Effects of Ambulation During First Stage of Labour on Maternal and Neonatal Outcomes: A Randomized Controlled Trial
Phase: NA
Conditions: Labor Pain
Sponsor: Mutah University

Ambulation during the first stage of labour
Effects of ambulation during the first stage of labour on maternal and neonatal
outcomes: A randomized controlled trial
Study Protocol with SAP 
March 1, 2018
 
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Ambulation during the first stage of labour
Effects of ambulation during first stage of labour on maternal and neonatal
outcomes: A randomized controlled trial
Introduction
There is clear and important evidence that walking and upright positions in the first stage
of labour reduces the duration of labour, the risk of caesarean birth, the need for epidural,
(Lawrence, Lewis et al. 2013). In addition,  ambulation and upright position have not
been found to be associated with increased intervention or negative effects on mothers'
and babies' wellbeing (Lawrence, Lewis et al. 2013). Women, particularly who have low
risk labour, are highly advised to follow upright positions, and encouraged and assisted to
assume whatever positions they choose (Lawrence, Lewis et al. 2013; Ondeck 2014).
 
Research confirms that movement is a safe and healthy coping strategy for pain, and
confining labouring women to bed increases pain and decreases women’s satisfaction
with their birth experience (Romano and Lothian 2008; Ondeck 2014). An experimental
study was conducted in Mangalore to examine the effect of ambulation during the first
stage of labour on the intensity of labour pain, length of the first stage of labour, and use
of analgesia, the study comprised of 40 primigravid mothers and they were grouped as
experimental  and  control  through  randomization,  experimental  group  received
ambulation, the other group did not. Pain was assessed through Visual Analog Pain Scale
and observational  checklist was used to assess the outcome of labour there was a
significant difference in duration of first stage of labour between the experimental and
control group but no significant difference in overall outcome of labour. The mean pain
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Ambulation during the first stage of labour
score for experimental group was (6.8) which was less than the main pain score of control
group. The findings of the study revealed that ambulation was effective to reduce the
intensity of labour pain among primigravid mothers (Savitha, Nayak et al. 2013).
Another experimental study was conducted to evaluate the effectiveness of back massage
versus ambulation during first stage of labour among primigravid mothers in terms of
pain and anxiety, an experimental research approach with pre-test post test control group
design was undertaken on 90 primigravid mothers (30 in each experimental group1,
experimental group 2 and control group). Purposive sampling technique was used to
select the primigravid mothers. There was a significant difference in mean pre-test and
post-test labour pain  scores  and anxiety scores  during first stage of labour among
primigravid mothers .It was concluded that back massage and ambulation was effective to
reduce the level of labour pain and anxiety among primigravid mother during first stage
of labour(Bala, Babu et al. 2017).
 
Ambulation and upright position were found to positively affect the progress of labour
and a woman’s behavioural response to childbirth.  An  updated  systematic review of  25
studies  with  a  total  of  5218  women,  done  to  assess  the  effects  of  upright
positions(walking, sitting, standing, kneeling) versus recumbent positions (supine, semi
recumbent, lateral) for women in the first stage of labour on the length of labour, and
other outcomes. Results showed that the duration of labour was approximately one hour
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Ambulation during the first stage of labour
shorter for women randomized to upright as opposed to recumbent positions(Lawrence,
Lewis et al. 2013). 
A quasi experimental study conducted to determine the effectiveness of ambulation
during first stage of labour, on the outcome of labour. A post test only control group
design was used in 60 samples. Results revealed that ambulation during first stage of
labour was effective in reducing duration of labour (t value = -2.27 and p value <0.05)
also in bringing positive behavioural response (Mann-Whitney U test, p value< 0.05).
Authors concluded that ambulation during first stage of labour was effective in reducing
the duration of labour and to bring out good behavioural response in primigravid women.
