r‘lESlS This is to certify that the thesis entitled AN INVESTIGATION OF THE RELATIONSHIP BETWEEN THE RECUMBENT POSITION AND THE SECOND STAGE OF LABOR presented by Sandra Lee Hayes has been accepted towards fulfillment of the requirements for Master of Science A ‘. Nursing egree 1n //w flip, Major professor Date 6/10/83 0-7639 MS U is an Affirmative Action/Equal Opportunity Institution ‘ MSU LIBRARIES “- RETURNING MATERIALS: Place in book draa‘to remove this checkout from your record. FINES will be charged if book is returned after the date stamped below. AN INVESTIGATION OF THE RELATIONSHIP BETWEEN THE RECUMBENT POSITION AND THE SECOND STAGE OF LABOR By Sandra Lee Hayes A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN NURSING College of Nursing 1983 Copyright by SANDRA LEE HAYES 1983 ABSTRACT AN INVESTIGATION OF THE RELATIONSHIP BETWEEN THE RECUMBENT POSITION AND THE SECOND STAGE OF LABOR By Sandra Lee Hayes Consumers have begun to question and challenge the routine use of many obstetrical practices surrounding childbirth. The recumbent position, although tradi- tionally used in this country for over 100 years, has not been scientifically evaluated. Thus, a retrospective sur- vey of primiparous women was undertaken to explore the relationship between the recumbent position and the length of the second stage of labor. Data was collected from the hospital records of 21 women who met the established criteria. Data was analyzed using descriptive statistics, Pearson Product MOment Corre- lations and Pearson Point Bi-Serial Correlations. The mean length of the second stage was 46.6 minutes with a standard deviation of 21.1. Sparks,* using the same methodology as the present study, evaluated the upright position. A mean of 60.9 minutes and a standard deviation of 35.4 was identified by Sparks. No statis- tical difference was found between the means of the up- right and recumbent position (p:,05). *Sparks, B. An Investigation of the Relationship Between the Upright Position and the Second Stage of Labor. Un- published masters Ehesis, MiChigan State University, 1983. To Geoff, Allyson and Rachel who made completion of this project possible and to Barbara whose friendship knows no limits. ii ACKNOWLEDGEMENTS Having completed the final requirement that sig- nifies the end of this phase of my formal education, there are many people that deserve special attention and thanks. Although many more people contributed to my achievement, these people stand out for their signifi- cant contributions: Dr. Barbara Given, Chairperson of my thesis committee, whose constant encouragement and support has made the conduct of research exciting and whose influence has caused me to see the importance of my contribution to nursing research. Dr. Rita Gallin whose editorial comments have been invaluable and whose wit and humor have enabled me to laugh when a release from the seriousness of the thesis was most needed. Mildred Omar, Jackie Wright and Deborah Zuidema, members of my thesis committee, who patiently endured re— write after re-write and provided comments, suggestions and questions that directed my research. My husband, Geoff, and our daughters, Allyson and Rachel, who altered their schedules and lives to facili- tate my education. They provided the constant reassur- ance, encouragement and most of all the love that was iii necessary to complete my degree requirements. Barbara Taylor Sparks without whose friendship, encouragement and comradery completion of this project would have been impossible. Though the research has come to an end and the thesis is finally finished, a true friendship never ends, rather it continues to grow beyond all bounds and expectations. iv TABLE OF CONTENTS Chapter page I THE PROBLEM ................................... 1 Introduction ............................... 1 Collaborative Effort ....................... 3 Purpose .................................... 4 Historical Developments .................... 7 Current Implications ....................... 12 Conceptual Definitions ..................... l7 Lithotomy Position ...................... l7 Recumbent Position ...................... l8 Upright Position ........................ 18 Birthing Chair .......................... 18 Primipara ............................... 18 Second Stage of Labor ................... l9 Uncomplicated Pregnancy ................. l9 Scope ...................................... 20 Assumptions ................................ 20 Limitations ................................ 21 Overview of the Chapters ................... 24 II CONCEPTUAL FRAMEWORK .......................... 26 Lithotomy Position ......................... 26 Upright Position ........................... 34 II (Cont) Variables Affecting the Second Stage of Labor ................................ 35 Controlled Variables .................... 35 Intervening Variables ................... 40 Comparison Between Lithotomy and Upright Position ................................ 45 Florence Nightingale's Theory of Nursing... 47 III LITERATURE REVIEW ............................ 57 Introduction ............................... 57 Trends in Childbirth Practices in the United States ........................... 58 Cross Cultural Birthing Practices .......... 62 Consumer Issues ............................ 65 Primipara .................................. 75 Second Stage of Labor ...................... 75 Uncomplicated Pregnancy .................... 76 Birthing Position .......................... 76 Length of Second Stage of Labor ............ 80 Controlled Variables ....................... 87 Medications ............................. 88 Forceps ................................. 90 Fetal Presentation and Position ......... 91 Maternal Pelvic Measurements ............ 91 Age ..................................... 92 Childbirth Education .................... 92 vi III (Cont) Maternal Complications ................. 93 Support Persons ........................ 93 Intervening Variables ..................... 95 Rupture of Membranes ................... 96 Race ................................... 101 Marital Status ......................... 105 Obesity ................................ 105 Episiotomy ............................. 107 Use of Fetal Monitors .................. 108 Summary of the Literature Review .......... 115 IV METHODOLOGY .................................. 117 Overview .................................. 117 Research Design ........................... 118 Selection of Study Subjects ............... 118 Instrumentation and Data Collection ....... 132 Field Procedures .......................... 137 Research Permission .................... 137 Pre-test ............................... 137 Data Analysis ............................. 140 Descriptive Statistics ................. 140 Inferential Statistics ................. 140 Summary ................................... 142 V DATA PRESENTATION ............................ 144 Overview .................................. 144 Presentation of Research Questions ........ 144 vii V (Cont) Study Population ........................... 147 Results .................................... 148 Characteristics of Study Subjects ....... 148 Demographic Descriptors .............. 148 Intervening Variables ................ 148 Incidental Variables ................. 154 Summary--Characteristics of Study Subjects .......................... 160 Data Presentation for Research Questions ............................ 161 Research Question 1 .................. 161 Research Question 2 .................. 163 Research Question 3 .................. 163 Research Question 4 .................. 164 Summary--Research Questions 1-4 ...... 166 Research Question 5 .................. 169 Research Question 6 .................. 169 Research Question 7 .................. 170 Research Question 8 .................. 170 Summary--Research Questions 5—8 ...... 170 Research Question 9 .................. 171 Research Question 10 ................. 175 Research Question 11 ................. 175 Summary--Research Questions 9-11 ..... 178 Interpretation of Findings ................. 179 viii V (cont) Methodological Problems ..................... 189 Relationship of Results to Conceptual Framework ................................ 191 Relevance of the Study ...................... 193 Summary ..................................... 194 VI SUMMARY AND CONCLUSIONS ........................ 197 Overview .................................... 197 Summary of Findings ......................... 197 Recommendations and Implications for Nursing .................................. 206 Nursing Education ........................ 206 Nursing Service .......................... 210 Nursing Research ......................... 216 Conclusions ................................. 221 APPENDICES APPENDIX A: PERMISSION FOR RESEARCH PROJECT ....... 226 B: COMMUNICATION WITH NURSING STAFF, ST. LAWRENCE HOSPITAL ............... 232 C: STATISTICAL INFORMATION ON STUDY BY SPARKS .............................. 235 REFERENCES ............................................ 242 ix Table Table Table Table Table Table Table Table Table Table Table Table Table O‘U‘l-DLAJ 10 11 12 13 LIST OF TABLES Advantages and Disadvantages of the Lithotomy Position ..................... Advantages and Disadvantages of the Upright Position ....................... Controlled Variables ...................... Intervening Variables ..................... Demographic Descripters ................... Nightingale's Environmental Variables ..... Age Distribution of Women in the Recumbent Position ............................... Type of Health Insurance Coverage of Women in the Recumbent Position ........ Frequency Distribution of the Intervening Variables in the Recumbent Position.... Pounds of Weight Gain in Pregnancy of Women in the Recumbent Position ........ Frequency Distribution of the Incidental Variables in the Recumbent Position.... Length in Minutes of the Second Stage of page 31 36 37 41 44 51 149 150 151 155 156 Labor of Women in the Recumbent Position 162 Correlation Values for Variables and the Length of the Second Stage of Labor-- Recumbent Position ...................... 165 Table 14 Correlation Values for the Relationship Between Age and Lacerations and the Position Used for the Second Stage of Labor ................................ 176 Table 15 A Comparison of Mean and Standard Devia- tion Values--Second Stage of Labor-- Current Studies and That of Liu ......... 181 xi Figure Figure Figure Figure Figure Figure Figure Figure APPENDICES A1 A2 A3 A4 A5 O‘U‘IJ-‘w LIST OF FIGURES The Role of Nursing ....................... Variables Affecting Birth and the Environment ............................ Screening Tool 1 .......................... Screening Tool 2 .......................... Data Collection Tool ...................... Length of the Second Stage of Labor with Frequency of Occurrence in a Recumbent Position ............................... Length of the Second Stage of Labor with Frequency of Occurrence in an Upright Position ............................... Comparison of Length of Second Stage of Labor with Frequency of Occurrence in the Upright and Recumbent Positions.... Letter Concerning Confidentiality ......... Communication from Nursing Office ......... Letter to Hospital Research Review Committee .............................. Communication to Nursing Office ........... Communication to Human Subjects Review Committee, M.S.U ....................... xii page 55 56 123 125 128 164 168 173 226 227 228 229 230 A6 B1 B2 C1 C2 C3 C4 C5 C6 C7 Permission from Human Subjects Review Committee, M.S.U ........................ 231 Communication from Nursing Office to Labor and Delivery Department ................. 232 Introductory Letter to Labor and Delivery Staff ................................... 233 Age Distribution of WOmen in the Upright Position ................................ 235 Type of Health Insurance Coverage in the Upright Position ........................ 236 Weight Gain in Pregnancy of Women in the Upright Position ........................ 237 Frequency Distribution of the Intervening Variables in the Upright Position ....... 238 Frequency Distribution of the Incidental Variables in the Upright Position ....... 239 Length of the Second Stage of Labor of Women in the Upright Position ........... 240 Correlation Values for Variables and the Length of the Second Stage of Labor Upright Position ........................ 241 xiii CHAPTER I THE PROBLEM Introduction In the late 18008 the movement from.home to hospital birth began (Banta & Thacker, 1979). Public Health Officials and physicians determined that painless childbirth was possible, but only if the birth occurred within the hospital under the direct supervision of a physician. Along with a change in location for the birth came multiple other changes in the whole birth- ing event. An experience that had been considered normal, frequently involving many family members and friends, was radically altered into a pathological event that warranted medical and technological inter- vention. When births occurred in the home, the woman in labor was allowed to choose whatever position was most comfortable for delivery. With the advent of hospital births and the use of general anesthesia to produce a painless event, the woman was required to assume a recumbent position that would facilitate the adminis- tration of the anesthesia and thereby allow the physician to deliver the infant. Although general anesthesia is no longer used for vaginal deliveries, the use of a recumbent position remains entrenched by tradition. Satisfaction with and acceptance of current birthing practices has been called into question as consumer involvement in health care issues has increased over the past several years. Concerned consumers and providers are questioning the importance of many routine obstetrical practices and asking for scientific justification for their use (Arms, 1975; Corea, 1977). One area of particular concern to the consumer is the use of the lithotomy position for the second stage of labor. Since this practice has been questioned by consumers and since several noted authors (Banta & Thacker, 1979; Haire, 1972; Jordan, 1980) have identified this obstetrical practice as being rooted in tradition, it therefore seems appro- priate to evaluate scientifically the relationship between the lithotomy position and the length of the second stage of labor in an effort to address consumer concerns. In this chapter a description of the collabora- tive effort with Barbara Taylor Sparks will be discussed. The purpose of this research project will be identified and the relevance to current nursing practice postulated. The methodology used in this study will be summarized, followed by a discussion of the historical developments surrounding the birth process. Current implications of the historical trends previously identified will then be presented. Definitions of concepts, scope of the project, assumptions and limitations will then be addressed. Finally, an outline for the remainder of the thesis will be presented. Collaborative Effort To produce more clinically applicable results, portions of this research effort were done in collabora- tion with Barbara Taylor Sparks (1983). The data from the two projects when analyzed separately add to the body of scientific knowledge related to child- birth. When the results of the two projects are comparatively analyzed, alterations in current obstetrical practices may be forthcoming. Individually the results of the projects increase the scientific data base: collectively the results relate to broader consumer issues and may influence clinical practices. The research question to be addressed by this study is: What is the length of the second stage of labor in primiparous women with uncomplicated preg- nancies who use the recumbent position? The research question in the study by Sparks (1983) is: What is the length of the second stage of labor in primiparous women with uncomplicated pregnancies who use the upright position? The broader question to be answered by the results of the two studies combined is: Is there a significant difference in the length of the second stage of labor in primiparous women with uncomplicated pregnancies who use a recumbent position than in primiparous women with uncomplicated pregnancies who use an upright position for the second stage of labor? In collaboration with Sparks (1983), Chapter II (Conceptual Framework), Chapter III (Literature Review) and portions of Chapter IV (Methodology) were written. The research methodology and the screening and data collection tools used were identical in both studies making direct comparison of the results of the studies possible. Purpose Many current obstetrical practices had their origin late in the 19th century when the movement from home to hospital births began. Although use of these practices has become entrenched in hospital routine, the efficacy of most have not been scientifically evaluated (Haire, 1972; Banta & Thacker, 1979). Since the advent of the consumer movement in the late 19603, many traditional health care practices have been questioned. One area of particular concern to consumers is related to childbirth. The lack of flexi- bility in hospital routines and the inability to have choices regarding the birthing event are objections frequently voiced by consumers. As hospital personnel have continued unresponsive to consumer requests and needs, more and more families are choosing to deliver at home (Cogan & Edmunds, 1978; Conklin & Simmons, 1979). In this author's opinion, home births are often unsafe. The availability and use of specially trained nurse midwives in the United States is limited, thus, women who choose to deliver at home are often attended by lay midwives who have had little or no training. Medical back up and specially equipped ambulance services are usually unavailable. Thus, the woman who chooses to deliver at home and experiences some type of maternal or fetal complication is likely to lack access to the providers she needs. If the increasing incidence of home births is related to consumer dissatisfaction with current hospital practices, what then can we, as concerned providers, do to make the hospital environment a more satisfying place in which to give birth? One way of addressing consumer concerns is to examine suggested alternatives to the current medically mandated practices. While evaluating the alternatives is important, it seems critical also to examine and evaluate scientifically those practices that are currently used routinely. Through an examination of both the current practices and possible alternatives, it may be possible to create a more flexible health care system that is responsive to consumers as individuals. This study is directed at one very specific consumer concern: the use of the lithotomy position for the second stage of labor. The purpose of the project is to impirically evaluate the relationship between the use of the lithotomy position and the length of the second stage of labor. More specifically, the question is: What is the mean length of the second stage of labor in primiparous women who use the recum- bent position for delivery? A study by Sparks (1983) examined the upright position as an alternative to the lithotomy position for the second stage of labor. When the results from the two studies are compared, it will be possible to make a statement about the effi- cacy of the two positions relative to the length of the second stage of labor. If use of the alternative position (upright) is associated with a second stage of labor not statistically longer than that in the lithotomy position, then at least relative to length, the upright position should be an acceptable alterna- tive. The combined results of the two studies will give the health care community research data that can be used to determine acceptable alternatives to the routine use of the lithotomy position. It is hoped that this research effort will provide impetus for further studies to evaluate other routine obstetrical practices in current use. If, as providers, we can begin to evaluate critically and scientifically our health care practices, we may be able to create a more flexible approach to patient care. We may be able to offer choices and not simply impose rules. We may be able to create an atmosphere within the hospital setting that is flexible--an atmosphere in which each woman and her family are viewed as individuals. In so doing, we may help consumers to see the hospital birth setting as one that can and will meet their needs, as well as provide safe care. Historical Developments Health is the movement toward wholeness, growth and life, toward individual res- ponsibilities for our own bodies. (American Friends Service Committee, 1970) Practices related to childbirth in the United States have moved dramatically away from concepts embodied in the above quote. Obstetrical practices have become much more interventionist since childbirth moved into the hospital setting and continued technological dis- coveries have made the pregnant woman less and less responsible for her own body and her own health. The history of obstetrical practice in the United States can be divided into three stages: the period when births took place in the home, the shift to hospital births, and the current move toward increased use of home births. Births occurred in the home from the time this country was first colonized until late in the 18003. Such home births were attended by midwives who con— tracted with patients to assist with their births (Devitt, 1979; Dye, 1980). During this early period, childbirth was viewed as a natural event, an event primarily controlled by the woman in labor with some assistance from the midwife (Jordon, 1980). The laboring woman assumed the most comfortable position, most often some type of upright position (Haire, 1972). In fact, Naroll, Naroll and Howard (1961) indicate that some form of the upright position (sitting, kneeling, squat- ting) was used across most of the world prior to medical intervention in the birth event. Late in the 18008 the practice of giving birth at home began to change. The birth event shifted from a normal, natural one to a pathological occurrance that was considered best handled in a hospital under the close supervision of a physician. With the develop- ment of general anesthetic agents, physicians announced that the pain experienced with childbirth could be eliminated, but only if the birth occurred in the hos- pital (Devitt, 1979). Initially only the upper class used hospitals for childbirth. Gradually, however, the practice filtered down to other social classes. A painless childbirth was accomplished through use of general anesthesia. It became readily apparent, however, that anesthesized women could not effectively push their babies through the birth canal and thus,in 1932 DeLee developed an instrument called obstetrical forceps to assist with the delivery (Devitt, 1979). The combined use of general anesthesia and forceps soon became routine procedure for hospital deliveries. To facilitate introduction of the anesthesia and application of the forceps the patient's position was changed from upright to recumbent. The change in position for birth provided the physician convenient access to the perineum, enabling him to utilize forceps and create episiotomies without diffi- culty or inconvenience (Atwood, 1976; Hugo, 1977; Me Kay, 1980; Roberts, 1980). During this second stage of obstetrical develop- ment, childbirth became entrenched as a pathological 10 event that warranted hospitalization and increasing technological intervention. By 1975 over 90% of all deliveries occurred in hospitals (Pearce, 1976). Accord- ing to Jordon (1980), the events surrounding childbirth in 1975 bear little resemblance to the event as it occurred in the 15003. The movement to the hospital for childbirth stimulated increased medical and techno- logical intervention in an event that was once basically controlled by the laboring woman herself. WOmen were deprived of control over their bodies and over the birth (McKay, 1982). The woman did not give birth: the physician delivered the baby. The rise of the consumer movement in the 19603 marked the third stage of obstetrical development in the United States. The women's call for equality and human rights directed part of their attention toward health care issues. WOmen began to demand more respon- sibility and involvement in the care of their own bodies. One area of health care vitally important to women is pregnancy and childbirth. A3 women become more involved in the childbirth practices in the United States, they also become more knowledgeable about practices in other countries. They ask: If the United States has such excellent care for pregnancy and delivery, why is our infant mortality rate higher than that in countries where less medical intervention is present? 11 In point of fact, the infant mortality rate in the United States was 15.3/1000 live births in 1976/1977, while in Holland and Japan where less medical interven- tion is used, the rates were 9.5/1000 and 8.9/1000 respectively (World Health Organization, 1979). Yet, medicine justifies control of the birth by contending that infant outcome is improved when a high level of medical intervention is present. The infant mortality rates provided by the World Health Organization, however, do not support this contention. As consumers have become more knowledgeable about their own health care system and about health care in other countries, they have begun to question directly much that is currently espoused by the medical community. In the late 19603, the health care community did make an attempt to respond to some of the consumer con- cerns surrounding childbirth. The concept of Family Centered Maternity Care was developed and adopted, at least in name, by obstetrical departments all over the country. By definition, Family Centered Maternity Care offered the pregnant woman and her family an opportunity to participate in the total birthing event (Lerch, 1974). In reality, however, members of the woman's family were simply allowed to stay with her during labor. When the woman was moved to the delivery room, the family members returned to the father's waiting room. The family members 12 that were allowed to be present during labor were also limited. That is, generally only one person could be with the woman at a time and children were not allowed in the labor rooms. Children were also not allowed to visit their mother and new sibling following the delivery. It is this author's experience, that although the Family Centered concept was advertised by obstetrical units, in practice the only family involvement that was permitted in many hospitals was the presence of a visitor during labor. In retrospect, it appears that the health care community, in an attempt to respond to consumer concerns, developed the concept of Family Centered Maternity Care 223 most often instituted it in name only. As the medical community has continued to be unresponsive to consumer requests for more control and choice in the birthing event, consumers have increasingly turned to home birth as an alternative. Current Implications The current consumer involvement with health care issues has spurred a growing call for change in the way the health care system responds to patients' needs. Consumers have become more knowledgeable about their health care needs and more assertive about the right to participate actively in the care of their bodies. Support groups like the Consumer Task Force 13 On The Childbearing Year in Lansing, Michigan have been organized to help educate families about choices related to childbirth. Resources such as the Lansing Area Doctorsrfixectory (1980) have been completed to help consumers become knowledgeable about the routine practices obstetricians utilize in their practice, i.e., episiotomies, forceps, intravenous fluids. Books such as Our Bodies Our Selves (Boston WOmen's Health Collective, 1979) and Immaculate Deception (Arms, 1975) have been published to help increase con- sumer awareness of issues related to women's health. With this increased awareness and knowledge, more and more consumers are asking to reassume more control over the birth event. Some are negotiating with health care providers for less medical intervention and more personalized support (Banta & Thacker, 1979). Others, however, are withdrawing from the medical scene altogether and are turning to lay midwives and home deliveries (L'Esperance, 1979). The exact number of home births in a community is difficult to determine because of the ambiguous nature of the lay midwives' practice in relation to the law. In many areas in the United States, the legality of practicing as a lay midwife is unclear. Thus, families who utilize the services of a lay midwife are hesitant to discuss or disclose information concerning their experiences. l4 L'Esperance (1979) identified two projects, however, in which 300 families in California and 69 families in Arizona who had experienced home births were studied, suggesting that at least in some areas a significant number of home births occur. Despite this increase, some very real issues of concern surrounding home births exist. First, most physicians and certified nurse midwives will not attend home deliveries. Thus, most home births are attended by lay midwives whose training and expertise vary widely. Often the lay midwife is unequipped to handle emergencies that may occur, leaving the mother and infant without adequate care. The credibility that lay midwives have with licensed health care pro- viders is questionable, at least in part, due to their lack of formal, standardized training. Further, at least in the State of Michigan, lay midwives tend to. be available only through an underground system since their right to practice is not clearly defined by the law. A question also arises as to the criminal lia- bility of the lay midwife in the event a problem occurs during the delivery. If a physician assumes responsi- bility for the care of a woman and/or her baby after a problem has occurred in a lay midwife assisted delivery, will that physician be running the risk of a law suit for a situation that he did not have complete 15 control over? The lack of credibility with health care providers and the threat of potential law suits make planned medical back-up unavailable, in most cases, to the lay midwife. The concept of home birth is not an unsafe alternative if_the home birth is attended by a licensed physician or a certified nurse midwife. The safety problem arises, however, when the only attendent avail- able for a home birth is a lay midwife. Most physicians will not consider participating in a home delivery. Certified nurse midwives, who might be more likely to participate in home deliveries than physicians, are not allowed to practice in many states in this country. Thus, the option for a home birth is a lay midwife. It seems apparent, then, that if the trend toward lay midwife attended home birth is to be reversed, we must create a more flexible hospital situation res- ponsive to patients as individuals. As providers, we must critically evaluate current practices in light of consumer requests and develop a flexible approach toward care. There can be no argument that the technological advances of recent years have produced healthy infants in high-risk situations that might otherwise have been impossible (Banta & Thacker, 1979). The problem comes when the high technology approach 16 is used routinely for all births. If we can return to the view that normal pregnancy and delivery is a natural process and support this process by offering choices and flexibility in our routines, we may be able to once again bring birthing back into the safe environment of the hospital. To do this, we must respond to consumer requests such as options in birthing position. The traditional lithotomy position has been used primarily for the convenience of the birth attendent. Consumers have complained that this position is uncomfortable and unnatural and suggest an alternative posture, the upright position. In response, some hospitals recently have introduced a modern version of the old birthing chair. The rediscovery of the birthing chair has increased the interest in some form of an upright position. Some providers are also allowing their patients to use the squatting or kneeling position as an alternative posture for the second stage of labor. Other patients are simply being allowed to sit up in bed to push rather than lay flat on their backs. Nevertheless, only a minimal number of patients who desire to use an alternative position are allowed to do so. This research project examined the length of the second stage of labor using a recumbent position. l7 Utilizing the data from the study by Sparks (1983) it will be possible to determine if the length of the second stage of labor in the two positions is significantly different. Since several experts in the field of obstetrics (Pritchard & MacDonald, 1980; Willson, Beecham & Carrington, 1975; Jensen, Benson & Bobak, 1980) have identified the second stage of labor as important to fetal well-being, evaluation of birthing positions relative to length is important. By utilizing the results of the two studies, we, as nurses, will be better able to act as advocates for our clients. We will be prepared with scientific evidence to initiate change in a system that, to date, has often resisted change and rested on rigid tradition. To collect data for this study, the survey approach via a retrospective chart review was used. Conceptual Definitions* Lithotomy Position. The lithotomy position is a position commonly used during birthing in hospitals. While on a delivery table, a woman lies on her back, legs flexed on the thighs, thighs flexed on the belly, and abducted (Miller & Keene, 1972). The lithotomy position is also called the neutral position; the line *Conceptual definitions written in collaboration with Barbara Taylor Sparks. 