European Journal of Obstetrics & Gynecology and Reproductive Biology 208 (2017) 46–54

Contents lists available at ScienceDirect

European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Review article

Position for labor and birth: State of knowledge and biomechanical

perspectives
David Desseauvea,b,* , Laetitia Fradetb , Patrick Lacoutureb , Fabrice Pierrea
a
Service de Gynécologie-Obstétrique et Médecine de la Reproduction, Centre Hospitalier Universitaire de Poitiers, France
b
Institut Pprime UPR 3346-CNRS, Axe RoBioSS, Université de Poitiers, France

A R T I C L E I N F O A B S T R A C T

Article history:
Received 29 August 2016 This review aims to examine how childbirth position during labour affects maternal, fetal and neonatal
Accepted 10 November 2016 outcomes. Epidemiological data suggest that vertical birthing positions have many benefits. But when we
consider the players and mechanisms of delivery, including the forces generated to move the fetus and
Keywords: obstacles to its progression, many questions remain about the advantage of one position over another.
Delivery Thus, childbirth could be considered in a way as an athletic feat that probably requires the choice of
Position optimal positions. These should be individually suited to each woman at different stage of labour to
Maternal improve its efficiency and effectiveness.
Labour
Tweetable abstract: Beyond epidemiological data, biomechanical investigations is necessary to assess
Biomechanics
birth’s position.
Outcomes
ã 2016 Elsevier Ireland Ltd. All rights reserved.

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Positions for giving birth: a conflict between monitoring, efficiency, and comfort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Horizontal position: a women’s or obstetrician’s choice? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Obstetric outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Mode of delivery and duration of labor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Fetal outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Maternal outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Limitations in the interpretation of results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Definition of position: an exposure bias? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Epidural analgesia: a confounding bias? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Obstetrical mechanics and position for giving birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
The descending fetus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
The obstacles to the moving fetus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
The pelvis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
The uterine cervix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Soft tissues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Uterine contractions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Effect of gravity? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
The questions that remain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

* Corresponding author at: Service de Gynécologie-Obstétrique et Médecine de la

Reproduction, CHU de Poitiers, 2 rue de la Milétrie, CS 90577, 86021 Poitiers Cedex,
France.
E-mail address: david.desseauve@univ-poitiers.fr (D. Desseauve).

