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CHAPTER – 1

INTRODUCTION

The children are the heritage of God and fruit of the womb is God`s

reward.Child birth is an unique boon given to women folk. Every woman

experiences immeasurable bliss and bless while carries a baby in her womb. She is

blessed by becoming a mother. The agony and anguish of labour will vanish, the

very moment when she sees her baby. The travail seems not a matter on seeing a

robust child.

Rewardingly aiding child birth by reducing labour pain perception and

duration of labour, minimizing the risk for operative deliveries and to enhance

satisfaction of the parturient mothers with child birth rather seeming most important

and considered as major implications of intra and post partum care.

Labour and child birth is an unpredictable process and is a time of

excitement and anticipation, along with uncertainty, anxiety, and fear. Most of the

primi mothers feel great anxiety about child birth and worry how they will cope with

the challenges of labour. So the memories and experiences of labour and birth remain

with women throughout their lives.

The experience of labour pain is a complex and multifaceted response to

sensory stimuli generated during childbirth. Labour pain and methods to relive it are

the major concern for the parturient mothers. Complimentary/Alernative Medicine

(CAM) or non pharmacological methods of pain relief are implemented as a part of

nursing care practice that can be safely introduced during early labour and it may

proceed with pharmacological intervention that the women want to choose as the

labour progress.

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Labor, delivery, birth, and parturition are common term used to describe

the child birth. It is defined as, the physiological processes by which a fetus is

expelled from the uterus to the outside world. The World Health Organization

(WHO) defines normal birth as: “spontaneous in onset, low-risk at the start of labor

and remaining so throughout labor and delivery”.The infant is born spontaneously

with vertex presentation between 37 and 42 completed weeks of pregnancy and after

the birth mother and infant are in good condition [1]. It is divided in to three stages

such as first, second and third stage of labour.

First stage begins with regular uterine contractions and ends with

complete cervical dilatation at 10 cm and divided into a latent phase and an active

phase. The latent phase starts with mild, irregular uterine contractions that soften and

shorten the cervix and the contractions become progressively more rhythmic and

stronger. There are various definitions available for the active stage of labour. The

University of Texas Health Science Center at San Antonio (UTHSCSA) describes it

is occurring at a cervical dilation of 3 to 4centimeters [2], while American college of

obstetrics and gynecology(ACOG) describes it is occurring at 5 cm for multiparous

women and at 6 cm for nulliparous women [3]. In Sweden, the onset of the active

phase of labor is defined as when two of the criteria are met such as three to four

contractions every ten minutes, rupture of membranes, cervical dilation of 3 to 4

centimeters [4]. Clearly, the support and care they receive during this time is critical.

The overall aim of caring for women during labour and birth is to engender a positive

experience for the woman and her family, while maintaining their health, preventing

complications, and responding to emergencies.

Globally almost all the women perceived childbirth as a painful

experience in their life time .This perception of labour pain varies from women to

women and influenced by fear and anxiety levels, experience with prior childbirth,

cultural ideas of childbirth and pain is one of the important factor determines the

women’s experience with child birth [5,6]. During the first stage of labor, women

usually perceive the visceral pain of diffuse abdominal cramping due to uterine

contractions. In the second stage of labor, there is a sharper and more continuous

somatic pain in the perineum. Pain in contractions has been described as feeling

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similar to very strong menstrual cramps. Crowning may be experienced as an intense

stretching and burning.

Based on physiology of labour there are mainly five causes for labour

pain. Firstly during the uterine contraction, the blood flow to the uterus is blocked

that deprives oxygen supply to the uterine muscle is a source of pain. Secondly,

during labour the baby’s head puts pressure on cervix and stretches to open causes

pain. Thirdly, the ligaments, nerves, muscles and joints surrounding the uterus

stretched and exposed to pressure causes pain during labour. Fourthly the pelvic

floor, bladder, rectum and urethra are put under great pressure during labour. Finally,

the body natural response to stress, anxiety and fear causes production of stress

hormone catecholamine decreases oxygen supply to the uterus and placenta and

produce ineffective contraction and increasing pain. There are other factorsassociated

with labour pain are child birth preparation, physical environment, immobility, or

medical intervention.

The choice of movements and position changes play a key role in

determining the perception of labour pain, the mother's comfort level during birth

and enhancing positive maternal and fetal outcome. During the first stage of labour,

mothers who are engaged with various movements and position changes help them

respond to pain in active way and shorten the duration of the first stage of

labour[7].Activity during labour provides distraction from discomfort and enhances a

sense of greater freedom and control and provides a way to release muscle tension. In

fact, women who use movements in labour report that it is effective method of

relieving pain and restricting women’s movements during labour may result in worst

birth outcome and decreases women’s satisfaction with their birth experiences. [8]

Today in modern obstetrics most of the child birth is managed by the

‘Active Management of Labour’with induction of labour, epidurals and electronic

fetal monitoring and most of these whole cascade of interventions leads to

complicated birth. ‘Active Birth’ generated with freedom of movement considered as

a very effective intervention to enhance the birth outcome since it does not causes

side effects and complications. Freedom of movement causes many physiological

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changes which contribute many benefits to the mother, baby and enhances the labour

process itself. As for pain is considered, when the mother moves around and being

upright during labour, experiences less pain than in lying down position because of

couple of different reasons. One reason is due to if the mother lies on her back, the

uterus muscle works harder to remain tiltes forward and efficient. Another is lying

down position restricts the pelvic bone from moving and constrict the space within

the pelvis .Due to these reasons mother experiences severe pain and increases the

chance for requiring analgesics and epidurals and these both actions are not favour

for the baby to mold and descend through the pelvis interrupt the labour process may

lead to prolong labour or failure to progress.

