Content uploaded by Afaf Mohamed Mohamed Emam
Author content
All content in this area was uploaded by Afaf Mohamed Mohamed Emam on Jul 31, 2018
Content may be subject to copyright.
http://jnep.sciedupress.com
Journal of Nursing Education and Practice
2018, Vol. 8, No. 7
113
Published by Sciedu Press
ORIGINAL RESEARCH
Upright versus recumbent position during first stage of
labor among primipara women on labor outcomes
Afaf Mohamed Mohamed Emam1, Ahlam Eidah Al-Zahrani2
1Faculty of Nursing, Benha University, Benha, Egypt
2Faculty of Nursing, King Abdulaziz University, Jeddah, Saudi Arabia
Received: December 13, 2017 Accepted: February 8, 2018 Online Published: March 15, 2018
DOI: 10.5430/jnep.v8n7p113 URL: https://doi.org/10.5430/jnep.v8n7p113
ABSTRACT
Objective: The aim of this study was to assess the effect of upright versus recumbent position during the active phase of first
stage of labor among primipara women on labor outcomes in term of progress, duration of labor, mode of delivery, neonatal
outcome and maternal satisfaction with assumed position.
Methods: Quasi experimental design was used. The study was conducted in the labor unit in obstetric department at Benha
University Hospital. A purposive sample of 100 parturient women in 1st stage of labor were recruited in the study, they divided
into two groups; upright group (50) and recumbent group (50). Data were collected through four main tools: Structured
Interviewing questionnaire sheet, Structured Observational Checklist include (Partograph and Apgar score), Visual analogue pain
intensity scale and maternal satisfaction with assumed position questionnaire.
Results: revealed that high statistical significant difference between the upright and recumbent groups in term of decrease
interval and increases duration, frequency and intensity of uterine contraction, cervical dilatation and fetal head descent/fifth
among the upright group. While the recumbent group showed less progress. Moreover, the recumbent group expressed more pain
score, consume longer duration of 1st , 2nd , 3rd stage of labor than the upright group and statistical significant difference in Apgar
score of the neonate during both first and fifth minute. In addition, the upright group had higher satisfaction scores compared to
those assumed recumbent positions (p < .001).
Conclusions: Upright position had positive effect on progress of labor, decreased duration of the three stages of labor, better
neonatal outcomes and improving parturient women’s satisfaction with assumed position. The study recommended that all
parturient women in low-risk labor should be informed about the benefits of assuming upright positions during first stage of labor,
and be encouraged and supported to use them.
Key Words: First stage of labor, Upright position, Recumbent position, Labor outcomes
1.I NTRODUCTION
Childbirth is unique process for women. It is important pe-
riod in woman’s life and ends with giving baby which is
the most wonderful moment in women’s life, highly joyful
experience and celebrated event to their families.[1] The pro-
cess of giving a baby occurs in several stages which lasting
from hours to few days starting from onset of regular uterine
contraction to deliver the baby and placenta. The first stage
of labor is longer and painful. In primipara, usually lasts
from 12 to16 hours and about 6 to 8 hours for multipara.
First stage of labor consisted of three phases; latent, active
and transitional phase.[2]
A previous study conducted by Lawrence et al.[3] mentioned
∗Correspondence: Afaf Mohamed Mohamed Emam; Email: afaf_emam52@yahoo.com; Address: Faculty of Nursing, Benha University, Benha,
Egypt.
http://jnep.sciedupress.com
Journal of Nursing Education and Practice
2018, Vol. 8, No. 7
114
ISSN 1925-4040 E-ISSN 1925-4059
that, it is more common for women in both high- and low-
income countries giving birth in health facilities, to labor in
bed. There is no evidence that this is associated with any
advantage for women or babies, although it may be more
convenient for staff. Observational studies have suggested
that if women lie on their backs during labor this may have
adverse effects on uterine contractions and impede progress
in labor, and in some women reduce placental blood flow.
As well as Priddis et al.[4] reported that, position during labor
is influenced by cultural factors, obstetric practices, place of
delivery, technology and preference of the mother and health
care providers. Maternal positioning during labor affects
many aspects of the anatomy and physiology adaptations
needed to influence all aspects of labor including powers,
passage, passenger and psyche. In addition, influences the
characteristics and effectiveness of uterine contractions, fetal
well-being, maternal comfort, course of labor and enhancing
satisfaction with the birth experience.
Generally, women lie in the recumbent position (including
supine, semi-recumbent and lateral) during first stage of la-
bor makes it easier for nurses to monitor progress and carry
out procedures that restrict mobilization such as abdominal
examination to assess uterine contractions, to perform vagi-
nal examinations to assess progress of labour and invasive
manoeuvres, to check the fetal head position and to assess
the fetal heart rate as stated by Martin et al.[5] Unfortunately,
Recumbent positions results in supine hypotension dimin-
ished uterine activity and a reduction in the dimensions of
the pelvic outlet Leifer.[6]
Conversely, it is necessary for women to deliver naturally
to walking around, standing, sitting, kneeling or squatting,
which allow “gravity effect” to speed the cervix dilation.
Gizzo et al.[7] reported that an upright position (including
walking, sitting, standing, kneeling and squatting) during
first stage of labour have less vulvar edema and less blood
loss. If the membranes are intact, the woman is allowed to
walk about. This attitude prevent vena cava compression and
encourage descent of the head. Ambulation can reduce the
duration of labour, need for analgesia and improve maternal
comfort.
Actively promoting and encouraging women to mobilize dur-
ing childbirth is a safe, effective way of providing optimum
care to healthy women, it is a cost-effective way of reducing
complications. Mobilization improves frequency, strength
and length of contractions, decrease the use of oxytocin to
augment labour and improves oxygen supply to the fetus.
