Childbirth in Supported Sitting Maternal Position

Thilagavathy Ganapathy
Professor, HOD, Dept. OBG Nursing, The Oxford College of Nursing, The Oxford Educational Institution,
6/9, I Cross, Hongasandra, Begur, Bangalore-68
ABSTRACT
Objective: To compare the effects of supported sitting versus the supine- lithotomy maternal birthing
position in healthy primigravidae on the obstetrical , perinatal outcome and maternal birthing
experiences.
Design: Two groups randomized interventional design.
Setting: Municipal Maternity Corporation Hospital, Bangalore, Karnataka.
Methods: Healthy primigravidae [n=200] randomly allocated to supported sitting [n =100] & supinelithotomy[n =100] maternal birthing position during the second stage of labor. Analysis was performed
by SPSS version-15, relevant descriptive and inferential statistics computed for data presentation.
Main outcome measure: Duration of second stage third stage, rate of instrumental delivery, intensity
of intrapartal pain, FHR pattern, APGAR scores of the newborn, amount of blood loss and maternal
birthing experiences.
Results: Supported sitting position during second stage of labor was associated with a shorter
duration of second , third stage of labor, fewer reports of excruciating intrapartal pain, fewer rates
of instrumental delivery, irregular FHR pattern, higher APGAR scores, minimal blood loss and
favorable maternal birthing experiences.
Conclusion: In healthy primigravidae supported sitting position was associated with benecial
obstetrical, perinatal outcome and favorable maternal birthing experiences.
Key words: Supported Sitting, Supine- Lithotomy, Obstetrical and Perinatal Outcome.

INTRODUCTION
The appropriateness of maternal birthing position
in healthy primigravidae during the second stage of
labor has been a controversy and debated while the
evidence on which to have recommendations remain
inconclusive. Most previous studies evaluating the
effects of upright maternal birthing position versus
the supine- lithotomy position during labor suggest
the advantages of upright position in terms of shorter
duration of labor, less intrapartal pain, increased
pelvic diameters, more efcient uterine contractions,
Correspondence Address :
Thilagavathy G,
Professor, HOD, Dept. OBG Nursing,
The Oxford College of Nursing,
The Oxford Educational Institution,
6/9, I Cross, Hongasandra,
Begur, Bangalore-68.
M= 9900795255
Email: thilkg@gmail.com

minimal risk of aorta caval occlusion, fewer rates of

instrumental delivery, irregular FHR pattern, higher
APGAR scores and increased incidence of postpartum
hemorrhage.1,2
In a randomized control trials by Gupta1, Dejonge3
and Bomm4 who compared upright versus supinelithotomy/birthing position concluded that the
upright position resulted in shorter duration of
labor, less intrapartal pain, with insignificant
difference in instrumental delivery, fetal heart rate
pattern, episiotomy, postpartum hemorrhage and
recommended the use of upright position during labor.
Current knowledge on comparing the upright versus
horizontal position on duration of second , third stage
of labor and maternal subjective delivery experiences
is limited. Increased knowledge sought in this upright
versus horizontal maternal birthing position on
obstetrical, perinatal outcome and maternal experience
may be of importance for individual counseling
of parturients, their families and health personnel
practicing obstetrics. The primary objective of this

88

International Journal of Nursing Education. July-Dec., 2012, Vol. 4, No. 2

study was thus to compare the obstetrical, perinatal

outcome and maternal birthing experiences in the
supported sitting versus supine-lithotomy maternal
birthing position groups.
MATERIAL & METHODS
The study was conducted in Municipal Maternity
Corporation Hospital labor room , Bangalore,
Karnataka, from April 2008 to September 2009.
Formal written permission and ethical clearance were
obtained from the concerned authorities of Municipal
Maternity Corporation hospitals{MMCH}; Bruhat
Bangalore Maha Nagrae Palike {BBMP} and the study
center before conducting the study. A priori power
calculation determined that a sample size of at least 100
participants in interventional group{supported sitting
maternal birthing position} and 100 in control group
{supine-lithotomy position} would be able to detect a
25% difference in the outcome of labor between the two
groups, with 80% power and an alpha level of 0.05{two
tailed}. Totally 200 normal low risk term primigravidae
between 38-42 weeks of gestation with spontaneous
onset of labor, single vertex fetus in anterior position,
adequate pelvis presenting in active phase of labor
and who have had minimum ve antenatal checkups,
admitted for normal delivery in the Yediur {MMCH},
labor rooms were selected by purposive sampling
technique. Primigravidae with obstetrical, medical
& surgical, gynecological, psychiatric risk factors
complicating pregnancy, maternal fetal complications
during pregnancy and labor were excluded. After a
detailed discussion and actual demonstration of both
the position, they were randomly assigned by coin
toss method, head to the supported sitting birthing
position {experimental group} and tail to supine
lithotomy position {control group} and an informed
consent was obtained from the participants of both the
groups. Participants in both the groups were mobile
during the rst stage of labor . Baseline maternal and
fetal parameters were monitored and the onset of the
second stage was conrmed by vaginal examination
for full [10cm] dilatation and effaced cervix with
occiput internal rotation complete along with the
presumptive signs of second stage of labor and the
participants were placed in their assigned birthing
positions.
In the experimental group, during the second
stage of labor, the participants upper back were
elevated to 600 angle to assume upright supported
sitting birthing position by the simple backrest
attached adjustable standard delivery cot as felt most
comfortable and desirable by the participants. While
in the control group, the participants assumed the
supine lithotomy- lying at on their back position.
Intensive monitoring of their progress and constant

