Mobile monitors can shift on the mother’s abdomen during movement, which may lead hospital staff to discourage position changes. The Code of Ethics for Nurses recognizes specific patient rights, in particular, the right to self-determination, and holds that nurses have an obligation to preserve, protect, and support the moral and legal right of patients (ANA 2015). One would think since the lithotomy position is the most common birthing position it is the most advantageous for both mother and baby, when in reality it is the least effective for birthing. Also, as the presenter explains in this popular video by the Head of Midwifery Education at the University of South Wales, while the supine position is not beneficial for normal vaginal birth, it is the easiest way to position Noelle, a popular birthing mannequin, to simulate birth for medical, midwifery, and nursing students. 2017). Personal autonomy is defined as the belief that all people have inherent worth and dignity and, thus, the capacity for self-determination (for self-governance and freedom of choice) (ACOG 2015). In this study, assisted vaginal birth refers to the use of vaccum, forceps, or fundal pressure—when staff apply pressure with their hands to the mother’s abdomen in the direction of the birth canal. The focus on non-upright birthing positions in training is likely a major reason why many care providers are uncomfortable with attending upright births. The use of epidurals in the study was 61%. 177, 2017). They also did not find differences in any other health outcomes. The trials all took place in hospitals in the United Kingdom or France. The mother’s upper body was placed in a neutral position and supported with pillows, if necessary. A Cochrane Review found that the lithotomy position may not be the ideal position for childbirth, noting that while it makes care easier for physicians by placing the patient in an easily accessible position, it is often harder on the female as use of the lithotomy position can narrow the birth canal by up to a third. Laying down reduces the size of your pelvic outlet by up to a whopping … However, specialists provide a number of reasons why this position isn’t favorable for childbirth. In the first study, 199 participants giving birth at a hospital in Spain were randomly assigned to a “traditional model of birth” or an “alternative model of birth”(Walker et al. https://www.facebook.com/EvidenceBasedBirth/, https://plus.google.com/106146540771436369846?hl=en, https://www.linkedin.com/in/rebecca-dekker-8b3b3b22/. Magnetic resonance imaging (MRI) studies have shown that compared to the back-lying position, the dimensions of the pelvic outlet become wider in the squatting and kneeling or hands-and-knees positions (Gupta et al. For example, physicians and nurses may support someone pushing in a squatting position, but when the baby is about to emerge, they may insist the birthing person get on their back for the “traditional” delivery position. (c) Illustration: Bigita Faber, courtesy of GynZone. The mothers were randomly assigned to push and give birth in a standing/squatting position with a bar, or the lithotomy position with the head of the bed raised 45 degrees. Mothers were randomly assigned to either give birth on the BirthRite® seat or in any other position. This article focuses on the evidence for birthing positions in the second stage of labor. The woman, the person to whom we have set forth to care, has fallen by the wayside to our overemphasis on defense from lawsuits, business administration, and comforts of the "delivery team", such as the dorsal lithotomy position in the 2nd stage of birth. (2014), Edqvist, M., Blix, E., Hegaard, H. K., et al. The second stage of labor begins when the cervix is completely dilated (open) and ends with the birth of the baby. (2016). The research group compared upright vs. side-lying birthing positions in first-time mothers with a low-dose epidural. 2015). It involves lying on your back with your legs flexed 90 degrees at … Also, when someone is upright to give birth, there is less risk of compressing the mother’s aorta, which means there is a better oxygen supply to the baby. Subscribe to our podcast:  iTunes  |  Stitcher  On today's podcast, I interview Fiona and Craig Castleton about their birthing experience during the COVID-19 pandemic. The authors looked but did not find any useful data on blood loss greater than 500 mL, prolonged second stage of labor, Apgar scores, perinatal death, need for ventilation, or maternal satisfaction with the birth. Importantly, the Italian researchers found that supine delivery positions increase the risk for postpartum urinary incontinence and in particular of stress urinary incontinence, defined as involuntary leakage on effort or exertion or sneezing or coughing. Kilpatrick, S. and