Implementing the Promotion of Ambulation and Upright Positioning During the First Stage of Labor

Although mobility in labor for low-risk women is supported by professional organizations such as the American Academy of Pediatrics, American Congress of Obstetricians and Gynecologists, the Association of Women's Health, Obstetric and Neonatal Nursing, and the Royal College of Obstetricians and Gynaecologists, its use in some hospitals does not match this recommendation. This practice-change project introduced evidence-based guidelines regarding ambulation and upright positioning in a small labor and delivery unit in a large urban area in which approximately 90-95% of laboring patients remain in bed.

The aims of this project included: 1) establishing baseline knowledge and attitudes of unit staff regarding ambulation and upright positioning; 2) developing and implementing a guideline promoting the use of ambulation and upright positioning during the first stage of labor; 3) increasing patient satisfaction with the labor experience.

In order to translate the evidence into practice, evidence-based guidelines were developed and implemented to promote ambulation and upright positioning during the first stage of labor at a suburban hospital’s labor and delivery unit using the Knowledge to Action (KTA) translational framework by Graham et al. (2006).  KTA is appealing because it has the ability to be fluid in its steps if needed; however, it lays out a logical and sequential path for moving from knowledge to action and implementation. 

Buy-in was sought from key stakeholders including: the Chief Nursing Officer (CNO), Chief of Obstetrics, Chief of Obstetrical Anesthesia, Director of the labor and delivery unit, Unit Nursing Supervisors, and key unit staff such as charge nurses and tenured OBTs.  Letters of project endorsement from the Director of the unit and the CNO were received. Preparation of the unit staff began with educational in-services regarding the proposed change.  During these in-services, knowledge and attitudinal assessments were collected before and after the in-service.  These assessments were developed specifically for use during the project, and helped serve as points of specific data collection. During this time, the unit staff was introduced to the proposed practice change in a document titled, “Guidelines: Ambulation and upright positioning during the first stage of labor.” This document served as a guide for the proposed practice change.  The nurses and unit staff were also oriented to the data collection procedure for the purposes of the project during these meetings. 

Pre-implementation baseline data was collected via chart review by the Project Manager to ascertain the frequency of patients’ upright positioning and mobility as was currently practiced on the unit.  During implementation, nurses used paper documentation regarding use of upright positioning and mobility during labor, patient demographics, length of labor, adverse maternal/fetal outcomes, type of labor (spontaneous, induction, or augmentation), type of anesthesia at delivery, cervical dilation at time of epidural anesthesia, and mode of delivery.  

Thirty-three patients were included in the study project, 18 nurses were included in a pre-test and first post-test, and 15 nurses were included in a second post-test. Results indicated that during implementation, 89.2% of eligible patients participated in data collection and used ambulation and upright positioning during their labors. Nursing data suggested that nurses felt comfortable caring for mobile laboring women and believed they should have the option to do so.  After implementation, an increased percentage of nurses responded they currently offer mobility in labor.

This study is the first in recent literature to assess nursing knowledge and attitudes towards the mobile labor patient. The results also agree with current literature in regards to the safety of ambulation and upright positioning, as well as patient desire to do so.

The findings of this project are similar to those of other studies.  As in other studies, women find the use of ambulation and upright positioning during labor satisfying (Bloom et al., 1998; Frenea et al., 2004; Miquelutti et al., 2007; Stremler et al., 2005).  This study went a step further, asking the participant to rate her satisfaction with different positions using a Likert scale. These findings also agreed with existing literature and showed that the majority of participants liked the individual positions used over the course of their labor (Bloom et al., 1998; Frenea et al., 2004; Miquelutti et al., 2007; Stremler et al., 2005).  The data collected during the participants’ labor revealed no NICU admissions for infants of any of the study participants, which also supports previous literature’s findings of no adverse neonatal outcomes (Albers et al., 1997; Ben Regaya et al., 2010; Bloom et al., 1998; Karraz, 2003; Miquelutti et al., 2007; Stremler et al., 2005; Vallejo et al., 2001).

This project also examined the nursing knowledge, attitudes, and beliefs surrounding ambulation and upright positioning during labor in order to facilitate the practice change.  Overall, the nurses indicated good knowledge of the benefits of such positioning, and felt they were comfortable caring for these patients.  However, it is noted that some knowledge deficits about the benefits of mobility in labor existed as evidenced by pre-test data, but these knowledge deficits decreased on the subsequent post-tests, in that 100% of nurses were answering correctly.  After implementation, nurses agreed patients should have the option to be mobile.  This finding suggests that, in this institution, nurses feel comfortable caring for and supporting patients who desire mobility during labor.  Likert scale scores improved after the first post-test, suggesting the in-service given with the project manager was helpful in empowering the nurses’ feelings and beliefs about ambulation and upright positioning.  When the second post-test was given after cessation of patient data collection, the nursing Likert-scale scores changed.  It appears that nurses, in general, had a tendency to answer on either extreme of the Likert scale.   In future studies, it may be helpful to have a free-text section for comments from nursing staff about why they scored sections as they did.

As a result of this project, more patients ambulated and assumed upright positioning on this unit than had previously, and more nurses reported offering mobility in labor to their patients than prior to implementation.   During implementation, 33 out of 37 eligible patients (89.2%) had data collected and used upright positioning and ambulation during their labor.  This is noticeable improvement, as only 10-15% of patients were mobile during labor before implementation.  Promoting upright positioning and mobility is an important step in empowering women and their care providers during labor, and is widely accepted among professional organizations.