In contrast, walking and engaging in various movements such as swaying

on a birth ball, rocking movement suses the gravity and helps the baby progress

through the birth canal and helps the baby align in to favorable position for birth and

there is 90% chance of turning babies from posterior to anterior position. Sitting on a

ball and semi sitting is widening the pelvic outlet nearly by 30%.

Today, there are wide ranges of non-pharmacological interventions

available to help the laboring women to manage labour pain, enhance the good

labour outcome and child birth experience during labour. Among the numerous

practices such as massage, acupressure, acupuncture, aromatherapy, transcutaneous

electrical nerve stimulation, and hydrotherapy, the movements and position changes

like gentle walking, swaying, rocking and semi sitting position received special

attention as it is simple, inexpensive and harmless intervention.

1.1 BACKGROUND OF THE STUDY

Global Scenario on birth outcome

The WHO estimates that about 536,000 women of reproductive age die

each year due to pregnancy related complications, nearly 99% of these deaths occur

in the developing countries. These maternal deaths are almost equally divided

between African and Asian countries (253,000), with about 4% (22,000) occurring in

Latin America and the Caribbean and less than 1% (2,500) in the more developed

regions of the world. There is a wide range of disparity seen among the regions in

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maternal mortality rate also [9].Globally maternal mortality rate (MMR) is estimated

to be 400 per 100,000 live births. It is higher in Africa (830), followed by Asia (330),

Oceania (240), Latin America and the Caribbean (190), and at the bottom the

developed countries. [10]

Reduction of maternal mortality has been a common and major goal or

issue for the most of the countries and conducted several international conferences

related to this issue. Currently Safe Motherhood Initiative emphasis attention to the

consequences of poor maternal health in developing countries, and initiate

appropriate action to address the high rates of maternal deaths and disability.The

specific activities of safe motherhood strategies include, the provision of antenatal

care, presence of skilled assistance for normal deliveries, making appropriate referral

for women with obstetric complications, postnatal care, family planning and other

reproductive health services.

In addition to this, the Millennium Development Goals (MDGs) were

adopted by the international community at the United Nations Millennium Summit in

2000.The MDG- 5 is the corner stone of the strategy to improve maternal health

includes two targets such as, to reduce maternal mortality by three quarters between

1990 and 2015 and to achieve universal access to reproductive health by 2015.

Pondering to first target, according to the WHO 2005 report, mortality ratios are still

high in 56 out of the 68 priority countries where 98% of maternal deaths occur and

exceeding 300 maternal deaths per 100,000 live births. The global maternal mortality

ratio is 400 maternal deaths per 100,000 live births. This average annual decrease of

less than 1% is far below the 5.5% annual decline that is required to achieve the

MDG-5. Regarding the second target, increasing deliveries assisted by skilled

attendance is one of the indicators of progress towards MDG-5. According to WHO,

the proportion of births in low- and middle-income countries assisted by a skilled

birth attendant increased from 47% in 1990 to 61% in 2000.The countries with the

lowest proportions of skilled health attendants at birth were eastern Africa (34%),

western Africa (41%) and south-central Asia (47%), which also had the highest

numbers of maternal deaths. In every region, the presence of skilled birth attendants

is lower in rural than in urban areas. WHO report says that it is estimated that 34% of

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the mothers deliver with no skilled attendant; this means there are 45 million births

occurring at home without skilled health personnel each year. Skilled attendants

assist in more than 99% of births in developed countries compared with 62% in

developing countries. [11]

In recent scenario, according to World Health Organization report the

rate of caesarian sections at between 10% and 15% of all births in developed

countries compared to about 20% in the United Kingdom and 23% in the United

States. In 2003, the Canadian caesarian section rate was 21%, with regional

variations. The UK National Health Service stated that the risk of death for the

laboring mother increased as three times that of a vaginal birth. [12] Recently a study

published in Obstetrics and Gynecology found that women who had multiple

Caesarean sections were more likely to have problems with later subsequent

pregnancies, and recommended that women who want larger families should not

seek elective Caesarean section . The risk of potentially life-threatening condition

placenta accreta, is only 0.13% after two Caesarean sections, but increases to 2.13%

after four and then to 6.74% after six or more surgeries. Moreover, similar rise in the

risk of emergency hysterectomies at delivery were found. The findings were based

on outcomes from 30,132 Caesarean deliveries [13]. It was supported by a study on

‘Risks of adverse outcomes in the next birth after a first cesarean delivery’ found that

women who had just one previous Caesarean section were more likely to have

problems with their second birth. Women who delivered their first child by

Caesarean delivery had increased risks for malpresentation, placenta previa, ante

partum hemorrhage, placenta accreta, prolonged labor, uterine rupture, preterm birth,

low birth weight, and stillbirth in their second deliveries. However, the authors

concluded some risks may be due to confounding factors related to the indication for

the first Caesarean, rather than due to the procedure itself. [14]

In addition to this, the psychological risks and implications that a

Cesarean birth also should be overlooked. After obstetric intervention during the

birthing process and Cesarean section mothers can experience increased incidence

of postnatal depression, and can experience significant psychological birth trauma

and ongoing birth-related post-traumatic stress disorder. [15-18]

