http://doi.org/10.33698/NRF0151 – Kumud, Avinash Kaur Rana, Seema Chopra

Abstract: Labour pain is auniversal phenomenon.The first stage of labour is longer and painful in both primiparous and multiparous mothers.A quasi-experimental study was undertaken to determine the effect of upright positions (including standing, sitting) on duration of first stage of labour among nulliparous mothers. Sixty nulliparous mothers with single live fetus in cephalic presentation,between 32-41 weeks of gestation were included. The study was carried out in Labour room of Post Graduate Institute of Medical Education and Research, Chandigarh during the period August-September 2011.After selection by purposive sampling method women were consecutively randomly allocated into study (group I) and control (group II) groups, each with 30 patients.Upright positions were given to group-I during active phase of first stage of labour. Progress of labour was assessed through partograph. The mean duration of active phase of 1st stage of labour was 4 hours in Group-I compared to 6 hours in Group-II (P value: <0.001). The mean reduction in duration of active phase of first stage of labour in Group-I was 2 hours. The results of the study concluded that maintenance of upright positions during the first stage of labour reduces the duration of first stage of labour.

Key Words:

Upright  positions,  duration   of    first stage of labour, nulliparous.

Correspondence at:

Dr. Avinash Rana

Lecturer,National Institute of Nursing Education PGIMER, Chandigarh.

Introduction

Maternal and perinatal mortality and morbidity are major public health problems in India. It has been seen that majority of perinatal deaths have intrapartum origin and results as a consequence of interventions carried out around the time of delivery. In India 62% of pregnant women receive antenatal care and only 42% deliver at a health facility. [1]

Perinatal mortality and morbidity also depend on duration of labour. Prolonged labour may lead to increased maternal and neonatal mortality and morbidity due to increased risks of maternal exhaustion, post- partum haemorrhage, sepsis, fetal distress and asphyxia and requires early detection and appropriate clinical response. The causes of prolonged labour relate to maternal age, induction of labour, epidural analgesia and high levels of maternal stress hormones, but are unknown in most cases. Duration of labour is different among nulliparous and multiparous mothers and also varies in all stages of labour. In nulliparous mothers the duration of first stage of labour is 8-12 hours whereas in multiparous it is 5-6 hours.

There are many interventions to increase the uterine contractions and to decrease the duration of first stage of labour like giving drugs such as oxytocin (pitocin), drotaverin, buscopan, epidosin etc., amniotomy and maintaining upright positions and mobility which includes walking, sitting, standing, kneeling and squatting. [2, 3] Evidence based studies shows that maintaining upright positions and mobility in first stage of labour increases the uterine contractions and decrease the duration of first stage of labour and is the safest method.[4]

Mendez et al. evaluated Effects of standing position on spontaneous uterine contractility on 20 normal nulliparous who were changed from supine to standing position and vice versa at intervals of approximately 30 minutes. The study reported that: The intensity of contractions was significantly higher in 15 out of the 20 patients in standing position, uterine activity increased significantly in half of them, and patients reported more comfort in this position. The average duration of labour was 3 hours 55 min. No maternal and fetal complications were reported, after adopting standing position during first stage of labour. [5]

Similar type of study was done by Diaz A.G et al. on Vertical position during the first stage of the labour, and neonatal outcome. They concluded that duration of the first stage is shortened in 25% – this shortening may reach 34% in the nulliparous.The incidence of forceps delivery diminishes and perinatal morbidity and mortality is not increased. [6] In 2009, a systematic review was conducted by Cochrane Collaboration, to assess the effects of 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 the mother and the baby. Overall, the first stage of labour was approximately one hour shorter in women who maintained upright positions.[7]

However, in spite of three decades of research, the effect of upright positions on duration of labour continues to be debated. No standard protocol has been made and practiced for maintaining upright positions during the first stage of labour in India. So the study was conducted to assess the effect of upright positions on duration of first stage of labour.

Objective

To determine the effects of upright positions (including standing, sitting) on duration of first stage of labour among nulliparous mothers.

