ABSTRACT OF THESIS THE RELATIONSHIP BETWEEN THE INCIDENCE OF OCCIPUT POSTERIOR FETAL POSITION AT BIRTH TO MATERNAL LABOR POSITIONS IN PATIENTS WITH

Transcription

1 ABSTRACT OF THESIS THE RELATIONSHIP BETWEEN THE INCIDENCE OF OCCIPUT POSTERIOR FETAL POSITION AT BIRTH TO MATERNAL LABOR POSITIONS IN PATIENTS WITH EPIDURALS The literature regarding the cause of occiput posterior fetal position is controversial. Regardless of the etiology, delivery of an infant in the occiput posterior position has potential dangers for mother and child. While there is increasing use of epidural analgesia in the United States, the literature is lacking on interventions to facilitate rotation of malpositioned fetuses in women with epidurals. This study used physical theory to explore the relationship between maternal positions in labor and fetal position at delivery using a retrospective chart review. Results of this research study showed that those who used many different maternal positions in labor delivered occiput anterior more frequently.

2 THE RELATIONSHIP BETWEEN THE INCIDENCE OF OCCIPUT POSTERIOR FETAL POSITION AT BIRTH TO MATERNAL LABOR POSITIONS IN PATIENTS WITH EPIDURALS By Lorie A. Lape, BSN, RNC-OB Julianne Ossege, PhD, CFNP, Committee Chair Christina Rust, MSN, RNC-OB, Committee Member

3 THE RELATIONSHIP BETWEEN THE INCIDENCE OF OCCIPUT POSTERIOR FETAL POSITION AT BIRTH TO MATERNAL LABOR POSITIONS IN PATIENTS WITH EPIDURALS Investigational Project An Investigational Project submitted in partial fulfillment of the requirements for the degree of Master of Science in Nursing at Northern Kentucky University By Lorie A. Lape, BSN, RNC-OB Cincinnati, Ohio Director: Dr. Marilyn Schleyer Chair, Advanced Nursing Highland Heights, Kentucky 2011

4 UMI Number: All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent on the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. UMI Copyright 2011 by ProQuest LLC. All rights reserved. This edition of the work is protected against unauthorized copying under Title 17, United States Code. ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, MI

5 Copyright by Lorie A. Lape 2011

6 DOCUMENT RELEASE X I authorize Steely Library to reproduce this document in whole or in part for purposes of research. I do not authorize Steely Library to reproduce this document in whole or in part for purposes of research. Signed: Lorie A. Lape Date: March 28, 2011

7 Acknowledgments: The author wishes to thank her family for their encouragement, understanding and patience during this process. Also, a special thanks to Michael Crossman, MD; Christina Rust, MSN, RNC-OB; Patricia Sisson; and Kim Dinsey-Read, MSN, RN. iii

8 Table of Contents INTRODUCTION 1 Statement of the Problem 2 Significance of Study 3 Theoretical Framework 4 Research Question 5 Variables 5 Limitations 6 REVIEW OF THE LITERATURE 7 Summary 14 Design and Methodology 16 Research Type and Design 16 Design 17 Setting 17 Sample 17 Data Collection 18 Human Subject Protection 19 Data Analysis 19 PRESENTATION, ANALYSES, INTERPRETATIONS OF DATA 20 Sample Demographics 20 Maternal Positions During Labor 21 Maternal Position During Labor and Fetal Position at Birth 23 Maternal Positions Related to Fetal Positions 26 Introduction 29 Discussion and Implications 29 Discussion of findings 31 iv

9 Implications for research, theory and practice 31 Summary and conclusions 33 REFERENCES 34 APPENDIX A 39 v

10 Introduction Prior to the invention of forceps in the 17 th century, historical art rarely showed childbirth in a supine position (lying on the back) (Keen, DiFranco, & Amis, 2004). During the first half of the 20 th century, decreased mobility during labor was evident sometimes women were even restrained during birth (Johnson, Johnson, & Gupta, 1991). The supine position for childbirth has resulted as a convenience for the delivering medical personnel (Andrews & Andrews, 1983). Simkin and O Hara (2002, p. S148) determined that as the place of birth shifted from home to hospital during the first half of the 20 th century, numerous changes in care, such as the use of narcotics or anesthesia, high patient-to-nurse ratios, connections to intravenous lines, electronic monitors, and other devices, made it safer or more convenient if the woman remained in bed. Malpositions seem to be occurring more frequently now than ever before. The supine position in pregnancy promotes poor alignment of the fetal presenting part within the pelvic inlet (Fenwick & Simkin, 1987). Immobility limits the fetal dexterity, decreasing the baby s ability to flex, engage into the pelvis, find the best fit, rotate and descend (Zwelling, 2010, p. 74). Delivering a fetus whose presentation is cephalic but whose position is not anterior is much more difficult for the mother. It increases the risk for operative vaginal deliveries and is associated with more third and fourth degree perineal lacerations (LeRay, Carayol, Jaqquemin, Mignon, Cabrol, & Goffinet, 2005). The anterior fetal position is the optimal position it occurs when the fetal back is against the front of the mother

