The Influence of Maternal Position on Time of Spontaneous Rupture of the Membranes, Progress of Labor
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Copyright 01979 Birth and the Family Journal
The Influence of Maternal Position
on Time of Spontaneous Rupture
of the Membranes, Progress of Labor,
and Fetal Head Compression
Roberto Caldeyro-Barcia, M. D.
ABSTRACT: The results of the Latin American Collaborative Study of maternal Position in Labor
are presented. 225 women comprised the “horizonta1”groupand 145 were allowed to assume the
position of choice during labor. All women were matched otherwise and had normal pregnancies
and onset of labor. Maternal position had no effect on time of spontaneous rupture of membranes,
Labor was 36% shorter in primiparous women and 25% shorter in all women who were upright
during labor. Maternal position had no effect on fetal head molding or Type I and Type 11 heart
rate patterns. The upright position was preferred by 95% of women. (Birth Fam J6:1, Spring19791
As many people are aware, until late in cause it might be beneficial for the
the 18th Century most women in the mother or the fetus. Vaginal examina-
world adopted an upright position during tions, obstetrical maneuvers and the
the first, second and third stages of labor. application of the Chamberlen forceps
This might have been standing, sitting, were all easier to do when the woman
kneeling or squatting, but always with was recumbent in bed. The first written
the trunk more vertical than horizontal. document proposing that the knees be
In 1738, the French obstetrician, drawn up was the 1824 book, System of
Frangois Mauriceau, proposed the recum- Midwifery, by William Pott Dewees,M.D.,
bent position in bed to replace the sitting a Philadelphia obstetrician. He insisted
position on the birth stool. Since Mauri- that delivery is best achieved when the
ceau was the obstetrician to the Queen mother is lying on her back and her
of France, he was able to impose this knees are drawn up.
position, which then became popular
throughout Europe and spread across The “Lying-In Bed” continued as the
major posture for parturition during the
the Atlantic. According to the book of
19th and early 20th Centuries, when
Mauriceau, the recumbent position was
most births were taking place in the
introduced to facilitate the management
home. As hospital births increased, the
of labor by the accoucheur and NOT be-
bed was replaced by the delivery table,
and the woman lay on her back in the
Koberto Caldeyro-Barcia, M.D., is an ICEA Consultant, lithotomy position for the birth. The use
President of the International Federation o f Gyne-
cologists and Obstetricians, Professor and Director of of both the delivery table and the lithot-
the Latin American Center f o r Perinatology and omy position has spread, during this
IIuman Development, World IIealth Organization in century, to modern, up-to-date maternity
Montevideo, Uruguay. This paper was presented at t he
ICItA Biennial Convention i n Kansas City, Kansas, hospitals in most of the civilized areas of
Ju n e 18, 1978. the world.
B i r t h and t h e F a m i l y Journal VoI. 6:l Spring 1979 7iifhdrtUB R h d l u s
l" 1544
Figure 1. In Europe the most common position
for delivery was using the birth stool. There
were many varieties, but allfollowed the pattern
of the one shown here.
Figure 2. A n Iroquois Indian woman giving
birth in the nineteenth century. (Englemann,
1882
Figure 3. Squatting position among the Ton-
h-awa Indians (U.S.A.) (Englemanri, 1882)
Figure 4. A n ancient ceramic from Peru, sliow-
ing a woman in second stage, her husband
behind her giving physical and moral support,
a midwife attending. This position was used in
diflerent cultures all over the world.
