Minimizing Genital Tract Trauma and Related Pain Following Spontaneous Vaginal Birth

Leah L. Albers, CNM, DrPH; Noelle Borders, CNM, MSN


J Midwifery Womens Health. 2007;52(3):246-253. 

In This Article

Positioning for Birth

Most women in the United States push and give birth while lying flat on their backs. The first Listening to Mothers Survey[22] estimated that 74% of women who delivered vaginally in 2002 did so while in a recumbent or lithotomy position. But upright or lateral positions for birth are associated with greater maternal comfort and less perineal injury.[23] A Cochrane review on this topic combined data from 20 clinical trials that included 6135 women. Compared with women who gave birth in supine or lithotomy positions, women who were upright or side-lying reported greater comfort, had fewer episiotomies (RR = 0.83; 95% CI, 0.75-0.92), and had a slightly shorter second stage (mean = 4.3 min; 95% CI, 2.9-5.6).[22] Some of the included studies suggested that upright positions for birth are associated with greater blood loss, but this could be because blood loss may be more visually apparent to the clinician when the woman is upright. Given the variability in quality of the included studies, the review concluded that no clear indication of harm is associated with upright or lateral positions for birth, and therefore, women should be encouraged to choose their own position according to individual preference.

Two recent studies from Australia have examined the relationship between birth position and perineal outcomes in retrospective analyses of large datasets.[24,25] These studies are from teaching hospitals where most births were attended by midwives. In both settings, an "intact perineum" was defined as no tears or minor but unsutured trauma, and in both, the baseline rate of "intact" was 55%. Shorten et al.[24] used multivariable regression techniques to analyze data from 2891 women who had normal vaginal births. An intact perineum was most likely with delivery in a side-lying position. Approximately 12% of all women used a lateral position for birth, and of these, 67% experienced no lacerations that required suturing. Soong and Barnes[25] analyzed data from 3756 women who had spontaneous vaginal births. Women who gave birth on all fours were the least likely to experience any genital tract trauma that required suturing. Approximately 10% of women gave birth on all fours, and of these, 61% were judged as having intact perineums. Also, 22% of women in this analysis used epidurals, and these women were more likely to have sutured obstetric lacerations, especially if bed-confined and immobile (OR, 1.5; 95% CI, 1.1-2.1). Together, these studies argue for alternatives to supine or lithotomy positions for birth and maternal choice in the matter.

Upright or lateral positions for birth are more comfortable and may increase the woman's sense of control. This may facilitate her ability to work with her clinician to control the expulsion of her infant. In addition, some positions make performance of episiotomies more difficult and, therefore, may indirectly encourage clinician patience.


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