Running head: PERINEAL TRAUMA 1

Perineal Trauma in the Third and Fourth Degree

Taylor Rackey

HLTH 1030

Instructor: Gina Gerboth, MPH, RM, CPM, IBCLC

August 22nd, 2018

PERINEAL TRAUMA 2

Perineal Trauma

During the second stage of labor during childbirth, as baby is making their descent

through the birth canal, the head will crown at the opening of the vagina. As the baby’s head

emerges, and the shoulders rotate to birth the body, the birthing person may experience some

type of perineal tearing. As stated in the article written by Thomas, MD, (2017) a perineal tear is

“a tear or injury to the skin and/or muscles between the vaginal introitus and the anal opening,”

(Thomas, 2017, p. 1). While perineal tearing during childbirth is a common occurrence, being

reported to happen in 90% of deliveries, as shared in the article by Richmond, MD (2014) the

severity of lacerations range from the first through fourth degrees (Richmond, 2014).

While a first degree perineal tear involves a laceration of the vaginal opening and

perineal skin, and a second degree tear involves the muscles, in an article by R. Goh, D. Goh,

and Ellepola (2018), third and fourth tears are more severe and are classified as perineal trauma.

R. Goh, D. Goh and Ellepolla share how third and fourth degree lacerations have a larger risk of

“resulting in ongoing symptoms that can have a significant impact on a woman’s quality of life,

“with the most common being dyspareunia, perineal pain, and flatal and faecal incontinence,”

(Goh, Goh, Ellepola, 2018, p. 3). Unlike first and most second degree tears which do not require

sutures to repair, but are more so optional to the birthing person, third and fourth degree perineal

tears involve separation of both the skin and muscles of the vagina, all the way to the anus. In a

document released by the Auckland District Health Board (2017) titled “Perineal Tears-Third

and Fourth Degree (OASIS),” the classification of third degree tears can be subdivided into 3

further categories including: 3A: a partial tear that includes the external sphincter , but involves

less than 50% of the thickness, 3B: more than 50% of the thickness involved or a complete tear
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of the external sphincter, and 3C: internal sphincter is also torn; a 4th degree tear is a 3rd degree

tear, plus the separation of the anal/rectal epithelium (“Perineal Tears-Third and Fourth Degree

(OASIS),” pg 2.)

According to the guidelines released by Fernando, Sultan, Freeman, Williams, and

Adams (2015), the reported rate of third and fourth degree perineal tears in England has risen

from 1.8% in 2000, to a staggering 5.9% in 2011 among first-time vaginal births (Fernando,

Sultan, Freeman, Williams, Adams, 2015). While the trend is said to not reflect necessarily

poor-quality of care that is being given, but that Fernando et. al, (2015) states that “it may

indicate, at least, in the short term, an improved quality of care through better detection and

reporting,” (Fernando et. al, 2015, p. 5). Before detection and reporting however, comes

prevention. Studies have shown there are various ways to reduce the risk of perineal tearing,

including that of being under care of a midwife for labor and delivery. Midwives have been

known to include the use of waterbirth, in which a baby is born while being fully immersed in

water during the transition from womb to world. In a journal article written by Nutter, Meyer,

Shaw-Battista, and Marowitz (2014) authors found an association between the decrease in third

and fourth degree tears and a promotion in having an intact perineum post-delivery (Nutter,

Meyer, Shaw-Battista, Marowitz, 2014). With the integration of midwifery in low-risk

pregnancies however, comes the rate of severe perineal tears in highly experienced midwives,

versus an inexperienced midwife. As shown in the study completed by Mizrachi, Leytes, Levy,

Hiaev, Ginath, Bar, and Kovo (2017) it was concluded that those birthing persons under the

guidance of an inexperienced midwife (>2 years experience) during delivery, using a “hands-on”

guided technique to help protect the perineum, were more likely (0.5% occurrence) to experience
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a severe perineal tear than that of an experienced midwife (<10 years experience) (0.2%

occurrence) (Mizrachi, Leytes, Levy, Hiaev, Ginath, Bar, Kovo, 2017).

