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. I also talk about what our plans are for the year 2021. Not a single medical student had seen a baby born in an upright position on their clinical rotation. We now have wireless, waterproof continuous monitors available in some hospitals. The Cochrane meta-analysis found no differences between groups as far as Cesarean rates, severe perineal tears, mothers’ need for blood transfusion, number of babies admitted to neonatal intensive care units, or perinatal deaths. So far, most lay people also consider this position a common position and are best used as in many TV shows that we've seen so far, usually always use this position. [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. Subscribe to our podcast:  iTunes  |  Stitcher On today’s podcast, we will be speaking with Mystique Hargrove, EBB Featured Instructor, and our new Podcast Coordinator. It is best practice for hospitals, obstetric providers, and nurses to support women in their right to choose positions for pushing and delivery. The group that changed positions had fewer Cesareans (1% vs. 10%)  and fewer cases of vacuum/forceps (24% vs. 39%). (2015), The Epidural and Position Trial Collaborative Group (2017), Gupta, J. K., Sood, A., Hofmeyr, G. J., et al. So, upright vs. non-upright birthing positions may not have much of an effect on blood loss. The lower episiotomy rate with upright birthing positions, however, seems to hold in both high and low-episiotomy settings (Thies-Lagergren 2013). The lithotomy position is often used during childbirth and surgery in the pelvic area. This is and always has been the state of hospital-based obstetrics. Lithotomy position is one of the most common birth positions, especially in hospitals because it is one of the easiest position for birth helper, especially if you use an epidural. These monitors (like the Novii) are an option for mothers who want to use the shower or birth pool and labor/birth in multiple positions, but whose care providers want continuous or intermittent electronic fetal monitoring. In my discussions with professionals and parents in a variety of geographic locations, I have heard that many providers may be willing to support pushing in upright positions (passive or active second stage), but few obstetricians will attend an actual birth or “delivery” during an upright position. Importantly, the Italian researchers found that supine delivery positions increase the risk for postpartum urinary incontinence and in particular of stress urinary incontinence, defined as involuntary leakage on effort or exertion or sneezing or coughing. A recent Cochrane review looked at evidence for upright vs. non-upright birthing positions among people with epidurals (Kibuka & Thornton 2017). [5][6], http://www.urology-textbook.com/lithotomy-position.html, "Position in the second stage of labour for women without epidural anaesthesia", "Editorials — July 1, 2000 - American Family Physician", "Improving women's experience during speculum examinations at routine gynaecological visits: randomised clinical trial", Effect Of Lithotomy Position On Spinal Anesthesia, https://en.wikipedia.org/w/index.php?title=Lithotomy_position&oldid=999876581, Creative Commons Attribution-ShareAlike License, This page was last edited on 12 January 2021, at 11:35. Over the past few years, I have traveled across the U.S. speaking and giving presentations at various regional conferences. 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. (2016), Cheyney, M., Bovbjerg, M., Everson, C., et al. How much urine do you usually leak? 2014). 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. In the first study, 199 participants giving birth at a hospital in Spain were randomly assigned to a “traditional model of birth” or an “alternative model of birth”(Walker et al. The lithotomy position involves the positioning of an individual's feet above or at the same level as the hips (often in stirrups), with the perineum positioned at the edge of an examination table. 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. 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. 2014). 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. 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. No other position could be worse than this position for childbirth. More than 60% of people giving birth to a single baby in the U.S. use epidural or spinal analgesia (ACOG, Practice Bulletin No. Evidence and ethical guidelines support this bottom line! This study involved 102 first-time mothers giving birth without epidurals in Turkey (Moraloglu et al. Mothers with epidurals may feel an urge to push, or pressure, or no sensation at all—depending on the individual and the medications used. Mobile monitors are designed to free up mothers, but they are not a perfect replacement for intermittent auscultation. But sometimes we use lithotomy position for normal birth or when stitches are minimal. 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. 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. More than half (57%) of the first-time mothers used epidurals and 26% of the people who had given birth before used epidurals. When does the urine leak? The third trial was a very large randomized, controlled trial on birthing positions conducted by a group in the United Kingdom (U.K.) called the Epidural and Position Trial Collaborative Group (The Epidural and Position Trial Collaborative Group 2017). 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 is the lithotomy position, which has you lying back in the supine position with your thighs flexed and your legs in stirrups. 