The Ineffective Lithotomy Position

The lithotomy position has been widely used by obstetricians as it allows easiest access to the mother. However, this position is not based in evidence.  It carries a multitude of adverse effects, including narrowing the pelvic outlet, placing pressure on the tailbone, restricting the mother's movement, placing undue stress on the perineum thus increasing the risk of tearing, working against gravity, increasing discomfort, lengthening the pushing stage, increasing the risk of a fetal malpresentation, and effectively making the mother push uphill against gravity. 


If a mother is placed in this position during her labour, it compresses the main blood vessels including the vena cava, which limits blood flow to the baby and places it at greater risk of incurring fetal distress.  Lower rates of blood flow also causes more mothers and babies to die unnecessarily during childbirth.


Roberto Caldeyro-Barcia, past president of the International Federation of Obstetricians and Gynecologists, summarized the lithotomy position quite nicely in his statement, "Except for being hanged by the feet, the supine position is the worst conceivable position for labor and delivery".


Use of the lithotomy position has declined in all industrialized nations with one exception - the United States.   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.


Avoiding the Lithotomy Position

Choosing a care provider wisely will limit the chances of being expected or restricted to giving birth in this position.  Take the interview process seriously.  Ask the tough questions and be prepared to keep searching for a provider who provides evidence-based care. It is also helpful to state preferences for pushing in a birth plan.  If birthing in a hospital, be prepared that the nursing staff may be uninformed in effective birth positioning.


In most cases, this lack of evidence-based care is due to ignorance, not malice.  Physicians are simply practicing what they have been taught.  Their actions in promoting the lithotomy position are the result of a broken maternity care system that fails to educate its students in evidence-based maternity care.



References

Seehusen Dean A. et al, Improving women's experience during speculum examinations at routine gynaecological visits: randomised clinical trial British Medical Journal. 2006;333:171 (22 July), doi:10.1136/bmj.38888.588519.55


Anema J. G. ; A. F. Morey, J. W. McAninch, L. A. Mario and H. Wessells Complications related to the high lithotomy position during urethral reconstruction The Journal of Urology (J. urol.) 2000, vol. 164, no2, pp. 360-363 (42 ref.) ISSN 0022-5347.


Cohen, Stephen A., MD and W. Glenn Hurt, MD Compartment Syndrome Associated with Lithotomy Position and Intermittent Compression Stockings Obstetrics & Gynecology, 2001;97:832-833.


Johanson, Richard, Mary Newburn, and Alison Macfarlane Has the medicalisation of childbirth gone too far? British Medical Journal 2002;324:892-895, published 13 April 2002


Bachmann, Gloria, M.D. 2001 The Importance of Obtaining a Sexual History. UMDNJ Robert Wood Johnson Medical School New Brunswick, New Jersey.


Gupta JK, Hofmeyr GJ, Smyth R. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD002006. DOI: 10.1002/14651858.CD002006.pub2.


Hunter S, Hofmeyr GJ, Kulier R. Hands and knees posture in late pregnancy or labour for fetal malposition (lateral or posterior). Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD001063. DOI: 10.1002/14651858.CD001063.pub3.


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