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Hands-and-Knees Positioning During Labor With Epidural Analgesia
JOGNN
CASE REPORT
Hands-and-Knees Positioning During Labor With Epidural Analgesia Robyn Stremler, Stephen Halpern, Julie Weston, Jennifer Yee, and Ellen Hodnett
Correspondence Robyn Stremler, RN, PhD, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Room 288, Toronto, ON, M5T 1P8, Canada. [email protected]
ABSTRACT Hands-and-knees position has shown promise as an intervention to improve labor and birth outcomes, but no reports exist that examine its use with women laboring with epidural analgesia. Concerns of safety, effects on analgesia, and acceptability of use may limit use of active positioning during labor with regional analgesia. This article presents a case study series of 13 women who used hands-and-knees position in the first stage of labor.
JOGNN, 38, 391-398; 2009. DOI: 10.1111/j.1552-6909.2009.01038.x Accepted May 2009
Keywords Hands-and-knees labor position epidural
Robyn Stremler, RN, PhD, is an assistant professor at the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada. Stephen Halpern, MD, MSc, is a professor in the Department of Anesthesia, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, ON, Canada. Julie Weston, RN, MSc, is senior research coordinator at the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada. Jennifer Yee, RN, MSc, is a research nurse in the Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada. Ellen Hodnett, RN, PhD is Heather M. Reisman Chair and professor at the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada.
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urses assist laboring women to change their position during labor; positioning techniques are a type of comfort measure identi¢ed as an important component of labor support (Hodnett, 1996). Many laboring women wish to change position during labor and are encouraged to move among positions of usual care (Hundley, Milne, Glazener, & Mollison, 1997), but usual labor care is often centered on alternating between passive positions such as semi-sitting, sitting, and side-lying positions. Women might walk or stand during labor, although time spent in these positions is usually limited. Walking during labor may be limited because of caregiver reluctance to allow women to ambulate, because some women prefer to labor in bed (Roberts, Mendez-Bauer, & Wodell, 1983), and because cultural expectation may be to lie in bed for labor.
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Two large North American trials and two national surveys in the United States demonstrated that most women who labor in North American hospitals have continuous electronic fetal heart rate monitoring (EFM), regional analgesia, and intravenous oxytocin (Declercq, Sakala, Corry, & Applebaum, 2006; Declercq, Sakala, Corry, Applebaum, & Risher, 2002; Hodnett et al., 2002, 2008). Given the restrictions on movement posed by these interventions, it is not surprising that hospitalized women in labor spend much time in passive positions.
Hands-and-knees positioning has shown promise as an intervention to improve labor and birth outcomes (Stremler et al., 2005). Hands-and-knees position involves the laboring woman on all fours, so that her abdomen is suspended and her hips are at right angles to the £oor or bed. A randomized, controlled trial (RCT) of hands-andknees positioning for women laboring with a fetus in occipitoposterior (OP) position found reductions in persistent back pain and consistent trends toward bene¢t of use with respect to fetal head rotation following use of the position, fetal head position at delivery, operative delivery, 1 minute Apgar score, and time from randomization to delivery (Stremler et al.). There are multiple pathways whereby hands-andknees positioning during labor may increase the likelihood of spontaneous vaginal birth. Lying on the back or semi-sitting can result in poor alignment of the presenting fetal part with the pelvic canal. In recumbent positions, the spine is extended and the pelvis is tilted anteriorly; because the fetus is propelled in a line parallel with the maternal spine, this directs the presenting part into the pubis. When in hands-and-knees position, with the uterus falling forward, the angle between the uterus and the maternal spine is increased, the fetal head is directed toward the pelvic inlet, and £exion of the fetal head is encouraged (Fenwick & Simkin,1987).
& 2009 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
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Hands-and-Knees Positioning with Epidural
Hands-and-knees position has shown promise as an intervention to improve labor and birth outcomes.
When lying down or semi-sitting, the laboring woman’s weight is carried by the sacrum and coccyx, restricting posterior movement of the sacrum and thereby reducing pelvic outlet dimensions. In hands-and-knees position, the coccyx is freely mobile, which increases the diameter of the pelvic outlet (Biancuzzo, 1993a; Fenwick & Simkin, 1987; Hunter, Hofmeyr, & Kulier, 2007). Use of handsand-knees positioning may also allow gravity and buoyancy to act on the fetus, promoting rotation to or maintenance of the fetal head in the optimal anterior position (Andrews & Andrews,1983). Uterine blood £ow may also be improved in handsand-knees position. Supine positioning is known to compress the maternal inferior vena cava and aorta, which diverts blood to the internal vertebral venous plexus around the spinal canal (Hunter et al., 2007). Such compression of the inferior vena cava can lead to maternal hypotension, slow labor progress, and cause fetal distress (Oxorn, 1986). This may be avoided by using hands-and-knees position so that the weight of the uterus no longer occludes major blood vessels. Given the potential bene¢ts of hands-and-knees positioning, it may be especially important to examine its use for women laboring with an epidural given that use of epidural is associated with persistent malrotation, longer second stage, use of oxytocin, and instrumental delivery (Anim-Somuah, Smyth, & Howell, 2005; Leighton & Halpern, 2002; Lieberman, Davidson, Lee-Parritz, & Shearer, 2005). Because these deleterious outcomes may be related to pelvic £oor laxity and less e⁄cient descent and rotation through the birth canal, increasing mobility and optimizing relationships between the maternal pelvis and fetal head through the use of hands-and-knees may be bene¢cial. In spite of potential bene¢ts, hands-and-knees positioning for women laboring with an epidural elicits concerns about safety and acceptability. Orthostatic hypotension when moving to upright positions is a potential side e¡ect of epidural use (Mayberry, Clemmens, & De, 2002; Thorp & Breedlove, 1996); the e¡ects of hands-and-knees positioning on heart rate and blood pressure have not previously been examined. Concerns may also exist related to potential for falls due to reduced proprioceptive
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awareness and motor control with epidural analgesia. Similarly, while catheter dislodgements are rare events with epidural analgesia, it is unknown if hands-and-knees positioning increases risk of occurrence. The manipulation of body position required to move from a semi-sitting to hands-andknees position may increase the risk of shifting the position of the epidural catheter which may result in dislodgement or a change in e⁄cacy of analgesia. Finally, women’s views on the acceptability of hands-and-knees positioning during the ¢rst stage of labor with an epidural are needed before the position can be recommended for use.
