Running head: INTEGRATIVE REVIEW 1

Integrative Review

Jenna Witte

Bon Secours Memorial College of Nursing

Dr. Holowaychuk

Nursing Research NUR 4122

November 12, 2019

“I pledge.”
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Abstract

The purpose of this integrative review is to evaluate research literature that examines and

compares the effects of non-supine positioning versus supine positioning on labor and delivery

outcomes. Prior research indicates that modified supine and lithotomy positions are the preferred

maternal positions during delivery despite evidence that supports upright or lateral positioning as

superior practice. The PICO question under examination is: In laboring women, what is the

effect of non-supine positioning during the second stage of labor on maternal outcomes

compared with supine positioning? The research design is an integrative review. The databases

used to discover articles were EBSCO CINAHL Complete, EBSCO Medline Complete, and

Academic Search Complete. Once appropriately filtered, the results yielded 332 articles and five

met the inclusion criteria. All five articles suggest that non-supine positioning during the second

stage of labor results in improved maternal outcomes compared to supine positioning. Specific

findings include reduced length of labor, increased rate of perineal intactness, and lower pain

severity rating. Limitations to the review are comprised of a predetermined deadline for the

assignment, the researcher’s lack of expertise, and a restriction on the number of articles allowed

for review. Implications of this review include modifying current obstetrical practice to employ

non-supine maternal positioning during labor and delivery to achieve improved outcomes for

mothers. Recommendations for future research involve exploring maternal perception of varied

labor positioning, provider preference of delivery position, and the effects of various maternal

positioning on neonatal outcomes.

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Integrative Review

The purpose of this integrative review is to evaluate research literature that examines and

compares the effects of non-supine positioning versus supine positioning on labor and delivery

outcomes. Supine positions are linked to longer labors, increased pain, higher risk of Cesarean

delivery, negative neonatal outcomes, and more (Louwen, Daviss, Johnson, & Reitter, 2017;

Valiani, Rezaie, & Shashahan, 2016; Zhang et al., 2016). Despite these drawbacks, the modified

lithotomy position is the most commonly practiced maternal position during labor and delivery.

Possible influences on the continued popularity of supine positioning may include provider

preference, cultural norms, and resistance to change in medical practice (Moraloglu et al., 2017).

The World Health Organization recommends employing non-supine postures (Zhang et al.,

2016), including standing, squatting, sitting, lying laterally, and kneeling on hands-and-knees.

Several studies support a correlation between non-supine positioning and improved

maternal outcomes such as shorter labor, decreased rate of perineal lacerations, decreased pain

experienced by the mother, and lower incidence of medical interventions like synthetic oxytocin

and manual maneuvering of the fetus (Hickey & Savage, 2019; Louwen et al., 2017; Valiani et

al., 2016). Two studies even suggest a link between non-supine postures and decreased incidence

of emergent Cesarean deliveries (Hickey & Savage, 2019; Louwen et al., 2017). A determined

association between non-supine positioning and improved labor and delivery outcomes will

indicate a necessity for obstetrical practice change, particularly for providers to educate and

encourage mothers to labor and give birth in a position other than on their backs. The aim of this

review is to analyze and consider prior research material as it concerns the researcher’s PICO

question: In laboring women, what is the effect of non-supine positioning during the second

stage of labor on maternal outcomes compared with supine positioning?

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Design and Search Methods

The research design is an integrative review. The articles were obtained using three

search engines, EBSCO CINAHL Complete, EBSCO Medline Complete, and Academic Search

Complete. The search terms included ‘maternal positioning’, ‘delivery position’, ‘labor position’,

‘supine position’, ‘squatting position’, ‘pushing’, ‘hands and knees’, and ‘vaginal delivery’. The

query originally yielded 13,487 articles from EBSCO CINAHL Complete, 37,831 articles from

Academic Search Complete, and 45,968 articles from EBSCO MEDLINE Complete. This was a

limit to the search process as the vast number of available articles made it impossible for the

researcher to effectively evaluate each one. The results were then filtered to list only scholarly,

peer-reviewed, and full-text academic journal articles written in English and published within the

last five years. The search was narrowed further to include only articles related to the fields of

obstetrics and maternal health which yielded 332 results. These search restrictions ensured

satisfactory, contemporary research and provided the researcher with a manageable number of

articles to review.

