Who decides the position for birth? A follow-up study of a randomised controlled trial

Women's experience of adopting lateral positions during the second stage of labour compared with conventional lithotomy positions: A cross-sectional study

AIMS

Maternal positions during childbirth play an important role in safe vaginal births and might also influence women's childbirth experiences greatly. Lateral positions, as a potential position to reduce negative maternal and neonatal outcomes, have become popular in recent years, especially in China where the adoption of conventional lithotomy positions is still common. However, the childbirth experience of those who gave birth in lateral positions has been rarely studied. This study aimed to describe and compare women's childbirth experiences of adopting the newly introduced lateral positions and the conventional lithotomy positions during the second stage of labour.

STUDY DESIGN

A cross-sectional study was conducted in two tertiary hospitals in China involving a total of 658 primiparous and parous women who adopted lateral and lithotomy positions during the second stage of labour from July to November 2020. Sociodemographic characteristics, maternal and neonatal outcomes as well as childbirth experience assessed by the Childbirth Experience Questionnaire (CEQ) were collected. This study followed the STROBE guidelines.

RESULTS

Women who once adopted lateral positions during the second stage of labour had better positive childbirth experiences compared with those in the lithotomy positions group, as demonstrated by their overall higher CEQ scores. Women in the lateral position group also reported better participation and perceived safety, and a greater sense of control during childbirth. Lateral positions remained an influential factor in CEQ scores after controlling for potential confounders. In this study, adverse maternal and neonatal outcomes were rare. Women in lateral positions had comparatively better perineal outcomes.

CONCLUSION

This study described and compared women's childbirth experiences of adopting conventional lithotomy positions and lateral positions during the second stage of labour using a valid instrument. Women who adopted lateral positions during the second stage of labour reported better childbirth experiences than those giving birth in the conventional lithotomy positions. Thus, assisting women in giving birth in lateral positions might be a promising way to improve women's childbirth experience.

Women's experiences with planned singleton upright breech birth - A phenomenological study

OBJECTIVE

To explore the experience of primi- and multiparous women with planned singleton upright breech births.

METHOD

We conducted face-to-face, in-depth interviews with five primiparous and five multiparous women who underwent a physiological breech birth at one hospital in Norway and analyzed the data using Giorgi's descriptive phenomenological method.

RESULTS

The phenomenon of women's experiences with physiological breech birth yielded four main constituents: "Mental preparedness and control", "The importance of shared decision-making and sufficient information", "Trust and the many 'faces' of birthing staff", and "'I actually did it!': Coping and control in the upright breech position". The significance of readiness, the influence of previous experiences and information, and the establishment of trust in midwives and gynecologists emerge as dominant themes. The sense of co-determination, control, and mastery is also highlighted.

CONCLUSIONS

Our findings underscore the pivotal role of personal attributes in fostering mental preparedness when confronted with unforeseen aspects of childbirth. Notably, women's experiences with upright breech birth vary; while some perceive it as an ideal birth, others find it more challenging. Factors such as unpreparedness, lack of information, diminished co-determination, and loss of control negatively impact birth experiences. This study's findings underscore the significance of tailoring maternity care to individual needs and improving information sharing. These measures are paramount for optimizing women's experience during upright breech births.

Fostering childbirth education on upright positions and mobility during labor in nulliparous women

BACKGROUND

Upright labor positions and movement during labor have a positive effect on childbirth, yet the predominant labor positions are still horizontal. Therefore, it is important to explore how it is possible to improve childbirth education, particularly its instructional design, to strengthen women's self-efficacy toward the use of upright positions and mobility during labor. The aim of the study was to evaluate the impact of an instructional approach based on a cognitive engagement ICAP (Interactive, Constructive, Active, Passive) framework on the development of knowledge, attitudes, and self-efficacy expectations toward upright positions and mobility during labor.

METHODS

A prospective quasi-experimental study was conducted among nulliparous women from the ultra-orthodox Jewish community (n = 74). While the control group (n = 34) participated in routine childbirth education, the intervention group (n = 36) learned with childbirth education that included interactive and constructive cognitive engagement activities. Participants in both groups completed a set of questionnaires regarding knowledge, attitudes, and self-efficacy.

