 2, patients were asked to walk at least 15
minutes of each hour or at approximately 25 percent of the duration of the first stage of
labor.
Fetal heart rate was continuously monitored, and 5001000 milliliter (ml) of Ringers
lactate solution infused IV before the epidural analgesia. A lumbar epidural catheter was
inserted 45 cm into the L3-4 or L4-5 interspace through a 18-gauge Tuohy needle with
the patient in the sitting position. After a test dose of 3 ml of 2% lidocaine with 1:200,000
epinephrine, a first analgesic dose of a total of 15 ml of a solution containing 0.08%
bupivacaine with 1:200,000 epinephrine and 1 g/ml of sufentanil was injected through
the epidural catheter in 2 boluses 5 minutes apart. In Group 2, ambulation was permitted
15 to 20 minutes after the initial injection, provided there were no adverse maternal or
fetal side effects, such as postural hypotension, motor block in lower limbs,
proprioception impairment, and fetal heart rate decelerations. The patient was
accompanied by her spouse or a midwife at all times while walking around the labor and
delivery
suite.
The level of pain was assessed using a visual analog scale (VAS). VAS, a scaling
procedure used to measure certain clinical symptoms (e.g. pain, fatigue) by having the
patient indicate on a straight line the intensity of the symptoms (Polit & Beck, 2008), is a
useful tool for quantitative assessment of pain. In this study, 0 mm equaled no pain; 100
mm was equal to the greatest amount of pain, and adequate analgesia was defined as a
VAS <30 mm. In both groups, intermittent top-up of 15 ml of the 0.08% bupivacaine
solution was administrated by the anesthesiologist whenever the patient had pain again. If
pain persisted for 15 minutes after the top-up (VAS >30 mm), an additional 5 ml of
0.25% bupivacaine was given. The maximal dose of sufentanil did not exceed 30 g. The
management of analgesia was under anesthesiologist care only. The women were asked to
return to bed when they requested an epidural top-up or if they experienced weakness or
sensory changes. Walking ended when examination by the midwife revealed full cervical
dilation. In spontaneous labor, augmentation with oxytocin was used if labor was
considered ineffective, preceded by an amniotomy if the fetal membranes were intact.
Oxytocin administration was standardized according to department standards.
The present study indicates that ambulation for more than 25 percent of the first stage of
labor under epidural analgesia did not significantly change the length of the labor or other
outcomes of labor and delivery. The mean walking time of the 25 participants who
actually walked was 64 34 min (mean sd). This time corresponds to 29% 16% of
the interval from epidural insertion to complete cervical dilation (first stage). However,
this result may have been affected by the fact that there was epidural anesthesia on board
for the mothers and may have prevented them from freely ambulating for greater periods
of time. There was no abnormality of fetal heart rate during ambulation. Three babies
were born with an Apgar score less than 7 at 1 minute, which resolved at 5 minutes. Two
of these babies were of mothers from Group 1, and one from Group 2. However, there
was an evident reduction in analgesic requirements in the ambulatory group, and a
reduction for an increase in oxytocin dosing. In addition, ambulation led to a significantly
larger number of patients able to spontaneously void and in less need for bladder

catheterization in the last hour of labor (Frenea et al, 2004). The interview on the day
after delivery revealed that many women were extremely satisfied in both groups, and
that most of the ambulatory patients (28 out of 30) would choose to walk again during a
future labor (see tables 6 and 7 below).

Table 6: Pain Visual Analog Scale (VAS) scores in Group 1 (recumbent) and Group 2
(ambulatory).
(Frenea, et al. 2004)
Table7:
Labor
and
delivery outcomes in the
Group 1 (recumbent)
and
Group
2
(ambulatory)
Group 1

Group 2

Duration of labor (min):

epidural-delivery
epidural-CCD (a)
expulsion phase (a)

289 164
199 111
62 59

304 137
239 125
56 42

Cervical dilation rate (cm/hr) (a)

Oxytocin augmentation
Oxytocin (mIU/min) (b)

2.5 1.7
27
10.2 8.8

1.9 1.1
24
6.4 2.2

Bupivicaine (mg/h)

8.4 3.6

6.4 2.2

P value
0.70
0.23
0.65
0.17
0.69
0.03
0.01

Top-ups
3.4 1.7
3.0 1.2
0.36
Interval between top-up (min)
116 39
135 44
0.07
Deliveries
(#):
23
19
Spontaneous
4
6
0.65
Forceps
4
5
cesarean
Birth weight (g)
3417 435
3229 406
0.09
Apgar <7 at 5 min (n)
0
0
Umbilical artery pH
7.24 0.09
7.27 0.06
0.16
Values are mean sd.CCD = complete cervical dilatation. For all comparisons, the
number of subjects was 31 (Group 1) and 30 (Group 2), except in (a) (28 and 25,
respectively) and in (b) (27 and 24, respectively). (Frenea, et al, 2004).

There were several reasons why this studys data might have possibly failed
to show an effect of ambulation on labor duration. First, fewer than half of the
patients who had been assigned to walk did so and the time spent walking was
short, or defined as a minimum of five minutes walking per hour. Due to this
limitation, it would be difficult to accurately measure how prolonged
ambulation can affect labor progression. Second, the fact that the authors
included women whose labors were being augmented might have significantly
affected the results of the study. In addition, according to the authors, the
midwives who were responsible for oxytocin management did not receive
specific instructions regarding its administration and any set criteria that might
have been considered a valid variable (Frenea, et al, 2004). As a result, the
overall length of labor was similar between groups and oxytocin augmentation
did not affect the requirement for bupivacaine (Frenea et al, 2004). The results
of this study suggest that the lack of benefit on duration of labor may be offset
by the use of smaller doses of oxytocin in the ambulatory group (Frenea et al,
2004). Nevertheless, the data regarding other variables, such as patient
satisfaction with ambulation and ability to void, do coincide with improved
maternal outcomes of ambulation previously mentioned in this inquiry.
The

