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Second-stage positioning in nurse-midwifery practices
SECOND-STAGE POSITIONING IN NURSE-MIDWIFERY PRACTICES Part 1: Position Use and Preferences Lisa Hanson,
CNM, DNSc
ABSTRACT A national survey of 800 certified nurse-midwives (CNMs) in active clinical practice was conducted from April through June 1994. The purpose of the survey was to study the extent to which eight operationally defined positions were used by CNM-attended women during the second stage of labor and factors that affected their use. This, the first of a two-part article, describes the positions used as well as the CNMs’ preferences for the eight second-stage positions. The most frequently used second-stage position was sitting; the lithotomy position was rarely used by the CNMs. The survey findings reflect the preferences of birthing women. q 1998 by the American College of Nurse-Midwives. INTRODUCTION
Throughout history, care providers have influenced the choice of birth positions (1– 6). The lithotomy position is the most widely used position for the second stage of labor (7). Since most births in the United States are physician-attended, little specific information regarding position use in midwifery* practice was known until recently. In 1987, Adams (8) conducted a large national survey of 1,183 certified nurse-midwives (CNMs) and identified that most CNMs (93.7%) used positions other than lithotomy for some births. Specifically, 97.5% of CNMs made decisions regarding the positions of women in labor; however, there was no detailed information about which positions were used by midwives* (8). The management of the second stage of labor is of interest to CNMs and certified midwives (CMs)* who promote noninterventive birth practices. The position that the mother assumes for the second stage of labor can significantly influence its management. For example, the use of the lithotomy position for pushing in the second stage of labor may necessitate the use of interventions. An operative delivery for nonreasurring fetal status or fetal acidosis may have resulted from supine hypotension (9,10). Conversely, the use of a birth position such as all-fours may necessitate a limited use of
Address correspondence to Lisa Hanson, CNM, DNSc, Marquette University College of Nursing, Nurse-Midwifery Program, Clark Hall 363, PO Box 1881, Milwaukee, WI 53201-1881.
320 q 1998 by the American College of Nurse-Midwives Issued by Elsevier Science Inc.
technologic monitoring and equipment and traditional sterile delivery techniques (11). Position changes and mobility in labor have been used throughout history to promote progress, prevent or alleviate dystocias, reduce maternal discomfort, and facilitate birth (1– 4). Alternatives to the lithotomy position such as sitting, side-lying, all-fours, and squatting, have been studied, meta-analyzed and found to be safe (12). The use of the birthing chair, however, has been found to increase the risk of postpartum blood loss for the mother. The standing position has had only limited study and may be associated with an increased incidence of third-degree tears (13). The use of the kneeling position for the second stage of labor has not been scientifically studied. This article is based on a study that was designed to investigate the extent to which eight second-stage positions were used by CNM-attended clients and to describe factors that affect their use, including midwife preferences (14). Part two of this article will describe factors that affect the use of these positions in midwifery practice. The focus of this investigation was CNM providers’ self-reports of positions used by their clients for the second stage of labor. CNMs listen to women and consider client’s desires in plans of management. The interaction between provider and client regarding position choice was not explored in this study. METHODS
A self-administered questionnaire was developed for this mailed national survey on maternal positions used in the second stage of labor. The survey was initially developed by the author and reviewed by a panel of ten CNM content experts. An initial pretest was mailed to a sample of 10 practicing CNMs. Finally, the survey was pretested with three practicing CNMs; the intensive
*CNMs/CMs and midwives as used herein refer to those midwifery practitioners who are certified by the American College of NurseMidwives (ACNM) or the ACNM Certification Council, Inc.; midwifery refers to the profession as practiced in accordance with the standards promulgated by the ACNM.