x B i r t h and the Family Journal VOI. 6:1 Spring 1979Figures 5 and 6 . Here, Dr. Caldeyro-Barcia 's eldest daughter, in labor during her third pregnancy, demonstrates the sitting position, which she preferred most of the time, and standing and walking, which she did .from time to time. Her husband and father are with her. Her uterine cotitractioris and the .fetal heart rate were monitored continuously to provide data Jor the study. Birth and the F a m i l y Journal Val. 6 : l Spring 1979 9
The lithotomy position is n o t natural These were the conditions fulfilled by
or convenient for labor. It causes well- all the subjects included in this study:
known ill-effects, such as the compres- Low-risk labors: uncomplicated preg-
sion by the uterus against the spine of nancies
the inferior vena cava, aorta, iliac arteries Labor started spontaneously at term
and ureters. This pressure completely Cervical dilatation progressing normal-
disturbs the maternal circulation and the ly from 3 t o 5 cm
output of urine. Disturbances of the
maternal circulation have an unfavorable Single live fetus, cephalic presentation
and distressing effect on the fetus. Anterior position, unruptured mem-
A return t o a natural position was branes
started in New York by Forrest H. No cephalo-pelvic disproportion
Howard, M.D., in 1954. He designed a Normal pelvis
table with a back that could be lifted These are the most favorable condi-
from the horizontal to the vertical posi- tions you can find. They wanted t o have
tion, so that the mother was sitting up- this homogeneous group in order t o rule
right during labor. His table did not out as far as possible any variables which
become popular, perhaps because he could interfere with the study. The only
insisted that the back of the table be factor which changed was the mother’s
completely vertical. This position is not position in labor.
very comfortable for the mother. The mother’s position during labor
Other tables have adjustable back rests was selected at random; at each hospital,
and the angle can be varied from 15 t o 50% of the laboring mothers remained in
about 55 degrees. Dr. Newton found that the recumbent position in bed during the
women were most comfortable when first stage. This was the usual practice at
their backs were between 30 and 45 these hospitals. The other 50% of the
degrees up from the horizontal position. mothers were allowed to stand up, walk,
At our center in Montevideo, we use or sit o r lie in bed as they chose. Only
an adjustable table. The inclination of 5% of the mothers preferred to lie down;
the back and the position of the foot 95% preferred t o stand, walk o r sit.
holders can be changed. The woman is The two groups of mothers (“hori-
free t o move arms and legs, and there zontal” and “vertical”) were carefully
are hand grips for helping her t o push matched t o assure that there were no
during second stage. With this type of significant differences in any other vari-
table, the obstetrician o r midwife also ables which might influence the course
has great facility to maneuver t o attend of labor. The two groups were matched
the birth of the child. for parity (there were equal numbers of
mothers with 0, 1, 2, 3, 4, 5, 6 and 7 pre-
vious pregnancies), maternal weight,
height, age, weight gain. In addition,
The Latin American Collaborative Study neonatal data were matched for these
on Maternal Position During Labor factors: birthweight, height, loops of um-
bilical cord, perimeters of head, abdomen
The Latin American Collaborative and thorax. There were no significant
Study on Maternal Position During Labor differences found between the vertical
represented the coordinated efforts of 1 1 and the horizontal groups for any of
Maternity Hospitals in 7 countries: El these factors.
Salvador, Costa Rica, Venezuela, Brazil,
Uruguay, Argentina and Chile. The pro- There were 225 women in the “liori-
ject was directed by R. Schwarcz, G. zontal” group and 145 in the vertical
D i u , R. Fescina and R. Caldeyro-Barcia. group.
10 Birth and t h e F a m i l y Journal VoI. 6 : l S p ring 1979The management of the labors was Results
conservative. The membranes were not
ruptured artificially. No medication was Figure 7 illustrates the phase of labor
given routinely, no oxytocin, sedatives, at which the membranes ruptured spon-
analgesia, anesthesia, except local anes- taneously in the two groups. In the great
thesia for episiotomy. Less than 3% of majority of labors (whether spent in the
labors required medication, and the data horizontal or vertical position) spontane-
from these medicated labors are not in- our rupture occurred at an advanced
cluded in this study. This very low need phase of labor. In 85% of cases, spontan-
for medication can be explained by the eous rupture occurred at 9 cm orbeyond.
fact that all women and their husbands Now, what are the differences in
were prepared by the psychoprophylactic uterine contractions occurring when the
method, and that many could select woman is lying on her left side and on
favorable positions for labor. her back? As seen in Figure 8, this graph
Figure 7. The influence of maternal position on time of spontaneous rupture of the membranes
20:.
n c MATERNAL
POS IT1ON
HORIZONTAL
---.I
N = 153 labors
10 *
i
%
30 4
MATERNAL
POSITION
VE RTlCAL
N = 90 labors
10.
