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Download by: [Hacettepe University] Date: 22 December 2016, At: 22:09
The Journal of Maternal-Fetal & Neonatal Medicine
ISSN: 1476-7058 (Print) 1476-4954 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmf20
The influence of different maternal pushing
positions on birth outcomes at the second stage of
labor in nulliparous women
Ozlem Moraloglu, Hatice Kansu-Celik, Yasemin Tasci, Burcu Kısa Karakaya,
Yasar Yilmaz, Ebru Cakir & Halil Ibrahim Yakut
To cite this article: Ozlem Moraloglu, Hatice Kansu-Celik, Yasemin Tasci, Burcu Kısa
Karakaya, Yasar Yilmaz, Ebru Cakir & Halil Ibrahim Yakut (2017) The influence of different
maternal pushing positions on birth outcomes at the second stage of labor in nulliparous
women, The Journal of Maternal-Fetal & Neonatal Medicine, 30:2, 245-249, DOI:
10.3109/14767058.2016.1169525
To link to this article: http://dx.doi.org/10.3109/14767058.2016.1169525
Accepted author version posted online: 30
Mar 2016.
Published online: 19 Apr 2016.
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ISSN: 1476-7058 (print), 1476-4954 (electronic)
J Matern Fetal Neonatal Med, 2017; 30(2): 245–249
!2016 Informa UK Limited, trading as Taylor & Francis Group. DOI: 10.3109/14767058.2016.1169525
ORIGINAL ARTICLE
The influence of different maternal pushing positions on birth outcomes
at the second stage of labor in nulliparous women
Ozlem Moraloglu
1
, Hatice Kansu-Celik
1
,Yasemin Tasci
1
, Burcu Kısa Karakaya
1
, Yasar Yilmaz
1
, Ebru Cakir
1
, and
Halil Ibrahim Yakut
2
1
Perinatology Unit, Zekai Tahir Burak Women’s Health Education and Research Hospital, Ankara, Turkey and
2
Neonatology Unit, Zekai Tahir Burak
Women’s Health Education and Research Hospital, Ankara, Turkey
Abstract
Objectives: To assess the effects on neonatal and maternal outcomes of different pushing
positions during the second stage of labor in nulliparous women.
Methods: This prospective study included 102 healthy, pregnant, nulliparous women who were
randomly allocated to either of two positions: a squatting using bars (n¼51), or a supine
position modified to 45 degree of semi-fowler (n¼51) during the second stage of labor.
Duration of the second stage of labor, maternal pain, postpartum blood loss, abnormal fetal
heart rate patterns that required intervention, and newborn outcomes were compared
between the two groups.
Results: The trial showed that women who adopted the squatting position using bars
experienced a significant reduction in the duration of the second stage of labor; they were less
likely to be induced, and their Visual Analog Scale score was lower than those who were
allocated the supine position modified to 45 degree of semi-fowler during second stage of
labor (p50.05). There were no significant differences with regard to postpartum blood loss,
neonatal birth weight, Apgar score at one and five minutes, or admission to the Neonatal
Intensive Care Unit.
Conclusions: In healthy nulliparous women, adopting a squatting position using bars was
associated with a shorter second stage of labor, lower Visual Analog Scale score, more
satisfaction, and a reduction in oxytocin requirements compared with adopting the supine
position. For Turkish women, the squatting position is easy to adopt as it is more appropriate in
terms of Turkish social habits and traditions.
Keywords
Pushing, second stage of labor, squatting
position, supine position, visual Analog
Scale
History
Received 12 February 2016
Revised 15 March 2016
Accepted 20 March 2016
Published online 18 April 2016
Introduction
In current obstetric practice, the optimum maternal position
during the second stage of labor and at delivery is unclear.
Upright positions that include squatting, sitting, kneeling, and
standing during delivery have become more popular since the
eighteenth century because of the potential beneficial effects
on neonatal and maternal outcomes [1]. The squatting
position during the second stage of labor has become
increasingly popular in recent years, although maternal and
fetal risks and benefits are not clearly known [2,3]. Several
studies have shown that all upright positions (i.e. squatting,
kneeling, sitting in a birth chair) during labor and at delivery
have been associated with less severe pain [4], increased
pelvic dimensions [5], more efficient contractions [6], a
shorter second stage of labor, reduced risk of aortocaval
compression, and improvement of acid–base outcomes in
newborns [7,8]. However, there appears to be an increased
postpartum hemorrhage risk in some upright positions, such
as semirecumbent and birth seat [9,10].