http://dx.doi.org/10.1016/j.ejogrb.2016.11.006
0301-2115/ã 2016 Elsevier Ireland Ltd. All rights reserved.
 D. Desseauve et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 208 (2017) 46–54
Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Introduction
For several years, some postural approaches widely dissemi-
nated and marketed, have offered alternatives for women’s
positions at delivery [1]. Although these approaches appear to
be improving womens’ satisfaction, their effects in optimizing
spontaneous vaginal birth are still to be demonstrated.
We will begin by describing the different approaches to
positions for giving birth and the literature about their obstetric
impact. Then we will compare them with theories on obstetrical
mechanics. We will conclude with propositions on the potential
ways that research should be developed to answer the questions
that remain about positions for giving birth and obstetrical
mechanics.
Positions for giving birth: a conflict between monitoring,
efficiency, and comfort
Definition
The position for giving birth most widely used in maternity
units is based on the work of the 18th-century obstetrician,
François Mauriceau.1 This position, still called the semirecumbent
or the French birthing position was described in the 18th century
and developed into the recumbent or lithotomy position [2]. All of
these positions are considered horizontal, based on the position of
the waist relative to the horizontal plane [3]. Nonetheless, other
positions have been widely reported since early Antiquity,
especially those referred to as upright. In a 1961 study, Naroll
et al. reported that among 76 traditional cultures, only 14
spontaneously opt for a dorsal position for childbirth [4].
Engelmann and Jarcho observed that women, not influenced by
Western conventions, do not adopt the dorsal position and change
positions – mainly upright – during labor [5,6].
For midwives and others health care providers, Atwood’s article
remains the reference for the definition of these positions; it
nonetheless lacks precision [7]. Upright or vertical positions are
sometimes summarized as those where the woman’s feet are on
the ground, without any real consideration for the position of the
spine. Thus, in a very schematic presentation, positions for giving
birth are classified into two main groups (Table 1), depending on
the angle made by the horizontal plane and the line linking the
midpoints of the third and fifth lumbar vertebrae. When this line is
greater than 45 , the position is considered upright or vertical. It is
labeled horizontal when this angle is less than 45 . The squatting,
seated, suspended or standing positions, with their variants, are
therefore in the category of positions considered upright, while the
dorsal decubitus, lithotomy, gynecological, and lateral positions
and their variants are considered horizontal [7].
Unfortunately, this definition isn’t always quite so strict. Some
studies define upright positions by an angle greater than 30 [8].
1
According to some authors, Mauriceau, who was also a Greek scholar, was
inspired by Aristotle’s description of this birthing position, despite its rarity during
Antiquity
47
Epidemiology
Because women’s positions in the delivery room are not
routinely collected, their distribution is difficult to assess. Reviews
of the literature on the subject, essentially include randomized
trials, that seek to measure the obstetric consequences of specific
positions [9–11]. Accordingly, they do not provide precise
epidemiologic information about positions for giving birth. Studies
on the subject are rare and we were able to find only two
observational studies. An observational study of a large Swedish
cohort (12,782 women) sought to estimate the impact of positions
for giving birth on perineal tears and lacerations; it reported that
83.9% of births took place in a horizontal position [12]. Vertical
birth for giving birth position, like squatting, is rarely used in
countries with high medicalization of birth (less than 1% of women
during labor), while this position is most commonly used in
countries where childbirth occurs mainly at home (38.9% in Nepal)
[13]. A Brazilian study observed the same results, with 82.3% of
1079 women in a horizontal position [14]. The latter study also
offered a glimpse of the distribution of other positions for giving
birth: 16% in a left lateral position, 0.8% squatting or crouching,
0.7% on all fours, and 0.2% standing.
Horizontal position: a women’s or obstetrician’s choice?
The positions that women take in the delivery room are in fact
largely influenced by constraints related to the monitoring and
intervention during labor [15].
In a permanent effort to control residual risks as in aviation,
obstetricians promote the routine use of continuous fetal heart rate
monitoring, which is facilitated by the horizontal positions [16]. In
upright positions, walking around requires telemetric fetal heart
rate monitoring, which is available in very few maternity wards.
Horizontal positions also facilitate obstetric intervention and
monitoring of the progression of labor, by their easy access to the
woman’s perineum, particularly in the second phase of labor.
Obstetric outcomes
Although the lithotomy position still seems to optimize
obstetric monitoring and intervention today, it does have an effect
on the course of labor and on women’s comfort. Many authors have
suggested that upright positions have several obstetrical advan-
tages compared with horizontal positions [8]. The principal data
describing these advantages involve three types of outcomes:
obstetrical (duration of labor, use of operative vaginal or cesarean
delivery), fetal (fetal heart rate abnormalities), and maternal
(perineal lacerations, episiotomy, postpartum hemorrhage, and
pain).
Mode of delivery and duration of labor
A recent meta-analysis, which included 25 studies and 5218
women showed a reduction in the duration of the first stage of
labor for women in the upright compared to horizontal positions.
This study classified walking, use of a birth cushion, and seated,
standing, and kneeling positions as upright, while supine, semi-
recumbent, and lateral positions were treated as horizontal. The
time gained with the upright positions for labor is thought to be an
hour on average, but it may be significant only in multiparas (mean
gain of 90 min).
48 D. Desseauve et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 208 (2017) 46–54

Table 1
Classification of birthing positions according to Atwood [7].

Atwood’s classification

Supine Position Lateral (Sim’s) position

Semi-recumbent (trunk tilted to 30 to the horizontal
Lithotomy position
Trendelenburg’s position (head lower than pelvis)
Neutral Position Line connecting the center of a woman’s third and fifth vertebrae is more horizontal than vertical
Upright position (with gravity involved) Sitting (obstetric chair/stool)
Kneeling
Squatting unaided or using squatting bars
Squatting aided with birth cushion or partner

Cochrane review showed that upright positions might shorten
the second stage by approximately 4 min (4.28 min 95% CI [2.93–
5.63]). it also reduced the incidence of operative vaginal deliveries
(RR = 0.80 95% CI [0.69–0.92]) but had no effect on the cesarean rate
during this stage of labor. On the contrary, the rates of operative
vaginal or cesarean deliveries didn’t differ significantly for women
in upright compared with horizontal positions during the first
stage [11]. The same review reported that the position during the
first stage of labor had no significant impact on the duration of the
second stage [11].
Fetal outcome
Various hypotheses suggest that upright or lateral positions
may decompress the intra-abdominal vessels and thereby improve
uteroplacental perfusion and diminish the occurrence of fetal heart
rate (FHR) abnormalities [17]. To our knowledge, two studies
[18,19] have reported fewer FHR abnormalities in upright than in
horizontal positions. Their results are often reported in the various
reviews on this topic [8,20] but they must be interpreted with
prudence: as for one, the results are only of borderline significance
(OR = 0.28, 95% CI [0.08–0.98]), while the other only studied a small
number of individuals [18,19].
Maternal outcomes
According to Lawrence et al. women’s position during the first
stage of labor doesn’t influence their risks of second-degree
lacerations, episiotomy, or postpartum hemorrhage.
During the second stage of labor, upright, compared to
horizontal, positions may increase the risks of second-degree
lacerations (RR = 1.30, 95% CI [1.09–1.54]) and postpartum hemor-
rhage (RR = 1.76, 95% CI [1.34–3.32]) while reducing the risk of
episiotomy (RR = 0.73, 95% CI [0.64–0.84]) [8]. This association
between position for the birth, and sphincter ruptures was
reinforced by data from Sweden (where upright position was
commonly used in the 90ths). Samuelssson et al. suggested indeed
that the visualization and manual protection of perineum in
lithotomy position during the expulsion are important in
preventing sphincter injury [21]. This result was reinforced by a
great reduction of sphincter rupture (4.03–1.17%, p < 0.001) after a
national intervention in Norway which recommended the
lithotomy position during the expulsion stage and manual support
of perineum [22].