18 connecting the center of the woman's 3rd and 5th lumbari vertebrae is more horizontal than vertical (McKay, 1980; Atwood, 1976; Narrol, Narrol & Howard, 1961). Recumbent Position. A recumbent position is a position in which the line connecting the center of the woman's 3rd and 5th lumbar vertebrae is below 30°. The most commonly used recumbent position is the lithotomy position described above. Upright Position. An upright position is a posi- tion commonly used during birthing in cultures other than the United States. Women are erect: standing, sitting, squatting or kneeling. The line connecting the center of a woman's 3rd and 5th lumbar vertebrae is more vertical than horizontal, i.e., greater than 30° (Liu, 1974). Birthing Chair. A birthing chair is a chair used to support pregnant women in their labor and delivery, often with a cut-out seat. Its purpose is to allow women to push the fetus down the birth canal while in an upright position. Sometimes there are foot supports to aid the woman in her efforts to push. The birthing chair can be a straight backed, modern chair turned on its side, a stool, or a modern adapta- tion of a delivery table (Caldeyro-Barcia, 1979). Primipara. A primipara is a woman who has delivered her first infant after the period of viability, regardless 19 of whether the child is living at birth (Agnew, et al., 1965; Lerch, 1974; Fitzpatrick, 1971; Jensen, Benson & Bobak, 1980; Olds, et al., 1980). Lerch (1974) further defines the state of viability as 25 weeks gestation and beyond, thus indicating that first tri- mester abortions or miscarriages do not influence the parity of a woman. Second Stage of Labor. The second stage of labor is the stage in the process of birth that begins with complete dilation of the cervix (10 cm. in diameter) and ends with the delivery of the infant (Pritchard & MacDonald, 1980; Olds, et al., 1980; Lederman, et al., 1979; Jensen, Benson & Bobak, 1980; Bergsjo & Halle, 1980; Bergsjo, Bakketeig & Eikom, 1979). Uncomplicated Pregnancy. An uncomplicated pregnancy has been defined in the literature only by stating what it is not. Therefore, for the purposes of this study, absence of all of the following will indicate an uncomplicated pregnancy (Leitch & Tinker, 1980; Pritchard & MacDonald, 1980). Pregnancy Induced Hypertension Chronic Hypertension Toxemia Chronic Lung Disease Pre-eclampsia Multiple Births Eclampsia Breech Presentation Diabetes Mellitus Incompetent Cervical Os 20 Heart Disease Bleeding--2nd or 3rd Trimester Renal Disease Age--below 16 yr. or Abnormal Fetal Position 35 yr. and above Scope In the present study, the length of the second stage of labor in women who use the lithotomy position was examined. One independent variable, position used for the second stage of labor and one dependent vari- able, the length of the second stage of labor were evaluated. The study by Sparks (1983) examined the upright position as the independent variable and the same dependent variable. The current study acknowledges that there may be other factors that affect the length of the second stage of labor (maternal fatigue, fetal size, maternal feelings about the pregnancy). The focus of this study, however, was primarily related to the length of the second stage in those women who used the recumbent position. Assumptions* In this study the researcher makes the following assumptions: *Assumptions written in collaboration with Barbara Taylor Sparks. 21 The literature review throughout these theses is representative of the work that has been done on the obstetrical issue of position forthe second stage of labor. The obstetrical care of patients using the recumbent position and patients using the upright position was similar in quality. Accurate data were retrieved from the charts regarding course of pregnancy, second stage of labor, and use of the upright and recumbent positions. Length of labor is important to maternal and fetal well-being (Bryant & Danforth, 1977). Position of women in the second stage of labor significantly influences the length of second stage of labor (Liu, 1974, 1979; McKay, 1980, Caldeyro-Barcia, 1979). Limitations* The limitations of the study are: 1. One hospital site was used, thus limiting the generalizability of the results. Charts of twenty-five women who used the *Limitations written in collaboration with Barbara Taylor Sparks 22 upright position and twenty-one women who used the recumbent position were reviewed. The size of the sub-population in each birthing position may have been too small to reflect the true relationship between birth position and length of the second stage. All patients in the sub-populations were similar; that is, they all chose to deliver their babies in a hospital with a physician provider. It is possible that they were different, psychologically or physiologi- cally, from women who chose to deliver at home. Thus, it is not possible to gen- eralize the results to a home birth popu- lation. Equal numbers of clinic patients and pri- vate doctor patients were not required. It is possible that a differnt type of woman goes to a clinic rather than a doc- tor in private practice, and that this difference may affect the length of labor. All information about pregnancy and delivery may not have been accurately or consistently documented in the prenatal records or labor and delivery forms. 10. 23 The position described as recumbent may have been somewhat variable, that is some women may have been lying flat on their backs with their thighs elevated and abducted, and some women may have been somewhat propped up from the waist, with their thighs elevated. Some women may have changed position during the second stage of labor, either from the recumbent to upright or the reverse. If this change was documented in the chart, these patients were eliminated from the studies. In the rush of delivery, however, this change of position may not have been documented. All the desired data was not consistently available on the charts, and thus some aspects of data anlaysis were limited, i.e., specific Eype of occupation. As a result of additional documentation required on hospital records for the studies, nurses may not have consistently or accurately documented this information. Patients may have been in the second stage of labor prior to the actual determination,by vaginal exam, of the 24 onset of this stage. Overview of the Chapters In the preceding pages, the purpose of the study was discussed and the research question presented. Background material related to the research question was addressed and assumptions and limitations of the study were identified. In Chapter II the concepts used in this study are defined and a conceptual framework based on Florence Nightingale's Theory of Nursing is presented. Chapter 111 contains a review of literature relevant to birthing position and the second stage of labor. Classic research as well as consumer publi- cations and discussions in the area of birthing position are presented. In Chapter IV the methodology used in this project is identified and discussed. In Chapter V the data are presented and the results discussed. Significant data and results from the study by Sparks (1983) also are presented and compared with the results from this study. The last chapter, Chapter VI, contains a discussion that identifies the implications of this study for nursing. The areas of nursing education, nursing service, and nursing research are addressed in this chapter. 25 Implications for nurses as consumer advocates are also presented. CHAPTER 11* CONCEPTUAL FRAMEWORK In this chapter, the concepts of lithotomy posi- tion and upright position will be discussed and related to the second stage of labor. Other variables that may affect delivery will then be described. Following this description, an explanation of Florence Nightingale's Theory of Nursing will be presented. Finally, it will be shown how this research derives from Nightingale's con- cepts. Lithotomy Position The lithotomy position is defined as lying with the back flat and with the knees drawn up and spread wide apart by "stirrups" or leg supports (Haire, 1972; Atwood, 1976). This recumbent position was first introduced to obstetrics by Francois Mauriceau in the 17th century because it made the use of forceps easier (Liu, 1979). The lithotomy position was introduced in America in the 18003 by Dewees, again to facilitate the use of forceps. Since the introduction of the position by Dewees, the lithotomy position has grown *This chapter written in collaboration with Barbara Taylor Sparks. 26 27 in use and popularity until it is now the accepted position for the majority of all hospital vaginal de- liveries (Pritchard & MacDonald, 1980). The lithotomy position for delivery has become a custom and thus, has decreased the opportunity for women to choose their position for delivery (Liu, 1979). Liu (1979) indicated that when current Western obstetrical practices are used, labor and delivery are viewed as strict surgical procedures that dictate the lithotomy position in which fetal monitors, forceps deliveries and episiotomies can be easily used. Bryant and Dan- forth (1977) identified two purposes that the lithotomy position serves: 1) ease of control of asepsis and 2) convenience of the birthing attendent. In addition, the position provides other advantages to the attendent: fetal heart tones can be auscultated without a position change, external efforts can be brought into play (appli- cation of fundal pressure), anesthesia can be introduced, controlled and managed easily, and episiotomies can be easily made and repaired (Moir, 1964; Atlee, 1956; Roberts, 1980). The birthing attendent assumes control and the patient is perceived as passive. In short, the advantages of the lithotomy position are related to provider ease and convenience, not to patient comfort, patient desire, or physiologic principles. By contrast, the disadvantages of the lithotomy 28 position are experienced by the mother and the fetus. Supine hypotensive syndrome and postural shock can occur rapidly when the heavy gravid uterus compresses the vena cava (Atwood, 1976; McKay, 1980), a problem that does not occur in the upright position (Liu, 1979). In the lithotomy position the inferior vena cava is compressed by the gravid uterus causing venous pooling in the lower extremeties, a decreased blood return to the heart, decreased cardiac output leading to decreased uterine blood flow, fetal acidosis and fetal hypoxia (Atwood, 1976; Liu, 1979). Liu (1979) also indicated that in the recumbent position, the weight of the brain substance falls toward the frontal lobes. The frontal lobes of the fetal brain are less well developed than are the older occipital lobes and are therefore more apt to sustain injury during the labor and delivery process (Liu, 1979). Use of the lithotomy position, then, produced conditions that are potentially threatening to the well being of the fetus. In 1909 King noted that a woman in the recumbent position was deprived of both thigh pressure on the walls of the abdomen and uterus and the effects of gravity which act together to decrease the time of labor (Liu, 1979). Further, there is an increased need for episiotomies with the lithotomy position due 29 to the increased tension on the pelvic floor and the stretching of the perineal tissue (Cogan & Edmunds, 1978; Haire, 1972). Liu (1979), applying Newton's law of gravity to the birthing process, indicated that it seems to be more mechanically advantageous to expel a fetus toward earth than along a horizontal plane. Caldeyro-Barica (1979), on research of 370 women, reported that the intensity of uterine contractions and the efficiency of cervical dilatation decrease when women deliver in the lithotomy position rather than in the upright position. Liu (1974), in her research, found that the duration, intensity, and fre- quency of uterine contractions decreased in the recum- bent position and that the second stage of labor was longer for women who delivered in the lithotomy position than for women who delivered in the upright position. Hugo (1977) stated that due to the abnormal stretch created by the use of stirrups, the lumbar curve of the back is not supported and a high incidence of back strain occurs when the lithotomy position is utilized for labor and delivery. Further, prolonged pressure from stirrups and straps may cause thrombosis in leg veins, damage the perineal nerves, and cause temporary, but painful leg cramps (Bryant & Danfortn 1977; McKay, 1980). Yet another disadvantage of the lithotomy position 30 is the inability of the patient to respond appropriately to sensory input. During the second stage of labor the activity of birth attendents surrounding the labor- ing mother greatly increases. The woman is basically unable to change her position due to the use of stirrups or leg supports and thus cannot visualize most of the activity that is occurring around her. The woman can hear sounds related to the activity but without the visual input, she is unable to appropriately interpret the meaning of the sounds. Activity at the delivery end often proceeds as if the patient were not conscious. According to McKay (1980) this inability to move creates a psychological deficit. Assuming that many women desire active involvement in the complete birth experi- ence, the limitations imposed by the lithotomy position may result in feelings of frustration and/or disappoint- ment with the birth process (Jordan, 1980; McKay, 1982). The patient's control of the birth is decreased and ultimately the mother's responsibility for the birth is relinquished to the physician. The mother does not give birth: the physician delivers the infant (Sparks, 1981; Jordan, 1980). A summary of the advan- tages and disadvantages of the lithotomy position in relation to physiology, provider and patient are pre- sented in Table #1. 31 Table 1 Advantages and Disadvantages of the Lithotomy Position Advantages Disadvantages Provider Easy administration of NONE medications . Easy forceps application . Easy episiotomy creation and repair . Asepsis easy to maintain . Patient perceived as passive U‘b MN H Patient 1. Able to be passive and l. Decreases control over uninvolved if desires birthing process 2. Shifts responsibility for the birth to the physician 3. Decreases use of senses Physiologic NONE l. Postural shock 2. Backache and back strain 3. Unnatural pushing position 4. Decreases uterine activity 5. Potential for thrombosis, nerve damage and leg cramps (use of stirrups) 6. Potential aspiration of vomitus 7. Abnormal perineal stretching 8. Frontal lobes of fetal head receive most pressure from uterine contractions 9. Potential acid-base dis- turbances that lower fetal ph and stress fetus 32 Upright Position The term physiologic position has been used by many authors to indicate positions that vary from semi- upright (head elevated 30 degrees) to squatting, kneel- ing, sitting, or standing erect (McKay, 1980; Howard, 1958; Hugo, 1977). Although the term physiologic posi- tion has many variations, it is clear from the literature that some type of upright, non-recumbent, position is assumed. As early as 2500 B.C. the physiologic position was used for childbirth (Atwood, 1976). This fact is known because of the existence of primitive birthing stools (Atwood, 1976). Naroll, Naroll and Howard (1961) indicate that even today in non-European soci- eties, uninfluenced by modern Western medical practices, women normally assume some kind of upright position for childbirth. Over the centuries the "posture aids," as Atwood (1976) describes the birthing stool or chair, have been modified, adapted and modernized until the models used today include electronic height and posi- tion control. The principles behind the use of the upright position for delivery, however, remain unchanged. The upright position has many advantages. Research done by Caldeyro-Barcia (1979) identifies that in the upright position, the synergistic effects of gravity in combination with uterine contractions and efficient 33 use of the abdominal muscles produce more effective bearing-down efforts. Caldeyro-Barcia (1979) further states that contractions in the upright position are more efficient than in the recumbent position by 1.7 to 1.9 times. Liu's (1974) research indicates that in the upright position, contractions lasted a mean of 6.52 seconds longer, were 10.01 mmHg. more intense, and occurred at a frequency of 0.40 more contractions per 20 minute period as compared to contractions in the recumbent position. McKay et a1. (1978) quote Ehrstrom's research that identifies enlargement ranging from 0.5 to 1.5 cms of the pelvic measures in the maternal sitting position. Use of the upright position, then, actually facilitates slight enlargement of the birth canal. The increased effectiveness of the contractions, the increased efficiency of bearing-down efforts, and the increased pelvic measures in the upright position act together to shorten the second stage of labor and, thus, decrease fatigue, increase feelings of accomplishment, and in- crease active participation and involvement by the woman in the birthing process (McKay, 1980; Hugo, 1977; Caldeyro-Barcia, 1979). McKay et a1. (1978) and Hugo (1977) further report increased patient comfort in the upright position and a decreasd need for pain relief via medication. Further, 34 in the upright position the need for episiotomies decreases, probably because the perineum is able to stretch more naturally in response to the descent of the fetal head (McKay, 1980; Hugo, 1977). Liu (1979) indicates that in the upright position, the major force from the uterine contractions is placed on the occipital lobes of the fetal head. These lobes are laid down early in fetal development and, thus, are older and stronger than the frontal lobes that receive the greatest amount of pressure from uterine contrac- tions in the recumbent position. Finally, the upright position allows the woman full use of her senses. She is able to see, hear, and integrate what is happening around her. The patient is able to retain some measure of control and assume the major portion of responsi- bility for the birth (McKay, 1980). The disadvantages of the upright position are primarily experienced by the provider. Notelovitz (1978) states that in the upright position, it is difficult to "control" the birth process, administer analgesics or anesthetics, apply forceps, and create and repair episiotomies. The literature to date has not identified any physiologic disadvantages to the patient. It is possible, however, that some may exist. Local clinical specialists report increased fetal bruising and perineal edema following delivery in an 35 upright position (Bays & Curtain, 1982). These obser- vations, however, have not been substantiated by formal studies or research, nor mentioned in the literature. In sum, by contrast with the lithotomy position, the advantages of the upright position are related to the patient and the disadvantages primarily related to the provider (see Table #2). Variables Affecting the Second Stage of Labor A pregnant woman comes to labor and delivery with an individualized background made up of social, psycho- logical, spiritual and physiological factors (Jensen, Benson.& Bobak, 1981). The sum of these factors plus the birthing environment determine the process and outcome of the birth experience. Realizing that the woman functions based on an interaction of all of the above spheres, it is inappropriate to assume that any one aspect of her environment or make-up independently influences the length of the second stage of labor. With this understanding, identification and discussion of some of the variables that may affect the length of the second stage of labor will follow. Controlled Variables (See Table 3). Medication for analgesia and anesthesia has an effect on uterine activity. Lowensohn et a1. (1974) states that there is a definite depression of uterine activity after 36 Table 2 Advantages and Disadvantages of the Upright Position Advantages Disadvantages Provider 1. Electronic controls to l. Difficult to administer adjust height and position analgesics or anesthetics as needed 2. Difficult to "control" 2. Actively involved patient birth process 3. Difficult to apply forceps 4. Difficult to create and repair episiotomies Patient 1. Increased ability to l. Necessitates active actively participate in involvement on the part the birth of the patient 2. Retains responsibility 2. Decreases use of medica- for the birth tions for pain relief 3. Less medical intervention necessary-~less medica- tion, decreased use of forceps and episiotomies 4. Sensory input appropri- ately integrated Physiologic l. Enlargement of pelvic 1. Possible increase in measures perineal edema 2. Forces of gravity and 2. Possible increase in the expulsion are synergized amount of fetal bruising 3. Shortened delivery time 4. Decreased need for episi- otomies 5. Natural pushing position 6. Longer, more intense, more efficient contractions 7. Pressure from contractions on older, better developed lobes of fetal head Fewer threatening altera- tions in fetal ph due to decreased uterine blood flow 37 Table 3 Controlled Variables Medications Use of Forceps Age Childbirth Education Support Person present during Labor and Delivery Fetal Presentation and Position Pelvic Measurements 38 administration of epidural anesthesia for pain asso- ciated with labor. Haire (1972) and Pritchard and MacDonald (1980) indicate that all regional anesthesia, including pudendal block, inhibit the mother's ability to push the baby down the birth canal and, thus, prolong labor. Position of the fetus in the birth canal also can affect the length of the second stage of labor. Jensen, Benson and Bobak (1981) and Pritchard and MacDonald (1980) indicate that persistent occiput posterior or occiput transverse positions may prolong the second stage of labor and may ultimately result in manual or forceps rotation and/or forceps delivery. Pelvic anatomical problems or abnormal pelvic measurements also can adversely affect the progress of labor (Caldwell & Moloy, 1933; Jensen, Benson & Bobak, 1981; Pritchard & MacDonald, 1980; Willson, Beechan & Carrington, 1975). The adequacy, however, of the maternal pelvis is a more pragmatic descriptor of the possibility of vaginal birth. Adequate pelvic measurements are determined by the size and position of the infant. Normal pelvic measurements are deter- mined by statistical norms. Thus, an adequate pelvis for a particular size infant may not be a "normal" pelvis. The presence of support person(s) for the woman 39 in labor has been identified by Haire (1972) and Sosa et a1. (1980) as positively affecting progress in labor. A support person is defined as a person whose function is to remain with the mother as a lay helper throughout the labor and delivery (Jensen, Benson.& Bobak, 1981). The support person is traditionally a family member or close personal friend. When the woman in labor is separated from her family and/or friends, maternal fear and anxiety are elevated (Haire, 1972). One of the striking results Lederman et a1. (1978) report in their research is that in the presence of maternal anxiety, there is an increased flow of epinepherine which lowers uterine contractility and potentially prolongs labor. An additional variable affecting the length of labor is childbirth education. Women who have partici- pated in childbirth classes tend to have better control of their fears and anxiety level. Haire (1972) cites a Canadian study that demonstrated that women who were prepared for participation in the birth process tended to experience shorter labors. Due to the physiological changes that occur as the body ages, it might be expected that the age of the woman could affect the length of labor. The lit- erature to date, however, has not dealt with age as a factor affecting the length of labor except in 40 high risk groups, i.e., women under 16 years of age and 35 years of age and older. Women in these age groups will not be included in this study. A variable that clearly needs to be controlled is the mechanical extraction of the infant from the vagina via obstetrical forceps. Pritchard and Mac Donald (1980) validate that this obstetrical inter- vention, i.e., the use of forceps, changes the normal length of the second stage of labor. Intervening Variables (see Table 4). Research has been done on how the length of labor is influenced by the stage of labor (1st or 2nd) in which rupture of membranes occur. Lynaugh (1980) analyzed several studies in which this problem was addressed. Conflict- ing and inconclusive results are reported in the review, leading to the conclusion that at this time it cannot be definitively said that Ehep the membranes rupture affects the length of labor. Race is another variable that has been studied in relation to the length of labor. Duignan (1975) demonstrated that the progress of the first stage of labor was identical regardless of race. Research results have subsequently been published that support these findings (Thom, Chan & Studd, 1979). The use of fetal monitoring must also be con- sidered as a variable possibly affecting the length 41 Table 4 Intervening Variables Rupture of Membranes Race Marital Status Episiotomy Use of Fetal Monitors Lacerations Type of Physician Own or On-call Physician Type of Childbirth Education Weight Gain 42 of labor. Buchan (1980) and Roux (1976) demonstrated that anticipation of internal fetal monitoring can be a significant source of emotional stress and anxiety to the laboring woman. As early as 1955 Garcia and Garcia (1955) identified that fearful patients had longer labors and more epinepherine-like substances in their blood. Patients with the highest serum epini- pherine levels also experienced labor inertia. More recently, Lederman et a1. (1978) looked at this same issue. Working with women in labor iden- tified as having ”higher anxiety levels” they found that women with high anxiety levels had increased levels of ephinepherine and subsequent poor progress in labor. Thus, it would be logical to conclude that anticipation of internal fetal monitoring can cause anxiety, result- ing in a longer labor. Obesity has long been thought to affect labor adversely and to be associated with a variety of serious complications during pregnancy, labor, and delivery (Pritchard & MacDonald, 1980). Gross, Sokol and King (1980), however, found no significant differences in the length of labor in obese, (90+Kg.), and normal weight patients. Cogan and Edmunds (1978) indicate that a high percentage of women who deliver in hospitals have episiotomies performed. Since this procedure enlarges 43 the outlet of the birth canal, it shortens the second stage of labor (Cogan & Edmunds, 1978). There are many other factors of interest to these researchers that have not been addressed in the literature. Although no direct relationship to the length of the second stage of labor has been previously identified, the following variables were included in these studies to provide further research issues and questions. They are: the amount of weight gained during pregnancy, the marital status of the patient, lacerations, the type of physician from whom the patient received care, whether the patient was delivered by her own physician or a physician "on-call" and the type of childbirth education classes taken. In sum, several variables, other than birthing position, have been identified as affecting the length of the second stage of labor. The variables identified as controlled variables have been shown by research to affect the length of the second stage of labor. The present studies will focus primarily on birthing position, although data will be collected on the intervening variables identified. In addition, data will then be collected on several demographic descrip- tors that will be used to further describe the characteristics of the samples (see Table 5). 44 Table 5 Demographic Descriptors Age Occupation Type of Insurance 45 Comparison betwen Lithotomy and Upright Position When we look at the relationship between the lithotomy position and the second stage of labor, several conclusions can be drawn. First, the lith- otomy position is an unnatural position for the pushing process that is necessary for expulsion. The woman, flat on her back, is pushing without the added assistance of gravity. The inability to push effectively often creates the "need” for the use of forceps. The application of forceps necessitates some type of regional anesthesia, thereby further decreasing the woman's ability to push effectively (Haire, 1972). Given the lithotomy position, the inability to push effectively, use of forceps and subsequent need for regional anesthesia, the "natural” length of the second stage of labor may be altered. Because the length of the second stage may be altered, forceps assisted deliveries will not be included in the present studies. A second conclusion concerns a decrease in the intensity and efficiency of uterine contractions which occurs in the lithotomy position as compared to an upright position. The change in uterine function adds to the length of labor (Caldeyro-Barcia, 1979; Liu, 1974). Third, the active involvement in the birthing 46 process and ultimately the responsibility for the birth itself, are given up by the woman due to the psychological and sensory deprivation that occurs in the lithotomy position. In summary, the lithotomy position tends to ham- per the normal physiological processes necessary for birth; it decreases the woman's active involvement and increases the opportunity and need for medical intervention in the second stage of labor. In contrast, use of an upright position creates a more natural position for pushing. The impact of gravity coupled with uterine contractions and the use of abdominal muscles, synergize to create effective bearing-down efforts. The ability of the woman to push effectively can greatly alter the length of the second stage of labor (Caldeyro-Barcia, 1979). Uterine contractions are longer, more intense, and more efficient in the upright position as compared to the lithotomy position (Liu, 1974, 1979). These increased uterine effects, added to the synergistic effects of the bearing down efforts, act together to decrease the length of the second stage of labor. The productive bearing-down efforts also tend to decrease the need for pain relief and decrease the use of forceps (Hugo, 1977). Last, but equally important, is the ability of 47 the woman in the upright position to be actively in- volved and maintain some control and responsibility for the birth. Sensory input is appropriately inte- grated, fear and anxiety of the unknown is decreased due to the ability to see what is going on, and thus, c00peration is enhanced leading to a shorter second stage of labor. The upright position then aids the normal physio- logic processes of expulsion, increases the woman's active involvement and responsibility for the birth, and decreases the need for medical intervention in the second stage of labor. Florence Nightingale's Theory of Nursipg An explanation of Florence Nightingale's Theory of Nursing will now be presented and a discussion of how this research is derived from her concepts will be explored. The "core concept" of Nightingale's theory is the environment (Torres, 1980). Nightingale's emphasis on the physical environment is not surprising given the war situation that existed at the time of her writing. Nightingale's activities occurred during a crisis situation for her countrymen. She needed to respond in a way that would give rapid and widespread results. It then follows that her emphasis would be 48 on the physical environment, where the conditions were blatently destructive to health. The environ- ment of the patient was broadly encompassing and although Nightingale did not specifically identify the psychological and social environments as being distinguishable from the physical environment, she addressed all three in her practice of nursing (Torres, 1980). Murray and Zentner (1975) stated that the environment, as defined by Nightingale, is "all external conditions and influences affecting the life and development of an organism and capable of preventing, suppressing or contributing to disease or death" (p. 149). Only when the physical environ- ment is cared for can the psychological (emotional) and social environments be directly addressed (Torres, 1980). The three components, however, must be seen as interrelating rather than as separate, distinct parts (Torres, 1980). This interrelatedness is echoed more currently in Maslow's Hierarchy of Needs, in which he posits that physical needs must be ful- filled before psychological and social needs can be addressed (Maslow, 1954). Maslow and Nightingale would both support the idea that one must first meet the physical needs and the needs of the physical environ- ment before the psychological and social needs can be addressed directly. 49 The goal of nursing for Nightingale is to create an environment in which patients heal themselves, that is, to assist patients to maintain their vital powers so that they are able to meet their own needs (Torres, 1980). Nursing is distinct from medicine and is a non-curative, interventionist practice (Torres, 1980). Nursing assists the patient to maintain a proper environment in which nature can act and the body can heal itself (Nightingale, 1859). To implement Nightingale's theory, then, one must focus on adjustments or alterations in the environ- ment (Torres, 1980). Nightingale was a strong proponent of human rights and strongly objected to man being used as a "passive pawn" controlled by another individual (Palmer, 1977). She stressed reliance on observa- tion, fact, and experience in order to validate needs and inveighed against reliance on conventional practices (Palmer, 1977). Nightingale has been des- cribed as "a 'herald of revolt' against the barriers of convention, both in thought and conduct" (Palmer, 1977, p. 85). The key point in Nightingale's theory is the relationship between the patient's condition and the patient's nature (Torres, 1980). By altering the ten physical environmental variables Nightingale 50 identifies, (see Table 6) the nurse creates the proper situation in which nature can act to preserve health and prevent disease and injury (Given, 1981). If the physical environment is cared for, emphasis on the psychological and social environment will necessari- ly follow. For example, if a pregnant woman is allowed to assume an upright position instead of a recumbent position for the second stage of labor, it will be necessary for the provider/s to relate to the woman as a whole entity rather than a "reproductive process." By altering the physical environment (changing the birthing position from recumbent to upright), a change has also occurred in the patient's psychological and social milieu. Although Nightingale never directly identified a spiritual environment in her theory, Palmer (1977) speaks of her as a proponent of the modern concept of "wholistic man." In this sense, then, for Night- ingale the spiritual dimension can be said to be the patient's condition and nature which reflect his or her value system. These research projects are a logical extension of Nightingale's Theory of Nursing. The authors are surveying the physical environment, more specifi- cally, the position used for giving birth, and how the position used affects the length of the second 51 Table 6 Nightingale's Environmental Variables Cleanliness Ventilation Air Light Noise Water Bedding Drainage warmth Diet 52 stage of labor. The research question in Nightingale's terms is: If the birthing position is altered from the traditional lithotomy position to an upright posi- tion, will a better environment be created in which nature can act to preserve the health of the mother and infant? Since use of the lithotomy position is rooted in tradition and not based on research or scientific principles, Nightingale's theory supports the authors' systematic investigation of this position. The lithotomy position has also altered the view of child- birth from one of a natural process to one which be- comes more pathologically oriented. The lithotomy position creates a situation in which medical inter- vention is easily instituted and often needed in order to complete the birth process. In the lithotomy posi- tion, the environment is such that nature cannot fully act to preserve health. Intervention decreases the woman's responsibility for and control of the birth and makes her a "passive pawn" controlled by the phy- sician. Nightingale's views on human rights would conflict with this dehumanization of the woman. The upright position combines the scientific principle of gravity and the physiologic forces of the uterine contractions and the abdominal wall muscles. This synergistic effect creates effective bearing-down 53 efforts which in turn propels the fetus down and out the birth canal, a natural process (McKay, 1980). Use of the upright position does not create a situa- tion that is conducive to easy medical intervention with forceps and/or anesthetics. In contrast, the need for such medical intervention is decreased because of the productive pushing efforts. By freeing the woman from the delivery table (the lithotomy position) and using the upright position, the physical environment is altered. Following the principles laid down by Nightingale, it is the researchers' proposition that this environmental change creates a better condition in which nature can act. With an alteration in the birthing position, the psychological and social environments may also be altered. The woman experiences less fear and anxiety, is more actively involved as a participant in the birthing process, and is better able to inter- pret sensory input. These research projects follow Nightingale's Theory of Nursing by examining two alternative posi- tions as part of the physical environment, and asks, Does one position allow nature to act better than the other? Either environment examined may have a direct effect on the pyschological, social and spiritual environments of the woman. The way in which Nightingale's 54 theory was adapted and utilized as a basis for these research projects is depicted in Figures 1 and 2. 