Position in Labour and Delivery: Based on the best available research evidence

Position in Labour and Delivery: Based on the best available research evidence
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http://kpibu.blogspot.com/2014/10/posisi-dalam-masa-persalinan-dan_24.html


Picture: AnteNatal

Interest in maternal position during labour is not new, but only recently has there been any well controlled research to access the validity of the various strongly held opinions.

At the present time lying down in labour is common in many maternity units, with 74% of women in the world adopting a semi recumbent position (1). The available data cast doubt on the wisdom of this practice (2)


Picture: Lying down in labour


Will you lie down, stand up sit or squat - or do a mixture of all four?
No one knows for sure what the best is for you and your baby when you go into labour.

About three quarters of women spend their labour lying on their backs propped up with pillows or wedges.

But most say, they’d like to be upright next time – and research suggests they might be better off that way.

This information explains what we know about the advantages and disadvantages of different positions. It’s worth thinking about what you’d like to do – if you want to kneel or squad, you may need to practice now!

Researchers have looked at the advantages of being upright during the first stage of labour – form the time contraction starts until you’re ready to push – and in the second stage - when you start to push and the baby is born.

The position you give birth in is up to you.

Just because all the pictures in these blog seem to show women lying their backs, it doesn’t mean that is the right way for you.

Whatever thoughts you have now about how you’d like to give birth, you should be flexible. You may well want to change position lots of times. If you get tired and want to lie down for a while, you could try propping yourself up with pillows or lying on your side. Lying flat on your back reduces the blood flow to your baby.

Some of the equipment used during labour, for example the machines that monitor your baby’s heat beat, and epidurals, stop you moving about freely. Talk to your midwife about how these things will affect your position before you decide to use them. If you would like to know more about different positions during labour and delivery, discuss this information with your midwife or doctor.


Picture: Birth stools

Being upright – how could it help? 

  • 1.       Gravity could help your baby move down more easily and more quickly
  • 2.       There is less pressure on the blood vessels that go to your womb – these provide your baby’s oxygen supply
  • 3.       Your baby could be in a better position for moving through your pelvis
  • 4.       Your contractions could work better. This helps you to open up more quickly
  • 5.       When you squat or kneel, your pelvis may open wider and make more room for the baby to come through


Gambar: Close physical contact, encouraging and soothing words, and eye to eye contact help

What we don’t know
These advantages and disadvantages were found out by research, but there are lots of things we still don’t know. For example, if you are free to use any position you like, will you naturally find the positions which are most comfortable for you?

Maybe just being able to choose for you is the most important thing, not the positions themselves.

Have a go!
Why not try out various positions at home or in your parent-craft classes? If you are having your baby in hospital you can check what’s available in the way of bean bags, chairs, birth stools and so on. Ask if you can’t find what you want. The midwives should be able to get what you need or you may be able to bring something in yourself.

What we know:  First Stage
Being upright during the first stage could mean standing, sitting, squatting, kneeling or walking around. The research compared these positions with lying down. Advantages in being upright:

  • 1.       It is less painful
  • 2.       There is less need for an epidural or painkilling injection.
  • 3.       Labour could be slightly shorter

Disadvantages: There are no known disadvantages

What we know:  Second Stage
Being upright during the second stage could mean kneeling, squatting, sitting fairly straight or using a birth stool. Most of the research so far has been done on women sitting on the birth chairs or stools. Advantages in being upright:

  • 1.       It is more comfortable and less painful
  • 2.       Pushing is easier
  • 3.       There is less chance of having a suction cup, forceps or caesarean delivery
  • 4.       There is less chance of getting an infection in your womb
  • 5.       There is less chance of tearing your vagina or the skin between your vagina and anus
  • 6.       Babies stand a better chance of breathing well right after they’re born
  • 7.       Labour could be shorter

Disadvantages:

  • 1.       There is more chance or tearing your labia -  the lips around the vagina
  • 2.       If you use a birth chair or stool you may lose more blood, but not enough to cause problem. This doesn’t seem to happen in order upright positions
Position in Labour and Delivery
Several theoretical physiological advantages have been proposed for upright posture during labour:
  • 1.       Utilization of gravity may improve fetal descent
  • 2.       Lessened risk of aorto-caval compression and compromised uterine blood flow
  • 3.       Improved alignment of the fetus for passage through the pelvis
  • 4.       Stronger and more efficient uterine contractions, aiding cervical dilatation
  • 5.       Increased pelvic outlet diameters in squatting or kneeling postures (3)
 
Upright positions are almost always chosen by women in traditional societies (4 – 6), which suggests that women do not naturally choose to lie down to labour and give birth.

The Research Evidence
The research on the effect of maternal position in labour on outcomes has not been thorough; many of the trials conducted on the first stage are methodologically poor, and most of the second stage trials have focused only on the use of birth chairs (7). All the trials have taken place in a hospital setting. The summary of the evidence is given below. It is based primarily on randomized, controlled trials (RCTs).

