Abstract
Background
Labour is a physiological process. Before the seventeenth century, the upright birthing position was common in western countries. The supine position became popular because of the convenience for health professionals rather than the benefits for women.
Aims and Objectives
To compare the outcomes of normal deliveries between squatting and lying down positions and to assess the risks and benefits of squatting position during the second and third stages of labour and its comparison with the lying down position.
Methodology
A hospital-based prospective randomized controlled study was conducted in the Department of Obstetrics and Gynaecology in tertiary care centre carried over a period of 18 months among 212 female patients in labour assigned in Group A squatting position and Group B lying down position.
Results
The mean age of patients in Group A was 23.30 ± 4.30 years and Group B was 23.81 ± 4.13 years. The mean duration of second and third stages of labour in both multigravida and primigravida patients was significantly lower in Group A (p < 0.05). The mean amount of blood loss in Group A was significantly higher compared to Group B (p < 0.05). The mean VAS score assessing severity of pain at second stage and third stage of labour was significantly lower in Group A compared to Group B (p < 0.05).
Conclusion
Squatting position was found much convenient for mothers in terms of less duration of second stage of labour, less number of patients administered oxytocin, lesser extension of episiotomy and greater maternal satisfaction on severity of pain.
Keywords: Squatting position, Lying down positions, VAS score, Second and third stages of labour
Introduction
Labour is a physiological process. Women today have limited experience with physiological birth, largely because of the technological approach favoured in hospitals. Before the seventeenth century, the upright birthing position was common in western countries [1, 2]. The supine position became popular because of the convenience for health professionals rather than the benefits for women [3, 4].
The lithotomy position, with a mother flat on her back and her feet in stirrups, has become the standard position in hospitals and is considered the ideal posture for doctors to deliver the baby due to easy access. Thus, recumbent position makes it easier to palpate the mother's abdomen in order to monitor contractions, to perform vaginal examinations and invasive manoeuvres. But, for the mother, who has to push her baby uphill against the force of gravity while lying on her back, it may not be so ideal. Moreover, because of increased risk of maternal abdominal blood vessel compression, less effectiveness of uterine contractions, less perineal muscle relaxation, high rate of analgesia request and longer labour duration, recumbent position seems to be associated with more operative deliveries, severe pain, abnormal foetal heart trace and greater episiotomy rate [5, 6].
Tearing is also much more common due to the mother's perineum being stretched by the positioning of the stirrups Where western health care has not had much influence, the upright position is still very common [7, 8].
The World Health Organization (WHO) has also recommended use of the upright position for labour and childbirth under Category A—i.e. a practice clearly useful and effective—while the supine lithotomy has been categorized as Category B—i.e. a practice very clearly harmful, ineffective and to be eliminated from practice. Thus, there is a need for consideration of maternal foetal outcomes in lying down position, in terms of labour pain, extension of episiotomy, prolonged second stage of labour, second and third degrees of perineal tear, shoulder dystocia and retailed placenta, as these are risk factors for complications related to normal delivery.
Materials and Method
A hospital-based prospective randomized controlled study was conducted in the Department of Obstetrics and Gynaecology, Dr. Shankarrao Chavan Government Medical College and Hospital, Nanded, Maharashtra, carried out over a period of 18 months from 1 January 2018 to 30 June 2019 among 212 female patients randomly assigned in the following two groups till the sample size was achieved in the said duration.
Group A: 106 Patient in squatting position (experimental group)
Group B: 106 Patient in lying down position (control group)
The sample size was calculated on the basis of a similar study conducted by Valiani M et al. [9] that compared the visual analog scale (VAS) in the latent phase of the second phase of labour between the squatting and lithotomy positions. The power of the study was fixed as 0.8 and α error as 5%. Considering a non-inferiority or superiority margin of 1 and a sampling ratio of 1 between the two groups, the sample size was calculated as 192. A dropout rate of 10% implied, resulting in a total sample size of 212, i.e. 106 patients in each group.
Both the group were mobile during first stage of labour. For the experimental Group A, squatting position, “Squatting birthing (Pregnancy) Chair” was used. In this chair, sufficient height (740 cm) and variation in angle of backrest (90–125 degrees) can be provided. Height increases comfort to mother as well as doctor and also additional gravity advantage. The control Group B assumed the routine line of lying down position, i.e. flat on the back supine lithotomy position. Intensive monitoring of their progress and constant physical and emotional support were given by the researcher.
During the third stage of labour, subjects assumed same position as assigned earlier based on their groups. After the placental delivery, the back rest was lowered to horizontal position. Medio-lateral episiotomies were given according to stretchability of the perineal tissues. The use of outlet forceps was limited to patients who had a prolonged second stage of labour due to the inability to push. The women of both groups were placed in the supine position for repair of episiotomy.
