Perceptions of women and partners on labor and birth positions: A meta-synthesis.

BACKGROUND: The risks and benefits of different birthing positions are commonly studied, but both paternal and maternal preferences and experiences of different birth positions are not examined. Therefore, this systematic review aims to explore the perceptions of women and their partners on birthing positions during the first and second stage of labor, so that maternity health care practitioners can provide better quality patient-centered care. METHODS: Six databases were searched from each database's inception through November 2020. Qualitative or mixed-methods studies exploring perceptions of women and/or their partners on birthing positions were included in the review. Key information and findings of the studies were extracted; qualitative data were meta-summarized, then meta-synthesized using thematic analysis. RESULTS: Seven studies were included, and four themes emerged: (a) Influences on choice and preference; (b) mixed experiences from "pain" to "more in control"; (c) impact on postpartum health; and (d) ways to empower couples in their choice. CONCLUSIONS: Women's preferences for birthing positions were influenced by a myriad of personal and socio-cultural beliefs and traditions. Findings suggest a need for health care practitioners to build better rapport and provide more culturally relevant informational support to both women and their birthing partners, so they are better able to make informed decisions on their preferred birthing position.

Why do women assume a supine position when giving birth? The perceptions and experiences of postnatal mothers and nurse-midwives in Tanzania.

BACKGROUND: Before the advent of Western medicine in Tanzania, women gave birth in an upright position either by sitting, squatting or kneeling. Birthing women would hold ropes or trees as a way of gaining strength and stability in order to push the baby with sufficient force. Despite the evidence supporting the upright position as beneficial to the woman and her unborn child, healthcare facilities consistently promote the use of the supine position. The purpose of this study was to explore the perceptions and experiences of mothers and nurse-midwives regarding the use of the supine position during labour and delivery. METHODS: We used a descriptive qualitative design. We conducted seven semi-structured interviews with nurse-midwives and two focus group discussions with postnatal mothers who were purposively recruited for the study. Qualitative content analysis guided the analysis. RESULTS: Four themes emerged from mothers' and midwives' description of their experiences and perceptions of using supine position during childbirth. These were: women adopted the supine position as instructed by midwives; women experience of using alternative birthing positions; midwives commonly decide birthing positions for labouring women and supine position is the best-known birthing position. CONCLUSION: Women use the supine position during childbirth because they are instructed to do so by the nurse-midwives. Nurse-midwives believe that the supine position is the universally known and practised birthing position, and prefer it because it provides flexibility for them to continuously monitor the progress of labour and assist delivery most efficiently. Mothers in this study had no other choice than to labour and deliver their babies in the supine position as instructed because they trusted midwives as skilled professionals who knew what was best given the condition of the mother and her baby.

Maternal position during the second stage of labor and maternal-neonatal outcomes in nulliparous women: a retrospective cohort study.

BACKGROUND: The existing evidence is insufficient to draw conclusions about the association between maternal position in labor and obstetrical outcomes. OBJECTIVE: This study aimed to evaluate the effects of different maternal positions during the second stage of labor among women with and those without epidural analgesia on important obstetrical outcomes including perineal damage. STUDY DESIGN: In this retrospective cohort study, we collected data of women who delivered vaginally over a 2-year period. The associations between maternal and gestational characteristics and several obstetrical outcomes were analyzed. We considered perineal damage as the primary outcome. Secondary outcomes were the incidence of operative vaginal births, duration of fetal descent, intrapartum blood loss, and 1-minute and 5-minutes Apgar scores. RESULTS: A total of 2240 nulliparous, at-term pregnancies were included. Of those, 76.9% gave birth in a supine position and 23.1% gave birth in alternative positions. The results showed that regardless of the use of epidural analgesia, nonsupine positions in the second stage of labor are associated with a significant reduction in the risk of both episiotomy and perineal damage to any degree (P<.0001) and to a reduction in the duration of fetal descent (Spearman rho, 9.17; confidence interval, 3.07-15.32; P=.003). No statistically significant differences were found in the 1-minute and 5-minutes Apgar score between the 2 groups. CONCLUSION: Our results show that nonsupine positions in the second stage of labor and at the time of birth are associated with a significant increase in having an intact perineum and a reduction in any perineal trauma and in the need for an episiotomy regardless of the use of epidural analgesia.

Exploring the perspective of nursing staff or caregivers on birthing positions in Central India.