encouragement, physical and emotional support were

given to the participants by the researcher to boost
their condence and cooperation to achieve positive
effects and active participation in labor process . Fetal
heart rate was monitored by Doppler fetal heart rate
monitoring device.
Once the birth was imminent, right medio lateral
episiotomy was given and delivery was conducted in
their allotted position The woman continued to remain
in the same allotted position during the third stage
of labor. After the delivery of the placenta and the
membranes the women were placed in the lithotomy
position for the repair of episiotomy by lowering the
backrest to a horizontal position.
The main outcome variables measured were
the duration, frequency, strength of the uterine
contractions, maternal blood pressure, bearing down
efforts, duration of second and third stages of labor,
method of vaginal delivery, amount of blood loss
by the observational rating scale, quality of fetal
heart rate pattern by the Doppler fetal heart rate
monitoring device , intensity of labor pain perceived
by the primigravidae by Visual Analogue Pain
Scale{VAS-100mm}, Apgar scores of the newborns
at 1 and 5 minutes of birth by Apgar Scoring Index
and maternal birthing experiences by womans post
partum opinnionaire.
FINDINGS
The two groups were homogenous with regard to
all demographic and obstetrical variables [ Table-1] as
analyzed by Chi-square and Fishers exact test . This
indicated that random assignment was valid and the
selection bias could not have inuenced the outcome
variables.
The student t test was used to compare the mean
differences on the obstetrical and perinatal outcome
in the supported sitting versus lithotomy position
groups. The ndings of the study revealed that the
supported sitting position was generally associated
with efficient uterine contractions 92 Vs 66{92%
Vs 66%} t=21.052, spontaneous bearing down
efforts{92% Vs 66%} t=18.714, absences of supine
hypotension 0 Vs 17 {0%Vs 17%}; a fewer reports of
excruciating intrapartal labor pain 15 Vs 58 {15% Vs
58%} t=10.390, decreased need for oxytocin 8 Vs
27{8%vs 27%,}, analgesics 15 Vs 58 {15% Vs 58%},
shorter duration of second stage of labor {56 Vs 67
minutes} t=14.403, third stage of labor, {12 Vs 22
minutes} t= 23.872, a fewer instrumental deliveries
8 Vs 42{8%vs 42%} t= 4.255, insignicant amount of
blood loss{340 Vs330ml} t=1.649, a fewer irregular
fetal heart rate pattern 7 Vs 13{ 7% Vs 13%} t= 4.320,
higher Apgar scores 9 at 1minute 74 Vs 51{74% Vs 51%}

International Journal of Nursing Education. July-Dec., 2012, Vol. 4, No. 2 89

t= 3.450 and 10 at 5 minutes of birth 87 Vs 71 {87 %

Vs 71%} t= 3.240 . [Table-2]
Table:1. Baseline Characteristics of the Participants:
N=100+100= 200
Baseline characteristics

Mean + SD

Maternal birthing position

Supported Sitting

Supine-Lithotomy

Maternal Age {Yrs}

21.4 + 2.02

21.3 + 1.94

Gestational Weeks

40 + 1.07

40+1 + 1.14

62 + 4.97

63 + 5.42

Maternal Hb {gm%}

10.7 + 0.43

10.6 + 0.41

Newborn Weight{Kgs}

2.920 + 0.24

2.930 + 0.25

Maternal Weight{Kgs}

Table:2. Maternal birthing Positions On Obstetrical &

Perinatal Outcome. N=100+100= 200
Obstetrical &
Perinatal Outcome

Supported
Sitting

Supine
-Lithotomy

t[198] value

Efficient Uterine
contraction

92

92

75

75

21.052**

Drop in Baseline
Blood pressure

17

17

4.989**

Intensity of labor
pain

16

16

58

58

10.390**

{Score >90mm in
VAS}

93

93

87

87

4.320**

Regular
pattern

FHR

100

100

72

72

14.403**

Duration of 2nd stage

<70 mts

100

100

51

51

23.872**

Duration of 3rd stage

<20 mts

42

42

4.255**

Assisted Vaginal
Delivery--

74

74

51

51

3.450**

{Forceps/Vacuum/ }

84

84

71

71

3.240**

Apgar Sore 9 at 1
minute.

