Standard of Care Series Part Three
Restricted Movement During Labor
When you think about the birth of the baby, I would not be surprised at all if the image that came to mind included the mother on her back with feet in stirrups or in a semi-seated position in the bed. Based on what movies and TV tell us, this is how people give birth...in the bed. Not to mention in most hospital rooms, the bed is the focal point, giving the visual impression that that is where labor and birth are meant to happen. While birthing lying in the bed is always an option, there are several advantages to upright birthing positions when it comes to physiologic birth.
For one, when we are upright, the uterus is able to contract more strongly and efficiently. These productive contractions help baby to get into a better position to move through the pelvis. Another advantage to upright positions is that it does not compress the mother’s aorta, which can happen when a mother lies on her back (this is why during pregnancy, it is not recommended that you sleep on your back; it has always confused me why this was discouraged for pregnancy but an okay thing to do during labor for various lengths of time). When the aorta is compressed, it can compromise the baby’s oxygen supply. A third advantage is that when upright positions are used, gravity works in our favor to help bring baby down and out.
In short, research has found that “being restricted to bed leads to longer, more painful labors, and increases your chances of requesting an epidural or giving birth by Cesarean. Babies born to mothers who labored in bed-lying positions are also more likely to be admitted to the newborn intensive care unit” (Dekker, 2019, p 21).
Additionally, research shows there may be higher rates of satisfaction and a more positive birth experience when upright positions are used. As discussed in yesterday’s post, the birth experience matters. Birth matters.
In Babies Are Not Pizzas, Rebecca shares that she was told that she had to stay in bed because her water had broken and an upright position may cause a cord prolapse. After researching this claim, she found that you are not more likely to experience cord prolapse just because your water broke at the onset of labor.
In the American Congress of Obstetricians and Gynecologists (ACOG) Committee Opinion on the Approaches to Limit Interventions During Labor and Birth, it is stated that “frequent position changes during labor to enhance maternal comfort and promote optimal fetal positioning can be supported” (2017).
Ultimately, the birthing person has the right to labor and give birth in whatever position is most comfortable for them.
You can find more on the evidence of birthing positions here.
Continuous Fetal Monitoring
One of the more likely barriers of freedom of movement during labor is continuous fetal monitoring. Typically upon arriving at the hospital in labor, one of the first things that takes place is an initial strip with an external fetal monitor (EFM). One strap around the birthing person's abdomen monitors contractions with a pressure sensor while another strap around the birthing person's abdomen monitors the baby’s heart rate using ultrasound. Both of these are linked to a machine that provides a print out of the readings. The print out communicates information to the birth team regarding the frequency and duration of contractions (not their intensity though), and how the baby’s heart rate is changing with the contractions. Often times, the initial strip is done in triage to have a baseline measure, but research has found there is no benefit to initial monitoring and it may result in the provider wanting the birthing person to receive continuous monitoring through labor.
Researchers have found that continuous monitoring readings can be inaccurate about what is happening with the baby. Additionally, research has not found that continuous monitoring reduces the rate of stillbirth or newborn death; however, it has been shown to increase the birthing person’s likelihood of having a Cesarean. Essentially, it has not been found to significantly increase safety for the baby, but it does increase risks to the birthing person.
Another consideration is that often times, being on the monitor limits or prohibits the birthing person’s mobility in labor. Some providers may allow movement with the monitors, while others may insist that the birthing person remains in the bed while on the monitor. We have already looked at restricting movement in labor, and know that evidence has shown this to be a harmful practice.
Another option of fetal monitoring in labor is with wireless monitors, which some hospitals are now offering. In this way, the birthing person has more freedom of movement because there are not wires tethering them to the machine, and they can even be used with hydrotherapy. More research is needed with the wireless monitors, however. With any form of continuous monitoring, there is still the chance that the monitors may shift which may result in the insistence that movement be restricted, and some birthing people feel that the focus has shifted from them to the monitor and the print out leading to less labor support.
An evidence based option for fetal monitoring during labor is called intermittent auscultation (or hands-on-listening). With hands-on-listening, the provider is listening to the baby’s heart rate at regular intervals throughout labor for short periods of time while placing a hand on the birthing person’s abdomen to feel the contractions. Then the information about the baby’s heart rate is documented. Often in the US, a handheld fetal doppler ultrasound device is used to listen to the baby’s heart rate. This option allows for freedom of movement, hydrotherapy, more frequent check-ins with the provider at regular intervals, and is linked to fewer Cesareans and forceps/vacuum assisted births.
One barrier to receiving the evidence based option of intermittent monitoring using a hand-held Doppler device during labor is lack of training for hospital staff in this form of monitoring. In the American Congress of Obstetricians and Gynecologist’s (ACOG) Committee Opinion on the Approaches to Limit Interventions During Labor and Birth, it is stated that “to facilitate the option of intermittent auscultation, obstetrician–gynecologists and other obstetric care providers and facilities should consider adopting protocols and training staff to use a hand-held Doppler device for low-risk women who desire such monitoring during labor” (2017).
As with any decision in labor, the pros and cons to the various forms of fetal monitoring in labor should be discussed with your provider so that an informed decision can be made, taking into consideration your individual health history and your values, goals and preferences.
You can find the one page hand out or the full article on the evidence of fetal monitoring here.
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*Disclaimer: These posts are not intended to be construed as medical advice and are for educational purposes only. Each pregnancy and labor is unique. If you have questions or concerns, please consult your provider.