Birthing Positions: Supporting a Woman's Choice in Labour

It could be argued that the ideal position for a woman to birth in is the one she adopts if she is not told what to do.

For midwives, the question is, which positions have the best maternal outcomes and how can this information be used to support the women in their care?

Movement as a Coping Strategy

For a long time lying supine was the most commonly used birthing position. Gupta et al. 2017, make the point that this may largely be because birthing assistants are more comfortable with the lying, or semi-sitting position because this is how most are trained to attend births.

However, there are many studies that suggest the supine position is linked to multiple negative maternal and neonatal outcomes. For example, Modrzejewska, Torbé and Torbé (2019) suggest horizontal positions are much less favourable, simply because when a woman's weight is mainly supported by her back she needs to push against gravity, putting the foetus in an unfavourable drive angle in relation to the pelvic floor.

On the other hand, women who use upright mobile positions are known to have shorter labours, receive less intervention, report less severe pain, and describe more satisfaction with their birthing experience compared to women using recumbent positions. Added to this, the freedom to be mobile in labour is likely to be safer because it does not disrupt the normal physiological processes of birth (Ondeck 2014).

Benefits of the Upright Position

Throughout labour and delivery, maternal positions play an important role in the descent of the foetal head and it’s now widely acknowledged that remaining upright has greater benefits in facilitating the progress of labour compared to horizontal positions.

For example, the most recent Cochrane review exploring the impact of different birthing positions shows that upright positions can reduce the duration of the second stage of labour by a mean of 6.6 minutes compared with supine positions (Huang et al. 2019).

Several physiological mechanisms are known to assist the progress of labour when a woman adopts an upright position:

• Gravity assists the effort of pushing.
• Contractions are stronger and more effective.
• The size of the pelvic diameter naturally increases enabling faster progress.

(Huang et al. 2019)

Whilst there is no compelling evidence to prove that upright positions affect the intensity of contractions, or the rates of caesarean section, many other benefits have been recognised.

• Vertical positions such as standing, squatting and kneeling are associated with a reduction in the duration of the second stage of labour.
• Upright positions are associated with a significant reduction in instrumental deliveries.
• Greater alignment of the foetus during the passage through the pelvis assists delivery.
• Contractions assisted by gravity help support the birthing process.

(Royal College of Midwives 2018)

Modrzejewska, Torbé and Torbé, 2019 add the following benefits in support of upright birthing:

• Vertical positions make it possible to maintain the mobility of the pelvic floor, especially the sacroiliac joints, which allows it to reach its optimal capacity.
• Staying in motion and in an upright position until the end of labour ensures maximal relaxation of the pelvic floor muscles.
• Vertical positions increase the strength, frequency and regularity of uterine contractions.
• The direction of gravity coinciding with the direction of expulsive uterine contractions allows the cervix to open more quickly.
• Perineal damage is reduced as the pressure of the foetal head is focused more evenly in the centre of the outlet, rather than on the perineum, allowing the tissues to be stretched more evenly.

Upright positions are also associated with a reduction in pain, which as Modrzejewska, Torbé and Torbé, (2019) suggest can be explained by the possibility of ‘discharging the tension’ through greater freedom of movement together with less compression of the pelvic nerves by the pregnant uterus and foetus.

These advantages are making upright birthing a popular choice for many women, but there are also some disadvantages associated with the upright position such as an increased risk of postpartum haemorrhage as well as greater difficulties in accurate monitoring.

Evaluating the Research

Researching birthing positions can be fraught with difficulty as none of the recent studies adequately defines or describes the positions, or their biomechanical impact in detail. As Desseauve et al. (2017) points out, the effect of one position relative to that of another requires precise definitions of each position and their maternal biomechanical consequences, as well as safe measurement methods.

Gupta et al. 2017 agree, suggesting that overall research evidence based on the latest Cochrane review is not of good quality. Whilst most researchers agree that the length of time women had to push may be reduced, the effect was very small, and any benefits might be outweighed by the tendency to lose more blood. In other words, the results should be interpreted with caution because of poorly conducted studies, variations between trials and how the findings were analysed.