The main outcome of variable measured was duration of second and third stages of labour and amount of blood loss, and the relevant data pertaining to these outcomes were recorded by the researcher. The data thus obtained were analysed for the results.
Statistical Analysis
Quantitative data were presented with the help of mean and standard deviation. Comparison among the study group was made with the help of unpaired t test as per results of normalcy test. Qualitative data were presented with the help of frequency and percentage table. Association among the study groups was assessed with the help of Student’s t test and Chi-squared test. (p value less than 0.05 is taken significant.) Appropriate statistical software, including MS Excel and SPSS version 20, was used for statistical analysis.
Inclusion Criteria
All female patients in primigravida and multigravida between > 37 to < 41 weeks of gestation.
Those with single live pregnancy with vertex presentation, anterior position, adequate pelvis presenting in active labour with no history of high-risk pregnancy and antenatal high-risk pregnancy.
Those willing to provide informed consent.
Exclusion Criteria
All those with high-risk pregnancy (including preterm delivery, foetal distress, premature rupture of membranes (PROM) > 12 h, severe pregnancy-induced hypertension (PIH), imminent eclampsia, eclampsia, severe anaemia, known case of heart diseases, known case of thyroid disorders, malpresentation, congenital anomalous baby, foetal weight > 3.5 kg)
Those unwilling to participate in the study.
Results
In Table 1, Group A had 47.2% patients in the age group of 21–25 years. The mean age of patients was 23.30 ± 4.30 years. Group B had 50% patients in the age group of 21–25 years, and the mean age of patients was 23.81 ± 4.13 years. The difference in mean age of patients in both the groups was statistically not significant (p > 0.05). 30.2% patients in Group A were primigravida, while 69.8% patients were multigravida. 28.3% patients in Group B were primigravida, while 71.7% patients were multigravida. The difference was statistically not significant (p > 0.05).
Table 1.
Distribution of pregnant mothers
| Age-wise distribution of pregnant mothers | |||
|---|---|---|---|
| Age (years) | Group A n (%) | Group B n (%) | p Value |
| 18–20 years | 34 (32.1%) | 26 (24.7%) | > 0.05 |
| 21–25 years | 50 (47.2%) | 53 (50%) | |
| 26–30 years | 14 (13.2%) | 18 (16.9%) | |
| > 30 years | 8 (7.5%) | 9 (8.4%) | |
| Total | 106 (100%) | 106 (100%) | |
| Gravidity-wise distribution of pregnant mothers | |||
| Primigravida | 32 (30.2%) | 30 (28.3%) | > 0.05 |
| Multigravida | 74 (69.8%) | 76 (71.7%) | |
| Total | 106 (100%) | 106 | |
In Table 2, total duration of labour in second stage was significantly lower in multigravida patients of Group A compared to Group B (p < 0.05). The total duration of labour in second stage was significantly lower in primigravida patients of Group A compared to Group B (25.37 ± 1.45 min vs. 35.49 ± 1.07 min; p < 0.05). The mean duration of second stage of labour in Group A was significantly lower compared to Group B (p < 0.05). The mean duration of third stage of labour in Group A was significantly lower compared to Group B (p < 0.05).
Table 2.
Distribution of pregnancy outcomes (maternal factors)
| Total duration of Labour | |||
|---|---|---|---|
| Gravida | Group A (mean ± SD | Group B (mean ± SD) | p Value |
| Primigravida | 25.35 ± 1.46 | 35.51 ± 1.08 | < 0.05 |
| Multigravida | 25.37 ± 1.45 | 35.49 ± 1.07 | < 0.05 |
| Total duration of stage of labour | |||
| Second stage of labour | 25.35 ± 1.45 | 35.50 ± 1.07 | < 0.05 |
| Third stage of labour | 12.19 ± 1.23 | 21.98 ± 1.26 | < 0.05 |
| Amount of blood loss during labour | |||
| Amount of blood loss | 335.89 ± 9.91 | 323.84 ± 20.98 | < 0.05 |
| Necessity of episiotomy | |||
| GroupAn(%) | GroupBn(%) | p Value | |
| Necessity of episiotomy | 58 (54.7%) | 64 (60.4%) | > 0.05 |
| Requirement of oxytocin | |||
| Requirement of oxytocin | 42 (39.6%) | 58 (54.7%) | < 0.05 |
The mean amount of blood loss in Group A was significantly higher compared to Group B (p < 0.05). Episiotomy was given to 54.7% patients in Group A and 64 60.4% patients in Group B.
39.6% patients in Group A and 54.7% patients in Group B required oxytocin and this difference was significant (p < 0.05).
