I recently had two patients who wanted to deliver on “all fours” as it was a more comfortable position.

One baby’s heart rate slowed every time the mother adopted the “all fours” position but was normal when she was in another position. As a consequence, we had to encourage her to adopt a different position, which did not result in slowing of the baby’s heart rate. She went on to have a spontaneous vaginal delivery with an intact perineum.

The second patient did delivery in the “all fours” position. She also had a spontaneous vaginal delivery with an intact perineum.

The only logical explanation in the first case where there was slowing of the baby’s heart rate when in the “all fours” position is there was squashing of the baby’s umbilical cord in this position with, as a consequence, less oxygen getting to the baby.

As long as baby’s wellbeing is not compromised, I am very happy for a woman (without an epidural block) to adopt in second stage labour whatever position is most comfortable and most efficient. Efficiency is a more important consideration then comfort, as the most comfortable position may not result in descent of the baby’s head through the birth canal

I don’t have rigid views about the position for pushing. I have managed women who have successfully delivered babies while adopting all possible positions and I am happy with that. As long as the position works in effecting a normal delivery and as long as the baby’s wellbeing is not put at risk, I am happy.

There is a lot said about this topic. At the end of the day, all women are different and every labour and delivery is different. One woman’s preference will not be the same as another. What may be advocated by one won’t necessarily be the preference of another. The position a woman adopts with one delivery may not be her preference for delivery in her next pregnancy. I consider the ultimate goal is a normal delivery of a healthy baby, with an intact perineum, and meaning whatever works, works.

Also see Avoiding tearing with childbirth

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