Journal of Nurse-Midwifery • Vol. 43, No. 5, September/October 1998 0091-2182/98/$19.00 • PII S0091-2182(98)00033-0
interview technique (15) was employed, which increased the reliability of the survey instrument by assuring that the questions were interpreted in the manner that the author intended. Two phases of the second stage of labor (pushing and birth) were also operationally defined on the survey instrument as follows: 1) pushing was defined as the time from consistent or active maternal bearing down, after complete dilatation of the cervix, to crowning of the fetal head and 2) birth was defined as the time from crowning of the fetal head to complete delivery of the baby’s body. Eight second-stage positions were operationally defined for the study using pictures based on definitions formulated by Roberts and Van Lier (16). Figure 1 contains the pictures and the operational definitions as they appeared in the survey. Survey questions were designed to obtain CNMs’ own estimates of the percentages of their intrapartum clients that used the pushing phase and birth phase positions during the previous year. The CNMs also described their encouragement or discouragement of each of the positions in their practices. For demographic information, CNMs reported their geographic region, scope of practice, as well as the nature of the practice setting and the percent of births they attended at each site. Using a computer-generated random numbers table, a simple random sample of 800 CNMs was drawn from the list of 2,709 midwives who were members of the American College of Nurse-Midwives (ACNM) and in active clinical practice in the United States in 1994. The survey was sent to the sample, with a follow-up mailing 1 month later to the 400 CNMs who had not responded by that time. The data were coded and entered into the Statistical Package for the Social Services (SPSS) and verified for accuracy. Descriptive statistics were performed to analyze the use of the eight second-stage positions for pushing and for birth. RESULTS
After two mailings one month apart, a total of 439 (54.9%) of the 800 CNMs who were surveyed had returned usable questionnaires. Table 1 contains CNM respondent demographic information. The average percent of births attended at each site are described in Table 2.
Lisa Hanson received her bachelor’s degree in nursing from the University of Wisconsin, Milwaukee and her nurse-midwifery education and DNSc from Rush University, Chicago. Dr. Hanson is an assistant professor at Marquette University College of Nursing and a faculty member of the Nurse-Midwifery Program. In 1987, she co-founded the Nurse-Midwifery Center, a service affiliated with University of Wisconsin-Madison Medical School, Milwaukee Clinical Campus at Sinai Samaritan Medical Center. She continues in a full scope faculty practice there.
The median percentages of use of the positions for the pushing and birth phases are presented in Figure 2 in the form of a histogram. The median was used because the distributions of the percentages were skewed; thus the means did not accurately reflect the central tendency of the distributions of second-stage position use in this sample. The majority of the respondents reported use of all seven of the nonlithotomy positions studied. Of the respondents, 265 (60.5%) indicated that all women in their practices (100%) used nonlithotomy positions for their births. The median percent use of nonsupine birth positions (sitting, side-lying, squatting, all-fours, standing, and kneeling) was 87.8% according to the CNMs sampled. Sixteen percent of the CNMs reported the use of nonsupine positions by all (100%) of their clients. Although only three CNMs (0.7%) indicated that lithotomy was used exclusively (100% of the time) in their practices for second-stage labor, 21 (5%) respondents reported that three fourths of the women they attended used the lithotomy position. The encouragement of the use of the second-stage positions is presented in Table 3. The CNMs encouraged nonsupine positions and discouraged the use of the two supine positions at high rates; the lithotomy position was discouraged by 80.4% of the CNM respondents, and the dorsal by 38.6%. The remaining six positions were discouraged by smaller percentages of the CNMs (0.5– 7.3%). DISCUSSION
The sample of survey respondents was representative of the population of ACNM members by region of residence and in terms of demographic and practice information (17,18). There was a relatively even distribution of respondents among the six ACNM regions with a range of 55– 84 participants per region. Region 1, the smallest ACNM region, also had the smallest number of survey respondents. Sitting and side-lying, the two most frequently used maternal positions for both pushing and birth, were also those that were encouraged by large portions of the CNMs in their practices. These findings were not surprising, but confirm that many CNMs are influential in the use of nonsupine second-stage positions and in avoiding the lithotomy position. CNMs reported that clients in their practices used the positions they encouraged. Sitting, the position reportedly used most often by the midwife-attended women, offers the advantages of supported upright positions for laboring women and convenience for the birth attendant. Several CNMs indicated that they used a birthing stool, which they felt was distinctly different, in terms of its effect on perineal
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FIGURE 1. Operational definitions of maternal positions used in the study. (a) Lithotomy: weight on back with knees bent or up on chest, back elevated less than or equal to 30 degrees with or without stirrups. (b) Dorsal recumbent: weight on back with knees bent, back elevated less than or equal to 30 degrees with or without footrests. (c) Sitting upright: weight on buttocks, back elevated greater than 30 degrees. Includes sitting on a commode. (d) Squatting: weight on feet with knees bent, with or without support. (e) Side-lying: weight on either side with thighs flexed. (f) All-fours: weight on knees supported by hands or elbows. (g) Kneeling: weight on knees with legs flexed. (h) Standing: weight on feet, with or without support. Data from Roberts and Van Lier (16).
