Step 4: Provides the Birthing Woman With Freedom of Movement to Walk, Move, Assume Positions of Her Choice

Abstract

Step 4 of the Ten Steps of Mother-Friendly Care insures that women have the freedom to walk, move, and assume positions of their choice during labor and birth. The rationales and the evidence in support of this step are presented.

Step 4: Provides the birthing woman with the freedom to walk, move about, and assume the positions of her choice during labor and birth (unless restriction is specifically required to correct a complication) and discourages the use of the lithotomy position.

Freedom of movement in labor appears to facilitate the progress of labor and enhance childbirth satisfaction. Restricting women's movement may have adverse effects.

Freedom of Movement

Rationale for Compliance	Evidence Grade
No evidence of harm found for freedom to ambulate, move about, or change position during labor and birth when restriction is not required to correct a complication.		NEH
The lithotomy position reduces blood flow to the fetus, adversely affecting the fetal heart rate. In addition, the lithotomy position raises levels of maternal stress hormones, thereby reducing uterine contractility and labor progress (Simkin, 2002).	Quality:	A
	Quantity:	B
	Consistency:	A**
Ambulation, movement, and changes of position during the first stage of labor may shorten labor; no evidence suggests ambulation increases duration of labor (Albers, 1997; Simkin, 2002).	Quality:	A
	Quantity:	B
	Consistency:	B
Women who ambulated during the first stage of labor were less likely to have a surgical delivery, defined as cesarean section or forceps or vacuum extraction (Albers, 1997).	Quality:	A
	Quantity:	B
	Consistency:	NA*
When allowed the freedom to ambulate, move, and change position during labor and birth, most women choose to do so and find this to be an effective form of pain relief (DeClerq, 2002; Simkin, 2002).	Quality:	A
	Quantity:	B
	Consistency:	A
Changes of position during second-stage labor—including ambulation, standing, kneeling, squatting, and the use of a chair or stool—in women with epidural analgesia provided no significant reductions in instrumental and operative delivery, as well as no increased risk of harm to the mother or infant from allowing the mother to use these positions when her muscle tone permitted (Roberts, 2005).	Quality:	A
	Quantity:	B
	Consistency:	A**
Women who chose a nonsupine position for birth had shorter second stages of labor, required less pain relief medication, and had fewer abnormal fetal heart rate patterns (Simkin, 2002).	Quality:	A
	Quantity:	B
	Consistency:	A**
Women who assumed a nonsupine position for birth had fewer perineal injuries (Shorten, 2002; Soong, 2005; Terry, 2006), less vulvar edema, and less blood loss (Terry, 2006).	Quality:	A
	Quantity:	A
	Consistency:	A
Hands-and-knees positioning of a woman during the first stage of labor when her fetus is in a cephalic presentation but occipitoposterior position increased the chance of fetal rotation to the occipitoanterior position and significantly reduced her experience of persistent back pain (Stremler, 2005).	Quality:	A
	Quantity:	B
	Consistency:	A
Hands-and-knees positioning of a woman, as compared with sitting, during the second stage of labor is associated with a more favorable maternal experience and less pain with no significant difference in the duration of labor (Ragnar, 2006).	Quality:	A
	Quantity:	B
	Consistency:	NA*
Birth attendant preference rather than maternal preference most often indicated maternal position for birth (Shorten, 2002; Soong, 2005; Terry, 2006).	Quality:	A
	Quantity:	B
	Consistency:	A

A = good, B = fair, NA = not applicable, NEH = no evidence of harm, SR = systematic review

Quality = aggregate of quality ratings for individual studies

Quantity = magnitude of effect, numbers of studies, and sample size or power

Consistency = the extent to which similar findings are reported using similar and different study designs

^*only one study

^**multiple studies in SR

INCLUDED STUDIES

• Albers, L., Anderson, D., Cragin, L., Daniels, S. M., Hunter, C., Sedler, K. D., et al. (1997). The relationship of ambulation in labor to operative delivery. Journal of Nurse-Midwifery, 42(1), 4–8.

• DeClercq, E., Sakala, C., Corry, M., Applebaum, S., Risher, P. (2002). Listening to mothers: Report of the first national U.S. survey of women's childbearing experiences. New York: Maternity Center Association.

• Ragnar, I., Altman, D., Tyden, T., Olsson, S. E. (2006). Comparison of the maternal experience and duration of labor in two upright delivery positions—A randomised controlled trial. British Journal of Obstetrics and Gynaecology, 113(2), 165–170.

• Roberts, C., Algert, C., Cameron, C., Torvaldsen, S. (2005). A meta-analysis of upright positions in the second stage to reduce instrumental deliveries in women with epidural analgesia. Acta Obstetricia et Gynecologica Scandinavica, 84,794–798.

• Shorten, A., Donsante, J., Shorten, B. (2002). Birth position, accoucheur and perineal outcomes: Informing women about choices for vaginal birth. Birth, 29(1), 18–27.

• Simkin, P., O'Hara, M. (2002). Nonpharmacologic relief of pain during labor: Systematic reviews of five methods. American Journal of Obstetrics and Gynecology, 186, S131–S159.

• Soong, B., Barnes, M. (2005). Maternal position at midwife attended birth and perineal trauma: Is there an association? Birth, 32(3), 164–169.

• Stremler, R., Hodnett, E., Petryshen, P., Stevens, B., Weston, J., Willan, A. R. (2005). Randomized controlled trial of hands-and-knees positioning for occipitoposterior position in labor. Birth, 32(4), 243–251.

• Terry, R., Wescott, J., O'Shea, L., Kelly, F. (2006). Postpartum outcomes in supine delivery by physicians versus nonsupine delivery by midwives. The Journal of the American Osteopathic Association, 106(4), 199–202.

EXCLUDED STUDIES

• Allahbadia, G., Vaidya, P. (1992). Why deliver in the supine position?Australian and New Zealand Journal of Obstetrics & Gynaecology, 32(2), 104–106. Reason: Data included in Gupta (2003).

• Andrews, C., Chzanowski, M. (2002). Maternal position, labor and comfort. Applied Nursing Research, 3(1), 7–13. Reason: Data included in Simkin (2002).

• Bloom, S., McIntire, D., Kelly, M., Beimer, H., Burpo, R., Garcia, M., et al. (1998). Lack of effect of walking on labor. New England Journal of Medicine, 339(2), 76–79. Reason: Data included in Simkin (2002).

• Carlson, J., Diehl, J., Sachtleben-Murray, M., McRae, M. (1986). Maternal position during parturition in normal labor. Obstetrics and Gynecology, 68, 443–447. Reason: Data included in Simkin (2002).

• Gupta, J., Hofmeyr, G. (2003). Position in the second stage of labour for women without epidural anaesthesia. The Cochrane Database of Systematic Reviews, Issue 3. Art. No. CD02006.pub2. DOI:10.1002/14651858. CD002006.pub2. Reason: Data included in Simkin (2002).

• Rooks S. (1999). Evidence-based practice and its application to childbirth care for low-risk women. Journal of Nurse-Midwifery, 44(4), 355–369. Reason: Not applicable. No meta-analysis included, rendering material an article rather than a systematic review.