RELATIONSHIP POSITION RAINING ABOUT AND
COMBINATION WITH LONG TIME II
Pregnant women who face the birth process
will experience anxiety because labor is
identical with pain, fatigue and even a life-
threatening struggle. The mother experiences
pain in the labor process, one of which is
caused by discomfort and non-freedom in
choosing a push position in labor. Most
pushing positions have been determined by a
helper with the aim of facilitating the delivery
process.
The recumbent position on the back is more
beneficial for the midwife or physician in the
process of assisting labor to intervene or a
specific maneuver if necessary. Birth helpers
both midwives and doctors prefer patients in
supine positions at the time of straining,
because the helper is easier to monitor the
condition of the fetus, easy to do
catheterization, easy to perform episiotomy
and facilitate the installation of infusion if the
need. (Aprillia Y. 2011)
Maternity should be allowed to move freely
like standing, sitting, kneeling, squatting or
choosing another position during labor. These
positions are very useful during labor, as they
correspond to the gravity of the earth so that
it will facilitate the process of descending the
lowest part of the fetus. The best position in
the delivery process is the most comfortable
position for mothers (Aprillia Y. 2011)
Many women, both in developed and
developing countries who give birth in health
care facilities, usually sleep in supine position.
The position of women during childbirth is also
influenced by local culture. (Makuch MY.
2010) Survey results obtained from women
who gave birth in the United States by
interview method, found that as many as 57%
of women who gave birth to vaginal wearing
supine position while pushing to remove the
baby. The position of half-sitting childbirth as
much as 35%, the position of the likes of
patients 4%, upright position
ie squatting or sitting 3%, and with the
position of hands and knees (crawling) 1%.
Positions that vary according to the patient's
desire will add comfort and help decrease the
baby. There is no position that can be
regarded as the best position for mother and
baby, each position has advantages and
disadvantages that may be helpful in different
situations (Joyce T. DiFranco, Amy M. Romano,
Ruth Keen 2007)
Maternity erect or lying on the side is more
advantageous than supine position or
lithotomy that includes shorter stage II, fewer
perineal lacerations and less pain.3 According
to Gupta et al, women who give birth to
supine positions feel more painful, while in
upright position , pain felt lighter (Gupta JK,
Hofmeyr GJ, Smyth RMD, 2007). According to
Gupta and Hofmeyr who did the research
between upright or oblique position compared
to supine position or lithotomy was associated
with the second stage of the second trial of 10
trials, which was 4.29 minutes, with a 95%
confidence interval (IK) of 2.95 to 5.64
minutes. This shows a very significant result in
an upright or oblique position. (Gupta JK,
Hofmeyr GJ, Smyth RMD. 2007). Meta-analysis
analyzes compare supine positions with other
delivery positions, the outcomes in the supine
birth position of the mother are more painful
and the maternal satisfaction of the low lying
position. (De Jonge A, Teunissen TA, Lagro-
Janssen AL 2004)
The problem of push position has long been
debated but the underlying evidence is less
than convincing. Most previous studies
assessed the mother's position during labor
focus on comparing erect positions with
supine. Although upright posture has shown
an increase in postpartum hemorrhage but has
benefits including pain reduction, increased
pelvic space dimensions, lower aortocaval
compression risk and more efficient uterine
contractions. (Ragnar I, Altman D, Tyden T,
Olsson S-E. 2006). Until now the benefits and
risks of various positions still require further
research, should women be allowed to choose
the position of childbirth in accordance with
his wishes. (Gupta JK, Hofmeyr GJ, Smyth
RMD, 2007)
The supine position is the position where the
front body is facing upwards. (Ministry of
National Education 2007). Helper is usually
very fond of this position because it provides a
lot of ease in doing the action. Combination
position at the time of pushing is a
combination of several positions that can be
applied at the time of mother push (Ministry
of National Education 2007). The combination
position at the time of strain in this study is a
combination of two positions that are tilted
and semi-sitting at the time of delivery.
Effective pushing mothers can be measured
from the length of the second stage. The
effectiveness of pushing provides psychic
support for maternity mothers when the
strength of pushing them to produce progress
from the birth process. When the mother is
told that the strain is good, then the mother
will be more excited to push for the process of
delivery immediately resolved properly.
According to research results Yvonne et al,
long time II on multiparas as much as 79.7%
between 0-1 hours, 10.7% 1-2 hours, while
4.6% between 2-3 hours and 5.0% experienced
second stage more than 3 hours. (Yvonne W,
Cheng MD, Linda M, Hopkins MD, Russell K,
Laros Jr., Aaron B, Caughey MD 2007)
the lower back, while the push with the
combination position of 3 people no
complaints pegel / sore in the back the
bottom, while 1 person says a little bit sore on
the lower back.
This study aims to determine the relationship
between the second stage of time between
stretching position on the back and the
position of the combination at the time of
straining.
METHOD
The design of this study is a cross-sectional
study, ie data retrieval at the start of the
complete opening of the cervix as the patient
begins to be led in follow-up until the entire
body of the baby is born. The target
population in this study were all maternal
mothers. The affordable population in this
study were all maternity mothers on supine
positions at Rumah Maternity (RB) Fatimah,
with address Jl. Agil Kusumadiya Gg. Sempalan
Jati Kulon 3/3 Kudus, and maternity mothers
who use the combination position of tilted and
semi-sitting, at Bidan Kasmanita Private
Practice (BPS) with the address of Peganjaran
Village 3/2 Bae Subdistrict Kudus District in
October-December 2012. Sampling done by
consecutive sampling that meets inclusion and
exclusion criteria with sample size of 20 per
group. The data collected were tested for data
normality with Shapiro-Wilk test and Mann-
Whitney test was performed. (Nor Asiyah,
2013)

