PUERPERAL WOMEN ’ S PERCEPTIONS ON VERTICAL AND HORIZONTAL DELIVERIES

This qualitative study aims to better understand the perceptions of puerperal women regarding their experiences in vertical and horizontal deliveries and identify positive and negative aspects of each position. Semi-structured interviews were carried out with ten puerperal women hospitalized in the rooming-in unit of a teaching hospital. After thematic analysis – Collective Subject Discourse – positive aspects of the vertical position emerged, namely: greater comfort, freedom of movement, reduction of the expulsive effort, favors women’s participation. Negative aspects were listed as discomfort and lack of obstetric intervention. Positive aspects of the horizontal position were reported as quickness, feelings of security and of being helped. Negative aspects were related to discomfort and difficulty in exerting strength. Positive aspects of the vertical position and negative aspects of the horizontal position stood out more intensely and frequently, and are in accordance with scientific evidence.

This qualitative study aims to better understand the perceptions of puerperal women regarding their experiences in vertical and horizontal deliveries and identify positive and negative aspects of each position.Semi-structured interviews were carried out with ten puerperal women hospitalized in the rooming-in unit of a teaching hospital.
After thematic analysis -Collective Subject Discourse -positive aspects of the vertical position emerged, namely: greater comfort, freedom of movement, reduction of the expulsive effort, favors women's participation.
Negative aspects were listed as discomfort and lack of obstetric intervention.Positive aspects of the horizontal position were reported as quickness, feelings of security and of being helped.Negative aspects were related to discomfort and difficulty in exerting strength.Positive aspects of the vertical position and negative aspects of the horizontal position stood out more intensely and frequently, and are in accordance with scientific evidence.

INTRODUCTION
In most civilizations, childbirth has been performed with the woman in the vertical position.From the 16 th century onwards, the lying position was adopted, putting women in an anti-physiological position, which contributed to the use of unnecessary technology (1) .
After the medicalization of childbirth, the gynecological position during the expulsive period started to be considered the most adequate to perform healthcare procedures and was adopted as a classical position during childbirth.As in other obstetrical interventions, this position was indiscriminately adopted without properly evaluating its effectiveness and safety (2)(3)(4) .
Currently, the World Health Organization (WHO) recommends, based on scientific evidence, that parturients are not put in the gynecological position during labor and delivery because it is considered harmful and ineffective.However, every woman should be free to choose her position (5) .
Recent evidence shows that the vertical or lateral position, when compared to the horizontal position (supine or gynecological), reduces the duration of the expulsive period, complaints of severe pain, number of C-sections, the need for episiotomy, and alterations in fetal heartbeat.However, the use of this position is related to the increasing number of second-degree perineal laceration cases and blood loss of more than 500 ml.
Considering the risks and benefits of different positions, women should be allowed to make informed decisions on which position to adopt during delivery (6) .
In general, maternities in Brazil still recommend the horizontal position during delivery and do not allow women to choose (7) , although some maternities started to attend deliveries in the vertical or lateral position, based on WHO recommendations for childbirth care (8-9)   .
The implementation of non-supine positions in the expulsive period has been one of the evidencebased practices, which is part of the transition from the care model focused on technology to one focused on physiology (9) .However, it is necessary to verify how women have experienced this change in childbirth position so as to evaluate whether women consider this practice favorable.
Thus, this study aimed to discover how puerperal women perceive childbirth in the vertical and horizontal positions, identifying positive and negative aspects of each position during the childbirth experience.The concept of vertical position in this study refers to childbirth attended on an obstetric table without leg holders, which allows the parturient to squat at the moment of expulsion.This practice was gradually incorporated by the entire health team at the HU/UFSC maternity, according to women's choice.In the horizontal position, also described as gynecological or supine position, the parturient is put in gynecological position with ankles support.In international literature, the vertical position is classified as non-supine and the horizontal one as supine (6,11)   .Interviewed women were between 20 and 37 years old, four were married and six were in stable unions, nine were white and one was black.With regard to schooling, four had complete primary school and two had incomplete primary school; three did not complete secondary school and one was attending college.Six women had paid work, three were housewives and one was a student.Regarding parity and participation in educative activities during the prenatal period, six were secundipara (G 2 P 2 ) and four were multipara (G 4 P 4 -two; G 5 P 4 -one; G 5 P 3 -one); three had not participated in any lecture for pregnant women, six participated in between one and three and one in eight lectures.

