Mobility as an Effective Non-pharmacological Method for Parturition: A Pilot Study

Abstract

Background

Childbirth is a transformative process. Modern healthcare offers pharmacological and non-pharmacological interventions for safe and improved childbirth experience. Studies have found that maternal mobility during the first stage of labour has a significant effect on maternal and child outcomes. A pilot study was done to find the effect of mobility during the first stage of labour on maternal satisfaction and foetal outcome.

Method

An experimental study was done with 60 primigravida women with uncomplicated antenatal history reporting to the labour room of a tertiary care government hospital in Delhi chosen as study participants. Validated and reliable tools were used to measure labour, maternal and neonatal outcomes within 24 h post-delivery.

Results

The results showed that there was an impact on mobility intervention during the first stage of labour on parturition (p = .03) and significant maternal satisfaction (p = .001). However, the neonatal outcome of both groups was not significant.

Conclusion

Mobility was an effective non-pharmacological intervention for enhancing parturition and maternal satisfaction. Mobility during the first stage of labour can be recommended for practice guidelines for all midwives in the labour room as a protocol.

Introduction

Childbirth is a transformative event in a woman’s life, marked by physical and emotional challenges. ¹ The dynamics of labour and delivery have evolved over time, with present-day maternity care focusing on a holistic and positive birthing experience. Pharmacological options such as epidural analgesics and intravenous opioids not only manage labour pains but also has the potential to regulate uterine contractions and expedite labour through the use of neuropeptides like oxytocin. ² Conversely, non-pharmacological methods, such as various positions, breathing techniques, aroma therapy, transcutaneous electrical nerve stimulation and hydrotherapy, provide pain relief and promote maternal mobility, facilitating foetal descent. ³ Mobility of the mother during labour has been recognised as an important non-pharmacological intervention by various research studies.^4–8

One notable reference to mobility during childbirth comes from the work of Grantly Dick-Read, a British obstetrician who published ‘Childbirth Without Fear’ in 1933. ⁹ His ideas laid the foundation for future research and practices related to childbirth. In the mid-20th century, there was a shift towards medicalised childbirth practices, which often restricted a woman’s mobility during labour and delivery. However, as the natural childbirth movement gained momentum in the 1960s and 1970s, researchers began to investigate the benefits of mobility and various birthing positions, and a number of studies have recognised the pivotal role of maternal mobility during labour in shaping parturition, maternal satisfaction and foetal outcomes.^4–8

Maternal mobility during labour enhances foetal and maternal outcomes through several physiological mechanisms. Upright positions, walking and, most importantly, movement encourage the foetus’s descent due to gravity, thereby shortening the duration of labour. Movement also facilitates optimal foetal positioning, reducing the risk of complications. Moreover, the mobility of the mother enhances blood circulation and oxygenation to the placenta, thereby promoting foetal well-being. Maternal mobility minimises pressure on the maternal organs, reducing pain and promoting relaxation, thereby lowering stress hormones and the need for pain relief interventions. Additionally, improved pelvic alignment supports the baby’s passage through the birth canal. Overall, maternal mobility optimises the physiological processes of labour, fostering a positive birthing experience while reducing the risk of complications for both mother and baby. ¹⁰

The WHO has consistently advocated for the promotion of maternal mobility during labour as part of its ‘Safe Childbirth Checklist’ and other guidelines. These recommendations also align with the principles of respectful maternity care, acknowledging that women should have the autonomy to move and choose positions that feel comfortable and natural during labour, as long as there are no contraindications or complications that necessitate immobility. ¹¹

Pain during labour and delivery is a great determining factor of the mother’s satisfaction with the birthing experience. A research study has indicated that the pain score of women (mean pain 6.8) who were encouraged mobility during labour was significantly less than the mean pain score (7.5) among women in the control group. ⁴ Literature has speculated that mobility could have alleviated maternal pain by allowing women to find more comfortable positions, reducing pressure on specific areas and facilitating the baby’s descent. This improved comfort, in turn, could also decrease reliance on pain relief interventions, contributing to a more positive and empowering birthing experience.

Literature has documented that failure to progress in labour, such as slow cervical dilation or inadequate descent of the baby, can lead to a higher likelihood of caesarean section delivery. Studies have documented that the mobility of the mother significantly decreased during the first stage of labour, thereby serving the dual role of enhancing the birthing experience of the mothers and potentially contributing to a lower caesarean section rate. ⁶

Though there are a number of studies to recommend mobility during the first stage of labour, this is not practiced in India. This may be due to inconclusive guidelines provided by the competent authority. ¹² The poor integration of mothers’ mobility during labour in clinical practice may also be due to the lack of sufficient research evidence conducted in the Indian scenario. Moreover, it is felt that the mobility of mothers during labour is not only a simple, safe ¹³ and cost-effective intervention but also a non-pharmacological strategy, which can be initiated by a midwife in labour room, thereby reducing the use of more expensive interventions for managing labour and delivery. The result of the study will also generate evidence in support of an intervention that has the potential to empower women to use autonomy to choose a natural method like their own positions and movement during one of the best episodes in a woman’s life. With this in view, this study was conducted to assess the effectiveness of mobility on parturition, maternal satisfaction and foetal outcome in labour room.

