Update on Nonpharmacologic Approaches to Relieve Labor Pain and Prevent Suffering

Penny Simkin, PT; April Bolding, PT

Disclosures

J Midwifery Womens Health. 2004;49(6) 

In This Article

Maternal Movement and Positioning

Historically and cross-culturally, laboring women have always walked, moved, and changed positions spontaneously to make themselves more comfortable.[34,35] Observational studies indicate that this is still true in settings where the environment is conducive.[36,37] Besides self-initiated comfort-seeking movements, women's caregivers often suggest specific positions that are thought to accelerate labor progress, slow down expulsion, or correct a fetal or maternal problem (e.g., fetal heart rate decelerations, malposition, maternal back pain or other pain, blood pressure abnormalities, or inadequate contractions). In most birthing environments today, however, women are restricted from walking or moving freely, not because it is intrinsically dangerous, but because with conventional obstetric management, it is nearly impossible. In fact, "Listening to Mothers," a national survey of childbearing experiences in the United States between the years 2000 and 2002,[38] found that after admission to the hospital, most women (71%) did not walk around. The most common reason they gave was that they were "connected to things" (67%), followed by "unable to support self due to pain medication" (32%), and "told not to walk around" (28%). Sixty percent, however, did report changing positions (presumably while in bed) to relieve pain during labor.

Pelvic dimensions vary with differences in maternal positions, according to a study of 35 nonpregnant nulliparous and parous women using magnetic resonance imaging.[39] Both squatting and kneeling while leaning forward increased the anterior-posterior and transverse diameters in both the midpelvis and pelvic outlet, compared with the supine position (interspinous diameter increased 8 ± 7 mm in squatting and 6 ± 7 mm in kneeling, P < .001).[39] Squatting also increased the intertuberous diameter (3 ± 7 mm, P = .01) and decreased the obstetric conjugate diameter (2 ± 4 mm, P = .01). The findings noted in this study can be expected to be even more dramatic in pregnant women who have more joint mobility. Pelvic dimensions change with movement -- walking, swaying, lunging, or flexing and extending the legs. Such movements are thought to facilitate fetal rotation or descent, which could, in turn, mitigate the pain associated with abnormal positions or prolonged labor.[40]

Effectiveness of Maternal Position Changes in Reducing Pain and Suffering During Labor

First Stage of Labor. Most scientific trials of movement and positioning during labor have compared various upright positions with horizontal positions for their effects on pain and labor progress. Our search revealed 14 controlled trials of positioning during the first stage of labor in healthy women at term. Thirteen were included in a recent systematic review of selected nonpharmacologic methods of pain relief,[10] and one[41] was published after the review. Eight of these trials (N = 311) used each woman as her own control by having her take one specified position for 15 to 30 minutes and then alternate to another for the same length of time. In 7 of these, the women were asked to alternate positions several times or until complete dilation; in one,[41] they took each position only once. The positions included sitting, standing, or walking versus supine or sidelying; hands and knees versus supine or sidelying; and other combinations. The women's pain and progress were assessed in each position.

None of the women in these 8 trials found the supine position more comfortable than other positions. Comparing 30-minute periods of standing with supine or with sitting, the women reported less pain while standing. Comparing sitting with supine, the women reported less pain while sitting. Comparing sitting with sidelying, the women reported less pain with sitting until 6 cm and then less pain with sidelying from 7 to 10 cm. Other comparisons revealed few differences in pain indicators. Vertical and sidelying positions were accompanied by more progress than sitting or supine.

Six other trials evaluated in the systematic review[10] (N = 2629) compared 2 groups -- an experimental group who were encouraged to remain upright (sit up, stand, or walk) during the first stage, and a control group, who remained sidelying or supine. Except for one trial, the upright women were allowed to lie down if they wished. Of these 6 trials, 3 found decreased pain in upright positions, 2 found no difference, and 1 (in which women were forced to remain upright throughout the first stage) found increased pain. Three trials found decreases, and 3 found no differences in duration of labor. No trial found longer labors in the women who assumed upright positions. One trial assessed satisfaction with the option of walking, which was very high in the upright group. No trial found that upright positions caused any harm to healthy women.

Second Stage of Labor. A recent Cochrane Review of 19 randomized controlled trials[42] (N = 5764) compared supine positions with upright positions during the second stage of labor. Most investigated such outcomes as duration of second stage, maternal perineal condition, postpartum bleeding, newborn outcomes, and others. Only one of the trials asked women to rate their pain.[43] In this study, fewer women in the group assigned to a squatting position reported severe pain than those in the group assigned to a supine position. The authors of this Cochrane Review concluded that there is no indication of harm from upright positions during second stage and that "… women should be allowed to make informed choices about the birth positions … they might wish to assume for delivery of their babies."[42]

In summary, these trials in both the first and second stages of labor suggest that the use of upright positions, interspersed with other positions, decreases pain and may shorten labor. No trials of positions have compared a policy of restriction of movement with a policy of freedom of movement. However, several descriptive studies report findings consistent with pain reduction and enhanced satisfaction from freedom of movement; for example, women voluntarily change position during labor and birth when unrestricted,[36,37] they express satisfaction if encouraged to move freely,[10] but they are frequently kept from moving freely in the hospital environment.[38] Furthermore, the fact that there were high rates of attrition in the trials in which women were assigned to prolonged periods of upright positions also indicates that women prefer to change positions freely. Until appropriate studies produce new information, women with no risk factors should be educated about potential advantages for comfort and labor progress and encouraged to move freely in labor and birth.

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