55 Figure 1. The Role of Nursing ADAPTED FROM NIGHTINGALE’S CONCEPT OF NURSING To Help Patients Suffering From Disease Live Healthy I _ In Condition For Nature to Act To II Restore Health Cure Disease I Preserve Health Prevent Disease and Injury 56 Figure 2. Variables Affecting Birth and the Environment LABOR Physical Environment (position) Nursing Intervention 'Age *Forceps *Medications 'Fetal Position 1'Fetal Presentation 'Support Person 'Maternal Anatomy *Childbirth Education Fetal Monitor Use Rupture oi Membranes Race Weight gain Obesity Episiotomy — O ~ ’ v \ Patient Condition o' and Nature b-I-II Psychological Spiritual Social Environment Environment Environment ,- <1 BIRTH ADAPTED FROM NIGHTINGALE’S CONCEPT OF NURSING °Theee Variables were Controlled CHAPTER III LITERATURE REVIEW* Introduction The literature discussed in this chapter is organized into six topic areas. First, the litera- ture related to the trends in childbirth practices in the United States is reviewed followed by cross- cultural birthing practices. Next the literature from professional and lay sources related to current consumer trends is critiqued. The general references that are used to define the concepts of second stage of labor, uncomplicated pregnancy and primiparous women are then discussed and evaluated. Presented next is a review of the literature related to the key concept of these theses, birthing position. Finally, the literature that addresses several controlled variables and intervening variables and their relationship to the length of the second stage of labor is presented. This literature review directed the development of the instruments used to screen charts and collect data in these studies. *This chapter is written in collaboration with Barbara Taylor Sparks. 57 "K. 58 Trends in Childbirth Practices in the United States In the early 19003 most births occurred in the home. Today, by contrast, almost all births occur in hospitals amid a plethora of technology. To under- stand this transition, it is important to trace its historical roots. The purpose of this section is to present a brief discussion of the trends in childbirth practices in the United States. In the mid 19703 numerous articles began to appear in scientific journals, identifying historical practices and current trends in obstetrical care. Two classics of that period are Atwood (1976) and Haire (1978). Atwood's approach is an extensive review of previous anthropological and physiological discussions and re- search pertaining to birthing position. He relates this previously published literature to past culturally patterned behavior and draws conclusions about the meaning of the birth event. Atwood concludes that birthing posture is determined by cultural norms and that there is no one ”correct" birth position. He further states that the female body has been shown to be adaptable to many positions and cultural practices. Atwood's meticulous review, published in 1976, appears to be the foundation for numerous subsequent articles and research on this subject. One such article by Hugo (1977) reviews three currently used birthing 59 positions and the rationale for their use. Hugo iden- tifies the lack of current research justifying the use of any of the positions. Use of the lithotomy posi- tion evolved for attendent convenience at the beginning of the 19th century and since that time has become a cultural norm within this country. The routine use of lithotomy position in the United States differs from birth positions used in most other cultures. Hugo feels that women's comfort and ability to participate have not been considered by practitioners whose patients use the lithotomy position and suggests that this issue bears further examination. Hugo's conclusions concerning culturally determined birthing positions support Atwood's, and thus lend credibility to both authors work. The other classic work of the 19703 is Haire's The Cultural Warping of Childbirth. In contrast to Atwood's somewhat physiologic approach to birth practices, Haire approaches the history and development from a sociological perspective. She identifies trends in childbirth practices from the early 19003, as does Atwood. She then focuses on emerging technological advances, their meaning to the populous and medical community, and their integration into obstetrical prac- tice. Haire carefully reviews changing norms and approaches to patient care in the field of obstetrics. Among those changes identified are the transition from 60 an upright to a recumbent position for birth, use of routine episiotomies, and an increased use of medi- cations in labor. She concludes, in agreement with Hugo, that many practices have been integrated into routine hospital procedures, despite the fact that they have not been supported by scientific research. In reviewing Haire's thorough and important contribu- tion to the clarification of childbirth practices, one must recognize that Haire was affiliated with the International Childbirth Education Association (ICEA) at the time of 1mm“ publication. This organization is committed to "educated parental participation and decreased obstetric intervention in uncomplicated labors" (ICEA Review, 1978). Given the commitment of the organi- zation that commissioned Haire to write this review, the work could be viewed by some as biased. Despite this potential bias, few articles were published in the next few years on the subject of birth practices in the United States that did not refer to the issues presented in Haire's work. A purely historical perspective on birthing practices in the United States is supplied by Devitt (1977). In his discussion he provides statistics related to maternal and perinatal mortality and morbidity. He also presents past legislation enacted that directly or indirectly affected obstetrical care. Although 61 the focus of this article differs from others previously discussed, the trends of increased technological and medical intervention in birth are consistent with those presented by Atwood and Haire. Several years after the Haire and Atwood articles were published, many other articles on the same subject began to appear. In all of them, a brief historical perspective was provided (Caldyro-Barcia, 1979; Dye, 1980; Roberts, 1980; McKay, 1980; Naroll, Naroll & Howard, 1980). They all consistently identify the trend from home to hospital birth in the early 19003 that occurred when female midwives were replaced by male physicians as birth attendents. The advent of physicians delivering in hospitals marked the change in the perception of birth from a normal process in which limited intervention was necessary to an event that necessitated both physician attendence and tech- nological intervention. Interestingly, although the professional back- grounds of the authors reviewed are widely divergent, i.e. Atwood--anthropologist, Hugo--nurse midwfie, Devitt-- B.A. biology, Haire--consumer, and although their approaches to the topic of birthing practices are varied, they all arrive at similar conclusions. These authors present various examples of the trend from home to hospital birth, and the increased use of 62 technology that seems both a cause and a result of hospital birth. The trends cited are all consistent and also confirm previous information presented by Atwood and Haire. A factor identified by all authors mentioned above is that many current obstetrical practices are routed in tradition, and have not been based on the results of scientific inquiry. One such practice is the use of the lithotomy position for the second stage of labor. This use of the lithotomy position, and current consumer dissatisfaction with it, provided the impetus for the current studies. Cross Cultural Birthing Practices Both the health status of a population and a society's response to problems of health are shaped by the socioeconomic and political organization, as well as the culture of the society. To understand what is unique to one health care system vis-a-vis another, as well as to suggest possible future directions for change in our system, it is important to compare the birthing practices in other cultures to our own. The purpose of this section is to describe birthing positions used in countries other than the United States. In 1961 Naroll, Naroll, and Howard examined 104 reports of anthropologists, government officials, 63 missionaries and other ethnographers ”from a sample of 75 non-European societies" chosen from the Human Relations Area Files (HRAF) (p. 953). The HRAFs are made up of multiple diverse studies from different countries. They are a compilation of ethnographies ranging over time, and gathered by researchers from different backgrounds with various degrees of knowledge concerning the research process. Thus, different and non-standardized methods have been used in collect- ing and analyzing data. The authors found in their search that in most non-European societies examined, women normally used an upright position for childbirth. Although Naroll, Naroll, and Howard (1961) did not control definitions and methods, they did attempt to evaluate the data collection process and content for random error or bias and found none that were statistically signifi- cant. While this work is not offered as a scientific study, it would seem that the consensus of the report is worth noting; some form of upright position is used for birth in many countries. Notelovitz (1978) and McKay (1978) report the same findings as Naroll, Naroll, and Howard (1961). They found that in countries that have not been influ- enced by Western medical practices and technology, women assume some kind of upright posture for birth. 64 Stanton (1979) provides a sampling of observations made by social scientists and physicians who have wit- nessed birthing practices of people in "traditional" societies. She also found a wide variety of positions used for birth, and suggested that knowledge and under- standing of this variety "might add perspective and create flexibility within our own cultural practices” (p. 925). Consistent with authors previously discussed, Jordan (1980) in Birth In Four Cultures identifies frequent use of some form of the upright position for birth in the Yucatan and Holland. Jordan discusses in depth the concept that individual cultures justify their birthing practices as superior to others without necessarily objectively evaluating them. Thus, cul- tural justification limits the exploration of old or new potentially useful birthing practices. Through extensive use of participant observation, Jordan pro- vides data related to birthing practices in four countries. She then presents the significance of these practices within the context of their cultural milieu. Jordan's work is provocative and valuable as it provides a unique perspective from which one can view birthing practices. She posits that because of the cultural acceptance of currently used practices, a system evolves in which tradition dictates, and 65 alternative practices are few. The use of the lithotomy position for the second stage of labor is one such culturally dictated practice in the United States. In sum, all of the literature previously dis- cussed identifies the routine use of some form of the upright position for the second stage of labor in many societies. Nevertheless, no literature was found that correlates any birthing position with maternal or fetal outcome. So, while it is known that the upright posi- tion is commonly used in many societies, it is not known how the use of this position effects the birthing process. Consumer Issues To understand consumers' dissatisfaction with current birthing practices in the United States, a selected review of the literature was conducted. It is apparent that within the last 15 years, consumers in the United States have become increasingly critical of "routine" birthing practices. In addition to cri- ticizing the established practices, consumers also are exploring possible alternatives. In this section of the chapter, articles written by consumers and articles written about consumers by health care pro- viders are examined. One of the earliest products of the feminist 66 movement in the 19603 is a book published by the Boston Health Collective (1979). The focus of this book is self help. Assuming that women desire more control over their bodies and their health care, the book was written to provide women with facts, information, and methods for enlightened self care. The significance of this work is that it was one of the earlier consumer activist publications that encouraged and assisted women to assume more control over their own health care. Two other well known books, Immaculate Deception by Arms (1975) and The Hidden Malpractice by Corea (1977) are openly critical of current obstetrical norms and practices. Both Arms and Corea discuss how active involvement and responsibility for the birth process are inappropriately transferred from the woman to the physician. Further, Arms states that physician inter- ference in normal childbirth degrades women and en— dangers their babies. Arms and Corea present scenarios of hospital experiences involving medical intervention. Arms, more than Corea, draws conclusions about current birth practices, based on actual, but atypical, birth experiences. The importance of these two books is that they are widely read by consumers and when these same consumers negotiate for obstetrical care, they do so with a higher awareness of controversial issues, 67 i.e., routine episiotomies. Numerous articles have appeared in newspapers, lay magazines and lay journals that advocate and report variations in routine childbirth practices (Clark & Gosnell, Newsweek, 1981; Kaplan, "Family Weekly", Lansinngtate Journal, 1982; Nolan, Health Care News, 1982; Otten, Saturday EveninggPost, 1982; Gilette, Ethicon, 1982; Norwood, New York, 1982; Greene, Country_Journal, 1983). TOpiCS addressed range from birth position and use of the birthing chair to nurse or lay midwives as birth attendents. If one looks at the difference in reader appeal between New York Magazine and the Family Weekly supplement of the Lansing State Journal, it is clear that the subject of birthing alternatives appeals to multiple segments of the population. Michelle Harrison, a physician in advanced training, has written a book, A Woman In Residence (1982) aimed at consumer readership. In her book, Harrison has shared with the reader her increasing frustration with the humiliating way that traditional medical practi- tioners treat women. Harrison reiterates Corea's state- ment that many physicians demean and often act disrespect- fully toward female patients. Support for Harrison's opinions are illustrated in her book by specific examples, many of which relate to birthing practices. The book 68 is clearly aimed at consumer readership by virtue of both the language used and the publishing house from which it was printed. Discussions of consumer dissatisfaction with birthing practices are also increasingly evident in scientific journals. One such article by L'Esperance (1979i published in a major nursing journal, contains a discussion of the increased movement toward home birth as a manifestation of the consumer's "healthy aggression.” L'Esperance contends that this behavior develops out of a perceived threat to a woman's autonomy and self control that is imposed by present maternity care and suggests that one method of decreasing this threat is to allow the patient to select childbirth options. The nurse, according to L'Esperance, can therapeutically intervene by facilitating communication between the consumer and physician. The importance of this article is that it raises provider awareness of the reasons for consumer behavior and identifies nursing interventions to help consumers more effectively communicate with providers. In addition to provider discussions of consumer wishes surrounding the birth process, research has been done to measure scientifically expressed consumer satisfaction with current birthing practices. One such study by Pridham and Schutz (1983) is a major H 69 and unique contribution to clarifying parental goals relative to the birthing experience. The study was done to "assess to what degree the providers involved were giving obstetric care that was oriented to family goals" (p. 15). A research group composed of nurse clinicians, family practice residents, faculty physicians and staff nurses from a midwestern university conducted a survey using a retrospective self-reporting approach. The survey was designed to evaluate parental goals, plans, and evaluation related to their birthing experi— ence. Two specific areas were addressed: plans made, accomplished or not accomplished, and parental wishes for the next birth experience. The participants in the survey were obstetric families receiving care from the department of family medicine at a university hos- pital. A 158 item questionnaire was developed by the research group based on their literature review and their own experiences. The content validity of the questionnaire was established by consensus of the re- search group, and the tool was pilot tested on 10 families. The questions asked addressed five areas of previously expressed concern surrounding the birth experience. One such area was desire for alternative labor and delivery positions. The questionnaire con- sisted of 80% check-list or Likert scale items and 70 20% open-ended questions. The open-ended questions were coded by two people with an interrater reliability of 89.6%. Of the 149 questionnaires that were sent to families having delivered within the last 13 months, 91 (61%) were returned. Background variables such as parity, age, marital status and attendance at child- birth classes were reported. Frequency tables were used to display the results as absolute frequencies and as percentages of the sample. Pridham and Schutz concluded from their results that most parents had the experiences that they wanted in the birth process and primarily desired more infant- family interaction following birth. Of particular interest to these studies is the data that indicated 3% of the sample planned to use alternative birthing positions but could not, and 11% would like to try an alternative position with subsequent deliveries. The data also indicated that 23% of the sample would like to deliver in a labor/birthing room next time. While the overall percentages are small, of sig- nificance is the disparity between the percentage of families who desire an alternative position (11%) and the percentage of families who would like to deliver in the labor/birthing room (23%). It is unclear what this inconsistency means for the following reasons. First, what questions were asked and how were they 71 phrased? If the question asked was: Would you rather sit up or lie down to have your baby?, the response elicited might be different from that obtained if the question had been phrased: Would you like to use an alternative birthing position? Second, what type of question was used to gain this information, open-ended or forced choice? Third, did a few people express the desire for several changes or did several people express the desire for a few changes? In the study by Pridhamand Schutz it is unclear whether the 11% that desire an alternative birthing position are part of the 23% that desire use of the labor/birthing room. It is difficult to interpret the results of any individual category within the data. This difficulty results from the fact that while demographic variables were carefully presented relative to the total group of respondents, there is no information that describes the characteristics of various subgroups that expressed dissatisfaction. For instance, it is unclear whether the people who desired an alternative birthing position were different in any way from those who did not. Given the eight women who had cesarean. section births and the two women who delivered at home, the potential for demographic variability is great. The lack of consistency related to method and location of birth in the research sample can be considered a limitation 72 of the study. The study has other limitations as well. The sample included only patients who went to family prac- tice clinics. These patients may be different from those who seek care from an OB/GYN specialist. Thus, the generalizability of the results is limited. The questionnaires were sent to families that had delivered over a 13 month period. No specific information, how- ever, was provided related to differences in length of time since delivery and reported dissatisfaction. This is important when one considers that women 13 months post partum may have worked through conflicts pertaining to delivery much more thoroughly than women who delivered three weeks prior to receiving the survey. The study indicated that a birthing room became available during the last two months that the survey was conducted. It is unclear how many respondents actually used the birthing room and if this affected their wishes for the next birth experience. Did any of the 23% who wished delivery in a labor/birthing room for the next delivery use it previously, or had they all delivered in the delivery room? This infor- mation is particularly important to the issues con- cerning birthing process but is not available in the article reviewed. Pridham and Schutz also do not state when the data 73 were collected. This information is important because of the increased consumer awareness related to birthing position over the last two years. It is reasonable to speculate that these data could have been collected as long as three years ago, thus indi- cating a lower level of consumer awareness than currently exists. The speculation that the data were collected several years ago is reinforced by the fact that the most current bibliographic reference was from 1978. In sum, did the families in the study know enough about alternative birthing positions to make their responses relevant to clinical practice in 1983? There are many limitations to the study that have been discussed. Nevertheless, it is significant that researchers are beginning to determine scientifically what consumer needs are,with the long term goal of adjusting health care practices to meet these needs if possible. While there is an abundance of lay literature that addresses consumer concerns about the birth experience, there is little research other than the :work of Pridham and Shutz that scientifically evaluates consumer interest in alternatives. Providers dis- regard the consumer demands in the interest of "safe" health care, but are unable to provide the consumer with scientific evidence to support their position. 74 Thus, a schism between consumer wishes and the credi- bility of some routine obstetric practices is estab- lished. In summarizing the literature related to consumer issues, there is consistency between what consumers are writing for consumers, what providers are writing for consumers, and what nurse providers are writing for nurses about consumers. It is important to note, however, that a very small number of nurses are writing for nurses or consumers and furthermore that articles written by obstetricians addressing consumer needs were not found by these authors. The consensus of the articles reviewed in this section was that consumer requests for individualized care and less medical intervention may indeed be reasonable and merit scien- tific inquiry. These findings are of the utmost significance to these researchers as they provide justification for the research questions. That is, is the consumer request for alternative birthing positions a reasonable request relative to the length of the second stage of labor? Having discussed the literature related to trends in childbirth practices in the United States, the litera- ture dealing with cross cultural birthing practices, and the literature that addresses consumer concerns 75 related to birthing practices, literature related to the major concept of these theses is next reviewed. Primipara The definition of the concept primipara used in these studies evolved from a review of medical and nursing text books widely used in this country. In all texts reviewed, the definition of primipara is consistent; a woman who has given birth to her first infant after the period of viability, regardless of whether the child is living at birth (Agnew et al., 1965; Pritchard & MacDonald, 1980; Lerch, 1974; Fitz- patrick, 1971; Jensen, Benson & Bobak, 1980; Olds et al., 1980). Lerch (1974) further defined viability as that of an infant of 25 weeks gestation and beyond. Second Stage of Labor Medical and nursing textbooks were again used to define the concept of the second stage of labor. This stage begins with complete dilatation of the cervix and ends with delivery of the infant. The texts were consistent in their definition (Pritchard & Mac Donald, 1980; Wilkerson, 1973; Olds et al., 1980; Jensen, Benson & Bobak,1980; Fitzpatrick, 1971). Current - researchers in the field of childbirth identify the same definition of the second stage of labor as do the authors cited above (Lederman et al., 1979; Bergsjo 76 & Halle, 1980; Bergsjo, Bakketeig & Eikom, 1979). Uncomplicated Pregnancy While reviewing the literature to formulate a definition of uncomplicated pregnancy, it became clear that the concept is indirectly defined by stating what it is not. In other words, the absence of the follow- ing abnormalities of pregnancy indicate an uncomplicated pregnancy: toxemia, pre-eclampsia, eclampsia, diabetes mellitus, heart disease, renal disease, age less than 16 or greater than 35, chronic hypertension, chronic lung disease, multiple births, breech presentation, incompetent cervical os, bleeding in the 2nd or 3rd trimester, and abnormal fetal position. The literature reviewed on this subject were well known and accepted medical and nursing text books (Pritchard & MacDonald, 1980; Isselbocker et al., 1980; Juhasz, 1973; Lerch, 1974; Leitch & Tinker, 1978; Olds et al., 1980; Jensen, Benson & Bobak, 1980). BirthingiPosition The literature reviewed relative to birthing position can be divided into three categories: those articles that define specific birthing positions, reviews and discussions of various birthing positions, and research based articles on birthing position. Naroll, Naroll and Howard (1961) identify definitions 77 of the lithotomy and upright position that have been used consistently over the last 22 years. These definitions are used in the current classic discussion on birthing positions by Atwood (1976) and more recently by McKay (1980), a nurse researcher involved inter- nationally in issues related to childbirth. Liu (1974) refined Naroll, Naroll & Howard's definition of the upright position, for the purpose of her own research on the effects of an upright position during labor. Liu's refined definition is as follows: A woman is in an upright position when the line connecting the 3rd and 5th lumbar vertebrae is greater than 30° from the horizontal plane. This definition has practical application in a research context, as position can be more consistently labeled either upright or recumbent. Although Liu created a definiton of upright that is easily measured, no mention was made in her article about how the definition was established. Indeed, nothing was found in the literature that validated a definition of any specific position. It has merely been assumed that the definition is adequate. A definition of the lithotomy position, in the cultural context of the United States, is addressed by Miller and Keene (1972) and Atwood (1976). That is, the lithotomy position is described as the woman lying on her back, legs flexed on thighs, thighs flexed 78 on abdomen and abducted. The same definiton of lithotomy position is consistently found in the most recent medical and nursing text books (Pritchard & MacDonald, 1980; Jensen, Benson & Bobak, 1981). The definition of lithotomy position was further refined by Liu (1974). Liu stated that a woman is in a lithotomy position when the line connecting the 3rd and 5th lumbar vertebrae is less than 30° and the patients thighs are flexed on the abdomen with the legs abducted. In addition to articles that primarily define birthing positions, many articles discuss use of posi- tion and the effect on various aspects of labor. Hugo (1977) and Atwood (1976) provide a literature review and discussion of several birthing positions. In these articles the authors provide information related to the physiologic effects of the upright and recumbent position on labor. Hugo presents a concise summary of these issues while Atwood presents a comprehensive and detailed examination of past and present litera- ture on the subject. Despite the differences in approach, these two authors agree on the relative ad- vantages and disadvantages of both the upright and recumbent position and conclude that the upright position is more advantageous to the mother and fetus, but less convenient for the attendant. This issue 79 of attendent convenience is supported in the discussions presented by Gilder (1977) and Andrews (1980). While Hugo and Atwood discussed the lithotomy and upright position, McKay (1978) and Liu (1979) focused exclusively on the advantages of the upright position. In addition to supporting each other's conclusions, McKay's and Liu's conclusions are consistent with the earlier work done by Hugo (1977) and Atwood (1976), thus lending credibility to all the authors' works. Russell (1982), as early as 1969, identified specific numerical increases in the anterior-posterior and transverse pelvic diameters in the upright position. These values were determined through the use of x- rays during labor. Ehrstrom's work,as reported by McKay (l978),again using x-ray, also found increased pelvic diameters in the upright position. Since Russell and Ehrstrom established the presence of increased pelvic diameters in the upright position, it would seem to follow that progression through labor is faster in the upright position. Indeed, Liu (1979) and Roberts and Mendez-Bauer (1980) report that women who used an upright position had a shorter labor. They did not attribute this shorter length of labor to increased pelvic measurements however, but rather to a different set of variables, i.e., force of gravity and the more effective use of abdominal and thigh muscles. 