75

75

74

74

1.649NS;p>0.001

Apgar Sore 10 at 5
minutes.
Estimated Blood
Loss {300-500

Table 3: Association between the selected variables and

the outcome of labor. N=100+100= 200
Variables

Maternal birthing position

Supported Sitting

Supine- Lithotomy

Chi-square/ Fishers exact probability test [df1]

Maternal Weight

0.090** NS

0.165**NS

Maternal Hemoglobin 0.319 ** NS

0.335 **NS

Neonatal Weight

3.050**NS

3.470** NS

Use of Oxytocin

0.661** NS

0.548** NS

Use of Analgesics

0.717 ** NS

0.837 ** NS

NS = Not signicant

Regarding maternal birthing experiences majority

of the participants in the supported sitting maternal
birthing position group reported that they experienced
the position more comfortable for giving birth 92 Vs
54 {92% Vs 54%}, more perceived feelings of being
safe while pushing 94 Vs60{94%Vs 60%}, increased

perception of their active participation during pushing

92 Vs 23 {92% Vs 23%}, a fewer perception of prolonged
second stage of labor 21 Vs 89{21% Vs 89%}, reduced
perception of their delivery process more difcult 35
Vs 77{35%Vs 77%} and higher preference 93 Vs 61
{93% Vs 61%} of their assigned position for their next
childbirth.
The Chi square and Fishers exact probability
test were used to nd out the association between
the outcome of labor in the supported sitting and
the lithotomy maternal birthing position and the
selected variables such as the maternal weight
, hemoglobin level, neonatal weight, the use of
oxytocin and the analgesics. The result revealed no
signicant association between the outcome of labor
in the supported sitting and the lithotomy position
at p>0. 01 level and the selected variables such as
the maternal weight X2= 0.090 Vs X2= 0.165; neonatal
weight X2=3.050 Vs X2= 3.470; maternal hemoglobin
gm% X2=0.319 Vs X2=0.335; use of oxytocin X2= 0.717
Vs X2=0.837 and analgesics X2= 0.661Vs X2= 0.548.
[Table-3]
DISCUSSION
The most important nding of the present study
was that the supported sitting maternal birthing
position during the second and third stages of labor
was generally associated with a benecial obstetrical
and perinatal outcome with regard to shorter duration
of second and third stages of labor, efcient uterine
contractions and spontaneous bearing down efforts.
These clinical benets are presumed to be due to the
effects of gravity in upright birthing position that
augments the force of contractions, rapid descent of the
fetus and widening of the pelvic diameters. Consistent
ndings were reported by a randomized trials by
Gupta JK1{2004}, Nikodem VC 2{2006} and Bomm H
4
that the use of any upright position during second
stage of labor results in shorter duration of labor due
to efcient uterine contraction.
All the participants in the supported sitting position
[100%] maintained the normal baseline blood pressure
throughout and where as 17[ 17%] of the participants
in the supine lithotomy position had a drop in their
baseline blood pressure by 5 % . This could be possible
because in supine position , the weight of the gravid
uterus compresses the major abdominal blood vessels
resulting in supine hypotension. Similar findings
were reported by Ariel 5 who evaluated the effects of
supine versus non supine position on the maternal
blood pressure by the ultrasound estimation of blood
ow in the right branch of the uterine artery among
normal primigravidae that the maternal blood volume
fell rapidly from upright to supine position resulting

90

International Journal of Nursing Education. July-Dec., 2012, Vol. 4, No. 2

in supine hypotension.
In supported sitting position group there were a
fewer reports of excruciating intrapartal labor pain
as compared to supine lithotomy position group.
There was statistically a signicant reduction in the
labor pain scores by 12mm in VAS-100mm in the
supported sitting position group, which is consistent
with the ndings of Adachi 6 who evaluated the effects
of upright versus supine lithotomy position among
low risk term primigravidae, that the upright posture
during labor resulted in signicant reduction of labor
pain intensity by 13mm in VAS.
The present study revealed a signicant reduction in
the rate of instrumental delivery among the supported
sitting position group participants as compared to
supine lithotomy, which could be presumed to be due
to increased pelvic diameters and spontaneous bearing
down efforts in the upright birthing position. Similar
ndings were reported by Dejonge 3 that the use of
upright maternal position during labor signicantly
reduces the rate of instrumental delivery.
Supported sitting position was associated with a
benecial fetal and neonatal physiological parameters
in terms of fewer irregular FHR pattern and higher
Apgar scores of the newborns as compared to supine
lithotomy position. Similar ndings were reported
by Cito 7 who evaluated the effects of upright versus
supine lithotomy position on the FHR pattern among
low risk term primigravidae, that the supine lithotomy
position during labor was associated with a greater
number of variable deceleration of FHR pattern than
the upright maternal posture.
There were insignicant difference in the estimated
average amount of blood loss between the two groups[
340 Vs 330ml] which is consistent with the ndings of
Terry RR 8{2006} and Bodner A 9 {2003}. This indicates
that the upright supported sitting position is a safe
alternative maternal birthing position in terms of blood
loss during labor.
A supported sitting maternal birthing position was
associated with a more favorable maternal birthing
experiences in terms of fewer reports of excruciating
intrapartal labor pain, greater level of comfort, more
ease in pushing , greater perception of their active
participation during pushing, more perceived feelings
of being safe and greater degree of satisfaction. This
may be explained by the supported sitting position
being more exible when it comes to moving the
lower back, diverting some of the pressure to lower
spine may result in lower level of pain and greater
level of comfort . Consistent ndings were reported by
Mayberry 10 who compared womens preferences for
upright versus supine posture during labor, without

