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Factors influencing maternal positions during labor
Lorraine Searle

Posted April 2010

Abstract
Maternal body positions have a significant influence on the course of labor, affecting
maternal comfort and maternal and fetal physiology. Upright positions in the first
stage are those that avoid lying flat, and can include walking. Upright positions in the
second stage include sitting, squatting or kneeling and being on hands and knees.
Laboring women who adopt a more upright position for labor experience decreased
pain, fewer fetal heart rate abnormalities, a shorter second stage; fewer assisted births
and episiotomies; more second degree perineal tears and more blood loss estimated as
over 500 ml (Gupta et al., 2004 Soong & Barnes 2005; Stremler et al. 2005; De Jonge,
2007, Lawrence 2009). Midwives and other health care providers have a significant
influence on the positions of laboring women, through encouragement and bedside
guidance. There is ever increasing medicalization to childbirth; with this trend,
women have less choice in positioning options due to anesthesia and monitoring
technology constraints. Routine technologic interventions such as electronic fetal
monitoring and epidural anesthesia have altered the course of natural childbirth.

Midwives generally encourage laboring women to be mobile as long as possible and

to adopt whatever position is most comfortable, however, there are indications and
contraindications for the use of certain positions during the course of labor. Modifying
intrapartum care to reflect current evidence, regarding the factors that influence
maternal positions in labor will improve the maternity care that women and families
receive. Health professionals working in obstetric care need to be aware of the
evidence based practice regarding maternal positions in labor to enable women to
make informed choices. The conceptual framework guiding this study is
kinesthesiology, body position and movement. This inquiry will explore the factors
that influence maternal positions during labor.
(Word count 289)

Text
Chapter 1: Statement and Significance of the problem.
Introduction to the problem:

Maternal body positions have a significant influence on the course of labor, affecting
maternal comfort and physiology. Laboring women who adopt a more upright
position for labor experience decreased pain, fewer fetal heart rate abnormalities, a
shorter second stage; fewer assisted births and episiotomies; more second degree
perineal tears and more blood loss estimated as over 500 ml (Gupta et al., 2004 Soong
& Barnes 2005; Stremler et al. 2005; De Jonge, 2007, Lawrence 2009). Upright
posture is supported by radiological evidence of increased anterioposterior and
transverse pelvic diameters, resulting in an increase in the total outlet in both the
squatting and kneeling positions (Gupta et al.2004). Position changes that are
consistent with anatomic principles, such as squatting or kneeling positions to enlarge
the pelvis, are generally safe and acceptable to women. Laboring women with
ultrasound diagnosed OP fetuses demonstrated that periods in the hands and knees
position significantly reduced the likelihood of persistent severe back pain and that
this position was acceptable to the women (Stremler.et.al, 2005). Benefits and risks
of selected maternal positions in labor are listed in table 1.

Routine technologic interventions such as continuous fetal monitoring and epidural

analgesia have altered the types of positions a laboring woman can assume (Spiby,
2003). Although midwives tend to encourage women to utilize physiology and gravity
to their advantage during labor by encouraging positional changes, the expectations,
experience and education of the midwife attending the woman at birth will influence
the range of positions they encourage and facilitate women to adopt.

Upright positions in the first stage are those that avoid lying flat, and can include
walking. Upright positions in the second stage include sitting, squatting or kneeling
and being on hands and knees. Recumbent positions include supine, lateral, lithotomy
and semi recumbent with the use of pillows and wedges. The factors that influence
maternal positions in labor include health provider preference and training, birthing
equipment availability, analgesia choice, fetal monitoring method and nutritional
policy in labor. (See table 2)

BENEFITS: RISKS:

Increased diameters of pelvic Increase in second

inlet and outlet degree tears
Increase in blood loss
Improved uterine contractility >500ml
Improved fetal well being Practitioner resistance
Reduced duration of second
stage labor Maternal fatigue
High dose epidural
Reduction in assisted deliveries block
Reduction in episiotomies
Decreased pain
Increased feeling of maternal
control/ increased partner
involvement

TABLE 1: Benefits and risks of the upright position for labor and birth

FACTORS THAT INFLUENCE MATERNAL

POSITIONS IN LABOR
Maternal preference and maternal ability
Health provider preference
Health provider training
Birthing environment (Home, Birthing Center, Hospital)
Analgesia choice (epidural, narcotics)
Fetal monitoring method
Intravenous fluids

Table 2: Factors that influence maternal positions in labor

Women use various positions, supine and non supine, if they are left to choose (De
Jonge, 2004). The supine position however has become so common that neither health
care workers nor women regard this as an intervention (De Jonge 2004).The common
use of interventions and treatments during labor which include use of continuous
electronic fetal monitoring, methods of pain relief such as epidural analgesia and
intravenous infusions affect a woman’s mobility and use of postural change in labor
(Spiby et al. 2003; Declercq et al., 2006).
Other actions such as the environment and views of health practitioners can influence
a woman’s choice of labor position. (Albers 2007, Jonge et al 2008). There are
significant advantages to assuming an upright position in labor and birth, such as
stronger and more efficient uterine contractions aiding cervical dilatation, increased
pelvic inlet and outlet diameters and improved uterine contractility. However women
often are persuaded to conform to medical procedures. In American culture, the most
common image of the laboring woman is on her back in a bed. Women need to be
made aware of alternative positions and advantages and disadvantages in order for
them to make an informed choice (De Jonge et al., 2008).

Throughout history women in most cultures have used both the upright position and
alternative positions to give birth to babies. Not until the advancement of technology,
which began in the seventeenth century with the advent of the forceps, did women
give birth in the supine position. (Boyle, 2000).The supine position became
increasingly popular within Western societies as the standard position during labor. In
the early 18 th Century, a prominent French physician, Francois Mauriceau,
introduced the supine positions to facilitate the care of women and to enhance
obstetric performance and maneuvers, which then became largely adopted throughout
western countries (Diaz et al, 1980). In the last century, childbirth has progressively
moved from a woman supported experience in the home to a medical intervention
within the hospital (Albers 2007).

Scope of the problem:

According to The National Center for Health Statistics a total of 4,317,119 births were
registered in the United States in 2007 (NCHS 2007).
Most women have the potential to have a physiologic labor and birth; one that starts
and proceeds on its own, without routine use of interventions or drugs (Albers, 2007).
In a survey entitled Listening to Mothers (2006), fifty seven percent reported that they
gave birth lying flat on their backs (Declercq et al, 2006). Further research suggests
that although upright positions may be difficult after certain pain relief administration,
upright positions could still be achieved with the use of lower dose epidurals (Suplee
& Gennaro 2003). Women in labor typically enter an unfamiliar, busy institutional
setting to receive care from an array of strangers where numerous technical care
measures are routinely used, such as continuous electronic fetal monitoring and
epidural anesthesia. In 2002, a national sample of 1583 recently delivered women
reported their experiences with health care during maternity care. A full 93%
reported having had electronic fetal monitoring; while 71% labored in bed (Declercq,
2002).Intravenous infusion during labor has become a routine procedure for a high
percentage of women in labor throughout the United States, these procedures may
affect a woman’s mobility and use of postural coping strategies in labor (Spiby et al.,
2003).

Significance to women’s health:

Factors such as the ability to maintain some level of autonomy, ability to mobilize and
change positions unprompted, in an environment conducive to welcoming partners
and family members are important contributors to patient satisfaction. Patient
satisfaction plays a significant role in determining the pattern of one’s health seeking
behavior in the future (Hodnett et al., 2007).
Upright positions and mobility may be more pleasant for laboring women and may
have distinct advantages in promoting progress leading to a spontaneous vaginal birth.
Mobility may be more pleasant for laboring women and their partners. Women need
to be made aware of alternate positions and advantages and disadvantages in order for
them to make an informed choice. Women are less likely to assume positions that are
unfamiliar to them. Midwives and other obstetric health care personnel should be
proactive in offering advice on alternative positions and resources to help women to
be as comfortable as possible throughout labor. If women use birthing chairs, they
should be encouraged to move about between contractions to reduce vulvae
congestion and use an alternative aids such as a birthing char (De Jonge et al, 2008).
Use of the lateral position for birth appears to protect the perineum and squatting
using a birthing chair has been reported as a predisposing factor for third and fourth
degree tears (Lawrence, 2009). The woman’s birth experience should focus on her
individual needs and the experience she has should be facilitated by the midwife to
ensure that she has choice and control over her position for labor and birth.

Significance to midwifery:

The practice of midwifery emphasizes safe, competent clinical management and

advocates non intervention in normal processes (ACNM, 1997).
Every individual has the right to safe satisfying and health care with respect for
human and cultural variations. The normal process of pregnancy and birth can be
enhanced through education, health and supportive intervention (ACNM, 1997). The
widespread use of the supine position during labor can be considered an intervention
in the natural course of labor that, while appropriate in limited instances, is overused
in current care for laboring women with detrimental effects to women, their labor
process and their babies (Jonge 2004). The advice given by midwives is an important
factor influencing the choice of birthing position. Midwives play an important role
empowering women to adopt the positions that are most suitable for them at pivotal
times during labor and providing ongoing support and advice throughout pregnancy
and labor. Midwifery practice requires knowledge of research and an awareness of the
need for critical analysis of personal practice. Midwives need to be aware of evidence-
based practice related to maternal positioning in labor to promote normal birth for
child bearing women. This inquiry will look at the factors that influence maternal
positions in labor.