Material and Methods

A quasi experimental research design was employed in the study to evaluate the effect of upright positions on duration of first stage of labour among nulliparous mothers.Null hypothesis(H0) was used: There is no difference in the duration of first stage of labour with or without maintenance of upright positions among nulliparous mothers at 0.05 level of significance.

The study was conducted in Labour room of Nehru Hospital, PGIMER, Chandigarh which is located at 3rd floor of the building with a capacity of 18 beds. Labour room has been par titioned into four sections – observation room, delivery room, nursery, postnatal room, and eclampsia room.Study subjects were selected from the labouring mothers admitted in Labour Room. The target population was nulliparous mothers (18-35 years) with 32 weeks to 41weeks of gestational age and in active phase of first stage of labour admitted in Labour Room during the month of July and August, 2011. The subjects were recruited by purposive sampling technique from the target population. Women were consecutively randomized allotted into study (group I) and control (group

  1. II) groups, each with 30 patients after excluding high risk factors like pre eclampsia, eclampsia, antepartum haemorrhage, and any contraindications to vaginal

The study was carried out in three steps: Development of procedure and tools, Intervention (Providing upright positions), and Assessment of duration of first stage of labour. Firstly, protocol was developed for the maintenance of upright positions during active phase of first stage of labour. The tools for data collection were: Socio demographic profile, modified partograph (2nd page of standardized par tograph by WHO) and proforma to assess the duration of first stage of labour.The tools and protocol were developed through review of relevant literature and validated by ten experts from field of nursing and department of Obstetrics and Gynaecology. After validation of tool pilot study was conducted in labour room of PGIMER, Chandigarh for assessing feasibility of the study. Results of the pilot study indicated that study was feasible.

Data was collected after getting permission from head of the department of Obstetrics and Gynaecology and ethical clearance from ethical committee. Study subjects were selected and after taking the written consent, they were enrolled in the study. They were explained about the purpose of the study and were told that data so collected will be kept confidential & will be used only for research purpose. They were given full autonomy to participate in the study.Only one subject was taken at a time to prevent contamination in two groups.

After recruiting the subjects for the study, socio-demographic details were collected. Assessment was done when mother was in active phase of first stage of labour and having consistent labour pains with cervix 3 cm dilated.Intervention (upright positions) was given to the subjects of experimental group. Sitting positions were given on the bed with the support of back rest and also provided on chair and stool. Standing positions were provided with the suppor t of bed, table and chair. These positions were given alternatively for the 15- 20 minutes according to her comfort and in between mothers were permitted to lie down on bed for 10-15 minutes.

Subjects of control group were assessed without intervention with normal routine care as usual provided in labour room. The subjects (experimental & control group) were kept under observation throughout the procedure and monitored for any discomfort and fetal heart rate. With the help of modified partograph subjects were monitored for fetal heart rate, vital signs, per vaginal examination and type, duration, and intensity of uterine contractions continuously till second stage of labour.Assessment performa for duration of labour was used to collect information related to labour and delivery details, mode of delivery, duration of labour, and baby details. The data was analyzed using descriptive and inferential statistics. Analysis was carried out with the help of statistical package for social sciences (SPSS-16) program. The findings were interpreted and presented with the help of tables and graphs.

Results

As per socio demographic data summarized in the table 1, 56.7% subjects in experimental group and 63.3% subjects in control group were in the age group of 24-29 year resulting in the mean age of 25.60 ± 3.32 years in experimental group compared to mean age of 26.87 ± 3.42 years in the control group. In experimental group, more than half of subjects (53.3%) had 2-4 family members, whereas in control group half of subjects (50%) had 5-7 family members. 66.7% subjects in experimental group and 63.3% subjects in control group were from urban area. Majority of subjects in both the groups had joint family (80% in experimental group & 76.7% in control group).

