Both groups were instructed to delay pushing and everyone eventually gave birth in the lithotomy position. About 80% of participants assigned to both the upright and side-lying groups were able to move around, meaning that they had true low-dose epidurals. [3], A Cochrane Review found that the lithotomy position may not be the ideal position for childbirth, noting that while it makes care easier for physicians by placing the patient in an easily accessible position, it is often harder on the female as use of the lithotomy position can narrow the birth canal by up to a third. One of our reviewers spoke with a care provider who had the opportunity to ask a room full of medical students in the Southeastern U.S. if any of them had ever seen an upright birth on their OB rotation. The study included 1,020 mothers giving birth vaginally for the first time between 37 weeks and 41 weeks 6 days. In comparison with non-upright positions, people who were randomly assigned to upright positions in the second stage of labor were: * The lower risk of episiotomies with giving birth in upright positions was offset by a higher risk of second degree tears. Despite its widespread use, continuous electronic fetal heart rate monitoring is not evidence-based in most cases. Mystique (She/They) is a certified full spectrum doula who serves BIPOC... Don't miss an episode! 177, 2017). So far, researchers have not identified clear benefits or risks from birthing in upright vs. non-upright positions. It’s important to look at the evidence on birthing positions based on whether or not people had epidurals, because different positions may have different effects depending on whether or not you have an epidural. In lieu of the lithotomy position, the Cochrane Review recommended Women make informed choices about birthing positions and find the position that is most comfortable for them. This study found no difference in the rate of forceps or vacuum assistance. There is also the lateral position where you give birth while lying on your side. The passive waiting phase of the second stage of labor is a period of rest (sometimes called “laboring down”) when the baby rotates and descends toward the pelvic floor. We found one randomized trial that was too new to be included in the 2017 reviews. One randomized trial found that the use of a birth seat may shorten the length of the second stage of labor, result in less synthetic oxytocin for labor augmentation, and lead to fewer episiotomies and greater satisfaction with childbirth. A small minority push and give birth in other positions such as side-lying (3%), squatting or sitting (4%), or hands-and-knees position (1%) (Declercq et al. The position of the pelvis when in dorsal lithotomy places the birth canal at an angle that actually makes the baby travel upward. Future research should avoid grouping the side-lying position with the other non-upright positions, since side-lying allows for more flexibility in the sacrum area, so it may be more beneficial. 2017). There are three other randomized, controlled trials that looked at birthing positions in people with epidurals, but were not included in the Cochrane meta-analysis. The probability of an intact perineum increased in deliveries performed by midwives. More than 60% of people giving birth to a single baby in the U.S. use epidural or spinal analgesia (ACOG, Practice Bulletin No. The first study from Sweden looked at strategies care providers can use in the second stage of labor to improve health outcomes (Edqvist et al. Among people who experienced labor in the U.S. in 2012 and 2013, the majority were given electronic fetal monitoring (EFM) either continuously (60%) or for most of the time during labor (20%) (Declercq et al. 2017). Subscribe to our podcast:  iTunes  |  Stitcher On today's podcast, I wrap up all the resources we created at Evidence Based Birth in 2020, as well as the challenges we faced as a team. Although they may not know the term, any television viewer can recognize the lithotomy position: the feet-in-stirrups, hair-perfectly-blown-out posture women assume for giving birth. Given the evidence and ethical guidelines, medical schools and residency programs should begin training medical students and resident physicians on how to support women in various birthing positions. Sitting upright on a birth ball. Lateral position = lying on your side. Upright birthing positions may also shorten the second stage of labor and reduce the use of augmentation with synthetic oxytocin. The group that changed positions had fewer Cesareans (1% vs. 10%)  and fewer cases of vacuum/forceps (24% vs. 39%). The position is frequently used and has many obvious benefits from the doctor's perspective. Those benefits are more likely when the side-lying