Chapter 2: Conceptual Framework & Review of Literature

Restatement of the problem

There is evidence from the literature that upright positions and being upright in the
first stage of labor reduce the length of labor and do not appear to be associated with
increased intervention or negative effects on the mother' and babies' well-being.
Women should be encouraged to take up whatever position they find most
comfortable during labor. The benefits of upright posture include a shorter second
stage of labor, a small reduction in assisted deliveries, and a decreased episiotomy rate
but an increased risk of severe blood loss. Birth position is influenced by many factors
and the research investigating women's perceptions of comfortable positioning, and
the extents to which women are influenced in relation to birth position are important
contributions to the knowledge on the topic.

The purpose of this inquiry is to explore the factors that influence maternal positions
in labor. Physical benefits that have been associated with the non supine positions are
increased uterine pressure, more effective bearing down effects, improved fetal
positioning, reduced risk of aorta caval compression and increased diameters of the
pelvis, psychological benefits include reduced pain/backache, increased feeling of
being in control and more effective communication with health professionals (Michel
et al., 2002; De Jonge, 2004; Soong & Barnes, 2005; Stremler et al.,2005; Lawrence
et al., 2009).

The majority of women in Western societies deliver in a supine position. It is claimed

that the supine position enables the midwife/obstetrician to monitor the fetus better
and thus to ensure a safe birth (Gupta, 2004). There is controversy around whether
being upright or lying down has advantages for women delivering their babies.
Several physiological advantages have been claimed for nonrecumbent or upright
labor which includes: the effects of gravity, lessened risk of aorto-caval compression,
stronger and more efficient uterine contractions, alteration in pelvic dimensions and
reduction of back pain. The literature remains sparse with respect to the influence of
co morbid medical conditions influencing position in labor.
Conceptual Framework

Conceptual frameworks help guide a study to a conclusion by organizing the

phenomena in an orderly coherent system. This involves integrating new research and
existing knowledge through a review of prior research on a specific topic, then
identifying or developing an appropriate framework. The overall purpose is to make
the research findings more meaningful and generalizable, helping the reader
understand the assumptions or conclusions and to identify possible biases the
researcher may have that could influence the conclusion of the study. Research useful
for clinical practice should provide evidence to support scientific approaches or
strategies in caring for women (Polit et al., 2001).

The conceptual framework guiding this study includes kinesthesiology. This is the
study of body position and movement.

The pelvis is comprised of two hip bones that are joined anteriorly via the symphysis
pubis (3.5 cm long), and posteriorly they articulate with the sacrum (12 cm long) at
the sacro-iliac joint. Each hip bone is composed of three bones that are joined together
at the acetabulum; these bones are the pubis, ischium and Ilium. The female pelvis is
tilted forwards relative to the spine. The angle of inclination is variable between
different individuals and between different races; in adult Caucasian females, the
pelvis is usually about 55° to the horizontal plane. Pelvic ‘tilt’, or inclination, is
position-dependent and increases with growth into adulthood. The ‘true’ pelvis is
bounded anteriorly by the symphysis pubis, the iliopectineal line laterally, and the
sacrum posteriorly. It is composed of an inlet, a cavity and an outlet. The pelvic inlet
of an adequately sized gynecoid pelvis is usually more than 12 cm antero-posteriorly,
and 13.5 cm in the transverse diameter. The inlet is bounded anteriorly by the pubic
crest, posteriorly by the promontory of the sacrum, and laterally by the ilio-pectineal
line. The antero-posterior diameter of the pelvic inlet is also known as the true
conjugate. However, clinically the most important diameter is the obstetric conjugate,
which is the line between the promontory of the sacrum and the innermost part of the
symphysis pubis – it is usually more than 10 cm. The line between the sacral
promontory and the lowermost point of the symphysis is termed the diagonal
conjugate. The mid cavity is spacious yet shallow, with both antero-posterior and
transverse diameters usually approximately 12.5 cm. The birth canal narrows down
inferiorly in the transverse section at the level of the ischial spines, but still measures
more than 10 cm. In an ideal pelvis the ischial spines do not indent prominently into
the pelvic cavity. The pelvic outlet is bounded by the inferior aspect of the pubic arch
anteriorly, the tip of the coccyx posteriorly, and the ischial tuberosities and the
surrounding ligaments laterally, with diameters of 12.5 cm antero-posteriorly and 11
cm transversely (Gabbe et al., 2007).
OBSTETRIC CONJUGATE & SAGITTAL OUTLET (Michel et al., 2002)

Conceptual Map

A conceptual map or diagram is a way to visualize a phenomenon, or the inter-

relationship of theories present within a framework. Conceptual maps outline
variables under investigation and the causal relationship between them. A schematic
representation of a theory or conceptual model that graphically represents key
concepts and linkages among them (Polit & Beck, 2008).For the purpose of this study,
the following framework was used.

Factors influencing maternal positions in labor

Literature Review

According to Polit and Beck (2008), the reviewer must start with a question,
formulate and implement a plan for gathering information, and analyze and interpret
the information. A systematic literature review of articles dating from 1980 to 2009
was performed using Medline, CINAHL Pub med and Midirs. The searches for
relevant research articles were further supplemented by evaluating the various
bibliographies of relevant research papers as well as through references made in the
body of the literature. This literature search included an international perspective. Key
words that were used for the search included: maternal positions, labor first stage,
second stage, mobility, birthing, parturition and pelvimetry. Approximately 32
suitable articles were retrieved and ten of these articles were reviewed, summarized
and critiqued. Full text documents were obtained at the hospital medical library of
Flagler Hospital, St Augustine, Florida.
Body mechanics

The objective of Michel, et al. (2002) study was to measure the impact of supine and
upright birthing positions on magnetic resonance imaging (MRI) pelvimetric
dimensions. The study population comprised of thirty-five non pregnant female
volunteers, aged 22-43 years old. Each volunteer provided informed written consent
following full explanation of the examination procedure. The study protocol received
approval from the institutional review board. Eligibility criteria were used to establish
population characteristics and used to maximize the validity of the population
construct (Polit & Beck, 2008). The women were recruited in to two groups which
included a nulliparous group and a parous group. Nine parous women had one child;
one had two children. All had delivered vaginally at least 9 months before inclusion.

Imaging Technique: A 0.5-T low field vertically open configuration magnet system
was used with the body flex surface coil. Imaging was performed with patients in the
supine, hand knee, and squatting positions (See diagram 1 & 2).A special wooden
construction allowed women to maintain the upright position in the scanner. To avoid
displacement, the body flex coil was used. A T1- weighted fast spoiled gradient- echo
sequence was performed with the patient in the mid sagittal, axial, and oblique, which
was defined in the study as the plane of sacral promontory to the top of the symphysis,
planes. The total individual study time was less than 60 minutes in all cases. Image
Analysis: The obstetric conjugate; sagittal outlet; and interspinous, intertuberous, and
transverse diameters were measured on MR console using the same radiology
technician. The obstetric conjugate and the sagittal outlet were both assessed in the
mid sagittal plane. The interspinous and intertuberous diameters were assessed in the
axial plane. The study provides photographs of these positions. Continuous variables
were presented as means and standard deviations. Absolute pelvic measurements in
the three positions and the differences between them were compared using Wilcoxon's
signed rank test with Bonferroni's adjustment. The data were tested for correlation
with body weight, body mass index, and age using Spearman's rank correlation
coefficient and for differences between the nulliparous and parous groups using the
Mann-Whitney test. A p value of less than 0.05 was considered statistically
significant. Statistical analysis was performed using Stat view 5.0.1 software.

Results: MR pelvimetry in the three positions was feasible in all subjects although the
hand to knee and squatting positions were difficult to maintain. Individual study time
and positioning took less than 60 minutes. Diagnostic quality images were obtained in
every volunteer and samples of these images and dimensions were provided in the
article.
Patients in the hand to knee and squatting position, the sagittal outlet (11.8 +/- 1.3 cm;
p=0.002 and p=0.01, respectively); Interspinous diameter (11.6+/- 1.1 cm and 11.7 +/-
1.0 cm vs. 11.0 +/- 0.7 cm; p< 0.0001, in both cases). Intertuberous diameter was
wider with patients in the squatting position than in the supine position (12.7+/- 0.8
cm vs. 12.4 +/- 1.1 cm; p= 0.01). Transverse diameter did not change significantly in
any position (See Table 3).
TABLE 3. Pelvic Measurement for 35 Women in Supine, Hand-to-Knee, and
Squatting Positions (Michel et al., 2002)

Supine Hand-to-Knee Squatting

Mean ± Range Mean ± Range Mean ±
Parameters SD (cm) (cm) SD (cm) (cm) SD (cm) Range (cm)

Obstetric 12.4 ± 10.7- 12.4 ± 10.5- 12.3 ± 10.6-

conjugate 0.9 14.6 0.8 14.0 0.8 13.7
Sagittal outlet 11.5 ± 9.5-14.3 11.8 ± 9.6-14.6 11.7 ± 9.4-14.5
1.3 1.3 1.3
Interspinous 11.0 ± 9.7-12.4 11.6 ± 10.1- 11.7 ± 10.0-
diameter 0.7 1.1 14.4 1.0 14.7
Intertuberous 12.4 ± 10.1- 12.5 ± 11.2- 12.7 ± 11.3-
diameter 1.1 15.5 0.8 14.5 0.8 14.6
Transverse 12.9 ± 11.7- 12.8 ± 11.8- 12.8 ± 11.3-
diameter 0.7 14.4 0.7 14.0 0.8 14.3

Diagram 1. Hand to knee position (Michel et al., 2002)

Diagram 2 Squatting position (Michel et al., 2002).

