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Are upright birthing positions harmful?

Just a few weeks before her death last year, Karen Kilson, a beloved local doula and childbirth educator, sent me this email:

Screen shot 2010-04-08 at 12.52.51 PM

She didn’t hear back from me, because it was one of too many emails I let sit in my inbox until I had the time to write a coherent response. And in the meantime she passed away.

Karen was a life-long learner and was in fact studying to sit for her Lamaze Certification Exam when she died. She shared information as voraciously as she collected it. So in her memory, I thought I would respond to her email here on the blog as part of the Fifth Healthy Birth Blog Carnival.

Karen hit on an important conundrum. Unlike practices that have benefits and no documented harms, such as movement and upright positions in the first stage of labor, continuous labor support, and skin-to-skin contact after birth, the Cochrane Systematic Review shows that upright positions are associated with a statistically significant increase in the likelihood of blood loss exceeding 500 milliliters, the clinical definition of postpartum hemorrhage. I have in fact personally heard care providers citing this finding as a rationale for keeping women in the traditional stranded beetle position.

So, are women trading an increased risk of postpartum hemorrhage for the benefits of being off their backs?

A critical look at the evidence in context suggests that the answer is “almost certainly not.”  Here’s why:

1. Some of the trials included in the Cochrane review used unreliable methods of estimating blood loss, such as simple visual estimation. This would probably bias against upright positions, since in addition to seeing blood loss, when the woman is upright you can hear it, too.  However, the result was statistically significant even after the Cochrane reviewers excluded the studies that used clearly unreliable estimation methods.

2. Blood loss greater than 500 milliliters may be the clinical definition of postpartum hemorrhage, but very few women losing that amount of blood would exhibit symptoms or need treatment. After all, a healthy non-pregnant person donates that much blood at a blood drive, and pregnant women have 50% more blood than non-pregnant people, which their bodies are designed to get rid of after birth. A much more meaningful definition for postpartum hemorrhage might be 1000ml or even 1500ml, significant postpartum anemia, or need for blood transfusion. The only one of these outcomes that the Cochrane review reports is blood transfusion, for which there was no significant difference between upright and supine positions.

3. One study with particularly rigorous methodology found increased blood loss in the sitting or semi-sitting positions compared with recumbent positions, however the difference was observed only when perineal trauma occurred. This suggests that it is not the position the woman assumes in second stage but the position she assumes after birth and before necessary perineal repairs that contributes to excess blood loss.

Restricting women to give birth on their backs poses significant risks, including an increased likelihood of perineal trauma, a small increase in the likelihood of an instrumental vaginal birth, more fetal heart rate decelerations, and more severe pain. Then there are the intangible benefits, which come out loud and clear in many of the phenomenal contributions to the second stage Blog Carnival (which I will post at the end of the weekend). The statistically significant excess in an arbitrary amount of blood loss does not outweigh those benefits, whether or not the excess is an artifact of measurement errors. The excess blood loss seen with the combination of upright positions and perineal trauma underscores the need to minimize perineal trauma during birth. Effective strategies for reducing trauma include avoiding episiotomy, instrumental vaginal birth, or the combination of the two, supporting spontaneous pushing, and birthing the baby’s head between contractions.

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  1. April 8th, 2010 at 13:59 | #1

    I saw that factoid when I was doing my research for this last Healthy Birth Blog, I am so glad you presented this information!

  2. April 8th, 2010 at 14:01 | #2

    I was wondering about that blood loss thing…Thanks for breaking it down so clearly.

  3. April 8th, 2010 at 14:53 | #3

    I have a fairly important question concerning this. Did the Cochrane review take into account the use of cord traction and fundal massage by practitioners immediately post partum. Both of these have been linked, as well, to post-partum hemorrhage.

  4. April 8th, 2010 at 15:07 | #4

    hihi I can’t help but laugh at the stranded beetle, it’s the first time I see that expression.
    Anyhow, thanks for another to the point article!

  5. April 8th, 2010 at 15:41 | #5

    Thank you for writing this Amy. While I am not looking at it from the birth perspective, or research view, Karen was like a second mother to me, and it still brings tears to my eyes to read her emails or look at her e-mail signature.

  6. avatar
    Karen
    April 8th, 2010 at 16:36 | #6

    Oh!!! I didn’t know Karen Kilson died:( I had worked with her in CT years ago advocating and organzing workshops but moved away and lost touch.

  7. April 8th, 2010 at 18:56 | #7

    Two thoughts: the increased blood loss that was noted only when perineal trauma occurred could have been blood loss from lacerations. Some lacerations bleed like crazy until you get them repaired, and can contribute significantly to overall blood loss.

    The other thought I had is this: when a woman has had a baby and then gets up to the bathroom, or to walk around, she typically has a gush of bleeding when she initially becomes upright. If we were comparing women in a recumbent position with women in an upright position, blood loss may be greater because of gravity. There is going to be a certain amount of blood loss after every delivery, and perhaps these women (in the upright group) are getting their blood loss out of the way more quickly because of being upright versus lying in bed. We know that women who have c-sections often bleed less in the postpartum period, because the uterus has been manually “cleaned out” more. Perhaps being upright aids in expulsion and involution better than recumbent positions. I think this would make a great study–measuring actual blood loss by weighing pads, and comparing whether total blood loss overall (not just calculated at time of delivery) is really about the same in both groups.