It improves alignment of pelvic bones and the shape and
capacity of pelvis, and optimizes the good fit between fetus
and pelvis.[8]
Prolonged labour may increase the risk of maternal and
neonatal morbidity and mortality due to increase risks of
mother exhaustion, postpartum haemorrhage, sepsis and fatal
distress and requires early detection and appropriate medical
response. Pharmacological measures are using to enhance
contractions of the uterus and to decrease the duration of
labour. These measures are costly and cause adverse effects
on the women.[9] Encouraging upright position during the
first stage of labour has been a safe non-pharmacological
intervention used for many years. It is an effective and safest
intervention to increase the uterine contractions and to de-
crease the duration of labour; if not contraindicated.[10]
Nurses providing care in first stage of labor need to provide
clear, consistent, and evidence based explanation of both the
risks and benefits of the used positions and enable women to
make decisions about the position choices which will afford
the most comfort. Moreover, increasing a woman’s sense
of control may have the effect of decreasing the need for
analgesia.[11]
1.1
Significance of the problem
Childbirth medicalization has reduced the parturient opportu-
nity to labor and deliver in a spontaneous position, constrict-
ing women to assume the recumbent one. Birth positions
are an important area of practice, in the past dominated by
traditional and old practices. In recent years, this has been
challenged by midwives, women and obstetricians, and the
advantages of the upright position have been highlighted,
supported by research and evidence.[7,12] Also, the effects of
different maternal positions during labor on maternal-fetal
and neonatal outcomes are rarely in agreement and available
evidences in this field are often controversial and fragmen-
tary. There is a lack of studies which address the effect of
two positions during the active phase of first stage of labor
on labor outcomes at Benha University Hospitals. Hence, the
current study aims to assess the effect of upright versus re-
cumbent position during first stage of labor among primipare
on labor outcome.
1.2
Aim of this study
This study aimed to assess the effect of upright versus re-
cumbent position during the active phase of first stage of
labor among primipara women on labor outcome in term
of progress of labor, duration of labor, method of delivery,
neonatal outcome and maternal satisfaction with assumed
position.
1.3
Research hypothesis
The researchers hypothesized that the parturient women who
assumes upright positions during the first stage of labor
would be have faster progress of labor, shorten duration
115
Published by Sciedu Press
http://jnep.sciedupress.com
Journal of Nursing Education and Practice
2018, Vol. 8, No. 7
of labor, batter labor and neonatal outcome and higher sat-
isfaction with this position compared to those who assume
recumbent position.
2.S UBJECTS AND METHOD
2.1
Research design
Quasi-experimental research design was utilized to fulfill the
aim of this study.
2.2
Setting
This study was conducted in labor unit of obstetric depart-
ment at Benha University Hospital.
2.3
Sampling
Sample type: A purposive sample was used in collecting
the data.
Sample size: A total of 100 parturient primipara were re-
cruited in this study according to the following criteria: in
early active phase of 1st stage of labor (i.e., from 4 cm to
6 cm cervical dilation), age between 20-35 years, with nor-
mal body mass index, labor occurring between gestational
weeks 37 and 41, with a normal course of pregnancy, a single
viable fetus with occipto anterior position, with spontaneous
onset of labor, with intact membranes, free from any medical
or obstetrical problems, and accepting to participate in the
study.
Sampling technique: Data were collected for a period of
six months, in order to avoid bias through data collection the
parturient women with previous criteria and admitted to the
previous study setting for first three months from beginning
of data collection were recruited at the upright group (n = 50)
which assumed one of upright positions as (standing, sitting,
kneeling, squatting) during the active phase of first stage of
labor and other parturient women with same criteria, who
admitted at the second three months of data collection were
recruited at recumbent group (n = 50) which assumed one
of the recumbent positions as supine, semi recumbent, left
lateral) during the active phase of first stage of labor.
2.4
Tools for data collection
Four tools were used for collecting data.
1)
Structured interviewing questionnaire: It was designed
and used by the researcher after reviewing the related litera-
ture. It consisted of two parts:
First part: Socio demographic data of studied sample such
as (age, educational level, residence, occupation, and gesta-
tional age).
Second part: Initial assessment on admission such as (fre-
quency, duration, interval and intensity of uterine contraction,
cervical dilatation, fetal head decent and pain intensity).
2)
Structured observational checklist: It was constructed
by the researcher after reviewing related literature that cov-
ered the labour progress and labour and neonatal outcomes.
It included:
a) Partograph as appointed by WHO[13] is a graphic record-
ing used to monitor the progress of labor in term of dilatation
of cervical, the fetal head descent, progress of uterine con-
traction (duration, frequency, interval and intensity), duration
of first, second and third stage of labor.
b) Apgar score as appointed by Virginia[14] used to evaluate
neonatal outcome. It is calculating by adding points (2, 1,
or 0) for heart rate, respiratory effort, muscle tone, response
to stimulation, and skin coloration; a score of ten represents
the good condition. It is done at first and fifth minutes af-
ter birth and if the score remains low may be repeated later.
Score(≤ 4) indicates sever asphyxia, (5-7) indicates moder-
ate asphyxia and (8-10) indicates good condition.
3)
Visual analogue pain intensity scale (VAS): It is a stan-
dardized linear scale developed by Freyd et al.,[15] and it was
adopted and used by the researcher to assess the severity of
pain. It is a self-reported 10 cm horizontal line which repre-
sents the subjective estimation of pain intensity. It comprises
0-10 point, the two opposite ends representing no pain to
severe pain as follows: No pain (0), Mild pain (< 4),
Moderate pain(4-6), Sever pain (7-10).
4)
Maternal satisfaction with assumed position: It is self
reported assessment and containing two-item questionnaire
developed by the researcher. Each parturient women were
asked to respond to two questions: 1) Are you satisfied with
your position assumed during 1st stage of labor? 2) Do
you prefer this assumed position in the next labor? Their
responses were recorded as either yes or no.
2.5
Tools validity and reliability
Tools content validity was reviewed for appropriateness of
items by five an expert jury panel in the field of maternity
nursing and obstetric medicine specialty. The questionnaires
were modified according to the panel judgment on clarity of
sentences and appropriateness of content. The reliability was
done by Cronbach’s Alpha coefficient test equal to 0.85.
