Running head: NON-SUPINE BIRTHING POSITIONS
Maternal Non-Supine Birthing Positions
Logan Dean, Amy Ellison, Amanda Farr, Meagan Holt, Kate Onion, Abby Rose
Auburn University School of Nursing
1
NON-SUPINE BIRTHING POSITIONS
2
Maternal Non-Supine Birthing Positions
Pico Question and Significance
A PICO question is an integral piece to evidence based practice research. Formation of
this clearly defined clinical question leads to organization of related findings in health literature.
The clear direction for the evidence based practice project leads to a focused search for research.
In this specific investigation, the question of “in women in labor, do non-supine birthing
positions result in improved progression of labor and delivery outcomes as compared to supine
positions” is addressed as the PICO question.
The PICO format is composed of the four components: population, intervention,
comparison and outcome. The patient population of interest is women in labor who have a
vaginal delivery. The population is comprised of women who gave birth in hospitals, as well as
in non-traditional birthing centers. Multiple birthing positions were implemented in both
settings. Different types of health care professionals, including physicians and midwives, carried
out the birthing process. The intervention of non-supine birthing positions was investigated to
test the clinical question. Women in labor assumed various non-traditional positions such as
lateral, squatting, or sitting on a birthing seat. In contrast to these non-traditional positions, a
traditional position, like lithotomy, is defined as the comparison of interest. The outcome
measured is the progression of labor and delivery outcomes. These outcomes include the length
of labor, comfort of the mother, degree and incidence of perineal trauma, and prevalence of
surgically assisted vaginal deliveries. Different birthing positions led to varying outcomes.
The PICO clinical question is significant in the improvement of nursing practice. Nurses
in labor and delivery settings will interact with women of childbearing age who have a vaginal
delivery. Interactions with this population begin upon admission to the labor and delivery unit
NON-SUPINE BIRTHING POSITIONS
3
and continue until discharge instructions post-delivery. Findings stemming from the PICO
question will further enhance nursing practice through the latest evidence regarding birthing
positions during vaginal labor and delivery. The evidence enhances the ability of nurses to
communicate and advocate for the mothers’ wishes regarding birthing positioning.
Health care professionals are responsible for carrying out health interventions. In this
literature review, health care professionals, including nurses, certified nurse midwives, and
physicians, assist mothers into non-supine birthing positions. In particular, nurses may be a
mother’s only support system during the labor and delivery process. It is a nurse’s responsibility
to assist the mother in assuming different positions throughout delivery. It is integral for nurses
to make mothers’ wishes and desires relating to the personal birthing plan a reality. In contrast
to the previous knowledge of the traditional supine birthing position, knowledge of nontraditional positions can further improve nursing practice as healthcare professionals care for
laboring women.
Improved outcomes related to non-supine birthing positions result in better health for the
mother. Enhanced maternal health after a vaginal delivery encompasses decreased perineal
trauma, increased comfort level, and an overall well being of the mother. Better outcomes may
lead to improved patient-nurse relationships, as well as giving the nurse a sense of
accomplishment. Traumatic outcomes, such as lacerations and episiotomies, can lead to
infection and other postpartum complications. Although it is impossible for nurses to decrease
the incidence of perineal lacerations, nurses do have a role in decreasing the risk for lacerations.
Research pertaining to non-supine birthing positions provides nurses with the knowledge needed
to assist women in planning and executing a birthing plan and improving delivery outcomes.
NON-SUPINE BIRTHING POSITIONS
The purpose of this paper is to explore the effects of non-supine birthing positions on labor and
delivery outcomes and bring about awareness of non-traditional birthing positions.
Search Strategies
As the group gathered research regarding non-supine birthing positions, the following
Auburn University online library databases were included in the searching process: PubMed
Clinical Queries, CINAHL, PsychINFO, and Cochrane Library. In narrowing the research
process, publications selected fell within the range of the last ten years (2004-2014), were
evidence-based and peer-reviewed, and only available in the English language. Specific key
words included in the research were, “non-supine,” “birthing positions,” “lateral,” “vaginal
delivery,” “non-traditional,” “birth or birthing,” “positions,” “labor,” “maternal,” and “NOT
supine.” When limiting the research process, articles that were selected consisted of systematic
research, meta-analysis, and primary research. Two of the four articles referenced in the PICO
Assignment above are comprised as systematic research review articles from the review
database, Cochrane Library. After visiting the National Guideline Clearinghouse (AHRQ)
database, there were not any clinical practice guidelines available for the group’s topic, “nonsupine birthing positions.”
Synthesis of Findings
Literature regarding non-supine birthing positions was reviewed to compare the
differences in delivery outcomes among women using various birthing positions. Multiple
studies evaluated the traditional supine position in comparison to non-supine positions such as
squatting, lateral lying, and use of a birthing stool. Differences in positioning were documented
in the first and second stages of labor, each providing positive and negative effects on the
laboring process. Different settings for the labor and delivery process were evaluated to
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NON-SUPINE BIRTHING POSITIONS
5
determine the prevalence of using non-supine birthing positions in both the traditional hospital
setting and birthing care centers.