The resulting articles were additionally screened for significance to the PICO question set

forth by this researcher: In laboring women, what is the effect of non-supine positioning during

the second stage of labor on maternal outcomes compared with supine positioning? If the article

under appraisal did not include length of labor, labor position, perineal laceration/episiotomy,

pain rating, Cesarean section, and/or neonatal outcome as variables, then it did not meet the

inclusion criteria and was consequently omitted from this review. After exhaustive screening of

many articles, five quantitative studies were located and referenced for this integrative review.

Findings and Results

The findings and results of the five appraised studies suggest that non-supine maternal
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positioning in labor is associated with improved maternal outcomes when compared to supine

maternal positioning (Hickey & Savage, 2019; Louwen et al., 2017; Moraloglu et al., 2017;

Valiani et al., 2016; Zhang et al., 2016). A summary of the research articles is attached via

Appendix 1. This review is organized around the following themes discovered amongst laboring

women who practice non-supine positioning during labor and birth: length of second stage labor,

perineal injury, and pain severity.

Length of Second Stage Labor

Three of the five research articles employed quantitative studies to discover the

relationship between various labor positions and length of labor and found upright positioning to

be effective in reducing the time spent laboring (Hickey & Savage, 2019; Louwen et al., 2017;

Moraloglu et al., 2017). In the first study conducted by Hickey & Savage (2019), the authors

examined the links between the use of a peanut ball (PB), which is a positioning device used to

assist laboring women into various open-pelvic lateral positions, and labor outcomes of women

who receive epidural anesthesia. This quasi-experimental comparison study sampled 343

mothers presenting at one unnamed hospital in active labor. 164 participants were randomly

selected to be in the experimental group, using a PB for lateral positioning during labor, and the

residual participants were placed in the control group and remained in a supine position during

labor without the use of a PB. Data collection methods used for this study included chart reviews

and convenience samples assessing for variables such as birth type, occurrence of induction,

length of first and second stages of labor, use of PB, and nursing support. The data was analyzed

using a one-sided z test with pooled variance and multivariate analysis. Two-sample t tests and

Fisher exact tests were implemented to compare differences between the two sample groups.

Additionally, multiple linear regression models were employed to determine a quantifiable link
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between the use of a PB and length of labor. These analysis methods are appropriate for this type

of study. Results suggest that while the use of a PB alone does not reduce the length of labor, the

second stage of labor is shorter when mothers make frequent lateral position changes.

Next, in the second quantitative study, Louwen et al. (2017) evaluated the effects of

upright positioning on vaginal breech delivery outcomes with a primary motivator of unearthing

possible links to emergent Cesarean section deliveries. This retrospective cohort study assessed

the outcomes of 750 women with term breech deliveries who presented at a German hospital

over the span of seven and a half years. Data was collected via documentation review using

patient hospital charts to assess for labor position, length of first and second stages of labor,

occurrence of cord entanglement and birth injuries to the neonate, incidence of maternal perineal

injury, rate of emergent Cesarean delivery, and fetal/neonatal morbidity and mortality. The data

was then analyzed by two researchers with no direct connection to the hospital from whence the

data came; specific data analysis techniques were not described in the article which is a

limitation of this study. The results generated from this research indicate that when upright

positioning is adopted, the second stage of labor is an average of 42% shorter than when the

mother lies supine.

