Observing Position and Movements in Hydrotherapy: A Pilot Study
Mary Ann Stark, PhD, RNC, Bronson School of Nursing, Western Michigan University, 1903 W. Michigan Ave. Kalamazoo, MI 49008
Objective: To observe and describe the positions and movements women choose while immersed in water during the first stage of labor.
Design: Descriptive, observational pilot study.
Setting: A rural community hospital that provided hydrotherapy in labor.
Participants: Women (N = 7) who intended to use hydrotherapy in labor were recruited prenatally from a midwife-managed practice.
Measures: For 15 minutes of each hour during the first stage of labor, position and movements of the participants were observed and recorded on a laptop computer. The observational tool was developed for this study from a review of the literature and interviews with nursing experts; 435 observations were recorded. Women were free to choose when and how long to use hydrotherapy and had no restriction on their positions and movements.
Results: Only 3 of the 7 participants labored in the tub. Women demonstrated a greater range of positions and movements in the tub than in bed, both throughout labor and during late first-stage labor (7-10 cm of dilatation). Women had more contractions and made more rhythmic movements while in the tub than in bed.
Conclusions: Hydrotherapy may encourage upright positions and movements that facilitate labor progress and coping, helping women avoid unnecessary interventions.
Many complementary measures are available to give comfort to women in labor. Hydrotherapy, which is immersion in a tub of water for therapeutic effects, and spontaneous maternal movement are nonpharmacologic therapies thought to promote maternal comfort and reduce need for interventions such as epidural analgesia during labor (Simkin & O’Hara, 2002).
Hydrotherapy may be effective in giving relief from pain while promoting labor progress by allowing the laboring woman freedom to move and change positions. When immersed in water, the laboring woman may experience decreased environmental resistance, allowing her to move and change positions easily. Hydrotherapy also allows use of rhythmic movements, such as effleurage or swaying, which may assist in coping during labor (Simkin & Ancheta, 2005). Researchers have not examined whether women in hydrotherapy use positions and movements known to facilitate labor and promote comfort. The purpose of this pilot study was to observe and describe the positions and movements women chose while laboring in water and compare them to positions and movements women used when not immersed during labor.
Review of literature
Hydrotherapy often is used for its therapeutic effects (Smith & Michel, 2006). Several physiologic changes occur with submersion in warm water. Buoyancy allows for support of extremities, while hydrostatic pressure gives equal resistance to all muscle groups, providing stability. This support and stability allow for freedom of movement and a sense of weightlessness that may encourage movement.
Warm water promotes local vasodilatation that promotes muscle relaxation and reduces pain of tense muscles (Mackey, 2001). With relaxation and comfort, stress hormone production may decrease. Increased comfort with submersion and decreased stress hormone production may improve uterine contractility. In a study of nulliparas with dystocia, immersion in water reduced the rate of labor augmentation without resulting in longer labors (Cluett, Pickering, Getliffe, & St. George Saunders, 2004). This indicates that hydrotherapy, while often used for comfort, may be beneficial for labor progress. Finally, hydrostatic pressure moves fluid from the extravascular to the intravascular spaces reducing blood pressure and edema (Florence & Palmer, 2003; Simkin & O’Hara, 2002).
While hydrotherapy has several potential physiologic benefits for laboring women, concern about its safety has prompted further research (McCandlish & Renfrew, 1993; Ohlsson, Buchhave, Leandersson, Rydhstrom, & Sjolin, 2001). In spite of some anecdotal reports of negative outcomes, in a systematic review of eight randomized controlled trials involving 2939 women, hydrotherapy was not associated with longer labor, increased operative deliveries, or poorer neonatal outcomes (Cluett, Nikodem, McCandlish, & Burns, 2004).
The effectiveness of hydrotherapy as a complementary therapy for pain relief in labor was supported by several studies (Benfield, Herman, Katz, Wilson, & Davis, 2001; Cammu, Clasen, Vam Wettere, & Derde, 1994; Cluett, Pickering, et al., 2004) and a systematic review of research (Cluett, Nikodem, et al., 2004). In addition, hydrotherapy has been found to decrease anxiety (Benfield et al.) and promote relaxation (Cammu et al.). Increased maternal satisfaction with freedom of movement during hydrotherapy also was reported (Cluett, Pickering, et al.). Hydrotherapy may give women more control in decisions during their labor and provide an additional option in coping with labor pain (Baxter, 2006; Simkin & O’Hara, 2002).