Authors conclusions. The sagittal outlet and interspinous diameter were significantly
greater in the hand to knee position and squatting positions than in the supine position,
as was the intertuberous diameter in the squatting position. The obstetric conjugate
was the only dimension to be significantly smaller in the upright squatting position
than in the supine position. The obstetric conjugate of the pelvic inlet is the distance
from the sacral promontory to the superior aspect of the symphysis pubis and usually
measures 10-11 cm, midcavity is the measurement between the ischial spines, usually
the smallest diameter of the pelvis and should be greater than 10 cm. The pelvic outlet
the anteroposterior diameter from the coccyx to the symphysis pubis usually 13 cm
and the transverse diameter between the ischial tuberosities around 8 cm (Gabbe,
2002). The study's data confirms those published by Russell, (1969) who found a
significant increase in interspinous diameter in the last trimester of pregnancy and
after childbirth on changing from supine to the sitting position although further
research by Gupta, (1994) found no significant change in inlet and outlet dimensions
between patients in the sitting and squatting positions using lateral radiographic
pelvimetry. The authors attribute this to the limited size of their study population.
Differences in posture can significantly increase female pelvic dimensions and
provides objective confirmation of the advantages of changing birthing position to
facilitate vaginal birth.

The weakness identified in the study was that no pregnant women were included in
the study; this limitation is recognized by the authors. Prevention of measuring the
influence of pregnancy related joint laxity in late gestation can be considered a
limitation; also considering changes in pelvic dimensions become more pronounced in
pregnancy. Ethical considerations of scanning stress for pregnant women in the
squatting and hands and knees position in an exhausting position to hold and image
quality was recognized as a limitation within the study. See diagram 1 & 2 for hand to
knee position and squatting position.

The author's research purpose is stated unambiguously in the study and is easy to
identify, the implications of female pelvic outlet dimensions have a profound
significance for midwifery practice and the choice women make regarding positions
used for delivery. The research design was appropriate; as mentioned by Polit and
Beck (2008) the research design incorporates some of the most important
methodologic decisions researchers make. Although the sample size was small, the
measurements changes were being compared from the same subject each time thereby
reducing the need for a large number, which according to Polit and Beck (2008) is
appropriate for this study type. The study was subject to external review, informed
consent was obtained and designed to minimize risks of the participants. The
importance of informed consent means that participants have adequate information
regarding the research, are capable of comprehending the information, have the power
of free choice enabling the participant to consent or decline voluntarily (Polit & Beck,
2008).The findings of the study show that changes in birthing position augment pelvic
dimensions and therefore can be obstetrically advantageous in factors influencing
maternal positions in labor.

Chen et al. (1987) carried out a study to determine which components of uterine
activity are affected by different positions of labor. The study took place at the
Department of Obstetrics and Gynecology, Oita Medical College, Japan. During
September 1983 and April 1985,183 patients who had taken prenatal classes, had full
term spontaneous labors and a single fetus in cephalic presentation were enrolled in
the study. Sixty seven patients were excluded from the study for reasons as follows:
oxytocin augmentation, cesarean section and request for epidural analgesia leaving
116 participants for inclusion in to the study. There is no mention of ethical approval
or consent having been obtained. The women were assigned following the order of
admission to one of three groups: 1) Sitting for the entire labor, first on a sofa and
then in a birthing chair, with a back elevation of 65 degrees; 2) Supine in first stage
and sitting in the birthing chair for 2nd stage; and 3) Supine for the entire labor, dorsal
or lateral in bed with a pillow in first stage and lithotomy in second. Amniotomy was
performed at 3-4cm and the fetal heart rate was monitored by an electrode on the fetal
scalp and the intrauterine pressure monitored by insertion of an open tip catheter in to
the amniotic cavity. To allow full mobility during the first stage, direct monitoring
was transmitted via a telemetry system (model 315; Corometrics Co.) In second stage,
women were told to bear down only with an involuntary urge. No analgesia or
anesthesia except local was used. The mean resting uterine pressure was greater for
both nullips and multips when sitting; however, no difference was observed between
sitting and supine position during contractions. See table 4 for the pressure values and
p values.

For nullips, there was no significant difference between the two positions in length of
time from 5-10cm, but the second stage was significantly shorter for those sitting. For
multips, the first stage was significantly shorter for women who were sitting, but there
was no difference in length of second stage.

Table 4: Modified Montevideo units of uterine contractions (Chen et al., 1987)

mm/Hg per uterine contractions (Chen et al., 1987)

There were no significant differences in fetal heart tracings or umbilical cord pH

between groups.
The results of the study indicate that the elevated resting pressure helps enhance the
expulsive force rather than uterine contractility. The non-supine position results in
stronger bearing down efforts which are important in the progress of labor in the
second stage. Maternal position does not affect uterine contractility, the increased
resting pressure in the sitting position is of some importance in supplementing the
downward delivery force and increased bearing down in the sitting position could help
to significantly shorten the duration of the third stage.

Chen's study showed a weakness regarding allocation concealment and ethical

approval agreement was not mentioned in the article. Not having formal ethics
approval opens the study to criticism with respect to participant protection, participant
equitability, participant confidentiality and welfare (Polit & Beck, 2008).Following
randomization there was a high number of women who failed to meet on going
criteria and therefore dropped out of the study out which can lead to bias. Both of
these studies help to define objectively the enhancement in pelvic outlet and the
enhancement in uterine work both of which result in shorter duration of the second
stage of labor. This information is useful in the education of both providers and
patients.

Provider preference

Ank De Jonge (2008) conducted a qualitative study to ascertain how independent

midwives in the Netherlands reach decisions on which positions to use for women in
the second stage of labor.
The method: Six focus groups (4-6 midwives in each group), with a purposive sample
of 31 midwives, were conducted in 2006-2007 in the Netherlands. Interviews were
conducted either in the midwives’ homes or midwifery practices and lasted between
1-1.5 hrs. Prior to each interview, a questionnaire was sent to participants to collect
data on individual and practice demographics. Midwife researchers conducted most of
the focus groups, assuming roles as moderator and assistant. In one research group a
research psychologist was the assistant. Notes were taken and non verbal
communication observed. The data was interpreted using Thachuk's models of
informed consent and informed choice.

Thachuk distinguishes the medical model of informed consent as one that is based on
the right to relevant information and competent and non-coerced consent. The woman
is a passive recipient of the information and choices the professional decides to give.
In the midwifery model of informed choice, the locus of power is shifted to the
woman as the primary decision maker. The relational aspect of autonomy is
emphasized, and both the midwife and the woman actively participate in the process
of informed choice (Thachuk, 2007). All interviews were transcribed and a software
program was used to aid the analysis.
Findings: Thachuk’s models helped distinguish between two different approaches of
midwives to women's positions during labor. When giving informed consent,
midwives explicitly ask a woman's consent for what they themselves prefer. When
offering informed choice, a woman's preference is the starting point, but midwives
will suggest other options if this is in the woman's interest. Obstetric factors and
midwives working conditions are reasons to deviate from women's preferences
(Jonge, 2008). In order for midwives to give women informed choice regarding
birthing positions, information needs to be given throughout the ante partum period
and women's preferences discussed. Women should be prepared for the
unpredictability of feelings during the reality of labor and obstetric factors that
develop that may interfere with choices. Equipment for non-supine births should be
midwife-friendly such as birthing balls and wall bars and midwives and students
should be able to gain experience in assisting with non-supine positions.

The strengths of the study: The research question is congruent with a qualitative
approach. An appropriate design was used within the study; a focus group study of
independent midwives who work autonomously in their practice, this generates more
ideas through the exchange of different approaches to dealing with birthing positions.
Participants were encouraged to express their views openly. There is limited research
in to the views of midwives on birthing positions and the findings in the study
heightened the need for further research in to this area.

The weakness of the study: Some of the midwives knew the interviewers which
according to (Polit & Beck, 2006) could be construed as bias. Knowledge of the group
facilitator may lead the participant, so therefore some threat of potential biases exists
between midwives and participants. No distinction is given within the study between
the second stage position and delivery position which is significant to the findings. A
definition needs to be addressed between these two areas. The study provides valuable
insight and information regarding the influence of midwives and maternal position
choice in labor and highlights the fact that there is limited research in to midwives
views of birthing positions and the difficulty of offering choice to women when
certain societies are heavily biased towards the use of the supine position. Women
need evidence based information on the advantages and disadvantages of alternate
birthing positions in order to make informed choices. The distinction between
informed consent and informed choice plays a relevant role in this research. The
limitation of the midwives experience in non-supine positions favors a greater bias
towards practitioner preference influencing the final position assumed for the
delivery. This would suggest benefit in training practitioners in the methods of non-
supine deliveries. This study helps to define where we are at present with respect to
practitioner preference for the maternal position at the time of delivery. With this
information, future studies and training can be designed to more adequately educate
and counsel the providers as well as the patients with respect to their options for
positions in labor and delivery.

