Image Source: '© Sharon Muza

Today, author Henci Goer takes a look at a new Cochrane Systematic Review; 'Maternal positions and mobility during first stage labour' and finds that the results of this review support the 2nd Lamaze International Healthy Birth Practice: Walk, move around and change positions throughout labor. Families taking Lamaze childbirth classes learn how they can promote physiologic birth by using a variety of positions throughout their labor, but women don't have to take a childbirth class to know that walking and trying different positions reduces pain and speeds up labor. Intuitively, women respond to the needs of their baby and their body during labor. Henci examines the review and shares some of the benefits that were found in the women who followed the 2nd Healthy Birth Practice to promote safe and healthy birth. - Sharon Muza, Community Manager.

Advocates for physiologic care in labor will be pleased, although not surprised, to know that a Cochrane systematic review supports mobility and upright positioning in first-stage labor (the cervical dilation phase) (Lawrence 2013.) The review includes 18 randomized controlled trials (RCTs) comprising 3337 women not having epidurals at trial entry and 7 trials comprising 1881 women in which all participants had epidurals or combined spinal-epidurals at trial entry.

The body of data poses challenges in analysis and interpretation. Trials were published between 1963 and 2012 and conducted in 13 countries. As reviewers note, this means that they took place in highly varied cultural and healthcare contexts, equally varied expectations on the part of staff and laboring women, and with evolving healthcare technologies, all of which could influence results. In addition, comparison 'treatment' and 'control' groups also varied widely and overlapped among them. So, for example, one trial compared walking with remaining in bed in whatever posture, including upright postures; another compared walking with recumbent postures; and still another combined sitting and walking as upright postures and compared them with recumbent postures. That being said, here is what the reviewers found:

Compared with recumbent postures and bed care, upright postures and walking in women without epidurals at trial entry:

¢ Shortened first-stage labor duration by a mean difference of 1 hour 22 minutes in women overall (15 trials, 2503 women) and by 1 hour 13 minutes in first-time mothers (12 trials, 1486 women). In women with prior births (4 trials, 662 women), duration differed by only 34 minutes, and the difference just missed achieving statistical significance, that is, statistical analysis shows that the difference is unlikely to be due to chance. By comparison, rupturing membranes, commonly used to 'get the show on the road,' had no effect on first-stage duration in women overall (5 trials, 1127 women) (Smyth 2013), and too few women were reported according to first-time or prior births to draw meaningful conclusions.

¢ Decreased likelihood of cesarean delivery (14 trials, 2682 women) by 30%. Likelihood decreased by 20% in first-time mothers (8 trials, 1237 women) and 40% in women with prior births (4 trials, 775 women), but the differences didn't achieve statistical significance probably because aggregated numbers were too small (underpowered) and cesarean rates too low to detect a difference. By contrast, rupturing membranes increases the likelihood of cesarean surgery by 30%, a risk that misses achieving statistical significance by a whisker and probably would have achieved significance had not so many women assigned to 'conserve membranes' actually had their membranes ruptured (Smyth 2013).

¢ Reduced use of epidural analgesia (9 trials, 2107 women) by 20%.

¢ Didn't increase satisfaction or decrease complaints of pain, but only one small study (107 women) measured satisfaction, and among the three trials (338 women) evaluating pain, women reported less pain in two of them, but in the third (201 women), which comprised 60% of the population overall, participants assigned to sit or walk were not allowed to lie down at any time during first stage. Bloom et al. (1998), by far the largest of any of the trials at 1067 participants, wasn't included in the pain and satisfaction assessments probably because they took a different approach. They asked women who walked whether they would want to walk in a future labor. Ninety-nine percent said 'Yes,' which would seem a ringing endorsement of ambulation.

¢ Showed no evidence of increasing maternal, fetal, or neonatal harm. In fact, one small trial (200 women) reported significantly fewer admissions to neonatal intensive care.

Benefits were maintained when subgroupings of upright postures were compared with subgroupings of recumbent postures, as for example, walking compared with recumbent/supine/lateral or sitting and standing, squatting, kneeling, or walking compared with recumbent/supine/lateral.

No benefits were found for walking or upright postures (7 trials, 1881 women) in women who had epidurals or combined spinal-epidurals at trial entry. This doesn't really mean much, though, because in some trials, substantial percentages of women assigned to walk didn't actually do so, and in others 'ambulation' was defined to be as little as 5 minutes of walking per hour.

The review leaves some questions open: Can mobility be used to treat delayed progress? Should women with ruptured membranes be allowed to walk? What about women at risk for fetal compromise? To the first question, it makes sense to encourage walking and upright positioning as a first-line measure to treat progress delay. The alternatives, rupturing membranes and oxytocin augmentation, have potential harms while walking and position changes don't. To the second, when upright, gravity would tend to bring the presenting part downward to block the cervical opening, thereby protecting against umbilical cord prolapse. A common sense approach might be to monitor fetal heart tones throughout a contraction upon the woman first assuming an upright position and repeat whenever she returns to an upright position after lying down. To the last question, studies would need to be done, but rupturing membranes increases risk of fetal compromise by releasing the fluid that prevents umbilical cord compression (you can't compress a liquid), and augmentation increases contraction intensity, which also could increase risk of compromise in a vulnerable fetus.