In our study, 51.9% neonates in Group A were males, while 48.1% neonates were females, and in Group B, 54.7% neonates were males, while 45.3% neonates were females. In Table 3, showing pregnancy outcomes related to neonatal factors, mean foetal weight of neonates in Group A and Group B was comparable and statistically not significant (p > 0.05). There was significantly lower mean APGAR score in Group A compared to Group B at 1 min (p < 0.05), and at 5 min, mean APGAR score in Group A and Group B was comparable (p > 0.05).
Table 3.
Distribution of pregnancy outcomes (neonatal factors)
| Distribution of pregnancy outcomes (neonatal factors) | |||
|---|---|---|---|
| Group A (mean ± SD) | Group B (mean ± | p Value | |
| Birth weight (kgs) | 2.85 ± 0.31 | 2.82 ± 0.34 | > 0.05 |
| APGAR score | |||
| 1 min | 7.40 ± 0.78 | 7.68 ± 0.58 | < 0.05 |
| 5 min | 8.77 ± 0.54 | 8.92 ± 0.84 | > 0.05 |
| Distribution of neonates according to foetal complications | |||
|---|---|---|---|
| Group A n (%) | Group B n (%) | p Value | |
| Foetal distress | 4 (3.8%) | 3 (2.8%) | > 0.05 |
| NICU Admission | 2 (1.9%) | 3 (3.8%) | |
In Table 4, there was significantly higher incidence of episiotomy extension in Group A compared to Group B (p < 0.05) and incidence of other maternal complications was not statistically significant (p > 0.05).
Table 4.
Incidence of maternal complications
| Maternal complications | Group A n (%) | Group B n (%) | p Value |
|---|---|---|---|
| Perineal tear I° | 5 (4.5%) | 4 (3.6%) | > 0.05 |
| Perineal tear II° | 2 (1.8%) | 1 (0.9%) | > 0.05 |
| Forceps delivery | 1 (0.9%) | 1 (0.9%) | > 0.05 |
| Ventouse delivery | 4 (3.6%) | 2 (1.8%) | > 0.05 |
| Episiotomy extension | 8 (7.2%) | 1 (0.9%) | < 0.05 |
The severity of pain in patients was assessed by VAS score. Table 5 shows significantly lower mean VAS score at latent and active phase of second stage of labour and third stage of labour in Group A compared to Group B (p < 0.05). The mean VAS score at fourth stage of labour was comparable in Group A and Group B (p > 0.05) (Fig. 1).
Table 5.
The severity of pain in patients was assessed by VAS score
| VAS score | Group A (mean ± SD) | Group B (mean SD) | p Value |
|---|---|---|---|
| Latent phase of second stage of labour | 2.52 ± 0.86 | 5.31 ± 2.45 | < 0.05 |
| Active phase of second stage of labour | 6.16 ± 1.37 | 7.54 ± 1.65 | < 0.05 |
| Third stage of labour | 1.54 ± 0.66 | 2.75 ± 1.34 | < 0.05 |
| Fourth stage of labour | 1.49 ± 0.50 | 1.88 ± 0.81 | > 0.05 |
Fig. 1.
Squatting birth chair and its framework
Discussion
The present study was conducted to compare normal delivery-related complications and outcome during squatting versus lying down position.
In the present study, mean age of patients in Group A was 23.30 ± 4.30 years, while in Group B mean age of patients was 23.81 ± 4.13 years. The difference in mean age of patients in both the groups was statistically not significant (p > 0.05). This was similar to the studies of Valiani M et al. [9] and Dani A et al. [10].
In our study, 30.2% patients in Group A were primigravida, while 69.8% patients were multigravida, and in Group B, 28.3% patients were primigravida, while 71.7% patients were multigravida. The difference was statistically not significant (p > 0.05). The results were comparable to other similar study Dani A et al. [10], where parity-wise distribution was similar between the squatting and Dorsal recumbent group with no significant variation between the two groups.
In our study, it was observed that the total duration of labour in second stage was significantly lower (p < 0.05) in multigravida of Group A (25.35 ± 1.46 min) as compared to Group B (35.51 ± 1.08 min). The total duration of labour in second stage was significantly lower (p < 0.05) in primigravida of Group A (25.37 ± 1.45 min) compared to Group B (35.49 ± 1.07 min). Also, the mean duration of third stage of labour in Group A (12.19 ± 1.23 min) was significantly lower (p < 0.05) compared to Group B (21.98 ± 1.26 min). This was concordant to other studies Thilagavathy G [11] and Dani A et al. [10], which reported mean duration of second stage of labour in primigravida in similar range of 25–26 min and 35–36 min and in multigravida 12.6 min and 21.7 min for squatting and Dorsal recumbent groups, respectively. The statistically significant differences between the positions were also similarly reported in these studies.