Medical technology

Al-Mufti, Morey, Shennan, & Morgan (1997) conducted a quantitative, prospective

study to determine the effect of patient controlled combined spinal epidural analgesia
on maternal pulse and blood pressure and fetal heart rate in primigravid women, when
adopting different positions in labor. Prospective studies, according to Polit and Beck
(2008), are considerably stronger than retrospective studies, although not as powerful
as prospective studies that involve a prior hypotheses and the comparison of cohorts
known to differ on a presumed cause (Polit and Beck, 2008).A total of 55 primigravid
women were included prospectively in the study which was carried out at a teaching
hospital in London, England. Ethical approval was obtained; procedures need to be
developed to ensure the study adheres to ethical principles (Polit & Beck, 2008).

Recruitment for this study occurred after successful placement of a combined spinal-
epidural analgesia placed at the request of primips at term (37 completed weeks or
more) and once screening for appropriateness of mobilization had been made. This
screening was performed by the anesthetist 20 min after placement of the analgesics.
A record was made of the level of the sensory block, presence of sympathetic block
and the ability of the woman to raise her legs straight off the bed against resistance.

Forty women had supervised standing top up's (re-dosing of epidural analgesia) given
by an anesthetist. A further 15 women had patient controlled epidural analgesia
(PCEA) top up's given in each of the standing, sitting and lying positions. Systolic,
diastolic and mean arterial blood pressure and pulse rate were measured using a
pregnancy validated automatic ambulatory blood pressure monitor and recordings of
changes in BP noted for the first half an hour following top up. Fetal
cardiotocography (CTG) was recorded for 30 minutes, using Hewlett Packard 80240A
CTG Telemetry monitor, before and after epidural top up. The first 40 women studied
following insertion of spinal injection, were asked to lie on their side for half an hour
and then asked to stand and a top up of 10ml of fentanyl and 0.1% bupivacaine were
injected, by the anesthetist. BP and pulse rate were recorded on two occasions prior to
analgesia and while each woman was standing. Women were asked to stand for half
an hour while measurements of BP and pulse rate were recorded every 6 minutes. In
the second part of the study, 15 women with PCEA top ups were asked to adopt three
positions: left lateral position, sitting and ambulating for at least half an hour after
giving their own top ups. Each woman with PCEA was asked to adopt each of the
three different positions at least once at random; this allowed assessment of the
changes in BP and pulse rates as well as CTG changes when top ups were given in
these three positions of subjects whose scores on a dependent variable are used to
evaluate. Polit and Beck (2008) refer to this as a comparison group, a group of
subjects whose scores on a dependent variable are used to evaluate the outcomes of
the group of primary interest. Fetal heart rate decelerations were classified by two
experienced independent obstetricians, blinded both to the time of top up and the
position the woman was in when receiving the top up, this was recorded using FIGO
classifications (International Federation of Gynecology and Obstetrics). Normal
distributions of BP and pulse rate data were confirmed by plotting values against their
normal scores. Statistical analysis was carried out using paired t test. Fisher Exact test
was used to compare proportions of women with CTG changes in the different
positions that the women adopted. A clinically significant fall in BP was considered to
be a fall in systolic BP < 100mg Hg. Ethical approval was obtained to use ambulatory
BP monitoring on all participants.

Results: In the first 40 women, there was no clinically significant fall in blood
pressure (<5mm Hg).The subsequent 15 women who had PCEA top ups had no fall in
blood pressure in the standing and sitting positions, though the average BP fell
significantly when a top up was given in the lying position. Maternal heart rate
increased significantly at 12 minutes post top up when the women were in the
standing position (p=0.0018). BP and pulse recordings pre top up were BP 127/ 79,
pulse 85; after 6 minutes BP 126/78, pulse 90 after 12 minutes BP 123/77, pulse 94
and after 30 minutes BP 123/75, pulse 86 In the 15 women who had PCEA top ups,
the CTG monitoring showed improvement in decelerations when women were in the
standing position but deterioration when in the lying position (p<0.01).Five out of
forty women had decelerations present from the top up and in three of these the
decelerations improved after top up. Following standing top up in 10/15 women the
decelerations improved (disappeared or decreased in frequency) and none had
deteriorated. On sitting, six cases improved and one deteriorated. In the lying position,
only two improved and seven actually deteriorated. Significantly more women
therefore had improved decelerations when top ups were given standing as compared
with lying (P<0.01).

The weakness in this study included the small number of participants. Fifty-five
women were recruited of which only five women had top up's in the lying position.
The smaller sample size tends to produce less accurate estimates than larger ones
(Polit & Beck, 2008).Another weakness identified was the lack of stringent inclusion
criteria. CTG monitoring has been shown to have a wide range of interpretation
although the authors made an attempt to address this by having two independent
obstetricians classify the strips according to FIGO classification and having them
blinded to the arms the participants were in. There is no mention as to the level of
concordance between the two experts reviewing the CTG monitoring. The strengths
included that a prospective design was used, and the study was performed in a single
institution which allows for consistency, although having multiple sites is
advantageous in terms of enhancing the generalizability of the study findings. (Polit &
Beck, 2008). The BP and pulse observations were obtained by validated automated
equipment which reduces chance of error (Polit &Beck, 2008).

In summary, a combination of spinal and epidural analgesia with low dose

bupivacaine and fentanyl maintains motor function and allows women to walk about
during labor and may cause less hypotension than when a woman is lying down. This
would be more conducive to maintaining maternal choice of positioning. Reduced
hypotension post epidural placement would also reduce the added stress experienced
by the patient and family as a result of the fetal heart monitoring changes. This study
with its objective assessment of blood pressure changes and fetal heart tone changes is
useful in guiding future studies in exploring the utility of mobile epidurals which in
itself would serve to reduce significantly the one of the barriers to non-supine
positions in labor in that the women who choose epidural anesthesia would be able to
support themselves in these positions.

Perineal trauma

Soong & Barnes (2004) conducted a quantitative study to examine the association
between maternal position at birth and perineal outcome in women who had a
midwife attended spontaneous vaginal birth and an uncomplicated pregnancy at term.
Methods: Data from 3,756 births in a major public tertiary teaching hospital were
eligible for analysis. The larger the sample size, the more representative of the
population it is likely to be (Polit & Beck, 2008). The necessity for sutures in perineal
trauma was evaluated and compared for each of the following: maternal age, first
vaginal delivery, induction of labor, not occipitoposterior, use of regional anesthesia,
deflexed head and newborn birth weight> 3,500g. Birth positions were compared
against each other. Study variables included age, parity, maternal position at time of
birth, accoucheur, flexion of the head, analgesia use, previous perineal trauma, need
for suture of the trauma, birth weight, type and degree of perineal trauma and
estimated blood loss. The attending midwife encouraged women to give birth in
positions with which they felt most comfortable using. Subgroup analysis determined
whether birth positions mattered more or less in each of the major factors studied.
Statistical analyses were performed using Statistical Package for Social Science
software. The chi square test was used to compare categorical variables, and p values
of < 0.05 were considered statistically significant; odd ratios and 95% confidence
intervals were calculated.
Results: Most women , 65.9% gave birth in the semi recumbent position, 14.6 % in
the lateral position, 1.3% supine, 0.7% lithotomy, 1.4 % kneeling , 9.9% all fours, 1.3
% squatting, 0.8%, 4.1% standing. Of the 3,756 women, 1,679 women, (44.5%)
required perineal suturing; semi recumbent position, defined as forty five degrees,
was associated with the need for perineal sutures, whereas all fours was associated
with reduced need for sutures. When regional anesthesia was used, semi recumbent
position was associated with a need for suturing, and lateral position associated with a
reduced need for suturing.

The weaknesses of the study, which were identified by the authors, included: unequal
groups, birth positions were not randomly assigned and therefore an association
between birth positions and alternate obstetric factors that may affect perineal status.
Lack of statistical significance in other birth positions cannot be taken as evidence of
no difference because the numbers may be too few in certain groups. Strength of the
study included a large sample size of eligible women over a three year period. Having
a study sample of this size over a three year time period allows for more information
to be gathered making the research more descriptive, with improved accuracy and
reliability of the results (Polit & Beck, 2008). The author concluded that women
should be given the choice to give birth in whatever position they find comfortable.
Maternity practitioners have a responsibility to educate women regarding birth
position and potential effects on perineal trauma. This study was large though lacked
prospective randomization. Specific classification of perineal trauma was not given. A
grade three laceration or more has greater consequence on sphincter performance.
This information would lend more weight to deciding on which position is best
assumed. This study suggests some benefit could be made from delivering in the all
fours or left lateral position with respect to reducing need for perineal suturing. This
information would be useful in counseling practitioners as well as patients on
drawbacks with delivering in the semi-recumbent position versus the all fours and the
left lateral.

Back pain

Adachi, Shimada and Usui (2003) provided quantitative research to determine if

maternal position reduced the intensity of pain during cervical dilatation from 6-8
centimeters. The study was carried out in Tokyo, Japan on 30 primiparous and 19
multiparous women (N = 58) who alternately assumed the sitting and supine positions
for 15 minutes during cervical dilatation from 6-8 centimeters. Labor pain was
measured by the visual analog scale (VAS), which has a horizontal line marked in
millimeters from 0 to 100 with two opposing extremes at each end (i.e., no pain and
worst possible pain) A score was determined by measuring the distance from the no
pain end to location marked.