Passenger

A quantitative randomized trial conducted by Stremler, et al (2005) evaluated

the effect of maternal hands-and-knees positioning on fetal head rotation from
occipitoposterior (OP) to occipitoanterior (OA) position, persistent back pain,
and other perinatal outcomes. This large randomized, controlled trial involved
thirteen labor units in university-affiliated hospitals in Argentina, Australia,
Canada, England, Israel and the United States, included 147 women over a
period of 28 months. The mothers were all over 37 weeks gestation, and
confirmed by ultrasound to have fetuses in an occipitoposterior position.
Seventy women were randomized to the interventional group, which assigned
women to the hands-and-knees position for 30 minutes over a one-hour period
during labor. The rest of the participants were the control group, and were
allowed to use any position other than the hands-and-knees during labor. The
primary outcome studied was the rotation of the fetal head. Other outcomes
included persistent back pain, a questionnaire evaluation of the womans
experience of personal control during labor and birth, in addition to additional
labor and delivery outcomes that were retrieved from a later chart review.
The results of the study revealed that 16 percent of the women allocated to use
the hands-and-knees positioning had fetal heads in OA position after the one
hour study period compared with seven percent in the control group (RR
2.42%; 95% CI 0.88-6.62; number needed to treat 11). Furthermore, persistent

back pain scores, which were obtained by having the woman answer a Short
Form McGill Pain Questionnaire (SF-MPQ) were significantly reduced in the
intervention group. No statistically significant differences were found between
study groups on the other outcomes. However, results did show a beneficial
effect on outcomes for the intervention group, especially in operative delivery,
fetal head position at delivery, one-minute Apgar scores, and method of
delivery
(Strembler,
et
al,
2005).
This study demonstrates that the hands-and-knees position had a positive effect
on both the maternal as well as fetal outcomes. As a well-designed prospective
randomized trial, the study clearly outlined the benefit of using this posture
during a labor complicated by a fetus in an OP position. The authors did point
out that the sample size for this trial may not have been large enough to
consider some of the data, especially other outcomes, to be considered
statistically significant and to have statistical power. Statistically significant
data is not likely to result from chance fluctuations at the specified level of
probability (Polit & Beck, 2008). In addition, most participants of the study
were randomized at about three centimeters dilation, and over half were
ruptured. It was noted that the effect of hands-and-knees positioning may be
influenced by the degree of dilation, engagement, and membrane status
(Strembler, et al, 2005). Finally, it may be difficult for some women to hold
such a posture, especially without adequate support, which may have
influenced the outcomes due to inadequate time spent on hands-and-knees.
Despite these limitations, the hands-and-knees position has been shown to
improve outcomes for both the mother and baby, and should be utilized in the
presence
of
a
persistent
OP
position
of
the
fetus.
The

Passage

With an increasing use of epidural anesthesia for pain control, more laboring
women are subjected to recumbent positioning due to their inability to mobilize
after its administration. Compared to high-dose epidurals where mobility is
impossible, mobile epidurals have been shown to reduce instrumental vaginal
delivery rates (Wilson, MacArthur, Cooper, & Shennan, 2009). Ambulation in
an upright posture during labor was studied by Wilson, MacArthur, Cooper, and
Shennan (2009), who studied 1052 primiparous women in two tertiary care
hospitals in the United Kingdom. Women who were planning on delivering at
these hospitals were given educational material regarding epidural anesthesia at
34 weeks gestation, and were later counseled upon request of anesthesia by the
administering anesthesiologist prior to obtaining consent. In this study
particularly, obtaining informed consent is essential in order for the participants

to have adequate information regarding the research. It is also important be able

to fully comprehend all the information presented, have the power of free
choice, and be able to consent or decline voluntarily (Polit & Beck, 2008).
After their consent for epidural anesthesia, the participants were randomized to
either the control group consisting of high-dose epidural, Combined Spinal
Epidural (CSE), or Low-Dose Infusion (LDI). This trial was approved by the
local
ethics
committee.
The data was collected throughout labor and delivery by the attending
anesthesiologist and midwife. Women were also interviewed 24-48 hours after
delivery by a research midwife. The primary outcome studied was mode of
delivery, with secondary outcomes including progress of labor, effectiveness of
pain relief, neonatal effects, requirement of urinary catheterization, and the
level of maternal mobility achieved during labor. Women, who stood out of bed
or walked for a total of at least one hour of first stage labor after epidural
insertion, were considered ambulatory. Women who remained in bed
throughout labor, despite normal power or walked for less than an hour in total,
were considered sedentary. Data revealed that there were no differences in
the mode of delivery between the first stage ambulatory and sedentary groups
(See Table 8). Women, who attained a greater level of mobility during first
stage in the mobile group were no more likely to progress to spontaneous
vaginal delivery (Wilson, MacArthur, Cooper, & Shennan, 2009).

Table 8: Observational analysis of first stage ambulatory and sedentary women by

epidural technique and delivery mode.
CSE n = 351
LDI n = 352
Delivery mode Ambulator
Sedentary 218
Ambulatory 128 Sedentary 222
y 133
SVD
Instrumental
Caesarean

(Wilson,

61 (46%)
36 (27%)
36 (27%)

MacArthur,

89 (41%)
66 (30%)
63 (29%)

Cooper,

54 (42%)
37 (29%)
37 (29%)

&

96 (43%)
61 (28%)
65 (29%)

Shennan,

2009)

However, the results of this study did suggest that in women who progressed to
vaginal delivery, ambulation in the second stage of labor was associated with a
greater likelihood of a spontaneous delivery, although only a very small portion
of women (11 percent) chose to ambulate during second stage. The study does

mention that the low-dose infusion epidural is a safe and effective form of pain
relief that offers women the opportunity to stay mobile, if they chose to do so
during labor. In addition, the researchers believe that the preservation of motor
function in the lower body and perineum may be enough to assist voluntary and
involuntary maternal efforts to expel the fetus without the assistance of
gravity, despite presenting data that does not support this statement (Wilson,
MacArthur,
Cooper,
&
Shennan,
2009).
One major limitation in the description of the results of this study was that the
authors failed to identify other outcomes studied and focused on specifically the
delivery mode and the mothers ability to stay mobile after initiation of
anesthesia. Although they clearly outline no difference in between the two
groups pertaining to the mode of delivery, there is no mention of the data
addressing neonatal outcomes and duration of labor. A strength of this trial
included a large sample size studied, since a smaller sample size tends to
produce less accurate estimates (Polit & Beck, 2008). This study, however, does
not indicate any negative effect of ambulation on either maternal or fetal wellbeing. The duration of ambulation is not clearly stated by the authors and the
average time mothers spent walking was also not stated. The right dose of
walking with epidurals is not well-defined, which can influence the outcomes
of this study. Therefore, mobility and upright positioning remains a safe
alternative for women who chose to labor in positions other than supine.
A more biomechanical perspective of how positioning effects the passage
was studied by Michel, et al (2002) with the use of magnetic resonance imaging
(MRI). These researchers measured the impact of supine and upright birthing
positions on MRI pelvic dimensions. Thirty five, non-pregnant female
volunteers were recruited, ages 22 through 43 years old, and assigned to two
groups nulliparous and parous. Most parous group participants had one child,
with one having had two children. All parous women studied delivered at least
nine months prior to imaging. A 0.5-T low field vertically open configuration
magnetic system was used. Imaging was performed with the participants in the
supine, hand-to-knee (with the woman on hands and knees leaning on a small
cube for support), and squatting positions. The obstetric conjugate, sagittal
outlet, and interspinous, intertuberous, and transverse diameters were measured
on the MR console by the same radiology technician. The obstetric conjugate
and the sagittal outlet were both assessed in the mid-sagittal plane. The
interspinous and intertuberous diameters were assessed in the axial plane.
After reviewing the images and assessing the measurements, the researchers
concluded that changes in birthing position augment pelvic dimensions and
might therefore be obstetrically advantageous (Michel et al, 2002). The results