The squatting position is considered to be the most natural
position for various cultures including those in Anatolia, the
Middle East, and Africa, especially for women who are in the
habit of squatting to defecate. In Turkey, however, the
majority of women deliver in a supine lithotomy or semi-
recumbent position because fetal monitoring is easier in these
positions and because they are widely-used in modern
Western obstetrics. There are many reasons why pregnant
women are in supine position during the second stage of
labor, and research has reported this – such as preference of
the practitioner, cultural influences, and hands on/hands
poised preference of accoucheur [11,12].
A recent systematic review reported that there was no
statistically significant reduction in the duration of the second
stage of labor, but that blood loss greater than 500 ml was
more common in women allocated to any upright position
[13]. However, the authors concluded that current evidence on
the effectiveness of various delivery positions is inconclusive.
Address for correspondence: Hatice Kansu-Celik, Zekai Tahir Burak
Women’s Health Education and Research Hospital, Talatpa¸sa Bulvarı
158/5, Cebeci 06510, Ankara, Turkey. Tel: + 90 312 310 31 00. Fax:
+90 312 312 49 31. E-mail: h_kansu@yahoo.com
A recent meta-analysis suggested that women should be
encouraged to deliver in whatever position is most comfort-
able for them [14].
The aim of this study is to determine the neonatal and
maternal outcomes, the duration of the second stage of labor,
maternal experience of pain during the second stage of labor
by Visuel Analog Scale (VAS) score, and blood loss among
healthy, pregnant, nulliparous women who push in squatting
position compared with those who push in supine position
modified to 45 degree of semi-fowler during second stage of
labor.
Methods
This study compares two different pushing positions in second
stage, squatting vs. supine, in terms of maternal and neonatal
outcomes. The study is a randomized, controlled trial of 102
births that took place at a maternity hospital in Ankara,
Turkey between December 2013 and May 2014. The project
was approved by the hospital’s local ethical committee. The
criteria of inclusion were nulliparous women with a singleton
live cephalic presentation between 37 and 42 weeks in active
labor who did not receive an epidural anesthesia. Women
were excluded if they had a history of uterine scarring or
pregnancies complicated by evidence of a fetal congenital
malformations gestational diabetes, hypertension or chronic
illness or if her labor was complicated by a first-stage
cesarean or maternal fever.
After obtaining informed consent from the patients,
random selection was carried out before the selected cases
entered the second stage of labor; for each case, midwives
opened a sealed envelope containing one of the two sets of
instructions. One set of instructions indicated that, they
should encourage the patient to adopt the squatting position
using bars. The second set of instructions was to recommend
the use of the supine lithotomy position modified to 45 degree
of semi-fowler (control group) during the second stage of
labor. The second stage of labor was defined as the interval
between the complete opening of the cervix until delivery of
the baby. The squatting position was defined as the patient’s
weight resting on her feet, knees bent (Figure 1). The supine
position was defined as the patient lying on her back [15]
modified to 45 degree of semi-fowler
Women who adopted the squatting position were moni-
tored in standing for five minutes at 10-minute intervals.
Patients were encouraged to squat whenever they felt a strong
urge to push during the contraction. Where contractions
became infrequent, a low-dose intravenous oxytocin infusion
was administered. For patients in the supine position, pushing
was recommended whenever a woman felt the urge to bear
down during the contraction. Fetal heart rate was recorded for
five minutes at 10-minute intervals. For randomization to be
complete, the allocated pushing position was maintained until
the fetal head was crowning. At this stage, all patients were
taken to the delivery table and delivery took place in the
lithotomy position modified to 45 degree of semi-fowler. A
medio-lateral episiotomy was administered to some patients
who were estimated to give birth large fetuses with ultrasound
calculations or who have rigid vaginas on pelvic exam (in
case of necessity). In both groups, delivery and the third stage
of labor were conducted with the patient in the supine
position. There were no instrumental deliveries among the
group. Obstetricians and midwives attended these births.
Data were collected on the variables. Demographic
characteristics included age, body mass index (BMI), gesta-
tional age, educational level, presence of antenatal follow-up,
presence of membrane rupture durations, and any requirement
for increased oxytocin medication. Other variables comprised
maternal hemoglobin (Hb) levels before and after delivery,
postpartum decrease in Hb level, VAS score, first and fifth-
minute Apgar scores, birth weight, and NICU admission.