RESULTS AND DISCUSSION
Of the ten interviewed puerperal women, eight were accompanied by their husband in their last delivery; one was accompanied by her sister and only one had no companion.All gave birth in the vertical position in the last delivery and the one before was in the horizontal position.All newborns from their last delivery were full-term with no clinical intercurrence that indicated hospitalization in the neonatal intensive therapy unit.

Positive aspects regarding vertical and horizontal positions during delivery
Central ideas that emerged from interviews with puerperal women expressing positive aspects of deliveries in vertical and horizontal positions are presented in Table 1.Of the 20 clinical randomized trials analyzed in a systematic review on positions in the second stage of labor, nine appointed reduced duration of this stage when the parturient assumes non-supine position (lateral or vertical) compared to supine or gynecological position (6) .CSD 1's testimony exemplifies how women perceive reduction of the expulsive period, which improves their experience.
Pelvic dimensions are significantly expanded in vertical positions and increased efficiency of uterine contractions also occur because the aorta artery and vena cava are not occluded, which favors labor and delivery.It also favors the parturient's perception on the gradient of increasing uterine contractions and increased pressure on the perineum (1) .
On the contrary, according to the CSD of the CI 7, the feeling that the delivery is faster is associated to medical interventions, especially the episiotomy.In a study on the perception of women regarding episiotomy, the majority of them reported its need so as to have the labor channel expanded to avoid risks to the baby, since the vagina cannot extend itself (12) .
Episiotomy is a surgical procedure generally performed during childbirth in Latin America, while its use is reduced in European countries (13) .Brazil presents high rates of episiotomy, which is performed in approximately 94.2% of normal deliveries (2) .It contributes to the "naturalization" of the procedure because it makes some women consider this medical intervention, oftentimes unnecessary and routinely (5)   used, as something positive that helps to end the delivery faster.There is a diminished feeling of intense pain during the expulsive period in the vertical or lateral position when compared to the supine or gynecological position (6) .The perception that the vertical position contributes to exert strength and expel the fetus due to gravity was also described in another qualitative study.However, in this case, professionals considered the parturient was being rebellious because she insisted on being kept in this position and confined her to the delivery table (14) .
CI 4 -The parturient manages to participate more and watches the birth of her child in the vertical position The vertical childbirth favors the parturient's participation, eases the observation of conducts performed and visualization of the birth, which are factors emotionally important to enable a positive experience in labor.The satisfaction with the delivery can be increased if women have the option to choose the position of delivery (11) .However, CI 8 reports that the health professional's active work during the attended birth is positive when women expect them "to help" and transfer responsibility to Support from a companion can influence the woman's perception of the delivery regardless of the adopted position.Results from a clinical trial show that women who are supported by a companion of their choice during labor get more satisfied with the medical care and orientation received, which indicates positive change in the way health professionals deliver care (15) .The women observed the difference between postpartum with (horizontal delivery) and without perineal suture (vertical delivery), associating integral perineum with faster recovery.Rates of intact perineum are higher among women who adopt nonsupine positions (sitting, kneeling, squatting) during delivery than those who adopt the supine position (11)   .
Lateral or vertical positions are associated to a reduced number of episiotomies (6) .Thus, vertical position during delivery is one of the strategies to reduce perineal trauma, swelling of the vulva and episiotomy (11,6) .
Negative aspects of the vertical and horizontal positions during delivery The negative aspects of the horizontal position were more intensely reported by puerperal women when compared to reports on the vertical position (Table 2).1).This fact shows the veracity of what puerperal women reported from their experience.The factors that influenced the position adopted by women during labor are innumerous and complex and it is difficult to identify the instinctive conduct women would adopt because this is strongly influenced by cultural standards recommended by care permeated by medical procedures (6) .Perhaps modern western women do not have the muscles required to stay in other positions like squatting, kneeling or in knee-chest position for long periods (4) .
The squatting position supported by a stool or a cushion can be attractive to women during delivery (6) .
It is important to highlight that the squatting position is not always addressed in educative activities during prenatal care.Moreover, not all of them participated in this practice as observed in this study.
The reduction of obstetrical interventions, especially episiotomy, associated to a more passive posture of the professional who attends the labor, generates the feeling of not being "helped" in these women (CI 2).This perception might be due to the interventionist practice in which the professional is the protagonist and women play a passive role, a practice that has become culturally accepted.This finding is supported by research in which none of the women interviewed expected natural childbirth without intervention.The author stresses that women know traditional hospital routines due to their previous childbirth experience and that they already know what to expect from care and do not know alternatives to the care offered by the biomedical model (16)   .In contemporaneous practice, the supine position has always been associated to the convenience and visibility of professionals who take This is an exploratory qualitative study, carried out with puerperal women attended in the teaching hospital at the Federal University of Santa Catarina (HU/ UFSC).Ten women who gave birth in vertical and horizontal positions were interviewed in the rooming-in unit upon their hospital discharge from November 2006 to February 2007.A semi-structured interview with a thematic script was used and recorded.The number of puerperal women was established during data collection by information saturation, that is, when information became repeated.Recorded interviews were fully transcribed, checked and corrected by listening to the recordings a second time.To organize data originated from interviews, Ethnograph version 5.0 software was used.Through thematic content analysis, central ideas and key expressions were identified, based on which the Collective Subjective Discourse was constructed.It consisted of a synthesis, in the first person singular, of key-expressions, which corresponded to each Central Idea.This methodological proposal for the organization and tabulation of qualitative data is based on the assumption that collective thinking can be seen as a set of discourses on a given topic (10) .The Research Ethics Committee at the Federal University of Santa Catarina approved the research protocol (No. 276/06).Participants were informed on the objectives and the research development and agreed to participate through a written free and informed consent term.Ethical aspects are in accordance with Resolution 196/96.