indicate the sagittal outlet and interspinous diameter to be wider in the hand-toknee and squatting positions than in the supine position (3 5 mm, p = 0.002
and 2 5 mm, p = 0.01, respectively). The interspinous diameter was greater in
the hand-to-knee and squatting positions than in the supine position (6 7 mm
and 8 7 mm; p < 0.0001 in both cases). Intertuberous diameter was greater in
the squatting position than in the supine position (3 7 mm, p = 0.01), but not
greater than in the hand-to-knee position (Michel, et al, 2002). The obstetric
conjugate was the only parameter to be significantly smaller in the upright
squatting position than in the supine position (2 4 mm, p = 0.01), but not in
the hand-to-knee position. Transverse diameter did not change significantly in
any
position.
One major limitation of the study was that the researchers used non-pregnant
women. The authors acknowledge this limitation and the fact that their choice
of participants influenced their ability to measure the impact of pregnancyrelated joint laxity in late gestation (Michel, et al, 2002). The researchers
acknowledge that it would be difficult to recruit pregnant women for this trial
due to ethical consideration of fetal exposure to MRI and the need for
participants to assume a given position for a long period of time leading to
exhaustion. On the other hand, the changes in pelvic dimensions observed in
non-pregnant women should become even more pronounced during delivery
(Michel, et al, 2002) as well as during labor, facilitating a quicker descent,
alignment and progression. Therefore, this study clearly demonstrated that
women should be encouraged to assume upright positioning during labor, and
especially
during
delivery.
The

Psyche

Adachi, Shimada and Usui (2003) conducted a quantitative study in order to

determine if maternal position reduces labor pain during cervical dilation from
six to eight centimeters. Thirty nine (n=39) primiparas and 19 multiparas from
Tokyo, Japan, between 37 to 42 weeks gestation, were studied. All participants
had no obstetric risk factors and had a single fetus in a cephalic presentation.
No pharmacologic methods for pain relief were used during the study by any of
the women. Participants were asked to alternately assume sitting and supine
positions for fifteen minutes during their labor beginning with the cervical
dilation of six centimeters until eight centimeters dilated. Labor pain was
measured with the use of the visual analog scale (VAS), a horizontal line
marked in millimeters from zero, or no pain, to 100, worst possible pain. The
mothers were asked to rate their pain perception at the time, as either being
continuous, occurring with contraction, as well as the location of the pain, as
occurring in the back, the abdomen or both. The women were randomly

assigned to either the sitting or supine group and then asked to alternate.
Results showed the pain scores for the sitting positions to be lower compared to
the scores for those in the supine position, especially for back pain (p < 0.001).
Mothers that reported pain only with contractions as well as those with
continuous back pain had similar relief with sitting (p = 0.001). No major
differences were noted in the perception of abdominal pain in either position (p
= .011). The researchers concluded that the sitting position was an effective
method for the relief of lower back labor pain during the active phase of labor.
This study demonstrates the positive effect on maternal psychological state and
coping effort during the most challenging, transitional stage of labor. Upright
positioning during this time demonstrated to be an effective method in helping
women cope with the painful stimuli, when compared to supine positioning.
Although the study was small and included a limited number of participants,
the researchers were able to randomize the women and therefore strengthen the
studys design, which is often difficult to do with laboring women. The results
of this study reveal benefit in the upright positioning for labor by affecting the
maternal comfort and improving the outcome for maternal ability to cope with
pain. One drawback in applying this particular study to the general American
population is the difference in cultural expression of pain. Among Japanese
women, vaginal deliveries are usually performed with minimal medication, and
the mother tries to be very stoic, using breathing exercises taught during
pregnancy (Purnell & Paulanka, 2003). In the Japanese culture, for the woman
to give into pain dishonors the husbands family, and mothers are said to
appreciate their babies more if they suffer in childbirth (Purnell & Paulanka,
2003). These variations in childbirth practices and beliefs between the Japanese
and American cultures may make the results of this study not as applicable to
the general population in this country. However, it still serves as a good
example of upright positions as one method of pain relief that can be used by
women
if
they
chose
to
do
so
during
labor.
A nonexperimental, descriptive observational pilot study by Stark, Rudell, and
Haus (2008) set out to observe and describe the different positions women
chose while immersed in water during the first stage of labor. Pilot studies are a
small-scale version, of trial run studies, done in preparation for a major study,
or parent study (Polit & Beck, 2008). The outcomes of a pilot study serve as
lessons that can inform subsequent efforts to generate strong evidence for
practice (Polit & Beck, 2008). Seven women from a small, rural community
hospital were recruited for this trial. Three of the women were delivering their
first child and the others have previously given birth. Most women were single,
and all were Caucasian. All were receiving care in a nurse-midwifery practice

