Maternal Positioning in Labor With Epidural Analgesia

Maternal Positioning in Labor With Epidural Analgesia

Results From a Multi-site Survey Kathy Gilder, BSN, RN Linda J. Mayberry PhD, FAAN, RN Susan Gennaro, PhD, FAAN, RN Donna Clemmens, PhD, RN In 1997, AWHONN published the results from its second national research utilization project focused on second-stage labor nursing care, and specifically, positioning. One of the major findings from this project was the lack of evidence available for nurses to use in modifying care for women receiving epidural analgesia. A recent systematic review of studies (Gupta & Nikodem, 2000) addressing positioning during labor demonstrated the possible benefits of upright positioning, including, a slight reduction in the duration of second-stage labor fewer assisted deliveries and second degree perineal tears reports of less severe pain However, there remains little data about how positions can or should be modified when women have epidural analgesia. While there is a growing prevalence of low-dose epidural techniques that presumably allow more women the increased mobility necessary to change positions, particularly upright, several questions need to be asked: To what extent is upright positioning currently used with women who have epidurals? What are considered the prevailing restrictions toward the use of upright positions when women receive epidurals? What do labor and delivery nurses recommend as the most comfortable yet safe upright positions for women with epidural analgesia? To answer these questions, a survey was designed consisting of multiple forced-choice and open-ended questions that specifically asked nurses about their current and recommended practices related to the use of upright positioning during first- and second-stage labor. Five labor and delivery (L&D) units representing a cross-section of hospitals were approached and agreed to participate in the project: New York University Medical Center, New York, NY Brigham and Women s Hospital, Boston, MA St. Josephs Medical Center, London, Ontario, Canada Mercy Fitzgerald Hospital, Philadelphia, PA Miami Valley Hospital, Dayton, OH Each unit has 24-hour anesthesia coverage and a delivery rate ranging from 100 to 300 deliveries per month at the time of the survey. The average epidural rate reported by nurses was approximately 60 percent,

Table 1 Most Common Positions in Second-Stage Labor Results reflect survey of women with epidural anesthesia and show use of more than one position during labor: Low Fowler s with knees pulled back: 46 percent Modified throne position: 35.4 percent Side-lying: 17.7 percent Upright with the squatting bar: 8 percent Upright with tug-of-war: 5.3 percent Knee-chest: 4.4 percent with the rate at one of the project hospitals reaching 95 percent. The L&D units included in the study currently use Hill- Rom Affinity III birthing beds. It was important to find out to what extent birthing beds with moveable apparatus were helpful to nurses when promoting upright positions in the care of laboring women. Hill-Rom Corp. underwrote expenditures for the survey distribution and the costs for site visits by team members. A designated nurse project coordinator was initially contacted by Kitty Johnson, RNC, BSN, Hill-Rom Clinical Services Manager of the Maternal Business Unit. Each project site coordinator was oriented to the project by one or more of the team members, who included Ms. Johnson, Dr. Linda Mayberry and Dr. Susan Gennaro. Staff nurses on each of the units were encouraged to consider the patient care situations they encountered during daily clinical practice for a two-month period of time prior to completing the survey. In all, 250 surveys were distributed and 113 were returned (45 percent return rate). Key Findings Regarding the use of upright positioning, when asked if maternal position changes during the first stage of labor were encouraged, 79.6 percent responded always. However, less than half (43.4 percent) of the nurses said they always encourage variation in positions during the second or pushing stage. Figure 1: Low Fowler s position with knees pulled back What positions did the nurses indicate were used most often during second-stage labor (see Table 1)? The survey results indicated that the most common position during second-stage labor in women with epidural analgesia was the low Fowler s with knees pulled back (46 percent) (see Figure 1). The next most common position was a modified throne position in which the woman sits upright with the bottom part of the bed lowered with the feet on the lower portion of the bed (35.4 percent) (Figure 2). Other positions that were identified within the survey, although much less frequently, included side-lying (17.7 percent), upright tug-of-war (5.3 percent) with the bar (Figure 3a) and with the nurse (Figure 3b), knee-chest (4.4 percent) and upright with the squatting bar (8 percent) (Figure 4). Nurses were also asked to what extent their patients ambulated during labor. Approximately 44 percent of the nurses said that none of their patients were able to get out of bed after getting an epidural and 81.4 percent said that none of the patients were allowed to actually walk. Nurses from the project sites offered specific suggestions on how they encourage upright positions, even with some degree of leg weakness. For example, the throne position or having the woman squat while leaning against the elevated head of the bed is often used (Figure 5). Also recommended was using the Kathy Gilder, BSN, RN, is at New York University Medical Center, New York City, NY. Linda J. Mayberry, PhD, FAAN, RN, is associate professor at the School of Education, Division of Nursing, New York University. Susan Gennaro, PhD, FAAN, RN, is professor in the School of Education, University of Pennsylvania, and a member of the AWHONN Lifelines Editorial Advisory Board. Donna Clemmens, PhD, RN, is a postdoctoral fellow at the School of Nursing at Yale University in New Haven, CT. The authors have received funding for this project from the Hill-Rom Corporation and the Hugoton Foundation. Figure 2: Modified throne position 42 AWHONN Lifelines Volume 6, Issue 1