11 (Andrews & Andrews, 2004). Malpositions occur when the fetal back is against the mother s back (posterior position) and when the fetal back is against the mother s side (transverse position) (Andrews & Andrews, 2004). Statement of the Problem Fetal malpositions significantly prolong the second stage of labor and increase the incidence of cesarean delivery (Hanson, 2008). Other studies have noted postpartum hemorrhage and puerperal infection as a result of malposition (Reichman, Gdansky, Latinsky, Labi, & Samueloff, 2008). Ridley (2007) also lists oxytocin augmentation, anal sphincter injury, severe perineal laceration, and instrumental vaginal delivery as complications of occipitoposterior malposition. Ponkey, Cohen, Heffner, and Lieberman (2003) found significantly lower 1-minute Apgar scores in infants born in the occiput posterior position. Psychological effects include feelings of loss of control by the mother (Andrews & Andrews, 1983). Factors that have contributed to the decrease in labor patients mobility are increased medical management (for example, epidurals), obesity, and patients and nurses limited understanding regarding the benefits of mobility to facilitate labor progress (Zwelling, 2010). Sabsamruei and Tanprasertkul (2010) suggest that maneuvers for correcting malrotation in labor may have a major role for decreasing obstructed labor and the primary cesarean section rate. Fitzpatrick, McQuilllan, and O Herlihy (2001) proposed that labor unit population s ethnicity and differing practices may influence the incidence of persistent occiput posterior. For example, it was standard practice at Fitzpatrick s institution to rotate 2

12 posterior fetuses with forceps. Also, different cultures such as sedentary Western cultures tend to have a higher incidence of posterior fetuses. Significance of Study The purpose of this quantitative study was to assess the prevalence of occipitoposterior fetal position at birth in a population of parturients with epidurals at a Midwest suburban hospital. The literature contains a great deal of research on maternal positioning to rotate the fetus but it typically involves mothers experiencing natural childbirth (no anesthesia). The Midwest suburban hospital where this research took place had an approximate 90% epidural rate (C. R., personal communication, June 29, 2009). The literature cites the hands and knees position as one of the most effective positions for fetal rotation. Laboring women with an epidural generally are not able to hold themselves up in the hands and knees position due to the numbness they experience in the lower halves of their bodies (Stremler et al, 2009). According to the CDC, cesarean rates have risen 46% since 1996 (CDC, 2005). The population studied had a cesarean section rate of 33% in 2008 (C. R., personal communication, June 30, 2009). Indications for cesareans include (but are not limited to): failure to progress, cephalopelvic disproportion, persistent malposition (Simkin, 2000); dystocia, asynclitism, and failure to descend (Fenwick & Simkin, 2005); breech, and repeat cesarean section (Taffel & Placek, 1983). The rationale for this retrospective study was to explore the relationship between maternal labor positioning in those with epidurals, and fetal position at delivery. According to Andrews and Andrews (2004, p. 134), variations of the hands-and-knees 3

13 posture remain the optimal postures for rotating malpositions. However, anesthesia safety protocols often prohibit women with epidurals from getting out of bed (Mayberry, Clemmens, & De, 2002). Women are confined to bed in the recumbent position more often with the use of epidurals and the resulting immobility (Mayberry et al., 2002). In Dundes 1987 paper entitled The Evolution of Maternal Birthing Position, it is discussed how Westerners came to adopt horizontal and lithotomy (lying on back with legs in stirrups) positions. Dundes (1987) asserts that these positions were adopted without the verification of appropriateness or scientific research. Theoretical Framework Physical theory is credited in the literature for rotating malpositioned fetuses (Andrews & Andrews, 2004; Ridley, 2007; & Stremler, Hodnett, Petryshen, Stevens, Weston, & Willan, 2005). The physical forces of gravity, buoyancy and friction act on the fetus in the uterus (Andrews & Andrews, 2004). Gravity pulls the fetus toward the earth. Buoyancy is attracting the fetal body in an upward direction, opposite gravity. The walls of the uterus provide friction against the short axis of the fetus (i.e. against fetal parts) (Andrews & Andrews, 2004). With the exception of the fetal head, the fetal back is the heaviest part of the fetal body (Andrews, 2004). Maternal posturing in the hands and knees position has the potential to create a driving force to facilitate overcoming the frictional forces resisting rotation (Andrews & Andrews, 2004). Gravity explains the rotation of the fetus from OP (occiput posterior) to OA (occiput anterior) in the mother in the hands and knees 4

14 position. In other words, in the hands and knees position, the maternal abdomen is hanging downward and the fetus is buoyant in the amniotic fluid. According to Physical Theory, that buoyancy and gravity would naturally encourage the second heaviest part of the fetus, the spine, to move toward the Earth, thus rotating the fetus into the OA position. Position change can enhance or block the natural gravitational forces already at work in the gravid abdomen. Epidurals provide motor blockade, which in turn affects maternal positioning during labor (Bianchi & Adams, 2009). Zwelling (2010) states that if the fetal and maternal vital signs are within normal limits after the epidural, the maternal position should be changed every minutes to facilitate the best fit of the fetus through the pelvis. Mayberry, Strange, Suplee, and Gennaro (2003) reinforce nurses need to assess the patient s mobility and individualize care according to that mobility. Research Question What is the relationship between the incidence of occiput posterior fetal position at birth to maternal labor positions in patients with epidurals at a Midwest suburban hospital? Variables The variables for this study were as follows: Parity (conceptual): The number of viable births. Parity (operational): The number of viable births as noted on the prenatal record. Induction (conceptual): The use of synthetic oxytocin to initiate or augment contractions. 5