Educational level was classified according to the number of
years at primary school, secondary school, high school and
university (1 ¼uneducated, 2 ¼0–8 years, 3 ¼more than 8
years). Their most recent antenatal capillary Hb level was
recorded for all patients; postpartum Hb levels were tested at
the sixth hour.
The primary outcome was defined as the duration of the
second stage of labor. Mothers were also asked to estimate
their experience of pain during the second stage of labor on a
10-point scale (VAS score). They were given a number of top
and bottom of the scale that represents their pain intensity
(1 ¼no pain at all, 10 ¼unbearable pain).
Data were evaluated using SPSS for Windows 11.5 (SPSS
Inc., Chicago, IL). An independent sample t-test was used to
compare the squatting and supine groups for continuous
variables with normal distribution. Shapiro–Wilk’s tests were
used whether continuous variables have normal distribution or
not. All variables had normal distributions. Chi-Square and
Fisher-Exact tests were used for categorical data. The
significance boundary was given as 0.05. In a study done
by Ragnar et al. [16], for mean values, duration of second
stage was 48.5 minutes in kneeling position and 41 minutes in
sitting position, in this study we calculated minimum sample
size as 46 persons per groups with 90% power and 0.05 type 1
error (R open source program 3.0.1.).
Results
Description of sample
Two patients were excluded from the study as they required
cesarean sections (one patient from the squatting group with a
Figure 1. Squatting position during second stage with midwifery
assistance.
246 O. Moraloglu et al. J Matern Fetal Neonatal Med, 2017; 30(2): 245–249
diagnosis of cephalopelvic disproportion and one patient from
the supine group with a diagnosis of recurrent late deceler-
ation). The age difference between women in the two groups
was statistically significant, with women in the squatting
group being 23.96 ± 3.75 versus 22.04 ± 3.46; p¼0.009.
There were no other significant differences between the
groups. Demographic characteristics are shown in Table 1.
Maternal outcomes
The duration of the second stage of labor was shorter for the
squatting group and the difference was statistically significant
(21.02 ± 5.60 min versus 55.40 ± 6.91 min; p50.001,
Figure 2). Requirements for increased amounts of oxytocin
were significantly higher in the supine group modified to 45
degree of semi-fowler (62% versus 40%; p50.05). VAS
scores were better for the squatting group. Adopting the
supine position during the second stage of labor was
associated with a higher level of delivery pain (p50.001).
All patients in the squatting group were maintained this
position during pushing. We did not have any drop-out rate.
No maternal complications (i.e. postpartum hemorrhage or
endometritis) were observed. Pregnancy outcomes and labor
durations are shown in Table 2.
There were no significant differences in the decrease in
maternal Hb levels between the squatting and supine groups
(0.3 g/dl and 0.5 g/dl, respectively). There were also no
significant differences in maternal Hb levels before and after
delivery.
Most women gave birth spontaneously. There was no
statistically significant difference between the groups for
numbers of women applying episiotomies; 12 (25%) women
in the supine group and 11 (22%) in the squatting group. One
patient in the squatting group and two patients in the supine
group had second degree of paraurethral tears; however, this
was not statistically significant. All three patients recovered
fully from the paraurethral tears without any sutures. No
patients in the study had extended episiotomies or anal
sphincter injuries.
Neonatal outcomes
There were no significant differences between the two groups
with regard to mean infant birth weight, one and five-minute
mean Apgar scores, and need for neonatal resuscitation. None
of the neonates in either group had fetal complications such as
shoulder dystocia, asphyxia, or meconium aspiration syn-
drome. Neonatal outcomes are shown in Table 3.
Discussion
The most important finding of the present study was that the
duration of the second stage of labor. The mean length of the
second stage of labor was 34 minutes shorter in the squatting
group than in the supine group. The most recent Cochrane
meta-analysis, which was published in 2012, interpreted 22
trials and suggested that the use of any upright or lateral
position, compared with supine or lithotomy position, did not
show a significant reduction in the duration of the second
stage of labor. The average reduction in the duration of
Figure 2. The frequency distribution graph
comparing the two groups for duration of
second stage.
Table 1. Demographic characteristics.
