Fadhilah Hannidhiya

Dokumentasi Asuhan Kebidanan Intranatal Fisiologis
Kala I Persalinan
Tanggal Pengkajian : 04-12-2021

Waktu Pengkajian : 04.40 WITA
Tempat Pengkajian : Klinik Bersalin Ramlah Parjib 1 – Ruang VK
Oleh : Fadhilah Hannidhiya Hardana
Kala I Persalinan
S:
1. Alasan Datang
Ibu merasakan tanda tanda persalinan yang makin dekat
2. Keluhan Utama
Ibu mulai merasakan perut kencang-kencang, kontraksi semakin sering dan terdapat
pengeluaran lendir darah.
3. Riwayat Kesehatan Sekarang
Pada tanggal 04-12-2020 pukul 04.40 WITA ibu datang ke Klinik Bersalin Ramlah Parjib
1 dengan keluhan perut makin sakit , kencang-kencang dan keluar lendir darah..
Pergerakan janin semakin aktif. Ibu sudah makan dan minum di pagi harinya.
Selanjutnya, ibu dilakukan pemeriksaan umum dan pemeriksaan dalam.
4. Pola Fungsional Kesehatan
Pola Saat Ini
Makan 2x sehari dan terakhir makan pada pukul 21.00
Nutrisi WITA dan minum hampir 1 botol air mineral 1,5L.
Eliminasi Ibu sudah BAB 1x, BAK 3x sehari
Istirahat Ibu susah beristirahat malam ini karna kontraksi
Personal Hygiene Ibu sudah mandi dan ganti baju
5. Riwayat Psikososiokultural Spiritual

a. Psikologis : ibu mengatakan merasa cemas dan khawatir terhadap keadaannya
saat ini akibat nyeri kontraksi yang semakin lama semakin sering dan semakin sakit
b. Sosial : selama persalinan, ibu ditemani oleh suami
c. Kultural : tidak ada kebudayaan atau adat istiadat yang dapat membahayakan
proses persalinan ibu
d. Spiritual : tidak ada kegiatan keagamaan maupun kebiasaan khusus yang dapat
membahayakan proses persalinan ibu, pada saat menjelang persalinan ibu terus
berdoa sesuai keyakinannya
O:
1. Pemeriksaan Umum
Keadaan umum : Sedang
Kesadaran : Compos Mentis
Tanda-tanda vital :
Tekanan darah :110/80 mmHg
Nadi : 82 x/menit
Pernapasan : 22 x/menit
Suhu : 36,5oC.
Antropometri :
Berat Badan saat ini : 88 kg.
2. Pemeriksaan Fisik
Wajah : simetris,pucat, tidak ada chloasma gravidarum, tidak
oedem
Mata : simetris, tidak ada perdarahan, tidak ada pengeluaran
kotoran, konjungtiva pucat, sklera putih, penglihatan tidak kabur, tidak
oedem palpebra
Payudara :simetris,bersih, puting menonjol, tidak ada pembengkakan, tidak ada
pembesaran kelenjar limfe, tidak ada dimpling, sudah ada pengeluaran
kolostrum
Abdomen : tidak terdapat linea nigra, tidak ada bekas luka operasi, pembesaran
abdomen sesuai usia kehamilan
TFU : 30 cm
Leopold I : pada fundus teraba bagian lunak, kurang bulat dan kurang
melenting (bokong janin)
Leopold II : teraba bagian panjang dan keras seperti papan pada
abdomen sebelah kanan ibu (punggung kanan) dan teraba
bagian kecil janin pada abdomen sebelah kiri ibu
(ekstremitas janin)
Leopold III : pada segmen bawah rahim teraba bagian keras, bulat dan
melenting dan sudah tidak dapat digoyangkan lagi (kepala
janin)
Leopold IV : bagian terbawah janin sebagian besar sudah masuk ke pintu
atas panggul (divergent)
DJJ : 147 x/menit
TBJ : (30-11) x 155 = 2945 gram
His : 5 x 10’ = 40-45”
Genetalia : terdapat pengeluaran lendir darah
Ekstremitas :
Kanan Atas : simetris, tidak ada oedem, reflek bisep (+), reflek trisep (+), CRT
< 2 detik
Kiri Atas : simetris, tidak ada oedem, reflek bisep (+), reflek trisep (+), CRT
< 2 detik
Kanan Bawah : simetris, tierdapat oedem, tidak ada varises, reflek babinski (+),
homan sign (-), reflek patella (+), CRT < 2 detik
Kiri Bawah : simetris, terdapat oedem, tidak ada varises, reflek babinski (+),
homan sign (-), reflek patella (+), CRT < 2 detik
3. Pemeriksaan Khusus
Pemeriksaan dalam
Tanggal : 04-12-2021
Jam : 04.45 WITA
Oleh : Mahasiswa dan Bidan Fika
Hasil : terdapat pengeluaran lendir darah, tidak ada oedem, tidak ada jaringan
parut, portio tipis lunak, effacement 75% %, pembukaan 8 cm, ketuban utuh,
presentasi puncak kepala, denominator ubun ubun kecil (UUK), penurunan kepala
hodge III.
Pemeriksaan his : 5x10’ = 40-45’’
Dilakukan pemantauan kala I oleh bidan dan mahasiswa.
4. Pemeriksaan Penunjang
Pemeriksaan laboratorium dilakukan pada tanggal 04-12-2021 pukul 04.45 WITA.
Rapid Test Antigen : Non Reaktif
A:
Diagnosis : G2P1001 usia kehamilan 38 minggu 0 hari,
inpartu kala I fase aktif .
Janin tunggal ,hidup ,intrauterin.
Masalah : tidak ada
Diagnosis Potensial : tidak ada
Masalah Potensial : tidak ada
Kebutuhan : Observasi Kala I dan Persiapan Persalinan
P:
Tanggal/Ja Paraf
Penatalaksanaan
m
Menjelaskan hasil pemeriksaan pada ibu, bahwa kondisi
04-12-20 ibu normal, ibu dan janin dalam keadaan sehat. Saat ini Pembimbing
04.45 ibu sudah pembukaan 8cm, ketuban utuh, dan his 5x10’ dan Mahasiswa
WITA = 40-45’’
; ibu mengetahui kondisi diri dan janinnya
Mengajarkan ibu untuk melakukan teknik nafas dalam
04.50 Mahasiswa
pada saat kontraksi tiba untuk mengurangi nyeri.
WITA
; ibu mengerti dan melakukannya
Menganjurkan ibu untuk tidur/baring dalam posisi miring
04.52 kiri, agar bagian terendah janin (kepala) turun lebih cepat Mahasiswa
WITA ke serviks.
; ibu mengikuti anjuran yang diberikan
Menganjurkan ibu tetap mendapat asupan selama proses
menjelang persalinan nanti, seperti minum teh manis atau
04.55 Mahasiswa
minum air putih untuk memberikan tenaga pada ibu saat
WITA
menghadapi persalinan.
; ibu telah minum teh manis dan air putih
Memberikan support mental kepada ibu dan keluarga
04.56 dalam menghadapi persalinan, agar ibu lebih merasa Mahasiswa
WITA tenang dan kuat dalam menghadapi persalinannya.
; ibu yakin bisa melewati semua ini dengan lancar
Menganjurkan ibu untuk miring kiri agar dapat
04.57 7WI Mahasiswa
membantu mempercepat pembukaan.
TA
; ibu berbaring dan miring kiri
Menyiapkan partus set, APD lengkap sesuai protokol
04.58 kesehatan Covid-19 serta kelengkapan lainnya untuk Mahasiswa
WITA menolong persalinan.
; Perlengkapan pertolongan persalinan telah siap
Memakai APD lengkap sesuai protokol kesehatan Covid-
05.00 19 Mahasiswa
WITA ; APD lengkap sesuai protokol kesehatan Covid-19 telah
dipakai
Mengobservasi his dan djj.
05.05 Mahasiswa
; his : 5x10’ = 45-50”, djj terdengar jelas, frekuensi
WITA
teratur, djj : 143 x/menit
Maternal positions and mobility during first stage labour
(Review)
Lawrence A, Lewis L, Hofmeyr GJ, Dowswell T, Styles C
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2009, Issue 4
http://www.thecochranelibrary.com
Maternal positions and mobility during first stage labour (Review)

Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Analysis 1.1. Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 1 Duration
of first stage of labour (hours): all women. . . . . . . . . . . . . . . . . . . . . . . . . 44
Analysis 1.2. Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 2 Mode of
birth: spontaneous vaginal; all women. . . . . . . . . . . . . . . . . . . . . . . . . . 45
birth: operative/assisted: all women. . . . . . . . . . . . . . . . . . . . . . . . . . . 46
birth: caesarean section: all women. . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Analysis 1.7. Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 7 Maternal
pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Analysis 1.8. Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 8 Maternal
pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Analysis 1.9. Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 9 Analgesia
type. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Analysis 1.10. Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 10
Analgesia amount. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Duration of second stage of labour (minutes). . . . . . . . . . . . . . . . . . . . . . . . 52
Augmentation of labour using oxytocin. . . . . . . . . . . . . . . . . . . . . . . . . . 53
Artificial rupture of membranes. . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Estimated blood loss > 500 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Perineal trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Analysis 1.17. Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 17 Fetal
distress (requiring immediate delivery). . . . . . . . . . . . . . . . . . . . . . . . . . 55
Analysis 1.19. Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 19 Apgar
scores. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Admission to NICU. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Perinatal mortality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Analysis 2.1. Comparison 2 Upright and ambulant positions versus recumbent positions or bedcare (with epidural: all
women), Outcome 1 Duration of first stage of labour: time of epidural insertion to complete cervical dilation
(minutes). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Maternal positions and mobility during first stage labour (Review) i
women), Outcome 2 Mode of birth: spontaneous vaginal. . . . . . . . . . . . . . . . . . . 58
women), Outcome 3 Mode of birth: operative spontaneous/assisted. . . . . . . . . . . . . . . . 59
women), Outcome 4 Mode of birth: caesarean section. . . . . . . . . . . . . . . . . . . . . 60
women), Outcome 6 Maternal pain. . . . . . . . . . . . . . . . . . . . . . . . . . . 60
women), Outcome 7 Analgesia type. . . . . . . . . . . . . . . . . . . . . . . . . . . 61
women), Outcome 8 Analgesia amount. . . . . . . . . . . . . . . . . . . . . . . . . . 62
women), Outcome 9 Duration of second stage of labour (minutes). . . . . . . . . . . . . . . . 63
women), Outcome 10 Augmentation of labour using oxytocin. . . . . . . . . . . . . . . . . . 63
women), Outcome 12 Hypotension requiring intervention. . . . . . . . . . . . . . . . . . . 64
women), Outcome 17 Apgar scores. . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Analysis 3.1. Comparison 3 Standing and walking versus non-ambulant positions, Outcome 1 Duration of the first stage of
labour. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . . 67
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Maternal positions and mobility during first stage labour (Review) ii

[Intervention Review]
Maternal positions and mobility during first stage labour
Annemarie Lawrence1 , Lucy Lewis2 , G Justus Hofmeyr3 , Therese Dowswell4 , Cathy Styles5
1
Institute of Women’s and Children’s Health (15), The Townsville Hospital, Douglas, Australia. 2 The School of Women’s and Infants’
Health/The School of Paediatrics and Child Health, The University of Western Australia, Subiaco, Australia. 3 Department of Obstetrics
and Gynaecology, East London Hospital Complex, University of the Witwatersrand, University of Fort Hare, Eastern Cape Department
of Health, East London, South Africa. 4 Cochrane Pregnancy and Childbirth Group, School of Reproductive and Developmental
Medicine, Division of Perinatal and Reproductive Medicine, The University of Liverpool , Liverpool, UK. 5 Institute of Women’s and
Children’s Health, The Townsville Hospital, Douglas, Australia
Contact address: Annemarie Lawrence, Institute of Women’s and Children’s Health (15), The Townsville Hospital, 100 Angus Smith
Drive, Douglas, Queensland, 4810, Australia. annemarie_lawrence@health.qld.gov.au. annielaw@bigpond.net.au. (Editorial group:
Cochrane Pregnancy and Childbirth Group.)
Cochrane Database of Systematic Reviews, Issue 4, 2009 (Status in this issue: Unchanged)
DOI: 10.1002/14651858.CD003934.pub2
This version first published online: 15 April 2009 in Issue 2, 2009.
Last assessed as up-to-date: 30 December 2008. (Help document - Dates and Statuses explained)
This record should be cited as: Lawrence A, Lewis L, Hofmeyr GJ, Dowswell T, Styles C. Maternal positions and mobility during first
stage labour. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD003934. DOI: 10.1002/14651858.CD003934.pub2.
ABSTRACT
Background
It is more common for women in the developed world, and those in low-income countries giving birth in health facilities, to labour
in bed. There is no evidence that this is associated with any advantage for women or babies, although it may be more convenient for
staff. Observational studies have suggested that if women lie on their backs during labour this may have adverse effects on uterine
contractions and impede progress in labour.
Objectives
The purpose of the review is to assess the effects of encouraging women to assume different upright positions (including walking,
sitting, standing and kneeling) versus recumbent positions (supine, semi-recumbent and lateral) for women in the first stage of labour
on length of labour, type of delivery and other important outcomes for mothers and babies.
Search strategy
We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (November 2008).
Selection criteria
Randomised and quasi-randomised trials comparing women randomised to upright versus recumbent positions in the first stage of
labour.
Data collection and analysis
We used methods described in the Cochrane Handbook for Systematic Reviews of Interventions for carrying out data collection, assessing
study quality and analysing results. A minimum of two review authors independently assessed each study.
Main results
Maternal positions and mobility during first stage labour (Review) 1
The review includes 21 studies with a total of 3706 women. Overall, the first stage of labour was approximately one hour shorter for
women randomised to upright as opposed to recumbent positions (MD -0.99, 95% CI -1.60 to -0.39). Women randomised to upright
positions were less likely to have epidural analgesia (RR 0.83 95% CI 0.72 to 0.96).There were no differences between groups for
other outcomes including length of the second stage of labour, mode of delivery, or other outcomes related to the wellbeing of mothers
and babies. For women who had epidural analgesia there were no differences between those randomised to upright versus recumbent
positions for any of the outcomes examined in the review. Little information on maternal satisfaction was collected, and none of the
studies compared different upright or recumbent positions.
Authors’ conclusions
There is evidence that walking and upright positions in the first stage of labour reduce the length of labour and do not seem to be
associated with increased intervention or negative effects on mothers’ and babies’ wellbeing. Women should be encouraged to take up
whatever position they find most comfortable in the first stage of labour.
PLAIN LANGUAGE SUMMARY
Mothers’ position during the first stage of labour
Women in the developed world and in health facilities in low-income countries usually lie in bed during the first stage of labour.
Elsewhere, women progress through this first stage while upright, either standing, sitting, kneeling or walking around, although they
may choose to lie down as their labour progresses. The attitudes and expectations of healthcare staff, women and their partners have
shifted with regard to pain, pain relief and appropriate behaviour during labour and childbirth. A woman semi-reclining or lying down
on the side or back during the first stage of labour may be more convenient for staff and can make it easier to monitor progression and
check the baby. Fetal monitoring, epidurals for pain relief, and use of intravenous infusions also limit movement. Lying on the back
(supine) puts the weight of the pregnant uterus on abdominal blood vessels and contractions may be less strong than when upright.
Effective contractions help cervical dilatation and the descent of the baby.
The results of the review suggest that the first stage of labour may be approximately an hour shorter for women who are upright or
walk around during the first stage of labour. The women’s body position did not affect the rate of interventions. The review authors
identified 21 controlled studies from a number of countries that randomly assigned a total of 3706 women to upright or recumbent
positions in the first stage of labour. Nine of the studies included only women who were giving birth to their first baby. The length of
the second stage of labour and the numbers of women who achieved spontaneous vaginal deliveries or required assisted deliveries and
augmentation were similar between groups, where reported. Use of opioid analgesia was no different, although women randomised to
upright positions were less likely to have epidural analgesia. In those studies specifically examining position and mobility for women
receiving epidural analgesia (five trials, 1176 women), an upright or recumbent position did not change the length of the first stage of
labour (time from epidural insertion to complete cervical dilatation) or rates of spontaneous vaginal, assisted and caesarean delivery.
Little information was given on maternal satisfaction or outcomes for babies.
BACKGROUND
there is a preference to lie down (Roberts 1980; Roberts 1984;
In cultures not influenced by Western society, women progress Williams 1980). This may explain why women in randomised
through the first stage of labour in upright positions and change trials frequently have difficulty maintaining the position to which
position as they wish with no evidence of harmful effects to either they have been assigned (Goer 1999), and suggests that there may
the mother or the baby (Andrews 1990; Gupta 2004; Roberts not be a perfect universal position for women in the first stage of
1989). It is more common for women in the developed world to labour.
labour in bed (Boyle 2000; Roberts 1989; Simkin 1989). However,
when these women are encouraged, they will choose a number Recumbent (lying down) positions in the first stage of labour can
of different positions as the first stage progresses (Carlson 1986; have several practical advantages for the care provider; potentially
Fenwick 1987; Roberts 1989; Rooks 1999). Some studies have making it easier to palpate the mother’s abdomen to monitor con-
suggested that as a woman reaches five to six centimetres dilatation, tractions, perform vaginal examinations, check the baby’s position,
and listen to the baby’s heart. Some developments in technology ing, squatting and all fours) positions with recumbent
such as fetal monitoring, epidurals for pain relief and the use of positions (supine, semi-recumbent and lateral) assumed
intravenous infusions have all made it difficult and potentially un- by women in the first stage of labour on maternal, fetal
safe for women to move about during labour. and neonatal outcomes.
Numerous studies have shown that a supine position in labour
The secondary objectives are:
may have adverse physiological effects on the condition of the
woman and her baby and on the progression of labour. The weight
• to compare the effects of semi-recumbent and supine
of the pregnant uterus can compress the abdominal blood vessels,
positions with lateral positions assumed by women in
compromising the mother’s circulatory function including uterine
the first stage of labour on maternal, fetal and neonatal
blood flow (Abitbol 1985; Huovinen 1979; Marx 1982; Ueland
outcomes;
1969), and this may negatively affect the blood flow to the placenta
(Cyna 2006; Roberts 1989; Rooks 1999; Walsh 2000). The effects
• to compare the effects of walking with upright non-
of a woman’s position on the frequency and intensity of contrac-
walking positions (sitting, standing, kneeling, squat-
tions have also been examined (Caldeyro-Barcia 1960; Lupe 1986;
ting, all fours) assumed by women in the first stage of
Mendez-Bauer 1980; Roberts 1983; Roberts 1984; Ueland 1969).
labour on maternal, fetal and neonatal outcomes;
The findings indicated that contractions increased in strength in
the upright or lateral position compared to the supine position and • to compare the effects of walking with recumbent posi-
were often negatively affected when a labouring woman lay down tions (supine, semi-recumbent and lateral) assumed by
after being upright or mobile. This effect can often be reversed if women in the first stage of labour on maternal, fetal and
the woman returns to an upright position. Effective contractions neonatal outcomes;
are vital to aid cervical dilatation and fetal descent (Roberts 1989;
• to compare allowing women to assume the position/s
Rooks 1999; Walsh 2000) and therefore have an important role
they choose with recumbent positions (supine, semi-
in helping to reduce dystocia (slow progress in labour).
recumbent and lateral) assumed by women in the first
Moving about can increase a woman’s sense of control in labour stage of labour on maternal, fetal and neonatal out-
by providing a self-regulated distraction from the challenge of comes.
labour (Albers 1997). Support from another person also appears
to facilitate normal labour (Hodnett 2007). Increasing a woman’s
sense of control may have the effect of decreasing her need for METHODS
analgesia (Albers 1997; Hodnett 2007; Lupe 1986; Rooks 1999)
and it has also been suggested that upright positions in the first
stage of labour may increase women’s comfort (Simkin 2002). Criteria for considering studies for this review
Because different groups advocate various positions in the first
stage of labour, it seems particularly important to assess the avail-
Types of studies
able evidence so that positions which are shown to be safe and
effective can be encouraged. Randomised or quasi-randomised trials. We planned to include
cluster randomised trials which were otherwise eligible. Cross-over
A related Cochrane review focuses on maternal position for fetal trials might be useful for short-term outcomes such as fetal heart
malpresentation in labour (Hunter 2007). rate patterns, but would not be appropriate for the main outcomes
of this review and were not included.
OBJECTIVES Types of participants

The purpose of this review is to assess the effects of different upright Women in the first stage of labour.
and recumbent positions and mobilisation for women in the first
stage of labour on length of labour, type of delivery and other Types of interventions
important outcomes for mothers and babies.
The type of intervention was the position or positions assumed
by women in the first stage of labour. The positions assumed by
a women in the first stage of labour can be broadly categorised as
The primary objective is:
being either upright or recumbent.
The positions considered recumbent were:
• to compare the effects of upright (defined as walking
and upright non-walking, e.g. sitting, standing, kneel- • semi recumbent;

• lateral; 1. quarterly searches of the Cochrane Central Register of
• supine. Controlled Trials (CENTRAL);
2. weekly searches of MEDLINE;
The positions considered upright included:
3. handsearches of 30 journals and the proceedings of ma-
• sitting; jor conferences;
• standing; 4. weekly current awareness alerts for a further 44 journals
• walking; plus monthly BioMed Central email alerts.
• kneeling; Details of the search strategies for CENTRAL and MEDLINE,
• squatting; the list of handsearched journals and conference proceedings, and
• all fours (hands and knees). the list of journals reviewed via the current awareness service can
be found in the ‘Specialized Register’ section within the edito-
Types of outcome measures rial information about the Cochrane Pregnancy and Childbirth
Primary maternal outcomes: Group.
Trials identified through the searching activities described above
• length of first stage of labour; are each assigned to a review topic (or topics). The Trials Search
• type of delivery (spontaneous vaginal delivery, operative Co-ordinator searches the register for each review using the topic
vaginal or caesarean); list rather than keywords.
• maternal satisfaction with positioning and with the
childbirth experience.
Searching other resources
Primary fetal and neonatal outcomes: We performed a manual search of the references of all retrieved
• fetal distress requiring immediate delivery; articles and contacted expert informants.
• use of neonatal mechanical ventilation. We did not apply any language restrictions.
Secondary maternal outcomes:

• pain as experienced by the woman; Data collection and analysis
• use of analgesics (amount and type, e.g. epidu-
We used methods described in the Cochrane Handbook for Sys-
ral/opioid);
tematic Reviews of Interventions for data collection, assessing study
• length of second stage of labour;
quality and analysing results (Higgins 2008).
• augmentation of labour using oxytocin;
• artificial rupture of membranes;
• spontaneous rupture of membranes; Selection of studies
• hypotension requiring intervention; A minimum of two review authors independently assessed for in-
• estimated blood loss > 500 ml; clusion all the potential studies identified as a result of the search
• perineal trauma (including episiotomy and third and strategy. We resolved any disagreement through discussion, or
fourth degree tears). when required we consulted an additional person.
Secondary neonatal outcomes:
Data extraction and management
• Apgar of less than seven at five minutes following deliv-
We designed a form to extract data. At least two review authors
ery;
extracted the data using the agreed form. We resolved discrepancies
• admission to the neonatal intensive care unit.
through discussion, or if required we consulted a third author. We
entered data into Review Manager software (RevMan 2008), and
checked for accuracy.
Search methods for identification of studies When information regarding any of the above was unclear, we
attempted to contact authors of the original reports to provide
Electronic searches further details.
We searched the Cochrane Pregnancy and Childbirth Group’s Tri-
als Register by contacting the Trials Search Co-ordinator (31 De- Assessment of risk of bias in included studies
cember 2008). Two review authors independently assessed risk of bias for each
The Cochrane Pregnancy and Childbirth Group’s Trials Register study using the criteria outlined in the Cochrane Handbook for
is maintained by the Trials Search Co-ordinator and contains trials Systematic Reviews of Interventions (Higgins 2008). We resolved
identified from: any disagreement by discussion or by involving a third assessor.