2.6
Ethical considerations
Ethical approval from the Nursing Faculty Ethical Commit-
tee of Benha University was obtained. Informed consent was
obtained from enrolled women after clarifying the purpose of
this study. Confidentiality of collecting data was maintained
as well as respect of women’s privacy was totally ensured.
Each participant was informed that that participation is vol-
116
ISSN 1925-4040 E-ISSN 1925-4059
http://jnep.sciedupress.com
Journal of Nursing Education and Practice
2018, Vol. 8, No. 7
untary and has a right to withdraw from the study at any time
without given any reason.
2.7
Pilot study
The pilot study was carried out on 10.0% of the sample (10)
parturient primipara to test the applicability and clarity of the
study tools, as well as determine the time needed to fill the
study tools and find out any problem that may interfere with
the process of collecting data. And accordingly the necessary
modifications were done in the form of added or omission
of some questions. Women included in the pilot study were
excluded from the main study sample.
2.8
Procedure
The following phases were adopted to fulfill the aim of the
current study: Assessment, implementation, and evaluation
phases. These phases were carried out from beginning of
January 2016 to the end of June 2016 covering six months.
An official permission was granted from the Dean of the
Faculty of Nursing, Benha University and delivered to the
director of Benha University Hospital in order to obtain their
approval for conduction of the research after explaining its
purpose. The previous mentioned settings were visited by
the researchers three days/week from 9.00 am and extended
to 2 hours after delivery of the mother.
2.8.1
Assessment phase
This phase encompassed interviewing the parturient primi-
para to collect the socio-demographic data, the researchers
greeted each women at the beginning of the interview, ex-
plained the aim, duration, and activities of the study and
taken informed consent. Then each participant assigned to
either upright or recumbent group according to their choose.
The baseline data of labor condition, such as uterine con-
traction (duration, interval, frequency and intensity) cervical
dilatation, fetal head descent/fifths were assessed on admis-
sion in both groups by the researcher by using tool (2) and
assessed the level of pain by using tool (3).
2.8.2
The implementation phase
During this phase, parturient primipara in both groups were
received the same management of first stage of labor ac-
cording to the applied guidelines in study setting except for
assumed position during 1st stage of labor. Each women in
the upright group were individually met in the latent phase,
mean while, an explanation of the benefits of changing their
position from walking, standing, sitting, kneeling and squat-
ting during first stage of labor. At the beginning of active
phase of labor, women were encouraged to assume one of
upright positions (i.e., walking and upright non-walking as
sitting, standing, kneeling, or squatting). Walking out of
bed and tell her to return to bed when medical or nursing
intervention needed, sitting position was assumed on chair
or in the bed with support the back, standing position with
support on wall was achieved by herself. Each women were
encouraged to assume such positions alternatively for the
15-20 minutes every one hour according to her comfort and
in between women were permitted to lie down on bed for
10-15 minutes and advice her to repeated these position up to
10 cm cervical dilatation. And tell her to return in bed if the
membrane ruptured. While, women in the recumbent group
were assumed one of recumbent position as supine, semi
recumbent and left lateral for 15-20 every hour and lasting
more than 50% of the first stage of labor duration.
2.8.3
The evaluation phase
The researcher evaluated and compared the effect of the up-
right and recumbent positions during first stage of labor on
progress of labor and labor outcomes, through assessing the
progress of labor every hour in terms of duration, interval, fre-
quency of uterine contraction, cervical dilatation, the descent
of fetal head/fifth and pain intensity. Besides the duration
of the first, second, third stage of labor, mode of delivery,
neonatal condition using (tool 2, 3). Maternal satisfaction
about the position they assumed and their preferences to this
position in next labor were assessed using (tool 4).
2.9Statistical analysis
The collected data were organized, categorized, tabulated and
analyzed using the Statistical Package for Social Sciences
(SPSS version 20.0). Descriptive statistics were applied (e.g.,
mean, standard deviation, frequency and percentages). Test
of significance (chi square and paired t test) was applied to
test the study hypothesis. A statistically significant differ-
ence was considered at p ≤ .05, and a highly statistically
significant difference was considered at p ≤ .001.
3.R ESULTS
Table 1 shows socio-demographic data of the studied sample.
It was reveled that 48% & 56% of both upright and recum-
bent groups respectively were in age group (25-30) years
with mean age (26.18 ± 4.08 & 25.24 ± 4.09) respectively,
around half (48% & 54%) of both groups had secondary
education respectively. In addition, more than half of both
groups (54% & 60%) are live in rural areas respectively. The
majority (82.0% & 88.0%) of both groups were housewife
respectively. There was no statistically significant differ-
ences between both groups related to their age, the level of
education, occupation, residence and gestational age.
117
Published by Sciedu Press
http://jnep.sciedupress.com
Journal of Nursing Education and Practice
2018, Vol. 8, No. 7
Table 1. Distribution of the studied sample according to their socio-demographic data (n = 50 for each group)
Variable
Upright group (50)
Recumbent
Group (50)
χ2
P Value
No
%
No
%
Age (years)
20- < 25
3
6.0
2
4.0
0. 93
.86
25- < 30
24
48.0
28
56.0
.
