Appropriate maternal positions in the active phase of second stage labour play a vital role in enhancing positive maternal and fetal outcomes (Garbelli and Lira, 2021; Kibuka et al, 2021). During early first stage labour, women are encouraged to be as mobile as possible and embrace positions that they are comfortable with in the active phase, in preparation for the birth of their baby. Possible positions include supine or recumbent positions, where the woman lies on her back with her knees flexed and legs apart, with (such as in the lithotomy position) or without supported feet (Mselle and Eustace, 2020). A horizontal or lateral position has the woman lying on her side (Gupta et al, 2017), while standing, squatting, seated and kneeling are categorised as upright positions, including ‘all fours position’ where the woman is kneeling and bent forward to support her weight with her arms (Gizzo et al, 2014; Desseauve et al, 2017).
Supine positions were popular and commonly adopted in labour and birth until the mid-17th century, when obstetricians determined that a recumbent position, a slight modification to the supine position, was easier for forceps deliveries and claimed that these positions were more convenient (Modrzejewska et al, 2019). However, recent evidence has highlighted the importance of encouraging mobile and upright positions during labour and birth, which is recommended by the World Health Organization (2021a). In contrast, the supine position has frequently been associated with hypotension and fetal heart rate abnormalities (Garbelli and Lira, 2021). Despite evidence against the use of supine positions, the literature suggests that women most commonly assume these positions during childbirth (Kopas, 2014; Zileni et al, 2017).
A brief review of the literature demonstrated that there has been extensive research, either in the form of narrative (Hollins Martin and Martin, 2013), descriptive (Huang et al, 2019; Garbelli and Lira, 2021) or systematic reviews (Gupta et al, 2017; Kibuka et al, 2021), focused on scientific evidence in terms of maternal positions and anatomical structure in association with the physiology of labour. In particular, there are numerous studies on the association of labour and birth positions, and management of second stage labour (Gizzo et al, 2014; Mselle and Eustace, 2020; Kibuka et al, 2021). These encompass different positions to ensure labour progress is hastened and not hindered (Huang et al, 2019; Weckend et al, 2022), determining positions suitable for interventionist and non-interventionist labour pain management (Gimovsky and Berghella, 2022), and identifying positions that frequently result in episiotomy (Huang et al, 2019). Thus, the benefits and drawbacks of different maternal positions in active labour have been extensively explored.
The International Confederation of Midwives (2017) and the Nursing and Midwifery Council (2018) in the UK, the Nursing and Midwifery Board of Australia (2008) and the Nursing Board for Brunei (2010) emphasise that to provide evidence-based practice, midwives have a responsibility to acknowledge current research findings by translating knowledge into practice. Despite research advocating upright positions as more favourable than the supine position, specific literature on midwives’ practice of maternal positions in active labour is limited. The authors’ anecdotal clinical experiences in Brunei Darussalam highlighted that nearly all women, both low- and high-risk, frequently adopt either the supine or lithotomy positions during labour and birth. Practice of other positions was not witnessed.
The present study was conducted to explore global studies of midwives’ practice of maternal positions in second stage labour, and establish what could be learnt and adapted for use in Brunei. The findings will hopefully inform the design and implementation of educational strategies to enhance midwives’ knowledge and skills, in order to inform practice and develop confidence and competence in caring for women who choose various maternal positions during labour and birth.
Methods
An integrative review was considered suitable for this study, as this methodology allows inclusion of data from all types of literature to fully answer review questions (Whittemore and Knafl, 2005; Souza et al, 2010). The review was carried out between January and April 2022, and enabled synthesis of current knowledge on the topic, examining the applicability and implications of the findings to nursing and midwifery practice (Souza et al, 2010) in consideration of their strengths and limitations.
Stages of the review
The review stages identified by Whittemore and Knafl (2005) and Souza et al (2010) were compared and contrasted by the review team. To reach a consensus, several meetings were held and any discrepancies in the team were discussed. A simplified version of the stages is shown in Table 1.