Squatting
(n¼50)
Supine
(n¼50) p
Age 23.96 ± 3.75 22.04 ± 3.46 0.009*
BMI (kg/m
2
) 29.15 ± 3.80 30.23 ± 3.42 NS
Education n(%)
1 5 (10.0%) 8 (16.0%)
2 33 (66.0%) 36 (72.0%) NS
3 12 (24.0%) 6 (12.0%)
No antenatal follow-up n(%) 3(6%) 6 (12%) NS
Gestational age (week) 39.46 ± 1.13 39.60 ± 1.16 NS
Presence of MR n(%) 23 (46.0%) 22 (44.0%) NS
Birthweight (g) 3202 ± 369 3314 ± 439 NS
Large babies (44000 g) 1 (2%) 2 (4%) NS
Education ¼1: uneducated, 2: 0–8 years, 3:48 years. BMI: Body Mass
Index, MR: Membran rupture, NS: non-significant.
*Statistically significant difference p50.05.
DOI: 10.3109/14767058.2016.1169525 The squatting position during the second stage of labor 247
second stage was 3.24 minutes for primigravid women.
However, the meta-analysis findings that women who used
a birth cushion had significantly shorter second stages of
labor compared with those adopting the supine position are
similar to those in our study [14]. Gardosi et al. demonstrated
that the mean duration of the second stage of labor was
14 minutes shorter in the squatting group (using a birth
cushion) than in the semi-recumbent group [17]. Our study
showed that the squatting position using bars for support had a
more marked reduction in the second stage of labor compared
with the supine position modified to 45 degree of semi-fowler.
It is possible that both immediate active pushing in the second
stage and the squatting position supported by bars may be
important factors in shortening the second stage. In our study,
the use of bars helped mothers to maintain the squatting
position and so made it easier to adopt this method throughout
the second stage of labor. All patients adopting the squatting
position completed the second stage without any complaint or
fatigue. It is easy for Turkish women who use the alaturca
toilet for defecation to maintain the squatting position.
Alaturca toilets mentioned squatting toilets without seats
and it showed an empirical data that alaturca toilet was used
by 70%of Turkish people. It may be harder for Western
women to sustain long periods in squatting position.
Physiologic benefits postulated for an upright rather than
recumbent position include the positive effect of gravity on
the uterus, lessened risk of aortocaval compression and
improved acid–base outcomes in the newborns, stronger and
more efficient contractions, improved alignment of the fetus
for passage through the pelvis, and an increase in pelvic
dimensions (radiological evidence of larger anterior-posterior
and transverse pelvic outlet diameters) [14]. For women in an
upright position, major outcomes appear to be similar whether
kneeling or sitting [16].
Another parameter evaluated in maternal outcomes is the
amount of blood loss during delivery. The definition of
postpartum hemorrhage after vaginal delivery is the loss of
500 ml or more of blood from the genital tract. Although the
estimation of blood loss (EBL) at delivery is a subjective
measurement, it is, nevertheless, the method most frequently
used to evaluate birthing process outcomes. However, the use
of EBL has been associated with an underestimate of the loss.
In research literature, EBL has been calculated by the amount
of blood collected in a receptacle, but subjective perceptions
of EBL may be affected by birth position. Considering these
limitations, other methods for EBL have been proposed
together with alternative postpartum hemorrhage (PPH)
definitions (e.g. 10% drop in hematocrit/Hb) [13]. In this
study, therefore, we used the maternal Hb levels before and
after delivery to make an objective assessment.
In the research literature, EBL greater than 500 ml has
been found to be more common where the upright position
was adopted during the second stage of labor [14]. In a recent
randomized controlled trial in Sweden evaluating outcomes
on a birth seat compared with other birth positions, EBL
between 500 and 1000 ml was more common with the birth
seat. However, there was no decrease in postpartum Hb levels
after 24 and 36 h (10). In a similar way, we also found that
there was no difference between the two groups in terms of
the decrease in postpartum maternal Hb levels after six hours.
Some authors have concluded that the squatting position
increases pressure on the perineum and may cause edema and
increased blood loss from perineal tears [4,18]. It is possible
that the shorter duration of the second stage and immediate
pushing may have prevented the buildup of pressure on the
perineum. In our study, pushing at upright position only
during second stage of labor, not at delivery, may obtain an
advantage for avoiding blood loss.
A previous study carried out by Ragnar et al. showed that
adopting the kneeling position during the second stage of
labor was associated with a lower delivery pain score, a less
frequent perception of prolonged labor, and greater comfort in
giving birth compared with the sitting position [16]. The
women in our study who adopted the squatting position
experienced less pain compared with subjects in the supine
position group. This may be related to the shorter duration of
the second stage and a reduced requirement for oxytocin
induction. Our research has shown that factors such as
maternal feelings of control, increased mobility, and increased
diameter of the pelvic outlet are all factors that could
contribute to a shorter duration of second stage.