Please see the ’Risk of bias’ tables following the Characteristics of We have described for each included study the completeness of
included studies tables for the assessment of bias for each study. outcome data, including attrition and exclusions from the analy-
sis. We state whether attrition and exclusions were reported, the
(1) Sequence generation (checking for possible selection numbers (compared with the total randomised participants), rea-
bias) sons for attrition/exclusion where reported, and any re-inclusions
We described for each included study the methods used to gener- in analyses which we have undertaken.
ate the allocation sequence to assess whether methods were truly We assessed the methods as:
random. • adequate (e.g. where there was no missing data or low
We assessed the methods as: levels (less than 10%) and where reasons for missing
data were balanced across groups);
• adequate (e.g. random number table; computer random
• inadequate (e.g. where there were high levels of missing
number generator);
data (more than 10%));
• inadequate (odd or even date of birth; hospital or clinic
• unclear (e.g. where there was insufficient reporting of at-
record number); or
trition or exclusions to permit a judgement to be made).
• unclear.
(5) Other sources of bias and overall risk of bias

We described for each included study any important concerns we
(2) Allocation concealment (checking for possible selection had about other possible sources of bias.
bias) We have made explicit judgements about risk of bias for important
We described for each included study the method used to conceal outcomes both within and across studies. With reference to 1-4
the allocation sequence in sufficient detail and determined whether above, we assessed the likely magnitude and direction of the bias
group allocation could have been foreseen in advance of, or during, and whether we considered it was likely to impact on the findings.
recruitment, or changed afterwards. We have explored the impact of risk of bias through undertaking
We have assessed the methods as: sensitivity analyses; see Sensitivity analysis below.
• adequate (e.g. telephone or central randomisation; con-
secutively numbered sealed opaque envelopes); Measures of treatment effect
• inadequate (open random allocation; unsealed or non- We carried out statistical analysis using the Review Manager soft-
opaque envelopes, alternation; date of birth); ware (RevMan 2008). We used fixed-effect meta-analysis for com-
• unclear. bining data in the absence of significant heterogeneity if trials were
sufficiently similar. When significant heterogeneity was present,
(3) Blinding (checking for possible performance bias) we used a random-effects meta-analysis.
We have described for each included study the methods used to
blind study personnel from knowledge of which intervention a Dichotomous data
participant received. We have described where there was any at- For dichotomous data, we have presented results as summary risk
tempt at partial blinding (e.g. of outcome assessors). It is impor- ratio (RR) with 95% confidence intervals (CI).
tant to note that with the types of interventions described in this
review, blinding participants to group assignment is generally not Continuous data
feasible. Similarly, blinding staff providing care is very difficult, For continuous data (e.g. maternal pain and satisfaction when
and this may have the effect of increasing co-interventions, which measured as scores or on visual analogue scales) we have used the
in turn may affect outcomes. The lack of blinding in these studies mean difference (MD) if outcomes were measured in the same way
may be a source of bias, and this should be kept in mind in the between trials. We used the standardised mean difference (SMD)
interpretation of results. to combine trials that measured the same outcome, but used dif-
We assessed the methods as: ferent methods.
• adequate, inadequate or unclear for participants;
• adequate, inadequate or unclear for personnel; Unit of analysis issues
• adequate, inadequate or unclear for outcome assessors.
Cluster-randomised trials
(4) Incomplete outcome data (checking for possible
We intended to include cluster-randomised trials in the analyses
attrition bias through withdrawals, dropouts, protocol
along with individually randomised trials, and to adjust sample
deviations)
sizes using the methods described in Gates 2005 and Higgins 2008.

We identified no cluster randomised trials in this version of the risk of bias associated with a particular aspect of study quality (e.g.
review, but if we identify such trials in future searches we will inadequate allocation concealment or high levels of attrition), we
include them in updates. explored this by sensitivity analysis.
Dealing with missing data

For included studies, we noted levels of attrition. Where data were
not reported for some outcomes or groups we attempted to contact
the study authors for further information. RESULTS
Intention to treat analysis (ITT)

We had intended to analyse data on all participants with avail- Description of studies
able data in the group to which they were allocated, regardless
See: Characteristics of included studies; Characteristics of excluded
of whether or not they received the allocated intervention. If in
studies.
the original reports participants were not analysed in the group to
which they were randomised, and there was sufficient information
in the trial report, we have attempted to restore them to the correct Results of the search
group (e.g. we did this for the data from the Calvert 1982 study). We identified a total of 53 reports representing 47 studies by the
search strategy.
Assessment of heterogeneity Included studies

We examined heterogeneity using the I² statistic. Where we have We included 21 studies with a total of 3706 women in the review.
identified high levels of heterogeneity among the trials (greater Studies were carried out in a number of countries; seven in the UK
than 50%), we explored it by pre-specified subgroup analysis and (Broadhurst 1979; Calvert 1982; Collis 1999; Fernando 1994;
by performing sensitivity analysis. A random-effects meta-analysis Flynn 1978; McManus 1978; Williams 1980); five in the USA (
was used as an overall summary for these comparisons. Andrews 1990; Bloom 1998; Mitre 1974; Nageotte 1997; Vallejo
2001); two in France (Frenea 2004; Karraz 2003); and one each in
Subgroup analysis and investigation of heterogeneity Finland (Haukkama 1982;), Sweden (Bundsen 1982), Hong Kong
Where data were available, we had planned subgroup analyses by: (Chan 1963), Japan (Chen 1987), Australia (MacLennan 1994),
- nulliparous versus multiparous women. Brazil (Miquelutti 2007) and Thailand (Phumdoung 2007). Sev-
However, several trials recruited only nulliparous women, and in eral of the studies included only nulliparous women (Andrews
other trials results were presented separately for nulli- and mul- 1990; Chan 1963; Collis 1999; Fernando 1994; Miquelutti 2007;
tiparous women and no overall findings (for all women irrespec- Mitre 1974; Nageotte 1997; Phumdoung 2007; Vallejo 2001). We
tive of parity) were reported. For example, for the primary review have set out details of inclusion and exclusion criteria for individual
outcome (duration of the first stage of labour) of the nine trials studies and descriptions of the interventions in the Characteristics
providing data, four provided mean figures for nulli- and multi- of included studies tables.
parous women, but no overall mean. Thus, for pragmatic reasons
(in order to use all available data from trials) we have reported Excluded studies
overall results for all women, but in the analysis data have been
We excluded 25 studies from the review. Several of the studies
grouped according to parity if this is how data were presented in
were not randomised trials or it was not clear that there had been
the trial reports.
random allocation to groups (Allahbadia 1992; Asselineau 1996;
We had also planned subgroup analysis by:
Caldeyro-Barcia 1960; Solano 1982); two of the studies used cross-
over designs (Melzack 1991; Molina 1997). One study was ex-
- women with a low-risk pregnancy (no complications, greater
cluded because the rate of attrition meant that it was difficult to
than or equal to 37 weeks’ gestation, singleton with a cephalic
interpret results: in the Diaz 1980 study, more than 30% of the in-
presentation) versus high-risk pregnancy.
tervention group were excluded post-randomisation because they
Data were not available to carry out this analysis.
did not comply with the protocol. In the Hemminki 1983 study,
women in the two study groups received different packages of care,
Sensitivity analysis so it was not possible to separate out the possible treatment effect
We carried out sensitivity analyses to explore the effect of trial of maternal position on outcomes. The McCormick 2007 study
quality for important outcomes in the review. Where there was had not taken place.

In some studies, the intervention was not comparing mobility or Blinding
upright positions with recumbent positions; for example, Cobo In interventions of this type, blinding women and clinical staff
1968 and Wu 2001 examined lying in bed on one side rather to group allocation is not generally feasible. It is possible to have
than the other, or lying supine. In some studies position/mobility partial blinding of outcome assessors for some types of outcomes,
was compared with a different type of intervention, for exam- but it was not clear that this was achieved in any of the included
ple the Hemminki 1985 study included women experiencing de- studies. The lack of blinding may introduce bias, and this should
lay in labour and compared immediate oxytocin with ambulation be kept in mind in the interpretation of the results.
and delayed oxytocin. Similarly, Read 1981 examined oxytocin
in labour. The COMET 2001 study compared women receiving
different types of epidural, while in the Hodnett 1982 study the Follow up and exclusions
main focus was on electronic fetal monitoring, and ambulation Details regarding loss to follow up are set out in the risk of bias
was an outcome rather than part of the intervention. Three stud- tables. In general, loss to follow up was not a serious problem
ies focused on interventions in the second, rather than in the first in these studies, as many of the outcomes were recorded during
stage of labour (Hillan 1984; Liu 1989; Radkey 1991). labour.
Several studies, which may otherwise have been eligible, focused In one study (Chen 1987), there was a high level of post-randomi-
on outcomes which had not been pre-specified in this review. For sation exclusion in both study groups (37%). This study was also
example, Danilenko-Dixon 1996 focused on cardiac output, while at high risk of bias because of poor allocation concealment. A sen-
the study by Schmidt 2001 and those by Ahmed 1985, Cohen sitivity analysis was carried out to examine the effects on results of
2002 and Schneider-Affeld 1982 (reported in brief abstracts) did excluding this study, along with those others at high risk of bias
not provide sufficient information on outcomes or present out- for poor or unclear allocation concealment.
come data in a form that we were able to use in the review. In one study we did not use the whole sample in the analyses.
In the study by Phumdoung 2007, women were randomised into
five separate groups (see Characteristics of included studies for
a description of the groups); we selected the two groups which
Risk of bias in included studies we thought best represented upright and recumbent positions to
include in the analyses.
The overall quality of the included studies was difficult to assess as
many of the studies gave very little information about the methods
used. Other potential sources of bias
There was wide variation in the types of interventions tested in
these studies. Some authors gave very little information on the in-
Allocation
tervention, for example at what stage in labour it was started, what
The method of sequence generation was often not mentioned in exactly women were asked to do and what instructions were given
the included studies. In the studies by Miquelutti 2007 and Vallejo to women in the control groups. This lack of detail means that the
2001, a computer generated list of random numbers was used; interpretation of results is not simple. Further, co-interventions in
five of the included studies utilised a quasi-randomised design, included studies also varied. Readers should bear this variability
where the allocation to groups was according to hospital or case- in mind when reading the results of the review.
note number or by alternate allocation (Calvert 1982; Chan 1963;
Chen 1987; Haukkama 1982; Williams 1980); for the rest, the
method of sequence generation was not stated.
The methods used to conceal group allocation from those re-
Effects of interventions
cruiting women to the trials were also frequently not described.
Six studies referred to group allocation details being contained Upright positions (including sitting, standing, walking
in envelopes; in the studies by Collis 1999, MacLennan 1994 and kneeling) versus recumbent positions - 16 trials,
and Miquelutti 2007 the envelopes were described as sealed and 2530 women
opaque, and in the other studies envelopes were variously described
as plain, numbered or sealed (Frenea 2004; McManus 1978). In
sensitivity analysis where studies of better and poorer quality have Duration of labour
been separated, we regarded the six studies which give details of
allocation concealment as the better quality studies, while we re-
garded those studies where allocation concealment was inadequate Duration of the first stage of labour
(e.g. in the quasi-randomised studies) or where methods were un- The duration of the first stage of labour varied considerably within
clear as of poorer quality. and between trials. There were high levels of heterogeneity when

studies were pooled (I2 = 79%). Hence, results need to be inter- There were no differences identified between groups in terms of
preted with caution, and in view of high levels of heterogeneity, reported discomfort or requests for analgesia, although relatively
we have used a random effects model for these analyses. few trials examined these outcomes, and findings were inconsis-
Overall, for all women, the first stage of labour was approximately tent. Most studies collected information on the types of analge-
one hour shorter for those randomised to upright compared with sia women received. There were no differences between groups
supine and recumbent positions; this analysis included pooled in terms of use of opioid analgesia, although women randomised
results from nine trials (including 1677 women) and the difference to upright positions were less likely to have epidural analgesia,
between groups was statistically significant (MD -0.99, 95% CI - and this difference reached statistical significance (RR 0.83 95%
1.60 to -0.39) (Analysis 1.1). CI 0.72 to 0.96, P = 0.01). The amount of analgesia received by
For nulliparous women, the length of the first stage of labour women in the two groups was measured in one trial, but the dif-
was not significantly different between groups; for multiparous ference between groups was not statistically significant (Analysis
women, the duration of first stage was approximately half an hour 1.10).
shorter for those randomised to upright positions, but the evidence
of a difference between groups did not reach statistical significance. Interventions in labour
Duration of the second stage of labour

Augmentation of labour using oxytocin
There was no difference between groups in the length of the sec-
Women randomised to upright versus recumbent positions had
ond stage of labour in the two trials that reported this outcome (
similar rates of augmentation of labour (Analysis 1.12). In two
Analysis 1.11).
studies, amniotomy was carried out routinely on all women in-
cluded (Chen 1987; MacLennan 1994); one study examined dif-
Mode of birth
ferences in amniotomy rates in women allocated to upright com-
pared with recumbent positions. There were no differences be-
Spontaneous vaginal birth tween groups (Haukkama 1982).
Results were similar for women randomised to upright versus re-
cumbent positions, and this finding applied to both nulli- and Maternal outcomes
multiparous women. There were no significant differences be- Few studies reported maternal outcomes, so there was very little
tween groups in the numbers of women achieving spontaneous information on rates of post-partum haemorrhage and perineal
vaginal deliveries (Risk ratio (RR) 1.01, 95% confidence interval trauma. Results from single trials suggest no significant differences
(CI) 0.97 to 1.05) (Analysis 1.2). between groups.
Operative spontaneous or assisted delivery Fetal and neonatal outcomes

Women randomised to upright positions had similar rates of as- Again, there was little information from included studies on out-
sisted deliveries compared with those randomised to recumbent comes for babies. There were no significant differences between
positions (Analysis 1.3). Again, these results applied irrespective groups in terms of fetal distress and neonatal Apgar scores. Ad-
of parity. mission to special care units was only reported in one study and
was slightly more likely for babies born to mothers randomised
Caesarean delivery to upright positions, but this difference did not reach statistical
Women encouraged to maintain upright positions had slightly significance (Analysis 1.20. One study examined perinatal deaths;
lower rates of caesarean section compared with those in compari- no deaths in either group were recorded (Bloom 1998)
son groups. However, the strength of evidence was weak, and re-
sults did not reach statistical significance (overall RR 0.73, 95% Upright (including walking) versus recumbent
CI 0.51 to 1.07) (Analysis 1.4). positions - with epidural (five trials, 1176 women)
Analysis for this comparison is for all women, irrespective of parity.
Maternal satisfaction We had planned subgroup analysis by parity; however, of the five
While some studies collected information on satisfaction with spe- trials contributing data, three recruited nulliparous women only
cific aspects of care (e.g. satisfaction with pain relief ), we were not (Collis 1999; Nageotte 1997; Vallejo 2001) and the remaining
able to pool results, as none of these studies collected information two studies did not report results separately for nulliparous and
on women’s satisfaction with their general experience of childbirth. multiparous women (Frenea 2004; Karraz 2003).
Maternal pain and analgesia Duration of labour

Duration of the first stage of labour studies. Further, the three studies where women maintained non-
There were no differences between groups in terms of the length ambulant positions examined different types of intervention in
of the first stage of labour (i.e. time from epidural insertion to different settings. All the women in the study by Mitre 1974 had
complete cervical dilatation) (Analysis 2.1). amniotomies and were confined to bed. Women in the study by
Chen 1987 were provided with a settee and encouraged to sit on
it, but could walk around if they wished to. In the Phumdoung
Mode of delivery
2007 study, women alternated between a semi-kneeling position
Rates of spontaneous vaginal, assisted and caesarean delivery were and a semi-recumbent position. All of this variation means that
similar for women randomised to upright versus recumbent posi- it is difficult to draw firm conclusions about the most favourable
tions (Analysis 2.2; Analysis 2.3; Analysis 2.4). positions for women to adopt.
Maternal pain, satisfaction and other outcomes Subgroup analysis

There were no statistically significant differences between groups
in terms of maternal satisfaction, women receiving oxytocin aug- Low- and high-risk groups
mentation, women experiencing hypotension, women requiring
Data were not available to carry out this analysis.
additional analgesia, or the amount of analgesia women received
(Analysis 2.5 to Analysis 2.14). However, few trials measured these
outcomes and results are based on results from only one or two Sensitivity analysis
studies. For the primary review outcomes, we carried out a sensitivity anal-
ysis whereby those trials with poor allocation concealment (e.g.
alternate group allocation) or where no information on allocation
Neonatal outcomes
concealment had been provided, were taken out of the meta-anal-
There was no information on perinatal mortality or admission to ysis to see if this would change the direction of results or the size of
special care units (Analysis 1.20; Analysis 2.18 ). There were no the effect. For duration of length of first stage, only one trial was
differences between groups in the incidence of Apgar scores of less left when trials with a high risk of bias were removed. In this trial
than seven at one and five minutes (Analysis 2.17). there were no significant differences in duration of the first stage of
labour between the ambulant and comparison groups, irrespective
Trials where ambulation was encouraged and trials of parity (MD -0.25, 95% CI -1.68 to 1.18) (McManus 1978).
where women were confined to bed or sitting When all trials were included results had suggested a shorter dura-
In order to address the question of whether standing and walking, tion of first stage for those women in the intervention groups. For
rather than sitting or upright bed positions were associated with mode of delivery, three trials were included ( MacLennan 1994;
shorter length of labour, we carried out further analysis. In this McManus 1978; Miquelutti 2007). Here, there were no signifi-
analysis (Analysis 3.1) the majority of trials where women were cant differences between groups in terms of spontaneous vaginal,
encouraged to get out of bed and ambulate were analysed sepa- assisted vaginal or caesarean births. This finding was similar to
rately from the three trials (Chen 1987; Mitre 1974; Phumdoung that resulting from the inclusion of all trials.
2007) where women were encouraged to sit or maintain non-
ambulant positions. In this analysis we have only included nulli-
parous women as two of the three trials examining non-ambulant
positions (Mitre 1974; Phumdoung 2007) only recruited such DISCUSSION
women, and the third provided separate data for these women.
The objectives of this review were to assess the effects of positions
Results suggest that non-ambulant upright positions (sitting in bed
and mobility during the first stage of labour on length of labour,
or on a sofa, or semi-kneeling in bed) were associated with shorter
type of delivery and other important outcomes for mothers and
labours compared with comparison groups (MD -1.92 95% CI
babies.
-2.83 to -1.01) whereas, for studies examining ambulation, the
difference between intervention and comparison groups was not Women who were upright or mobile had a shorter first stage of
significant (MD -0.20 95% CI -1.36 to 0.96). For each of these labour compared with women who were supine (MD -0.99, 95%
comparisons, the level of heterogeneity was high and we have used CI -1.60 to -0.39). Shorter length of labour is an important out-
a random effects meta-analysis. Overall, I2 was 83% and there come, as every contraction is potentially painful. Women ran-
were differences in the direction of findings, and in the size of the domised to upright positions were also less likely to have epidural
treatment effect, so these results should be viewed with caution. As analgesia. However, there was little evidence that position or mo-
well as statistical heterogeneity, we suspected clinical heterogeneity, bility had any effect on the rate of other interventions or on the
as there was wide variation in the mean length of labour in different wellbeing of mothers and babies.