0
4 5
cervical dilatation (crn) Second Stage
~
Figure 7. These graphs illustrate the phase of labor a t which the membranes ruptured spontaneous-
ly in the two groups. In the great majority of labors (whether spent in the horizontal or vertical
position) spontaneous rupture occurred at an advanced phase of labor. In 8.5% o f cases, spontaneous
rupture occurred ({t9 cm or beyond. (Diaz et al, 1 9 77)
Birth and the F a m i l y Journal Vol. 6: 1 Spring 1979
11Figure 8. The influence of maternal position on strength and frequency of
uterine contractions during labor
FULL T E R M PREGNANCY
Spontaneous Onset of Labor
Cervical Dilatation - 3 cm
on left side on back
mm Hg. +I
I
u-
L . & I I I I h 1 1 1 1 ~ ~ 1 1
0 5 10 15 30 minutes
~ TONUS 6 mm Hg 7 rnrnHg
INTENSITY 53 mm Hg 23 mm Hg
FREQUENCY 3.2 cont./lO rnin 5.2 cont./lO rnin
UT. ACTIVITY 170 Montevideo units 120 Montevideo units
~~
Figure 8. As seen in this graph of uterine Contractions occurring during
30 min. of the labor of a woman typical of those in our study, contraction3
are stronger but less frequent when the woman is on her side, than whev;
on her back. (Figure redrawn from Caldeyro-Barcia et al, 1978)
of uterine contractions occurring during labor. Delivery was spontaneous after
30 min. of the labor of a woman typical 4 hrs. 15 min. of labor. Apgar scores
of those in our study, contractions are were 8 a t 1 , 5, and 10 min. of age. The
stronger but less frequent when the wom- mother stood and lay supine alternately
an is on her side, than when on her back. for 30 min. periods. Dilatation and in-
A similar change is found when the tensity of contractions were far greater
woman goes from a supine position to a while she was standing; frequency of
standing position, except that there is n o contractions did not change.
difference in the frequency of contrac- Uterine activity, measured in Monte-
tions. The intensity of contractions is video Units, is computed by multiplying
greater, and the frequency of contrac- the frequency of contractions per 10
tions is about the same when the woman min. by the intensity in mm Hg. The
is standing, than when she is lying on her mean uterine activity in 20 normal full-
back. Therefore, the efficiency in dilating term labors spent in the horizontal posi-
the cervix is much greater when standing tion was 129 Montevideo Units; that of
than when supine or in the side-lying 20 normal full-term labors spent in the
position. vertical position was 160 Montevideo
Another illustration of the difference Units. Contractions are more efficient in
in labor progress accomplished in the the vertical and sitting positions whcn
standing and supine positions is the compared to the horizontal position.
labor of a 22 year-old primigravida This means that the work of the uterus
at 37 weeks’ gestation. Pregnancy had results in more dilatation when the worn-
been normal and her membranes had an is vertical o r sitting than when she is
ruptured spontaneously at the onset of horizontal, by 1.7 t o 1.9 times.
12 Birth and the Family Journal Vo!. 6:1 Spring 1979Maternal Position
HORIZONTAL
N=51
MEAN 259 rnin
MEDIAN 225 min iWhat is the influence of maternal In the upright position the effect of
position on the duration of the first stage gravity on the fetus is synergistic with
of labor? In order t o make for more effects of uterine contractions and of
precision in our study, we measured the bearing-down efforts. In fact, gravity
length of time beginning when the moth- adds 35 m m Hg to the pressure exerted
er was at 4 t o 5 cm. of cervical dilatation by the fetal head on the cervix in the
and ending when she was at 10 cm. We first stage o r on the birth canal in the
divided our results to show the influence second stage of labor.
of' maternal position on the duration of This was well-shown by Dr. Mendez-
the first stage for primigravidas only and Bauer in 1976. He placed a balloon be-
for all subjects in the study. tween the fetal head o r bag of waters
Figure 9 indicates those primigravidas and the cervix, and recorded the pressure
who spent the first stage of labor in the on that balloon when the woman was
vertical position had shorter first stages supine and when she was standing. Pres-
by a median length of 78 minutes (or sure in the balloon increased by 35 mm
36% shorter). Hg when the woman changed from the
Figure 10 shows a similar difference supine t o the standing position. This in-
in the duration of the first stage when crease in pressure may explain the in-
primigravidas and multigravidas were creased efficiency of uterine contractions
combined in the study. The vertical posi- while standing.