that encouraged hydrotherapy and performed water births. Participants were

screened for ineligibility for hydrotherapy, which included being greater than
41 weeks or less than 37 weeks gestation, amnionitis, malpresentation,
receiving intravenous therapy, intravenous or intramuscular narcotic, or a labor
epidural, positive for HIV, hepatitis, or active herpes simplex, or a
nonreassuring fetal heart rate pattern. Two participants were excluded due to
cesarean
delivery
and
precipitous
birth.
The mothers were given the freedom to choose their positions and movements
and to decide when and how long to use hydrotherapy during labor. For 15
minutes of each hour during the first stage of labor, the women were observed
and their positions and movements were noted, while current obstetrical
(contraction pattern and cervical status), maternal, fetal, and environmental
(including tub and room temperature) factors were recorded (see Table 9). In
order to record maternal position and movements during labor, an observational
measurement instrument was created, revised, tested, and revised again. The
researchers used literature review on positions and movement in labor, and
constructed observational categories such as maternal posture, location,
movements, and whether movements were rhythmic, such as, rocking or
swaying. A total of 435 observations were made and recorded, with the women
both
in
tubs
and
in
beds.
It was observed that women preferred to move more often in the tub rather than
in bed. Seven different positions were recorded as the mother was in the
hydrotherapy tub, but only four positions were observed while in bed (see Table
10). Women in the tub chose more positions that were upright, along with more
torso, pelvic, and rhythmic movements, especially during the transitional phase
from seven to ten centimeters dilatation (see Table 11). The most common
position for women in hydrotherapy was sitting in a reclining position, while
most of the women in bed were semirecumbent. In addition, women were
observed contracting during the majority of the time in the tub, while
participants in bed only contracted 25.9 percent of the time. An important
observation during this study was that women moved more often while in the
tub and their movements were more rhythmic, indicating that the womans
natural urge to mobilize can be beneficial in encouraging fetal descent and
alignment as well as for coping (Stark, Rudell & Haus, 2008).
Table 9: Study Participants
Previous
Participant
Age
Births
A
32
1

Time in
Epidural
tub
75 min No

#
of Observations in
Observations tub
33
33

B
C
D
E
F
G
Total

19
18
21
23
20
23

0
0
2
1
0
2

0 min
0 min
0 min
114 min
188 min
0 min

Yes
No
No
No
No
Yes

21
78
16
39
127
121
435

0
0
0
39
51
0
123

Table 10: Movements observed in First-Stage of Labor

In Hydrotherapy (n=123 observations)
In Bed (n=282 observations)
n (%)
n (%)
Torso
48 (39.0)
Torso
46 (16.3)
Pelvis
21 (17.1)
Pelvis
20 (7.1)
Rhythmic
23 (19.7)
Rhythmic
19 (6.7)
*While in the tub, women assumed upright positions known to facilitate fetal descent and
labor progress more often than when in bed. (Stark, Rudell & Haus, 2008).
Table 11: Movements observed in Late First-Stage of Labor (7-10 cm)
In Hydrotherapy (n=106 observations)
In Bed (n=93 observations)
n (%)
n (%)
Torso
43 (40.6)
Torso
12 (12.9)
Pelvis
20 (18.9)
Pelvis
0 (0)
Rhythmic
22 (20.8)
Rhythmic
1 (1.1)
(Stark, Rudell & Haus, 2008).

Despite their unique approach to studying movement and positioning during

hydrotherapy, this study has several limitations. A small, poorly diverse sample
size makes this data harder to generalize the results to the overall population,
however being that this research was only a pilot study, it is expected that a
limited sample size would be used. With this limited sample, the authors were
able to show that this study could potentially serve a greater purpose in
describing positioning in labor if done on a larger scale with a large, diverse
sample population. All women were cared for by midwives who encouraged
particular birthing techniques, including hydrotherapy and mobility, making the
studied population more biased towards the natural birthing. Also, there was a
variation of labor length among women, making some more predisposed to a
longer mobile phase than others. The researchers also note that most
observations of women in water occurred during late labor, but the same is not
true for those women who labored in bed. No birth outcomes or subjective data

such as pain levels were collected, which could have revealed additional
information regarding the effect of hydrotherapy, mobility and positioning in
labor. The authors also point out that the observational tool was new and
previously
untested.
This study contributes to this inquiry by revealing the positive effects on the
mothers ability to mobilize and change position at will when she is not
restricted to the bed for labor. Obstetric care has a history of unchecked
practice, which is one reason why interventions with little or no benefit
continue to be used, and those with potential for improving outcomes and
experiences are slow to be adopted (Lugina, Mlay, Smith, 2004). The current
practice of laboring in bed is mainly attributed to the lack of knowledge
regarding the maternal drive that enables the mother to follow her own
instinctive, rhythmic pattern of movement. While an upright position is
optimal for fetal descent and may provide more comfort, laboring in bed may
suggest to women that they should lie down rather than assume upright
positions (Stark, Rudell & Haus, 2008). This research allows us to observe
laboring women in a less restricted environment that encourages maternal
adaptations to the physical challenge of labor, and shows that when given the
ability, women chose to move and adapt their bodies to a position that promotes
comfort and labor progress.
The effect of walking on labor and delivery was studied by Bloom, et al (1998)
among women with uncomplicated pregnancies between 36 and 40 weeks
gestation in spontaneous labor at the Parkland Memorial Hospital, in Dallas.
The women were randomly assigned to be confined to a labor bed (the usualcare group) or to walk as desired during the first stage of labor (the walking
group). The women assigned to the usual-care group were permitted to assume
their choice of supine, lateral, or sitting positions during labor. The women in
the walking group were encouraged to walk, but were instructed to return to
their beds when they needed intravenous or epidural analgesia or when the
second stage of labor began. Walking was quantified by the use of either nurses
attending each walking woman and recording the number of minutes spent
walking as well as women wearing pedometers. Labor outcomes were
documented by certified nurse-midwives attending each woman. Delivery
outcomes were recorded by the attending nurse, and the data sheets were later
checked for accuracy by research nurses. The infants outcomes were abstracted
from
newborn-discharge
records.
Results of this trial revealed no significant differences between groups in any
characteristics of labor, including the length of the first and second stages of
labor, the need for oxytocin, the development of chorioamnionitis, and the use

of analgesia. Similarly, walking had no effect on the length of the first stage of
labor (Bloom, et al, 1998). Approximately 22 percent of the women randomly
assigned to the walking group did not walk during labor. At the same time,
these women had significantly faster labors, which may have precluded their
walking, as believed by the authors of the study. Furthermore, the findings
showed no significant differences in the frequency of episiotomy, use of
forceps, and cesarean delivery between the two groups (see Table 12 and 13).
Also, no significant differences in the infants outcomes, both in the delivery
room and in the nursery, were found between the two groups.
Table 12: Delivery Outcomes in Walking and Usual-Care Groups
Walking
Group Usual-Care Group
Outcome
P- value
(n=536)
(n=531)
n (%)
Episiotomy
122 (23)
124 (23)
0.86
Spontaneous Delivery
490 (91)
483 (91)
0.39
Forceps Delivery
23 (4)
17 (3)
0.35
Shoulder Dystocia
1 (0.2)
2 (0.4)
0.56
Cesarean
Delivery
17
(3) 17
(3) 0.98
Dystocia
5
(1) 12
(2) 0.08
Fetal
distress
1
(0.2) 1
(0.2) 0.99
Breech
presentation
0
1
(0.2) 0.32
Prolapsed
cord
23 (4)
31 (6)
0.25
Total
(Bloom, et al, 1998).
Table 13: Comparison of the Effect of Walking on Selected Labor and Delivery
Outcomes in Nulliparous and Parous Women *
Outcome
Nulliparous Women
Parous Women
Walking
Usual Care
Walking
Usual Care
Group
Group
P value Group
Group
P value
(n=272)
(n=272)
(n=264)
(n=259)
Labor hours
7.63.9
7.33.9
0.47
4.62.4
4.72.4
0.60
First
Stage
1.00.9
0.90.8
0.46
0.20.3
0.20.3
0.42
Second Stage
Labor
augmentation no. 95 (35)
99 (36)
0.72
27 (10)
38 (15)
0.12
(%)
Forceps delivery
21 (8)
15 (6)
0.30
2 (1)
2 (1)
0.99
no. (%)
Cesarean
birth
19 (7)
21 (8)
0.74
4 (2)
10 (4)
0.10
no. (%)

