Upright labor positions deliver better outcomes.

Following up on my recent attendance at the Cochrane Colloquium, I have been looking through the reviews from the Pregnancy and Childbirth Group to find topics of interest. Since I have been using birthing balls in labor, and selling them on my website, I was particularly drawn to a systematic review of randomized controlled trials of maternal position during the second stage of labor. This review showed that use of any upright or lateral position, compared with supine or lithotomy positions, is associated with:

1. Reduced duration of second stage of labor (12 trials – mean 5.4 minutes, 95% confidence interval (CI) 3.9-6.9 minutes). This was largely due to a considerable reduction in women allocated to use of the birth cushion in one study from India.

2. A small reduction in assisted deliveries (vacuum and forceps) (17 trials – odds ratio (OR) 0.82, 95% CI 0.69 – 0.98).

3. A reduction in episiotomies (11 trials – OR 0,73, 95% CI 0.64 – 0.84).

4. A smaller increase in second-degree perineal tears (10 trials – OR 1.30, 95% CI 1.09 – 1.54).

5. Increased estimated risk of blood loss > 500ml (10 trials – OR 1.76, 95% CI 1.34 – 3.32).

6. Reduced reporting of severe pain during second stage of labor (1 trial – OR 0.59, 95% CI 0.41 – 0.83).

7. Fewer abnormal fetal heart rate patterns 1 trial – OR 0.31, 95% CI 0.11 – 0.91).

(Citation: Gupta JK , Nikodem VC. Woman’s position during second stage. Cochrane Library)

I find this evidence too compelling to be ignored by those of us involved in the care of laboring women.

There have been varied hypotheses about the reasons for the advantages of non-recumbent positions, such as stronger and more effective uterine contractions (Caldeyro-Barcia 1960), and improved alignment of the fetus for passage through the pelvis (Gold 1950); and also lessened risk of aorto-caval compression and improved acid-base outcomes in the newborn (Ang 1969, Humphrey 1974, Scott 1963). Until recently in the history of childbearing, women would try to avoid the dorsal position and would change position during labor when and as she wished (Engelmann 1882). Different upright positions were achieved using posts, hammocks, furniture, ropes or knotted pieces of cloth, kneeling, crouching or squatting using bricks, stones, a pile of sand, or a birth stool (Englemann 1881).

Today, most women deliver in a dorsal, semi-recumbent or lithotomy position. We all know that it is easier for the midwife to monitor the baby and see what is happening if the woman is in a dorsal or semi-recumbent position (yes, the ubiquitous semi-Fowler’s position), and we know that this is the position modern Western women expect to assume to birth their babies (or, all too often, to be delivered of them). After all, the TV screen in the labor room is positioned so that the view is best from the semi-recumbent position in the bed, so women just naturally get into bed and slide down into that position. Then they stay there.

I would like to propose that we, as midwives, using the best available evidence, make a non-recumbent position the default position for second stage of labor, and use a recumbent position only for specific situations. Why don’t we do this now? I would hazard that the reasons have more to do with habit, hospital protocols, fatigue or overwork (I am frequently too tired or too busy to try something different, even if it occurs to me that it might help) than with a conviction that the semi-Fowler’s position is better. Even with an epidural, most women can sit in a chair, on a commode, or on a birthing ball next to the bed; or they can stand next to the bed and lean over it, with support from another person. Remembering the significant advantages of an upright position, I would like to challenge all of us to use this evidence to encourage our patients to sit, squat, kneel, or stand to push their babies out.

If you are a midwife with a lot of experience with non-recumbent positions and their advantages or disadvantages, I would like to hear from you. (The citations above can be found in the Cochrane Library: Gupta JK , Nikodem VC. Woman’s position during second stage.)

NS, 12/31/2001