Case Reports The women in these case reports are a subset of those in a larger RCTof hands-and-knees positioning during labor with an OP fetus (Stremler et al., 2005). Institutional research ethics board approval was attained, and 147 women were randomly assigned to the hands-and-knees group (greater than or equal to 30 minutes of hands-and-knees positioning over a 1 hour study period) or the control group (1 hour of usual care positioning) following con¢rmation of OP position of the fetal head by ultrasound. Women were assessed for ability to use hands-and-knees position before randomization; to be eligible the woman required the ability to £ex her hips and knees to move into hands-and-knees position, bear her own weight in hands-and-knees position, and remain stable. If needed, women were helped into hands-andknees position by their nurse or midwife. In training, before commencement of the study, sta¡ were encouraged to enroll women who may have needed some assistance getting into and out of handsand-knees position. However, to limit burden and to re£ect the nature of care in a labor and birth unit, sta¡ were not expected to enroll women who needed to be physically supported in the position throughout the 1 hour study period.Thirteen women with epidural were assigned to the hands-andknees positioning group. Baseline maternal heart rate and blood pressure and the highest and lowest maternal heart rate and blood pressure recorded while using handsand-knees position with epidural analgesia were abstracted from the medical chart. Baseline was de¢ned as the measurement closest to, but no more than 2 hours before use of hands-and-knees position, and with epidural analgesia in place. Cardiovascular instability was de¢ned as greater than 20% change from baseline for heart rate, systolic blood pressure, or diastolic blood pressure, or
JOGNN, 38, 391-398; 2009. DOI: 10.1111/j.1552-6909.2009.01038.x
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Hands-and-Knees Positioning with Epidural
Stremler, R., Halpern, S., Weston, J., Yee, J. and Hodnett, E.
less than 90 mm Hg systolic pressure while using hands-and-knees position. To determine the e¡ects of hands-and-knees positioning on analgesia women’s pre- and postintervention back pain scores using a self-report, vertical,10-point Visual Analogue Scale (VAS) were examined. Visual Analogue Scale for pain measurement has excellent reliability and validity (Scott & Huskisson, 1976), and there is good correlation between horizontal and vertical VAS (Breivik & Skoglund, 1998). The VAS had a marked sliding piece, which the laboring woman moved along the line to represent the amount of back pain she was experiencing with the anchors of the line representing no back pain at all and the worst back pain imaginable. Gradations on the back of the VAS allowed the nurse or midwife to measure and record the score. The VAS was completed immediately before randomization and immediately following completion of the 1 hour study period in which hands-and-knees position was used. As a measure of acceptability of hands-and-knees positioning to women, the nurse or midwife recorded the amount of time spent in hands-andknees position by the woman. In the postpartum period, women completed a questionnaire in which they were asked ‘‘If you were to give birth again, would you like to use hands and knees position?’’ If women responded no, they were asked to select reasons: embarrassing, awkward, uncomfortable, tiring, or their own reason. If women responded yes, they were asked to select reasons from more comfortable, helps labor progress, or provide their own response. These questions were investigator designed and do not have evidence of reliability or validity, but future preferences are indicators of satisfaction with care (Hodnett, 2002). Women were also asked to provide written comments about their experience using hands-and-knees positioning. Case characteristics are displayed in Table 1. Women were recruited from three urban, universitya⁄liated hospitals (Cases 1-9 in Central Canada, Cases 10-12 in Atlantic Canada, and Case 13 in Israel). Mean maternal age was 33.5 2.7 years and mean gestational age was 40.1 1.3 weeks. All women received continuous EFM. Data related to cardiovascular stability, analgesia e⁄cacy, and acceptability of use of hands-and-knees position are displayed in Table 2. There were no documented falls or catheter dislodgements during use of hands-and-knees position. No women used hands-and-knees positioning beyond the 1 hour study period required by the RCT protocol.
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Limited data exist related to safety and acceptability of use of hands-and-knees position during labor with an epidural.
Discussion Although there was variation in time spent in handsand-knees position, all but one woman spent at least 30 minutes in hands-and-knees positioning. Five women spent 50 minutes or more in handsand-knees position, taking only brief rests in other positions. These women all noted that they were comfortable in hands-and-knees position, which likely explains why they spent very little time during the hour in alternate positions, although they were allowed to do so. Seven women spent relatively equal amounts of time in hands-and-knees position and resting in another position or receiving nursing care such as fetal assessment or changes of gowns and pads. One woman was unable to continue in hands-and-knees position due to fetal heart rate decelerations; she did note that in the brief time she used the position she was comfortable. The possibility exists that use of hands-andknees position contributed to the abnormal fetal heart rate pattern, but decelerations had also been observed before participation in the study. Re£ective of variation in clinical practice, there were di¡erences across cases in drugs used for initiation and maintenance of epidural analgesia and amount of time the epidural was in place before hands-andknees position. Variation in epidural, progress of labor, or use of hands-and-knees position may have led to the two observed increases in pain during use of hands-and-knees position. One woman required an epidural bolus during use of hands-and-knees position, yet maintained a pain score of 0 after use of the position while another woman’s pain score increased from no pain to mild pain. Most women in the case series experienced no change in the e⁄cacy of their epidural ; 10 women maintained pain scores of 0 and 7 of those women noted that they felt comfortable using the position. Pain level during use of hands-and-knees position with epidural analgesia should be assessed to verify that maternal comfort is maintained. Responses to the question about future use of hands-and-knees position were mixed. Eight women stated that they would use the position in a future labor, with 6 of them either citing increased comfort as a reason for doing so or describing feelings of comfort in their written comments. Two of the 8 women noted that they had used hands-and-
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Hands-and-Knees Positioning with Epidural
Table 1: Case Characteristics Length of Time Cervical Dilatation
Epidural in Place
Case
Parity
in the Hour Before HK
Epidural Initiation
Epidural Maintenance
1
Nulliparous
3-6 cm
CSE with opioid
Continuous infusion with opioid
Before HK (hr) 3.02
2
Nulliparous
Not available
Epidural without opioid
PCEA with opioid
0.85
3
Nulliparous
46 cm
CSE with opioid
Continuous infusion with opioid
2.17
4
Nulliparous
o3 cm
Epidural with opioid
PCEA with opioid
3.40
5
Nulliparous
46 cm
Epidural with opioid
PCEA with opioid
9.40
6
Nulliparous
Not available
Epidural with opioid
PCEA with opioid
2.17
7
Nulliparous
3-6 cm
Epidural without opioid
PCEA with opioid
5.05
8
Nulliparous
Not available
CSE with opioid
PCEA with opioid
3.75
9
Nulliparous
Not available
Epidural with opioid
Continuous infusion with opioid
2.88
10
Nulliparous
46 cm
Epidural with opioid
PCEA with opioid
10.92
11
Nulliparous
Not available
Epidural with opioid
PCEA with opioid
2.42
12
Nulliparous
3-6 cm
Epidural with opioid
PCEA with opioid
8.87
13
Multiparous
3-6 cm
Epidural without opioid
Epidural bolus as needed
3.60
Note. CSE 5 combined spinal-epidural analgesia; HK 5 hands-and-knees positioning; PCEA 5 patient-controlled epidural analgesia.
knees position during their pregnancies and found it bene¢cial. Women who have been taught in prenatal classes to use position changes as a way of coping with labor wish to have their use encouraged and reinforced by nurses (Spiby, Henderson, Slade, Escott, & Fraser,1999). Nurses should assess what positions women have used prenatally to determine what they have found helpful.