Also ambulation did not have any adverse effect on neonatal outcome. It was observed by
the investigator that, having the choice to ambulate is well accepted by women when they
were told the potential benefits of ambulation. Also it is a cost effective intervention
which the nurse can implement independently (Prabhakar, George et al. 2015).
A systematic review of the effect of ambulation and maternal position during the first
stage of labour on duration of this stage was done. All randomized controlled trials
carried out to assess this effect were taken into consideration in this review. Authors
concluded  that adoption of the upright position or ambulation during first stage of labour
may be safe, but considering the available evidence and its consistency, it cannot be
recommended  as  an  effective  intervention  to  reduce  duration  of  the  first  stage  of
labour(Souza, Miquelutti et al. 2006) .
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Ambulation during the first stage of labour
A randomized controlled trial was conducted to evaluate the vertical position adopted by
nulliparous women during labour in terms of pain and satisfaction with the position. The
study was based on a secondary efficacy analysis of data from 107 nulliparous women
enrolled in which the vertical position adopted during the dilation phase of labour was
evaluated. The analysis involved comparing the median percentages of the duration for
which women remained in the vertical position for each of the variables studied.  Results
revealed that  at 4 cm of dilation, the women with a pain score < 5 remained longer in the
vertical position during labor compared to those with a score >7 (p=0.02). At 4 and 6 cm
of dilation, the women who reported greater satisfaction remained more than 50% of the
time in the vertical position (p=0.02 and p=0.03, respectively). Authors concluded that
vertical position helped relieve labour pain and increased comfort and patient satisfaction
(Miquelutti, Cecatti et al. 2009).
Significance of the study
Despite evidence in the literature that ambulation and upright positioning during labour
does not harm mother, fetus, or newborn, there is evidence that women are still largely
confined to bed during the first stage of labour(Simkin and Bolding 2004). The increased
use of medical  interventions  such as  epidural  analgesia,  continuous  electronic  fetal
monitoring, intravenous infusions for fluids and electrolytes, and a restrictive birthing
environment limits women’s instinctive responses to labour pain and contractions rather
than assisting the woman to cope with the pain and anxiety of labour  (Simkin and
Bolding 2004)
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Ambulation during the first stage of labour
In Jordan practices in maternity wards are not based on best evidence(Shaban, Hatamleh
et al. 2011).  The majority of health facilities restrict movement during labour, women
were confined to bed in the lithotomy position and most of these facilities strap women in
the delivery position, women have no choice to assume the position they prefer during
labour and delivery  (Khresheh, Homer et al. 2007; Sweidan, Mahfoud et al. 2008;
Shaban, Hatamleh et al. 2011).    The practice of restricting women’s movement in labour
is contrary to the statements and recommendations of professional organizations advocate
for women to move about during the first stage of labour, as long as they remain low-risk
(WHO 1996; Ondeck 2014).
Implementing  evidence-based  maternity  care  in  developing  countries  with  limited
resources  such  as  Jordan  is  particularly  challenging,  and  requires  commitment  to
applying the most up to date evidence to clinical decisions. 
Purpose of the study
The purpose of this study is to begin investigation that could help provide a better quality
of care during birth and improve maternity outcomes in one Jordanian hospital. The
process was introducing an evidence-based practice of encouraging women to ambulate
and assume the upright position during the first stage of labour and observing if results
would suggest low cost modifications for the maternity health service environment,
especially the labour ward. This is the first study that has attempted to implement and
evaluate such an intervention in Jordan.
Aim
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Ambulation during the first stage of labour
To examine the effect of ambulation (walking) during first stage of labour on maternal
and neonatal outcomes.  
Methods
Design
A randomised controlled study will be conducted with primiparous women who come to
give birth at Al- Karak Hospital in Jordan. In the intervention group women will be
encouraged to ambulate and women in the control group will receive usual maternity
care. Women will be subsequently randomised into the groups using a table of random
numbers.   “Ambulation during labour” here will refer to moving from place to place
during the first stage of labour that reduces the amount of time a woman spends laying
down during this stage (measured by recording the number of minutes spend on walking).