80 Despite the fact that for several decades evidence has been available that indicates the physiologic advantages of the upright position, custom.more than scientific knowledge has continued to dictate the recum- bent birthing position (Roberts & Mendez-Bauer, 1980; Nobel, 1981; McKay, 1978). In sum, many authors have identified advantages of the upright position and several have concluded that one advantage is a shorter length of labor. This advantage, however, is attributed to compatible but different factors involved in the birth process and the upright position. Length of the Second Stage of Labor In the literature search relative to the length of the second stage of labor, few research articles were located that measured this important parameter. One frequently cited article by Hellman and Prystowsky (1963) utilized data from 1937-1945. These data were collected in a retrospective chart review from a major university hospital in Maryland. A sample of 13,377, including multiparas and primiparous women, was used to establish a norm for the length of the second stage of labor. High risk pregnancies, according to present standards, were eliminated from the sample. No mention of birthing position or use of medications during labor was discussed. The results were presented as median 81 rather than mean durations for multiparas and primiparas due to a "skew distribution." Hellman and colleague found that in primiparas the median duration was slightly under 50 minutes and in multiparas the median duration was slightly under 20 minutes. Although the scope of this study was ambitious, it is difficult to assess the meaning of the results because of the way the data were presented. The only graph that plots numbers of deliveries against minutes of the second stage of labor combines primiparas and multiparas. Given this obtuse graphic and the imprac- ticability of presenting raw data due to the size of the study, further analysis of the data becomes limited. Distribution around the median is unknown. Interestingly, the medians established in this dated study continue to be the norms for the duration of the second stage of labor cited in major medical and nursing test books today (Willson, Beecham & Carrington, 1975; Pritchard & MacDonald, 1980; Jensen, Benson, & Bobak, 1981). Since this study is still widely accepted as valid, it is with frustration that these authors note our inability to use this research as a norm with which to compare our results. There are three reasons for this: 1) the distribution curve around the median cannot be compared since it is not available in Hellman and Prystowsky's study, 2) no information on use of 82 medication was presented and drugs were frequently used during that period of time for labor and delivery (see Chapter I and III), 3) position for the second stage of labor is not stated. In looking at current studies that measure the duration of labor, one finds a different approach from that of Hellman and Prystowsky (1963). Rather than just identifying the normal length of labor, current researchers have studied variables that affect the length of the second stage of labor. Of particular interest to these authors are the articles that relate birthing position to the length of labor. Liu (1974) studied the effects of the upright and recumbent positions on labor in sixty primiparous women who received care from OB/GYN departments in two separate cities. Strict psychologic and physiologic criteria were used to determine eligibility for the study. Liu reviewed antenatal records to select subjects. Thirty women were assigned to the experi- mental group and thirty to the control group. Subjects in the study were paired in terms of their sequential admission to the hospitals. The only difference in the groups was the use of the upright position for labor in the experimental group. The investigator collected all the data related to the length of the second stage of labor herself. She found "the first 83 and second stages of labor were shorter among women in the upright position" (p. 2205). The mean value for primiparous women in the upright position was found to be 34.0 minutes, and the mean value for primiparous women in the recumbent position was 74.67 minutes. From this finding she concludes that the upright posi- tion is advantageous for women because reducing the length of labor reduces the danger to the mother and infant. This well organized and conducted study has two limitations. First, the data analysis is problematic. The only data presented related to the length of the second stage of labor are the mean durations in the upright and recumbent positions. No raw scores were presented and no statistical analysis other than the means were reported. A glance at the minimal data shown indicates an impressive difference between the means, i.e., 40.67 minutes. Neither the significance level nor the standard deviation are given. Thus, one is unable to understand the results comprehensively. A second and less important limitation of this study is the level of generalizability possible due to the strict criteria used for inclusion in the study. Therefore, the results cannot be applied to women who do not fit within the study criteria. Given the similarity between the criteria used 84 in Liu's research and that of the present studies, a basis for comparing mean values for the length of the second stage of labor exists. A more thorough comparison of results would have been possible if Liu had published more statistical information about her study. Nevertheless, the lack of other well controlled studies on the length of the second stage of labor makes Liu's the only benchmark available to use for purposes of comparison. In contrast to the well controlled and well con- ducted study of Liu, a study conducted by McManus and Calder (1978) lacks credibility both in design and execution. In their study 40 subjects were divided into four equal subgroups; multigravida women in an upright position, multigravida women in a recumbent position, primigravida women in an upright position and primigravida women in a recumbent position. All subjects were induced. The reasons for induction were not given but were said to be "similar." The lateral recumbent and upright positions were used, but the absence of definitions of the positions makes is unclear how the researchers determined position for the pur- poses of their study. A few parameters of pregnancy were controlled, i.e., no multiple pregnancies or breech presentations. McManus and Calder concluded that there was no 85 difference in the length of labor between the upright and recumbent groups for either multigravidas or primigravidas. These reported results must be examined in light of several significant limitations of the study. First, the small sample size is compromised by its subdivision into four groups. Second, the reasons for induction are stated as being similar, but they are never clearly identified. Three, amniotomy was the initial means of induction followed by oral pros- taglandins for all subjects. In addition, some sub- jects also received IV oxytocin for induction. Thus, not all subjects received the same intervention. Consistency of intervention was also not maintained in relation to ”mode of delivery”: some patients de- livered spontaneously, some had forceps assisted deliveries, and two patients actually had caesarean sections. It is unclear at what point during labor interventions took place and therefore how intervention affected the length of the labor. In the data pre- sented, the length of labor for those who delivered spontaneously vs forceps assisted vs caesarean section are not reported separately. Rather, the raw data are reported as one meaningless mean. Further, the level of significance is not reported. The incon- sistency between the findings of Liu (1974) and those 86 of McManus and Calder (1978) are of minimal concern to these researchers because of the significant limi- tations of the McManus and Calder study. A study often cited by researchers in the field of childbirth is that of Calderyo-Barcia (1979). This study was conducted in 11 hospitals in seven South American countries and was directed by a group of four, including Caldeyro-Barcia. The following conditions were fulfilled by all subjects included in the study: low risk labors, uncomplicated pregnancies, spontaneous onset of labor, normal cervical dilation from 3-5 cms, single fetus in vertex presentation, anterior position, no rupture of membranes prior to onset of labor, no cephalopelvic disporportion, normal pelvis, no medica- tions or oxytoxics. The subjects were randomly selected and matched for gravidity, parity, maternal height and weight, age, and weight gain. Caldeyro-Barcia completed the study with 225 women who used the "hori- zontal" position and 145 women who used the "vertical" position. The results showed that labor from 4-5 cm. dilatation to 10 cm. dilatation was shorter in the vertical position than in the horizontal position by 78 minutes, at the p = 0.006 level of significance. Further increase in the intensity and duration of uterine contractions and a more rapid rate of dilata- tion occurred in the vertical position. The frequency 87 of contractions, however, was unchanged. Unfortunately, evaluation of this study is limited since no raw data are presented and, more importantly, statistical methods were not discussed. Another problem with the study report is that the "horizontal" and "vertical" positions are not defined. Given that this study was conducted in 11 hospitals, located in 7 countries, and directed by 4 people, the potential for differing and inconsistent interpreta- tions of the positions is great. Considering the large scope and detailed plan of the study, one might assume that the positions were specifically defined and consis- tently reported. The article describing the research, however, does not address this issue. A limitation of Caldeyro-Barcia's work that directly relates to these research studies is that he did not evaluate the effects of the two positions on the length of the second stage of labor. Thus, an opportunity to measure the duration of the important second stage of labor, given the tightly controlled sample already selected, was lost. Controlled Variables It has been thought, and in fact substantiated by research, that many variables affect the physiologic process of birth. The literature has shown that the 88 following variables may affect the length of labor and therefore they were controlled in the present studies: use of medications, use of forceps, fetal presentation and position, pelvic measurements, ma- ternal age, childbirth education, maternal complica— tions and the presence of support persons in labor. Medications. A type of medication commonly used to enhance and accelerate labor during the intrapartum period is oxytocin (Haire, 1978; Dutton, 1978). Haire indicated that ”oxytocic agents...are administered to intensify artifically the frequency and/or the strength of the mother's contractions as a means of shortening the mother's labor" (p. 19). This statement is consistently supported by other commonly acknowledged experts in the field of obstetrics (Pritchard & Mac Donald, 1980; Jensen, Benson & Bobak, 1981). Prit- chard and MacDonald (1980) discuss the effects of meperidine, an analgesic commonly used during labor, and conclude that its use may increase uterine activity and thus shorten the natural length of labor. The literature reviewed consistently states that the use of regional anesthesia can result in depression of uterine contractions and thus prolong labor (Jensen, Benson, & Bobak, 1981; Haire, 1978; Pritchard & Mac Donald, 1980). Regional anesthesia is defined as para- cervical blocks, caudals and epidurals. Haire (1978) 89 in her extensive review further states more specifically that regional anesthesia inhibits the mother's ability to push the baby out and thereby prolongs the second stage of labor. Lowenshon et a1. (1974), using a sample of 65, did a highly technical study that measured the change in intrauterine pressure following the injection of epidural anesthesia. The level of uterine activity was evaluated for one ten-minute period prior to intro- duction of the epidural, to establish a baseline. Following introduction of the epidural, uterine activity was measured for three ten minute periods and these results were compared with the pre-anesthetic findings and also with a group of 20 women in the control group who had no anesthesia. The results were as follows: after administration of epidural anesthesia there was marked decrease in uterine activity, which remained below the baseline determinations for thirty minutes. A difference in uterine activity between the experimental and control also existed, and was reported significant at the P §,0.05 level. Lowensohn et al. suggest that the common practice with epidural anesthesia is to give hourly injections to maintain pain control. If medica- tion is added hourly, and uterine activity drops sig- nificantly after each administration of medication, 90 one could conclude that labor would be prolonged when epidural anesthesia was used. The one limitation of this study relates to the method used for determining baseline levels of uterine activity. It is unclear just how these baseline levels were established, even though it is stated that they were done over a ten minute period. Were there contractions occuring during baseline measurement time? If there were uterine contractions, were the heights of the contractions averaged to determine each woman's baseline value? Since not all women were at the same point in labor when the baseline was determined, does this make any difference in baseline determinations? Returning to the original premise that regional anesthesia prolongs labor, the research findings of Lowensohn et a1. seem to support this statement. There- fore, it is important to control medications when study- ing the effects of birthing position on length of the second stage of labor. Forceps. A review of the literature regarding obstetrical forceps indicates that their use shortens the length of the second stage of labor (Pritchard & MacDonald, 1980; Haire, 1978; Jensen, Benson & Bobak, 1981; Clark & Affanso, 1979). 91 Fetal Presentation and Position In the review of major medical and nursing obstetri- cal text books, one finds the commonly held opinion that any fetal presentation, other than vertex, is considered abnormal (Pritchard & MacDonald, 1980; Jensen, Benson & Bobak, 1981; Clark & Affanso, 1979). The literature demonstrates that the result of fetal malpresentation is dystocia, thereby leading to pro- longed labor (Pritchard & MacDonald, 1980; Jensen, Benson & Bobak, 1981). These same authors also report a prolonged labor when the fetus is in an occiput posterior or occiput transverse position. Maternal Pelvic Measurements. As with abnormal fetal presentations and positions, the literature also includes discussion of the relationship between contrac- ted maternal pelvises and dystocia. In an abstract, Caldwell and Moloy (1933) described their study of anatomical variations in the pelvis, the obstetrical significance of these variations and the prognostic importance to the process of birth. As a result of their study, Caldwell and Mcfloy concluded that a pro- longed labor may result when pelvic resistance due to abnormal maternal measurements is encountered. This conclusion, based on Caldwell and Mxioy's original work, has been widely cited in obstetrical texts over the last fifty years (Oxorn, 1968; Willson, Beecham 92 & Carrington, 1975; Jensen, Benson & Bobak, 1981; Pritchard & MacDonald, 1980). Age, A search of the Index Medicus, Cumulative Index of Nursing Literature and the International Index for Nursing Literature produced no citations that deal with maternal age and the length of labor. The only exception to this is relative to the use of age as a high risk determinent (Jensen, Benson 8 Bobak, 1981; Pritchard & MacDonald, 1980). Childbirth Education Beck and Siegel (1980) provide an extensive review of the literature on prepared childbirth and its effect on labor and delivery. They conclude that although research has been done to measure the effect of psycho- prophylaxis on labor, "lethal research errors" (p. 441) inherent in the studies make their conclusions question- able. Nevertheless, Beck and Siegel conclude that it is reasonable to consider childbirth education as an effective means of reducing stress during labor and delivery and that an interface between psychosomatic research and childbirth is warranted. Haire (1978) has also addressed the subject of childbirth education in her review. She indicates that several studies report a decrease in the length of labor in women who are prepared to participate in 93 the birth process. Beck and Siegel (1980) in their reviews come to a different conclusion than Haire (1978) with regard to the effects of childbirth education on labor. In view of these differences, it would seem that in studies related to birthing practices, the variable of childbirth education should be held constant. In so doing, one would consistently control for the effects of childbirth education whatever the effects are ulti- mately found to be. Maternal Complications. The medical and nursing text books reviewed are consistent in the information they contain regarding maternal complications and their possible effect on the length of labor. Due to an increased level of personnel and technological inter- ventions required when maternal complications are present, the normal length of labor may be either length- ened or shortened depending upon the particular inter- vention (Pritchard & MacDonald, 1980; Jensen, Benson & Bobak, 1981; Clark & Affanso, 1979; Willson, Beecham & Carrington, 1975). Support Persons. Sosa et a1. (1980) provide excellent support for the contention that the presence of a lay support person during labor can influence the length of labor. Their research was conducted in a Guatemalan City Hospital where primiparous women 94 with uncomplicated pregnancies were studied. Upon admission to the hospital the women were randomly assigned to either a control or experimental group. As a result of the control criteria it was necessary to admit a total of 136 women initially to the study to obtain a final sample of 40, 20 in each group. Women in the experimental group were allowed to have a lay support person (doula) during labor and delivery. Those in the control group, in accordance with the normal hospital policy, had no support person present. Other factors related to care and intervention during labor and delivery were consistent between the two groups. Patients were excluded from the study if any of the following complications occurred: fetal dis- tress, prolonged labor, need for augmentation, caesarian section, forceps, apgar scores less than 8, meconium stained amniotic fluid, or fetal respiratory distress. The physicians who eliminated the patients with compli- cations from the study were unaware of the nature of the study. The results of the study indicated that there was no statistical significance between groups related to marital status, age, infant birth weight or infant sex. The mean length of labor in the control group was 19.3 hours, and in the experimental group was 8.7, showing a significant difference at the P.: 0.001 level. 95 These figures indicate total labor time; the second stage was not reported separately. The findings of this well designed and carefully implemented study appear clear. A support person attend- ing the women in labor appears to be a factor that shortens the length of labor. This is an important finding, despite the fact that it was reported on women in South America and therefore has somewhat limited generalizability. In subsequent research designs measur- ing factors which involve the length of labor, the presence of a support person must be held constant to avoid confounding effects. Haire (1978), citing several earlier studies, also confirms the importance of a support person's presence during labor. She indicated that this support reduces fear, which has been shown to adversely affect uterine motility and blood flow. Intervening Variables Several variables were measured in these studies although they were not controlled. The variables are: rupture of membranes, race, marital status, obesity, episiotomy, use of fetal monitoring, lacerations, type of physician, birth attendent--own or "on call", and type of childbirth education. These variables were included to better describe the characteristics of 96 the samples and to provide further potential research questions relative to the length of the second stage of labor. The following discussion includes a critique of the literature related to these variables. Rupture of Membranes. Lynaugh (1980) conducted a systematic review of the literature related to elec- tive amniotomy to determine if routine rupture of membranes is warranted. Lynaugh reviewed each study relative to design, method, results and conclusions. The author concluded that there is little agreement in the literature as to the effect of amniotomy on the length of labor. Although the clinical impression of many practitioners is that amniotomy shortens labor, some research supports this contention and other studies do not. As a result of this dicotomy, several research articles will be individually reviewed. The first article is the result of research done in England by Bainbridge, Nixon and Smyth (1958) between 1953 and 1956. In this retrospective study, 3750 consecu- tive hospital deliveries were reviewed. Included in this number were 2324 primiparas and 1426 multiparas. Patients with twins or whose labors ended in cesearean sections were excluded. Patients were divided into groups according to parity, and when their membranes ruptured relative to stage of labor. Information was abstracted from patient 97 charts recorded previously by "students and midwives." The data were collected and analyzed by one investigator. The researchers conclude that there is no significant effect on the length of the second stage of labor, although total labors longer than average were associated with intact membranes,and total labors shorter than average were associated with ruptured membranes. There are many blatent limitations to this large, although dated study. There was no control group in this project. "Averages" of length of total labor and the first stage were given. How these averages were derived mathematically, or the source of the figures used to compute the averages is unknown. We only know the age and delivery data of the patients; nothing about medications, position, pregnancy complications or chronic illnesses, marriage, race, etc. is provided. Thus, many intervening variables may have had an effect on the results. Two final limitations need to be dis- cussed. First, although some terms were specifically defined, the definitions presented were not always consistent with those used by the majority of practi- tioners in the 50's as well as today. Second, the definition of the term pre-eclamptic/toxemic was changed during the study to include a wider group of patients; Thus, any results related to this group are suspect. Despite the limitations of this study, it is included 98 because it continues to provide a "scientific" rational for physicians to rupture membranes routinely to facili- tate faster labor. In contrast to Bainbridge, Nixon and Smyth (1958). Laros, Work and Witting (1972) conducted a well designed and controlled experiment in which they examined the relationship between amniotomy and the length of several stages of labor. A prospective study with 125 patients was done at a Southeastern Michigan hospital. Random assignment to experimental and control groups was done when cervical dilatation was 5-8 cms. All patients had a vertex presentation and were at 36-44 weeks gestation. In the experimental group, amniotomy was performed at this time. Labor management for both groups was the same, with the exception of the amniotomy. Patients were compared on the basis of intervening variables (medications, method of delivery), using chi-square analysis,and no significant differences were found between groups on the non-labor parameters. Data for multips and primiparas were analyzed separately. The results indicated a significantly shorter second stage of labor (P 330.01) in primiparous women in the experimental group. Although the researchers stated they used a "normal group of patients", they failed to discuss what constitues a normal patient. They also were not specific as to where the patient samples 99 were obtained. Were they all from one hospital, or several? Were demographic variables other than age and gestation consistent between groups? Despite these few unanswered questions, the design and methods for this study were excellent and lend credibility to the results. The importance of this study is the differing results from those of Bainbridge, Nixon, and Smyth (1958) relative to amniotomy and labor length in the second stage. Bainbridge, Nixon and Smyth (1958) concluded that amniotomy shortens the total length of labor. Laros, WOrk, and Whitting (1972) concluded that amniotomy shortens the second stage of labor, and thus decreases the total length of labor. Although these studies differ in method as well as some aspects of the results, they both conclude that amniotomy shortens some aspect of labor and together provide increased justification for this intervention in labor. Friedman and Sachtleben (1963) conducted a study that found no difference in the length of any phase of labor related to amniotomy. Using a sample of 1729 patients, they divided this number into three sequential groups; group I (experimental N=709), group 11 (control N=280) and group III (experimental N=740). The experi- mental groups had amniotomy soon after labor was estab- lished. This time of amniotomy varied relative to 100 cervical dilatation, depending on dilatation at the time of hospital admittance. Group III duplicated experimental group I to act as a double check on results. The data from primiparas and multiparas were analyzed separately. Intervening variables, uterine stimulation, malposition, and multiple pregnancies were analyzed in all three groups and no significant differences were found. It was found that "amniotomy, as a therapeutic procedure, is ineffectual in producing abbreviations in any of the phases of the first stage of labor consistently" (Friedman & Sachtleben, 1963, p. 767). Friedman and Sachtleben (1963) go on to con- clude that there is "remarkable consistency...of the second stage...regardless of the time of rupture of the membranes" (p. 767). Although the sample size is large, several limi- tations are evident. The results and discussion portion of this lengthy article are difficult to understand. These portions are verbose, and the statistics appear only in the tables. The narrative presents comparisons that are difficult to find in the tables. For example, when the results are discussed, they are discussed in terms of ”remarkable consistency" instead of statis- tical significance. What does this mean? The authors do publish some of their data but it is not compiled and presented in useful ways. This limits both the 101 understanding and applicability of the results. This article was reviewed because it was a study of significant size that disputed previously found research on the effect of amniotomy on the length of labor. Therefore, it raises aquestion as to whether artificial rupture of membranes does indeed alter the natural length of the second stage of labor as was indicated by Laros, Work and Whitting (1972). In summary, both the review done by Lynaugh (1980) and the research efforts individually presented and critiqued above, lead one to conclude that at this time there is uncertainity as to just what effect rupture of the membranes has on the length of labor. Since this uncertainty exists, in any research studying the length of labor, it would seem important to at least record in what stage the membranes were ruptured and whether they were ruptured artificially or spon- taneously. In so doing, one would be able to better describe the characteristics of the sample. Rapg, Duignan, Studd and. Hughes (1975) conducted a large prospective study in England to evaluate the effects of different racial groups on the length of labor. Of the 3217 consecutive labors that were evalua- ted, a sample of 1306 was obtained that met the extensive established criteria. Races included in this study were white (N=866), Asian (N=341), and Black (N=99). 102 Racial groups included: White (Western European women), Asian (immigrants from India, Pakistan and Bangladesh) and Blacks (immigrants from the West Indies and Africa). Both multiparous and primiparous women were studied. The mean duration of the second stage of labor was found to be 41.5 minutes in primiparous women, including all races studied. The duration of the second stages ranged from 3 minutes to 115 minutes, although 83% of the subjects had a second stage of greater than 60 minutes. Separating the length of the second stage by race, Duignan, Studd and Hughes (1975) found that: white primiparous women had a longer second stage than Asian primiparous women at the significance level of P.§ 0.01, Asian primiparous women had a longer second stage than Black primiparous women (P.: 0.05), and White primiparous women had a longer second stage than Black primiparous women (P.fi 0.001). Although this study identified significant differen- ces in the duration of second stage labor between races, the authors did not provide mean values according to race, only for the larger groupings of multiparous and primiparous women. Specific mean values for each race would have made the data more useful as a compari- son for further research. Data collection techniques were not discussed in the article, however, all of the labor data was coded by the authors in preparation 103 for computerized analysis. It was noted earlier in this discussion that the Asian and Black racial groups had immigrated to England from other countries. Factors of national difference prior to immigration, such as nutrition or pre-natal self-care customs, as well as racial differences could possibly account for the findings. Thus, the study has limited generalizability to a poulation that may be racially different but includes people who are not recent immigrants. Since it was not possible to find research done in the United States comparing race and the duration of labor, this study is helpful despite the limited generalizability. Considering the results of Duignan, Studd and Hughes (1975), further studies comparing length of second stage labor must take race into consideration, relative to research design. If this is neglected, one would be unable to distinguish if differences in the labor were due to the variables being tested, or whether race had a confounding effect. A more recent study, again done in England, was conducted by Tom, Chan and Studd (1979). Using the same racial groups from the same geographical regions as those identified by Duignan, Studd and Hughes (1975), a study to identify normal and dysfunctional labor in any of the above groups was done. Racial composition in primigravidas was as follows: White (N=588), Black 104 (N=120), Asian (N=26). With a total N=l643, primi- gravidas and multigravidas, each racial group was also divided according to first or subsequent pregnancies. All patients had a spontaneous onset of labor and a single fetus in the cephalic presentation. Some members of the sample received medical labor augmentation and/or others epidural analgesia" on request. The time of admission to the hospital was considered the beginning of the first stage. The mean length of labor for the first stage was not different between racial groups. No mention was made of the length of the second stage in any group. In critiquing this article several limitations are evident. First, there is a much higher percentage of white patients (79%) than either Black (17%) or Asians (3.5%) patients. 13 it possible that there was no difference between races because of the small numbers of Blacks and Asians in the sample? Second, since the first stage of labor began on admission to the hospital, the length of this stage depended on when the woman chose to come into the hospital. No specific criteria related to cervical dilation was used to standardize when the first stage began. Thus, some women may have been admitted at 2 cm while others were admitted at 8 cms, making the measurement of the length of the first stage inconsistent. 105 The article indicates that some patients received intravenous augmentation, and some elected to receive regional anesthesia. Both of these factors are known to affect the length of labor, and yet, in the results, the data from these patients were not analyzed separately. Lastly, in this study, Thom, Chan and Studd did not evaluate the length of the second stage of labor and yet they measure fetal outcome after birth, thus nega- ting possible negative effects of the entire second stage of labor on the fetus. This article was reviewed in hopes that it would contribute information relative to racial differences and length of labor. However, due to its poor design and inadequate analysis and reporting, it provides little light on the issues it purports to address. Marital Status. A search of the Index Medicus, Cumulative Index to Nursing and Allied Health Literature and the International Nursing Index produced no refer- ences that address the issue of marital status and the length of labor. Obesity. Gross, Sokol and King (1980) designed and conducted a prospective study comparing pregnancy risk factors in an obese and nonobese population. Obese patients were defined as being 90+Kg before pregnancy and equaled 10.1% (279) of the total sample of 2746. The data were collected over a 13 month period at a 106 large metropolitan Midwest hospital. All patients had received prenatal care. Extensive comparisons of pregnancy risk factors were carried out using contingency tables and chi-square analysis. Using a significance level of P §_.001, no signifi- cant differences between the obese and non-obese groups were found during the first or second stages of labor. This includes no differences in the length of the second stage of labor. This study is comprehensive, both in sample size and in number of risk factors studied. It carefully identifies risk factors in a sample of obese pregnant women and then compares the frequency of their occurrance to the frequency in a non-obese group of pregnant women. The definition of obesity is specific and easily measurable. The definition yields a group of obese patients that include a range of obesity levels. There are two limitations identified in this study. Data were collected by use of a compu- terized form twice during each subject's pregnancy. The literature does not report who collected the data, how it was collected, and, if more than one person collected it, were their methods consistent? was there interrater reliability? The second limitation, particu- larly relevant to these studies, is the reporting of the data on duration of the second stage of labor. Mean durations (or raw scores) were not given, only 107 frequencies in percent of those women whose second stage of labor exceeded 2.5 hours were presented. It is also not clear how Gross, Sokol and King arrived at the figure of 2.5 hours as an indicator of labor abnormality and the need for intervention. Why did they determine that beyond 2.5 hours was too long for the second stage of labor? They cite no references. This study is relevant because it indicates there is no significant difference in the length of the second stage of labor in obese and non-obese pregnant women. Therefore, it is not important to control for obesity when studying factors that affect the length of the second stage of labor. Episiotomy. Cogan and Edmunds (1978) provide a review of the literature surrounding the use of episiotomy over the past two hundred years. They con- clude from their review that one result of episiotomy creation is a shortened second stage of labor. Cogan and Edmunds (1978) also identify a frequency of episiotomy use in vaginal deliveries that exceeds 70% in the United States. Since the vast majority of women delivering in metropolitan hospitals have routine episiotomies with each birth, it is the opinion of these authors that one must identify whether a woman has had an episiotomy or not. This knowledge will help accurately interpret any data results related to the length of 108 the second stage of labor. Use of Fetal Monitors. Various research articles identify prolonged labor in patients that experience increased levels of anxiety. Research has further correlated an increased level of anxiety with the use of electronic fetal monitoring. In the following dis- cussion, research that addresses these two issues will be reviewed. Garcia and Garcia (1955) studied the effects of plasma epinepherine on the uterine contractions of 33 laboring women. In the study, the patients were divided into three groups: patients who had normal labors (N=10), patients who were fearful of labor (N=l8) and patients who experienced labor inertia (N=5). Venous blood was drawn immediately following a uterine contrac- tion when the patients had reached 5-6 cm dilation. The blood samples were also drawn prior to use of any medications for pain, sedation or labor stimulation. The blood samples were then processed using a very technical procedure to preserve the epinepherine present in the plasma. Contractions in rat uteri were chemically stimulated every two minutes and the uterine activity was recorded using a kymograph. Known quantities of l-epinepherine were then introduced into the rat uteri and the contrac- tions were again measured using the kymograph. Following 109 these determinations, samples of the plasma drawn from the laboring women were introduced into the rat uteri and the contractions were measured