Table 1. Stages of the integrative review
| Stage | Actions taken |
|---|---|
| 1: establish review question |
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| 2: search strategy |
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| 3: data abstraction and display |
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| 4: quality assessment |
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| 5: study selection |
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| 6: data synthesis |
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| 7: conclusion drawing |
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Development of review question
In formulating the research question, the population, intervention, comparison, outcomes and time framework was used (Ubbink et al, 2013). This framework is useful in efficient searching and inclusion of high-quality evidence, improves the specificity and clarity of clinical problems, and leads to more precise search results (Ubbink et al, 2013). Table 2 presents the review question formulation using this framework. The question developed was ‘what is midwives’ practice of maternal positions throughout the active phase of second stage of labour?’. Active second stage labour was the focus, in order to explore positions that specifically facilitate the birth of the baby.
Table 2. Framework for developing review question and generating keywords
| PICOT | Focus | Keywords |
|---|---|---|
| P (patient/population) | Midwives | Midwi*; maternity healthcare professionals |
| I (intervention) | Labour and birth positions | Labour; childbirth; position*; birth* |
| C (comparison) | N/A | N/A |
| O (outcomes) | Practice | Practice; practise; skill; perception; experience; knowledge |
| T (time) | Throughout active phase of second stage labour | Active phase; second stage; delivery |
Search strategy
Keywords were generated for an easy and efficient search and to assist in database searching from the index terms created using the framework (Table 2). Boolean operators (AND, OR) and truncations (*) were applied as conjunctions to combine or exclude keywords in the search, resulting in more focused and productive results. This method eliminates inappropriate hits that must be reviewed before discarding (Souza et al, 2010).
The online databases PubMed, ScienceDirect and Scopus were used, as well as manual searching using Google Scholar. These databases were chosen as they provided the most widely accessible resources. Table 3 presents the inclusion criteria for filtering. These were vital features of the target literature that the researcher used to answer the review question (Patino and Ferreira, 2018).
Table 3. Inclusion and exclusion criteria for study selection
| Inclusion | Exclusion | Rationale |
|---|---|---|
| Published in English | Not published in English | Correct interpretation and avoid bias from translation (McKenna, 2022) |
| Publication year: 2015-2022 | Published before 2015 | Obtain relevant studies and exclude outdated evidence (Lund et al, 2021) |
| Full text available | Abstract only | Obtain details on study (Paul and Barari, 2022) |
| Primary literature: quantitative and qualitative research | Secondary literature: eg systematic reviews | Originality of findings from primary literature (Lund et al, 2021) |
| Participants are midwives (if midwives are only one participant group, only findings on midwives will be extracted) | Only addresses women, fathers, other healthcare workers, and diverse set of midwives or other healthcare professionals | Evaluate and synthesise focus of the review (Rethlefsen et al, 2021). If participants are diverse, it will not be possible to track midwives’ responses |
The preferred reporting items for systematic reviews and meta-analysis was used to guide the literature search strategy (Page et al, 2021). This provided a visual of the stages of screening, filtering and selection of papers to be included (Figure 1). The combined keywords search identified 454 articles from the databases (n=412) and Google Scholar (n=42). The first and last authors independently scanned all titles and abstracts for inclusion. Any discrepancies were moderated by the second author. This identified 118 articles, with 304 discarded as they were irrelevant and 32 duplicates removed. A further 106 articles were excluded as they did not meet the inclusion criteria.
The full texts of the remaining 12 eligible articles were screened by two reviewers, with five articles meeting the inclusion criteria, which were included in the review. The final studies were verified for inclusion by all authors. The excluded articles did not focus on midwifery practice, only discussed the advantages and disadvantages of various positions, the effects of positions on labour pain or episiotomy, or focused on women.