RESULTS

The post-test analysis revealed that women in the intervention group compared to the control group gained significantly higher knowledge scores (p < 0.05), more positive attitudes (p < 0.001), and stronger self-efficacy expectations toward upright positions and mobility during labor (p < 0.01).

CONCLUSIONS

The findings suggest that by fostering women's cognitive engagement levels during childbirth education toward the interactive and constructive modes of the ICAP framework, women's self-efficacy to move during labor and to use upright positions can be induced. These results can serve as a foundation to improve the overall effectiveness of childbirth instruction.

TRIAL REGISTRATION

The study was registered retrospectively.

Barriers and facilitators of implementing the practice programme for upright positions in the second stage of labour: A mixed-method study

OBJECTIVE

To explore the possible barriers and facilitators to implementing the Upright Positions in the Second Stage of Labour (UPSSL) programme in Chinese healthcare settings.

DESIGN

A mixed-method convergent design with the guidance of Consolidated Framework for Implementation Research (CFIR).

METHODS

An online survey study and semi-structured interviews were conducted between March and May 2023. Healthcare professionals were recruited from four hospitals in Shijiazhuang, China. One hundred and thirty-one participants completed the survey study, and 23 of them were interviewed individually. Descriptive statistics evaluated the possible barriers and facilitators of implementing the UPSSL programme within the CFIR framework quantitatively. Guided by the CFIR framework, qualitative data were analysed using directed content analysis to summarize healthcare professionals' perspectives on barriers and facilitators of the UPSSL programme.

RESULTS

Multiple intersectional barriers and facilitators were identified from the survey and semi-interviews. Healthcare professionals believed that the UPSSL programme has a scientific evidence base, systematic contents, and possible benefits for women. However, various barriers existed at individual, system, and organizational levels. Major barriers included healthcare professionals and women's safety concerns towards the use of upright positions during childbirth, the healthcare professionals' unfamiliarity with assisting an upright position birth, poor adaptability of the programme protocol, inadequate facilities and staffing, and a lack of readiness to change in the clinical setting.

CONCLUSIONS

To facilitate the implementation of the UPSSL programme in China, tailored antenatal education on upright positions, especially addressing safety-related issues, should be provided to pregnant women, their families, or peers to enhance their understanding of and familiarity with such positions. Healthcare professionals should also be offered adequate training opportunities and necessary facilities. Furthermore, national-level policy changes might be required to address midwifery workforce shortages. Additionally, further research is warranted to select, adapt, and test effective implementation strategies for programme adoption.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

What problem did the study address? The adoption of upright positions during the second stage of labour could promote better maternal and neonatal outcomes and a positive childbirth experience. However, the adoption of upright positions during the second stage of labour is suboptimal in healthcare settings in China. Barriers and facilitators of implementing upright positions during childbirth are unclear. What were the main findings? A range of barriers and facilitators within the CFIR framework to promote upright positions during childbirth from healthcare professionals' perspectives were identified, and the major barriers included safety concerns towards and unfamiliarity with an upright position birth, inadequate facilities and staffing, and a lack of readiness to change in the clinical setting. Where and on whom will the research have an impact? This study will enable a better understanding of the barriers and facilitators to promoting upright positions in the second stage of labour in China. The smooth and effective implementation of the UPSSL programme could help to promote better maternal and neonatal outcomes and improve women's childbirth experiences.

REPORTING METHOD

The reporting of this study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) and Good Reporting of A Mixed Methods Study (GRAMMS) guidelines.

PATIENT OR PUBLIC CONTRIBUTION

In this study, healthcare professionals were involved in refining the topic guides and survey questions. Additionally, findings from the interviews were returned to them for comments and corrections.

Implementation of the Practice Programme for Upright Positions in the Second Stage of Labour and the birth experience of Chinese women: A qualitative study

OBJECTIVE

Upright positions in the second stage of labour are recommended by many international organizations. However, they have not been widely used worldwide, especially in China. One of the important factors is the absence of a practice programme based on the best available evidence. We thus developed a Practice Programme for Upright Positions in the Second Stage of Labour following the UK Medical Research Council framework. Under the guidance of the programme, whether the use of upright positions can improve the maternal birth experience is a question of great concern. This study aimed to explore the birth experience of Chinese women who adopted upright positions in the second stage of labour.

