Labor Position and Its Impact on The Birth Process: A Literature Review

• Hamdiah Ahmar, S.St, M.Keb
• Sherllia Sofyana
• Siti Suciati
• Ernawati Ernawati
• Firda Liantanty

Vol. 5 No. 2: 2025 | Pages: 97-108

DOI: 10.47679/jchs.2025115   Reader: 4510 times PDF Download: 1284 times

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Abstract

INTRODUCTION

The childbirth process is a pivotal event in the lives of women and their families, significantly impacting maternal and neonatal outcomes, as well as long-term maternal physical and psychological well-being (Renfrew et al., 2014). Throughout history, preferences for labor positions have shifted considerably, influenced by cultural beliefs, medical advancements, and technological progress. Historically, many cultures favored upright positions such as squatting, kneeling, or standing, recognizing the benefits of gravity and natural physiological mechanisms in facilitating childbirth (Dekker, 2017; Gizzo et al., 2021). Evidence from anthropological studies also highlights how various cultures around the world traditionally used vertical and mobile positions during labor to optimize maternal comfort and reduce the duration of labor (Dundes, 1987).

However, the lithotomy position, wherein the mother lies flat on her back with legs elevated, became increasingly prevalent in Western medicine, largely because it allowed healthcare providers greater ease in monitoring fetal progress and performing medical interventions (Mselle & Eustace, 2020; Lawrence et al., 2013). Despite this medical convenience, substantial criticism has emerged over recent decades, emphasizing that the lithotomy position often restricts maternal mobility, prolongs labor duration, increases perineal trauma, and negatively impacts maternal satisfaction and comfort (Scholten et al., 2024; DiFranco & Curl, 2014).

In recent years, growing awareness of the physiological and psychological benefits of alternative birthing positions has sparked renewed interest among healthcare providers, researchers, and mothers themselves (Berta et al., 2019; Hemmerich et al., 2019). Modern studies consistently demonstrate that positions such as squatting, standing, kneeling, or side-lying significantly reduce labor duration, enhance maternal comfort and satisfaction, and minimize the incidence of perineal injuries and medical interventions like episiotomies or instrumental deliveries (Scholten et al., 2024; Gupta et al., 2017; Walker et al., 2018). A systematic review by Thies-Lagergren et al. (2013) similarly reported that upright positions are consistently associated with improved maternal satisfaction and fewer perineal complications compared to recumbent positions.

Despite compelling evidence supporting these alternative positions, their routine implementation in clinical practice remains limited. Barriers to adoption include a lack of awareness and adequate training among healthcare professionals, restrictive hospital protocols, limited facility designs that accommodate mobility, and deeply rooted cultural attitudes among medical staff and patients who are accustomed to traditional supine positions (Mselle & Eustace, 2020; Fu et al., 2023; Glover et al., 2024). Additionally, women’s personal preferences for birth positions often go unfulfilled due to institutional norms and authoritative healthcare practices, leading to reduced autonomy and satisfaction during childbirth (Scholten et al., 2024; Bohren et al., 2019).

Given these critical insights, a significant research gap persists regarding the effective integration and consistent application of alternative labor positions into routine childbirth practice, specifically concerning outcomes such as labor duration, perineal integrity, maternal comfort, and reduced medical intervention rates. Although numerous studies have highlighted the benefits of alternative labor positions, their practical implementation remains sporadic and lacks standardization across diverse clinical settings (Walker et al., 2018; Satone & Tayade, 2023). Hence, further investigation through systematic reviews, clinical trials, and policy-oriented research is essential to bridge these gaps, optimize maternal health outcomes, and inform evidence-based clinical guidelines (Renfrew et al., 2014; Gizzo et al., 2021).

Therefore, this literature review aims explicitly to investigate the impact of different labor positions, focusing particularly on specific clinical outcomes: duration of labor, perineal integrity, maternal comfort, and the incidence of medical interventions. By synthesizing recent empirical evidence and systematically evaluating current recommendations, this review seeks to inform healthcare practitioners and policymakers about practical strategies to enhance maternity care quality and maternal satisfaction through flexible and evidence-based labor position options.