Controversies around the topic of perineal trauma include that of an episiotomy, in which

a care-provider makes a surgical cut in the muscle, between the vagina and anus to provide room

for the birth of the baby’s head just before delivery. Despite numerous recommendations against

the routine use of episiotomy, this disparity is still occurring without evidence to support such

overuse. In an article released by the American College of Obstetricians and Gynecologists

(2016), it was stated that “data show that obstetric care providers can help to lower the severity

of obstetric lacerations with simple interventions including avoiding routine episiotomy”

(ACOG, 2016, p. 1). In addition, research has been shown, according to a study completed by

Doğan, Gün, Özdamar, Yılmaz., and Muhçu (2017), a vaginal delivery that included a

mediolateral episiotomy was associated with “decreased sexual functioning as well as sexual

desire, arousal and orgasm within postpartum five years” (Doğan, Gün, Özdamar, Yılmaz,

Muhçu, 2017, p.1).

While most birthing persons will experience some form of laceration during childbirth,

some cases will result in trauma of the third and fourth degree. With this degree of severity,

requiring suturing to repair, prevention put in place by care providers have been shown to

increase positive outlooks on outcomes. However, despite recommendations from the American

College of Obstetricians and Gynecologists, providers are still performing routine episiotomies

in countries around the world, causing severe obstetric perineal lacerations. This unnecessary

procedure has been proven to lack evidence, while being strongly associated with morbidities

and postpartum dysfunction..

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Perineal lacerations in the third and fourth degree are source of extreme pain for some

birthing persons after the event of childbirth. However, it is apparent that there are varying

demographics that are more susceptible to the maternal morbidity of perineal trauma than others.

Factors that can relate to and influence severe lacerations can include race, income, and age;

various populations can also influence certain demographics that are affected by severe perineal

lacerations.

Socioeconomic risks are factors that relate to and influence each other that can include

employment, education, and income. According to Cartwright, Tikkinen, and Cardozo (2009),

studies have shown that those women in the highest socioeconomic class are at a risk of more

than two times as likely to suffer from a sphincter injury than those in the lowest socioeconomic

class (Cartwright, Tikkinen, Cardozo, 2009). In addition, it is claimed by ​Caroci da Costa ​and

Riesco (2006), that socioeconomic status is a predictor of perineal trauma in a first time birthing

person (​Caroci da Costa​, Riesco, 2006). Low socioeconomic status refers to those who have to

work in order to survive. This group consists of people who do not have any money in their

savings account, they struggle to pay their bills, are employed at low wage jobs, and may also be

in debt.

Other attributing factors that are risks for severe perineal lacerations in the third and

fourth degree include certain populations that are affected. According to an article published by

the Second Australian Atlas of Healthcare Variation (2017), titled “Third and Fourth Degree

Perineal Tears,” it was found that birthing persons living in a remote area were less likely to

experience a third or fourth degree laceration than someone who lived in a major city (2.1% in a

remote area, compared to 3.2% in a major city). In relation, it was also shown that both the
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Aboriginal and Torres Strait Islander women who gave birth vaginally were reported to

experience less overall third and fourth degree perineal lacerations than that of non-indigenous

women (1.8% of the indigenous women, and 3% of the non-indigenous women)(“​Third and

Fourth Degree Perineal Tears​,” 2017). According to Stewart, Davies, Kendall, Knights,

Wilkins, East and Wallace (2013), incidences of perineal trauma among populations have been

reported, seen among women of South/South-East/East Asian descent who have a higher rate of

third and fourth degree tears and episiotomy than that of Australian born or West Asian women

(Stewart, Davies, Kendall, Knights, Wilkins, East, Wallace, 2013). Finally, evidence has shown,

according to Kettle and Tohill (2008), that the incidence between anal sphincter tearing varies

between 0.5% in the United Kingdom, while rates are as high as 7% in Canada (Kettle, Tohill,

2008).

With demographic being influenced by social and economic factors, there is evidence to

show that upper-class, more affluent groups of birthing persons are more at risk of experiencing

severe perineal lacerations. As shared by Sathiyasekaren, Palani, Iyer, Edwards, Dharmappal,

Rahi, Stanly, and Varadarajan (2007), those birthing persons who were privately insured were

twice as likely to have an episiotomy performed than a birthing person who is insurance with a

state-funded medicaid program (Sathiyasekaren, Palani, Iyer, Edwards, Dharmappal, Rahi,

Stanly, Varadarajan, 2007). In addition to race, and socioeconomic class, location is a factor that

has been found to influence perineal lacerations in the third and fourth degree, showing varying

demographics in those birthing persons delivering in a remote area, versus those delivering in a

major city; in addition to those differing risks found between indigenous birthing persons and

non-indigenous birthing persons.