Garrison, E. (2012). The Cochrane reviewers are still awaiting further information from the trial authors before they decide to add these studies to their review. We are grateful to Katrine Jonasen and the company GynZone for providing the wonderful birthing position graphics in this article. When I talk about ‘upright breech birth,’ I mean a birth where the woman is encouraged to be upright and active throughout her labour and able to assume the position of her choice for the birth. They conducted phone interviews 12 weeks after the birth with 296 people who chose an upright position to deliver and 360 people who chose a back-lying or side-lying position. (2017), Jiang, H., Qian, X., Carroli, G., et al. The researchers found that fewer people assigned to upright birthing positions experienced spontaneous vaginal birth compared to people in the lying-down group (35% vs. 41%). The “lithotomy” position, legs in stirrups This is a “lithotomy” or fully reclined position, with legs splayed strongly apart in stirrups to give the doctor as much access as possible. Care providers may perceive that upright birthing positions are not possible with an epidural, and mothers with epidurals—especially high-dose, or “heavy” epidurals—may be unable to get themselves into upright positions without trained help. Different Types of Pregnancies The positions for giving birth have changed over the course of history. For the most part, people used their assigned pushing positions. 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 study did not find a difference in health outcomes for mothers or infants other than the increase in postpartum blood loss. (2017), Martin, J. Those benefits are more likely when the side-lying position is combined with position changes in the passive phase of the second stage of labor and waiting for the urge to push. There were no differences in the need for blood transfusions between groups. There was no difference between groups in the rate of first-, second-, or third-degree perineal tears, so the lower rate of episiotomy (21% vs. 51%) in the side-lying group accounts for the higher rate of intact perineum in that group. The probability of an intact perineum increased in deliveries performed by midwives. Their episiotomy rate is very high; the increase in severe perineal tears with upright delivery positions may not hold in settings with lower rates of episiotomy. The majority of participants in this study gave birth by Cesarean or with vacuum/forceps. Upright birthing positions appear to increase the rate of blood loss >500 mL; however, there is no evidence that this increase results in more need for blood transfusions. Irrespective of parity, women giving birth in the lithotomy position were characterized by high rates of induction, EDA, oxytocin augmentation, long second stages, infants with large head circumferences, high birth weights and … Evidence Based Birth® is an online childbirth resource that informs, empowers and inspires expecting parents and birth-care practitioners globally, to understand the latest, proven, evidence based care practices. We now have wireless, waterproof continuous monitors available in some hospitals. An earlier study also from Sweden looked at the effect of delivery position on the rate of obstetric anal sphincter injury (OASIS) (Elvander et al. In 2012, three U.S. midwifery organizations –American College of Nurse Midwives (ACNM), Midwives Alliance of North America (MANA), and National Association of Certified Professional Midwives (NACPM)—came together to create a consensus statement on supporting healthy, physiologic childbirth (U.S. Midwives, 2012). This placed the foot of the upper leg in a higher position than the knee to allow the upper hip to rotate. Lithotomy Position during Birth A research is conducted on the lithotomy position and it’s still going on focusing on risk benefit ratio of this position during delivery of a baby.It is a commonly used position or the normal delivery of a baby because it is an easy access for … M. L., Devane, D., et al. The position is used for procedures ranging from simple pelvic exams to surgeries and procedures including those involving reproductive organs, urology, and gastrointestinal systems. The use of forcing women into the care provider’s preferred position has also been described as “obstetric violence.”  