Method: Eligibility criteria included: women 37-42 weeks gestation, 6-8 centimeters
dilated, no obstetric risk factors, single fetus in cephalic presentation, no use of
pharmacologic pain relief, uterine contractions occurring at intervals of 5 minutes or
less, Japanese as the native language. Exclusion criteria included: an accelerated
progress of labor during the intervention, inducement of labor, preference of particular
position. Informal written consent was obtained from each participant. Pain intensity
was measured using the visual analogue scale (VAS), which has a horizontal line
marked in millimeters from 0 to 100 with two opposing extremes at each end; no pain
and worst possible pain. VAS has been used in various clinical trials to measure pain
and is reported to be reliable as a pain measuring instrument (Lundeberg,
2001).Participants marked the line representing the perceived intensity of labor pain
with two opposing extremes at each end no pain and worst possible pain.

Design: A randomized and cross over study in which the same group of subjects
served as both the control and experimental group was used to control the influence of
these factors (Polit and Beck, 2008). Participants were randomly assigned to one of
two groups in which either the supine or sitting position was first used and then
alternated with the other position to avoid order effect. Analyses were performed
using SPSS for windows, Advanced Statistics Release 9.0J. Unpaired t-test and
Fisher's exact-test methods were used to compare the back ground variables.
According to Polit and Beck (2008), these methods are appropriate for small sample
sizes (Polit & Beck, 2008).

Results: The pain scores for the sitting position were significantly lower than those of
the supine position. See table 5 below. The Wilcoxon signed-ranks test showed the
VAS scores the total labor pain which was defined as both abdominal and lumbar
pain, during contraction values (p=.011), continuous total labor pain (p= .001), lumbar
pain during contraction (p < .001) in the sitting position which was significantly lower
than in the supine position. The diminished pain scores were greater than 13
millimeters, which is the minimum clinically significant change in patient pain
severity as measured with the 100 millimeter VAS. The largest decrease occurred in
lower back pain. No significant differences were found for abdominal pain scores in
either the sitting or supine positions.
Table 5:

The strength of the study includes the design that was used, using a randomized
method for allocation in to two groups and the strict screening criteria to meet
eligibility. If subjects are placed in groups randomly, there should be no systematic
bias in the groups with respect to attributes that could affect the dependent variable
(Polit & Beck, 2008).Adequate power was pre determined using the two tailed t test
with a significance level of 0.05. Based on this, the minimum sample size for this
cross over design was 43 and this was exceeded by the final recruitment number of
58. Screening criteria and the randomization allows for the two groups to be similar,
making the results more valid (Polit & Beck, 2008).The sample size of the study was
small but should not interfere with the efficacy of the study between pain intensity
measurements. The statistical data analysis was appropriate, the authors made efforts
to examine the comparability with regards to abdominal pain and lumbar pain. (Polit
& Beck, 2008). The instrument used to assess labor pain, VAS, has been reported to
be a reliable measuring instrument Jackson, 2001; Gallagher, 2001 .This study
highlights the importance of maternal position especially when lumbar pain appears to
be the most distressing component. This study being well designed with
randomization and prospective in nature with the use of validated tools for assessment
of variables makes a solid argument for laboring in the late first and early second
stage in the non-supine/sitting position. This information further endorses to
practitioners and patient the benefits of maintaining mobility and avoiding
confinement to the bed during labor.

Perineal trauma and Back Pain

De Jong, Johanson, Baxen, Adrians, Van der Westhuisen & Jones (1997) designed a
randomized controlled trial to assess the maternal and neonatal effects of upright
compared with recumbent positions during delivery, in terms of defined outcome
variables. The study was conducted at a midwife based maternity unit in Cape Town
South Africa. Women were assessed for eligibility; 517 women were included all
having singleton pregnancies with a cephalic presentation, at >34 weeks of gestation
with no risk factors present. Randomization envelopes were prepared from a single
computer generated number sequence and late in the first stage of labor women were
randomized by the use of sealed opaque consecutively numbered envelopes, and
participants were allocated to either the squatting in the second stage group or the
routine management group. At the end of the study, all the envelopes were accounted
for. Until the beginning of the second stage of labor management of the two groups
were identical with women being encouraged to mobilize, sit or recline. In both
groups fetal monitoring was performed according to the standard practice of
intermittent auscultation, with cardiotocograph tracing if abnormalities were heard.
The routine management of labor was unchanged .The routine management of labor
and CTG monitoring was not defined in the study which can be seen as a weakness.
Analgesia was given by means of pethidine or hydroxyzine as required. The second
stage of labor and delivery was accomplished with the woman in the supine position
on a delivery bed supported by a partner. The upright second stage management
involved a squatting posture on a stool covered with a foam mattress, with helpers
supporting her on both sides. All details of the delivery were recorded and the
woman's subjective assessment of the delivery was recorded the following afternoon
by an independent midwife blinded to the mode of delivery. The principal outcomes
of the study were the proportion of women with a hemoglobin of <11 g/dl on the
second day after delivery, and second or third degree injuries of the perineum.

Power of the study and methods of analysis: The baseline incidence of low Hb levels
in the study was approx 35% and the baseline incidence of second or third degree
injuries about 5%. A study with 250 women in each arm would have a power of 90%
(p=0.05) detecting a difference in the proportion of low hemoglobin levels, if this
level were increased by 45% , or of only 75% of detecting a doubling of the
proportion of perineal injuries by 10% by adoption of the upright position. Power
analysis can be used to reduce the risk of a false positive by estimating in advance
how big a sample is needed (Polit & Beck, 2008). The Mann Whitney U test was used
to test differences of non-normally distributed continuous variables, with X square test
being used to analyze frequency variables, the results were reported as odds ratios
(95% confidence interval).Meta- analysis of the results of this paper combined with
previous studies was carried out using Review Manager. The study protocol was
approved by the University of Cape Town Ethics Committee. Results: Of the 517
women in the trial, 257 were allocated to the upright group for delivery and 260 were
assigned to the recumbent group. Thirteen women in the upright group and 12 in the
recumbent group required transfer before delivery for instrumental deliveries, low
hemoglobin, one with eclampsia. Women who adopted the upright posture for
delivery experienced less pain, pain assessment was recorded the following afternoon
by an independent midwife using the Trent test X squared (validated pain score) (1 df)
= 7.98, exact P= 0.0034., Women in the upright posture also experienced less perineal
trauma and fewer episiotomies also experienced less pain than those who delivered in
the supine position. There were no significant differences in length of labor, or
amount of blood loss, although there were significantly fewer episiotomies in the
upright position. There were no differences between groups in terms of the total
number of women with perineal trauma requiring suturing. There were no significant
differences between the outcome of the fetus and newborn infant in the groups. Fewer
women in the upright group had significant pain during delivery.

The authors of this study show that an upright birthing position will not adversely
affect labor outcome for women but may be beneficial as significantly fewer women
experience discomfort in the second stage and a reduction in the number of third
degree tears. Data, regarding EBL suggests an increase in the rate of post partum
hemorrhage; this however is not supported by objective evidence of postnatal
hemoglobin measurements and rates of blood transfusions. For women of low
obstetrical risk, choice of posture during delivery should be encouraged. Weaknesses
that were identified included: no validated pain scale tool was used; estimated blood
loss was assessed by visual assessment. Objective laboratory measurements are
advised to examine the difference in blood loss (Polit & Beck, 2008). There is no
mention as to how the third stage was managed with respect to whether a physiologic
or active. The unclear parameters and measurements by the authors and their failure to
define labor protocols and routine CTG monitoring compromises the validity of their
conclusions and reproducibility (Polit & Beck, 2008).The strength of the study was
that it was a prospective study, adequately powered in a single institution. The use of
randomized envelopes, prepared from a single computer-generated number sequence,
and sealed using opaque envelopes enhanced the credibility of the study. This study
though weakened by some design flaws does provide evidence to support the safety of
non-supine labor and delivery especially in the areas of pain and perineal trauma. This
information could used to design future studies and encourage better practitioner
education in the area of non-supine labor.

Back Pain

Stremler, Hodnett, Petryshen, Stevens, Weston, Willan (2005) conducted a

quantitative randomized trial on one hundred and forty seven pregnant women to
evaluate the effect of maternal hands and knees positioning on fetal head rotation
from occipitoposterior to occipitoanterior position, persistent back pain and other
perinatal outcomes. Methods: Thirteen labor units in university affiliated hospitals
participated in this multicenter randomized controlled trial, for a 28 month period in
2000-2002 in Argentina, Australia, Canada, England, Israel and the United States.
According to Polit & Beck, multi-site sampling allows the results to be more
generalizable. Research ethics board approval was obtained for all participating
centers. Study participants included 147 women laboring with a fetus at > 37 weeks
gestation and confirmed by ultra sound to be in the occipitoposterior position. Seventy
women were randomized to the intervention group which included maintenance of the
hands and knees position for at least 30 minutes over a one hour period during labor
and 77 to the control group, no hands and knees position. The primary outcome was
fetal rotation and the secondary outcome was level of back pain and women's views
with respect to positioning.