Fig. 1. Principal obstetric outcome explored in the 3 Cochrane reviews [8,9,20] comparing upright and horizontal positions for giving birth (odds ratio, with 95% confidence
interval).
 D. Desseauve et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 208 (2017) 46–54
Pain
In both the first and the second stages of labor, the parturient’s
position, whether upright or horizontal, does not affect her level of
pain [10,11]. In women without epidurals, upright positions are
reported to reduce the pain during labor (RR = 0.73, 95% CI [0.6–
0.90]) [9].
Limitations in the interpretation of results
The results and interpretation of the extensive reviews of the
literature, presented above, must be considered in balancing the
indisputable statistical power due to the number of subjects with
the questions raised by the definition of the interventions. Another
caution to bear in mind when interpreting the results is in the use
of epidural analgesia.
Definition of position: an exposure bias?
The studies suffer from a major exposure bias concerning
exposure classification (i.e. position). The absence of specific
descriptions and of any verification of the positions of the lower
limbs, and spine, makes the interpretation of these studies and the
comparison of positions for giving birth very imprecise. Moreover
upright position includes walking, in several studies [11]. Walking
cannot be compared with other position because it combines the
effect of the vertical position and pelvic movements, which is more
difficult to analyze.
Doubt remains then as to whether it is the upright position per
se that is favourable or does the upright position induce a specific
position of the lower limbs, and spine, that is favourable? There are
probably as many possible birth positions (upright or horizontal)
as ways for the head to meet the pelvis. What do obstetrical
mechanics tell us about this?
Epidural analgesia: a confounding bias?
Epidural analgesia is used for pain relief in labour by 78%
women in France [23]. One corollary to this mode of analgesia is
frequent, and frequently ignored, motor block. For obvious safety
reasons – to minimize the risk of falls – epidurals are often
associated with horizontal delivery positions. A walking or mobile
epidural is an analgesic alternative compatible with upright
Fig. 2. Comparison of the duration of the second stage of labor between the upright and horizontal positions for 3 Cochrane reviews on this subject [8,9,20]. Mean difference,
with 95% confidence interval).
49
positions with benefits for delivery outcome [25]. Its principal
constraint is the need to check the absence of motor block with a
sufficient analgesic effect. Its use is thus far marginal in France and
in other countries because several safeguards are necessary for safe
ambulation [24]. There is probably an association between position
and epidural analgesia which probably explains in part the low
prevalence of upright positions in many countries with high
epidural rates.
To eliminate the potential confounding induced by the use of
epidurals, two recent literature reviews studied the effect of
positions for giving birth in the second stage of labor while taking
epidural use into account. Gupta et al. studied the results for
women without epidurals while Kempt et al. examined the results
for a group of women who all had epidurals [9,20]. In the women
without epidurals, the comparison of maternal and fetal outcome
between the upright and horizontal positions did not differ
significantly from Gupta’s observations in an earlier study that did
not distinguish groups by epidural use [8] (see Figs. 1 and 2). On the
other hand, when all women had epidurals, neither maternal nor
fetal outcome differed between the two categories of position [20].
This absence of effect of delivery positions with epidural might be
explained by the reduction in uterine muscle activity caused by the
epidural and, even, by a motor block that also frequently inhibit
perineal muscle action [25,26]. In addition, some upright positions,
such as squatting, are difficult to maintain under epidural
anesthesia which leads to great variation in the exposure to
different positions during these studies [27,28].
Obstetrical mechanics and position for giving birth
Epidemiologic studies and clinical trials judge the effect of one
intervention compared with another retrospectively, often dis-
regarding their understanding of the mechanisms actually
involved. A basic description of these mechanisms, however,
would not only improve our understanding of the benefits
observed of one position for giving birth compared with another
but also our ability to reproduce them.
Human birth results from complex mechanisms involving:
& the passenger, a moving body: the fetus
50 D. Desseauve et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 208 (2017) 46–54

Fig. 3. Impact of hyperflexion on the position of the pelvic inlet.