30-35
23
46.0
20
40.0
Mean ± SD
26.18±4.08
25.24 ± 4.09
Educational level
Illiterate/read & write
4
8.0
3
6.0
2.04
Primary/preparatory
20
40.0
18
36.0
.56
Secondary
24
48.0
27
54.0
University
2
4.0
2
4.0
Occupation
Employed
9
18.0
6
12.0
0.70
.40
Housewife
41
82.0
44
88.0
Residence
Rural
27
54.0
30
60.0
1.96
.16
Urban
23
46.0
20
40.0
Gestational age at birth (weeks)
Mean ± SD
39.20 ± 0.55
39.60 ± 0.38
0.342
According to Table 2, the mean duration of uterine contrac-
tion in seconds among the upright and recumbent groups
was 19.38 ± 0.60 & 19.40 ± 0.49 at baseline with no sta-
tistically significant difference, but after assuming upright
position highly statistically significant difference between
both groups in the 1st hour was noticed (26.10 ± 0.24 &
21.50 ± 0.50) respectively, 2nd hour (44.94 ± 1.73 & 27.00
± 1.26) respectively, 3rd hours (66.00 ± 1.51 & 35.62 ±
0.63) respectively and 4th hours (70.80 ± 1.98 & 44.16 ±
1.50) respectively. As shown the upright group had a higher
mean duration of uterine contraction than the recumbent
group (p < .001*). Table 2 also shows no statistically signif-
icant difference between both groups regarding interval of
uterine contraction at baseline. In contrast in 1st hour after
assuming upright position statistically significant differences
were noticed between both groups for the favor of the upright
group (10.14 ± 0.72) shows less interval than the recumbent
group (12.48 ± 0.50). In 2nd, 3rd , and 4th hours (4.12 ±
0.77, 2.62 ± 0.53 & 0.95 ± 0.05) respectively compared
with higher mean score among the recumbent group (11.18
± 0.39, 8.24 ± 0.42 & 2.50 ± 0.50) respectively with highly
statistically significant differences between both groups (p <
.001*).
As regards the mean number of uterine contractions/10 min-
utes, no statistically significant difference between both
group at baseline assessment (1.12 ± 0.06 & 1.56 ± 0.65)
respectively. However, after one hour statistically significant
difference was noted between both groups. Also a highly
statistically significant progress of frequency of uterine con-
tractions/10 minutes was evident among the upright group
in 2nd hour (4.06 ± 0.71), 3rd hour (4.88 ± 0.33), and 4th
hour (5.06 ± 0.37). On the other hands the recumbent group
shows slow progress of frequency of uterine contraction in
the 2nd , 3rd and 4th hours (1.84 ± 0.3, 2.50 ± 0.50 & 3.58
± 0.50) respectively (p < .001*).
Table 3 shows no statistically significant differences between
the upright and recumbent groups regarding intensity of uter-
ine contraction before intervention (p < .05). However, after
assuming different position a highly statistically significant
differences was obvious between both groups. The improve-
ment in intensity of uterine contraction was evident among
the upright group. Notably, in 1st hour (48.0% & 18.0%) of
the upright group had moderate and sever intensity compared
to (38.0% & 14.0%) of the recumbent group. Moreover,
marked progress in intensity in the upright group 2nd , 3rd
and 4th hours (22.0%, 70.0% & 100.0%) had sever intensity
compared to (12.0%, 36.0% & 66.0%) respectively of the
recumbent group (p <.001*).
Table 4 reveals that there was no statistically significant dif-
ference between the upright and recumbent group in relation
to cervical dilatation at baseline. However, a highly statisti-
cally significant difference was found between both groups
in the 2nd , 3rd & 4th hours after implementing different
position as the upright group had a higher mean score of
cervical dilatation (5.68 ± 0.47, 9.02 ± 0.32 & 9.94 ± 0.24)
118
ISSN 1925-4040 E-ISSN 1925-4059
http://jnep.sciedupress.com
Journal of Nursing Education and Practice
2018, Vol. 8, No. 7
respectively compared to 4.08 ± 0.80, 5.54 ± 0.50 & 6.48 ±
0.50 respectively of the recumbent group (p < .001*). Also
no significant difference is recognized between both groups
at baseline regarding the fetal head descent/fifth. A slight im-
provement in the head descent was noted among the upright
group after one hour with significant difference and highly
statistically significant after 2nd , 3rd , & 4th hours from as-
suming upright position. Concerning mean score of pain,
no significant difference was noted between the both groups
at baseline. However, one hour from assuming positions
the upright group experienced less pain than the recumbent
group (p < .001*). A high statically significant difference
was noted between both groups after the 2nd , 3rd & 4th hours
(p < .001*).
Table 2. Distribution of the studied sample according to assessment of uterine contraction (n = 50 for each group)
Variable
Upright group (50)
Recumbent Group (50)
N = 50 Mean ± SD
N = 50 Mean ± SD Paired T test (p)
1-Duration of uterine contractions (seconds)
At baseline
50
19.38 ± 0.60
50
19.40 ± 0.49
0.15 (.89 )
After one hour
50
26.10 ± 0. 24
50
21.50 ± 0.50
4.49 (˂ .048)*
After two hours
50
44.94 ± 1.73
50
27.00 ±1.26
9.45 (˂ .0001)**
After three hours
50
66.00 ± 1.51
50
35.62 ± 0.63
13.54(˂ .0001)**
After four hours
6
70.80 ± 1.98
50
44.160 ± 1.50
5.66 (˂ .0001)**
2-Interval of uterine contractions (minutes)
At baseline 50 15.12 ± 0.74
50
14.88 ± 0.52
0.79 (.049)*
After one hour
50
10.14 ± 0.72
50
12.48 ± 0.50
0.045*
After two hours
50
4.12 ± 0.77
50
11.18 ± 0.39
7.49 (˂ .0001)**
After three hours
50
2.62 ± 0.53
50
8.24 ± 0.43
5.34 (˂ .0001)**
After four hours
6
0.95 ± 0.05
50
2.50 ± 0.50
3.88 ( .001)**
3-Number of uterine contractions/10 minutes)
At baseline
50
1.12 ± 0.06
50
1.56 ± 0.65
1.70 (.32)
After one hour
50
2.78 ± 0.41
50
1.68 ± 0.47
3.12 (.05)*
After two hours
50
4.06 ± 0.71
50
1.84 ± 0.37
11.40 (˂ .0001)**
After three hours
50
4.88 ± 0.33
50
2.50 ± 0.50
13.95 (˂ .0001)**
After four hours
6
5.06 ± 0.37
50
3.58 ± 0.50
7.38 (˂ .0001)**
*Statistically significant difference (p < .05), **A highly statistically significant difference (p ≤ .001).