15 Induction (operational): The intravenous administration of synthetic oxytocin to laboring women in Labor & Delivery to initiate or enhance contractions for the purpose of promoting labor. Variation of maternal positions (conceptual): The variety of positions used during labor and delivery. Variations of maternal positions (operational): The number of different positions used during labor and delivery as documented on the nurses notes. Route of delivery (conceptual): Spontaneous vaginal delivery, cesarean section delivery, or instrumental delivery (vacuum- or forceps-assisted). Route of delivery (operational): Spontaneous vaginal delivery, cesarean section delivery, or instrumental delivery (vacuum- or forceps-assisted) as noted on the delivery record. Limitations The author recognized certain limitations of this study. Maternal position during labor is multifactoral. Laboring women could refuse to change positions in labor. Once the patient is settled into a comfortable position she may not wish to move and could resist the suggestion of the nurse to change positions. Another limitation is the varying degree of immobility associated with a labor epidural. The motor blockade level of anesthesia could vary with providers and variations of drug mixtures, thus resulting in different levels of mobility from patient to patient. 6

16 Chapter 2 Review of the Literature Epidurals are the gold standard for relieving labor pain (O Sullivan, 2009). Assisting women with epidurals into various positions without assistance from others can be difficult (Gilder, Mayberry, Gennaro, & Clemmens, 2002). Gilder et al (2002) also noted that the literature is lacking on how positions can or should be altered for those with epidural analgesia. In the U.S., recumbency and bed confinement are routine positions for labor patients, perhaps due to the benefits to the clinicians and the institutions (Albers, 2007). Clinician preference partially determines consumer choices in maternity care (Albers, 2007). Zwelling articulated it is not uncommon for a woman to remain in a semi-fowler position in bed from the time she is admitted through most of her labor (2010, p. 73). A study of Labor and Delivery nurses by Gilder et al (2002) revealed nurses complaints about patients reluctance or refusal to change position during labor. Although laboring women are encouraged to maintain any position they find comfortable (Gupta & Nikodem, 1999), a prudent nurse caring for a woman with an epidural should educate the woman on the benefits of position change in labor. This research study explored the relationship between malpositioned fetuses with maternal position in laboring women with epidurals. Gupta and Nikodem (2000) wrote a case report on maternal posture in labor. Their work summarizes the history of labor positions and historically, a supine position was rare. During the past 300 years in Western culture, a change to recumbent positions has occurred despite the lack of supporting scientific evidence. Recumbency was first 7

17 preferred in France in the 17 th century with the manifestation of obstetric surgeons. Birth transitioned from the home to the hospital. The use of drugs such as paralyzing agents and general anesthesia became more commonplace during the beginning of the 20 th century. Because of this, immobility during labor and/or restraint during birth were not uncommon. Gupta and Nikodem (2000) found the evidence contradictory on the benefits of upright and supine positions in the first stage of labor. However, Gupta and Nikodem found more evidence to support upright positioning in 2 nd stage. Interestingly, Gupta and Nikodem noted a patient bias in which most women expect a delivery in bed, either in left lateral or semi-recumbent position. Historically, squatting was a favored position for birth, but Western women are unaccustomed to squatting. Gupta and Nikodem conclude that women should assume any position which provides comfort in labor. Andrews & Andrews (1983; 2004) have written sentinel research on successful rotation of malpositioned fetuses. The researchers list the hands-and-knees position as the most successful posture for rotation. However, these articles fail to mention the use of epidural analgesia, possibly because Andrews and Andrews research began before the popularity of epidurals. Andrews and Andrews 1983 research is a randomized control trial (RCT) with an N=100. Criteria were: normal intrauterine pregnancy, 38+ weeks gestation, posterior or transverse fetal position, not in labor, and the woman had to be in good health. Their exclusion criteria were: previous cesarean or uterine surgery, hydramnios, toxemia, diabetes, multiple gestation and/or transverse lie. The women were randomly assigned to 1 of 5 posture groups. Group 1 (HK) was positioned on their hands and knees with 8

18 lower back arched. Group 2 (PR) was positioned on hands and knees plus they used the pelvic rock slowly and rhythmically. Group 3 (ST) was positioned on their hands and knees with their lower backs arched plus used abdominal stroking. Group 4 (COMB) was positioned on hands and knees plus used the pelvic rock plus stroking ten times plus rested in hands and knees for 30 seconds at the end. Group 5 (SIT) was sitting up (control group). Two nurse midwives were the examiners. One assessed fetal position using Leopold s maneuvers and the other helped the women into their assigned positions (posturing). The dependent variable was fetal position. The independent variable was posturing. After the posturing exercises the fetal position was reassessed. If the fetus was occiput anterior, the woman lay in the Sims position (lying on side with superior knee and thigh lifted well above inferior leg, inferior arm is behind the woman and her chest is tilted forward so she rests on it) for 10 minutes. If the fetus was not occiput anterior, the woman was assigned to 1 of 5 original posture groups for 10 minutes. The fetal position was then reassessed. A contingency table showed the rotation frequencies. Chi-square was used to test the statistical hypothesis to determine whether the observed frequencies of rotation and non-rotation for each of 2 posture groups being compared respective to each hypothesis could have occurred under the statistical null hypothesis. Computation was done on a DEC System 20 using SPSS. Sixty of 100 had fetal rotation occur with the first posturing exercise. Sixteen out of 50 had rotation with the second posturing exercise. There was a significant difference between the proportion of rotation versus non-rotation (p=0000). The limitations of this study were that the women were not in 9

