Some researchers consider that, in well-nourished people, there is little impact from blood loss of mL—an amount equal to a routine blood donation Begley et al. However, in low-income countries where mothers may be poorly nourished and anemic, this amount of blood loss can be harmful. So, upright vs. The way care providers handle the third stage of labor, on the other hand, seems to have more of an impact on the amount of postpartum blood loss.
In contrast, with active management the care provider usually gives the mother a drug to make the uterus contract, clamps the cord early, and gently pulls on the cord while pressing on the uterus to deliver the placenta.
It would be interesting to see research comparing active management of the third stage of labor in upright vs. The Gupta et al. Without these important details, it is difficult to draw conclusions about the effect of upright birthing positions on postpartum blood loss. Three out of four trials that measured pain found a reduction in pain with upright birthing positions.
They also found that when people gave birth in upright positions, their labors were shortened by about six minutes; however, the evidence for this outcome was of very low quality. When they left out the poorer quality studies, there were no differences in length of labor between groups. This meta-analysis included fewer studies 22 vs. There were no differences between the upright and non-upright groups for any other health outcomes. We found one randomized trial that was too new to be included in the reviews.
This study involved first-time mothers giving birth without epidurals in Turkey Moraloglu et al. The study showed that the people who stood, then squatted down with a bar to push during contractions, had shorter second stages of labor by about 34 minutes. They also experienced less pain, were less likely to receive artificial oxytocin Pitocin to augment labor, and had higher satisfaction with the birth experience, compared with the group that pushed and gave birth while back-lying in a raised bed.
There were no differences between groups in postpartum blood loss. A recent Cochrane review looked at evidence for upright vs. Studies could be included if people were randomly assigned to upright vs. Combined, there were people from five randomized, controlled trials. The trials all took place in hospitals in the United Kingdom or France.
There was also no difference in perineal tears requiring stitches, abnormal fetal heart rate patterns, low cord pH, or NICU admissions. The authors looked but did not find any useful data on blood loss greater than mL, prolonged second stage of labor, Apgar scores, perinatal death, need for ventilation, or maternal satisfaction with the birth.
The Cochrane authors concluded that, at this time, there is not enough evidence to recommend specific birthing positions for people with epidurals.
There are three other randomized, controlled trials that looked at birthing positions in people with epidurals, but were not included in the Cochrane meta-analysis. The Cochrane reviewers are still awaiting further information from the trial authors before they decide to add these studies to their review. People assigned to the traditional model began pushing in the lithotomy position immediately after they reached ten centimeters, and also gave birth in the lithotomy position. People assigned to the alternative model delayed pushing and gave birth in a specific type of side-lying position.
The group assigned to delayed pushing was instructed to change position every minutes after reaching full dilation and begin active pushing efforts only after feeling a strong urge to push. Hospital staff assisted them in moving into different positions like sitting, kneeling, side-lying, or hand-and-knees. If, after 2 hours in the passive phase, the epidural prevented people from feeling an urge to push, they were asked to start pushing with each contraction.
When people in the delayed pushing group were ready to begin pushing efforts, trained staff assisted them in moving into a specific side-lying position. In this position, the lower leg remained extended on the bed and the upper leg rested flexed on the stirrup. This placed the foot of the upper leg in a higher position than the knee to allow the upper hip to rotate. This study provides evidence that in people laboring with epidurals, delayed pushing with position changes and active pushing and delivery in the side-lying position may reduce the rate of assisted vaginal birth, the length of the active pushing phase, and the rate of perineal trauma without adding risks for mothers or babies.
However, as the next study found, it may be possible to achieve these benefits using only delayed pushing and position changes in the passive phase of the second stage of labor. The second study, also conducted in Spain, randomly assigned people to position changes every five to 30 minutes in the passive phase of the second stage of labor or to the supine position for the entire second stage Simarro et al.
Both groups were instructed to delay pushing and everyone eventually gave birth in the lithotomy position. The people assigned to position changes during the passive phase of the second stage of labor had better outcomes than the group that was supine for the entire second stage, even though everyone gave birth in the same back-lying position.
They also experienced shorter second stages of labor 95 minutes vs. The third trial was a very large randomized, controlled trial on birthing positions conducted by a group in the United Kingdom U.
The research group compared upright vs. Between and , a total of 3, people were enrolled in the study from 41 maternity care centers in the U. To be included in the study, the first-time mothers had to be over the age of 16, carrying a single, head-down baby at 37 weeks or greater, planning to give birth vaginally, and in the second stage of labor with low-dose epidural medication.