INTRODUCTION: Maternal birthing positions refer to the various physical postures a pregnant mother may assume at the time of delivery. The World Health Organisation recommends that woman should be given an opportunity to make a choice on the type of position to use during labour. Alternative birth positions are associated with lower incidence rates of performing episiotomy, less perineal tears and less use of instrumental deliveries. Nurses' perspective on women's positions has rarely been explored in India. Present study aims at assessing the knowledge regarding alternative birth positions among nursing officers. MATERIALS AND METHODS: This cross-sectional observational study was conducted on 52 nursing officers who were posted in the labour room. A pretested questionnaire was administered to them. Data analysis was done using SPSS software version 22. RESULTS: Majority (82.7%) of nursing officers felt that there is a need of giving a choice to the woman regarding alternate birth position. 76.9% of them were aware of position other than lithotomy. Around 48.1% would recommend squatting position to a woman in labour. Ease and convenience in conducting the delivery was the foremost reason chosen in advocating a birth position. Whereas overcrowding in the labour room, ignorance about alternate positions and difficulty in converting to instrumental delivery were cited as reasons of not recommending these positions. CONCLUSION: Educating nursing officers about emerging evidence regarding birthing positions will enable them to give accurate information to women.

The effects of squatting while pregnant on pelvic dimensions: A computational simulation to understand childbirth.

Biomechanical complications of childbirth, such as obstructed labor, are a major cause of maternal and newborn morbidity and mortality. The impact of birthing position and mobility on pelvic alignment during labor has not been adequately explored. Our objective was to use a previously developed computational model of the female pelvis to determine the effects of maternal positioning and pregnancy on pelvic alignment. We hypothesized that loading conditions during squatting and increased ligament laxity during pregnancy would expand the pelvis. We simulated dynamic joint moments experienced during a squat movement under pregnant and non-pregnant conditions while tracking relevant anatomical landmarks on the innominate bones, sacrum, and coccyx; anteroposterior and transverse diameters, pubic symphysis width and angle, pelvic areas at the inlet, mid-plane, and outlet, were calculated. Pregnant simulation conditions resulted in greater increases in most pelvic measurements - and predominantly at the outlet - than for the non-pregnant simulation. Pelvic outlet diameters in anterior-posterior and transverse directions in the final squat posture increased by 6.1 mm and 11.0 mm, respectively, for the pregnant simulation compared with only 4.1 mm and 2.6 mm for the non-pregnant; these differences were considered to be clinically meaningful. Peak increases in diameter were demonstrated during the dynamic portion of the movement, rather than the final resting position. Outcomes from our computational simulation suggest that maternal joint loading in an upright birthing position, such as squatting, could open the outlet of the birth canal and dynamic activities may generate greater pelvic mobility than the comparable static posture.

Birth outcomes and usability of Relaxbirth® for upright positioning intrapartum: A retrospective case control study.

INTRODUCTION: The aim of this study was to pilot Relaxbirth® (Relaxbirth®, Ltd., Helsinki, Finland), an investigational device designed to facilitate upright positioning intrapartum. The objective was to 1) compare birth outcomes with and without the use of Relaxbirth®, and 2) assess device usability. METHODS AND MATERIALS: Study design: prospective product use and retrospective case control study at one perinatal center in Ohio. INCLUSION CRITERIA: ≥18 years old, <300 lbs. women with a low-risk, term gestation of a singleton, vertex fetus, and vaginal birth between January 2013 to June 2016. Participants who used the Relaxbirth® device intrapartum (RB group) were retrospectively case-matched to controls (CON group) according to age, race, insurance, gravida/parity, gestational age and labor type. Birth outcomes (primary outcome) were compared between groups. Providers and women who used Relaxbirth® assessed usability of the device with the Modified System Usability Scale Tool (secondary outcome). RESULTS: Of the n = 60 included in the final analysis, RB women (n = 30) pushed for a shorter average duration compared to CON women (n = 30) [34 min (±48) versus 60 min (±63), p = 0.023]. RB women did not experience more adverse birth outcomes including: longer second stage duration, operative vaginal delivery, malpresentation, perineal laceration/episiotomy, higher blood loss, or low Apgars. Usability survey results were favorable (Total Average Scores: providers 74.1; RB 83.6). CONCLUSION: Clinical experience with the Relaxbirth® device was positive at this pilot site. The device was associated with favorable birth outcomes and usability, suggesting potential as a safe and novel adjunct to promote intrapartum choices, upright positioning and maternal satisfaction.

Development and validation of a computational model for understanding the effects of an upright birthing position on the female pelvis.