DESIGN

This qualitative descriptive study was conducted as part of an implementation study that developed an evidence-based intervention and used strategies to integrate the evidence-based intervention into routine obstetric clinical practice.

SETTING

The maternity department of a tertiary comprehensive hospital in Hebei Province, China.

PARTICIPANTS

Semi-structured interviews with twelve eligible women who adopted upright positions in the second stage of labour were conducted between March and April 2022. Qualitative data were analyzed by using conventional content analysis.

FINDINGS

The average age of included women was 26.5 ± 3.5 years, and ten of them were primiparous women. Eight women adopted epidural analgesia during labour to relieve labour pain. All women gave birth in at least one type of upright position in the passive second stage of labour and adopted the semi-recumbent position in the active second stage of labour. Through conventional content analysis, we found that the use of upright positions in the second stage of labour could possibly promote an overall positive birth experience. Women giving birth in upright positions generally perceived they were more involved in their birthing process, and had greater physical and mental capacity to cope with childbirth.

KEY CONCLUSIONS

Women have a positive birth experience when using upright positions in the second stage of labour.

IMPLICATIONS FOR PRACTICE

This study suggests upright positions could improve women's birth experience and have the potential to be widely applied in clinical practice.

[Care in a natural birth center and due compliance with national guidelines]

The scope of this article is to analyze the compliance of the care offered by Casa de Parto David Capistrano Filho-RJ with the recommendations of the National Guidelines for Care in Natural Childbirth. It involved a descriptive cross-sectional study with 952 observations, from 2014 to 2018. This included analysis of compliance using a judgment matrix and then classified as total compliance (≥75.0%), partial compliance (50.0%-74.9%), incipient compliance (49.9%-25.0%) and non-compliance (less than 24.9%). The results of the judgment matrix show that care in the aspects of labor, delivery and newborn care is in full compliance with the recommendations of the Guidelines. The care at the Casa de Parto Birth Center, conducted by obstetric nurses, follows the recommendations of the national guidelines, and has been seen to incorporate a de-medicalized, personalized form of care, which respects the physiology of childbirth. They also develop a model of their own technologies of care, constituting non-invasive technologies of obstetric nursing care.

AMBAR: A midwifery-led training program to improve obstetric and neonatal practices among low-risk births in Mexico

BACKGROUND

Birth care in Mexican health institutions is highly medicalized and of poor quality because of the prevalence of outdated and dangerous practices. AMBAR-a training program for health care providers on the use of evidence-based midwifery practices-was implemented during 2016-2018 and evaluated to assess the impact of training on key practices.

METHODS

For this mixed-methods study, we evaluated the effects of a training program implemented in three public hospital networks in Mexico. Qualitative data were collected and integrated into the program before evaluating the effects of the intervention on 10 birth practices, 5 beneficial and 5 potentially harmful. Quantitative data on birth practices and covariates were collected at six time points (baseline and 5 follow-ups) in a final sample of 330 direct observations. Effect estimates were obtained by longitudinal logistic and Poisson regression models, adjusted for confounding variables.

RESULTS

AMBAR had a significant effect on 4 of the 10 birth practices that were evaluated. Beneficial practices, such as skin-to-skin contact (P = 0.003) and delayed cord clamping (P = 0.039), increased significantly. Harmful when overused birth practices, such as vaginal examinations (P = 0.001), and cesarean birth (P < 0.001) decreased significantly.

CONCLUSIONS

Midwifery-based training programs for health care providers can have an impact on the quality of care of birthing people and newborns, increasing the use of evidence-based practices and decreasing frequently overused practices.

Barriers and facilitators to the implementation of a practice programme for upright positions in the second stage of labour in China: A qualitative study

OBJECTIVE

Upright positions in the second stage of labour are recommended by many labour and birth guidelines, but they have not been widely used in China and the implementation varies greatly. Given this, we developed a Practice Programme for Upright Positions in the Second Stage of Labour (UPSSL Programme). Whether the UPSSL Programme can be translated into action in the local context is a crucial issue that needs to be further explored. This study aimed to explore barriers and facilitators to the implementation of the UPSSL Programme in the Chinese context to facilitate the integration of evidence and routine clinical practice.