In both the groups’ majority of subjects were having income Rs.10001 to 40000/- (76.7% in experimental & 66.7 % in control), resulting in the mean income of Rs. 26100 ± 16084.58 in experimental group compared to mean income of Rs. 28333.33 ± 19446.36 in the control group. 60% subjects in experimental group and 56.7% in control group were graduate or above. 76.7% subjects in experimental group and 83.3% in control groupwere not working. Both the groups were found to be homogenous in terms of age, number of family members, locality, type of family, religion, income, educational status, and occupation of the subjects as per chi-square test (p>0.05).

Table1: Socio-Demographic people of subjects                                    N=60

 

VARIABLES EXPERIMENTAL GROUP (n1=30) f (%) CONTROL GROUP (n2=30) f (%) x2

df p value

AGE

(in years) 18-23

24-29

>30

 

09(30.0)

17(56.7)

04(13.3)

 

03(10.0)

19(63.3)

08(26.7)

 

04.44

02

0.11 NS

NO. OF FAMILY MEMBERS

2-4

5-7

>8

 

16(53.3)

09(30.0)

05(16.7)

 

11(36.7)

15(50.0)

04(13.3)

 

02.54

02

0.28 NS

LOCALITY     0.073
20(66.7) 19(63.3) 1
Urban
Rural 10(33.3) 11(36.7) 0.79 NS
TYPE OF FAMILY     0.10
24(80.0) 23(76.7) 01
Joint
Nuclear 06(20.0) 07(23.3) 0.75
INCOME

<10000

 

03(10.0)

 

04(13.3)

0.75
10001-40000 23(76.7) 20(66.7) 02
>40000 04(13.3) 06(20.0) 0.69 NS
EDUCATION      
18(60) 17(56.7) 0.57
Graduate & above
10+2 07(23.3) 08(26.7)
 
Matric 03(10.0) 04(13.3) 03
Primary & below 02(6.7) 01(3.3) 0.90 NS
OCCUPATION     06.08
23(76.7) 25(83.3) 1
Not working
Working, 07(23.3) 05(16.7) 0.52 NS

NS=Non Significant

Mean ± SD (Age) = 25.60 ± 3.32 yrs (Experimental Group) &26.87 ± 3.42 yrs (Control Group).

Mean ± SD (Income) = Rs. 26100 ± 16084.58 (Experimental Group) & Rs. 28333.33 ± 19446.36 (Control Group).

Table 2 shows that most of the subjects in both groups were primi gravida i.e., 90% in experimental group and 73.3% in control group. 33.3% of the mothers in experimental group had period of gestation between 34+1 to 36 weeks whereas in control group 56.7% of the mothers had period of gestation between 38+1 to 40 weeks. Mean period of gestation in experimental group was 37.05±2.18 weeks where as in control group it was 38.35±2.0

weeks. 36.7% baby’s bir th weight in experimental group was 2000 grams whereas in control group 13.3% babies had birth weight 2000 grams. Mean weight in experimental group was 2502.7±635.09 grams and in control group was 27336.6±483.93 grams. Both the groups were found to be homogenous in nature, in terms of gravida, POG, and birth weight of the baby as per chi-square test (p >0.05).

Table 2: Distribution of the subjects according to gravida, period of gestation (POG), and birth weight of the baby.   N=60

VARIABLES EXPERIMENTAL SUBJECTS( n1=30)

f (%)

CONTROL SUBJECTS( n1=30) f (%) 2 df

P value

GRAVIDA      
Primi Gravida 27(90) 22(73.3) 2.78
Multi Gravida 3(10) 8(26.7) 1
      0.95 NS
POG (Weeks)      
32-34 2(6.7) 1(3.3)  
34+1-36 10(33.3) 2(6.7) 8.91
36+1-38 7(23.3) 7(23.3)  
38+1-40 8(26.7) 17(56.7) 4
>40 3(10) 3(10) 0.06 NS
 

BIRTH WEIGHT OF

     
THE BABY (Grams)      
2000 11(36.7) 4(13.3) 4.814
2001-2999 9(30) 15(25) 2
>3000 10(33.3) 11(36.7) 0.09 NS

Distribution of subjects according to mode of labour and mode of delivery.

