European Journal of Obstetrics & Gynecology and

Reproductive Biology 92 (2000) 273–277 www.elsevier.com / locate / ejogrb

Case Report

Maternal posture in labour

a, b
Janesh K. Gupta *, Cheryl Nikodem
a
Department of Obstetrics and Gynaecology, University of Birmingham, Birmingham Women’ s Hospital, Edgbaston, Birmingham B15 2 TG, UK
b
Department of Obstetrics and Gynaecology, Coronation Hospital and University of Witwatersrand, Private Bag X21, Newclare 2112, South Africa

Received 14 May 1999; received in revised form 23 September 1999; accepted 8 November 1999

Abstract

The position adopted naturally by women during birth has been described as early as 1882 by Engelmann. He observed that primitive
woman, not influenced by Western conventions would try to avoid the dorsal position and was allowed to change position as and when
she wished. Different upright positions could be achieved using posts, slung hammock, furniture, holding on to a rope, knotted piece of
cloth, or the woman could kneel, crouch, or squat using bricks, stones, a pile of sand, or a birth stool. Today the majority of women in
Western societies deliver in a dorsal, semi-recumbent or lithotomy position. It is claimed that the dorsal position enables the
midwife / obstetrician to monitor the fetus better and thus to ensure a safe birth.
This paper examines the historical background of the different postions used and its evolution throughout the decades. We have
reviewed the available evidence about the effectiveness, benefits and possible disadvantages for the use of different positions during the
first and second stage of labour.  2000 Elsevier Science Ireland Ltd. All rights reserved.