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TABLE 1
TABLE 2
CNM Demographic Information
Summary of CNM Births by Site*
Age (years) Years of intrapartum practice teaching Number of births in the last year Sex Female Male Education Basic nursing Baccalaureate Associate Diploma Other Highest degree earned Masters Baccalaureate Associate Diploma Doctorate Missing
Mean
Range
42.9 8.5
26–68 0–37
86.7
2–500
%
% Hospital LDR/LDRP Traditional L&D In-Hospital birth center Freestanding birth center Home birth
97.5 2.5 55.3 18.0 19.4 7.3 70.0 16.2 5.9 5.3 1.8 0.8
N 5 428.
anatomy and birth physiology, from the use of a sitting position where the sacrum was fixed against an object such as a bed; however, concerns that the use of birthing stools may be associated with increased immediate pospartum blood loss (12,19) suggest the need for additional research in this area. The survey findings were compared to the results of two earlier studies of birth positions in which women were encouraged to assume the positions of their own
64.4 15.8 9.7 5.4 4.1
* N 5 430. Each respondent estimated the percentage of births they attended in each site; therefore the percentages provided above are averages for the sample and exceed 100% total. LDR, labor, delivery, recovery room; LDRP, labor, delivery, recovery, postpartum room; L&D, labor and delivery.
choice. One study used the clients of CNMs (20) and the other used clients of physicians (21). There was commonality across studies with regard to the two most frequently used positions in each of the three studies (sitting and side-lying). The clients of the CNMs in this study most frequently gave birth in the sitting and side-lying positions, the same positions that women self-selected in the previous two studies. Therefore, women’s desires appear to be reflected in this aspect of midwifery practice. The literature supports the safety of nonlithotomy maternal positions for the midwifery management of the second stage of labor. The impact of various positions on variables such as Apgar scores, umbilical cord pH, fetal heart rate patterns, perineal outcomes, incidence of operative delivery and second-stage labor length, and maternal preference and pain perception have all been studied (11,20,21,22); however, further research under controlled conditions seems warranted.
FIGURE 2. Median percent use of the second stage positions. Note: The median percent use of lithotomy, standing, and kneeling was zero for pushing and birth phases.
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TABLE 3
CNM Encouragement of the Second-Stage Positions Position
% Encouraged Use
Side-lying Squatting Sitting Standing Kneeling Dorsal [supine] All-fours Lithotomy [supine]
88.8 82.2 73.5 34.5 27.6 25.3 7.1 7.1
N 5 420.
