The effects and outcomes of different maternal positions on the second stage of labor

R Jyoti; Mudita Sharma; Shatrughan Pareek

doi:10.4103/mjhs.mjhs_49_21

REVIEW ARTICLE

Year : 2022 | Volume : 10 | Issue : 2 | Page : 21-24

The effects and outcomes of different maternal positions on the second stage of labor

R Jyoti¹, Mudita Sharma², Shatrughan Pareek³
¹ Department of Maternal Health, Lady Harding Medical College, New Delhi, India
² Department of Nursing, AIIMS, Bhopal, Madhya Pradesh, India
³ Department of Nursing, Indian Railway Health Services, Bikaner, Rajasthan, India

Date of Submission	08-Jul-2021
Date of Decision	26-Dec-2021
Date of Acceptance	17-Jan-2022
Date of Web Publication	29-Apr-2022

Correspondence Address:
Shatrughan Pareek
Department of Nursing, Indian Railway Health Services, Bikaner, Rajasthan
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjhs.mjhs_49_21

Abstract

Introduction: Maternal and child health is an important public health issue, especially in developing countries like India. Maternal and child health services help to determine maternal and neonatal morbidity and mortality in a country. The second stage of labor is the most stressful part of childbirth process and the proper maternal position during this period is paramount for women's safe vaginal birth. Midwives play a pivotal role in managing maternal positions during the second stage of labor. However, there is limited evidence to support an ideal maternal position during the second stage of labor.
Methodology: All studies that explored the effects of positioning during the second stage of labor were retrieved. Only four major databases, Google Scholar, ResearchGate, PubMed, and Shodhganga, were searched. The keywords used for search included the second stage of labor, maternal position, upright position, left lateral position, squatting position, and maternal outcomes. The search criteria included studies published from 2008 to 2021. Out of 154 research articles, only 14 studies were included for the review process.
Results: The positions such as maternal upright, lateral position, squatting position, and sitting position are beneficial for the maternal and neonatal outcome. The mean length of the second stage of labor was shorter in squatting primiparas and multiparas than in semirecumbent women, whereas lithotomy and supine positions during labor are associated with poor maternal and fetal outcomes.
Conclusion: The selected positions during the second stage of labor have shown positive outcomes for the pregnant and her child. The findings should be introduced in midwifery education programs and in clinical practice as a method to improve the care of women during the second stage of labor.

Keywords: Left lateral position, maternal outcomes, maternal position, second stage of labor, squatting position, upright position

How to cite this article:
Jyoti R, Sharma M, Pareek S. The effects and outcomes of different maternal positions on the second stage of labor. MRIMS J Health Sci 2022;10:21-4

How to cite this URL:
Jyoti R, Sharma M, Pareek S. The effects and outcomes of different maternal positions on the second stage of labor. MRIMS J Health Sci [serial online] 2022 [cited 2023 Apr 2];10:21-4. Available from: http://www.mrimsjournal.com/text.asp?2022/10/2/21/344434

Introduction

Labor and delivery are major challenges worldwide, especially in developing countries.^[1] The health status of mother and baby is important for every nation. The actual and potential complications related to pregnancy and labor process can contribute significantly to maternal and fetal morbidity and mortality. The labor process is an exciting, anxiety provoking but rewarding time for the women.^[2],[3] The second stage of labor is most crucial for a woman and health-care provider, the appropriate maternal position during the second stage of labor is important for childbirth process.^[4] Health-care providers play an important role in managing maternal positions during the second stage of labor.^[5] The second stage begins with the full cervical dilatation (approximately 10 cm) and ends with the delivery of baby. The second stage can last from minimum of 20 min (in multiparous woman) to maximum of 2 h (in nulliparous woman). The uterine contractions will last about 45–90 s at intervals of 3–5 min. The second stage is often divided into a passive phase (before 4 cm of cervical dilatation), an active phase (4–10 cm of cervical dilatation).^[4] When a laboring woman is in the upright position to give birth, there is a lesser risk of compressing the mother's aorta, which means there is a better oxygen supply to the baby.^[7] Upright positioning also helps the uterus contract more strongly and efficiently; as a result, it helps the baby get in a better alienation of fetus to maternal pelvis. Several evidence-based guidelines suggested that maternal positions serve the nonpharmacological intervention to facilitate the progress of childbirth.^{[6],[7],[8],[9],[10]} Semi-Fowler's and side-lying positions provide comfort and convenience to mothers. These positions result in preserving the energy, especially when the women have stood up or walked for a long time.^[11]

Methodology

The review not only gives an insight into the impacts of the upright position, left lateral position, and squatting position during the second stage of labor but also highlights its associated positive effects in terms of maternal and neonatal outcomes. There were some variations in the study setting, subjects, sample selection, sample size, and study duration. In the present review, we included all pregnant women irrespective of whether they were preterm or postterm. Our review had several limitations that should be recognized. First, we restricted our search only to Google Scholar, ResearchGate, PubMed, and Shodhganga. The keywords searched for the study were the second stage of labor, maternal position, upright position, left lateral position, squatting position, and maternal outcomes [Figure 1]. The papers published in a time period of year 2008–2021 were selected.

