What Position Should I Labor In During Stage Two?

Now that Cali, a 28-year-old first time mom, has been briefed on the position options during stage one of labor, including the knowledge that moving and adjusting position as she wishes increases comfort and control, her pelvic floor physical therapist dives into her options for stage two of labor. Stage two consists of two phases. The first is a passive stage that occurs from 10 centimeters of dilation until mom begins to push the baby out. The second phase is the active pushing phase resulting in the arrival of your new baby!  

Two Cochrane reviews, which are considered the highest level of medical evidence, were performed regarding the outcomes of birthing position on stage two of labor. One looked at women who gave birth without epidural anesthesia and the other looked at women with epidural anesthesia. 

The first Cochrane reviewed looked at 30 randomized controlled trials with 9,015 women who gave birth without epidural anesthesia and found some slight differences between women who gave birth in upright positions versus those who gave birth in laying down positions. Upright positions referred to sitting, birthing stools, chairs, squatting or kneeling. Laying down positions included Sim’s position (laying on your left side with your left leg straight and right leg bent), semi-recumbent (slightly inclined position while laying on your back), lithotomy position (laying on your back with your feet in stirrups), or Trendelenburg position (laying flat on your back with the bed declined so your feet are higher than your head). Both women who were pregnant for the first time and those who had more than one pregnancy were studied. Upright positions were found to have a slight reduction in second stage duration (about 6 minutes), especially for first timers. There was also a reduction in episiotomy rates and instrument assisted deliveries in upright positions. On the other hand, upright positions were found to have increased blood loss greater than 500 milliliters and a possible increase in second degree tears as compared to laying down positions. There was no significant difference in positions with regards to third- and fourth-degree perineal tears, caesarean section, or difference in the babies who were admitted to the neonatal intensive care unit. Interestingly, babies born to mothers in upright positions were found to have less instances of distress indicated by fast or irregular heartbeats.

Now, some women opt for an epidural because it is the most effective pain relief method during labor. Therefore, it is important to look at how position may or may not influence birth outcomes as there is generally an increase in second stage duration and instrumental assist (forceps or vacuum) with the use of an epidural.

The second Cochrane review assessed upright versus laying down positions for women in the second stage of labor with epidural anesthesia. Laying down positions included laying on the left or right side and semi-recumbent positions but did not include laying flat on the back or lithotomy positions.  A review of 8 randomized controlled trials with 4,4664 women were used to compare positions. Initially, there was little difference in operative births between women in recumbent versus upright positions including cesarean or instrumental vaginal delivery. However, when researchers specifically looked at high-quality studies, they found that upright positions did increase the risk of instrumental delivery about 10% and cesarean births about 30%. There was low quality evidence indicating whether upright positions influenced second stage duration. Position in the second stage had little to no difference on postpartum hemorrhaging or tears that required stitches. Recumbent (laying down) positions were found to have a slightly higher maternal satisfaction than upright positions. High-quality evidence did show improved outcomes for women who moved between laying down positions on their sides and avoided laying flat on the back. This resulted in more normal births, a better experience, and no harm to mother or baby when compared to upright positions.

Keep in mind that even though one type of position may not be the gold standard, position change during labor can play a role in outcomes. A study compared postural changes during the second stage of labor versus the passive supine (laying down) position with mothers who had received epidural analgesia and were monitored by multiple disciplines, including a physiotherapist! Postural changes included sitting with the back resting against a birthing ball, kneeling with back supported straight against the bed’s head, hands-and-knees with the chest against a birthing ball, or laying on a side with either top leg bent and upper leg stretched or both legs bent, and laying on back with either legs bent or stretched. Positions were kept for 5 to 30 minutes. Most women (39.7%) chose four positions with the most favorable position being hands-and-knees followed by sitting with the back against a birthing ball, laying on a side, kneeling, and lying flat on their back. There were significantly fewer instrumental deliveries and cesarean sections in the group that performed position change, as well as a significantly shorter duration of the second stage of labor. Additionally, episiotomies were more frequent in the group that did not position change while first-degree perineal tears were significantly more frequent in those that did perform position change. 

The most important component is the freedom for mom to make decisions prior to and during delivery. It has been found that perceived control and a physiological birth (non-instrument assisted) were associated with increased childbirth satisfaction. Fewer depressive symptoms were found at 2 months post-partum in those with a higher childbirth satisfaction and fewer anxiety symptoms were associated with increased perceived control. Perceived control is “the extent to which a mother believes her actions influenced or shaped the conditions of the birth environment” and is affected by factors like actively participating in decision making and birthing without complications and/or medical intervention.

There are many factors to consider when we are discussing birth position, including mother’s choice, setting, medical intervention and provider preference. It is thought that the laying down, or supine positions, were more convenient for healthcare providers to assist during labor and delivery. Some women might prefer upright positions as they feel it is more comfortable and allows the pelvis to expand and uses gravity to assist the baby into the birth canal.  

Overall, whether you choose to have an epidural or not, the most important factor is that you feel empowered with knowledge and choices before and during your labor. When in labor, remember to change positions at least every 30 minutes to increase comfort, reduce episiotomy risk, reduce likelihood of a cesarean, and reduce instrumental assisted birth. Do what feels best for your body as “women should be encouraged to give birth in whatever position they find comfortable”. If you are feeling overwhelmed by the options available to you, reach out to your local pelvic floor physical therapist to help walk you through different positions to find what works best for you!

Written by Jordan Schmidt, PT, DPT

References

1. Gupta, J. K., Sood, A., Hofmeyr, G. J., & Vogel, J. P. (2017). Position in the second stage of labour for women without epidural anaesthesia. The Cochrane database of systematic reviews, 5(5), CD002006. https://doi.org/10.1002/14651858.CD002006.pub4 
2. Walker, K. F., Kibuka, M., Thornton, J. G., & Jones, N. W. (2018). Maternal position in the second stage of labour for women with epidural anaesthesia. The Cochrane database of systematic reviews, 11(11), CD008070. https://doi.org/10.1002/14651858.CD008070.pub4  
3. Simarro, M., Espinosa, J., Salinas, C., Ojea, R., Salvadores, P., Walker, C., & Schneider, J. (2017). A Prospective Randomized Trial of Postural Changes vs Passive Supine Lying during the Second Stage of Labor under Epidural Analgesia. Medical Sciences, 5(1), 
4. Townsend, M., Brassel, A., aafi, M., & Grenyer, B. (2020). Childbirth satisfaction and perceptions of control: postnatal psychological implications. British Journal of Midwifery, 28(4), 225-233.