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While there is no current legislature overseeing guidelines to prevent perineal trauma,

each individual care provider may have their own policies in place. Perineal trauma resulting in

third- and fourth-degree lacerations can result from spontaneous injury or may be due to an

episiotomy. Relevant techniques used to assist in preventing perineal trauma include antenatal

perineal massage, warm compress during the second stage of delivery, and hands-on method

during second stage. In a recent article written by Oakes (2017), it was shared how a

combination of evidence-based interventions were found to be helpful in the reduction of

perineal trauma cases. The cohort study of 272,161 deliveries primarily measured the incidence

rate of third-and fourth-degree perineal lacerations occurring both with and without the use of

instrumental delivery (ie. vacuum, or forceps). Developed by the Military Health System, this

sequence of interventions known by the mnemonic “SAFE PASSAGES,” was found to reduce

the ratio of obstetric perineal trauma in both military and public community hospitals.

With the main emphasis of achieving a slow and controlled delivery, SAFE PASSAGES”

is designed around ultimately minimizing unnecessary stain on the perineum, using techniques of

conditioning, positioning, and relaxation. The first intervention, referring to the “S,”

recommends that birthing persons “start” perineal massage at 36 weeks gestation. From the

Cochrane Library, Beckmann and Scott (2013) share how the implementation of perineal

massage can help to prevent trauma from occurring during childbirth. Researchers share that

antenatal perineal massage is associated with an overall reduced risk of trauma that required a

repair using sutures. In addition perineal massage was found to reduce the event of a birthing

person requiring an episiotomy (Beckmann, Scott, 2013).

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Another intervention, Oakes states (2017), being the “P” of SAFE PASSAGES,” is the

protocol for “placing” a warm compress on the perineum of the birthing person to help

encourage stretching and relaxation (Oakes, 2017). A study overseen by Essa, and Izmel (2015),

was conducted to determine the efficiency of a warm compress on the perineum during the

second-phase of labor amongst primapare persons. It was found that more than three-fifths

(62.5%) of the study group (with warm compress) had an intact perineum compared to the

control group (no warm compress), which were reported at 2.5%. Researchers found, of those

with a perineal tear, almost one-half (48%) had a third-degree laceration requiring repair,

compared to zero cases found in the study group with the use of warm compress (Essa, Izmel,

2015).

Finally, Oakes (2017) shares another intervention of the SAFE PASSAGES protocol,

with an “S” in the pneumonic referencing that the perineum should be “supported” during the

second-stage of delivery (Oakes, 2017). This support Oakes (2017) states, references using “one

hand of the delivering practitioner, forming a U-shape with the thumb and forefinger, with the

first webspace overlying the posterior fourchette” (Oakes, 2017, p. 3). It was shared in a

peer-reviewed article by Antonakon (2017), that the “hands-on” approach during crowning at the

second phase, helped to reduce obstetrical anal sphincter injuries (OASIS) by up to 23%, and

overall reduce the rates of third-and fourth-degree perineal lacerations by 71% (Antonakon,

2017). In a large study consisting of two cohorts of birthing persons, Norway’s largest hospital

was compared on OASIS before and after the implementation of a training designed for

providers to help protect the perineum. Researchers Laine, Skjeldestad, Sandvik, and Staff

(2012), found that among 31,709 deliveries, incidence rates of OASIS were reduced by 50%
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after the perineal support training, declining from 4% to 1.9% (Laine, Skjeldestad, Sandvik,

Staff, 2012).

With perineal trauma being associated with both short-term and long-term maternal

morbidity, multiple approaches are used by birthing persons to address this subject, which may

include water birth, maternal positioning, and out of hospital (OOH) birth setting such as home,

or freestanding birth center. It has been shown that the use of a midwife for maternity care has

also been claimed to reduce the rates of perineal trauma, while increasing overall rates of

maternal satisfaction of care. However, the United States medical model has lacked to see much

of a change in the overall approach of evidence-based advancements towards the reduction of

perineal trauma.