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. In this position, the lower leg remained extended on the bed and the upper leg rested flexed on the stirrup. (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. Women who gave birth in a 30-degree upright position had more intense uterine contractions than women delivered in the flat recumbent position. Finally, doulas can also nurture a supportive environment for a variety of birthing positions. Laying down reduces the size of your pelvic outlet by up to a whopping … We would also like to thank Cristen Pascucci for her medical editing assistance. New observations and scientific findings, combined with a greater sensitivity to patient needs have raised awareness of the physical and psychological risks the position may pose for prolonged surgical procedures, pelvic examinations, and, most notably, childbirth. It would be interesting to see research comparing active management of the third stage of labor in upright vs. non-upright positions, to see if gentle “tugging” on the cord puts upright mothers at greater risk of postpartum blood loss, due to the effects of gravity. This is especially true with un-medicated or “natural” childbirth, since movement and positioning are proven pain management strategies that, for some, could mean the difference between coping vs. suffering. In the U.S., for example, the overall rate of vacuum/forceps births is only around 3% (Martin et al. This meta-analysis included fewer studies (22 vs. 32) but found similar results as far as a decrease in risk of vacuum or forceps-assisted birth and episiotomy, and an increase in risk of postpartum blood loss. Lithotomy is when we put a woman’s legs up in stirrup; sometimes this can be essential for an assisted birth with forceps or ventouse (suction cup) or if stitching is required. The use of continuous EFM often means that mothers cannot move freely or change positions easily during labor, and that they may lose the option of water immersion in a birth pool for pain management. 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. Also, it may be possible to reduce the rate of tears by using evidence-based pushing methods in the second stage of labor. In summary, evidence from randomized trials suggests that for people without epidurals, upright positions during the second stage of labor provide several benefits: a lower risk of abnormal fetal heart te patterns, less pain, and less use of vacuum/forceps and episiotomy. So far, researchers have not identified clear benefits or risks from birthing in upright vs. non-upright positions. 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. We were surprised to see such high rates of intervention in this study—the rate of vacuum/forceps births was 51%-55% and more than half (55%-59%) of people received an episiotomy. In another study, researchers in Italy explored what effect birthing positions may have on urinary incontinence (Serati et al. : a position of the body for medical examination, pelvic or abdominal surgery, or childbirth in which the individual lies on the back with the hips and knees flexed and the legs spread and raised above the hips often with the use of stirrups … the lithotomy position remains the most commonly used birth position although decades of research demonstrate its severe physiological detriments … Expectant management of the third stage of labor means that the care provider takes a ‘hands-off’ approach, and the mother delivers the placenta spontaneously by pushing or with the help of gravity or, sometimes, with nipple stimulation. We are grateful to Katrine Jonasen and the company GynZone for providing the wonderful birthing position graphics in this article. The researchers determined that the odds of second degree tears were less likely in the people who received woman-centered care compared to those who received standard care. A., Salinas, C., et al. However, not all types of continuous EFM restrict mothers from movement and the option of water immersion. The research group compared upright vs. side-lying birthing positions in first-time mothers with a low-dose epidural. In these studies, people were randomly assigned to either upright or non-upright positions during the second stage of labor. Originally published on October 2, 2012 and updated on February 2, 2018 , All Rights Reserved. The meta-analysis found that in people with epidurals, being upright during the second stage of labor made no difference in the rate of Cesareans, forceps/vacuum-assisted births, or the length of the pushing stage. 2017). It is an attempt to control a woman’s body and decisions and may involve coercion, bullying, threats, and withdrawal of support, as well as other violations of informed consent and physical force. CHILD BIRTH 391 2 (0%), and in lithotomy position is 1%.5 Physiological advantages of squatting versus lithotomy position includes use of gravitational force to assist patient effort to bear down, productive uterine contractions and less aortocaval, intrauterine fetal cord compression They defined non-upright positions as side-lying, semi-sitting, and lithotomy. Upright birthing positions may also shorten the second stage of labor and reduce the use of augmentation with synthetic oxytocin. of the lithotomy position and alternative labor positions were hand selected for further review. This study found no difference in the rate of forceps or vacuum assistance. Don't miss an episode! The second stage of labor begins when the cervix is completely dilated (open) and ends with the birth of the baby. The survey data showed that delivering in upright positions was related to a lower episiotomy rate (30% vs. 41%) but a slightly higher rate of third- and fourth-degree perineal tears compared to delivering in the supine position (1.35% vs. 0%). This article focuses on the evidence for birthing positions in the second stage of labor. In research, the second stage is often divided into a passive phase, an active phase, and the actual birth of the baby—when the baby actually emerges (Roberts 2002). Additional searches were conducted including search terms: “lithotomy,” “lateral,” “all fours,” “hands and knees,” “birth stool,” “sitting,” semi-recumbent,” “semi-seated,” “standing,” OR The lithotomy position was an ergonomic nightmare for both mother and baby. Lithotomy position = lying on your back in a supine position with hips and knees flexed, thighs apart, and legs supported in raised stirrups. 