& obstacles to the passage: Some authors assess that future studies on maternal position and

the bony passage through the pelvis, which presents three the descending fetus must resort to ultrasound assessment which
narrower passages or straits (upper, middle, and lower), is more precise than clinical examination for fetal head position or
which may be obstacles to be overcome by the descending orientation [34,35].
fetus or at the very least, elements of friction.
& the cervix, which will first undergo structural modifications The obstacles to the moving fetus
(ripening) and then dilate under the influence of uterine
contractions. The pelvis
& the soft tissue, specifically the musculotendinous tissue of the
pelvic floor. Pelvic dimensions. The movements of the pelvis and the
modification of the area around the entry to the pelvic inlet are
 A motor: uterine contraction and maternal pushing during the consistent with the theories of Faraboeuf published at the
expulsion stage. beginning of the 20th century [36] and described in obstetrics
textbooks [29]. These theories propose that the phenomena of
During delivery, continuous mechanical and biological inter- nutation and counternutation can significantly affect pelvic
actions occur between these different components and culminate dimensions, for example, by increasing the diameter of the
in birth. Few studies have examined the influence of position on pelvic inlet by 10 mm. Similarly, still according to Faraboeuf,
each of them. these movements of nutation and counternutation of the pelvis
may be accentuated, respectively, by the hyperflexion and
The descending fetus hyperextension of the thighs. A position for giving birth that
involves thigh hyperflexion may therefore affect the pelvic
Mechanical constraints during delivery depend on the fetal diameter.
diameters facing each obstacle. Ideally, the fetus will present with Some studies have sought to confirm these hypotheses but with
a maximally flexed head, which produces the minimal head divergent results. Thus it has been shown that some positions, such
diameter (sub-occipito-bregmatic diameter) at the entry to the as on all fours or squatting may increase some pelvic dimensions
pelvic inlet [29]. by 6–8 mm, in particular the bispinous diameter [37,38]. On the
The head is the most important part for obstetrical mechanics
because of its pseudo-incompressibility. Fetal molding is nonethe-
less possible by the overlapping of the occipital, parietal, and
frontal bony plates at the sutures, which reduces these diameters.
Except for exceptional and evident maternal or fetal malfor-
mations, there remains to this day no scientifically demonstrated
explanation of the causes of deflexion of the fetal head.
The maternal complications associated with delivery in an
occipito-sacral position are well known and postural treatment is
regularly proposed to correct this type of position [30,31].
Accordingly, several articles reviewed and summarized by
Hunter et al. proposed adapting the position for giving birth in
cases of posterior positions, hypothesizing that a maternal position
on all fours would induce better flexion, which in turn would
promote the rotation [32]. This maternal position should promote
flexion of the fetal head in moving it closer to the posterior bony
(occipital) contact point and distancing it from the anterior
(frontal) contact. A randomized trial assessing the impact of
positioning to correct this type of dystocia proved negative [33]. Fig. 4. The concept of an obstetric chute.
 D. Desseauve et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 208 (2017) 46–54
other hand, a more recent radiologic study studying pelvic
movement during MacRoberts’ manoeuvre (Fig. 3) shows that
this position does not modify pelvic diameter [39]. (Two points
may explain these divergent results. First, these studies do not at
all consider thigh flexion, although according to Faraboeuf, thigh
position can accentuate pelvic movements. Second, they do not
consider the ligamentous laxity of the study participants. That is,
these studies consider cohorts of women who are not pregnant and
thus avoid the impact of pregnancy on ligamentous laxity [40].
Now, this laxity increases almost constantly during pregnancy and
probably affects the ligaments of the pelvic bones [41].
Orientation of the pelvis and action on the spine. The position of the
legs, thighs and curvature of the lumbar spine, affect obstetrical
mechanics, as Aspasia, a midwife and Pericles’ partner, pointed out
two and a half millennia ago (cited by Aetius Amidenus, original
classical Greek text in Appendix A): “If the difficulty comes from the
curvature of the lumbar region, he (the physician) will put the
parturient in a position with her knees flexed so that, with the vulva
situated at the top, the pathways are easier” [42]. In a horizontal
position for example, reduction of the angle between the axis of
engagement and the horizontal, represented on Fig. 4 by the alpha
angle, may help to reduce the obstacle to fetal progression by
reducing the protrusion of the sacral promontory by obtaining a
