Positioning the birth

Many women enter pregnancy having only seen labour occur on television, where women are laid on a bed, knees up, chin to chest, ‘purple pushing’ interspersed with screaming. Understandably, this can lead to some nervousness on the pregnant woman’s part!

The weight of research[1] shows that upright labouring positions can provide advantages to a birthing mother. In an upright position, gravity can assist the baby within the uterus by bringing it down and out, as well as helping keep it in the optimal foetal position when coupled with leaning forward. Being upright can also reduce the risk of aorto-caval compression which could result in a reduced blood supply to the baby. Upright positioning uses gravity to bring a stronger connection between the baby’s head and the cervix, releasing oxytocin and giving more efficient uterine contractions. In traditional squat and kneeling positions the pelvic dimensions become wider, allowing the baby to pass through with more ease. As well as increasing the comfort of the mother and improving the overall birth experience, the positive impact of these positions on the pace and efficiency of labour tend to make interventions less necessary and therefore less common.

The benefits of upright positioning don’t stop there either. Studies have shown that an upright position during the first stage can both reduce pain in the labouring woman[2] and shorten that stage, reducing the need for pain relief and preventing exhaustion in the woman. Interestingly the physical position a woman is in to give birth can also have a psychological impact: being able to find a comfortable position and knowing that the woman’s own movements are helping the baby be born more easily can give feelings of control and stem any fear and anxiety arising from the situation. By reducing stress and discomfort, these psychological responses to a good birthing position can make the whole experience more positive.

Despite the considerable evidence for the benefits of upright birthing positions, the actual positions that women give birth in do not reflect the evidence or national evidence based practice guidelines and nearly half of deliveries are made in a semi-recumbent position[3]. In developed countries where pregnancy and labour has become medicalized, interventions such as foetal monitoring and different types of analgesia can limit the options for position of a birthing woman[4]. A Cochrane review theorises that women are encouraged to push in supine or semi-recumbent positions simply because it is more convenient for the healthcare professional to gain access to the woman rather than being beneficial to the woman. Women ‘choose’ these positions on the basis that they think it is expected of them when presented with a bed in a hospital setting, coupled with the cultural expectation ingrained in them as seen previously, through the medium of television[5]. It is important that the woman knows what positions will help her and to have the confidence to try these positions without being led by the healthcare practitioner in attendance.

A Cochrane review[6] compared the risk of interventions and birth outcomes for upright birthing positions in comparison to non-upright birthing positions and concluded that upright positions can be associated with a shorter length of first stage of labour; a reduction in the use of epidural analgesia; almost a quarter less likely to have an assisted delivery; 20% less likely to have an episiotomy but 35% more likely to have a second-degree tear; 50% of births are less likely to have an abnormal foetal heartrate and 65% are more likely to have a blood loss of more than 500mL. The review found that there was no difference in birthing positions on the length of the second stage of labour; emergency caesarean rates; third or fourth-degree tears; blood transfusion rates; neonatal admissions or perinatal deaths. As there is only a negative impact on second-degree tear rates and blood loss by being in an upright birthing position, it seems clear that upright birthing positions really are the most beneficial, especially as tears can heal more quickly and neatly than episiotomies and there is no knock-on effect on blood transfusions needed.

The birth position chosen by the labouring woman may have a specific purpose. Different positions can bring relief to different complications. For example, if shoulder dystocia presents then the Gaskin Manoeuvre[7] of turning onto all fours and being on hands and knees will cause changes to the pelvic shape which will allow the shoulder to release and the baby to be born.  All fours positioning will be useful for women whose baby is or has turned occiput posterior in labour. Gravity and rotations can help the baby rotate to anterior position[8] although Balaskas points out that when the baby begins to crown each woman should become as vertical as possible to help it out. The use of these positions and a mother’s existing familiarity with them will help to reduce the need for interventions.

There is not just a physiological impact from birth positions on a woman, but psychological too, and these can prefigure the birth itself. Knowing that she can speed up her labour or slow it down if she feels overwhelmed puts her in a position of power. A woman who feels like she is in control of her birth, who feels as though she has a variety of tools at her fingertips to assist a range of experiences she may encounter, will be more empowered to deal with how her labour goes. In contrast, being in a supine position promotes a vulnerability in a healthcare setting that the woman must shed in order to birth most effectively; being upright will automatically help with that.

Ultimately a woman must birth in the position in which she is most comfortable, and the care providers around her must work with her to help her accomplish that goal.

[1] MIDIRS (2008) Positions in labour and delivery. Informed choice for professionals leaflet Bristol: MIDIRS. See also: Gupta, J et al (2012) Position in the second stage of labour for women without epidural anaesthesia Cochrane Database of Systematic Review

[2] Miquelutti, MA, Cecatti, JG (2009) The vertical position during labour: pain and satisfaction Revista Brasileira de Saude Materno Infantil

[3] Royal College Of Midwives (RCM) 2010 The Royal College of Midwives’ Survey of positions used in labour and birth London : RCM

[4] 2016, W.H.O. (2015) Position in the second stage of labour for women without epidural anaesthesia. Available at: http://apps.who.int/rhl/pregnancy_childbirth/childbirth/2nd_stage/tlacom/en/

[5] The Royal College of Midwives (2012) Evidence Based Guidelines for Midwifery Led Care in Labour: Positions for Labour and Birth

[6] Gupta, J et al (2012) Position in the second stage of labour for women without epidural anaesthesia Cochrane Database of Systematic Review

[7] Gaskin, I.M. (2003) Ina May’s guide to childbirth. New York: Random House Publishing Group.

[8] Balaskas, J (1989) New Active Birth: A Concise Guide to Childbirth, London: HarperCollins

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