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CLINICAL PRACTICE

Midwives should support women


to mobilize during labour
Many other adverse effects of a lack of movement coupled with maintaining a non-upright
position have also been documentedin the
This article analyses why midwives should encourage and support
women to mobilize during labour and maintain upright positions during
literature. These adverse effects will reduce the
labour and childbirth. A systematic analysis of the literature regardingwomans ability to birth her baby without medical
this issue will be constructed. An outline of the role of the midwife andintervention.

Abstract

why it is important that they encourage and support women to mobilize


Mobilizing
during labour and maintain upright positions is presented.

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

Early studies on childbirth evaluating the effect


rom analysis of the literature, it is evident
of mobilizing in the first stage of labour found
that there is no universal definition of anthat walking is associated with less frequent use
upright position during labour and child- of narcotic analgesia (Flynn et al, 1978; Albers
birth. To avoid confusion, the term upright willet al, 1997). The reduced use of narcotics during
refer to the sitting position, with the woman childbirth has important implications, as the
constantly at an angle of 45 degrees or more, administration of narcotics is associated with
kneeling, squatting, on all-fours, and the standing
an increased incidence of abnormal fetal heart
position. Non-upright positions refer to recum-rate patterns (Hill et al, 2003), which may lead
bent, semi-recumbent, lithotomy, supine or the
to a cascade of intervention during childbirth,
lateral position. Mobilizing refers to walking and
increased incidence of babies admitted to the
moving freely.
neonatal unit and adverse neonatal neuroTowards the end of pregnancy, changes in alogical effects that may last for days, such as
womans hormones cause relaxation of the ligadecreased alertness and impaired rooting and
ments and cartilage in her pelvic joints. This sucking reflexes, which affect the womans ability
allows more movement during childbirth in
to breastfeed (Sosa et al,2004). There may also
the sacro-iliac joints and the pubic symphysis,be an association betweenthe fetuss exporesulting in slight changes in the shape and diamsure to narcotics during labour and adult drug
eters of her pelvis (Russell, 1969; Michel et al,abuse (Jacobson et al, 1990, Nyberg et al, 2000).
2002; Simkin, 2003). These changes facilitate the
Interventions to increase breastfeeding rates and
passage of the baby through the pelvis (Simkin
reduce adult drug abuse also have substantial
and Ancheta, 2005).
public health implications.
When a woman mobilizes during labour and
Operative delivery
adopts upright positions during labour and childAlbers et als (1997) and Flynn et als (1978) studies
birth, these changes to the ligaments and cartilage
in the pelvic joints are optimized (Simkin and also found a lower rate of operative delivery when
Ancheta, 2005). Furthermore, the adoption of women were encouraged to walk during the first
of labour. Albers et als (1997) controlled trial
upright positions employs the effect of gravitystage
to
apply the presenting part to the cervix, improving
consisting of observational data, comparing 771
women who walked for a significant portion of the
the effectiveness of contractions in dilating the
cervix. These affects will aid descent of the fetus
first stage of labour with 907 women who laboured
in bed. Flynn et als (1978) randomized prospective
through the birth canal. Thus, the womans ability
to birth her baby more effectively and withoutstudy consisted of 68 women. Half of these women
medical intervention is enhanced. Conversely,
walked
a
during the first stage of labour and half
laboured in bed in the recumbent position. This
lack of movement coupled with maintaining nonupright positions will reduce the available space
study also found that women who walked during
within the womans pelvis. Furthermore, it willthe
notfirst stage of labour had a shorter first stage,
the fetal heart rate patterns during labour were
take advantage of the benefits of gravity, making
the contractions less effective.
reassuring, the babys apgar scores were higher and
British Journal of Midwif ery Augus t 2010 V ol 18, No 8