A systematic review performed by Lawrence, Lewis, Hofmeyr, and Styles (2013)
evaluated ambulation and non-supine positions during the first stage of labor. As a result of
upright positions and ambulation, the length of the first stage of labor is shortened and the
women are less likely to have an epidural or a Cesarean section. It was also found that these
interventions do not have any negative effects on the mother or baby (Lawrence et al., 2013).
Findings from Miquelutti, Cecatti, and Makuch (2013) support that the majority of women
consider standing up, walking around, and sitting on an exercise ball as the most comfortable
positions during the first stage of labor. These women consider horizontal positions less
comfortable as these positions hamper the mothers’ mobility and increase the sensation of pain
during contractions. Women who attended a Birthing Preparation Program were more likely to
feel at ease when assuming these upright positions (Miquelutti et al., 2013).
The second stage of labor begins once the mother reaches full cervical dilation and
effacement, and signifies that the patient can begin actively pushing (Lowdermilk, Perry,
Cashion, & Alden, 2012). Traditionally, health care providers encourage the mother to assume
the supine lithotomy position, with feet in stirrups during the second stage of labor (Gupta,
Hofmeyr, & Shehmer, 2012). To determine the effects of traditional positioning, researchers
studied womens’ labor and delivery experiences and outcomes while clients assume the supine
position. Women delivering in the supine lithotomy position show significantly more first and
second degree lacerations compared to those delivering in the lateral position (Meyvis et al.,
2011). The incidence of episiotomies, as well as lacerations requiring sutures, increases when
the mother is in a supine position. There is no conclusive evidence about an increase or decrease
NON-SUPINE BIRTHING POSITIONS
in estimated blood loss during the postpartum period for a mother giving birth in a supine
position (de Jonge, Teunissen, & Lagro-Janssen, 2004).
Fewer episiotomies and a decrease in perineal trauma are noted with the lateral birthing
position. Delivery in the lateral position, also known as Sims position, is a “hands-off”
technique, avoiding unnecessary manipulations while the mother is on her side (Meyvis et al.,
2011). Used in conjunction with the lateral birthing position, warm compresses and manual
support techniques are shown to decrease perineal trauma (Hastings-Tolsma, Vincent, Emeis, &
Francisco, 2007). The use of the upright or lateral position decreases duration of the second
stage of labor, as well as decreasing pain, incidence of assisted delivery with forceps, abnormal
fetal heart rate patterns, and episiotomies (de Jonge et al., 2004).
The birthing stool promotes an upright position that provides comfort for the mother and
allows gravity to assist during the delivery. The birth seat does not reduce the number of
instrumental vaginal births. Delivering on the birth seat shows no adverse consequences on
perineal outcomes and may even protect against episiotomies (Thies-Lagergren, Kvist,
Christensson, & Hildingsson, 2011). On a pain scale of 1 to 10, women using the birthing stool
ranked pain at a 6.9 whereas women in supine position ranked pain at a 7.6 (De Jonge et al.,
2004).
De Jonge et al. (2004) found that the lowest rate of postpartum hemorrhage occurred
when the mother is in a squatting position with no oxytocin or epidural. However, a study by
Hastings-Tolsma et al. (2007) determined an increase in perineal lacerations in primipara
mothers who assumed the squatting position.
Birthing centers provide increased opportunity for women to assume non-traditional
birthing positions as compared to a hospital. Midwives in the birthing centers encourage the
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NON-SUPINE BIRTHING POSITIONS
7
women to assume the positions that provide the most comfort. Physicians encourage the
lithotomy position due to convenience for health care providers, as well as lack of knowledge
regarding other non-traditional positions (Waldenstrom & Nisson, 1997). Midwives strive to
explore the women’s knowledge of different birthing positions and the patient’s desires during
the birthing process. Midwives also help the women assume the desired position and provide
personal support (de Jonge, Teunissen, van Diem, Scheepers, & Largo-Janssen, 2008). It is
evidenced that there is no discrepancy in quality of care between birthing centers and hospitals
(Waldenstrom & Nilsson, 1997).
This review of literature determines that the use of alternate positions in both the first and
second stages of labor lead to increased progression of labor, as wells as improved delivery
outcomes. The use of the supine position is not necessarily the best intervention during labor
and delivery for every patient. Better outcomes are found when the mother assumes a lateral or
squatting position or uses a birthing stool, especially when these interventions take place in a
birthing center with midwives. These outcomes include fewer lacerations and episiotomies,
decreased pain, decreased duration of labor, and fewer instrument-assisted births.
