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Positions for birth: does it really matter?
DR MARY ROSS-DAVIE
MAMA CONFERENCE, APRIL 2016
Session Aims• Think a bit about the historical and cultural context of positions in labour and birth and current practice
• Review the evidence base for mobility and upright positions in labour and birth
• Begin to think about how we can shift current practice norms towards more mobility and upright positions
Declaration of interest… Personal…
Declaration of interest…Professional
Historical and Cultural
What are we doing? 2015 Scottish Maternity
Service User survey , results
What are we doing?
What are we doing? 32% gave birth in an upright position
In England CQC survey, 35% described giving birth with legs in stirrups
THE EVIDENCE
Active and upright labour: a key part of support
Women’s Definitions of support
• Presence of nurse/midwife
• Enabled to feel in control
• Caregiver presents a positive, calm, friendly attitude
• Feeling cared for as an individual
• Praise, reassurance and encouragement
• Help with breathing and relaxation
• Being treated with respect
• Being kept informed
• Being involved in decisions
• Ensuring partner feels supported and involved
• Physical support such as touch and help with position changes
Lesser and Keane 1956 Shields 1978Field 1987Kintz 1987Bryanton 1994 & 2008Tarkka and Paunonen 1996Holroyd 1997Watkins 1998Lavender 1998 &9Powell-Kennedy 2000Miltner 2000 Tumblin 2001 Bowers 2002, Hodnett 1996, 2002 & 2006,Matthew and Callister 2003Goodman et al 2004Lundgren 2005
Newburn and Singh 2005Larkin and Begley 2009
‘Intrapartum support: What do women want?’ Evidence Based Midwifery, June 2014http://issuu.com/redactive/docs/ebm_june_2014
Hierarchy of evidence
25 methodologically variable studies5218 women
Lawrence et al 2013Upright v Recumbent
(standing, sitting, kneeling, walking) (supine, semi-recumbent and lateral)
Upright intervention group 1st Stage – 1 hour 22 minutes shorter
Less Likely to have a Caesarean – RR 0.71
Less Likely to have an Epidural – RR 0.81
Babies less likely to be admitted to SCBU – RR 0.20 (but just one study, 200 women)
(Continuous support v intermittent support
0.58 hour shorter, Caesarean RR 0.78, Epidural RR 0.93)
They conclude…There is clear and important evidence that walking and upright positions in the first stage of labour reduces the duration of labour, the risk of caesarean birth, the need for epidural and does not seem to be associated with increased intervention or negative effects on mothers’ and babies’ well being.
Based on the current findings, we recommend that women in low-risk labour should be informed of the benefits of upright positions, and encouraged and assisted to assume whatever position they choose
Gupta et al 2012‘Position in 2nd stage of labour for women without an epidural’
22 Trials, variable quality
7280 women
Upright positions v recumbent
Significant reduction in operative deliveries (RR0.78)
Significant reduction in episiotomies (RR 0.79)
Fewer abnormal fetal heart rates (RR 0.46)
Non-significant reduction in duration of 2nd stage (- 3.71 min)
Increased 2nd degree tears and blood loss >500ml (but this was around 60ml)
Kemp et al, 2013‘Position in 2nd stage for women with an epidural’
5 RCTs
879 women
Non-significant difference in operative deliveries RR 0.97
Reduction in length of 2nd stage -22.98 mins
But no difference in perineal trauma and fetal distress, low cord ph or admission to SCBU
NICE Intrapartum Care guideline 2014
Encourage and help the woman to move and adopt whatever positions she finds most comfortable throughout labour.