19 labor and none of them had epidurals. However, the study clearly reveals maternal posturing is clinically valuable in rotating fetal malposition. In Andrews and Andrews 2004 study, they reviewed three of their previous studies, including the 1983 study mentioned above, and took the intervention one step further to see if rotating the fetus into the anterior position during pregnancy would increase the chances of the fetus being in the anterior position at the onset of labor (N=86). The women assumed their assigned posture (sitting or hands and knees) for 10 minutes three times daily until the onset of labor. Studies 1, 3, and 4 had a control group. Approximately half of those women who started the study with a posterior baby and performed the hands and knees posture exercise three times daily began labor with an anterior fetus (their babies were in the correct position for birth). Lieberman, Davidson, Lee-Parritz & Shearer (2005) reviewed three observational studies in which epidural use was associated with occiput posterior position at delivery. Lieberman et al determined that it is not possible to distinguish from these studies whether epidural analgesia contributes to occiput posterior position or whether women with occiput posterior infants have more painful labors and request epidural analgesia more often (p. 974). One wonders if the decreased mobility associated with epidural analgesia contributes to occiput posterior fetal position. Lieberman et al (2005) performed their own prospective cohort study (N=1562). They evaluated changes in fetal position during labor by using serial ultrasound exams. The ultrasounds were done at enrollment, on epidural administration, four hours after the first ultrasound if there was no epidural in place by this time, and again when in active labor (greater than 8cm dilated). Fetal head position was then noted at delivery. 10

20 Inclusion criteria were: nulliparous (had never given birth), spontaneous or induced trial of labor, greater than or equal to 37 weeks gestation, live singleton pregnancy, and vertex (head down presentation). Exclusion criteria were: type I diabetes, leiomyomata (uterine fibroids), and uninterpretable ultrasound. Lieberman et al gathered the following information from the patient charts: gestational age, birth weight, newborn head circumference, and fetal position at delivery. Results revealed fetal position at enrollment was not a high predictor of anterior position at delivery. The researchers concluded, epidural analgesia was associated with occiput posterior but not occiput transverse fetal position at delivery (Lieberman et al, 2005, p. 978). Contrary to Andrews and Andrews, Lieberman et al felt that fetal position at delivery was not determined until very close to delivery. Lieberman et al also suggest that fetal malpositions contribute the higher rates of operative delivery in women with epidurals. LeRay, Carayol, Jaquemen, Mignon, Cabrol & Goffinet (2005) performed a retrospective study assessing whether the station of the fetal head (how low in the birth canal) at epidural placement is related to the risk of malposition during labor. Their sample included 398 participants. Two hundred of the 398 were diagnosed with malposition at 5cm dilatation. The variables in their study were the station and cervical dilatation at epidural placement, labor induction, parity and macrosomia. LeRay et al used the chi-square test to compare the groups and the Anova to compare quantitative variables based on fetal head station at epidural placement. The characteristics of the sample in this study were: mean age 31 years, 59% nulliparas (never given birth), mean gestation 39.5 weeks, 21.4% induced labors, 50% malposition at 5cm, mean birth 11

21 weight 3390 grams, cervical dilatation at epidural placement: 2cm, (17.8%); 3cm(57.8%); 4cm(24.4%); and fetal head station at epidural placement: -5(3%), -4(17.1%), -3(39.4%), -2(39.2%), -1(0.7%), 0(0.5%), and +1(0%). The study showed that epidural placement when the fetus was high (not engaged) in the pelvis was associated with a higher percentage of occiput posterior and transverse positions during labor. A limitation noted was that the researchers did not differentiate between occiput posterior and transverse fetal malpositions. These research findings are significant because they show that receiving epidural analgesia when the fetus is high (not engaged in the pelvis) is associated with a higher rate of occiput posterior and transverse positions during labor, independent of other risk factors evaluated (LeRay et al, 2005). Stremler, Hodnett, Petryshen, Stevens, Weston & Willan (2005) performed a randomized controlled trial of hand-and-knees positioning for occipitoposterior (OP) position in labor, (n = 147). Inclusion criteria were laboring, at least 37 weeks gestation, and occipitoposterior confirmed by ultrasound. The intervention group consisted of 70 randomized women who assumed the hands-and-knees position for at least 30 minutes out of a one-hour period during labor. The control group consisted of 77 laboring women who did not use the hands-and-knees position during the one-hour period. All participants were evaluated by ultrasound after the one-hour period to assess fetal position. The post-study ultrasound found 16% of the intervention group to be OA compared to 7% of the control group. Stremler et al analyzed dichotomous variables (i.e. fetal head position) using a contingency table chi-square (or Fisher exact test if the 12

22 numbers were decreased). The dichotomous variables were presented as relative risks having 95% confidence intervals when appropriate. Stremler et al (2005) concluded that the hands-and-knees position of laboring women with OP fetuses helps decrease back pain and is comfortable for laboring women. Furthermore, these researchers conclude that although this study indicates hands-and-knees may improve birth outcomes, more research is indicated, to determine if hands-and-knees positioning promotes fetal head rotation to occiputoanterior and reduces operative delivery (p. 243). Stremler, Halpern, Weston, Yee, and Hodnett (2009) researched an area that had not been studied before: The effects of being in the hands and knees position with an epidural on 1) heart rate and blood pressure, 2) epidural catheter dislodgement and 3) women s feelings regarding the acceptance of the use of this position (N=147). Ultrasound confirmed the fetus was occiput posterior (OP). Some women were then randomly assigned to maintain the hands and knees position for at least 30 minutes out of an hour. The control group maintained usual positioning. Only 13 of the 147 subjects were able to hold themselves up in the hands and knees position. Maternal heart rate and blood pressure were recorded during the hands and knees position and compared to the baseline vital signs (taken within 2 hours before hands and knees positioning). Back pain was rated before and after hand and knees positioning using the Visual Analog Scale (VAS). To measure acceptability of the hands and knees position, the time spent in hands and knees was recorded and post partum questionnaires were given to indicate satisfaction of care. 13