METHOD

This literature review was conducted using a qualitative descriptive approach to systematically evaluate the scientific findings related to birthing positions and their impact on the labor process. The systematic search was executed in April 2025 utilizing three reputable databases: PubMed, SpringerLink, and ScienceDirect. These databases were selected due to their comprehensive and multidisciplinary collections, which encompass a wide range of peer-reviewed journals relevant to maternal and reproductive health research (Aromataris & Pearson, 2014; Higgins et al., 2022). The keywords employed in the search process were carefully chosen to accurately reflect the research objectives, namely: "birthing position," "delivery position," "maternal outcomes," and "alternative position during labor." These keywords were combined using Boolean operators (AND, OR) to optimize search results and capture all relevant studies.

Inclusion criteria were rigorously defined to ensure methodological validity and relevance of the evidence synthesized. Specifically, quantitative studies, systematic reviews, and guidelines issued by reputable international health organizations such as the World Health Organization (WHO) that clearly addressed the impact of birthing positions on key clinical outcomes—including duration of labor, perineal trauma, postpartum hemorrhage, maternal comfort, and medical intervention needs (e.g., episiotomy, instrumental delivery)—were included. Publications were limited to those available in English or Indonesian to facilitate comprehensive analysis and interpretation.

Conversely, opinion pieces, editorials, and case reports were explicitly excluded because these forms of literature often lack empirical rigor, systematic analysis, and reproducible methodologies, potentially introducing bias and limiting generalizability (Higgins et al., 2022). This exclusion ensured that the synthesized evidence presented in this review is founded on robust empirical data, thereby enhancing the reliability and applicability of the conclusions drawn.

The selection process adhered strictly to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a widely recognized protocol designed to ensure clarity and transparency in reporting systematic reviews (Page et al., 2021). The PRISMA approach involved sequential steps including the initial identification of studies through database searching, removal of duplicates, screening of titles and abstracts for relevance, full-text review for eligibility assessment, and the final selection of studies meeting all inclusion criteria. Additionally, the quality of the selected articles was systematically evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. The GRADE methodology enabled the categorization of evidence quality (high, moderate, low, or very low) based on considerations of study limitations, consistency, directness, precision, and risk of publication bias (Guyatt et al., 2011).

The analytical approach employed in this literature review was a narrative synthesis, selected due to the heterogeneity of study designs, outcomes, and measurement methods among the included articles. Narrative synthesis provided a structured approach for summarizing and interpreting findings from diverse methodologies, allowing a coherent and comprehensive understanding of the evidence regarding labor positions and their effects on childbirth outcomes (Popay et al., 2006)

Figure 1.

RESULTS AND DISCUSSION

The findings from the reviewed studies are presented systematically according to clearly defined thematic categories: duration of labor, perineal trauma risk, maternal comfort, and medical interventions. This structured thematic approach enhances clarity and allows easy comparison of outcomes across different labor positions.

Duration of Labor

The duration of the second stage of labor significantly varies depending on the labor position adopted. Upright positions—including squatting, sitting, kneeling, and standing—have consistently demonstrated effectiveness in shortening labor duration. According to Berta et al. (2019), flexible sacrum positions (squatting, sitting, kneeling) significantly reduced the duration of labor by an average of 21 minutes compared to supine positions. Gupta et al. (2017) also supported these findings, documenting a reduction of approximately six minutes in labor duration with upright positions, although the evidence quality was rated as very low due to heterogeneity and potential biases. In contrast, Walker et al. (2018) observed longer labor durations with upright positions among women using epidural anesthesia, highlighting the significance of individual clinical conditions when evaluating labor positions.

Perineal Trauma Risk

The impact of birthing positions on perineal integrity has been extensively examined, revealing significant differences between various positions. The lateral (side-lying) position was consistently associated with optimal perineal outcomes, reducing the occurrence of trauma and the need for episiotomies. Shorten et al. (2002) reported that 66.6% of women maintained an intact perineum in the lateral position, while positions such as squatting demonstrated mixed outcomes, potentially increasing perineal injury in certain contexts. Olson et al. (1990) and De Jonge et al. (2004) corroborated the benefits of lateral and semi-sitting positions, particularly among multiparous women, emphasizing the role of parity and birth attendants in perineal trauma outcomes.

Maternal Comfort

Maternal comfort and satisfaction are crucial aspects of the childbirth experience, strongly influenced by the freedom and autonomy to choose preferred labor positions. Berta et al. (2019) and Satone & Tayade (2023) highlighted higher maternal satisfaction and comfort levels when mothers were empowered to select their labor positions. Conversely, Walker et al. (2018) indicated that upright positions might slightly reduce maternal satisfaction among women receiving epidural anesthesia, emphasizing the importance of personal preference and clinical contexts.