*Plusminus
values
are
means
SD.
Labor augmentation was defined as stimulation of labor with oxytocin because of
inadequate
uterine
contractions. (Bloom, et al, 1998).

However, women in both groups were later questioned regarding whether or

not they would chose to walk during a future labor. Among the women who
were assigned to the walking group and who actually walked, 99 percent of
women answered yes. Similar results were among women who were among
the usual-care group, with the overwhelming majority stating that they would
prefer to walk in the future. This finding clearly shows that despite this studys
failure to demonstrate the benefits of walking during labor on maternal and
neonatal outcomes, womens preferences still need to be given considerable
attention. The authors state that they do not interpret the finding that walking
does not shorten the first stage of labor as either an indictment or an
endorsement of current birthing practices (Bloom, et al, 1998).
The limitations of the study included the lack of incorporation of maternal
satisfaction with ambulation as part of the outcomes studied. The findings
reveal a high percentage of women who responded positively to ambulation and
would chose to do so with subsequent labors. Furthermore, the women assigned
to the usual-care groups, were allowed to assume an upright position in bed,
such as sitting and high-fowlers positions. These positions may have
contributed to improved outcomes for the mothers in this group due to the
known benefit of upright postures on labor progress, and maternal and neonatal
outcomes. Also, a large number of women in the walking group did not actually
walk. This fact, the authors mainly attributed to the mothers precipitous labors
that might have prevented the woman from extensive ambulation, consequently
leading to improved data for this group, as far as labor duration which may not
have necessarily been associated with the maternal position. Since this study
did not show any negative effects of walking during labor on maternal or
neonatal outcomes, it is safe to say that women who chose to walk during this
time should be encouraged to do so. The data on the participants satisfaction
with walking and decision to ambulate during a future labor further supports
this
conclusion.
Summary
In conclusion, there are still factors that are not well understood about how
mobility and positioning affects maternal, fetal and neonatal outcomes.
Although several earlier studies have shown upright positioning and ambulation
during labor to be beneficial, more recent research has failed to demonstrate a

difference in outcome, especially during the administration of epidural

analgesia. No harmful effects from ambulation or upright posture have ever
been recorded, and all research ultimately supports the use of these techniques
for women, if there are no contraindications against them.
The physiological benefits of upright positioning for the pregnant female are an
established fact. Mechanisms of gravity promote the natural physiological
positive feedback through endocrine and neurological mechanisms, such as the
prostaglandin release and Fergusons reflex. The improved uterine blood flow
limits aortocaval compression in the supine position, resulting in stronger, more
coordinated uterine contractions needed for fetal expulsion.
Research has also demonstrated that maternal mobility and upright posturing
affect the womans ability to cope with the pain experienced during labor. Some
movements, such as pelvic rocking or swaying, may facilitate fetal descent,
while a rhythmic pattern of movements assists in coping with the pain of labor
(Simkin & Ancheta, 2005). It is important to point out that it is difficult to study
mobility and positioning in laboring women for several reasons. First, it is hard
to assign women to remain in one single position over a desired period of time
due to the overall stress of labor and the physical difficulty of holding to one
posture for any extended period of time. Second, even when women do chose a
position, they tend to remain in this position for a limited amount of time, and
restricting a woman to an uncomfortable position is not feasible and unethical.
The mothers preferences and her condition may change during labor, resulting
in certain choices to be limited or even restricted. Many women may choose an
upright or ambulant position in early first stage labor and choose to lie down as
their labor progresses (Lawrence, Lewis, Dowswell & Styles, 2009). Also,
labor can take a turn in both maternal and fetal status, causing the sample size
to decrease from what was previously intended due to ineligibility of the
mother to further participate in the study. And lastly, womans perception of her
labor experience depends on many factors, which makes it particularly difficult
to
study
any
one
single
variable.
Despite the lack of support for improved outcomes for selected variables, little
evidence exists of negative effects of ambulation, mobility, and upright
positions in the first stage of labor. In addition to the data on the known and
newly studied positive effects of these techniques, such as shorter labor
duration, these practices should be encouraged and supported in all settings
where mothers are assisted during labor and delivery. This is especially true
being that the adverse physiologic effect of a prolonged supine position has
been identified in most research on maternal positioning in pregnancy.
Therefore, women should be encouraged to take up whatever position they

find most comfortable while avoiding spending long periods supine(Lawrence,

Lewis, Dowswell & Styles, 2009). Midwives and healthcare providers caring
for laboring women need to be aware of these facts and support women to
remain mobile and assume upright positioning whenever possible.

Chapter 3: Methodology
Research

Design

In obstetrics, control of labor pain and prevention of suffering are major

concerns of clinicians and their clients (Simkin, 2004).With the increase in use
of epidural anesthesia in the hospital setting, womens mobility is greatly
affected during labor and birth. Surveys of obstetric anesthesia practice in the
United States reveal that the use of epidural analgesia has increased over the
past two decades (Chestnut, 2004). A national estimate in 2006 determined the
rate of epidural anesthesia use for pain relief was 76 percent, which grew from
63 percent in 2002 (Declereq, Sakala, Corry, & Applebaum, 2006). Several
contributing factors to this rising trend include the availability of skilled
anesthesia care providers, as well as information and advice provided to
pregnant women by obstetricians, nurses, childbirth educators, family and
friends
(Chestnut,
2004).
A quantitative study was chosen for this inquiry in order to describe womens
position experiences during the first stage of labor receiving epidural
anesthesia. Specifically, a descriptive nonexperimental design is used for this
project to bring awareness of positioning with this method of pain control.
Descriptive studies outline frequency of occurrence of behavior or condition
rather than study a relationship, and do not necessarily focus on one variable
(Polit & Beck, 2008). The purpose of this design is to describe the status of
positioning as the main variable in order to describe what is current in practice
and raise awareness (Polit & Beck, 2008). This research focuses on describing
observations such as different positions assumed by women with epidurals
during first stage of labor. Also included is the assessment of additional
variables, which include available support and the ability of the woman to stay
mobile
with
epidural
anesthesia
to
an
extent.
One major disadvantage of nonexperimental studies is that, compared with
experimental research, they are weak in their ability to reveal causal
relationships (Polit & Beck, 2008). These studies are susceptible to faulty
interpretations and selection bias, which is due to the self-selection of
preexisting groups being studied. In addition, behavior, states, attitudes, and