The results of preliminary studies conducted RESULTS

on 7 Private Practice Midwives (BPS) in 4 sub-
The result of the research on the supine
districts resulted in more midwives advocating
position and the combination with the second
patients in supine position when pushing 5
stage of time which is shown in table 1 is the
midwives (71%) than midwives who encourage
characteristic of the subjects in both groups
patients to use a combination position while
did not show any significant difference
pushing as much as 2 midwives (29%). With
because all values p ˃ 0.05; based on the
the problems felt by the patient in using
homogeneity of the subject, the data can be
supine position at interview with parturien
compared.
with 10 parturien who pushed on the back
position all complained very sore and sore on
Characteristics of Standing Position Value p *) Factors Affecting Position Together
Lie (n = 20) Combination (n = 20) Value Test Value p
Laid back (n = 20) Combinations (n = 20)
Secondary time (min)
a. Mean (SD)
1. Parity b. Median
c. Range Z m-w = 1,822 0,036
a. 2 16
19.5 (10.9)
b. 3 4
16
c. 4 0 3-40 14.8 (9.7)
2. Age of mother (th) 11
5-45
a. ≤ 25 5

b. 26-30 7

c. ˃ 30 8 The second stage comparison of the push

position according to table 2 shows that
3. History the mean (mean), standard deviation (SB)
and median on the supine position are
Rupture higher than the combination pushing
position, with the shortest span of 3
a. Torn 19 minutes and the longest 40 minutes for the
b. Whole 1 supine position. As for the time that is
more than 60 minutes does not exist in
4. Education both positions. Based on the Mann-
Whitney Test in the second stage of time,
Mother 4 the supine stretch position and the
combination with the 1-sided test showed
a. SD a significant difference (p = 0,036). Nor
Asiyah. 2013).
b. SMP 6
Calculation of risk relative to the second
c. SMA 9 stage of the second stage in the supine
position and the combination at the time
1 of straining.

Long time II
Push position ≤ 20 minutes> 20
minutes Relative risk
Laid back (n = 20) 13 7

Combination (n = 20) 17 3
Based on the above table it can be seen
that in the supine position the possibility
of long time II is 2.33 times slower than
the combination position.