sort of “obstetric chute”. This concept could be applied in all kind of
birth position.
According to Rosa, it may be possible to orient the pelvis to
correct the defects in its inclination, which may be a major cause of
mechanical dystocia [43–45]. In these case reports on so-called
rational obstetrical mechanics, he reported that a global obstetric
approach including the position of the woman as well as the
architecture of the pelvis enables vaginal delivery without
difficulty in cases in which cesareans appeared necessary [45].
Certainly, these articles date back to a period when cesareans were
not performed in conditions as safe as they are today. But his
report, based on clear obstetrical reasoning, implies that delivery
can occur only when the uterine contraction, the axis of
engagement, the descending fetus and the pelvic diameters all
fit together.
Some authors have successfully attempted to act on the
orientation of the pelvic inlet and any lumbar lordosis, as for
example, Ghermann et al. have done, using MacRoberts’ maneuver
(see Fig. 3) [39]. The particularity of this maneuver, from a
Fig. 5. Result of the forces present at delivery a) In an upright position b) in a horizontal position. Legend: UC Uterine Contraction, G Gravity, R Result.
51
biomechanical perspective, is that this position solicits the lumbar-
pelvic-femoral complex. This complex has been intensively studied
in orthopedics, especially in relation to hip prosthesis and their
effects on pelvic stability and position [46]. The interrelation of
these three elements has not been explored very well in obstetrics,
especially in terms of the positions of women during labor.
The uterine cervix
The uterine cervix has a contradictory role during pregnancy.
During pregnancy, the cervix has a protecting role. During this
period of time, cervix has to remain firmly closed by providing
sufficient resistance to pressure from the above growing struc-
tures. At the opposite, at delivery, the cervix has to soften in order
to let the fetus go through. Consequently, during childbirth, it can
be seen as an obstacle to pass. Nearly 10% of C-section (stagnation
of dilatation) in the USA are for example attributed to cervix
unappropriated dilatation according to Barber et al. [47].
Women’s positions do not appear a priori to affect the structure
or position of the cervix as an obstacle to the passenger.
Nonetheless, upright positions, by shortening the first stage of
labor and therefore the stage of cervical dilatation, seem to act on
the cervix.
Glass et al. consider the uterus as a sort of elastomer similar to
nylon [48]. A force applied to this type of material for a minimum
duration and intensity can shorten its hysteresis loop, by
preventing a return to the initial state [49]. The shortened loop
may be the mechanism that explains the influence of position on
cervical dilatation. In this case, the influence of positions on
cervical dilatation may come instead from the forces exerted on the
cervix by more effective uterine contractions or greater movement
by the fetus – the only actions that can shorten this loop.
Soft tissues
The influence of the woman’s position during labor on the soft
tissue as an obstacle to fetal descent is not well known. During the
fetal-pelvic confrontation, the resistance at play includes, as
mentioned previously, the bony pelvis but also the soft tissues that
surround it and which are the source of the concept of a soft pelvis
as a musculoaponeuvrotic funnel that closes the bony cavity and
creates a perineal pelvic floor.
The deformation of these soft parts is manifested principally by
the stretching of the levator ani muscle. According to the obstetric
model developed by Ashton-Miller et al., at delivery these muscles
52 D. Desseauve et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 208 (2017) 46–54
should support being stretched 3.26 times their length, although
we know that the striated muscles of the body usually rupture
when stretched to 1.5 times their length [50]. The literature has not
adequately or directly evaluated the viscoelastic properties of the
pelvic floor; rather what is assessed is the force supported by the
pelvic floor, using the term tone. In an observational prospective
case-control study, Aran et al. observed that women who
underwent cesareans for failed induction had higher pelvic tone
than those with vaginal deliveries [51].
The impact of the pelvic floor during delivery is still poorly
understood: some hypothesize that an overdeveloped pelvic floor
might obstruct the fetal exit, but other results seem to show the
inverse [52–54]. The respective roles of flexibility, elasticity, and
force production in this muscle group remain to be described in
detail, to improve our understanding of its role during delivery. The
pelvic floor may have a mixed role: active in the orientation of the
presentation by the forces it exerts, and passive by the deformation
it undergoes. The attempts to model the muscle activity of the
pelvic floor during delivery have shown that the forces exerted by
the perineal muscles on the passenger increase as it descends