An upright position in the first stage is defined in these trials to mean any position that avoids lying flat, and may include ambulation.

Upright in the second stage includes the use of a birth chair, sitting more than 45⁰ from the horizontal, squatting, kneeling and being on the hands and knees. Recumbent positions include supine, lateral, lithotomy and semi-recumbent using pillows and wedges.


Gambar: Firm pressure or massage on your lover back can help during a contraction

The First Stage
The limited evidence available suggests that women being upright in the first stage of labour results in:
  • 1.       Less severe pain (8 -11)
  • 2.       Less need for epidural anesthesia and for narcotics (12 – 14)
  • 3.       Lower rate of loss of beat to beat variability in the fetal heart rate (12)
  • 4.       Reduced length of the first stage of labour (12, 23 – 24)

No measurable effects were detected on:
  • 1.       Rate of assisted delivery
  • 2.       Rate of caesarean delivery
  • 3.       Fetal or neonatal outcomes (15)

No research has addressed women’s preferences on position in the first stage. Several of the papers reported that many women did not comply with their allocated position: many of those allocated to remain recumbent chose to sit or move about, and many of those allocated to adopt an upright position became tired and wanted to lie down (16 -17)

It was observed that women changed position frequently, especially in the first half of their stage (18 – 19), but that as labour progressed many preferred to recline (6, 11 – 13, 20 – 22).

The Second Stage
 In 13 of the 17 RCTs, which assess the effects of position on the second stage of labour women sat on something: in three studies they were propped up in the bed (20, 29, 34) in one day sat on a cushion (19); and in nine they used a rigid chair or stool (17, 24-28, 31 – 33). Thus the findings may reflect the use of a birth chair rather than the upright position per se.




Picture: Keeping upright and moving around shorten your labour (a, b, and c)

Systematic review of these trials (35) shows that women being upright during the second stage results in:
  • 1.       Less discomfort
  • 2.       Less intolerable pain
  • 3.       A shorter second stage of labour when no oxytocin is used
  • 4.       Bearing down being less difficult
  • 5.       Fewer assisted and caesarean birth
  • 6.       Fewer perinea and vaginal tears
  • 7.       More labial tears
  • 8.       More women with a blood loss over 500ml, in women using birth chairs or stools
  • 9.       Fewer postpartum wound infections
Length of the Second Stage Of Labour  
In 11 of the 17 RCTs oxytocin was used and this may well have masked any differences in the duration of labour that might arise due to the position adopted (3, 16, 17, 19, 25 – 29, 31, 33). In only one of these was there a significant difference in the length of labour (17), labour was shorter in the upright group. Of the six RCTs in which no oxytocin was used (20, 23, 24, 30, 32, 34) two found no significant difference in duration (20, 32) and the other four found that the second stage of labour was significantly shorter in the upright group.

Maternal Blood Loss:
Women who gave birth in the upright position were significantly more likely to have a recorded blood loss of 500 ml or more (17, 31 – 33). However, the excess of postpartum hemorrhage (PPH) was exclusively among those women who were using a birth chair and there was no significant increase in the requirement for blood transfusion (17, 25).

In two studies that used both a soft cushion or no birthing aid there was no significant difference in blood loss and PPH rates between the two groups (3, 19). Only one trial reported on the hemoglobin level on 3rd or 4th day (25) and this showed no significant difference.

The difference in blood loss between those in birth chair and those in other upright position might explained by either increased congestion in the vulva as the venous return is impeded by the woman’s buttocks and thighs bearing down against the hard edge of the chair or stool or by the more complete collection and measurement of the blood loss that sitting on a rigid birthing aid permits or both (19, 36).

Vulvae Edema
The data on vulvae edema are not conclusive (17, 19) though there is some observational evidence that vulvae edema is associated with sitting for prolonged periods on birth chairs or stools (37 – 39).

Women’s Preferences
Most of the women who gave birth lying down said they would prefer a different position next time. Women in the upright groups expressed a preference for an upright position for their next birth. Those who had given birth previously in a recumbent position, and so were able to make a comparison, preferred being upright and would choose an upright position for a future labour (3, 16, 17, 19, 24-26, 28, 35)

Interpreting the evidence: The choice of position
While 87% of maternity units claim that women are allowed to adopt whatever position they choose (1), the great majority of women spend all their labour recumbent or semi-recumbent (1). To a large extent women will choose to do what they think is expected of them, culturally and socially (17-18, 40), and they less likely to assume positions that are unfamiliar to them. Images of birth that women will have seen in films and books and the experiences of their friends and family are all likely to be of birth lying down. Antenatal classes may help in this regard as an opportunity for women to try out a variety of labour positions.

The expectations, experiences and trainings of the midwives and doctors attending women at birth will influence the range of position they encourage and allow women to adopt. If care givers are not confidents in delivering women in whatever position the mother finds most comfortable, this will restrict women’s choices. Some women do not know what they want to do when overwhelmed by labour and will rely on the midwife to explore with them a range of possible options.