Upright, natural birthing positions, such as squatting, are associated with several clinical benefits, yet recumbent positions are still most common during delivery in most health centres. The biomechanics of birth positioning are not yet fully understood; therefore, our objectives were to develop and validate a computational model that could determine pelvic kinematics under loading conditions resulting from an upright birthing position. A three-dimensional model of the pelvic region was created from MRI scans of a non-pregnant subject. Bones were designated rigid segments with sacroiliac and pubic symphysis joint motion constrained only by contact surfaces and ligaments modeled as non-linear spring elements. Actuating torques at the lumbosacral and hip joints were defined based on motion analyses of squatting. The model was validated by comparing simulation results with data from the literature and in vivo MRI data from three subjects in a kneel-squat position. Good agreement was found between clinical pelvimetry measurements from the squat simulation and MRI data. Differences between simulation predictions were within one standard deviation of mean MRI kneel-squat results for all clinical measurements except one: the predicted increase in bispinous diameter was approximately 1.5 standard deviations less than that of the mean MRI results and still well within physiologic limits according to data in the literature. This model can, therefore, be used to provide further insight into the biomechanics of certain upright birthing positions, such as squatting.

Associations between improved care during the second stage of labour and maternal and neonatal health outcomes in a rural hospital in Bangladesh.

OBJECTIVE: To evaluate the efficacy of care in the second stage of labour with a package of interventions that included (1) maintaining the birthing position according to the woman's choice, (2) adopting a spontaneous pushing technique and (3) using a support person, to reduce maternal and neonatal complications. DESIGN: Used the data collected from two cohorts- before and after an initiative to improve care during the second stage of labour. SETTING: A rural hospital in Bangladesh where 90-100 deliveries are conducted monthly and cesarean section provision is not available. PARTICIPANTS: One thousand and fifty-one singleton pregnancies who attended the hospital for giving birth in the first stage of labour before full dilatation of the cervix and with cephalic presentation. MEASUREMENTS AND FINDINGS: Data were collected through a structured checklist and questionnaire completed by research assistants; and also retrieved from hospital case record files, and the ongoing demographic surveillance system database. Coverage of adopting the upright or lateral position in the post-intervention period increased to 76% from about 1% in the pre-intervention period, and the spontaneous pushing technique increased to 97% from 77% in the same period. The odds of combined maternal and neonatal complications decreased by 46% between pre- and post-intervention periods (odds ratio: 0.54, 95% confidence interval: 0.43-0.70). Frequency of episiotomy (from 43% to 29%, P < 0.001), cervical tear (3.8% to 1.5%, P = 0.02), and median blood loss (200 ml to 150 ml; P < 0.001) were reduced significantly in the same period. No significant associations were observed in perineal tear or birth asphyxia occurrences. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The study suggests that there is a beneficial effect of care during the second stage of labour with a package of interventions in reducing maternal and neonatal complications, particularly in reducing the frequency of episiotomy, cervical tear, and blood loss during delivery. The preferred choice of posture during giving birth, adopting a spontaneous pushing technique and continuous presence of support person during the second stage of labour may be encouraged for better health outcomes.

Mothers and midwives perceptions of birthing position and perineal trauma: An exploratory study.

BACKGROUND: Studies have associated lithotomy position during childbirth with negative consequences and increased risk of perineal injuries. AIMS: To identify prevalence rates of different birthing position and episiotomy and to explore the differences in perspectives of mothers and midwives about birthing positions and perineal trauma. METHODS: A survey involving 110 mothers and 110 midwives at two hospitals. Participants were mothers who had a vaginal birth/perineal injury and midwives who attended births that resulted in perineal injuries. Perceptions of mothers and midwives were analysed. Pearson's chi-square test was used to measure association between birthing positions and perineal trauma. FINDINGS: Mothers, n=94 (85%) and midwives, n=108 (98%) reported high rates of lithotomy position for birth. N=63 (57%) of mothers perceived lithotomy position as not being helpful for birth. In contrast, a similar number of midwives perceived lithotomy position as helpful, n=65 (59%). However, a high majority of mothers, n=106 (96%) and midwives, n=97 (88%) reported they would be willing to use alternative positions. Majority of mothers had an episiotomy, n=80 (73%) and n=76 (69%) reported they did not give their consent. N=59 (53%) reported they were not given local anaesthesia for an episiotomy. n=30 (27%) of midwives confirmed they performed an episiotomy without local anaesthesia. CONCLUSION: Care is not based on current evidence and embedded practices, i.e. birthing in lithotomy position and routine episiotomies are commonly used. However, this survey did find a willingness to change, adapt practice and consider different birthing positions and this may lead to fewer episiotomies being performed.

The role of maternity care providers in promoting shared decision making regarding birthing positions during the second stage of labor.