as before. By comparing the differences in heights of the uterine contractions with and without the l-epinepherine and with the plasma samples, the concentration of epinepherine in the plasma samples was extrapolated. In this study, Garcia and Garcia (1955) found: that the group with ”normal labors” had levels of plasma epinepherine so low that it was not possible to measure I! with the procedure used and the labors were all rela- tively short, the group that feared labor had a greater amount of plasma epinepherine detectable and a longer labor, and the group that experienced uterine inertia had levels of plasma epinepherine that were even higher and experienced prolonged labors requiring stimulation. In evaluating this research one must consider the small sample size that was used. Garcia and Garcia (1958), however, identify theirs as a preliminary report and acknowledge the small sample. Another limitation of the study is that although the mean lengths of labor are given for each group, and the mean levels for the plasma epinepherine for each group, there is no dis- cussion related to significance level. It is unclear whether the differences found are statistically signifi- cant. In the group with normal labors, the only 110 treatment was nursing care, while in the fearful group, sedation was used in all but two patients and in the inertia group sedation plus labor augmentation was used with all patients. A question arises as to how much the medications used effected the length of labor and how much the increased levels of epinepherine affec- ted the length of labor,or was it actually a combined affect of the two? One must also wonder whether the rat uteri used for this experiment respond in the same manner as the human uterus. Another question is, How were patients placed into the three groups? since no criteria or discussion related to this area was presented. It is important to note, however, that this study does provide some early scientific validity to the assertion that increased levels of epinepherine effect uterine function and prolong labor. The study also discusses the relationship between increased fear and increased levels of anxiety which other authors have researched more currently. This study provides data that must be considered when evaluating factors that effect the length of labor. An article by Roux (1976) discusses the use of electronic labor monitoring and subsequent patient responses to this technological advancement. Roux identifies a study that was done in 1970 in which 24% of the sample disliked and were frightened by the 111 instruments and procedures used with electronic monitor- ing. ”From the patient's point of view, monitoring can cause anxiety" (Roux, 1976, p. 150). If this is the case, that electronic monitoring can cause fear, and if we utilize the results of Garcia and Garcia's (1955) work, one could conclude that in some patients the use of electronic monitoring could lead to a longer labor. Thus, anyone doing research on the length of labor must know whether electronic monitoring was used and if it was used, one must be aware that its use might prolong labor in patients where fear associated with its use was present. Questioning whether psychological factors in preg- nancy"have an effect on the progress of labor, Lederman et a1. (1979) conducted a study of 32 married, primi- gravidas with no medical or obstetrical complications. In the third trimester of pregnancy, interviews were conducted to obtain data related to anxiety levels and certain psychological factors,and base-line levels of plasma epinepherine, non-epinepherine and cortisol were obtained. Information related to knowledge about labor was collected using a 23 item instrument specially constructed for this study. The State-Trate Anxiety Inventory was used to measure anxiety in pregnancy and labor. Catecholamine levels were determined by assay and cortisol levels by radioimmunoassay. Uterine 112 activity information was obtained from a uterine monitor. Three phases of labor were defined: phase one--onset of labor to 3 cms dilation, phase two-~3-10 cms dilation, and phase three--complete dilation to delivery (second stage of labor). At the beginning of each phase of labor, data was collected on anxiety level, plasma levels of catecholamines and cortisol, and uterine activity. The data related to psychological and demo- graphic variables was then analyzed to identify relation— ships to anxiety, biochemical levels and uterine activity at the onset of each phase. All but eight of the 32 patients received some type of analgesia and/or anes- thesia during labor. Twelve patients had oxytocin stimulated labors and sixteen patients had some type of regional anesthesia. While 16 patients had normal spontaneous vaginal deliveries (NSVD) 16 also had forceps assisted deliveries. Those with an NSVD had significantly shorter labors than those that were forceps assisted, P :30.05. The anxiety measured at the onset of phase II also correlated with the length of labor, i.e., those with higher scores on the anxiety scale had longer labors,(r = .43; P §_0.05). Lederman et a1. (1979) concluded then that anxiety at the onset of phase II labor may influence the progress of phase III (second stage of labor). Psychological conflicts centering around specific pregnancy factors, i.e., identification 113 of a mothering role and pregnancy acceptance were related to changes in the length of labor. This relationship was significant at the P §_0.05 level. One limitation of this study is related to the definition used for phase I labor. This phase was defined as being the onset of labor to 3 cm dilation, however, no criteria was identified for the determina- tion of the "onset of labor." One other question arises in relation to the 16 patients that received regional anesthesia. Were these 16 patients also the same 16 patients that had forceps assisted deliveries and higher anxiety levels? If so, was it the higher anxiety levels that caused the longer labors or was it the use of regional anesthesia that caused longer labors? Was it the increased anxiety levels that created the need for regional anesthesia or was there some other combined effect? The importance of this study is that it again demonstrates that a relationship exists between increased levels of epinepherine caused by elevated anxiety and the length of labor. In 1977 Beck (1980) studied, via post partum interviews, patient responses to fetal monitors. This was a replication of a 1972 study done by the same researcher. In the 1972 study, Beck found that 62% of the sample had an initial negative response, 38% had a neutral response and there were no positive 114 responses to fetal monitoring. In 1977, 8% of the initial responses were negative, 18% were neutral and 74% were positive. There was a significant positive relationship between age and positive initial response and marital status and positive initial response in the 1977 study. Beck (1980) concluded that patients were more familiar with the concept of fetal monitors in 1977 than they were in 1972 and extrapolates from this that prior knowledge makes the fetal monitor less threatening. After the interviews were conducted, two researchers independently categorized the responses as negative, neutral or positive with an interrater reliability of 95%, although no information was presented relative to the use of a tool or format for the inter- views. Based on this article it appears that patients on the East Coast of the United States had fewer negative initial responses to the use of fetal monitors in 1977 than they did in 1972. Why this change occurred is based on the assumption,by Beck,that increased knowledge increases acceptance. She arrives at this conclusion based on anecdotal conversations she describes in the article and fails to show scientific justification for this assumption. Even though the assumptions Beck makes are questionable, the data from the inter- views do indicate that some patients still have negative responses to fetal monitors. Therefore, data should 115 be collected regarding use of fetal monitors when studying factors that may effect labor. In summary, Roux (1976) and Beck (1980) conclude that for some patients the use of fetal monitors elicits negative responses and produces increased anxiety. Garcia and Garcia (1955) and Lederman et a1. (1979) demonstrate that increased anxiety causes increased levels of epinepherine which in turn causes decreased uterine activity and thus prolongs labor. Given this information, one doing research on the length of labor must collect data relative to the use of fetal monitors, as their use may contribute to changes in the length of the second stage of labor. The intervening variables listed below were included in the present studies because of research interest, however, no literature was found that discussed or measured their relationship to the length of the second stage of labor: type of physician, birth attendent-- own or "on call" physician, and type of childbirth education classes. Summary of the Literature Review A review of the existing literature has been pre- sented on the following areas: trends in childbirth practices in the United States, cross cultural birthing practices, consumer issues, general references used to 116 define concepts, literature related to birthing position and literature related to controlled and intervening variables. A great deal of information was found that addressed the areas of past and present birthing prac- tices, cross-culturally. The issue of consumer needs and requests was addressed both in the lay literature and in scientific journals. The area inadequately addressed in the scientific literature was that of birthing position and how it effects the length of the second stage of labor. What research was done had questionable results and/or was conducted in other countries. The present studies will attempt to contri- bute to the small body of scientific knowledge that exists in the United States relative to birthing posi- tion and the length of the second stage of labor. In the next chapter, the methods used in these studies will be presented. CHAPTER IV METHODOLOGY Overview In this chapter a discussion of the research design used in the present study and the study by Sparks (1983) will be presented. The screening tools, data collection instrument, and pretesting methods will be discussed. The sample size and selection, field procedures used for collecting and recording data and the types of statistical analysis that was used to interpret the data will also be presented. Two separate studies were conducted: one measured the length of the second stage of labor in the recum- bent position; the second measured the length of the second stage of labor in the upright position. The methodology used for both studies was identical, but the data for each birthing position were analyzed separately. Further data analysis was done comparing the results of both surveys, thus providing an answer to the broader question, is the length of the second stage of labor significantly shorter in an upright or recumbent position? 117 118 Research Design The survey approach was used to determine the length of the second stage of labor under different physical conditions (birthing position). The survey approach was chosen because of the research question being studied. The researchers are simply asking "What is?". The investigators want to know if, under the conditions currently existing, there is a relation- ship between birthing position and the length of the second stage of labor. The survey approach was also chosen because the data was collected from existing hospital records. Use of the record review method, a survey of information already available, facilitated data collection as soon as approval from the research review board at St. Lawrence Hospital and from the University Committee on Research Involving Human Subjects (UCRIHS) was granted. Selection of Study Subjects The populations utilized by the present studies were chosen from primiparas delivering at St. Lawrence Hospital who met Step 1 and Step 2 criteria. A primi- para is defined as a woman who has delivered her first infant after the period of viability, 25th week gesta- tion and beyond, regardless of whether the child is living at birth (Agnew et al., 1965; Lerch, 1974; 119 Fitzpatrick, 1971; Jensen, Benson & Bobak, 1980; Olds et al., 1980). Thus, women who have had abortions or miscarriages prior to 25 weeks gestation are still considered primiparous. The women also met further criteria established for uncomplicated pregnancies by these projects. Absence of the following conditions identified an uncomplicated pregnancy (Leitch & Tinker, 1980; Pritchard & MacDonald, 1980): 4 Pregnancy Induced Hypertension (P.I.H.) Toxemia Pre-eclampsia Eclampsia U'l-I-‘UJNH Diabetes - gestational, adult onset, juvenile onset 6. Heart disease - cardiac anomalies, valve damage from rheumatic fever 7. Renal disease - history of renal failure past or present 8. Chronic hypertension - as defined by medical diagnosis 9. Chronic lung disease - emphysema, COPD, adult asthma 10. Multiple births - this pregnancy 11. Incompetent cervical OS - diagnosis and/or treatment during this pregnancy 12. Vaginal bleeding - second or third trimester 120 13. Age - under 16 years old; 35 years and older Although items 1-4 all indicate variations of the same medical condition, each term was included because consistency of useage of any one has not been demonstrated by the medical profession. Thus, medical identification of any one of the four diagnoses (PIH, toxemia, pre-eclampsia, eclampsia) indicated a high risk situation and made that chart inappropriate for inclusion in these studies. A medical diagnosis of diabetes, either adult onset, juvenile onset, or gestational, indicated a high risk situation. The researchers did not utilize labtests to determine diabetic patients. A specific diagnosis of diabetes, in any one of the three forms previously identified, must have been apparent within the chart to make the chart inappropriate for the studies. Cardiac anomalies or cardiac valve damage as a result of rheumatic fever were heart disease conditions that caused exclusion from the studies. Again, either of these conditions must have been indicated as a medical diagnosis within the chart and, thus, were not to be determined by the researchers. Any evidence of past or present renal failure, again as a specific medcical diagnosis, indicated a high risk situation. The researchers did not infer 121 kidney failure from results of any diagnostic or laboratory procedures. Chronic hypertension was not identified by the researchers based on existing blood pressure readings prior to the 20th week of gestation. (Blood pressure readings of 140/90 before the 20th week of gestation indicate chronic hypertension (Willis, 1982)). Chronic hypertension must have appeared as a medical diagnosis in order to cause exclusion from the studies. Presence of a medical diagnosis of chronic ob- structive pulmonary disease (COPD), emphysema or adult asthma indicated chronic lung disease and thus necessitated exclusion of the record for use in these studies. Evidence of more than one fetus in the present pregnancy caused exclusion. A medical diagnosis of incompetent cervical OS diagnosed prior to or during this pregnancy and treated by Shirodkar, cerclage, or similar procedure indicated a high risk patient and thus necessitated exclusion of the record. Presence of vaginal bleeding during either the second or third trimester, as recorded on the prenatal record or as stated as a medical diagnosis, excluded the record from use in these studies. Vaginal bleeding, not spotting, must have been documented on the record. 122 Patients under 16 years of age or 35 years or older at the onset of this pregnancy, as determined by birth month and year, were considered high risk and not appropriate as defined by the study criteria. Screening Tool #1 (see Figure 3) was used as the initial step in determinating the population for the present studies. Screening Tool #1 was used initially on all obstetrical charts of primiparous women, who delivered vaginally, to exclude any high risk patients. If the chart review with Screening Tool #1 did not indicate any high risk factors, step two was begun with each chart, utilizing Screening Tool #2 (see Figure 4) to further define the apprOpriate population. Each of the seven areas in Screening Tool #2 were considered with every chart that had been previously deemed acceptable by Screening Tool #1. Each of the factors in Screening Tool #2 have been shown by previous research to affect the length of the second stage of labor, and thus by use of this tool a more homogeneous population was obtained. Attendance at childbirth education classes was recorded as ”yes” or "no" or "not indicated." A "yes" response did not differentiate what type of classes or how many classes were attended, but only that the patient said she had attended formal classes. The requirement for this research was that all patients 123 Figure #3 Prior to Nursing Intervention After Nursing Intervention CODE # SCREENING TOOL #l* l. PIH (as defined by medical diagnosis) YES NO 2. Toxemia (as defined by medical diagnosis) YES NO 3. Pre-eclampsia (as defined by medical diagnosis) YES NO 4. Eclampsia (as defined by medical diagnosis) YES NO 5. Diabetes (as defined by medical diagnosis) Adult Onset: YES NO Gestational: YES NO Juvenile Onset: YES NO 6. Heart Disease (as defined by medical diagnosis) Cardiac Anomalies: YES NO Mitral Stenosis: YES NO Valve Damage as a result of Rheumatic Fever: YES NO Pulmonary Hypertension: YES NO 7. Renal Disease (as defined by medical diagnosis) History of Renal Failure Past or Present: YES NO *Developed in collaboration with Barbara Taylor Sparks 124 Figure 3 (cont) 8. 10. ll. 12. 13. 14. 15. Chronic Hypertension (as defined by medical diagnosis) YES____NO____ Chronic Lung Disease (as defined by medical diagnosis) Emphysema: YES NO Adult Asthma: YES NO C.O.P.D.: YES NO Multiple Birth this Pregnancy: YES NO Incompetent Cervical OS (diagnosed and/or treated during this pregnancy) YES NO Vaginal Bleeding--2nd or 3rd Trimester: YES NO Age: Under 16 yrs of age YES NO 35 years of age or older YES NO Evidence of Mid or High Forceps: YES NO Evidence of Substance Abuse (as defined by medical diagnosis) YES NO 125 Figure #4' Prior to Nursing Intervention After Nursing Intervention CODE # SCREENING TOOL #2* l. Childbirth Education: YES NO NOT INDICATED 2. Support Person Present: Labor-~YES NO NOT INDICATED Delivery--YES NO NOT INDICATED 3. Maternal Pelvic Measurements: Adequate Marginal Not Adequate Not Indicated 4. Fetal Presentation: Breech--YES NO 5. Fetal Position: Persistent Occiput Posterios--YES NO 6. Medications given during lst or 2nd stage of Labor: YES NO If Yes: Name Route Amount Time Stage of Labor *Developed in collaboration with Barbara Taylor Sparks 126 Figure 4 (cont) 7. Stage of Labor: lst stage--Time of Onset Time of Completion 2nd stage--Time of Onset Time of Completion 3rd stage--Time of Onset Time of Completion 8. Forceps Used: YES NO ACCEPTABLE: YES NO (if No, Why? 127 must have attended childbirth education classes. Evidence of a support person present during labor was recorded by a "yes", or "no", or ”not indicated," and evidence of a support person present during delivery was recorded in the same manner. The criteria was to have a support person present during both labor and delivery. A labor and delivery nurse on duty did not qualify as the support person for these studies and,thus,if the nurse was the only support person present, the record was excluded from the present studies. The area related to adequacy of maternal pelvic measurements was recorded as ”adequate", ”not adequate", "marginal", or "not indicated." The researchers recog- nize that this was one area where medical documentation may frequently be absent. Ideally pelvic adequacy, or the lack thereof, would be indicated and only those patients with adequate pelvic measurements would be included in these studies. Following a small pre- testing of the screening tools and data collection tool, however, it was obvious that very few charts would actually have information related to pelvic ade- quacy documented. A consultation with T. Kirschbaum, M.D., Professor and Chairman, Department of Obstetrics and Gynecology, College of Human Medicine, Michigan State University and with J. Walczak, D. 0., Professor 128 Figure #5 Prior to Nursing Intervention After Nursing Intervention CODE # squat : DATA COLLECTION TOOL‘ kneel chair 1. AGE: 2. MARITAL STATUS: Married Single (never married) Separated Divorced Widowed 3. RACE: Oriental Black White Other Not Indicated 4. INSURANCE: Private Company Medicaide Private Pay--no insurance 5. OCCUPATION: Patient Spouse 6. GRAVIDITY: 7. PHYSICIAN: Private Physician OB Clinic OB/GYN Family Practice General Practice HMO 8. CHILDBIRTH EDUCATION: Lamaze Expectant Parents Classes 9. TYPE OF ANESTHESIA USED FOR DELIVERY: Local Pudendal Paracervical None *Developed in collaboration with Barbara Taylor Sparks 129 Figure 5 (cont) 10. FETAL POSITION AT DELIVERY: LOA LOP ROA ROP OA ll. POSITION FOR 2ND STAGE OF LABOR: Upright Recumbent 12. LENGTH OF LABOR: lst stage--Time of Onset Time of Completion 2nd stage--Time of Onset Time of Completion 3rd stage--Time of Onset Time of Completion 13. EPISIOTOMY: YES NO If Yes--What Kind: LML RML ML Extensions: YES NO If Yes--What Kind: 1° 2° 3° 4° Lacerations: YES NO If Yes-~What Kind: Perineal 1° 2° 30 40 14. FETAL MONITOR: YES NO If Yes--What Kind: lnternal External Interna1-—Time put on Time removed External--Time put on Time removed 15. PERINEAL EDEMA: YES NO l6. DELIVERY BY: Own Physician On-Call Physician 17. IV RUNNING FOR HYDRATION: YES NO If Yes--What Kind: 18. INFANT APGAR: lMin 5Min 19. DATE AND TIME OF LAST MEAL: 130 Figure 5 (cont) 20. RUPTURE OF MEMBRANES: Spontaneous Artificial Time 21. WEIGHT AT TERM: 22. WEIGHT GAIN DURING PREGNANCY: ACCEPTABLE: YES NO Is any data missing? YES NO If Yes--What? Is the data that is missing: Absolutely Necessary Desireable 131 of Obstetrics and Gynecology, College of Osteopathic Medicine, Michigan State University, resulted in con- sensus that for the purposes of these studies, it was reasonable to assume pelvic adequacy if: 1) total labor time was 22 hours or less, 2) vaginal delivery occurred without forceps, 3) no oxytoxics were used to augment labor, 4) APGAR scores were 8 or greater. In order to be included in these studies, patients either met the above four criteria for determining pelvic adequacy,or pelvic adequacy was specifically recorded in the patient's record. The adequacy of pelvic measurements could be determined by vaginal exam and/or by x-ray, pelvimetry, or ultrasound. Fetal presentation was evaluated to rule out breech infants delivered vaginally. Responses were dichoto- mized as "yes" or "no". To rule out records where the fetus was in a per- sistent occiput posterior position, fetal position was evaluated and thus the choice of responses was persistent occiput posterior: yes or "no". Medication useage during the first or second stage of labor was evaluated. The desire was to have no medications used in order to rule out any effect that they might have had on the length of labor. The res- ponses related to medication useage were "yes" or H H 0 no 132 With the knowledge that the use of forceps can alter the natural length of the second stage of labor, patients that had forceps assisted deliveries were eliminated from these studies. The possible responses were forceps used: yes or "no". When a chart met the criteria established in Screen- ing Tool #2, i.e., evidence of attendance at childbirth education classes, evidence of a support person present during labor and delivery, adequate maternal pelvic measurements, no breech presentations or persistent occiput posterior positions, no medications during the first or second stage of labor and no use of for- ceps, the researchers proceeded to data collection. Each chart was given a code number at the onset of screening #1 and the same code number was used for screening #2 and for data collection. The code number given could in no way identify a particular chart once data collection was completed. Thus, that was the researchers way of assuring confidentiality and a lack of risk to the patients whose charts were audited for these studies. Instrumentation and Data Collection The two researchers did the data collection together. Case numbers of primiparous patients with vaginal deliveries were obtained from the record book of all deliveries that is kept in the labor and delivery 133 department. Personnel in medical records secured records for the researchers to audit on a weekly basis in the medicalrecords department. Records were audited a maximum of six months previous to the day that data collection was begun and the process of data collection continued for five months until the desired sample size for each birthing position was obtained. An instrument was developed for this project to record information directly from the charts (see Figure 5). The sociodemographic data included were as follows: age, marital status, race, type of insurance and type of occuptaion. The statement related to occupation was recorded just as it was on the record. These areas were used as general descriptors of the samples studied and this information was collected from the hospital admission form on the record. Information concerning gravidity was included, again, as a descriptor of the sample characteristics. This information was found on the pre-natal record. The type of physician from whom the patient received obstetrical care allowed the researchers to determine whether there was a relationship between the type of physician and birthing position in the samples. The name of the physician was checked againt the yellow pages phone directory for determination of speciality, 134 OB/GYN, General Practice, Family Practice. The pre- natal record indicated also whether the patient was a private patient or a clinic patient. There are two primary types of childbirth educa- tion in the Lansing area, the Lamaze and the Expectant Parents Classes. Because of differences in approach between the two types of classes, the researchers wanted to determine whether there was a relationship between the birthing position used and the type of childbirth classes attended. This information was available on the pre-natal record or on the labor and delivery record. Information regarding the fetal position at delivery was necessary since the literature has shown that pos- terior positions, left occiput posterior, right occi- put posterior, generally take longer to deliver than do anterior positions (Pritchard & MacDonald, 1980). The importance of this issue is that if in women who delivered upright there were a greater number of infants in the posterior position, then there were in women who delivered in a recumbent position, the mean length of the second stage of labor in the upright position could have been skewed by fetal position. Thus, the researchers needed to know if the posterior position influenced the length of labor. Position at birth was recorded on the delivery room record. 135 The delivery room record contained information related to birthing position and the length of the stages of labor. Birthing position and length of the second stage of labor were the two pieces of informa- tion needed to answer the basic research questions of these studies. Presence of an episiotomy, extensions,and lacera- tions are all pieces of information that were used to compare characteristics of patients in each birth- ing position. This information came from the delivery room record. Information related to perineal edema was avail- able on the recovery room or post partum records. This piece of information was asked for by the administra- tors at St. Lawrence Hospital because some post partum staff felt that there was an increase in the incidence of perineal edema in patients that used the upright position as compared to those who used the recumbent position. Delivery by "own physician" or "on-call physician" was information that was available on the delivery room record. If a patient was delivered by someone other than her own physician, she may not have been able to deliver in the position that she desired and this information was used when describing the charac- teristics of each sample. 136 Intravenous fluids running for hydration and infant apgar scores are information that could be used in the future to further analyze and compare characteristics of the samples in the two birthing positions. IV information was available either on the labor record or on the delivery room record, and infant apgars were available on the delivery room record. In the previous discussion the importance of each piece of information desired for data collection was discussed. The necessary data were obtained from several portions of the patient's record: hospital admission form, pre-natal record, labor and delivery records, recovery room record and post partum record. Reliability and validity determination of the screening tools and data collection tool were not necessary or appropriate since these studies utilized only existing objective data. Interrater reliability related to chart audits was established. Both re- searchers independently audited the same eight charts. Interrater reliability was determined by the following widely accepted formula: the number of items both researchers identified similarly was divided by the total number of items. The result of this equation equaled the interrater reliability stated as a percent. The interrater reliability of these studies was >90Z. 137 Field Procedures Research Permission. The research proposal was presented both verbally and in writing to the nursing administrators at St. Lawrence Hospital. Permission was obtained, in writing, for the data collection from the Chairman of the Research Committee, St. Law- rence Hospital (see Appendix A--Figures Al-AA). The appropriate material for approval by the Michi- gan State University Committee on Research Involving Human Subjects (UCRIHS) was forwarded to that office and approval was granted from that committee (see Appendix A--Figures A5 and A6). When UCRIHS approval was received, the researchers met with all of the nurses on the staff in the labor and delivery department at St. Lawrence Hospital. A brief explanation of the studies was given, with speci- fic discussion of how the results might be helpful to them in their clinical practice. A letter with the same information was sent to each staff nurse, to rein- force the concepts previously discussed and to remind them of the studies (see Appendix B--Figures B1 and B2). Pre Test. The screening tools were pre-tested until eight charts met the criteria for Screening Tool #1 and Screening Tool #2. The data collection tool was then pre-tested on these eight charts to deter- mine if the data needed for the studies were available 138 on the charts or if additions to the current charting practices needed to be made in order to assure the presence of such information. Data determined to be necessary for inclusion in these studies were as follows: type of physician, fetal position at delivery, birthing position and length of the second stage of labor. The remainder of the data would allow a much more complete description of the pOpulations in the two studies, and the identifica- tion of existing relationships, but were not absolutely necessary to answer the primary research questions. As a result of the pre-test procedure, two charting adjustments were made. First, because of the obscure placement on the admission form, information on child- birth education classes was not consistently recorded. Therefore, the researchers highlighted this on the form by underlining it in red. Second, no place existed on the labor and delivery form to record the maternal position used for the second stage of labor. The researchers added another information category on the delivery room record. This consisted of a line with the words Position: upright, recumbent, with space between to check one or the other. To assist the nursing staff to evaluate objectively whether upright or recumbent position was used by the patient, diagrams were posted in all birthing and 139 delivery rooms. These diagrams graphically indicated the angle of 30° between the patient's lumbar vertebrae and the horizontal plane. In addition to the diagrams, a protractor was used to determine a 30° angle on all birthing beds and delivery tables. A piece of red tape was used to identify the 30° mark. Thus, any time the red tape was visible, the patient was considered upright. If the red tape was not visible, the patient was considered recumbent. In addition to charting adjustments, it was found that the notation of pelvic measurement adequacy was frequently omitted. It was at this point Drs. Kirschbaum and Walzak were consulted relative to the feasibility of establishing alternative criteria for the determination of adequate pelvic measurements. The total number of charts audited was 247. From this audit a sample of 25 subjects who used the upright position and 21 subjects who used the recumbent posi- tion was obtained. The combined sample size of 46 was 142 of the total number of charts audited. The primary reason that charts were rejected was due to the use of medications during the first or second stage of labor. 