Some things about childbirth are easy to plan: where to deliver, at a hospital or at home; who to have by our side, an obstetrician or a midwife; what to call the new baby once he or she is born. However, there are plenty of complications that we can’t predict, such as perineal tears, pelvic organ prolapse, onset of urinary and/or fecal incontinence, delivering with forceps or vacuum assistance, and emergency c-section, to name a few – and it’s these unpredictabilities that make us anxious. I am often asked by patients and doulas if one birthing position is better than another to help reduce the chances of these unpleasant complications. It’s a good question!
Most women in the USA who give birth in hospitals do so lying on their backs, in what is called the “dorsal position.” Why is this? Are there alternative positions that could be somehow better, either for mother or child? I found a Cochrane Review, from 2012, to help us find the answer.
A quick aside: a Cochrane Review is the highest standard in evidence-based research within the medical community.1 It is a systematic review on the primary research given for a specific topic. A team of authors comes together to answer a specific question: in our case, what is the best position to give birth in? The authors comb through published journal articles, including international ones, excluding any articles that are biased, and come up with a conclusion. This conclusion helps practitioners provide consistent treatment. Cochrane Reviews are even regularly updated in order to maintain this standard.
So, what does the Cochrane Review have to say about birthing positions? In Position in the second stage of labour for women without epidural anaesthesia (Review), authors Gupta, Hofmeyr, and Shehmar assessed 22 studies involving a total of 7,280 women.2 They initially compared any upright position (squatting, kneeling, sitting, using a birthing stool or a chair) to “dorsal” position: lying on your back (“supine”), being in a semi-reclined position, or in “lithotomy” position (which means lying on your back, your legs up and open, and your feet in stirrups, like in the movies). They also compared specific upright positions (birthing or squatting stool, birth cushion, and birthing chair) to supine position.
The authors looked at how the position used during birth affected the chances of various complications. When comparing any upright position to supine position, the authors found that, women giving birth in an upright position had about a 20% lower chance of needing an assisted delivery, a 20% lower risk of episiotomy, and about 50% lower probability of their fetus having an abnormal heart rate.
They also found that while some studies seemed to show that giving birth in an upright position could lead to higher risk of blood loss and 2nd degree perineal tearing, they did not find these studies convincing.
The chances of needing a C-section was about the same between the two positions. They also found there was no significant reduction in the duration of the second stage of labor when the upright position was used. Being upright doesn’t necessarily mean you’ll deliver quickly!
At least, not very quickly: many of the studies’ conclusions are in terms of the differences between positions being “not significant,” which means that the data they had wasn’t good enough to detect small effects. If the birthing position was going to make a big difference in the chances of a complication, perhaps they would have seen it. Weighing all of this up, the review’s authors concluded that upright positioning seems to lead to no harmful effects to either the mother or the baby.
So, why is a dorsal position so often recommended? The Cochrane Reviewers put it this way: “It is claimed that the dorsal position enables the midwife/obstetrician to monitor the fetus better and thus to ensure a safe birth, but it may be more convenient and give better control for the caregiver.” Lying on your back makes it easier for the medical staff to make sure everything is alright with your baby.
The research featured in this review came from a study where the mother had not had an epidural painkiller. I’m not sure what impact this will have on the pros and cons of upright positioning, but there’s a 2013 follow-up Cochrane Review on this very topic. I’ll make that the subject of a future post!
Please feel free to share your comments or questions in the reply box below. Also, please feel free to check out our prior blogs on Labor and Delivery, Coached vs. Maternal Pushing, and Understanding Breech Babies.
- The Cochrane Collaboration. Cochrane Community (beta). http://community.cochrane.org/cochrane-reviews 2015.
- Gupta, J.K., et al. Position in the second stage of labour for women without epidural anaesthesia (Review). The Cochrane Library 2012; Issue 5.
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.
Comments
I like this article.Thank you, I would like be kept up to date on this information. As a Doula some of my clients have been put into the on their back position when they didn’t want to. I have often thought it was for the viewing purposes of the medical practitioner.