Clinical Question

During the first stage of labor, what is the effect of maternal positioning on duration of the first stage of labor, type of delivery, maternal satisfaction, and neonatal and maternal outcomes?

Evidence-Based Answer

Upright positions include sitting, standing, walking, and kneeling. Based on heterogenous results, women who maintained upright positions had a first stage of labor that was about one hour less than women who were supine or reclined. There were no differences in type of delivery, and there were insufficient data on maternal satisfaction and maternal and neonatal outcomes. (Strength of Recommendation = A, based on consistent and good quality patient-oriented evidence).

Practice Pointers

Most women in the United States deliver their babies in hospitals. To facilitate intravenous infusions, epidurals, and maternal and fetal monitoring, women often spend much of the first stage of labor in supine or recumbent positions.

In this Cochrane review, the authors found 21 studies (n = 3,706) comparing upright with recumbent maternal positions during the first stage of labor. Overall, compared with recumbent positions, women who maintained upright positions had a duration that was approximately one hour less for the first stage of labor (mean difference = −0.99; 95% confidence interval [CI], −1.60 to −0.39). Participants in upright positions also were less likely to have epidural analgesia (risk ratio = 0.83; 95% CI, 0.72 to 0.96).

In a related Cochrane review, assuming a hands and knees maternal position for 10 minutes at a time in late pregnancy did not appear to help rotate babies who presented in occipitoposterior positions, which was based on an analysis of three trials (n = 2,794) that found the maternal position rotates babies temporarily, but the babies do not maintain their occipitoanterior position.¹ Maternal positioning on hands and knees may be beneficial in labor to reduce backache, but there is insufficient evidence that it improves labor outcomes.

Studies of maternal positioning in labor are challenging because it is not possible to have participants blinded to allocation groups, and it is difficult to standardize the intervention. Many women cannot easily maintain the position to which they were randomized once their cervical dilation is greater than 5 to 6 cm. Also, the measures taken to encourage adherence to protocols can vary by study.

Other Cochrane reviews have documented the benefit of continuous intrapartum support from early labor in decreasing labor duration, likelihood of spontaneous vaginal birth, likelihood of intrapartum analgesia, and dissatisfaction with childbirth experiences.^2,3 It is especially beneficial to have continuous support from a person who is not a member of the hospital staff.² For low-risk deliveries, home-like birth settings in proximity to medical wards are associated with reduced medical intervention, higher rates of spontaneous vaginal birth, and increased maternal satisfaction.³

These studies lend support to the recommendation that women should be encouraged to labor in the position they find most comfortable.^1–3