Materials and methods

Design and Setting

An experimental study was conducted in a government hospital labour room that predominantly serves economically disadvantaged women who receive cost-free maternity care. It operates throughout the day and night with skilled obstetricians and midwives and additionally functions as a teaching hospital for nursing students pursuing general nursing and midwifery training.

Population, Sample and Sampling

The population selected for the study were primigravida women who reported for delivery with a gestation of 36–41 weeks with a single viable foetus with no maternal and foetal complications and having an intact amniotic membrane and fulfilling the criteria.

Instruments

Measurable elements used for the study were socio-demographic data and obstetrical and clinical history. An observation checklist was used to observe perineal outcomes such as tear, oedema, valval hematoma, episiotomy and other perineal injuries. Women were given a score of 1 each for the absence of injuries in these six aspects. Therefore, the maximum possible score in Section A was 6. Section B of this tool comprised a checklist where the researcher noted the presence or absence of complications such as antepartum, intrapartum and postpartum haemorrhage and delayed labour with a prolonged duration that needs medical intervention to accelerate the birthing process. The tool that measured maternal outcome was based on maternal satisfaction post-delivery on her pain experience during labour, perineal outcome and initiating breastfeeding to the neonate evaluation of the tool ranged from 0 to 20; the higher the score, the higher the satisfaction level.

Regarding neonatal outcome, an observational checklist was used where all the newborn babies born to the participating women were assessed for trauma at birth, APGAR score at 1 minute, abnormality in heart rate, requirement of resuscitation and initiation and maintenance of breastfeeding.

APGAR is a standardised tool with a score ranging between 0 and 10; the higher the score, the higher the neonatal outcome which was interpreted by the researcher and the observer independently, and there was a cent present agreement on both observations.

Data Collection

A pilot study was conducted during the period of October to November 2021 on 30/30 experimental and control groups who were admitted to the labour ward and met the inclusion and exclusion criteria. Allocation of women to the experimental and control groups was done by recruiting women to the groups on alternate days of the week. The mobility intervention was carried out by the researcher for the experimental group, encouraging and supporting the women in the first stage of labour to walk on the floor for 20 minutes when it was comfortable for them to do so. The researcher also observed the well-being of women and foetus for 10 mi while recording in the WHO partograph for immediate action if warranted.

Data Analysis

Data analysis was carried out using Microsoft Excel, SPSS and R software measuring central tendency, dispersion, association of attributes and cause-and-effect relationship.

Results

(A) Socio-demographic Profile of the Group Under the Study

The age range of women in the experimental group was 19–30 years, and in the control group, it was 19–33 years. Most of the women in both groups completed education till middle school and all participating women were homemakers. Most women in both groups were Hindus and belonged to joint family. The monthly income of the families of the participants was similar in both groups and was between INR 5,000 and 15,000. Regarding habits, none of the participants reported any history of addiction towards tobacco or alcohol.

(B) Obstetrical Profile of the Participants

All the participants in both groups were booked cases and had undergone regular antenatal visits during their pregnancy time. Most (18 out of 30) of the participants in the experimental group were between 39 and 40 weeks of gestation. In the control group, the majority (16 out of 30) were between 39 and 40 weeks of gestation, and 2 participants in this group were above 41 weeks of gestation and the rest (12 out of 30) of them were within 36–38 weeks of gestation. In the experimental group, 27 women had normal vaginal delivery, 2 women had vacuum delivery and only 1 woman had a caesarean section due to signs of foetal distress. In the control group, 24 women had normal vaginal deliveries, 3 women had vacuum delivery and another 3 women had a caesarean section due to foetal distress and failure to progress in labour.

(C) Effect of Mobility on Parturition

In this study on the parturition of the women including observing pre- and post-delivery, all observations on prepartum, intrapartum, postpartum, duration of labour and mode of delivery were recorded using an observation checklist.

The comparison of perineal outcome scores of experimental and control groups showed a mean value of 5.3 and 5.1 in the experimental and control groups, respectively, with an SD of 0.48 and 0.31 and a t-test value of 2.25.

The perineal outcome score of the experimental group (Mean: 5.3) is found to be better than that of the control group (Mean: 5.1). This difference in the mean of the two groups is found to be statistically significant with p = .03. This indicates that the perineal outcome among the participants who underwent mobility intervention was significant.

Comparison of complications and medical intervention incorporated during delivery between the experimental and control groups with sample size 30/30 showed the following:

Prolonged labour	nil/12
LSCS	01/03
Assisted delivery	02/03

The above data showed that the experimental group did not experience prolonged labour, whereas women in the control group (12 out of 30) experienced prolonged labour and a higher rate of LSCS and instrumental delivery. Both groups did not have any major post-natal complications within 24 h post-delivery.

(D) Influence of Mobility on Maternal Satisfaction

Maternal satisfaction was derived for 24 h of observation of experimental and control group scores on pain, perineal outcome, duration of labour and postnatal challenges to initiate breastfeeding to the newborn neonates (Table 1).

Table 1.