Table 5 illustrates the percent distribution of the study women
according to the duration of the 1st , 2nd and 3rd stage of
labor. Duration of the 1st stage was 10 to 12 hours of the
upright group (92%) compared to 66% of the recumbent
group. However, the duration of the 2nd stage of labor was
10 to 30 minutes of the upright group, 14% of compared to
(8%) of the recumbent group. On the other hand, duration
of the 2nd stage more than 30 minutes to 1 hour among the
majority (86%) of the upright group compared to 56% of the
recumbent group (p < .001*). Furthermore, the duration of
the 3rd stage of labor was 10 to 20 minutes among the up-
right group (92%) compared to 42% of the recumbent group.
There were statistically significant differences between the
upright and recumbent group regarding duration of 1st , 2nd
and 3rd stage of labor.
Table 6 shows that 14.0% and 86.0% of upright group had
spontaneous vaginal delivery and vaginal delivery with an
episiotomy compared to 8.0% & 92.0% of the recumbent
group respectively, and 10.0% & 10.0% had forceps or ven-
touse delivery in the recumbent group compared to nothing
in upright group (p < .04*). Also all participant in upright
group had spontaneous delivery of placenta compared to 98%
of the recumbent group.
Table 7 shows significant difference between both groups
in relation to Apgar score of the neonate during both first
and fifth minute (p < .05). Meanwhile, there was no statis-
tical significance difference between both groups regarding
admission of the neonate to neonatal intensive care unit.
Table 8 shows highly statistically significant differences be-
tween the upright and recumbent groups regarding satisfac-
tion with assumed position and preference of this assigned
position in the next labor (p < .001*).
119
Published by Sciedu Press
http://jnep.sciedupress.com
Journal of Nursing Education and Practice
2018, Vol. 8, No. 7
Paired T test (p)
Mean ± SD
N = 50 Mean ± SD N = 50
Recumbent Group (50)
Upright group (50)
Variable
Table 3. Distribution of the studied sample according to intensity of uterine contraction (n = 50 for each group)
Intensity of uterine contractions Upright group (50) Recumbent Group (50) χ2 P
No % No %
Before assume different position
Mild
45
90.0
43
86.0
0.77 (.5)
Moderate
1st hour
5
10.0
7
14.0
Mild
17
34.0
24
48.0 29.54 (˂ .001)**
Moderate
24
48.0
19
38.0
Sever
9
18.0
7
14.0
2nd hour
Mild
4
8.0
15
30.0 48.32 (˂ .001)**
Moderate
35
70.0
29
58.0
Sever
11
22.0
6
12.0
3rd hour
Mild
0
0.0
9
18.0 57.24 (˂ .001)**
Moderate
15
30.0
23
46.0
Sever
35
70.0
18
36.0
4th hour
Mild
N = 6
0
0.0
N = 50
4
8.0 14.46 (˂ .001)**
Moderate
0
0.0
13
26.0
Sever
6
100
33
66.0
*Statistically significant difference (p < .05), **A highly statistically significant difference (p ≤ .001).
Table 4. Distribution of the studied sample according to mean cervical dilatation (cm), fetal head descent/fifths and mean
pain scores (n = 50 for each group)
1-Cervical dilatation (cm)
Before assume different position
50
3.26 ± 0.69
50
3.14 ± 0.35
0.53 (.59)
After one hour
50
4.42 ± 0.56
50
3.62 ± 0.53
4.99 (.037)*
After two hours
50
5.68 ± 0.47
50
4.08 ± 0.80
13.38 (˂ .001)**
After three hours
50
9.02 ± 0.32
50
5.54 ± 0.50
27.59 (˂ .001)**
After four hours
6
9.94 ± 0.24
50
6.48 ± 0.50
29.76 (˂ .001)**
3-Fetal head descent/fifth
Before assume different position
50
4.80 ± 0.40
50
4.38 ± 056
2.28 (.745)
After one hour
50
3.88 ± 0.33
50
4.14 ± 0.35
3.96 (.009)**
After two hours
50
2.18 ± 0.44
50
4.02 ± 0.14
13.29 (˂ .001)**
After three hours
50
0.85 ± 0.11
50
3.39 ± 0.62
25.11 (˂ .001)**
After four hours
6
0.31 ± 0.14
50
3.11 ± 0.53
14.39 (˂ .001)**
Mean Pain Scores
Before assume different position
50
7.61 ± 0.47
50
7.60 ± 0.74
0.136
After one hour
50
6.64 ± 0.48
50
8.22 ± 0.65
(˂ .001)**
After two hours
50
6.84 ± 0.37
50
8.56 ± 0.50
(˂ .001)**
After three hours
50
7.38 ± 0.49
50
9.36 ± 0.48
(˂ .001)**
After four hours
6
7.68 ± 0.47
50
9.74 ± 0.44
(˂ .001)**
**A highly statistically significant difference (p ≤ .001).
120
ISSN 1925-4040 E-ISSN 1925-4059
http://jnep.sciedupress.com
Journal of Nursing Education and Practice
2018, Vol. 8, No. 7
p
χ2
%
No % No
Recumbent Group (50)
Upright group (50)
Variable
Table 5. Distribution of the studied sample according to duration of first, second and third stage of labor (n = 50 for each
group)
Duration of 1st stage of labor (hours)
8- < 10
4
8.0
0
0.0
23.14 .000**
10- < 12
46
92.0
33
66.0
12-14
0
0.0
17
34.0
Duration of 2nd stage of labor (minute)
˂ 30 minutes
7
14.0
4
8.0 17.76 .001**
30 minutes-one hour
43
86.0
28
56.0
˃ one hour
0
0.0
18
36.0
Duration 3rd stage of labor (minute)
10-20 minutes
46
92.0
21
42.0
28.27
.001**
30 minutes > 20-
4
8.0
29
58.0
Note. χ2 Chi-Square test. **Highly statistically significant differences (p ≤ .001).