Quality assessment, verification and selection
Critical appraisal was conducted using the Joanna Briggs Institute (2017) appraisal tools for methodological quality. The extent to which a study addressed the possibility of bias in its design, conduct and analysis was examined and each study was assessed for its congruity between methodology, data collection and analysis with respect to the study aims. Three reviewers initially conducted the appraisal, which was checked and confirmed by the final author. All articles met all or most of the criteria and were included in the review.
Data analysis
The data were extracted and organised by the review team (Table 4). These data were further thematically analysed using Braun and Clarke (2021). Key findings from the studies were identified, compared and contrasted. Two authors independently read each study and highlighted key words and phrases that sounded and meant the same. On completion of coding, all members of the review team cross-checked the codes and discussed the results. Any inconsistencies or discrepancies were discussed until the review team reached an agreement. Similar patterns or codes, which were grouped together, were also consistently refined by the review team.
Results
The included studies were published in peer-reviewed journals and were conducted in five countries: South Africa (n=20 midwives) (Musie et al, 2019), Nigeria (n=110 midwives) (Diorgu et al, 2016), Tanzania (n=4 enrolled nurse-midwives and n=3 registered nurse-midwives) (Mselle and Eustace, 2020), China (n=17 midwives) (Zang et al, 2021) and Italy (n=115 midwives) (Garbelli and Lira, 2021). Three were descriptive qualitative studies (Musie et al, 2019; Mselle and Eustace, 2020; Zang et al, 2021) and two were descriptive quantitative studies (Diorgu et al, 2016; Garbelli and Lira, 2021). All were conducted in hospital settings, except Garbelli and Lira (2021), which was conducted in birth centres.
There were no specific indications of whether women were low- or high-risk for all studies. Two studies included women and midwives as study participants (Diorgu et al, 2016; Mselle and Eustace, 2020), from which only data on midwives were extracted. A summary of the studies is presented in Table 4.
Table 4. Summary of included articles
| Details | Aims and objectives | Sample and setting | Methods | Key findings |
|---|---|---|---|---|
| Diorgu et al (2016) | Identify prevalence of different positions, and explore differences in mothers’ and midwives’ perspectives of positions and perineal trauma | Sample: 110 midwives, 110 mothers Setting: two hospitals in Port Harcourt, Nigeria | Design: descriptive quantitative Data collection: survey questionnaire |
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| Mselle and Eustace (2020) | Explore perceptions and experiences of mothers and nurse-midwives regarding the use of supine birthing positions | Sample: four enrolled nurse-midwives, three registered nurse-midwives, 16 postnatal mothersSetting: Mugana Designated District Hospital, Missenyi District, Kagera, Tanzania | Design: descriptive qualitativeData collection:semi-structured interviews (nurse-midwives), focus group discussions (postnatal mothers) |
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| Musie et al (2019) South Africa | Explore and describe factors hindering midwives’ use of alternative birth positions during labour in a public hospital | Sample: 20 midwives Setting: public hospital in Central Tshwane, Pretoria, South Africa | Design: descriptive, exploratory, qualitativeData collection: semi-structured interviews |
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| Garbelli and Lira (2021) Italy | Investigate knowledge and skills regarding maternal positions in labour among midwives and describe variables that influence proposal of maternal positions | Sample: 115 midwives Setting: eight birth centres in Brescia, northern Italy | Design: Quantitative, observational, descriptive, cross-sectionalData collection: online questionnaire |
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| Zang et al (2021) China | Explore midwives’ perceptions of assisting women in upright positions during second stage labour | Sample: 17 midwives Setting: labour wards of two maternity hospitals and two general hospitals in China | Design: Descriptive qualitative study Data collection: Semi-structured interviews |
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Four main themes were created: maternal positions practised by midwives, midwives as the prime decision maker, midwives’ personal convenience and comfort, and barriers to practice of maternal positions.