Practices used to address this topic have included water birth, which is the act of giving

birth in a large tub or specialized pool. As these types of births occurring in the water tend to be

less hands-on, and even hands-free, the question of concern has been based around whether

delivery of the newborn while immersed in water is more protective of the perineum. While there

are other pertaining factors that are involved rather than if the birth took place on land or in the

water, Nutter, Shaunette, Shaw-Battista, and Marowitz (2014) share that a waterbirth is

associated with a decreased rate of an episiotomy, in addition to severe perineal lacerations. This

review investigated the overall claim among 13 studies, finding that there were higher instances

of a waterbirth being associated with an intact perineum, compared to those births occurring on

land (Nutter, Shaunette, Shaw-Batista, Marowitz, 2014). In an examination conducted by

Menakaya, Albayati, Velia, Fenwick, and Angstetra (2012), researchers gathered in total 438

birthing persons as participants, making it the largest study on water birth occurring in an
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Australian setting. Among those who took part, 40% of those birthing persons in the water birth

group had an intact perineum, as opposed to those 31% of persons in the standard land-birthing

group. Among those who did experience a perineal laceration, it was said that 80% of the

third-and fourth-degree perineal tears that were observed were seen in the land-birthing group, at

a rate of 4:1 than was seen in the waterbirth group (Menakaya, Albayati, Velia, Fenwick,

Angstetra, 2012).

In modern obstetrics, birthing persons have been encouraged to start pushing at the time

of complete cervical dilation. Osborne and Hanson (2014) state that a majority of midwives use a

more supportive approach called delayed pushing, which includes waiting for one to express the

urge to push before initiating the action of bearing down (Osborne & Hanson, 2014). With

conflict between waiting to push, and being directed to do so, Kopas (2014) claims that the

“management of the second-stage of labor often follows tradition-based routines rather than

evidence-based practices” (Kopas, 2014, p. 1). The Royal College of Midwives (2018) shared a

study that compared the outcomes of birthing persons who were given the option to choose their

own pushing style. Researchers found more cases of perineal trauma with those who chose

directed-pushing, where the birthing person is instructed to hold their breath, and push in

increments of 10 seconds through each contraction (The Royal College of Midwives, 2018). In

addition, the American College of Obstetricians and Gynecologists, furthermore, Lemos,

Amorim, Dornelas de Andrade, Al de Souza, Sapral, and Correia (2017) share that, while

delayed pushing for those birthing persons with an epidural helps to reduce the time that one

spends pushing while giving birth, it may on the other hand, increase the duration of the second

stage of labor (Lemos, Amorim, Dornelas de Andrade, Al de Souza, Sapral, & Correia, 2017).
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The influence of birthing while lying on one's back has been referenced since King Louis

XIV who lived in the late 1600’s, as it was shared by Dundes (1988), who claimed that the man

enjoyed watching women deliver their babies lying down in a way that he could observe

(Dundes, 1988). Despite this perverted thinking, western culture still has a majority of those

birthing in this unfavorable position, DiFranco, and Curl (2014) share that studies show most

birthing persons today deliver their baby in a supine position, with a directed style of pushing

despite the vast knowledge that proves its disadvantages. Researchers show that positions such as

squatting, kneeling, or standing work better with gravity to help the baby move down into the

birthing persons pelvis (DiFranco & Curl, 2014). In addition, maternal positioning research has

seen, according to Lodge and Haith-Cooper (2016), that kneeling and all-fours positions were

found to be the most protective of an intact perineum, a position that Dekker (2012) reports to

occur in around 1-3% of all hospital births. (Haith-Cooper, 2016, Dekker, 2012). Despite this

evidence-based research, Dekker (2012) reveal that 68% of those delivering vaginally in a

United States hospital reported lying on their back to push at the second-stage of labor (Dekker,

2012). Finally, when researchers Meyvis, Van Rompaey, Gourmans, Truijen, Lambers, and

Mestageh (2012) compared maternal pushing positions, it was found that persons birthing in the

lithotomy position resulted in more cases of perineal trauma than those pushing in a lateral

position (Meyvis, Van Rompaey, Gourmans, Truijen, Lambers, and Mestageh, 2012).