Table 6. Distribution of the studied sample according to mode of delivery and mode of placental delivery (n = 50 for each
group)
Variable Upright group (50) Recumbent Group (50) χ2 p value
No % No %
Mode of delivery
Spontaneous vaginal delivery
7
14.0
4
8.0
Vaginal delivery with an episiotomy
43
86.0
46
92.0
71.61
.004*
Forceps delivery
0
0.0
5
10.0
Ventouse delivery
0
0.0
5
10.0
Mode of placental delivery
Spontaneous delivery
50
100.0
49
98.0
86.16
.06
Manual separation
0
0.0
1
2.0
Note. χ2: Chi-Square test, *Statistically significant difference (p < .05)
Table 7. Distribution of the studied sample according to neonatal outcome (n = 50 for each group)
Upright group (50) Recumbent Group (50)
Variable χ2 p
No % No %
Apgar score at first minute
Good (8-10)
32
64.0
19
38.0
6.99 0.003**
Moderate asphyxia (5-7)
15
30.0
24
48.0
Sever asphyxia (≤ 4)
3
6.0
7
14.0
Apgar score at fifth minute
Good (8-10)
46
92.0
37
74.0 5.88 (0.05)*
Moderate asphyxia (5-7)
3
6.0
11
22.0
Sever asphyxia (≤ 4)
1
2.0
2
4.0
Admission to the neonatal intensive care unit
Yes
2
4.0
4
8.0 11.16 .06
No
48
96.0
46
92.0
Note. χ2: Chi-Square test, No statistically significant difference (p > .05), *Statistically significant difference (p < .05), **A highly statistically significant difference (p ≤ .001).
121
Published by Sciedu Press
http://jnep.sciedupress.com
Journal of Nursing Education and Practice
2018, Vol. 8, No. 7
p
χ2
%
No % No
Recumbent Group (50)
Upright group (50)
Variable
Table 8. Distribution of the studied sample according to satisfaction with assumed position and preference of this position
in the next labor (n = 50 for each group)
Are you satisfied with your position assumed during 1st stage of labor
Yes
39
78.0
13
26.0
6.99
.001**
No
11
22.0
37
74.0
**A highly statistically significant difference (p ≤ .001), χ2: Chi-Square test.
4.D ISCUSSION
Despite a growing body of evidence reporting physical bene-
fits for birthing women and their babies when women adopt
an upright position, most women worldwide, with some few
exceptions, currently give birth to their babies lying in a bed,
on their backs which is a practice not based on systematic
scientific research.[12] The effect of upright versus recum-
bent position during first stage of labor on maternal-fetal
and neonatal outcomes are rarely in agreement and available
evidences in this field are often controversial and fragmen-
tary.[16,17] WHO[18] concluded that there is no evidence to
support of recumbent position during the first stage of labor.
But there is evidence that upright positions during the first
stage of labor shorten the duration of labor and decreased
intervention and not effects on mothers and fetus wellbeing.
Therefore, maternity nurses should encourage women to take
up whatever position they find most comfortable in the first
stage of labor. This study has shed some lights on effect of
upright versus recumbent position during first stage of labor
among primipare on labor outcomes.
The results of this study will be discussed in frame of pre-
viously mentioned research hypothesis. As regards general
characteristic of studied sample, the present study revealed
that participants of both upright and recumbent groups were
homogenous in demographic characters with no statistical
significant difference. This homogeneity is useful in limiting
extraneous variables, which may interfere with the effects
of the intended intervention on labor progress and labor out-
come. These findings were in the same line with Gizzo et
al.,[7] who reported in their study about women’s choice of
positions during labor that no significant difference between
upright and recumbent groups for age, educational level, ges-
tational age. Regarding progress of uterine contraction it
was obvious that women who assumed upright position dur-
ing first stage of labor had improved the progress of uterine
contraction, whereas no statistically significant differences
between the upright and recumbent group at baseline assess-
ment, however highly significant differences was evident
among the upright group in term of increase number of uter-
ine contraction/10 minutes, intensity and increased duration,
as well as decreased interval during the 2nd , 3rd and 4th
hours after assumed upright position. Likewise, the recum-
bent group show less progress of uterine contraction. These
findings may be that the upright positions may benefit from
gravity effect which potentially prevent aortocaval compres-
sion, resulting in strengthened uterine contraction. Effective
contractions are vital to cervical dilatation and fetal descent.
This finding was in the same line with Lawrence et al.[3]
who studied the maternal positions and mobility during first
stage labor and found that the strength of uterine contractions
increased in the upright position compared to the supine po-
sition. Moreover agreed with Kumud et al.[9] who studied
the effect of upright positions on the duration of first stage of
labor among nulliparous mothers and reported that parturient
women who assumed upright positions had increase strength
of uterine contractions than those assumed supine position.
Concerning the pain intensity the findings of the present
study revealed high statistical significant differences between
the upright and recumbent group in the Mean Pain Scores
during the 2nd , 3rd , and 4th hours after assumed upright
position. These may be due pain during the first stage of
labor result from a combination of uterine contractions and
cervical dilation.[19] Painful sensations travel from the uterus
through visceral afferent or sympathetic nerves that enter
the spinal cord through the posterior segments of thoracic
spinal nerves. Maternal physical and psychological comfort
in labor is crucial for preventing additional stress. This can
further be accomplished by allowing the mother to move
freely and follow her body’s signals to mobilize and change
position during labor. These findings was in the same line
with Angel Rajakumari et al.[20] who studied the effective-
ness of selected nursing measures on labor outcome among
primigravid mothers and reported that mothers who main-
tained upright positions had significantly less pain than those
5.88 .001**
28.0
72.0
14
36
72.0
28.0
Do you prefer this assumed position in the next labor?
Yes 36
No 14
122
ISSN 1925-4040 E-ISSN 1925-4059
http://jnep.sciedupress.com
Journal of Nursing Education and Practice
2018, Vol. 8, No. 7
in other position. Moreover, Chaillet et al.[21] found that
women who spent the early stage of labor in the upright
position had less pain than in the supine position.
As regards cervical dilatation the present study findings
showed significant improvement of cervical dilatation during
the 2nd , 3rd and 4th hours of assuming the upright posi-
tion than in the recumbent position. These findings may be
due to that upright and mobile positions use the downward
force of gravity which assists the fetal head to descent into
the pelvis. As the head is applied directly and evenly on
the cervix, uterine contractions are intensified in frequency,
strength, and regularity. It is this uterine efficiency which
help in cervical dilatation and effacement. The present study
findings is compatible with the results of Hassan[22] studied
the effect of pelvic rocking exercise using sitting position
on birth ball during the first stage of labor on its progress
and found significant improvement of cervical dilatation in
the study group after intervention than the control group.