Maternal positions practised by midwives
The maternal positions practised by midwives in all studies could be grouped into upright and supine positions. Upright positions referred to kneeling, squatting, standing and sitting, while Musie et al (2019) classified side-lying positions as upright; the reason for this was unclear. In all studies, supine positions referred to any position where the woman lay on her back with her knees flexed and legs apart, with feet either supported (for example, lithotomy) or not.
Midwives as the prime decision maker
The three studies from Africa (Diorgu et al, 2016; Musie et al, 2019; Mselle and Eustace, 2020) highlighted that decisions about maternal positions were more commonly made by midwives based on their knowledge and experience. Musie et al (2019) reported that in South Africa, some midwives agreed to involve the woman in making decisions on positions that were more comfortable. Although most midwives had different opinions of whether women should be involved in making decisions, it was frequently reported that they did not have time to teach mothers alternative birth positions and that there would be no point letting women choose their preferred position, as they believed that midwives were more knowledgeable and competent in this area (Musie et al, 2019; Mselle and Eustace, 2020).
Midwives’ personal convenience and comfort
Three studies reported that midwives preferred the supine position, specifically the lithotomy position, as compared to upright positions (Diorgu et al, 2016; Musie et al, 2019; Mselle and Eustace, 2020). These positions were reported to be appropriate and comfortable, allowing midwives to assist women more efficiently (Diorgu et al, 2016; Musie et al, 2019; Mselle and Eustace, 2020). Despite midwives’ beliefs that the supine position was the best, safest, most helpful and best-known position, they were also aware of its disadvantages, such as the potential for nerve compression, which could lead to supine hypotension. Despite this, they preferred the supine position as they were familiar with it (Musie et al, 2019; Mselle and Eustace, 2020). Midwives also asserted that supine positions gave them freedom when assisting women during childbirth, and allowed them to perform proper observations, as it gave a good view of the perineum and easy labour monitoring, and minimised midwives’ physical strain during birth (Musie et al, 2019; Mselle and Eustace, 2020).
Midwives were reported to be insensitive and inconsiderate of women's preferred birthing positions, as they focused on how helpful the supine position was for themselves (Diorgu et al, 2016; Musie et al, 2019; Mselle and Eustace, 2020). However, Garbelli and Lira (2021) reported that midwives preferred upright birthing positions, as aortocaval compression brought on during prolonged cardiotocograph monitoring in supine positions had the potential to compromise placental perfusion and fetal oxygenation. Similarly, the study from Nigeria reported that the majority of midwives would be willing to adopt upright positions if these were taught, promoted and accepted as options by women (Diorgu et al, 2016).
Barriers to practice
The reported barriers to practising alternative positions included limited clinical practice of upright and other positions, a lack of confidence among midwives and/or women in practising positions, women's preferences and shortages of human resources and infrastructure (Diorgu et al, 2016; Musie et al, 2019; Mselle and Eustace, 2020; Garbelli and Lira, 2021; Zang et al, 2021).
Limitations to knowledge and skills
Mselle and Eustace (2020) reported that midwives did not assist or advise women to use upright positions because they themselves did not have good knowledge of these positions. Midwives were concerned that they did not have the necessary skills to facilitate upright positions and lacked knowledge of the potential risks of supine positions, which led to a lack of confidence in practising these positions (Mselle and Eustace, 2020). Similar concerns were reported by midwives in South Africa (Musie et al, 2019) and China (Zang et al, 2021), where midwives were mostly taught supine positions during training. One study further reported that, although the majority of midwives had good or excellent knowledge of the specific benefits of upright birthing positions in labour, there was a contradiction with the reality of childbirth (Garbelli and Lira, 2021).