The true benefits of mobility are almost certainly much greater than the review shows. This is because RCTs are analyzed according to 'intent to treat,' that is, participants are kept with their assigned group regardless of their actual treatment. To do otherwise would negate the point of random assignment, which is to avoid bias; however, when substantial percentages of participants receive the treatment of the other group, as is the case with many of the mobility RCTs, it both diminishes differences between groups and makes it harder to detect a significant difference between them. This was a problem in all the mobility RCTs, not just the ones where women already had regional analgesia on board. Again, take Bloom et al. (1998): among women assigned to walk, 22% - approaching 1 in 4'never walked at all, and of the women who did, the mean time spent out of bed was an hour mostly because of policies that kept them in, or returned them to, bed.

The reviewers conclude:

[W]e believe wherever possible, women should be informed of the benefits of upright positions, encouraged and supported to take up whatever positions they choose, they should not have their freedom of movement options restricted unless clinically indicated, and they should avoid spending long periods supine (p. 23).

It isn't enough, though, to advise women that it's a good idea to stay mobile and stay off their backs unless staff follow through on not restricting freedom of movement. As matters currently stand, conventional hospital labor management couldn't do a better job of restricting mobility if that were its intended goal. To turn that around, hospitals would need to:

¢ Provide an environment conducive to mobility, including ample space for moving around and props such as birth balls, rocking chairs, and cushions,

¢ Provide comfort measures such as hot and cold packs, private showers, and soaking tubs to reduce and delay use of epidural analgesia,

¢ Train staff in encouraging and providing physical assistance in changing positions, in the use of mobility props, and in how to provide emotionally supportive care,

¢ Welcome doulas who can share the burden of providing physical and emotional support,

¢ Use intermittent listening to fetal heart tones except when continuous monitoring is medically indicated,

¢ Reserve IVs for medical indications, which would mean allowing women oral intake of fluids and calories, and

¢ When mobility-inhibiting interventions are required or the woman desires an epidural, minimize their impact by such measures as telemetry monitoring, inserting IV catheters in the forearm rather than the hand or wrist or using saline locks instead of IVs, and encouraging women with epidurals to assume upright positions and change positions periodically.

In other words, promoting mobility in labor is the proverbial tip of the iceberg. Floating below is the vast bulk of providing physiologic care. That won't be easy for a number of reasons.

For one thing, medical research principles require that investigators define the intervention under evaluation precisely and maximize compliance with its administration. But this is the direct opposite of women doing what instinctively feels best in an environment that encourages their experimentation and is free from elements that inhibit or restrict them. We have no trials that compare this style of care with conventional medical-model management, which means we don't have data showing the true degree of harm arising from confining and circumscribing mobility in labor or the magnitude of the benefits to be gained with promoting it. Without that knowledge, there is little incentive to change.

For another, in the topsy-turvy world of medical-model research, maternal movements and physiologically normal behaviors are framed as 'interventions.' This means that being up and around and having the freedom to labor in the positions of the woman's choice has to prove itself, not confinement to bed and positioning restriction. What is more, to institute change, the 'intervention' must prove itself superior according to medical model concepts of improved outcomes, or conventional management stands, however much that management lacks an evidence basis. This explains how Bloom and colleagues could entitle their trial 'Lack of effect of walking on labor and delivery' despite walking having no harms and 99% of women who walked wanting to do so again in a future labor.

Finally, powerful forces line up against instituting the sweeping changes that would be required to convert to mobility-friendly care. Inertia is one. People will generally resist change even when it benefits them personally, which in this case it doesn't. Economics is another. The costs of maintaining a 24/7 obstetric analgesia service demand that most women have epidurals while any renovation expenses, such as providing private showers, soaking tubs, or telemetry monitoring, would not be reimbursed. Hospital culture is perhaps the biggest obstacle of all. 'This is the way we've always done it' and 'what is must be right' are potent impediments to improvement. Specifically, so long as reducing cesarean rates isn't a shared, strongly-held goal, and a cursory glance at hospital cesarean rates shows that it isn't in most hospitals'motivation to change will be low.

All of this is to say that reform won't be easy, not that it can't be done, and, I would add, the wellbeing of mothers and babies obliges us to try. In that interest, can we crowd source strategies? Are any hospitals in your community mobility friendly? What are their practices and policies? Have any of you been involved in projects to increase mobility in labor, and if so, what went well and what would you do differently?

References

Bloom, S. L., McIntire, D. D., Kelly, M. A., Beimer, H. L., Burpo, R. H., Garcia, M. A., & Leveno, K. J. (1998). Lack of effect of walking on labor and delivery. N Engl J Med, 339(2), 76-79. http://www.ncbi.nlm.nih.gov/pubmed/9654537?dopt=Citation

Lawrence, A., Lewis, L., Hofmeyr, G. J., & Styles, C. (2013). Maternal positions and mobility during first stage labour. Cochrane Database Syst Rev, 10, CD003934. doi: 10.1002/14651858.CD003934.pub4 http://www.ncbi.nlm.nih.gov/pubmed/24105444

Smyth, R. M., Markham, C., & Dowswell, T. (2013). Amniotomy for shortening spontaneous labour. Cochrane Database Syst Rev, 6, CD006167. doi: 10.1002/14651858.CD006167.pub4 http://www.ncbi.nlm.nih.gov/pubmed/23780653

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