Wednesday, July 22, 2009

Beds and birth rooms

Henci Goer recently wrote about a pilot study examining the effect of birth room design & furniture on the progress of labor. In her Science & Sensibility post, The Labor Environment: “Many things that count cannot be counted”, Goer discussed the study's design:
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....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.
As Goer noted, the results were promising, although the sample size was quite small (it was just a pilot study):
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.
I found another article discussing this research at VOA News: Re-Thinking Delivery Room Design Eases Labor. The lead researcher, University of Toronto nursing professor Ellen Hodnett, conceived of the study after noting women's behavior when they were giving birth at home. They moved around a lot and used household furniture to aid their labors. She commented:
They used a dining room table to lean over. They used the bathtub. They walked around the garden. They were moving, or on all fours, or side-lying on a mat on the floor… a variety of things…And that struck me, even then, that there were more opportunities, more ways for a woman to help herself to be more comfortable and perhaps her labor to be more effective if she were not confined to a bed.
Particularly interesting were Hodnett's comments on how the presence of a bed in a central location predisposes women to staying in bed, rather than moving around:
Doctors and midwives agree it's better for a woman to move around while she's in labor. Walking and changing position makes her more comfortable and helps the labor progress. But in many countries, women giving birth in hospitals are often instructed to lie in bed while their labor progresses.

University of Toronto nursing professor Ellen Hodnett observed that in many modern - and even some not-so-modern hospitals - a bed was at the center of the labor room.

"That bed is a problem," Hodnett says. "Because it's a central focus of the room, and it sends messages that that's where you're supposed to be in labor. And yet, we have pretty good evidence that spending long periods of time in bed, particularly confined in the way that a hospital labor bed confines you, is not conducive to normal, healthy labor progress."
Goer also noted how the presence of a delivery bed influences women's mobility in labor:
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.”)
Switching from a delivery bed in the center of the room to a large, low mattress with several pillows in the corner of the room was something that French obstetrician Michel Odent did when he became the head of the maternity department at Pithiviers, France in the 1970s:
Before: Typical French delivery room

After: birth room & pool room
In hospital birthing rooms I have visited personally, the bed is the central focus of the room. Even the flooring and ceiling materials emphasize the bed's central role in the drama to unfold: inlaid patterns around the bed circumscribe the area where birth is allowed to occur, and the spotlights on the ceiling further dictate the location of birth. These photos are from the new UIHC maternity wing in Iowa City, where I did my PhD. Notice the inlaid pattern in the flooring around the bed and the spotlights in the ceiling:

And these photos of my local hospital's LDRP rooms. Again, notice the inlaid pattern in the flooring that outlines and emphasizes the centrality of the bed. The room revolves around the bed: the couch and rocking chair face it, the monitoring equipment surrounds it, and the lights focus on it:

I would love to see pictures of the modified birth rooms from Hodnett's study. Sometimes simple and inexpensive changes are better than the newest high-tech bed.


  1. You're right about the floor inlay! What a insidious reminder that the bed is "where it's at".

    A year or two ago, I went to a presentation by Holly Kennedy who did research in the UK looking at maternity care practices in a district in London with excellent "normal birth" rates. There was a high home birth rate in this district, but she focused on what was going on in hospitals, where the outcomes were also excellent. One of the things she noticed is that, while the labor bed is still central in the room, the cleaning staff are instructed to return it to the most elevated position after cleaning the room. Then, when the next woman is admitted, there isn't an expectation that she will get straight into the bed. Instead, the bed was most commonly used as a place for the midwives to spread out their paperwork. They also kept EFM machines in the hallway and only rolled them in whenever needed. Lots of little tricks to transform a typical labor room into one that encourages mobility. With all that said, I too would love to see the room described in Hodnett's research.

    As always, thanks for the link to Science & Sensibility!

  2. I hate hospital birth rooms. You're right - they all center around the bed. I remember pacing anxiously around the room when in labor with Jameson, looking for *something else*...but there was just wall, wall, machine, wall, bed, wall, wall. The "furniture" is part of the wall so that doesn't count either, and as we all know it's just designed to cleverly conceal more machines.

  3. I was recently discussing with a friend the layout of hospital birth rooms. I had never thought much about the bed being the center of attention. (Of course, I don't think much of hospital birth). But, I was talking about how hospitals are trying to make the rooms seem "homey", yet when delivery time comes, the spotlights come out, the shiny utensils are wheeled in, and the room transforms so much, you wouldn't recognize it! I love the photo of the french birth room with the low bed in the corner.

  4. I love this. So my main question is, did the OBs get on their knees to catch the babies? Which of course is possible, but doubt many I have seen in action would be willing to.

    Not only are most hospital births about the bed, but also the stupid machine. Everyone watches the machine and not the mom.