140 Data Analysis Portions of both research projects were done jointly. The results of the surveys were analyzed separately and then the two study results were compared. The reason for comparing the results from the two studies is that the clinical applicability will be greater than if one were to use only the individual results. In the present studies both descriptive and inferen- tial statistics were used. Descriptive Statistics. The descriptive statistics used included frequencies, means and standard deviations. Descriptive statistics allow one to describe quantita- tive information and to organize numbers thereby inter- preting numerical information (Polit & Hungler, 1978). These calculations were used to describe what is. What is the average (mean) length of the second stage of labor in the recumbent position? or, in-the recumbent position, what is the average variance of the second stage of labor around the mean value (standard deviation). Frequency distributions were tabulated on intervening variables, incidental variables and demographic descrip- tors as they related to the position used for the second stage of labor. Inferential Statistics. Inferential statistical techniques used were Pearson Product Moment Correlation and Pearson Point Bi-Serial Correlation. Inferential 141 statistics allow one to draw conclusions and to gener- alize to a larger class of individuals based on infor- mation from a smaller group of subjects (Polit & Hungler, 1978). Use of the Pearson correlational techniques does not show that one factor causes another factor to occur, but rather identifies a relationship between the factors. In the present studies the Pearson Point Bi—Serial technique was used to identify the magnitude and direction of the relationship between the variables and the length of the second stage of labor when dichoto- mous and interval data were compared. The Pearson Product Moment Correlational technique was used to identify the magnitude and direction of the relationship between the variables and the length of the second stage of labor when both of the variables produced interval data. The correlation coefficients are identified by use of the letter(r). The numerical range of(r) is from —1.00, indicating a negative relationship, to 1.00 indicating a positive relationship. The strength of the relationship is scored by use of the following categories: 142 Value of r Strength of relationship 0.00 to 0.20 No significant relationship 0.20 to 0.35 very slight 0.35 to 0.65 fair to moderate 0.65 to 0.85 marked to fairly high 0.86 to 1.00 High to very high (Borg & Call, 1979, pp. 513-514) The Student's Two-Tailed T-Test was the statistical technique used to test the difference between the mean length of the second stage of labor in the upright position and the mean length of the second stage of labor in the recumbent position. The two-tailed t-test was used because there was no hypothesis made regarding the possible results. Correlations and t-tests are also described relative to their statistical significance. The statistical significance level for the present studies was set atIP§305. AQP value greater than 0.05 was considered not statistically significant. Summary The methodology for the present research studies was presented in Chapter IV. The selection of a research design was discussed and criteria used for sample selection was presented in depth. Field procedures were outlined and instrumentation and data collection techniques were 143 presented. Finally a brief description of the statis- tical methods and rationale for use with data analysis were addressed. In Chapter V the data results and analysis of the research questions are presented. CHAPTER V DATA PRESENTATION Overview The data presented in this chapter describe the characteristics of the study subjects and the relation- ship between the use of the recumbent position and the length of the second stage of labor. Analysis was also done to identify any relationships that existed between several other variables and the length of the second stage of labor. Comparative analysis done on the data obtained in this study and a similar study done by Sparks (1983) is then presented. Following presentation of the data from this study and selected results from the study by Sparks (1983), a discussion of the results is offered. Finally, a summary of the data and its meaning is presented. Presentation of Research Questions In Chapter V data will be presented and discussed on the following four research questions related to this research project. Research Question 1 What is the mean length of the second stage of labor in primiparous women with uncomplicated pregnancies who 144 145 use the recumbent position? Research Question 2 Do any of the intervening variables correlate with the length of the second stage of labor in women who use the recumbent position? Research Qpestion 3 Do any of the demographic descriptors correlate with the length of the second stage of labor in women who use the recumbent position? Research Question 4 Do any of the incidental variables correlate with the length of the second stage of labor in women who use the recumbent position? Data from the study by Sparks (1983) will be briefly presented and discussed related to the following four research questions. Research Question 5 What is the mean length of the second stage of labor in primiparous women with uncomplicated pregnancies who use the upright position? Research Question 6 Do any of the intervening variables correlate with the length of the second stage of labor in women who use the upright position? Research Question 7 Do any of the demographic descriptors correlate with 146 the length of the second stage of labor in women who use the upright position? Research Question 8 Do any of the incidental findings correlate with the length of the second stage of labor in women who use the upright position? Finally, the combined data from the present study and the study by Sparks (1983) will be presented and discussed. The three research questions growing out of the combined data follows. Research Question 9 Is there a statistically significant difference in the mean length of the second stage of labor in primi- parous women with uncomplicated pregnancies who use an upright or a recumbent position? Research Question 10 Is there a significant correlation between age and position used for the second stage of labor? Research Question 11 Is there a significant correlation between lacera- tion and the position used for the second stage of labor? Having identified the research questions to be considered, a brief discussion of the population, sub- population and study subjects is presented. The criteria for inclusion in the present study were discussed in detail in Chapter IV. The process by which the study 147 subjects were identified from the study population, how- ever, is once again presented. Study Population The population identified for use in this study consisted of primiparous women who experienced vaginal deliveries in a Midwestern Metropolitan Catholic Hospi— tal. All women who met the population criteria and delivered in this hospital between May, 1982 and Novem- ber, 1982 were included. From the population, a sub- population was identified by a two-fold screening process. First, Screening Tool #1 (see Chapter IV, Figure 3) was used to identify those women in the population who had experienced uncomplicated pregnancies. Second, Screening Tool #2 (see Chapter IV, Figure 4) was used on those women with uncomplicated pregnancies to identify a group of subjects who met the remaining criteria estab- lished for the present study. The study subjects used in this project were iden- tified as those women in the sub-population who utilized the recumbent position for the second stage of labor. The subjects used in the project by Sparks (1983) were determined in the same manner, but her subjects used an upright position for the second stage of labor. 148 Results From the data collected, the following character- istics of the study subjects were identified. See Tables 7-12 for the absolute frequencies and relative frequencies on each identified variable. Characteristics of Study Subjects. Demographic Descriptors. The demographic descrip- tors used in the present study were age and type of insurance (see Tables 7-8 for the absolute and relative frequencies). The age of the study subjects ranged from 17 to 33 years, with a mean age of 24.1 years and a standard deviation of 3.8 years. The majority of the study subjects (66.7%) fell at or below the mean relative to age. All 21 study subjects had private insurance coverage. Due to the retrospective approach used for data collection, it was not possible to deter- mine occupation. Intervening Variables. The intervening variables measured in the present study were marital status, race, type of physician, type of childbirth classes, presence of episiotomy, presence of laceration, use of fetal monitors, rupture of membranes, and own or on-call physician (see Table 9 for the distribution and percentage of all intervening variables). Of the 21 subjects, 19 (90.5%) were married and 149 Table 7 Age Distribution of Women in the Recumbent Position (N = 21) Age, Years Number of Subjects Percentage 17 1 4.8 18 2 9.5 22 l 4.8 23 5 23.8 24 5 23.8 25 1 4.8 26 2 9.5 28 2 9.5 31 1 4.8 33 ___ 4.8 TOTAL 21 100.0 Mean = 24.1 years Median = 23.8 years Mode = 23.0 years Standard Deviation = 3.8 years 150 Table 8 Type of Health Insurance Coverage of WOmen in the Recumbent Position (N = 21) Type of Insurance Number of Subjects Percentages Private Pay 0 0.0 Medicaid 0 0.0 Private Insurance 21 100.0 Total 21 100.0 151 Table 9 Frequency Distribution of the Intervening Variables in the Recumbent Position (N = 21) Number of Variable Subjects Percentage Marital Status Married 19 90.5% Single _2_ _2;§Z Total 21 100.02 Race White 20 95.2% Unknown _l 4.8% Total 21 100.0% Type of Physician OB/GYN 18 85.72 Family Practice 3 14.2% General Practice _9 Total 21 100.0% Type of Classes Lamaze 8 38.1% Expectant Parents 11 52.4% Type Unknown 2 _2;§Z_ Total 21 100.0% Table 9(Con't) 152 Number of Variable Subjects Percentage Episiotomy Yes 18 85.8% No __3_ M Total 21 100.0% Laceration Yes 8 38.1% No 12 21322. Total 21 100.0% Fetal Monitor Yes 18 85.8% No _3 14.22 Total 21 100.02 Rupture of Membranes Artificial 9 42.92 Spontaneous _g_ §Z;lz Total 21 100.0% Physician Own 18 85.8% On Call _2_ liL2Z Total 21 100.0% 153 2 (9.5%) were single, never having been married. With the exception of one subject whose race was unknown, all subjects were white. The racial make-up of the study subjects is similar to the majority of the women who deliver at the hospital where the study was con- ducted (Baker, 1983). Of the 21 subjects, 18 (85.7%) received care from an OB/GYN specialist, while 3 (14.2%) received care from family practice physicians. The majority attended Expectent Parent Classes (N=ll, 52.3%) while approximately one-third (38.0%) attended Lamaze Classes. Information about 2 (9.5%) of the sub- jects was not available. An episiotomy was performed on over four-fifths (N-18, 85.7%) of the women and only 3 (14.2%) had no episiotomies. The occurrance of a laceration during the delivery was present in 8 (38.0%) women. Of the 8 women who experienced a laceration, 5 (23.8%) also had an episiotomy performed. The majority of the study subjects 13 (61.9%) had no lacerations. Use of some type of electronic fetal monitoring was used in 18 (85.7%) of the study subjects. Electronic monitoring was not used in the remaining 3 (14.2%) subjects. Of the 21 study subjects, 9 (42.8%) had an artificial rupture of the membranes, while the mem- branes of 12 (57.1%) spontaneously ruptured. The pri— vate physicians of 18 (85.7%) subjects completed the delivery. The remaining 3 (14.2%) were delivered by 154 a physician on-call, not the patient's own physician, Incidental Variables. The incidental variables measured in the present study were: weight at term, weight gain, gravidity, type of health care setting in which care was received, fetal position, type of fetal monitor, APGAR at 1 minute, APGAR at 5 minutes, stage in which rupture of the membranes occurred and the use of intravenous fluids. The frequency distri- butions and percentages for all incidental variables can be found in Tables 10 and 11. The amount of weight gained during pregnancy ranged from 14 to 48 pounds, with the mean weight gain being 31.6 pounds. According to Jensen, Benson and Bobak (1981) the normal weight gain for most healthy pregnant women is 24 to 30 pounds. In the present study 5 (23.8%) of the women fell within the normal range identified by Jensen, Benson and Bobak (1981), 3 (14.3%) fell below and 13 (61.9%) were above. The average weight gain identified by Jensen, Benson and Bobak (1981) is 24 pounds, while the mean identified in the present study is 31.6 pounds: 7.6 pounds higher. 0f the 21 study subjects, 8 (38.0%) fell below the mean identified in the present study and 13 (61.9%) were above the mean weight gain. Four-fifths of the study subjects (85.7%) were gravida 1, while only 3 (14.2%) were gravida 2. 155 Table 10 Pounds of Weight Gain in Pregnancy of Women in the Recumbent Position (N = 21) Pounds Gained Number of Subjects Percentage 14 l 4.8 18 2 9.5 22 l 4.8 27 2 9.5 28 l 4.8 30 1 4.8 32 4 19.0 33 1 4.8 35 3 14.0 37 1 4.8 40 1 4.8 42 l 4.8 47 l 4.8 48 .1 1.3; Total 21 100.0 Mean = 31.6 pounds Median = 32.1 pounds Mode = 32.0 pounds Standard deviation = 8.9 pounds 156 Table 11 Frequency Distribution of the Incidental Variables in the Recumbent Position (N = 21) Variable Number of subjects Percentage Gravidity Gravida l 18 85.7 Gravida 2 _2. 1442_ Total 21 100.0 Source of Patient Clinic patient 0 HMO patient 8 38.1 Private patient 13 glL2 Total 21 100.0 Fetal Position LOA 6 28.8 LOP l 4.8 RCA 3 14.2 0A 10 47.4 Unknown _l_ _4;§_ Total 21 100.0 157 Table 11(Con't) Variable Number of subjects Percentage Monitor type External only 15 71.5% Internal only 1 4.8% Both 2 9.5% Neither _3| 14422. Total 21 100.0% Apgar @ 1 minute 5 1 4.8% 6 0 7 2 9.5% 8 14 66.6% 9 _4 11.1% Total 21 100.0% Apgar @ 5 minutes 8 4 19.2% 9 16 76.0% 10 .1 .43: Total 21 100.0% 158 Table 11(Con't) Variable Number of subjects Percentage Stage of ROM lst 14 66.7% 2nd 1 4.8% Before lst _6 2§;§%. Total 21 100.0% IV fluids Yes 3 14.2% No 18. 81-8 Total 21 100.0% 159 Approximately two-thirds of the women (N = 13, 61.9%) received care from physicians in private practice. The remaining 8 (38.0%) received care from physicians working in a Health Maintenance Organization (HMO). There were no patients who received care in a hospital clinic setting in the present study. The Left Occiput Anterior (LOA) position was evident in 6 (28.5%) deli- veries, Left Occiput Posterior (LOP) position in 1 (4.8%) delivery, Right Occiput Anterior (ROA) in 3 (14.2%) deliveries, Occiput Anterior (0A) in 10 (47.6%) deliveries and in l (4.8%) the position was not recorded. According to Pritchard and MacDonald (1980) about two- thirds of all vertex presentations are in the left posi- tion, with LOA being the most common. Because of the 10 deliveries where the position was simply recorded as 0A, it is not possible to identify the percentage of left positions in the present study. Pritchard and MacDonald (1980) also indicate that anterior posi- tions are more common than posterior positions. In the present study 19 (90.5%) of the infants were in the anterior position which is consistent with the norm identified by Pritchard and MacDonald (1980). Of the 18 subjects on which fetal monitors were used, 15 (71.4%) had external monitors only, 1 (4.7%) had only an internal monitor and 2 (9.5%) had both an external and internal fetal monitor during labor. 160 The infant apgars at 1 minute ranged from 5 to 9 with a mean apgar of 8.0. At the one minute mark 1 (4.7%) infant had an apgar of 5: 2 (9.5%) infants had apgars of 7: 14 (66.6%) had apgars of 8 and 4 (19.0%) had apgars of 9. The 5 minute infant apgars ranged from 8 to 10 with a mean of 8.9. Of the 21 infants studied, 4 (19.0%) had apgars of 8, 16 (76.0%) had apgars of 9 and 1 (4.8%) had an apgar of 10. One- quarter (N = 6, 28.5%) of the women's membranes ruptured prior to the onset of the first stage of labor, while two-thirds (66.7%) had membranes rupture during the first stage of labor. Only 1 (4.8%) woman had rupture occur during the second stage of labor. Most women (N = 18, 85.7%) received no intravenous therapy during labor. Summary--Characteristics of Study Subjects. In summary, most of the women included in the present study had similar care and are representative of the women that deliver in the hospital where the study was conduc- ted. They were similar demographically, i.e., the majori- ty of the women were 22 to 28 years of age and all women had private insurance coverage. All but two women were married and all but one woman was Caucasian. The study subjects also received similar care, in that 18 of the 21 received care from an OB/GYN physician. The labor and delivery period also was similar for all of the 161 study subjects. In the majority of the women, rupture of the membranes occurred spontaneously and in the first stage of labor. Some type of electronic fetal monitor- ing was used with most women and most women did not have intravenous fluid therapy. The majority of the study subjects also had episiotomies performed. The descriptive findings and characteristics of the study subjects were presented in the previous section. Descriptive statistics were used for the demo- graphic descriptors, the intervening variables and inci— dental variables. The findings in the present study were also compared to the established norms in the gen- eral obstetric population. In the following section the data will be presented related to the research questions. Data Presentation for Research Questions. Research Question 1. What is the mean length of the second stage of labor in primiparous women with uncomplicated pregnancies who use the recumbent position? The second stages of labor of the 21 study subjects ranged from 14 to 98 minutes, with a mean length of 46.6 minutes and a standard deviation of 21.1. The median score was 42.0 and the mode was 30.0. The absolute frequencies and percentages can be seen in Table 12. More than one-half of the subjects (N = 12, 57.1%) had second stages of labor that were shorter than the mean. 162 Table 12 Length in Minutes of the Second Stage of Labor of Women in the Recumbent Position (N = 21) Time in Minutes Number of Subjects Percentage 14 l _ 4.8 20 22 30 31 32 36 40 41 42 43 51 54 61 67 68 69 78 98 bbbbbbbwbbbbbbbot‘b oooooooooomoouaoooooooooooooomoooo |HHHHHHHNHHHHHHHNHH Total 21 10 O 0 Mean = 46.6 minutes Median 8 42.0 minutes Mode - 30.0 minutes Standard deviation = 21.1 minutes 163 The remaining 9 subjects experienced second stages that were longer than the mean. A normal distribution curve is approximated when the lengths of the second stages of labor are graphically plotted against the frequency of occurrence (see Figure 6). Research Question 2. Do any of the intervening variables correlate with the length of the second stage of labor in women who used the recumbent position? Utilizing the Pearson Product Moment Correlational technique, no significant relationships (p 3 .05) were found between any of the intervening variables and the length of the second stage of labor in the recumbent position (see Table 13). Research Question 3. Do any of the demographic descriptors correlate with the length of the second stage of labor in women who used the recumbent posi- tion? There were no significant relationships between the demographic descriptors and the length of the second stage of labor in women who used the recumbent posi- tion (p 5 .05) (see Table 13). Research Question 4. Do any of the incidental variables correlate with the length of the second stage of labor in women who used the recumbent position? Again, there were no significant relationships (p £_.05) between any of the incidental variables and 164 SN .2 2:: H25 ozoomm no 1525 mmDSCwE m o 2 31 o: a: 2: a a e. a mmuscHE Ne cmwpm: r 4‘ p _ ,_ _ e _ _ b _ woDDCwE c.0q cmoz .cowuflmom ucmneoomm m CH mocwuusooo mo mocmsvmum nuw3 Honmq mo mmwum pcooom on» mo sauce; .9 muomwm SiOBPBflS jO EDEN/VON 165 Table 13 Correlation Values for Variables and the Length of the Second Stage of Labor Recumbent Position Variable r value P value Episiotomy .02 .46 Age .04 .44 Marital .03 .44 On call MD .22 .16 Childbirth ed .08 .38 Laceration .29 .11 Fetal monitor .31 .09 Weight @ term .07 .39 *Level of significance P :_.05 166 the length of the second stage of labor in women who used the recumbent position. Summary—-Research Questions 1-4. The descriptive and inferential statistics used to answer the four research questions identified by this study have been presented. The mean length of the second stage of labor in the recumbent position was 46.6 minutes with a stan- dard deviation of 21.1 minutes. There were no relation- ships identified between the intervening variables, demographic descriptors, or the incidental variables and the length of the second stage of labor. In the next section a brief presentation of the results obtained in the study by Sparks (1983) will be provided. In the study by Sparks (1983) the inter- vening variables, demographic descriptors and incidental variables were the same as in the present study. The four primary research questions in the study by Sparks (1983) are the same as the ones in the present study, except Sparks studied the upright position and the present study addressed the recumbent position. The frequencies of many of the variables in the upright and recumbent groups were similar, although not identical. In both groups, the majority of the women were white, married, primigravidas, with private insurance coverage. The age range, mean age and standard deviations for age were nearly identical between groups. 167 Differences between the upright and recumbent groups were apparent, however, in four areas. First, although the mean, median and standard deviation for weight gain were almost identical between groups, the majority of the subjects in the upright group experienced weight gains that fell below the mean. The majority of the women in the recumbent group experienced weight gains that were above the mean. Second, the frequency of lacerations in the recumbent group is more than twice that of the upright group, i.e., 38% in the recumbent group and 16% in the upright group. Third, the recum- bent subjects utilized the services of an HMO physician 18% more often than did the upright group, and the up- right group utilized the services of a private physician 18% more often than did the recumbent group. Finally, when the distribution curves of the upright and recum- bent groups that plot the length of the second stage of labor against the frequency of occurrence are com- pared, the curve of the recumbent group resembles a normal distribution (see Figure 6). The curve that represents the upright group resembles a bi-modal, non- normal, distribution (see Figure 7). Due to the small sample size, it is unclear whether the distribution of the upright group really is bi-modal, or whether with a larger sample the distribution would resemble a bell-shaped curve. See Appendix C for frequency 168 «.mm mmuscfia mm mmuscwa we meadows m.oo nufl3 .uonmq mo mmmum pcoomm may mo sumcwq .1... 9:3 mofim ozoomm no :5sz as o: 3 2: g a e. a a cmflpmz _ _ p _ _ _ u L _ a _ I cams Fiflw \X/H “*4 c / x / 1 11 1 // \ < / N 1m \ , / / 7 \\ In I \ /¢ 1% K 11., .cowuwmom Havana: on Ca mocmunsooo mo wocmskum .h musmwm 81331908 30 HEEL/VON 169 distributions and percentages related to the study by Sparks (1983). ' Research Question 5. What is the mean length of the second stage of labor in primiparous women with uncomplicated pregnancies who deliver in the upright position? Twenty-five women used the upright position. The length of the second stage of labor for these women ranged from 18 minutes to 130 minutes, with a mean length of 60.9 minutes and a standard deviation of 35.4. The mode was 27.0 and the median was 46.0. More than one- half (60%) of the subjects had second stages of labor that were less than the mean, while the remaining 10 subjects had second stages that were longer than the mean. When the length of the second stage of labor is plotted against the frequency of occurrence, the resultant distribution does not resemble a bell-shaped curve. The non-normal distribution was expected due to the wide variation between the mean, median and mode. It is unclear whether the bi-modal distribution is an actual representation of the relationship that exists between the upright position and the length of the second stage of labor, or as was discussed above, it is a result of a small sample size. A much larger study would be necessary to clarify this relationship. Research Question 6. Do any of the intervening 170 variables correlate with the length of the second stage of labor in women who used the upright position? One variable, laceration, did show a significant correlation with the length of the second stage of labor. A very slight relationship between the two variables was identified indicating that those women without lacera- tions were likely to experience longer labors than those women with lacerations in the upright position (r = .34, p 3 .05). Research Question 7. Do any of the demographic descriptors correlate with the length of the second stage of labor in women who used the upright position? One demographic descriptor, age, did show a fair to moderate relationship with the length of the second stage of labor, (r = .44, p i .05). That is, the length of the second stage of labor increased directly with the age of the women. Research Question 8. Do any of the incidental variables correlate with the length of the second stage of labor in women who used the upright position? No significant relationships were identified between any of the incidental variables and the length of the second stage of labor (p §_.05). Summary-—Research Questions 5-8. The descriptive and inferential statistics used to answer the four research questions from the study by Sparks (1983) 171 have been presented. The mean length of the second stage of labor in women who used the upright position was 60.9 minutes, with a standard deviation of 35.4. One intervening variable, laceration, had a positive relationship with the length of the second stage of labor, (r = .34, p 5 .05). That is, those women in the upright group without lacerations were more likely to experience longer second stages of labor. One demo- graphic descriptor, age, also correlated with the length of the second stage of labor, (r = .44, p §_.05). Thus, as the age of the woman increased, so did the length of the second stage of labor. Having presented the data on the four research questions from the present study and the four questions from the study by Sparks (1983), data will now be pre- sented that describe the results from the combined data of the two studies. Research Question 9. Is there a statistically significant difference in the mean length of the second stage of labor in primiparous women with uncomplicated pregnancies who use an upright or a recumbent position? There was no statistically significant difference found between the mean lengths of the second stage of labor in the upright and recumbent groups (p §_.05). The actual level of significance between the two means was p = .111. The mean length for the upright group 172 was 60.9 minutes with a standard deviation of 35.4 minutes. The mean length in the recumbent group was 46.6 minutes with a standard deviation of 21.1 minutes. The numerical difference between the means was rela- tively small, 14.3 minutes. The distribution, es- pecially in the upright group, was scattered (see Figures 6, 7, & 8). That is, there was little tendency for clustering around the mean. In fact, as has been discussed earlier, a bi-modal distribution is sugges- ted. In the recumbent group, a more normal distribu- tion was evident with more clustering around the mean. Although the difference between the means in the two groups did not reach significance (p 5 .05), the difference did approach the identified significance level. It is also important to note that the differences between the means approached significance in the opposite direction than was expected, i.e., the mean length in the recumbent position was shorter than the mean length in the upright position rather than visa versa. Why this is true is unclear. Possibly, since age correlated with the length of the second stage in the upright position, the older women in the study may have caused the mean to be higher than was expected. In fact, if one superimposes the distribu- tion curves of the two groups, upright and recumbent, 173 is; mofim ozoomm no 157m: of oS 2: cm em 9. FL/” _ b! b _1 b p (L! _ \ signers: « 1| IIEoEnS .GOHUHmom Damnedowm paw ucmwumo cm a“ mocwuudooo mo >ocmsvmum :ufl3 Monmq mo mmmum oaoomm may mo summed mo COmwummEoo .m wusmflm SlOBPSflS :JO HBBWHN 174 it is apparent that the curve from the recumbent group and the curve from the first mode in the upright group are nearly the same. What is not known is whether the bi-modal distribution is a true representation or whether a normal distribution would be evident in a larger study. It is possible that in a larger study the differences would reach statistical signifi- cance. The lack of statistical significance was established by using a two tailed t-test, based on pooled variance estimates. The pooled variance estimates were necessary because of the unstable variances and unequal distribu- tions. It is possible that this instability occurred, at least in part, because of the small sample size in each group. The two tailed t-test was appropriately used, even though the variance and distribution of each group were unstable,because the t-test is robust to violation of normality and variance if the sample sizes are fairly equal (Hayes, 1973). The number of study subjects were nearly equal, N = 25 in the upright group and N = 21 in the recumbent group. Since the variances were unstable and the distri— butions were not equal, a non-parametric statistical test was also conducted. Using a Mann-Whitney U test, which tests the difference between two independent samples, no significant difference was found between 175 the mean length of the second stage in the upright and recumbent groups (p i .05). Research Question 10. Was there a significant correlation between age and position used for the second stage of labor? This question was asked because age had been shown to have a significant positive relationship with the length of labor in the upright position but not in the recumbent position. Using the Pearson Product Moment Correlational technique, no significant correlation was identified (see Table 14). Research Question 11. Was there a significant correlation between lacerations and the position used for the second stage of labor? This question was asked because once again the presence of a laceration had a positive correlation with the length of labor in the upright position, but there was no relationship identified in the recum- bent position. Therefore, the question arose as to whether a difference in frequency of lacerations between the upright and recumbent groups was present. The Pearson Point Bi-Serial Correlational technique was used for statistical analysis and a very slight correlation was observed, r = .25 (see Tablellfl. This means that the women who were recumbent were more 176 Table 14 Correlation Values for the Relationship between Age and Lacerations and the Position Used in the Second Stage of Labor Variable r value P value Laceration .25 .04* Age .05 .36 * P :_.05, subjects in the recumbent position were more likely to experience a laceration 177 likely to have lacerations. It is important to note that even though women in the recumbent position were more likely to have a laceration, the presence of a laceration did not correlate with the length of the second stage of labor, i.e., the presence of a laceration did not mean that the woman had a shorter second stage than she would have had without the laceration. When the birth canal is too small to allow delivery of the fetus, nature acts and causes tissue to split, thereby enlarging the birth canal, i.e., a laceration occurs. One would expect that the occurrence of a laceration would hasten the delivery of the infant. The results of the present study on the recumbent position, however, do not support this assumption. Nature acts and creates a laceration, but due to the position of the patient, nature is prohibited from further facilitating a shorter second stage of labor. The woman is not able to push effectively when in the recumbent position, and the forces of gravity are not able to aid expulsion. Therefore, although nature acts initially to facilitate the delivery by creating a laceration, nature's further action is restricted by the use of the recumbent position. 178 The incidence of lacerations in women who used the recumbent position was greater than in women who used the upright position. It is possible that the increased number of lacerations in the recumbent position is at least partially due to the abnormal ten- sion that is placed on the perineal tissues when a woman is placed in stirrups. The normal elasticity of the perineal tissues is disturbed and sufficient enlargement to accommodate the fetal head is often not possible. Thus a laceration occurs. In the upright position, when nature acts to have to create a laceration, nature is further able to act to shorten the length of the second stage of labor. Summarye-Research Questions 9-11. The analysis of the results from the two studies indicated that there was no statistically significant difference between the mean lengths of the second stage of labor in the upright and recumbent groups. The frequency of lacerations in the recumbent group was statistically different from that in the upright group, indicating that those women who delivered in the recumbent posi- tion were more likely to have a laceration (r = .25, p i .05). There was no relationship identified between age and position used for the second stage of labor. 