When considering the results from the review, it is worth not- tural and healthcare context is likely to have been different at dif-
ing that designing trials to examine interventions in this area is ferent times and in different settings, and there have also been
challenging, and it is difficult to avoid bias. It is not possible to changes in healthcare technologies. Within these changing con-
blind women and caregivers to group allocation. In addition, it texts, the attitudes and expectations of healthcare staff, women and
is difficult to standardise interventions. For the trials included in their partners towards pain, pain relief and appropriate behaviour
the review, there was considerable variation in the interventions during labour and childbirth have shifted. All of these factors are
women received. Even where interventions appeared similar in dif- important in the interpretation of results.
ferent studies, it is likely that women’s experience varied; this sort
This review needs to be looked at alongside other related Cochrane
of intervention cannot be easily controlled. Women may have had
reviews focusing on care during labour (e.g. Cluett 2002; Gupta
difficulty maintaining the intervention position or preferred alter-
2004; Hodnett 2007; Hunter 2007). While position in the first
native positions. There was also variation in caregiver behaviour in
stage of labour may have an independent effect, the position in
relation to study protocols; in some studies women were strongly
second stage and other variables (e.g. the presence of a birth com-
encouraged by staff to mobilise (e.g. in the study by Miquelutti
panion) are also important.
2007, any woman in the intervention group that remained in bed
for more than 30 minutes was asked to get out again); in other
studies, women had more choice and more gentle encouragement.
In one study the intervention was only encouraged during the day AUTHORS’ CONCLUSIONS
as it was not felt that women would like to walk around at night
(Karraz 2003), and in this same study, women in the compari- Implications for practice
son group were not allowed out of bed even to walk to the toilet. Upright positions and walking are associated with a reduction in
Further, there was huge variability in the amount of time women the length of the first stage of labour, and women randomised
actually followed the protocol in terms of ambulation or staying to upright positions may be less likely to have epidural analge-
in bed. For example, in the Calvert 1982 study, less than half of sia, but there was little evidence of differences for other maternal
the women in the intervention group chose to get out of bed at all, and infant outcomes. Despite the limited evidence from trials in-
and those that did get out, only tended to do so for short periods cluded in the review, observational studies suggest that maintain-
of time. . ing a supine position in labour may have adverse physiological ef-
fects on the woman and her baby (Abitbol 1985; Huovinen 1979;
Heterogeneity in study findings also created problems in inter-
Marx 1982; Roberts 1989; Rooks 1999; Walsh 2000). There-
preting results. For the main outcome - length of the first stage of
fore, women should be encouraged to take up whatever position
labour - there was considerable variation within and between stud-
they find most comfortable while avoiding spending long periods
ies in terms of group means. Various studies defined and measured
supine. Women’s preferences may change during labour. Many
the length of the first stage of labour in different ways. Measure-
women may choose an upright or ambulant position in early first
ment may have commenced on admission or at various points of
stage labour and choose to lie down as their labour progresses.
cervical dilatation according to different hospital policies or study
designs.
Implications for research
We were not able to answer several of the questions set out in Overall, the quality of the studies included in the review was mixed
the protocol. There were no studies comparing different types of and most studies provided little information on methods. Min-
upright position, e.g. sitting up in bed or on a chair versus walking imising risk of bias in trials on this topic is challenging, as blinding
or kneeling, or other upright positions. Results suggest that non- is not feasible and it is difficult to standardise interventions. At the
ambulant upright positions may reduce the length of labour, but same time, some aspects of study design can be controlled.
only three studies (all with a high risk of bias) examined non-
walking positions and results were difficult to interpret because of Some considerations for future research are as follows.
the variability of interventions.
• There is a need for high-quality trials in this area, with
Few of the studies collected outcome data on many of the re- particular attention given to allocation concealment.
view outcomes such as pain, maternal satisfaction, and neonatal
outcomes. Most of the included studies collected information on • Trialists should clearly explain how they have defined
mode of birth, but few had the statistical power to detect differ- the first stage of labour.
ences between groups. • There is a need to improve and standardise measure-
ment of pain.
Studies were carried out over a long period: from the early 1960s
(Chan 1963) through to 2007 (Miquelutti 2007; Phumdoung • There is an urgent need to collect information on out-
2007); and in a number of different healthcare settings. The cul- comes for mothers, such as satisfaction with the experi-

ence of childbirth, and more information is needed on
pain and the effect of position on complications such
as haemorrhage.
• Few trials assessed outcomes for babies and future stud-
ies need to focus on this.
• Studies are needed which compare different upright po-
sitions (e.g. sitting upright versus walking) and different
lying positions (e.g. lying on side versus back).
ACKNOWLEDGEMENTS
We would like to thank Philippa Middleton, Caroline Crowther,
Lea Budden and Joan Webster for their advice on early versions of
this review.
As part of the pre-publication editorial process, this review has been
commented on by two peers (an editor and referee who is external
to the editorial team), a member of the Pregnancy and Childbirth
Group’s international panel of consumers and the Group’s Statis-
tical Adviser.
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Andrews CM, Chrzanowski M. Maternal position, labour and com-
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Chan DPC. Positions during labour. British Medical Journal 1963;
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Goer H. Does walking enhance labor progress?. Birth 1999;26(2): B. Ambulation in labour with an epidural: the effect on analgesic
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Anesthesia & Analgesia 2004;98(1):224–9. acceptability of ambulation in spontaneous labour. British Journal of
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Haukkama 1982 {published data only}
Haukkama M, Purhonen M, Teramo K. The monitoring of labor by References to studies excluded from this review
telemetry. Journal of Perinatal Medicine 1982;10:17–21.
Karraz 2003 {published data only} Ahmed 1985 {published data only}
Karraz MA. Ambulatory epidural anaesthesia and the duration of Ahmed LT, Bouchetara K. The influence of maternal position on
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22. 9.
MacLennan 1994 {published data only} Allahbadia 1992 {published data only}
MacLennan AH, Crowther C, Derham R. Does the option to am- Allahbadia GN, Vaidya PR. Why deliver in the supine position?.
bulate during spontaneous labour confer any advantage or disadvan- Australian and New Zealand Journal of Obstetrics and Gynaecology
tage?. Journal of Maternal-Fetal Medicine 1994;3:43–8. 1992;32(2):104–6.
Asselineau 1996 {published data only}
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McManus TJ, Calder AA. Upright posture and the efficiency of
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peridurale lors du travail modifie–t–elle les conditions d’extraction
Miquelutti 2007 {published data only} foetale?]. Contraception, Fertilité, Sexualité 1996;24(6):505–8.
Miquelutti MA, Cecatti JG, Makuch MY. Upright position during
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JJ, Pose SV, et al.Effect of position changes on the intensity and
Mitre 1974 {published data only} frequency of uterine contractions during labor. American Journal of
Mitre IN. The influence of maternal position on duration of the Obstetrics and Gynecology 1960;80(2):284–90.
active phase of labor. International Journal of Gynecology & Obstetrics
Cobo 1968 {published data only}
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Cobo E, De Bernal MM, Quintero CA, Cuadrado E. Neurohypophy-
Nageotte 1997 {published data only} seal hormone release in the human. III. Experimental study during
Nageotte M, Larson D, Rumney P, Sidhu M, Hollenback K. A labor. American Journal of Obstetrics and Gynecology 1968;101:479–
prospective randomized study of intrapartum epidural vs combi- 89.
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Cohen 2002 {published data only}
American Journal of Obstetrics and Gynecology 1997;176(1 Pt 2):S22.
Cohen S, Ayers C, Zada Y, Trnovski S, Burley E, Maestrado P. A
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comparison of continuous epidural-PCA analgesia for labor pain with
Epidural analgesia compared with combined spinal-epidural anal-
or without maternal ambulation [abstract]. Anesthesia & Analgesia
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Medicine 1997;337(24):1715–9.
COMET 2001 {published data only}
Phumdoung 2007 {published data only}
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porn R. The effects of the PSU Cat position and music on length
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COMET Study Group. The comparative obstetric mobile epidural
Vallejo 2001 {published data only} trial (C.O.M.E.T.). Ambulatory epidural analgesia, delivery mode
Vallejo M, Firestone L, Mandell G, Jaime F, Makishima S, Ra- and pain relief: a randomized controlled trial. The C.O.M.E.T.
manathan S. The effect of sitting and ambulating on labor dura- Study Group. [abstract]. European Journal of Anaesthesiology 2000;
tion and maternal outcome [abstract]. Anesthesiology 2001;94(1A): 17:782–3.
Abstract no: A7. COMET Study Group, Wilson MJ. A randomised controlled trial
Vallejo M, Mandell G, Jaime F, Ramanathan S. Ropivacaine for walk- comparing traditional with two “mobile” epidural techniques: effect
ing epidural analgesia during labor. Regional Anesthesia and Pain on urinary catheterisation in labor [abstract]. Anesthesiology 2002;96
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Vallejo MC, Firestone LL, Mandell GL, Jaime F, Makishima S, Comparative Obstetric Mobile Epidural Trial (COMET) Study
Ramanathan S. Effect of epidural analgesia with ambulation on labor Group UK. Effect of low-dose mobile versus traditional epidural tech-
niques on mode of delivery: a randomised controlled trial. Lancet Hillan 1984 {published data only}
2001;358(9275):19–23. Hillan EM. The birthing chair trial. Research and the Midwife
Duhig K, MacArthur C, Shennan AH, The COMET Study Group. Conference; 1984; Manchester, UK. 1984:22–37.
The hypotensive and fetal heart rate response to low dose epidurals: Stewart P, Hillan E, Calder A. A study of the benefits of maternal
analysis of an RCT data set [abstract]. Journal of Obstetrics and Gy- ambulation during labour and the use of a birth chair for delivery.
naecology 2007;27(Suppl 1):S63–S64. Proceedings of 8th European Congress of Perinatal Medicine; 1982
Elton C, Bharmal S, May AE, COMET Study Group. Does walking Sept 7-10; Brussels, Belgium. 1982:Abstract no: 113.
in labour with regional blockade affect the mode of delivery? [ab- Stewart P, Hillan E, Calder AA. A randomised trial to evaluate the
stract]. International Journal of Obstetric Anesthesia 2002;11 Suppl: use of a birth chair for delivery. Lancet 1983; Vol. 1:1296–8.
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Hodnett 1982 {published data only}
Hussain for the COMET Study Group. Haemodynamic changes
Hodnett ED. Patient control during labor: effects of two types of
with ’mobile’ epidurals in labour: is it safe for women to ambulate?
fetal monitors. Journal of Obstetric, Gynecologic and Neonatal Nursing
[abstract]. Anesthesiology 2001;94(1A):Abstract no: A63.
1982;2:94–9.
Shennan AH, COMET Study Group. The effect of low-dose ’mobile’
compared with traditional epidural techniques on mode of delivery: Liu 1989 {published data only}
a randomised controlled trial [abstract]. Journal of Obstetrics and Liu, Y. The effects of the upright position during childbirth. Image:
Gynaecology 2001;21 Suppl 1:S19. Journal of Nursing Scholarship 1989;21(1):14–8.
Wilson MJ, COMET Study Group. The comparative obstetric mo- McCormick 2007 {published data only}
bile epidural trial (C.O.M.E.T.). A randomized controlled trial [ab- McCormick C. A randomised controlled trial of the effect of am-
stract]. British Journal of Anaesthesia 2001;87(4):659P. bulation in the first stage of labour in terms of duration of labour
Wilson MJ, Cooper G, MacArthur C, Shennan A, Comparative Ob- of women with a previous caesarean section. controlled-trials.com
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ized controlled trial comparing traditional with two “mobile” epidu-
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97(6):1567–75. Melzack R, Belanger E, Lacroix R. Labor pain: effect of maternal
position on front and back pain. Journal of Pain and Symptom Man-
Danilenko-Dixon 1996 {published data only} agement 1991;6(8):476–80.
Danilenko-Dixon DR, Tefft L, Cohen RA, Haydon B, Carpenter
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1996;175:867–72. relationship with the patient’s position. Journal of Pain and Symptom
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Diaz 1980 {published data only}
Diaz AG, Schwarcz R, Fescina R, Caldeyro-Barcia R. Vertical position Radkey 1991 {published data only}
during the first stage of the course of labor, and neonatal outcome. Radkey AL, Liston RM, Scott KE, Young C. Squatting: preventive
European Journal of Obstetrics & Gynecology and Reproductive Biology medicine in childbirth?. Proceedings of Annual Meeting of Society
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Divon 1985 {published data only}
Read 1981 {published data only}
Divon MY, Mushkat Y, Sarna Z, Zimmer EZ, Vilensky A, Paldi E.
Read JA, Miller FC, Paul RH. Randomized trial of ambulation vs
The association between fetal heart rate patterns and maternal posture
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and Reproductive Biology 1983;15:129–39. Solano 1982 {published data only}
Solano F, Gallo M, Llamas C, Requena F, Arbues J. Perinatal effects
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Hemminki E, Lenck M, Saarikoski S, Henriksson L. Ambulation livery. Effects on the mother-child couple [Efectos perinatales de la
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∗
Indicates the major publication for the study

CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]
Andrews 1990
Methods Randomised trial.
Participants 40 women randomised.

Inclusion criteria - nulliparous women with a medically uncomplicated pregnancy with
a single vertex fetus in an anterior position, spontaneous onset of labour at 38 to 42
weeks’ gestation, adequate pelvic measurements and intact amniotic membranes at the
beginning of the maximum slope in their labour (4 to 9 cm dilatation).
Interventions Intervention group: 20 - upright: standing, ambulating, sitting, squatting, or kneeling.

Comparison group: 20 - recumbent: supine, lateral, or prone - hands and knees.
All women - position assumed when cervical dilatation was from 4 to 9 cm; women were
free to choose several variations within each position group.
Women in both groups were free to assume positions from the other group for routines
of care or rest; these activities were documented.
Outcomes Length of first stage of labour.

Pain.
Analgesia amount.
Notes Upright group - 15 women chose to lie down after receiving medication for rest; 5 of these
women 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.
Women in the recumbent position were monitored externally more often (n =13) than
women in the upright position (n =1), which may have been an additional source of
discomfort for women in the recumbent group.
Risk of bias
Item Authors’ judgement Description
Adequate sequence generation? Unclear Described as ’randomly assigned’.
Allocation concealment? Unclear Not stated.
Blinding? No Not feasible.

Women

Clinical staff

Andrews 1990 (Continued)
Blinding? Unclear Not stated.

Outcome assessor
Incomplete outcome data addressed? Yes No losses to follow up.

All outcomes
Bloom 1998
Participants 1067 women randomised.

Inclusion criteria - women (nulliparous and multiparous) with uncomplicated pregnan-
cies between 36 and 41 weeks’ gestation and in active labour, having regular uterine con-
tractions with cervical dilatation of 3 to 5 cm, and fetuses in cephalic presentation. Fetal
membranes could be intact or ruptured. Exclusion criteria - women with any known
complication of pregnancy, including breech presentations.
Interventions Intervention group: 536 assigned to walking (walking as desired). Women were encour-
aged to walk but were instructed to return to their beds when they needed intravenous
or epidural analgesia or when the second stage of labour began.
Comparison group: 531 to labour in bed (usual care - confined to a labour bed). Women
were permitted to assume their choice of supine, lateral or sitting positions during labour.
All women - electronic fetal heart rate monitoring was not used routinely.
Women whose fetuses had heart-rate abnormalities during routine surveillance con-
ducted every 30 minutes with handheld Doppler devices, women who had meconium
in the amniotic fluid, and women in whom labour was augmented by the administration
of oxytocin underwent continuous electronic fetal monitoring, which prohibited further
walking.
Pelvic examinations were performed approximately every 3 hours - ineffective labour

was suspected if the cervix did not dilate progressively during the first two hours after
admission. If the fetal membranes were intact, amniotomy was performed. If a woman
had hypotonic uterine contractions, and no further cervical dilatation after an additional
2-3 hours, labour was augmented by intravenous oxytocin (initial dose 6 mU per minute,
increased every 40 mins by 6 mU per minute to a maximum of 42 mU per minute.
Dystocia was diagnosed if labour had not progressed in 2-4 hours.
In both study groups, the positions permitted during birth included the lateral (Sims’)
position and the dorsal-lithotomy position, with or without obstetrical stirrups.
Women in both groups wore pedometers (for the walking group only, nurses recorded
the number of minutes spent walking).

Bloom 1998 (Continued)
Outcomes Length of first stage labour.

Length of second stage labour.
Type of birth.
Fetal distress.
Analgesia.
Augmentation.
Perineal trauma.
Fetal distress.
Notes
Risk of bias

Women

Clinical staff

Outcome assessor
Incomplete outcome data addressed? Yes No losses to follow-up.

All outcomes
Broadhurst 1979
Participants 50 (8 primiparous and 17 multiparous in each group).
Interventions Intervention group: 25 - ambulation.

Comparison group: 25 - bed care.
Outcomes Pain.
Analgesia.
Notes

Broadhurst 1979 (Continued)
Risk of bias
Adequate sequence generation? Unclear Describled as ’randomly allocated’.

Women

Clinical staff

Outcome assessor
Incomplete outcome data addressed? No No losses to follow up.

All outcomes
Bundsen 1982
Participants 60 women undergoing induction of labour.
Interventions Intervention group: 40 ambulation (telemetry).

Comparison group: 20 bed care.
All women: induced - primary amniotomy and immediate internal monitoring.
Outcomes Type of delivery.

Pain.
Notes
Risk of bias
Adequate sequence generation? Unclear Described as ’randomization to three groups’.
Blinding? No
Women

Bundsen 1982 (Continued)
Blinding? No
Clinical staff
Blinding? No
Outcome assessor
Incomplete outcome data addressed? Yes No losses to follow up apparent.

All outcomes
Calvert 1982
Methods Quasi-randomised trial.
Participants 200 women randomised. Inclusion criteria - women with a single fetus of at least 37 weeks’
gestation; vertex presentation and no contraindication to vaginal birth; in spontaneous
labour with uterine contractions occurring at least every 10 mins and a cervix at least
2.5 cm dilated.
Exclusion criteria - women who had previously suffered a stillbirth or neonatal death or
who had undergone a caesarean section.
Interventions Intervention: Ambulation with telemetry monitoring (women advised that they could
get of bed to walk, sit in an easy chair or use the day room).
Intervention group - ambulant women monitored with telemetry (n = 100).
Comparison group - conventional cardiotocography (women nursed in bed) (n = 100).
All women - all patients in bed were nursed in the lateral position or with a lateral tilt.
Outcomes Length of first stage.

Type of delivery.
Woman’s pain.
Analgesia.
Length of second stage.
Apgar < 7 at 5 mins.
Notes Telemetry group: 45% elected to get out of bed (and then only for short periods); average
time out of bed = 1 hour 44 mins (range - 3 mins to 4 hours 20 mins) which was 30%
of the monitored first stage of labour; 34 (75%) of those who left their beds initially
elected to stay in bed by the time they reached a cervical dilatation of 7 cm.
Risk of bias
Adequate sequence generation? No Described as ’Final digit of hospital number (odd or even)’.

Calvert 1982 (Continued)
Allocation concealment? No Described as ’Final digit of hospital number (odd or even)’.

Women

Clinical staff

Outcome assessor

All outcomes
Chan 1963
Participants 200 women randomised. Inclusion criteria - primiparous. Exclusion criteria - planned
elective caesarean section.
Interventions Intervention group:100 women were kept in the erect postion (sit or walk).
Comparison group: 100 women were kept in a supine or lateral position.

Type of delivery.
Pain.
Analgesia.
Fetal distress.
Notes
Risk of bias
Adequate sequence generation? No Alternate group allocation.
Allocation concealment? No
Incomplete outcome data addressed? Unclear No loss to follow up.

All outcomes

Chen 1987
Participants 116 women (185 women randomised, 116 included in the analyses).
Inclusion criteria - women with uneventful pregnancies, full term, spontaneous labours,
with a single fetus in cephalic presentation.
Exclusion criteria - women received oxytocin augmentation; caesarean section due to
cephalo-pelvic disproportion or fetal distress; women requested and received epidural
anaesthesia; child with congenital anomalies; tococardiogram records were unsuitable
for reading (n = 67 exclusions after group allocation).
Interventions Amniotomy performed when cervical dilatation reached 3 to 4 cm.

Intervention group (sitting): Women free to assume any comfortable position in home-
like part of obstetric unit (furnished with desk, chair, sofa but no bed). Most sat on a
sofa (back of sofa at 65 degree angle from horizontal) with their knees flexed. When each
woman’s cervix became fully dilated, she was transferred to a birthing chair
Comparison group (supine): Women to maintain dorsal or lateral recumbent position.
No analgesia or anaesthesia used except for pudendal nerve block or perineal infiltration
of xylocaine.
Experimental group (1): sitting position during the entire course of labour (n = 41).
Comparison groups (2): supine position in the first stage and birthing chair in the second
stage (n = 32); (3): supine position throughout labour (n = 43).

Type of delivery.
ARM.
Notes
Risk of bias
Adequate sequence generation? No Described as ’Allocated following the order of their admission
into the study’.
Allocation concealment? No Described as ’Allocated following the order of their admission

into the study’.

Women

Clinical staff

Chen 1987 (Continued)

Outcome assessor
Incomplete outcome data addressed? No 67 participants were excluded after group allocation (37%).
All outcomes Some of the reasons for exclusion are unlikely to have related to
the intervention (e.g. children born with congenital abnomali-
ties) but other reasons may have related to group allocation (e.g.
oxytocin augmentation, caesarean for fetal distress).
Collis 1999
Methods Randomised trial
Participants 229 women (153 were in spontaneous labour and 76 had labour induced).
Inclusion criteria - nulliparous women in spontaneous or induced labour who requested
regional analgesia (given CSE); cephalic singleton pregnancy from 36 to 42 weeks’ ges-
tation, with no other pregnancy complications, e.g. pregnancy-induced hypertension.
Interventions Intervention group: encouraged to spend at least 20 mins of each hour out of bed (n =
110) - walking, standing, sitting in a rocking chair.
Comparison group: encouraged to stay in bed (n = 119) - sitting up in bed or lying on

either side.
All women - continuous fetal monitoring.
500-1000 ml Hartmann’s solution infused as a preload; CSE - 27-G Becton-Dickinson
Whitacre 119 mm spinal needle and 16-G Tuohy needle; long spinal needle inserted
through Tuohy needle into cerebrospinal fluid (needle-through-needle CSE). Subarach-
noid injection of 25 g fentanyl and 2.5 mg bupivacaine
Labours were managed according to the department’s standard practice (cervical dilata-
tion was assessed every 3 hours and if dilatation had not increased by 2 cm, amniotomy
was performed; if the membranes were intact, this was followed 2 hours later (if progress
of labour was still inadequate) by augmentation of labour with oxytocin. If the mem-
branes were ruptured and inadequate progress of labour was noted, then oxytocin was
started without waiting for another 2 hours. The mothers were allowed up to 2 hours
in the second stage of labour. If at the end of the second hour, birth was not imminent,
instrumental delivery was performed.

Type of delivery.
Analgesia.
Apgar.

Collis 1999 (Continued)
Notes 51/110 women in the intervention group achieved at least 30% of time out of bed, 15
women spent no time out of bed, 44 spent 1 to 29%, 32 spent 30-59% and 19 women
spent > 60% of time out of bed. Reasons for not ambulating:
16 women developed motor block, fatigue in 25 mothers, midwife instruction in 10
cases.
Comparison group: 16/119 women got of bed (15 between 1-29% of the time and 1
between 30-59% of the time.
Reasons for ambulating: passing urine.
Risk of bias
Adequate sequence generation? Unclear Not stated.
Allocation concealment? Yes Described as ’sealed opaque numbered envelopes’.

Women
Blinding? Unclear Described as ’Obstetrician was not aware which group the
Clinical staff mother was in’.
Blinding? Unclear Described as ’Obstetrician was not aware which group the
Outcome assessor mother was in’.

All outcomes
Fernando 1994
Participants 40 nulliparous women receiving a CSE.
Interventions Intervention group: out of bed (sitting in rocking chair, stand by bed, walk about) (n =
20).
Comparison group: staying in bed (n = 20).
All women - spinal injection of bupivacaine 2.5 mg and fentanyl 25 g using a 27 gauge,
1119 mm Becton-Dickinson Whitacre spinal needle through a 16 gauge Braun Tuohy
needle, followed by epidural top ups of 10 mg bupivacaine in 10 ml with 2 g/ml of
fentanyl.

