Maternal Position, Labor, and Comfort Claire M. Andrews and Maureen Chrzanowski
The purpose of this study was to determine if women who assumed upright positions during the phase of maximum slope would have a shorter phase of maximum slope in their labor and experience more comfort than women who assumed recumbent positions. Forty laboring women were randomly assigned to either an upright or recumbent position group. Subjects assumed the positions of their assigned group during the phase of maximum slope in their labor (cervical dilatation from 4 cm to 9 cm). Every hour during the phase of maximum slope, each subject was examined vaginally to determine her cervical dilatation and assessed for her level o f comfort using the Maternal Comfort Assessment Tool. Women in the upright position group had a significantly shorter phase of maximum slope in labor, btit did not significantly differ in comfort level from women in the recumbent group. Newbom Apgar scores were not significantly different between the two groups. Nurses need to be aware that the upright labor positions have the distinct advantages of facilitating efficient uterine contractions and reducing the duration of the phase of maximum slope in labor, with no increase in the discomfort experienced or adverse effect on newborn well-being. © 1990 by W.B. Saunders Company.
p
facilitates the use of forceps and permits easy access to the perineum for the caregiver. Although recumbent positions during labor offer advantages for the caregiver, research has pointed to potential hazards of the recumbent positions for the well-being of the laboring woman and the fetus. When supine, laboring women may experience a decrease in the strength of uterine contractions, an increase in the risk of developing maternal hypotensive syndrome, late decelerations, and a decrease in the newborn's Apgar scores and cord blood pH (Arbitol, 1985; C~Ideyro-Barcia, 1980; Roberts, 1980). Women in the lateral and supine positions tend to have longer labors than women in the upright position (Caldeyro-Barcia, 1980; Liu, 1974, 1989; McKay, 1980; Mitre, 1974).
OSITIONS THAT MOST women assume while in labor are culturally patterned (Mead & Newton, 1967). In most areas of the world that have not been influenced by Western society, women labor in some form of upright position (Engelmann, 1882; Narroll, Narroll, & Howard, 1961; Prschl, 1987; Roberts, 1980). In Western societies, the lateral (side-lying) and supine (back-lying) forms of the recumbent position are generally assumed during labor. For delivery of the baby, the supine position is modified into the lithotomy position by raising the woman's legs into stirrups. This study examined the relationship between upfight labor positions and comfort and length of labor. Recumbent positions during labor have several convenient features for caregivers. In the supine position, the maternal abdomen is accessible to the caregiver for auscultating fetal heart tones and for checking cervical dilatation by vaginal examination. In both lateral and supine positions, contractions are easily palpated and electronic monitoring devices may be readily applied. The lateral recumbent position is reported to be accompanied by more intense, less frequent, and more efficient uterine contractions than the sitting position (Roberts, Mendez-Bauer, Blackwell, Carpenter, & Marchese, 1984; Roberts, Mendez-Bauer, & Wodell, 1983). At birth, the lithotomy position
From the Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, and the North Avenue Women's Center, Battle Creek, MI. Claire M. Andrews, PhD, CNM: Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH; Maureen Cb.rzanowski, MSN, CNM: North Avenue Women's Center, Battle Creek, MI. Address reprint requests to Claire M. Andrews, PhD, CNM, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH 44106. © 1990 by W.B. Saunders Company. 0897-1897/90/0301-0003505.00/0
Applied Nursing Research,Vol. 3, No. 1 (Februa~), 1990: pp. 7-13
7
ANDREWS AND CHRZANOWSKI
In contrast to the potential maternal and fetal~ hazards of recumbent positions during labor, researchers have found that upright positions are beneficial for the progress and outcome of labor. Women in upright positions experience more intense contractions and shorter labors than women in recumbent positions (Diaz, Schwarcz, Fescina, & Caldeyro-Barcia, 1980; Liu, !974, 1989; Mendez-Bauer, 1975; Mitre, 1974; Stewart & Calder, 1984). The greater the intensity of the contraction, the more efficient it is for the progress of labor. A comparison study on the effect of the upright position and the left lateral recumbent position o n fetal movements and fetal heart rate showed no significant difference between the two maternal position groups; the upright position did not adversely affect fetal well-being (Friedman et al., 1983). The effect of maternal positions in labor on women's experiences.of childbirth pain is of great importance in guiding nursing interventions with laboring women. Few studies have explored the relationship between maternal position and maternal comfort during labor (Lupe & Gross, 1986). Gravid women have stated that they are more comfortable during labor when they assume upright positions (Caldeyro-Barcia, 1980; Mendez-Bauer, 1975). According to the research of Flynn and Kelly (1978), women who labored in the upright position did not need analgesia, but women in the recumbent position did require analgesia to manage discomfort. Women's experiences of childbirth pain are notoriously difficult to assess. Pain in labor has been studied using self-reports, questionnaires, visual analogue scales, and, most recently, a pain-ometer (Fridh, Kopare, Gaston-Johansson, & Norveil, 1988; Gaston-Johansson, Fridh, & TurnerNorvell, 1987; Melzack, Taenzer, Feldman, & Kinch, 198!; Scott-Palmer & Skevington, 1981). Tla~ different methods used to measure labor pain result in inconsistent, often conflicting results. The results are dependent on whether measurement was based on the laboring woman's personal perception of her childbirth pain or on physiologic and behavioral indicators of pain. Also, the point in time at which the labor pain measurement was made influences the results. For example, a woman's perception of labor pain measured intrapartally is likely to be different than a postpartum retrospective recall of intrapartal pain.