Three women described additional bene¢ts of hands-and-knees position in labor including increased progress, movement of the fetus, and feelings of strength while using the position. Hands-and-knees positioning can be seen as an active as opposed to passive form of maternal positioning. Such active positioning may facilitate feelings of control or active participation in labor, which leads to increased satisfaction with childbirth (Brown & Lumley,1994). Four women stated they would not use hands-andknees position in a future labor. One of those women did not give a reason for this choice and noted in her comments that she felt comfortable during use of the position, so this may have been a response error. The woman who required increased epidural analgesia felt uncomfortable in handsand-knees position as did the woman whose pain
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score increased over the study period. One woman responded that she would not use the position again as she found it uncomfortable, awkward, and tiring; she additionally commented that it did not help to change the fetal head position. In this small sample, there was variation in acceptability of use of hands-and-knees position, highlighting that nurses must assess women’s views of e⁄cacy of positions. No falls or catheter dislodgements were observed among the 13 women. Missing heart rate and blood pressure data during this time were surprising given that all the women had epidural analgesia in place, and frequent charting of such data are standard of care in the participating institutions. Although one woman experienced an increase of greater than 20% from baseline, her heart rate remained within normal parameters, so this increase is likely not clinically signi¢cant. Missing data and the rarity of events such as falls and catheter dislodgements limits conclusions around e¡ects of hands-andknees position on safety. A large sample of women using hands-and-knees position would be required to provide conclusive evidence that use of the position did not increase risk. The women in the case series suggested simple strategies for making hands-and-knees position
JOGNN, 38, 391-398; 2009. DOI: 10.1111/j.1552-6909.2009.01038.x
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Hands-and-Knees Positioning with Epidural
Stremler, R., Halpern, S., Weston, J., Yee, J. and Hodnett, E.
Table 2: Cardiovascular Stability, Epidural Analgesia Efficacy and Acceptability of Hands-and-Knees Position Would Woman Cardiovascular
Use HK Again
Amount of Time
Instability
Pain VAS Score
and Reasons
Case
in HK (min)
During HK
After Use of HK
Given?
Other Comments
1
55
None
0
Yes
I found this position not only
More comfortable Helps labor progress 2
60
None
0
No
comfortable in labor but in the pregnancy (last 2 months) as well. Alleviating pressure from my back giving a sense of weightlessness. I was very comfortable during HK. I feel this was because of adjustment of the hospital bed and epidural analgesia.
3
40
None
0 (Epidural bolus required)
No Uncomfortable
I did not ¢nd the position very comfortable. I had to stop hands and knees as my lower back started to hurt and ache notwithstanding that I had an epidural. I do not know if it was caused by HK or if the ache was caused by the fact that the epidural strength lessened.
4
55
None
0
Yes More comfortable
5
32
None
0
No
Very comfortable. Felt the fetus move. Relieved some backache. Very easy to maintain position. No comments
Awkward Uncomfortable Tiring Didn’t help (change baby’s position) 6
55
None
0
Yes More comfortable
Comfort level was ¢ne. I used the position when ¢rst in labor before the epidural as it made me feel I could manage the pain better. Had to lie down once the epidural was administered for fetal monitoring.
7
30
None
0
Yes
Was a bit di⁄cult staying in that position with pressure on your hands. With the IV in my hand made it a bit uncomfortable. In HK I swayed side to side as well. Felt a bit more at ease doing this.
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Hands-and-Knees Positioning with Epidural
Table 2. Continued Would Woman Cardiovascular
Use HK Again
Amount of Time
Instability
Pain VAS Score
and Reasons
Case
in HK (min)
During HK
After Use of HK
Given?
Other Comments
8
50
HR increase
0
Yes
For ¢rst time that I tried this position
from 68 to 84
I was feeling pressure because of epidural, but by thinking that I was working for my child I was feeling very comfortable and strong. Using pillows as a support of my hands was very comfortable.
9
30
HR none; BP
0
Yes
missing
I used HK during my pregnancy as part of my yoga so I was comfortable with this position. When I began my labor I used this position to help reduce the back pain. I found it unbearable to stay lying or in side-lying during contractions.
10
3
BP none; HR
Not available as fetal
missing
Yes
I was only in HK for about 60 s. The
heart rate
baby’s heart beat dropped in half.
decelerations
I was told to go back to the side
occurred and HK was
position. I did ¢nd that leaning on
discontinued
the ball made HK very comfortable.
11
32
HR missing; BP
1.75
No
missing
Before epidural could not use HK at allçtoo uncomfortable. After epidural tried again but still uncomfortableçleaning on elbows helped some.
12
31
HR missing; BP
0
Yes
missing
Only di⁄culty was the IV needle sticking into arm during position holdçuncomfortable. Other than thatç¢ne.
13
33
HR missing; BP missing
Not available as
Postpartum
delivered
questionnaire
precipitously
not
Postpartum questionnaire not completed
completed Note. BP 5 blood pressure; HK 5 hands-and-knees positioning; HR 5 heart rate; VAS 5 visual analogue scale (score range 0-10).
more comfortable, which nurses could easily implement. To relieve weight-bearing from the hands a surface may be provided (e.g. birthing ball, pillows, head of the bed, bedside table) on which a woman could lean with her forearms while still maintaining her hips directly over her knees with the abdomen hanging freely. If hands-and-knees position is used
396
by laboring women, a position of rest that does not bear weight on the wrists or knees should be alternated with hands and knees position at least every 15 minutes (Biancuzzo,1993b). Although 8 women stated that they would use hands-and-knees position in future labors, none
JOGNN, 38, 391-398; 2009. DOI: 10.1111/j.1552-6909.2009.01038.x
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Hands-and-Knees Positioning with Epidural
Stremler, R., Halpern, S., Weston, J., Yee, J. and Hodnett, E.
continued to use the position after the required study hour, although they were free to do so. This may suggest limited acceptability of the position. Alternately, there may have been women who wished to use hands-and-knees positioning that were unable to do so. As labor progresses, interventions may increase making use of handsand-knees position more di⁄cult; for example, internal EFM may be used and decreased mobility due to increased sensory and motor blockade may occur. Nurses’ preferences regarding positioning may also be in£uential ; some women may need assistance, encouragement, or approval from clinicians in order to use hands-and-knees position.
Intrapartum nurses should assess women’s experiences using hands-and-knees position including ease of use of the position and efficacy of analgesia.
Acknowledgments Funded by Canadian Institutes of Health Research RCT grant MCT 50421 and Fellowship and New Investigator Awards.
