The Labor Environment: “Many things that count cannot be counted”
The June 2009 issue of Birth contains the results of a pilot study gauging the effects of modifying the labor room to encourage mobility, reduce stress and anxiety, and discourage routine medical intervention. Investigators randomly allocated 62 healthy women in spontaneous labor to either a modified room or the standard labor room. Women attended by midwives or doulas were excluded from participating, effectively creating a study population not predisposed to be mobile in labor.
Changes to the labor environment were relatively modest. The most radical innovation was to remove the labor bed, replacing it with a portable double-sized mattress and pillows in the corner of the room on the floor. The investigators noted that the bed is a major reason for lack of mobility. Its prominence conveys that it is the appropriate place for laboring women, and a woman in bed offers ready access for interventions, an observation backed up by research. (Both Listening to Mothers surveys reported that few women were mobile after hospital admittance. In the first survey, two-thirds of the women gave as a reason that they were “connected to things” and more than one-quarter said they were “told not to walk around.”) Rooms were also equipped with a birth ball, a chair that promoted sitting upright or leaning forward, an LCD projector with a selection of movies of calming nature images, an mp3 player with a selection of music, and a chart illustrating upright labor and birth positions. All labor rooms had a private bathroom and lacked windows. No nursing alterations were made other than mandating intermittent auscultation, leaving the overhead light off, keeping the door closed, and putting a sign on it asking people to knock before entering.
The trial was too small to draw firm conclusions, but the results certainly support conducting a larger one. Sixty-six percent of the women in the modified room reported spending less than half of their time in labor in bed versus 13% of women in the standard room, and only 35% spent three-quarters or more of their time in bed versus 87% of women in the standard room. (The bed was brought back at the woman’s – mostly for epidural analgesia – or caregiver’s request.) Women in the modified room were significantly less likely to have oxytocin augmentation (40% vs. 68%), and those who had it got it later in labor. Women also had somewhat shorter labors on average and longer times to initiation of analgesia/anesthesia. Before you get too excited at the effect on hospital-based management, though, overall, only 75% of this ultra-low-risk population—18 of whom had prior births—had spontaneous vaginal births. The cesarean rate was 11%, and 15% of women having vaginal birth had instrumental deliveries. Assignment to the modified room made no difference. Women liked the modified room and made use of its features. Interestingly, some nurses and doctors noted that the atmosphere affected them positively as well. Staff disapproval was an obstacle, however. Twenty percent recommended putting the bed back, a few disliked the room or felt it was unsafe, resistance to change was a problem in one of the two participating hospitals, and three hospitals declined to participate.
What is the “science” lesson here? Randomized controlled trials normally test by exposing participants to a specific intervention while trying to hold all other factors constant. So, for example, past trials of mobility in labor assigned women to walk or not, or to assume a particular position or not. But effective labor care cannot be reduced to a set of rules. It may be a calming and enabling environment that supports moving freely rather than a particular position or movement that affects labor progress. In addition, labor progress will be impacted by the messages, covert and overt, women receive from their environment and those who attend them. Conventionally designed trials, however well-constructed, executed, and intentioned, will inevitably fail at assessing benefits of physiologic care because they do not take these factors into account. Indeed, they are specifically designed not to. By refreshing contrast, the investigators in this pilot trial understood that they needed to take a systems approach. They created an environment that offered new possibilities and gave women freedom to engage with it, which the women did, benefitting thereby. Still, even in this study, one wonders what results investigators might have gotten had women had additional amenities such as deep tubs, access to the outdoors, and natural light, and even more important, had their caregivers all been trained in, and encouraging of, practices that promote effective labor.
Hodnett, E. D., Stremler, R., Weston, J. A., & McKeever, P. (2009). Re-conceptualizing the hospital labor room: The PLACE (Pregnant and Laboring in an Ambient Clinical Environment) pilot trial. Birth, 36(2), 159-166.
Declercq, E., Sakala, C., Corry, M. P., & Applebaum, S. (2006). Listening to Mothers II: Report of the Second National U.S. Survey Of Women’s Childbearing Experiences. New York: Childbirth Connection.
Declercq, E., Sakala, C., Corry, M. P., Applebaum, S., & Risher, P. (2002). Listening to Mothers: Report of the First National U.S. Survey of Women’s Childbearing Experiences. New York, NY: Maternity Center Association.
Title quotation from:
Jadad, A. R., & Enkin, M. W. (2007). Randomized controlled trials: Questions, answers and musings (2nd ed.). Oxford: Blackwell Publishing.
A Fancy Maternity Bed (featuring a laboring woman who seems just to be getting in the way)