through the pelvis [55]. These finite-element models are simu-
lations that do not allow us to go further in understanding labor.
Nonetheless, they may make it possible to model the variations in
muscle activity induced by different positions for giving birth.
Coming back to maternal positions, there is up to now no reason
to evoke any influence of the position on the perineum properties.
Uterine contractions
Uterine contractions play an essential role in obstetrical
mechanics. That is, a contraction modifies the intrauterine
pressure, which in turn exerts a force enabling fetal movement.
The force exerted by the fetus on the deformable soft tissues also
depends on the uterine contraction.
As we have already pointed out, many studies report that the
first stage of labor is shortened in women in upright positions,
compared to those in horizontal positions [8,11]. One hypothesis
explaining these results may be that uterine contractions are more
effective in an upright position. Nonetheless, in principle there are
no physiological explanations for the advantage of an upright
compared to a horizontal position in terms of the intensity of
uterine muscle activity.
Mendez-Bauer has shown that the intensity of uterine
contractions (measured with intrauterine pressure sensors)
increases when the woman moves into an upright position during
labor [56]. However, Chen et al. and failed to confirm these
findings; they found no real difference between upright and
horizontal positions in terms of intensity [56]. The limitations of
intrauterine pressure sensors, which provide more qualitative than
quantitative information on the contractions, may, however,
explain the differences in these conclusions [57].
Effect of gravity?
Another hypothesis advanced to explain the advantage of
upright over horizontal positions in shortening the time of labor
lies in the contribution of gravity to the force acting on the
“descending passenger” [58]. Horizontal positions may reduce a
part of the gravity that acts on the fetus through the birth canal and
thus compromise progression. The direction of the various forces
present (gravity, force due to uterine contraction, and Archimedes’
buoyancy, which we are ignoring here) diverge as the torso inclines
towards the horizontal (see Fig. 5). We can thus easily understand
that the forces acting on the descending fetus will be most
effective, to the extent that, they are closest to the direction of
gravity, as in upright positions. Ashton-Miller et al. estimate that
the pelvic floor is subjected to a force on the order of 37 N in an
upright position compared with 19 N in supine (for a differential of
18 N), while a peak uterine contraction can engender a force on the
pelvic floor of 54 N, and voluntary pushing 120 N. These estimates
indicate that the role of gravity during labor is not negligible, but is
much more limited than during pushing [50].
The questions that remain . . .
In 1952, Rosa formulated the possibility of optimizing the
woman’s position to promote the course of labor. Several case
reports describe the application of these principles to dystocia
[45]. Rosa’s approach requires control of the positions of the pelvis
and spine, by, for example, acting on the mother’s flexion of her
thighs. As aforementioned, Faraboeuf also proposed that the
dimensions of the pelvis could be enlarged slightly by positioning
the pelvis favorably by inducing hyperflexion of the thighs.
One pathway that research in obstetric biomechanics might
follow would be to characterize the influence of the position of the
thighs, pelvis, and spine on positions for giving birth to improve
our understanding of the source of their differences in obstetric
outcome.
New methodological solutions are also needed to improve the
measurement of the intensity of the force of uterine contractions
but also to characterize more clearly the properties of the maternal
soft tissue deformed by the fetus (pelvic floor and cervix). Only
then can we fully establish and understand the role of positions for
giving birth.
Well-being during delivery presumes aiming toward a birth as
physiological as possible. The role of the professional is thus to
optimize this difficult event by increasing the woman’s efficiency
while diminishing her exertion, fatigue, and perceived pain, and
simultaneously ensuring the primary objective: the well-being of
mother and child. This probably requires scientifically validated
support and a return to a purely fundamental and modern
approach through the resources available in biomechanic labora-
tories. The properties of a material, the measurement of types of
forces, characterization of positions of human parts – all of these
are elements to be fully investigated by biomechanics. All of the
factors playing a role during delivery must therefore be studied in
relation to and for the purpose of optimizing the position for giving
birth.
A delivery that can be envisioned as a sports event probably
requires the choice of optimal positions individual to each woman
at different stages of labor to improve her efficiency and her
effectiveness [59].