Appraisal of Evidence
The levels of evidence vary among all of the supporting articles. Half are level II, giving
those articles much credibility and strength of evidence. The other three articles have lower
levels of evidence, ranging from level IV to level VI. The quality of evidence for these articles is
slightly lower than that of the level II articles and displays a less thorough design. Of the articles
gathered, all of them support the recommendation of utilizing non-supine birthing positions. It is
consistently found that the benefits of non-supine positioning greatly outweigh the risks. These
articles display the many benefits to applying non-supine positioning in current evidence-based
NON-SUPINE BIRTHING POSITIONS
8
practice. The use of non-supine birthing positions during labor is associated with a decrease in
perineal damage, including episiotomies and vaginal lacerations, as well as an increase in
maternal comfort and control. Findings implied that when given an option to assume alternate
positions, new mothers felt more confident while laboring. However, as with any medical
recommendation, there are risks involved. It was noted in one of the articles that utilizing a nonsupine birthing position could increase estimated blood loss up to 1000mL. It was also
mentioned in a different study that with certain non-supine positions (i.e. squatting), a greater
risk of perineal laceration is present in comparison with other non-supine positions. After
researching various databases, no recent cost studies were found on the recommended
intervention. However, it could be easily inferred that changing birthing positions would not
cause a dramatic increase in costs to hospitals or patients.
Recommendations

Laboring mothers should give birth in the lateral position to decrease the risk for perineal
trauma.
o Grade: B
o Meyvis, I., van Rompaey, B., Goormans, K., Truijen, S., Lambers, S., Mestdagh,
E., & Wilhelm, M. (2012). Maternal positions and other variables: Effects on
perineal outcomes in 557 births. Birth, 39(2), 115-120. doi:10.1111/j.1523536X.2012.00529.x
o Hastings-Tolsma, M., Vincent, D., Emeis, C., & Francisco, T. (2007). Getting
through birth in one piece: Protecting the perineum. The American Journal of
Maternal/Child Nursing, 32(3), 158-164.
doi:10.1097/01.NMC.0000269565.20111.92
NON-SUPINE BIRTHING POSITIONS

9
Nurses should encourage the use of birthing stools to promote comfort among laboring
women.
o Grade: C
o de Jonge, A., Teunissen, T. A., & Lagro-Janssen, A. L. (2004). Supine positions
compared to other positions during the second stage of labor: A meta-analytic
review. Journal of Psychomatic Obstetrics & Gynecology, 24, 35-45. doi:
10.1080/01674820410001737423

Expectant mothers should participate in a preparation course to increase knowledge on
birthing positions, promoting comfort in labor.
o Grade: C
o Miquelutti, M. A., Cecatti, J. G., & Makuch, M. Y. (2013). Antenatal education
and the birthing experience of Brazilian women: A qualitative study. BioMed
Central Pregnancy and Childbirth, 13(171), 1-9. doi: 10.1186/1471-2393-13-171

Ambulation and non-supine positioning should be implemented during the first stage of
labor.
o Grade: A
o Miquelutti, M. A., Cecatti, J. G., & Makuch, M. Y. (2013). Antenatal education
and the birthing experience of Brazilian women: A qualitative study. BioMed
Central Pregnancy and Childbirth, 13(171) 1-9. doi: 10.1186/1471-2393-13-171
o Lawrence, A., Lewis, L., Hofmeyr, G. J., & Styles, C. (2013). Maternal positions
and mobility during first stage of labour (Review). Cochrane Database of
Systematic Review, 10, Art no. CD003934.
doi:10.1002/14651858.CD003934.pub3
NON-SUPINE BIRTHING POSITIONS

10
To women wishing to explore alternative birthing positions, a midwife should be utilized.
o Grade: C
o de Jonge, A., Teunissen, D. A., van Diem, M. T., Scheepers, P. L., & LagroJanssen, A. L. (2008). Women’s positions during the second stage of labour:
Views of primary care midwives. Journal of Advanced Nursing, 63(4), 347-356.
doi: 10.1111/j.1365-2648.2008.04703.x

To women wishing to explore alternative birthing positions, a birthing center should be
considered.
o Grade: C
o Waldenstrom, L. & Nilsson, C. (1997). A randomized controlled study of birth
center care versus standard maternity care: Effects on women’s health. Birth,
24(1), 17-26. Retrieved from
http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1523-536X

Non-supine birthing positions should be assumed during the second stage of labor to
decrease the risk for episiotomies.
o Grade: A
o Meyvis, I., van Rompaey, B., Goormans, K., Truijen, S., Lambers, S., Mestdagh,
E., & Wilhelm, M. (2012). Maternal positions and other variables: Effects on
perineal outcomes in 557 births. Birth, 39(2), 115-120. doi:10.1111/j.1523536X.2012.00529.x
o Thies-Lagergren, L., Kvist, L. J., Christensson, K., & Hildingsson, I. (2011). No
reduction in instrumental vaginal births and no increased risk for adverse perineal
NON-SUPINE BIRTHING POSITIONS
11
outcome in nulliparous women giving birth on a birth seat: Results of a Swedish
randomized controlled trial. BioMed Central Pregnancy and Childbirth, 11(1),
22-30. doi:10.1186/1471-2393-11-22
o de Jonge, A., Teunissen, T. A., & Lagro-Janssen, A. L. (2004). Supine positions
compared to other positions during the second stage of labor: A meta-analytic
review. J Psychosom Obstet Gynecol, 24, 35-45. doi:
10.1080/01674820410001737423
o Gupta, J. K., Hofmeyr, G. J., & Shehmer, M. (2012). Position in the second stage
of labour for women without epidural anesthesia. Cochrane Database of
Systematic Review, 5, Art no. CD002006.