Figure 1: The process of articles being reviewed and selected for the effect and outcomes maternal positions on the second stage of labor

Click here to view

Inclusion criteria

The study has below-listed inclusion criteria:

The sample was composed of pregnant women planned for normal vaginal birth
Includes both primiparas and multiparas woman
Woman in the spontaneous second stage of labor
Woman without any labor complications
Woman who did not use any analgesia/anesthesia during delivery
Woman undergoing normal institutional delivery.

Exclusion criteria

A study was excluded in the case of:

Elective or emergency cesarean section
Assisted birth (forceps and vacuum delivery)
No case studies are included
No home deliveries are included
Excludes stillbirth/intrauterine death
Woman who used any analgesia during labor
Woman not indicated to ambulate during the second stage.

Discussion

The maternal positions during the second stage of labor have significantly impacted their childbirth outcomes and experiences.^[12] The findings related to maternal positions in the second stage of labor were associated with minimal perineal lacerations and fewer episiotomies.^[13] Maternal upright and lateral position benefits the maternal and neonatal outcomes. Furthermore, squatting position and sitting position affect maternal and neonatal outcomes in terms of less incidence of perineal trauma and reduced blood loss.^[6] In addition, in a review, Katsuko S. and Shigeko H. revealed that maternal positions, i.e., lateral position, hands and knees position, and squatting position, were associated with less with birth injuries and better hemostasis.^[13] A cohort study described that the mean length of the second stage of labor was 23 min shorter in squatting primiparas and 13 min lesser in squatting multiparas than in semirecumbent position during the second stage of labor. A study highlighted that squatting women required significantly less labor stimulation by oxytocin during the second stage (P = 0.0016). Moreover, less severe perineal lacerations were occurred and fewer episiotomies were performed in the squatting group (P = 0.0001).^[14] The data regarding the prevalence of upright position during the second stage of labor are limited. In this context, Peppe et al. communicated that the prevalence of upright position during the second stage of labor was 42%.^[15] The incidence of severe perineal trauma was low among women with upright position during the second stage of labor.^[15] Berta et al. highlighted that the duration of the second stage was reduced in cases of a flexible sacrum birthing position. Furthermore, the study revealed a decline in duration of the second stage of labor among multigravida in a flexible sacrum birthing position, with a mean duration from 3.2 to 34.8 min. In addition, the pooled mean difference with the random effect model was 21.118 (confidence interval: 11.839–30.396) min.^[7] In an experimental study, Lin et al.^[12] explored that squatting with ankle supports was helpful in reducing the delivery time by averaged 25.79 min less the time for semirecumbent group. Moreover, the interval between the start of pushing to baby birth averaged 25.21 min less for the experimental group than for semirecumbent group (F = 6.14, P < 0.05). Therefore, squatting with ankle support position was significantly effective in declining the caring needs of women during the second stage of labor.^[12] The incidence of severe perineal trauma was low among women with upright position during the second stage of labor.^[15] There are some effects of maternal position on surgical outcomes of the labor. In a systematic review, Walker et al. stated that left or right lateral and semirecumbent positions may decline the need for operative birth and cesarean section without more instrumental labor.^[5] The position during the second stage of labor can decline the induced labor process. Moraloglu et al. communicated a significant reduction in the duration of the second stage of labor in the squatting position using bars. Furthermore, squatting position using bars was also effective in increasing satisfaction and a decrease in oxytocin requirements compared with the supine position.^[16] Few studies have suggested that position has an effect on labor pain. In this reference, Gizzo S and Di Gangi S described that alternative maternal positioning may positively influence labor process reducing maternal pain, operative vaginal delivery, cesarean section, and episiotomy rate. Women should be encouraged to move and deliver in the most comfortable position.^[17] In nulliparous women, lying down position in the second stage of labor helps more spontaneous vaginal births.^[6] Moreover, some of the studies have narrated that there is no significant effect of maternal position on maternal and fetal outcomes. In this context, a systematic review by Kobra Mirzakhani et al. stated that various maternal positions during the first and second stages of labor did not affect maternal, fetal, and neonatal outcomes.^[17] Lithotomy and supine position are associated with increased incidence of severe perineal trauma and blood loss, increased duration of labor, and increased fluctuations in fetal heart rate pattern.^[6] There are some benefits and risk factors of different positions during the second stage of labor, but positions such as maternal upright, lateral position, squatting position, and sitting position have shown positive outcomes for the pregnant and her child.^[18],[19] There is a need of multiple researches to identify a particular position for the second stage to decrease maternal and fetal complications.

Conclusion

Maternal position in the second stage of labor plays an important role in maternal and fetal outcomes. Maternal birthing position has an effect on reduction in duration of the second stage of labor with a considerable variation was reported. The positions such as maternal upright, lateral position, squatting position, and sitting position are beneficial for the maternal and neonatal outcome. The mean length of the second stage of labor was shorter in squatting primiparas and multiparas than in semirecumbent women. The position was also effective in declining severe perineal lacerations, episiotomies, and labor stimulation by oxytocin during the second stage, whereas lithotomy and supine positions during labor are associated with poor maternal and fetal outcomes. The positive outcomes of selected positions during the second stage of labor should be discussed among health-care providers who care for women during labor and childbirth. Laboring women should be encouraged to choose their comfortable birth position.

Significance of the study

This article aims to review and compare the benefits and risks of common maternal positions during the second stage of labor, thereby providing midwives evidence-based practical guidelines. This information may be introduced in midwifery education programs and in clinical practice as a method to improve the care of women during the second stage of labor.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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