Fernando 1994 (Continued)
Outcomes Apgar.
Notes
Risk of bias
Adequate sequence generation? Unclear Described as ’randomly allocated’.

Women

Clinical staff

Outcome assessor

All outcomes
Flynn 1978
Participants 68 (17 primigravidae and 17 multigravidae in each group, 33 cephalic and 1 breech
presentation in each group).
Inclusion criteria - women in spontaneous labour.
Interventions Intervention group: allowed to walk around while being continuously monitored by
telemetry.
When intravenous treatment was necessary (e.g. because of ketonuria or delay in labour)
the women returned to bed.
Comparison group: recumbent (nursed in the lateral position with conventional bedside
monitoring of fetal heart and intrauterine pressure).
All patients were nursed in bed during the second and third stages of labour.
Dilatation of the cervix and station of the presenting part were assessed at the start of
monitoring and every two to three hours during labour.
Analgesia was administered when the midwife thought the woman was becoming dis-
tressed with pain.

Flynn 1978 (Continued)
Augmentation in labour with oxytocin or prostaglandin was given when indicated by

delay in labour.

Type of delivery.
Analgesia.
Augmentation.
Blood loss.
Apgar.
Notes
Risk of bias
Adequate sequence generation? Unclear Described as ’randomised prospective’.

Women

Clinical staff

Outcome assessor

All outcomes
Frenea 2004
Participants 61 women.
Inclusion criteria - women with uncomplicated term singleton pregnancies from 37 to
42 weeks’ gestation in a fixed cephalic uncomplicated presentation, and 3 to 5 cm cervical
dilatation at the time of epidural insertion. Women could be in spontaneous labour or
admitted for elective induction. A normal fetal heart rate pattern was also required.
Exclusion criteria - unfixed cephalic presentation, cervical dilatation more than 5 cm, a
contraindication to epidural analgesia, or a systolic arterial blood pressure < 100 mmHg
before epidural insertion, twin pregnancy, history of caesarean birth, and any known
complications of pregnancy including breech presentation.

Frenea 2004 (Continued)
Interventions Intervention group: ambulation (n = 30).

Women were asked to walk at least 15 mins of each hour or for 25% of the duration of
the first stage of labour.
Ambulation was permitted 15-20 mins after the initial injection, provided there was no
postural hypotension, no motor block in lower limbs, no proprioception impairment
and no fetal heart rate decelerations.
The women were asked to return to bed when they requested an epidural top-up or if
they experienced weakness or sensory changes. Walking ended when examination by a
midwife revealed full cervical dilatation.
Comparison group: recumbent (n = 31).
Confined to bed in dorsal or lateral recumbent position.
Monitoring of labour was as for the ambulatory group, but without telemetry. Epidural
analgesia of intermittent administrations of 0.08% bupivacaine-epinephrine plus 1 g/ml
of sufentanil.

Type of delivery.
Analgesia.
Notes
Risk of bias
Adequate sequence generation? Unclear Not stated.
Allocation concealment? Yes Described as ’sealed numbered envelopes’.

Women

Clinical staff

Outcome assessor

All outcomes

Haukkama 1982
Inclusion criteria: healthy women with an uneventful pregnancy, giving birth between
38 and 42 weeks.
Interventions Intervention group: cardiotocography by telemetry (n = 31).

Telemetry women were encouraged to sit or walk during the opening phase of labour.
Comparison group: conventional cardiotocography (n = 29).
All women - nitrous oxide-oxygen, pethidine (usual dose 75 mg given once or twice) or
epidural block were used for analgesia when needed.

Type of delivery.
Analgesia.
Augmentation.
ARM.
Notes
Risk of bias
Adequate sequence generation? Unclear Described as matched pairs ’allocated at random’ to one of two
groups.

Women

Clinical staff

Outcome assessor

All outcomes
Karraz 2003

Karraz 2003 (Continued)
Participants 221 (144 nulliparas - 97 (69.3%) in the ambulatory group and 47 (63.5%) in the non-
ambulatory group.
Inclusion criteria: women with uncomplicated singleton pregnancies who presented in
spontaneous labour between 36 and 42 weeks’ gestation or who were scheduled for
induced labour.
Study conducted in daytime only (as women in labour at night are less inclined to walk).
Exclusion criteria - women with pre-eclampsia or previous caesarean.
Interventions Intervention group: ambulatory (walked, sat in a chair or reclined in a semi-supine

position (n = 141) - as long as they demonstrated:
acceptable analgesia; acceptable systolic blood pressure and ability to stand on one leg.
Comparison group: non-ambulatory (not allowed to sit, walk or go to the toilet); they
had to remain in the supine position or to lie in a semi-supine or lateral position (n =
74).
All - intermittent epidural injection of 0.1% ropivacaine with 0.6 µg/ml sufentanil.
Repeat injections were given when the women requested additional pain relief.
Outcomes Length of labour.

Type of delivery.
Analgesia.
Augmentation.
Notes
Risk of bias
Adequate sequence generation? Unclear ’Randomly divided’ in a 2:1 ratio.

Women

Clinical staff

Outcome assessor
Incomplete outcome data addressed? No 6 women were excluded after randomisation.

All outcomes

MacLennan 1994

Inclusion criteria: women in spontaneous established labour (presence of regular con-
tractions less than 10 mins apart and cervical dilatation of 3 cm or more) with a singleton
fetus in a cephalic presentation between 37 and 42 weeks’ gestation who had the ability
to ambulate in labour.
Exclusion criteria: women undergoing intravenous therapy, with hypertension (> 90
mmHg diastolic blood pressure), epidural or narcotic analgesia at or before entry to trial,
evidence of possible fetal distress, previous prostaglandin treatment, induced labour and
a physical inability to ambulate.
Interventions Intervention group: ambulate as desired (n = 96).

Women were encouraged to ambulate but were also given the option of sitting or lying
down when they wished.
Comparison group: recumbent.
Most women chose a semi-recumbent posture with the head end of the bed at 45 degrees
but they could also be on their side with lower elevation of the head.
After entry to the trial, all women had an artificial rupture of the membranes if they had
not already spontaneously ruptured.

Analgesia.
Augmentation.
Apgar.
Admission to NICU.
Notes
Risk of bias
Adequate sequence generation? Yes Described as ’Balanced variable blocks with stratification by par-
ity’.
Allocation concealment? Yes Opaque, sealed envelopes.

Women

Clinical staff

Outcome assessor

MacLennan 1994 (Continued)

All outcomes
McManus 1978
Participants 40 women (20 primigravidas and 20 having their second or third confinement).
Inclusion criteria - gestational age 38 weeks or more, and cervical score 6 or greater.
Exclusion criteria - multiple pregnancies or breech presentations.
Interventions Intervention group: upright - encouraged to “be up and about”. If woman wished to go
to bed, she was nursed in a sitting position with the aid of pillows.
Comparsion group: recumbent - nursed in the lateral position
Labour was induced by forewater amniotomy and 0.5 mg PGE2 immediately after
amniotomy and hourly thereafter until labour was considered to be established.
If labour was not established an hour after the 6th PGE2 tablet (i.e. 6 hours after
amniotomy), intravenous oxytocin was given.

Analgesia.
Augmentation.
ARM.
Blood loss.
Fetal distress.
Apgar.
Notes
Risk of bias
Adequate sequence generation? Unclear Described as ’randomised prospective study’.
Allocation concealment? Unclear Described as ’randomly allocated according to the contents of a

plain envelope’.

Women

Clinical staff

McManus 1978 (Continued)

Outcome assessor

All outcomes
Miquelutti 2007
Participants 107 women attending a hospital in Brazil (2005-6).

Inclusion criteria - low-risk nulliparous women, at term, in labour, aged 16 - 40 years.
Cervical dilation between 3cm and 5cm. Singleton fetus in cephalic presentation.
Exclusion criteria - contraindications to upright position or booked for elective caesarean
section.
Interventions Intervention group - (n = 54) women received written information/education involving

the use of models on the benefits of maintaining an upright position and encouraged to
stand, walk, sit, crouch or kneel. If women remained supine for more than 30 minutes
they were encouraged to return to an upright position.
Comparison group - (n = 53) routine care, women were not encouraged to adopt any
position and were allowed to move around and adopt any position they chose.
Outcomes Mode of delivery, duration of labour, augmentation, episiotomy, Apgar score, maternal
preferences.
Notes Women in the intervention group remained upright for 57% of the time compared to
28% for women in the comparison group.
Risk of bias
Adequate sequence generation? Yes Computer generated.
Allocation concealment? Yes Sealed, opaque envelopes opened sequentially.

Women
Blinding? No
Clinical staff
Blinding? No
Outcome assessor

Miquelutti 2007 (Continued)
Incomplete outcome data addressed? Yes Few women lost to follow up.
All outcomes
Mitre 1974

Inclusion criteria - women who had been admitted to the labour room and had term
pregnancies; were in the latent phase of labour or the active phase with the cervix between
1 and 3 cm; no medical stimulation of labour was required; no evidence of cephalopelvic
disproportion; no history of surgery or trauma to the cervix; normal prenatal course;
cephalic presentation.
Interventions Intervention group: sitting (n = 50).

All women were allowed to sit up after the amniotomy had been performed and the
presenting part was engaged. The women were allowed to lie down from time to time,
if they desired.
Comparison group: supine (n = 50).
All women were placed in the supine position and allowed to turn on their sides.
Direct fetal and maternal monitoring was performed randomly on several women in
both groups, using a choriometric unit.
Outcomes Length first stage labour.

Apgar.
Notes
Risk of bias
Adequate sequence generation? Unclear Described as ’divided randomly into two groups’.

Women

Clinical staff

Outcome assessor

Mitre 1974 (Continued)

All outcomes
Nageotte 1997
Participants 761 (total of 3 arms; only 2 arms (n = 505) used here.

Inclusion criteria: nulliparous women in spontaneous labour or with spontaneous rupture
of membranes at 36 weeks or more with a fetus in the vertex position, who requested
epidural analgesia.
Interventions Intervention group: ambulation encouraged (n = 253).

Ambulation was defined as a minimum of five mins of walking per hour.
Comparison group:ambulation discouraged (n = 252).
All women had CSE.
All women received a minimum of 1000 ml of lactated Ringer’s solution intravenously
during the 30 mins preceding the placement of the epidural needle. CSE - intrathecal
narcotic with a continuous low-dose epidural infusion. After the location of the epidural
space with an 18-gauge Tuohy needle, a 11.9 cm 27-gauge Whitacre spinal needle was
passed through the epidural needle into the subarachnoid space. Then 10 g of sufentanil
in 2 ml of normal saline was infused and the spinal needle removed. An epidural catheter
was advanced 3 cm into the epidural space and a continuous infusion of 0.0625 %
bupivacaine with 2 g of fentanyl per millilitre was given at a rate of 12 ml per hour.
Subsequent bolus doses of epidural solution were given as requested (12 ml of 0.0625%
bupivacaine).

Pain.
Hypotension.
Apgar.
Notes
Risk of bias

Women

Nageotte 1997 (Continued)

Clinical staff

Outcome assessor

All outcomes
Phumdoung 2007
Methods Randomised trial. Randomised in blocks.
Participants Women recruited from a hospital in Southern Thailand. (2 groups used in this analysis
(n = 83)).
Inclusion criteria - married, primiparous women aged 18 - 35 years and in latent phase
for > 10 hours. Singleton fetus, cephalic presentation, gestation 38 - 42 weeks, fetal
weight 2500 - 4000 g.
Exclusion criteria - had analgesia before recruitment, induced labour, membrane rupture
> 20 hours previously, psychiatric problem, infection, asthma or objection to interven-
tion.
Interventions 5 separate intervention groups (described below). In this review we have included data
from two groups:
Intervention group - CAT position alternating half hourly with head high position (CAT
position = facing towards bed head at 45 degrees with knees bent, taking weight on knees
and elbows; head high position = lying at a 45-degree angle) (n = 40).
Comparison group - supine in bed (n = 43).
Outcomes Duration of first stage.

Pain.
Notes Complicated study design with five study groups:

1. CAT position alternating with head-high position with music (n = 40).
2. CAT position alternating with head-high position (n = 40).
3. CAT position alternating with supine position (n = 40).
4. Head-high position (lying in bed on back at 45 degrees) (n = 41).
5. Supine in bed (n = 43).
In this review we have used data for groups 2 and 5 in the analyses.
(It was not clear what ’CAT’ signified)
Risk of bias

Phumdoung 2007 (Continued)
Adequate sequence generation? Unclear No information.
Allocation concealment? Unclear Described as ’random assignments’.

Women
Blinding? No
Clinical staff
Blinding? No
Outcome assessor
Incomplete outcome data addressed? Yes Three women were lost to follow up as they had caesarean sec-
All outcomes tions during the first stage of labour. It was not clear whether
this was before randomisation. No other loss to follow up was
apparent.
Vallejo 2001

Inclusion criteria - nulliparous women, 36 - 42 weeks’ gestation, singleton pregnancy
in the vertex position and 3-5 cm cervical dilatation at the time of epidural insertion.
Women with uncomplicated pregnancies who presented in spontaneous labour or who
were scheduled to be admitted for elective induction of labour (indications for elective
IOL included post dates (> 42 weeks) and patient preference).
Exclusion criteria - pre-eclampsia, diabetes mellitus, preterm gestation (< 36 weeks) and
post-term gestation (> 42 weeks).
Interventions Intervention group: AEA with ambulation, sitting in a chair or both (n = 75).
After 1 hour, women with a modified Bromage score of 5 who could stand on one foot
(right and left) without assistance (all women in this group were able to do this) and
without hypotension (systolic blood pressure < 100 mmHg or a decrease of 20 mmHg),
were encouraged to ambulate with a support person (spouse or friend). If the woman
could not comply with ambulation, she was encouraged to sit in a chair.
Ambulation was defined as a minimum of 5 min of walking per hour.
Women were not allowed to ambulate if there were persistent fetal decelerations and were
not allowed to be out of bed in the second stage of labour when women were actively
pushing.
Comparison group: AEA without ambulation or sitting in a chair (n = 76).
Women were confined to bed, encouraged to stay recumbent in a lateral position, and
were not allowed to raise the head of the bed more than 45 degrees from horizontal.

Vallejo 2001 (Continued)
All - AEA blocks initiated with 15-25 ml ropivacaine (0.07%) plus 100 g/ml fentanyl,
no test dose, to achieve a T10 dermatome sensory level. After achieving adequate pain
relief, a continuous infusion of 0.07% ropivacaine plus 2 g/ml fentanyl at 15-20 ml/hour
was administered.

Type of delivery.
Pain.
Augmentation.
Apgar.
Notes
Risk of bias
Adequate sequence generation? Yes Described as ’random number computer-generated program’.

Women

Clinical staff

Outcome assessor
Incomplete outcome data addressed? No 9 women were excluded.

All outcomes
Williams 1980
Participants 103 women (48 ambulant (25 primigravidae); 55 recumbent (30 primigravidae)).
Inclusion criteria - women in spontaneous labour with no risk factors.
Interventions Intervention group: ambulatory (n = 48).

Women were informed about the possible benefits of ambulation and were encouraged
to walk about during the first stage of labour

Williams 1980 (Continued)
Women who refused ambulation or who requested to return to bed were allowed to do
so.
Any woman who developed abnormalities of the fetal heart rate or fresh meconium
staining of the amniotic fluid was returned to bed
Women who requested or who were advised to have an epidural also returned to bed
but those requiring oxytocin augmentation of labour carried their intravenous infusions
with them.
Comparison group: recumbent (n = 55).

Type of delivery.
Analgesia.
Apgar score.
Notes
Risk of bias
Adequate sequence generation? No Described as ’divided into two groups according to their hospital
number’.
Allocation concealment? No See above.

Women

Clinical staff

Outcome assessor

All outcomes
AEA: ambulatory epidural analgesia

ARM: artificial rupture of the membranes
CSE: combined spinal epidural
G: gauge
IOL: induction of labour
Mins: minutes
mU: mlli-units
NICU: neonatal intensive care unit

Characteristics of excluded studies [ordered by study ID]
Ahmed 1985 Brief abstract, data for the single result presented were not in a form we were able use in the review.
Allahbadia 1992 Not clear that this was an RCT. States that ’patients were selected at random’ but it was not clear that
allocation to experimental and control groups was random.
Asselineau 1996 Not randomised.
Caldeyro-Barcia 1960 1. Observational - Not RCT.

2. Not all women were in the first stage of labour.
Cobo 1968 Intervention not relevant. Study examining lying on side versus lying on back.
Cohen 2002 No outcomes relevant to the review reported.
COMET 2001 The trial compared low-dose combined spinal epidural and low-dose infusion techniques and traditional
epidural techniques.
Danilenko-Dixon 1996 The purpose of this study was to compare cardiac output after epidural analgesia in both positions.
Diaz 1980 This study use quasi-randomised group allocation, but more than a third of the experimental group
were excluded from the analysis; women that did not comply with the protocol were excluded post
randomisation.
Divon 1985 No data relevant to the review were reported. Outcomes - BP, uterine work and beat to beat variability.
Ducloy-Bouthors 2006 Outcomes relevant to the review not reported
Hemminki 1983 In this study the comparison was between two management policies rather than two different treatments.
One group was nursed in bed and one group was encouraged to mobilise but there were also other differences
in the treatment the two groups received which may have had an effect on outcomes. Women nursed in
bed had routine amniotomy, women in the ambulant group did not; monitoring was also different in the
two groups. These differences in management mean that it is not possible to assess the effect of position
on outcomes.
Hemminki 1985 Compared ambulation with immediate oxytocin.
Hillan 1984 Only randomised for the second stage of labour.
Hodnett 1982 All bed care patients had an epidural and not all ambulant patients did.
Liu 1989 Intervention not relevant, study deals with the second stage of labour.
McCormick 2007 Study not completed - no results reported.

(Continued)
Melzack 1991 Cross-over design, no data reported for the first phase of the trial.
Molina 1997 Cross-over design, no data reported for the first phase of the trial.
Radkey 1991 Second stage of labour only.
Read 1981 Comparing ambulation with oxytocin.
Schmidt 2001 Does not fit primary objectives.
Schneider-Affeld 1982 No quantitative outcome data presented.
Solano 1982 Not randomised.
Wu 2001 Intervention not relevant to review outcomes. Study examining lying on one side rather than the other to
correct fetal malpresentation.
BP: blood pressure

RCT: randomised controlled trial

DATA AND ANALYSES
Comparison 1. Upright and ambulant positions versus recumbent positions and bed care
No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size
1 Duration of first stage of labour 9 1677 Mean Difference (IV, Random, 95% CI) -0.99 [-1.60, -0.39]
(hours): all women
1.1 Nulliparous women 8 927 Mean Difference (IV, Random, 95% CI) -0.97 [-1.96, 0.02]
1.2 Multiparous women 5 682 Mean Difference (IV, Random, 95% CI) -0.52 [-1.04, 0.00]
1.3 Mixed or unclear parity 1 68 Mean Difference (IV, Random, 95% CI) -2.60 [-4.11, -1.09]
2 Mode of birth: spontaneous 11 2217 Risk Ratio (M-H, Fixed, 95% CI) 1.01 [0.97, 1.05]
vaginal; all women
2.1 Nulliparous women 6 986 Risk Ratio (M-H, Fixed, 95% CI) 0.99 [0.93, 1.06]
2.2 Multiparous women 4 647 Risk Ratio (M-H, Fixed, 95% CI) 1.02 [0.99, 1.06]
2.3 Mixed or unclear parity 5 584 Risk Ratio (M-H, Fixed, 95% CI) 1.03 [0.94, 1.13]
3 Mode of birth: operative/ 10 2110 Risk Ratio (M-H, Fixed, 95% CI) 0.99 [0.78, 1.26]
assisted: all women
4 Mode of birth: caesarean section: 10 2110 Risk Ratio (M-H, Fixed, 95% CI) 0.73 [0.51, 1.07]
all women
5 Maternal satisfaction 0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
6 Maternal satisfaction 0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable
7 Maternal pain 5 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
7.1 Complaints of discomfort/ 2 230 Risk Ratio (M-H, Fixed, 95% CI) 1.21 [0.52, 2.81]
labour more uncomfortable
7.2 Requiring analgesia 4 1517 Risk Ratio (M-H, Fixed, 95% CI) 0.98 [0.93, 1.02]
8 Maternal pain 1 40 Mean Difference (IV, Fixed, 95% CI) 0.74 [-0.27, 1.75]
8.1 Comfort score 1 40 Mean Difference (IV, Fixed, 95% CI) 0.74 [-0.27, 1.75]
9 Analgesia type 8 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
9.1 Opioid 7 1681 Risk Ratio (M-H, Fixed, 95% CI) 0.97 [0.89, 1.06]
9.2 Epidural 8 1784 Risk Ratio (M-H, Fixed, 95% CI) 0.83 [0.72, 0.96]
9.3 Entonox 3 300 Risk Ratio (M-H, Fixed, 95% CI) 1.04 [0.74, 1.47]
10 Analgesia amount 1 40 Mean Difference (IV, Fixed, 95% CI) -17.5 [-36.89, 1.89]
10.1 Narcotics and other 1 40 Mean Difference (IV, Fixed, 95% CI) -17.5 [-36.89, 1.89]
analgesia
11 Duration of second stage of 2 1170 Mean Difference (IV, Fixed, 95% CI) 1.22 [-1.32, 3.75]
labour (minutes)
11.1 Nulliparous women 2 599 Mean Difference (IV, Fixed, 95% CI) 5.04 [-2.45, 12.53]
11.2 Multiparous women 2 571 Mean Difference (IV, Fixed, 95% CI) 0.72 [-1.97, 3.41]
12 Augmentation of labour using 7 1540 Risk Ratio (M-H, Fixed, 95% CI) 0.90 [0.77, 1.06]
oxytocin
13 Artificial rupture of membranes 3 216 Risk Ratio (M-H, Fixed, 95% CI) 1.34 [0.59, 3.04]
14 Hypotension requiring 0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
intervention
15 Estimated blood loss > 500 ml 1 40 Risk Ratio (M-H, Fixed, 95% CI) 0.33 [0.01, 7.72]
16 Perineal trauma 1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
16.1 Episiotomy 1 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
16.2 Second-degree tears 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
16.3 Third-degree tears 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
16.4 Any tear 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
17 Fetal distress (requiring 3 1307 Risk Ratio (M-H, Fixed, 95% CI) 0.54 [0.25, 1.18]
immediate delivery)
18 Use of neonatal mechanical 0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
ventilation
19 Apgar scores 6 679 Risk Ratio (M-H, Fixed, 95% CI) 0.70 [0.38, 1.28]
19.1 Apgar < 7 at 1 min 3 280 Risk Ratio (M-H, Fixed, 95% CI) 0.58 [0.30, 1.12]
19.2 Apgar < 7 at 5 mins 4 399 Risk Ratio (M-H, Fixed, 95% CI) 3.27 [0.34, 31.05]
19.3 apgar < 5 at birth 0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
20 Admission to NICU 1 196 Risk Ratio (M-H, Fixed, 95% CI) 1.56 [0.45, 5.37]
21 Perinatal mortality 1 1067 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
Comparison 2. Upright and ambulant positions versus recumbent positions or bedcare (with epidural: all women)
No. of No. of
1 Duration of first stage of labour: 3 433 Mean Difference (IV, Fixed, 95% CI) 14.14 [-15.23,
time of epidural insertion to 43.51]
complete cervical dilation
(minutes)
2 Mode of birth: spontaneous 5 1161 Risk Ratio (M-H, Fixed, 95% CI) 0.97 [0.89, 1.06]
vaginal
3 Mode of birth: operative 5 1161 Risk Ratio (M-H, Fixed, 95% CI) 1.16 [0.93, 1.44]
spontaneous/assisted
4 Mode of birth: caesarean section 5 1161 Risk Ratio (M-H, Fixed, 95% CI) 0.91 [0.70, 1.19]
5 Maternal satisfaction 0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
6 Maternal pain 1 505 Risk Ratio (M-H, Fixed, 95% CI) 0.88 [0.70, 1.11]
6.1 Requiring additional 1 505 Risk Ratio (M-H, Fixed, 95% CI) 0.88 [0.70, 1.11]
Bupivocaine bolus doses
7 Analgesia type 5 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
7.1 Opioid 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
7.2 Epidural 5 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
8 Analgesia amount 4 843 Mean Difference (IV, Fixed, 95% CI) -0.70 [-1.34, -0.06]
8.1 Bupivocaine 3 463 Mean Difference (IV, Fixed, 95% CI) -0.79 [-1.48, -0.09]
8.2 Ropivacaine 1 151 Mean Difference (IV, Fixed, 95% CI) 19.70 [0.77, 38.63]
8.3 Fentanyl 1 229 Mean Difference (IV, Fixed, 95% CI) -0.38 [-1.99, 1.23]
9 Duration of second stage of 2 204 Mean Difference (IV, Fixed, 95% CI) 2.35 [-15.22, 19.91]
labour (minutes)
10 Augmentation of labour using 5 1161 Risk Ratio (M-H, Fixed, 95% CI) 0.98 [0.90, 1.07]
oxytocin
11 Artificial rupture of membranes 0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
12 Hypotension requiring 3 781 Risk Ratio (M-H, Fixed, 95% CI) 1.12 [0.52, 2.45]
intervention
13 Estimated blood loss > 500 ml 0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
14 Perineal trauma 0 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
14.1 Episiotomy 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
14.2 Second-degree tears 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
14.3 Third-degree tears 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
15 Fetal distress (requiring 0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
immediate delivery)
16 Use of neonatal mechanical 0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
ventilation
17 Apgar scores 5 986 Risk Ratio (M-H, Fixed, 95% CI) 1.02 [0.39, 2.66]
17.1 Apgar < 7 at 1 min 1 151 Risk Ratio (M-H, Fixed, 95% CI) 1.01 [0.31, 3.36]
17.2 Apgar < 7 at 5 mins 4 835 Risk Ratio (M-H, Fixed, 95% CI) 1.04 [0.21, 5.05]
18 Admission to NICU 0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
19 Perinatal mortality 0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
Comparison 3. Standing and walking versus non-ambulant positions
No. of No. of
1 Duration of the first stage of 8 927 Mean Difference (IV, Random, 95% CI) -0.97 [-1.96, 0.02]
labour
1.1 Studies where ambulation 5 684 Mean Difference (IV, Random, 95% CI) -0.20 [-1.36, 0.96]
was encouraged
1.2 Studies where women 3 243 Mean Difference (IV, Random, 95% CI) -1.92 [-2.83, -1.01]
were not ambulant

