WHO recommendation on birth position (for women without epidural analgesia)

Husband talks to his wife as she sits in a birthing pool during labour.

WHO recommendation on birth position (for women without epidural analgesia)

 

Recommendation

For women without epidural analgesia, encouraging the adoption of a birth position of the individual woman’s choice, including upright positions, is recommended.

(Recommended)

 

Publication history

First published: February 2018

Updated: No update planned

Assessed as up-to-date: February 2018

 

Remarks

  • The evidence suggests that upright birth positions during the second stage of labour might reduce episiotomy and instrumental vaginal births but might also be associated with increased risk of postpartum haemorrhage (PPH) and second-degree tears. However, most evidence is of low certainty and the GDG agreed that the difference in benefits and harms between upright and recumbent positions might not be clinically apparent.
  • It is important that any particular position is not forced on the woman and that she is encouraged and supported to adopt any position that she finds most comfortable. 
  • The health care professional should ensure that the well-being of the baby is adequately monitored in the woman’s chosen position. Should a change in position be necessary to ensure adequate fetal monitoring, the reason should be clearly communicated to the woman. 
  • A practical approach to positioning in the second stage for women desiring an upright birth position might be to adapt to a semi-recumbent or all-fours position just before expulsion of the fetus, to facilitate perineal techniques to reduce perineal tears and blood loss.

 

Background

Globally, approximately 140 million births occur every year (1). The majority of these are vaginal births among pregnant women with no identified risk factors for complications, either for themselves or their babies, at the onset of labour (2, 3). However, in situations where complications arise during labour, the risk of serious morbidity and death increases for both the woman and baby. Over a third of maternal deaths and a substantial proportion of pregnancy-related life-threatening conditions are attributed to complications that arise during labour, childbirth or the immediate postpartum period, often as result of haemorrhage, obstructed labour or sepsis (4, 5). Similarly, approximately half of all stillbirths and a quarter of neonatal deaths result from complications during labour and childbirth (6). The burden of maternal and perinatal deaths is disproportionately higher in low- and middle-income countries (LMICs) compared to high-income countries (HICs). Therefore, improving the quality of care around the time of birth, especially in LMICs, has been identified as the most impactful strategy for reducing stillbirths, maternal and newborn deaths, compared with antenatal or postpartum care strategies (7).

Over the last two decades, women have been encouraged to give birth in health care facilities to ensure access to skilled health care professionals and timely referral should the need for additional care arise. However, accessing labour and childbirth care in health care facilities may not guarantee good quality care. Disrespectful and undignified care is prevalent in many facility settings globally, particularly for underprivileged populations, and this not only violates their human rights but is also a significant barrier to accessing intrapartum care services (8). In addition, the prevailing model of intrapartum care in many parts of the world, which enables the health care provider to control the birthing process, may expose apparently healthy pregnant women to unnecessary medical interventions that interfere with the physiological process of childbirth.

As highlighted in the World Health Organization (WHO) framework for improving quality of care for pregnant women during childbirth, experience of care is as important as clinical care provision in achieving the desired person-centred outcomes (9).

This up-to-date, comprehensive and consolidated guideline on intrapartum care for healthy pregnant women and their babies brings together new and existing WHO recommendations that, when delivered as a package of care, will ensure good quality and evidence-based care in all country settings. In addition to establishing essential clinical and non-clinical practices that support a positive childbirth experience, the guideline highlights unnecessary, non-evidence-based and potentially harmful intrapartum care practices that weaken women’s innate childbirth capabilities, waste resources and reduce equity.

To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.

In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.

 

Methods

These recommendations were developed using standard operating procedures in accordance with the process described in the WHO handbook for guideline development (10). Briefly, these procedures include: (i) identification of priority questions and outcomes; (ii) evidence retrieval and synthesis; (iii) assessment of the evidence; (iv) formulation of the recommendations; and (v) planning for implementation, dissemination, impact evaluation and updating of the guideline.

The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (11) and Confidence in the Evidence from Reviews of Qualitative research (CERQual) (12) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions.

The GRADE evidence-to-decision (EtD) framework (13), an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at two technical consultations in May and September 2017. In addition, relevant recommendations from existing WHO guidelines approved by the Guidelines Review Committee (GRC) were systematically identified and integrated into this guideline for the purpose of providing a comprehensive document for end-users.

 

Further information on procedures for developing this recommendation are available here.