squatting bar to rest legs in a semireclined position and using a towel wrapped around the top of the bar for support (Figure 6). Nurses mentioned using mirrors while women assume a squatting position to visualize progress. Another common practice among the nurses surveyed was to spend considerable time explaining to women and support partners about the benefits of upright positioning. As one nurse stated, Patients respond when they know you know what you are doing. Finally, one nurse recommended using cute names that make the position more appealing to the patient and families. For example, I will tell the patient that they are the Queen for the day and often position them in the throne position. Everyone generally gets a good chuckle from this and it lightens the tension. Evidence exists that demonstrates that upright positioning is safe in nonanesthetized women. For example, in a recent study comparing supine versus squatting on a birthing stool during the second stage, no differences were found in fetal and neonatal outcomes (DeJong et al., 1997). However, the relative maternal/ fetal risks of upright positioning with epidurals have not been studied extensively. One example of a study that did evaluate women with epidurals showed no differences in either fetal or neonatal outcomes when women ambulated during labor for short periods versus another group confined to bed (Collis, Harding, & Morgan, 1999). Evaluation of the significance of fetal heart rate decelerations with upright positions other than ambulation have not been studied in women who receive epidurals. Barriers to Upright Positioning The fact that the more recumbent low Fowler s position was prevalent at the project sites was not surprising given the various barriers to the use of upright positioning that were identified by nurses. The majority of nurses (52.2 percent) said that the biggest barrier to using upright positions in second-stage labor was lower extremity weakness due to the epidural block. According to one nurse, A high percentage of patients get epidurals early and expect to feel nothing. Another barrier for many nurses (33.6 percent) was that patients and physicians were not open to the use of upright positions. As one nurse stated, many of the doctors prefer to have patients pushing in low Fowler s and the obstetricians and family doctors want to deliver in the easiest position for them. Nurses complained about an apparent passivity on the part of a large proportion of women during labor to change positions and how it was common for women to actually refuse. Other women were disinclined due to fatigue. Nurses in the survey expressed concern that some of the fatigue was related to women not getting adequate rest during the first stage with too many visitors and phone calls. Finally, a factor influential in nurses decisions on whether or not to use upright positions was the risks for maternal and fetal intolerance of labor (71.7 percent). Concerns about maternal hypotension, headaches and, most frequently, the occurrence of nonreassuring fetal heart rate patterns were described by the nurses. Discussion There are several good reasons to encourage the type of upright position changes presented here throughout both the first and second stages of labor. First, previous studies have reported that women prefer to be upright during labor. It makes sense that staying in the same position for too long will contribute to Figure 3: Upright tug-of-war position increased discomfort, particularly during a long labor, and negatively impact the sense of personal control that most women desire during labor. Second, poor posture and stressed positions during labor that could be associated with prolonged periods of time in bed with epidural analgesia have been suggested as causative in the postpartum back pain experienced by some women (MacEvilly & Buggy, 1996). A recent study found that women with epidurals compared to those without had an increased incidence of backaches in the early postpartum (Okojie & Cook, 1999). Finally, the potential physiological advantages of enlisting the force of gravity and increasing the efficiency of uterine contractions have been cited often in the published literature. The nurses surveyed in this project stated that they would be more likely to use upright positions during labor if lighter epidurals were used (49.6 percent) and if there was the availability of increased staffing (13.3 percent). Based on these and other comments from the nurses surveyed, it s clear that helping women with epidurals move into many positions (such as squatting) without assistance from others is often not easy. As one nurse poignantly stated, some upright positions are diffi- February/March 2002 AWHONN Lifelines 43