Conflict of interest
The authors have no conflict of interest to report.
Acknowledgements
We would like to thank Pascal Luccioni, Associate Professor in
HISOMA laboratory for his help for the translation of ancient Greek
text.
We likewise wish to thank Eleanor Hickey for her midwife
vision, Mathieu Menard PhD student at Pprime institute for the
illustrations, and Jo Ann Cahn, for translating and editing the
original manuscript.
Appendix A.
Original classical Greek text: [42]
 D. Desseauve et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 208 (2017) 46–54
References
[1] Ducloy-Bouthors A-S, De Gasquet B, Davette M, Cuisse M. Postures maternelles
pendant le travail: description et interférence avec l’analgésie péridurale. Ann
Fr Anesth Reanim 2006;25:605–8.
[2] Dunn PM. Francois Mauriceau (1637–1709) and maternal posture for
parturition. Arch Dis Child 1991;66:78–9.
[3] Androutsos G. La lithiase urinaire et son traitement par Ambroise Paré (1509–
1590)]. Prog Urol 2004;14:109–17.
[4] Naroll F, Naroll R, Howard FH. Position of women in childbirth. A study in data
quality control. Am J Obstet Gynecol 1961;82:943–54.
[5] Engelmann GJ. Labor among primitive peoples. JH Chambers & Company;
1884.
[6] Jarcho J. Postures & practices during labor among primitive peoples:
adaptations to modern obstetrics. PB Hoeber; 1934.
[7] Atwood RJ. Parturitional posture and related birth behavior. Acta Obstet
Gynecol Scand 1976;55:3–25.
[8] Gupta JK, Hofmeyr GJ. Position for women during second stage of labour.
Cochrane Database Syst Rev 2004;1:CD002006.
[9] Gupta JK, Hofmeyr GJ, Shehmar M. Position in the second stage of labour for
women without epidural anaesthesia. Cochrane Database Syst Rev 2012;5:
CD002006.
[10] Gupta JK, Nikodem VC. Woman’s position during second stage of labour.
Cochrane Database Syst Rev 2000;2:CD002006.
[11] Lawrence A, Lewis L, Hofmeyr GJ, Styles C. Maternal positions and mobility
during first stage labour. Cochrane Database Syst Rev 2013;10:CD003934.
[12] Gottvall K, Allebeck P, Ekeus C. Risk factors for anal sphincter tears: the
importance of maternal position at birth. BJOG 2007;114:1266–72.
[13] Lien Y-S, Chen G-D, Ng S-C. Prevalence of and risk factors for pelvic organ
prolapse and lower urinary tract symptoms among women in rural Nepal. Int J
Gynaecol Obstet 2012;119:185–8.
[14] da Silva FMB, de Oliveira SMJV, Bick D, Osava RH, Tuesta EF, Riesco MLG. Risk
factors for birth-related perineal trauma: a cross-sectional study in a birth
centre. J Clin Nurs 2012;15–16:2209–18.
[15] Spiby H, Slade P, Escott D, Henderson B, Fraser RB. Selected coping strategies in
labor: an investigation of women’s experiences. Birth 2003;30:189–94.
[16] Müller M. Risk and error management: can medicine benefit from lessons
learned in aviation. Bundesgesundheitsblatt Gesundheitsforschung Gesund-
heitsschutz 2015;58:95–9.
[17] Cyna AM, Andrew M, Emmett RS, Middleton P, Simmons SW. Techniques for
preventing hypotension during spinal anaesthesia for caesarean section.
Cochrane Database Syst Rev 2006;4:CD002251.
[18] Golara M, Plaat F, Shennan AH. Upright versus recumbent position in the
second stage of labour in women with combined spinal-epidural analgesia. Int
J Obstet Anesth 2002;11:19–22.
[19] de Jong PR, Johanson RB, Baxen P, Adrians VD, van der Westhuisen S, Jones PW.
Randomised trial comparing the upright and supine positions for the second
stage of labour. Br J Obstet Gynaecol 1997;104:567–71.
[20] Kemp E, Kingswood CJ, Kibuka M, Thornton JG. Position in the second stage of
labour for women with epidural anaesthesia. Cochrane Database Syst Rev
2013;1:CD008070.
[21] Samuelsson E, Ladfors L, Wennerholm UB, Gåreberg B, Nyberg K, Hagberg H.
Anal sphincter tears: prospective study of obstetric risk factors. BJOG
2000;107:926–31.
[22] Laine K, Pirhonen T, Rolland R, Pirhonen J. Decreasing the incidence of anal
sphincter tears during delivery. Obstet Gynecol 2008;111:1053–7.
[23] Blondel B, Lelong N, Kermarrec M, Goffinet F, National Coordination Group of
the National Perinatal Surveys. Trends in perinatal health in France from 1995
to 2010. Results from the French National Perinatal Surveys. J Gynecol Obstet
Biol Reprod (Paris) 2012;41:1–15.
[24] Wong CA. Advances in labor analgesia. Int J Womens Health 2010;1:139–54.
[25] Bates RG, Helm CW, Duncan A, Edmonds DK. Uterine activity in the second
stage of labour and the effect of epidural analgesia. Br J Obstet Gynaecol
1985;92:1246–50.
[26] Bicknell RJ, Leng G, Russell JA, Dyer RG, Mansfield S, Zhao BG. Hypothalamic
opioid mechanisms controlling oxytocin neurones during parturition. Brain
Res Bull 1988;20:743–9.
53
[27] Gardosi J, Sylvester S, B-Lynch C. Alternative positions in the second stage of
labour: a randomized controlled trial. Br J Obstet Gynaecol 1989;96
(November):1290–6.
[28] Wong CA. Nerve injuries after neuraxial anaesthesia and their medicolegal
implications. Best Pract Res Clin Obstet Gynaecol 2010;24:367–81.
[29] F. Cunningham, K. Leveno, J. Hauth, Williams obstetrics, 24 ed., 2014.
[30] Cheng YW, Hubbard A, Caughey AB, Tager IB. The association between
persistent fetal occiput posterior position and perinatal outcomes: an example