 

Recommendation question

For this recommendation, we aimed to answer the following questions:

  • For women without epidural analgesia in the second stage of labour (P), does the adoption of an upright birthing position (e.g. sitting, standing or squatting) (I), compared with a recumbent position (C), improve birth outcomes (O)?

 

Evidence summary

The evidence is derived from a Cochrane systematic review that included 32 individual RCTs conducted in low-, middle- and high-income countries (14).

Thirty trials involving 9015 women contributed data on upright compared with recumbent positions. Trial participants were nulliparous and/or parous women with uncomplicated singleton pregnancies at more than 36 weeks of gestation, except in two trials that included earlier gestations. Ten trials compared a birthing/squat stool, nine trials compared a birthing chair, and three trials compared a birth cushion with recumbent controls.

Comparison: Upright position compared with recumbent position in second stage of labour

Maternal outcomes

Duration of labour: Evidence on the duration of labour from 19 trials (5811 women) is of very low certainty due to design limitations and high inconsistency across studies in the meta-analysis. However, on sensitivity analysis, whereby studies at high risk of bias were excluded, low-certainty evidence suggests that an upright birth position may make little or no difference to the duration of the second stage in minutes (10 trials, 2499 women, MD 4.34 fewer minutes, 95% CI 9.00 fewer to 0.32 more).

Mode of birth: Low-certainty evidence suggests that an upright position may reduce instrumental vaginal birth (21 trials, 6481 women, RR 0.75, 95% CI 0.66–0.86; absolute risk difference: 32 fewer per 1000 [from 18 to 44 fewer]) but may make little or no difference to caesarean section (16 trials, 5439 women, RR 1.22, 95% CI 0.81–1.81). On sensitivity analysis, whereby studies at high risk of bias were excluded, the certainty of evidence of a reduction in instrumental vaginal birth became high (10 trials, 2534 women, RR 0.71, 95% CI 0.56–0.90) and the certainty of evidence of no effect on caesarean section became moderate (9 trials, 2544 women, RR 1.47, 95% CI 0.88–2.46).

Perineal/vaginal trauma: Low-certainty evidence suggests that an upright position may reduce episiotomy (17 trials, 6148 women, RR 0.75, 95% CI 0.61–0.92; absolute risk difference: 101 fewer [from 32 to 158 fewer]) and may increase second-degree perineal tears (18 trials, 6715 women, RR 1.20, 95% CI 1.00–1.44; absolute risk difference: 25 more per 1000 [from 0 to 56 more]). On sensitivity analysis, whereby studies at high risk of bias were excluded, the certainty of evidence of an increase in second-degree tears became high (9 trials, 2967 women, RR 1.35, 95% CI 1.10–1.67). A third-degree tear involves injury to the anal sphincter complex and a fourth-degree tear extends through the anal sphincter complex to involve the anal epithelium. Evidence on third- or fourth-degree perineal tears is of very low certainty overall, however, on sensitivity analysis, low-certainty evidence suggests that upright positions may have little or no effect on third- or fourth-degree tears (3 trials, 872 women, RR 1.46, 95% CI 0.44–4.79).

Maternal morbidity: Low-certainty evidence suggests that an upright position may increase estimated blood loss greater than 500 mL (15 trials, 5615 women, RR 1.48, 95% CI 1.10–1.98; absolute risk difference: 21 more per 1000 [from 4 to 43 more]). On sensitivity analysis, the certainty of this evidence increased to moderate.

Pain intensity: Low-certainty evidence on maternal pain suggests that there may be little or no difference in pain in the second stage of labour with an upright position, as measured with a visual analogue scale (1 trial, 155 women, MD 0.32 higher, 95% CI 0.16 lower to 0.8 higher), or postpartum pain (1 trial, 155 women, MD 0.48 lower, 95% CI 1.28 lower to 0.32 higher). Further evidence on pain intensity measured in one trial (90 women) is of very low certainty. Low-certainty evidence suggests that there may be little or no difference in analgesia requirements during the second stage (7 trials, 3093 women, RR 0.97, 95% CI 0.93–1.02).

Birth experience: The review did not report on birth experience outcomes.

Fetal and neonatal outcomes

Perinatal hypoxia-ischaemia: The review did not report 5-minute Apgar score less than 7, cord blood acidosis, or hypoxic-ischaemic encephalopathy (HIE) outcomes.

Fetal distress: Moderate-certainty evidence suggests that upright positions are probably associated with fewer abnormal FHR patterns (2 trials, 617 babies, RR 0.46, 95% CI 0.22–0.93).