Analysis 1.1. Comparison 1 Upright and ambulant positions versus recumbent positions and bed care,
Outcome 1 Duration of first stage of labour (hours): all women.
Review: Maternal positions and mobility during first stage labour
Comparison: 1 Upright and ambulant positions versus recumbent positions and bed care
Outcome: 1 Duration of first stage of labour (hours): all women
Study or subgroup Upright Recumbent Mean Difference Weight Mean Difference

N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
1 Nulliparous women
Haukkama 1982 13 10.2 (5.4) 12 8.9 (4.6) 2.0 % 1.30 [ -2.62, 5.22 ]
McManus 1978 10 10.5 (3.7) 10 10.5 (4.4) 2.3 % 0.0 [ -3.56, 3.56 ]
Williams 1980 25 7.9 (4.9) 30 7.4 (3.2) 4.5 % 0.50 [ -1.74, 2.74 ]
Chen 1987 22 3.25 (2.25) 38 4.23 (2.5) 8.0 % -0.98 [ -2.21, 0.25 ]
Andrews 1990 20 3.9 (1.5) 20 5.41 (1.5) 9.3 % -1.51 [ -2.44, -0.58 ]
Phumdoung 2007 40 3.54 (1.91) 43 6.33 (2.1) 9.6 % -2.79 [ -3.65, -1.93 ]
Mitre 1974 50 5.47 (1.71) 50 7.25 (1.64) 10.4 % -1.78 [ -2.44, -1.12 ]
Bloom 1998 272 7.6 (3.9) 272 7.3 (3.9) 10.4 % 0.30 [ -0.36, 0.96 ]
Subtotal (95% CI) 452 475 56.5 % -0.97 [ -1.96, 0.02 ]

Heterogeneity: Tau2 = 1.38; Chi2 = 40.85, df = 7 (P<0.00001); I2 =83%
Test for overall effect: Z = 1.93 (P = 0.054)
2 Multiparous women
Haukkama 1982 18 5.6 (3.8) 17 6.6 (4.1) 3.7 % -1.00 [ -3.62, 1.62 ]
Williams 1980 23 6.3 (2.9) 25 7.8 (5.4) 4.1 % -1.50 [ -3.93, 0.93 ]
McManus 1978 10 5.3 (1.4) 10 5.6 (2.1) 6.6 % -0.30 [ -1.86, 1.26 ]
Chen 1987 19 1.2 (0.75) 37 2.08 (1.08) 11.0 % -0.88 [ -1.36, -0.40 ]
Bloom 1998 264 4.6 (2.4) 259 4.7 (2.4) 11.3 % -0.10 [ -0.51, 0.31 ]
Subtotal (95% CI) 334 348 36.7 % -0.52 [ -1.04, 0.00 ]

Heterogeneity: Tau2 = 0.12; Chi2 = 6.73, df = 4 (P = 0.15); I2 =41%
3 Mixed or unclear parity
Flynn 1978 34 4.1 (3.17) 34 6.7 (3.17) 6.8 % -2.60 [ -4.11, -1.09 ]
Subtotal (95% CI) 34 34 6.8 % -2.60 [ -4.11, -1.09 ]

Heterogeneity: not applicable
Total (95% CI) 820 857 100.0 % -0.99 [ -1.60, -0.39 ]
-4 -2 0 2 4
Favours upright Favours recumbent

Outcome 2 Mode of birth: spontaneous vaginal; all women.
Outcome: 2 Mode of birth: spontaneous vaginal; all women
Study or subgroup Upright Recumbent Risk Ratio Risk Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 Nulliparous women
McManus 1978 5/10 5/10 1.00 [ 0.42, 2.40 ]
Williams 1980 17/25 21/30 0.97 [ 0.68, 1.39 ]
Chen 1987 22/22 30/38 1.25 [ 1.05, 1.49 ]
Miquelutti 2007 31/54 36/53 0.85 [ 0.63, 1.14 ]
Chan 1963 71/100 70/100 1.01 [ 0.85, 1.21 ]
Bloom 1998 232/272 236/272 0.98 [ 0.92, 1.05 ]
Subtotal (95% CI) 483 503 0.99 [ 0.93, 1.06 ]

Total events: 378 (Upright), 398 (Recumbent)
Heterogeneity: Chi2 = 7.94, df = 5 (P = 0.16); I2 =37%
2 Multiparous women
Williams 1980 23/23 25/25 0.0 [ 0.0, 0.0 ]
McManus 1978 10/10 9/10 1.11 [ 0.85, 1.44 ]
Chen 1987 18/19 36/37 0.97 [ 0.86, 1.10 ]
Bloom 1998 258/264 247/259 1.02 [ 0.99, 1.06 ]
Subtotal (95% CI) 316 331 1.02 [ 0.99, 1.06 ]

Heterogeneity: Chi2 = 1.00, df = 2 (P = 0.61); I2 =0.0%
Bundsen 1982 38/40 17/20 1.12 [ 0.92, 1.36 ]
Flynn 1978 32/34 23/34 1.39 [ 1.09, 1.78 ]
Haukkama 1982 27/31 24/29 1.05 [ 0.85, 1.30 ]
MacLennan 1994 64/96 72/100 0.93 [ 0.77, 1.12 ]
Calvert 1982 77/100 78/100 0.99 [ 0.85, 1.15 ]
Subtotal (95% CI) 301 283 1.03 [ 0.94, 1.13 ]

0.1 0.2 0.5 1 2 5 10

Favours recumbent Favours upright
(Continued . . . )

(. . . Continued)
Total (95% CI) 1100 1117 1.01 [ 0.97, 1.05 ]
0.1 0.2 0.5 1 2 5 10

Outcome 3 Mode of birth: operative/assisted: all women.
Outcome: 3 Mode of birth: operative/assisted: all women

1 Nulliparous women
McManus 1978 4/10 4/10 1.00 [ 0.34, 2.93 ]
Chen 1987 0/22 8/38 0.10 [ 0.01, 1.65 ]
Williams 1980 7/25 8/30 1.05 [ 0.44, 2.49 ]
Bloom 1998 21/272 15/272 1.40 [ 0.74, 2.66 ]
Chan 1963 21/100 21/100 1.00 [ 0.58, 1.71 ]
Subtotal (95% CI) 429 450 1.01 [ 0.72, 1.43 ]

2 Multiparous women
Williams 1980 0/23 0/25 0.0 [ 0.0, 0.0 ]
Chen 1987 1/19 1/37 1.95 [ 0.13, 29.45 ]
McManus 1978 0/10 1/10 0.33 [ 0.02, 7.32 ]
Bloom 1998 2/264 2/259 0.98 [ 0.14, 6.91 ]
Subtotal (95% CI) 316 331 0.91 [ 0.24, 3.49 ]
0.01 0.1 1 10 100

(Continued . . . )

(. . . Continued)
Haukkama 1982 4/31 3/29 1.25 [ 0.30, 5.10 ]
Bundsen 1982 2/40 3/20 0.33 [ 0.06, 1.84 ]
Flynn 1978 2/34 10/34 0.20 [ 0.05, 0.85 ]
Calvert 1982 18/100 15/100 1.20 [ 0.64, 2.25 ]
MacLennan 1994 26/96 21/100 1.29 [ 0.78, 2.13 ]
Subtotal (95% CI) 301 283 0.98 [ 0.70, 1.39 ]

Total (95% CI) 1046 1064 0.99 [ 0.78, 1.26 ]
0.01 0.1 1 10 100


Outcome 4 Mode of birth: caesarean section: all women.
Outcome: 4 Mode of birth: caesarean section: all women

1 Nulliparous women
Chen 1987 0/22 0/38 0.0 [ 0.0, 0.0 ]
Williams 1980 1/25 1/30 1.20 [ 0.08, 18.23 ]
McManus 1978 1/10 1/10 1.00 [ 0.07, 13.87 ]
Chan 1963 7/100 5/100 1.40 [ 0.46, 4.26 ]
Bloom 1998 19/272 21/272 0.90 [ 0.50, 1.64 ]
Subtotal (95% CI) 429 450 1.01 [ 0.61, 1.67 ]

2 Multiparous women
McManus 1978 0/10 0/10 0.0 [ 0.0, 0.0 ]
Williams 1980 0/23 0/25 0.0 [ 0.0, 0.0 ]
Chen 1987 0/19 0/37 0.0 [ 0.0, 0.0 ]
Bloom 1998 4/264 10/259 0.39 [ 0.12, 1.24 ]
Subtotal (95% CI) 316 331 0.39 [ 0.12, 1.24 ]

Flynn 1978 0/34 1/34 0.33 [ 0.01, 7.91 ]
Haukkama 1982 0/31 2/29 0.19 [ 0.01, 3.75 ]
Bundsen 1982 0/40 3/20 0.07 [ 0.00, 1.35 ]
MacLennan 1994 6/96 7/100 0.89 [ 0.31, 2.56 ]
Calvert 1982 5/100 7/100 0.71 [ 0.23, 2.18 ]
Subtotal (95% CI) 301 283 0.55 [ 0.29, 1.07 ]

0.01 0.1 1 10 100

(Continued . . . )

(. . . Continued)
Total (95% CI) 1046 1064 0.73 [ 0.51, 1.07 ]
0.01 0.1 1 10 100

Outcome 7 Maternal pain.
Outcome: 7 Maternal pain
Study or subgroup Upright Recumbent Risk Ratio Weight Risk Ratio

1 Complaints of discomfort/labour more uncomfortable

Chan 1963 8/100 0/100 5.9 % 17.00 [ 0.99, 290.62 ]
Haukkama 1982 2/17 7/13 94.1 % 0.22 [ 0.05, 0.88 ]
Subtotal (95% CI) 117 113 100.0 % 1.21 [ 0.52, 2.81 ]

2 Requiring analgesia
Broadhurst 1979 9/25 25/25 4.1 % 0.37 [ 0.22, 0.62 ]
Chan 1963 45/100 35/100 5.7 % 1.29 [ 0.91, 1.81 ]
Calvert 1982 98/100 98/100 15.9 % 1.00 [ 0.96, 1.04 ]
Bloom 1998 452/536 455/531 74.3 % 0.98 [ 0.94, 1.04 ]
Subtotal (95% CI) 761 756 100.0 % 0.98 [ 0.93, 1.02 ]

0.1 0.2 0.5 1 2 5 10


Outcome 8 Maternal pain.

N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Comfort score
Andrews 1990 20 12.53 (1.63) 20 11.79 (1.63) 100.0 % 0.74 [ -0.27, 1.75 ]
Total (95% CI) 20 20 100.0 % 0.74 [ -0.27, 1.75 ]

-10 -5 0 5 10
Outcome 9 Analgesia type.
Outcome: 9 Analgesia type

1 Opioid
McManus 1978 19/20 16/20 3.4 % 1.19 [ 0.93, 1.51 ]
Broadhurst 1979 9/25 18/25 3.9 % 0.50 [ 0.28, 0.89 ]
Haukkama 1982 16/31 21/29 4.7 % 0.71 [ 0.47, 1.07 ]
Flynn 1978 14/34 26/34 5.6 % 0.54 [ 0.35, 0.84 ]
MacLennan 1994 39/96 40/100 8.4 % 1.02 [ 0.72, 1.43 ]
Calvert 1982 73/100 73/100 15.7 % 1.00 [ 0.84, 1.18 ]
Bloom 1998 285/536 271/531 58.4 % 1.04 [ 0.93, 1.17 ]
Subtotal (95% CI) 842 839 100.0 % 0.97 [ 0.89, 1.06 ]

0.1 0.2 0.5 1 2 5 10

(Continued . . . )

(. . . Continued)
2 Epidural
McManus 1978 4/20 2/20 0.7 % 2.00 [ 0.41, 9.71 ]
Williams 1980 3/48 4/55 1.3 % 0.86 [ 0.20, 3.65 ]
Haukkama 1982 3/31 5/29 1.8 % 0.56 [ 0.15, 2.14 ]
Broadhurst 1979 0/25 7/25 2.6 % 0.07 [ 0.00, 1.11 ]
Flynn 1978 0/34 8/34 3.0 % 0.06 [ 0.00, 0.98 ]
Calvert 1982 16/100 22/100 7.7 % 0.73 [ 0.41, 1.30 ]
MacLennan 1994 43/96 52/100 17.9 % 0.86 [ 0.64, 1.15 ]
Bloom 1998 167/536 184/531 64.9 % 0.90 [ 0.76, 1.07 ]
Subtotal (95% CI) 890 894 100.0 % 0.83 [ 0.72, 0.96 ]

3 Entonox
McManus 1978 1/20 2/20 5.4 % 0.50 [ 0.05, 5.08 ]
Calvert 1982 18/100 13/100 35.4 % 1.38 [ 0.72, 2.67 ]
Haukkama 1982 20/31 21/29 59.1 % 0.89 [ 0.63, 1.26 ]
Subtotal (95% CI) 151 149 100.0 % 1.04 [ 0.74, 1.47 ]

0.1 0.2 0.5 1 2 5 10


Outcome 10 Analgesia amount.
Outcome: 10 Analgesia amount

1 Narcotics and other analgesia

Andrews 1990 20 21.25 (31.29) 20 38.75 (31.29) 100.0 % -17.50 [ -36.89, 1.89 ]
Total (95% CI) 20 20 100.0 % -17.50 [ -36.89, 1.89 ]

-100 -50 0 50 100

Outcome 11 Duration of second stage of labour (minutes).
Outcome: 11 Duration of second stage of labour (minutes)

1 Nulliparous women
Williams 1980 25 45 (34) 30 43 (21) 2.7 % 2.00 [ -13.30, 17.30 ]
Bloom 1998 272 60 (54) 272 54 (48) 8.7 % 6.00 [ -2.59, 14.59 ]
Subtotal (95% CI) 297 302 11.4 % 5.04 [ -2.45, 12.53 ]

2 Multiparous women
Williams 1980 23 17 (11) 25 14 (8) 21.3 % 3.00 [ -2.48, 8.48 ]
Bloom 1998 264 12 (18) 259 12 (18) 67.3 % 0.0 [ -3.09, 3.09 ]
Subtotal (95% CI) 287 284 88.6 % 0.72 [ -1.97, 3.41 ]

-50 -25 0 25 50
(Continued . . . )

(. . . Continued)
Total (95% CI) 584 586 100.0 % 1.22 [ -1.32, 3.75 ]
Test for subgroup differences: Chi2 = 1.13, df = 1 (P = 0.29), I2 =12%
-50 -25 0 25 50
Outcome 12 Augmentation of labour using oxytocin.
Outcome: 12 Augmentation of labour using oxytocin

Chen 1987 0/1 0/1 0.0 [ 0.0, 0.0 ]
McManus 1978 2/20 4/20 0.50 [ 0.10, 2.43 ]
MacLennan 1994 15/96 12/100 1.30 [ 0.64, 2.64 ]
Flynn 1978 6/34 12/34 0.50 [ 0.21, 1.18 ]
Haukkama 1982 20/31 19/29 0.98 [ 0.68, 1.43 ]
Miquelutti 2007 25/54 24/53 1.02 [ 0.68, 1.54 ]
Bloom 1998 122/536 137/531 0.88 [ 0.71, 1.09 ]
Total (95% CI) 772 768 0.90 [ 0.77, 1.06 ]

0.1 0.2 0.5 1 2 5 10


Outcome 13 Artificial rupture of membranes.
Outcome: 13 Artificial rupture of membranes

Chen 1987 41/41 75/75 0.0 [ 0.0, 0.0 ]
McManus 1978 20/20 20/20 0.0 [ 0.0, 0.0 ]
Haukkama 1982 10/31 7/29 1.34 [ 0.59, 3.04 ]
Total (95% CI) 92 124 1.34 [ 0.59, 3.04 ]

0.1 0.2 0.5 1 2 5 10

Outcome 15 Estimated blood loss > 500 ml.
Outcome: 15 Estimated blood loss > 500 ml

McManus 1978 0/20 1/20 100.0 % 0.33 [ 0.01, 7.72 ]
Total (95% CI) 20 20 100.0 % 0.33 [ 0.01, 7.72 ]

0.01 0.1 1 10 100


Outcome 16 Perineal trauma.
Outcome: 16 Perineal trauma

1 Episiotomy
Bloom 1998 122/536 124/531 0.97 [ 0.78, 1.21 ]
2 Second-degree tears
3 Third-degree tears
4 Any tear
0.01 0.1 1 10 100

Outcome 17 Fetal distress (requiring immediate delivery).
Outcome: 17 Fetal distress (requiring immediate delivery)

McManus 1978 0/20 1/20 8.5 % 0.33 [ 0.01, 7.72 ]
Chan 1963 4/100 4/100 22.8 % 1.00 [ 0.26, 3.89 ]
Bloom 1998 5/536 12/531 68.7 % 0.41 [ 0.15, 1.16 ]
Total (95% CI) 656 651 100.0 % 0.54 [ 0.25, 1.18 ]

0.01 0.1 1 10 100


Outcome 19 Apgar scores.
Outcome: 19 Apgar scores

1 Apgar < 7 at 1 min

Fernando 1994 2/20 2/20 1.00 [ 0.16, 6.42 ]
McManus 1978 0/20 2/20 0.20 [ 0.01, 3.92 ]
Calvert 1982 10/100 17/100 0.59 [ 0.28, 1.22 ]
Subtotal (95% CI) 140 140 0.58 [ 0.30, 1.12 ]

2 Apgar < 7 at 5 mins
Haukkama 1982 0/31 0/29 0.0 [ 0.0, 0.0 ]
Fernando 1994 0/20 0/20 0.0 [ 0.0, 0.0 ]
Williams 1980 1/48 0/55 3.43 [ 0.14, 82.25 ]
MacLennan 1994 1/96 0/100 3.12 [ 0.13, 75.75 ]
Subtotal (95% CI) 195 204 3.27 [ 0.34, 31.05 ]

3 apgar < 5 at birth
Subtotal (95% CI) 0 0 0.0 [ 0.0, 0.0 ]
Test for overall effect: not applicable
Total (95% CI) 335 344 0.70 [ 0.38, 1.28 ]
0.01 0.1 1 10 100


Outcome 20 Admission to NICU.
Outcome: 20 Admission to NICU

MacLennan 1994 6/96 4/100 100.0 % 1.56 [ 0.45, 5.37 ]
Total (95% CI) 96 100 100.0 % 1.56 [ 0.45, 5.37 ]

0.1 0.2 0.5 1 2 5 10

Outcome 21 Perinatal mortality.
Outcome: 21 Perinatal mortality

Bloom 1998 0/536 0/531 0.0 [ 0.0, 0.0 ]
Total (95% CI) 536 531 0.0 [ 0.0, 0.0 ]