Lastly, in a randomized controlled trial performed by Moraloglu et al. (2017), the

researchers compared pushing in a squatting position in the second stage of labor to pushing in a

supine position; the researchers also examined the consequential effects on mothers and

neonates. The study sample was comprised of 102 women whose deliveries took place at a

Turkish hospital from December 2013 to May 2014. The patients were randomly placed into one

of two groups: group 1 assumed a squatting position while pushing and group 2 assumed a

supine position while pushing. Data was collected by chart review, observation, and interview,
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assessing for variables including demographic information, pre- and post-delivery maternal

hemoglobin levels, duration of labor, visual analog scale (VAS) pain score, neonate Apgar

scores, and the mother’s subjective pain level using a numeric scale. Data analysis was

performed using an independent sample t-test, Shapiro-Wilk’s tests, Chi-square tests, and Fisher-

exact tests, all of which are reliable analytic methods. The findings of this research study indicate

that the duration of the pushing stage of labor while squatting is shorter by an average of 34

minutes when compared to mothers who push while lying supine.

Perineal Injury

Two of the five research articles discovered a link between non-supine labor positions

and decreased rate of perineal lacerations, including episiotomies (Louwen et al., 2017; Zhang et

al., 2016). In the retrospective cohort study completed by Louwen et al. (2017), the researchers

examined the effects of upright positioning in vaginal breech deliveries on maternal and neonatal

outcomes. At the conclusion of this study of 750 German mothers who vaginally delivered

breech infants, it was learned that there are fewer third- and fourth-degree perineal lacerations in

mothers who deliver in an upright position compared to those who deliver on their backs.

In a randomized controlled trial performed by Zhang et al. (2016), the authors compared

the supine delivery position with the hands-and-knees delivery position as they relate to maternal

and neonatal outcomes. This quantitative study sampled 886 actively laboring women presenting

to 11 Chinese hospitals over the span of seven months; 440 women were randomly placed in the

control (supine) group and 446 were randomly placed in the experimental (hands-and-knees)

group. Methods of data collection included observation, interviews, and electronic case notes

assessing for episiotomy rate, degree of perineal laceration, rate of delivery/length of labor, rate

of shoulder dystocia, postpartum bleeding, neonatal Apgar scores, and rate of neonatal asphyxia.
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The data was analyzed using the SPSS Statistics for Windows version 21 program and the

researchers performed an independent sample t-test and Chi-square test. A logistic regression

model was implemented to specifically evaluate the factors affecting episiotomy rate. The data

analysis methods utilized are appropriate for a study of this type. The results suggest that the

hands-and-knees position is not only associated with increased perineal intactness and decreased

incidence of episiotomy, but they also indicate that this position may be specifically protective of

the perineum as it improves blood circulation to the genitals and alleviates perineal swelling.

Pain Severity

Two of the five research articles discovered a correlation between non-supine positioning

and decreased maternal pain severity (Moraloglu et al., 2017; Valiani et al., 2016). The

randomized controlled trial by Moraloglu et al. (2017) examined differences between the

outcomes of Turkish mothers who pushed and delivered in a squatting position and the outcomes

of those who pushed and delivered in a supine position. Maternal pain of the 102 laboring

women was measured using VAS and a subjective numeric pain scale rating. The statistically

significant results indicate improvement in both VAS and subjective pain scores when women

squatted while pushing.

The fifth study analyzed in this integrative review, a comparative clinical trial completed

by Valiani et al. (2016), inspected the effect of various labor positions on a mother’s pain

severity. The sample size consisted of 96 laboring women who presented to a single Iranian

hospital. These women were randomly selected and divided into three groups: the women in

group one maintained lithotomy position throughout their labor and birth, the women in group

two maintained a sitting position in a labor chair, and the women in group three maintained a

squatting position. The data – labor position, stage and phase of labor, and maternal pain
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intensity – were gathered through interviews and observations. Maternal pain intensity was

measured using a numeric VAS and a verbal McGill Pain Questionnaire which are suitable

methods of pain measurement. The data was then analyzed using SPSS version 11 and the

authors performed Chi-square tests and Kruskal-Wallis tests to determine statistical significance

among the research findings; these are appropriate analytic procedures for a study of this kind.