It was observed in our study that the mean amount of blood loss in Group A (335.89 ± 19.91 ml) was significantly higher (p < 0.05) compared to Group B (323.84 ± 20.98 ml). This was consistent with similar studies of de Jong PR et al. [12], Nasir A et al. [12] and Dabral A et al. [13], where it had been observed that adopting squatting position during childbirth had markedly shortened the third stage of labour, reducing the average blood loss to less than 500 ml.
In our study, episiotomy was given to 54.7% patients in Group A and 60.4% patients in Group B. The difference was statistically not significant (p > 0.05). This finding was consistent with the studies of Dani A et al. [10], Thilagavathy G [11], Nasir A et al. [12], Rodrigues S et al. [14] and Hong-Yu Z et al. [15].
It was observed in the present study that 39.6% patients in Group A and 54.7% patients in Group B required oxytocin. There was significant difference between the groups (p < 0.05). Dani A et al. [10] noted similar observations in their study.
It was observed in our study that the incidence of maternal complications (perineal tear I°, perineal tear II, forceps delivery and ventouse delivery) were comparable between the groups and statistically not significant (p > 0.05). However, there was significantly higher incidence of episiotomy extension in Group A compared to Group B (p < 0.05) which was similar to the observations noted in the studies of Dani A et al. [10], Nasir A et al. [12] and Gupta JK et al. [16].
In the present study, the mean VAS score at latent phase of second stage of labour was significantly lower (p < 0.05) in Group A (2.52 ± 0.86) compared to Group B (5.31 ± 2.45). Similarly, the mean VAS score at active phase of second stage of labour (6.16 ± 1.37 for Group A and 7.54 ± 1.65 for Group B; p < 0.05) and third stage of labour (1.54 ± 0.66 for Group A and 2.75 ± 1.34 for Group B; p < 0.05) was significantly lower in Group A compared to Group B. The mean VAS score at fourth stage of labour was comparable (p > 0.05) in Group A (1.49 ± 0.50) and Group B (1.88 ± 0.81). This is similar to other studies of Dani A et al. [10], Thilagavathy G [11], Valiani M et al. [15], Nasir A et al. [9], Fraser M et al. [17], Dabral A et al. [13] and Moraloglu et al. [18], indicating that pain severity based on VAS was significantly less in squatting than dorsal recumbent position.
It was observed in our study that the mean APGAR score in Group A was significantly lower compared to Group B at 1 min (7.40 ± 0.78 vs. 7.68 ± 0.58; p < 0.05). The mean APGAR score in Group A and Group B was comparable at 5 min (8.77 ± 0.54 vs. 8.92 ± 0.84; p > 0.05). This was consistent with the studies of Dani A et al. [10] Thilagavathy G [11] and Dabral A et al. [13].
In the present study, 3.8% neonates in Group A were diagnosed with foetal distress and 1.9% neonate’s required NICU admission, while 2.8% neonates each in Group B were diagnosed with foetal distress and required NICU admission. The difference was statistically not significant (p > 0.05). This was in concordance to the studies of Dani A et al. [10], Nasir A et al. [9], Terry RR et al. [19], Moraloglu O et al. [18] and Hong-Yu Z et al. [15].
Conclusion
While comparing normal delivery in squatting position versus lying down position, squatting position for second stage of labour was found much convenient for mothers' in terms of less duration of second stage of labour, less need of oxytocin administration, lesser extension of episiotomy and greater maternal satisfaction on VAS.
Funding Statements
None
Priyanka Vijay Shedmake
had done her M.B.B.S. From Shri Vasantrao Naik Government Medical College ,Yavatmal, and doing M.S.(OBGY and GYNAE) from Shankarrao Chavan Government Medical College ,Nanded; Shyamrao R. Wakode is a professor and Unit Head, Department of Obstetrics and Gyanaecology.
Compliance with Ethical Standards
Conflict of interest
There was no conflict of interest among authors.
Ethical Approval
The research involves human participants, and ethical clearance had been taken from institute’s ethical committee.
Informed Consent
Informed consent was taken from the participants before conduction of the study.
Footnotes
Dr. Priyanka Vijay Shedmake, Department of Obstetrics and Gynaecology, Dr. Shankarrao Chavan Medical College and Hospital Vishnupuri, Government Maharashtra, Nanded, India. Shyamrao R. Wakode is a professor and Unit Head, Department of Obstetrics and Gynaecology, Dr. Shankarrao Chavan Government Medical College and Hospital Vishnupuri, Nanded, Maharashtra, India.
Publisher's Note
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