REFERENCES Andrews, C. M., & Andrews, E. C. (1983). Nursing, maternal postures, and fetal position. Nursing Research, 32, 336-341. Angus, J., Hodnett, E., & O’Brien-Pallas, L. (2003). Implementing evidence-based nursing practice: A tale of two intrapartum nursing
Women may wish to try other positions but if not supported in doing so by their care provider are unlikely to initiate position changes on their own, particularly with an epidural in place. Incorporating hands-and-knees positioning into a nurse’s repertoire is simply an expansion of commonly used labor support techniques. However, nurses require familiarity and comfort with hands-and-knees position and must have the time and be willing to provide physical assistance and psychological support to the woman for her to assume alternate positions. Furthermore, institutional support is needed to introduce practice change related to positioning during labor with an epidural. Success of nursing practice change is in£uenced by the social context of the unit, including formal and informal policies (Angus, Hodnett, & O’Brien-Pallas, 2003; Hodnett et al.,1996).
units. Nursing Inquiry, 10, 218-228. Anim-Somuah, M., Smyth, R., & Howell, C. (2005). Epidural versus nonepidural or no analgesia in labour. Cochrane Database of Systematic Reviews, 4, CD000331. DOI: 10.1002/14651858.CD000331. pub2. Biancuzzo, M. (1993a). Six myths of maternal posture during labor. American Journal of Maternal Child Nursing, 18, 264-269. Biancuzzo, M. (1993b). How to recognize and rotate an occiput posterior fetus. American Journal of Nursing, 93, 38-41. Breivik, E. K., & Skoglund, L. A. (1998). Comparison of present pain intensity assessments on horizontally and vertically oriented visual analogue scales. Methods and Findings in Experimental and Clinical Pharmacology, 20, 719-724. Brown, S., & Lumley, J. (1994). Satisfaction with care in labor and birth: A survey of 790 Australian women. Birth, 21, 4-13. Collis, R. E., Davies, D. W. L., & Aveling, W. (1995). Randomised comparison of combined spinal-epidural and standard epidural analgesia in labour. Lancet, 345, 1413-1416. Declercq, E. R., Sakala, C., Corry, M. P., & Applebaum, S. (2006). Listening to mothers II: Report of the second national U.S. survey of women’s childbearing experiences. Retrieved January 6, 2009 from http:// www.childbirthconnection.org/article.asp?ClickedLink=205&ck=
While positioning is a key component of labor support, little empirical evidence exists linking positioning strategies to improved labor and birth outcomes. Given that women have expressed satisfaction with epidural techniques that allow for mobility (Collis, Davies, & Aveling, 1995) it is important to consider hands-and-knees positioning as an option during labor with epidural. Although there are trends toward bene¢t of use of handsand-knees position with respect to optimal fetal head position and decreased operative delivery (Stremler et al., 2005), the small sample size of this case series of women who used the position with an epidural limits our ability to draw conclusions around safety and acceptability of the position. Given the potential for improvement in birth outcomes, more research with a larger sample size is needed to rigorously examine safety, acceptability, and the e¡ects of hands-and-knees position on labor and birth outcomes in a large RCTof laboring women, including those with epidural.
JOGNN 2009; Vol. 38, Issue 4
10068&area=2 Declercq, E. R., Sakala, C., Corry, M. P., Applebaum, S., & Risher, P. (2002). Listening to mothers: Report of the ¢rst national U.S. survey of women’s childbearing experiences. Retrieved January 6, 2009 from
http://www.childbirthconnection.org/article.asp?Clicked
Link=205&ck=10068&area=2 Fenwick, L., & Simkin, P. (1987). Maternal positioning to prevent or alleviate dystocia in labor. Clinical Obstetrics and Gynecology, 30, 8389. Hodnett, E. (1996). Nursing support of the laboring woman. Journal of Obstetric, Gynecologic & Neonatal Nursing, 25, 257-264. Hodnett, E. D. (2002). Pain and women’s satisfaction with the experience of childbirth: A systematic review. American Journal of Obstetrics and Gynecology, 186, S160-S172. Hodnett, E. D., Kaufman, K., O’Brien-Pallas, L., Chipman, M., Watson-MacDonell, J., & Hunsburger, W. (1996). A strategy to promote researchbased nursing care: E¡ects on childbirth outcomes. Research in Nursing and Health, 19,13-20. Hodnett, E. D., Lowe, N. K., Hannah, M., Willan, A., Stevens, B., Weston, J., et al. (2002). E¡ectiveness of nurses as providers of birth labor support in North American hospitals. Journal of the American Medical Association, 288, 1373-1381. Hodnett, E. D., Stremler, R., Willan, A. R., Weston, J. A., Lowe, N. K., Simpson, K. R., et al. (2008). E¡ect on birth outcomes of a formalized ap-
397
Hands-and-Knees Positioning with Epidural
proach to care in early labour assessment units: An international,
Mayberry, L. J., Clemmens, D., & De, A. (2002). Epidural analgesia side
randomised controlled trial. British Medical Journal, 337, a1021.
e¡ects, co-interventions, and care of women during childbirth:
DOI: 10.1136/bmj.a1021.
A systematic review. American Journal of Obstetrics and Gynecol-
Hundley, V. A., Milne, J. M., Glazener, C. M., & Mollison, J. (1997). Satisfaction and the three C’s: Continuity, choice and control. Women’s views from a randomised controlled trial of midwife-led care. British Journal of Obstetrics and Gynaecology, 104, 1273-1280. Hunter, S., Hofmeyr, G. J., & Kulier, R. (2007). Hands and knees posture in late pregnancy or labour for fetal malposition (lateral or posterior). Cochrane Database of Systematic Reviews, 4, CD001063. DOI: 10. 1002/14651858.CD001063.pub3 Leighton, B. L., & Halpern, S. H. (2002). The e¡ect of epidural analgesia on labor, maternal and neonatal outcomes: A systematic review. American Journal of Obstetrics and Gynecology, 186, S69-S77. Lieberman, E., Davidson, K., Lee-Parritz, A., & Shearer, E. (2005).
Appleton & Lange. Roberts, J. E., Mendez-Bauer, C., & Wodell, D. A. (1983). The e¡ects of maternal position on uterine contractility and e⁄ciency. Birth, 10, 243249. Scott, J., & Huskisson, E. C. (1976). Graphic representation of pain. Pain, 2, 175-184. Spiby, H., Henderson, B., Slade, P., Escott, D., & Fraser, R. B. (1999). Strategies for coping with labour: Does antenatal education translate into practice? Journal of Advanced Nursing, 29, 388-394. Stremler, R., Hodnett, E., Petryshen, P., Stevens, B., Weston, J., & Willan, A. R. (2005). Randomized controlled trial of hands-and-knees position-
Changes in fetal position during labor and their association with
ing for occipitoposterior position in labor. Birth, 32, 243-251.
epidural analgesia. American Journal of Obstetrics and Gynecol-
Thorp, J. A., & Breedlove, G. (1996). Epidural analgesia in labor: An eval-
ogy, 105, 974-982.
398
ogy, 186, S81-S93. Oxorn, H. (1986). Oxorn-foote human labor & birth (5th ed.). Norwalk, CT:
uation of risks and bene¢ts. Birth, 23, 63-83.