The frequency of dorsal recumbency for pushing (10%) and birth (7%) in midwifery practices was an unexpected finding; the use of the dorsal position was encouraged by one fourth of the CNMs surveyed. As a supine position with an elevation of less than or equal to 30 degrees, the dorsal position is similar to the lithotomy position in that it results in negative hemodynamic consequences for the laboring woman (23,24), negates the advantages of gravity and abdominal muscle power that aid in pushing (25,26,27), prevents the parturient from actively participating in the birth process (22), and has been associated with increased maternal pain (22,28,29). The relative prevalence of dorsal position usage in CNM practice may reflect a lack of application of the scientific knowledge about the disadvantages of the lithotomy position to this supine position. When a woman assumes the dorsal position it may even appear that her back is elevated; however, unless her back is elevated greater than 30 degrees, the negative consequences of the supine position will occur (30). This study had several limitations. First, the responses were based on respondents’ estimates regarding the percentage that each position was used for the past year. Although this may be more accurate and useful information than a rank order list of most frequently used positions, it is nonetheless limited by the recall ability of the participants. Second, the study did not capture the interaction between the position the woman assumes and the effect of the place of birth, nor between parity and additional individual client variables that impact position, such as analgesia and epidural use. Further, the use of positions was investigated from the perspective of the CNMs rather than that of the birthing women themselves. Future studies that collect prospective data derived from both the birthing women and the midwives that care for them in labor would be useful to highlight the dynamic interpersonal relationships that appear to impact position choice and use in the second stage of labor. Midwives were found to encourage the use of alterna-
324
tives to the lithotomy position for the second stage of labor. The use of alternatives to the lithotomy position reflects scientifically-based clinical practice and further reflects the preferences of the clients that midwives serve. CNMs and CMs should actively promote the use of alternatives to the lithotomy position. The knowledge embedded in the unique practice of midwifery would serve to benefit all women’s birth experiences.
This work was supported in part by a research grant from the Nurse-Midwifery Center, Department of Obstetrics and Gynecology, UW-Madison Medical School Milwaukee Clinical Campus. The author would sincerely like to thank the CNMs who generously participated in the survey.
REFERENCES 1. Engelman GJ. Labor among primitive people. New York: AMS Press, 1882. 2. Clarke AP. The influence of position of the patient in labor in causing uterine inertia and pelvic disturbances. JAMA 1891;16: 443–5. 3. Hemminki E, Virkkunen A, Makela A, et al. A trial of delivery on a birth chair. Obstet Gynecol 1986;6:162–5. 4. Householder MS. Historical perspective on the obstetric chair. Surg Gynecol Obstet 1974;139:423–30. 5. Jarcho J. The role of posture in obstetrics. Surg Gynecol Obstet 1929;48:257– 64. 6. Roberts JE. Alternative positions for childbirth: part II second stage of labor. J Nurse Midwifery 1980;25:13–9. 7. Cunningham FG, MacDonald PC, Leveno KL, Gant NF, Gilstrap LC, editors. Conduct of normal labor and delivery. In: Williams obstetrics. 19th ed.. Norwalk, Connecticut: Appleton & Lange, 1993: 380. 8. Adams C. American nurse-midwifery: 1987. Washington (DC): American College of Nurse-Midwives, 1989. 9. Humphrey MD, Chang A, Wood EC, Morgan S, Hounslow D. A decrease in fetal pH during the second stage of labor, when conducted in the dorsal position. Br J Obstet Gynaecol 1974;81:600 –2. 10. Arbitol M. Supine position in labor and associated fetal heart rate changes. Obstet Gynecol 1985;65:481– 6. 11. Meenan AL, Gaskin IM, Hunt P, Ball CA. A new (old) maneuver for the management of shoulder dystocia. J Fam Pract 1991;32: 625–9. 12. Sleep J, Roberts J, Chalmers I. Care during the second stage of labor. In: Chalmers I, editor. Effective care in pregnancy and birth. Oxford: Oxford University Press, 1989. 13. Gareberg B, Magnusson B, Wennerholm U, Wennergren M, Hagberg H. Birth in standing position: a high frequency of third degree tears. Acta Obstet Gynecol Scand 1994:73:630 –3. 14. Hanson L. Factors affecting the use of maternal positions for the second stage of labor: A survey of certified nurse-midwives.[unpublished dissertation]. Chicago: Rush University, 1996. 15. Royston, PN. Using the intensive interviews to evaluate questions. Proceedings of the fifth conference on Health Survey Research Methods; 1989 May; Keystone, CO. 16. Roberts J, Van Lier D. Debate: which position for the second stage? Childbirth Educator 1984;Spring:33– 43.