The upright group was assigned to be moving on foot, standing, sitting, kneeling, or in any other upright position. The non-upright group was assigned to side-lying with the hospital bed raised up 30 degrees. For the most part, people used their assigned pushing positions. Strangely, this was a very low spontaneous vaginal birth rate in both groups.
These numbers are strangely high. In the U. The researchers did not find a difference between groups in rates of failure to progress or fetal distress leading to vacuum or forceps. They also did not find differences in any other health outcomes.
It could be that people with low-dose epidurals have a greater chance of giving birth spontaneously when they use a side-lying position for the second stage of labor rather than an upright position. However, the findings from this study should be taken with caution—they may not apply to settings with more support for spontaneous vaginal birth where there is less use of vacuum or forceps. The study included 1, mothers giving birth vaginally for the first time between 37 weeks and 41 weeks 6 days.
The author found that the birth seat resulted in a shorter second stage of labor by an average of minutes and less use of artificial oxytocin for augmentation of labor. There did not appear to be increased risk to the infant from the mother's nonsupine posture. Conclusion: Nonsupine positions during labor and delivery were found to have clinical advantages without risk to mother or infant.
Enhanced maternal outcomes included improved perineal integrity, less vulvar edema, and less blood loss. The authors compared postpartum maternal and neonatal outcomes resulting from supine vs nonsupine birthing positions in women at two obstetrics practices. Maternal birthing position is an aspect of obstetrics that has come under increased scrutiny. These factors often determine what birthing position is chosen for the parturient. Many previous studies on maternal birthing positions have focused on perineal trauma.
These factors include parity, 6 — 8 , 10 , 11 infant birth weight, 6 , 8 , 10 and use of anesthesia and analgesia. Maternal birthing position appears to be an important factor in postpartum outcomes.
Renfrew et al 9 conducted a systematic review of the English-language literature to identify and assess clinical procedures that reduce morbidity associated with trauma to the genital tract during birth. They identified maternal position as a factor warranting further study. Maternal positioning may affect the physiological health of the mother and infant, as well as the psychological well-being of the mother. Many women choose to work through second-stage labor by assuming a variety of body positions rather than a single unchanging one.
Satisfaction with the birth experience may be enhanced if a woman is given the option of choosing her birthing position. The main purpose of the present study is to compare the effects of nonsupine and supine positions during second-stage labor and delivery on perineal integrity, vulvar edema, and blood loss.
The study is a nonrandomized controlled trail of births that took place at these two hospitals between June and October Potential participants were given the option of taking part in the study and were told they could choose either supine or nonsupine delivery.
Participants were entered into the study in a nonconsecutive manner at each of the two hospitals during a month period. Definitions of maternal positions, perineal integrity, and other clinical terms agreed upon by all providers prior to collection of data by Terry et al.
Definitions are based on descriptions by Roberts and Kriz. The criteria for inclusion in the study were 37 completed weeks of gestation, spontaneous or induced singleton pregnancy, spontaneous vaginal delivery, and cephalic presentation.
Patients with evidence of congenital malformation, diabetes mellitus, pregnancy-induced hypertension, or use of epidural anesthesia were excluded from the study. Obstetricians or family practitioners attended these births. The definitions of these birthing positions and other clinical aspects of the present study were derived from Roberts and Kriz.
Women in this group were free to assume any or all of these nonsupine positions while laboring. All patients were from a white, rural population. Nurse midwives, whose education and training included the use of episiotomy when clinically indicated, attended these births. Data on the following variables were collected: Apgar score; estimated blood loss; fetal position at delivery; gravida number; infant birth weight; length of first, second, and third stage of labor; maternal postpartum hematocrit; maternal height and weight; number of children previously born to the mother; perineal integrity; and vulvar edema.
Data were collected from summary sheets completed by the practitioners following each birth. Neither provider nor parturient could be identified in the data analysis. Both groups included similar numbers of primiparous and multiparous patients. We did not detect outcome differences between the variables we measured in the primiparous patients vs the multiparous patients in either the supine or nonsupine group.
Outcomes of perineal trauma are shown in Table. More research into the benefits and risks of different birthing positions would help us to say with greater certainty which birth position is best for most women and their babies. Overall, women should be encouraged to give birth in whatever position they find comfortable. The findings of this review suggest several possible benefits for upright posture in women without epidural anaesthesia, such as a very small reduction in the duration of second stage of labour mainly from the primigravid group , reduction in episiotomy rates and assisted deliveries.