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. 2015). 2017), a higher second degree tear rate in exchange for a lower episiotomy rate may be an acceptable trade-off for some people. 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. In 2012, three U.S. midwifery organizations –American College of Nurse Midwives (ACNM), Midwives Alliance of North America (MANA), and National Association of Certified Professional Midwives (NACPM)—came together to create a consensus statement on supporting healthy, physiologic childbirth (U.S. Midwives, 2012). [4], Patients have reported feeling a loss of control and increased sense of vulnerability when examined in the lithotomy position because they cannot see the area being examined. 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. 2017). Intrapartum interventions during birth are of an intrusive nature to the body of the woman, whether epidural, induction, instrumental use, cutting the perineum, and the lithotomy position. Both the Committee on Ethics of the American College of Obstetricians and Gynecologists (ACOG) and the American Nurses Association (ANA) have issued statements affirming the importance of patient autonomy. Subscribe to our podcast:  iTunes  |  Stitcher  On today's podcast, I interview Fiona and Craig Castleton about their birthing experience during the COVID-19 pandemic. Sitting upright on a birth ball. Studies could be included if people were randomly assigned to upright vs. non-upright positions during the second stage of labor, but not necessarily for the active pushing phase or actual birth. 2014). 2017). Everyone included gave birth vaginally to a single baby without an episiotomy. Mothers were randomly assigned to either give birth on the BirthRite® seat or in any other position. In some un-medicated births, the active pushing phase may be more accurately described as the fetal ejection reflex—where the mother waits for her baby to descend and then her body expels the baby with little or no conscious effort (Newton 1987). When continuous EFM has been compared with intermittent auscultation (listening to the baby’s heart rate at regular intervals with a handheld device), continuous EFM has been linked to lower rates of newborn seizures but has not improved rates of cerebral palsy or infant death. (2016), Simarro, M., Espinosa, J. They also did not find differences in any other health outcomes. . In hospital births—where the majority of people give birth in back-lying positions—we see a similar rate (15%) of people with postpartum blood loss greater than 500 mL when expectant management (defined below) is used in the third stage of labor, and a rate of 5% when active management is used (Begley et al. Fiona and Craig welcomed their first baby in April 2020 — when everything was... Don't miss an episode! Featured Image credit to: Birth Becomes Her. This placed the foot of the upper leg in a higher position than the knee to allow the upper hip to rotate. In their guidelines, they urge midwives to be proactive in demonstrating and encouraging different positions in labor, since women often “choose” to do what is expected of them, and the most common image of the laboring woman is “on the bed.” Since the environment is key to freedom of movement, RCM suggests that there should be a variety of furniture and props available in the room to encourage people to try different positions: bean bags, mattresses, chairs, and birth balls. To assess urinary function, the mothers were asked questions like: How often do you leak? References to the position have been found in some of the oldest known medical documents including versions of the Hippocratic oath (see lithotomy); the position is named after the ancient surgical procedure for removing kidney stones and bladder stones via the perineum. Personal autonomy is defined as the belief that all people have inherent worth and dignity and, thus, the capacity for self-determination (for self-governance and freedom of choice) (ACOG 2015). 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. Use of the lithotomy position has declined in all industrialized nations with one exception - the United States. 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. (2017), Moraloglu, O., Kansu-Celik, H., Tasci, Y., et al. 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. 2017). Finally, research has shown that upright birthing positions may increase maternal satisfaction and lead to more positive birth experiences (Thies-Lagergren 2013). 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. Normal labor and delivery. There was no difference between the groups as far as perineal tears, but the birth seat was linked to fewer episiotomies— 2% of the mothers who gave birth on the birth seat had an episiotomy compared to 14% of those who gave birth in other positions. The position of the pelvis when in dorsal lithotomy places the birth canal at an angle that actually makes the baby travel upward. In contrast, a U.S. home birth midwife told us that the majority of her clients spontaneously choose the hands-and-knees position (Personal communication, K. Brown, Feb. 8, 2018). There is also the lateral position where you give birth while lying on your side. This is in contrast to the classic lithotomy position, in which the woman is flat on … An observational study found lower odds of second-degree tears when upright or side-lying positions were combined with a policy of spontaneous (non-directed) pushing and delivering the baby’s head and shoulders in separate contractions. 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. The Code of Ethics for Nurses recognizes specific patient rights, in particular, the right to self-determination, and holds that nurses have an obligation to preserve, protect, and support the moral and legal right of patients (ANA 2015). 