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17. Lehrman EJ, Paine LL. Trends in nurse-midwifery: results of the 1988 ACNM Division of Research mini-survey. J Nurse Midwifery 1990;35:192–203. 18. Scupholme A, DeJoseph J, Strobino DM, Paine LL. Nursemidwifery care to vulnerable populations–phase 1: demographic characteristics of the national sample. J Nurse Midwifery 1992;37:341–7. 19. Waldenstrom U, Gottvall K. A randomized controlled trial of birthing stool or conventional semirecumbent positions for second stage labor. Birth 1991;5–10. 20. Rossi MA, Lindell SG. Maternal positions and pushing techniques in a nonprescriptive environment. J Obstet Gynecol Neonatal Nurs 1986;15:203– 8. 21. Carlson JM, Diehl JA, Sachtleben-Murray M, McRae M, Fenwick L, Friedman EA. Maternal positions during parturition in normal labor. Obstet Gynecol 1986;68:443–7. 22. Newton M, Newton M. The propped position for the second stage of labor. Obstet Gynecol 1960;15:28 –34.
23. Bonica JJ. Obstetric analgesia and anesthesia. 2nd ed. Seattle: World Federation of Anesthesiologists, 1980. 24. Ueland K, Novy MJ, Peterson EN, Metcalf J. Maternal cardiovascular dynamics IV: the influence of gestational age on the maternal cardiovascular response to posture and exercise. Am J Obstet Gynecol 1969;104:856 – 64. 25. Mengert W, Murphy D. Intra-abdominal pressures created by voluntary muscular effort. Surg Gynecol Obstet 1933;57:745–51. 26. Newton M. The effect of position on the course of the second stage of labor. Surg Forum 1956;7:517–20. 27. Howard FH. Delivery in the physiologic position. Obstet Gynecol 1958;111:318 –22. 28. Caldeyro-Barcia R. The influence of maternal bearing down effort. Birth Fam J 1979;6:16 –20. 29. Schneider-Affed F, Martinm K. Delivery from a sitting position. J Perinat Med 1982;10:70 –1. 30. Fenwick L, Simkin P. Maternal positions to prevent or alleviate dystocias in labor. Clin Obstet Gynecol 1987;30:831.
UPCOMING ANNUAL MEETINGS of the American College of Nurse-Midwives 44th: 45th: 46th: 47th: 48th: 49th:
Orlando, Florida May 28–June 3, 1999 Buena Vista Palace Hotel Anchorage, Alaska May 5–11, 2000 Convention Center Washington, DC June 1–7, 2001 Ramada Renaissance Hotel Atlanta, Georgia May 24–30, 2002 Atlanta Marriott Marquis Palm Desert, California May 30–June 5, 2003 Marriott’s Desert Springs Resort New Orleans, Louisiana May 28–June 3, 2004 New Orleans Marriot
For further information contact: The American College of Nurse-Midwives 818 Connecticut Avenue NW Suite 900 Washington, DC 20006 Phone: 202/728-9860 Fax: 202/728-9897 E-mail: [email protected] Web site: www.midwife.org
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325
CNM, DNSc
ABSTRACT A national survey of 800 certified nurse-midwives (CNMs) in active clinical practice was conducted from April through June 1994. The purpose of the survey was to study the extent to which eight operationally defined positions were used by CNM-attended women during the second stage of labor and factors that affected their use. This, the first of a two-part article, describes the positions used as well as the CNMs’ preferences for the eight second-stage positions. The most frequently used second-stage position was sitting; the lithotomy position was rarely used by the CNMs. The survey findings reflect the preferences of birthing women. q 1998 by the American College of Nurse-Midwives. INTRODUCTION
Throughout history, care providers have influenced the choice of birth positions (1– 6). The lithotomy position is the most widely used position for the second stage of labor (7). Since most births in the United States are physician-attended, little specific information regarding position use in midwifery* practice was known until recently. In 1987, Adams (8) conducted a large national survey of 1,183 certified nurse-midwives (CNMs) and identified that most CNMs (93.7%) used positions other than lithotomy for some births. Specifically, 97.5% of CNMs made decisions regarding the positions of women in labor; however, there was no detailed information about which positions were used by midwives* (8). The management of the second stage of labor is of interest to CNMs and certified midwives (CMs)* who promote noninterventive birth practices. The position that the mother assumes for the second stage of labor can significantly influence its management. For example, the use of the lithotomy position for pushing in the second stage of labor may necessitate the use of interventions. An operative delivery for nonreasurring fetal status or fetal acidosis may have resulted from supine hypotension (9,10). Conversely, the use of a birth position such as all-fours may necessitate a limited use of
Address correspondence to Lisa Hanson, CNM, DNSc, Marquette University College of Nursing, Nurse-Midwifery Program, Clark Hall 363, PO Box 1881, Milwaukee, WI 53201-1881.