While hydrotherapy in labor is safe and effective in helping women cope with labor, few women use hydrotherapy during labor. In the “Listening to Mothers” national surveys (Declercq, Sakala, Corry, & Applebaum, 2006; Declercq, Sakala, Corry, Applebaum, & Risher, 2002), only 6% of each sample reported using hydrotherapy sometime during labor; these women found it very helpful or somewhat helpful. In an earlier national study, 14.9% of women used hydrotherapy in labor (CNM Data Group, 1998).
This study observed and described the positions and movements women chose while laboring in water.
Positioning and movement have been used to promote progress of labor and maternal coping. Most beneficial in labor are positions in which the axis of the woman’s body is upright or vertical (sitting, standing, and squatting). In upright positions, the dimensions of the bony pelvis are increased (Michel et al., 2002). In an early study of the effect of position on effectiveness of contractions, Roberts, Mendez-Bauer, and Wodell (1983) found that upright position produced more effective uterine contractions than supine position.
Position also has been related to pain in labor. In a study comparing sitting and supine positions on labor pain, women reported significantly less lumbar pain (both continuous and during contractions) while sitting (Adachi, Shimada, & Usui, 2003) but no significant difference in total pain or abdominal pain (either continuous or during contractions) related to position (Adachi et al.). Simkin and Bolding (2004) in a systematic review of research on labor position and pain reported that when women served as their own controls, no researchers reported women had greater comfort in a supine position.
While an upright position is optimal for fetal descent and may provide more comfort, laboring in bed may suggest to women that they should lie down rather than assume upright positions. In the recent “Listening to Mothers” survey, 42% of women reported using position changes or movement, or both, during labor for promoting comfort Declerq et al. (2006). Laboring in a tub may facilitate upright positions, but previous research has not addressed this.
Some movements, such as pelvic rocking (tilting the pelvis anteriorly and posteriorly) or swaying (moving the pelvis from side to side), may facilitate fetal descent, while a rhythmic pattern of movements assists in coping with the pain of labor (Simkin & Ancheta, 2005). Ambulation is an example of an upright position that includes rhythmic movement. In a large multisite study of midwife-managed women at low risk, those who were upright and ambulated at least half of their labor had a lower operative delivery rate (2.7%) than those who did not ambulate significantly (5.5%) (Albers et al., 1997). In addition, those who ambulated used less narcotic analgesia. In spite of the effectiveness of ambulation in providing comfort and supporting progress during labor, 24% of women in the “Listening to Mothers II” survey reported ambulating after being admitted in labor (Declerq et al., 2006). Simkin and Ancheta suggest that rhythmic and repetitive movements are instinctive and indicate that the woman is effectively and actively coping with labor. Allowing women the freedom to move may provide maternal comfort while encouraging fetal rotation or descent Simkin & Bolden (2004). Hydrotherapy enables more freedom of movement than when laboring in bed, but no researchers have reported whether women move more in hydrotherapy than when laboring in bed.
In summary, hydrotherapy provides physiologic benefits that may promote normal labor. The ability to move more easily in water may encourage women to assume positions and movements that may facilitate labor progress and provide a means for coping with discomforts. No research has described the position and movements of women who labor in hydrotherapy. Research questions for this observational study were: What movements and positions do laboring women use in hydrotherapy? Do women laboring in water choose different positions than when not immersed during labor? Do laboring women move more in water than when they are not laboring in hydrotherapy?
A descriptive observational pilot study was conducted.
Since an observational tool was not available, one was developed for this study. Following a review of the literature on positions and movement in labor, the tool was drafted. Maternal posture (such as supine, Sims lateral, semirecumbent, on hands and knees, sitting upright, sitting reclined, standing or kneeling, or squatting), location (in tub, bed, chair, on birthing ball or ambulating), movements (such as of torso, pelvic, and extremities), and whether movements were rhythmic were examples of observational categories. Two certified nurse-midwives and several nurses who encouraged hydrotherapy in labor reviewed the instrument and offered revisions. The nurse researcher and a student research assistant tested the revised instrument while watching videos of women in labor, and revisions were made.
The instrument was loaded into the qUALqUANT program, which was developed for classroom observations and used in other studies (Rieth, Haus, & Bahr, 1989). The program prompted the observer to watch the laboring woman’s position and movements for 10 seconds. At the end of 10 seconds, a small tone sounded to alert the observer to answer questions on the screen. The observer was asked a question, such as “What is her position?” and given a list of possible positions. The observer would click the appropriate one based on the previous 10-second observation. When that question was answered, another question appeared on the screen, until all questions were answered. After all questions were answered, the researcher was prompted to begin another observation period. Following training in observing women in labor and using the observational tool, interrater reliability between the primary researcher and research assistant was 0.93. Intrarater reliability was not calculated.