CI 7 -
The delivery is faster in the horizontal position due to the episiotomy.I think the horizontal position is better because when I was there with nine of dilatation I simply went to the delivery room and they already made that little cut.Then, on the first or second try the baby got out.In the squatting position, you try once, twice, thrice and then there's a time you have no strength anymore and […] oh! they let it tear (CSD 7).

CI 3 -
Strength is better directed in the vertical position, which reduces effort The position helps us to exert strength, it's much easier […] you manage to direct your strength to your legs.I'm not very agile in crouching down and getting up […]so I thought I'd have cramps, but I had no problem at all, I felt more comfortable.It's better even for you to exert your strength because, in the other (horizontal position), you have no way to support your feet, your legs are dropped down.In this one (vertical position) you support your feet and it seems everything works faster.The squatting has several advantages: it's the position, the gravity, it's less painful, […] the labor is very painful, but at the moment of expulsion it was easier, so I see advantages in squatting (CSD 3).

8 -
The horizontal position generates security and feeling of being "helped" I think that lying down you feel safer, it seems the professional helps you more.In the horizontal position I had a companion and in this one I had nobody [...] I didn't have a companion and felt really alone.So, I felt safer when people were there accompanying me because even when I had to exert strength they helped me more and, in the squatting position, they'd only say: strength and you can do it, you can do it, and I did (DCS 8).

CI 5 -
Postpartum recovery is faster in the vertical position It seems I recovered faster, because they didn't cut anything, there was only an internal stitch.I had almost ten stitches in the first (horizontal delivery), almost ten stitches in the second and third and in this one (vertical delivery) I did not have a single one.And it seems it was so fast I didn't suffer so much (CSD 5).
They were emphatic and systematically argued what was perceived as positive in one position and what was negative in the other.We consider it was due the characteristics of the women who were chosen to participate in the study, that is, they gave birth in both positions, which allowed them to compare their experiences.The same comparison occurred with negative aspects of the horizontal position (CI 3, 4, 5 and 6, Table2) since they correspond to aspects appointed as positive of the vertical position and were inversely experienced in this position.

IC 1 -
Dissatisfaction associated to discomfort in vertical positionI felt dissatisfied in the squatting position, I felt really uncomfortable.I guess it can be better, but you have to be trained during pregnancy […] Then it can be better, because […]you have to know what to expect.I got like, my leg got numb because I didn't know how to get in a good position (CSD 1).

CI 4 -
Horizontal position makes it difficult for women to communicate with the professional who performs the delivery [ ] ....when you're lying down you see virtually nothing... you raise your legs and that's a barrier between you and the physician...you know...in the squatting position you're on top and see everything and I didn't even get embarrassed (CSD 4).

Table 1 -
Puerperal women's central ideas on positive On the one from my first daughter I didn't see anything, they took her from there, took her to the doctors' procedures, then they brought me the girl.And there (vertical position) you can see everything.So I think that for the mother it's more thrilling, you see when they cut the cord […] I could see everything, so I liked it very much (CSD 4).
Listen!I think that, in this (vertical delivery) we participate more[…]the nurse only helped me when the child was coming out, pulling the little head from one side to the other.I did this myself[…]you see everything, you see the child.

Table 2 -
Central ideas on the negative aspects of the vertical and horizontal positions during delivery.