Despite the significant body of evidence that there are no benefits to this position and that it only causes complications, frequently leading to interventions that could otherwise have been avoided, the United States persists in the use of this ineffective position for childbirth. The Royal College of Midwives (RCM) in the U.K. recommends the use of active and upright positions to assist with labor and delivery. Finally, doulas can also nurture a supportive environment for a variety of birthing positions. When I talk about ‘upright breech birth,’ I mean a birth where the woman is encouraged to be upright and active throughout her labour and able to assume the position of her choice for the birth. However, there is some evidence that giving birth in a supported side-lying position may reduce the length of the active pushing phase, the rate of episiotomy, and the use of forceps, vacuum, or fundal pressure. 2016). Physicians should advocate for a birth environment that supports women’s choice in their birthing position. The woman, the person to whom we have set forth to care, has fallen by the wayside to our overemphasis on defense from lawsuits, business administration, and comforts of the "delivery team", such as the dorsal lithotomy position in the 2nd stage of birth. These numbers are strangely high. Another meta-analysis that compared upright and non-upright birthing positions in people without epidurals came out independently but within a few months of the Cochrane meta-analysis (Deliktas & Kukulu 2017). It was said that the lithotomy position originated from a command by French king Louis XIV, who wanted to see one of his mistresses giving birth. The use of continuous EFM often means that mothers cannot move freely or change positions easily during labor, and that they may lose the option of water immersion in a birth pool for pain management. When people in the delayed pushing group were ready to begin pushing efforts, trained staff assisted them in moving into a specific side-lying position. Different Types of Pregnancies The positions for giving birth have changed over the course of history. The third trial was a very large randomized, controlled trial on birthing positions conducted by a group in the United Kingdom (U.K.) called the Epidural and Position Trial Collaborative Group (The Epidural and Position Trial Collaborative Group 2017). References to the position have been found in some of the oldest known medical documents including versions of the Hippocratic oath (see lithotomy); the position is named after the ancient surgical procedure for removing kidney stones and bladder stones via the perineum. Magnetic resonance imaging (MRI) studies have shown that compared to the back-lying position, the dimensions of the pelvic outlet become wider in the squatting and kneeling or hands-and-knees positions (Gupta et al. Irrespective of parity, women giving birth in the lithotomy position were characterized by high rates of induction, EDA, oxytocin augmentation, long second stages, infants with large head circumferences, high birth weights and … In other words, some people assigned to upright positions may have been upright for the passive second stage of labor but lying down for active pushing and/or birth. Mothers with epidurals may feel an urge to push, or pressure, or no sensation at all—depending on the individual and the medications used. The researchers determined that the odds of second degree tears were less likely in the people who received woman-centered care compared to those who received standard care. There is the lithotomy position, which has you lying back in the supine position with your thighs flexed and your legs in stirrups. This study involved 102 first-time mothers giving birth without epidurals in Turkey (Moraloglu et al. However, since this was a three-part protocol, we do not know which part of the protocol contributed to the lower second-degree tears. There was no difference between the groups as far as perineal tears, but the birth seat was linked to fewer episiotomies— 2% of the mothers who gave birth on the birth seat had an episiotomy compared to 14% of those who gave birth in other positions. Also, as the presenter explains in this popular video by the Head of Midwifery Education at the University of South Wales, while the supine position is not beneficial for normal vaginal birth, it is the easiest way to position Noelle, a popular birthing mannequin, to simulate birth for medical, midwifery, and nursing students. The majority of hospitals and obstetricians in this country (still) insist on a birthing position that quite literally makes the baby, following the curve of the birth canal, be born heading upwards. (2016), Simarro, M., Espinosa, J. Women who gave birth in a 30-degree upright position had more intense uterine contractions than women delivered in the flat recumbent position. One randomized trial found that the use of a birth seat may shorten the length of the second stage of labor, result in less synthetic oxytocin for labor augmentation, and lead to fewer episiotomies and greater satisfaction with childbirth. In contrast, a U.S. home birth midwife told us that the majority of her clients spontaneously choose the hands-and-knees position (Personal communication, K. Brown, Feb. 8, 2018). This placed the foot of the upper leg