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by Avery, Melissa D

Care providers may also be more comfortable with the lying or semi-sitting position because this is how most are trained to attend births Gupta et al. Also, as the presenter explains in this popular video by the Head of Midwifery Education at the University of South Wales, while the supine position is not beneficial for normal vaginal birth, it is the easiest way to position Noelle, a popular birthing mannequin , to simulate birth for medical, midwifery, and nursing students. The focus on non-upright birthing positions in training is likely a major reason why many care providers are uncomfortable with attending upright births.

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. Not a single medical student had seen a baby born in an upright position on their clinical rotation. If a physician has only been trained in birth with the mother in the lithotomy position, they may not feel that they can safely handle complications if the mother were in an upright position.

The fact that most people in the U. Voogt, January Finally, there are system pressures in hospitals that limit caregivers from truly supporting birthing people. A mother with an epidural may need two assistants to help her balance in certain positions, which is not possible if a hospital is short-staffed on nurses, or if the nurse is supposed to be charting on the computer every five to ten minutes for medical, legal, and insurance reasons.

If hospitals were willing to invest in more hands-on care to support birthing women, we would likely see more auscultation and more staff support for position changes during labor.

Leaving Well Alone: A Natural Approach to the Third Stage of labour

In a recent Cochrane review and meta-analysis, Gupta et al. In these studies, people were randomly assigned to either upright or non-upright positions during the second stage of labor. Studies could still be included in the meta-analysis if they assigned people to upright positions during the passive second stage of labor but not during the active pushing phase. The researchers defined upright positions as sitting on a birthing stool or cushion, kneeling, hands-and-knees, and squatting.

They defined non-upright positions as side-lying, semi-sitting, and lithotomy. In comparison with non-upright positions, people who were randomly assigned to upright positions in the second stage of labor were:. However, since other researchers have found strong evidence that natural tears heal easier and are less traumatic to tissue than episiotomies Jiang et al. Also, it may be possible to reduce the risk of perineal tears with upright positions by changing the methods used in the second stage of labor e.

The authors questioned the accuracy of this finding because the blood loss was based on care provider estimates, which is not an accurate way of measuring blood loss. There were no differences in the need for blood transfusions between groups.

Some researchers consider that, in well-nourished people, there is little impact from blood loss of mL—an amount equal to a routine blood donation Begley et al. However, in low-income countries where mothers may be poorly nourished and anemic, this amount of blood loss can be harmful. So, upright vs. The way care providers handle the third stage of labor, on the other hand, seems to have more of an impact on the amount of postpartum blood loss. In contrast, with active management the care provider usually gives the mother a drug to make the uterus contract, clamps the cord early, and gently pulls on the cord while pressing on the uterus to deliver the placenta.

It would be interesting to see research comparing active management of the third stage of labor in upright vs. The Gupta et al. Without these important details, it is difficult to draw conclusions about the effect of upright birthing positions on postpartum blood loss. Three out of four trials that measured pain found a reduction in pain with upright birthing positions. They also found that when people gave birth in upright positions, their labors were shortened by about six minutes; however, the evidence for this outcome was of very low quality.

When they left out the poorer quality studies, there were no differences in length of labor between groups. This meta-analysis included fewer studies 22 vs. There were no differences between the upright and non-upright groups for any other health outcomes.

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We found one randomized trial that was too new to be included in the reviews. This study involved first-time mothers giving birth without epidurals in Turkey Moraloglu et al. The study showed that the people who stood, then squatted down with a bar to push during contractions, had shorter second stages of labor by about 34 minutes. They also experienced less pain, were less likely to receive artificial oxytocin Pitocin to augment labor, and had higher satisfaction with the birth experience, compared with the group that pushed and gave birth while back-lying in a raised bed.

Supporting a Physiologic Approach to Pregnancy and Birth : Melissa D. Avery :

There were no differences between groups in postpartum blood loss. A recent Cochrane review looked at evidence for upright vs. Studies could be included if people were randomly assigned to upright vs. Combined, there were people from five randomized, controlled trials. The trials all took place in hospitals in the United Kingdom or France. There was also no difference in perineal tears requiring stitches, abnormal fetal heart rate patterns, low cord pH, or NICU admissions. The authors looked but did not find any useful data on blood loss greater than mL, prolonged second stage of labor, Apgar scores, perinatal death, need for ventilation, or maternal satisfaction with the birth.

The Cochrane authors concluded that, at this time, there is not enough evidence to recommend specific birthing positions for people with epidurals. 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 Cochrane reviewers are still awaiting further information from the trial authors before they decide to add these studies to their review. People assigned to the traditional model began pushing in the lithotomy position immediately after they reached ten centimeters, and also gave birth in the lithotomy position.

People assigned to the alternative model delayed pushing and gave birth in a specific type of side-lying position. The group assigned to delayed pushing was instructed to change position every minutes after reaching full dilation and begin active pushing efforts only after feeling a strong urge to push. Hospital staff assisted them in moving into different positions like sitting, kneeling, side-lying, or hand-and-knees. If, after 2 hours in the passive phase, the epidural prevented people from feeling an urge to push, they were asked to start pushing with each contraction.

When people in the delayed pushing group were ready to begin pushing efforts, trained staff assisted them in moving into a specific side-lying position.

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In this position, the lower leg remained extended on the bed and the upper leg rested flexed on the stirrup. This placed the foot of the upper leg in a higher position than the knee to allow the upper hip to rotate. This study provides evidence that in people laboring with epidurals, delayed pushing with position changes and active pushing and delivery in the side-lying position may reduce the rate of assisted vaginal birth, the length of the active pushing phase, and the rate of perineal trauma without adding risks for mothers or babies.

However, as the next study found, it may be possible to achieve these benefits using only delayed pushing and position changes in the passive phase of the second stage of labor.

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The second study, also conducted in Spain, randomly assigned 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. Both groups were instructed to delay pushing and everyone eventually gave birth in the lithotomy position. The people assigned to position changes during the passive phase of the second stage of labor had better outcomes than the group that was supine for the entire second stage, even though everyone gave birth in the same back-lying position.

They also experienced shorter second stages of labor 95 minutes vs. The third trial was a very large randomized, controlled trial on birthing positions conducted by a group in the United Kingdom U. The research group compared upright vs. Between and , a total of 3, people were enrolled in the study from 41 maternity care centers in the U. 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.

The upright group was assigned to be moving on foot, standing, sitting, kneeling, or in any other upright position. The non-upright group was assigned to side-lying with the hospital bed raised up 30 degrees.

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For the most part, people used their assigned pushing positions. Strangely, this was a very low spontaneous vaginal birth rate in both groups. These numbers are strangely high. In the U. The researchers did not find a difference between groups in rates of failure to progress or fetal distress leading to vacuum or forceps. They also did not find differences in any other health outcomes.

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. However, the findings from this study should be taken with caution—they may not apply to settings with more support for spontaneous vaginal birth where there is less use of vacuum or forceps.

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