This is one of six Care Practice Papers from the Lamaze Institute for Normal Birth.

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A pregnant woman in a Lamaze class asks about the mixed messages she has seen about birth. “In class, I see pictures of women walking, using tubs, or sitting on birth balls. But in the birth stories on TV, it seems like women spend most of their time in bed. Is being out of bed and moving around important?”

Freedom of movement is important in making the birth of your baby easier. It is the best way for you to use gravity to help your baby come down and to increase the size and shape of your pelvis. It allows you to respond to pain in an active way, and it may speed up the labor process.⁷

In contrast to what you see on popular TV shows in the United States, pictures from throughout history and across cultures show women in many different positions for labor. According to the Cochrane Pregnancy and Childbirth Group, a respected international organization that defines best practices based on research, giving a laboring woman the freedom to move and choose her own position is most likely beneficial.⁵ Activity provides distraction from discomfort, a sense of greater personal freedom, and a chance to release the muscle tension that can increase pain. In fact, women who use movement in labor report that it is an effective method of relieving pain.¹⁰ Restricting women’s movement may result in worse birth outcomes and may decrease women’s satisfaction with their birth experiences.¹⁰

Why Movement Helps
When you walk or move around in labor, your uterus, a muscle, works more efficiently.⁶ Changing position frequently moves the bones of the pelvis to help the baby find the best fit through your birth canal, while upright positions use gravity to help bring the baby down.⁷ When labor slows, a change in position often will help you “find your rhythm” again. If your baby is in a posterior position (with the back of the baby’s head toward your spine), getting on your hands and knees helps the baby rotate and decreases back pain.¹¹ If your baby is posterior, labor may be very long and difficult until the baby rotates to an anterior position, with the back of the head toward your front.

At times during labor, you may feel tired and need to rest in a comfortable position. However, according to a 2003 study published in Nursing Research, a laboring woman’s lower back pain is worse when she is lying down.¹ You can get the rest that that you need without having more pain if you have options for resting other than lying on your back.

What Research Tells Us
Researchers who examined all of the published studies on freedom of movement in labor found that, when compared with policies restricting movement, policies that encourage women to walk or change position in labor may result in the following outcomes:

• shorter labors,
• more efficient contractions,
• greater comfort, and
• less need for pain medicine in labor.^8,9

In fact, no woman who participated in any of the research studies said that she was more comfortable on her back than in other positions.⁸ No study has ever shown that walking in labor is harmful in healthy women with normal labors.¹⁰ One study published in The New England Journal of Medicine in 1998 did not find that women who walked had shorter labors; however, the women in the study who walked were so satisfied that 99% of them stated that they would like to walk again during future labors.³

Another study, published in the Journal of Midwifery & Women’s Health, found that, in hospitals that did not routinely use interventions, such as continuous electronic fetal monitoring, and did not restrict food or drink in normal labors, women who spent at least half of active labor walking decreased their chances of having forceps or vacuum-assisted births or cesarean surgery.² This study suggests that freedom of movement may be more beneficial when used along with the other care practices that support normal birth.

The Role of Support and the Birth Setting
Without encouragement, due to cultural conditioning and the central location of the bed in most birth settings, many women will unfortunately not move in labor.⁸ However, when laboring women are encouraged to move and do not have restrictions, they walk and change position frequently.⁸ Although your hospital may not have a policy that requires that you labor in bed, the routine use of continuous electronic fetal monitoring, intravenous lines (IVs), drugs to induce or speed up labor, and epidurals do limit your movement and often will confine you to bed. When women who took part in a survey about their childbirth experiences were asked why they did not walk around during labor, the Number One answer they gave was, “connected to things”.⁴

If we want to improve women’s comfort in labor and support normal birth, interventions such as electronic fetal monitoring and IVs should be used only when complications make them necessary. If it becomes medically necessary to use these interventions, including epidural anesthesia, you should be guided to continue to move in whatever way you can. For example, your nurse or labor partner can help you change from utilizing a side-lying position to leaning over the back of the bed or on the squat bar. If there is a medical reason that you need continuous electronic fetal monitoring, this can occur while you sit on a birth ball or in a rocking chair. Monitoring does not mean you must stay in bed.

Practicing Helpful Positions and Movements
In childbirth education classes, you will practice various positions and movements, including how to rock your pelvis and use techniques such as the lunge, the stomp/squat, slow dancing, the knee/chest position, and stair climbing. If you practice with aids, such as a birth ball or a rebozo (a Mexican shawl), you will find it easier to use them in labor. When you have tried different positions and movements before labor, you have more confidence to use them during labor.

