Less perineal damage in sitting position not explained by changing position to perform an episiotomy

Perineal damage is a common complication in childbirth. Perineal damage causes pain and discomfort and can be immobilizing for women. Furthermore, it is a risk factor for blood loss and infection. Perineal damage can be a spontaneous rupture of tissues or an incision of the perineum (episiotomy). We know that women who give birth lying down on their back are more likely to have an episiotomy than women who give birth in an upright, sitting position. It is possible that women in upright position during the second stage (pushing) of labour are asked to lie down if a professional needs to perform an episiotomy. To test this hypothesis we looked at data from a Dutch prospective cohort study to determine whether the episiotomy rate is higher in women who change from upright to horizontal position compared to women who are in horizontal position all the time, and to women who give birth in sitting position.

Fig. 1. Study groups

Data from 1.196 women with a low risk of complications who were in primary midwifery care during birth were analyzed. All positions during the second stage and the position at the moment of birth were carefully recorded. Three groups were identified and compared: 1) women with horizontal positions during second stage and lying down on their back at birth (horizontal/supine); 2) women with upright and horizontal positions during second stage, supine position at birth (various/supine); 3)  women who were in sitting position during second stage of labour and at birth. (Fig. 1). In the data analysis groups were compared and the risk for a specific outcome was adjusted for known risk factors that can also influence the perineal damage rate; age, birth weight, duration of second stage of labour and whether the woman had given birth before.

The results show that women who gave birth in sitting position had a much lower episiotomy rate (OR: 0.28; 0.14-0.56) and showed a trend to a higher intact perineum rate (OR: 1.40; 0.96–2.04) compared with women who were in horizontal position during the entire second stage. The intact perineum rate of the group that used horizontal and upright positions during second stage and gave birth in supine position did not differ from the group that was in horizontal position during the entire second stage, and neither did the episiotomy rate.

So, the higher episiotomy rate in supine birth position cannot be explained by changing from upright to supine position when an episiotomy is indicated. Therefore, the higher episiotomy rate in supine birth position should be explained by other factors, such as the birthing position itself and/or restraint in midwives to perform an episiotomy in women who give birth in upright positions relative to supine position. Upright positions at birth are still controversial. It is reassuring that there is growing evidence that there is no reason to avoid upright positions in order to reduce the chance of perineal damage. For now, women can be encouraged to choose any position that they are comfortable with during childbirth.

Willemijn D.B. Warmink-Perdijk
Midwifery Science, AVAG and the EMGO Institute for Health and Care Research,
VU University Medical Center, Amsterdam, The Netherlands

 

Publication

Better perineal outcomes in sitting birthing position cannot be explained by changing from upright to supine position for performing an episiotomy.
Warmink-Perdijk WD, Koelewijn JM, de Jonge A, van Diem MT, Lagro-Janssen AL
Midwifery. 2016 Mar

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