Comparison of Maternal Satisfaction Scores Between Experimental and Control Groups.

Maternal Satisfaction	Experimental	Control	t-test	dof	p-Value
Mean	19.2	18.5	4.37	58	.001*
SD	0.66	0.57

Note: *p < .001 significant.

Table 1 signifies that the t-test between the experimental and control groupsrevealed M:19.2 and M 18.5, t (58) = 4.37, p = .001, which proved that mobility intervention had a positive influence on maternal satisfaction.

(E) Newborn Outcome

The newborn babies of the participating women were assessed for trauma at birth, APGAR score at 1 minute, requirement of resuscitation and initiation and maintenance of breastfeeding.

Comparison of maternal satisfaction based on neonatal outcome scores between experimental and control groups showed M 5.97/6.0, SD 0.18/0 and t-test value 0.99 with a p-value 0.34. p < .05 was considered significant.

It was found that none of the babies had any birth-related trauma nor had any difficulty in initiating breastfeeding in any of the groups (data not shown in Table 1). Table 1 shows that a two-tailed independent group was used to test for differences in neonatal outcome scores among babies in experimental and control groups. The t-test revealed that the mean neonatal outcome score in the experimental group (Mean: 5.97) was not significantly different from that of the control group (Mean: 6.0), with t (58) = 0.34 and p = .34.

Discussion

This pilot study was carried out in the labour room of the NCR Delhi hospital on 30/30 experimental and control groups of primigravida who were at 36–41 weeks of gestation and had no maternal and foetal complications, with an aim to implement mobility during the first stage of labour and to study its impact on parturition, maternal satisfaction and neonatal outcome. The intervention suggests that it was effective on the progress of parturition and maternal satisfaction; however, it had no significance on neonatal outcome.

However, the findings that none of the newborn babies in the experimental group had an optimal score in APGAR and had no requirement for resuscitation indicate that the mobility of the mother during the first stage of labour had no harmful effect on the neonates. ACOG in 2017 guidelines for labour intervention underscored that change in maternal positioning and ambulation has a positive effect both on the mother and her foetus. ¹²

In this study, prolonged labour with uterine contractions and pain for more than 20 h from the start of contractions to the birth of the newborn was recorded among 12 primigravids in the control group, whereas none of the participants in the experimental group had prolonged labour. This finding is in accordance with a study which found that walking during labour helped the women in the experimental group to shorten their duration of labour. ¹⁴ WHO recommends supporting mobility though they do not have evidence to support it. ¹⁵

Studies have indicated that women assume many different positions during the progress of labour and it is extremely difficult to isolate any particular position for the expectant mother to ensure both safety and comfort. ¹⁰ However, a recent meta-analysis of RCTs has shown that, in comparison with the traditional supine position of women during labour, upright positions including walking, sitting, kneeling, standing and so on could reduce the duration of labour significantly (mean difference of −1.36 h; 95% CI, −2.22 to −0.51). ¹⁰

There are a number of studies that recommend mobility during the first stage of labour that has a significant impact on maternal satisfaction. The study finding is in concurrence where 40% of women who adopted mobility during labour and expressed that mobility should be adopted as a protocol in labour room and 50% recommended the same to family and friends as there was less pain and discomfort during the first stage of labour. ⁴

A positive birthing experience and maternal satisfaction enhance confidence and mental well-being for future pregnancies and a stronger bond with mother and child.

It may also positively influence the overall health-seeking behaviour of women. This finding supports that a woman’s autonomy on her body outweighs rigid healthcare protocols. Confining the women to the bed during labour aids healthcare providers in monitoring, benefiting their assessment. However, such positions can be uncomfortable for women in labour influencing their overall satisfaction of the birthing experience.

There is constant observation during the first stage of labour in the labour room for all patients.

This study does not show significance in neonatal outcomes of both experimental and control groups. However, none of the babies born to the mothers exposed to mobility intervention had any resuscitative requirement and had optimal APGAR scores. The corpus of literature suggests that the outcome of the newborn baby is optimal when the mothers move and ambulate during the first stage of labour.^{10, 11}

It is beyond doubt that taking a side-lying or kneeling position during the first stage of labour allows the women to relax between contractions, thereby preserving energy. ¹⁶ However, in these positions, the women lose the advantage associated with gravity that is present in a mobile and ambulated position. Another opinion is that restricting the women to the bed during labour and childbirth allows the presenting part of the baby to descend slowly thereby reducing the chances of perineal tear. ¹⁷ However, in this study, the findings of having significantly better perineal outcome scores among the experimental group participants give the contrary view and reflect that mobility during the first stage of labour has no damaging effect on the perineum.

This is an experimental pilot trial that has its own limitations. Based on the finding of the study, mobility is recommended as a protocol during the first stage of labour in the labour room for women who do not have maternal and foetal complications.

Conclusion

Mobility during the active first stage of labour has a significant influence on parturition and maternal satisfaction. The study recommends mobility as it does not give any disadvantage to the neonatal outcome. By reducing the chances of prolonged labour, the study generates evidence in support of mobility during labour. Mobility is a safe intervention that is non-pharmacological and can be adopted by midwives and healthcare providers in the labour room setup.