179 Interpretation of the Findings The research problem for the present study was to identify the mean length of the second stage of labor in women who used a recumbent position. Coupled with the results from the study by Sparks (1983), the results from the current study were analyzed to answer the broader question of whether there was a statisti- cal difference between the mean length of the second stage of labor in the upright and recumbent positions. The data presented in the first portion of this chap- ter provided an answer to both of these questions, i.e., the mean length of the second stage of labor in the recumbent position was 46.6 minutes and there was no statistically significant difference identified between the recumbent and upright groups relative to the mean length of the second stage of labor. In the remainder of this chapter, an interpreta- tion of the results will be presented, including a discussion of unexpected findings and a comparison with previous research findings. The relationship of the results to the conceptual framework will be addressed and finally a discussion of how the results address the need for scientific evaluation of currently used traditional practices will be presented. The results from the present study identify a mean length of 46.6 minutes and a standard deviation 180 of 21.1 minutes for the second stage of labor in women who used the recumbent position. This mean is much shorter than the two hour limit that has been tradi- tionally identified as a safe length for the second stage (Pritchard & MacDonald, 1980). Thus, at least in terms of safety, use of the recumbent position for the second stage of labor falls well within the "safe" range. This safe range, however, has been established by tradition, not by scientific evaluation. The mean length of the second stage of labor for women who used the recumbent position in Liu's (1974) study was 74.6 minutes. The difference between the mean in the present study and the mean in Liu's study is considerable, 28.0 minutes (see Table 15). Since Liu did not report the standard deviation in her study, it is impossible to compare the variances of her study and the present study. Thus, reasons for the inconsis- tent results cannot be specifically identified. In Liu's study the age of the subjects was controlled, 20- 25 years. In the present study the age range was from 17-33 years. Thus, some of the discrepancy between the present study and the study by Liu could be a result of the age difference between the samples. Liu also did the recording of all the data during the labor and delivery period herself. In the present study, the labor and delivery nurses were responsible for recording 181 Table 15 A Comparison of Mean and Standard Deviation Values Second Stage of Labor Current Studies and that of Liu Category Hayes Sparks Liu (1974) Upright Position Mean (in Minutes) 60.9 34.0 Recumbent Position Mean (in Minutes) 46.6 74.6 Standard Deviation (in Minutes) 21.1 35.4 Unknown 182 the information regarding the patient's intrapartum experience. It is possible that the difference in recording techniques used between Liu's study and the present study might account for some of the differences in results. The remainder of the results from this project indicate that there is no statistically significant relationship between any of the identified variables and the length of the second stage of labor. The results from the study by Sparks (1983) identi- fy a mean length of 60.9 minutes and a standard devia- tion of 35.4 minutes for the second stage of labor in women who used the upright position. Once again this mean falls within the safe range identified for the length of the second stage of labor. Even though the mean length in the upright position was 14.3 minutes longer than the mean in the recumbent position, the mean for the upright position still falls within the safe range for the length of the second stage of labor. Thus, use of the upright position is appropriate if one desires a second stage of less than two hours. The mean from Sparks' study was 26.9 minutes longer than the mean for the upright position reported by Liu (1974), i.e., 34.0 minutes (see Table 15). Nevertheless, since the standard deviation was not reported, the amount of variances can not be established. Therefore, 183 the reason for the difference between the mean estab- lished by Liu and the mean established by Sparks cannot be identified. As with the recumbent group, however, the age of the subjects in the study by Sparks and the study by Liu were not the same. Thus, some of the inconsistencies between the results of the two studies might be due to the age differences of the subjects. One other possible difference between the two studies relates to the recording of information during the intrapartum period. In Liu's study she recorded her own information: in the study by Sparks, the labor and delivery nurses recorded the information. This difference in recording methodology could be responsible for the differences in the results between the two studies. Sparks found significant correlations between two variables and the length of the second stage of labor. There was a fair to moderate correlational relationship between age and the length of the second stage of labor (r = .44, p 5 .04), i.e., as the age of the patient increased so did the length of the second stage of labor in the upright position. In Sparks' study, the age range was 17-32 years. It was suggested in Chapter II that one might expect the length of labor to increase somewhat, as the age of the woman increased, given the general physiological changes that occur with the aging 184 process. No literature was found, however, that addresses this possibility. Nevertheless, the research findings from the study by Sparks (1983) do demonstrate a relationship between age and the length of the second stage of labor in the upright position. These initial findings by Sparks, then, warrant further investigation and research. The other variable in Sparks' study that had a significant correlation with the length of the second stage of labor was lacerations. A very slight relation- ship between the two variables was identified (r = .34, p i .05). The correlation identified indicates that women who have lacerations tend to have shorter second stages of labor in the upright position. A laceration occurs when the size of the birth canal is not large enough to allow the fetus to be expelled. Thus, one would assume that once a laceration had occurred, the birth process would be facilitated. The study by Sparks validates this assumption. In the upright posi- tion, once the laceration occurred, the forces of gravity, the contraction of uterine and abdominal mus- cles and the mother's bearing down efforts combined to create a shorter second stage than would have occurred without a laceration. Having provided an interpretation of the results 185 from the present study and the study by Sparks (1983), the combined results from the two studies will be dis- cussed. The mean length of the second stage of labor in the recumbent position was 46.6 minutes, while in the up- right position the mean length was 60.9 minutes. Based on previous research done by Liu (1974) it was thought that the women who used an upright position would have a shorter second stage than those who used the recumbent position. The results of the current studies are, how- ever, different from those presented in Liu's (1974) article. Lius identified a mean length of 34.0 minutes in the upright position and a mean of 74.67 minutes in the recumbent position. Three important questions need to be asked in rela- tion to the inconsistent results between Liu's study and the present studies. First, why did women who used the recumbent position have longer labors in Liu's study and shorter labors in the current studies, while labors in the upright position were shorter in Liu's work and longer in the present studies? The answer to this question is not readily available. Several possible explanations, however, can be suggested. Since Liu did not publish any of her raw data, it is difficult to compare her sample with the present study subjects for similarity. Liu's sample may have been quite dissimilar 186 from the current study subjects. It is known that Liu's sample was younger than the study subjects used in the current studies. This difference could account for some of the inconsistent results. Liu also did not report the standard deviation in her two groups of subjects, so it is unclear whether the variances were different than those in the current studies. If the variances in the study by Liu and the present studies were not similar, then it is possible that the women Liu evaluated were inherently different from those women in the present studies. If this were true, one would not expect the results to be consistent. It is also unclear whether outliers might have greatly affec- ted the calculation of the means, either artificially shortening or lengthening the true means in Liu's study. Since Liu did not present any frequency tables in her article, the possibility of outliers cannot be excluded. Second, Liu found a large difference between the means of the upright and recumbent groups--40.0 minutes-- while the differences between the means in the current studies is only 14.3 minutes. Again, if the samples contained outliers that caused the means to be non- representative, the difference between the means may also have been greatly affected. Finally, the question arises as to why Liu found a 187 statistically significant difference between the means and the difference between the means in the present studies did not reach significance. First, if outliers were present in one or both of Liu's groups, this could account for the significant difference between the means. Liu also did not identify the significance level used in her study. The level she used might have been much lower than was used in the present studies. Second, Liu was present during all of the labors and deliveries, so the same person was recording the data for all of the study subjects. In the present study and the study by Sparks (1983) the nurses in the labor and delivery department recorded the information used in the studies. Thus, one difference between Liu's research and the present studies may be related to the consistency with which the data was recorded. It is assumed that Liu remained consistent in her method of recording through out her project. Since Liu was not directly involved in patient care, she was able to document information as it occurred, rather than having to chart in retro- spect as is often the case in a busy labor and delivery department. In the present studies the nurses may have had to rely on memory when they documented the onset of the second stage of labor. If this was the case, some of the lengths of the second stage of labor could have been altered by several minutes. Thus, the possibility 188 of inconsistent and/or inaccurate documentation in the present studies could be responsible for the absence of a significant difference. It is also unclear in Liu's study whether some specific schedule for vaginal exams was used or whether, as in the present studies, the exams were done strictly as the health care provider saw appro- priate. In Liu's study, if there was some specific routine used for vaginal exams, the patients may have been examined more or less frequently than in the present studies. Therefore, the documentation of the onset of the second stage could have been influenced by the fre- quency of vaginal exams. If in Liu's study there was a prescribed schedule for vaginal exams and in the present studies there was not, this difference in procedure may have accounted for some of the inconsistency in results. Lastly, it is possible that the number of study subjects in the present study and thesmudy by Sparks (1983) were too small to yield statistically significant results. In Liu's study, however, only 30 subjects were included in each group. In the present studies there were 21 in the recumbent group and 25 in the up- right group. Even with a larger number of study sub- jects, it is possible that there would still be no significant difference between the means. It is also possible that Liu's (1974) results may not be an accurate indicator of the true relationship between position and 189 the length of the second stage of labor, and that the results of the present study and the study by Sparks (1983) are reflective of that relationship. Clearly more research needs to be done to provide a clearer picture of the relationship between position and the length of the second stage of labor. Methodological Problems In addition to those problems that have been dis- cussed above, i.e., inconsistent, inaccurate recording; small sample size, several other methodological problems may have affected the results of the study. First, the documentation related to the onset of the second stage of labor may have been affected by the frequency with which vaginal exams were performed. There- fore, the accuracy of the actual lengths of the second stage of labor could be questioned. Second, the weight of the baby was not recorded, so there was no way to identify whether the size of the baby affected the length of the second stage of labor. It is possible that those women who had the longest labors also had large infants. Third, information was not recorded related to the stage of labor the woman was in upon ad- mission to the hospital. Information also was not recorded as to the phase of labor (level of activeness) nor the fatigue level of the woman. If the patient 190 was admitted in a prolonged latent phase and was already fatigued, these factors could have affected the length of the second stage of labor. Finally, one of the most important limitations is related to the way in which the two birthing positions were defined. It is possible that the 300 angle identified as the level above which an upright position was assumed created a position that was not different enough from the recumbent position to produce statistical significance. For example, an up- right position above 55°, as has been suggested by Roberts (1983) may have been needed for a difference to occur. If the two positions being evaluated were poten- tially not physically different, then the fact that no statistical difference was found is not surprising. It is interesting to note, however, that the definitions used in the present studies were the same definitions used by Liu (1974) and she did identify a significant difference between the two groups. The retrospective survey approach used in the present studies was advantageous because it facilitated rapid data collection with a minimal time and financial commit- ment on the part of the researchers. The retrospective approach also served to help test the effectiveness of the study design, conceptual definitions and instruments in a way that was cost effective. The retrospective approach did, however, have some limitations that must be 191 addressed when considering a larger study. First, the only data that can be collected is what was recorded, i.e., if the researcher desires information about patient occupation, but nothing is indicated on the chart about occupation, then the researcher has no way of obtaining that information. As has been mentioned previously, the accuracy and consistency of recording is dependent upon others outside the research team. Thus, the validity of the identified results may be questionable. It would be important when doing a larger study on birth- ing position to utilize a prospective design in order to deal with the important methodological problems in- herent in the retrospective approach. The retrospective design does work well for conducting a pilot study prior to a large research project. The retrospective approach allows the researchers to identify problems that were unknown or unexpected in a way that is cost effective and time efficient. Relationship of Results to Conceptual Framework Nightingale's Theory of Nursing was used as the basis for the conceptual framework in the present study because of the important part the environment plays in her theory. One of the reasons that many consumers are dissatisfied with hospital births is because of the rigid environment that is currently a part of the hospital setting. The 192 present study and the study by Sparks (1983), utilizing Nightingale's theory, evaluated the effect of two different physical environments (birthing positions), on the length of the second stage of labor. The results from the two studies indicate that there is no statis- tical difference between the two positions. At least in relation to the length of the second stage of labor, both positions are equal. Thus, it would seem that which ever position was preferred by the client would be apprOpriate. Nightingale would agree with the pre- vious statement, as she believed that in order to put the patient in the best condition for nature to act, one must consider the physical environment realizing in so doing the social, psychological and spiritual environments as well will be affected. Since one posi- tion cannot be said to be better than the other, the position used for the second stage of labor should be based on the patient's individual choice, barring the occurrence of any complications. In the conceptual framework utilized in this study it has been said that nursing is to put healthy mothers and infants in a condition for nature to act to preserve health and prevent disease and injury. The results from the present study and the study by Sparks (1983) have identified that neither birthing position can be said to be better than the other relative to the length of the 193 second stage. If it is true that either position is acceptable, then as nurses we must assess what the client feels is the best position for her, the position in which nature can best act for her, and then facilitate use of that position. Relevance of the Study The results of the present studies provide important and necessary information regarding birthing positions. To date there have been few scientific evaluations of current birthing practices conducted. The present studies have partially addressed one area of concern, that being the relationship of birthing position to the length of the second stage of labor. The present studies have focused on the aspect of length in each position. It is clear that many more variables need to be scien- tifically evaluated to fully understand the importance and meaning of the position used for birth. The present studies have produced results, however, that support the use of either position when length of the second stage is considered. It seems, then, that the results from the present study and the study by Sparks (1983) begin to address the need identified in Chapter I for scientific evaluation of currently used traditional practices. 194 Summary The information presented in Chapter V included data related to the present study, the study by Sparks (1983) and the combined data from the two studies. A mean of 46.6 minutes for the second stage of labor in the recumbent position with a standard deviation of 21.1 minutes was identified. In the upright position a mean of 60.9 minutes for the second stage of labor was identified with a standard deviation of 35.4 minutes. None of the variables identified had significant corre- lations with the length of the second stage of labor in the recumbent position (p 5 .05). In the upright position age correlated with the length of the second stage of labor (r = .44, p 5 .05). Thus as the age of the patient increased, the length of the second stage of labor tended to increase in the upright position. One other variable, laceration, demonstrated a significant relationship with the length of the second stage of labor in the upright position (r = .34, p j .05). This relationship indica- ted that those women without lacerations tended to have longer second stages of labor in the upright position. The student's two tailed t-test, based on pooled variance estimates, was used to calculate the difference between the means of the upright and recumbent groups. Due to the unstable variances and distributions, a 195 non-parametric test, the Mann-Whitney U Test was also conducted. With these statistical techniques, no sig- nificant difference was found between the means of the two groups (p i .05). Since age showed a positive correlation with the length of the second stage of labor in the upright position and no relationship between age and the length of the second stage was identified in the recumbent group, analysis was carried out to identify whether age and position used were correlated. No significant correlation was identified. The presence of a laceration correlated with the length of the second stage of labor in the upright group, but not in the recumbent group, so once again analysis was conducted to identify whether there was a relationship between lacerations and position used. A correlation of r = .25,(p S 05)was identified, indica— ting that women who were recumbent were more likely to have a laceration. The most significant findings produced in the pre- sent studies are the mean values for the second stage of labor in the upright and recumbent group and the fact that no statistically significant difference was found between the means of both groups. In Chapter VI the implications for nursing as they 196 relate to education, service and research will be presented. CHAPTER VI SUMMARY AND CONCLUSIONS Overview In Chapter VI a summary of the research findings is presented. In addition, conclusions are drawn with im- plications and recommendations for nursing education, nursing service, and nursing research. Summary of Findinge A retrospective survey was conducted to evaluate the relationship between birthing position and the length of the second stage of labor. The present study identified the length of the second stage of labor in primiparous women with uncomplicated pregnancies who used the recumbent position. A study by Sparks (1983), done concurrently with the present study, examined the same question for women who used an upright position. The data from the two studies were analyzed together to answer the broader and more clinically applicable question; is there a significant difference in the mean length of the second stage of labor in primiparous women with uncomplicated pregnancies who use an upright or a recumbent position? The impetus for the present 197 198 study, and the study by Sparks (1983) came from the increasing consumer dissatisfaction with the birthing practices currently being used in hospitals. With the beginning of the consumer movement in the 19603 came an increased awareness and concern over health care issues. One specific health issue called into question was the medically mandated practices associated with childbirth. Not only was there an increased consumer awareness concerning health care issues in the United States, but these same consumers were becoming more knowledgeable about health care practices in other countries as well. This increased knowledge caused consumers to begin questioning cer- tain practices that were carried out in the United States. Many questions arose as to why in the United States the recumbent position was used for birthing while in many other countries some form of upright position was used almost exclusively. When consumers asked this question of providers, a satisfactory answer was not forthcoming. Further investigation by consumer groups and providers alike brought the realization to light that many practices currently being routinely used in the childbirth experience, including use of the recumbent position, have their basis only in tradition, never having been scientifically evaluated. 199 Consumers are also objecting to the current assump- tion that birth is a pathological event and therefore should include much technological and medical inter- vention. Prior to the discovery of anesthetic agents in the late 18003, childbirth was considered a normal, natural process, and it occurred in the home. With the availability of anesthesia, and a promise of pain- less childbirth, deliveries moved from the home to the hospital where one intervention seemed to necessitate another and another. What was once a normal, natural event has been altered by the use of IV's, monitors, medications, instruments, sterile delivery rooms and rigid policies for most deliveries regardless of the nature of the delivery, i.e., high risk or low risk. Because of the consumer dissatisfaction with many current practices surrounding the birth experience, and the unwillingness of many providers to alter these practices, an increasing number of home births are occurring. The relative safety of giving birth at home is questionable since the majority of home births are attended by lay midwives whose training and com- petence vary widely. As was previously stated in Chapter I, this author views the practice of lay mid- wife attended home births as an unsafe alternative to a hospital birth. if the home births that are 200 occuring were attended either by physicians or certi- fied nurse midwives, then, in this author's opinion, the option of giving birth at home would be a safe alternative. Most physicians, however, will not par- ticipate in home deliveries, feeling that the security of the hospital delivery room with all of its emer- gency equipment is much preferable to delivering in a home where the amount of equipment and number of trained personnel are very limited. If certified nurse midwives are to participate in home deliveries, they need the assurance of medical back-up which physicians are reluc- tant to give. Thus, most certified nurse midwives do not participate in home deliveries either. The number of certified nurse midwives in this country, although growing, is still small and they are not evenly dis- persed geographically, so even if nurse midwives were actively participating in home deliveries, much of the country would not have access to their services. Thus, even though home deliveries, attended by physi- cians or certified nurse midwives, appears to be a safe option, it seems unlikely that this option will be readily available in the near future to all fami- lies who desire a home birth. It seems that a more "immediate" answer to the problem of lay midwife attended home deliveries is 201 to create an atmosphere within the hospital setting that is more flexible and responsive to the individual needs of the pregnant woman and her family. It seems important, then, to begin to evaluate some of the currently used practices and the alternative approaches that consumers are requesting, and where possible to be flexible in the care provided. In an attempt to evaluate consumer concerns about rigid hospital practices, the present study and the study by Sparks (1983) were undertaken. It is hoped that through the use of the scientifically obtained results from the two studies, a reversal in the increas- ing trend toward lay midwife attended home births will be possible. In Chapter II the concepts related to the research problem were presented, defined and discussed and the conceptual framework was presented. The conceptual framework for the current project was based on Night- ingale's Theory of Nursing. The basis of Nightingale's theory is that the environment (physical, psychologi- cal, social and spiritual) must be such that nature can act to preserve or restore health. In other words, Nightingale said that nurses or doctors do not heal the body, the body heals itself. It is the responsibility of the health care provider to put the patient in such a condition that the body can heal 202 itself. If as health care providers we create such rigid policies in our hospitals that patients feel forced to deliver at home, it does not seem that we are putting the body in the best condition to heal itself. The present study and the study by Sparks (1983) have been undertaken in an attempt to offer some scientific justification for a more flexible birthing environment within the hospital setting. If flexibility becomes the key word in responding to consumer requests regarding the birthing event, it may be possible to maintain the hospital as an acceptable place to deliver. In so doing, this author feels that as health care providers, we are putting the patient in the best possible condition in which nature can act. If flexibility is not instituted, and the number of home births continues to increase, then the environment the patient finds herself in may be unsafe for the mother and the infant. That is, nature may not be in the best possible condition in which to act. A review of the literature related to the present study is presented in Chapter III. In doing a litera- ture search it was found that very little research has been done on the length of the second stage of labor. Several authors identify that an upright position is 203 better than a recumbent position for the second stage of labor; this conclusion, however, is often based on judgement and intuition rather than on a large body of scientifically conducted research (Caldeyro-Barcia, 1979; Atwood, 1976; McKay, 1980). A review of the literature was also done to identify the historical trends related to childbirth in the United States, trends in cross cultural birthing practices and con- sumer issues related to childbirth practices. Litera- ture related to the intervening variables identified in the present study was also presented and critiqued. The literature reviewed revealed a paucity of research related to the mean length of the second stage of labor. It was also found that a minimal amount of research has been done on variables that might affect the length of the second stage of labor. The methodology that was used to develop and imple- ment a retrospective survey was presented and discussed in Chapter IV. The population utilized in the present study were primiparous women who experienced vaginal deliveries at a Midwestern Metropolitan Catholic Hospi- tal. Screening Tool #1 (see Chapter IV, Figure 3) was used to determine a sub-population from the popula- tion described above, eliminating those women who had experienced complications during the pre-natal or labor and delivery periods. Screening Tool #2 (see 204 Chapter IV, Figure 4) was then used to assure similarity concerning seven variables that have been shown to affect the length of labor. When the requirements for Screening Tool #1 and Screening Tool #2 were met, data collection proceeded using a data collection tool developed speci- fically for the present study and the study by Sparks (1983). The study subjects utilized in the present study were those women who met the criteria established in Screening Tools #1 and #2 aud_who used the recumbent position for the second stage of labor. The study sub- jects in the project done by Sparks (1983) met the same criteria as those in the present study, however, in Sparks' (1983) study, the women used an upright position for the second stage of labor. Chapter V included a presentation of the research question and identified and discussed the statistical techniques used in analyzing the data. The results were also presented and an interpretation of the results offered. Descriptive statistics used inthe present study included frequencies, percentages, means and standard deviations. Inferential statistical techniques used were the Pearson Product Moment Correlation and the Pearson Point Bi-Serial correlation. A total of eleven research questions were identified; four from the current study, four from the study by 205 Sparks (1983) and three from the combined data from the two studies. The mean values and the standard deviations for the length of the second stage of labor were iden- tified for primiparous women who used the recumbent position and for primiparous women who used the upright position. The mean for the recumbent group was shorter than the mean value for the upright group, however, the difference between these means was not statistically sig- nificant. It is important to note, however, that the difference between the means did approach the identified significance level. In the recumbent group, none of the identified variables (intervening, demographic, inciden- tal) significantly correlated with the length of the second stage of labor. In the upright group a fair to moderate correlation was identified between age and the length of the second stage of labor (r = .44). This relationship suggests that as the age of the patient increased, so did the length of the second stage of labor. The intervening variable, laceration, also correlated with the length of the second stage of labor in the upright position (r = .34). A very slight rela- tionship between the variables was identified indica- ting that those women without lacerations tended to have longer second stages of labor. Since age and lacerations correlated with the length of the second stage of labor in the upright position, 206 but not in the recumbent position, analysis was carried out to determine whether these two variables correlated with the position used for the second stage of labor. With the variable age, no significant relationship was identified. With the variable laceration, however, a very slight correlation was identified, indicating that women who were recumbent were more likely to have lacera- tions, (r = .25). Recommendations and Implications for Nursing The results of the present study and the study by Sparks (1983) have implications for nursing education, nursing service and nursing research. A discussion follows in which the implications will be identified and recommendations made for each of the three areas of nursing. Nursing Education. The results of the present studies indicate that there is no significant difference between the mean lengths of the second stage of labor in women who used the upright or recumbent position. Thus, it would seem that at least relative to the length of the second stage of labor, either the upright or recumbent position would be acceptable. Since one of the major consumer concerns relates to the routine use of the lithotomy position for the second stage of labor, the results from the present studies indicate that the 207 upright position is an acceptable alternative. With these results in mind, nursing educators at all levels of education must begin to alter their instruction to include alternative birthing positions and a type of nursing care that is more responsible to individual needs. Nurses who do respond to individual needs truely practice the concept of family centered maternity care, responding to and supporting the family in their attempts to deal with the birthing event in a meaningful and appropriate way for them. Nursing educators at all levels must insure that the maternity content presented does indeed teach a family centered approach. That being, not just the allowing of some members of the family to be present during labor and/or delivery, but also assessing the unique individual needs of the family, and then providing care that meets those assessed needs whenever possible. Family centered care cannot be pro- vided if every family admitted to labor and delivery must follow the same rules and receive the same type of care. Nursing educators must be sure that the concept of family centered maternity care is fully understood and integrated into the practice styles of their students. The key word when truely providing family centered care is flexibility. Educators of nursing students must teach about the concept of flexibility 208 but more importantly, they must demonstrate and role model flexibility as they interact and relate with patients and their families. Before faculty can teach flexibility to their students, however, they must believe in and practice flexibility themselves. One method of fostering a flexible approach in faculty is to assure that as faculty, they regularly attend a variety of professional meetings or seminars. Exposure to different approaches and methods potentially expands one's ability to pro- vide the care that is needed by a broad variety of patients. For at least the past ten years, hospital obstetri- cal units have been espousing the family centered approach to maternity care. And yet, many of the young nurses that are graduating and working in labor and delivery today are no different in their approach to patients than nurses were before the family centered approach was instituted. What then does this say to maternity nursing educators? Quite obviously, it says that we have been relatively unsuccessful in our attempts to teach flexibility and attention to unique individual needs. In the opinion of this author, nursing education has been unsuccessful in this area because flexibility has been talked about, discussed and pro- posed, but rarely demonstrated by clinical faculty. 