Wednesday, September 02, 2009

The Evidence Says: Upright Position for Labor

I don't know about you, but I have been teaching upright positioning in first (and second) stage of labor for over 25 years. During the 90s and early years of this century, I saw a great retreat from autonomy during labor and birth by both women and their support partners (excluding doulas). However now, armed with research, women are staging a push back against policies, practice guides and practitioners who do not practice evidence based medicine in maternity care. I personally feel that the access of expectant parents to the evidence is credited both to the internet and to the tireless professionals who bring the evidence (in easy to understand terminology) to those parents.

Inspired by the early writings of Caldeyro-Barcia, I have continued to encourage expectant mothers change positions every 20-30 minutes to facilitate the cardinal movements of the baby. Authors now have reviewed the effects of upright positions (walking, sitting, standing, kneeling) versus recumbent positions (supine, lateral). Looking at 21 studies and totalling over 3700 women, the conclusion is that upright positioning reduces length of labor and does not seem to be associated with increased intervention or negative effects on mothers' and babies' wellbeing. In fact, these researchers feel that "women should be encouraged to take up whatever position they find more comfortable in the first stage of labor." (Cochrane Database Review April 15, 2009: Lawrence, A.; Lewis, L. ; Hofmeyr, GJ; Dowswell, T.; and Styles, C).

Similarly, a Cochrane Database Review in 2004 of 5764 participants demonstrated that upright positioning reduced the need for assisted delivery (forceps and vacuum), reduction in episiotomy and perineal tears, reduced pain during second stage of labor and fewer abnormal fetal heart rate. In November of 2008, AWHONN (The Association of Women's Health Obstetrics and Neonatal Nurses announced the release of Nursing Care and Management of the Second Stage of Labor: Evidence-Based Clinical Practice Guideline (2nd Edition). The 2nd edition of the clinical practice guideline includes updated literature sources that provide current and important evidence about the benefits of upright positioning, delayed and non-directed pushing during the second stage of labor. Use of these techniques during this critical time in labor has been shown to optimize outcomes for both the mother and her newborn. "It's vital to have the best evidence-based information available to ensure optimal care for women and their newborns during this critical period," says AWHONN Interim Executive Director, Karen Peddicord, RNC, PhD. "This guideline emphasizes the importance of educating women about and supporting them through the second state of labor. Incorporation of the guideline elements into childbirth education programs can promote consistency between what is taught about the second stage of labor and what is practiced in a clinical setting."

The evidence is in the medical literature and the nursing literature.
Let the push back continue....

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