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Researchers such as Ross and colleagues found in their study, after

reviewing more than 1 million deliveries in Sweden from 1987 to 1995 and found

that the relative risk of pulmonary embolism with cesarean delivery was

approximately 7, after excluding women with preeclampsia, the increase in risk was

4-fold relative to vaginal delivery [19]. This same result was found in another study

of nearly 400,000 births that found approximately 4-fold higher rate of deep vein

thrombosis in women undergoing cesarean delivery as compared with vaginal

delivery. [20]

Regarding Blood loss, it is greater during a cesarean delivery than a

vaginal delivery. However, the transfusion rate remains low at 1% to 2% of patients

undergoing cesarean section[21]. Infection is one of the most common complications

of cesarean delivery. Wound infections occur in 2.5% to 16% of cesarean delivery

[22].Women who delivered by cesarean section more commonly experience more

pain after delivery compared with those having vaginal deliveries and most of the

women who undergo cesarean deliveries are more likely to report incisional pain to

be a problem in the first 2 months after delivery [23-26]. A study of 242 primiparous

women reported that, those who delivered by caesarian section (both elective and

emergency) required narcotic pain medications compared with 11% of those who

delivered vaginally in immediate post natal period. [27]

In a meta-analysis of 43 studies published between 1979 and 1993,

Dimatteo and colleagues found that women who delivered healthy babies by

cesarean section (both planned and unplanned) were more likely to report

dissatisfaction with their birth experience compared with those who delivered

vaginally [28]. Generally, a woman who had a cesarean delivery typically needed

longer hospital stay than one who had a vaginal delivery and has increased risk for

readmission [29]. Although cesarean deliveries are typically performed for the

benefit of the fetus, it also produces risks for the newborn. In fact, a large

observational study of more than 580,000 deliveries in California found that babies

both born by planned as well as unplanned cesarean deliveries had a nearly 4-fold

risk of dying before discharge compared with those delivered vaginally (8 deaths per

10,000 births for each planned or unplanned cesarean deliveries and 2 per 10,000 for

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those delivered vaginally) [30]. Moreover, a review of nearly 30,000 births found

that the incidence of Transient Tracheponea of the newborn is about 3 times more

common after elective cesarean delivery than after vaginal delivery (3.1% v. 1.1%,

respectively) [31].

The leading indications for cesarean delivery (85%) are previous

cesarean delivery, breech presentation, dystocia or obstructed labour, and fetal

distress. [32]

In 1990 obstructed labour ranked 41st in Global Burden of Disease,

representing 0.5% of the burden of all conditions and 22% of all maternal conditions

[33]. It is well statistically proved that prolonged or obstructed labour is still a major

cause of high maternal and perinatal morbidity and mortality globally, especially in

the developing countries of the world. Maximum number of the deaths from

obstructed labour are mainly associated with hemorrhage, ruptured uterus, infections,

metabolic, and electrolyte derangements. [34-36]

Today many child births are achieved through medical or surgical

induction of labour. The prevalence of labour induction in the United States is 22%,

this rate is more than doubled from 1990 to 2006. [37] The rate of elective induction

vary widely among hospitals (12 percent to 55 percent) and among individual

physicians (3 percent to 76 percent) in the Listening to mothers II survey reported

that more than four out of 10 mothers (41 percent) their caregiver tried to induce

labor and elective inductions can causes almost double the risk for a cesarean for

some women, depending on the individual physician’s practice style and medical

speciality [38]. All of these statistics are even more frightening when compared to

the World Health Organization’s reported that appropriate induction rates in any

geographic region should not exceed 10 percent. In 2004 and 2005, one in every five

deliveries in the UK was induced less than two thirds of women gave birth without

further intervention, with about 15% having instrumental births and 22% having

emergency caesarean sections.

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Induction of labour has a large impact on the health of women and their

babies and so needs to be clearly clinically justified. A recent study of a U.S.

healthcare system showed that babies born by induction at 37 weeks were 22.5 times

more likely to need a ventilator at birth, and babies born at 38 weeks 7.5 times more

likely, when compared to babies born at 39 weeks. Babies born too soon are also

more likely to experience serious complications, including fever, infection,

respiratory distress syndrome , and transient tachypnea of the newborn. These babies

may look normal, but have an increased risk of difficulties with vision and hearing,

feeding and digesting their food, regulating their body temperature, and are more

likely to need phototherapy to treat jaundice [39-41]. A Swedish study showed a

nearly 3 times greater risk of asphyxia (oxygen deprivation) for babies born after

augmentation with Pitocin. [42]

Epidural analgesia is a commonly employed technique of providing pain

relief during labor to the parturient mothers. In the United States, the number of

parturient given intra partum epidural analgesia is reported to be over 50 percent at

many institutions. A recent survey of obstetric anesthesia in the United States

indicated that the percentage of women given intra partum epidural analgesia

increased from 22 percent in 1981 to 51 percent in 1992 at hospitals performing at

least 1,500 deliveries annually [43]. At the same time the complications of epidurals

to the laboring mother and their baby are inevitable. Severe low blood pressure can

also result from compression of the mother’s aorta and vena cava blood vessels since

all mothers must lie essentially flat on their back after epidural anesthesia .Fetal heart

rate decelerations can occur following the use of epidurals and babies prone to

develop fetal distress after epidural anesthesia [44]. Mothers who deliver under

epidurals have less frequent and ineffective uterine contractions and they may need

oxytocin infusion to improve labor and produce good strength contractions .Mothers

having epidurals have longer labors and have a higher incidence of the use of

oxytocin than mothers having non-medicated deliveries. Large doses of epidurals

causes loss of desire and the ability to bear down and push to the parturient mothers

and this ultimately ends with increased use of forceps and vacuum extractions over

women having unmedicated deliveries. [45-47]