320 q 1998 by the American College of Nurse-Midwives Issued by Elsevier Science Inc.
technologic monitoring and equipment and traditional sterile delivery techniques (11). Position changes and mobility in labor have been used throughout history to promote progress, prevent or alleviate dystocias, reduce maternal discomfort, and facilitate birth (1– 4). Alternatives to the lithotomy position such as sitting, side-lying, all-fours, and squatting, have been studied, meta-analyzed and found to be safe (12). The use of the birthing chair, however, has been found to increase the risk of postpartum blood loss for the mother. The standing position has had only limited study and may be associated with an increased incidence of third-degree tears (13). The use of the kneeling position for the second stage of labor has not been scientifically studied. This article is based on a study that was designed to investigate the extent to which eight second-stage positions were used by CNM-attended clients and to describe factors that affect their use, including midwife preferences (14). Part two of this article will describe factors that affect the use of these positions in midwifery practice. The focus of this investigation was CNM providers’ self-reports of positions used by their clients for the second stage of labor. CNMs listen to women and consider client’s desires in plans of management. The interaction between provider and client regarding position choice was not explored in this study. METHODS
A self-administered questionnaire was developed for this mailed national survey on maternal positions used in the second stage of labor. The survey was initially developed by the author and reviewed by a panel of ten CNM content experts. An initial pretest was mailed to a sample of 10 practicing CNMs. Finally, the survey was pretested with three practicing CNMs; the intensive
*CNMs/CMs and midwives as used herein refer to those midwifery practitioners who are certified by the American College of NurseMidwives (ACNM) or the ACNM Certification Council, Inc.; midwifery refers to the profession as practiced in accordance with the standards promulgated by the ACNM.
Journal of Nurse-Midwifery • Vol. 43, No. 5, September/October 1998 0091-2182/98/$19.00 • PII S0091-2182(98)00033-0
interview technique (15) was employed, which increased the reliability of the survey instrument by assuring that the questions were interpreted in the manner that the author intended. Two phases of the second stage of labor (pushing and birth) were also operationally defined on the survey instrument as follows: 1) pushing was defined as the time from consistent or active maternal bearing down, after complete dilatation of the cervix, to crowning of the fetal head and 2) birth was defined as the time from crowning of the fetal head to complete delivery of the baby’s body. Eight second-stage positions were operationally defined for the study using pictures based on definitions formulated by Roberts and Van Lier (16). Figure 1 contains the pictures and the operational definitions as they appeared in the survey. Survey questions were designed to obtain CNMs’ own estimates of the percentages of their intrapartum clients that used the pushing phase and birth phase positions during the previous year. The CNMs also described their encouragement or discouragement of each of the positions in their practices. For demographic information, CNMs reported their geographic region, scope of practice, as well as the nature of the practice setting and the percent of births they attended at each site. Using a computer-generated random numbers table, a simple random sample of 800 CNMs was drawn from the list of 2,709 midwives who were members of the American College of Nurse-Midwives (ACNM) and in active clinical practice in the United States in 1994. The survey was sent to the sample, with a follow-up mailing 1 month later to the 400 CNMs who had not responded by that time. The data were coded and entered into the Statistical Package for the Social Services (SPSS) and verified for accuracy. Descriptive statistics were performed to analyze the use of the eight second-stage positions for pushing and for birth. RESULTS
After two mailings one month apart, a total of 439 (54.9%) of the 800 CNMs who were surveyed had returned usable questionnaires. Table 1 contains CNM respondent demographic information. The average percent of births attended at each site are described in Table 2.