We found that women in the squatting group are less likely
to receive oxytocin augmentation; 40% of patients used
oxytocin during the second stage as compared with 62% in the
supine group. These findings were statistically significant
(p¼0.045). This can be explained by maternal expulsive
forces facilitated by the force of gravity and stronger and more
efficient uterine contractions while in the squatting
position [19].
Table 2. Outcomes of the current pregnancy and labor durations.
Squatting Supine
(n¼51) (n¼51) p
Delivery mode n(%)
Spontaneously 50 (98) 50 (98) NS
Cesarean section 1 (2) 1 (2) NS
Duration of 2nd stage (min) 21.02 ± 5.60 55.40 ± 6.91 50.001
Duration of 3rd stage (min) 6.18 ± 1.77 5.92 ± 1.60 NS
Oxytocin uses n(%) 20 (40) 31 (62) 0.045
Perineal laseration (only 2)n(%) 1 (2) 2 (4) NS
VAS score n(%)
1–5 18 (36) 0 (0) 50.001
5–10 32 (64) 50 (100) 50.001
Hb (before delivery, g/dl) 12.15 ± 1.08 12.16 ± 1.11 NS
Number of low Hb’s (10) n(%) 2 (4) 2 (4) NS
Hb (after delivery, g/dl) 11.84 ± 1.25 11.64 ± 1.22 NS
Decrease in Hb level (g/dl) 0.31 ± 0.64 0.53 ± 0.62 NS
Number of low Hb’s (10) n(%) 6 (12) 6 (12) NS
Values are indicated as mean± SD. p50.05, significant. Hb:
Hemoglobin, VAS: Visual analog scale.
Table 3. Neonatal characteristics.
Squatting (n¼50) Supine (n¼50) p
Birthweight (g) 3202 ± 369 3314 ± 439 NS
Apgar*
1st min 8 (7–8) 8 (7–8) NS
5th min 10 (9–10) 10 (9–10) NS
NICU (n,%) 3 (6.0%) 5 (10.0%) NS
*Median (Min–Max), Mean ± SD for Birthweight. NICU: Requirement
of neonatal intensive care unit.
248 O. Moraloglu et al. J Matern Fetal Neonatal Med, 2017; 30(2): 245–249
In routine practice in Turkey, the supine position modified
to some degree of semi-fowler is the most widely-used
position in the second stages of labor, and at delivery. This
study was planned as a preliminary study to investigate VAS
score of patient, duration of the second stage, and maternal-
fetal outcomes with push in squatting position during the
second stage of labor.
This study has several limitations. For women who gave
birth in the supine group and in the squatting push position
group, the episiotomy rates were 25% and 22%, respectively.
Although recently literature suggested that episiotomies at
birth should be personalized and restricted, doctors are still
performing routine episiotomies in nulliparous women who
give birth in hospital in Turkey. One of the other limitations of
our study was women randomized to the squatting group were
moved after crowning of the fetal head to lithotomy for the
completion of second stage. Lithotomy position is the
traditional way of giving birth in hospital in Turkey.
Besides, obstetricians have some drawbacks such as: the
fear of being unable to protect perineum during the birth or in
case of possible shoulder dystocia which might need maneu-
vers as they are not very well-experienced in squatting
position births generally in Turkey. Therefore, the duration of
second stage and related outcomes may not be accurately
measured in this study.
Our result suggests that the squatting position is a natural
and, therefore, the preferable position for Turkish women. In
addition, some studies have indicated that it is easier for
mothers to push down when the squatting position is adopted
[19,20].
Conclusion
For low-risk, nulliparous women, squatting position during
second stage of labor has no deleterious effects to the
mother or fetus. This study found squatting position has
several benefits and no detrimental effects. In contrast to
other studies that used a non-blinded subjective measure of
blood loss, no difference in blood loss was found using
hemoglobin and change in hemoglobin as objective indica-
tors of blood loss. Squatting position should be offered to
women in second stage of labor, particularly in situations
where expedited delivery may be indicated. Indeed, there
are a number of benefits for the mother, including a
shortening of the second stage of labor, improvement in
pain scores, and decreasing oxytocin requirement. Midwives
support is important for correct application and continued
use of this position.
Declaration of interest
The authors report no declarations of interest.
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DOI: 10.3109/14767058.2016.1169525 The squatting position during the second stage of labor 249