  8. avatar
    Marjorie
    April 8th, 2010 at 22:32 | #8

    “Blood loss greater than 500 milliliters may be the clinical definition of postpartum hemorrhage, but very few women losing that amount of blood would exhibit symptoms or need treatment.”

    +500 mls= PPH?

    “While the average blood loss for a vaginal birth is about 500 cc (about two cups), the average blood loss with cesarean section is twice that much, about four cups or one quart. Most healthy pregnant women can tolerate this type of blood loss without any difficulty.”

    http://www.healthline.com/yodocontent/pregnancy/complications-cesarean-section.html

  9. avatar
    Marjorie
    April 8th, 2010 at 22:33 | #9

    Considering the above it seems like upright positions are still safer than surgery in terms of blood loss.

  10. April 9th, 2010 at 08:27 | #10

    You bring up a good point, Veronica. They researchers give no information about the usual care/management in third stage in these trials. We don’t know if active management of third stage labor is the usual practice in the setting, and we certainly don’t know for individual women in the study what medications or procedures they experienced in third stage. This further limits our ability to know what is really going on that is contributing to excess blood loss. However, these were randomized, controlled trials which means that women had an equal chance of being assigned to an upright or a recumbent (on the back) position. So there’s no reason to think that management of third stage would be systematically different between the two groups.

    By the way, fundal massage and cord traction, as components of active management of third stage labor, are associated with a statistically significant decrease (not increase) in blood loss greater than 500cc. The clinical significance of this decrease is up for debate, however, and I understand that a new, more nuanced, Cochrane systematic review is forthcoming to replace the withdrawn review that is used to justify routine active management.

  11. April 9th, 2010 at 08:39 | #11

    I think that is the point – that blood loss in upright positions is blood loss from lacerations (spontaneous or surgical). It makes physiological sense that sitting on a rigid surface such as a birth stool or chair may interfere with venous return of blood. Indeed, in the Cochrane review the studies that showed the largest magnitude of difference in blood loss between the upright and recumbent groups were the birth stool trials.

    The Dutch researchers who discovered that excess blood loss originates from perineal damage also offer alternative hypotheses – including the effect of gravity and hydrostatic pressure or a prostaglandin effect on uterine atony. But my own suspicion is that it has to do with venous return. It would be interesting to see a study comparing women who remain upright after an upright birth with those who are put on their backs or sides. In the meantime, I think if a woman clearly has a bleeding laceration, it is reasonable to get her off a birth stool or lower the head of the hospital bed and have her bring her legs together until the repair can be performed.

    I also think you have a good point with the gravity thing. Some of the studies of third stage management that do actually follow women beyond the initial blood loss (through the entire “fourth stage” for instance) have found that differences disappear. We may find that women who bleed more initially bleed less later on and vice versa.

  12. April 9th, 2010 at 08:42 | #12

    You’re absolutely right. A woman has to lose 1000ml of blood in a c-section in order to be considered to have “hemorrhaged”. Everyone pretty much agrees that 500ml is not clinically significant, and yet it is the threshold in almost every study reporting on postpartum blood loss/hemorrhage.

  13. avatar
    Nicholas Fogelson, MD
    April 9th, 2010 at 11:47 | #13

    Mothers increase total blood volume 2-3 liters froth prepregnant state to term. The loss of 1-1.5 liters of blood is fairly well tolerated by mothers, much less 500cc. Women that lose a lot of blood will be anemic, which may effect functional status in the postpartum period, but it takes a pretty low hemoglobin for that to be an issue. A very important part is where the mom starts. A mom with a hgb of 12-13 will do much better with large blood loss than a woman iron deficient with a hgb of 9.

  14. avatar
    Carol Van Der Woude
    April 9th, 2010 at 12:30 | #14

    One of the standard practices of the home birth group that I worked with, was to get the new mom up as soon as the placenta was out and the perineum was inspected. We walked her to a chair and then she breastfed the baby. The principle was that a woman’s uterus was assisted in contracting by getting her up to walk as soon after birth as possible.@BirthSense

  15. April 10th, 2010 at 12:39 | #15

    I also don’t get the idea that > 500 ml = hemorrhage, and we were told in school that obstetricians and obstetric nurses typically “eyeball” the blood loss, and if it seemed normal, they simply come up with a number of 500 or less.

  16. April 26th, 2010 at 01:48 | #16

    You bring up a good point, Veronica. They researchers give no information about the usual care/management in third stage in these trials. We don’t know if active management of third stage labor is the usual practice in the setting, and we certainly don’t know for individual women in the study what medications or procedures they experienced in third stage. This further limits our ability to know what is really going on that is contributing to excess blood loss. However, these were randomized, controlled trials which means that women had an equal chance of being assigned to an upright or a recumbent (on the back) position. So there’s no reason to think that management of third stage would be systematically different between the two groups.

    By the way, fundal massage and cord traction, as components of active management of third stage labor, are associated with a statistically significant decrease (not increase) in blood loss greater than 500cc. The clinical significance of this decrease is up for debate, however, and I understand that a new, more nuanced, Cochrane systematic review is forthcoming to replace the withdrawn review that is used to justify routine active management.

  17. January 23rd, 2012 at 04:07 | #17

    wow, awesome blog article.Thanks Again. Will read on…

  1. April 9th, 2010 at 11:22 | #1