DESIGN

A descriptive qualitative design was adopted.

SETTING

The study was conducted in the maternity unit of a tertiary general hospital in China.

PARTICIPANTS

A purposeful sampling was used to recruit midwives, obstetricians and their leaders. Data were collected through semi-structured face-to-face interviews. The Consolidated Framework for Implementation Research was used to guide the development of interview guide and the analysis of qualitative data. The study was reported following the Standards for Reporting Qualitative Research.

FINDINGS

Twelve eligible participants were interviewed, including eight midwives, two obstetricians, the head nurse of the delivery room, and the head of the maternity unit. Eight barriers and 10 facilitators were identified by using the directed content analysis. The barriers to implementing the UPSSL Programme were professionals' concerns about the potential risks of the programme (relative advantage), higher complexity (complexity), placement method of upright positions presented without pictures (design quality & packaging), staff shortage (cost), limited understanding of parturients' needs (patient needs & resources), lack of a training protocol for professionals (available resources), professionals' limited knowledge and skills in the programme (knowledge & beliefs about the intervention), and lack of confidence in the successful implementation of the programme (self-efficacy).

KEY CONCLUSIONS

Participants expressed several barriers and facilitators to implementing the UPSSL Programme in clinical practice in the Chinese context.

IMPLICATIONS FOR PRACTICE

The findings provide a reference for the development of targeted implementation strategies that could promote the integration of evidence and routine clinical practice, and thus facilitate the normative application and promotion of upright positions in China.

Perceptions of women and partners on labor and birth positions: A meta-synthesis

BACKGROUND

The risks and benefits of different birthing positions are commonly studied, but both paternal and maternal preferences and experiences of different birth positions are not examined. Therefore, this systematic review aims to explore the perceptions of women and their partners on birthing positions during the first and second stage of labor, so that maternity health care practitioners can provide better quality patient-centered care.

METHODS

Six databases were searched from each database's inception through November 2020. Qualitative or mixed-methods studies exploring perceptions of women and/or their partners on birthing positions were included in the review. Key information and findings of the studies were extracted; qualitative data were meta-summarized, then meta-synthesized using thematic analysis.

RESULTS

Seven studies were included, and four themes emerged: (a) Influences on choice and preference; (b) mixed experiences from "pain" to "more in control"; (c) impact on postpartum health; and (d) ways to empower couples in their choice.

CONCLUSIONS

Women's preferences for birthing positions were influenced by a myriad of personal and socio-cultural beliefs and traditions. Findings suggest a need for health care practitioners to build better rapport and provide more culturally relevant informational support to both women and their birthing partners, so they are better able to make informed decisions on their preferred birthing position.

Chinese midwives' perceptions on upright positions during the second stage of labour: A qualitative study

OBJECTIVE

Upright positions are recommended by many international organizations due to their positive effects on improving birth outcomes. The effects can only be achieved when upright positions are properly adopted by women under the guidance of midwives. However, whether midwives in China have a clear understanding of upright positions during the second stage of labour is an issue that has not been explored. The aim of this study was to explore midwives' perceptions on assisting women in upright positions during the second stage of labour in the context of China.

DESIGN

A qualitative descriptive design was adopted. We analysed the data using the conventional content analysis and reported the study in line with the COREQ checklist.

SETTING

The study was conducted at the labour wards of two maternity hospitals and two general hospitals in China where the adoption of upright positions was encouraged during the second stage of labour.

PARTICIPANTS

Semi-structured individual interviews with 17 midwives were conducted between May and July 2020.

FINDINGS

Three main themes were identified: (1) safety and availability; (2) unclear method of implementation; (3) lack of knowledge of the potential risks and precautions. Midwives' perceptions were based primarily on clinical experience rather than evidence-based practice. Their perceptions on the indications and contraindications of upright positions were divergent and ambiguous. Midwives' suggested that the indications and contraindications should be adjusted in the context of China. Time limit for keeping an upright position and maternal pushing during uterine contractions were two questions that still confused midwives. Midwives lacked knowledge of the potential risks of upright positions and rarely systematically summarized the precautions.