Perinatal mortality: Low-certainty evidence suggests that there may be little or no difference in perinatal mortality with upright positions (4 trials, 982 babies, RR 0.79, 95% CI 0.51–1.21) (15).

Additional considerations

A population-based study of 113 000 women conducted in Sweden of obstetric anal sphincter injury (OASI) and birth position found an increased risk of OASI with lithotomy position in nulliparous and parous women, a decreased OASI risk with a lateral birth position in nulliparous women, and no clear difference in risk with supine, kneeling, standing or all-fours positions (16). Squatting and birth seats were associated with an increased OASI risk in parous women but not in nulliparous women. Overall, 57% of nulliparous women and 26% of parous women underwent epidural analgesia in this study and findings were not reported separately according to its use.

A 2013 Cochrane systematic review found that the duration of labour with upright and ambulant positions compared with recumbent positions and bed care for the first stage of labour is probably about 1 hour and 22 minutes shorter (15 trials, 2503 women average MD -1.36 hours, 95% CI -2.22 to -0.51) (15). Findings also suggest that upright positions in the first stage probably reduce caesarean section (14 trials, 2682 women, RR 0.71, 95% CI 0.54–0.94) and epidural use (9 trials, 2107 women, RR 0.81, 95% CI 0.66–0.99). These effects did not occur in a comparison involving women with epidural analgesia.

Values

Findings from a review of qualitative studies looking at what matters to women during intrapartum care (17) indicate that most women want a normal childbirth with good outcomes for mother and baby (high confidence in the evidence). Findings also suggest that women are aware of the unpredictability of labour and childbirth and are fearful of potentially traumatic events (including medical interventions and maternal and fetal morbidities), so they would value any technique that reduces their potential exposure to these kinds of outcomes (high confidence in the evidence). Findings also suggest that women expect labour and childbirth to be painful but they would like to be in control of the labour process with the support of kind, caring staff who are sensitive to their needs. Women would also like to give birth in a safe, supportive environment that may include the freedom to move around (high confidence in the evidence).

Resources

No research evidence on resources was found.

Additional considerations: Evidence on effects suggests that upright birth positions might reduce instrumental vaginal births and episiotomy but might increase second-degree tears and PPH, therefore, the cost-effectiveness is unclear. Health care professionals accustomed to supporting women to give birth in recumbent positions would require training on how to support women to give birth in an upright position. Upright positions do not necessarily require additional props (e.g. birth cushions).

Equity

No direct evidence was found on the impact of the different birth positions on equity. However, indirect evidence from a review of barriers and facilitators to facility-based birth indicates that many women have a “fear of cutting” by health workers (e.g. episiotomy and caesarean section) and that this is probably a significant barrier to the uptake of facility-based birth by disadvantaged women in LMICs (moderate confidence in the evidence) (8). Therefore, birth practices that reduce these medical interventions might improve equity.

Additional considerations: Offering women birthing options that include those that are acceptable within their local customs and norms could positively impact on equity, through increasing facility-based births in settings where women generally avoid hospital birth because of the lack of alternative birthing options. In addition, encouraging upright labour and birth positions in well-resourced settings might have a positive impact on equity by reducing unnecessary medical interventions and associated resource use among more advantaged women.

Acceptability

A systematic review of qualitative studies exploring women’s experiences of intrapartum care (18) found that women wanted the freedom to adopt various positions during the second stage of labour (low confidence in the evidence). In most cases, a non-supine position was perceived to be more empowering and less painful and to facilitate an easier birth, although the supine position (on a bed) was still viewed as the more traditional approach to giving birth (low confidence in the evidence). The review also reported findings on health care professionals’ experiences (18), which showed that staff tried to be responsive to women’s needs but tended to favour the supine position as it made monitoring, medical intervention and the childbirth process easier for them to manage (moderate confidence in the evidence).

Additional considerations: Data from cross-sectional surveys conducted in Africa (Malawi and Nigeria) showed that more than 90% of women were aware of the supine or semirecumbent positions for labour and childbirth but less than 5% were aware of alternative positions (e.g. squatting, kneeling, and on hands and knees). Data from the study in Nigeria also showed that only 18.9% of women would have been prepared to adopt an alternative position if it had been suggested by a health care professional (157, 158).

Feasibility

A systematic review of qualitative studies exploring women’s experiences of intrapartum care (18) found that women were sometimes unaware of non-supine positions and felt that different options for birth positions should have been highlighted during antenatal care (low confidence in the findings). Findings on health care professionals’ experiences from the same systematic review showed that providers were often unaware of or inexperienced in the use of non-supine positions. Staff also raised safety concerns about women coming “off the bed” and in certain contexts (LMICs) felt that overcrowding in birth rooms prevented women from adopting an upright position (low confidence in the evidence).