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Considering the episiotomy rate in the United States is currently around

35%. In some Latin American countries and also Taiwan, it is accepted practice to do

an episiotomy on all primi mothers, the rates are close to 90%. China, Spain, South

Africa and Turkey also report extremely high episiotomy rates ranging from 60% to

almost 90%, whereas Sweden has a low 9.7% episiotomy rate. [48]

Indian Scenario on birth outcome

According to united nations report, the current Maternal Mortality Rate

(MMR) of Indiais 212 per one lakh live births, whereas the country`s Millennium

Development Goal in this respect is 109 per one lakh live births by 2015, India is

likely to miss the Millennium Development Goal (MDG) related to maternal health

as one maternal death is being reported every 10 minutes in our country now [49].

Institutional deliveries or facility-based births are often promoted for reducing

maternal and neo-natal mortality. Yet, many women in low- and middle-income

countries, including India, continue to deliver babies at home without the presence of

a skilled attendant.

About half of all births in India in 2007-2008 occurred at home without

skilled birth attenders (District Level Household Survey (DLHS-3). Out of the 284

districts, in nine high-focus states which account for 62% of maternal deaths in the

country, According to Annual Health Survey (AHS- 2011), institutional delivery is

less than 60% in 170 districts. In Tamil nadu36.5% delivery occurs in private health

sector and the rest 53.8% institutional delivery occurs in private sectors. According

to National family health survey -3, in India Kerala, Goa and Tamil Nadu are the best

performing States in the country during 2010-11. [50].

The below table illustrate that the States of India ranked in order of

percentage of children delivered in hospital.

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Table 1.1: States of India ranked in order of percentage of institutional delivery

States Institutional delivery (%) Rank

Kerala 100 1

Goa 93 2

Tamilnadu 90 3

Andra Pradesh 69 4

Karnadaka 67 5

Maharashtra 66 6

Mesorom 65 7

Gujarat 55 8

Jmmu and Kashmir 54 9

Punjab 53 10

Sikkim 49 11

Tiripura 49 11

Himachala Pradesh 44 13

West Bengal 43 14

Whole India 41 15

Haryana 39 16

Orrisa 39 16

Uttarakhand 36 16

Rajasthan 32 19

Arunachal Pradesh 31 20

Madhya Pradesh 30 21

Manipur 30 21

Meghalaya 30 21

Assam 23 24

Bihar 22 25

Utterpradesh 22 25

Jaharkhand 19 27

Chhattisgarh 16 28(Source: National Family Health survey-3)

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A study from South India showed that presence of assistance during

delivery can reduce the risk of obstructed labour and it is highly associated with the

place of delivery [51].Another study also presented the role of assisted skilled birth

attendants in preventing direct and indirect cause of maternal deaths such as,

infection, shock, blood loss, convulsions, and surgical procedures, such as caesarean

delivery [52]. In India, a study on analysis of choice of delivery location showed that

maternal and, paternal education, and scheduled caste status were the predisposing

factors that determined the choice of private facilities, public and home

deliveries [53]. Recently a survey conducted among 100 parturient mothers in

Chennai, India, found that only half of the participants were in favor of labour pain

being relieved, Hence, only 23% women reported have plans to use analgesia during

labour [54].

To promote institutional birth, Indian Government is implementing the

program called Janani SurakshaYojana (JSY) is a safe motherhood intervention

under the National Rural Health Mission (NRHM) being implemented with the

objective of reducing maternal and neo-natal mortality by promoting institutional

delivery among the poor pregnant women. It is a 100 % centrally sponsored scheme

and it integrates cash assistance with delivery and post-delivery care.JSY is a

conditional cash transfer programme that provides a cash incentive to women who

give birth at public health facilities. Rural women receive Rs.1,400 ($28 approx.) and

urban women receiveRs.1,000 ($20 approx.) upon delivery at a public health facility.

All services provided at the public health facility are free of charge.The success of

JSY has been mixed so far- the percentage of mothers availing financial assistance

ranges from less than 15% in Jharkhand to about 60% in Orissa (AHS 2011).

The World Health Statistics (WHS), 2012, released on May 18 published

in Times of India, said 9% of all births in India were by Caesarian section. The latest

figure has gone up by 5% since nearly one in 10 women in India, who gave birth

between 2005 and 2010, had gone under the surgical knife. Dr. P K Shah, President

of The Federation of Obstetric and Gynecological Societies of India (FOGSI) said

that deliveries by C-section have increased by about 25% in teaching hospitals and

by at least 50% in private hospitals over the last two decades. A World Health

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Organization study, which reviewed 110,000 births from nine countries in

Asia including India in 2010, had revealed that more than 60% of the hospitals

studied, where these C-sections took place, did it for financial gains and not because

it was actually required and another WHO study found that "In Asia, some women

opt for the caesarian surgery to choose their delivery day after consulting fortune

tellers for lucky birthdays or times and others are due to fear painful natural births.

