Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Abstract
and medical
intervention
Karen Baker
Midwif e, Calder dal e
Birth Centr e and
P os tgr aduat e MSc
s tudent, Salf or d
Univ er sity
492
CLINICAL PRACTICE
women had more effective uterine contractions.
A
effects,
which could not be said for use of
study by Read et al (1981) also found such women
narcotic analgesia or oxytocin.
had more effective uterine contractions.
When labour is augmented by oxytocin, the
woman needs continuous fetal heart rate moniOxytocin
toring, which is associated with an increased
Read et als (1981) study was a randomized risk of caesarean section and instrumental
controlled trial involving 14 women who weredeliveries, all of which increase the morbidity of
either encouraged to walk during the first stage
mother and baby (Alfrevic et al, 2006; National
of labour or confined to bed with the admin- Institute for Health and Clinical Excellence
istration of oxytocin for labour augmentation. (NICE), 2007). If the womans membranes have
The study found that walking during the activenot ruptured, she will need to have them artififirst stage of labour was as effective, if not more
cially ruptured (ARM) before administration of
so, than an intravenous infusion of oxytocin. the oxytocin infusion (NICE, 2007). She will also
This finding was also supported by Hemminki need to have a cannula inserted. ARM and the
et als (1985) study. However, the studies by insertion of a cannula are painful, invasive proceFlynns et al (1978), Hemminki et al (1985)
dures and using oxytocin to augment labour is
and Read et al (1981) were small randomized also highly prescriptive. These interventions
controlled trials, so the generalizability of the may increase a womans risk of infection and
findings may be limited.
labour may be more painful for her (Bricker and
By contrast to the above studies, two largerLucas, 2000; Howarth and Botha, 2001; NICE,
randomized controlled trials by Bloom et al
2007; 2008; Brown et al, 2008).
(1998) and Hemminki and Saarikoski (1983)
Furthermore, continual electronic fetal monifound no benefits when women walked during
toring and an intravenous infusion will reduce
the active first stage of labour compared with a womans ability to mobilize (Garcia et al,
women labouring in bed. Hemminki and 1985; Newburn and Singh, 2003; 2005). This
Saarikoskis (1983) study found no reduction in
is important, as Bloom et al (1998) concluded
oxytocin use (to augmentate labour), instru- that women valued mobilizing in labour. They
mental delivery, or caesarean section and Bloom
reported that 99% of the women who walked
et al (1998) found no reduction in length of first
during their labour said they would choose to
stage of labour, use of oxytocin, analgesia, or walk again (Bloom et al, 1998) Furthermore, it
instrumental or caesarean section delivery.
has been commented that mobilizing during
However, both studies were flawed. In
labour may also distract the woman from her
Hemminki and Saarikoskis (1983) study, 315 discomfort and may increase her sense of control
women were encouraged to walk or sit duringduring labour (Alber et al, 1997). Thus, aspects
labour and 312 women recerived the usual care
of care that increase rather than decrease a
of lying on their side during labour and walking
womans ability to mobilize during labour will
on request. Approximately half the women increase her satisfaction with her care.
who were encouraged to walk did so during
early labour and less than 10% chose to walk Womens views
during the later part of dilatation. In Bloom et A questionnaire survey by Newburn and Singh
(2005), on behalf of the National Childbirth
als (1998) study, 536 women were encouraged
to walk during labour and 531 received usual Trust (NCT), was sent out in January 2005April
2005 to women in the UK following the birth of
care, consisting of lying or sitting in bed during
labour. Of the 536 women who were encouraged
their baby (it was also available on the NCTs
website). Six hundred and seventy-six women
to walk, the mean walking time was 56 minutes,
furthermore, 22% of these 536 women chose responded to the questionnaire. Findings from
this study reported that women valued being
not to walk. Hence, these studies are not a true
reflection of the effect of mobility and upright able to move freely during labour. Interestingly,
women who reported that they were not able
positions on labour outcomes.