exception more positive responses from women using

the upright posture. The results showed that women
were able to maintain the upright posture throughout
the second stage following the epidural analgesic
administration with no adverse effect on maternal and
neonatal outcome.
The strengths of this study was homogenous
characteristic of the study participants with regard
to demographic and obstetrical variables, random
assignment of the participants to the groups, strict
inclusion criteria and low attrition rate of participants
from the assigned delivery position {0.02%}. A
limitation of the present study may be the limited
ability to generalize the findings to a population
including pre , post maturity, multiple pregnancy,
malpresentation, malpositions of the fetus and labor
induction.
CONCLUSION
In short the ndings of the present study suggest
that supported sitting maternal birthing position
during labor results in beneficial obstetrical and
perinatal outcome and a favorable maternal birthing
experiences without any risk to mother and fetus.
ACKNOWLEDGMENTS
I thank my guide Dr. G. Kasthuri, all the mothers
who participated, all the health professionals of
MMCH, Clinical authorities of BBMP and the
biostatistics department.
Conict of Interest: None
REFERECES
1.

2.

3.

4.

5.

Gupta JK, Hofmeyr GJ, Smyth R. Position in the

second stage of labor for women without epidural
anesthesia, Cochrane Database of Sys Rev; Issue
I , Art No CD002006; Doi 10 1002/14561858
CD002006,pub2.
Gupta JK, Nikodem VC. Womans position
during second stage of labor. Update in Cochrane
Data base. Sys. Rev. 2004(1): CD 00 2006.
DeJong A, Teunissen TA, Lagro - Janssen AL;
Supine position compared to other positions
during the second stage of labor: a meta analytic
review; J Psychosom Obstet Gynaecol; 2004 Mar;
25{1} 35-45.
Bomm-Hyppolito S; Inuence of the position of
the mother at delivery over some maternal and
neonatal outcomes; Int J Gynaecol Obstet; 1998;
Dec 63 suppl I; S67-S73.
Ariel J; Jaffa I; Gull RA; Joseph B; Lessing I W;
Effect of the Supine position on Uterine and

International Journal of Nursing Education. July-Dec., 2012, Vol. 4, No. 2 91

6.

7.

8.

Umbilical blood owduring the third trimester

of uncomplicated pregnancies in Multiparous
patients; Gynecol Obstet Invest ; 2001; 52{4} 252-6.
Adachi K, Shimada M, Usui A. The relationship
between the parturients positions and perceptions
of labor pain intensity; Nursing Research; 2003;
Jan-Feb; 52{1}; 47-51.
Cito Giuseppe; Luisi Stefano; Mezzesimi A;
Cavicchioli C; Calonaci G; Petraglia F; Fetal heart
rate pattern during nonstress test and fetal heart
rate patterns; Acta Obstet Gynecol Scand ; 2005
Apr: 84{4}; 335-338.
Terry RR, Westcott J, Oshea L, Kelly F. Post
partum outcomes in supine delivery by physicians

9.

10.

versus non supine delivery by midwives J . Am.

Osteopath. Assoc. 2006 Apr; 106 (4) 199-202.
Bodner-Adler. B, Bodner K, Kimberger O,
Lozanov P, Husslein P,Mayerhofer,K.; Womens
position during labor; Inuence on Maternal and
Neonatal Outcome; Wien Klin Wochenschr; 2003
Oct 31;115{19-20}720-3.
Mayberry LJ, Strange LB, Suplee PD, Gennaro
S, Use of upright positioning with epidural
analgesia; Findings from an observational study;
MCN AMJ Maternal Child Nursing ; 2003;MayJune; 28{3} 152-159.

Copyright of International Journal of Nursing Education is the property of Dr. R.K. Sharma and its content may
not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written
permission. However, users may print, download, or email articles for individual use.