KEY CONCLUSIONS

This study shows that assisting women to give birth in upright positions during the second stage of labour can be a challenge for midwives in China, and also highlights the need for clarifying the detailed implementation methods of upright positions in the context of China by evidence-based approaches.

IMPLICATIONS FOR PRACTICE

An evidence-based protocol for implementing upright positions during the second stage of labour should be developed to guide midwives' practice and facilitate the successful use of upright positions in China.

Why do women assume a supine position when giving birth? The perceptions and experiences of postnatal mothers and nurse-midwives in Tanzania

BACKGROUND

Before the advent of Western medicine in Tanzania, women gave birth in an upright position either by sitting, squatting or kneeling. Birthing women would hold ropes or trees as a way of gaining strength and stability in order to push the baby with sufficient force. Despite the evidence supporting the upright position as beneficial to the woman and her unborn child, healthcare facilities consistently promote the use of the supine position. The purpose of this study was to explore the perceptions and experiences of mothers and nurse-midwives regarding the use of the supine position during labour and delivery.

METHODS

We used a descriptive qualitative design. We conducted seven semi-structured interviews with nurse-midwives and two focus group discussions with postnatal mothers who were purposively recruited for the study. Qualitative content analysis guided the analysis.

RESULTS

Four themes emerged from mothers' and midwives' description of their experiences and perceptions of using supine position during childbirth. These were: women adopted the supine position as instructed by midwives; women experience of using alternative birthing positions; midwives commonly decide birthing positions for labouring women and supine position is the best-known birthing position.

CONCLUSION

Women use the supine position during childbirth because they are instructed to do so by the nurse-midwives. Nurse-midwives believe that the supine position is the universally known and practised birthing position, and prefer it because it provides flexibility for them to continuously monitor the progress of labour and assist delivery most efficiently. Mothers in this study had no other choice than to labour and deliver their babies in the supine position as instructed because they trusted midwives as skilled professionals who knew what was best given the condition of the mother and her baby.

A review and comparison of common maternal positions during the second-stage of labor

The second-stage of labor is the most stressful part of childbirth process and the proper maternal position during this period is paramount for women's safe vaginal birth. Midwives play a pivotal role in managing maternal positions during the second-stage of labor. However, there is limited evidence to support an ideal maternal position during the second-stage of labor. Further, the difference between different maternal positions might not be apparent. This paper aims to review and compare the benefits and risks of common maternal positions during the second-stage of labor, thereby to provide midwives evidence-based practical guidelines.

Stress caused by environmental effects on the birth process and some of the labor hormones at rats: ideal birth environment and hormones

OBJECTIVE

The aim of this study was to compare the effect of environmental conditions on the birth hormones and the labor of rats.

MATERIALS AND METHODS

This Study is animal experiment. A total of of 18 pregnant Sprague Dawley rats were divided into control, stress and enriched groups. Animals in the stress group were exposed to unexpected variable stress paradigm three times a day during the third trimester of their pregnancies. Whereas animals raised in the enriched environment were kept in larger cages equipped with various toys. They were subjected to open field test for 5 minutes in the last trimester. Blood samples were taken from the tail vein at the beginning of birth, and 10 parameters (including corticotropin-releasing hormone, oxytocin, endorphin, epinephrine, norepinephrine, prolactin, estrogen, progesterone, vasopressin, and brain-derived neurotrophic factor) involved in labor were assessed. Kruskal Wallis, Mann Whitney U, and Spearman's rho correlation analysis were used to compare data.

RESULTS

Interactions of hormones were significantly different among the groups. While hormonal interactions in the control group were similar to the physiological parameters, other groups displayed various results. There were significant (p < .05) differences in the values of corticotropin-releasing hormone (CRH) and vasopressin hormone levels. In the open Field test, standing distribution scores of animals displayed differences among control, stress and enriched environment groups (p < .05).