Eligible women were recruited based on the occurrence of one or more of the
following criteria presumed to indicate labor with a malpositioned fetus: persistent
back pain, slower than normal progress, vaginal examination, recent ultrasound,
Leopold's maneuvers or abdominal contours suggesting occipitoposterior position,
irregular contraction pattern, urge to push before full dilatation, suprapubic pain, fetal
heart rate located at the maternal flank or edematous cervix. Eligible women were
required to be in hospital in early or active labor with a singleton pregnancy in
cephalic presentation at > 37 weeks gestation, occipitoposterior position of the fetal
head confirmed by ultrasound examination. Women were excluded if second stage of
labor was expected within one hour, complications of pregnancy or any other
contraindications to assuming a hands and knees position such as an immobilizing
epidural. Following informed consent an ultra sound confirming occipitoposterior
position was performed and if confirmed, the laboring woman was asked to complete
the Short Form Mc Gill Questionnaire and then randomized. The randomization
process involved prognostic stratification for parity and anesthesia use, incorporated
random block sizes of 4-6 which was controlled with the use of a telephone- based,
computerized randomization system. Group allocation remained unknown to
clinicians and research assistants collecting the data. Women assigned to the
intervention group were asked to maintain the hands and knees position for as much
time as possible over a period of 60 minutes, for a minimum of 30 minutes in total the
information was recorded on trial data forms by the midwife, nurse or labor partner.
Women assigned to the control group were able to use any position except the hands
and knees position. Participants were asked to complete a questionnaire before
discharge to verify compliance with the assigned group and determine maternal
evaluations of positions used. The questionnaire contained the Labor Agentry Scale, a
unifactorial, 10 item, Likert-type rating scale used in many studies of women's
experiences of personal control during labor and birth. Cronbach’s alpha reliability
coefficient for the Labor Agentry Scale has consistently been shown to be > 0.88.
(Stremler et al., 2005). Data was scanned directly in to the study data base using
TELEform software and statistically analyzed using SAS version 8.2. Demographic,
maternal satisfaction. A two sided significance level of 0.005 (two sided) was used for
other comparisons, to account for multiple comparisons and preference variables were
analyzed and compared using descriptive statistics.

Results: Women randomized to the intervention hands and knees group had
significant reductions in persistent back pain. Eleven women (16%) allocated to use
hands and knees positioning had fetal heads in occipitoanterior position following the
1 hour study period compared with 5 (7%) in the control group (p value 0.18).Trends
toward benefit for the intervention group were seen for several other outcomes,
including operative delivery. Maternal hands and knees positioning during labor with
a fetus in the occipitoposterior position enhances fetal rotation, reduces persistent
back pain and is acceptable to laboring women. The strengths of this study included a
well designed prospective randomized trial. Inclusion criteria were clear and
objectively determined. Outcome measures were clear and determined by using
validated tools, VAS and SF-MPH. The weakness identified was that the study was
underpowered - 364 predicted participants needed and 147 were obtained. This meant
that statistical significance was unlikely to be demonstrated. This study further
reinforces previous findings on the benefits of all fours with respect to back pain
reduction in labor.
This well designed study, although under-powered, with multinational input is useful
in guiding future research in answering the question of whether the all fours position
is especially useful in women laboring with an occipitoposterior position in order to
reduce the risk of instrumental or operative delivery.

Maternal preference
De Jonge & Largo-Janssen (2004) conducted a qualitative study to gain insight into
the influences on women's use of birthing positions, and in to the labor experiences of
women in relation to the birthing positions they used. The study took place in the
Netherlands from April to December 2002. A pilot cohort study was conducted in to
the advantages and disadvantages of the supine position versus other positions during
the second stage of labor. A purposive sampling methodology was used. The inclusion
criteria included: women who commenced the second stage of labor under midwifery
care. Written consent was obtained and medical data regarding delivery was collected
and a registration form completed with questions relating to birthing positions. A
survey questionnaire was sent to the women for completion approximately 6 weeks
following delivery to provide quantitative information about their experiences and
health problems. Although this approach is cost effective for reaching geographically
dispersed respondents it tends to yield low response rates. Individual interviews were
held to collect in depth, personal data. Women were questioned about positions used
both the first and second stage. Choice of where the interview took place was given to
the woman i.e., home, health facility etc and written consent obtained at the
commencement of interviews. Complete anonymity was used; two researchers have
access to the original interviews. The interviewer was also one of the midwives who
provided care for the woman and assisted in five of the deliveries. All interviews were
recorded, transcribed and analyzed by the interviewer. Background information from
the pilot was used; free text, filled in by the midwives on the registration forms and by
the women on the questionnaires which was used in the analysis. This triangulation of
methods which is research designed to develop or refine methods of obtaining,
organizing, or analyzing data (Polit & Beck, 2008), was thought to enhance the
quality of findings. Coding categories were used to analyze data and themes were
formulated and discussed by the second researcher.

Results: Advice given by the midwife was the most important factor that influenced
the choice of birthing position. Other influences on the use of birthing positions
included information women obtained from midwives during antenatal classes,
information via the media and other women's stories. The strength of this study was
that women were given a choice of where interviews took place, by one researcher
using a triangulation method. The strengths of interviews outweigh those of
questionnaires because of the depth of questioning involved (Polit & Beck, 2008).
The design of this study lacked use of validated questionnaires, research was
conducted by a midwife who also performed 25% of the deliveries, and questionnaires
were sent six weeks following delivery which makes it difficult for women to
recollect information. The study was small. No mention is given to the response rate
of the questionnaire.
Authors conclusions. The author concluded that the experience of type and intensity
of pain and accompanying preference for a certain birthing position varied widely.
Women were most familiar with the supine position. This was due to the dominance
of this position in the westernized societies. Women wanted practical information
from midwives regarding various positions during the ante partum and intrapartum
period. Choice of birthing positions was influenced more by the midwife than by the
women's personal preference. Future research needs to examine factors that would
enable midwives and other obstetric health professionals to empower women to have
informed choice. This study is valuable in that there is very limited data published
exploring women's views on their perspective of delivery position through an in depth
interview in a non threatening environment. This study helps to highlight the need for
further research perhaps with validated questionnaires on assessing maternal
preferences in different cultures.

Olson & Cox, (1990) conducted a study to evaluate the relationship between maternal
birthing position and perineal outcome. The study was a retrospective descriptive
analysis of the perineal outcome of 335 patients who gave birth vaginally between
December 1980 and December 1988.Women attended childbirth education classes as
part of their prenatal care and during these classes, birthing positions and perineal
injury were topics of discussion, which included a film illustrating different birthing
positions. Selection criteria involved low risk obstetric women, with a mean age of
24.5 years, generally healthy, living in a rural family physician group practice located
in a community in northwestern Wisconsin. The study examined the outcome of 335
patients who gave birth vaginally, women whose babies were delivered by cesarean
section (n=102, 21.9%), and those that gave birth in other facilities including at home
(n=29, 6.2%).
Data was collected from labor and delivery summaries completed by the obstetric
nurses and birth reports completed by the obstetric nurses and birth reports completed
by the physicians. These reports included data on maternal birthing position, perineal
outcome, complications during delivery such as shoulder dystocia, and reasons for
episiotomy if performed. Perineal outcome was recorded as one of four mutually
exclusive outcomes: intact perineum, second degree laceration needing repair,
episiotomy and third degree perineal injury and episiotomy extension. Parity was
treated as a dichotomous nominal variable, and analyses were conducted on
primiparous and multiparous women. Maternal position was treated as a nominal
variable. Birthing positions were defined as lithotomy or dorsal recumbent on a
delivery bed, sitting position in the birthing chair, with a few women assuming a
lateral or side lying position while using the birthing bed. See table 6 defining birthing
positions.

Data was analyzed by primiparous or multiparous status, birthing position and

perineal outcome. Chi square tests of independence were used to examine the
association among factors, and a p value < .05 was considered statistically significant.
Excluded from the analysis were women whose babies were delivered by cesarean
section and those giving birth in other facilities including home. Of the 335 women
who gave birth vaginally, 113 were primiparous and 222 were multiparous. Sixty six
percent of the women whose babies delivered vaginally attended a series of childbirth
education classes as part of their prenatal care. The most common birthing position
used by women in the study was the semi sitting or Fowler's position in the birthing
bed (43.6%; n= 146). Ninety-four women (28%) gave birth on the delivery table from
the lithotomy or recumbent position with legs in stirrups. Eighty women (23.9%) used
the birthing chair and gave birth while in a sitting position. The lateral or sitting lying
position on the birthing bed was assumed by 15 women (4.5%). Multiparous women
used the semi sitting position in the birthing bed more frequently than primiparous
women The use of a particular for delivery varied with parity (X 2= 8.009, df =3,
p<.05). Primiparous women were more likely to use the lateral, sitting or lithotomy
positions on the bed, chair and table.