Even today some women undergo an operation wrongly believing that it is less

risky [55].

Based on DLHS-3 data, the caesarean section delivery rate in India is 9.2

per cent and among the large states which has population 10 million and above as per

2001 censes and the proportion of women who have undergone caesarean deliveries

is the highest in Kerala (31.8 per cent) followed by Andhra Pradesh (29.3 per cent)

and Tamil Nadu (23.2 per cent) and the lowest in Rajasthan and Jharkhand (4.2 per

cent in both the states). Except Karnataka, in all other southern states, Caesarian-

section (CS) delivery has crossed 15 per cent as reported by the WHO. In Andhra

Pradesh, Kerala and Tamil Nadu, even in rural areas, caesarean delivery rates are

much higher than15 percent [56].

Another striking difference in c-section rates in India is in the rural-urban

disparity. In 1998-99, it was around 4.8% in rural areas and 14.9% in urban areas. It

has increased to 6.2% in rural areas and 17.8% in urban areas during 2005-06. The

higher urban rates may be a reflection ofcombination of factors like high utilization

of maternal health services, faster fertility decline and larger concentration of private

hospitals, etc.

India is also experiencing a rapid increase in c-section delivery along

with an increase in institutional deliveries and growing access to gynaecological and

obstetric care. The high rural urban differences in rates invoke speculation on the

possible reason for such an increase. From the National Family Health Survey

(NFHS 1,2&3) the trend of c-section deliveries analysed fromb1992-93 to 2005-06

shows an upward trend in c-section rates. The present analysisis based on the data

derived from different rounds of NFHS. At theall-India level, the rate has

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increasedfrom 2.9% of the childbirth in 1992-93 to 7.1% in 1998-99 and further to

10.6%in 2005-06.

Source: National Family Health Survey Rounds 1,2 & 3

Fig.1.1: Percentage of C-Section Delivery from1992-93, 1998-99 and 2005-06,India

Childbirth is a universally celebrated natural event; yet for many

thousands of women in India, it is becoming a matter of concern due to the over-

medicalisation .Studies have also shown that over the past few decades childbirth is

increasingly influenced by medical technology. Johanson says that the normal birth

has become too “medicalised” and the higher rates of unnecessary obstetrical

intervention raise concern for the mother’s health [57].

According to Love.N, non pharmacological approaches are mainly

directed at prevention of sufferings where as pharmacological approaches are

directed only at elimination of physical sensation of labour pain.These apporoches

includes varity of techniques that address not only the physical sensation of pain but

also attempt toprevention of sufferings by enhancing the psycoemotional and

spiritual component of care and in this approach the pain is perceived as a side effect

of normal process of labour. Reassurance, guidance, encouragement, unconditional

acceptemce of coping styles are used.These techniques can be used combained or

sequentialy to increase the total effect [58].

The ideal birth environment for non pharmacological approaches foster

the sense of comfort and privacy. This environment contains comfort aids, places to

walk, bathe and rest.The vital goal of caring women during labour and birth is to

2.9

7.1

10.6

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1992-93 1998-99 2005-06

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create a positive experience for the women and family. By providing additional

choices to attain comfort and pain relief for laboring women and at the same time

promoting their sense of control during birth process greatly helps to enhances the

maternal satisfaction with child birth .To achieve this aim one of the non-

pharmacological management is freedom of movement plays a key role in managing

labour and delivery as a normal process. Keeping in view and the above

background, the objective of this study is to assess the effectiveness of freedom of

movement during first stage of labour on maternal and fetal outcome, it also tries to

speculate on the possible complications and discusses its implication for maternal

health.

1.2 SIGNIFICANCE AND NEED FOR THE STUDY

Even before the development of modern obstetrics, debate existed with

respect to maternal position during labor. In the Guardian newspaper, the issues

regarding ‘posture in labour’ is the first matter presented in a recent report on the

maternity services by the Healthcare Commission. This report was highlighting that

in England, over half the women who gave birth in lying down (30%) or in the

lithotomy position (27%) during the time of the survey. This is a stark wake-up call

for many of the maternity practitioners, and recommended that there is still much to

be done to improve the birth experiences of the women. Even with a growing

evidence-base around posture and positions for labour and birth, it is evident from

this report thatsome maternity healthcare professionals remain loyal to ‘outland’ and

unsupported practices. [59]

Historically and transculturaiiy, during confinement and laboring period

women always wants to move, and change positions spontaneously to make

themselves more comfortable [60,61] and sometimes it is advised to them by the care

givers also. To attain this they are recommended to use any form of comfort devices

such as birth ball, rocking chair, backrest and extra pillows. Some observational

studies also show that is still true in settings where the environment is favourable

[62,63]. These specific positions and movements that are thought to accelerate the

labour process, or correct the maternal or fetal problem. A pilot study was recently

conducted at two Canadian hospitals suggested that women assigned to ambient

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room which had additional equipment for mobility such as birth balls and calm

atmosphere had positive birth experience and reduced need for oxytocic

infusion. [64]

Activity during labour offers distraction from discomfort and gives a

sense of greater freedom and provides a way to release muscle tension. In fact,

women who use movements in labour report that it is effective method of relieving

pain and restricting women’s movements during labour may result in worst birth

outcome and decreases women’s satisfaction with their birth experiences and no

study ever shown that walking in labour is harmful in healthy women with normal

labours. [65]

The Center of Disease Control and prevention in 2005 (CDC) reported

that the most common diagnostic reason or indication for 50% or more caesarian is

‘Failure to progress which can be caused by contractions aren’t vigorous enough to

dilate the cervix enough for the baby move through the vagina. Pondering to this

aspect, walk and move around during labour makes the uterus muscle works more

effectively [66]. Movements and changing position moves the bones of the pelvis

and help the baby the best fit and by using gravity helps the baby descend down to

the birth canal. [67]

Another main reason for caesarian deliveries is ‘fetal distress’ which is

used to describe any complications with the fetes such as abnormal heart rate from

poor oxygen supply which is mainly caused by recumbent positions. These two main

reasons of caesarian delivery are reduced if the women being upright during labour.