The Importance of Shared Decision Making

Midwives have always played a pivotal role in helping women find the best positions for labour and birth. Added to this, informed choice and the use of birth plans go a long way to help women feel confident in moving about and selecting the birth position of their choice.

This process of shared decision making is not a linear process, but rather a dynamic process that requires a variety of approaches. As Nieuwenhuijze et al. 2014 suggest, midwives should ideally take a flexible approach that incorporates clinical assessment as well as respecting the woman's personal preferences.

Having the flexibility to adapt the birth plan and respond as needs arise during the progression of labour is a position that is also endorsed by the Care Quality Commission (2018) who recommend that professionals should encourage and help the woman to move about and adopt whatever positions she finds most comfortable throughout labour.

It’s a recommendation echoed by the Royal College of Midwives (2018), who suggest that:

• Midwives should support women to adopt any position they choose during labour and birth and to change positions as and when they want to.
• Midwives should advise women that upright positions during the second stage of labour may reduce the likelihood of interventions such as instrumental births, episiotomies and concern about foetal heart patterns.

Practice Points

Most researchers agree that women should be encouraged to give birth in whatever position they find most comfortable (Gupta et al. 2017).

• Medical equipment should be made to work around a woman’s choice of positions.
• Many women strongly dislike the lithotomy position and its use should be limited to facilitating certain procedures such as instrumental delivery, or for foetal blood sampling and then discontinued immediately afterwards.

(Royal College of Midwives 2018)

Midwives, doulas and birthing assistants have always played an important role in supporting women in their use of different birthing positions. For women with low obstetric risk, the freedom to explore a range of positions during delivery should always be encouraged. It’s a core skill for midwives and doulas and a key contribution towards a positive birth experience.

References

• Care Quality Commission 2018, 2017 Survey of Women’s Experiences of Maternity Care Statistical Release [online] Newcastle upon Tyne: Care Quality Commission, p.40, viewed 22 November 2019, https://www.cqc.org.uk/sites/default/files/20180130_mat17_statisticalrelease.pdf
• Desseauve, D, Pierre, F, Gachon, B, Decatoire, A, Lacouture, P and Fradet, L 2017, ‘New Approaches for Assessing Childbirth Positions’, Journal of Gynecology Obstetrics and Human Reproduction, 46(2), pp.189-195
• Huang, J, Zang, Y, Ren, L, Li, F and Lu, H 2019, ‘A Review and Comparison of Common Maternal Positions During the Second-Stage of Labor’, International Journal of Nursing Sciences, 6(4), pp.460-467
• Gupta, J, Sood, A, Hofmeyr, G and Vogel, J 2017, ‘Position in the Second Stage of Labour for Women Without Epidural Anaesthesia’, Cochrane Database of Systematic Reviews
• Modrzejewska, E, Torbé, D and Torbé, A 2019, The Evolution of Maternal Birthing Positions, viewed 22 November 2019, http://dx.doi.org/10.5281/zenodo.3408045
• Nieuwenhuijze, M, Low, L, Korstjens, I and Lagro-Janssen, T 2014, ‘The Role of Maternity Care Providers in Promoting Shared Decision Making Regarding Birthing Positions During the Second Stage of Labor’, Journal of Midwifery & Women's Health, 59(3), pp.277-285
• Nieuwenhuijze, M, de Jonge, A, Korstjens, I, Budé, L and Lagro-Janssen, T 2013, ‘Influence on Birthing Positions Affects Women's Sense of Control in Second Stage of Labour’, Midwifery, 29(11), pp.e107-e114
• Ondeck, M 2014, ‘Healthy Birth Practice #2: Walk, Move Around, and Change Positions Throughout Labor', The Journal of Perinatal Education, 23(4), pp.188-193
• Royal College of Midwives 2018, 'Midwifery Care in Labour Guidance For All Women in all Settings, RCM Midwifery Blue Top Guidance', RCM, pp.16-17.