1. Historical background supported by bricks, stones, a pile of sand, or a birth stool

A cross-cultural and historical look at birth practices
shows that in traditional societies the woman is free to
move about and to change position as and when she wishes
[1–3]. A supine position is extremely rare, though women
may lie on their sides from time to time, interspersing this
with other upright positions. The midwife and others
helping may advise the woman to alter her position or
make a particular pelvic movement. They lend their own
bodies to her for physical support and may move with her
as she moves in synchronised rocking or circling of the
pelvis, and shifting weight between her feet. The labouring
woman may also have support in an upright position from
posts, slung hammock, or furniture, or may hold on to a
rope, knotted piece of cloth, or kneel, crouch, or squat
*Corresponding author. Tel.: 144-121-607-4751; fax: 144-121-414-
1576.
E-mail addresses: j.k.gupta@bham.ac.uk (J.K. Gupta),
091niko@chiron.wits.ac.za (C. Nikodem).
0301-2115 / 00 / $ – see front matter  2000 Elsevier Science Ireland Ltd. All rights reserved.
PII: S0301-2115( 99 )00272-9
[1,2].
In Western culture, in contrast, birth is perceived pri-
marily in terms of the activity of the uterus and the acts of
the attendants, rather than the woman giving birth [4].
During the past 300 years, medical opinion has favoured a
shift to recumbent positions but this has been implemented
without supporting scientific evidence [5].
The changes that led to the birth of recumbency in
labour began in France with the advent of obstetric
surgeons in the 17th century. These changes have been
tracked back to Amboise Pare and his followers in Hotel
Dieu, although it was popularised 50 years later by
François Mauriceau who held an influential position in the
French Court of Louis XIV [6]. The King supposedly
preferred the recumbent position for his labouring wife,
`
Louise De La Valliere, because of his own interest in
viewing the birth [7]. In 1668, when only 31, Mauriceau
published his great work Traite´ des Malaides des Femmes
´ [8]. Two years later Mauriceau was
Grosses et Accouchees
visited by Hugh Chamberlen, a member of the British
274 J.K. Gupta, C. Nikodem / European Journal of Obstetrics & Gynecology and Reproductive Biology 92 (2000) 273 – 277
aristocracy that possessed the secret of the obstetric
forceps, who then translated the book into English. The
influence of this work on many aspects of midwifery at
that time was immense [9].
2. Twentieth century perspective
There are thought to be several factors that have
influenced the reinforcing of the recumbent position for
labour during this time. It is suggested by Wooden [10],
that the social and health care practices that prevailed
during the late 19th and early 20th centuries were con-
comitant with changes introduced by the Industrial Revolu-
tion. Among these care practices was the transition of
childbirth from the home to the hospital. Although the
initial rationale of professional hospital maternity practice
was ‘protection’ of pathologic cases, the hospital environ-
ment imposed medical institutionalisation on all childbear-
ing women, even when the pregnancy or birth was a
normal healthy one. In addition, the prevailing Victorian
ideal of ‘pure womanhood’ at that time contributed to
reinforcing a ‘sick’ role on the parturient. Thus, diseases
focus and sick role orientation contributed to the care of
the labouring woman, as of any other hospitalised patient,
in bed. This basic inconsistency of a disease-oriented
approach when no disease existed has continued to char-
acterise maternity care [11,12]. Simultaneously, female
midwives were being ‘replaced’ by male midwives and
physicians, culminating in the development of a different
obstetric viewpoint: that of perinatal medicine. Immobility
during labour and even restraint during birth became
common phenomena, especially as the use of drugs
(paralysing agents and general anaesthetics) became more
frequent especially during the first half of the 20th century.
As one of today’s most prolific writers on this topic has
aptly summarised: ‘In contemporary Western Society the
culture pattern imposed on women is predominantly
medical. Medicine has taken over from religion the power
and authority of the priesthood. Birth is a medical crisis,
the termination of a disease called ‘pregnancy’. Labour is
the sum of the interaction between the ‘passage, the
powers and the passenger’. The woman has no part in this
equation. There is a skeletal framework, uterine contrac-
tions, and a fetus. This reproductive mechanism is always
at risk of functioning ineffectively. The obstetrician is the
senior mechanic and primer of the endocrine pump’ [4].
3. Different postures
Man differs from apes by his standing posture, but this
is only one among some 1000 body positions of which he
is capable of [13]. There are a whole complex of factors —
anatomical, physiological, psychological, cultural, environ-
mental, technological — that are involved in the evolution
of the many different postural habits that people of all
races, cultures and times have assumed. There are postures
that can be considered universal. The ordinary upright
stance, with the arms hanging straight down or with the
hands clasped in front or behind belongs to this category
together with the deep squat. Interestingly, a quarter of
mankind habitually takes the load off its feet by crouching
in a deep squat, both at rest and at work. Chair sitting,
however, does not belong to this category [13].
4. Clinical studies
Several physiological advantages have been claimed for
non-recumbent or upright labour: (i) the effects of gravity,
(ii) lessened risk of aorto-caval compression and improved
acid–base outcomes in the new-borns [14–16], (iii)
stronger and more efficient uterine contractions [17,18],
(iv) improved alignment of the fetus for passage through
the pelvis (‘drive angle’) [19], and (v) radiological evi-
dence of larger antero-posterior [20] and transverse [21]
pelvic outlet diameters, resulting in an increase in the total
outlet area in the squatting [22–24] and kneeling positions
[24].
5. First stage of labour
Clinical studies reporting outcomes from comparing
upright and supine positions in the first stage of labour
have been inconclusive and provided conflicting evidence.
A prime example of this is aptly illustrated by the various
studies reporting the benefits of ambulation in the first