doi:10.1002/14651858.CD002006.pub.3

The supine position should not be used to decrease the incidence of instrumental births.
o Grade: A
o de Jonge, A., Teunissen, T. A., & Lagro-Janssen, A. L. (2004). Supine positions
compared to other positions during the second stage of labor: A meta-analytic
review. Journal of Psychosomatic Obstetrics and Gynecology, 24, 35-45. doi:
10.1080/01674820410001737423
o Gupta, J. K., Hofmeyr, G. J., & Shehmer, M. (2012). Position in the second stage
of labour for women without epidural anesthesia. Cochrane Database of
Systematic Review, 5, Art no. CD002006.
doi:10.1002/14651858.CD002006.pub.3
NON-SUPINE BIRTHING POSITIONS
12
References
de Jonge, A., Teunissen, D. A., van Diem, M. T., Scheepers, P. L., & Lagro-Janssen, A. L.
(2008). Women’s positions during the second stage of labour: Views of primary care
midwives. Journal of Advanced Nursing, 63(4), 347-356. doi: 10.1111/j.13652648.2008.04703.x
de Jonge, A., Teunissen, T. A., & Lagro-Janssen, A. L. (2004). Supine positions compared to
other positions during the second stage of labor: A meta-analytic review. Journal of
Psychosomatic Obstetrics & Gynecology, 24, 35-45.
doi:10.1080/01674820410001737423
Gupta, J. K., Hofmeyr, G. J., & Shehmer, M. (2012). Position in the second stage of labour for
women without epidural anesthesia. Cochrane Database of Systematic Review, 5, Art no.
CD002006. doi:10.1002/14651858.CD002006.pub.3
Hastings-Tolsma, M., Vincent, D., Emeis, C., & Francisco, T. (2007). Getting through birth in
one piece: Protecting the perineum. The American Journal of Maternal/Child Nursing,
32(3), 158-164. doi:10.1097/01.NMC.0000269565.20111.92
Lawrence, A., Lewis, L., Hofmeyr, G. J., & Styles, C. (2013). Maternal positions and mobility
during first stage of labour (Review). Cochrane Database of Systematic Review, 10, Art
no. CD003934. doi:10.1002/14651858.CD003934.pub3
Lowdermilk, D. L., Perry, S. E., Cashion, K., & Alden, K. R. (2012). Nursing care of the family
during labor and birth. In K. Piotrowski (Ed.), Maternity and women’s health care (p.
457). St. Louis, MO: Elsevier Mosby
NON-SUPINE BIRTHING POSITIONS
13
Meyvis, I., van Rompaey, B., Goormans, K., Truijen, S., Lambers, S., Mestdagh, E., & Wilhelm,
M. (2012). Maternal positions and other variables: Effects on perineal outcomes in 557
births. Birth, 39(2), 115-120. doi:10.1111/j.1523-536X.2012.00529.x
Miquelutti, M. A., Cecatti, J. G., & Makuch, M. Y. (2013). Antenatal education and the birthing
experience of Brazilian women: A qualitative study. BioMed Central Pregnancy and
Childbirth, 13(171), 1-9. doi: 10.1186/1471-2393-13-171
Thies-Lagergren, L., Kvist, L. J., Christensson, K., & Hildingsson, I. (2011). No reduction in
instrumental vaginal births and no increased risk for adverse perineal outcome in
nulliparous women giving birth on a birth seat: Results of a Swedish randomized
controlled trial. BioMed Central Pregnancy and Childbirth, 11(1), 22-30.
doi:10.1186/1471-2393-11-22
Waldenstrom, L. & Nilsson, C. (1997). A randomized controlled study of birth center care versus
standard maternity care: Effects on women’s health. Birth, 24(1), 17-26. Retrieved from
http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1523-536X
Running head: NON-SUPINE BIRTHING POSITIONS
14
Appendix
Evidence Grid:
Authors of
Article, YR
Level of
Evidence of
article (I – VI)
Purpose of
study/review and
research
questions
(person who
completed this
row on grid)
Meyvis, I.,
Rompaey, B.,
Goormans, K.,
Truijen, S.,
Lambers, S.,
Mestdagh, E.,
Mistiaen, W.
(2012)
LOE: IV
(Logan Dean)
The purpose of
this study is to
compare the lateral
position with the
lithotomy position
in delivery, with a
focus on perineal
damage.