Test for overall effect: Z = 0.0 (P < 0.00001)
0.1 0.2 0.5 1 2 5 10


Analysis 2.1. Comparison 2 Upright and ambulant positions versus recumbent positions or bedcare (with
epidural: all women), Outcome 1 Duration of first stage of labour: time of epidural insertion to complete
cervical dilation (minutes).
Comparison: 2 Upright and ambulant positions versus recumbent positions or bedcare (with epidural: all women)
Outcome: 1 Duration of first stage of labour: time of epidural insertion to complete cervical dilation (minutes)

Frenea 2004 25 239 (125) 28 199 (111) 21.1 % 40.00 [ -23.96, 103.96 ]
Collis 1999 110 414 (185) 119 433 (194) 35.8 % -19.00 [ -68.09, 30.09 ]
Vallejo 2001 75 240.9 (146.1) 76 211.9 (133.9) 43.1 % 29.00 [ -15.72, 73.72 ]
Total (95% CI) 210 223 100.0 % 14.14 [ -15.23, 43.51 ]

-100 -50 0 50 100

epidural: all women), Outcome 2 Mode of birth: spontaneous vaginal.
Outcome: 2 Mode of birth: spontaneous vaginal

Frenea 2004 19/30 23/31 6.2 % 0.85 [ 0.61, 1.20 ]
Vallejo 2001 51/75 56/76 15.3 % 0.92 [ 0.75, 1.13 ]
Collis 1999 59/110 64/119 16.9 % 1.00 [ 0.78, 1.27 ]
Karraz 2003 117/141 56/74 20.2 % 1.10 [ 0.94, 1.27 ]
Nageotte 1997 142/253 150/252 41.3 % 0.94 [ 0.81, 1.09 ]
Total (95% CI) 609 552 100.0 % 0.97 [ 0.89, 1.06 ]

0.1 0.2 0.5 1 2 5 10


epidural: all women), Outcome 3 Mode of birth: operative spontaneous/assisted.
Outcome: 3 Mode of birth: operative spontaneous/assisted

Frenea 2004 6/30 4/31 3.5 % 1.55 [ 0.49, 4.95 ]
Vallejo 2001 10/75 5/76 4.4 % 2.03 [ 0.73, 5.65 ]
Karraz 2003 11/141 6/74 6.9 % 0.96 [ 0.37, 2.50 ]
Collis 1999 36/110 39/119 33.1 % 1.00 [ 0.69, 1.45 ]
Nageotte 1997 70/253 59/252 52.2 % 1.18 [ 0.88, 1.59 ]
Total (95% CI) 609 552 100.0 % 1.16 [ 0.93, 1.44 ]

0.1 0.2 0.5 1 2 5 10


epidural: all women), Outcome 4 Mode of birth: caesarean section.
Outcome: 4 Mode of birth: caesarean section

Frenea 2004 5/30 4/31 4.2 % 1.29 [ 0.38, 4.35 ]
Vallejo 2001 14/75 15/76 16.0 % 0.95 [ 0.49, 1.82 ]
Collis 1999 15/110 16/119 16.5 % 1.01 [ 0.53, 1.95 ]
Karraz 2003 13/141 12/74 16.9 % 0.57 [ 0.27, 1.18 ]
Nageotte 1997 41/253 43/252 46.3 % 0.95 [ 0.64, 1.40 ]
Total (95% CI) 609 552 100.0 % 0.91 [ 0.70, 1.19 ]

0.1 0.2 0.5 1 2 5 10

epidural: all women), Outcome 6 Maternal pain.
Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio

1 Requiring additional Bupivocaine bolus doses

Nageotte 1997 85/253 96/252 100.0 % 0.88 [ 0.70, 1.11 ]
Total (95% CI) 253 252 100.0 % 0.88 [ 0.70, 1.11 ]

Total events: 85 (Treatment), 96 (Control)
0.01 0.1 1 10 100

Favours treatment Favours control

epidural: all women), Outcome 7 Analgesia type.
Outcome: 7 Analgesia type

1 Opioid
2 Epidural
Fernando 1994 20/20 20/20 0.0 [ 0.0, 0.0 ]
Frenea 2004 30/30 31/31 0.0 [ 0.0, 0.0 ]
Karraz 2003 141/141 74/74 0.0 [ 0.0, 0.0 ]
Nageotte 1997 253/253 252/252 0.0 [ 0.0, 0.0 ]
Vallejo 2001 75/75 76/76 0.0 [ 0.0, 0.0 ]
0.1 0.2 0.5 1 2 5 10


epidural: all women), Outcome 8 Analgesia amount.
Outcome: 8 Analgesia amount

1 Bupivocaine
Karraz 2003 117 27 (11) 56 23 (11) 3.3 % 4.00 [ 0.50, 7.50 ]
Frenea 2004 30 6.4 (2.2) 31 8.4 (3.6) 18.2 % -2.00 [ -3.49, -0.51 ]
Collis 1999 110 6.74 (2.74) 119 7.43 (3.46) 62.6 % -0.69 [ -1.50, 0.12 ]
Subtotal (95% CI) 257 206 84.2 % -0.79 [ -1.48, -0.09 ]

2 Ropivacaine
Vallejo 2001 75 118.7 (70.1) 76 99 (45.9) 0.1 % 19.70 [ 0.77, 38.63 ]
Subtotal (95% CI) 75 76 0.1 % 19.70 [ 0.77, 38.63 ]

3 Fentanyl
Collis 1999 110 17.38 (6.41) 119 17.76 (5.97) 15.7 % -0.38 [ -1.99, 1.23 ]
Subtotal (95% CI) 110 119 15.7 % -0.38 [ -1.99, 1.23 ]

Total (95% CI) 442 401 100.0 % -0.70 [ -1.34, -0.06 ]
Test for subgroup differences: Chi2 = 4.68, df = 2 (P = 0.10), I2 =57%
-100 -50 0 50 100


epidural: all women), Outcome 9 Duration of second stage of labour (minutes).
Outcome: 9 Duration of second stage of labour (minutes)

Frenea 2004 25 56 (42) 28 62 (59) 41.2 % -6.00 [ -33.36, 21.36 ]
Vallejo 2001 75 97.3 (76) 76 89.1 (67.3) 58.8 % 8.20 [ -14.71, 31.11 ]
Total (95% CI) 100 104 100.0 % 2.35 [ -15.22, 19.91 ]

-100 -50 0 50 100

epidural: all women), Outcome 10 Augmentation of labour using oxytocin.
Outcome: 10 Augmentation of labour using oxytocin

Frenea 2004 24/30 27/31 7.5 % 0.92 [ 0.73, 1.15 ]
Vallejo 2001 27/75 31/76 8.7 % 0.88 [ 0.59, 1.32 ]
Karraz 2003 65/141 35/74 13.0 % 0.97 [ 0.72, 1.32 ]
Collis 1999 75/110 83/119 22.5 % 0.98 [ 0.82, 1.16 ]
Nageotte 1997 173/253 171/252 48.4 % 1.01 [ 0.89, 1.14 ]
Total (95% CI) 609 552 100.0 % 0.98 [ 0.90, 1.07 ]

0.2 0.5 1 2 5

epidural: all women), Outcome 12 Hypotension requiring intervention.
Outcome: 12 Hypotension requiring intervention

Karraz 2003 0/141 0/74 0.0 [ 0.0, 0.0 ]
Nageotte 1997 2/253 4/252 0.50 [ 0.09, 2.69 ]
Frenea 2004 9/30 6/31 1.55 [ 0.63, 3.82 ]
Total (95% CI) 424 357 1.12 [ 0.52, 2.45 ]

0.1 0.2 0.5 1 2 5 10


epidural: all women), Outcome 17 Apgar scores.
Outcome: 17 Apgar scores

1 Apgar < 7 at 1 min

Vallejo 2001 5/75 5/76 1.01 [ 0.31, 3.36 ]
Subtotal (95% CI) 75 76 1.01 [ 0.31, 3.36 ]

2 Apgar < 7 at 5 mins
Fernando 1994 0/20 0/20 0.0 [ 0.0, 0.0 ]
Frenea 2004 0/30 0/31 0.0 [ 0.0, 0.0 ]
Collis 1999 2/110 1/119 2.16 [ 0.20, 23.53 ]
Nageotte 1997 1/253 2/252 0.50 [ 0.05, 5.46 ]
Subtotal (95% CI) 413 422 1.04 [ 0.21, 5.05 ]

Total (95% CI) 488 498 1.02 [ 0.39, 2.66 ]
0.01 0.1 1 10 100


Analysis 3.1. Comparison 3 Standing and walking versus non-ambulant positions, Outcome 1 Duration of
the first stage of labour.
Comparison: 3 Standing and walking versus non-ambulant positions
Outcome: 1 Duration of the first stage of labour
Study or subgroup Ambulant Non ambulant Mean Difference Weight Mean Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
1 Studies where ambulation was encouraged

Haukkama 1982 13 10.2 (5.4) 12 8.9 (4.6) 4.7 % 1.30 [ -2.62, 5.22 ]
McManus 1978 10 10.5 (3.7) 10 10.5 (4.4) 5.4 % 0.0 [ -3.56, 3.56 ]
Williams 1980 25 7.9 (4.9) 30 7.4 (3.2) 9.5 % 0.50 [ -1.74, 2.74 ]
Andrews 1990 20 3.9 (1.5) 20 5.41 (1.5) 15.8 % -1.51 [ -2.44, -0.58 ]
Bloom 1998 272 7.6 (3.9) 272 7.3 (3.9) 17.0 % 0.30 [ -0.36, 0.96 ]
Subtotal (95% CI) 340 344 52.5 % -0.20 [ -1.36, 0.96 ]

2 Studies where women were not ambulant
Chen 1987 22 3.25 (2.25) 38 4.23 (2.5) 14.3 % -0.98 [ -2.21, 0.25 ]
Phumdoung 2007 40 3.54 (1.91) 43 6.33 (2.1) 16.1 % -2.79 [ -3.65, -1.93 ]
Mitre 1974 50 5.47 (1.71) 50 7.25 (1.64) 17.0 % -1.78 [ -2.44, -1.12 ]
Subtotal (95% CI) 112 131 47.5 % -1.92 [ -2.83, -1.01 ]

Total (95% CI) 452 475 100.0 % -0.97 [ -1.96, 0.02 ]
-10 -5 0 5 10
HISTORY
Protocol first published: Issue 4, 2002
Review first published: Issue 2, 2009
11 November 2008 Amended Converted to new review format.

CONTRIBUTIONS OF AUTHORS
The text of the review was drafted by Lucy Lewis, Therese Dowswell and Annemarie Lawrence. Justus Hofmeyr and Cathy Styles
commented on drafts. Data extraction and data entry were carried out by Lucy Lewis, Therese Dowswell and Annemarie Lawrence.
DECLARATIONS OF INTEREST
None known.
SOURCES OF SUPPORT
Internal sources
• Griffith University, School of Nursing, Nathan Campus, Queensland, Australia.

• Centre for Clinical Studies - Women’s and Children’s Health, Mater Hospital, South Brisbane, Queensland, Australia.
• The University of Liverpool, UK.
• University of Adelaide, Australian Research Centre for Health of Women and Babies,Women’s and Children’s Hospital,
Adelaide, South Australia, Australia.
• James Cook University, School of Midwifery and Nutrition, Townsville, Queensland, Australia.
• University of Queensland, School of Nursing and Midwifery, Royal Brisbane and Women’s Hospital, Brisbane, Queensland,
Australia.
External sources
• Department of Health and Ageing, Commonwealth Government, Canberra ACT, Australia.

• National institute for Health Research, UK.
NIHR NHS Cochrane Collaboration Programme Grant Scheme award for NHS-prioritised centrally-managed, pregnancy
and childbirth systematic reviews: CPGS02
DIFFERENCES BETWEEN PROTOCOL AND REVIEW

The methods section has been updated to reflect changes in methods and software.
INDEX TERMS
Medical Subject Headings (MeSH)

Labor Stage, First [∗ physiology]; Posture [∗ physiology]; Randomized Controlled Trials as Topic; Supine Position [physiology]; Time
Factors; Walking [∗ physiology]

MeSH check words
Female; Humans; Pregnancy

Research
Lisa Hinton, Louise Locock and Marian Knight
Support for mothers and their families after

life-threatening illness in pregnancy and childbirth:
a qualitative study in primary care
INTRODUCTION may have lost their baby as a result of

Abstract It is estimated that for every 100 women their illness. Babies delivered preterm may
giving birth in the UK, there will be one need to spend long periods in neonatal
Background woman experiencing a near miss: an intensive care. These experiences are a long
One in 100 women who give birth in the UK
develop life-threatening illnesses during obstetric complication requiring urgent way away from normal birth and physical
childbirth. Without urgent medical attention live-saving medical care.1 Potentially 8000 and psychological follow-up from hospitals
these illnesses could lead to the mother’s women and their families each year have varies around the country.
death. Little is known about how the experience The aim of this study was to explore
to cope with a life-threatening emergency
of severe illness in childbirth affects the
mother, baby, and family. and its aftermath. The causes of these near the long-term impact of a near-miss
misses are varied but include pre-eclampsia, obstetric emergency. The study examines
Aim specifically the primary care support and
As part of the UK National Maternal Near-miss
haemorrhage, thrombosis, and sepsis, and
Surveillance Programme, this study explored the may in some cases require an emergency services women may need after discharge.
experiences of women and their partners of life- hysterectomy or preterm delivery. Mother It was not possible to find any previous work
threatening illnesses in childbirth, to identify the and newborn are often separated because that has directly addressed this issue. The
long-term impact on women and their families.
women may have to spend time in intensive study draws on qualitative interviews with
Design and setting care or a high-dependency unit. Their babies women and their partners who experienced
Qualitative study based on semi-structured may be born prematurely and require a near-miss event in childbirth in the UK as
narrative interviews. Interviews were conducted
in patients’ homes in England and Scotland neonatal intensive care. part of the National Maternal Near-miss
from 2010 to 2014. Recent studies draw attention to the Surveillance Programme.
potential for long-term psychological
Method
An in-depth interview study was conducted with and emotional impact on women of METHOD
36 women and 11 partners. A maximum variation maternal morbidities.2–6 In addition to their Women who experienced a life-threatening
sample was sought and interviews transcribed for physical recovery, women can experience complication in pregnancy (defined as
thematic analysis with constant comparison.
anxiety, isolation, and flashbacks in the ‘severe maternal illnesses which, without
Results aftermath. Birth trauma can have lasting urgent medical attention, would lead to a
Women’s birth-related illnesses often had long- consequences that impact negatively on mother’s death’)9 were invited to take part
lasting effects on their mental as well as physical
health, including anxiety, panic attacks, and
maternal, infant, and family wellbeing.7 in an interview study. The women’s partners
post-traumatic stress disorder. In some cases Medically-complicated pregnancies can were also invited.
the partner’s mental health was also affected. impact negatively on breastfeeding rates.3,8
Women often described feeling isolated. Their Women may be discharged from hospital Sample
experiences can have a profound impact on their
relationships, family life, career, and future fertility.
having had major surgery and emergency It was aimed to include a maximum variation
While some women described receiving good treatment or time in intensive care. Some sample of women living in the UK,10,11
support from their GP, others felt there was little
support available for them or their families after
discharge from hospital.
L Hinton, BA, DPhil, senior qualitative researcher, Address for correspondence
Conclusion Health Experiences Research Group, Nuffield Lisa Hinton, Health Experiences Research Group,
A near-miss event can have long-lasting and Department of Primary Care Health Sciences, Nuffield Department of Primary Care Health
major effects on women and their families. Medical Sciences Division, University of Oxford, Sciences, Medical Sciences Division, Gibson
Support in primary care, including watchful Oxford. L Locock, BA, MPhil, PhD, associate Building, 1st Floor, Radcliffe Observatory Quarter,
waiting for mental health impacts, can play a professor and director of applied research, Health Woodstock Road, Oxford OX2 6GG, UK.
valuable role in helping these families come Experiences Research Group, Nuffield Department
E-mail: lisa.hinton@phc.ox.ac.uk
to terms with their emergency experience. of Primary Care Health Sciences, Medical Sciences
The findings highlight the importance of Submitted: 13 April 2015; Editor’s response:
Division, University of Oxford, Oxford and NIHR
communication between primary and Oxford Biomedical Research Centre, Oxford. 11 May 2015; final acceptance: 11 June 2015.
secondary care. M Knight, MA, MPH, DPhil, FFPH, FRCPE, ©British Journal of General Practice
professor of maternal and child population health, This is the full-length article (published online
Keywords National Perinatal Epidemiology Unit, Nuffield 1 Sep 2015) of an abridged version published in
childbirth; maternal illness; primary care; Department of Population Health, University of print. Cite this article as: Br J Gen Pract 2015;
qualitative; support.
Oxford, Oxford. DOI: 10.3399/bjgp15X686461
e563 British Journal of General Practice, September 2015

Not all those who volunteered were
How this fits in? interviewed, but the authors sought to
ensure that a representative range of
One in 100 women who give birth in the UK conditions and times since the event were
develop life-threatening illnesses during
included, to understand the longer-term
childbirth. Without urgent medical attention
these illnesses could lead to the mother’s effects of a near-miss event. Although the
death. Research into the long-term impact sample included more interviewees from
of these experiences indicates that they professional classes than others, it does
have long-lasting effects on women’s represent a broad socioeconomic diversity.
mental as well as physical health, and
impact their families. Support in primary Interviews
care can play a valuable role in helping
Interviews took place between 2010 and
these families come to terms with their
emergency experience.
2014. After obtaining informed consent, one
of the authors interviewed participants in the
setting of their choice (usually their home).
Participants were asked about their or their
covering a wide range of conditions, based partner’s experiences of pregnancy and life-
on the principal causes of direct maternal threatening illness. The interview started
with an open-ended narrative section where
deaths identified in recent (2011) maternal
responders described what had happened,
death enquiry reports (Table 1).12 The overall
followed by a semi-structured section with
sample included 36 females, and 10 male
prompts to explore any relevant issues
and one female partner (Table 2).
that had not already emerged, including
Recruitment packs were distributed
their recovery and family life since their
through a number of routes to ensure a near miss. The interviews were all audio or
wide, varied sample; routes included support videotaped (to allow for dissemination on
groups, the National Childbirth Trust, social the website Healthtalk.org), and transcribed
network forums (Mumsnet and Netmums), verbatim.
a metropolitan newspaper advertisement,
intensive care clinicians contacted through Analysis
the Intensive Care National Audit and The transcripts were read and re-read, a
Research Centre, advertisement in the UK coding frame was constructed and the data
Obstetric Surveillance System newsletter, coded. Anticipated and emergent themes
and word of mouth. To try and reach a wider were then examined across the whole
ethnic minority population, recruitment data set as well as in the context of each
packs were translated into Bengali and person’s interview. A qualitative interpretive
distributed through a consultant in an approach was taken, combining thematic
east London hospital. A British Somali analysis with constant comparison.13,14
interviewee was recruited through a local NVivo (version 9) was used to facilitate the
women’s support group. analysis.
The analysis presented here focuses
on how responders described their
Table 1. Conditions experienced by participants experiences after discharge from hospital
and particularly their needs for primary
Conditiona n (Partner, n) care support.
Uterine rupture 4 (2)
RESULTS
Haemorrhage 5 (2)
The women in the study had spent
Haemorrhage and hysterectomy 9 (2)
varying amounts of time in hospital as
Placenta praevia 3 (1) a consequence of their life-threatening
Placenta percreta 2 illnesses. In addition to their physical
Placental abruption 1 (1) recovery, they described the emotional
Amniotic fluid embolism 3 (2)
impact of their emergency and the
challenges of settling back to normal
Pulmonary embolism 5 (1)
life. There was often no follow-up, either
Pre-eclampsia 3 physical or psychological, from hospital so
HELLP syndrome 2 (1) GPs were in the front line, caring for and
Septicaemia 2 supporting women and their families.
Other, for example appendicitis or failed intubation 4 (1)
Isolation
a
Some women had multiple morbidities and appear in more than one category. HELLP = H (haemolysis) EL (elevated
liver enzymes) LP (low platelet count).
Women described the difficulties they
faced settling back into their social
British Journal of General Practice, September 2015 e564

relationships with family, friends, and their For first-time mothers this was particularly
local community. They often felt isolated; challenging. They felt excluded from normal
physically isolated because they were not support routes such as postnatal groups, or
well enough to get out to see people and local playgroups:
unable to link with normal post-delivery
support networks that other mothers could ‘I think one of the hardest things was I
access. Emotionally, women often found it felt very alienated from my peers at the
hard to relate to others who had no idea of time ... And it didn’t take long before I
the trauma they had experienced and how distanced myself quite quickly. I felt very
long recovery might take. bitter, very uncomfortable being round
One woman felt that her family and people who seemingly had it so easy.’ (Cara,
friends quickly forgot what she had been 29, hysterectomy with her first child)
through (please note: the ages of the study
participants listed after the quotes reflect ‘Well, I would have silenced the group if I
their age (years) at time of illness, not at had even mentioned any of it. So the kind
interview): of things that they were mentioning that
were bothering them, I was just thinking, try
‘As soon as I came out they didn’t care. dying in childbirth, you know, I felt like I was
That’s when I really needed my friends. so out of, out of kilter with their experiences.
That’s when I needed people to be there So the things that were bothering me were
for me.’ (Anna, 29, in intensive care with so extreme that there wasn’t a forum for
septicaemia and needed a hysterectomy) me to discuss it.’ (Paula, 43, amniotic fluid
embolism)
In particular, women felt isolated from
other new mothers because their birth ‘It’s a really hard thing to describe, but you
experience had been such a traumatic event, almost feel excluded by the fact that you’ve
which they did not feel they could share. had such a major event that you don’t
want to always be coming in and saying,
“Well, hey, I had the worst scenario”.’
(Karen, 42, postpartum haemorrhage and
Table 2. Sociodemographic characteristics of participants (n = 47) hysterectomy)
Characteristic n
Physical recovery
Age at the time of interview, years Women’s experiences were very varied,
21–30 3 due to the wide range and severity of their
31–40 31
illnesses and how long they had been
≥40 13
hospitalised. Several had undergone major
Age at time of near miss event, years surgery (for example, a hysterectomy, a
21–30 11 much more substantial operation than a
31–40 31
caesarean section), and 18 had spent some
≥40 5
time in high dependency or critical care.
Sex Women were often very physically weak,
Female (mothers) 36
and felt bed or wheelchair-bound, when
Male or female (partners) 11 (10 male, one female partner)
discharged. Those who had had abdominal
Occupation surgery (caesarean or hysterectomy) were
Professional 21
still in pain, which took several weeks to
Other non-manual 13
subside:
Skilled manual 4
Unskilled manual 2
Other, such as housewife or student 7 ‘Very, very tired. Really, really tired. Tired
and sore.’ (Karen, 42, hysterectomy)
Ethnic group
White British 42
British Pakistani 1
Responder (R):‘I couldn’t move. I couldn’t
White Australian 2 straighten myself up. It was an effort to
White Israeli 1 go upstairs to the toilet. I couldn’t cook. I
British Somali 1 couldn’t hold the babies. My son was only
Time since near miss, years four and then obviously the middle one
<1 9 now, he was only 11 month old. He wasn’t
1–2 16 walking. I couldn’t pick him up and it was
2–5 16 like that for at least a week. I was basically
5–9 4 just stuck on the couch.’
≥10 2 Interviewer:‘Okay and did you recover
physically quite quickly?’