Table 3 shows that in experimental group, 50% of the subjects had spontaneous onset without acceleration of labour whereas, in control group these were 10%. In experimental group 3.3% subjects had spontaneous onset and acceleration of labour with other drugs (Drotaverin, Epidosin, and Buscopan) and 16.7% in control group. 3.3% subjects in experimental group had spontaneous onset and acceleration of labour with pitocin but in control group these were 10%. There was no single subject in the experimental group who had spontaneous onset and acceleration of labour with both pitocin as well as with other drugs (Drotaverin, Epidosin, and Buscopan) but in the control group these were 13.3%. Subjects who had induction with pitocin were 43.3% in experimental group and 23.3% in control group. No subject in experimental group had both-induction with pitocin and acceleration with other drugs whereas in control group these were 26.7%. 100% of subjects in experimental group had normal vaginal delivery whereas in the control group, 73.3% subjects had normal vaginal delivery and 26.7% had forceps and Ventouse delivery.

Results revealed that subjects who had maintained upright positions significantly less acceleration of labour with pitocin and with other drugs and they had normal vaginal delivery as per chi-square test (p<0.001).

Comparison of duration of active phase of 1st stage of labour among nulliparous mothers between experimental & control group.

Table 4 shows comparison of duration of active stage of first stage of labour between experimental and control groups. The findings revealed that 93.3% of subjects in experimental group had duration of active phase of first stage of labour between 201-400 minutes as compared to 63.3% in control group. No subject in the experimental group had active phase of first stage of labour>400 minutes but in the control group, 36.3%subjects had duration of active phase of first stage of labour>400 minutes. The results revealed that there is significant difference in the both groups in terms of duration of active phase of first stage of labour as per chi-square test (p<0.001). Subjects in experimental group had shorter duration of labour as compared to control group.

Comparison of duration of active phase of 1st stage of labour among nulliparous mothers between experimental & control group.

Table 5 shows the comparison of mean duration of active phase of 1st stage of labour among nulliparous mothers between experimental & control group. The mean duration of active phase of first stage of labour in experimental group was 241.33± 36.46 minutes whereas; in control group it was 365.83± 103.10 minutes.

The results revealed that there was significant difference between the mean duration of active phase of 1st stage of labour among experimental and control groups as per independent t-test (p<0.001) i.e active phase of 1st stage of labour was significantly shorter in experimental group as compared to control group.

The mean reduction of active phase of 1st stage of labour was 125.5 minutes (2 hours).

Table 3: Distribution of subjects according to Mode of labour and Mode of delivery.

N=60

VARIABLES EXPERIMENTAL SUBJECTS

( n1=30)f (%)

CONTROL SUBJECTS

( n2=30)f (%)

+2  df P value
MODE OF LABOUR      
Spontaneous onset of labour      
Without acceleration 15(50) 3(10)  
Acceleration with other drugs* 1(3.3) 5(16.7) 25.47
Acceleration with Pitocin 1(3.3) 3(10) 5
Acceleration with both-pitocin & 0(0) 4(13.3) 0.0001
other drugs.      
Induction with pitocin 13(43.3) 7(23.3)  
Both-Induction with pitocin & 0(0) 8(26.7)  
acceleration with other drugs.      
MODE OF DELIVERY      
Normal vaginal delivery 30(100) 23(76.7) 9.23
Forceps and ventouse 0(0) 7(23.3), 1
delivery     0.002

*Other drugs= Drotaverin, Epidosin, Buscopan.