Additional considerations: The adoption of upright positions will require additional training and practise as many practising doctors and midwives may not be familiar with the method. Facilities employing a younger generation of doctors and midwives may not have experienced personnel on staff, which may slow down implementation even when a policy of offering upright birth options is in place. Safety concerns about the baby falling on the floor during an expulsive second stage would need to be addressed by appropriate training and provision of supportive birthing facilities

 

Further information and considerations related to this recommendation can be found in the WHO guidelines, available at:

http://apps.who.int/iris/bitstream/10665/250796/8/9789241549912-websupplement-eng.pdf?ua=1

http://apps.who.int/iris/bitstream/handle/10665/260178/9789241550215-eng.pdf;jsessionid=7E800B590A164DC7FC879E73B480D6FC?sequence=1

 

Implementation considerations

The successful introduction of evidence-based policies related to intrapartum care into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.

The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.

An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.

Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.

Health policy considerations 

  • A firm government commitment to increasing coverage of maternity care for all pregnant women giving birth in health care facilities is needed, irrespective of social, economic, ethnic, racial or other factors. National support must be secured for the whole package of recommendations, not just for specific components.
  • To set the policy agenda, to secure broad anchoring and to ensure progress in policy formulation and decision-making, representatives of training facilities and professional societies should be included in participatory processes at all stages. 
  • To facilitate negotiations and planning, situation-specific information on the expected impact of the new intrapartum care model on service users, providers and costs should be compiled and disseminated.
  • To be able to adequately ensure access for all women to quality maternity care, in the context of universal health coverage (UHC), strategies for raising public funding for health care will need revision. In low-income countries, donors could play a significant role in scaling up implementation.

 

Organizational or health-system-level considerations 

  • Long-term planning is needed for resource generation and budget allocation to address the shortage of skilled midwives, to improve facility infrastructure and referral pathways, and to strengthen and sustain good-quality maternity services.
  • Introduction of the model should involve training institutions and professional bodies so that preservice and in-service training curricula can be updated as quickly and smoothly as possible. 
  • Standardized labour monitoring tools, including a revised partograph, will need to be developed to ensure that all health care providers (i) understand the key concepts around what constitutes normal and abnormal labour and labour progress, and the appropriate support required, and (ii) apply the standardized tools.
  • The national Essential Medicines Lists will need to be updated (e.g. to include medicines to be available for pain relief during labour). 
  • Development or revision of national guidelines and/or facility-based protocols based on the WHO intrapartum care model is needed. For health care facilities without availability of caesarean section, context- or situation-specific guidance will need to be developed (e.g. taking into account travel time to the higher-level facility) to ensure timely and appropriate referral and transfer to a higher level of care if intrapartum complications develop. 
  • Good-quality supervision, communication and transport links between primary and higher-level facilities need to be established to ensure that referral pathways are efficient. 
  • Strategies will need to be devised to improve supply chain management according to local requirements, such as developing protocols for obtaining and maintaining stock of supplies. 
  • Consideration should be given to care provision at alternative maternity care facilities (e.g. on-site midwife-led birthing units) to facilitate the WHO intrapartum care model and reduce exposure of healthy pregnant women to unnecessary interventions prevalent in higher-level facilities. 
  • Behaviour change strategies aimed at health care providers and other stakeholders could be required in settings where non-evidence-based intrapartum care practices are entrenched. 
  • Successful implementation strategies should be documented and shared as examples of best practice for other implementers. User-level considerations 

 

Community-level sensitization activities should be undertaken to disseminate information about: 

  • respectful maternity care (RMC) as a fundamental human right of pregnant women and babies in facilities; 
  • facility-based practices that lead to improvements in women’s childbirth experience (e.g. RMC, labour and birth companionship, effective communication, choice of birth position, choice of pain relief method);
  • and unnecessary birth practices that are not recommended for healthy pregnant women and that are no longer practised in facilities (e.g. liberal use of episiotomy, fundal pressure, routine amniotomy).

 

Research implications

The GDG did not identify any priority question related to this recommendation.

 

Related links

WHO recommendations on intrapartum care for a positive childbirth experience

(2018) - full document and evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Maternal Health

 

 

References

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Citation: WHO Reproductive Health Library. WHO recommendation on birth position for women without epidural analgesia (February 2018). The WHO Reproductive Health Library; Geneva: World Health Organization.