Based on several evidenced based clinical trials it is proved that changing

positions and moving around during labor and birth offers several benefits which

include gravity. There are reduced risks of aorta cava compression, better alignment

of the fetus, more efficient contractions, and increased pelvic outlets. [68]

In contrast, According to new Cochrane review, lying flat on one’s back

during labor can increases pressure on the blood vessels in the abdomen which

reduces with circulation and lowers maternal blood pressure, which ultimately

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decreases fetal heart rate or contribute to fetal distress, including cord compression,

which may lead to continuous fetal monitoring, in creased risk of shoulder

dystocia/problems with fetal presentation, or a prolonged pushing phase.

More over, WHO has recommended the use of upright position for labor

and childbirth- Category A - a practice clearly useful and effective and the supine-

lithotomy as Category B - a practice very clearly harmful, ineffective and to be

eliminated from the practice. [69]

Although there is no harmony in opinions, one fact does repeatedly arise

is the comfort of the mother and her feeling of freedom and wellbeing should be well

thought out. All authorities recommended that encourage women to ambulate and the

use of movements and change position empower them to cope better with labour.

Movement such as walking helps the baby progress through the birth

canal and put pressure on cervix that encourages the cervix to open as needed for the

labour to progress and mothers who ambulated for significant amount of time during

labour had half the rate of operative delivery. [70]

Globally, in today’s scenario the birth ball has become standard

equipment in many hospitals and birthing center. It is versatile and portable comfort

device and it can be used to adopt variety of positions during pregnancy and labour.

Selecting appropriate size of the ball is determined by the height of the women using

it. The mother who is on 140-165 cm height the medium 55cm height ball is

considered appropriate to use whereas the mothers who are in more than 165 cm

height should adopt large 65 cm ball. During labour pelvic rocking is very beneficial

to reduce the backache and sitting on the ball encourages a natural swaying or

rotating motion of the pelvis, promotes fetal descent. The ball provides perineal

support without a lot of pressure and relieves fatigue and enhances support to knee

joints, ankle and knee. So the mother can be mobile for longer period of time. The

sitting position assumed on the ball, similar to a squat, opens the pelvis, helping to

speed up labour and gently moving on the ball greatly reduces the pain of

contractions [71] With the ball on the floor or bed, the mother can kneel and lean

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over the ball, encouraging pelvic motion which can aid a posterior baby in turning to

the correct position, thus allowing labour to progress more quickly. This position

is wonderful for a mother who is having back labour caused by a posterior

position. [72, 73]

Notelovitz stated that the baby will find it easier to be born if the mother

was in semi sitting position and combination of the muscular action of the womb,

mothers pushing effort and the gravity is the powerful one. [74]

Throughout the scientific development of obstetrics, this controversy has

been examined several times under different perspectives. From the physiological

standpoint, the supine position has been observed to be associated with the

compression of abdominal blood vessels and impairment of fetal nutrition and

oxygenation. It has also been argued that this position would negatively interfere

with uterine contractions. However, upright position during first stage of labor may

improve maternal comfort and reduce the need for analgesia. In this context, labor

without bed confinement became part of a set of actions involved in promoting the

empowerment of women and the humanization of labor, In accordance with these

views, an argument was built in favour of the upright position during labor.

Most of the women are giving birth in health-care facilities, usually in

lying down position on the bed. Unfortunately, the use of these horizontal birth

positions is rooted in convenience for doctors, not based on research

evidence [75]. Although the advantages of movements and position changes to

facilitate labour process have been discussed in literature for more than 3 decades, at

present scenario making the mother to adopt various movements and positions are

considered as challenging, inconvenient for obstetricians and midwives for their risk

focused assessment and management. So their use is restricted, discouraged and

impossible. National survey of child bearing experiences in united states depicts that

71% of women said not walk around and most reason they gave was they were

‘connected to things’ (67%), due to pain medication (32%) and told not to

walk(28%). [76]

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In addition to this, lack of women centered environment in the present

maternity hospitals and birthing units are fully equipped with modern technological

instruments in order to ensure that births are safe and this medicalised hospital

environment contributed to the increasing rate of interventions like induction,

epidurals, instrumental deliveries and caesarean sections and the additional risks that

these interventions bring [77,78]. The bed, occupies the majority of space in the

birthing unit and seeming to suggest that birth should only be on the bed, has become

a major concern in the changes needed to correct the birthing environment.