Discussion
The supine position is the position where
the front body is facing upwards.
(Ministry of National Education 2007).
Supine positions include lithotomy
position, dorsal rekumben, Walcher and
knee position of the chest. The position of
the walcher makes the pervis leaning
forward as the illium bone moves back
and forth on the sacroiliac joint, so the
vera conjugate is wider but the pelvic
outlet is narrower. The position of the
lithotomy makes the pelvis leaning back
so that the pelvic entrance shortens while
the outer door of the pelvis widens.
(Verralls, S. 2003).
The above positions will decrease blood
flow to the uterus thus reducing the
strength and frequency of uterine
contractions as well
a lot of pressure on the coccyx while
pushing, so many women do not like this
position. That's because the mother feels
uncomfortable, in addition to also have to
push with the opposite direction of
gravity, causing the mother should push
for longer. This position is not practical in
terms of comfort or increased uterine
contractions. (De Jonge A, Teunissen TA,
Lagro-Janssen AL. 2004), (Nasir A,
Noorani KJ, 2007), (Caldeyro-Barcia, R.
qtd in O'Mara, P. Facciolo, J, and Ponte,
W. 2003).
The study of the differences in the second
stage of time and the incidence of perineal
rupture in the straining position between
the back and the maternal combination
was performed in two different places.
The supine position was held in RB
Fatimah with 20 respondents, while the
combination position was held in BPS
Kasmanita with 20 respondents as well.
This research was conducted by
comparative analytic method with
prospective approach, by doing direct
observation. Research subjects were
observed to continue from the first stage
until the labor process was completed.
Data taken by observation that is start of
second stage (complete cervical clearance)
until baby born and observe of perineum
rupture happened on research subject.
(Nor Asiyah, 2013).
Normality test data done on the
characteristics of the subject, obtained p
value> 0.05 so that no different
meaningful or comparable. Result of
research for comparison of second stage
of time at push position between supine
and combination got mean value,
standard deviation and median on supine
position higher than combination position
with shortest time span of 3 minutes and
longest 40 minutes for supine position.
Based on Mann-Witney Test with 1 side
test, p = 0,036 or p <0,05 so the conclusion
is meaningful or long time of second in the
supine position longer than the
combination position at the time of
straining. (Nor Asiyah, 2013).
Gupta and Nikodem, examined women's
position in the second stage of labor with
randomized or quasi-randomized trials
with rigorous monitoring. Data analysis
was done through independent selection
and data release by both authors.
Disagreements are resolved through
consensus with editors. Meta-analysis of
data created using log Revolution logic.
The results of the upright or oblique
position compared with the supine
position were the reduction of the second
stage of labor on acquired from women
using upright or tilted positions with 12
trials, averaging 5.4 minutes (IK 3.9-6.0
minutes). (Gupta JK, Hofmeyr GJ, Smyth
RMD. 2007).
According to the revised edition of Gupta
and Hofmeyr research in maternal
position studies during the second stage of
labor, the results obtained in women who
used upright or oblique positions
compared with supine or lithotomy
positions, the second stage of labor on 10
trials was 4.29 minutes with 95% IK 2, 95-
5.64 minutes (Gupta JK, Nikodem VC.
2004).
The second stage of the second in the
stretched position of the back is longer
because in this position the axis of the
birth canal in the LAP decreases slightly
and the PTP leveled while the PBP
slightly rose upward. This condition
causes the movement of the fetal head to
fight the gravity of the earth in the phase
of decrease and expenditure of the head,
so the mother must push stronger and
longer so that the fetal head can be born
soon. In this position the mother will
experience very pain in the lower back,
because the fetal head which is the fetal
organ of the toughest to suppress the
mother's tail bone in a very long time. The
pain felt by the maternal mother will
interfere with the concentration of the
mother at the time of pushing so that the
mother's strength in pushing less than
optimal. (Nor Asiyah, 2013).
Supine position also results in a severe
uterus as it contains the conception results
will suppress the inferior vena cava that is
inverted to the uterus. This can lead to
blood circulation that carries the hormone
oxytocin, oxygen and glucose inhibited up
in the smooth muscle of the uterus. The
hormone oxytocin produced by the
posterior pituitary will be inhibited up to
the smooth muscle of the uterus so that
uterine contractions are less than optimal.
(Nor Asiyah, 2013).
Oxygen other than necessary for fetal
breathing is also required by the uterine
muscle for the process of glycogen
oxidation in the uterine muscle in order to
be used to perform contraction / work of
the uterine muscle. The need for impaired
oxygen supply to the uterine muscle will
result in weakened uterine muscle
contraction. (Nor Asiyah, 2013).
Glucose is the sugar in the blood that is
most easily processed into energy so that
the uterine muscles are able to contract to
release the results of conception. Supply
of glucose that is inhibited to the uterine
muscle resulted in the uterine muscle was
forced to break down glikogennya, but to
break glycogen, uterine muscle also
requires oxygen so that on the supine
position contraction will be weak or even
no contraction. If that happens so, the
second stage of the second time in labor
will run slowly can even lead to the old
partus / abandoned partus. (Nor Asiyah,
2013).
Stretching position on the back also
makes the mother a bit hard to breathe /
deep when going to start pushing because
the height of the uterus rather pressing
the diaphragm so that the lungs are not
able to inflate optimally to accommodate
enough oxygen when pushed. A long
breath is needed for the mother to be able
to push stronger and longer so that the
lowest part of the fetus can go down
significantly. (Nor Asiyah, 2013). In the
position of tilting the mother is not able to
take advantage of the force of gravity
because the road is flat, but in this
position the mother does not experience
lower back pain so that the mother can be
more comfortable and focused in pushing.
Tilted position also does not cause
emphasis on the veins that go to the
uterus, so that the supply of oxytocin,
oxygen and glucose are indispensable for
the process of contraction of the uterus is
not inhibited. (Nor Asiyah, 2013).
Semi-seated position does cause excessive
pressure on the mother's sacrum, either
from the weight of the mother's upper
body and from the weight of the fetus so
that the mother will feel the pain. This
pain will increase if this position is
maintained for a long time, but at least a
semi-sitting position can still take
advantage of the slightest gravitational
force. The position of pushing a
combination between tilting and half-
sitting will provide a lot of benefits if time
the combination is right. (Nor Asiyah,
2013).
Midwives should provide information on
the push position options that can be used
when women give birth, during pregnancy
and discuss about the benefits and
disadvantages of the positions they can
use, for their delivery (De Jonge A,
Teunissen D, Van Diem M, Scheepers P,
& Lagro -Janssen A. 2008).
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