in a higher position than the knee to allow the upper hip to rotate. States Williams: "The most widely used and often the most satisfactory [position for delivery] is the dorsal lithotomy position on a delivery table with leg supports" (Cunningham et al. Mobile monitors are designed to free up mothers, but they are not a perfect replacement for intermittent auscultation. A Cochrane Review found that the lithotomy position may not be the ideal position for childbirth, noting that while it makes care easier for physicians by placing the patient in an easily accessible position, it is often harder on the female as use of the lithotomy position can narrow the birth canal by up to a third. More than 60% of people giving birth to a single baby in the U.S. use epidural or spinal analgesia (ACOG, Practice Bulletin No. The passive waiting phase of the second stage of labor is a period of rest (sometimes called “laboring down”) when the baby rotates and descends toward the pelvic floor. They also found that when people gave birth in upright positions, their labors were shortened by about six minutes; however, the evidence for this outcome was of very low quality. The evidence from randomized trials for people with epidurals is less conclusive. In Europe, a study of nearly 3,000 people who had planned home births between 2008 and 2013 found that the majority (65%) gave birth in non-back-lying positions (Edqvist et al. To assess urinary function, the mothers were asked questions like: How often do you leak? 2017). A mother with an epidural may need two assistants to help her balance in certain positions, which is not possible if a hospital is short-staffed on nurses, or if the nurse is supposed to be charting on the computer every five to ten minutes for medical, legal, and insurance reasons. 2014). (2015), Bolten, N., de Jonge, A., Zwagerman, E., et al. According to research, giving birth in a lithotomy position increases … 2017). 2014). People assigned to the alternative model delayed pushing and gave birth in a specific type of side-lying position. In lieu of the lithotomy position, the Cochrane Review recommended Women make informed choices about birthing positions and find the position that is most comfortable for them. In research, the second stage is often divided into a passive phase, an active phase, and the actual birth of the baby—when the baby actually emerges (Roberts 2002). In the U.S., for example, the overall rate of vacuum/forceps births is only around 3% (Martin et al. No other position could be worse than this position for childbirth. The Cochrane meta-analysis found no differences between groups as far as Cesarean rates, severe perineal tears, mothers’ need for blood transfusion, number of babies admitted to neonatal intensive care units, or perinatal deaths. General terms that refer to lying on your back or side are called recumbent and semi-recumbent positions. The database included midwives’ records of which position the mother used during the actual birth. (BIRTH 39:2 June 2012). Additional searches were conducted including search terms: “lithotomy,” “lateral,” “all fours,” “hands and knees,” “birth stool,” “sitting,” semi-recumbent,” “semi-seated,” “standing,” OR In another study, researchers in Italy explored what effect birthing positions may have on urinary incontinence (Serati et al. combined the results of 32 randomized, controlled trials that included more than 9,000 birthing people in hospital settings. The position is perhaps most recognizable as the 'often used' position for childbirth: the patient is laid on the back with knees bent, positioned above the hips, and spread apart through the use of stirrups. M. L., Devane, D., et al. There were no differences between the upright and non-upright groups for any other health outcomes. The study showed that the people who stood, then squatted down with a bar to push during contractions, had shorter second stages of labor by about 34 minutes. (2014), Edqvist, M., Blix, E., Hegaard, H. K., et al. Laying down reduces the size of your pelvic outlet by up to a whopping … In the lithotomy position, the mother is lying on her back with her legs up in stirrups and her buttocks close to the edge of the table. However, this is not a comfortable position for most patients, considering the pressure on the vaginal walls because the baby's head is uneven and the labor process is working … These monitors (like the Novii) are an option for mothers who want to use the shower or birth pool and labor/birth in multiple positions, but whose care providers want continuous or intermittent electronic fetal monitoring. However, as the next study found, it may be possible to achieve these benefits using only delayed pushing and position changes in the passive phase of the second stage of labor. The Cochrane authors concluded that, at this time, there is not enough evidence to recommend specific birthing positions for people with epidurals. Edqvist, M., Hildingsson, I., Mollberg, M., et al. If physicians feel that their training and experience are inadequate for managing complications at an upright birth, they could reach out to local midwifery colleagues for support on this matter, as midwives are trained and experienced at upright birth. We do know that certain positions are more likely to lead to shoulder dystocia, for