In addition, Lawrence[3] found that women who assumed
the upright position and frequently change it during the first
stage of labor had improved cervical dilatation than those
who assumed the supine position.
Concerning the descent of the fetal head the results of the
current study showed a significant difference during the 2nd,
3rd and 4th hours after assuming upright position than in the
recumbent position. These findings may be due to that up-
right position, movements with different positions increase
strengthen of pelvic floor muscles, increase diameters of
pelvis, and consequently help with descent of fetus into the
vaginal outlet. The present findings is compatible with Gizzo
et al.[7] who found that vertical positions appeared helpful
in descent of fetal head during labor, decreasing the rate
of operative vaginal deliveries and cesarean delivery. Also
these findings are in the same line with Simkin et al. and
Storton[23,24] who reported that the upright positions aid in
bring the baby down by using gravity, whereas frequently
changing maternal position moves the bones of the pelvis,
helping the baby down in the pelvis.
Regarding duration of 1st , 2nd and 3rd stage of labor, the
present study findings revealed a highly significantly shorter
duration of three stages among the upright than the recum-
bent group. These findings may be due to that during the
first stage of labor, upright positions such as sitting, standing
and kneeling allow the abdominal wall to relax and influence
gravity causes the uterine funds to fall forward. This directs
the fetal head into the pelvic inlet in an anterior position and
applies direct pressure to the cervix which helps to stimulate
and stretch the cervix. An upright position during the second
stage of labor has been associated with a decreased caesarean
birth, instrumental delivery and reduction in labor duration.
These findings are in agreement with Angel Rajakumari et
al.[20] who concluded that selected nursing measures is an ef-
fective method to reduce the duration of labor and enhances
for the normal vaginal delivery. Also this results in same line
with Hassan[22] who revealed that a high significantly shorter
duration of 1st , 2nd and 3rd stage of labor among the study
group than the control group.
Additionally, this finding is in congruence with Lawrence
et al. and Gizzo et al.[3,7] the first concluded that the mean
duration of labor among women who assumed alternative
upright position was significantly less than those who are
adopted supine or recumbent position. The second study,
in the comparison of upright and ambulant positions versus
recumbent positions during the first stage, concluded that
labor is shorter by approximately one hour and 22 min for
women randomized to upright as opposed to recumbent posi-
tions. As well as, this finding in the same line with Kumud et
al.[9] who found that the average reduction in the first stage
of labor in experimental group was 2 hours.
Concerning mode of the delivery the findings of the present
study revealed that the majority of participant in upright
group had vaginal delivery with episiotomy compared the
most in the recumbent group, and ten percent had forceps
and ventouse delivery in the recumbent group compared to
nothing in upright group. Also, all participant in upright
group had spontaneous delivery of placenta compared to
98% in the recumbent group with no statistically significant
difference. These findings are in the same line with Kumud
et al.[9] who found that women who assumed upright posi-
tions during the first stage of labor had vaginal delivery and
no any women had delivered by using forceps and ventouse.
On other hand, these findings disagree with Lawrence et
al.[25] who found that there were no significant differences
between women randomized to upright versus recumbent
positions in achieving spontaneous vaginal deliveries and
assisted deliveries.
In relation to neonatal outcome the findings of present study
revealed that a higher and good Apgar score of neonates
among upright group when compared with recumbent group.
Meanwhile, there was no significance difference between
both groups regarding admission of the neonate to inten-
sive neonatal care unit. These findings were disagree with
Lawrence et al.[25] who found no significant differences
between the studied groups in terms of fetal distress and
neonatal Apgar scores. Admission to neonate special care
units was reported only in one study and more likely for
babies delivered to mothers assigned to upright positions, but
this difference did not reach statistical significance.
123
Published by Sciedu Press
http://jnep.sciedupress.com
Journal of Nursing Education and Practice
2018, Vol. 8, No. 7
As regards maternal satisfaction with positions were assumed,
the findings of the present the study showed that more than
three quarter of upright group was satisfied with assuming
upright position compared to about one quarter of recum-
bent group was satisfied with recumbent position. Moreover,
nearly three quarters in upright group were preferred to as-
sume the upright position in the next labor compared to more
than one quarter in recumbent group who anticipated to as-
sume recumbent position in the next labor. These findings
are in the same line with Prabhakar et al.[26] who studied
the effectiveness of ambulation during first stage of labor,
on the outcome of labor among primigravida women and
found that mothers were stay in bed and not walk around
experienced lower satisfaction with childbirth than mothers
that were walk around or move from one position to another.
Also these findings supported by Hodnett et al.[10] who found
that women who encouraged to assuming upright position
were satisfied and more comfortable. On the other hand
this findings disagree with Mathew et al.[27] who found that
women who were choosing side lying or lying on back in
first stage of labor were more satisfied.
5.C ONCLUSION
Based on the findings of the present study, it can be con-
cluded that the results of the present study support its hy-
pothesis and revealed that assuming upright position during
first stage of labor results in advantages for the parturient
primipara woman by significant improvement in the progress
of labor, shorten duration of the three stages of labor, faster
fetal head descent, significant reduction of pain score and
good Apgar score. And a highly statistical significant differ-
ence regarding maternal satisfaction and preference of the
assumed position in next labor.
Recommendation
Based on the findings of the present study, the following
recommendations were suggested:
(1)
All parturient women in low-risk labor should be in-
formed about the benefits of assuming upright posi-
tions during first stage of labor, and be encouraged and
supported to use them.
(2)
In service education program for maternity nurses
about different maternal positions during labor.
(3)
Poster, pamphlets and video illustrating the benefit
of upright positions should be available in antenatal
clinics and labor unit.
(4)
Replicated the study on a larger sample for generaliz-
ing the findings.