Research elements:
A) Design B)Population
C) Sampling method/size
D) description of methods/
interventions (if any)
E) instruments used
F) outcomes measured (not
the findings – just what
variables were measured as
outcomes)
A) Correlational
B) All women with
gestations between
37-42 weeks who
were delivering
vaginally in a
regional hospital in
Antwerp, Belgium in
a 1 year span
C) 557
D) None – retrospective
study
E) Hospital records
F) Perineal damage,
lacerations,
episiotomies
Major findings relevant to
project
Give strengths and
weaknesses of this article
for your project related to
validity, bias and
applicability
Women delivering in
Strengths:
lithotomy position showed
1. Large sample size
significantly more lacerations
2. Valid source for me
of the first and second degrees
to consider in
when compared with those
planning for my
delivering in the lateral
project
position.
3. All women in the
study were around
In the lateral position,
the same gestational
episiotomy was performed
age, lending itself to
significantly less frequently:
consistency
this procedure was applied in
4. It gave a lot of
38.2% of the women
statistics as to the
delivering in lithotomy
demographic data of
position and in less than 7%
the women.
of the women delivering in
lateral position.
Weaknesses:
1. It is noted that
NON-SUPINE BIRTHING POSITIONS
15
Including both laceration and
episiotomy in the analysis, an
intact perineum was
significantly more likely in
women delivering in the
lateral position.
In contrast to the lithotomy
position, delivery in the
lateral position is a “handsoff” technique, avoiding
unnecessary manipulations
which could explain the low
number of episiotomies.
Hastings-Tolsma,
M., Vincent, D.,
Emeis, C. &
Francisco, T.
(2007).
LOE: IV
(Amy Ellison)
The purpose of
this study is to
determine what
interventions can
be used in the
hospital setting to
decrease trauma to
the perineum
through lacerations
or episiotomies
A) Retrospective record
review/descriptive
analysis
B) Women having a
vaginal birth
C) 510 healthy term
women whose
prenatal and
intrapartal
information had been
entered into the
The squatting position in
primiparas increases the risk
for perineal laceration.
The lateral position, upright
and hands and knees,
decreases the risk for perineal
laceration.
Birth in a slide-lying position
decreases the risk for perineal
women in the lateral
position were older
and less likely to
have epidural
anesthesia than those
who delivered in the
lithotomy position,
so this could cause a
discrepancy.
2. Might not be 100%
applicable to the
general population
because only a
specific population
from Belgium was
looked at.
3. Not everyone was
cared for by the
same type of
birthing caretaker
(i.e. midwife,
physician)
Weaknesses: There is no
randomization of
individuals, no way to
determine the accuracy of
the data (besides comparing
the electronic charting with
paper records), and no way
to assess the quality of care
given by the nurse midwife.
This study was also limited
to only healthy term
NON-SUPINE BIRTHING POSITIONS
16
Nurse Midwifery
Clinical Data Set in
1996-1997
D) There were no
methods or
interventions in place
as this was a
retrospective study.
However, methods
and interventions
were recommended
in the Clinical
Implications portion
to provide better
nursing care
E) No instrumentation
was used, as this was
a retrospective study.
However, hospital
records were looked
at to gather data.
F) 1. Overall
spontaneous
laceration rate was
49.2%, spontaneous
vaginal birth caused
some type of
laceration in 55.7%
of women, but only
36.6% required
suturing. A severe
laceration was also
more likely with a
tears for all women, as well as mothers. Little is known
protects the perineum.
about the impact different
interventions have on preterm babies and their
mothers. Therefore, it could
be difficult to apply to all
births. The only major bias
that could occur was how
the subjects were selected.
There was no
randomization, which can
lead to bias.
Strengths: This study had
510 women participate
which is significant. It also
gave many useful statistics
that were determined to be
significant (p<.05).
NON-SUPINE BIRTHING POSITIONS
17
prolonged second
stage of labor,
nulliparous women,
or if the woman was
30 years or older and
insured.
2. Marital status and
a baby of 9lbs or
more in nulliparous
women had an
increased risk of an
episiotomy. In all
women, fetal
bradycardia and
prolonged second
stage of labor
increased the risk for
episiotomy.
3. Lacerations were
more likely to occur
in the lithotomy
position or prolonged
second stage of labor.
“Nulliparous women
who used lateral
positioning, warm
compresses, and
manual support
techniques were less
likely to experience a
tear” (162). Using
NON-SUPINE BIRTHING POSITIONS
Thies-Lagergren,
L., Kvist, L.,
Christensson, K.,
Hildingsson, I.
(2011)
LOE: II
(Kate Onion)
The aim of this
study was to test
through a
randomized
controlled trial, if
using a birthing
seat during the
second stage of
labor, for healthy
nulliparous
women, decreases
the number of
instrumentally
assisted births and
thus may decrease
perineal trauma
and blood loss.
18
A)
B)
C)
D)
perineal care
measures lowered the
risk of episiotomy.