The relationship of labor pain to a wide variety of psychosocial and physiologic variables has been investigated with conflicting results. Maternal age, socioeconomic indicators, childbirth educational preparation, maternal confidence, level of fear or anxiety, history of menstrual discomfort, prepregnancy body weight, and degree of cervical dilatation are but a few of the variables examined with labor pain (Fridh, Kopare, Gaston-Johansson, & Norvell, 1988; Gaston-Johansson, Fridh, & Turner-Norvell, 1987; Lowe, 1989; Melzack, Taenzer, Feldman, & Kinch, 1981; Reading, & Cox, 1985; Scott-Palmer, & Skevington, 1981). However, analyses of labor pain have not included important physical variables such as maternal position and fetal-pelvic relationships.
The relationship of labor pain to a wide variety of psychosocial and physiologic variables has been investigated with conflicting results. Despite the previously mentioned disadvantages of the recumbent positions and the advantages of the upright positions, women in the United States continue to labor in some form of recumbent position. This traditional pattern is likely influenced by the standard practice of caregivers and by institutional policies that offer women little choice in the position assumed in labor. The purpose of this study was to determine if women who assume upright positions during the phase of maximum slope have a shorter phase of maximum slope in their labor and appear more comfortable than women who assume recumbent positions. METHOD
Over a 3-month period, a convenience sample of 40 laboring womenparticipated in the study at a health maintenance organization in a large midwestern city. All participants were nulliparous, experiencing a medically uncomplicated pregnancy with a single vertex fetus in an anterior position, spontaneous onset of labor at 38 to 42 weeks gestation, adequate pelvic measurements, and intact amniotie membranes at the beginning of the phase
MATERNAL POSITION, LABOR AND COMFORT
Table 1. Frequencies of the Descriptive Variables for the Position Groups Race Position Group
Upright Recumbent
Presenceof Support Person
Marital Status
White
Black
Other
Married
Single
Yes
No
12
7
1
13
7
17
3
8
11
1
11
9
18
2
N = 40.
of maximum slope. Participants were randomly assigned to one of two maternal position groups, upright (n = 20) and recumbent (n = 20). The women were free to choose several variations within each position group. Variations of the upright position included standing, ambulating, sitting, squatting, or kneeling. Variations of the supine position included supine, lateral, or prone positions such as the hands and knees position. Subjects in both groups were free to assume positions from the other group for routines of'care and for rest; these activities were documented. Demographic variables for the upright and recumbent position groups are summarized in Tables 1 and 2. During data collection, 15 Of the participants in the upright group chose to lie down after receiving medication for rest. Of this group, 5 immediately returned to the upright position stating that the contractions were more painful when they were lying down. The remaining 10 chose the lateral position to rest for up to 1 hour during the study period. Two instruments were used to collect information related to the effect of the maternal position on labor in the phase of maximum slope and on maternal comfort. The first instrument, developed specifically for this study, was used (a) to gather demographic information; (b) to gather information theoretically related to the experience of childbirth pain (childbirth preparation, presence of la° bor support person); and (c) to record the length of the phase of maximum slope in labor. The phase of maximum slope, a subdivision of the first stage of labor, is the most active phase of labor, during which rapid cervical dilatation takes place (from 4 to 9 cm). The length of the phase was determined by the first recorded time that cervical dilatation was assessed to be 4 .cm and on the first recorded time that dilatation was assessed to be 9 cm. The Maternal Comfort Assessment Tool, developed by Chrzanowski and Young for this study, was the second data collection instrument used. The tool estimates the level of maternal comfort by
measuring the laboring woman's focus of attention, eye contact during contractions, breathing pattern and vocal behavior during contractions, muscle te.nsion and activity during contractions, and verbalizations regarding ability to continue with labor. In addition, vital signs; degree of cervical dilatation; duration, frequency, and intensity of contractions; medications; and use of monitoring apparatus are recorded on the Maternal Comfort Assessment Tool. When the scores for each category of observable behavior in the tool are added, the highest possible comfort score for each contraction is 14 and the lowest is 0. The tool is included in Table 3. Comfort scores for a series of three contractions were recorded by one of the investigators on an hourly basis during the phase of maximum slope and averaged for a mean hourly comfort score. The hourly comfort scores were then averaged to obtain an overall mean comfort score for each woman. Vital signs, cervical dilatation, frequency, intensity, length of contraction, and general comments regarding maternal position changes were assessed by the patient's nurse and recorded on an hourly basis. A prestudy interrater reliability for the tool was obtained by the investigators. Assessments were independently made on each of a series of three contractions with five patients. The percentage of agreement was 89%. Interrater reliability also was obtained during the study on each of a series of three contractions for Table 2. Measures of Central Tendencies for Age of Subjects and Gestational Age in the Two Position Groups Position Group
Mean
Mode
Range
Age
Upright Recumbent
22.75 21.15
18.0 18.0
17-36 16-28
Gestational Age
Upright Recumbent
39.95 40.15
40.0 41.0
38-42 38-42
N=40.