Recommendations from Lamaze International
Freedom of movement makes labor easier. Like many women throughout the world, you can use movement to make labor more comfortable and your contractions more effective. Although no single labor position is always the best, your freedom to choose and respond in your own way allows your birth to unfold without artificial restrictions. Birth is an active process and, with support from your labor companions, you will respond to make birth easier for yourself and your baby. Lamaze International encourages you to plan to be active in labor, to practice labor and birth positions during pregnancy, and to choose a care provider and birth setting that provide many different options for using movement. Lamaze International urges care providers to allow laboring women freedom of movement in labor and to avoid routine interventions that restrict movement.

Acknowledgements
The six care practice papers were originally developed in 2003 by Lamaze^® International. The primary authors of the first edition of Care Practice Paper #2 were Teri Shilling, MS, IBCLC, CD(DONA), LCCE, FACCE, and Joyce DiFranco, RN, BSN, LCCE, FACCE. The following members of the Lamaze International Education Council contributed to and reviewed the first edition of Care Practice Paper #2:

• Debby Amis, RN, BSN, CD (DONA), LCCE, FACCE
• Elena Carrillo de Reyes, CD (DONA), LCCE, FACCE
• Diana Chiaverini, RN, MEd, LCCE, FACCE
• Jeannette Crenshaw, RN, MSN, IBCLC, LCCE, FACCE
• Caroline Donahue, RN, MA, LCCE, FACCE
• Jeanne Green, MT, CD (DONA), LCCE, FACCE
• Judith Lothian, RN, PhD, LCCE, FACCE
• Michele Ondeck, RN, MEd, IBCLC, LCCE, FACCE
• Sandra Steffes, RN, MS, LCCE, FACCE

The May 2007 edition of Care Practice Paper #2 was revised and updated by Teri Shilling, MS, IBCLC, CD(DONA), LCCE, FACCE, and Joyce DiFranco, RN, BSN, LCCE, FACCE, and edited by Amy M. Romano, MSN, CNM.

References

1. Adachi, K., Shimada, M., & Usai, A. (2003). The relationship between the parturient’s positions and perceptions of labor pain intensity. Nursing Research, 52(1), 47-51.
2. Albers, L., Anderson, D., Cragin, L., Moore Daniels, S., Hunter, C., Sedler, K., et al. (1997). The relationship of ambulation in labor to operative delivery. Journal of Nurse‑Midwifery, 42(1), 4-8.
3. Bloom, S. L., McIntire, D. D., Kelly, M. A., Beimer, H. L., Burpo, R. H., Garcia, M. A., et al. (1998). Lack of effect of walking. The New England Journal of Medicine, 339(2), 117-118.
4. Declercq, E. R., 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: Maternity Center Association (now, Childbirth Connection).
5. Enkin, M., Keirse, M. J., Neilson, J., Crowther, C., Duley, L., Hodnett, E., et al. (2000). A guide to effective care in pregnancy and childbirth. New York: Oxford University Press.
6. Roberts, J. E., Mendez-Bauer, C., & Wodell, D. A. (1983). The effects of maternal position on uterine contractility and efficiency. Birth,10(4), 243-249.
7. Simkin, P., & Ancheta, R. (2005). The labor progress handbook (2nd ed.). Malden, MA: Blackwell Science.
8. Simkin, P., & Bolding, A. (2004). Update on nonpharmacologic approaches to relieve labor pain and prevent suffering. Journal of Midwifery and Women’s Health,49(6), 489-504.
9. Simkin, P., & O’Hara, M. (2002). Nonpharmacologic relief of pain during labor: Systematic reviews of five methods. American Journal of Obstetrics and Gynecology, 186(Suppl. 5), S127-S159.
10. Storton, S. (2007). The Coalition for Improving Maternity Services: Evidence basis for the ten steps of mother-friendly care. Step 4: Provides the birthing woman with freedom of movement to walk, move, assume positions of her choice. The Journal of Perinatal Education, 16(Suppl. 1), 25S-27S.
11. Stremler, R., Hodnett, E., Petreshen, P., Stevens, B., Weston, J., & Willan, A. R. (2005). Randomized controlled trial of hands-and-knees positioning for occipitoposterior position in labor. Birth, 32(4), 243-251.

• Freedom of movement makes labor easier.
• If you walk and change position in labor, you may have faster labor, experience increased comfort, be more likely to give birth vaginally, and have a better sense of control.
• You will have more freedom of movement if you choose a provider and birth setting that give you many options for movement and that do not routinely use medical interventions.