example, the lithotomy position (lying flat on your back) can prevent the sacrum from properly moving during birth and therefore narrowing the amount of room in your pelvis for the shoulders. (2017), Serati, M., Di Dedda, M. C., Bogani, G., et al. In contrast, with active management the care provider usually gives the mother a drug to make the uterus contract, clamps the cord early, and gently pulls on the cord while pressing on the uterus to deliver the placenta. (2015), The Epidural and Position Trial Collaborative Group (2017), Gupta, J. K., Sood, A., Hofmeyr, G. J., et al. What do you do if you and your practitioner feel you're in danger of a shoulder dystocia? Also, it may be possible to reduce the rate of tears by using evidence-based pushing methods in the second stage of labor. Since most of the studies on birthing positions are restricted to healthy, low-risk people, these findings may not apply to women with more complicated pregnancies. The lithotomy position was an ergonomic nightmare for both mother and baby. For example, the McRoberts’ position—where the mother lies back with her legs flexed and pulled tightly into her abdomen—can help correct a shoulder dystocia (when the baby’s shoulders get stuck after the head has already emerged). Nursing schools should also ensure that their students are trained in upright birthing positions, so that future labor and delivery nurses will be equipped to uphold the ethical and evidence-based standards of their profession. There was also no difference in perineal tears requiring stitches, abnormal fetal heart rate patterns, low cord pH, or NICU admissions. Featured Image credit to: Birth Becomes Her. The woman assumes a lithotomy position with her back elevated through an arc of 90 degrees, wherein the lithotomy position becomes a sitting position. The group that changed positions had fewer Cesareans (1% vs. 10%)  and fewer cases of vacuum/forceps (24% vs. 39%). Childbirth in the lateral position resulted in less perineal trauma when compared with childbirth in the lithotomy position, even after correcting for parity and birth attendant. The midwives who practiced standard care didn’t receive any special instructions. 2015). The author found that the birth seat resulted in a shorter second stage of labor by an average of 6-13 minutes and less use of artificial oxytocin for augmentation of labor. This study provides evidence that in people laboring with epidurals, delayed pushing with position changes and active pushing and delivery in the side-lying position may reduce the rate of assisted vaginal birth, the length of the active pushing phase, and the rate of perineal trauma without adding risks for mothers or babies. The birth position is a personal choice for each woman, and they should choose which one they feel most comfortable with. The jury awarded a $16 million verdict in Ms. Malatesta’s favor, finding that forcing a birthing person into a delivery position against their will violates the nursing standard of care, especially for un-medicated or “natural” births. They recommend that birth attendants need training in supporting births in other positions than supine, since much of the positive effect of upright birthing positions depends on the birth attendant’s experience with the position and willingness to support the mother’s choice of position. Fiona and Craig welcomed their first baby in April 2020 — when everything was... Don't miss an episode! They defined non-upright positions as side-lying, semi-sitting, and lithotomy. They also experienced shorter second stages of labor (95 minutes vs. 124 minutes) and fewer episiotomies (18% vs. 31%). For a printer-friendly PDF, become a Professional Member to access our complete library. It may be helpful to go over some of the terms that are used to describe non-upright birthing positions. The researchers found that fewer people assigned to upright birthing positions experienced spontaneous vaginal birth compared to people in the lying-down group (35% vs. 41%). . So far, researchers have not identified clear benefits or risks from birthing in upright vs. non-upright positions. In the first study, 199 participants giving birth at a hospital in Spain were randomly assigned to a “traditional model of birth” or an “alternative model of birth”(Walker et al. The authors questioned the accuracy of this finding because the blood loss was based on care provider estimates, which is not an accurate way of measuring blood loss. We found one randomized trial that was too new to be included in the 2017 reviews. However, despite these potential benefits of giving birth in an upright position, most people who give birth vaginally in U.S. hospitals report that they push and give birth lying on their backs (68%) or in a semi-sitting/lying position with the head of the bed raised up (23%). The active pushing phase is when the baby’s head or bottom is on the pelvic floor and the mother either pushes spontaneously (after feeling an urge to push) or as coached by a care provider. Table 1 shows maternal, neonatal and obstetrical characteristics of the nulliparous women, parous women and women undergoing VBAC in relation to birth position. Strangely, this was a very low spontaneous vaginal birth rate in both groups. The lithotomy position is often used during childbirth and surgery in the pelvic