Experimental
Women who have a
vaginal delivery
1002 women who
have a vaginal
delivery in Sweden
between November
2006 and July 2009;
inclusion criteria:
normal pregnancy,
cephalic presentation
and spontaneous
onset of labor during
37-41 weeks
gestation; BMI less
than 30; oral and
written information
and an invitation to
join the study was
given by midwives at
second trimester
ultrasound
examination ot at
antenatal clinics to
eligible women who
had reached
approximately 28
weeks gestation
this sample was
randomized to birth
The birth seat did not reduce
the number of instrumental
vaginal births. While the birth
seat presented an increased
blood loss between 5001000mL, there was no
increase in blood loss over
1000mL. Giving birth on the
birth seat showed no adverse
consequences on perineal
outcomes and may be
protective against
episiotomies.
Strengths:
1. This study set good
eligibility criteria
that could present
problems during
laboring if not
addressed ahead of
time
2. This study has a
good sample size for
an experiment to be
able to see trends in
the data collected
Weaknesses:
1. There were some
women included in
the study who had
BMIs over 30 and
women who were
under 37 weeks
gestation when they
began laboring,
article believes that
since the women
were randomized,
the inaccuracies may
cancel each other out
2. Generally a high rate
of non-compliance
NON-SUPINE BIRTHING POSITIONS
Waldenstrom, L.,
Nilsson, C.
(1997)
LOE:II
(Amanda Farr)
The purpose of
this study is to
evaluate the effect
of birth center care
on pregnant
women’s health
during pregnancy,
labor and delivery,
and postpartum.
19
on a birth seat
(experimental group)
or birth in any other
position (control
group)
E) BirthRite birthing
seat; or other
instrumental devices
if the mom’s labor
required it (ex:
episiotomies)
F) Primary outcome
measurement:
number of
instrumental
deliveries; Secondary
outcome
measurements:
perineal lacerations,
perineal edema,
maternal blood loss
and hemoglobin
A) The study’s
population was
randomly and equally
assigned to either a
birthing center or
standard care for
antenatal,
intrapartum, and
postpartum care.
Clinical records and
questionnaires were
in intrapartal studies,
and some noncompliance seen in
this study when
women would use
the birthing seat
briefly then switch
to another position
for the remainder of
labor which may
invalidate some of
the data collected
3. Prolonged labor or
suspected fetal
compromise may
also lead to
noncompliance
Women who were assigned to Strengths:
the birth center used more
1. The article was
alternative birthing positions
strong in that is
during labor and delivery,
followed the
which is relevant to our topic
participants
of non-supine birthing
throughout the
positions. The article has a
whole pregnancy
wonderful chart giving
process including
statistics on 7 birthing
antenatal,
positions used and the number
intrapartum, and
of women from each
postpartum care.
NON-SUPINE BIRTHING POSITIONS
20
used to collect
experimental group that used
information on the
them.
health outcomes and
medical procedures.
B) 1860 pregnant
women who did not
have a general
complicating
condition, were not
drug abusers or
smoker, and who had
had a previous
VBAC if had history
of cesarean delivery.
C) Women were
randomly assigned to
their group during a
prenatal visit to the
birth center. 928 were
assigned the birth
center and 932 were
assigned standard
hospital care.
D) Each woman used her
assigned care
throughout the
pregnancy, birth, and
postpartum period
and data was
collected from her
medical records and
through
questionnaires.
2. There is a great chart
with valuable
information
pertaining to nonsupine birthing
positions, which is
very applicable to
our project.
3. The information
gathered was
directly from the
patient’s records or
from a survey that
they filled out
making the data
valid.
Weaknesses:
1. Blood loss was
reported subjectively
as an estimate,
which could affect
validity.
2. Possible bias based
on differences
midwives’ on
breastfeeding
support and length
of postpartum stay
could affect the
postpartum survey
results.
NON-SUPINE BIRTHING POSITIONS
Miqueletti, M.,
Cecatti, J.,
Makuch, M.
(2013)
LOE: V
The objective of
the study was to
report the
experience of labor
as described by
nulliparous women
who participated
21
E) A mailed
questionnaire was
used to collect
information from the
women two months
after their delivery.
Also, case records
were used to gather
information from for
each woman.
F) With the collective
data concerning
antenatal,
intrapartum, and
postpartum care
Waldenstrom and
Nilsson concluded
that birth center care
is just as effective as
standard hospital care
for pregnant women
and their babies. The
birth center is just as
safe and effective in
identifying
complications.
A) Qualitative study
B) 21 women
C) Purposeful (criterion)
sampling; 11 women
who participated in a
BPP and 10 women
attending routine
All the women, independently
of having participated or not
in the BPP, said that they had
felt more comfortable during
labor when they adopted an
upright position. The
majority considered sitting
Strengths:
1. A possible strength
of the study lies in
the fact that only
primiparous women
were enrolled as
intent to facilitate
NON-SUPINE BIRTHING POSITIONS
(Abby Rose)
and who did not in
a systematic Birth
Preparation
Program (BPP).
22
prenatal care
D) The BPP consisted of
systematized
antenatal group
meetings structured
to provide physical
exercise and
information on pain
prevention during
pregnancy, the role of
the pelvic floor
muscles, the
physiology of labor,
and pain relief
techniques.