Shortage of human resources and infrastructure
Midwives in South Africa (Musie et al, 2019) and China (Zang et al, 2021) reported difficulties implementing upright positions during labour because of human resource shortages. This referred to shortages of available midwives generally, and of those who had the skills to practice upright birthing positions (Musie et al, 2019; Zang et al, 2021). In China, some midwives reported that upright positions were not encouraged in women with normal labour progress because it was thought that these positions required a minimum of two midwives when assisting women (Zang et al, 2021). The reasons for this perception were unclear. Six out of 17 midwives believed that upright positions could only be used when labour progress was slow (Zang et al, 2021).
Barriers caused by infrastructure included limitations to the available equipment and the design of birthing environments (Musie et al, 2019; Zang et al, 2021). Some midwives reported a shortage of birthing stools, balls and pools in the labour ward (Musie et al, 2019). However, others reported that the labour ward's electronic beds allowed women to use other positions; the barrier in these cases was that midwives had insufficient knowledge of how to use the beds for upright positions.
Discussion
The aim of this integrative study review was to explore the evidence of midwives’ practice of maternal positions throughout active second stage labour. Four themes emerged: maternal positions practised by midwives, midwives as the prime decision maker, midwives’ personal convenience and comfort; and barriers to practice of maternal positions.
The review identified two groups of common birthing positions, upright and supine. However, classification of birthing positions in the five reviewed studies (Diorgu et al, 2016; Musie et al, 2019; Mselle and Eustace, 2020; Garbelli and Lira, 2021; Zang et al, 2021) were inconsistent with other reviews, which have reported up to five different groups of birthing position (Lawrence et al, 2009; Gupta et al, 2017; Kibuka et al, 2021). There is ongoing debate surrounding the complexities of classifying maternal positions; however, it was not within the scope of this review to explore classifications, but instead identify those most commonly practised, and the justifications for such practice.
According to nursing and midwifery regulations from around the world (Nursing and Midwifery Board of Australia, 2008; Nursing Board for Brunei, 2010; 2013; United Nations, 2017), it is a woman's right to make autonomous decisions according to her wishes. Nieuwenhuijze et al (2014) highlighted that involving women in decision making throughout labour is crucial. Despite this, midwives were reported to be the primary decision makers in terms of maternal position during labour and birth (Diorgu et al, 2016; Musie et al, 2019; Mselle and Eustace, 2020). Midwives’ attitudes and approaches are key to whether women receive woman-centred midwifery care (Baldwin et al, 2019). Women's involvement in labour decision making is important, and a lack of influence over decision making is likely to lead women to feel out of control during childbirth and unable to make informed choices (Elmir et al, 2010). Only one study in the present review reported that midwives involved women in decision making regarding maternal position (Musie et al, 2019). Women may therefore have limited choices for position during labour (Diorgu et al, 2016; Musie et al, 2019; McCauley et al, 2019; Mselle and Eustace, 2020).
In the present review, midwives’ decisions for maternal position were reported to be based on personal convenience and comfort, without accounting for women's preferences or comfort (Diorgu et al, 2016; Musie et al, 2019; Mselle and Eustace, 2020). The majority of midwives preferred to use supine, rather than upright, positions. They were aware of the disadvantages of supine positions, but these were outweighed by the ease, comfort, familiarity and midwives’ preference for using supine positions. However, Garbelli and Lira (2021) reported that midwives preferred upright positions, in line with Ayres-de-Campos et al (2015), whose guidance advises avoiding prolonged monitoring in supine positions. Many studies have highlighted that upright positions have advantages over supine positions in promoting maternal and neonatal outcomes (Gaffka, 2016; Gupta et al, 2017; Berta et al, 2019). This evidence is also supported by the World Health Organization's (2021a) guideline to prioritise women's choice in the practice of upright positions.
It has been recognised that organisations’ policies and models of care play an important role in implementation of woman-centred care (Baldwin et al, 2019). This should be borne in mind when considering the evidence from this review in terms of midwives’ practice. It is possible that midwives practising in midwifery-led models of care have greater autonomy in assisting women (Newton et al, 2016). Future research should explore birth positions in relation to models of midwifery care.