JOGNN, 38, 391-398; 2009. DOI: 10.1111/j.1552-6909.2009.01038.x
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CASE REPORT
Hands-and-Knees Positioning During Labor With Epidural Analgesia Robyn Stremler, Stephen Halpern, Julie Weston, Jennifer Yee, and Ellen Hodnett
Correspondence Robyn Stremler, RN, PhD, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Room 288, Toronto, ON, M5T 1P8, Canada. [email protected]
ABSTRACT Hands-and-knees position has shown promise as an intervention to improve labor and birth outcomes, but no reports exist that examine its use with women laboring with epidural analgesia. Concerns of safety, effects on analgesia, and acceptability of use may limit use of active positioning during labor with regional analgesia. This article presents a case study series of 13 women who used hands-and-knees position in the first stage of labor.
JOGNN, 38, 391-398; 2009. DOI: 10.1111/j.1552-6909.2009.01038.x Accepted May 2009
Keywords Hands-and-knees labor position epidural
Robyn Stremler, RN, PhD, is an assistant professor at the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada. Stephen Halpern, MD, MSc, is a professor in the Department of Anesthesia, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, ON, Canada. Julie Weston, RN, MSc, is senior research coordinator at the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada. Jennifer Yee, RN, MSc, is a research nurse in the Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada. Ellen Hodnett, RN, PhD is Heather M. Reisman Chair and professor at the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada.
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urses assist laboring women to change their position during labor; positioning techniques are a type of comfort measure identi¢ed as an important component of labor support (Hodnett, 1996). Many laboring women wish to change position during labor and are encouraged to move among positions of usual care (Hundley, Milne, Glazener, & Mollison, 1997), but usual labor care is often centered on alternating between passive positions such as semi-sitting, sitting, and side-lying positions. Women might walk or stand during labor, although time spent in these positions is usually limited. Walking during labor may be limited because of caregiver reluctance to allow women to ambulate, because some women prefer to labor in bed (Roberts, Mendez-Bauer, & Wodell, 1983), and because cultural expectation may be to lie in bed for labor.
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Two large North American trials and two national surveys in the United States demonstrated that most women who labor in North American hospitals have continuous electronic fetal heart rate monitoring (EFM), regional analgesia, and intravenous oxytocin (Declercq, Sakala, Corry, & Applebaum, 2006; Declercq, Sakala, Corry, Applebaum, & Risher, 2002; Hodnett et al., 2002, 2008). Given the restrictions on movement posed by these interventions, it is not surprising that hospitalized women in labor spend much time in passive positions.
Hands-and-knees positioning has shown promise as an intervention to improve labor and birth outcomes (Stremler et al., 2005). Hands-and-knees position involves the laboring woman on all fours, so that her abdomen is suspended and her hips are at right angles to the £oor or bed. A randomized, controlled trial (RCT) of hands-andknees positioning for women laboring with a fetus in occipitoposterior (OP) position found reductions in persistent back pain and consistent trends toward bene¢t of use with respect to fetal head rotation following use of the position, fetal head position at delivery, operative delivery, 1 minute Apgar score, and time from randomization to delivery (Stremler et al.). There are multiple pathways whereby hands-andknees positioning during labor may increase the likelihood of spontaneous vaginal birth. Lying on the back or semi-sitting can result in poor alignment of the presenting fetal part with the pelvic canal. In recumbent positions, the spine is extended and the pelvis is tilted anteriorly; because the fetus is propelled in a line parallel with the maternal spine, this directs the presenting part into the pubis. When in hands-and-knees position, with the uterus falling forward, the angle between the uterus and the maternal spine is increased, the fetal head is directed toward the pelvic inlet, and £exion of the fetal head is encouraged (Fenwick & Simkin,1987).
& 2009 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
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Hands-and-Knees Positioning with Epidural
Hands-and-knees position has shown promise as an intervention to improve labor and birth outcomes.
When lying down or semi-sitting, the laboring woman’s weight is carried by the sacrum and coccyx, restricting posterior movement of the sacrum and thereby reducing pelvic outlet dimensions. In hands-and-knees position, the coccyx is freely mobile, which increases the diameter of the pelvic outlet (Biancuzzo, 1993a; Fenwick & Simkin, 1987; Hunter, Hofmeyr, & Kulier, 2007). Use of handsand-knees positioning may also allow gravity and buoyancy to act on the fetus, promoting rotation to or maintenance of the fetal head in the optimal anterior position (Andrews & Andrews,1983). Uterine blood £ow may also be improved in handsand-knees position. Supine positioning is known to compress the maternal inferior vena cava and aorta, which diverts blood to the internal vertebral venous plexus around the spinal canal (Hunter et al., 2007). Such compression of the inferior vena cava can lead to maternal hypotension, slow labor progress, and cause fetal distress (Oxorn, 1986). This may be avoided by using hands-and-knees position so that the weight of the uterus no longer occludes major blood vessels. Given the potential bene¢ts of hands-and-knees positioning, it may be especially important to examine its use for women laboring with an epidural given that use of epidural is associated with persistent malrotation, longer second stage, use of oxytocin, and instrumental delivery (Anim-Somuah, Smyth, & Howell, 2005; Leighton & Halpern, 2002; Lieberman, Davidson, Lee-Parritz, & Shearer, 2005). Because these deleterious outcomes may be related to pelvic £oor laxity and less e⁄cient descent and rotation through the birth canal, increasing mobility and optimizing relationships between the maternal pelvis and fetal head through the use of hands-and-knees may be bene¢cial. In spite of potential bene¢ts, hands-and-knees positioning for women laboring with an epidural elicits concerns about safety and acceptability. Orthostatic hypotension when moving to upright positions is a potential side e¡ect of epidural use (Mayberry, Clemmens, & De, 2002; Thorp & Breedlove, 1996); the e¡ects of hands-and-knees positioning on heart rate and blood pressure have not previously been examined. Concerns may also exist related to potential for falls due to reduced proprioceptive
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awareness and motor control with epidural analgesia. Similarly, while catheter dislodgements are rare events with epidural analgesia, it is unknown if hands-and-knees positioning increases risk of occurrence. The manipulation of body position required to move from a semi-sitting to hands-andknees position may increase the risk of shifting the position of the epidural catheter which may result in dislodgement or a change in e⁄cacy of analgesia. Finally, women’s views on the acceptability of hands-and-knees positioning during the ¢rst stage of labor with an epidural are needed before the position can be recommended for use.