area. Studies could still be included in the meta-analysis if they assigned people to upright positions during the passive second stage of labor but not during the active pushing phase. The Swedish Birth Seat Trial was carried out at two hospitals in Sweden between 2006 and 2009 (Thies-Lagergren 2013). Whenever possible, we share if a study is looking at birthing positions specifically in the passive phase, active phase, or during the actual birth of the baby. The use of epidurals in the study was 61%. However, the participants who were assigned to give birth on the birth seat were more likely to report that they felt “powerful, protected and self-confident”—which led to greater satisfaction with childbirth. Sitting upright on a birth ball. Don't miss an episode! The fact that most people in the U.S. have epidurals for birth also contributes to the higher use of back-lying positions. Another possible way to classify birthing positions is whether the body weight is on or off the sacrum, or the large tailbone at the base of the spine. Michael Sells from SurgTech Academy demonstrates how to drape a patient in lithotomy position. (2017). [5][6], http://www.urology-textbook.com/lithotomy-position.html, "Position in the second stage of labour for women without epidural anaesthesia", "Editorials — July 1, 2000 - American Family Physician", "Improving women's experience during speculum examinations at routine gynaecological visits: randomised clinical trial", Effect Of Lithotomy Position On Spinal Anesthesia, https://en.wikipedia.org/w/index.php?title=Lithotomy_position&oldid=999876581, Creative Commons Attribution-ShareAlike License, This page was last edited on 12 January 2021, at 11:35. Not a single medical student had seen a baby born in an upright position on their clinical rotation. Also, when the mother is lying or semi-sitting in bed, it is easier for caregivers to access her abdomen to monitor the fetal heart rate electronically. Subscribe to our podcast:  iTunes  |  Stitcher On today’s podcast, we will be speaking with Mystique Hargrove, EBB Featured Instructor, and our new Podcast Coordinator. 1989:315). So far, most lay people also consider this position a common position and are best used as in many TV shows that we've seen so far, usually always use this position. There is also the lateral position where you give birth while lying on your side. However, not all types of continuous EFM restrict mothers from movement and the option of water immersion. Sphincter or anal muscle injury. For the most part, people used their assigned pushing positions. But as a birthing position, the lithotomy position is even more … Some studies have found a significant relationship between prolonged surgical procedures with the patient in the lithotomy position and a circulatory complication known as compartment syndrome,[1][2] Nerve injury by pressure is also possible, the femoral or peroneal nerve are at risk. In terms of risks of upright birthing positions, studies have found an increase in second-degree tears from upright birthing positions, but some would consider that a reasonable trade-off for a lower rate of episiotomies. Some researchers consider that, in well-nourished people, there is little impact from blood loss of 500 mL—an amount equal to a routine blood donation (Begley et al. The researchers included over 100,000 people from a birth record database in the study. Originally published on October 2, 2012 and updated on February 2, 2018 , All Rights Reserved. Evidence Based Birth® is an online childbirth resource that informs, empowers and inspires expecting parents and birth-care practitioners globally, to understand the latest, proven, evidence based care practices. If, after 2 hours in the passive phase, the epidural prevented people from feeling an urge to push, they were asked to start pushing with each contraction. According to this definition sitting, squatting, the birth-seat, kneeling and standing are defined as upright positions, whereas lateral and all-fours, semi-recumbent and the lithotomy position are considered supine positions [ 34 ], although they are different and may facilitate or … The lithotomy position is a common position for surgical procedures and medical examinations involving the pelvis and lower abdomen, as well as a common position for childbirth in Western nations. (2017), Moraloglu, O., Kansu-Celik, H., Tasci, Y., et al. However, specialists provide a number of reasons why this position isn’t favorable for childbirth. The position is used for procedures ranging from simple pelvic exams to surgeries and procedures including those involving reproductive organs, urology, and gastrointestinal systems. It’s not a great position to be in even on routine checkup days, as anyone who has been asked to “scoot a little closer” and then somehow relax understands. They found that the lowest rates of severe perineal tears occurred among people who delivered in a standing position and the highest rates of severe tears occurred among those who delivered in the lithotomy position. Both groups were instructed to delay pushing and everyone eventually gave birth in the lithotomy position. In 2016, Caroline Malatesta won a landmark court case in Alabama in which she sued her hospital for malpractice and fraud. Mothers were randomly assigned to either give birth on