position is combined with position changes in the passive phase of the second stage of labor and waiting for the urge to push. In terms of risks of upright birthing positions, studies have found an increase in second-degree tears from upright birthing positions, but some would consider that a reasonable trade-off for a lower rate of episiotomies. Irrespective of parity, women giving birth in the lithotomy position were characterized by high rates of induction, EDA, oxytocin augmentation, long second stages, infants with large head circumferences, high birth weights and … It could be that people with low-dose epidurals have a greater chance of giving birth spontaneously when they use a side-lying position for the second stage of labor rather than an upright position. The birth position is a personal choice for each woman, and they should choose which one they feel most comfortable with. (2017), Jiang, H., Qian, X., Carroli, G., et al. This placed the foot of the upper leg in a higher position than the knee to allow the upper hip to rotate. Many caregivers around the world still prefer non-upright positions today, even though current obstetric textbooks state that it is beneficial, especially for first-time mothers, to push in upright positions (Kilpatrick & Garrison 2012). 1989:315). Childbirth in the lateral position resulted in less perineal trauma when compared with childbirth in the lithotomy position, even after correcting for parity and birth attendant. They go on to say that continuous EFM has not improved outcomes for women with low-risk pregnancies, and those care providers should “consider training staff to monitor using a hand-held Doppler device (intermittent auscultation)…which can facilitate freedom of movement and which some women find more comfortable.” The statement concludes with a general recommendation that care providers can support frequent position changes during labor to enhance maternal comfort and promote optimal positioning of the baby, as long as they do not hinder monitoring and there are no complications. Finally, doulas can also nurture a supportive environment for a variety of birthing positions. Some researchers consider that, in well-nourished people, there is little impact from blood loss of 500 mL—an amount equal to a routine blood donation (Begley et al. ** Researchers found that people in the upright group were more likely to have an estimated blood loss greater than 500 mL. Positions that take the weight off the sacrum and allow the pelvis to expand might make spontaneous birth (birth without the use of vacuum or forceps assistance) more likely (Edqvist et al. Evidence and ethical guidelines support this bottom line! An earlier study also from Sweden looked at the effect of delivery position on the rate of obstetric anal sphincter injury (OASIS) (Elvander et al. In the lithotomy position, the mother is lying on her back with her legs up in stirrups and her buttocks close to the edge of the table. Fiona and Craig welcomed their first baby in April 2020 — when everything was... Don't miss an episode! In this study, assisted vaginal birth refers to the use of vaccum, forceps, or fundal pressure—when staff apply pressure with their hands to the mother’s abdomen in the direction of the birth canal. https://www.facebook.com/EvidenceBasedBirth/, https://plus.google.com/106146540771436369846?hl=en, https://www.linkedin.com/in/rebecca-dekker-8b3b3b22/. The lithotomy position was an ergonomic nightmare for both mother and baby. What do you do if you and your practitioner feel you're in danger of a shoulder dystocia? The second study, also conducted in Spain, randomly assigned 150 people to position changes every five to 30 minutes in the passive phase of the second stage of labor or to the supine position for the entire second stage (Simarro et al. (2017) meta-analysis does not provide details on how mothers were treated during the third stage of labor, or whether people remained upright for the third stage after giving birth in upright positions. Lithotomy position = lying on your back in a supine position with hips and knees flexed, thighs apart, and legs supported in raised stirrups. The woman assumes a lithotomy position with her back elevated through an arc of 90 degrees, wherein the lithotomy position becomes a sitting position. Magnetic resonance imaging (MRI) studies have shown that compared to the back-lying position, the dimensions of the pelvic outlet become wider in the squatting and kneeling or hands-and-knees positions (Gupta et al. It involves lying on your back with your legs flexed 90 degrees at … The “lithotomy” position, legs in stirrups This is a “lithotomy” or fully reclined position, with legs splayed strongly apart in stirrups to give the doctor as much