stage of labour. There are inevitable difficulties in design-
ing randomised clinical trials where it is impossible to
blind participants and caregivers to the group to which
they have been assigned, and very difficult to blind those
assessing outcomes. Furthermore, the study designs vary
greatly such that women who were assigned to an upright
could stand, walk or sit during the entire first stage of
labour, or to a group asked to remain recumbent in bed in a
supine or left lateral position [25–35]. Women not in-
frequently had difficulty in maintaining the assigned
position; Chan [26], for example, reported that women
assigned to maintain an upright position during labour
‘complained bitterly’ about remaining erect throughout
labour and wanted to rest in bed during the latter part. In
consequence, the conclusions varied considerably. A paper
that showed a benefit from ambulation [30] and that which
did not [31] supports this. In one trial [29] labour was
actually longer in the ambulant group than in the recum-
bent group. It has been suggested that there are too many
physiological and emotional variables associated with
labour to make the results of randomised studies in this
field of obstetrics meaningful [36]. One possible interpreta-
tion of these findings is that it is the short ‘easy’ labours,
 J.K. Gupta, C. Nikodem / European Journal of Obstetrics & Gynecology and Reproductive Biology 92 (2000) 273 – 277
which permit ambulation rather than ambulation producing
‘easy’ labours [37].
6. Second stage of labour
In contrast, studies carried out to investigate the effect of
maternal posture in the second stage of labour are easier to
interpret. Most have used specially manufactured birthing
chairs and compared the sitting position with the more
conventional ‘propped’ dorsal position [38–41]. This has
the advantage of standardising the posture adopted by
women in the study group. Although chairs are preferred
by some women, no advantages have been found with
regard to the length of second stage, need for instrumental
delivery or the degree of perineal trauma. However, there
Table 1
275
has been one consistent finding — birthing chair delivery
is associated with a greater blood loss at delivery [40–42].
It has been suggested that the squatting position is the
most effective position for pushing in the second stage of
labour as it enables the woman to direct her bearing down
force in the direction of the birth canal [43–47]. Altogether
there have been 18 randomised trials to assess the maternal
and neonatal effects of upright positions (which include
squatting, kneeling and birthing chairs) compared to re-
cumbent positions during the second stage of labour [50].
However, these trials exemplify the numerous difficulties
facing investigators who have attempted to study this area
of pregnancy, and there are a number of specific problems
in interpreting these results. In several of the studies,
women experienced difficulty in assuming the allocated
upright position, adopting instead the recumbent position
276 J.K. Gupta, C. Nikodem / European Journal of Obstetrics & Gynecology and Reproductive Biology 92 (2000) 273 – 277
for delivery. For example, in the trial by Gardosi et al.
[44], only 49% of women allocated to the upright position
were able to kneel or squat for the second stage of labour,
with 22% managing the upright position during delivery.
Only two women out of 73 managed to squat for the actual
delivery. This was also particularly the main problem in
the randomised study reported [48] where only 11 out of
49 women assigned to the squatting position actually
managed to maintain the unsupported squatting position
for delivery. Despite a second trial of attempting to assess
the supported squatting position, only three out of 13
managed to use the birth cushion effectively [49].
The systematic analysis of all the studies suggest that
the upright posture for the second stage of labour has
certain advantages over the dorsal position [50] (Table 1).
For women allocated to upright positions, the duration of
second stage of labour was reduced by 5.4 min (95%
confidence interval (CI) 3.9 to 6.9 min). There was a small
reduction in assisted deliveries, fewer episiotomies which
was partly offset by an increase in second degree perineal
tears. Postpartum haemorrhage based on estimation of
blood loss was more common although this was exclusive-
ly a problem in women using birthing chairs. Fewer
women reported experiencing severe pain at birth and
fewer abnormal fetal heart rate patterns were recorded. No
significant differences were demonstrated for: analgesia or
anaesthesia use during second stage of labour, Caesarean
section, third or fourth degree perineal tears, need for
blood transfusion, manual removal of the placenta, un-
pleasant birth experience, dissatisfaction with second stage
of labour (expressing a preference for the upright posture
in their next birth), feeling out of control, persistent occiput
posterior position, admission to neonatal intensive care
unit, birth injuries and perinatal death.
Despite the anatomic and physiologic advantages of the
upright posture, there is one important factor that seems to
influence the maintenance of the upright position, in
particular the squatting position. Most Western women are
unaccustomed to squatting and, therefore, have difficulty in
retaining this position for prolonged periods of time. This
may be due to two main reasons. Firstly, Western society
habits have adversely influenced the fitness and stamina to
maintain a squatting position. Secondly, midwifery and
patient bias has resulted in most expecting a delivery in
bed, in either a left lateral or semi-recumbent position.
Without the extra concern and motivation required to
achieve an upright birth, it would seem that midwifery and
patient expectation provide powerful resistance to change.
7. Conclusions
Overall, it is clear that no single care practice is best for
labour since it is a dynamic and not a static process. Care
providers and birth attendants should be willing, suffi-
ciently knowledgeable, and permitted by their institutions
to help the labouring woman try various birth positions
during labour. The available evidence suggests that the
upright posture in labour is not harmful to either mother,
fetus or to the progress of labour. Women should be
encouraged to adopt whatever posture they find comfort-
able in both the first and second stage of labour.
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