  5. I'm almost certain it was a midwife-led hospital unit, and having done hospital births myself (though usually a home birth midwife and before that a freestanding birth center), I have definitely been on my knees in a hospital room. I can't remember if I was inside or outside the floor inlay, though! :)

  6. It would have been physicians attending, not midwives: "Women attended by midwives or doulas were excluded from participating, effectively creating a study population not predisposed to be mobile in labor," writes Goer.

  7. Sorry, I was aware (from having read the study) that the women didn't actually give birth in the rooms, but forgot that Henci hadn't said as much in her article. So I was assuming Sheridan's question was about the UK hospital I was talking about in my previous comment.

    Here's a quote from the article itself. It makes it pretty clear that you can take the bed out of the hospital room, but you can't take the hospital out of the hospital room. (Emphasis mine.)

    "The standard labor bed was in the room for 0 to 25 percent of the time for 6 (20.6%) women, 25 to 49 percent of the time for 14 (48.3%) women, 50 to 75 percent of the time for 4 (13.8) women, and more than 75 percent of the time for 5(17.2%) women. One woman never used the standard labor bed; she gave birth on the floor mattress. Reasons for returning the standard labor bed to the ambient room were as follows: request for epidural analgesia (n = 18); artificial oxytocin infusion (n = 2, including 1 who was also having epidural analgesia); amniotomy (n = 2), physician request at time of delivery (n = 2); continuous electronic fetal heart rate monitoring needed (n = 1); woman requested standard bed (n = 3); and refusal by the charge nurse to allow setup of the ambient room (n = 1)."

  8. I delivered in a hospital with a midwife practice. It was in a "regular" hospital, but they reorganized the room for their "homestyle" births. They pushed the beds to the corner, put a futon on the floor, and broke out the birth stool. They had pools, also, but I labored at home and was too late for that.

    If they had asked me to get into a bed, I don't think I physically could have. I only felt comfortable on the floor.

    What I love is that it doesn't "cost" the hospital very much to do. Actually, they may save a few bucks if they didn't have the fancy monster beds.

  9. Lesley,
    That's cool that the midwives did their own "interior decorating"! I totally understand the feeling of not being able to get in bed. During both of my labors, once I knew it was the real deal and gave up on trying to sleep, I never once got near a bed or even laying down on a couch! I had to be upright, preferably leaning over something.

  10. "...refusal by the charge nurse to allow setup of the ambient room (n = 1)."

    No offense to nurses, but why would a nurse be allowed to refuse the ambient room set up? I guess it's possible that the mom was ambivalent about it and just went with what the nurse wanted?

    Interesting study. Having taken Wiesinger's "What Would Mammals Do" from Conscious Woman, I know how important the L&D environment is for physiological birth. It's why so many of us that understand and value true physiological birth prefer to stay home or go to a home-like environment such as a birth center.

  11. I often elevate the bed so women can stand up and lean on it. That way they are not encouraged to climb in the bed. I also like to walk to the nursery with the Mom to be and spouse. We have handles on the walls in case she needs to stop. I like to position them in the window of the nursery and pick up babies to encourage them. Mom's love to see new fresh babies. It makes them happy. SO I love to take these trips with new moms.

    Years ago when Epidurals were not readily availible, I would give women 10 IV of nubain with phenergan and 10 im. THen I would encourage them to take a nice tub and I wouls insert and IV since the hot water would make their veins huge!!!!! so they would be an easy stick. I would show the spouse how to pour warm water over her belly and play nice music to calm the whole room. Then she would pop up and say, "Pinky, the baby is coming!" I would check her and most times yes the baby was coming. IT was a nice birth. I miss those days! I never thought I would but I do.

  12. Wait, I'm confused - they put a standard bed back in the room for the birth? Except for just one birth? That's kind of a bummer. I was thinking the set up sounded kind of nice. I wonder if I'm allowed to share pictures of our labor suites? I'll email you some if I am. We have no inlay on the floor, but the bed is still the central focus, complete with the ceiling lights and all. We still try to keep clients out of them if we can. My client who birthed her baby today was barely ever in the bed and barely on the monitor (we do intermittent monitoring when we can.) This makes my nurses happy because it greatly decreases how much charting of fetal heart rate monitoring they have to do! Oddly, after an entirely upright labor this mama birthed her baby lying on her back by choice as she felt more comfortable - since she had a 6 minute second stage even being a little upright at the end just felt too intense.
    I was hoping this study encouraged births in the study set up - it's good for docs to get down on the floor!

  13. I would also have to say that the bed is another way, dating back to the victorians, to emphazize that womenhood, pregancy, labor, and birth is a sickness that when you are sick you need to lay down.


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