tion was associated with a shorter median Even though,as Mendez-Bauer reported
duration of first stage by 45 minutes, or in 1976, the vertical position of the
25%. mother causes an increase in pressure on
the fetal head, the vertical position
causes n o increase in the incidence of
Figure 11. The effect of maternal position in
!abor on incidence of caput succcdaneurn caput succedaneum (swelling of the tissue
over the fetal head caused by pressure
Percent of neonates with during labor) when the membranes are
c a p u t succedaneum intact. This is shown in Figure 1 1.
100 -
Another indication of fetal head com-
80 - "189 NZ126
pression is the number of Type I Dips or
60 -
early decelerations in the fetal heart
rate associated with uterine contractions.
40 - When the incidence of Type I, Type I1
and combined Types I & I1 were corn-
I6 %
20 - pared between vertical and horizontal
N-36 N1
:7 positions, there were n o significant dif-
0-1 I
ferences between the t w o groups in the
1 Horizontal I Vertical 1 incidence of each type of dip.
I
Disalignnient of cranial bones (mold-
MATERNAL POSITION ing) of the neonate was not associated
with maternal position during labor. Dis-
X2=0.89
Not Significant
alignment in one or more cranial sutures
(sagittal, coronal and/or lambdoid) was
The vertical positiotz causes 110 increase irt the
found i n 66% of neonates whose mothers
incidence 0 1 caput succedarteum (swelling o j spent labor in the vertical position; 69%
the tissue over the fetal liead caused by pressure in the horizontal position. The difference
during labor) whcri the membranes are iiituct. is not significant. Therefore, i n conclu-
(Diaz et al, I 9 77) sion, the vertical position of the mother
14 B i r t h and the Family J o u r n a l Vol. 6:l S p r i n g 1979in labor is not significantly associated contracting uterus. I. J Jap Obstet Gynecol Soc
(English) 13:16, J a n 1966.
with an increase in caput succedaneum,
fetal heart rate decelerations, or increased Caldeyro-Barcia R, Noriega-Guerra L, Cibilis
molding of the neonatal head. However, LA, Alvarez H e t al: Effect of position changes
as I reported in 1977 at the ICEA on the intensity and frequency of uterine con-
Eastern-Southern Regional Conference, tractions during labor. Am J Obstet Gynecol
80:284, Aug 1960.
early amniotomy is associated with a
shortening of labor by 28% and increased Caldeyro-Barcia R, Bieniarz J, Maqueda E: Com-
molding of fetal head by three times. pression of the aorta by the uterus in late
human pregnancy. Am J Obstet Gynecol 95:
What about the comfort of the moth- 795, 1 5 Jul 1966.
er? Does the fact that her labor is shorter
Caldeyro-Barcia R, e t al: Adverse perinatal ef-
when she is in the vertical position mean fects of early amniotomy during labor, in Gluck
that her labor will be more painful? The L (ed): Modern Perinatal Medicine. Chicago,
fact that 95% of mothers chose to be Year Book Medical Publishers, Inc. 1974 (also
vertical when they were given the choice available as a reprint from: Professional Educa-
between vertical and horizontal indicates tion Department, The National Foundation
March of Dimes, 1275 Mamaroneck Ave., White
that they were probably more comfort- Plains, NY 10605).
able when upright. We found that when
Englemann, George: Labor A m o n g Primitive
mothers spend time in different positions Peoples. Burke, Cleveland, 1882.
in labor (supine, lateral, sitting and stand-
Flynn A and Kelly J : Continuous fetal monitor-
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Summary Humphrey M et al: The influence of maternal
posture a t birth on the fetus. J Obstet Gynecol
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spontaneous labors, the vertical positions position on moulding and duration of labor.
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Birth and the Family Journal VOI. 6:l Spring 1979
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