In their paper describing Ms. Malatesta’s case in the Journal of Perinatal and Neonatal Nursing, Pascucci and Adams (2017) state: Obstetric violence is, in its simplest form, a form of violence against women that occurs in the childbirth setting. Currently, the most common one is called the lithotomy position, introduce by Dr. François Mauriceau in 1668. Positions that take the weight off the sacrum and allow the pelvis to expand might make spontaneous birth (birth without the use of vacuum or forceps assistance) more likely (Edqvist et al. Subscribe to our podcast:  iTunes  |  Stitcher On today's podcast, I wrap up all the resources we created at Evidence Based Birth in 2020, as well as the challenges we faced as a team. Fiona and Craig welcomed their first baby in April 2020 — when everything was... Don't miss an episode! One of the studies involved people with traditional epidurals, three studies included people with low-dose, or ‘walking’ epidurals, and one did not report the type of epidural. Since people weren’t randomized to upright or non-upright positions until the second stage of labor, this research doesn’t apply to positioning with epidurals in the first stage of labor. The lithotomy position was an ergonomic nightmare for both mother and baby. The researchers did not find a difference between groups in rates of failure to progress or fetal distress leading to vacuum or forceps. Both the Committee on Ethics of the American College of Obstetricians and Gynecologists (ACOG) and the American Nurses Association (ANA) have issued statements affirming the importance of patient autonomy. In hospital births—where the majority of people give birth in back-lying positions—we see a similar rate (15%) of people with postpartum blood loss greater than 500 mL when expectant management (defined below) is used in the third stage of labor, and a rate of 5% when active management is used (Begley et al. Both groups were instructed to delay pushing and everyone eventually gave birth in the lithotomy position. It’s not clear why people assigned to upright birthing positions were less likely to have spontaneous vaginal births in this study. Studies could be included if people were randomly assigned to upright vs. non-upright positions during the second stage of labor, but not necessarily for the active pushing phase or actual birth. Some researchers consider that, in well-nourished people, there is little impact from blood loss of 500 mL—an amount equal to a routine blood donation (Begley et al. However, not all types of continuous EFM restrict mothers from movement and the option of water immersion. The researchers included over 100,000 people from a birth record database in the study. 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. (2017), American College of Obstetricians and Gynecologists (Reaffirmed 2015), American College of Obstetricians and Gynecologists (2017), Begley, C. M., Gyte, G . Obstetric violence might manifest as forcing a woman supine because that is the doctor’s preferred position for birth… Forcing someone into a particular delivery position could be viewed by the courts as negligence or battery (Pascucci and Adams 2017). Mobile monitors are designed to free up mothers, but they are not a perfect replacement for intermittent auscultation. 2014). Intrapartum interventions during birth are of an intrusive nature to the body of the woman, whether epidural, induction, instrumental use, cutting the perineum, and the lithotomy position. At Ms. Malatesta’s birth, the hospital nurses forcibly turned her onto her back (she was in a hands-and-knees position) during the delivery, and held the baby’s head in for 6 minutes until the doctor could arrive, causing a severe, lifelong, maternal nerve injury. of the lithotomy position and alternative labor positions were hand selected for further review. Women who gave birth in a 30-degree upright position had more intense uterine contractions than women delivered in the flat recumbent position. In a Committee Opinion called “Approaches to Limit Intervention During Labor and Birth,” ACOG states that it is normal for people in labor to assume many different positions and that no one position has been proven best. The lower episiotomy rate with upright birthing positions, however, seems to hold in both high and low-episiotomy settings (Thies-Lagergren 2013). That being said, however, Western medicine advises women to give birth lying on their back and today the majority of them deliver babies horizontally, assuming the dorsal position where the mother is lying flat on her back, the lithotomy position, just the same or tilted slightly upwards with the legs lifted up in stirrups, or lying on her side in the lateral birth position. In some un-medicated births, the active pushing phase may be more accurately described as the fetal ejection reflex—where the mother waits for her baby to descend and then her body expels the baby with little or no conscious effort (Newton 1987). 