Medical Interventions

The reviewed studies indicate that birthing positions significantly impact the frequency of medical interventions during labor. Upright and lateral positions generally reduced the necessity for assisted deliveries and episiotomies, as demonstrated by Gupta et al. (2017), who reported moderate-quality evidence for reduced assisted deliveries (RR 0.75) and episiotomies (RR 0.75) in upright positions. However, upright positions also posed an increased risk of postpartum hemorrhage exceeding 500 mL, particularly when using a birthing chair (RR 1.48). These findings underscore the importance of tailored position selection based on individual risk assessments and clinical profiles.

To facilitate clearer and more efficient comparisons, a concise synthesis matrix (Table 1) summarizes the comparative advantages, disadvantages, and strength of evidence (GRADE) associated with each labor position.

Table 1. Comparative synthesis of labor positions based on duration of labor, perineal integrity, maternal comfort, medical interventions, and strength of evidence (GRADE).

Labor Position	Duration of Labor	Perineal Integrity	Maternal Comfort	Medical Interventions	Strength of Evidence (GRADE)
Upright (squatting, standing, kneeling)	Significantly reduced	Improved; fewer episiotomies	High satisfaction	Reduced assisted delivery; increased hemorrhage risk	Moderate
Lateral (side-lying)	Neutral to slightly reduced	Best perineal outcomes	Comfortable; good for rest	Reduced perineal trauma	Moderate
Supine/Lithotomy	Prolonged	Higher risk of trauma and episiotomy	Lower satisfaction	Higher rate of interventions	Moderate to high
Semi-sitting	Variable; generally reduced for multiparous	Reduced trauma in multiparous	Comfortable if angled properly	Mixed results; increased risk of bleeding in some cases	Low to moderate
Note: Strength of evidence rated according to the GRADE approach considering risk of bias, consistency, directness, precision, and publication bias.

DISCUSSION

The labor position is an important factor influencing the childbirth process and various related clinical outcomes, including the duration of labor, perineal integrity, maternal comfort, and the extent of required medical interventions (Gupta et al., 2017; Berta et al., 2019). Findings from this review suggest that upright positions such as standing, squatting, sitting, or kneeling provide physiological benefits by utilizing gravity, thus facilitating the acceleration of the second stage of labor, reducing labor duration, and minimizing the need for medical interventions (Satone & Tayade, 2023; Hemmerich et al., 2019). In contrast, the supine or lithotomy position is frequently associated with prolonged labor duration and an increased risk of perineal trauma (DiFranco & Curl, 2014).

Results from the study by Berta et al. (2019) indicate that upright positions significantly shortened the second stage of labor by approximately 21 minutes compared to supine positions. Similarly, Gupta et al. (2017) confirmed that upright positions reduce labor duration by around six minutes; however, the quality of evidence was rated as low due to heterogeneity among studies. Conversely, Walker et al. (2018) observed that for women receiving epidural anesthesia, upright positions might prolong labor and increase the risk of operative delivery. This underscores the importance of considering specific clinical circumstances, such as epidural anesthesia, in selecting the appropriate labor position (Walker et al., 2018; Gilder et al., 2002).

Perineal integrity is another critical aspect to consider when selecting labor positions. The lateral or side-lying position has consistently been associated with optimal perineal outcomes, characterized by lower rates of tears and episiotomies (Shorten et al., 2002; De Jonge et al., 2004). In contrast, the squatting position, although effective in expediting labor, can sometimes be associated with an increased risk of perineal trauma, especially among primiparous women without adequate positional support from healthcare providers (Shorten et al., 2002). Factors such as parity and healthcare provider experience, particularly midwives or obstetricians, significantly influence perineal integrity outcomes (Olson et al., 1990; De Jonge et al., 2004).

Besides physiological benefits, the choice of labor position is also closely related to maternal psychological comfort and overall satisfaction. Women who are provided autonomy to select their labor position have reported higher levels of satisfaction and more positive childbirth experiences (Scholten et al., 2024; Thies-Lagergren et al., 2013). Conversely, the lithotomy or supine positions are frequently criticized, not only for hindering natural labor physiology but also for reducing comfort and increasing pain perception, thereby negatively impacting maternal satisfaction with their childbirth experience (Bohren et al., 2019; DiFranco & Curl, 2014).