of propensity score and covariate distance matching. Am J Epidemiol
2010;171:656–63.
[31] Cheng YW, Shaffer BL, Caughey AB. Associated factors and outcomes of
persistent occiput posterior position: a retrospective cohort study from 1976
to 2001. J Matern Fetal Neonatal Med 2006;19:563–8.
[32] Hunter S, Hofmeyr GJ, Kulier R. Hands and knees posture in late pregnancy or
labour for fetal malposition (lateral or posterior). Cochrane Database Syst Rev
2007;4:CD001063.
[33] Desbriere R, Blanc J, Le DÛ R, Renner J-P, Carcopino X, Loundou A, et al. Is
maternal posturing during labor efficient in preventing persistent occiput
posterior position? A randomized controlled trial. Am J Obstet Gynecol
2013;208(60):e1–8.
[34] Malvasi A, Giacci F, Gustapane S, Sparic R, Barbera A, Tinelli A. Intrapartum
sonographic signs: new diagnostic tools in malposition and malrotation. J
Matern Fetal Neonatal Med 2016;29:2408–13.
[35] Ramphul M, Ooi PV, Burke G, Kennelly MM, Said S a T, Montgomery AA, et al.
Instrumental delivery and ultrasound: a multicentre randomised controlled
trial of ultrasound assessment of the fetal head position versus standard care
as an approach to prevent morbidity at instrumental delivery. BJOG
2014;121:1029–38.
[36] Farabeuf LH, Varnier H, Pinard A. Principes Fondamentaux D’Obstétrique,
Vérifiés, Rectifiés Ou Établis À L’Aide De L’éxpérimentation Sur Le Mannequin
Naturel Et De L’Observation Sur La Parturiente. Introduction À L’étude Clinique
Et À. La Pratique Des Accouchements. Paris: G. Steinheil; 1904.
[37] Russell JG. Moulding of the pelvic outlet. J Obstet Gynaecol Br Commonw
1969;76:817–20.
[38] Michel SCA, Rake A, Treiber K, Seifert B, Chaoui R, Huch R, et al. MR obstetric
pelvimetry: effect of birthing position on pelvic bony dimensions. AJR Am J
Roentgenol 2002;179:1063–7.
[39] Gherman RB, Tramont J, Muffley P, Goodwin TM. Analysis of McRoberts’
maneuver by x-ray pelvimetry. Obstet Gynecol 2000;95:43–7.
[40] Calguneri M, Bird HA, Wright V. Changes in joint laxity occurring during
pregnancy. Ann Rheum Dis 1982;41:126–8.
[41] Dumas GA, Reid JG. Laxity of knee cruciate ligaments during pregnancy. J
Orthop Sports Phys Ther 1997;26:2–6.
[42] Aetius Amidenus. In: lib XVI,25.
[43] Rosa PA. Pelvimetry, pelvigraphy and rational obstetrical mechanics. Bull Fed
Soc Gynecol Obstet Lang Fr 1951;3:398–408.
[44] Hainaut J, Rosa P. Example of rational mechanics applied to obstetrics. Bulletin
De La Fédération Des Sociétés De Gynécologie Et D’obstétrique De Langue
Française 1952;4:659–63.
[45] Rosa P. A new example of rational mechanics: spondylolisthesis and childbirth
by the natural route. Bull Soc R Belge Gynecol Obstet 1960;31:581–4.
[46] Lazennec J-Y, Rousseau MA, Catonne Y. Biomécanique du complexe lombo-
pelvi-fémoral Conséquences fonctionnelles des relations hanche-rachis.
Réflexions autour du bassin. Paris: Springer; 2011. p. 1–16.
[47] Barber EL, Lundsberg LS, Belanger K, Pettker CM, Funai EF, Illuzzi JL. Indications
contributing to the increasing cesarean delivery rate. Obstet Gynecol
2011;118:29–38.
[48] Glass BL, Munger RE, Johnson WL. Instrument to measure tissue softness of the
uterine cervix in pregnancy. Med Res Eng 1968;7:34–5.
[49] Moore DF, Geyer W. A review of hysteresis theories for elastomers. Wear
1974;30:1–34.
[50] Ashton-Miller JA, Delancey JOL. On the biomechanics of vaginal birth and
common sequelae. Annu Rev Biomed Eng 2009;11:163–76.
[51] Aran T, Osmanagaoglu MA, Kart C, Guven S, Sahin M, Unsal MA. Failed labor
induction in nulliparous women at term: the role of pelvic floor muscle
strength. Int Urogynecol J 2012;23:1105–10.
[52] Bø K, Fleten C, Nystad W. Effect of antenatal pelvic floor muscle training on
labor and birth. Obstet Gynecol 2009;113:1279–84.
54 D. Desseauve et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 208 (2017) 46–54
[53] Agur W, Steggles P, Waterfield M, Freeman R. Does antenatal pelvic floor
muscle training affect the outcome of labour? A randomised controlled trial.
Int Urogynecol J Pelvic Floor Dysfunct 2008;19:85–8.
[54] Salvesen KA, Mørkved S. Randomised controlled trial of pelvic floor muscle
training during pregnancy. BMJ 2004;329:378–80.
[55] Parente MP, Natal Jorge RM, Mascarenhas T, Silva-Filho AL. The influence of
pelvic muscle activation during vaginal delivery. Obstet Gynecol
2010;115:804–8.
[56] Chen SZ, Aisaka K, Mori H, Kigawa T. Effects of sitting position on uterine
activity during labor. Obstet Gynecol 1987;69:67–73.
[57] Steer PJ. Standards in fetal monitoring–practical requirements for uterine
activity measurement and recording. BJOG 1993;100(Suppl. 9):32–6.
[58] Gizzo S, Di Gangi S, Noventa M, Bacile V, Zambon A, Nardelli GB. Women’s
choice of positions during labour: return to the past or a modern way to give
birth? A cohort study in Italy. Biomed Res Int 2014;2014:638093.
[59] Desseauve D, Lacouture P, Pierre F. “Birth is like a marathon” revisiting
childbirth by using sports biomechanics approaches. [Internet]. 33rd
International Conference on Biomechanics in Sports; 2015; Poitiers. Dis-
ponible sur: http://isbs2015.sciencesconf.org/60518.