RCM Evidence Based Guidelines 2010Mobility and upright positions are recommended for:
Physiological Benefits
Effect of gravity on the fetus in utero
Reduced risk of aorto-caval compression
Better alignment of the fetus
Increased efficiency of contractions
Increased pelvic outlet
Psychological Benefits
Enables woman to feel more in control
Reduces severity of pain
RCT, Thies-Lagergren et al, 20111002 nullips
Birth seat v any other position
No reduction in instrumental births
Increase in blood loss >500ml, but not >1000ml
No increase in third degree tears
2nd stage significantly shorter
Literature Review: Romano and Lothian 2008, ‘Promoting, protecting and supporting normal birth, A look at the evidence’ 6 key practices
Avoid unnecessary Induction of labour
Nonsupine spontaneous
pushing
Continuous labour support
Freedom of movement
Avoid routine interventions and
restrictions
Keep mothers and babies together
Observational study: Reitter et al, 2014, ‘Does pregnancy and or shifting positions create more room in a woman’ pelvis?’
50 pregnant women, 50 non-pregnant
MRI to take pelvic measurements:
Transverse and AP
Significant increase in Transverse diameter of 0.9 – 1.9 cm (7-15%) in kneeling squat for pregnant and non-pregnant women
Bispinous diameter in pregnant group from 12cm in supine to 14.5 cm in kneeling squat
Some videos to illustrate what is happening
CUB animation:
https://youtube.com/watch?v=gVjqStN0yQ0&feature=youtu.be
Pelvis Movil
http://linkis.com/www.youtube.com/PGYUC
Expert Opinion: Simkin and Ancheta 2000To the traditional 3 Ps they added 2 more:
Powers Passenger Pelvis Pain Psyche
Nature’s carefully orchestrated plan for labor and birth is easily disrupted,
We need to be sure we know how to promote, protect and support the normal physiological process
So why not?
Strengths Weaknesses
Threats Opportunities
Some ideas…Strengths Weaknesses Opportunities Threats
Beds are moveable Beds are nearly always central in rooms
New equipment –can be used in labour wards
Rising IOL
Generally good size labour rooms, private
Lack of midwife-led home from home environments
Ever growing strong evidence base
Rising epidural rates
Availability of pools Low homebirth rate A growing number of enthusiastic midwives keen to implement
Growth of concern re OASIS
1 to 1 care in labour ?Static older workforce
EFM
Evidence from research about cultureDahlen et al 2013, study in Australia: women in midwife led units or receiving midwife led continuity models of care much more likely to labour and birth upright (kneeling all fours 48%, waterbirth 13%...)
Priddis et al 2012, literature review on the facilitators, inhibitors and implications of birth positioning, lack of good research. But very influenced by health professionals’ philosophy of care.
De Jonge et al, 2009, study in the Netherlands, found that older women with higher socio-demographic status were more likely to use upright positions in labour and birth.
So how can we bring change?
Using behaviour change approaches
Motivation
Action
Prompt
Behaviour changeBehaviour change is initiated and maintained through the development of strategies to increase and maintain motivation and to improve and broaden skills that enable motivation to be translated into action
Are we motivated to change?What is our goal?Are we satisfied with where we are?
Motivation
Setting clear measurable goals for behaviour change.How will we know if we have made a change?What are we doing well, how can we do more?
Action
‘Nudge’ theoryMake the right thing to do the easiest thing to doChange environmentRewards
Prompt
Making it happen where you work...
Motivation
Action
Prompt
Building motivation...Posters – changed regularly, with key facts and pictures:
‘Did you know upright positions can increase the transverse diameter of the pelvis by 15%?’
Rewards for improvements in numbers of women giving birth in an upright position – individual, shift or team?
Sell benefits of upright positions and activity for midwives’ health and well being
Action:Audit before and after.
RCM Birth positions audit tool
PromptsRight thing to do the easiest thing to do:
- Laminated pictures in rooms
- Sessions with MSWs on setting up rooms
- Start of shift room sweep,
- Pre-admission ‘nest building’
Upright positions – does it really matter?•Upright positions in labour shorten labour significantly, reduce the need for epidural analgesia, reduce caesarean sections. Fewer admissions to SCBU/ abnormal FHR/ low Apgars
• Psychological benefits for women
•No increase in OASIS, reduced episiotomies, more 2nd
degree tears
•Slight increase in blood loss (link to perineal trauma)
•We can improve what we are doing, the key is changing behaviours by midwives through building motivation, taking action and prompting positive behaviours.