access as possible. The position is used for procedures ranging from simple pelvic exams to surgeries and procedures including those involving reproductive organs, urology, and gastrointestinal systems. Generally, this is due to the fear of the unknown—since most providers and nurses are not trained in upright birth, and rarely (if ever) see them, they do not feel comfortable attending births in that manner. Physiologic refers to a healthy body’s normal function. They also experienced shorter second stages of labor (95 minutes vs. 124 minutes) and fewer episiotomies (18% vs. 31%). Physicians should advocate for a birth environment that supports women’s choice in their birthing position. Elvander, C., Ahlberg, M., Thies-Lagergren, L., et al. It’s not a great position to be in even on routine checkup days, as anyone who has been asked to “scoot a little closer” and then somehow relax understands. Between 2010 and 2014, a total of 3,236 people were enrolled in the study from 41 maternity care centers in the U.K. To be included in the study, the first-time mothers had to be over the age of 16, carrying a single, head-down baby at 37 weeks or greater, planning to give birth vaginally, and in the second stage of labor with low-dose epidural medication. Another possible way to classify birthing positions is whether the body weight is on or off the sacrum, or the large tailbone at the base of the spine. EBB 156- Nicole Deggins of Sista Midwife Productions on Navigating Systemic Racism in Birth Work, Supine (back-lying) with or without the head of the bed raised up, 25% less likely to have a forceps or vacuum-assisted birth, 54% less likely to have abnormal fetal heart rate patterns, 20% more likely to have a second-degree tear; the absolute risk was 15.3% for people in upright positions vs. 12.7% for those in supine positions *, 48% more likely to have estimated blood loss greater than 500 mL; the absolute risk was 6.5% for people in upright positions vs. 4.4% for those in supine positions **. (2016), Cheyney, M., Bovbjerg, M., Everson, C., et al. They recommend that midwives support mothers with suggestions on how to remain upright even if they’re in a situation that might limit mobility—such as with traditional EFM, intravenous (IV) fluids, and different medications for pain relief. The authors looked but did not find any useful data on blood loss greater than 500 mL, prolonged second stage of labor, Apgar scores, perinatal death, need for ventilation, or maternal satisfaction with the birth. Strangely, this was a very low spontaneous vaginal birth rate in both groups. Some epidurals can block the mother’s feeling to such an extent that the care provider might apply manual pressure to the inner part of the vagina to help with pushing efforts—a procedure that is most often done with the mother in the lithotomy position (Personal communication, S. Voogt, January 2018). People who gave birth on the birth seat were at increased risk of postpartum blood loss; however, the blood loss did not have an effect on hemoglobin levels 2-3 months postpartum. It would be an ethical violation for care providers to restrict a laboring woman’s freedom of movement or coerce her into specific labor or delivery position. In lieu of the lithotomy position, the Cochrane Review recommended Women make informed choices about birthing positions and find the position that is most comfortable for them. I also talk about what our plans are for the year 2021. The group that received woman-centered care used 1) spontaneous pushing (pushing efforts were not coached or directed), 2) flexible sacrum birthing positions (kneeling, standing, hands-and-knees, side-lying, birth seat), and 3) birth of the baby’s head and shoulders in two separate contractions. You can check out their Bundle of Birth apps– includes postpartum rehabilitation (, We particularly love their Birth Positions app! They conducted phone interviews 12 weeks after the birth with 296 people who chose an upright position to deliver and 360 people who chose a back-lying or side-lying position. These potential benefits must be balanced against the risk of more postpartum blood loss; however, the increased blood loss did not lead to worse health outcomes for the participants in this study. Mobile monitors can shift on the mother’s abdomen during movement, which may lead hospital staff to discourage position changes. There were no differences in the need for blood transfusions between groups. General terms that refer to lying on your back or side are called recumbent and semi-recumbent positions. Midwives treated 296 first-time mothers with a three-part protocol called “woman-centered care” and 301 first-time mothers with standard care. 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