From analysis of these studies regarding theto move freely during labour had a greater risk
effects of walking in the first stage of labour, itof an emergency caesarean section than those
is evident that walking during this period has women who were able to mobilize during labour
many beneficial effects on the birth outcome (Newburn and Singh, 2005). This study was a
and on the womans and her babys wellbeing.follow-up of a previous survey conducted by
At the very least, walking during the first stageNewburn and Singh (2003) on behalf of the
of labour was not identified with any adverse NCT. Although the findings in both surveys
British Journal of Midwif ery Augus t 2010 V ol 18, No 8
493
CLINICAL PRACTICE
were similar, their 2005 study findings were tions. Women who adopted upright positions
more generalizable, as the questionnaires were also less likely to have epidural analgesia.
completed were from a broader and more repreThere was little evidence in this review to show
sentative range of women. Thus, Newburn andthat the positions adopted or walking during the
Singh (2003; 2005) and Bloom et al (1998)
first stage of labour had any effect on the duration
demonstrate that women value being able to of the second stage of labour, mode of delivery,
mobilize during labour. Furthermore, Newburn interventions in labour, or on the wellbeing of
and Singhs (2005) survey also provides moremothers and babies.
evidence that enabling a woman to mobilize
However, what is surprising in the Lawrence et
during childbirth is an influential factor in
al (2009) review is that it found an increase in the
assisting women to have a vaginal birth.
epidural rate when women laboured in the recumbent position, but it did not find an increase in
Effects of adopting upright
the incidence of instrumental deliveries. As the
positions in labour
findings of an earlier study by Anim-Somuah et al
Other studies (Simkin and OHara, 2002; (2005) concluded, epidural analgesia during childSimkin and Bond, 2004; Lawrence et al, 2009)birth is associated with an increased incidence of
assessed the effects of mobilizing and postureinstrumental vaginal deliveries, which are assoduring the first stage of labour. They compared
ciated with an increased risk of maternal and
upright positions in the first stage of labour with
neonatal morbidity. Hence, if the epidural rate was
labouring in bed, adopting one or more non- found to be increased, there should be an associupright positions.
ated increase in instrumental vaginal deliveries,
Simkin and OHara (2002) conducted a systemresulting in an increased risk of maternal and
atic review of five non-pharmacological measures
neonatal morbidity.
for pain relief during the first stage of labour. Other studies such as De Jonge et al (2004)
They assessed maternal mobility and positioning
and Gupta et al (2004) have demonstrated
as one of these non-pharmacological measures.
beneficial effects of upright positions regarding
The overall findings of the review were that mobithe second stage of labour, such as shorter
lizing and upright positions during the first stage
second stage of labour, fewer episiotomies and
of labour increased maternal comfort and might
assisted births, less severe pain, they found
increase the progress of labour.
bearing down easier and had fewer fetal heart
Simkin and Bonds (2004) systematic update
rate abnormalities. This suggests that mainregarding approaches for relieving labour paintaining upright positions has maximum effect
and suffering further conclude that mobilizing when continually adopted throughout labour
and upright positions were more comfortable and childbirth.
for women and their labours may be shorter.
Both De Jonge et al (2004) and Gupta et al
However, 13 of the 14 trials identified in this (2004) were meta analyses. De Jonge et als (2004)
review were also included in Simkin and OHaras
analysis consisted of nine randomized controlled
(2002) study, therefore, it is not surprising they
trials and one cohort study and involved 2843
had similar findings.
women. The analysis by Gupta et al (2004) was
Lawrence et als (2009) study consisted of aa Cochrane review, consisting of 20 randomized
Cochrane review; these reviews are influentialcontrolled trials conducted between 1963 and 1999
in providing evidence to changing practice, as
and involving 6135 women.
they define best practice based on randomized It was also found in De Jonge et als (2004) and
controlled trials. Lawrence et als (2009) review
Gupta et als (2004) studies that women expeidentified 21 randomized controlled trials that
rienced an increase in blood loss greater than
took place within a hospital setting, in a variety
500mls and an increase in second degree tears.
of countries between 19602007. In total, 3706
The former may have been owing to the more effiwomen were assigned to upright or non-upright
cient collection of blood loss and the latter to a
positions during the first stage of labour; walking
reduced number of episiotomies carried out when
was identified as one of the upright positions in
the woman adopts upright positions. These similar
this study. All women were cared for in bed during
findings in De Jonge et als (2004) and Gupta et als
the second and third stages of labour.