23 The women in Stremler et al s 2009 study were recruited from 3 urban universityaffiliated hospitals. The mean maternal age was 33.5 ± 2.7 years and the mean gestation was 40.1 ± 1.3 weeks. All had continuous fetal monitoring. There were no documented falls or epidural catheter dislodgements during the hands and knees positioning. One woman in the study couldn t maintain the hand and knees position due to fetal heart rate decelerations but she also had decelerations prior to participation. There were varied responses on the acceptability of the hands and knees position and whether these women would choose this position again in future labors. The researchers admit that a larger sample than 13 is necessary to evaluate acceptability. Although frequent charting of heart rate and blood pressure was a standard of care at participating institutions, the researchers found this data missing on several charts. Again, the researchers noted that a larger sample is necessary to conclude that the hands and knees position did not increase risk of cardiovascular instability. Biancuzzo (1993) points out that hands and knees position may tire the woman s hands, so she recommends alternating hands and knees with the lateral recumbent position. Summary The literature is clear that maternal laboring positions have changed over the last few centuries. Likewise, the setting of labor and birth, the use of medication for maternal comfort, and the ability to monitor fetal position have also evolved. There is lack of concrete evidence regarding how labor and birth positions can or should be altered for those with epidural analgesia (Zwelling, 2010). 14

24 Except for the Stremler et al study (2009), the primary weakness in many of the studies in the literature is that those laboring women with epidurals were excluded from the position changes analyzed in the studies. Stremler et al (2005) stated that immobilizing anesthesia is a contraindication to assuming the hands-and-knees position. Since the caregivers providing interventions for fetal rotation typically have no control over the amount of immobility resulting from a labor epidural, alternate interventions for those with moderate degrees of immobility must be sought. A first step in that process is this research study which assessed the relationship between OP fetal position and maternal labor positions currently being used in a Midwestern suburban hospital. Information gained from this study will provide evidence regarding this relationship and provide a basis on which future research studies may expand. 15

25 Chapter 3 Design and Methodology Research Type and Design This study was quantitative, non-experimental, retrospective and descriptive. Occiput posterior, the most common malposition, is associated with higher rates of complications during labor and delivery (Hart & Walker, 2007). Complications include prolonged labor, dystocia (lack of progress in labor), chorioamionitis (infection in the bag of waters), third and fourth degree lacerations, operative vaginal delivery and cesarean section (Ponkey, Cohen, Heffner & Lieberman, 2003). Simkin and Ancheta state Because fetal malposition is a major cause of labor dystocia, and labor dystocia is the leading indication for primary cesareans, it seems obvious that high priority should be placed on diagnosing the OP fetus and instituting measures to rotate the fetus during labor (2005, p. 15). This study explored the relationship between maternal positioning and resulting fetal position at delivery, thus providing a precursor to experimental research. The case study reported by Stremler et al (2009) limited participation to women with epidurals who had the ability to flex her hips and knees to move into hands-and-knees position, bear her own weight in hands-and-knees position, and remain stable (p. 392). Without placing these limitations on the patient, this study allowed the transference of responsibility for maternal movements in labor to the caregiver. Therefore level of maternal mobility was not a factor in fetal position at delivery. 16

26 Design A descriptive research design was used. This design was appropriate to the research question because it explored the interrelationship between two variables: maternal position in labor and fetal position at delivery. Setting The sample included (N=100) deliveries in a Midwest suburban hospital with a level II labor and delivery unit. Level II hospitals care for appropriate high-risk women and fetuses, stabilize severely ill newborns before transfer to level III, and treat moderately ill larger preterm and term newborns. Level II labor and delivery units also perform routine perinatal care like level I units. The population of the community surrounding the Midwest suburban hospital is 360,106. In 2008, the median age of the population was 36.7, the poverty rate was 12.9%, and the median household income was $55,627 (Kentucky Cabinet for Economic Development, 2009). Sample The data collection was retrospective. Probability sampling was used with random selection. The sample inclusion criteria included adult laboring women with epidurals, 36 completed weeks gestation or greater, with a live, singleton, vertex fetus. The sample exclusion criteria included laboring women with less than 36 weeks completed gestation, scheduled cesarean sections, non-vertex presentations, VBACs (vaginal birth after cesarean), patients without epidurals, and those patients who have been in the hospital less than three hours. 17

27 The Midwest suburban hospital has approximately 3,500 deliveries per year. Approximately 30% are cesarean births. The prevalence of occiputoposterior is cited as up to 20% (Cunningham, Leveno, Bloom, Hauth, Gilstrap III & Wenstrom, 2005). In a hospital with 3,500 births per year there is potential for up to 700 occiputoposterior fetuses. Data Collection The researcher accessed patient charts through the medical records department of the participating hospital. A list of chart identifiers of live births was ascertained. Every 7 th chart was chosen for the study until 100 charts were sampled. A data collection tool (Appendix A) was created by the nurse researcher and validated by two experts in perinatal nursing. Data collected included maternal age, parity, delivery type, instrument use, station of head when instrumentation applied, length of 2 nd stage labor, whether or not the patient labored down, documented maternal positions, position of fetus at delivery, type of anesthesia, gestational age, race, AROM (artificial rupture of membranes) vs. SROM (spontaneous rupture of membranes), oxytocin use, fetal weight, private vs. clinic patient, and delivery by physician or midwife. Each chart was assigned an identification number. Data collection began after IRB approval. Data collection occurred February through March Weakness of the design included possible rival hypotheses (Polit & Beck, 2008) such as perhaps the fetus would have rotated despite the maternal positioning. Other weaknesses included lack of a control group and small sample size. 18