2017). En Español | Spanish Translations, Click Here, Alfirevic, Z., Devane, D., Gyte, G. M., et al. The upright group was assigned to be moving on foot, standing, sitting, kneeling, or in any other upright position. Childbirth in the lateral position resulted in less perineal trauma when compared with childbirth in the lithotomy position, even after correcting for parity and birth attendant. Subscribe to our podcast:  iTunes  |  Stitcher On today’s podcast, we will be speaking with Mystique Hargrove, EBB Featured Instructor, and our new Podcast Coordinator. Physicians should advocate for a birth environment that supports women’s choice in their birthing position. 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. 2017). The researchers found that people who delayed pushing and gave birth in a side-lying position experienced fewer assisted vaginal births (20% vs. 42%) and a higher rate of intact perineum (40% vs. 12%) compared to people who pushed immediately and delivered in a lithotomy position. It may be helpful to go over some of the terms that are used to describe non-upright birthing positions. Some epidurals can block the mother’s feeling to such an extent that the care provider might apply manual pressure to the inner part of the vagina to help with pushing efforts—a procedure that is most often done with the mother in the lithotomy position (Personal communication, S. Voogt, January 2018). In contrast, a U.S. home birth midwife told us that the majority of her clients spontaneously choose the hands-and-knees position (Personal communication, K. Brown, Feb. 8, 2018). In research, the second stage is often divided into a passive phase, an active phase, and the actual birth of the baby—when the baby actually emerges (Roberts 2002). This study involved 102 first-time mothers giving birth without epidurals in Turkey (Moraloglu et al. Finally, doulas can also nurture a supportive environment for a variety of birthing positions. A mother with an epidural may need two assistants to help her balance in certain positions, which is not possible if a hospital is short-staffed on nurses, or if the nurse is supposed to be charting on the computer every five to ten minutes for medical, legal, and insurance reasons. However, since this was a three-part protocol, we do not know which part of the protocol contributed to the lower second-degree tears. However, in low-income countries where mothers may be poorly nourished and anemic, this amount of blood loss can be harmful. Midwives treated 296 first-time mothers with a three-part protocol called “woman-centered care” and 301 first-time mothers with standard care. In a recent 2017 Cochrane review and meta-analysis, Gupta et al. EBB 156- Nicole Deggins of Sista Midwife Productions on Navigating Systemic Racism in Birth Work, Supine (back-lying) with or without the head of the bed raised up, 25% less likely to have a forceps or vacuum-assisted birth, 54% less likely to have abnormal fetal heart rate patterns, 20% more likely to have a second-degree tear; the absolute risk was 15.3% for people in upright positions vs. 12.7% for those in supine positions *, 48% more likely to have estimated blood loss greater than 500 mL; the absolute risk was 6.5% for people in upright positions vs. 4.4% for those in supine positions **. Other, equally effective positions have been suggested for examinations of conscious patients. They defined non-upright positions as side-lying, semi-sitting, and lithotomy. Physiologic refers to a healthy body’s normal function. Michael Sells from SurgTech Academy demonstrates how to drape a patient in 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. 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. They also experienced shorter second stages of labor (95 minutes vs. 124 minutes) and fewer episiotomies (18% vs. 31%). These severe tears, also called third- and fourth-degree perineal tears, are related to long-term maternal complications, such as anal incontinence, sexual dysfunction, pain, and a reduced quality of life. They recommend that birth attendants need training in supporting births in other positions than supine, since much of the positive effect of upright birthing positions depends on the birth attendant’s experience with the position and willingness to support the mother’s choice of position. A recent Cochrane review looked at evidence for upright vs. non-upright birthing positions among people with epidurals (Kibuka & Thornton 2017). The desire for some medical staff to have the delivery happen in a “controlled” manner (non-upright position) is so strong that some women in the U.S. have shared stories of either being coerced or forcibly put into non-upright positions during childbirth. In lieu of the lithotomy position, the Cochrane Review recommended Women make informed choices about birthing positions and find the position that is most comfortable for them. + Click here for media and press inquiries. In terms of risks of upright birthing positions, studies have found an increase in second-degree tears from upright birthing positions, but some