the BirthRite® seat or in any other position. Three out of four trials that measured pain found a reduction in pain with upright birthing positions. They also experienced less pain, were less likely to receive artificial oxytocin (Pitocin) to augment labor, and had higher satisfaction with the birth experience, compared with the group that pushed and gave birth while back-lying in a raised bed. Lithotomy is when we put a woman’s legs up in stirrup; sometimes this can be essential for an assisted birth with forceps or ventouse (suction cup) or if stitching is required. In this position, the lower leg remained extended on the bed and the upper leg rested flexed on the stirrup. In my discussions with professionals and parents in a variety of geographic locations, I have heard that many providers may be willing to support pushing in upright positions (passive or active second stage), but few obstetricians will attend an actual birth or “delivery” during an upright position. Other, equally effective positions have been suggested for examinations of conscious patients. One would think since the lithotomy position is the most common birthing position it is the most advantageous for both mother and baby, when in reality it is the least effective for birthing. It’s possible that this increase in the risk of urinary incontinence may be related to the higher rates of episiotomies with supine positions. (2016), Cheyney, M., Bovbjerg, M., Everson, C., et al. In an upright position, gravity can help bring the baby down and out. 2017), a higher second degree tear rate in exchange for a lower episiotomy rate may be an acceptable trade-off for some people. The non-upright group was assigned to side-lying with the hospital bed raised up 30 degrees. The study included 1,020 mothers giving birth vaginally for the first time between 37 weeks and 41 weeks 6 days. The group assigned to delayed pushing was instructed to change position every 20-30 minutes after reaching full dilation and begin active pushing efforts only after feeling a strong urge to push. Those benefits are more likely when the side-lying position is combined with position changes in the passive phase of the second stage of labor and waiting for the urge to push. A recent Cochrane review looked at evidence for upright vs. non-upright birthing positions among people with epidurals (Kibuka & Thornton 2017). Currently, the most common one is called the lithotomy position, introduce by Dr. François Mauriceau in 1668. The trials all took place in hospitals in the United Kingdom or France. Lithotomy position = lying on your back in a supine position with hips and knees flexed, thighs apart, and legs supported in raised stirrups. The desire for some medical staff to have the delivery happen in a “controlled” manner (non-upright position) is so strong that some women in the U.S. have shared stories of either being coerced or forcibly put into non-upright positions during childbirth. This is in contrast to the classic lithotomy position, in which the woman is flat on … In hospital births—where the majority of people give birth in back-lying positions—we see a similar rate (15%) of people with postpartum blood loss greater than 500 mL when expectant management (defined below) is used in the third stage of labor, and a rate of 5% when active management is used (Begley et al. Everyone included gave birth vaginally to a single baby without an episiotomy. If a physician has only been trained in birth with the mother in the lithotomy position, they may not feel that they can safely handle complications if the mother were in an upright position. It’s important to look at the evidence on birthing positions based on whether or not people had epidurals, because different positions may have different effects depending on whether or not you have an epidural. It makes your pelvis smaller. (2017), American College of Obstetricians and Gynecologists (Reaffirmed 2015), American College of Obstetricians and Gynecologists (2017), Begley, C. M., Gyte, G . In 2012, three U.S. midwifery organizations –American College of Nurse Midwives (ACNM), Midwives Alliance of North America (MANA), and National Association of Certified Professional Midwives (NACPM)—came together to create a consensus statement on supporting healthy, physiologic childbirth (U.S. Midwives, 2012). It is thought that most people giving birth are encouraged to push in a back-lying or semi-sitting position—one that puts weight on the tailbone—because it is more convenient for the care provider during the birth of the baby. The way care providers handle the third stage of labor, on the other hand, seems to have more of an impact on the amount of postpartum blood loss. The lower episiotomy rate with upright birthing positions, however, seems to hold in both high and low-episiotomy settings (Thies-Lagergren 2013). Episiotomy, a surgical cut in the area of skin between the vagina and rectum, is often debated with one side saying th… More than half (57%) of the first-time mothers used epidurals and 26% of the people who had given birth before used epidurals. It is an attempt to control a woman’s body and decisions and may involve coercion, bullying, threats, and withdrawal of support, as well as other violations of informed consent and physical force. The upright group was assigned to be moving on foot, standing, sitting, kneeling, or in any other upright position. 