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. Originally published on October 2, 2012 and updated on February 2, 2018 , All Rights Reserved. The active pushing phase is when the baby’s head or bottom is on the pelvic floor and the mother either pushes spontaneously (after feeling an urge to push) or as coached by a care provider. Physiologic refers to a healthy body’s normal function. 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. For the most part, people used their assigned pushing positions. Episiotomy, a surgical cut in the area of skin between the vagina and rectum, is often debated with one side saying th… It’s interesting to note that in research on planned home birth in the U.S.—where upright birthing positions are probably more common—an estimated 16% of people lose greater than 500 mL of blood postpartum (Cheyney et al. Despite the significant body of evidence that there are no benefits to this position and that it only causes complications, frequently leading to interventions that could otherwise have been avoided, the United States persists in the use of this ineffective position for childbirth. Nursing schools should also ensure that their students are trained in upright birthing positions, so that future labor and delivery nurses will be equipped to uphold the ethical and evidence-based standards of their profession. The position is frequently used and has many obvious benefits from the doctor's perspective. It involves lying on your back with your legs flexed 90 degrees at … The Cochrane reviewers are still awaiting further information from the trial authors before they decide to add these studies to their review. 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. However, there is some evidence that giving birth in a supported side-lying position may reduce the length of the active pushing phase, the rate of episiotomy, and the use of forceps, vacuum, or fundal pressure. They recommend that birth attendants need training in supporting births in other positions than supine, since much of the positive effect of upright birthing positions depends on the birth attendant’s experience with the position and willingness to support the mother’s choice of position. In a publication by the World Health Organization (WHO) called “Care in Normal Birth,” the WHO concludes that women in labor should adopt any position they like, while preferably avoiding long periods lying supine (WHO, 1996). Since people weren’t randomized to upright or non-upright positions until the second stage of labor, this research doesn’t apply to positioning with epidurals in the first stage of labor. In 2016, Caroline Malatesta won a landmark court case in Alabama in which she sued her hospital for malpractice and fraud. However, since other researchers have found strong evidence that natural tears heal easier and are less traumatic to tissue than episiotomies (Jiang et al. 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 … Their episiotomy rate is very high; the increase in severe perineal tears with upright delivery positions may not hold in settings with lower rates of episiotomy. (2017), Serati, M., Di Dedda, M. C., Bogani, G., et al. 2017). Nearly half (45%) of the participants used epidurals for pain relief during labor. We have all seen the portrayals of supine positions in movies and television. But as a birthing position, the lithotomy position is even more … The lithotomy position is a common position for surgical procedures and medical examinations involving the pelvis and lower abdomen, as well as a common position for childbirth in Western nations. It may be helpful to go over some of the terms that are used to describe non-upright birthing positions. Upright positioning also helps the uterus contract more strongly and efficiently and helps the baby get in a better position to pass through the pelvis. It is thought that most people giving birth are encouraged to push in a back-lying or semi-sitting position—one that puts weight on the tailbone—because it is more convenient for the care provider during the birth of the baby. A “dorsal recumbent” position is basically the same, except that the patient’s legs are not in stirrups but are flexed and on the bed. 2016). After she answers, the doula could tell the mother out loud in front of hospital staff, “You and your baby are safe and we are all on a team to support you and to honor your wishes.”, We would like to extend our gratitude to our expert reviewers for their valuable feedback and critique of this article before publication: Li Thies-Lagergren, midwife, PhD, Adjunct Lecturer, Lund University; Shannon J. Voogt, MD, Board-Certified in Family Medicine; Hannah Ellis, HCHD, doula at Happy Helper Doula Services in Alabama; and Jesanna Cooper, MD, OBGYN at Simon-Williamson Clinic in Alabama. However, in low-income countries where mothers may be poorly nourished and anemic, this amount of blood loss can be harmful. The group assigned to delayed pushing was instructed to change position every 20-30 minutes after reaching full dilation and begin active pushing efforts only after feeling a strong urge to push. 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. 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. 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. (2017), Martin, J. They found that the lowest rates of severe perineal tears occurred among people who delivered in a standing position and the highest rates of severe tears occurred among those who delivered in the lithotomy position. In the U.S., the American College of Obstetricians and Gynecologists (ACOG) recommends that, for most people giving birth, “no one position needs to be mandated nor proscribed” (2017). The desire for some medical staff to have the delivery happen in a “controlled” manner (non-upright position) is so strong that some women in the U.S. have shared stories of either being coerced or forcibly put into non-upright positions during childbirth. (2017). The Royal College of Midwives (RCM) in the U.K. recommends the use of active and upright positions to assist with labor and delivery. 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