characteristics are interrelated or correlated in many complex ways (Polit &

Beck, 2008). Therefore, the weaknesses for the research design of this inquiry
include all the mentioned variables that may influence the participants
experience, satisfaction and progress during labor with epidural anesthesia.
However, non-experimental descriptive research is often an efficient way of
collecting a large amount of data about a problem which are not always
amenable to experimentation (Polit & Beck, 2008). In this instance, with the
prevalence epidural anesthesia, descriptive observation serves as a means of
raising awareness of the degree of mobility and choice of positioning by
woman during labor. Finally, this research design is strong in realism and has
the intrinsic appeal for solving practical problems (Polit & Beck, 2008) which
can serve as a guide for further implementation of policy regarding women
during
first
stage
of
labor
receiving
epidural
anesthesia.
Internal

and

external

validity

In order to enhance rigor and strengthen the quantitative research design of this
study, it is important to think in advance of all the possible factors that could
undermine the validity of inferences (Polit & Beck, 2008). Internal validity
refers to the extent to which it is possible to make an inference that the
independent variable is truly causing or influencing the dependent variable and
that the relationship between the two is not the spurious effect of a confounding
variable
(Polit
&
Beck,
2008).
In this study, examples of threats to internal validity include the threat of
history and maturation. The threat of history refers to the occurrence of external
events that take place concurrently with the independent variable that can affect
the defendant variables. For this study, maternal positioning can be greatly
affected by the availability of support people for the mother during labor which
may influences her positioning while undergoing epidural anesthesia. Also,
other external events, such as comfort level, knowledge about the labor process,
and a non-supportive environment all pose a threat to internal validity. In order
to decrease the threat of history, all participants will have support from a
knowledgeable nursing staff that is trained in caring for patients with epidurals
and has some knowledge about different positioning in labor, especially for
those participants lacking the support of family or friends.
In a research context, maturation refers to the process occurring within subjects
during the course of the study as a result of the passage of time rather than as a
result of a treatment or independent variable (Polit & Beck, 2008). It is well
known that labor is a dynamic process that progresses with consequent increase

in sensations that affect the woman in many different ways as she experiences
birth. With progression of labor, the participant may become more reluctant to
change position due to certain sensations, or on the other hand prefer to change
positions more frequently to increase comfort. There are also certain positions
that are necessary during epidural anesthesia, such as those related to
hemodynamic changes that may occur with this form of pain relief. Therefore,
in order to decrease the threat of maturation during labor progression, the data
obtained from observation will be accounting for cervical dilation and phase of
active labor. As the patient approaches transition, it will be noted in the
observational data sheet in order to account for the state of labor at the time. In
addition, if any position assumed is due to necessary measures arising from the
effect of the epidural, the data will be recorded on the observation sheet by the
observer. Furthermore, epidural anesthesia may take different effect in patients
and influence mobility and sensation in the lower extremities depending on
dose and technique. Patients ability to move, lift and feel will be dependent on
the duration of the epidural anesthesia and the amount of medication received.
Therefore, the participants ability to move, lift and sensation will also be
recorded
as
part
of
data
recorded.
External validity concerns inferences about the extent to which relationships
observed in a study hold true over variations in people, conditions, and settings,
as well as over variations in treatments and outcome (Polit & Beck, 2008). It is
difficult to have adequate representation of participants that would generalize
results to all populations of laboring women overall. In order to decrease this
threat, an equal amount of nulliparous and multiparous women will be selected
for observation. The study design is also simplified in order to allow accurate
replication of this observational research. With an increasing use in epidural
anesthesia, other researchers have the opportunity to record maternal
positioning by observing mothers with epidurals during the first stage of labor.
This observational study may be replicated at different sites with different
populations of women, where epidural anesthesia is available to mothers for
pain control during labor. Multi-site research is powerful because more
confidence in the generalizability of the results can be attained if those results
have been replicated in several sites and with several populations of women
(Polit
&
Beck,
2008).
Sampling

methods

A sample of 30 (n=30) low risk, term (> 37 weeks) pregnant women, (15
nulliparous and 15 multiparous women) who meet inclusion criteria recruited at
the South Jersey Healthcare Regional Medical Center (SJHRMC) in Vineland,
New Jersey, will be chosen for this observational study through convenience

sampling. The average number of deliveries per year at SJHRMC is

approximately 2200 births. The approximate rate of epidural anesthesia in labor
is 28 percent. Despite the fact that a larger sample size is more representative of
the population and decreases sample error (Polit & Beck, 2008), due to the
certain constraints such as time, subject availability, and resources, a smaller
sample size is to be chosen using most conveniently available people as study
participants. Since this proposal will serve as a pilot study in order to trial this
type of research in this facility, a small sample size will be sufficient in this
case. Pilot studies are a trial run version done on a small-scale, and carried out
in preparation for a major study, known as the parent study (Polit & Beck,
2008). The results of a pilot study serve as lessons that can inform
subsequent efforts to generate strong evidence for practice (Polit & Beck,
2008).
The population of interest includes women who have planned on receiving
epidural anesthesia during the first stage of labor and those who are currently in
the active labor phase undergoing epidural anesthesia. All necessary
institutional permissions will be obtained with regards to recruitment of
participants and research. Upon admission to the Labor and Delivery unit, all
patients are questioned regarding their preference for pain control. Those
participants who express their interest in epidural anesthesia will be considered
for this study. The admitting care provider, who establishes that the possible
candidate meets the inclusion criteria, will notify the research team. A written
disclosure of the study will be provided to the potential participant by the
observer, along with the consent form upon admission. After the patient agrees
to be observed and a signed consent is obtained, the observer once again will
decide whether the participant still meets the inclusion criteria for the study and
may begin observation only after the patient has become active and has begun
to receive epidural anesthesia.
Table 14: Inclusion and Exclusion Criteria for Research Proposal
Inclusion Criteria
Exclusion Criteria
Low-risk no maternal/fetal complications Preterm
labor
>37
weeks
pregnant
women Labor
induction/augmentation
Cephalic
presentation Malpresentation
Epidural
anesthesia High-risk
pregnancy
Multiparas
(n=15) Labor
complications
Nulliparas
(n=15) Not
in
active
labor
Active labor (cervical dilation of at least Transitional phase of active labor
4cm but before 7-8 cm, with spontaneous
onset of regular uterine contractions)