The results of this study show that pain severity was lower in both the squatting and lithotomy

groups compared to the sitting group during the latent phase of labor; however, the pain severity

in the active phase of labor was lowest in the squatting group.

Discussion and Implications

The articles chosen for this review provide awareness regarding the effects of non-supine

positioning on outcomes of laboring mothers. The PICO question, in laboring women, what is

the effect of non-supine positioning during the second stage of labor on maternal outcomes

compared with supine positioning, was thoroughly informed by the research outcomes.

Quantitative research studies conducted by Hickey & Savage (2019), Louwen et al. (2017),

Moraloglu et al. (2017), Valiani et al. (2016), and Zhang et al. (2016) feature notable findings

regarding comparisons between supine and non-supine positioning in laboring women. Although

each study focused on very different and specific variables, the researchers commonly

discovered reduced length of second stage labor, lower rate of perineal injury, and decreased

pain severity as prevalent associations in pregnant women who utilize non-supine positions

during the birth process. Future research should explore maternal perception of varied labor

positioning, provider preference of delivery position, and the effects of various positioning on

fetal/neonatal health outcomes in order to obtain a more comprehensive understanding of varied

positioning during the birth process. The implications of these findings suggest that non-supine
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maternal posture in labor and delivery is significantly beneficial to laboring women and results in

improved maternal outcomes. Therefore, application of various non-supine positions can be used

as a non-pharmacological tool to reduce maternal labor pain, labor length, and perineal

laceration/episiotomy rate. Maternal positioning affects a myriad of variables in labor and the

benefits of non-supine posture on maternal outcomes cannot be overlooked. Obstetrical health

providers must realize the advantages of upright positioning over supine positioning and adjust

their practices to reflect the evidence.

Limitations

Several limitations of this integrative review are present, both on the part of the

researcher and within the articles referenced. First, the researcher lacks experience in performing

an integrative review and the resulting ineptitude may affect the accuracy of this review.

Secondly, only five articles were allowed to be included so this is not a comprehensive review.

Additionally, though the articles selected for review are considered current and applicable

research, they cannot be generalized due to the predetermined assignment deadline and the

resulting limited analysis time frame set forth by the class instructor. Finally, all five articles

used were quantitative studies, limiting data obtained from lived experiences which is necessary

for an equalized objective review.

Various limitations also appear in the research articles within this review. Hickey &

Savage (2019) concluded that their inclusion criteria limits the generalizability of the study

findings; additionally, variances in the time of applied interventions diminishes the

transferability of the results. In the study by Louwen et al. (2017), the authors acknowledge the

possibility of selection bias and the relatively small size of one of the comparison groups as

limitations of the research. Moreover, the researchers failed to discuss data analysis techniques
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which limits the reliability and repeatability of the study. Moraloglu et al. (2017) revealed a

limitation of their study to be birth practices in Turkish culture that affect the variable rates

measured in the article, potentially rendering some of the results unreliable. Valiani et al. (2016)

did not declare any limitations to their study, which is a limitation in and of itself due to the

imperfect nature of research. Lastly, the study performed by Zhang et al. (2016) established

several limitations including a large percentage of participant withdrawal, participant

noncompliance, and limited qualitative feedback.