INTRODUCTION: Through the use of a variety of birthing positions during the second stage of labor, a woman can increase progress, improve outcomes, and have a positive birth experience. The role that a maternity care provider has in determining which position a woman uses during the second stage of labor has not been thoroughly explored. The purpose of this qualitative investigation was to explore how maternity care providers communicate with women during the second stage of labor regarding birthing position. METHODS: A literature-informed framework was developed to conduct a process of deductive content analysis of communication patterns between nulliparous women and their maternity care providers during the second stage of labor. Literature discussing shared decision making, control, and predictors of positive birth experiences were reviewed to develop a coding framework. The framework included the following categories: listening to women, encouragement, information, offering choices, and style of support. Forty-one audiotapes of women and their maternity care providers during the second stage of labor were transcribed verbatim and analyzed. RESULTS: Themes identified in the transcripts included all those in the analytic framework, plus 2 added categories of communication: empathy and interaction. Maternity care providers in this study enabled women to select various birthing positions using a dynamic process that moved between open, informative approaches and more closed, directive approaches, depending on the woman's needs and clinical condition. As clinical conditions unfolded, women became more actively involved in shared decision making regarding birthing positions, and maternity care providers found the right balance between being responsive to the woman's questions or directives. DISCUSSION: Enabling shared decision making during birth is not a linear process using a single approach; it is dynamic process that requires a variety of approaches. Maternity care providers can support a woman to use different birthing positions during the second stage of labor by employing a flexible style that incorporates clinical assessment and the woman's responses.

[Analysis of potential for research on giving birth in an upright position in German hospitals]. / Potenzialanalyse zur aufrechten Gebärhaltung bei physiologischen Geburten in deutschen Kreißsälen.

HEALTH PROBLEM: In German hospitals, three quarters of all low-risk pregnant women give birth in the supine position, despite the fact that German, British and WHO guidelines do not recommend a supine birthing position which is associated with a higher risk to the health of both mother and fetus. CORPUS OF EVIDENCE: Based on 22 RCTs with 7,280 participants, a systematic Cochrane review (Gupta et al., 2012) revealed that an upright position - compared with a supine or lithotomy position - (1) has a positive impact on fetal heart rate patterns, (2) reduces the requirement for analgesic or anaesthetic medications in the second stage of labour, and (3) results in fewer episiotomies and (4) fewer instrumental deliveries. There is a lack of evidence regarding perceived maternal autonomy, self-efficacy and anxiety when giving birth. Furthermore, evidence on long-term effects is absent. Some studies indicate that the choice of an upright birthing position might be boosted by a supporting physical and social environment and by specially trained midwives. IMPLICATION FOR RESEARCH: There is a need for a feasibility study and a subsequent cluster RCT in the German healthcare context in order to investigate the effects of the upright posture for birthing on perceived maternal autonomy, self-efficacy and anxiety, on the reduction of perinatal complications and on long-term complaints. The complex experimental intervention consists of (1) evidence-based and user-friendly information for women and their partners, (2) facilitating the choice for an upright labour position by special training for midwives and (3) providing a supportive physical and social environment. Within the first study phase, the exploration of feasibility in terms of access to the target group and acceptance of the intervention by pregnant women, their partners and midwives is recommended. Thereby, the implementation of guidelines for upright labour and birth, the documentation and collection of outcome and cost data could be evaluated. Non-German instruments for measuring benefits, harms and long-term effects could be adapted to and validated for the German context.

Influence on birthing positions affects women's sense of control in second stage of labour.

OBJECTIVE: to explore whether choices in birthing positions contributes to women's sense of control during birth. DESIGN: survey using a self-report questionnaire. Multiple regression analyses were used to investigate which factors associated with choices in birthing positions affected women's sense of control. SETTING: midwifery practices in the Netherlands. PARTICIPANTS: 1030 women with a physiological pregnancy and birth from 54 midwifery practices. FINDINGS: in the total group of women (n=1030) significant predictors for sense of control were: influence on birthing positions (self or self together with others), attendance of antenatal classes, feelings towards birth in pregnancy and pain in second stage of labour. For women who preferred other than supine birthing positions (n=204) significant predictors were: influence on birthing positions (self or self together with others), feelings towards birth in pregnancy, pain in second stage of labour and having a home birth. For these women, influence on birthing positions in combination with others had a greater effect on their sense of control than having an influence on their birthing positions just by themselves. KEY CONCLUSIONS: women felt more in control during birth if they experienced an influence on birthing positions. For women preferring other than supine positions, home birth and shared decision-making had added value. IMPLICATIONS FOR PRACTICE: midwives can play an important role in supporting women in their use of different birthing positions and help them find the positions they feel most comfortable in. Thus, contributing to women's positive experience of birth.