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.