Supine Patient on her back with knees

Position slightly bent
Nonsupine :
Kneeling/
hands and Patients weight chiefly on her knees,
knees possibly also on her
arms, hands, or upper chest. Torso
bent at hips
Patient's weight supported by her buttocks
and thighs; knees bent; feet flat on bed or
Sitting floor
Patient's weight rests on her feet;
Squatting knees bent
Patient lies on her back with hips and knees flexed and thighs abducted
Lithotomy and externally rotated
Lateral Patient lies on her left or right side
Lying down, especially in a position of
Recumbent comfort or rest; reclining.
Dorsal Lying on the back, as in a supine
recumbent position.
TABLE 6: Definition of birthing positions

Results: Almost 30% (n=99) of the women gave birth with an intact perineum. The
incidence of episiotomy for the sample of women was 44% (n= 56) of the 335 women
and second degree laceration that needed repair, and 32 women (9.5%) experienced
third degree perineal injuries. A chi square test of independence was performed to
determine whether a relationship existed between maternal position and perineal
outcome. Women giving birth in the birthing bed were more likely to have an intact
perineum and less likely to have an episiotomy. Women who delivered in the
lithotomy position were more likely to have an episiotomy or third degree perineal
injury. There was no statistically significantly relationship between birthing position
and perineal outcome for primiparous women. A chi- square test of independence
was performed to determine whether a relationship existed between maternal position
and perineal outcome. The data indicated a relationship between maternal position and
perineal outcome (X 2 =43.34, df=3, p <.05). Women in the birthing bed were more
likely to have an intact perineum and less likely to have an episiotomy. Women who
delivered in a lithotomy position on the delivery table were more likely to have an
episiotomy or third degree perineal injury. The strength of the study is that the
number of participants is high, however the study failed to ascertain whether the
episiotomy groups were more likely to be attributable to the same practitioner and
whether one practitioner preferred certain positions more so than others. The study
failed to have predefined protocols as to when episiotomies would be considered or
even excluded as this would reduce bias (Polit & Beck, 2008). This study is useful in
reaching out to practitioners outside mainstream obstetrics, namely family
practitioners in considering non-supine positions and revisiting need for episiotomies.

Summary

The findings of this review suggest some possible benefits for the upright position,
with the possibility of increased risk of blood loss greater than 500ml. as a potential
adverse effect. The weight of the pregnant uterus can compress the abdominal blood
vessels, compromising the mother's circulatory function including uterine blood flow.
This may negatively affect the blood flow to the placenta, an idea that is further
endorsed by Cyna (2006). Women should be encouraged to give birth in the position
they feel most comfortable. Women should be allowed to make informed choices
about birth positions in which they might assume. In women without an epidural, a
number of observational studies have suggested that delivery in an upright position
results in a shorter labor, lower incidence of instrumental deliveries and episiotomies
and is a more comfortable delivery position. Chen’s small RCT appears to confirm
this as well as De Jonge (2004) and Gupta's (2004) systematic reviews. It has been
proposed by Chen (1987) that these benefits are due to a higher resting intrauterine
pressure which contributes to the downward delivery force and bearing down forces,
as well as contractions of greater intensity. The evidence supporting the all four
position for those women experiencing profound back pain with respect to pain
reduction is noted. Overall, the evidence is more robust with respect to enhanced
pelvimetry, enhanced efficiency with respect to uterine and maternal work in the
second stage, shorter duration of the second stage in primips and multips, improved
pain control with back pain and reduced perineal trauma in the all fours position and
left lateral position. The evidence is less conclusive with respect to perineal trauma
and the benefit of internal rotation from an occipitoposterior position to an
occipitoanterior position when adopting the all fours position. There is no clear
evidence on what laboring women actually prefer or will prefer with non-biased
education on their options given the prior evidence. Methodological problems were
identified with some of the studies and the appropriateness of a randomized controlled
trial to study this subject can be questioned. A cohort study may be a more appropriate
methodology, supplemented by a qualitative method to study women's experiences.

Chapter 3: Manuscript development

A manuscript option was decided upon to help impart knowledge to all obstetric
health care providers of the importance of empowering women and their families to
make informed choices about birthing positions based on the current research and to
promote and support a natural approach to normal childbirth.
The increasing medicalization of childbirth leads many women assuming that labor is
an illness and therefore the ideal place to deliver is within hospital, in bed, in the
supine position. This impression is further heightened where the delivery environment
is not conducive to alternative positions and the delivery bed remains the central focus
in many hospital delivery rooms. The routine use of the supine position can be seen as
an intervention in the natural course of labor, which was introduced without evidence
of its advantages compared to other positions (De Jonge et al., 2008).

Following research in to options for potential publication possibilities for manuscripts,

research was undertaken in to several midwifery and women's health related journals
and on line sources to be able to compare the journals, submission requirements and
their publication audience. The Journal of Midwifery and Women's Health. (JMWH),
American Journal of Maternity, Midwives Information and Resource Service
(MIDIRS), Web MD, were some of the resources researched as potential possibilities
for publication.
As a novice entering the world of publication possibilities, goals need to be realistic.
The underlying objective is to educate a diverse population of readers regarding
maternal positions in labor. The manuscript can help facilitate choice for women
where they may wish to adopt a variety of positions during labor and birth.
Midwifery Today (MT) is a journal that includes International Midwife, a quarterly
publication for birth practitioners. Midwifery Today is not as rigorous in their peer
review process because their focus is different than pure or applied science and a
different standard is applied. The journal has an emphasis on natural childbirth,
breast-feeding, networking and education for midwives. The journal is appealing to
midwives, student midwives, doulas, childbirth educators and women and their
partners who want a more natural and holistic approach to childbirth (Midwifery
Today, 2010). MT mentions their aim is to foster communication between
practitioners and families and to promote responsible midwifery and childbirth. MT
seeks a balance between scientific or technical material, and considers submissions on
all aspects of pregnancy and childbirth. When submitting an instructive article aimed
at midwifery procedure or practice, work needs to be factual and accurate.

Midwifery Today publishes articles from all over the world. Ninety-five percent of
what is published is original although occasionally reprints from other publications
are used. Most of the writers are midwives, doctors, doulas, childbirth educator’s
academics or other specialists.

Guidelines include an editorial style sheet and sample references for preferred
reference format and general style guides. An APA style is used. See appendix A for
publishing guidelines.
Articles can be sent via e mail, mail address or via electronic version on a disk.
Previously published articles will not be considered.
The Editorial Board of Midwifery welcomes manuscripts that address pregnancy,
birth and postpartum subjects that are directed toward midwives, student midwives,
doulas, childbirth educators or their clients. Manuscripts are reviewed by the editor
and rate of acceptance depends on quality of article and relevancy of subject (MT,
2010).

Factors Influencing Maternal Positions During Labor

Introduction

The birth of a child is one of the most significant events in a woman’s life. Practices
associated with childbirth are therefore important to the woman’s health and well-
being. Research indicates that left to their own devices women will choose a variety
of movements and positions to cope with labor (Simkin, 2002; Declercq et al., 2006).

Standing, walking, rhythmic swaying, leaning forward, and assuming the hands and
knees position are examples of movements and positions that women instinctively use
in response to pain or other sensations during labor. (See diagram of maternal
positions in labor)

Provider preferences, restrictive hospital policies, fetal monitoring and epidural

analgesia result in many women spending most of their labors and birth in bed, often
in the supine position.
The majority of women in Western societies deliver in a supine position. It is claimed
that the supine position enables the midwife or obstetrician to monitor the fetus better
and thus to ensure a safe birth however, this view ignores the comfort and optimal
physiological functioning of the mother which in turn preserves fetal health (Gupta,
2004).

Women's health practitioners have an obligation to teach women and their partners
how to find and determine the quality of evidence based information in order to make
informed choices this can be achieved by giving practical, supportive advice during
pregnancy and labor.
This article aims to look at factors that influence maternal positions in labor and
review current evidence regarding their use.

History

Throughout history women in most cultures have used both the upright position and
alternative positions to give birth to babies. (Gupta, 2004).Not until the seventeenth
century with the advancement of technology in the form of forceps deliveries were
women depicted giving birth in the supine position. (Boyle, 2000).

The supine position became increasingly popular within western societies as the
standard position during labor. In the early 18th Century, a prominent French
physician, Francois Mauriceau, introduced the supine positions to facilitate the care of
the women and to enhance obstetric performance and maneuvers. The supine position
then became largely adopted throughout western countries (Diaz et al., 1980). Prior to
the 20th century, birth was viewed as a normal process, it most often took place in the
home and was a social and emotional event shared by the woman and her family
(Zwelling, 2008).In the last century, childbirth has progressively moved from a
woman supported experience in the home to a medical intervention in the hospital
(Albers, 2007).

During the early 20th century the hospital became the preferred site for birth. Lying
down in labor was routine practice in many hospitals (Gupta et al., 2004). Many
health professionals today, mistakenly, continue to view the supine position as
advantageous, facilitating the midwife or obstetrician to monitor progression and
check the baby more effectively and so ensure a safer birth. The current research
available in fact calls this view in to question (Lawrence et al., 2009).

Mechanism of Labor

An understanding of the effects of various maternal postures on labor and birth begins
with an understanding of the physiologic consequences of assuming specific postures
and a review of the mechanics of labor. The mechanism of labor refers to the
movements made by the fetus during the first and second stage of labor. As the force
of the uterine contractions stimulates effacement and dilatation of the cervix, the fetus
moves toward the cervix. When the presenting part reaches the pelvic bones, it must
make adjustments to pass through the pelvis and down the birth canal (Gabbe et al.,
2007).