Lisa Hanson received her bachelor’s degree in nursing from the University of Wisconsin, Milwaukee and her nurse-midwifery education and DNSc from Rush University, Chicago. Dr. Hanson is an assistant professor at Marquette University College of Nursing and a faculty member of the Nurse-Midwifery Program. In 1987, she co-founded the Nurse-Midwifery Center, a service affiliated with University of Wisconsin-Madison Medical School, Milwaukee Clinical Campus at Sinai Samaritan Medical Center. She continues in a full scope faculty practice there.
The median percentages of use of the positions for the pushing and birth phases are presented in Figure 2 in the form of a histogram. The median was used because the distributions of the percentages were skewed; thus the means did not accurately reflect the central tendency of the distributions of second-stage position use in this sample. The majority of the respondents reported use of all seven of the nonlithotomy positions studied. Of the respondents, 265 (60.5%) indicated that all women in their practices (100%) used nonlithotomy positions for their births. The median percent use of nonsupine birth positions (sitting, side-lying, squatting, all-fours, standing, and kneeling) was 87.8% according to the CNMs sampled. Sixteen percent of the CNMs reported the use of nonsupine positions by all (100%) of their clients. Although only three CNMs (0.7%) indicated that lithotomy was used exclusively (100% of the time) in their practices for second-stage labor, 21 (5%) respondents reported that three fourths of the women they attended used the lithotomy position. The encouragement of the use of the second-stage positions is presented in Table 3. The CNMs encouraged nonsupine positions and discouraged the use of the two supine positions at high rates; the lithotomy position was discouraged by 80.4% of the CNM respondents, and the dorsal by 38.6%. The remaining six positions were discouraged by smaller percentages of the CNMs (0.5– 7.3%). DISCUSSION
The sample of survey respondents was representative of the population of ACNM members by region of residence and in terms of demographic and practice information (17,18). There was a relatively even distribution of respondents among the six ACNM regions with a range of 55– 84 participants per region. Region 1, the smallest ACNM region, also had the smallest number of survey respondents. Sitting and side-lying, the two most frequently used maternal positions for both pushing and birth, were also those that were encouraged by large portions of the CNMs in their practices. These findings were not surprising, but confirm that many CNMs are influential in the use of nonsupine second-stage positions and in avoiding the lithotomy position. CNMs reported that clients in their practices used the positions they encouraged. Sitting, the position reportedly used most often by the midwife-attended women, offers the advantages of supported upright positions for laboring women and convenience for the birth attendant. Several CNMs indicated that they used a birthing stool, which they felt was distinctly different, in terms of its effect on perineal
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FIGURE 1. Operational definitions of maternal positions used in the study. (a) Lithotomy: weight on back with knees bent or up on chest, back elevated less than or equal to 30 degrees with or without stirrups. (b) Dorsal recumbent: weight on back with knees bent, back elevated less than or equal to 30 degrees with or without footrests. (c) Sitting upright: weight on buttocks, back elevated greater than 30 degrees. Includes sitting on a commode. (d) Squatting: weight on feet with knees bent, with or without support. (e) Side-lying: weight on either side with thighs flexed. (f) All-fours: weight on knees supported by hands or elbows. (g) Kneeling: weight on knees with legs flexed. (h) Standing: weight on feet, with or without support. Data from Roberts and Van Lier (16).