ANDREWS AND CHRZANOWSKI
10
Table 3. Maternal Comfort Assessment Tool Subject number 1. Focus of Attention Able to follow directions Occasionally follows directions Unable to fellow directions 2. Eye contact during contractions Easily maintains eye contact when spoken to Occasionally makes eye contact when spoken to Unableto make eye contact when spoken to 3. Breathing Uses some form of controlled breathing during contractions Occasionally uses some controlled breathing during contractions Does not use controlled breathing during contractions 4. Vocal behavior No vocal sounds (with the exception of normal speech) with contractions Moans, whimpers, repeats sounds or words with contractions Screaming, crying (hysterical) with contractions 5. Muscle tension All muscles relaxed with contractions Face or one extremity tense with contraction Extremities held rigid; facial tension with contractions
(2) (1) (0)
(2) (1) (0)
(2) (1) (0)
(2) (1)
(0)
(2)
6. Activity during contractions Lies still in bed, rocks, ambulates or performs effieurage with contractions Occasional uncontrolled movements of extremities with contractions Tossing or thrashing in bed of entire body with contraction 7. Verbalizations Silent or expresses no doubt about ability to deal with labor Occasionally expresses doubts about ability to continue labor or deal with contractions Frequent requests for rescue from situation; continually doubts ability to continue labor or deal with contractions
(2) (1) (0)
Duration/frequency of contractions in seconds and minutes Intensity of contractions (m, mild; mo, moderate; st, strong) Monitor (I = internal, E = external) Medications Miscellaneous observations Total Score
Women in the upright position group had a statistically significant shorter phase of maximum slope in labor than women in the recumbent group (t(38) = 3.2, p = .003). The mean length of the phase of maximum slope for women who labored in recumbent positions was 324.75 minutes. Women in upright positions had a mean length of 234.50 minutes, a difference of 90.25 minutes. Women in the upright position group generally • established a more efficient contraction pattern earlier in the phase of maximum slope than women in the recumbent group. Generally, women in the upright position group had contractions that were more frequent, more intense, and longer lasting earlier in the phase of maximum slope than women in the recumbent group (Table 4). Because of the more efficient contraction pattern, the women in the upright position group experienced more rapid cervical dilatation during the phase of maximum slope (Table 4). Rapid cervical dilatation is promoted
(0)
Cervical dilatation in centimeters
(0)
RESULTS
(1)
Vital signs
(1)
five randomly selected subjects. The percentage of agreement was 91%.
(2)
by fetal descent; it is likely that gravitational forces assisted fetal descent in the upright position group. The length of the phase of maximum slope was positively correlated with age (r = .323, p = .021) and with race (r = .3227, p = .021) for the
Women in the upright position group generally established a more efficient contraction pattern earlier in the phase of maximum slope than women in the recumbent group.
entire sample. Younger women tended to have a shorter phase of maximum slope than older women. Black women tended to have a shorter phase of maximum slope than white women. Since most of the younger women were black, it could not be determined whether the decrease in the length of maximum slope was related to age, race, or a combination. The length of phase of maxi-
MATERNAL POSITION, LABOR AND COMFORT
11
Table 4. Hourly Means
n
Dilatat}on in cm
Frequency of Contraction in Minutes
Duration of Contraction in Seconds
Comfort Score
U R
20 20
4.0 4.0
3.6 4.3
54.8 46.1
13.7 13.1
2
U R
20 20
5.4 4.8
3.2 3.8
63.5 46.3
13.0 12.5
3
U R
20 20
6.8 5.7
3.0 3.8
66.8 53.3
12.6 12.5
4
U R
17 20
7.6 6.6
2.8 3.3
68.1 55.1
11.8 11.4
5
U R
14 19
8.9 8.0
3.2 3,1
62.9 57.8
11.4 11.0
6
U R
5 11
8.6 8.2
2.8 3.0
61.3 58.4
11.9 9.9
7
U R
3 7
9.0 9.0
2.5 2.1
60.0 66.0
12.5 8.2
Position Groups
1
Hour
N = 40. Abbreviations: U, upright; R, recumbent.