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

British Journal of Midwif ery Augus t 2010 V ol 18, No 8

CLINICAL PRACTICE
Perineal trauma

use this position has been highlighted in a study


Other studies (Soong and Barnes, 2005; Terry
byetStremler et al (2005). This study consisted of a
al, 2006) have found that upright birth positions
randomized controlled trial, involving 147 women
reduce perineal trauma. This has important impliwhose fetus was in the occipital-posterior position
cations for the woman, as injury to the genital(OP). It compared women who adopted the alltract during childbirth can result in adverse health
fours position for one hour in labour with women
outcomes for the woman, for example, tempowho did not use this position. Stremler et al (2005)
rary pain and discomfort to severe pain, bleeding,
found that this position significantly reduced back
dyspareunia and infection (Shorten et al, 2002).
pain and that there was a trend towards fetal rotaSoong and Barnes (2005) conducted a quantion to the occipital-anterior position (OA). This
titative study of 3756 women and found that finding is valuable as the optimal position for
women who birthed their babies in the semi- the baby during labour and birth is the OA posirecumbent position had a higher incidence of tion. The OP position can be associated with
perineal trauma that required suturing, whereas
more painful, longer and obstructed labours, and
the all-fours position was associated with reduced
difficult deliveries (Hunter et al, 2007). These assoperineal trauma. Terry et als (2006) study, a nonciated factors of the OP position will influence
randomized controlled trial, found that upright
the mothers and her babys ability to cope during
positions during labour and childbirth resultedlabour
in
and delivery, effecting their wellbeing.
less perineal trauma and less vulva oedema than
A Cochrane Review by Hunter et al (2007)
supine positions.
which analysed Stremler et als (2005) study and
confirmed their findings regarding reducing back
Left-lateral position
pain. However, it did not support Stremler et als
A multiple regression analysis of 2891 normal(2007) comment regarding a trend towards fetal
vaginal births by Shorten et al (2002) found rotation to the OA position. Hunter et al (2007)
a statistically significant reduction in perineal recommended that larger trials were needed to
trauma when women adopted the left lateral analyse this.
position to give birth, rather than an upright posiPromoting normality
tion. Furthermore, this study found that women
From the analysis of these research studies, it is
who gave birth in the squatting position experienced the most perineal trauma, and women who
evident that when women mobilize and maintain
upright positions throughout labour and birth it
adopted other upright positions did not experience less perineal trauma than those who gave
increases normal birth and maternal satisfaction
birth in the recumbent position. However, in with the childbirth event. It will also reduce interShorten et als (2002) study, the majority of the
women gave birth in non-upright positions (semirecumbent n =1619; lateral n =353) and only 2.1%
( n =62) gave birth in a squatting position. Hence,
the unequal sample size reduces the reliability of
the studys findings.
It is not possible to compare Shorten et als
(2002) findings regarding the benefits of the lateral
position with Soong and Barnes (2005) and Terrys
(2006) research findings, as none of the women in
their studies adopted the lateral position. However,
Gupta et als (2004) meta analysis included women
who adopted the lateral position in the second stage
of labour and found no benefits to the perineum.
Thus, although Shorten et als (2002) study provides
some evidence that the left lateral position during
childbirth protects the perineum, other studies do
not support this finding, so Shorten et als (2002)
findings have limited value at present.

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

birth for women with normal pregnancies and

births, is provided by midwives (Nursing and


women who adopted the allMidwifery Council (NMC), 2004). Women who
fours position [had] significantly are identified as having medical and obstetric
complications are cared for by midwives in
reduced back pain and ... there was
collaboration with medical staff. The midwives
role during childbirth is identified within the
a trend towards fetal rotation to the
Midwives Rules and Standards (NMC, 2004).
occipital-anterior position
NICE (2007) also outlines what care women

should receive during childbirth from the NHS


and by whom. It is clear from analysing these
ventions. Normal birth and reduced intervention
documents that midwives are perceived as
rates are crucial as childbirth that does not involve
the experts in normal pregnancy, labour and
medical intervention has substantial benefits for
postnatal period, that promoting normality
mother and baby. These benefits include faster
is a fundamental aspect of midwifery care
rates of recovery postpartum, increased maternal
and that midwives should promote practices
self-esteem, improved maternalinfant attach-that encourage normality. Clearly, supporting
ment and enhanced adaptation of the baby towomen to mobilize and maintain upright posiextrauterine life (Mercer and Skovgaard, 2004).
tions during labour and childbirth is one such
However, despite the advantages of womenpractice that is fundamental to promoting
mobilizing and maintaining upright positions normal childbirth.
during childbirth, a recent survey (Commission
Conclusion
of Healthcare Audit and Inspection, 2007),
involving over 26 500 women who completedWhat is evident is that mobilizing during labour
a postal questionnaire describing their expe- and maintaining upright positions during labour
riences of maternity care in England during and childbirth enhances the womans birth expeJanuary and February 2007, found that 57% rience, and supports the normal physiology of
of women gave birth lying down or lying with birth. However, there is no one optimal labour
and birth position for all women, as women
their legs supported in stirrups, adopting a
non-upright position. This is in spite of NICE are individuals and labour and childbirth is a
(2007) recommending that this position shoulddynamic event. Therefore, midwives need to
be discouraged, although the study did report encourage and support women in exploring posithat 61% of women felt they were able to move
tions that are optimal for them during labour and
around and adopt positions that made them childbirth, and to inform women of practices that
feel comfortable. The question must be askedwill affect their ability to mobilize and maintain
how the other 39% felt about being restricted.upright positions.
Furthermore, Waldenstrom and Gottvall (1991) Midwives should inform women of the many
highlighted that the majority of women will short- and long-term advantages of mobilizing
choose to do what they think is expected of during labour and adopting upright positions
them, both culturally and socially, and that
during labour and childbirth. Furthermore,
women are least likely to adopt positions thatmidwives must highlight the adverse effects to
are unfamiliar to them. It would be interestingwomen
to
of labouring and giving birth in bed,
adopting non-upright positions. This will enable
know how many of the 61% of women did adopt
positions that made them feel comfortable. women to make informed decisions regarding
It is evident from the Commission of their care.
BJM
Healthcare Audit and Inspection (2007) report
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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.