Conclusion

The findings identified within this integrative review emphasize the positive effects of

non-supine maternal positioning on labor and delivery outcomes which suitably inform and

relate to the PICO question. The results indicate that women who adopt non-supine postures

during labor and delivery experience benefits such as shorter labor, increased perineal intactness,

and reduced pain. The findings in this integrative review implicate the need for obstetric practice

modification. Obstetrical health care providers should acknowledge the evidence and discontinue

the utilization of supine and lithotomy positions as primary labor and delivery postures because

they are associated with lengthy labors, increased perineal injuries, and amplified pain, among

other undesirable outcomes. Thus, the adoption of various upright and lateral positions as the

preferential positioning for women in labor should be considered as a useful and effective non-

pharmacological tool to enhance labor and delivery and to achieve improved maternal outcomes.
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References

Hickey, L., & Savage, J. (2019). Effect of peanut ball and position changes in women laboring

with an epidural. Nursing for Women’s Health. 23(3), 245-252.

https://doi.org/10.1016/j.nwh.2019.04.004

Louwen, F., Daviss, B.-A., Johnson, K. C., & Reitter, A. (2017). Does breech delivery in an

upright position instead of on the back improve outcomes and avoid cesareans?

International Journal of Gynecology & Obstetrics, 136(2), 151–161. doi:

10.1002/ijgo.12033

Moraloglu, O., Kansu-Celik, H., Tasci Y., Karakava, B. K., Yilmaz, Y., Cakir, E., & Yakut, H.I.

(2017). The influence of different maternal pushing positions on birth outcomes at the

second stage of labor in nulliparous women. Journal of Maternal-Fetal & Neonatal

Medicine, 30(2), 245-249. https://doi.org/10.3109/14767058.2016.1169525

Valiani, M., Rezaie, M., Shashahan, Z. (2016). Comparative study on the influence of three

delivery positions on pain intensity during the second stage of labor. Iranian Journal of

Nursing and Midwifery Research, 21(4), 372-378. doi: 10.4103/1735-9066.185578

Zhang, H., Shu, R., Zhao, N., Lu, Y., Chen, M., Li, Y., Wu, J., Huang, L., Guo, X., Yang, Y.,

Zhang, X., Zhou, X., Guo, R., Li, J., Cai, W. (2016). Comparing maternal and neonatal

outcomes between hands-and-knees delivery position and supine position. International

Journal of Nursing Sciences, (3)2, 178-184. https://doi.org/10.1016/j.ijnss.2016.05.001

INTEGRATIVE REVIEW 13

Appendix I: Summary of the Literature Tables

Article Reference Hickey, L., & Savage, J. (2019). Effect of peanut ball and
position changes in women laboring with an epidural.
Nursing for Women’s Health. 23(3), 245-252.
https://doi.org/10.1016/j.nwh.2019.04.004
Background/Problem Background/Problem Statement: Women who undergo cesarean
Statement deliveries are at enormously increased risk for delivery-
associated complications. Epidurals are associated with longer
labors, increased operative (forceps, vacuum) vaginal birth
rates, and increased risk of cesarean birth. “Is the use of a
peanut ball (PB) combined with position changes associated
with better outcomes - specifically shorter labor and lower
cesarean rates - among women receiving epidural anesthesia?”
Conceptual/theoretical • No framework is identified.
Framework
Design/ Design/Method:
Method/Philosophical • Quantitative
Underpinnings • Quasi-experimental comparison group design
Sample/ Setting/Ethical Sample/Setting: 343 participants with 164 in the PB group. 10
Considerations women withdrew from the study. All laboring women
presenting to one particular hospital between November 2016
and October 2017 were potential participants; each woman was
randomly selected and randomly chosen for either the control or
variable group.

Ethical Considerations: This study received approval from the

hospital institutional review board. All women who met
inclusion criteria were given the opportunity to participate after
receiving an explanation of the study. Those who agreed to
participate gave written consent.
Major Variables Studied
(and their definition), if Major Variables:
appropriate • Length of labor: first and second stages
• Birth type
• Induction
• Nursing support
Measurement Tool/Data Data were collected via convenience sample and chart review.
Collection Method

Data Analysis Data analysis:

• Multivariate analysis
• one-sided z test with pooled variance
• descriptive statistics
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• two-sample t tests
• Fisher exact tests
• comparative analysis
• multiple linear regression model
• logistic regression model
• predictors
Findings/Discussion • Women in the PB group were 50% less likely to have a
cesarean
• Shorter length of labor with frequent lateral position
changes, including use of PB ball
• Greatest benefits when the PB ball is implemented in
women who are at <4 cm dilation
Appraisal/Worth to This article suitably informs the PICO question “In laboring
practice women, what is the effect of non-supine positioning during the
second stage of labor on postpartum outcomes compared with
supine positioning?” Using a PB in various lateral positions and
frequent position changes are associated with lower cesarean
rates and shorter labor. Obstetrical care teams should utilize
early placement of the PB and encourage frequent position
changes.
INTEGRATIVE REVIEW 15

Article Reference Louwen, F., Daviss, B.-A., Johnson, K. C., & Reitter, A.
(2017). Does breech delivery in an upright position
instead of on the back improve outcomes and avoid
cesareans? International Journal of Gynecology &
Obstetrics, 136(2), 151–161. doi: 10.1002/ijgo.12033
Background/Problem Background/ Problem Statement: There is limited research on
Statement how to improve vaginal breech births. The aim of this study is
to compare outcomes of vaginal breech deliveries in upright
positions versus those in dorsal recumbent positions and
planned cesarean section deliveries. “Does breech delivery in
an upright position instead of on the back improve outcomes
and avoid cesareans?”
Conceptual/theoretical • No framework is identified
Framework
Design/ • Quantitative
Method/Philosophical • Retrospective cohort study
Underpinnings
Sample/ Setting/Ethical Sample/Setting: 750 women with term breech deliveries at one
Considerations German hospital between January 1, 2004 and June 30, 2011.

Ethical considerations: Ethics approval was received in

November 2011 from the ethics committee at the study center.
Major Variables Studied Major Variables
(and their definition), if • vaginal delivery in dorsal position
appropriate • vaginal delivery in upright position
• cesarean delivery
• cesarean in labor (emergent C-section)
• length of labor: first and second stages
• cord entanglement
• birth injuries to the neonate
• perineal injury/episiotomy
• maneuvers to help deliver baby’s body and/or head
• fetal and neonatal mortality
• fetal and neonatal serious morbidity
Measurement Tool/Data Data were collected via documentation review using hospital
Collection Method charts.
Data Analysis Data was analyzed by two researchers who did not have a
direct connection to the hospital from where the data came.
Specific data analysis techniques were not described.
Findings/Discussion The results generated from this research indicate that non-
supine delivery positions are associated with better outcomes
for mother and baby; therefore, upright maternal positioning is
advantageous to mothers who vaginally birth breech babies.
• the second stage of labor was significantly shorter
• the cesarean rate decreased by 32%
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• there was a significantly lower rate of provider

maneuvers to the baby’s head or body
• there were fewer serious perineal lacerations
Appraisal/Worth to This article suitably informs the PICO question “In laboring
practice women, what is the effect of non-supine positioning during the
second stage of labor on postpartum outcomes compared with
supine positioning?” Obstetrical nurses, midwives, and
physicians should use this information to adapt their clinical
practice by encouraging mothers to give birth in upright
positions rather than supine positions in order to attain superior
neonatal and maternal outcomes.
INTEGRATIVE REVIEW 17

Article Reference Moraloglu, O., Kansu-Celik, H., Tasci Y., Karakava, B. K.,
Yilmaz, Y., Cakir, E., & Yakut, H.I. (2017). The
influence of different maternal pushing positions on birth
outcomes at the second stage of labor in nulliparous
women. Journal of Maternal-Fetal & Neonatal Medicine,
30(2), 245-249.
https://doi.org/10.3109/14767058.2016.1169525
Background/Problem Background/Problem Statement: Optimal maternal positioning
Statement during the second stage of labor is currently unknown. “Does
pushing in a squatting position result in better outcomes
compared with pushing in a dorsal recumbent position?”
Conceptual/theoretical • No framework is identified
Framework
Design/ Design/Method:
Method/Philosophical • Randomized, controlled trial
Underpinnings
Sample/ Setting/Ethical Sample/Setting: 102 women whose deliveries took place at one
Considerations Turkish hospital between December 2013 and May 2014.
Patients were randomly selected.