(2004) meta analysis are not surprising, as many of
Lawrence et al (2009) identified that, overall,
the studies indentified in them were the same. All
the first stage of labour was approximately one
nine of the randomized controlled trials identified
hour shorter for women who were allocated toin De Jonge et als (2004) study were included in
upright positions as opposed to non-upright posiGupta et als (2004) analysis.
494
CLINICAL PRACTICE
Perineal trauma
IS
TOCKP
HO
TO
All-fours position
The benefits of women adopting the all-fours
Maintaining
posi- upright positions during labour and childbirth supports normal birth
tion forone hour in labourwithwomenwhodid not
and enhances maternal satisfaction with the experience
British Journal of Midwif ery Augus t 2010 V ol 18, No 8
495
CLINICAL PRACTICE
CLINICAL PRACTICE
en/ab000331.html (accessed 26 July 2010)
Ball JA (1994) Reactions to Motherhood: the Role of
Postnatal Care, 2nd edition. Books for Midwives Press,
Cheshire
Bloom SL, McIntire DD, Kelly MA, Beimer H, Garcia M,
Burpo B, Leveno KJ (1998) Lack of effect of walking on
labour and delivery. N Engl J 339
Med
(2): 769
Bricker L, Luckas M (2000) Amniotomy alone for induction
of labour. Cochrane Database Syst Rev , Issue 4. Art. No.:
CD002862. DOI: 10.1002/14651858.CD002862
Brown HC, Paranjothy S, Dowswell T, Thomas J (2008)
Package of care for active management in labour for
reducing Caesarean section rates in low-risk women.
Cochrane Database Syst Rev , Issue 4. Art. No.:
CD004907. DOI: 10.1002/14651858.CD004907.pub2
Commission of Healthcare Audit and inspection (2007)
Womens Experiences of Maternity Care in the NHS in
England . Health Care Commission, London
De Jonge A, Lagro-Janssen A (2004) Birthing positions. A
qualitative study into the views of women about various
25(1):
birthing positions. J Psychosom Obstet Gynaecol
during childbirth . Clinical Guideline 55. NICE, London
4755
DeJonge A, Teunissen T, Lagro-Janssen A (2004) SupineNational Institute for Health and Clinical Excellence (2008)
position compared to other positions during the secondInduction of Labour. Clinical guideline 70. NICE, London
stage of labour; a meta-analytic review. J PsychosomNewburn M, Singh D (2003) Creating a better birth environment, womens views about the design and facilities
25(1): 3545
Obstet Gynaecol
Flynn AM, Kelly J, Hollins G, Lynch PF (1978) Ambulation in maternity units: A national survey . The National
Childbirth Trust, London
2(6137): 5913
in Labour. BMJ
Newburn
M,Singh D (2005) Are women getting the birth
Garcia J, Corry M, MacDonald D et al (1985) Mothers views
environment they need? Report of a national survey of
of continuous electronic fetal heart monitoring and
intermittent auscultation in a randomized controlled womens experiences . The National Childbirth Trust,
London
12(2): 7986
trial. Birth
Nursing and Midwifery Council (2004) Midwives Rules and
Gupta J, Hofmeyr G, Smyth R (2004) Position in the second
Standards . www.nmc-uk.org/Educators/Standards-forstage of labour for women without epidural anaesthesia.
education/Midwives-rules-and-standards/ (accessed 26
Cochrane Database Sys Rev http://www2.cochrane.org/
July 2010)
reviews/en/ab002006.html (accessed 26 July 2010)
Nyberg K, Buka SL, Lipsitt LP (2000) Perinatal medicine
Hemminki E, Lenck M, Saarikoski S, Henriksson L (1985)
as a potential risk factor for adult drug abuse in a North
Ambulation versus oxytocin in protracted labour: A pilot
11
American cohort. Epidemiology
(6): 7156
20(4):
study. Eur J Obstet Gynecol Reprod
Bio 199208
Read J, Miller F, Paul R (1981) Randomised trial of ambulaHemminki E, Saarikoski S (1983) Ambulation and Delayed
Amniotomy in the First Stage of Labour. Eur J Obstet tion versus oxytocin for labour enhancement: A prelimi139(6): 66972
nary report. Am J Obstet Gynaecol
12(3) 12939
Gynecol Reprod Bio
Russell JGB (1969) Moulding of the pelvic outlet. J Obstet
Hill JB, Alexander JM, Sharma SK et al (2003) A
Comparison of the effects of epidural and mependine Gynaecol Br Commonw 76(9): 81720
analgesia during labour on fetal heart rate. Obstet Shorten A, Donsante J, Shorten B (2002) Birth position,
Gynaecol102(2): 3337
accoucheur and perineal outcomes: Informing women
about choices for vaginal birth. 29(1):
Birth 8827
Howarth G, Botha DJ (2001) Amniotomy plus intravenous oxytocin for induction of labour. Cochrane Simkin P (2003) Maternal positions and pelvis revisited.