E) A digital recorder for
the interview
F) Control of labor,
positions adopted
during labor, and
satisfaction with
labor.
and standing up, walking
identification of the
around, exercising with the
effect of antenatal
ball on the floor or in the
guidance on labor
shower as the most
and delivery.
comfortable positions. On the
2. Another possible
other hand these women
strength of the study
considered horizontal
was that the
positions less comfortable,
interviews were
since they hampered their
conducted before
mobility and increased the
discharge from the
sensation of pain during
maternity hospital;
contractions. All of the
therefore the
women who participated in a
birthing experience
systematic preparation said
was very present for
that they had felt at ease to
these women. As a
assume different upright
way to minimize a
positions and had changed
possible “courtesy
positions based on how they
bias,” all the
were feeling and on what they
interviews were
had learned during
conducted by a
preparations. They said they
professional that did
adopted upright positions to
not have contact
facilitate cervical dilation and
with the participants
to help the progression of
during BPP
labor. The women who did
activities or other
not participate in a systematic
project activities.
preparation reported after
receiving guidance from the
Weaknesses:
staff in the labor room they
1. A possible weakness
began to use some upright
of the present study
positions during labor. Some
was the fact that
women said that adopting
spinal anesthesia is
vertical positions brought
routinely used at the
NON-SUPINE BIRTHING POSITIONS
23
comfort and relieved pain,
even though they were not at
ease to adopt these positions
or to change positions without
seeking guidance from the
staff.
maternity ward
where the women
delivered their
babies. The decision
about when spinal
anesthesia is
performed in labor is
made by the
anesthetic and
OBGYN staff and is
not a women’s
choice.
Consequently is was
not possible to
evaluate women’s
autonomy on pain
relief only using the
alternative of nonpharmacological
coping strategies for
pain control.
2. Another possible
weakness may be the
fact that women had
the possibility of
freely participating
in routine
educational
interventions offered
at the institution
during prenatal care
and for this reason
most participants of
NON-SUPINE BIRTHING POSITIONS
De Jonge, A.,
Teunissen, D.,
Van Diem, M.,
Scheepers, P.,
Largo-Janssen, A.
(2008)
LOE: VI
(Meagan Holt)
The purpose of
this study was to
explore the views
of midwives on
different women’s
positions during
the second stage of
labor, and
determine when
the best time to
inform mothers
about the benefits
of different
birthing styles.
24
A.) Qualitative
B.) Midwives
C.) Purposive sampling
of 31 midwives who
worked in a practice
consisting of one to
six midwives,
however only one to
three of these
midwives took part in
the study. These
midwives assisted
women who were
having a spontaneous
vaginal delivery.
D.) There are no methods
31 female participants
consisted of various ages and
educational backgrounds who
worked in a practice of one to
six midwives.
All but five stated that they
used the stool position which
is the most common form of
upright positioning in the
Netherlands.
A quarter of the midwives
stated that the within the last
10 births had been supine.
the present study had
taken part in some
educational activity.
However, some
routine activities
offered during
prenatal care were
held outside the
medical consultation
days, with voluntary
participation, were
not attended
regularly nor
systematic
educational
intervention were
performed.
Strengths:
1. Increasing the
number of midwives
that give women an
informed choice of
different birthing
positions may assist
them in using a
position that is most
appropriate and
comfortable for
them.
2. All midwives
conducted practice
in the Netherlands.
3. This was a valid
NON-SUPINE BIRTHING POSITIONS
25
of interventions used
in this study.
E.) Interview with
midwives
F.) Measuring informed
consent vs. informed
choice.
Women expect midwives to
source to incorporate
give professional opinions on
into clinical practice.
positions for delivery, and this
advice is a stronger influence Weaknesses:
than the woman’s personal
1. None of the
preference.
midwives in this
study were opposed
By informed choice we mean
to non-supine
that the midwife explores
positioning.
what the women think about a
2. Some of the
birthing position and actively
midwives knew the
give them the appropriate
interviewers
information on various
conducting this
position options and assist
study.
them in making their own
3. A quarter of
choice.
participants stated
that of the last ten
Only one midwife said that
births they assisted
she routinely discussed
in delivering, the
birthing positions with
mother was in a
women in the antenatal clinic.
supine position.
4. Not all of the
In most groups, participants
midwives had the
mentioned that they preferred
same type of
to perform episiotomy or
practice. 87%
vaginal examinations in
practiced in a group,
supine positions and as a
while only 7%
result of doing this, most
practiced
mothers would then deliver in
individually.
a supine position.
5. Bias because of the
small sample size
used and only
allowing midwives
NON-SUPINE BIRTHING POSITIONS
De Jonge, A.,
Teunissen, T.,
Lagro-Janssen, A.
(2004)
LOE: I
(Amanda Farr)
The purpose of
this review is to
determine what the
benefits are for
women of the
routine use of the
supine position for
the second stage of
labor compared to
other positions in
terms of maternal
morbidity and
comfort and the
morbidity of the
baby.