First stage

The first stage begins with regular uterine contractions and ends with complete
cervical dilatation at 10 cm (Gabbe et al., 2007).
An upright position in the first stage is defined as any position that avoids lying flat
and may include ambulation. See diagram of maternal positions in labor.
Factors such as the ability to maintain some level of autonomy, ability to mobilize and
change positions unprompted, in an environment conducive to welcoming partners
and family members are important contributions to patient satisfaction (Albers, 1997;
Hodnett, 2007). Patient satisfaction plays a significant role in determining the pattern
of one's health seeking behavior in the future. Upright positions and mobility are often
more pleasant for laboring women and have distinct advantages in promoting progress
leading to a spontaneous vaginal birth (Albers, 1997). Women need to be made aware
of alternative positions and advantages and disadvantages in order for them to make
an informed choice. A woman lying down or semi reclining on their side or back in
the first stage of labor may be more convenient for staff and can allow easier
monitoring of progression, such as performing vaginal examinations, checking baby’s
position and listening to the fetal heart rate (Gupta, 2004).See table 7 for factors
influencing maternal positions in labor. Research findings indicated that contractions
increased in strength in the upright or lateral position compared to the supine position
and were negatively affected when a laboring woman lay down (Lawrence, 2009).

FACTORS THAT INFLUENCE MATERNAL

POSITIONS IN LABOR
Maternal preference
Maternal ability
Other support personnel (partner, doula)
Health provider preference
Health provider training
Birthing environment (Home, Birthing Center, Hospital)
Analgesia choice (epidural, narcotics)
Fetal monitoring method
Intravenous fluids

TABLE 7: Factors that influence maternal positions in labor

Albers (1997) found that moving in labor can increase a woman’s sense of control by
providing a self regulated distraction from the challenge of labor. Increasing a
woman’s sense of control may also have the effect of reducing the need for analgesia
(Albers, 1997; Hodnett, 2007). This is further supported by Simkin, (2002) who
suggests that the upright position in the first stage of labor may increase a woman’s
comfort.

Upright positions and walking are associated with a reduction in the length of the first
stage of labor and women maybe less likely to have epidural analgesia. Women
should be encouraged to adapt whatever position they find most comfortable while
avoiding spending long periods in the supine position. Women’s preferences may
change during labor, whilst many may choose an upright position in the first stage
they may choose to lie down as their labor progresses. Earlier studies have suggested
that as a woman reaches five to six centimeters dilatation, there is a preference to lie
down (Williams 1980; Roberts 1984).This suggests that there may not be a universal
position for women in the first stage of labor (Lawrence, 2009).

Patient controlled epidural analgesia top ups with maternal mobility may be beneficial
to the fetus by reducing the hypotension associated with top ups in the lying position
(Al-Mufti et al., 2007). Women in labor typically enter an unfamiliar, busy
institutional setting to receive care from an array of busy strangers, where numerous
technical care measures are routinely used, such as continuous electronic fetal
monitoring and epidural analgesia. Intravenous infusions during labor, which are
mobility limiting and often create concerns about the intravenous infusions over that
of the woman, have become a routine procedure for a high percentage of women in
labor throughout the United States, these procedures may affect a woman's mobility
and use of postural coping strategies in labor (Spiby et al., 2003; Lawrence, 2009).

Second stage:

The second stage begins with complete cervical dilatation and ends with the delivery
of the fetus (Gabbe et al., 2007).
Upright positions in the second stage include sitting more than 45 degree from the
horizontal position, use of a birthing chair or ball, squatting or kneeling and being on
hands and knees. Recumbent positions include supine, lateral, lithotomy and semi
recumbent using pillows and wedges. See diagram of maternal positions in labor.

Maternal body positions have a significant influence on the course of labor, affecting
maternal comfort and physiology. The ability to move and adopt positions during
labor has been shown to help facilitate labor progress and decrease pain (Ragner et al.,
2006; Declercq et al., 2006).

Use of the left lateral position appears to protect the perineum and may prove
comforting following long periods in an upright position. Further studies indicated
that contractions increased in the lateral and upright positions (Roberts, 1984; Walsh
2000). Squatting using a birthing chair, although reportedly widening the pelvic
diameter, thereby creating more room for the baby to descend has also been reported
as a predisposing factor for third and fourth degree tears (Albers, 2003; Soong &
Barnes, 2005).Kneeling on all fours, side lying and semi sitting allows women to rest
between contractions and help conserve energy during contractions.

Physical benefits that have been associated with the non supine positions include
stronger and more efficient uterine contractions, aiding cervical dilatation and
therefore reduced risk of labor dystocia , utilization of gravity may improve fetal
descent and more effective bearing down effects; improved fetal positioning, reduced
risk of aorta caval compression and therefore improved acid base outcomes in the
newborns and increased diameters of the pelvis, psychological benefits include
reduced pain/backache, increased feeling of being in control and more effective
communication with health professionals (Simkin & O'Hara, 2002;De Jonge et al,
2004; Gupta, 2004; Soong, 2005; Stremler,2005; Altman, 2006; Declercq et al.,2006,
De Jonge et al., 2007; Lawrence et al., 2009).
Radiological evidence of the larger anterioposterior and transverse pelvic outlet
diameters results in an increase in the total outlet area in both the squatting and
kneeling position (Michel et al., 2002).

Women should be encouraged to take up whatever position they find most

comfortable during labor. The benefits of upright posture include a shorter second
stage of labor, a small reduction in assisted deliveries, and a decreased episiotomy rate
but an increased risk of severe blood loss. Further research indicates that an upright
position does not appear to be associated with increased intervention or negative
effects on the mothers' and babies' well-being (Mayberry et al., 2003; Gupta et al.,
2006). Birth position is influenced by many factors and the research investigating
women's perceptions of comfortable positioning, and the extents to which women are
influenced in relation to birth position are important contributions to the knowledge
on the topic.

The majority of women in Western societies deliver in a supine position. It is claimed

that the supine position enables the midwife or obstetrician to monitor the fetus better
and thus to ensure a safe birth however, this view ignores the comfort and optimal
physiological functioning of the mother which in turn preserves fetal health (Gupta,
2004).There is controversy around whether being upright or lying down has
advantages for women delivering their babies. Several physiological advantages have
been claimed for non recumbent or upright labor. Table 8 below shows benefits and
risks of the non supine position for labor and birth.

BENEFITS: RISKS:
Increased diameters of pelvic inlet and Increase in second degree tears
outlet
Improved uterine contractility Increase blood loss > 500 mls
Improved fetal well being Practitioner resistance
Reduced duration of second stage labor Maternal fatigue
Reduction in assisted deliveries High dose epidural block
Reduction in episiotomies
Decreased pain
Increased feeling of maternal control
Increased partner involvement

TABLE 8: BENEFITS & RISKS OF THE NON-SUPINE POSITION FOR

LABOR & BIRTH

According to De Jonge (2004) the advice given by midwives as well as the

environment in which the woman labors and gives birth are the most important factors
influencing the choice of birthing positions. Many women will choose to labor in a
recumbent or semi recumbent position because this is what they believe is expected of
them, both culturally and socially. If the only furniture available in a hospital labor
room is a bed that is what the woman will use. Hospital obstetric departments are
often not set up to accommodate alternate positions; with the bed often being the only
furniture provided for women. Comfortable chairs, birthing balls, beanbags and
furniture to accommodate the upright position such as wall bars, will enable women to
choose a variety of positions
(see diagram of maternal positions in labor).

MATERNAL POSITIONS IN LABOR

(Copyright :The Labor Progress Handbook Simkin & Ancheta 2002).

Cultural influences on maternal position

Women use various positions, supine and non supine, if they are left to choose (De
Jonge, 2004).The supine position has become so common that neither health care
workers nor women regard this as an intervention (De Jonge, 2004). The promotion of
hospital as the favored location of birth has meant that women tend to automatically
assume labor as an illness; the impression is further heightened where the delivery bed
remains the central focus in most delivery rooms. This is further supported by Albers
(2007); Jonge et al, (2008) who mention, that action such as the environment and
views of health practitioners can influence a woman's choice of labor position.

Where women are able to labor in their own home or a less medicalised environment,
they are frequently observed to instinctively adopt a range of alternative positions and
therefore maintain greater mobility. (Lawrence et al., 2009).The common use of
routine technological interventions during labor, such as electronic fetal monitoring
and methods of pain relief such as spinal epidural analgesia and intravenous infusions
such as those used for induction of labor affect a woman's mobility and use of postural
change in labor (Spiby et al., 2003).

Midwives generally encourage laboring women to be mobile as long as possible and

to adopt whatever position is most comfortable, however, there are indications and
contraindications for the use of certain positions during the course of labor. Modifying
intrapartum care to reflect current evidence, regarding the factors that influence
maternal positions in labor, will improve the maternity care that women and families
receive. Health professionals working in obstetric care need to be aware of the
evidence based practice regarding maternal positions in labor to enable women to
make informed choices.

Summary

Women's health practitioners have an obligation to teach women and their partners'
how to find and determine the quality of evidence based information in order to make
informed choices.
Most women have the potential to have a physiologic labor and birth; one that starts
and proceeds on its own, without routine use of interventions or drugs (Albers, 2007).
Factors such as the ability to maintain some level of autonomy, ability to mobilize and
change positions unprompted, in an environment conducive to welcoming partners
and family members are important contributions to patient satisfaction. Patient
satisfaction plays a significant role in determining the pattern of one's health seeking
behavior in the future. Upright positions and mobility are often more pleasant for
laboring women and have distinct advantages in promoting progress leading to a
spontaneous vaginal birth. Women need to be made aware of alternative positions and
advantages and disadvantages in order for them to make an informed choice. Women
should be encouraged to give birth in positions that they find comfortable while
avoiding spending long periods in a supine position. Midwives are in a unique
position to provide evidence-based care that promotes normal birth and provides
healthy outcomes.

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