The identified barriers to using upright birthing positions included limitations to knowledge and skills (Mselle and Eustace, 2020) and shortages of midwives, equipment and infrastructure (Musie et al, 2019; Zang et al, 2021). Although there are approximately 27 million nurses and midwives across the globe, there is an estimated global shortage of 900 000 midwives (World Health Organization, 2021b; 2022). A shortage of midwives can lead to being overworked, resulting in an inability to appropriately practise maternal positions, especially in situations requiring more than one professional.
Most midwives in the reviewed studies reported not having the skills to facilitate upright positions, which made them hesitant and uncertain, although they were taught the theory during midwifery training (Mselle and Eustace, 2020). Knowledge alone is insufficient and midwives need to be placed in clinical areas that enhance their skills so that they can ensure that their skills are sustained (Tura et al, 2022; Zdeba-Mozola et al, 2022). A study in Iran found that although midwives gained knowledge and skills during education and after qualification, this was insufficient to maintain skills, and assessment and skills training among employed midwives was suggested (Enteshari et al, 2020).
Difficulty in facilitating upright positions during labour is further worsened by shortages of equipment and infrastructure. Practising various maternal positions thus poses risks, meaning midwives are unable to adequately monitor labour progress and leading to delays in treatment, resulting in unnecessary obstetric complications for women (Berta et al, 2019).
Implications for midwifery practice
The Royal College of Midwives’ evidence-based ‘better birth’ initiative was implemented after evidence showed that many women struggled with the term ‘normal birth’, which led them to feel abnormal if their birth did not go according to plan (Sandall, 2017). In order to continue to provide the best possible midwifery care, research is needed to inform evidence-based midwifery practice. Midwifery practice of maternal positions should therefore be based on current evidence. However, the available studies of current practice are insufficient, conflicting and inconclusive.
This study identified existing knowledge and a gap between midwifery skills and practice. There is a need to develop midwives’ knowledge, identify skills to be improved, and augment critical thinking, judgement and decision making around maternal positions. Strategies to improve midwives’ practice of maternal positions, such as upskilling midwives and providing women with appropriate antenatal health education, should be implemented.
Midwives can only be confident in facilitating different birthing positions if they have adequate knowledge and essential skills. The International Confederation of Midwives (2019) mandates that midwives update their knowledge and skills regularly to enhance quality and safe midwifery care. Similarly, midwives play an important ethical role in ensuring that women can make informed choices and have influence over decision making (Nursing Board for Brunei, 2010). Women must be given a full explanation of the benefits of mobility and be supported to use different childbirth positions if they wish, helping them to find the most comfortable positions (Westbury, 2014).
Strengths and limitations
This review adds to existing knowledge on midwives’ practice of maternal positions during active labour. There are few existing studies of this topic, which led to limited data from the five studies included in this review. The included studies were from Africa, China and Italy, revealing a dearth of research elsewhere. Furthermore, only studies published in English were reviewed, and relevant studies in other languages may exist. Midwives’ practice of maternal positions in relationship to their demographic backgrounds, such as education, were not explored but would be beneficial in future research.
Conclusions
Although a substantial number of studies have been conducted to date on maternal positions during the active phase of second stage labour, only five studies investigated midwives’ practice. The findings vary as a result of differences in social context and healthcare systems between countries, and this integrated review on midwives’ practice of maternal positions is inconclusive. This review provides a basis for further research on midwives’ practice of maternal positions throughout the second stage of labour, and identifies a gap between midwives’ skills and current practice.
Key points
- This review explored the literature related to midwives’ practice of maternal positions during the active phase of second stage labour.
- The supine position was preferred to the upright position.
- Midwives were the prime decision makers for maternal positions based on their knowledge and experience.
- Midwives have substantial knowledge of varying positions during the active second stage of labour.
- Limitations to skills, experiences, human resources and infrastructure led to a lack of confidence, inhibiting midwives from using a variety of maternal positions.