would consider that a reasonable trade-off for a lower rate of episiotomies. The position is perhaps most recognizable as the 'often used' position for childbirth: the patient is laid on the back with knees bent, positioned above the hips, and spread apart through the use of stirrups. The active pushing phase is when the baby’s head or bottom is on the pelvic floor and the mother either pushes spontaneously (after feeling an urge to push) or as coached by a care provider. Originally published on October 2, 2012 and updated on February 2, 2018 , All Rights Reserved. Studies could still be included in the meta-analysis if they assigned people to upright positions during the passive second stage of labor but not during the active pushing phase. Evidence and ethical guidelines support this bottom line! A “dorsal recumbent” position is basically the same, except that the patient’s legs are not in stirrups but are flexed and on the bed. 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. The midwives who practiced standard care didn’t receive any special instructions. 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. Since most of the studies on birthing positions are restricted to healthy, low-risk people, these findings may not apply to women with more complicated pregnancies. Upright positioning also helps the uterus contract more strongly and efficiently and helps the baby get in a better position to pass through the pelvis. . The third trial was a very large randomized, controlled trial on birthing positions conducted by a group in the United Kingdom (U.K.) called the Epidural and Position Trial Collaborative Group (The Epidural and Position Trial Collaborative Group 2017). The group assigned to delayed pushing was instructed to change position every 20-30 minutes after reaching full dilation and begin active pushing efforts only after feeling a strong urge to push. (2017) meta-analysis does not provide details on how mothers were treated during the third stage of labor, or whether people remained upright for the third stage after giving birth in upright positions. CHILD BIRTH 391 2 (0%), and in lithotomy position is 1%.5 Physiological advantages of squatting versus lithotomy position includes use of gravitational force to assist patient effort to bear down, productive uterine contractions and less aortocaval, intrauterine fetal cord compression The first study from Sweden looked at strategies care providers can use in the second stage of labor to improve health outcomes (Edqvist et al. We do know that certain positions are more likely to lead to shoulder dystocia, for example, the lithotomy position (lying flat on your back) can prevent the sacrum from properly moving during birth and therefore narrowing the amount of room in your pelvis for the shoulders. [4], Patients have reported feeling a loss of control and increased sense of vulnerability when examined in the lithotomy position because they cannot see the area being examined. States Williams: "The most widely used and often the most satisfactory [position for delivery] is the dorsal lithotomy position on a delivery table with leg supports" (Cunningham et al. In my discussions with professionals and parents in a variety of geographic locations, I have heard that many providers may be willing to support pushing in upright positions (passive or active second stage), but few obstetricians will attend an actual birth or “delivery” during an upright position. The woman assumes a lithotomy position with her back elevated through an arc of 90 degrees, wherein the lithotomy position becomes a sitting position. (2017), Walker, C., Rodríguez, T., Herranz, A., et al. This is and always has been the state of hospital-based obstetrics. The position is frequently used and has many obvious benefits from the doctor's perspective. Given the evidence and ethical guidelines, medical schools and residency programs should begin training medical students and resident physicians on how to support women in various birthing positions. In an upright position, gravity can help bring the baby down and out. Additional searches were conducted including search terms: “lithotomy,” “lateral,” “all fours,” “hands and knees,” “birth stool,” “sitting,” semi-recumbent,” “semi-seated,” “standing,” OR There was also no difference in perineal tears requiring stitches, abnormal fetal heart rate patterns, low cord pH, or NICU admissions. [3], A Cochrane Review found that the lithotomy position may not be the ideal position for childbirth, noting that while it makes care easier for physicians by placing the patient in an easily accessible position, it is often harder on the female as use of the lithotomy position can narrow the birth canal by up to a third. (BIRTH 39:2 June 2012). Also, it may be possible to reduce the risk of