28 Human Subject Protection Confidentiality was maintained since no patient identifiers were recorded. This study received IRB approval from the hospital and NKU. As this study involved a chart review only, no consent was obtained. Data Analysis Descriptive statistics were performed. Frequency tables, means, standard deviation, and percentages were performed. The Burkhardt Statistical Center assisted with data analysis. The number of documented occipitoposterior (OP) births was compared to the number of maternal positions in labor. 19

29 Chapter 4 Presentation, Analyses, Interpretations of Data This research study explored the relationship of malpositioned fetuses with maternal positions in laboring women with epidurals. The research question was What is the relationship between the incidence of occiput posterior fetal position at birth to maternal labor positions in patients with epidurals at a Midwest suburban hospital? Sample Demographics The sample size was 100 and was randomized. Charts were reviewed using a data collection tool created by the researcher. Forty-two charts were excluded due to prematurity, malpresentation, natural childbirth, spinal anesthesia, VBAC, maternal age less than 18 years old, and scheduled c-sections. The remaining 58 charts included in the sample were females aged 18 to 38 years of age. The median age was 25. The mean was The gestational ages ranged from weeks, with a median of 39. The majority of the patients were Caucasian (87.9%), followed by Hispanic (5.2%), African-American (3.4%), Asian (1.7%), and other races (1.7%). Sixty-nine percent (n=40) had artificial rupture of membranes (AROM) and 31% (n =18) had spontaneous rupture of membranes (SROM). Forty-seven percent (n=27) of the sample experienced induction of labor with oxytocin. Thirty-one percent (n=18) received augmentation of labor with oxytoxin. Twenty-two percent (n=13) received no oxytocin. Forty women were private patients while 18 were clinic patients. One patient was delivered by a midwife, one by an RN and the remainder by physicians. The mean fetal weight was 3350 grams. 20

30 Maternal parity was fairly homogenous. Thirty patients were primigravidas (53%) and 28 were multiparous (48%). The mean length of 2 nd stage labor was 1.04 hours. Nearly fourteen percent of the sample had instrumental vaginal deliveries. Twenty three percent labored down. Eighty-three percent delivered vaginally while 17% had cesareans after laboring. Table 1 Ethnicity of Study Sample Race Frequency Percent Valid Caucasian/White African-American/Black Asian Hispanic Other Total Maternal Positions During Labor Eleven different maternal positions were noted in this study: left tilt, right tilt, left lateral, right lateral, hands-and-knees, birthing ball, low Fowler s, high Fowler s, semi- Fowler s, supine, and other. 21

31 Table 2 Frequency of Maternal Positions Used During Labor n=57 Maternal Position Position used Not used Missing data=1 Frequency (%) Left Tilt 33 (57.9%) 24 (42.1%) Right Tilt 26 (45.6%) 31 (54.4%) Left Lateral 31 (54.4%) 26 (45.6%) Right Lateral 32 (56.1%) 25 (43.9%) Hands-and-Knees 2 (3.5%) 55 (96.5%) Birthing Ball 2 (3.5%) 55 (96.5%) Tailor Sit 0 (0.0%) 57 (100.0%) Low Fowlers 4 (7.0%) 53 (93.0%) High Fowlers 33 (57.9%) 24 (42.1%) Semi-Fowlers 42 (73.7%) 15 (26.3%) Other 3 (5.3%) 54 (94.7%) One patient had no maternal positions documented. Those patients with documented positions used a mean of 3.84 different maternal positions during their labors (SD=1.5333). The range of maternal positions used was one to seven positions. The most frequently documented position was semi-fowlers (n=42), followed by left tilt and high fowlers (n=33 for both). The tailor sit position was not used at all. Fetal Position At Birth Three patients did not have fetal position at delivery recorded. Of those with recorded fetal position at delivery (n=55), 87.3% were OA, 10.9% OP, and 1.8% OT. Of those fetuses born in OA position (n=48), 91.7% were vaginal deliveries while 8.3% were cesarean deliveries. Of those fetuses born in OP position, 66.7% were vaginal 22

32 deliveries compared with 33.3% cesareans. The one fetus born in OT position was a cesarean delivery (100% cesarean rate). Table 3 Frequency of Fetal Position at Delivery Position of fetus at delivery Frequency Valid Percent Valid OA OP OT Total Missing 3 Total 58 Maternal Position During Labor and Fetal Position at Birth When one maternal position was used during labor in the patient with the epidural, 100% of the fetuses were born OA (n=3). When two positions were used, 90% delivered OA (n=9). Three positions used, 100% OA (n=11); four positions used, 90.9% OA (n=10); and when 5 or more positions were used, 73.7% fetuses were OA. The following table shows the number of different maternal positions used. 23

33 Table 4 Number of Maternal Positions Used in Labor Number of different maternal positions # Frequency Valid Percent Total Missing System 1 Total 58 There were 8 instrumental (operative) vaginal deliveries. Of those, 2 were OP (25%). Of the patients who labored down (n=13), 92.3% were OA, 7.7% OP, and 0% OT. Those who did not labor down (n=41) delivered 85.4% OA, 12.2% OP, and 2.4% OT. Fetal position according to race was as follows: Caucasians delivered OA in 87.5% of the sample, 12.5% OP, and 0% OT. African-Americans delivered OA 50%, OP 0%, and OT 50%. Asians delivered OA 100%. Hispanics delivered OA 100%. Other races delivered OA 100%. Those patients who delivered their fetus in the OA position had a mean age of 25.63; OP, 24.67; and OT, years. The second stage of labor for delivery of an OA fetus showed a mean of 0.94 hours while delivery of an OP fetus showed a mean of 24

