What Position Should I Labor In During Stage One?

Cali is a 28-year-old first time mom who is feeling overwhelmed about her birth plan. She has been receiving a lot of (mostly unwarranted) information from well-meaning people. Many are sharing their experiences and opinions on very personal decisions, such as a home versus hospital birth. Cali feels pretty confident with her decision on birth location, but she is starting to wonder if there are certain dos and don’ts when it comes to movement and positions during labor. She has decided to seek out the help from a local pelvic floor physical therapist for birth preparation to answer her questions. 

Like Cali, many of us really begin to dive into pregnancy and labor when we are planning or have recently become pregnant. The first step in planning our labor journey is understanding the process.  

Labor is made up of three stages. The first stage occurs when contractions encourage cervix dilation (opening) and effacement (thinning) to allow for the baby to move into the birth canal. Stage one of labor concludes with the full dilation of the cervix at 10 centimeters. Stage two is the pushing phase and stage three is the delivery of the placenta.  

Stage one labor is further divided into three parts. The first part is early labor, which occurs when contractions begin and ends when the cervix dilates to 5 centimeters. Women with uncomplicated pregnancies will often stay home during this period. Part two is called active labor and occurs when the cervix dilates from 6 centimeters to 10 centimeters. Contractions will become stronger, more regular, and closer together. The last part is often called transition and occurs when contractions become very close together (60 to 90 seconds) and you will feel intense pressure in the low back and rectum.  

It is important to keep in mind that there can be considerable variation in terms of stage one labor duration. For nulliparous women (women who have not given birth before), it can range between 1.67 to 18.22 hours. For multiparous women (women with more than one birth), it can range from 1.2 to 7.8 hours. 

A Cochrane systematic review, which is considered the highest standard for evidence-based healthcare, was performed that included 25 studies of 5,218 women and compared upright versus recumbent positions. Upright referred to any of the following variations: walking, sitting, standing, squatting, and kneeling. Recumbent positions include laying down flat on your back, laying on your side, or leaning back in a semi-reclined position. This review found that women in upright positions experienced a first stage of labor that was 1 hour and 22 minutes shorter as compared to those in recumbent positions. More specifically, sitting resulted in a stage one labor that was 2 hours and 23 minutes shorter while walking resulted in stage one that was 3 hours and 57 minutes shorter that those in a recumbent position.

 Women in an upright position were also less likely to have a caesarean section or epidural as a pain relief method. One study found that upright positions reduced the likelihood that baby was admitted to the neonatal intensive care unit. 

Upright positions are thought to assist with the descent of the baby’s head into the pelvis. When the baby’s head is applied directly and evenly over the cervix, uterine contractions increase in strength, frequency, and regularity. This allows for improved cervical dilation, which eventually leads to completion of stage one of labor.

There was no significant difference between pain and anxiety reported by women in upright positions versus bed care, although women in recumbent positions did report higher pain scores at 4 cm and 8 cm dilation in one trial of 87 women.

Additionally, women randomized to upright positions had less use of episiotomy, but this was not statistically significant.

It is important to note that there were no differences between upright versus recumbent positions for the duration of the second stage of labor or other outcomes related to mom and baby well-being. 

The key is for women to be able to move and change positions as quickly and easily as possible, especially as labor progresses. This can be done in a variety of places including the shower or bath and different equipment can be used like a recliner chair or birthing ball. 

A systematic review looked at three studies with 205 women and found that a birth ball can be effective to reduce labor pain. An additional study not included in the final review found that women who used a birth ball and warm bath had a statistically significant reduction in pain as compared to a warm water bath or birth ball alone.  

A sense of control during labor can be achieved by allowing for movement, which can influence level of pain. Other ways to improve comfort include rocking the hips side to side, heat, and massage in addition to water immersion. 

Laying down positions in stage one of labor are often encouraged by healthcare providers because they allow for easy access and monitoring. However, according to the Cochrane review, “Women should be encouraged and supported to use upright and mobile positions of their choice during first stage labor” and “should be encouraged to utilize positions which give them the greatest comfort, control and benefit during the first stage of labor.”1 This is further supported by The American College of Obstetricians and Gynecologists (ACOG) Committee Opinion that “For most women, no one position needs to be mandated or proscribed”.  

In summary, there is no one position fits all when it comes to stage one! There is evidence to support upright positions in terms of reducing stage one labor duration, reducing cesarean section and reducing epidural use as a form of pain relief; however, it is most important that the person laboring can move and adjust her position as she wishes to increase her sense of control and comfort. Cali, and other expecting mothers, can discuss and practice these options with their birth team. This is why it is so important to have a knowledgeable team to support you as you prepare for your baby! 

Written by Jordan Schmidt, PT, DPT 

References

1. Lawrence, A., Lewis, L., Hofmeyr, G. J., & Styles, C. (2013). Maternal positions and mobility during first stage labour. The Cochrane database of systematic reviews, (10), CD003934. https://doi.org/10.1002/14651858.CD003934.pub4 
2. Makvandi, S., Latifnejad Roudsari, R., Sadeghi, R., & Karimi, L. (2015). Effect of birth ball on labor pain relief: A systematic review and meta-analysis. The journal of obstetrics and gynaecology research, 41(11), 1679–1686. https://doi.org/10.1111/jog.12802 
3. (2019). ACOG Committee Opinion No. 766: Approaches to Limit Intervention During Labor and Birth.. Obstetrics and gynecology, 133(2), e164e173-ee173.