Recommended Position for Imminent Delivery with Severe Obesity
The patient should be placed in a supine position with the option to rapidly perform the McRoberts maneuver (legs hyperflexed tightly to abdomen), as this presentation indicates imminent vaginal delivery requiring a position that facilitates both delivery and potential management of shoulder dystocia. 1
Clinical Context and Positioning Rationale
This patient is in active labor with imminent delivery, evidenced by the fetal head bulging at the perineum between contractions. The clinical scenario describes normal labor progression, not a complication requiring emergency repositioning.
Primary Position Recommendation
Outside specialized maternity structures, guidelines recommend keeping the option open to rapidly place the patient in a supine position compatible with the McRoberts maneuver, which involves hyperflexing the mother's legs tightly to her abdomen with the possibility of lowering the fetal head in the umbilical-coccygian axis. 1
No single childbirth position is demonstrably superior to another, so caregivers should select the position in which both they and the patient will be most at ease to achieve delivery, in coordination with the patient. 1
Special Considerations for Severe Obesity
In severely obese patients, the supine head-up position may be preferable over the left lateral head-down position due to practical difficulties including difficulty turning heavier women, poor facemask seal, and unfamiliarity with lateral positioning. 1
Maternal positioning in left lateral decubitus or left pelvic tilt with lateral uterine displacement is essential after 20 weeks gestation to prevent aortocaval compression and maintain placental perfusion, but this applies primarily to procedures and situations where the patient is not actively delivering. 2
Why Other Positions Are Not Indicated
Knee-chest position (Option B) is used for breech presentation management, not for cephalic presentation with imminent delivery. Research demonstrates that knee-chest postural management does not effectively reduce breech presentation at term. 3
Trendelenburg position (Option D) is not indicated for normal labor and delivery, and would be contraindicated as it could worsen aortocaval compression in late pregnancy.
Fowler's position (Option A) while not contraindicated, is not the standard recommendation for imminent delivery requiring potential shoulder dystocia management.
Preparation for Shoulder Dystocia
In the event of proven shoulder dystocia, the McRoberts maneuver is recommended as first-line intervention, whether associated or not with suprapubic pressure, making the supine position optimal for rapid implementation. 1
The supine position allows for immediate transition to McRoberts maneuver if shoulder dystocia occurs, which is particularly important given the patient's severe obesity and associated increased risk of delivery complications. 1
Common Pitfalls
Failure to position obese patients appropriately can lead to difficulty with delivery mechanics and inability to rapidly implement emergency maneuvers like McRoberts if shoulder dystocia occurs. 1
Attempting lateral positioning in severely obese patients during active delivery creates practical challenges including difficulty turning, poor positioning for delivery assistance, and unfamiliarity for providers. 1