34 2.15 hours. Average gestational age for OA was weeks; OP, weeks; and OT, weeks. The average fetal weight for OA was grams (7.352 pounds); OP, grams (7.907 pounds); and OT, grams (8.288 pounds). Figure 1 Position of Fetus vs. Delivery Type Figure 1 Courtesy Burkardt Consulting Center! 25

35 Maternal Positions Related to Fetal Positions Maternal positions related to fetal positions are displayed in Table 5. The maternal positions most associated with a fetal OP position at birth were high fowlers and semi fowlers. The least associated positions were hands and knees and other. Other positions included chair, standing and walking. Table 5 Maternal Position in Labor Compared to Fetal Position at Delivery Position of Fetus at Delivery Maternal n OA OP OT Position Left Tilt (87.1%) 3 (9.7%) 1 (3.2%) Right Tilt (78.3%) 4 (17.4%) 1 (4.3%) Left (83.3%) 4 (13.3%) 1 (3.3%) Lateral Right (86.2%) 4 (13.8%) 0 (0%) Lateral Hand- 2 2 (100.0%) 0 (0%) 0 (0%) and- Knees Birthing 2 1 (50.0%) 1 (50.0%) 0 (0%) Ball Low 3 2 (66.7%) 1 (33.3%) 0 (0%) Fowlers High (80.6%) 5 (16.1%) 1 (3.2%) Fowlers Semi (85.0%) 5 (12.5%) 1 (2.5%) Fowlers Supine (90.9%) 1 (9.1%) 0 (0%) Other 3 3 (100.0%) 0 (0%) 0 (0%) Fetal position in labors with AROM was 84.2% OA, 13.2% OP, and 2.6% OT. Fetal position in labors with SROM was 94.1% OA, 5.9% OP, and 0% OT. Crosstabulation comparing fetal position to oxytocin use showed that induction of labor with oxytocin resulted in an OA fetus at delivery 81.5%, OP 14.8%, and OT 3.7%. Augmentation with oxytocin resulted in fetal positions of OA 86,7%, OP 13.3%, and OT 0%. Those patients with no oxytocin use delivered OA in 100% of the cases. See Table 6. 26

36 Table 6 Oxytocin Use Compared to Fetal Position at Delivery Crosstab Position of fetus at delivery OA OP OT Total Oxytocin use? Induction Augmentation Count % within Oxytocin use? 83.9% 12.9% 3.2% 100.0% Count % within Oxytocin use? 85.7% 9.5% 4.8% 100.0% Figure 2 Number of Different Maternal Positions by Position of Fetus Figure 2 Courtesy Burkardt Consulting Center! 27

37 Summary Laboring women with epidurals who used more of a variety of maternal positions delivered OA fetuses more often (see Figure 2). Those fetuses in OA position were ten times more likely to be delivered vaginally than by cesarean birth. 28

38 Chapter 5 Introduction Simkin (2010) describes an obstetrical package which consists of epidural analgesia, labor augmentation, and instrumental or cesarean delivery and is a complex, risky, and expensive solution to OP-related labor dystocia and arrest. Maternal positioning is a simple and cost-effective intervention that has the potential to decrease instrumental and cesarean deliveries. With the ever-growing popularity of labor epidurals, education regarding maternal positioning to increase the chances of spontaneous vaginal birth is important. There are numerous studies on the effects of maternal positioning on fetal position, however most of those studies do not address those with epidurals. This study was designed to explore the relationship between maternal positioning in labor of those with epidurals to fetal position at delivery. This study found that the maternal positions most often associated with OP fetuses were high fowlers and semi fowlers. The least associated positions were hands and knees and other (chair, standing and walking). Discussion and Implications Results of this research study showed that those who used many different maternal positions in labor delivered OA more frequently. The majority of fetuses in this study (n=48) were born in OA position. Ninety-two percent of those in OA position were born vaginally. Those patients using a variety of different (one to seven) maternal positions in labor delivered more babies in OA position. 29

39 Parity was one of the variables explored in this study. Almost half of the patients were nulliparous (had never given birth) (53%) while the remainder (48%) was multiparous. Parity did not appear to influence fetal position. Induction of labor was another variable explored in this study. Patients labors were induced in 46.6% of the cases and augmented 31% for a total of 77.6% oxytocin use. All patients without oxytocin use delivered OA. Those with oxytocin use delivered OA 83% of the time, OP 14%, and OT 2% of the time. Since the whole sample delivered OA 87% of the time, OP 11%, and OT 2%, the study results in those with oxytocin use do not differ greatly. Variation of maternal positions was another variable this study addressed. Interestingly, those patients who used 5 or more different maternal positions only delivered OA 73.7%, and delivered OP and OT 21.1% and 5.3% respectively. Those patients who used the least variation in maternal positioning, one, delivered OA 100% of the time. Those who used two or four different positions delivered OA about 90% of the time, OP 9-10% and OT 0%. It is also interesting to note that those patients who used the right tilt and high fowler s positions had the highest rate of posterior deliveries. High fowlers position is considered a non-recumbent position that is normally conducive to anterior fetal positioning. More research on recumbency and fetal position is needed. The final variable was route of delivery. Eighty-three percent of the laboring women in this study delivered vaginally while 17% delivered via Primary Cesarean Section. As noted previously, scheduled repeat c-sections were excluded from this study. Had the repeat cesareans been included, the c-section rate would be doubled. The sample in this study is well-representative of the population studied. 30