A study was recently conducted by the National Childbirth Trust (NCT)

in the UK in March 2003-4 provides convincing evidence that not laboring women

what they need in that space. The NCT surveyed 2,000 women who had given birth

between the years 2000 and 2003. The results showed that: Most women felt a clean

room with comfortable furniture for themselves and their companion and the ability

to move around were highly important .Most women felt the small spaces that did

not enable movement the hospital bed was not important as an adjustable device for

different positions in labour or in birth and many suggested it be moved out of the

way. The items that were considered important were a birthing pool, birth ball,

beanbags, floor mats, pillows and comfortable furniture. [79]

Over the past twenty years, policy makers, health professionals and even

the lay society are progressively using an evidence-based rationale to guide their

decisions. A considerable amount of knowledge had already been accumulated on

the subject more than twenty years ago, and the remaining facts available today have

been acquired over that interval of time. In summary, the purpose of the adoption of

an upright position has been the enhancement of uterine contractions and fetal

condition, and the promotion of maternal comfort. Nevertheless, although the issue

has frequently been examined, the optimal alternative remains unclear.

In today’s scenario immobility throughout the labour process become a

common practice. For many women ‘restriction to movement’ is believed as high

risk management intervention that make the mother connected with intravenous

therapy, fetal monitoring, epidural anesthesia, oxygen and suction devices and

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restrict the laboring women confined to bed. All of these highly developed

technology care are necessary for high risk women to maintain optimal birth

outcomes, the sense of normality should be maintained at least for low risk women.

A qualitative study conducted on Characteristics of a positive experience

of women who have unmedicated Childbirth. In this is descriptive study, seventeen

women were interviewed and themes were identified. All of the women reported

satisfying births, adding accompanying feelings of empowerment and well-being. An

overriding theme in each woman's birth story that made the birth experience positive

was the ability to control her body during labor and the ability to influence the

environment in which she labored and gave birth. Being able to move and change

positions freely were both key factors in determining a positive birth experience.

Additionally, the women expressed comfort from the presence of a spouse or trusted

individual. They found the help of an experienced woman or doula important. Many

were willing to change care providers to gain support for their desire for an

unmedicated birth. [80]

It is recommended that units to adopt flexible policies with respect to

maternal position in labour and birth, so that women can choose the most

comfortable positions. As well, members of the medical and nursing staff should be

encouraged to provide care for women who wish to assume non-recumbent as well as

recumbent postures. Vertical postures such as standing or walking, sitting, squatting,

and kneeling; various reclining positions with back support provided by a person, a

wedge, or an adjustable chair; and recumbent positions (supine or lateral-tilt) – all

are possible. In effect, women are likely to vary their position intermittently

throughout labour; the actual phase of labour may itself dictate the choice of posture

Although various position and movements adopted during labour,

controversy still exit to choose the best. Moreover evaluation of movements and

position changes adopted during labour with respect to pain relief, labour outcome

and maternal satisfaction yet to be clarified. In India there is a dearth of literature in

this area.

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Moreover in developed countries many hospitals today provide amenities

like birth ball, rocking chair, beanbags, tubs or showers, stretching ropes, furniture

and safe place to walk in birth suite in order to make women stay out of bed and

enhance the sense of control and satisfaction .But in developing countries like India

these options are lacking or unavailable in birth centers and hospitals.

In addition to this, International council for nurses established a theme

for international nurses 2013 is “closing the gap of millennium development goal”.

The nurses who are prepared to give midwifery care can contribute to achieve the

health related Millennium Development Goal 4 and 5 that reduction of childhood

mortality and promotion of women’s health. As an advanced nurse practitioner in

obstetrical and gynecological nursing they do expanded role in assessment,

diagnosis, selected nursing intervention, implementing intervention and evaluation to

provide comprehensive maternal nursing services and the extended role include

services in hospital, community and family are immense. Realizing this the

researcher is undertaken to introduce specific nursing intervention which are cost

effective, simple and mother friendly can reduce the maternal mortality and

morbidity. Midwives therefore need to be more aware of the social versus medical

model of midwifery and help women and their partners to have a better

understanding of the physiology and process of labour and the benefits of positioning

in labour. This will result in women receiving individualized, holistic, woman-

centered care and encouragement and support to choose whichever position is most

comfortable for them, be it standing, kneeling, sitting or lying. Despite all the

attention given to empowering women to have the type of birth experience they

prefer, medical professionals still pressure women into lying in bed during labor.

This issues on movements and position changes depicts that need for an

hour to be discussed and analyzed to make the birth “as nature intended” adding

accompanying feeling of empowerment, wellbeing with child birth.

The above factors developed interest and motivated the researcher to

select the problem for the present study “To evaluate the effectiveness of Freedom of

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movement during first stage of labour on maternal and fetal outcome among

parturient mothers”.

1.3 STATEMENT OF THE PROBLEM

“A study to evaluate the effectiveness of freedom of movement during

first stage of labour on maternal and foetal outcome among primi parturient mothers

at government hospital, Tambaram”.

1.4 OBJECTIVES

1. To assess and compare the post interventional maternal outcome (Labour

process, Labour outcome, child birth experience and maternal satisfaction)

among study and control group of primi parturient mothers.

2. To assess and compare the post interventional fetal outcome among study and

control group of primi parturient mothers.

3. To determine the effect of freedom of movement on maternal and fetal

outcome among study group of primi parturient mothers.

4. To associate the maternal and fetal outcome of study and control group of

parturient mothers with their selected demographic variables.

5. To co relate the child birth experience with maternal and fetal outcome among

study and control group of primi parturient mothers.