Setting 
The setting for this study will be the maternity ward at Al-Karak hospital, the main
governmental and teaching hospital in the southern region of Jordan. In 2016  2,808
births occurred in this hospital, 59% were caesarean births (Ministry of Health 2017).
In  this  hospital,  the  woman  usually  labours  in  26-  bed  ward  with  restrictions  on
movement. This is consistent practice nationally. Certified midwives, resident physicians,
and obstetricians  provide care. Midwives  in this hospital work with uncomplicated
labours and help obstetricians with complicated cases.
Sample and sampling 
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Ambulation during the first stage of labour
We will recruit consecutive eligible women interested in participating in the study, for a
period of one year.   All primiparous women with uncomplicated singleton pregnancies
between 37 and 41 weeks gestation, cephalic, with cervical dilatation 3 to 5cm who come
to give birth at Al-Karak hospital, between the 1st of January and the 30th of December
2018 will be approached for participation.  
Sample size
The sample size was calculated using the G power version 3.1. Based on difference
between two independent groups, alpha= 0.05, median effect size 0.3, power =95%,
sample size required for each group is 88 women. To overcome attrition,   25% of the
calculated sample will be added, the final sample size will be 110 women in each group. 
Data collection process 
 Data will be collected using structured tool developed by the researchers based on
literature review of research related to the current topic (appendix 1). The tool composed
of section collecting the socio-demographic data and another section collecting maternal
and neonatal outcomes.  The research tool was reviewed by a panel (n=3) of experts in
maternity health field. Before starting the study, the final version of the tool will be tested
in a pilot study to evaluate its feasibility, clarity, and reliability.  Assistant researcher
(midwife) will complete the first section of the tool, which related to socio-demographic
data, and will allocate participants to control and intervention group according to the
randomization list.
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Ambulation during the first stage of labour
The  principal  researcher  will  be  kept  blind  for  those  participants  who  are  in  the
intervention and control groups. Completing the second part of the study tool, which is
related to maternal and infant health outcomes, will be in maternal ward and by the
primary investigators 24 to 48 hours after birth.  
Outcomes Measurement 
The study outcomes have two main aspects; related to maternal outcomes and neonatal
outcomes.   The maternal outcomes will include 1. Duration of the first stage of labour
(defined as the time from the onset of regular contractions to the time of full cervical
dilatation of 10 cm as documented by the midwife)  2. Intensity of labour pain ( measured
by the Visual Analogue pain Scale rating from 0 to 10 in which the woman registers the
pain perception, considering 0 no pain and 10 the worst pain imaginable.)   3. Use of
analgesics (defined as used or not used), 3. Mode of birth (defined as normal, vacuum
extraction, forceps delivery, or cesarean section) 4. Woman satisfaction with the birth
experience (measured by research-based birth satisfaction and dissatisfaction items from
literature. Women will respond on a five-point Likert scale with agreements with the
statement).  
The new neonatal outcomes will include: 1. Apgar scores at  5 minutes  
Data analysis 
Data will be analysed using SPSS version 22. Descriptive statistics will be used to
describe the sample characteristic. According to the level of measurement, independent t-
test,  and  ANOVA will  be  used  to  examine  the  differences  between  study  groups
(intervention  and  control)  based  on  baseline  socio-demographic  date  and  health
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Ambulation during the first stage of labour
outcomes. Statistical assumptions  will be checked and ensured, and results will be
considered significant if P values were < 0.05.
Ethical consideration 
Approval to conduct the study will be obtained from the ethics committee at faculty of
nursing / Mutah University and the Ministry of Health (MOH).  Women will be informed
about the study and verbal and written consent for agreement will be obtained from each
woman (appendix 2).  Women will be assured that participation is voluntary and they
have the right to withdraw from the study at any time without giving any reason. Women
will be assured that their information will not be recognized in any products of this
research. 
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Ambulation during the first stage of labour
References 
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