Ethical Considerations: This study was approved by the

hospital’s ethical committee and participants gave informed
consent.
Major Variables Studied Major Variables:
(and their definition), if • Neonatal outcomes
appropriate • Maternal outcomes
• Duration of the second stage of labor
• Maternal experience of pain during the second stage of
labor by Visual Analog Scale (VAS) score
• Blood loss
Measurement Tool/Data Data were collected on the variables including demographic
Collection Method information, pre- and post-delivery maternal hemoglobin levels,
VAS score, neonate Apgar scores, and the mother’s subjective
pain level using a numeric scale. Data were collected by chart
review, observation, and interview.
Data Analysis Data Analysis:
• SPSS for Windows version 11.5
• Independent sample t-test
• Shapiro-Wilk’s tests
• All variables had normal distributions
• Chi-Square tests
• Fisher-Exact tests
• Significance boundary of 0.05
• R open source program
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• Minimum sample size of 46 persons per group, 90%

power, 0.05 type I error
Findings/Discussion • Duration of labor was shorter in squatting group
• Oxytocin requirements were higher in supine group
• VAS scores were better (lower) in squatting group
• No maternal complications in either group
• No significant difference in maternal blood loss between
the two groups
• No significant differences in neonatal outcomes between
the two groups
• Squatting position is associated with benefits to mother
and no detrimental effects to mother or neonate
Appraisal/Worth to This article suitably informs the PICO question “In laboring
practice women, what is the effect of non-supine positioning during the
second stage of labor on postpartum outcomes compared with
supine positioning?” Adopting a squatting position – rather than a
supine position – is beneficial to pregnant women in the second
stage of labor; it is associated with a shorter labor, less pain, and
less oxytocin requirements. Obstetricians and midwives should
consider the useful information in this study when preparing their
patients to push in order to achieve higher satisfaction by the
mother in her delivery.
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Article Reference Valiani, M., Rezaie, M., Shashahan, Z. (2016). Comparative

study on the influence of three delivery positions on
pain intensity during the second stage of labor.
Iranian Journal of Nursing and Midwifery Research,
21(4), 372-378. doi: 10.4103/1735-9066.185578
Background/Problem Background/Problem Statement: Management of labor pain is
Statement a large component of obstetrical care during labor and
delivery. “What is the effect of positioning a mother in three
different positions on her pain severity during the various
stages of labor? “
Conceptual/theoretical • No framework is identified
Framework
Design/ Design/Method:
Method/Philosophical • Quantitative
Underpinnings • Comparative study
• Clinical trial
Sample/ Setting/Ethical Sample/Setting: 96 laboring women presenting to one Iranian
Considerations hospital who met the inclusion criteria were randomly selected
and divided into three equal groups.

Ethical Considerations: Ethical approval was obtained by the

medical science university research and ethics committee.
Written consent was obtained from each participant.
Major Variables Studied Major Variables:
(and their definition), if • Lithotomy position
appropriate • Sitting position
• Squatting position
• Pain severity in second, third, and fourth stages of
labor
Measurement Tool/Data Data (pain intensity) was collected through interviews and
Collection Method observations. Pain intensity was collected using a numeric
Visual Analog Scale (VAS) and verbal scale of McGill.
Data Analysis Data Analysis:
• Chi-Square test
• Kruskal-Wallis test
• SPSS version 11
• Significance level considered p < 0.05
Findings/Discussion • Pain was significantly lower during the latent phase of
the second stage of labor in squatting and lithotomy
groups compared to sitting group.
• During the active phase of the second stage of labor,
pain was significantly lower in the squatting group
compared to lithotomy and sitting groups.
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• In the third stage of labor, pain was significantly lower