Case Reports The women in these case reports are a subset of those in a larger RCTof hands-and-knees positioning during labor with an OP fetus (Stremler et al., 2005). Institutional research ethics board approval was attained, and 147 women were randomly assigned to the hands-and-knees group (greater than or equal to 30 minutes of hands-and-knees positioning over a 1 hour study period) or the control group (1 hour of usual care positioning) following con¢rmation of OP position of the fetal head by ultrasound. Women were assessed for ability to use hands-and-knees position before randomization; to be eligible the woman required the ability to £ex her hips and knees to move into hands-and-knees position, bear her own weight in hands-and-knees position, and remain stable. If needed, women were helped into hands-andknees position by their nurse or midwife. In training, before commencement of the study, sta¡ were encouraged to enroll women who may have needed some assistance getting into and out of handsand-knees position. However, to limit burden and to re£ect the nature of care in a labor and birth unit, sta¡ were not expected to enroll women who needed to be physically supported in the position throughout the 1 hour study period.Thirteen women with epidural were assigned to the hands-andknees positioning group. Baseline maternal heart rate and blood pressure and the highest and lowest maternal heart rate and blood pressure recorded while using handsand-knees position with epidural analgesia were abstracted from the medical chart. Baseline was de¢ned as the measurement closest to, but no more than 2 hours before use of hands-and-knees position, and with epidural analgesia in place. Cardiovascular instability was de¢ned as greater than 20% change from baseline for heart rate, systolic blood pressure, or diastolic blood pressure, or
JOGNN, 38, 391-398; 2009. DOI: 10.1111/j.1552-6909.2009.01038.x
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Hands-and-Knees Positioning with Epidural
Stremler, R., Halpern, S., Weston, J., Yee, J. and Hodnett, E.
less than 90 mm Hg systolic pressure while using hands-and-knees position. To determine the e¡ects of hands-and-knees positioning on analgesia women’s pre- and postintervention back pain scores using a self-report, vertical,10-point Visual Analogue Scale (VAS) were examined. Visual Analogue Scale for pain measurement has excellent reliability and validity (Scott & Huskisson, 1976), and there is good correlation between horizontal and vertical VAS (Breivik & Skoglund, 1998). The VAS had a marked sliding piece, which the laboring woman moved along the line to represent the amount of back pain she was experiencing with the anchors of the line representing no back pain at all and the worst back pain imaginable. Gradations on the back of the VAS allowed the nurse or midwife to measure and record the score. The VAS was completed immediately before randomization and immediately following completion of the 1 hour study period in which hands-and-knees position was used. As a measure of acceptability of hands-and-knees positioning to women, the nurse or midwife recorded the amount of time spent in hands-andknees position by the woman. In the postpartum period, women completed a questionnaire in which they were asked ‘‘If you were to give birth again, would you like to use hands and knees position?’’ If women responded no, they were asked to select reasons: embarrassing, awkward, uncomfortable, tiring, or their own reason. If women responded yes, they were asked to select reasons from more comfortable, helps labor progress, or provide their own response. These questions were investigator designed and do not have evidence of reliability or validity, but future preferences are indicators of satisfaction with care (Hodnett, 2002). Women were also asked to provide written comments about their experience using hands-and-knees positioning. Case characteristics are displayed in Table 1. Women were recruited from three urban, universitya⁄liated hospitals (Cases 1-9 in Central Canada, Cases 10-12 in Atlantic Canada, and Case 13 in Israel). Mean maternal age was 33.5 2.7 years and mean gestational age was 40.1 1.3 weeks. All women received continuous EFM. Data related to cardiovascular stability, analgesia e⁄cacy, and acceptability of use of hands-and-knees position are displayed in Table 2. There were no documented falls or catheter dislodgements during use of hands-and-knees position. No women used hands-and-knees positioning beyond the 1 hour study period required by the RCT protocol.
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Limited data exist related to safety and acceptability of use of hands-and-knees position during labor with an epidural.
Discussion Although there was variation in time spent in handsand-knees position, all but one woman spent at least 30 minutes in hands-and-knees positioning. Five women spent 50 minutes or more in handsand-knees position, taking only brief rests in other positions. These women all noted that they were comfortable in hands-and-knees position, which likely explains why they spent very little time during the hour in alternate positions, although they were allowed to do so. Seven women spent relatively equal amounts of time in hands-and-knees position and resting in another position or receiving nursing care such as fetal assessment or changes of gowns and pads. One woman was unable to continue in hands-and-knees position due to fetal heart rate decelerations; she did note that in the brief time she used the position she was comfortable. The possibility exists that use of hands-andknees position contributed to the abnormal fetal heart rate pattern, but decelerations had also been observed before participation in the study. Re£ective of variation in clinical practice, there were di¡erences across cases in drugs used for initiation and maintenance of epidural analgesia and amount of time the epidural was in place before hands-andknees position. Variation in epidural, progress of labor, or use of hands-and-knees position may have led to the two observed increases in pain during use of hands-and-knees position. One woman required an epidural bolus during use of hands-and-knees position, yet maintained a pain score of 0 after use of the position while another woman’s pain score increased from no pain to mild pain. Most women in the case series experienced no change in the e⁄cacy of their epidural ; 10 women maintained pain scores of 0 and 7 of those women noted that they felt comfortable using the position. Pain level during use of hands-and-knees position with epidural analgesia should be assessed to verify that maternal comfort is maintained. Responses to the question about future use of hands-and-knees position were mixed. Eight women stated that they would use the position in a future labor, with 6 of them either citing increased comfort as a reason for doing so or describing feelings of comfort in their written comments. Two of the 8 women noted that they had used hands-and-
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Hands-and-Knees Positioning with Epidural
Table 1: Case Characteristics Length of Time Cervical Dilatation
Epidural in Place
Case
Parity
in the Hour Before HK
Epidural Initiation
Epidural Maintenance
1
Nulliparous
3-6 cm
CSE with opioid
Continuous infusion with opioid
Before HK (hr) 3.02
2
Nulliparous
Not available
Epidural without opioid
PCEA with opioid
0.85
3
Nulliparous
46 cm
CSE with opioid
Continuous infusion with opioid
2.17
4
Nulliparous
o3 cm
Epidural with opioid
PCEA with opioid
3.40
5
Nulliparous
46 cm
Epidural with opioid
PCEA with opioid
9.40
6
Nulliparous
Not available
Epidural with opioid
PCEA with opioid
2.17
7
Nulliparous
3-6 cm
Epidural without opioid
PCEA with opioid
5.05
8
Nulliparous
Not available
CSE with opioid
PCEA with opioid
3.75
9
Nulliparous
Not available
Epidural with opioid
Continuous infusion with opioid
2.88
10
Nulliparous
46 cm
Epidural with opioid
PCEA with opioid
10.92
11
Nulliparous
Not available
Epidural with opioid
PCEA with opioid
2.42
12
Nulliparous
3-6 cm
Epidural with opioid
PCEA with opioid
8.87
13
Multiparous
3-6 cm
Epidural without opioid
Epidural bolus as needed
3.60
Note. CSE 5 combined spinal-epidural analgesia; HK 5 hands-and-knees positioning; PCEA 5 patient-controlled epidural analgesia.
knees position during their pregnancies and found it bene¢cial. Women who have been taught in prenatal classes to use position changes as a way of coping with labor wish to have their use encouraged and reinforced by nurses (Spiby, Henderson, Slade, Escott, & Fraser,1999). Nurses should assess what positions women have used prenatally to determine what they have found helpful.