In addition , researchers have found an influence on birth setting and how it may affect

the rates of perineal trauma. Lindgren, Brink, and Klingberg-Allvin (2014) share that over the

last decade, the rate of perineal trauma among those persons birthing in a hospital have

increased, while the rate is lower among those birthing at home. Midwives in the study showed
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an overall theme among a number of categories, with the overall similarities and trends being

seen around not rushing the process of birth. In addition, guidance through previous talked about

fears and expectations, helping the birthing person by listening to what they need during the

present time, and being aware of any signs or signals of stress helped midwives to prevent

perineal trauma in those out of hospital (OOH) birth clients (Lindgren, Brink, &

Klingberg-Allvin, 2014). Finally, in a study comparing birth attendants in two primarily

indigenous cities, researchers ​Jesús-García, Paredes-Solís, Valtierra-Gil, Serrano-de los Santos,

Sánchez-Gervacio, Ledogar, Andersson, and Cockcroft (2018), found that 19% of those 1,636

birthing persons experienced perineal trauma, while 36% experienced perineal trauma with an

ob/gyn or nurse present at the time of birth (Jesús-García, Paredes-Solís, Valtierra-Gil,

Serrano-de los Santos, Sánchez-Gervacio, Ledogar, Andersson, & Cockcroft, 2018).

As shown, the use of midwifery care for those low-risk clients, has been seen to lower the

rates of perineal trauma seen in birthing persons. With water birth options available in more

midwifery practices rather than in a community-hospital setting, clients have been seen to have

higher rates of having an intact perineum and an overall higher rate of satisfaction with their

birth. With standardized regulation and more monitoring, clients are no longer free-moving or

ambulatory, and many are guided through hospital protocol that more than likely includes being

on one’s back to labor, and in the lithotomy position to push. Efforts should be made, given the

evidence and ethical guidelines, Dekker (2012) states, to help train medical students and staff

alike on how to support clients in various birthing positions, as movement and positioning have

been proven to be pain management techniques (Dekker, 2012).

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As midwives strive to reduce the rates of clients who experience perineal trauma, public

health models have neglected to follow evidence-based information that helps to prevent this

disparity. As shared by Bick, Ismail, Macdonald, Tohill, and Kettle (2012), the implementation

of evidence-based guidelines could reduce the overall maternal morbidity that is associated with

perineal trauma, however, despite this evidence, a small amount of attention is paid to the

importance of how midwives practice (Bick, Ismail, Macdonald, Tohill, & Kettle, 2012). In

return, this creates barriers that are experienced in the community setting which include social,

economic, and professional factors that, at times, inhibit midwives from practicing equally

amongst community providers. However, despite these barriers, midwives continue to provide

quality-based care with interventions, or the lack thereof, that have shown success in lowering

the rates of perineal trauma.

Historically, women have acted as midwives and birth attendants for thousands of

years. However, even with this cultural tradition, there are still many barriers that restrict a

midwife from practicing equally as other community care providers. With legislative barriers in

place, the North American Registry of Midwives (NARM) (2017) outlines the provisions that

restrict Certified Professional Midwives (CPMs) from practicing entirely in 4 of the states in the

U.S. , forcing birthing persons to seek other medical providers, travel across state lines for care,

find an unregulated and unlicensed “lay or underground midwife, or may ultimately make the

decision to birth unassisted (North American Registry of Midwives, 2017). In addition,

midwives experience tremendous economic barriers, as shown by Filby, McConville, and Portela

(2106) who explain that there is a lack of adequate wages being paid to midwives, that in turn,

are failing to provide enough to cover basic living costs (Filby, McConville, & Portela, 2016).
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Researchers stated that childbirth historically, was seen to be the domain of the home and

responsibility of the woman, however women are now suffering from what is termed as “gender

penalty,” with men who are said to “assume the leadership position of the hierarchy,

subsequently earning lower wages, largely because the job of related skills are not treated as

skills, but as the qualities of being a woman” (Filby, McConville, & Portela, 2016, p. 5). Finally

midwives experience barriers in regards to providing accessible care for those low-income

birthing persons who have medicaid or state-funded insurance. Currently, according to the North

American Registry of Midwives (NARM) (2017), only 14 of the 45 Certified Professional

Midwife (CPM) legal states receive medicaid reimbursement, showing an evident lack of

accessible midwifery care for low-income families (North American Registry of Midwives,

2017).