mum slope was not significantly correlated with marital status, gestational age, or presence of support person. The overall mean comfort score during the phase of maximum slope did not significantly differ between the upright (12.53) and recumbent (11.79) position groups (t(38) = 1.42, p = . 163). The nonsignificant difference is conceptually very significant for nursing practice. The finding provides empirical evidence that laboring in upright positions has no ill effect on a woman's level of comfort during labor (Table 4). Women in the upright position group generally established a more efficient contraction pattern, with more intense and frequent contractions than women in the recumbent group. It is reasonable to expect that comfort would be difficult to achieve in this group; the intensity and frequency of contractions would augment the pain experience. Yet, there was no significant difference between the comfort scores for the two groups. The nursing staff often remarked that women in the upright position group behaved differently than most laboring women; they appeared more comfortable than the nurses expected them to appear, especially early in the phase of maximum slope. In addition, women in the upright position group received significantly less narcotic and other analgesia (21.25 mg) than women in the recumbent group (38.75 mg) 0(38) = 1.77, p =
.085). One might speculate that the women who labored in upright positions may have experienced a higher degree of independence from caregivers and had more control of their labor than recumbent women, which resulted in increased psychological comfort, though no difference in physical comfort. Such psychological variables are not measured by the Maternal Comfort Assessment Tool used in this study. Two additional findings, related to external fetal monitoring, warrant discussion. Fkst, although no subjects were monitored at the beginning of the study period, women in the recumbent position group were monitored externally more often (n = 13) than women in the upright position group (n = 1). When external monitoring was used with a subject, her hourly mean comfort scores decreased from what they were before monitoring was started (r = - .2799, p = .085). There were no medical indications for monitoring women laboring in recumbent positions that were not also present in women in the upright positions. It is likely that the recumbent women were monitored by virtue of being in bed and more accessible. Upright participants were not as accessible because they often left their labor rooms or were ambulating in the hall. Finally, the newborn Apgar scores at 1 minute and 5 minutes after birth were not significantly different between the two labor position groups,
ANDREWS AND CHRZANOWSKI
12
although they were slightly higher for infants of women in the recumbent group (upright, 8.7 at 1 minute; recumbent, 8.25 at 1 minute). This finding lends reassurance that the upright labor positions does not have an adverse effect on newborn wellbeing, although this does not support the Flynn and Kelly (1978) observation that maternal upright positions are associated with improved infant outcomes. There are three possible explanations for the lack of significant difference in newborn Apgar scores. First, participants in both maternal position groups were medically at low risk and had been screened according to strict inclusion criteria. Infants of women experiencing low-risk pregnancies and labors rarely have difficulty at birth and tend to have high Apgar scores unrelated to maternal labor position. Second, newborn Apgar scores were rated by the subject's nurse in this study (i.e., whoever was assigned to the patient for care did the official Apgar score). Thus, the person who did the Apgar score was not consistent for subjects in both groups; the subjective component o f Apgar ratings was not controlled. Third, women in the recumbent position group tended to avoid the supine position, which is the recumbent position associated with the most detrimental effects on the fetus. NURSING IMPLICATIONS AND FURTHER RESEARCH
Maternal positioning is a useful intervention for nurses to incorporate into clinical practice with la-
boring women and in childbirth education programs. Nurses are frequently strong verbal advocates of ambulation during labor, a variation of the upright position. The findings of this study support the use of ambulation as a deliberate intervention. Nurses need to be aware that the upright labor positions have the distinct advantages of facilitating efficient uterine contractions and reducing the duration of the phase of m a x i m u m slope in labor, with no adverse effect on the "pain experienced. Though women in upright labor positions may be as physically uncomfortable as women in recumbent positions during the phase of maximum slope, they m a y experience beneficial psychological states during labor and birth. For the most part, hospital environments and health care personnel encourage laboring women to be recumbent; it is very difficult to offer support of equal impetus to the laboring woman so she believes that ambulation is truly an option. The woman who chooses to ambulate rather than to " g o to b e d " can replace the sense of illness from being in bed with a sense o f control over her own body. She can work with her body to accomplish a marathon event with little or no assistance from medicinal or mechanical interventions. Further research should examine the relationship between ambulation in labor and psychological well-being of the laboring woman and her labor support person. Investigation is needed to determine the effects of specific positions on the length of labor, maternal comfort, and fetal status in both normal and dysfunctional labor.
REFERENCES
Arbitol, M.M. (1985). Supine position in labor and associated fetal heart rate changes. Obstetrics and Gynecology, 65, 481-486. Caldeyro-Barcia, R. (1980). The influence of maternal position on time of spontaneous rupture of membranes, progress of labor and fetal head compression. Birth and the FamilyJournal, 6(1), 7-15. Diaz, A., Schwarcz, R., Fescina, R., & Caldeyro-Barcia, R. (1980). Vertical position during the fast stage of the course of labor, and neonatal outcomes. European Journal of Obstetrics and Gynecology, 11, 1-7. Engelmann, G. (1882). Labor among primitive peoples, showing the development of the obstetricscience of today. NY: AMS. Flynn, A., & Kelly, J. (1978). Ambulation in early labor. British Medical Journal, 2, 591-593. Fridh, G., Kopare, T., Gaston-Johansson, F., & Norvell, K.T. (1988). Factors associated with more intense labor pain. Research in Nursing and Health, 11, 117-124.
Friedman, M., Divon, M.Y., Zimmer, E.Z., Goldstein, I., Peretz, B.A., & Paldi, E. (1983). Nonstress test in standing and lying women. Early Human Development, 8, 317-322. Gaston-Johansson, F., Fridh, G., & Tumer-Norvell, K. (1987). Progression of labor pain in primiparas and multiparas. Nursing Research, 37, 86-90. •Liu, Y. (1974). Effect of maternal position during labor. American Journal of Nursing, 74, 2202-2205. Liu, Y. (1989). The effects of the upright position during childbirth. Image:Journal of Nursing Scholarship, 21(1), 14-18. Lowe, N.K. (1989). Explaining the pain of active labor: The importance of maternal confidence. Research in Nursing and Health, 12, 237-245. Lupe, P.J., & Gross, T.L. (1986). Maternal upright posture and mobility in labor: A review. Obstetrics and Gynecology, 67, 727-734. McKay, S. (1980). Maternal position during labor and birth: A reassessment. Journal of Obstetrics and Gynecologic Nursing, 9(5), 288-291.