in the squatting group compared to the other two
groups.
• In the fourth stage of labor, there was no statistical
significance in pain severity among the three groups.
Appraisal/Worth to This article suitably informs the PICO question “In laboring
practice women, what is the effect of non-supine positioning during the
second stage of labor on postpartum outcomes compared with
supine positioning?” The results from this study indicate that a
squatting position is associated with the least amount of pain
in the second stage of labor when compared to lithotomy or
sitting positions. Obstetricians, midwives, and maternal-care
nurses can take this information under consideration as their
patients labor, encouraging them into a squatting position if
they express a desire to lessen their pain.
INTEGRATIVE REVIEW 21

Article Reference Zhang, H., Shu, R., Zhao, N., Lu, Y., Chen, M., Li, Y., Wu, J.,
Huang, L., Guo, X., Yang, Y., Zhang, X., Zhou, X.,
Guo, R., Li, J., Cai, W. (2016). Comparing maternal and
neonatal outcomes between hands-and-knees delivery
position and supine position. International Journal of
Nursing Sciences, (3)2, 178-184.
https://doi.org/10.1016/j.ijnss.2016.05.001
Background/Problem Background/Problem Statement: Supine positioning is the most
Statement common maternal position for delivery even though the World
Health Organization (WHO) recommends non-supine
positioning. This study assesses the benefits of hands-and-knees
position at delivery versus supine position at delivery.
Conceptual/theoretical • No framework is identified
Framework
Design/ Design/Method:
Method/Philosophical • Quantitative
Underpinnings • Prospective, two-group randomized, controlled trial
Sample/ Setting/Ethical Sample/Setting: 886 actively laboring women presenting to 11
Considerations Chinese hospitals (chosen by convenience) between May 2012
and December 2012 who met the inclusion criteria were
randomly selected for this trial. 440 women were randomly
placed in the control (supine) group and 446 were randomly
placed in the experimental (hands-and-knees) group.

Ethical Considerations: Ethical approval was obtained by the

ethics board at all 11 hospitals. All participants gave written
informed consent.
Major Variables Studied Major Variables:
(and their definition), if • Episiotomy rate
appropriate • Degree of perineal laceration
• Rate of delivery/length of labor
• Rate of shoulder dystocia
• Postpartum bleeding
• Neonatal Apgar scores
• Rate of neonatal asphyxia
Measurement Tool/Data Data were collected from observation, interviews, and electronic
Collection Method case notes.
Data Analysis Data Analysis:
• IBM SPSS Statistics for Windows version 21
• Descriptive statistics
• Independent sample t-test
• Chi-Square test
• Logistic regression model
• Level of statistical significance set at p < 0.05
INTEGRATIVE REVIEW 22

• A total of 92 participants (48 per group) were required to

achieve a power of 80% at a significance level of 0.05
(two-sided)
Findings/Discussion • Intact perineum rate higher in hands-and-knees group
• Lower rate of episiotomy in hands-and-knees group
• Postpartum bleeding not statistically significant between
the two groups
• Four shoulder dystocias in the supine group; zero in the
hands-and-knees group
Appraisal/Worth to This article suitably informs the PICO question “In laboring
practice women, what is the effect of non-supine positioning during the
second stage of labor on postpartum outcomes compared with
supine positioning?” The results of this study indicate the hands-
and-knees position to be protective of the perineum, resulting in
less severe lacerations, if any, and a lower rate of episiotomy.
The findings also support the hands-and-knees position as a
possible way to prevent shoulder dystocia. Both of these findings
require further research and would have a significant impact on
clinical practice if the results are reproduced. Obstetrical care
providers who implement hands-and-knees positioning in their
patients could decrease the risk of severe perineal laceration and
rate of episiotomy and could potentially decrease the risk of
shoulder dystocia, an obstetrical emergency.