R:‘ [um] No, because I was going to the There was variation in when women and
hospital twice a day to see the baby and men first experienced anxiety, depression,
spending a lot of hours there.’ (Kerry, 25, or PTSD, how severe it was, and how long
placenta praevia) it took to recover. Lisa, 35, was interviewed
a year after her daughter was born. She
A common frustration for women was not described a very difficult year as she
being able to look after their children: experienced anxiety and panic attacks. But
felt she was getting over it and starting to
‘I was on a zimmer frame to start off with, feel a lot better: ‘I want to move on now’.
to keep my balance and ... and then I had
crutches to go home with. [um] And that Cara, 29, said she was ‘very depressed
was a whole new challenge, because it was, and manic about my research into what had
it was relief to be around my children, but happened’, in the first year, but each year
being around them and not being Mum, not got easier. But for some, their child’s first
really being Mum. That was hard, you know.’ birthday, marking the anniversary of their
(Anna, age 21: sepsis and hysterectomy) trauma, stirred emotions:
Although most women made a good ‘It was actually a year after that I felt that
recovery, it often took weeks or months. I needed more help. [um] But I think that
Scarring can be a problem for some women it just brought feelings out that I’d, I’d just
who have had life-threatening complications. bottled them up. I’d kind of packaged them
Both frightening and emotionally upsetting, away and said, that dealt with, and I hadn’t
it could also result in ongoing physical worked through my feelings, I’d just pushed
problems. Several women were dismayed them to one side and said, I don’t, that’s
as they realised they were going to be less fine, that’s okay. [um] Put a smiley face
fit for the rest of their lives. One woman on and got on with it. [laughs] [um] And it
developed long-term digestive problems worked short term, but then it came back
caused by her internal scar tissue: to bite me when I was least expecting it as
well actually and so I struggled quite a lot
‘It is a very odd thing, you catch yourself around his birthday.’ (Alison, 30, postpartum
thinking, oh now I’ve become someone who haemorrhage and hysterectomy)
is going to be less well for the rest of my
life, and that is a weird feeling.’ (Hannah, 34, Some were offered counselling through
uterine rupture) the hospital, GP, or health visitor. Some
sought counselling themselves. While some
Emotional recovery did not find it very helpful, many did. Others
Finding out what had happened, and coming wanted counselling but were not offered
to terms with the seriousness of their illness, any. There was great variation in when the
was often emotionally difficult for women. women felt ready to talk: some quite soon,
There was great variation in how these others not for a few months or even over
traumatic events affected people. Some felt a year.
it did not affect their mental health, but
others did, and described anxiety, panic Long-lasting effects
attacks, flashbacks, and post-traumatic While some women seemed resilient and
stress disorder (PTSD) in the aftermath of their emergency experience did not appear
their experiences. Partners could experience to have long-lasting effects on them or their
these, as well as the women. families, others were more affected.
Debbie had a uterine rupture and
was advised that she needed to seek Future pregnancy or fertility. Life-
psychological help: threatening emergencies could have
a profound impact on a woman’s fertility
‘”Because you’ve gone through trauma”. and future pregnancies. Some women had
And she actually said, “If you’re in a car hysterectomies to save their lives. While
crash nobody expects you just to get up on some did not feel this was a big issue if their
your feet again and carry on as normal, as families were complete, for others this was
soon as you’re physically healed, you know, devastating.
there’s issues you need to talk about and Several women need help weighing up
fears.” And she said, “There’s no difference the risks of another pregnancy, either with
here with you. You’ve gone something their GP or a consultant. Some women
very traumatic, and you should speak to were still potentially able to get pregnant,
somebody about it, if you’re not quite ready but were advised against it by doctors
to move on".' (Debbie, 29, uterine rupture) because the risks were too high.

Helen had HELLP syndrome with her Hanna had been in hospital for
first baby (HELLP is a complication of pre- several weeks with pre-eclampsia and a
eclampsia characterised by haemolysis, haematoma. When discharged, she was
elevated liver enzymes, and low platelets): frightened and told to contact her GP who
was reassuring and helpful, checking her
‘But the thing that worries me now, is that if bloods:
we want to have another child, [um] they’ve
said that the risk of it happening again is ‘ [S/He] called me at home to say,
20–30% which is much higher than what “Everything is fine. Don’t worry ... it’ll be
I’d like. And that’s the thing that concerns fine.” So for 2 weeks I was in contact with
me more now, that I know what it was and my GP and they really, really took care of
what we went through.’ (Helen, 31, HELLP me.’ (Hanna, 37, pre-eclampsia)
syndrome)
Lack of support. However, several women
Other family members. In terms of their were surprised there was no communication
relationships, many felt their experiences between the hospital and GP, who seemed
had made them stronger and brought them to have no idea what had happened. Some
closer. For others, staying together after women felt there was very little support for
such a traumatic event was challenging, them after discharge from hospital.
and some relationships did not survive the Rob’s wife had placenta praevia and a
experience. In terms of the wider family, hysterectomy. He went on to develop PTSD
there was a range of views. Some felt their himself. Rob felt their GP was ‘worse than
emergency had had a profound effect on useless’ and as a family they were left with
their children, while others felt it had little little support. Lack of support may affect
impact or even improved their relationships how women and their families recover.
with them. Sophie and Tom struggled after she had a
pulmonary embolism and haemorrhage.
Support They were told there was no help available
Women’s experience of support varied. for her after she was discharged and
Some felt that the support from their local at home looking after her newborn and
GP and health visitors was excellent, while toddler:
others would have liked more support after
such a traumatic time in hospital. ‘And I couldn’t understand that, because
I was still at risk. I still had a pulmonary
Examples of good care. Several women felt embolism. And I said, “Well what happens
they had very good care and support after if I’m on my own with the girls and I have
discharge. Women appreciated GPs who a heart attack? Is there anything that we
were in touch and reassuring, and midwives can do to reduce the impact on them if that
and health visitors who were aware of what were to happen?” And they just came up
they had been through and visited regularly. with nothing really.’ (Sophie, 36, pulmonary
Knowing that support was available from embolism and haemorrhage)
their GP made a real difference to women:
Some women described putting on a brave
‘She’s been in constant contact with us. If I face and this may have contributed to them
do need to have a chat and things I can go not getting the support that they needed.
and speak to her … I trust her 101%. She’s Joanna said her GP was very supportive but
just there, they’re just available.’ (Naomi, she often put on a front when seeing him,
35, emergency caesarean and Ogilvie so perhaps he was not aware how much
syndrome) the death of her baby had affected her. Ciara
and Michelle were asked to complete the
Kerry had panic attacks and anxiety after Edinburgh Postnatal Depression Scale with
her haemorrhage. Her GP was very patient, their health visitor, but said it was easy to
offering support and referral to counselling: know what the right answers were so as to
appear as if they were fine.
‘He was really patient, because I did
keep going back. I thought I had illness DISCUSSION
after illness. The words that he used did Summary
calm me down a lot ... Because I was so This study demonstrates the profound
frightened that I was going to die after long-term impact a near miss in childbirth
that. I always thought I had something life can have on new mothers. Their physical
threatening.’ (Kerry, 25, placenta praevia recovery could take a long time, and women
and haemorrhage) were often not able to look after their babies

as they wished in the early days. Emotional abilities to cope, the most effective ways of
recovery was often difficult, with some providing psychological help are not clear.16
women reporting anxiety, panic attacks, The literature surrounding PTSD after
flashbacks, and PTSD. Long-lasting effects childbirth is sparse and the authors are not
after discharge from hospital included fears aware of any research on how to support
about future fertility and pregnancies, social women and their families after a near miss.
isolation, and lack of support. Other family While studies have highlighted the potential
members were also potentially affected. long-term impact of a traumatic birth,7 there
Several women received very good care is little conclusive evidence on the best
and support after discharge, demonstrated way to support women and their families.
by GPs being in touch and reassuring, and While several studies have suggested the
midwives and health visitors being aware of importance of social support and community
what had happened and visiting regularly. resources in supporting women after a birth
There is already some follow-up in place trauma,17 the women who have experienced
in the NHS; currently after discharge most a near miss often appear to be unable to
women are visited by a midwife and then access standard support due to feeling their
a health visitor who usually carry out a experiences are so extreme or different to
postnatal depression screen. However, the norm. In addition, systematic reviews
this study highlights the importance of have shown that evidence for midwifery-
communication between primary and based counselling or formal postnatal
Funding secondary care, and demonstrates that debriefing interventions to effectively
knowing proactive support was available address mental health problems (including
This article presents independent research
from their GP team made a real difference PTSD) is inconclusive.18–20 However, Rowan
funded by the National Institute for Health
to women. et al19 suggested offering women the
Research (NIHR) under the ‘Beyond
opportunity to talk and the importance of
maternal death: improving the quality of
Strengths and limitations health professionals being alert to the signs
maternity care through national studies of
There are limitations to this study. The data and symptoms of mental health problems
near miss maternal morbidity’ programme presented are based on interviews with after childbirth.
(Programme Grant RP-PG-0608-10038). 36 women and 11 partners, and as with
The views expressed in this publication are qualitative studies aiming for a maximum Implications for research and practice
those of the author(s) and not necessarily variation sample, the findings are not There has been little research on the long-
those of the NHS, the NIHR, or the intended to be numerically representative. term impact of traumatic birth and how
Department of Health. The funders had no However, the sample was large enough to best to help women. There is inconclusive
role in the study design, data collection and reach data saturation and included good evidence on the impact of debriefing
analysis, decision to publish, or preparation variation in socioeconomic mix. Participants programmes. However, we know that
of the manuscript. were mostly of white British origin and those most likely to be well after childbirth
Ethical approval despite inclusion of women from Pakistani are women who had no complications, no
Ethics committee approval was given for this and Somali backgrounds, the ethnic diversity worries about their labour and birth, and
study by the Berkshire Ethics Committee, in the sample is not as wide as it might be. are given information about their choices
09/H0505/66. All participants gave informed While no account is static — people’s views for care.21
consent before taking part and have given and interpretation of their experiences are Women who experience a near miss
written consent to their interview data being likely to change over time — an effort was have had none of these. For them, there is
included in publications. made to interview individuals who were often no follow-up from hospital obstetric or
both close to events as well as those who midwifery staff. Primary care teams should
Provenance were talking about experiences that had be made routinely aware if a woman has
Freely submitted; externally peer reviewed. happened several years previously. had a near miss so that they can offer the
Competing interests support these women may need, and be
Comparison with existing literature aware that these new mothers may be
The authors have declared no competing
There are relatively few studies worldwide isolated from their peers and therefore
interests.
that have reported on the impact of life- potential support networks. GPs and
Open access threatening conditions in childbirth. The health visitors should be alert for mental
This article is Open Access: CC BY 3.0 license current study’s findings resonate with health problems developing, mindful of the
(http://creativecommons.org/licenses/ others reporting emotional trauma and impact that the near-miss experience can
by/3.0/). long-lasting effects.2,4–6,15 While there is have on the whole family (including the
agreement that traumatic events (outside woman’s partner and other children), and
Acknowledgements
of childbirth) can have significant impact be prepared to offer advice about future
The authors thank all the participants who on individuals’, families’, and communities’ pregnancies.
agreed to contribute their interviews to this
research.
Discuss this article
Contribute and read comments about this
article: bjgp.org/letters

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Complementary Therapies in Clinical Practice 35 (2019) 224–231
Contents lists available at ScienceDirect
Complementary Therapies in Clinical Practice

journal homepage: www.elsevier.com/locate/ctcp
Emotional freedom techniques and breathing awareness to reduce childbirth T

fear: A randomized controlled study
Pınar Irmak Vurala,∗, Ergül Aslanb
a
Istanbul Medipol University, Health Science Faculty, Department of Nursing, Ekinciler Street Nu.19 Kavacık, Beykoz, 34810, Istanbul, Turkey
b
Istanbul University-Cerrahpasa, Florence Nightingale Faculty of Nursing, Department of Women Health and Gynecologic Nursing, Abide-i Hürriyet Street, 34381, Şişli,
Istanbul, Turkey
ARTICLE INFO ABSTRACT
This research was presented and received the Background: Emotional freedom techniques (EFT) and breathing awareness (BA) are applicable during labour.
fourth prize in oral presentation at I. The present study aimed to determine the effectiveness of EFT and BA in the reduction of childbirth fear.
International and II. National Women's Health Materials and methods: This randomized controlled study included 120 pregnant women, of whom the EFT, BA
Nursing Congress in Istanbul, Turkey. and control groups. The women in the EFT and BA groups were offered their intervention in the latent, active
Keywords: and transition phases of labour.
Breathing awareness Results: There was no significant difference in the sociodemographic and obstetric factors between the groups
Childbirth fear (p > 0.05). The Subjective Units of Distress Scale in active and transition phases were significantly lower in the
Emotional freedom techniques
EFT group. The difference in the scores for the Wijma Delivery Expectancy/Experience Questionnaire (version B)
Labour
between the groups was significant (p < 0.001).
Conclusion: Both EFT and BA were observed to be beneficial in clinical practice; the EFT was found to be more
effective and permanent.
1. Introduction adaptation to motherhood roles and mother-infant attachment [1,5].