6. To co relate the maternal satisfaction with maternal and fetal outcome among

study and control group of primi parturient mothers.

1.4.1 Secondary Objective

To assess and compare the labour, puerperium and neonatal

complications among study and control group of primi parturient mothers.

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1.5 OPERATIONAL DEFINITION

1.5.1 Effectiveness

The term effectiveness refers to determining the extent to which freedom

of movement has brought outcome result in maternal and fetal outcome among primi

parturient mothers of the study group during the first stage of labour.

1.5.2 Freedom of movement

It is a major component of natural active birth management during labour

which will be provided by practicing various movements such as walking, rocking

with rocking chair, swaying on a birth ball and semi sitting position and each will

be provided for ten minutes with an interval of five minutes between during which

the mother can assume any comfortable position

Walking: Mother walks slow and gentle manner for the period of ten minutes with

five minutes rest period.

Rocking: Mother sits comfortably in rocking chair and rock back and forth for ten

minutes with five minutes rest period.

Swaying: Mother sits on a birth ball and sways her hips side to side and rotates her

hips for ten minutes with five minutes rest period

Semi Sitting: Mother sits in semi sitting position with the elevation of head end of

the bed at 45 degree with back rest or pillows and leg flexed which will be provided

for ten minutes.

This set of intervention provided for the mother 3 times with fifteen

minutes interval period from 3 cm cervical dilatation.

1.5.3 First stage of labour

It refers to active phase of labour which starts from 3 cm cervical

dilatation and with minimum 2 to 3 rhythmic uterine contractions in every 10

minutes lasting for 15 to 20 seconds to delivery of the baby and the placenta.

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1.5.4 Maternal Outcome

Maternal outcome refers to labour process, labour outcome, child birth

experience and maternal satisfaction of primi parturient mothers at the time of

delivery and post natal period.

Labour process: It refers to process which starts from 3cm dilatation till the

completion of three set of freedom of movement intervention. During this period,

� Maternal pulse, respiration- are measured manually by palpating radial artery and

counting radial pulse and respiration per minute and inferred as per American

Heart Association.

� B.P- is measured by standard, certified and regularly calibrated mercury

sphygmomanometer and inferred as per American Heart Association.

� Contraction pattern-Manual abdominal palpation and inferred using as per

partograph (WHO) guidelines.

� Cervical dilatations, effacement, station of the fetal head- were assessed by

performing per vaginal examination.

� Pain- Measured by numerical pain rating scale (American pain society).

� Discomfort- Measured by observational checklist.

� FHR- was measured by auscultation with the use of foeto scope inferred with

American college of nursing practice bulletin number 106.

Labour Outcome - It refers to assessment of delivery outcome include

� Type of delivery and perineum states- Measured by observational checklist.

� Duration of first stage of labour, Contraction pattern, Delivery of placenta and

membrane, use of analgesics augmentation with oxytocin, duration of second

stage of labour rupture of membrane- by partogragh(WHO).

� Presence of hypotension-by checking B.P with sphygmomanometer.

� Amount of bleeding - Measured by visual method.

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Child birth experience: It refers to assessment of perceived degree of control

experienced during labour and child birth among primi parturient mothers as

measured by Modified Labour Agentry Scale(LAS).

Maternal satisfaction: It refers to level of satisfaction with degree of freedom and

midwifery care during labour as measured by 3 point rating scale.

1.5.5. Fetal Outcome

Fetal outcome refers to assessment of birth outcome to the extent to

which the neonate has a healthy outcome at the time of delivery and post natal

period which includes Presence of fetal distress, APGAR Score at first minute,

APGAR Score at fifth minute, Presence of birth trauma, Admission to NICU as

measured by APGAR scoring and observational checklist.

1.5.6. Primi Parturient Mothers

Mothers who are pregnant at first time (G1, P0) and diagnosed as normal.

1.6 ASSUMPTIONS

• Primi parturient mothers those who are in active stage of labour experiences

severe pain.s

• Perception of labour pain is subjective.

• Freedom of movement may have impact on labour process, maternal outcome,

and maternal satisfaction.

1.7 RESEARCH HYPOTHESES

• RHI - There is a significant difference in post interventional level of

maternal outcome among primi parturient mothers between study and

control group.

• RH2 - There is a significant difference in post interventional level of fetal

outcome among primi parturient mothers between and study control

group

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• RH3 - There is a significant association in the level ofmaternal and fetal

outcome among study and control group of parturient mothers with

their selected demographic variables.

• RH4 - There is a significant correlation in child birth experience with

maternal and fetal outcome among study and control group of primi

parturient mothers.

• RH5 - There is a significant correlation in the maternal satisfaction with

maternal and fetal outcome among study and control group of primi

parturient mothers.

1.6.1 Secondary hypothesis

There is a significant difference in level of complication during the

labour, puerperium and neonatal complications among study and control group of

primi parturient mothers

1.8 DELIMITATIONS

• The duration of data collection period was delimited to one year only.

• The study sample size was 211primiparturiene mothers only.

• The study was further delimited to primi parturient mothers admitted in general

hospital Tambaram, Chennai

CHAPTERIZATION

Chapter-1: chapter 1 dealt with the Introduction, Back ground of the

study, Significance and need for the study, Statement of the problem, Objectives,

Operational Definitions, Assumptions and Hypothesis.

Chapter-2: Presents the overviews of literature that support the study

which is divided as Section I and II and Section III presents the Conceptual

framework.