cult on me and my back, not to mention that we don t have enough staff to help with positioning especially if the significant other can t or won t help. Another nurse pointed out the inherent difficulties of assisting grossly obese women to assume upright positions. Historically, it has been an important part of intrapartal care to engage partners in the activities surrounding labor support, and many of the nurses responding to this survey described their efforts to encourage this practice. However, it s important to remember that it s not always reasonable to expect that significant others can provide the necessary help. There might not be a partner or other support person available. Or, if there are support persons available, they might not be willing or able to help. For example, in the Orthodox Jewish culture, nurses may, of necessity, become the sole labor support for women from this group because husbands are forbidden to touch their wives during labor. Orthodox men are forbidden to have physical contact with women while they are bleeding. Clearly, if prevailing quality of care standards for laboring women are to promote active upright positioning alternatives, we need to examine strategies to ensure that this type of support at the bedside is provided, even on a busy unit. One possibility is more emphasis on the physical conditioning and team training of nurses to assist with the physical components of labor support. What should be the expectations for labor and delivery nurses in terms of physical prowess to support women Figure 6: Semi-reclined position Figure 4: Upright with squatting bar position in labor? Another option is to consider the expanded role of onsite doulas who can be trained to assist nurses with this aspect of labor support. Increased attention to the promotion of up-right positions in childbirth classes was also recommended by the nurses surveyed (38.1 percent). The issue of preparation for the kind of physical stamina and fitness required for Figure 5: Throne position labor by pregnant women needs to be highlighted more in consumer literature and by educators. Nurses stated that they spent considerable effort in teaching women during labor, but more preparation before labor obviously would be helpful. The final major issue addressed in the survey was use of the walking epidural. The apparent wide variation in the level of motor blockades administered to women in the project sites amid the considerable attention by anesthesia researchers on the use of low-dose epidural solutions was surprising. However, in these project sites, hospital policies were either conservative or prohibitive with regard to women getting out of bed or walking during labor because of presumably legitimate safety issues linked to physical instability. According to one nurse, A walking epidural is a misnomer. As the medication continues to infuse over several hours, patients lose sensation to their lower extremities. Another stated: Anesthesiologists often tell patients that they will receive a walking epidural and most of the time their legs are numb and they have urinary retention. Also, most of the women are on pitocin and the doctors do not want them to ambulate. It s difficult to assess exactly how prevalent the use of the walking epidural actually is in other hospitals throughout the U.S. and Canada, but caution should be exercised at this point as to blanket recommendations for encouraging ambulation during labor. More research in this area, including evaluation of fetal tolerance to this and other upright positions, is needed. Additionally, labor and delivery nurses need to engage in discussions with obstetrical and anesthesia colleagues to examine the issues surrounding use of epidurals for pain management. For example, should use of the more low-dose epidurals be encouraged so that we can evaluate policies surrounding increased mobility, upright positions and even ambulation among laboring women who receive epidural analgesia? What is the impact of the increased use of epidurals on nursing care including staffing considerations? 44 AWHONN Lifelines Volume 6, Issue 1

What Is Your Institution s Policy? The authors of this article and Lifelines would like to know what your hospital or institution s policy is regarding the use of walking epidurals. Would you send us an email, including the policy and addressing the following practices, to Lifelines@awhonn.org. If sufficient responses are received, we ll publish the results in an upcoming issue. Please include in your email the following: 1. Your institution s policy regarding the use of walking epidurals 2. Is the term walking epidural used at your hospital labor and delivery unit? 3. What is the estimated yearly epidural rate at your hospital labor and delivery unit? 4. What is the typical drug combination/dosage administered for the epidurals on your unit? 5. To what extent is patient-controlled epidural analgesia or PCEA provided on your unit? Please describe any strengths or limitations of this method based on your experience, if used. 6. Is effective pain relief always provided with the typical epidural drug combination/dosage administered? Why or why not? 7. Do any laboring women on your unit actually walk after receiving an epidural? If so, please describe what percentages and your view of any advantages or limitations. 8. Do you have any recommendations for improvng the care of women with low-dose or walking epidurals based on your experience? Please feel free to be specific with case examples. 9. What percentage of women are typically offered other pain management alternatives prior to receiving an epidural? Please describe type and your sense of extent of effectiveness. References Collis, R. E., Harding, S. A., & Morgan, B. M. (1999). Effect of maternal ambulation on labour with low-dose combined spinal-epidural analgesia. Anaesthesia, p. 535-539. DeJong, P. R., Johanson, R. B., & Baxen, P., Adrians, V. D., van der Westhuisen S., & Jones P. W. (1997). Randomized trial comparing the upright and supine positions for the second stage of labour. British Journal of Obstetrics and Gynaecology, 104, 567-571. Gupta, J. K., & Nikodem, V. C. (2000). Woman s position during second stage of labour (Cochrane Review). In The Cochrane Library, Issue 1. Oxford, UK: Update Software. MacEvilly, M., & Buggy, D. (1996). Back pain and pregnancy: A review. Pain, 64, 405-414. Okojie, P., & Cook, P. (1999). Immediate and delayed complications of epidural analgesia in labour and delivery. Journal of Obstetrics and Gynaecology, 19(4), 370-372. Has something we've written struck a nerve? We want to hear from fans and critics alike send your Letters to the Editor to: Email: Lifelines@awhonn.org or mail to: February/March 2002 AWHONN Lifelines 45