ACKNOWLEDGEMENTS
Researcher would like to thank all the mothers who partici-
pated in implementing of this study, all who have directly or
indirectly helped me to complete this study and their support
in each major step of the study.
CONFLICTS OF INTEREST DISCLOSURE
It was enormous-time consuming to continue evaluate the
effect of different maternal position on labor progress, labor
outcome and neonatal outcome. The researcher excluded
seven women from the study who didn’t commit to the se-
lected maternal position. All excluded women were replaced
with other randomly selected participant.
REFERENCES
[1]
Iravani M, Zarean E, Janghorbani M, et al. Women’s needs and ex-
pectations during normal labor and delivery. Journal of Nursing and
Midwifery Research. 2015.
[2]
Perry SE, Lowdermilk DL, Cashion MC. Maternal Child Nursing
Care. 3rd ed. Labor and Birth Process. 2014.
[3]
Lawrence A, Lewis L, Hofmeyr GJ, et al. Maternal positions and
mobility during first stage labor. Cochrane Database Syst Rev. 2013;
10: 1-10.
[4]
Priddis H, Dahlen H, Schmied V. What are the facilitators, inhibitors,
and implications of birth positioning? A review of the literature.
Women and Birth. 2012. PMid:21664208
https://doi.org/10.1
016/j.wombi.2011.05.001
[5]
Martin HJ, Martin RC. A narrative review of maternal physical activ-
ity during labor and its effects upon length of first stage. 2012.
[6]
Leifer G. Maternity Nursing: An Introductory Text, 11th edition,
Labor and Birth. 2013.
[7]
Gizzo S, Gangi SD, Noventa M, et al. Women’s Choice of Positions
during Labor: Return to the Past or a Modern Way to Give Birth? A
Cohort Study in Italy. 2014.
[8]
Edmonds K. Dewhurst’s Textbook of Obstetrics and Gynecology. 8th
ed. preterm Labor. 2015.
[9]
Kumud Rana AK, Chopra S. Effect of upright positions on the dura-
tion of first stage of labor among nulliparous mothers. Nursing and
Midwifery Research Journal. 2013.
[10]
Alden KR, Lowdermilk DL, Cashion MC, et al. Maternity and
Women’s Health Care, 10th edition. Nursing Care Of The Family
During Labor And Birth. 2014.
[11]
Hodnett ED, Gates S, Hofmeyr GJ, et al. Continuous support for
women during childbirth. Cochrane Database of Systematic Reviews.
2012. PMid:23076901 https://doi.org/10.1002/14651858.C
D003766.pub4
[12]
Ward S, Hisley S. Maternal-Child Nursing Care Optimizing Out-
comes for Mothers, Children, & Families, (4th edition). The Process
of Labor and Birth. 2015.
124
ISSN 1925-4040 E-ISSN 1925-4059
http://jnep.sciedupress.com
Journal of Nursing Education and Practice
2018, Vol. 8, No. 7
[13]
WHO. World Health Organization partograph in management of
labor. Lancet. 1994; 343: 1399-1404. PMid:7910888
[14]
Virginia. Apgar score “A proposal for a new method of evaluation of
the newborn infant”. Current Researches in Anesthesia & Analgesia.
1953
[15]
Freyd M. The graphic rating scale. Journal of Educational Psychology.
1923; 14: 83-102. https://doi.org/10.1037/h0074329
[16]
Gupta JK, Hofmeyr GJ, Shehmar M. Position in the second stage of
labor for women without epidural anesthesia. The Cochrane Database
of Systematic Reviews. 2012.
[17]
Kemp E, Kingswood CJ, Kibuka M, et al. Position in the second stage
of labor for women with epidural anesthesia. Cochrane Database of
Systematic Reviews. 2013.
[18]
The WHO. Reproductive Health Library (RHL) Maternal positions
and mobility during first stage of labor. Geneva: WHO. 2015.
[19]
Gabbe SG, Niebyl JR, Simpson JL. (Eds.). Obstetrics: Normal and
Problem Pregnancies (5th ed.). New York, NY: Churchill Livingstone.
2014.
[20]
Angel Rajakumari G, Sheela R, Soli TK. The effectiveness of selected
nursing measures on labor outcome among primigravid mothers. Jour-
nal of Science. 2015; 5(8): 716-719.
[21]
Chaillet N, Belaid L, Crochetière C. Non pharmacologic approaches
for pain management during labor compared with usual care: A
meta-analysis. Birth. 2014; 41: 122-37. PMid:24761801
https:
//doi.org/10.1111/birt.12103
[22]
Hassan NZ. Effect of pelvic rocking exercise using sitting position on
birth ball during the first stage of labor on its progress. IOSR Journal
of Nursing and Health Science (IOSR-JNHS). 2016; 5(4): 19-27.
[23]
Simkin P, Ancheta R. The labor progress handbook: Early interven-
tions to prevent and treat dystocia. 3rd ed. New York, NY: Wiley-
Blackwell. 2011.
[24]
Storton S. The coalition for improving maternity services: Evidence
basis of mother-friendly care. Step 4: Provide the birthing woman
with freedom of movement to walk, move, and assume positions
of her choice. The Journal of Prenatal Education. 2013; 16(Supp.
1): 25S-27S. PMid:18523670 https://doi.org/10.1624/1058
12407X173164
[25]
Lawrence A, Lewis L, Hofmeyr GJ, et al. Maternal positions and
mobility during first stage labor. Cochrane Database of Systematic
Reviews. 2011; 15(2).
[26]
Prabhakar D, George LS, Karkada S. Effectiveness of ambula -
tion during first stage of labour, on the outcome of labour among
primigravid women in selected hospitals of Palakkad District, Ker-
ala. International Journal of Nursing Education. 2015; 7(1): 1-6.
https://doi.
org/10.5958/0974-9357.2015.00001.
X
[27]
Mathew A, Nayak S, Vandana K. A Comparative study on effect
of ambulation and birthing ball on maternal and newborn outcome
among Primigravida mothers In selected Hospitals In Mangalore.
Nitte University Journal of Health Science. 2012; 2(2): 2249-7110.