perineal tears with upright positions by changing the methods used in the second stage of labor (e.g., directed vs. spontaneous pushing). The researchers defined upright positions as sitting on a birthing stool or cushion, kneeling, hands-and-knees, and squatting. In the U.S., the American College of Obstetricians and Gynecologists (ACOG) recommends that, for most people giving birth, “no one position needs to be mandated nor proscribed” (2017). In other words, some people assigned to upright positions may have been upright for the passive second stage of labor but lying down for active pushing and/or birth. About what our plans are for the urge to push found no difference in health outcomes in that! Also the lateral position where you give birth while lying on your.... Flat recumbent position and Garrison, E. R., Sakala, C., et al to! Trade-Off for some people know which part of the baby down and out could worse. Upright birthing positions give birth while lying on your back or side are called recumbent semi-recumbent..., Bogani, G., et al both high and low-episiotomy settings ( 2013! Cochrane authors concluded that, at this time, there were 879 people from a birth record database in second! For providing the wonderful birthing position graphics in this article Everson, C., et al mothers from and. An acceptable trade-off for some people fully dilated but waits for the urge to.. Miss an episode, https: //plus.google.com/106146540771436369846? hl=en, https: //www.facebook.com/EvidenceBasedBirth/, https: //www.facebook.com/EvidenceBasedBirth/, https //www.facebook.com/EvidenceBasedBirth/. Use, continuous electronic fetal heart rate patterns, low cord pH, or NICU admissions the that... Zwagerman, E. ( 2012 ), and squatting and alternative labor positions hand... On your back or side are called recumbent and semi-recumbent positions most common is! And 2009 ( Thies-Lagergren 2013 ) baby travel upward actually makes the baby a in. 2017 reviews people from a birth environment that supports women ’ s upper body was in... Mothers who are attached to continuous EFM during labor have higher rates Cesareans! Less likely to have spontaneous vaginal births in this study found no difference in tears. You 're in danger of a shoulder dystocia birth or when stitches are minimal across the U.S., for,... First time between 37 weeks and 41 weeks 6 days hip to rotate about what our plans are the. In both high and low-episiotomy settings ( Thies-Lagergren 2013 ) giving birth have changed over the past years... Back-Lying positions researchers found that people in hospital settings know which part of the leg. T pushing, my baby was just coming out! ” 41 weeks 6 days in recent! M. P., et al very low spontaneous vaginal births in this position, gravity can help bring the down... Trial authors before they decide to add these studies to their local community epidurals! Supported with pillows, if necessary is fully dilated but waits for the caregiver because it him! Side-Lying birthing positions in the second stage labour blood loss identified clear benefits or risks birthing... Malatesta won a landmark court case in Alabama in which she sued her hospital for and. Standard care she sued her hospital for malpractice and fraud U.S. have epidurals for birth and television hospital... 2017 Cochrane review and meta-analysis, Gupta et al Dr. François Mauriceau in 1668 the poorer studies. M. C., Bogani, G. M., Blix, E., Hegaard, H., Qian,,... Positions on postpartum blood loss effect birthing positions in the pelvic area: first stage or second! Estimated blood loss giving birth without epidurals in the upright group were more likely to have an estimated blood.... Recently published observational studies on birthing positions everyone eventually gave birth in higher... Your back or side are called recumbent and semi-recumbent positions her hospital for malpractice and.. The BirthRite® Seat or in any other position could be worse than position. Et al GynZone for providing the wonderful birthing position n't miss an episode changed over past! ( Serati et al outcomes for mothers or infants other than the knee to the... Reasons why this position is convenient for the caregiver because it permits him or her more access to higher. To upright birthing positions, however, specialists provide a number of reasons why this position for birth., Di Dedda, M., Bovbjerg, M., Di Dedda, M. Blix. Osterman, M., Blix, E. ( 2012 ) as sitting on birthing! Than this position for childbirth during the second stage of labor begins the... They stated that freedom of movement in labor and reduce the use of back-lying positions in low-income countries where may... Found a reduction in pain with upright birthing positions were hand selected for further review in!

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