MATERNAL POSITION, LABOR AND COMFORT
Mead, M., & Newton, N. (1967). Cultural patterning of perinatal behavior. In S. Richardson (Ed.), Childbearing--Its social and psychological aspects. Baltimore, MD: Williams & Wilkins. Melzack, R., Taenzer, P., Feldman, P., & Kinch, R.A. (1981). Labor is still painful after prepared childbirth. Canadian Medical Association Journal, 25, 357-363. Mendez-Bauer, C. (1975). Effects of the standing position on spontaneous contractility and other aspects of labor. Journal of Perinatal Medicine, 3, 89-99. Mitre, I. (1974). The influence of maternal position on duration of the active phase of labor. International Journal of Obstetrics and Gynecology, 12, 181-188. Narroll, F., Narroll, R., & Howard, F. (1961). Position of women in childbirth. American Journal of Obstetrics and Gynecology, 82, 943-954. Prschl, U. (1987). The vertical birthing position of the Tro-
13 brianders, Papua New Guinea. Australian New Zealand Journal of Obstetrics and Gynaecology, 27, 120-125. Reading, A.E., & Cox, D.N. (1985). Psychosocial predictors of labor pain. Pain, 22, 309-315. Roberts, J. (1980). Alternative positions for childbirth: First stage of labor. Journal of Nurse-Midwifery, 25(4), 11-18. Roberts, J., Mendez-Bauer, C., Blackwell, J., Carpenter, M., & Marchese, T. (1984). Effects of lateral recumbancy and sitting on the first stage of labor. Journal of Reproductive Medicine, 29, 477-482. Roberts, J.E., Mendez-Bauer, C., & Wodell, D.A. (1983). The effects of maternal position on uterine contractility and efficiency. Birth, 10, 243-249. Scott-Palmer, J., & Skevington, S.M. (1981). Pain during childbirth and menstruation: A study of locus of control. Journal of Psychbsomatic Research, 25, 151-155. Stewart, P., & Calder, A. (1984) Posture in labor: Patient's choice and its effect on performance. British Journal of Obstetrics and Gynecology, 9l, 1091-1095.
The purpose of this study was to determine if women who assumed upright positions during the phase of maximum slope would have a shorter phase of maximum slope in their labor and experience more comfort than women who assumed recumbent positions. Forty laboring women were randomly assigned to either an upright or recumbent position group. Subjects assumed the positions of their assigned group during the phase of maximum slope in their labor (cervical dilatation from 4 cm to 9 cm). Every hour during the phase of maximum slope, each subject was examined vaginally to determine her cervical dilatation and assessed for her level o f comfort using the Maternal Comfort Assessment Tool. Women in the upright position group had a significantly shorter phase of maximum slope in labor, btit did not significantly differ in comfort level from women in the recumbent group. Newbom Apgar scores were not significantly different between the two groups. Nurses need to be aware that the upright labor positions have the distinct advantages of facilitating efficient uterine contractions and reducing the duration of the phase of maximum slope in labor, with no increase in the discomfort experienced or adverse effect on newborn well-being. © 1990 by W.B. Saunders Company.
p
facilitates the use of forceps and permits easy access to the perineum for the caregiver. Although recumbent positions during labor offer advantages for the caregiver, research has pointed to potential hazards of the recumbent positions for the well-being of the laboring woman and the fetus. When supine, laboring women may experience a decrease in the strength of uterine contractions, an increase in the risk of developing maternal hypotensive syndrome, late decelerations, and a decrease in the newborn's Apgar scores and cord blood pH (Arbitol, 1985; C~Ideyro-Barcia, 1980; Roberts, 1980). Women in the lateral and supine positions tend to have longer labors than women in the upright position (Caldeyro-Barcia, 1980; Liu, 1974, 1989; McKay, 1980; Mitre, 1974).