Table 4: Duration of active phase of 1st stage of labour among nulliparous mothers between experimental & control group.                                                                                                                           N=60

VARIABLES EXPERIMENTAL SUBJECTS

( n1=30) f (%)

CONTROL SUBJECTS

( n2=30) f (%)

x2 df

P value

ACTIVE PHASE OF

1ST STAGE (Minutes)

<200

201-400

>400

 

 

2(6.7)

28(93.3)

0(0)

 

 

0(0)

19(63.3)

11(36.7)

 

 

14.72

2

0.001

Duration of active phase of 1st stage of labour (Range in minutes) = 180-720

Table 5: Mean duration of active phase of 1st stage of labour among nulliparous mothers between experimental & control group.                                                                                                               N=60

DURATION OF LABOUR STAGE

(Minutes)

EXPERIMENTAL SUBJECTS ( n1=30)

Mean± SD

CONTROL SUBJECTS ( n2=30)

Mean± SD

t-value df = 58

p value

Duration of active 241.33 ± 36.46 365.83 ± 103.10 6.236
phase of 1st stage     0.0001

Duration of Active phase of 1st stage (Range in minutes) = 180-720.

Discussion

Labour pain is a universal phenomenon. Duration of labour varies in all stages of labour and also among nulliparous and multiparous mothers. The first stage of labour is longer and painful in both primiparous and multiparous mothers. Prolonged labour may lead to increased maternal and neonatal mortality and morbidity due to increased risks of maternal exhaustion, post-par tum haemorrhage, sepsis, fetal distress and asphyxia and requires early detection and appropriate clinical response. The causes of prolonged labour relate to maternal age, induction of labour, epidural analgesia and high levels of maternal stress hormones, but are unknown in most cases.Various pharmacologic measures are used to enhance the uterine contractions and to decrease the duration of labour. These measures are costly and cause adverse effects on the mother. Maintaining upright posture during the first stage of labour has been a safest non- pharmacologic intervention used for many years. It is an effective and safest intervention to increase the uterine contractions and to decrease the duration of labour.

Various studies were conducted worldwide to determine the effect of upright positions in reduction of duration of first stage of labour. Most of the studies say that upright positions have effect in reduction of first stage of labour.5, 6,7 On the same lines the present study was undertaken with an objective to assess the effect of upright postures i.e., sitting and standing to decrease the duration of first stage of labour.

A systematic review conducted by Cochrane Collaboration,which included 21 studies revealed that first stage of labour was approximately one hour shorter for women randomized to upright as opposed to recumbent positions.7 In present study the average reduction in the first stage of labour in experimental group was 2 hours. In 1975, a study conducted by Mendez et al. on nulliparous mothers on Effects of standing position on spontaneous uterine contractility. The results of study revealed that the intensity of contractions was significantly higher in patients who maintained standing position. The average duration of labour was 3 hours 55 min.5 In present study also nulliparous mothers were included. Those mothers who maintained upright positions had significantly higher intensity of contractions. The average duration of first stage of labour was 4 hours (241.33 minutes) which is similar to results of this study.

A study conducted by Díaz A.G., et al on Vertical position during the first stage of labour. The results of the study revealed that when the mother remains in the ‘vertical’ position during the first stage of labour: duration of the first stage is shortened and the incidence of forceps delivery diminishes.6 In present study also mothers who maintained upright positions during first stage of labour all of them had normal vaginal delivery and no one had forceps and ventouse delivery.

In 1984, Stewart P. conducted a study on Posture in labour: patients’ choice and its effect on performance. Study included primigravida mothers who were in spontaneous labour. The results of study revealed that mothers who remained ambulant throughout had the shortest labours.8 In present study mothers had not same mode of labour, all mothers were included irrespective of their mode of labour. Some mothers had spontaneous onset and some had induction of labour and results of the present study also revealed that mothers who maintained upright posture had shor ter duration of labour.

The results of present study revealed that mean reduction of active phase of 1st stage of labour was 2 hours. The mean duration of labour in experimental group was significantly less than the control group. So the null hypothesis (H0) framed for the present study was rejected as there was reduction in the duration of first stage of labour in experimental group as compared to control group with maintenance of upright positions (p<0.05).

So it is concluded that maintenance of upright positions (sitting and standing) during the first stage of labour reduces the duration of first stage of labour. So it is recommended that:Upright positions should be given to all labouring mothers if not contraindicated, as it reduces the duration of first stage of labour.Study of effect of upright positions can be done on other aspects like maternal comfort, labour pains etc. Similar study can be replicated on large sample size.

References

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