40 Discussion of findings The data collection tool (appendix A) listed 11 maternal positions to record from the sample. However, no one in the valid sample used the tailor sit position and it was noted that the supine position was documented in eleven cases. The researcher did not anticipate finding the supine position used as often as it was. As noted in chapter 1, the supine position in pregnancy promotes poor alignment of the fetal presenting part within the pelvic inlet (Fenwick & Simkin, 1987). Although it is noted that those in the sample who delivered OP and OT used four to six different maternal positions, those who delivered OA used one to seven positions. The larger variation of positions could perhaps be explained by Zwelling s assertion that immobility limits the fetal dexterity, decreasing the baby s ability to flex, engage into the pelvis, find the best fit, rotate and descend (2010, p. 74). Since immobility limits these motions of the fetus, mobility, such as using one to seven maternal positions, perhaps encourages the fetus to perform these cardinal movements (flexing, rotating, and descending). The researcher noted that a greater number of maternal positions were used during labor when the fetus was OP. These findings were significant because a greater number of maternal positions were used during labor when the fetus was OP or the mother was uncomfortable and frequently changed position in an effort to find comfort. Implications for research, theory and practice While the findings of this study add insight to the potential relationship between maternal position and fetal position at birth, more research is needed to determine the mechanism of the relationship. Additionally, the cause and effect relationship needs to 31

41 be explored. Suggestions for future research include replicating this study with a larger sample size and asking if increased maternal positioning would decrease the cesarean rate? Although this study did not address maternal position and c-section rate, that relationship has been suggested in prior studies (Ridley, 2007; Sizer et al., 2000; & Zwelling, 2010). Physical theory was the basis of this research study. This study does not support physical theory in its findings since non-recumbent positions such as sitting on a birthing ball did not demonstrate a decrease in OP births (50% OP rate). However this may be attributed to the small sample size and low use of the birthing ball (n=2). Also, high fowlers, another non-recumbent position documented in this study, demonstrated one of the higher rates of OP incidence (16%). Andrews and Andrews (2004) point out the importance of not letting the maternal thighs indent the abdomen to achieve proper fetal rotation. There was no way to determine the extent of thighs indenting the abdomen in this retrospective chart review. Future research could be directed to comparing patients with early AROM versus SROM and the fetal position at birth. This would be significant because it could connect interventions such as artificial rupture of membranes to impaired fetal rotation. Andrews and Andrews (2004) believe amniotic fluid provides the buoyancy force in the physical theory. Implications for nursing practice include the promotion of frequent maternal position change in laboring patients with epidurals. Also, non-traditional maternal positioning such as hands-and-knees and others should be considered, especially if an OP fetus is suspected. Stremler et al (2009) studied the effects of being in the hands and knees 32

42 position with an epidural and found reductions in persistent back pain and operative delivery and increases in fetal rotation and 1 minute Apgar scores. A similar study with a larger sample would bring more rigor. Also, including a control group would be beneficial in comparing fetal position at delivery in laboring women with epidurals who use the hands and knees position to those who do not. Additionally, using ultrasound to determine fetal position is far superior to traditional digital exam (Sabsamruei & Tanprasertkul, 2010). Summary and conclusions This research study showed that a greater number of fetuses were born OA when there was a greater variation in maternal labor positions. Maternal positioning has been shown to be more conducive to fetal rotation (Adams & Bianchi, 2008; Albers, 2007); Andrews & Andrews, 1982, 2004; Biancuzzo, 1993; Fenwick & Simkin, 1987; Gilder et al., 2002; Hart & Walker, 2007; Johnson et al., 1991; Mayberry et al., 2002; Ridley, 2007; Romano & Lothian, 2008; Simkin, 2003, 2009; Stremler et al., 2005, 2009; Zwelling, 2010). More research is needed to determine the relationship between maternal labor position and fetal position at birth in women with epidurals. 33

43 References Albers, L.L. (2007). The evidence for physiologic management of the active phase of the first stage of labor. Journal of Midwifery & Women s Health, 52, (3), doi: /j.jmwh Andrews, C.M. & Andrews, E.C. (1983, November). Nursing, maternal postures, and fetal position. Nursing Research, 32(6), Retrieved May 30, 2009, from MEDLINE database. Andrews, C.M. & Andrews, E.C. (2004). Physical theory as a basis for successful rotation of fetal malposition & conversion of fetal malpresentation. Biological Research for Nursing. 6(2), Bianchi, A.L. & Adams, E.D. (2009). Labor support during second stage labor for women with epidurals. Nursing for Women s Health, 13(1), Biancuzzo, M. (1993). How to recognize and rotate an occiput posterior fetus. American Journal of Nursing, 93(3), Burkardt Consulting Center, Northern Kentucky University, Highland Heights, KY. Chaillet, N., Dube, E., Dugas, M., Francoeuer, D., Dube, J., Gagnon, S., Poitras, L., & Dumont, A. (2007). Identifying barriers and facilitators towards implementing guidelines to reduce caesarean section rates in Quebec. Bulletin of the World Health Organization, (85)10, Centers for Disease Control and Prevention (2006, November 21). Press Release from CDC s National Center for Health Statistics. Dundes, L. (1987). The evolution of maternal birthing positions. American Journal of Public Health,77(5),