However, there is an increased risk blood loss greater than mL and there may be an increased risk of second degree tears, though we cannot be certain of this. In view of the variable risk of bias of the trials reviewed, further trials using well-designed protocols are needed to ascertain the true benefits and risks of various birth positions. For centuries, there has been controversy around whether being upright sitting, birthing stools, chairs, squatting, kneeling or lying down lateral Sim's position, semi-recumbent, lithotomy position, Trendelenburg's position have advantages for women giving birth to their babies.
This is an update of a review previously published in , and To determine the possible benefits and risks of the use of different birth positions during the second stage of labour without epidural anaesthesia, on maternal, fetal, neonatal and caregiver outcomes. We searched Cochrane Pregnancy and Childbirth's Trials Register 30 November and reference lists of retrieved studies.
Randomised, quasi-randomised or cluster-randomised controlled trials of any upright position assumed by pregnant women during the second stage of labour compared with supine or lithotomy positions. Secondary comparisons include comparison of different upright positions and the supine position. Trials in abstract form were included. Two review authors independently assessed trials for inclusion and assessed trial quality.
The design enabled the researcher to gain broad and in-depth information from postnatal mothers about their experiences during labour and delivery, particularly in regard to birthing positions [ 14 ]. Mugana DDH is the faith-based bed referral hospital for Missenyi district. It serves a population of more than , in the district and receives patients and clients from nearby regions such as Mwanza, Geita, and Shinyanga.
It also serves patients from nearby countries including Uganda. Specifically, this study was carried out in the maternity unit that includes a labour ward, antenatal and postnatal clinics.
The labour ward has 7 delivery beds and there is an average of deliveries each month. About pregnant women attend the antenatal and postnatal clinics each month for check-ups. There are 36 nurse-midwives working in the maternity unit: 30 of them are on the labour ward and six are in the antenatal and postnatal clinics. In order to strengthen the credibility and to better understand the findings, we used two sources of data [ 14 , 15 ]: postnatal mothers and nurse-midwives.
Postnatal mothers were those who had given birth within six months, had more than one normal delivery and could speak Kiswahili. The nurse-midwives were required to work in the delivery room in order to be recruited into the study. We believed that these nurse-midwives would have the most accurate information regarding which birthing positions were used and the reasons for using that preferred position.
A purposive sampling strategy was used to recruit participants, ensured the gathering of thorough and in-depth information from the participants who had experience with the birthing positions. The nurse-midwife in charge of the maternity unit was asked to identify postnatal mothers and nurse-midwives who met the inclusion criteria. After these prospective participants were identified, the researchers approached them and described the aim of the study, the data gathering process and the voluntary nature of their participation.
The participants were further informed that there would be no direct benefit for their participation, but that the findings would be used to improve care to women during childbirth.
They were also told that they could withdraw their participation at any time, even after having provided consent. Those who agreed to participate were then asked to provide written consent after their questions and concerns were answered. This study included 23 participants: 16 were postnatal mothers, 4 enrolled nurse-midwives and 3 registered nurse-midwives. In Tanzania, a registered nurse-midwife is a health professional who has successfully completed three years of nursing training at an approved nursing institution and is authorized to practice nursing and midwifery, whereas an enrolled nurse-midwife has completed two years of nursing and midwifery training [ 16 ].
Two trained research assistants were recruited to assist the researchers with recording and making observations during focus group discussions. These research assistants were diploma-trained nurses who had had previous experience conducting health-related research. The integration of semi-structured interviews and focus group discussions provided a better understanding of the use of supine positioning during childbirth from the perspective of postnatal mothers and nurse-midwives and enhanced the credibility of the findings.
We conducted seven 7 interviews [ 17 ] with nurse-midwives using the SSI guide. The interview guide Additional file 1 was based on information gained from the literature review and included open-ended questions and probes.
The nurse-midwives were asked about their perception of the commonly used positions during childbirth and their experience with other birthing positions. Interviews took place within the hospital premises, in a quiet room that provided privacy from other nurse-midwives and postnatal mothers. All interviews were conducted by the second author LE , a midwife with experience conducting health research. Each interview was recorded, allowing the researchers to listen later to the interviews and reflect on the interview sessions.