OSITIONS THAT MOST women assume while in labor are culturally patterned (Mead & Newton, 1967). In most areas of the world that have not been influenced by Western society, women labor in some form of upright position (Engelmann, 1882; Narroll, Narroll, & Howard, 1961; Prschl, 1987; Roberts, 1980). In Western societies, the lateral (side-lying) and supine (back-lying) forms of the recumbent position are generally assumed during labor. For delivery of the baby, the supine position is modified into the lithotomy position by raising the woman's legs into stirrups. This study examined the relationship between upfight labor positions and comfort and length of labor. Recumbent positions during labor have several convenient features for caregivers. In the supine position, the maternal abdomen is accessible to the caregiver for auscultating fetal heart tones and for checking cervical dilatation by vaginal examination. In both lateral and supine positions, contractions are easily palpated and electronic monitoring devices may be readily applied. The lateral recumbent position is reported to be accompanied by more intense, less frequent, and more efficient uterine contractions than the sitting position (Roberts, Mendez-Bauer, Blackwell, Carpenter, & Marchese, 1984; Roberts, Mendez-Bauer, & Wodell, 1983). At birth, the lithotomy position
From the Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, and the North Avenue Women's Center, Battle Creek, MI. Claire M. Andrews, PhD, CNM: Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH; Maureen Cb.rzanowski, MSN, CNM: North Avenue Women's Center, Battle Creek, MI. Address reprint requests to Claire M. Andrews, PhD, CNM, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH 44106. © 1990 by W.B. Saunders Company. 0897-1897/90/0301-0003505.00/0
Applied Nursing Research,Vol. 3, No. 1 (Februa~), 1990: pp. 7-13
7
ANDREWS AND CHRZANOWSKI
In contrast to the potential maternal and fetal~ hazards of recumbent positions during labor, researchers have found that upright positions are beneficial for the progress and outcome of labor. Women in upright positions experience more intense contractions and shorter labors than women in recumbent positions (Diaz, Schwarcz, Fescina, & Caldeyro-Barcia, 1980; Liu, !974, 1989; Mendez-Bauer, 1975; Mitre, 1974; Stewart & Calder, 1984). The greater the intensity of the contraction, the more efficient it is for the progress of labor. A comparison study on the effect of the upright position and the left lateral recumbent position o n fetal movements and fetal heart rate showed no significant difference between the two maternal position groups; the upright position did not adversely affect fetal well-being (Friedman et al., 1983). The effect of maternal positions in labor on women's experiences.of childbirth pain is of great importance in guiding nursing interventions with laboring women. Few studies have explored the relationship between maternal position and maternal comfort during labor (Lupe & Gross, 1986). Gravid women have stated that they are more comfortable during labor when they assume upright positions (Caldeyro-Barcia, 1980; Mendez-Bauer, 1975). According to the research of Flynn and Kelly (1978), women who labored in the upright position did not need analgesia, but women in the recumbent position did require analgesia to manage discomfort. Women's experiences of childbirth pain are notoriously difficult to assess. Pain in labor has been studied using self-reports, questionnaires, visual analogue scales, and, most recently, a pain-ometer (Fridh, Kopare, Gaston-Johansson, & Norveil, 1988; Gaston-Johansson, Fridh, & TurnerNorvell, 1987; Melzack, Taenzer, Feldman, & Kinch, 198!; Scott-Palmer & Skevington, 1981). Tla~ different methods used to measure labor pain result in inconsistent, often conflicting results. The results are dependent on whether measurement was based on the laboring woman's personal perception of her childbirth pain or on physiologic and behavioral indicators of pain. Also, the point in time at which the labor pain measurement was made influences the results. For example, a woman's perception of labor pain measured intrapartally is likely to be different than a postpartum retrospective recall of intrapartal pain.
The relationship of labor pain to a wide variety of psychosocial and physiologic variables has been investigated with conflicting results. Maternal age, socioeconomic indicators, childbirth educational preparation, maternal confidence, level of fear or anxiety, history of menstrual discomfort, prepregnancy body weight, and degree of cervical dilatation are but a few of the variables examined with labor pain (Fridh, Kopare, Gaston-Johansson, & Norvell, 1988; Gaston-Johansson, Fridh, & Turner-Norvell, 1987; Lowe, 1989; Melzack, Taenzer, Feldman, & Kinch, 1981; Reading, & Cox, 1985; Scott-Palmer, & Skevington, 1981). However, analyses of labor pain have not included important physical variables such as maternal position and fetal-pelvic relationships.
The relationship of labor pain to a wide variety of psychosocial and physiologic variables has been investigated with conflicting results. Despite the previously mentioned disadvantages of the recumbent positions and the advantages of the upright positions, women in the United States continue to labor in some form of recumbent position. This traditional pattern is likely influenced by the standard practice of caregivers and by institutional policies that offer women little choice in the position assumed in labor. The purpose of this study was to determine if women who assume upright positions during the phase of maximum slope have a shorter phase of maximum slope in their labor and appear more comfortable than women who assume recumbent positions. METHOD
Over a 3-month period, a convenience sample of 40 laboring womenparticipated in the study at a health maintenance organization in a large midwestern city. All participants were nulliparous, experiencing a medically uncomplicated pregnancy with a single vertex fetus in an anterior position, spontaneous onset of labor at 38 to 42 weeks gestation, adequate pelvic measurements, and intact amniotie membranes at the beginning of the phase
MATERNAL POSITION, LABOR AND COMFORT
Table 1. Frequencies of the Descriptive Variables for the Position Groups Race Position Group
Upright Recumbent
Presenceof Support Person
Marital Status
White
Black
Other
Married
Single
Yes
No
12
7
1
13
7
17
3
8
11
1
11
9
18
2
N = 40.