Seven (N = 7) women who intended to use hydrotherapy participated in this study. Three of the women were giving birth to a first child (42.9%); all others had previously given birth. Most were single (n = 5, 71.4%) and all were White. One had a college education (14.3%); all others had a high school degree. Four were employed outside the home (57.1%) but only one (14.3%) reported an income greater than $50,000. All others reported yearly incomes less than $40,000. All were receiving care in a nurse-midwifery practice that encouraged hydrotherapy and performed water births; all delivered at a small community hospital that served a rural area. Women who participated in the study were given a $25 gift certificate to a discount department store.
Following approval from hospital and university institutional review boards, signs were placed in a midwifery clinic whose clients all delivered at a community hospital that provides hydrotherapy for labor and water birth. Pregnant women were recruited who intended to use hydrotherapy in labor, but because women were observed only during the first stage of labor, their interest in water birth was not pertinent to this research. At prenatal appointments, women who expressed interest in learning more about the study were informed that a student nurse research assistant would observe them intermittently during the first stage of labor. They gave informed consent and completed a demographic questionnaire at that time.
The research assistant was notified either by the nursing staff or the participant when a study participant presented at the birthing center in labor. According to hospital protocol, participants were screened by the hospital staff for their eligibility for hydrotherapy. Two volunteers developed conditions that made them ineligible for hydrotherapy (greater than 41 weeks or less than 37 weeks gestation; amnionitis; malpresentation; receiving intravenous therapy, intravenous or intramuscular narcotic, or a labor epidural; positive for HIV, hepatitis, or active herpes simplex; or a nonreassuring fetal heart rate pattern) and were not included in the data collection. One required a cesarean delivery upon arrival and the other had a precipitous delivery before any observations were made.
Participants were free to choose their positions and movements and to decide when and how long to use hydrotherapy. The women’s decision whether to use hydrotherapy was made in consultation with their labor nurses and nurse-midwife managing labor. For 15 minutes of each hour during the first stage of labor, the research assistant observed the position and movements of the participant, whether in the tub or not. A period of 15 minutes (15 observations) was chosen as the time sample to reduce concern about observer fatigue with longer observation periods. The research assistant continued to observe women for 15 minutes each hour during the entire first stage of labor. After the observation period, the research assistant recorded current obstetrical (contraction pattern and cervical status), maternal, fetal, and environmental (including tub and room temperature) factors.
Data entered into the qUALqUANT program were recorded in an Excel spreadsheet and imported to SPSS for analysis. Descriptive statistics were calculated for each variable of interest, and parametric and nonparametric statistics were used to compare positions and movements of women in hydrotherapy to those of women who were not in hydrotherapy. Women with longer labors contributed more observations. Because women were in hydrotherapy at different times during labor, a subset of the data was created using observations of each woman during late active labor (7-10 cm of dilatation). Descriptive statistics were computed for each variable of interest in this subset of data.
For the 7 women who provided data for the study, 435 observations were made. While all women intended to use the tub, four did not use the tub during any observation, while two were in the tub during all observations (see Table 1). Across the 7 participants, 123 (28.3%) observations were made while they were in hydrotherapy and 282 (64.8%) of observations when in bed. Few observations were made while women were walking (n = 18, 4.1%), sitting in a chair (n = 11, 2.5%), or on the birthing ball (n = 1, 0.2%). Data from these positions were not included in further data analysis to focus on differences between laboring in hydrotherapy and laboring in bed, the most common locations.
Table 1. Study Participants
The most common position for women in hydrotherapy was sitting in a reclining position, while most of the women in bed were semirecumbent. Women in the tub used seven different positions while women in bed were observed in four different positions, indicating women in hydrotherapy changed position more frequently. Women in hydrotherapy were observed more often in movements thought to facilitate descent of the fetus (torso and pelvic rocking and swaying) than women in bed (see Table 2). In addition, women in hydrotherapy more often used rhythmic movements than women in bed. Of the observations in the tub (n = 123), participants were contracting during the majority of observations (n = 64, 52.0%), while women in bed were contracting during 25.9% (n = 73) of those observations.
Table 2. Movements observed in First-Stage Labor
|Torso||48 (39.0)||Torso||46 (16.3)|
|Pelvis||21 (17.1)||Pelvis||20 (7.1)|
|Rhythmic||23 (18.7)||Rhythmic||19 (6.7)|
While in the tub, women assumed upright positions known to facilitate fetal descent and labor progress more often than when in bed.