209 If nursing education is to produce graduates who address the current consumer concerns related to birth- ing practices, nursing educators must be knowledgeable about these concerns and use creative approaches to educate students about consumer concerns. The concept of flexibility and individualization of care must be taught. Most critical, however, is to act as a role model for students when providing maternity care. By giving credibility and respect to the needs and requests of the patient and her family, and by demonstrating a flexible approach to the nursing care provided, nursing educators can have a great impact on the way future labor and delivery nurses will function. In order for nursing educators to role model a flexible approach to patient care, they should first develop credibility as a practitioner with the nursing staff. In order to establish their competence as a clinician, nursing educators should actually work as a "nurse" in the labor and delivery department. Once the nursing staff has recognized for themselves that the nurse educator is a competent clinician, and once the nurse educator has developed a good working relationship with the staff, then role modeling a flexible approach to care should be possible for the nurse educator. It is critically important, however, that the nurse edu- cator take the time to establish her credibility with 210 the staff, or attempts at demonstrating flexible, individualized care may be thwarted by staff nurses who are threatened by this approach to care. One way nursing educators can begin to demonstrate flexi- bility in the labor and delivery area is to support patients in their desire for a birthing position other than lithotomy. The results of the present studies would support the use of an upright position as an acceptable alternative. Nursing Service. The results of the present study and the study by Sparks (1983) identify mean lengths for the second stage of labor that fall well within the two hour limit that denotes a safe length for the second stage of labor (Pritchard & MacDonald, 1980). Since there was no statistical difference found between the means and since both means fall within the safe time limit, it would seem appropriate to support patients in their choice of positions rather than merely impose the lithotomy position on all patients. As with nursing education, flexibility in meeting patient's needs is critical. Traditionally labor and delivery nurses have not been particularly creative or imaginative in their approaches to patient care. Tradition has often determined nursing care as well as medical interventions. Consumers are now asking for a more flexible, individualized approach to the 211 nursing care provided. One area where flexibility should be possible is related to the position used for the major part of the second stage of labor. Since many patients do some part of their pushing in the labor room under the direction of the nurse, why do nurses insist that patients be flat or almost flat on their backs to push? The answer seems to be related to tradition. When patients do push in the delivery room they have traditionally been on the delivery table in the lithotomy position. If that works in the delivery room why not use the same position in the labor room. The consumer movement has challenged the use of the lithotomy position. The consumer movement has called into question some of the routine traditional practices related to childbirth. What the present studies have done is to evaluate from the perspective of time, the traditional use of the recumbent position and an alter- native position, the upright position. The results of the current studies indicate that relative to the length of the second stage, either position is accept- able. What this says to nursing practice is that patients should be allowed to choose whatever position seems best, most comfortable, most effective, most satisfactory to them. The results do not demonstrate that one position is better than the other, nor do the results imply that the upright position should be used 212 for all patients. By demonstrating that there is no significant difference in the two positions relative to length of the second stage, the results lead one to conclude that patient preference should be the determinent in the choice of a birthing position. Much of the nursing care provided in labor and delivery is determined strictly by the nursing staff. Therefore, providing flexible care that meets the needs of the individual patient is only as difficult as getting the nursing staff to stop relying on tra- ditional ways of functioning and begin using creative approaches to patient care. Nurses need to be encour- aged to evaluate patient requests based on knowledge of safety to the mother and fetus. Patient requests should ESE be evaluated based on whether they are consistent with the nurse's value system or beliefs. In other words, nurses must use a non-judgemental approach in providing safe nursing care. To create a flexible labor and delivery nursing staff, the nurse in charge must fully believe in the concept of flexibility and must be willing to work with the nursing staff amd administration to assure that patient needs are respected. Nurses who are responsi- ble for the staffing in labor and delivery must insist on having staff that are flexible and must insist that 213 nurses who maintain a rigid way of functioning are transferred out of the department. Without this deep commitment to flexible family centered care, nursing staffs that contain rigid traditionalists will continue to cause some pregnant women and their families to decide against the hospital for childbirth. Nurses in leadership positions must also be aware of the current research being done in the area of child- birth and must be able to evaluate the quality of the research and understand the implications for nursing practice. Results from research must then be trans- ferred to nursing staffs in such a manner that they can be practically applied to daily nursing care. In so doing, nursing is altering or augmenting care in res- ponse to scientific evaluations, and thus responding to consumer requests for evaluation of the currently used practices. Nursing, utilizing the results from the present studies, must also interface with the medical pro- fession and act as patient advocates for the patients in labor and delivery. Nurses are in a position to begin initiating changes in practice that have been traditionally determined by physicians. The nurses in the labor and delivery department spend much more time with the patient than does the physician. If the nurse spends some time with the patient and her family 214 identifying their desires related to birthing, then the nurse can act as an advocate with the physician to help the family achieve a satisfying experience. The nurse can make suggestions to the physician regarding certain procedures or can specifically re- quest particular orders that allow the patient to function as she desires, but still protects the safety of the mother and the baby. The results of the present study should be used by nurses to advocate patient choice in relation to position used for the second stage of labor. Nurses must also be willing to support patient choices when those choices are safe, but counter to physician preference. There are several barriers, however, to the flexi- bility that has been suggested above. First, the specific policies and procedures that are established by the hospital and the obstetric department may decrease the level of flexibility that is possible as nurses. This may be especially true in relation to who can visit the laboring mother, i.e., young children or non-family members. It may also be true in relation to the presence of a support person being present during all deliveries, even cesearean sections, or deliveries where maternal and/or fetal complications are expected. Nurses can, however, work to have 215 policies that prohibit flexibility changed so that individualized care can be provided. Second, specific physician's orders may limit the amount of flexibility the nurse can provide. The nurse can act as a patient advocate with the physician to insure that the patient's desires are made known. Third, one of the greatest barriers to flexible care relates to how much nurses see their practice as an independent function and how much they see their practice as being dependent upon the physician. If the nurses that work in labor and delivery view their practice as being dependent on the physician, then a very minimal level of flexibility will be present. Finally, the inability or unwillingness of nurses to be risk-takers also prohibits flexibility. Nurses who are unwilling to approach a physician with an alternative suggestion or who are unwilling to allow a patient to try something non-traditional but safe, will continue to provide the same kind of care for every patient. Although these barriers are significant, much can be done to decrease the effect they have on flexible care if nurses are willing to take risks, speak out, and work for change in the way the system currently functions. If these barriers continue and if the patient feels a lack of support from the nursing staff and the physician, then the obvious choice will 216 be to experience future deliveries in a different setting. Often the only option to the unacceptable atmosphere of the hospital is the home birth. In sum, nursing service must first provide a total staff in labor and delivery that is flexible and concerned with meeting the unique individual needs of each family. Second, the nursing leadership in the labor and delivery department must be knowledge- able about current research being done in the child- birth area and must be able to interpret the results of that research for nursing practice. Finally, nurses in labor and delivery must act as patient advocates with the medical profession to support the patients in choices surrounding the whole birthing experience. Utilizing the results from the present study and the study by Sparks (1983), nurses must support the patient in her choice of a position for the second stage of labor that is appropriate for the patient. Nursing Research. The results from the present study and the study by Sparks (1983) provide answers to some important questions. But they also raise many questions as well. One of the questions arising from the results of the present studies is related to the previous research that has been done by Liu (1974). The results 217 of the study by Liu (1974) indicate that in an upright position the mean length of the second stage of labor was shorter than the mean length in the recumbent posi- tion. Liu's (1974) study also identified a statistically significant difference between the mean values of the two groups. The results of the present studies are not consistent with those identified in Liu's (1974) research. In fact, the results of the present studies approach significance in the opposite direction. This inconsistency between Liu's results and the results of the present studies indicates that the precise rela- tionship between birthing position and the length of the second stage of labor is unclear. A much larger study must be conducted with the same rigid controls as those used in Liu's work and the present studies to provide more conclusive evidence of the relationship between position and the second stage of labor. In a larger study it would be important to assure consistency in dobumentation of the labor and delivery information. In other words, depending on the labor and delivery nurses for documentation would not be advisable. People not involved in patient care and who have been trained for the documentation procedure should be included in the research design. Those people doing the documentation must be trained to identify whether the nursing and medical management 218 of the women in the upright and recumbent groups is similar or different. If the management is different between the two groups, then comparing the results from the two groups is inappropriate, as any difference identified might well be due to the difference in management. Another recommendation regarding a larger study would be to define the upright position differently than was done in the current studies. Keeping the definition of the recumbent position at less than 30°, the upright position, based on work by Roberts (1983) might well be 550 and above, leaving a group between 30°-55O as an intermediate position. In this way any difference between recumbent and upright would be more evident. In a larger study it seems important to study at least three other variables not considered in the present studies. First, since Lederman et a1. (1979) identified that anxiety can lengthen labor, a measure- ment of the patient's anxiety level would be extremely beneficial in evaluating the results of a study on the length of labor. Second, it is possible that the fatigue level of the mother has an effect on the progress of labor (Roberts, 1983). With this possi- bility in mind, it would seem important to evaluate the mother's level of fatigue upon admission to the 219 hospital, i.e., has she been in labor at home for several hours and is already physically exhausted or was the onset of labor recent, so that her fatigue level is minimal. Finally, it seems important to carefully measure the length of the first stage of labor and compare that to the length of the second stage of labor. Since there is no one criteria that identifies the onset of the first stage used by providers, evaluation of the length of this stage is somewhat difficult. In the present studies, the onset of the first stage was by patient report. The patient was asked when her labor began and that time was recorded as the onset of the first stage. A much more rigid criteria for the onset of the first stage should be identified and measurement of that criteria should be controlled. In this way one would assure a more consistent determina- tion of the first stage of labor and this information would be more valuable when comparing the length of the first stage to the length of the second stage. In the study by Sparks (1983) a bi-modal distri- bution was depicted by graphically plotting the length of the second stage of labor against the frequency of that length. A much larger study would identify whether this bi-modal distribution in Sparks' 220 study was merely a result of a small sample size, and therefore a larger study would produce a normal distribution curve, g£_whether the bi-modal distribu- tion was indicative of a relationship not identified in Sparks' study. This question provides another reason for replication of the present studies on a much larger scale. Since the relationship between position and length of the second stage is uncertain at this point, a larger study should more fully evaluate this relation- ship, bu£_a larger study should also evaluate para- meters other than length in relation to birthing posi- tion. Variables such as patient satisfaction, patient comfort and patient participation in the birthing event should be evaluated in relation to the position used for the second stage of labor. It is possible that variables other than length of the second stage correlate positively with the birthing position used. It is also possible that factors other than length of the second stage are important about alternative birthing positions. Thus, to fully understand the relationship between birthing position and the second stage of labor many more variables besides length must be scientifically evaluated. In sum, the recommendations for nursing research include replication of the current studies with a 221 much larger sample size, documentation done by trained researchers who can also evaluate management for simi- larity between groups, and evaluation of variables such as patient comfort, patient anxiety, fatigue, length of the first stage, patient satisfaction and patient participation in relation to birthing position used. If this research is done, a much more complete picture related to alternative birthing positions will be available for nursing to use as a basis for care. Conclusion The conclusions that can be drawn from the present study and the study by Sparks (1983) are straight for- ward and uncomplicated. Since the results derived from the individual studies and the results from the analysis of the combined studies are not consistent with the previous work of Liu (1974) one could conclude that the relationship between birthing position and the length of the second stage of labor is yet undefined. This author is unwilling to assume that the relationship Liu identified is accurate and that the results of the present studies do not reflect the true relationship. Since Liu presented none of her descriptive data, other than the means, it is impossible to evaluate for further dissimilarity between the studies. Liu's study, having been done approximately ten years before 222 the present studies, may have been representative of the relationship between position and the length of the second sage of labor at that time, but due to unidentified changes in obstetrical patients or the care provided, the relationship may no longer be representative. Thus, the first conclusion is that a much larger study must be done to identify just what the relationship between position and length of the second stage of labor is. Since the present study and the study by Sparks (1983) were well designed and conducted, the fact that the results are not consistent with Liu's does not mean that the implications from the present studies can be ignored. Rather, the second conclusion from the present studies is that based on the results, either the recumbent or upright position is appropriate for use in the second stage of labor relative to length. The implications of this conclusion for nursing educa- tion, service and research have been discussed earlier in this chapter. To review those implications briefly again-nursing education must teach the concept of flexibility in the classroom as well as demon— strate flexibility in the clinical setting when helping patients meet their own needs. By providing a flexible approach to nursing care, the nurse is helping to put the patient in the best possible condition in which 223 nature can act. The nurse is following the principles of Nightingale's Theory of Nursing and helping create a situation where the body can care for itself. Nursing service must also require flexibility from the nursing staff that works in labor and delivery. Since nurses spend the most time with patients while they are in labor, nurses tend to have the greatest impact on patients perceptions of the birthing event. Nurses must respond to individual patient needs and requests whenever safety of the mother and infant is not jeopardized. Thus, nursing administration must first put a nurse in the supervisory or head nurse role who believes in flexi- bility and family centered maternity care. This nurse must be a risk-taker and one who believes in nursing as an independent and interdependent profession, but not one that is solely dependent on medicine. Second, nursing administration must support this head nurse in her efforts to hire and maintain nursing staff that avoid the rigid traditionalist positions so often found in labor and delivery. The implications for nursing research from the present studies are also quite clear. Nurses must con- duct a much larger study to identify the relationship between birthing position and the length of the second stage of labor. Nurses must also evaluate several other variables such as patient satisfaction and patient 224 comfort in relation to birthing position before the true value of alternative birthing positions will be understood. Scientific studies must be undertaken to evaluate alternatives that have been proposed by consumers. If nursing begins to scientifically evalu- ate current practices and the alternatives suggested by the consumer, then nursing will truely be acting in the role of patient advocate. Another conclusion that can be drawn from the pres- ent study of the recumbent position is that none of the variables identified correlated with the length of the second stage of labor. There may be variables that were not recognized in the present study that do have a relationship with the length of the second stage of labor. Further studies should include the variables identified in the present study as well as other variables to identify factors that affect the length of the second stage of labor. The study by Sparks (1983) did identify two vari- ables that had significant correlations with the length of the second stage of labor. Age had a slight corre- lation with length of the second stage indicating that in the upright position as the age of the patient increased, so did the length of the second stage of labor. One conclusion that can be drawn from this re- sult is that further research must be done to evaluate 225 whether there is an age after which use of the upright position is counter productive relative to the length of the second stage of labor. The most important conclusion that can be drawn from the present study and the study by Sparks (1983) is that very little scientific evaluation has been done in relation to current in-hospital childbirth practices. If nurses are to help alter the trend toward increased home births, then nursing must begin to actively address consumer concerns by instituting more research projects to evaluate childbirth issues. Nurses must also dissemi- nate the results of the research in professional journals so that the implications for nursing practice can be instituted by a broad number of nurses and hopefully create changes in current labor and delivery routines that will make the hospital a more acceptable and desire- able place in which to give birth. APPENDIX A PERMISSION FOR RESEARCH PROJECT TO: FROM: 226 Figure Al. Letter Concerning Confidentiality ST. LAWRENCE HOSPITAL A DIVISION OF SISTERS OF MERCY HEALTH CORPORATION May 3, 1982 Diane Torres, R.N. Scott Swisher, M.D. Chairman, HSRC Proposal submitted: Second stage of labor I have reviewed this proposal and have only one concern - that is how confidentiality is to be protected. The researchers should include a statement indicating no identified protocols which include the name and address will leave the record room. 227 Figure A2. Communication From Nursing Office St. Lawrence Hospital 1210 West Saginaw Lansing, Michigan 48914 May 11, 1982 Barbara Taylor Sparks 7966 Lovejoy Road Perry, Michigan 48872 Dear Barbara: You know from our recent telephone conversation that the St. Lawrence Hospital Human Subjects Research Committee has approved your proposed research project on "The Second Stage of Labor/Birthing Chair.” This approval is contingent to the receipt from you and your colleague, Sandy Hayes, of a letter in which you answer the committee's concern regarding how patient confidentiality will be protected. As you can see from the attached memo, they ask that you include a statement identifying protocols which insure the name and address will not leave the record room. Please send the letter addressed to Scott Swisher, M.D., Chairper- son, H.S.R.C., St. Lawrence Hospital: attention of Dawn Gribben, Medical Staff Secretary, with a copy to me. At that time then, Myra Bayes will contact you to set up a mutual time to introduce you and the data collection to Labor 8 Delivery Nursing Staff. You mentioned before that you would compose a letter to our staff explaining briefly the research project and how they will take part infit. We will distribute the letter before your introduction to the sta . . Let me say again, I am pleased that you brought the opportunity to do this project here to St. Lawrence and look forward to watching it develop and seeing the conclusions drawn from it. The greatest benefit we will derive will be the introduction and participation in "Nursing Research" at the staff nurse level. That excites me! Sincerely, Margaret E. Curtin RN Assistant Director--Nursing Department Head, Labor & Delivery MEC/mw cc: D. Torres M. Bayes Figure A3. 228 Letter to Hospital Research Review Committee May 13, 1982 Scott Siwsher, M.D. Chairman, Research Committee St. Lawrence Hospital Lansing, Michigan Dear Dr. Swisher, My colleague and I are pleased that we can move ahead on our research project at St. Lawrence Hospital. We are now in the process of submitting our proposal to the Human Subjects Review Committee at Michigan State, and have also scheduled our thesis proposal defense with- in the School of Nursing. We hope to do all data collec- tion this summer. Margaret Curtin mentioned to me that you wishes information about how we will protect patient confiden- tiality in our study. We have considered this issue carefully and believe we have insured confidentiality in the following ways. All charts will be audited within the medical records department. Only Sandra Hayes and myself will be collecting data. We will initially examine all charts of prima- gravidas to determine which patients meet our research criteria. Once we have picked the suitable charts, we will transcribe data from them to our research tool. I have included a copy of this tool for you to examine. No patient name or address will be copied from the chart to our research instrument. We will use only a coding number for use in our data analysis. I hope I have satisfied your concerns about patient confidentiality in our research project. If you have any further questions, please call me, either at work (353-4964) or at home (655-4449). We plan to complete this project, including data analysis and conclusions Winter term, 1983. We will send you a copy of our results at that time. CC: Thank you again for your help. Sincerely, Barbara Sparks Margaret Curtin 229 Figure A4. Communication to Nursing Office Margaret E. Curtin, RN Assistant Director-Nursing Department Head, Labor & Delivery St. Lawrence Hospital Lansing, MI 48914 May 13, 1982 Dear Maggie, We have enclosed a copy of our letter to Dr. Swisher, plus a copy of the tool we will be using to collect data. Our thesis proposal defense is scheduled for May 26. Spring term is finished June 12. Hopefully by that time our project will be approved by Human Subjects Review. Shortly after that we will be contacting you and Myra about several process issues, like who we work with in medical records, meeting with the staff nurses in L & D, and our projected timetable. We are still hoping to spend some hours in the Labor & Delivery area, as you suggested. Summer should give us both more time to arrange that. As always, if you have any questions, please feel free to call. We are delighted to be moving foreward on this project, particularly at St. Lawrence! Sincerely, Barbara Taylor Sparks Sandra Hayes 230 Figure A5. Communication to Human Subjects Review Committee, M.S.U. May 10, 1982 Dr. Henry E. Bredick Chairman, UCRIHS 238 Administration Building Michigan State University East Lansing, Michigan 48824 Dear Dr. Bredick: My colleague, Barbara Sparks, and I are graduate students in the MSU College of Nursing. We are conduct- ing a research project for partial fulfillment of the requirements for a Masters degree in Nursing Science. As is required by University policy, we are now applying to UCRIHS for approval of our data collection procedures. We are applying for exempt status according to category #5 as listed in the January, 1981 issue of the Federal Register, Research Development Memo July 10, 1981. Our study is a retrospective chart review of ob- stetric patients who have delivered at St. Lawrence Hospital, Lansing, Michigan. We will have up contact with the patients and there will be 22 way to identify the patient from the information abstracted onto our data collection tool. We have already received a consent from Dr. Scott Swisher, Chairman, Research Committee, St. Lawrence Hos- pital for data collection at that institution. If you have any further questions concerning our project, please contact me or my colleague. Thank you for your consideration in this matter. Sincerely, Barbara Sparks Sandra Lee Hayes 7995 Lovejoy Road 2412 Post Oak Lane Perry, Mich 48872 Lansing, Mich 48912 655-4449 484-3306 231 Figure A6. Permission From Human Subjects Review Committee, M.S.U. MICHIGAN STATE UNIVERSITY twwrnsm consume: ox RESEARCH wvou'mc um LANSING . anti-non - «an HL‘MA\ Stancrs (UCRIHS! I” AD‘IIVISTRRTIO\ BL 11 DING (sriuynai June I, 1982 Ms. Sandra Lee Hayes 2412 Post Oak Lane Lansing, Michigan 48912 Ms. Barbara Sparks 7996 Lovejoy Road Perry, Michigan 48872 Dear Ms. Hayes and Ms. Sparks: Subject: Proposal Entitled, “The Relationship Between the Length of The Second Stage of Labor, and Birthing Position“ I am pleased to advise that I concur with your evaluation that this project is exempt from fuii UCRIHS review, and approval is herewith granted for conduct of the project. You are reminded that UCRIHS approval is valid for one calendar year. If you plan to continue this project beyond one year, please make provisions for obtaining appropriate UCRIHS approval prior to June 1, i983. Any changes in procedures involving human subjects must be reviewed by the UCRIHS prior to initiation of the change. UCRIHS must aiso be notified promptly of any problems (unexpected side effects, complaints, etc.) invoiving human subjects during the course of the work. Thank you for bringing this project to my attention. If I can be of any future help, please do not hesitate to let me know. Sincerely, [l [figllllav Raymond W. Frankmann Vice Chairman, UCRIHS jms cc: Dr. Given APPENDIX B COMMUNICATION WITH NURSING STAFF ST. LAWRENCE HOSPITAL 232 Figure Bl. Communication From Nursing Office to Labor and Delivery Department MEMO TO: Myra Bayes RN, Head Nurse--L & D Nursing Staff, L & D FROM: Margaret E. Curtin RN, Assistant Director-- Nursing DATE: July 1, 1982 SUBJECT: Nursing Research Project "Compares timing of second stage of labor in women using the recumbant/upright position." It is with pleasure and anticipation that I introduce to you Barbara Sparks RN and Sandra Hayes RN, nurses in the graduate program at Michigan State University. The St. Lawrence Hospital Human Subjects Research Committee has authorized their research on ”the Second Stage of Labor/ Birthing Chair" to be done thru the facilities of the Labor/Delivery Unit. My pleasure is in seeing their involvement with our units, and my anticipation is the outcome of their work. I ask that you all cooperate with them by documenting the information they need to be retrieved in this manner: The position of the patient will be documented on the line for comments on "2nd stage labor" of the Delivery Record form. The use of the Birthing Chair will be noted by circling "chair" at the top of the Delivery Record form. Thank you for your interest and cooperation. MEC/mw 233 Figure 82. Introductory Letter to Labor and Delivery Staff 12!!! WEST IABINAW TELEPHONE LANSING. MICHIGAN 48914 fig AREA CODE 517/372-3le 1 C I J .A. 32’fl\\'5‘0 n0 9 H03 PITAL July 5, 1982 Nursing Staff Labor 5. Delivery Unit St. Iawrerrze Hospital This letter isabrief introduction, totellyouwhoweare, ardwhatour involvement with St. Lawrence Hospital is about. We are graduate students in the College of nursing at Michigan State University. Both of us have worked with obstetrical patients, arr! are interested in current controversies comer-rung their care. Weare partiaflarly interestedintheissueofpatients'positioninthe secondstaqeoflabor. Weplantomamrethetimirgoftheseoondstageof labor, in both a recumbent position (cm a delivery table) and an upright position (inabirthingchair). Wewishtodetermineifthe ofthe second stage is starter in an upright position than in a r t position. WeplantooollectthisinfamationfmndurtsofflmelaborandbeliveryUnit at St. Iawrence ibspital. Wealsoumiersmnd thereissanecomemabout perineal edanainwmmvd'ousethebirthingcmir. Wewilloanpile :infamationaboutthisismealso. Wetopetheinfomationwegathsrabmtptientsinmmborufluelivety mutwillbeusefultoym, tohelpymprovideoptimnmrsingcarearfl teaching to patients considering various positions for labor and birth. tbstoftheinfonnationwemedisrmtinelymtedonyuirdnrts. We reedtoaskymtomtjustucmrethims:positionusedinthesewrd stageoflabor,anduseofthede1iverytableorbirthirgclnir. Weplantomeetwithywractweekdurixgyuirreporttimes. Ongmlis Unfold: 1. Tometywanddescribemrsuadytoym. 2. Ibhearyoursuggestionscmnernixrgaxstndmaxfltofirdout fzunyoumwwecangathertheinfonnatimwemedinthemst efficientvay. areurrredictableinlaboraIfiDelivet-y. Altinaghwemedymrhelpto 234 Table B2 (Con't) Perrapsnectweekvecanalsodismssthebestmytosharethermlts of this study with you, so that they can be easily applied to the patient careissues thatyoudealwithinyourwork. Sincerely [W M £4) BarbaraSparksRN a/Ma 157/474a, P. A). SandraHayesRN BS/SH/nw CC: Dr. SoVisl'ler APPENDIX C STATISTICAL INFORMATION ON STUDY BY SPARKS 235 Table Cl Age Distribution of Women in the Upright Position (n=25) Age, Years Number of Subjects Percentage 17 l 4.0 18 l 4.0 20 4 16.0 21 2 8.0 22 2 8.0 23 2 8.0 25 4 16.0 26 4 16.0 27 2 8.0 28 l 4.0 29 l 4.0 32 ._l_ 4.0 TOTAL 25 100.0 Mean = 23.8 years Median = 24.6 years Mode = 20.0 years Standard Deviation - 3.6 years Type of Health Insurance Coverage 236 Table C2 of Women in the Upright Position (n=25) Type of Number of Insurance Subjects Percentage Private Pay 1 4.0 Medicaid 1 4.0 Private 23 2249 TOTAL 25 100.0 237 Table C3 Weight Gain in Pregnancy of Women in the Upright Position (n=25) Pounds Gained Number of Subjects Percentege_ 19 l 4.0 21 l 4.0 24 l 4.0 25 2 8.0 27 3 12.0 28 l 4.0 29 2 8.0 30 l 4.0 31 l 4.0 32 l 4.0 33 l 4.0 34 2 8.0 36 l 4.0 39 2 8.0 40 l 4.0 41 l 4.0 43 l 4.0 51 l 4.0 54 ._1 110. TOTAL 25 100.0 Mean = 32.7 lbs. Median = 31 lbs. Mode = 27 lbs. Standard Deviation = 8.6 lbs. 238 Figure C4 frequency Distribution of the Intervening Variables in the Upright Position (n-ZS) V3.12“? Marital Status Married Single TOTAL White Unknown TOTAL Type of Physician OB/GYN Family Practice General Practice TOTAL Type of Classes Lamaze Expectant Parent Unknown TOTAL Episiotomy Yes No TOTAL Laceration Yes No TOTAL Fetal Monitor Yes No Rupture of Membranes Artificial Spontaneous TOTAL Physician Own On Call TOTAL Number of Subjects 23 _2 25 23 _Z 25 Nl s-I urns-yo I H H u 25 23 N UM _2_1 24 ”I UP 11 1_4. 25 23 ”I v N Percgutage 92.0 8.0 100.0 36.0 60.0 4.0 100.0 16.0 84.0 100.0 239 Figure C5 Frequency Distribution of Incidental Variables in the Upright Position (n-25) Variable ___!!!9" of Sggjects Percentage Gravidity Gravida 1 21 04.0 Gravida 2 .3 16'0 TOTAL 25 100.0 Type of Patient Private Patient 20 00.0 Clinic Patient 0 0.0 HMO Patient _2 gggg TOTAL 25 100.0 Fetal Position LOA 12 48.0 LOP 1 4.0 RCA 4 16.0 0A 8 32.0 mama 1 mm TOTAL 25 100.0 Monitor Type External only 20 60.0 Internal only 0 0 Both 4 16.0 Neither _l __i_0 TOTAL 25 100.0 APGAR C I Idnute 5 0 0.0 6 l 4.0 7 l 6.0 8 15 60.0 9 1 eat Mean 6.2 TOTAL 25 100.0 APGAR Q 5 Iinute 6 0 0.0 9 23 92.0 m a 3m Mean 9.1 TOTAL 25 100.0 Stage of Rupture of Membranes First 10 72.0 Second 3 12.0 Before First _5 lggg TOTAL 25 100.0 Intravenous Fluids Yes 6 24.0 n u as TOTAL 25 100.0 240 Figure C6 Length of the Second Stage of Labor of Women in the Upright Position (n=25) Length in Minutes Number of Subjects Percentage 18 4.0 19 27 28 30 35 37 38 41 43 46 47 52 67 70 74 89 105 107 110 112 118 he id P‘ r4 pa H‘ r4 id H‘ *4 r4 94 P‘ no he re id P‘ r4 rd to h‘ P‘ .b .b .o .b .b .b .b .b .o .b b o- o- a: o- o» o- o- o» o- m» o 0 0 0 0 0 0 0 0 0 0 .0 0 0 0 0 0 0 0 0 0 0 0 130 TOTAL 25 H O O 0 mean = 60.9 minutes median = 46.0 minutes Mode = 27.0 minutes Standard deviation = 35.4 minutes 241 Table C7 Correlation Values for Variables and the Length of the Second Stage of Labor Upright Position Variable r Value P value Age .43 .01* Marital .32 .06 On call MD .12 .28 Childbirth education .32 .06 EPO or Lamaze Laceration .34 .045* Fetal monitor .28 .08 Weight at term .10 .32 * P§_.05 REFERENCES 242 References American Friends Service Committee: Society of Friends. 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