of maximum slope. Participants were randomly assigned to one of two maternal position groups, upright (n = 20) and recumbent (n = 20). The women were free to choose several variations within each position group. Variations of the upright position included standing, ambulating, sitting, squatting, or kneeling. Variations of the supine position included supine, lateral, or prone positions such as the hands and knees position. Subjects in both groups were free to assume positions from the other group for routines of'care and for rest; these activities were documented. Demographic variables for the upright and recumbent position groups are summarized in Tables 1 and 2. During data collection, 15 Of the participants in the upright group chose to lie down after receiving medication for rest. Of this group, 5 immediately returned to the upright position stating that the contractions were more painful when they were lying down. The remaining 10 chose the lateral position to rest for up to 1 hour during the study period. Two instruments were used to collect information related to the effect of the maternal position on labor in the phase of maximum slope and on maternal comfort. The first instrument, developed specifically for this study, was used (a) to gather demographic information; (b) to gather information theoretically related to the experience of childbirth pain (childbirth preparation, presence of la° bor support person); and (c) to record the length of the phase of maximum slope in labor. The phase of maximum slope, a subdivision of the first stage of labor, is the most active phase of labor, during which rapid cervical dilatation takes place (from 4 to 9 cm). The length of the phase was determined by the first recorded time that cervical dilatation was assessed to be 4 .cm and on the first recorded time that dilatation was assessed to be 9 cm. The Maternal Comfort Assessment Tool, developed by Chrzanowski and Young for this study, was the second data collection instrument used. The tool estimates the level of maternal comfort by
measuring the laboring woman's focus of attention, eye contact during contractions, breathing pattern and vocal behavior during contractions, muscle te.nsion and activity during contractions, and verbalizations regarding ability to continue with labor. In addition, vital signs; degree of cervical dilatation; duration, frequency, and intensity of contractions; medications; and use of monitoring apparatus are recorded on the Maternal Comfort Assessment Tool. When the scores for each category of observable behavior in the tool are added, the highest possible comfort score for each contraction is 14 and the lowest is 0. The tool is included in Table 3. Comfort scores for a series of three contractions were recorded by one of the investigators on an hourly basis during the phase of maximum slope and averaged for a mean hourly comfort score. The hourly comfort scores were then averaged to obtain an overall mean comfort score for each woman. Vital signs, cervical dilatation, frequency, intensity, length of contraction, and general comments regarding maternal position changes were assessed by the patient's nurse and recorded on an hourly basis. A prestudy interrater reliability for the tool was obtained by the investigators. Assessments were independently made on each of a series of three contractions with five patients. The percentage of agreement was 89%. Interrater reliability also was obtained during the study on each of a series of three contractions for Table 2. Measures of Central Tendencies for Age of Subjects and Gestational Age in the Two Position Groups Position Group
Mean
Mode
Range
Age
Upright Recumbent
22.75 21.15
18.0 18.0
17-36 16-28
Gestational Age
Upright Recumbent
39.95 40.15
40.0 41.0
38-42 38-42
N=40.
ANDREWS AND CHRZANOWSKI
10
Table 3. Maternal Comfort Assessment Tool Subject number 1. Focus of Attention Able to follow directions Occasionally follows directions Unable to fellow directions 2. Eye contact during contractions Easily maintains eye contact when spoken to Occasionally makes eye contact when spoken to Unableto make eye contact when spoken to 3. Breathing Uses some form of controlled breathing during contractions Occasionally uses some controlled breathing during contractions Does not use controlled breathing during contractions 4. Vocal behavior No vocal sounds (with the exception of normal speech) with contractions Moans, whimpers, repeats sounds or words with contractions Screaming, crying (hysterical) with contractions 5. Muscle tension All muscles relaxed with contractions Face or one extremity tense with contraction Extremities held rigid; facial tension with contractions
(2) (1) (0)
(2) (1) (0)
(2) (1) (0)
(2) (1)
(0)
(2)
6. Activity during contractions Lies still in bed, rocks, ambulates or performs effieurage with contractions Occasional uncontrolled movements of extremities with contractions Tossing or thrashing in bed of entire body with contraction 7. Verbalizations Silent or expresses no doubt about ability to deal with labor Occasionally expresses doubts about ability to continue labor or deal with contractions Frequent requests for rescue from situation; continually doubts ability to continue labor or deal with contractions
(2) (1) (0)
Duration/frequency of contractions in seconds and minutes Intensity of contractions (m, mild; mo, moderate; st, strong) Monitor (I = internal, E = external) Medications Miscellaneous observations Total Score
Women in the upright position group had a statistically significant shorter phase of maximum slope in labor than women in the recumbent group (t(38) = 3.2, p = .003). The mean length of the phase of maximum slope for women who labored in recumbent positions was 324.75 minutes. Women in upright positions had a mean length of 234.50 minutes, a difference of 90.25 minutes. Women in the upright position group generally • established a more efficient contraction pattern earlier in the phase of maximum slope than women in the recumbent group. Generally, women in the upright position group had contractions that were more frequent, more intense, and longer lasting earlier in the phase of maximum slope than women in the recumbent group (Table 4). Because of the more efficient contraction pattern, the women in the upright position group experienced more rapid cervical dilatation during the phase of maximum slope (Table 4). Rapid cervical dilatation is promoted
(0)
Cervical dilatation in centimeters
(0)
RESULTS
(1)
Vital signs
(1)
five randomly selected subjects. The percentage of agreement was 91%.