322
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TABLE 1
TABLE 2
CNM Demographic Information
Summary of CNM Births by Site*
Age (years) Years of intrapartum practice teaching Number of births in the last year Sex Female Male Education Basic nursing Baccalaureate Associate Diploma Other Highest degree earned Masters Baccalaureate Associate Diploma Doctorate Missing
Mean
Range
42.9 8.5
26–68 0–37
86.7
2–500
%
% Hospital LDR/LDRP Traditional L&D In-Hospital birth center Freestanding birth center Home birth
97.5 2.5 55.3 18.0 19.4 7.3 70.0 16.2 5.9 5.3 1.8 0.8
N 5 428.
anatomy and birth physiology, from the use of a sitting position where the sacrum was fixed against an object such as a bed; however, concerns that the use of birthing stools may be associated with increased immediate pospartum blood loss (12,19) suggest the need for additional research in this area. The survey findings were compared to the results of two earlier studies of birth positions in which women were encouraged to assume the positions of their own
64.4 15.8 9.7 5.4 4.1
* N 5 430. Each respondent estimated the percentage of births they attended in each site; therefore the percentages provided above are averages for the sample and exceed 100% total. LDR, labor, delivery, recovery room; LDRP, labor, delivery, recovery, postpartum room; L&D, labor and delivery.
choice. One study used the clients of CNMs (20) and the other used clients of physicians (21). There was commonality across studies with regard to the two most frequently used positions in each of the three studies (sitting and side-lying). The clients of the CNMs in this study most frequently gave birth in the sitting and side-lying positions, the same positions that women self-selected in the previous two studies. Therefore, women’s desires appear to be reflected in this aspect of midwifery practice. The literature supports the safety of nonlithotomy maternal positions for the midwifery management of the second stage of labor. The impact of various positions on variables such as Apgar scores, umbilical cord pH, fetal heart rate patterns, perineal outcomes, incidence of operative delivery and second-stage labor length, and maternal preference and pain perception have all been studied (11,20,21,22); however, further research under controlled conditions seems warranted.
FIGURE 2. Median percent use of the second stage positions. Note: The median percent use of lithotomy, standing, and kneeling was zero for pushing and birth phases.
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TABLE 3
CNM Encouragement of the Second-Stage Positions Position
% Encouraged Use
Side-lying Squatting Sitting Standing Kneeling Dorsal [supine] All-fours Lithotomy [supine]
88.8 82.2 73.5 34.5 27.6 25.3 7.1 7.1
N 5 420.
The frequency of dorsal recumbency for pushing (10%) and birth (7%) in midwifery practices was an unexpected finding; the use of the dorsal position was encouraged by one fourth of the CNMs surveyed. As a supine position with an elevation of less than or equal to 30 degrees, the dorsal position is similar to the lithotomy position in that it results in negative hemodynamic consequences for the laboring woman (23,24), negates the advantages of gravity and abdominal muscle power that aid in pushing (25,26,27), prevents the parturient from actively participating in the birth process (22), and has been associated with increased maternal pain (22,28,29). The relative prevalence of dorsal position usage in CNM practice may reflect a lack of application of the scientific knowledge about the disadvantages of the lithotomy position to this supine position. When a woman assumes the dorsal position it may even appear that her back is elevated; however, unless her back is elevated greater than 30 degrees, the negative consequences of the supine position will occur (30). This study had several limitations. First, the responses were based on respondents’ estimates regarding the percentage that each position was used for the past year. Although this may be more accurate and useful information than a rank order list of most frequently used positions, it is nonetheless limited by the recall ability of the participants. Second, the study did not capture the interaction between the position the woman assumes and the effect of the place of birth, nor between parity and additional individual client variables that impact position, such as analgesia and epidural use. Further, the use of positions was investigated from the perspective of the CNMs rather than that of the birthing women themselves. Future studies that collect prospective data derived from both the birthing women and the midwives that care for them in labor would be useful to highlight the dynamic interpersonal relationships that appear to impact position choice and use in the second stage of labor. Midwives were found to encourage the use of alterna-
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tives to the lithotomy position for the second stage of labor. The use of alternatives to the lithotomy position reflects scientifically-based clinical practice and further reflects the preferences of the clients that midwives serve. CNMs and CMs should actively promote the use of alternatives to the lithotomy position. The knowledge embedded in the unique practice of midwifery would serve to benefit all women’s birth experiences.
This work was supported in part by a research grant from the Nurse-Midwifery Center, Department of Obstetrics and Gynecology, UW-Madison Medical School Milwaukee Clinical Campus. The author would sincerely like to thank the CNMs who generously participated in the survey.
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