Willing to participate in this study

The observers for this study will be the research director/author of the study and a
research assistant. As part of the disclosure of this trial, the nursing staff at the study site
will be acquainted with the consents in order to recruit participants (see Appendix C). All
forms will be submitted to the author for review and analysis. As the participant is
recruited and all necessary consents are signed, the research assistant will set up a video
camera for recording of the duration of the observational time, or, if able, may be present
to record maternal positions. The gathered data will be presented to the research director
for
review.
Ethical

considerations

As part of the informed consent process, all eligible participants will have a full
disclosure of the goals and methods of this study. A signed consent form will be
necessary in order to participate in this research by all participants who are willing to be
observed during the first stage of labor (see Appendix C). Participants must be accepting
of at least a four hours observation period during the active phase, and allow for their
positioning to be recorded. All participants must also give consent to a review of medical
records by the research team in order to assess and establish their eligibility in this study.
Non-English speaking patients will be provided with appropriate disclosure of the study
goals and methods, as well as consents via written information or hospital phone
interpreter services. Permission and approval for this study will be sought from the
Philadelphia University Institutional Review Board and the SJHCRMC Institutional
Review
Board.
In addition, upon signing the consent, the patient gives permission for the research team
to observe any and all people present in the room who are either family members or
support people. During the observational period, the observer will be recording
information about maternal positioning and will document whether anyone has helped the
woman into a particular position or if the movement was voluntary. If the observer is not
able to directly observe the participant, a video camera will be set up for the duration of
the time and will record maternal behavior during the observation period. The RN taking
care of the patient will notify the researcher or the assistant when the patient has met any
of the exclusion criteria or time is sufficient to discontinue recording. Therefore, it is
important to note, that all participants and those present in the room, must be aware of
and willing to be observed during this study. No names of participants or support people
will be recorded for data. A subject ID number will be assigned to each participant and
identifying information will be kept secure and then destroyed at the end of this study.
Participants may terminate their observational session at any given time by verbalizing
their request to the observer. Due to the fact that labor and birth is a very personal and
intimate time in a familys life, much consideration will be given to not make the
participants feel as if they are being intruded upon by observers, either the researcher or
the
research
assistant.

Data

collection

procedures

Each participant will be observed for a minimum of four hours during the first stage of
labor after the epidural anesthesia has been placed and has taken full effect. Observation
is intrinsically appealing in its ability to capture a record of behaviors and events (Polit &
Beck, 2008). The observer will be assigned to one patient to record the patient's
positioning. With an observational approach, the observers are used as measuring
instruments and provide a uniquely sensitive and intelligent tool (Polit & Beck, 2008).
Patient positions will be recorded and will include time spent in each particular position,
whether the patient was able to move on her own, with the help of support person or staff,
and how long the woman spent in each observed position (see Appendix B). Structured
observation involves the collection of observational data using formal instruments and
protocols that dictate what to observe, how long to observe it, and how to record the
needed information (Polit & Beck, 2008). The observations will be conducted either with
researcher or research assistant direct observation during the allotted time, or with the use
of a video camera recording which will later be analyzed by the researcher or assistant.
Examples of limitations of observation include ethical difficulties and reactivity or
distorted behavior on the part of the study participants when they are aware of being
observed (Polit & Beck, 2008). Particularly in this study while being aware of the
research objectives, participating women may be more inclined to either change position
more frequently or not during the observation. In addition, in order to decrease observer
biases, careful training and review of the recording sheet which guides the observer will
be implemented. In addition, using video camera to record positioning and maternal
behavior may make the participants more at ease while in labor, which may affect the
outcomes
of
the
observational
study.
Data

analysis

Prior to the use of the observational data record by the researchers and participating
observers, it will be reviewed by a panel of experts at the Philadelphia University
Institute of Midwifery in order to rate each item along several dimensions. Among the
dimensions are the following (Polit & Beck, 2008):
1.
Clarity
of
wording
2.
Relevance
of
the
items
to
the
underlying
construct
3. Appropriateness of the items for the target population.
Next, in order to manage the gathered data, frequency distributions will be used. A
frequency distribution is a systemic arrangement of values from lowest to highest,
together with a count of the number of times each value was obtained (Polit & Beck,
2008), and consist of two parts:
1.
Observed
values
(Xs)
maternal
positions
2. Frequency of cases (fs)
This form of data analysis will help identify which maternal positions are observed most
frequently among women with epidural anesthesia during the first stage of labor. The
same will be done to assess whether the maternal position change was by maternal effort
or with the help of another person, and how long each position was utilized for by the

participant. The Statistical Package for the Social Sciences (SPSS) will be used as the
analysis software, which is a widely used computer program that calculates statistics
(Polit
&
Beck,
2008).
Later, in order to organize this data further, central tendency measures will be utilized to
determine which positions are used most by women with epidural anesthesia, and how
long the most frequently used position is maintained. In research, the mode, the median
and the mean are used to designate central tendency (Polit & Beck, 2008). The mode is
the most frequently occurring score value in a distribution. For this study, the mode will
be calculated for each position used and categorized as to by which category of women it
is used by (nulliparous vs. multiparous). Because the mean is the most stable index of
central tendency due to less fluctuation than modes or medians (Polit & Beck, 2008), it
will be used to calculate and illustrate the variables studied. The data will then be
displayed using a histogram with maternal positions and frequencies of each position
used by participants, lengths of each position used, and ability of mother to change
position. Below is an example of the hypothetical histogram which will be used to
analyze the data:

Table 15: Hypothetical Histogram of Maternal Positions with Epidural Anesthesia

during First Stage of Labor

Plan

for

disseminating

findings

In order to bring awareness of the maternal positions during the first stage of
labor among women with epidural anesthesia, the findings of this research will
be made available to a broad variety of readers. The summary and results of

this topic will be submitted in manuscript form to the Journal of Midwifery and
Womens Health. It will also be made available locally for the healthcare
institution where the study was conducted. The overview of the study and
results will be presented at the monthly OB department meeting, which is
typically attended by department physicians, midwives, nurses and
management. The results which are constructed into histograms may be made
available and posted on the maternity unit. In addition, this inquiry will be
included among other research proposals and inquiries under the Philadelphia
University Midwifery Institute Final Projects Database.
Appendix

Screening for Patient Eligibility

Patient Initials Subject ID
assigned by the researcher
Patient DOB
Gravida/Para
Gestational Age
Consent obtained?(circle one) Yes No

Active Labor?