Although the benefits of alternative labor positions have been extensively documented, the implementation of these practices still encounters various practical barriers in clinical settings. Key obstacles include inadequate training of healthcare providers on managing alternative labor positions and limitations in delivery room designs that do not support maternal mobility during labor (Mselle & Eustace, 2020; Glover et al., 2024). Additionally, hospital protocols and institutional policies tend to favor lithotomy positions, presenting further obstacles to everyday clinical practice (Mselle & Eustace, 2020; Fu et al., 2023). Furthermore, entrenched cultural perceptions and attitudes among both healthcare providers and patients contribute significantly to the limited routine implementation of alternative labor positions (Bohren et al., 2019).

These factors highlight the importance of continuous education and training for healthcare providers regarding the advantages of alternative labor positions and safe methods for clinical implementation (Scholten et al., 2024; Mselle & Eustace, 2020). Several studies have shown that educational interventions, such as simulation training or practical workshops on alternative labor positions, can enhance healthcare provider readiness in offering more flexible position options to patients (Thies-Lagergren et al., 2013; Glover et al., 2024).

In clinical practice, particularly for midwifery practitioners, findings from this review emphasize the significance of individualizing labor position choices based on specific clinical conditions, maternal preferences, and healthcare facility capabilities. For instance, the lateral position can be recommended for women with a high risk of perineal trauma, while upright positions may be more suitable for women not receiving epidurals and requiring expedited labor (Satone & Tayade, 2023; Gupta et al., 2017). Policies that support flexible labor position choices should be developed and communicated effectively to healthcare providers and patients, maximizing the benefits derived from evidence-based practices (WHO, 2018).

Variability in results across studies, particularly concerning epidural usage, suggests the need for further research exploring specific clinical conditions influencing the effectiveness of labor positions. Some studies indicate that the effectiveness of upright positions may vary significantly between populations with and without epidural anesthesia, suggesting that future research explicitly integrating these variables is essential for providing more accurate clinical guidance (Walker et al., 2018; Gilder et al., 2002).

In conclusion, this literature review affirms that no single labor position is universally ideal for all childbirth situations. Instead, the best approach is to provide various position options tailored to maternal preferences and specific clinical circumstances, supported by adequately trained healthcare providers and appropriate healthcare facilities. Policies supporting such flexibility will contribute significantly to enhancing maternal healthcare quality and improving maternal satisfaction with the childbirth experience.

CONCLUSIONS AND RECOMMENDATION

The literature review reveals that variations in birthing positions have a significant impact on the labor process and outcomes. Upright positions—such as standing, squatting, sitting, and kneeling utilize gravity to facilitate the descent of the fetus, shorten the second stage of labor, widen the pelvic outlet, and reduce the need for medical interventions such as cesarean sections and assisted deliveries. Among these, squatting and kneeling positions show higher effectiveness in accelerating fetal expulsion, while the lateral position helps preserve perineal integrity and reduce the risk of tearing.

However, position selection must be tailored to clinical conditions, such as the use of epidural anesthesia or the presence of postpartum hemorrhage risk, as some positions like semi-sitting may increase the likelihood of bleeding greater than 500 mL. In addition to physiological factors, maternal comfort and satisfaction are strongly influenced by the ability to choose a preferred birthing position.

Therefore, there is no single "best" position for all laboring women. Evidence-based practice recommends flexibility and individualization in position selection during childbirth. The routine use of the lithotomy position should be avoided due to its association with increased perineal trauma, maternal discomfort, and prolonged labor. Hospitals and healthcare facilities are encouraged to offer a wider range of birthing position options, allowing mothers to choose based on their comfort and clinical needs, supported by evidence of the benefits of alternative positions. Furthermore, educating pregnant women on the importance of being free to choose a comfortable birthing position is essential to promote maternal involvement in the labor process and to reduce childbirth-related anxiety.

Future research directions should prioritize longitudinal and population-based studies aimed at evaluating the long-term impacts of implementing recommended labor positions. Comprehensive longitudinal research would clarify sustained maternal health benefits, psychological impacts, and long-term satisfaction associated with routine adoption of flexible labor positions in diverse healthcare settings. Population-based studies could also elucidate variations in outcomes across different populations and healthcare systems, providing robust, generalizable data that can inform tailored clinical policies and guidelines (Renfrew et al., 2014; Walker et al., 2018).

In conclusion, integrating flexible and evidence-based labor position options into standard maternity care practice represents a critical advancement toward improving childbirth outcomes and maternal experiences. Strategic policy development, rigorous professional training, infrastructural adaptations, and targeted research investments are essential steps forward. By implementing these measures, healthcare systems can significantly enhance maternal care quality, optimize childbirth outcomes, and elevate overall maternal satisfaction.

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