The information gathered during the reflection sessions was then used to revise the guide to allow new emerging issues to be included. The FGD guide had only one main question followed by probing questions that asked postnatal mothers about their experience using birthing positions and how they chose the birthing position.
The questions in the guide were open-ended, which allowed the researcher to explore the perceptions and experiences of postnatal mothers on birthing positions without personalizing opinions. Each FGDs discussion was comprised of eight postnatal mothers who were able to freely discuss their perceptions and experiences on birthing positions.
Discussions were conducted in the hospital for convenience reasons. Postnatal mothers came from different areas, therefore, it was not possible to conduct these discussions in the community setting. The first author LE moderated the discussions and the research assistants took notes and made observations during the discussions.
Due to the difficulty of organising and getting an adequate number of postnatal mothers for the focus group discussions within the time allotted for the data collection, only two FGDs were conducted.
Nevertheless, group discussions with postnatal mothers yielded adequate information about their experiences with birthing positions and complemented the findings obtained from the semi-structured interviews. Studies [ 18 , 19 , 20 ] have recommended that at least two focus group discussions should be conducted to gain saturation if participants have the defining demographic characteristics. The use of the Kiswahili language during data gathering and the triangulation of the data collection methods and sources increased the trustworthiness of the findings [ 14 ].
All interviews and discussions were recorded after the participants provided verbal consent for their conversation to be recorded. The inductive method of qualitative content analysis guided the analysis of data [ 21 ]. The audio-recorded interviews and discussions were transcribed verbatim into Kiswahili and then translated into English using the semantic translation by the second author LE who is fluent in both languages. However, in order to ensure accurate and valid translations [ 22 ], the English transcripts were verified by the co-author LTM by comparing them with the original Kiswahili transcripts and the audio-recorded interviews and discussions.
The researchers discussed any discrepancies between them and then made minor edits to the English transcripts. The researchers analyzed the interviews and discussions in English from the translated transcripts separately.
These condensed meaning units were abstracted and labelled with a code. To ensure adequate translation, all codes and corresponding quotes were reviewed and re-labelled if necessary.
Women adopted the supine position as instructed by the midwives, 2. Women experience of using alternative birthing positions, 3. Midwives commonly decide birthing positions for labouring women and 4. Supine is the best-known birthing position. Codes and themes from the content analysis are provided in Table 1. Further, the District Medical Officer of Missenyi granted permission for data collection.
Informed written consent was obtained from each participant after they were informed about the study, assured of the confidentiality of information they provided and the voluntary nature of their participation. All participants were informed that interviews and discussions would be recorded and agreed that their anonymous quotes could be used. Four 4 were married and 6 were female. Characteristics of the postnatal mothers are presented in Table 2.
As shown in Table 1 , four themes regarding the use of the supine position during delivery emerged: two from postnatal mothers and two from nurse-midwives. The direct quotes from both groups of participants regarding their experiences and perceptions were included to ensure that the findings accurately reflected their accounts.
The supine position is one in which the woman lies on her back with her knees flexed and legs apart, with her feet either supported or not. For me to lie on the back it is good because it is not causing any difficulties. I usually see women lying on their backs. Postnatal mother, FGD None of the women in this study was given the opportunity to choose the position they preferred during childbirth.
Women adopted the supine position as instructed by the nurse-midwives:. Postnatal mother, 29 years old, para 3. Postnatal mother, 28 years old, para 3. Postnatal mother, 49 years old, para 6. Studies have reported the advantages of using alternative birthing positions to the mother and her newborn baby [ 23 , 24 ]. However, it was not common for information about these birthing positions to be included in antenatal health education, despite the fact that some postnatal mothers knew them:.
It was also learned from this study that mothers who had had the opportunity to use alternative birthing positions had had a very positive experience:. These include socio-demographic factors, birth environment, cultural norms, western culture, type of health care provider, level of education and the age of the woman giving birth [ 2 ]. It was learned in this study that the decision about which position women should assume when giving birth was commonly made by the nurse-midwives, based on their knowledge and experience.
Nurse-midwives believed that they are knowledgeable and competent in birthing practices, including the choice of birth positions. According to our findings, nurse-midwives thought that there would be no point in letting women choose their preferred birthing position:. If the woman chooses a position and at last she ends up with the problem, the midwife will be responsible.
Why should the midwife allow the woman to choose the position? NM worked in the labour ward for 5 years.
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