In the subset of data from late labor (7-10 cm), 208 observations were included. During this time of labor, women were observed more often in the tub (n = 106, 51.0%) than in bed (n = 93, 44.7%). At this time, women in hydrotherapy used six different positions, with sitting in a reclining position the most frequent. This is similar to the findings across phases of labor, in part because the observations during late labor comprised the majority of observations of hydrotherapy (106 of 123 observations, or 86.2% of all observations of hydrotherapy). In contrast, women observed in bed during late labor used only three positions with semirecumbent being the most common (n = 83, 89.2%).
When movement during this time of labor was examined, women in the tub moved torso and pelvis much more than the women in bed, who never were observed doing pelvic movements, and had less frequent torso movements (see Table 3). Rhythmic movements were more frequently observed in women in the tub and rarely observed when women were in bed. Women in the tub were having contractions during 51.9% (n = 55) of the observations, while women in bed were having contractions during 24.7% (n = 23) of the observations.
Table 3. Movement Observed in Late First-Stage Labor (7-10 cm)
|Torso||43 (40.6)||Torso||12 (12.9)|
|Pelvis||20 (18.9)||Pelvis||0 (0.0)|
|Rhythmic||22 (20.8)||Rhythmic||1 (1.1)|
In summary, women in hydrotherapy selected more positions and movements than when observed in bed. This finding was consistent throughout labor as well as during late first-stage labor (7-10 cm of dilatation). In addition, rhythmic movements were more common in the tub than in bed. Women were observed having contractions more often while in the tub when compared to when they were observed in bed.
While all the participants in the study indicated prenatally that they intended to use hydrotherapy during labor, and the tub was available for all participants, only three of the seven women who participated in the study actually used hydrotherapy in labor. In three large studies, hydrotherapy was used in 6% (Declercq et al., 2002, 2006) and 14.9% of labors (CNM Data Group, 1998). While hydrotherapy has been found to be effective in providing comfort during labor (Declercq et al.), the current study indicates that even though women may plan prenatally to use this complementary therapy, the realities of labor may interfere. Since study participants were not interviewed after labor, their reasons for not using hydrotherapy are unknown. In another study, 46% of women randomized to hydrotherapy did not use the tub (Rush et al., 1996). The reasons reported were “change of mind, pain or distress, an early request for epidural analgesia, or unavailability of a tub” (p. 140). Two of the four women in this study who did not use the tub requested epidurals. In a systematic review of 4 studies and 2406 women, the odds ratio for the use of epidural/spinal analgesia and paracervical block was .84 (confidence interval .71, .99) for women using hydrotherapy when compared to those who did not use hydrotherapy (Cluett, Nikodem, et al., 2004). This suggests that women who use hydrotherapy use these analgesic methods less often in labor. The women in this study who used the tub were in the tub for a total of 75″ to 188″ during labor, suggesting that they evaluated it positively enough to remain in the tub for longer period than reported in another study (median of 40″) (Rush et al.).
Health care providers’ discomfort with hydrotherapy may limit its use also (Cluett, Nikodem, et al., 2004). While most of the nurses and midwives in this study supported the use of hydrotherapy, some individual nurses were less encouraging than others. Further research is needed to better understand factors that promote and hinder the use of hydrotherapy.
Because the bed is central in birthing rooms, women who are not encouraged to get out of bed and ambulate are inclined to stay in bed (Simkin & O’Hara, 2002). In contrast, regardless of labor phase, women in the tub changed positions more frequently and selected more positions that were upright, promoting fetal descent (Michel et al., 2002). This finding suggests that movement and change of position in late labor may be related to the environment (whether in the tub or not), but in this descriptive study, no cause-and-effect relationship can be determined. Women were not randomly assigned to labor location, so the difference may have been due to women’s choice or other individual variations rather than the effect of the birthing environment.
An important observation was that women moved more often while in the tub and their movements were more rhythmic. Movement can be beneficial in encouraging fetal descent and alignment as well as for coping (Simkin & Ancheta, 2005). Hydrotherapy allows freedom of movement (Cluett, Pickering, et al., 2004), and in water, laboring women experience buoyancy which encourages movement (Cluett, Nikodem, et al., 2004), so women who choose to use hydrotherapy may be more inclined to move more frequently than women who chose to labor in bed. Rhythmic movements indicate effective coping in labor (Simkin & Ancheta). Because being in the tub allowed women more freedom of movement with less resistance, that the women in the tub had more rhythmic movements is not surprising.