(2)
by fetal descent; it is likely that gravitational forces assisted fetal descent in the upright position group. The length of the phase of maximum slope was positively correlated with age (r = .323, p = .021) and with race (r = .3227, p = .021) for the
Women in the upright position group generally established a more efficient contraction pattern earlier in the phase of maximum slope than women in the recumbent group.
entire sample. Younger women tended to have a shorter phase of maximum slope than older women. Black women tended to have a shorter phase of maximum slope than white women. Since most of the younger women were black, it could not be determined whether the decrease in the length of maximum slope was related to age, race, or a combination. The length of phase of maxi-
MATERNAL POSITION, LABOR AND COMFORT
11
Table 4. Hourly Means
n
Dilatat}on in cm
Frequency of Contraction in Minutes
Duration of Contraction in Seconds
Comfort Score
U R
20 20
4.0 4.0
3.6 4.3
54.8 46.1
13.7 13.1
2
U R
20 20
5.4 4.8
3.2 3.8
63.5 46.3
13.0 12.5
3
U R
20 20
6.8 5.7
3.0 3.8
66.8 53.3
12.6 12.5
4
U R
17 20
7.6 6.6
2.8 3.3
68.1 55.1
11.8 11.4
5
U R
14 19
8.9 8.0
3.2 3,1
62.9 57.8
11.4 11.0
6
U R
5 11
8.6 8.2
2.8 3.0
61.3 58.4
11.9 9.9
7
U R
3 7
9.0 9.0
2.5 2.1
60.0 66.0
12.5 8.2
Position Groups
1
Hour
N = 40. Abbreviations: U, upright; R, recumbent.
mum slope was not significantly correlated with marital status, gestational age, or presence of support person. The overall mean comfort score during the phase of maximum slope did not significantly differ between the upright (12.53) and recumbent (11.79) position groups (t(38) = 1.42, p = . 163). The nonsignificant difference is conceptually very significant for nursing practice. The finding provides empirical evidence that laboring in upright positions has no ill effect on a woman's level of comfort during labor (Table 4). Women in the upright position group generally established a more efficient contraction pattern, with more intense and frequent contractions than women in the recumbent group. It is reasonable to expect that comfort would be difficult to achieve in this group; the intensity and frequency of contractions would augment the pain experience. Yet, there was no significant difference between the comfort scores for the two groups. The nursing staff often remarked that women in the upright position group behaved differently than most laboring women; they appeared more comfortable than the nurses expected them to appear, especially early in the phase of maximum slope. In addition, women in the upright position group received significantly less narcotic and other analgesia (21.25 mg) than women in the recumbent group (38.75 mg) 0(38) = 1.77, p =
.085). One might speculate that the women who labored in upright positions may have experienced a higher degree of independence from caregivers and had more control of their labor than recumbent women, which resulted in increased psychological comfort, though no difference in physical comfort. Such psychological variables are not measured by the Maternal Comfort Assessment Tool used in this study. Two additional findings, related to external fetal monitoring, warrant discussion. Fkst, although no subjects were monitored at the beginning of the study period, women in the recumbent position group were monitored externally more often (n = 13) than women in the upright position group (n = 1). When external monitoring was used with a subject, her hourly mean comfort scores decreased from what they were before monitoring was started (r = - .2799, p = .085). There were no medical indications for monitoring women laboring in recumbent positions that were not also present in women in the upright positions. It is likely that the recumbent women were monitored by virtue of being in bed and more accessible. Upright participants were not as accessible because they often left their labor rooms or were ambulating in the hall. Finally, the newborn Apgar scores at 1 minute and 5 minutes after birth were not significantly different between the two labor position groups,
ANDREWS AND CHRZANOWSKI
12
although they were slightly higher for infants of women in the recumbent group (upright, 8.7 at 1 minute; recumbent, 8.25 at 1 minute). This finding lends reassurance that the upright labor positions does not have an adverse effect on newborn wellbeing, although this does not support the Flynn and Kelly (1978) observation that maternal upright positions are associated with improved infant outcomes. There are three possible explanations for the lack of significant difference in newborn Apgar scores. First, participants in both maternal position groups were medically at low risk and had been screened according to strict inclusion criteria. Infants of women experiencing low-risk pregnancies and labors rarely have difficulty at birth and tend to have high Apgar scores unrelated to maternal labor position. Second, newborn Apgar scores were rated by the subject's nurse in this study (i.e., whoever was assigned to the patient for care did the official Apgar score). Thus, the person who did the Apgar score was not consistent for subjects in both groups; the subjective component o f Apgar ratings was not controlled. Third, women in the recumbent position group tended to avoid the supine position, which is the recumbent position associated with the most detrimental effects on the fetus. NURSING IMPLICATIONS AND FURTHER RESEARCH
Maternal positioning is a useful intervention for nurses to incorporate into clinical practice with la-
boring women and in childbirth education programs. Nurses are frequently strong verbal advocates of ambulation during labor, a variation of the upright position. The findings of this study support the use of ambulation as a deliberate intervention. Nurses need to be aware that the upright labor positions have the distinct advantages of facilitating efficient uterine contractions and reducing the duration of the phase of m a x i m u m slope in labor, with no adverse effect on the "pain experienced. Though women in upright labor positions may be as physically uncomfortable as women in recumbent positions during the phase of maximum slope, they m a y experience beneficial psychological states during labor and birth. For the most part, hospital environments and health care personnel encourage laboring women to be recumbent; it is very difficult to offer support of equal impetus to the laboring woman so she believes that ambulation is truly an option. The woman who chooses to ambulate rather than to " g o to b e d " can replace the sense of illness from being in bed with a sense o f control over her own body. She can work with her body to accomplish a marathon event with little or no assistance from medicinal or mechanical interventions. Further research should examine the relationship between ambulation in labor and psychological well-being of the laboring woman and her labor support person. Investigation is needed to determine the effects of specific positions on the length of labor, maternal comfort, and fetal status in both normal and dysfunctional labor.
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