Probably the strongest determinant of maternal position, at a hospital birth particularly, is the environment in which the women labours and gives birth. Rarely, if ever, does a woman maintain herself in an upright position in labor without some kind of support, either mechanical (ropes or ledges) or human (5). If the only furniture provided in a hospital labour room is a bed, this is what women will use. Comfortable chairs, bean bags and floor mattresses will enable women to choose a variety of positions.

Some labour ward practice will restrict the movement of laboring women. Foremost among these are electronic fetal monitoring, the sitting of IV infusions and epidurals. Women giving birth at home usually have available a variety of props, sufficient space and companions to enable them to adopt a range of different positions.

What We Don’t Know
As the research on maternal position is so limited, there is a great deal that we do not know. Some of bigger gaps in our knowledge include:
  • 1.       Which factors determine a woman’s choice of position during delivery and birth?
  • 2.       Will a woman who is enable to choose her preferred position automatically adopt the positions that are most comfortable and least painful for her?
  • 3.       Is the ability of woman to move about and change position more important for improving outcomes than the adoption of any one particular position?
  • 4.       Would appropriate antenatal education encourage women in labour to adopt whichever among a range of positions they find most comfortable?
  • 5.       Do birthing chairs have any advantages over simpler aids such as firm surfaces, birth cushions, bean bags and human support?
  • 6.       Is there an optional position for delivery that minimizes the risk of perineal trauma?
  • 7.       What causes the higher incidence of PPH when birth chairs and stools are used?
  • 8.       Are the changes in position already used by some midwives for specific purposes, eg. Hands and knees position to encourage an OP baby to rotate, effective?
The Maternity Services
Labour rooms should routinely be furnished with a variety of props, chair, floor mattress, beanbags, beds, ledges, etc, so as to offer women genuine freedom of movement during labour. They need to be sufficiently spacious to enable a woman to assume whatever position she finds most comfortable.

Maternity units should instigate programmed of audit and evaluation to ensure that freedom of movement and choice of posture during labour and delivery are being encouraged effectively.

Implications of Practice
  • 1.       Midwives should be familiar with working with a variety of props, helping a woman to be as comfortable as possible whether she is standing, kneeling, sitting or lying. They should be flexible enough to be able to monitor the labour whatever the position of mother
  • 2.       Whilst the preferences of the laboring woman regarding her position are paramount, there are advantages to assuming an upright posture during labour. Midwives should genuinely encourage women to choose whatever position is most comfortable in either stage of labour, to change position as and when they wish, and be willing and be able to help women give birth in whatever position the mother finds most comfortable.
  • 3.       Disabled women may need extra support and props. Advice can be obtained from the organizations listed in the women’s leaflet.
  • 4.       Women are less likely to assume positions that are unfamiliar to them. In the West they sit, stand or lie. Squatting, kneeling or hands and knees position may need some antenatal exploration and practice (16, 18, 19)
  • 5.       If women use rigid birthing chairs or stools for the second stage of labour, they should be encouraged to move about between contractions to reduce vulval congestion and oedema
  • 6.       Midwives should discourage women from lying supine during labour. If a woman wishes to lie down at any stage or an intervention dictates that she does so, eg. Fetal blood sampling, she should be enabled, with the use of pillows and wedges, to be either semi recumbent or titled laterally.
  • 7.        The use of electronics fetal monitoring, intravenous infusions and different methods of analgesia will all affect a women’s mobility. Care givers should ensure that women are aware of this and make a fully informed choice as to their use.
  • 8.       One completion of training, all midwives and doctors should be experienced and confident in working with laboring women who adopt a variety of positions.


Picture: Keeping upright and moving around shorten your labour

Check list: Questions you may want to ask:
1.       If you want to give birth in hospital, these are some of the questions might want to ask:
a.       What furniture is there in the labour rooms apart from a bed?
b.      Are the labour rooms big enough for me to move about easily?
c.       Are there any policies or practices in my hospital that would stop me using upright positions while I am in labour?
2.       If you want to give birth at home, you might want to think about the following:
a.       What furniture is there in the room I plan to use while I am in labour?
b.      Is there anything I need to prepare or borrow to give me a choice of comfortable positions when I am in labour?
3.       After reading these narrations, there may be some things you are still not sure about. You can write down any questions you have and nay things you would like to discuss with your midwife or doctor, and please give us a comment here (bellow the story) 

Notes:
This information summarizes the most reliable research evidence available and has been extensively peer revised by international experts. These are also supported by the Royal College of Midwives, The Royal College of General Practitioners and the Royal College of Obstetricians and Gynecologists.  

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Other Sources:
1.       http://www.dailymail.co.uk/health/article-1170084/Take-stand-Lying-early-stages-childbirth-makes-longer-harder-says-midwife.html
2.       http://www.babyexpert.com/

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