The apparent increase in contraction rate while in hydrotherapy was consistent with the finding of a systematic review that efficiency of uterine contractions improved with changing positions (Simkin & O’Hara, 2002). In contrast, a supine position can compromise uterine blood flow and contractions (Enkin et al., 2000). In a randomized controlled trial of 99 nulliparas with dystocia, women randomized to hydrotherapy had similar length of labor and operative deliveries but used epidural analgesia less frequently when compared to women whose labors were augmented with oxytocin (Cluett, Pickering, et al., 2002).
Several limitations of this study must be acknowledged. First, the study was conducted in one small rural community hospital and included a small sample of women who were very homogeneous. Second, the number of observations was limited as several participants had short labors. Due to the study design, what women did while not being observed is not known. Some women may have behaved differently while the observer was in the room than when the observer was absent. Third, women who had longer labors contributed more data. This allowed two women who had longer labors to influence the data more than the others who had shorter labors. Fourth, most of the observations of women in hydrotherapy were in late labor (106 of 123 or 86.2%). This was not true of the observations of women in bed. Fifth, no birth outcomes or subjective data such as pain levels were collected. As noted, because of the design of this observational study, no causation can be attributed. Last, the observational tool was new and previously untested.
Baxter (2006) reported that 89% of women who used hydrotherapy had received information about it before labor. Nurses should teach women prenatally about the availability and benefits of hydrotherapy. Women can prepare for hydrotherapy by bringing a sports bra to wear in the tub. The partner could bring a bathing suit to join her in the tub or a change of clothes should some splashing occur.
Even for those not prepared in advance, hydrotherapy may be useful for women who have difficulty coping with labor. Nurses can encourage and support women who are not progressing quickly or having difficulty coping to use hydrotherapy before using medical interventions. Hydrotherapy allows a woman freedom of movement and just as important, the freedom to be an active participant in her labor and birth. In both ways, hydrotherapy supports the normal labor process.
While birthing centers may promote hydrotherapy as a comfort measure, other factors may inhibit its use. Further research is needed to understand barriers to the use of this effective comfort measure. Hydrotherapy requires nurses to have different skills and attitudes than traditional labor care (Albers, 2005). Nurses may be concerned about the safety or effectiveness of hydrotherapy, be unfamiliar with the equipment, or be concerned about their own comfort and safety, as the nurse is required to use different positions and movements than when providing care to a woman in bed. Nurses can evaluate their own comfort and learn more about hydrotherapy. Mentoring is valuable when a nurse familiar and comfortable with hydrotherapy works with another who is not yet comfortable with this therapy.
Hydrotherapy allows freedom of movement and freedom to be an active participant in her labor and birth, supporting the normal labor process.
Hospital policies and culture may influence use of hydrotherapy. The culture of a birthing unit can influence nurses’ freedom to provide supportive care. Lack of support or teamwork discourages nurses from learning new and initially uncomfortable roles and skills (Davies & Hodnett, 2002). Providers easily slip into “a culture of routines” (Gramling, Hickman, & Bennett, 2004, p. 47) when not supported by peers and administration. In many birthing centers, technology is rewarded, rather than supportive skills (Stark, 2003). However, hydrotherapy may be a “care package which includes not only the actual water, but the environment in which it is offered, and the interactions of the woman and her caregivers” (Cluett, Nikodem, et al., 2004, p. 6) and therefore requires a supportive environment and caregivers. Nurses can evaluate agency policies and procedures and support other nurses who are developing new labor support skills.
Further research is needed with a larger and more diverse sample. Because many other factors influence the use of hydrotherapy and position and movements in hydrotherapy, more variables should be included in future research. Labor support, mothers’ knowledge, preparation and preferences, and the culture of the facility are factors that should be considered when testing these complementary therapies. In addition, type of provider influences use of nonpharmacologic methods of pain relief. Patients with certified nurse-midwife providers used significantly more nonpharmacologic pain relief methods and were more mobile in labor (including walking and frequent position changes) than women who had physician providers (Cragin & Kennedy, 2006). Relationships between intrapartum nurses and other providers also can influence labor care practices. In a recent qualitative study, nurses who reported strong relationships with providers believed that they could perform more labor support interventions (Sleutel, Schultz, & Wyble, 2007). Understanding the many factors that can influence the use of hydrotherapy as a complementary labor support strategy is a goal for future research.
With mounting evidence that supports the benefit of limiting medical interventions during the course of labor (Albers, 2005; Humenick & Howell, 2003; Kennedy, 2006; Romano & Lothian (2008); Sleutel et al., 2007), hydrotherapy may encourage upright positions and movements that facilitate labor progress and coping, thus helping women avoid unnecessary interventions.
Funded by Bronson Methodist Hospital Research Fund. The assistance of Elizabeth Baty, BSN, RN, is acknowledged.