This blog series is designed to help women who are developing a birth plan join together with like-minded birthing professionals so as to have a shorter and safer labor and birth. Although written primarily for professional birth attendants, I hope information will be helpful to lay women planning their birth. Today we’ll look at the eighth “P” of my 10 “P’s” of keeping labor shorter and birth safer — positions (or position change).

Many maternity caregivers forget that “ambulation is also a treatment,”(17) however, “most laboring women expect to and are expected to labor mostly in bed,”(61) despite the fact that “women seem to prefer freedom of movement”(27,61, 74) in labor.

Avoiding the dorsal recumbent position in the labor bed, changing of positions in labor and delivery, and ambulation of the laboring patient may be helpful in preserving normal labor.

“Restriction of mobility, which occurs as a result of using fetal monitors and/or intravenous lines, results in increased epidural analgesia, increased diagnosis of ‘fetal distress,’ and increased cesarean section rates. Upright posture or ambulation was associated with decreased narcotic analgesia and epidural anaesthesia.”(75)

Position change in labor seems to be not only a critical element, but “unassisted laboring women will assume, over 50% of the time, standing, crouching, squatting, sitting, or kneeling positions.”(74)

“When given the freedom to assume any position desired without interference or instruction, (is associated with) a high degree of position change, with an average of 7.5 positions per woman.”(76)

“Physiologic positioning is a major component of pain management, and women throughout the world use body positioning to make labor more comfortable and efficient. Two factors distinguish a woman’s natural choice of position”(27) as opposed to the provider’s choice.

“First, there is no single ideal labor position — women will constantly change position to be comfortable”(27) and there appears to be no reason to stop them.

“Second, except in many Western industrialized countries, almost all women give birth in some form of upright position, be it standing, sitting, or squatting.”(27) “Position changes may also be useful in encouraging rotation of the head to an anterior position or in the alleviation of dystocia.”(77)

“There is good evidence that postion change is useful in achieving good progress in labor, is well tolerated, and can be safely accomplished. Position change may be more important than a single ‘best’ position.”(5)

“(Why do nurse midwives have lower cesarean section rates for dystocia (and presumably less dystocia) than family physicians?) It is possible that … subtle clinical differences … such … as the use of position change in labor or patient massage — clinical skills practiced by midwives but infrequently used by family physicians (may explain the difference).”(46)

“It appears clear that laboring women should move, change positions, move again, and avoid supine recumbency. Also, comfort, safety, and optimal physiologic functioning, not blind routine and physicians’ convenience, should be the criteria used in determining labor and delivery positions for each individual.”(75)

“Women and their birth attendants should be educated in and encouraged to practice different labor and birth positions to allow for greater opportunities to achieve comfort, alleviate dystocia or malposition, and better adapt to individual needs.”(5)

In summary, a recent meta-analysis reported that there are “… clear advantages for women in adopting an upright posture … when compared to being recumbent … less discomfort, intolerable pain, difficulty in bearing down, abnormal delivery, perineal/vaginal trauma, vulva edema, and wound infections”(78) as “positions and movement contribute to both comfort and labor progress … (and) if progress slows, a change of position or movement will often end it.”(61)

Here’s the entire series:

• Introduction
• The Costs of Abnormal Labor
• THE 10 P’s

1. Philosophy,
2. Partners,
3. Professionals,
4. Pain control,
5. Procedures,
6. Patience,
7. Preparation,
8. Positions,
9. Payment, and
10. Prayer.

• Summary

Citations:

(5) Smith MA, Acheson LS, Byrd JA, et. al. A critical review of labor and birth care.   J Fam Pract 1991;33:281-292.

(17) Young D. Crisis in obstetrics – the management of labor. Int J Childbirth Education 1987, August: 13-5.

(27) Fenwick L.  Birthing:  techniques for managing the physiologic and psychosocial aspects of childbirth.  Perinatal Nurs 1984, May/June:51-62.

(46) Hueston WJ, Rudy MA.  A comparison of labor and delivery management between nurse midwives and family physicians.  J Fam Pract 1993;37:449-454.

(61) Simpkin P.  Reducing pain and enhancing progress in labor: a guide to nonpharmcologic methods for maternity caregivers.  Birth 1995;22:161-71.

(74) Hundley VA, Cruickshank FM, Lang GD, et. al.  Midwife managed delivery unit: a randomized controlled comparison with consultant led care.  Br Med J 1994;309:1400-1404.

(75) McKay S, Mahan CS.  Laboring patients need more freedom to move.  Contemporary Ob/Gyn 1984;24:90-119.

(76) Carlson M, Diehl JA, Sachtleben-Murray M, McRae M, et.al.  Maternal position during parturition in normal labor.  Obstet Gynecol 1986;68:443-447.

(77) Andrews CM.  Changing fetal position.  J Nurs Midwife 1980;25:7-12.

(78) Nikodem VC.  Upright vs recumbent position during second stage.  In:  Pregnancy and childbirth module (eds. Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP), ‘Cochrane Database of Systematic Reviews’: Review No. 03335, 6 May 1994.  Oxford: Update Software, 1994, Disk Issue 1.