Increasing the self-confidence of women during labour is effective in
Complex feelings experienced in the first trimester of pregnancy are creating positive labour experiences and has a positive influence on a
affected by many factors and replaced by childbirth fear in the second woman's adaptation to motherhood [6].
and third trimesters. Childbirth fear can be a result of biological, psy- It has been reported that the prevalence of childbirth fear is 10%
chological and social factors. Prior obstetric and gynaecological ex- and is higher in the nullipara [7–9]. There have been various attempts
periences, fear of inability to give birth and to cope with pain and to reduce this fear, such as psychoeducation, relaxation techniques and
various psychosocial factors may create childbirth fear in pregnant hypnosis, which have been shown to reduce fear [10–12].
women [1]. Severe fear, especially in the third trimester, leads to an- Emotional Freedom Techniques (EFT) is a psychophysiological in-
xiety about the possibility of pain and stress during labour [2]. tervention that combines elements of cognitive behavioral therapy
If the primary cause of fear is not solved, the defense mechanism of (CBT), exposure therapy and somatic stimulation using acupressure
the body is activated. The symphatic nervous system starts to function, points. Because of this acupressure element, EFT is called “tapping”.
which causes the release of stress hormones and activates various me- The basic EFT protocol has been published as a simplified form of
chanisms of vasoconstriction [3]. Having fear and anxiety during labour thought field therapy [13,14]. Acupoint stimulation in EFT protocols
increases the secretion of stress hormones, such as cethacholamines breaks the cycle of sympathetic nervous system hyperarousal more
(adrenaline and noradrenaline) [4]. Excessive release of cortisol in the rapidly than other forms of desensitization, thus allowing for faster
presence of stress affects the secretion of oxytocin, which initiates la- symptom reduction, and it may also be beneficial for physical health
bour. As a result, labour becomes longer, the mother and the baby may [15]. The manualized, evidence-based expression of the method is de-
get tired, and lactogenesis is affected, which causes delayed lactation fined as “Clinical EFT” [16]. This method can be safely applied to all
and reduces the frequency of breastfeeding [5]. The hormone cortisol age groups, including the elderly, pregnant women and children. Stu-
can predispose to maternal and neonatal complications, emergency dies have cited hundreds of available EFT applications. Some of these
ceaserian section, postpartum emotional problems and difficulty in studies are randomized controlled studies, and positive results have
∗
Corresponding author.
E-mail addresses: pvural@medipol.edu.tr (P. Irmak Vural), ergul34tr@hotmail.com (E. Aslan).
https://doi.org/10.1016/j.ctcp.2019.02.011
Received 30 May 2018; Received in revised form 14 February 2019; Accepted 14 February 2019
1744-3881/ © 2019 Elsevier Ltd. All rights reserved.
P. Irmak Vural and E. Aslan Complementary Therapies in Clinical Practice 35 (2019) 224–231
Fig. 1. CONSORT flow diagram.
been obtained with clinical measurements [17]. EFT can be used in contribute to an increased level of fatigue and thus may result in ma-
many areas, such as for addiction, anger, sexuality, anxiety, beliefs, ternal dissatisfaction. The use of breathing patterns during labour
grief, confidence, death, forgiveness and creativity. It can produce po- should be recommended with caution, respecting patients' preferences
sitive effects and has no reported side effects so far [18]. In addition, it [26].
has been found that EFT is as effective as cognitive behavioral therapies There have been very few studies on the best ways for pregnant
in studies of depression, post-traumatic stress disorder (PTSD) and an- women to cope with childbirth fear. The present study focused on ex-
xiety in the clinical application of EFT in meta-analysis studies [19–21]. amining the effects of EFT and BA on reducing the fear felt by pregnant
Solving emotional problems by using EFT before labour empowers women during labour.
pregnant women to cope with fear and other negative situations during
labour. It can be implemented safely and effectively to help decrease 2. Materials and methods
pain during labour and to shorten the duration of labour [22].
Breathing awareness (BA) can provide physical, mental and emo- 2.1. Study design
tional control. Because deep breathing increases blood circulation and
oxygen flow and decreases stress, both mothers and their babies benefit This is an experimental, randomized, controlled study. It was con-
from it. If pregnant women learn about breathing awareness, they have ducted according to the CONSORT guidelines [27,28]. The study was
a calmer and more comfortable labour experience [23]. Slow and deep performed in the obstetric ward of an university hospital between April
breathing can help pregnant women to control themselves when uterine 2016 and May 2017. In 2016, 1417 vaginal births occurred in the
contractions start [24]. This maintains the well-being of the foetus and hospital. In each labour room, there is a bathroom, a toilet, a sofa for a
facilitates labour. BA allows pregnant women to manage their re- caregiver, a television, a refrigerator and a wardrobe. A female care-
spiratory muscles and control their pain and relaxation and increases giver can stay with a pregnant woman, and the pregnant woman can
their self-confidence [25]. Using complex breathing patterns may force walk in the suite and the corridor comfortably, have a shower when she
the woman to recruit accessory breathing muscles, which may wants, do relaxation exercises and contact the midwife or nurse easily.
225
2.2. Study sample The SUDS was developed by Wolpe. The SUDS is a very practical
tool commonly used as a subjective verbal rating of discomfort to assess
Eligibility criteria for participants were openness to communication, emotional responses. It is an 11-point scale, and 0 refers to a lack of
age 18–45 years, graduation from primary school, nulliparity, experi- discomfort, while 10 refers to unbearable discomfort [32]. During the
encing the latent phase of labour (cervix dilatation of 0–3 cm), preg- session process, energy therapies also introduce a reframing statement
nancy without maternal or foetal risk (e.g. multiparity and pre- (cognitive restructuring), helping the client to develop a new cognitive
eclampsia), achieving a score of ≤37 for the Wijma Delivery framework. Clients self-rate their level of distress on the SUDS after
Expectancy/Experience Questionnaire (version A) (W-DEQ-A), volun- each application of the procedure. Energy psychology interventions
tary participation in the study, and not having any analgesics or an- typically begin with a statement of self-acceptance, while stimulating
aesthesia during labour. one or more acupoints, which is believed to ameliorate the client's re-
Power analysis was made by considering the prevalence of child- sistance to treatment. The subject's distress level generally decreases by
birth fear in pregnant women reported in the literature to determine the two or more SUDS points per round of acupoint stimulation [33]. Re-
number of pregnant women to be included in each group [29]. The corded SUDS level testing provides written evidence to the pregnant
sample size was calculated using G*Power (v3.1.9.2). Considering that woman of beginning disturbance and ending calm. The testing can take
three independent groups would have a total of 105 pregnant women many forms, but it must be conducted to provide direction in an EFT
and that each group would have 35 pregnant women, the significance session and to track progress [34]. It is emphasized that SUDS should be
level, the effect size and the power of the study were found to be 5%, employed when EFT is implemented [16]. This allows pregnant women
0.80 and (1-β) 0.91, respectively. The study had a control group (C-G) to score their feelings of distress due to the stimulus causing fear. The
(n = 50) and two experimental groups: the EFT group (EFT-G) (n = 35) most important aspect of using SUDS is that pregnant women sub-
and the breathing awareness group (BA-G) (n = 35). jectively evaluate the discomfort they experience. Thus, an indicator
In the power analysis of the study, at least 105 samples in total were reflecting a change achieved by an intervention is obtained. The in-
calculated as sufficient. To make statistically stronger analyses, 120 ternal consistency coefficient for SUDS was found to be Cronbach's
pregnant women were studied. Before the study started, a descriptive alpha of 0.88.
characteristics questionnaire was piloted with three pregnant women
from each group. In accordance with the feedback obtained, the ques- 2.4. Interventions
tionnaire was revised, and these women were then not included in the
study. A total of 148 pregnant women were contacted (see Fig. 1). The descriptive characteristics questionnaire, W-DEQ-A and W-
Twenty-eight pregnant women were not included into the sample due DEQ-B were administered by a nurse blinded to the groups and the
to administration of epidural anaesthesia and/or caesarean section. All interventions. Emotional freedom techniques and breathing awareness
the pregnant women achieved a score of 16 or higher for the W-DEQ-A. were offered by the researcher, and the SUDS was also administered by
None of the pregnant women were excluded due to their score for the the researcher. All the pregnant women were followed from the latent
W-DEQ-A. The women were included into the study in the order of phase till 24 h after childbirth. The fact that each pregnant woman is
randomization. Numbers from 1 to 120 were randomized for 3 groups present in the individual labour room and not seeing one another re-
using random.org. A pregnant woman was asked to select a paper from moves the possibility of intergroup interaction. Assessments of current
a bowl with numbers up to 1–120, and the group was determined ac- labour processes were conducted by a doctoral degree nurse, who was
cording to the number in the paper selected by the pregnant woman. also this survey's researcher for the three groups.
2.3. Instruments 2.5. Study groups
Data were collected with the descriptive characteristics ques- EFT-G: The pregnant women in this group were offered the EFT
tionnaire, W-DEQ-A, Wijma Delivery Expectancy/Experience intervention. The EFT protocol was first explained orally and then de-
Questionnaire (version B) (W-DEQ-B) and the Subjective Units of monstrated for 15 min in the rooms of the pregnant women during the
Distress Scale (SUDS). first phase of delivery. In the first EFT session, the researcher did the
The descriptive characteristics questionnaire was created by the tapping, and in the following sessions, the pregnant women did it
researchers, and it was composed of 32 questions, 21 of which were themselves. When the pregnant women had no pain in each phase of
about sociodemographic factors and 11 were about obstetrics char- labour; i.e. latent phase (0–3 cm cervical dilatation), active phase
acteristics. (4–7 cm cervical dilatation) and transition phase (8–10 cm cervical di-
The W-DEQ-A was developed by Klaas and Barbro Wijma to mea- latation), three EFT sessions were performed. A total of nine EFT ses-
sure the childbirth fear experienced by prenatal women. It is composed sions were conducted with each pregnant woman. All the pregnant
of 33 items. It uses a 6-point Likert scale: 0 corresponds to completely, women were asked to score their fear of childbirth by using SUDS be-
and 5 corresponds to never. The lowest and the highest scores for the fore and after each EFT session. Twenty-four hours after childbirth, the
scale are 0 and 160, respectively. Higher scores indicate a higher degree W-DEQ-B was administered. Each EFT session was conducted as given
of childbirth fear. Scores of ≤37 are indicative of mild fear, scores of in the treatment protocol created by The EFT Manual (2nd edition), as
38–65 moderate fear, scores of 66–84 severe fear, and scores of ≥85 described in Craig's book [33].
clinical fear [30]. The internal consistency coefficient for the W-DEQ-A BA-G: This group was exposed to abdominal breathing awareness.
has been found to be Cronbach's alpha of 0.88. The researcher explained this intervention by demonstrating it for
The W-DEQ-B was created by Klaas and Barbro Wijma to evaluate 10 min in the pregnant women's room in the latent phase of labour. In
intrapartum childbirth fear in the postpartum period. It is composed of the first BA session, the researcher helped the women to control their
32 items. It uses a 6-point Likert scale: 0 corresponds to completely, and breathing by putting one hand on the pregnant women's abdomen and
5 corresponds to never. The lowest and the highest scores for the scale the other hand on the pregnant women's chest. After that, the re-
are 0 and 160, respectively. Higher scores show a higher degree of fear. searcher continued to accompany the pregnant women and encouraged
The scale has six subscales: worries about labour pain, lack of positive them to continue the BA session by themselves. There was no fixed
behaviour, loneliness, lack of positive feelings, worries about labour number of breaths. The women were asked to lie in a comfortable po-
and worries about the baby [31]. In the present study, the internal sition and breathe in and out calmly and smoothly at the beginning of
consistency coefficient for the W-DEQ-B was found to be Cronbach's each contraction. This method allowed the women to breathe in and out
alpha of 0.86. It was administered to the women 24 h after childbirth. calmly and slowly by using their abdomen. The objective of this
226
breathing is to take long breaths in and out as much as possible. The groups were similar in terms of sociodemographic and obstetric fea-
woman's back was supported by pillows or she lied down on one side. tures (Table 1).
Both hands were put on the abdomen. First, a short breath was given In this study, 120 women (100%) had childbirth fear. Eighty-four
out to clean the airway, and then breath was taken through the nose by women (70%) had a fear of experiencing very severe pain. Thirty-eight
blowing the abdomen, and it was given out through the nose as slowly women (31.7%) had childbirth fear as they did not know how delivery
as breathing in. Taking a short breath in and out was avoided. Each would occur. Thirty-four women (28.3%) were afraid of an inability to
breath should have lasted as long as a contraction. The body should give birth. Twenty-four women (20%) were afraid of possible damage
have been kept still and loose. The foetus was imagined during this to their babies.
process. While breathing in, the women imagined that a balloon was There was no significant difference in the scores for the W-DEQ-A
blown in the abdomen. During expiration, the air was breathed out between the groups (p > 0.05). However, the difference in the scores
slowly downwards and outwards [35]. The women, who continued to for the W-DEQ-B between the groups was significant (p < 0.001). This
use the BA in each contraction, scored their childbirth fear at the be- difference was due to the high score of the W-DEQ-B of the C-G. Both
ginning and end of each labour phase by using SUDS. Twenty-four EFT and BA interventions enabled to reduce the level of birth fear
hours after childbirth, the W-DEQ-B was administered. perceived at postpartum (Table 2).
C-G: The women in the C-G group were informed about the study in There was also a significant difference in the scores for the W-DEQ-B
their rooms in the latent phase of labour by the researcher. They were subscales related to lack of positive behaviour, loneliness, and worries
exposed to the standard care protocol of the clinic. The pregnant about childbirth (p < 0.05) (Table 3).
woman, who was close to birth, was covered, the necessary information There was a significant difference in childbirth fear measured with
was taken, she was taken to the labour room, and the medical treatment the SUDS in the latent phase between the groups (p = 0.010;
that her doctor decided upon was started. There was a companion to p < 0.05). After the intervention, the BA-G had a considerably higher
help the pregnant woman. The pregnant woman underwent a non-stress score for SUDS in the latent phase than the EFT-G, although the dif-
test (NST) during the birth process. The pregnant woman in the C-G was ference was not significant (p = 0.055; p > 0.05). After the interven-
not left alone, and the researcher spent time with the pregnant woman tion, the BA-G had a significantly higher score for SUDS in the active
during the treatment and follow-up. The SUDS was administered to the phase than the EFT-G (p = 0.001; p < 0.001). The scores for the SUDS
women three times in the latent, active and transition phases to de- during the transition phase differed significantly between the groups
termine the fear of childbirth. Twenty-four hours after childbirth, the (p = 0.008; p < 0.05). The EFT-G had a significantly lower score for
women were administered the W-DEQ-B. the SUDS in the transition phase than the BA-G (p = 0.001; p < 0.001)
(Table 4).
2.6. Ethical considerations
4. Discussion
Ethical approval was obtained from the Ethical Committee of the
Medipol University for Non-Interventional Research (approval Complementary therapies have been widely used to cope with
number:10840098-604.01.01-E.5573). The women who volunteered to various symptoms during pregnancy, childbirth and postpartum per-
participate in the study were informed about the study and approval iods. Despite the existence of studies showing that EFT and BA decrease
forms prepared for each group were read and signed by the women. anxiety and stress, their effects on childbirth fear have not been in-
Approval was also received from the hospital where the study was vestigated [22,24]. The present study is the first study to have con-
conducted. The researcher received advanced education about EFT and ducted randomized controlled EFT and BA applications to reduce the
breathing awareness while planning the study. The study was per- fear of childbirth. When the level of fear of childbirth was compared
formed in accordance with the “Ethical principles for medical research with the W-DEQ-A of the subjects participating in the sample of the
involving human subjects” of the Helsinki Declaration. study, it was determined that there was no difference between the
groups and that there was moderate childbirth fear. Childbirth fear may
2.7. Statistical analysis be at different levels among cultures, but when we looked at other
studies, we concluded that the level of fear of nullipara pregnancy is
Statistical analyses were conducted using the Number Cruncher higher. The nulliparity fear level was found to be similar in the Finnish,
Statistical System (2007) (Kaysville, Utah, USA). The descriptive sta- Swedish, Australian and many more nations [8,36,37].
tistics of mean, standard deviation, median, frequency, ratio and In the present study, there was a significant difference in the W-
minimum and maximum values were used. In addition, the Mann- DEQ-B subscales related to lack of positive behaviour, loneliness and
Whitney U test was used to compare quantitative data without a normal worries about labour between the experimental groups, and this dif-
distribution from the two groups. A one-way ANOVA was employed to ference was due to the high score average of the control group. It has
compare normally distributed data from three or more groups. Data been determined that standard hospital care does not contribute to
without a normal distribution from three or more groups were com- postpartum women's positive behaviour, feelings of loneliness and re-
pared using the Kruskal-Wallis test. The Wilcoxon signed-rank test was duction of worries about birth [39]. Likewise, in a study using the W-
used to perform intragroup paired comparisons of variables without a DEQ-B, the pregnant women who were motivated by health profes-
normal distribution. The paired samples t-test was used to perform in- sionals were shown to have lower scores for childbirth fear and de-
tragroup paired comparisons of variables with a normal distribution. pressive symptoms. The frequency of childbirth fear and depression
The Pearson's Chi-square test and Fisher-Halton test were used to symptoms is affected by intrapartum pain management and the car-
compare qualitative data. Statistical significance was set at p < 0.05. egiving process offered to women [39]. In the meta-analysis studies, in
which the EFT was evaluated clinically in the field of depression, PTSD
3. Results and anxiety, based on the positive outcomes, further studies were
needed to assess patient satisfaction, patient preference, accessibility,
There was no significant difference in age, education, health in- cost-saving and comparison to standard of care. In the clinic, women
surance and spouses’ education between the groups (p > 0.05). The who are supported with techniques to reduce their fear have satisfac-
number of pregnancies, the number of abortions, gestational week, tion after giving birth, thus preventing birth from being remembered as
weight gained during pregnancy, type of delivery, health problems in a traumatic experience [19–22].
pregnancy, the number of prenatal follow-up visits and meeting a In the current study, based on the SUDS scores, childbirth fear
woman giving birth did not significantly differ either (p > 0.05). The significantly decreased in both the EFT-G and the BA-G, but it increased
227
Table 1
Sociodemographic and obstetric characteristics of pregnant women by groups.
Groups p value
EFT-G (n = 35) BA-G (n = 35) C-G (n = 50)
a
Age (years) Min-Max (Median) 20-35 (27) 20-38 (26) 20-36 (27) 0.994
Mean ± SD 27.29 ± 3.97 27.51 ± 4.65 27.36 ± 4.19
a
Marriage Time (years) Min-Max (Median) 1-13 (2) 1-6 (3) 1-13 (2) 0.628
Mean ± SD 2.83 ± 2.11 2.74 ± 1.20 2.74 ± 2.00
c
Educational Status n (%) High school or lower education levels 12 (34.3) 8 (22.9) 6 (12) 0.130
University 22 (62.9) 24 (68.6) 39 (78)
Postgraduate 1 (2.9) 3 (8.6) 5 (10)
c
Income Status n (%) Lower than expenses 0 (0) 1 (2.9) 1 (2.0) 0.702
Equal to expenses 27 (77.1) 26 (74.3) 33 (66.0)
Higher than expenses 8 (22.9) 8 (22.9) 16 (32.0)
Body Mass Index n (%) Normal (18.5–24.9 kg/m2) 20 (57.1) 20 (57.1) 30 (60.0) c
0.937
Overweight (25.0–29.9 kg/m2) 13 (37.1) 14 (40) 19 (38.0)
Obese (≥30 kg/m2) 2 (5.7) 1 (2.9) 1 (2.0)
c
Number of pregnancies n (%) Once 32 (91.4) 31 (88.6) 46 (92.0) 0.920
≥2 3 (8.6) 4 (11.4) 4 (8.0)
c
Number of abortions n (%) None 32 (91.4) 30 (85.7) 46 (92.0) 0.638
≥1 3 (8.6) 5 (14.3) 4 (8.0)
a
Gestational week Range (Median) 35-42 (39) 35-41 (39) 35-41 (39) 0.774
Mean ± SD 39.11 ± 1.35 39.03 ± 1.12 38.94 ± 1.25
Mean ± SD 15.00 ± 4.51 15.29 ± 4.16 15.58 ± 4.31
a
Number of prenatal follow-up visits Range (Median) 5-15 (10) 5-17 (10) 5-15 (10) 0.447
Mean ± SD 9.91 ± 2.19 10.57 ± 2.36 10.50 ± 2.15
c
Is it a planned pregnancy? n (%) Yes 29 (82.9) 33 (94.3) 44 (88.0) 0.323
No 6 (17.1) 2 (5.7) 6 (12.0)
c
Type of Pregnancy n (%) Spontaneous 34 (97.1) 34 (97.1) 45 (90.0) 0.415
Through IVF 1 (2.9) 1 (2.9) 5 (10.0)
c
Health problems in pregnancy n (%) Yes 5 (14.3) 2 (5.7) 8 (16.0) 0.395
No 30 (85.7) 33 (94.3) 42 (84.0)
b
Seeing a woman giving birth before n (%) Yes 9 (25.7) 3 (8.6) 6 (12.0) 0.098
No 26 (74.3) 32 (91.4) 44 (88.0)
c
Her own birth based on what her mother told n (%) Normal birth 29 (82.9) 31 (88.6) 42 (84.0) 0.689
Difficult birth 0 (0) 0 (0) 2 (4.0)
Easy birth 6 (17.1) 4 (11.4) 6 (12.0)
Note. a: Kruskal-Wallis test, b: Pearson's Chi-square test, c: Fisher-Halton test, n: Number of participants, SD: Standard Deviation, EFT-G: Emotional Freedom
Techniques Group, BA-G: Breathing Awareness Group, C-G: Control Group, IVF: In Vitro Fertilization.
Table 2
The distribution of the W-DEQ-A and B scores by groups.
b
Groups p value
EFT-G (n = 35) BA-G (n = 35) C-G (n = 50)
W-DEQ-A Range (Median) 21-84 (56) 34-90 (54) 16-88 (56) F = 0.150
Mean ± SD 56.40 ± 16.20 54.34 ± 12.84 55.16 ± 17.43 0.861
W-DEQ-B Range (Median) 29-96 (60) 25-99 (61) 25-95 (76.5) F = 8.675
Mean ± SD 59.17 ± 18.52 59.57 ± 18.76 71.74 ± 13.74 0.001*
Test Value t = −0.811 t = −1.237 t = −5.821
a a a
p 0.423 0.224 0.001*
Note. a: Paired-samples t-test, b: One-way ANOVA test, *:p < 0.001, n: Number of participants, SD: Standard Deviation, EFT-G: Emotional Freedom Techniques
Group, BA-G: Breathing Awareness Group, C-G: Control Group, W-DEQ-A and B: Wijma Delivery Expectancy/Experience Questionnaire version A and B.
228
Table 3
Comparisons of the W-DEQ-B subscale scores between the groups.
b
W-DEQ-B Subscale Scores Groups p value
EFT-G (n = 35) BA-G (n = 35) C-G (n = 50)
Worries about labour pain Range (Median) 1.1–4.3 (2.5) 0.9-4.3 (2.5) 1.4–4.4 (2.5) F = 0.177
Mean ± SD 2.51 ± 0.96 2.56 ± 1.02 2.46 ± 0.52 0.838
Lack of positive behaviour Range (Median) 1-3 (2) 0.8-3.3 (1.8) 1.3–5 (3.5) F = 52.317
Mean ± SD 1.93 ± 0.67 1.94 ± 0.67 3.26 ± 0.74 0.001**
Loneliness Range (Median) 0-3 (1.3) 0–3.3 (1.1) 0.4-3.1 (2) F = 12.347
Mean ± SD 1.27 ± 0.64 1.26 ± 0.70 1.87 ± 0.66 0.001**
Lack of positive feelings Range (Median) 0.6-3.3 (2) 0.8-3.1 (1.9) 0.6-3.4 (2.3) F = 1.879
Mean ± SD 2.07 ± 0.77 2.04 ± 0.74 2.29 ± 0.60 0.161
Worries about labour Range (Median) 0-4 (1.7) 0-4 (1.3) 0-3 (2) F = 4.475
Mean ± SD 1.47 ± 0.98 1.47 ± 0.98 1.95 ± 0.71 0.013*
Worries about the baby Range (Median) 0–2.5 (1) 0–2.5 (1) 0-2 (1) χ2 = 1.913
a
Mean ± SD 0.80 ± 0.69 0.91 ± 0.56 0.88 ± 0.44 0.384
Note. a: Kruskal-Wallis Test, b: One-way ANOVA test, *: p < 0.05, **: p < 0.001, n: Number of participants, SD: Standard Deviation, EFT-G: Emotional Freedom
Techniques Group, BA-G: Breathing Awareness Group, C-G: Control Group, W-DEQ-B: Wijma Delivery Expectancy/Experience Questionnaire version B.
in the C-G. In a study using the visual analog scale (VAS) to determine care in clinics, but their psychological care needs such as anxiety and
childbirth fear, the nullipara were found to have higher VAS scores. The fear should also be assessed and realized. This will enable them to cope
women with the median VAS score of 2.7 ± 2.2 preferred vaginal with psychological and emotional problems during labour because EFT
birth, and those with the VAS score of 7.4 ± 2.7 preferred caeserian and BA practices are easy to learn, self-applied and effective techniques.
section [8]. These findings showed childbirth fear greatly affected the These techniques have proven their effectiveness in this study, and
type of delivery. Pregnant women should not only be given physical these techniques would be more effective if they were taught in the first
Table 4
The distribution of SUDS scores before and after the interventions by groups.
Groups p value
EFT-G (n = 35) BA-G (n = 35) C-G (n = 50)
SUDS in Latent phase

Before the interventions Range (Median) 1-8 (5) 1-8 (5) 1-9 (3) χ2 = 9.204
a
Mean ± SD 4.77 ± 2.18 4.57 ± 2.09 3.48 ± 1.94 0.010*
After the interventions Range (Median) 0-5 (2) 0-6 (2) – Z = −1.923
c
Mean ± SD 1.91 ± 1.52 2.80 ± 1.81 – 0.055
Test Value Z = −5.198 Z = −4.807

b b
p value 0.001** 0.001**
SUDS in Active phase

Before the interventions Range (Median) 3-9 (5) 4-9 (6) 2-10 (5) χ2 = 1.558
a
Mean ± SD 5.54 ± 1.27 6.06 ± 1.55 5.74 ± 1.79 0.459
After the interventions Range (Median) 0-6 (2) 2-7 (4) – Z = −4.021
c
Mean ± SD 2.51 ± 1.40 4.00 ± 1.48 – 0.001**
Test Value Z = −5.245 Z = −4.995

b b
p value 0.001** 0.001**
SUDS in Transition Phase

Before the interventions Range (Median) 4-10 [6] 5-10 [8] 5-10 [8] χ2 = 9.544
a
Mean ± SD 6.86 ± 1.57 8.00 ± 1.57 7.60 ± 1.44 0.008**
After the interventions Range (Median) 2-7 [4] 2-10 [6] – Z = −4.552
c
Mean ± SD 3.86 ± 1.44 5.94 ± 1.78 – 0.001**
Test Value Z = −5.211 Z = −5.012

b b
p value 0.001** 0.001**
Note. a: Kruskal Wallis Test b: Wilcoxon signed-rank test, c: Mann-Whitney U Test, *:p < 0.05, **:p < 0.001, SD: Standard Deviation, EFT-G: Emotional Freedom
Techniques Group, BA-G: Breathing Awareness Group, C-G: Control Group, SUDS: Subjective Units of Distress Scale.
229
trimester of pregnancy. There is still no definite information on how Funding

many sessions should the EFT be implemented. This technique can
usually be mastered in a single session and several of the articles in a This research did not receive any specific grant from funding
meta-analysis report significant results using only one guided session agencies.
[40]. Although the result is likely to be highly individualized, a pilot
study suggested that EFT generally achieved effective results in an References
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231

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Dokumentasi Asuhan Kebidanan Intranatal Fisiologis

Tanggal Pengkajian : 04-12-2021

Eliminasi Ibu sudah BAB 1x, BAK 3x sehari

Istirahat Ibu susah beristirahat malam ini karna kontraksi

Personal Hygiene Ibu sudah mandi dan ganti baju

5. Riwayat Psikososiokultural Spiritual

Lawrence A, Lewis L, Hofmeyr GJ, Dowswell T, Styles C

Maternal positions and mobility during first stage labour (Review)

Maternal positions and mobility during first stage labour (Review) ii

Maternal positions and mobility during first stage labour

PLAIN LANGUAGE SUMMARY

Mothers’ position during the first stage of labour

OBJECTIVES Types of participants

Maternal positions and mobility during first stage labour (Review) 3

Secondary maternal outcomes:

Maternal positions and mobility during first stage labour (Review) 4

(5) Other sources of bias and overall risk of bias

Maternal positions and mobility during first stage labour (Review) 5

Dealing with missing data

Intention to treat analysis (ITT)

Assessment of heterogeneity Included studies

Maternal positions and mobility during first stage labour (Review) 6

Maternal positions and mobility during first stage labour (Review) 7

Duration of the second stage of labour

Operative spontaneous or assisted delivery Fetal and neonatal outcomes

Maternal pain and analgesia Duration of labour

Maternal positions and mobility during first stage labour (Review) 8

Maternal pain, satisfaction and other outcomes Subgroup analysis

Maternal positions and mobility during first stage labour (Review) 9

Maternal positions and mobility during first stage labour (Review) 10

Maternal positions and mobility during first stage labour (Review) 13

Maternal positions and mobility during first stage labour (Review) 14

Maternal positions and mobility during first stage labour (Review) 15

Characteristics of included studies [ordered by study ID]

Methods Randomised trial.

Participants 40 women randomised.

Interventions Intervention group: 20 - upright: standing, ambulating, sitting, squatting, or kneeling.

Outcomes Length of first stage of labour.

Item Authors’ judgement Description

Adequate sequence generation? Unclear Described as ’randomly assigned’.

Allocation concealment? Unclear Not stated.

Blinding? No Not feasible.

Blinding? No Not feasible.

Maternal positions and mobility during first stage labour (Review) 16

Blinding? Unclear Not stated.

Incomplete outcome data addressed? Yes No losses to follow up.

Methods Randomised trial.

Participants 1067 women randomised.

Pelvic examinations were performed approximately every 3 hours - ineffective labour

Maternal positions and mobility during first stage labour (Review) 17

Outcomes Length of first stage labour.

Item Authors’ judgement Description

Adequate sequence generation? Unclear Described as ’randomly assigned’.

Allocation concealment? Unclear Not stated.

Blinding? No Not feasible.

Blinding? No Not feasible.

Blinding? Unclear Not stated.

Incomplete outcome data addressed? Yes No losses to follow-up.

Methods Randomised trial.

Participants 50 (8 primiparous and 17 multiparous in each group).

Interventions Intervention group: 25 - ambulation.

Maternal positions and mobility during first stage labour (Review) 18

Item Authors’ judgement Description

Adequate sequence generation? Unclear Describled as ’randomly allocated’.