Three women described additional bene¢ts of hands-and-knees position in labor including increased progress, movement of the fetus, and feelings of strength while using the position. Hands-and-knees positioning can be seen as an active as opposed to passive form of maternal positioning. Such active positioning may facilitate feelings of control or active participation in labor, which leads to increased satisfaction with childbirth (Brown & Lumley,1994). Four women stated they would not use hands-andknees position in a future labor. One of those women did not give a reason for this choice and noted in her comments that she felt comfortable during use of the position, so this may have been a response error. The woman who required increased epidural analgesia felt uncomfortable in handsand-knees position as did the woman whose pain
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score increased over the study period. One woman responded that she would not use the position again as she found it uncomfortable, awkward, and tiring; she additionally commented that it did not help to change the fetal head position. In this small sample, there was variation in acceptability of use of hands-and-knees position, highlighting that nurses must assess women’s views of e⁄cacy of positions. No falls or catheter dislodgements were observed among the 13 women. Missing heart rate and blood pressure data during this time were surprising given that all the women had epidural analgesia in place, and frequent charting of such data are standard of care in the participating institutions. Although one woman experienced an increase of greater than 20% from baseline, her heart rate remained within normal parameters, so this increase is likely not clinically signi¢cant. Missing data and the rarity of events such as falls and catheter dislodgements limits conclusions around e¡ects of hands-andknees position on safety. A large sample of women using hands-and-knees position would be required to provide conclusive evidence that use of the position did not increase risk. The women in the case series suggested simple strategies for making hands-and-knees position
JOGNN, 38, 391-398; 2009. DOI: 10.1111/j.1552-6909.2009.01038.x
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Hands-and-Knees Positioning with Epidural
Stremler, R., Halpern, S., Weston, J., Yee, J. and Hodnett, E.
Table 2: Cardiovascular Stability, Epidural Analgesia Efficacy and Acceptability of Hands-and-Knees Position Would Woman Cardiovascular
Use HK Again
Amount of Time
Instability
Pain VAS Score
and Reasons
Case
in HK (min)
During HK
After Use of HK
Given?
Other Comments
1
55
None
0
Yes
I found this position not only
More comfortable Helps labor progress 2
60
None
0
No
comfortable in labor but in the pregnancy (last 2 months) as well. Alleviating pressure from my back giving a sense of weightlessness. I was very comfortable during HK. I feel this was because of adjustment of the hospital bed and epidural analgesia.
3
40
None
0 (Epidural bolus required)
No Uncomfortable
I did not ¢nd the position very comfortable. I had to stop hands and knees as my lower back started to hurt and ache notwithstanding that I had an epidural. I do not know if it was caused by HK or if the ache was caused by the fact that the epidural strength lessened.
4
55
None
0
Yes More comfortable
5
32
None
0
No
Very comfortable. Felt the fetus move. Relieved some backache. Very easy to maintain position. No comments
Awkward Uncomfortable Tiring Didn’t help (change baby’s position) 6
55
None
0
Yes More comfortable
Comfort level was ¢ne. I used the position when ¢rst in labor before the epidural as it made me feel I could manage the pain better. Had to lie down once the epidural was administered for fetal monitoring.
7
30
None
0
Yes
Was a bit di⁄cult staying in that position with pressure on your hands. With the IV in my hand made it a bit uncomfortable. In HK I swayed side to side as well. Felt a bit more at ease doing this.
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395
Hands-and-Knees Positioning with Epidural
Table 2. Continued Would Woman Cardiovascular
Use HK Again
Amount of Time
Instability
Pain VAS Score
and Reasons
Case
in HK (min)
During HK
After Use of HK
Given?
Other Comments
8
50
HR increase
0
Yes
For ¢rst time that I tried this position
from 68 to 84
I was feeling pressure because of epidural, but by thinking that I was working for my child I was feeling very comfortable and strong. Using pillows as a support of my hands was very comfortable.
9
30
HR none; BP
0
Yes
missing
I used HK during my pregnancy as part of my yoga so I was comfortable with this position. When I began my labor I used this position to help reduce the back pain. I found it unbearable to stay lying or in side-lying during contractions.
10
3
BP none; HR
Not available as fetal
missing
Yes
I was only in HK for about 60 s. The
heart rate
baby’s heart beat dropped in half.
decelerations
I was told to go back to the side
occurred and HK was
position. I did ¢nd that leaning on
discontinued
the ball made HK very comfortable.
11
32
HR missing; BP
1.75
No
missing
Before epidural could not use HK at allçtoo uncomfortable. After epidural tried again but still uncomfortableçleaning on elbows helped some.
12
31
HR missing; BP
0
Yes
missing
Only di⁄culty was the IV needle sticking into arm during position holdçuncomfortable. Other than thatç¢ne.
13
33
HR missing; BP missing
Not available as
Postpartum
delivered
questionnaire
precipitously
not
Postpartum questionnaire not completed
completed Note. BP 5 blood pressure; HK 5 hands-and-knees positioning; HR 5 heart rate; VAS 5 visual analogue scale (score range 0-10).
more comfortable, which nurses could easily implement. To relieve weight-bearing from the hands a surface may be provided (e.g. birthing ball, pillows, head of the bed, bedside table) on which a woman could lean with her forearms while still maintaining her hips directly over her knees with the abdomen hanging freely. If hands-and-knees position is used
396
by laboring women, a position of rest that does not bear weight on the wrists or knees should be alternated with hands and knees position at least every 15 minutes (Biancuzzo,1993b). Although 8 women stated that they would use hands-and-knees position in future labors, none
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Hands-and-Knees Positioning with Epidural
Stremler, R., Halpern, S., Weston, J., Yee, J. and Hodnett, E.
continued to use the position after the required study hour, although they were free to do so. This may suggest limited acceptability of the position. Alternately, there may have been women who wished to use hands-and-knees positioning that were unable to do so. As labor progresses, interventions may increase making use of handsand-knees position more di⁄cult; for example, internal EFM may be used and decreased mobility due to increased sensory and motor blockade may occur. Nurses’ preferences regarding positioning may also be in£uential ; some women may need assistance, encouragement, or approval from clinicians in order to use hands-and-knees position.
Intrapartum nurses should assess women’s experiences using hands-and-knees position including ease of use of the position and efficacy of analgesia.
Acknowledgments Funded by Canadian Institutes of Health Research RCT grant MCT 50421 and Fellowship and New Investigator Awards.