Yes No
Dilation________________________
Effacement_____________________
Last cervical exam
Station_________________________
Presentation_____________________
Spontaneous onset of Labor? Yes No
Induction of Labor?
Yes No
Antepartum Complications? Yes No
Intrapartum Complications? Yes No

Epidural anesthesia in place? Yes No

Patient stable?
Yes No
FHT stable?
Yes No
Is patient able to: (Circle all Lift
legs
that apply)
Wiggle
toes
Lift
torso
Move from side

L
L
to

R
Bilateral
R
Bilateral
Yes
No
side Yes No

Feel
L
L
L
Lower
Upper
Chest

foot
calf
thigh

R
R
R

foot
calf
thigh

cold/touch:
Both
Both
Both
abdomen
abdomen

Appendix B
Observation Data Sheet
Patient
Initials______________________
________________________

Patient

Date
of
Observation_________________
___Observed___(check

Video

Start
Time
for
position:_______________
position:________________

End

Position

(circle

Lateral
L/R
Supine
Semi-Fowlers
Sitting
Knee-chest
Other

(circle

Lateral
L/R
Supine
Semi-Fowlers
Sitting
Knee-chest
Other

camera
one)
time

for

one)
By

maternal

effort?

With

help

from

tilt
Yes

Staff

No

Support people nice

Start
Time
for
position:_______________
position:________________
Position

ID

End

time

for

one)
By

maternal

effort?

With

help

tilt
Yes

Staff

No

Support people

from

Start
Time
for
position:_______________
position:________________
Position

(circle

Lateral
L/R
Supine
Semi-Fowlers
Sitting
Knee-chest
Other

Appendix

End

time

for

one)
By

maternal

effort?

With

help

from

tilt
Yes

Staff

No

Support people

Observation of Maternal Positioning during the First Stage of Labor in

Mothers
with
Epidural
Anesthesia
Investigator: Jane Letushko SNM, Midwifery Institute of Philadelphia
University
The purpose of this research project is to observe maternal positioning in mothers who
undergo epidural anesthesia for pain relief during the first stage of labor.
During this study, either an observer will be present to record your positioning OR a
video camera will be set up by the researcher or assistant which will record your positions
while epidural anesthesia has taken effect, after the onset of active labor and the onset of
regular uterine contractions with cervical dilation of at least 4 cm, diagnosed by your care
provider. If the data collection will be made directly by the research observer, then he/she
will be present during that time for duration of at least 4 hours or until you have reached
second stage or transitional phase of labor (about 7-8 centimeters dilation), as diagnosed
by your care provider. The researcher/observer will use a preprinted data sheet which will
be used to record the observations during that time period. Otherwise, the researcher will
not actively participate in any form of physical interaction with you. You may review the
observational data sheet which will be used to collect information during the research.
The information collected will be analyzed and grouped so that no identification of you
as an individual is possible and no personal information will be included in this research.
You may view the final report of this investigation. Observation or recordings may be
initially uncomfortable for some women. At any time during the study, the participant
may refuse to observation and recording either by the researcher or video camera taping.
This wish must be verbalized by the patient only. Your care will not be different in any
way regardless of participation. Any support people present in the room will also be
observed, therefore by consenting to participation, the woman must be aware of the fact

that all those present in the labor room at the time of observation are also included in this
research.

THIS IS TO CERTIFY THAT I,______________________(print name)

HEREBY agree to participate as a volunteer in the above-named project.
I hereby give permission to be observed during my labor after I have received
epidural anesthesia. I understand that, all present support people, family, and
any other persons are also included in this observational study. I understand that
my personal health records may be reviewed by the researchers in order to
assess whether I may be eligible for this study. I understand that the results of
this study may be published and may include direct quotes from my interview,
but my name will not be associated with the research.
I have been given the opportunity to ask whatever questions I desire, and all
such
questions
have
been
answered
to
my
satisfaction.
_________________________________________
Participant
_________________________________________
Witness
_________________________________________
Researcher
________________ (Date)
Appendix
Timetable
Proposal for IRB approval from South Jersey Healthcare Regional
2 months
Medical Center
Approval from Philadelphia University IRB
2 months
Completion of data collection (~6 months/until n=30)
6-12 months
Statistical analysis of data, entry, interpretation of data obtained
1 month
Composition of the formal report and manuscript
2 months
Total time of completion of project
~ 18-24 months

Budget
Researcher salary (0.2 FTE) 18-24 months
Assistant salary (0.2 FTE) 18-24 months
Paper supplies, printing cost
Statistical analysis for research data
Orientation
of
care
providers/nursing
design/participation
Total Budget

$26,000
$20,000
$1,000
$1,000
staff

to

study

Appendix E: Maternal Positions for First Stage of Labor

No benefit for mother of fetus

Supine

Standing/Walking

Easier access to patient for

EF
monitoring
and
procedures, such as vaginal
examinations, palpate fetal
position
Convenient for staff
can
help
labor
gain
momentum, especially in the
early
stages
good position for a back rub
rhythmic motions can be
soothing
effect of gravity on descent

Sitting/Rocking
decrease in pressure on major
maternal
blood
vessels

Swaying

helps ease low back pain

Provides
support
while
utilizing gravity to facilitate
descent
Encourages participation of
support
person
Rhythmic

motion

enables

$500
$48,500

better coping with labor pain

Helps ease lower back pain
Opens/widens

pelvis

Kneeling
Facilitates

descent

Good position for back rub

Widens
pelvis
Squatting

Semi-sitting

Facilitates
descent
and
rotation of fetus
May be utilized with epidural
anesthesia or while in bed
Upright
descent

posture promotes
and engagement

Good alternative to squatting

when woman too tired or has
epidural
may be utilized with epidural
anesthesia
decreases pressure on major
maternal
blood
vessels
Side-lying

decreases pressure on back

good alternative for women
with prolonged labors or who
are too tired to use upright
positions
Takes

pressure

off

spine

Facilitates rotation of the

fetus
Hands-and-knees

Decrease in pressure on major

maternal
blood
vessels
May be done while on labor
bed

Mayo Foundation for Clinical Education and Research (2010). Slide show: Labor
positions. Retrieved from http://www.mayoclinic.com/health/labor/PR00141

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