Database Syst Rev , Issue 3. Art. No.: CD003250. DOI: Birth30(2): 1302
Simkin P, Ancheta R (2005) The Labour Progress
10.1002/14651858.CD003250
Hunter S, Hofmeyr GJ, Kulier R (2007) Hands and knees Handbook . Blackwell Science, Oxford
posture in late pregnancy or labour for fetal malposi-Simkin P, Bond A (2004) Update on nonpharmacologic
tion (lateral or posterior). Cochrane Database Syst Revapproaches to relief of labour pain and suffering. J
49(6): 489504
http://www2.cochrane.org/reviews/en/ab001063.html Midwifery Womens Health
Simkin P, OHara M (2002) Nonpharmacologic relief of
(accessed 26 July 2010)
Jacobson B, Nyberg K, Gronbladh L et al (1990) Opiate pain during labour: Systematic reviews of five methods.
186(5 Suppl Nature): S13159
Am J Obstet Gynaecol
Addiction in Adult Offspring through Possible Adult
Soong B, Barnes M (2005) Maternal position at midwifeImprinting after Obstetric Treatment. 301
BMJ
(6760)
attended birth and perineal trauma: Is there an associa106770
32(3): 1649
Lawrence A, Lewis L, Hofmeyr GJ, Dowswell T, Styles C tion? Birth
Sosa CG, Balaguar E, Alonso JG et al (2004) Mepenidine for
(2009) Maternal positions and mobility during first stage
dystocia during the first stage of labour: A randomised
of labour. Cochrane Database System Rev http://www2.
191(4): 12128
cochrane.org/reviews/en/ab003934.html (accessed 26 controlled trial. Am J Obstet Gyneacol
Stremler R, Hodnett E, Petryshen P, Stevens B, Weston J,
July 2010)
Mercer J, Skovgaard R (2004) Fetal to neonatal transition:Willan A (2005) Randomized controlled trial of handsfirst do no harm. In: Downe S, ed. Normal Childbirth: and-knees positioning for occipito posterior position in
32(4): 24351
Evidence and Debate . Churchill Livingstone, Oxford: labour. Birth
Terry R, Westcott J, OShea L, Kelly F (2006) Postpartum
14160
outcomes in supine delivery by physicians vs nonsupine
Michel S, Rake A, Treiber K, Seifert B, Chaoui R, Huch
delivery by midwives. J Am Osteopath106
Assoc
(4): 199R, Marincek B, Kubik-Huch R (2002) MR Obstetric
Pelvimetry: Effect of Birthing Position on Pelvic Bony 202
Waldenstrom U,Gottval K (1991) A randomized trial of
179(4): 10637
Dimensions. AJR Am J Roentgenol
birthing stool or conventional semirecumbent position
National Institute for Health and Clinical Excellence (2007)
18(1): 510
for second-stage labour. Birth
Intrapartum care: care of healthy women and their babies
British Journal of Midwif ery Augus t 2010 V ol 18, No 8
497
Copyright of British Journal of Midwifery is the property of Mark Allen Publishing Ltd and its content may not
be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written
permission. However, users may print, download, orKey
email articles
for individual use.
points
Mobilizing
and u right ositions during labour and birth incr eases
l
hysiol ogic al birth.
Physiol ogic lal birth has subs t antial benefits f or mother and baby and
also has subs t antial ublic health im lic ations.
Mobilizing l and u right ositions during labour and birth has no kno wn
adv er se eff ects.
W omen sl satisf action with their birth e x erienc e is incr eased when
the y ar e abl e t o mo v e fr eel y during labour and birth.
Midwiv
es should r omot e mobilizing during labour and u right
l
ositions during labour and birth, as r omoting normal birth is a
fundament al as ect of midwif ery c ar e.