REFERENCES Andrews, C. M., & Andrews, E. C. (1983). Nursing, maternal postures, and fetal position. Nursing Research, 32, 336-341. Angus, J., Hodnett, E., & O’Brien-Pallas, L. (2003). Implementing evidence-based nursing practice: A tale of two intrapartum nursing
Women may wish to try other positions but if not supported in doing so by their care provider are unlikely to initiate position changes on their own, particularly with an epidural in place. Incorporating hands-and-knees positioning into a nurse’s repertoire is simply an expansion of commonly used labor support techniques. However, nurses require familiarity and comfort with hands-and-knees position and must have the time and be willing to provide physical assistance and psychological support to the woman for her to assume alternate positions. Furthermore, institutional support is needed to introduce practice change related to positioning during labor with an epidural. Success of nursing practice change is in£uenced by the social context of the unit, including formal and informal policies (Angus, Hodnett, & O’Brien-Pallas, 2003; Hodnett et al.,1996).
units. Nursing Inquiry, 10, 218-228. Anim-Somuah, M., Smyth, R., & Howell, C. (2005). Epidural versus nonepidural or no analgesia in labour. Cochrane Database of Systematic Reviews, 4, CD000331. DOI: 10.1002/14651858.CD000331. pub2. Biancuzzo, M. (1993a). Six myths of maternal posture during labor. American Journal of Maternal Child Nursing, 18, 264-269. Biancuzzo, M. (1993b). How to recognize and rotate an occiput posterior fetus. American Journal of Nursing, 93, 38-41. Breivik, E. K., & Skoglund, L. A. (1998). Comparison of present pain intensity assessments on horizontally and vertically oriented visual analogue scales. Methods and Findings in Experimental and Clinical Pharmacology, 20, 719-724. Brown, S., & Lumley, J. (1994). Satisfaction with care in labor and birth: A survey of 790 Australian women. Birth, 21, 4-13. Collis, R. E., Davies, D. W. L., & Aveling, W. (1995). Randomised comparison of combined spinal-epidural and standard epidural analgesia in labour. Lancet, 345, 1413-1416. Declercq, E. R., Sakala, C., Corry, M. P., & Applebaum, S. (2006). Listening to mothers II: Report of the second national U.S. survey of women’s childbearing experiences. Retrieved January 6, 2009 from http:// www.childbirthconnection.org/article.asp?ClickedLink=205&ck=
While positioning is a key component of labor support, little empirical evidence exists linking positioning strategies to improved labor and birth outcomes. Given that women have expressed satisfaction with epidural techniques that allow for mobility (Collis, Davies, & Aveling, 1995) it is important to consider hands-and-knees positioning as an option during labor with epidural. Although there are trends toward bene¢t of use of handsand-knees position with respect to optimal fetal head position and decreased operative delivery (Stremler et al., 2005), the small sample size of this case series of women who used the position with an epidural limits our ability to draw conclusions around safety and acceptability of the position. Given the potential for improvement in birth outcomes, more research with a larger sample size is needed to rigorously examine safety, acceptability, and the e¡ects of hands-and-knees position on labor and birth outcomes in a large RCTof laboring women, including those with epidural.
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10068&area=2 Declercq, E. R., Sakala, C., Corry, M. P., Applebaum, S., & Risher, P. (2002). Listening to mothers: Report of the ¢rst national U.S. survey of women’s childbearing experiences. Retrieved January 6, 2009 from
http://www.childbirthconnection.org/article.asp?Clicked
Link=205&ck=10068&area=2 Fenwick, L., & Simkin, P. (1987). Maternal positioning to prevent or alleviate dystocia in labor. Clinical Obstetrics and Gynecology, 30, 8389. Hodnett, E. (1996). Nursing support of the laboring woman. Journal of Obstetric, Gynecologic & Neonatal Nursing, 25, 257-264. Hodnett, E. D. (2002). Pain and women’s satisfaction with the experience of childbirth: A systematic review. American Journal of Obstetrics and Gynecology, 186, S160-S172. Hodnett, E. D., Kaufman, K., O’Brien-Pallas, L., Chipman, M., Watson-MacDonell, J., & Hunsburger, W. (1996). A strategy to promote researchbased nursing care: E¡ects on childbirth outcomes. Research in Nursing and Health, 19,13-20. Hodnett, E. D., Lowe, N. K., Hannah, M., Willan, A., Stevens, B., Weston, J., et al. (2002). E¡ectiveness of nurses as providers of birth labor support in North American hospitals. Journal of the American Medical Association, 288, 1373-1381. Hodnett, E. D., Stremler, R., Willan, A. R., Weston, J. A., Lowe, N. K., Simpson, K. R., et al. (2008). E¡ect on birth outcomes of a formalized ap-
397
Hands-and-Knees Positioning with Epidural
proach to care in early labour assessment units: An international,
Mayberry, L. J., Clemmens, D., & De, A. (2002). Epidural analgesia side
randomised controlled trial. British Medical Journal, 337, a1021.
e¡ects, co-interventions, and care of women during childbirth:
DOI: 10.1136/bmj.a1021.
A systematic review. American Journal of Obstetrics and Gynecol-
Hundley, V. A., Milne, J. M., Glazener, C. M., & Mollison, J. (1997). Satisfaction and the three C’s: Continuity, choice and control. Women’s views from a randomised controlled trial of midwife-led care. British Journal of Obstetrics and Gynaecology, 104, 1273-1280. Hunter, S., Hofmeyr, G. J., & Kulier, R. (2007). Hands and knees posture in late pregnancy or labour for fetal malposition (lateral or posterior). Cochrane Database of Systematic Reviews, 4, CD001063. DOI: 10. 1002/14651858.CD001063.pub3 Leighton, B. L., & Halpern, S. H. (2002). The e¡ect of epidural analgesia on labor, maternal and neonatal outcomes: A systematic review. American Journal of Obstetrics and Gynecology, 186, S69-S77. Lieberman, E., Davidson, K., Lee-Parritz, A., & Shearer, E. (2005).
Appleton & Lange. Roberts, J. E., Mendez-Bauer, C., & Wodell, D. A. (1983). The e¡ects of maternal position on uterine contractility and e⁄ciency. Birth, 10, 243249. Scott, J., & Huskisson, E. C. (1976). Graphic representation of pain. Pain, 2, 175-184. Spiby, H., Henderson, B., Slade, P., Escott, D., & Fraser, R. B. (1999). Strategies for coping with labour: Does antenatal education translate into practice? Journal of Advanced Nursing, 29, 388-394. Stremler, R., Hodnett, E., Petryshen, P., Stevens, B., Weston, J., & Willan, A. R. (2005). Randomized controlled trial of hands-and-knees position-
Changes in fetal position during labor and their association with
ing for occipitoposterior position in labor. Birth, 32, 243-251.
epidural analgesia. American Journal of Obstetrics and Gynecol-
Thorp, J. A., & Breedlove, G. (1996). Epidural analgesia in labor: An eval-
ogy, 105, 974-982.
398
ogy, 186, S81-S93. Oxorn, H. (1986). Oxorn-foote human labor & birth (5th ed.). Norwalk, CT:
uation of risks and bene¢ts. Birth, 23, 63-83.
JOGNN, 38, 391-398; 2009. DOI: 10.1111/j.1552-6909.2009.01038.x
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