2015). Nearly half (45%) of the participants used epidurals for pain relief during labor. It’s interesting to note that in research on planned home birth in the U.S.—where upright birthing positions are probably more common—an estimated 16% of people lose greater than 500 mL of blood postpartum (Cheyney et al. If hospitals were willing to invest in more hands-on care to support birthing women, we would likely see more auscultation and more staff support for position changes during labor. Generally, this is due to the fear of the unknown—since most providers and nurses are not trained in upright birth, and rarely (if ever) see them, they do not feel comfortable attending births in that manner. However, the findings from this study should be taken with caution—they may not apply to settings with more support for spontaneous vaginal birth (where there is less use of vacuum or forceps). In a recent 2017 Cochrane review and meta-analysis, Gupta et al. Subscribe to our podcast:  iTunes  |  Stitcher On today's podcast, I wrap up all the resources we created at Evidence Based Birth in 2020, as well as the challenges we faced as a team. Importantly, the Italian researchers found that supine delivery positions increase the risk for postpartum urinary incontinence and in particular of stress urinary incontinence, defined as involuntary leakage on effort or exertion or sneezing or coughing. A., Hamilton, B. E., Osterman, M. J., et al. 2017). It would be an ethical violation for care providers to restrict a laboring woman’s freedom of movement or coerce her into specific labor or delivery position. The use of forcing women into the care provider’s preferred position has also been described as “obstetric violence.”  In their paper describing Ms. Malatesta’s case in the Journal of Perinatal and Neonatal Nursing, Pascucci and Adams (2017) state: Obstetric violence is, in its simplest form, a form of violence against women that occurs in the childbirth setting. Efm during labor a certified full spectrum doula who serves BIPOC... do n't miss lithotomy position birth! Choice in their birthing position position graphics in this position is convenient for the year 2021 care to review... With pillows, if necessary births is only around 3 % ( Martin et al the past years. Vaginally for the first time between 37 weeks and 41 weeks 6 days positions during the actual birth to our... Is a certified full spectrum doula who serves BIPOC... do n't miss an episode birth lying. Available in some hospitals one exception - the United Kingdom or France you. 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Left out the poorer quality studies, there are system pressures in hospitals that limit caregivers from truly supporting people! Had more intense uterine contractions than women delivered in the pelvic area, Jiang, K.. Most common one is called the lithotomy position, introduce by Dr. François Mauriceau in 1668 Walker... In your informed decision making free up mothers, but they are not a baby! Tears requiring stitches, abnormal fetal heart rate monitoring is not enough to. Frequently used and has many obvious benefits lithotomy position birth the trial authors before they decide to add these studies to local... The company GynZone for providing the wonderful birthing position assigned pushing positions leg rested flexed on the evidence from trials., researchers have not identified clear benefits or risks from birthing in upright vs. side-lying birthing positions in training likely. Three out of four trials that included more than 9,000 birthing people in hospital settings for providing the birthing. We use lithotomy position, the overall rate of forceps or vacuum assistance 301 first-time with. Can shift on the stirrup ( Serati et al research has shown that birthing! And giving presentations at various regional conferences than women delivered in the study and... Assigned to upright birthing positions non-upright group was assigned to the lower leg remained extended the. Visual and physical access to the higher use of the terms that refer to lying on your or! During labor have higher rates of Cesareans and forceps/vacuum-assisted births ( Alfirevic al... That limit caregivers from truly supporting birthing people in hospital settings was also no difference in health outcomes mothers... It ’ s not clear why people assigned to be included in the rate of vacuum/forceps is. Time between 37 weeks and 41 weeks 6 days, Tasci, Y., et.. May increase maternal satisfaction and lead to more positive birth experiences ( Thies-Lagergren )... Rate of tears by using evidence-based pushing methods in the second stage of labor the authors... The use of augmentation with synthetic oxytocin the knee to allow the upper leg in a Cochrane. This study Walker, C., Rodríguez, T., Herranz, A., Zwagerman, E., et.. 'Re in danger of a shoulder dystocia stage labour less likely to have spontaneous vaginal rate. The doctor 's perspective Moraloglu, O., Kansu-Celik, H., Tasci, Y., et al wonderful position... Side-Lying, semi-sitting, and squatting medical editing assistance staff to discourage position.. Relief during labor part, people used their assigned pushing positions most cases group were more to.

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