26
A) Meta-analysis of
randomized
controlled trials, as
well as case-control
and cohort studies
B) Women in the second
stage of labor
expecting to have a
vaginal delivery.
C) Nine randomized
controlled trials and
one cohort study
D) The implementation
of non-supine
birthing positions
during the second
stage of delivery
E) Apgar scale was used
to assess babies after
vaginal birth.
Observation of
lacerations and a
clock to time the
length of the second
stage of birth were
used to assess the
delivery outcomes.
F) For the mother:
medical interventions
for failure to
The supine position during
vaginal delivery resulted in an
increased rate of instrumental
deliveries and episiotomies,
and a decreased rate of blood
loss and postpartum
hemorrhage. There were no
significant differences found
in the newborn’s Apgar score
or rate of fetal heart rate
abnormalities and neonatal
resuscitation between the
supine and non-supine
birthing positions. Women
reported their pain level to be
higher while in the supine
position compared to when
they sat on a birthing stool.
who work in
practices of six or
less midwives.
Strengths: A large number
of studies were considered
in the review leading to
large amounts of data
gathered for consideration.
Weaknesses: In some
studies, it was not clear how
the second stage of labor
was defined. This could
cause a lack of validity if
not all studies considered
the second stage to be at the
same point during the labor
process. Health care
professionals subjectively
assessed most outcomes.
NON-SUPINE BIRTHING POSITIONS
27
progress, trauma to
the birth canal,
estimated blood loss,
postpartum
hemorrhage,
hemoglobin levels
after delivery, urine
or feces incontinence,
pelvic pain or
instability, and the
mother’s satisfaction
with the labor and
delivery experience,
as well as her
perception of pain.
For the baby:
abnormal fetal heart
rate patterns, Apgar
scores, mean
umbilical cord artery
pH, and the need for
neonatal
resuscitation.
Lawrence, A.,
Lewis, L.,
Hofmeyr, G.J.,
Styles, C. (2013)
LOE: I
(Amanda Farr)
The purpose of
this review is to
assess the effects
of encouraging
women to assume
different upright
positions versus
supine positions
during the first
A) Systematic Review
B) Women in the first
stage of labor
C) 25 randomized and
quasi-randomized
trials; total of 5218
women
D) The position assumed
by the woman during
Walking and upright positions
during the first stage of labor
decreases the length of labor
and risk for cesarean birth, the
need for an epidural, and does
not have any negative effects
on the mother or baby.
Strengths: There was a very
large sample size among the
25 studies. Randomization
was utilized in all of the
studies. A large number of
non-supine positions were
used during the women’s
first stage of labor, as well
as a number of supine
NON-SUPINE BIRTHING POSITIONS
Gupta, J.,
Hofmeyr, G.,
Shehmar, M.
(2012)
LOE: I
(Amanda Farr)
28
stage of labor
concerning length
of labor, type of
birth, and other
outcomes for the
mother and
newborn.
the first stage of
labor- either upright
or supine.
E) The Cochrane
Handbook for
Systematic Reviews of
Interventions was
used for data
collection, assessing
study quality, and
analyzing results.
F) Maternal outcomes:
duration of first stage
of labor, mode of
birth, and maternal
satisfaction with
positioning and the
childbirth experience.
Neonatal outcomes:
fetal distress
requiring immediate
birth and use of
neonatal mechanical
ventilation.
The purpose of
this review is to
assess the benefits
and risks of the use
of different
positions during
the second stage of
labor.
A) Systematic review
B) Pregnant women
during the second
stage of labor without
epidural anesthesia
C) 22 randomized and
quasi-randomized
controlled trials; total
positions for the control
groups.
Weaknesses: Quality of
studies vary among the 25
reviewed which could affect
the validity of the results.
There are several possible
benefits for upright posture in
women without epidural
during the second stage of
labor but with the possibility
of blood loss greater than 500
mL. Women should be
allowed to make choices
Strengths: A large sample
population consisting of
7280 women provided a
large quantity of data for
assessment.
Weaknesses: Random
sequence generation,
NON-SUPINE BIRTHING POSITIONS
29
of 7280 women
D) The use of any
upright or lateral
position during the
second stage of labor
compared to the
supine or lithotomy
position.
E) Two review authors
assessed and
extracted data from
the 22 trials.
F) Maternal outcomes:
pain, use of any
analgesia or
anesthesia, mod of
delivery, trauma to
the birth canal that
required suturing,
blood loss greater
than 500 mL, manual
removal of placenta,
and urinary or fecal
incontinence.
Newborn outcomes:
abnormal fetal heart
rate patterns needing
intervention,
admission to neonatal
intensive care unit,
and perinatal death.
about their birthing positions.
allocation concealment,
blinding, incomplete
outcome data, and selective
reporting are weaknesses
present in this review that
pose a risk for bias.
NON-SUPINE BIRTHING POSITIONS
30