Midwifery-led interventions that are used in efforts to reduce perineal trauma include as

much physical support as emotional support for the birthing person. In an attempt to prepare one

mentally, midwives in the study by Lindgren, Brink, and Klingber-Allvin (2011), explain that

knowing that birthing person’s wants and needs, visiting fear before labor begins, and being able

to make the environment comfortable, helped to be part of a preparatory phase that is claimed to

contribute to a lower incidence of perineal trauma in homebirth settings. With gentle guidance in

helping the client to handle pain, midwives help the client to stay present while being in contact

with their body and its signals. (Lindgren, Brink, & Klingber-Allvin, 2011). These emotional

advancements to maintain that relationship between client and provider help to preserve both

authority and autonomy through which birth carries out in a normal physiological process. Other

efforts of midwives that influence the intervention towards reducing perineal trauma rates
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include episiotomies, which was previously explored and found to contribute to high rates of

third-and fourth-degree perineal lacerations. According to the American College of Nurse

Midwives (ACNM) (2012), a study was conducted to compare 90 midwifery practices’

benchmarking data, in reference to a national survey and birth data on obstetric procedures. It

was found by researchers that those birthing persons receiving care from a midwife has an

episiotomy rate of 3.6%, compared to the national average of 25% (American College of Nurse

Midwives, (2012).

While continuing to face barriers, restriction of practicing freely from state to state,

suffering from unequal wages, and the inability to be reimbursed for medicaid clients, midwives

still strive to provide the public with accessible care that includes health interventions to reduce

the rates of perineal trauma. With close contact relationships, longer prenatal visits, and a more

personalized experience, providers are able to engage with their clients, helping to alleviate fears,

focus on the wants and needs of the birthing persons during labor, and provide a comfortable

environment that promotes an intact perineum. Midwives will continuously work towards

progressively expanding the legalization of licensure in all states and fight towards medicaid

reimbursement and equality amongst all community care providers.

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References

American College of Nurse-Midwives. (2012, April). Midwifery: Evidence-Based Practice.

Retrieved August 12, 2018, from

http://www.midwife.org/acnm/files/cclibraryfiles/filename/000000002128/midwifery

evidence-based practice issue brief finalmay 2012.pdf

American College of Obstetricians and Gynecologists. (2016, June 22). Ob-Gyns Can Prevent

and Manage Obstetric Lacerations During Vaginal Delivery, Says New ACOG

Practice Bulletin. Retrieved June 21, 2018, from

https://www.acog.org/About-ACOG/News-Room/News-Releases/2016/Ob-Gyns-Can

-Prevent-and-Manage-Obstetric-Lacerations

Antonakou, A. (2017). Hands-on or hands-off the perineum at childbirth: A re-appraisal of the

available evidence. ​European Journal of Midwifery,1(​ October), 1-3.

doi:10.18332/ejm/78588

Auckland District Health Board. (2017, November 17). Perineal Tears - Third and Fourth Degree

(OASIS). Retrieved June 22, 2018, from

http://nationalwomenshealth.adhb.govt.nz/Portals/0/Documents/Policies/Perineal

Tears - Third and Fourth Degree (OASIS)_.pdf

Beckmann, M., & Scott, O. (2013). Antenatal perineal massage for reducing perineal trauma.

Cochrane Database of Systematic Reviews.​ doi:10.1002/14651858.CD005123.pub3

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Bick, D. E., Ismail, K. M., Macdonald, S., Thomas, P., Tohill, S., & Kettle, C. (2012). How good

are we at implementing evidence to support the management of birth related perineal

trauma? A UK wide survey of midwifery practice. ​BMC Pregnancy and Childbirth,12(​ 1).

doi:10.1186/1471-2393-12-57

Caroci da Costa, A., & Riesco, M. (2006). A Comparison of “Hands Off” Versus “Hands

On” Techniques for Decreasing Perineal Lacerations During Birth. Journal of Midwifery

Womens Health, 51(2), 106-111. doi:10.1016/j.jmwh.2005.10.017

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DiFranco, J. T., & Curl, M. (2014). Healthy Birth Practice #5: Avoid Giving Birth on Your Back

and Follow Your Body’s Urge to Push. ​The Journal of Perinatal Education,​ ​23(​ 4),

207–210. ​http://doi.org/10.1891/1058-1243.23.4.207

Doğan, B., Gün, I., Özdamar, O., Yılmaz, A., & Muhçu, M. (2016). Long-term impacts of

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perineal pain. ​The Journal of Maternal-Fetal & Neonatal Medicine,30(​ 4), 457-460.

doi:10.1080/14767058.2016.1174998
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Dundes, L. (1988). The Evolution of Maternal Birthing Position. ​Obstetrical & Gynecological

Survey,43(​ 1), 47-48. doi:10.1097/00006254-198843010-00013

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