CONCLUSION

These results showed that labor environment diversely affects physiology aspects of birth. It is known that many factors such as procedures in a hospital environment, birth environment, noise, and birth position affect the hormones at birth. Therefore, the birth environment, either at home or at the hospital, needs to be well-organized accordingly.

Factors hindering midwives' utilisation of alternative birth positions during labour in a selected public hospital

Background

An evidence-based practice suggests that the birth position adopted by women during labour has a significant impact on the maternal and neonatal birth outcomes. The birth positions are endorsed by guidelines of maternity care in South Africa, which documented that women in labour should be allowed to select the birth position of their choice, preferably alternative birth positions (including upright, kneeling, squatting and lateral positions) during labour. Thus, the lithotomy birth position should be avoided. However, despite available literature, midwives routinely position women in the lithotomy position during normal vertex births, which causes several adverse maternal outcomes (namely prolonged labour, postpartum haemorrhage) and adverse neonatal outcomes (such as foetal asphyxia and respiratory compromise).

Aim

The aim was to explore and describe factors hindering midwives’ utilisation of alternative birth positions during labour in a selected public hospital.

Setting

A public hospital in the Tshwane district, Pretoria were used in the study.

Methods

This study used the qualitative, exploratory and descriptive research design. This design gathered quality information on factors hindering midwives’ utilisation of alternative birth positions during labour in a selected public hospital.

Results

The study revealed the following themes: (1) midwives’ perceptions on alternative use of birth positions and (2) barriers to utilisation of alternative birth positions. The themes were discussed and validated through the use of a literature review.

Conclusion

The lack of skills and training during the midwifery undergraduate and postgraduate programme contributes to the midwives being incompetent to utilise alternative birth positions during clinical practice.

Nonpharmacological approaches to improve women's childbirth experiences: a systematic review and meta-analysis

Background: Childbirth is considered a significant experience in women's life. Different models of care and interventions without pharmacological approaches have been used to enhance women's positive childbirth experiences, but the most effective interventions have not been clearly identified.Objective: To assess the effectiveness of nonpharmacological approaches in improving women's childbirth experiences.Methods: We searched Cochrane Library, Medline, Web of Science, Embase, Scopus, ProQuest, Google Scholar, and Persian databases (Magiran, Scientific Information Database, and Barakat) from inception until December 2017. Randomized controlled trials and quasi-randomized controlled trials comparing interventions designed to improve women's childbirth experiences with standard cares were included in this review. Pharmacological interventions were excluded from the study. The outcome measure was women's childbirth experience. Heterogeneity was determined using the Cochrane's test and I² index. The standardized mean differences were pooled based on random effect models.Results: We included 19 studies (10,141 women) in the review. Results of the meta-analysis of 18 studies (8487 women) demonstrated that all the interventions with nonpharmacological approaches improved childbirth experiences (standardized mean difference: 0.49; 95% confidence interval: 0.33-0.66). But, subgroup meta-analysis showed that different models of midwifery care, support during labor and natural therapies were the most effective interventions in improving women's childbirth experience.Conclusions: Nonpharmacological interventions that enable women to feel supported, safe and respected can lead to improved childbirth experiences. However, there is a need for further studies with larger sample sizes and standardized tool to better assess the effectiveness of specific interventions on women's childbirth experiences.

Factors associated with obstetric anal sphincter injuries in midwife-led birth: A cross sectional study

INTRODUCTION

Obstetric anal sphincter injurie (OASI) in vaginal births are a serious complication, and are associated with maternal morbidity. Focus on modifiable factors in midwives clinical skills and competences contributing to prevent the occurrence of OASI are essential. The objective of this study was to investigate the association between OASI and factors related to midwife-led birth such as manual support of perineum, active delivery of baby's shoulders, maternal birth position, and pushing and breathing techniques in second stage of labour.

METHODS

A prospective cross sectional study including primiparous (n = 129) and multiparous (n = 628) women in midwife-led non-instrumental deliveries with OASI (n = 96) or intact perineum (n = 661). Data were collected in a university hospital in Norway with two different birth settings: an alongside midwife-led unit with approximately 1500 births per year and an obstetrical unit with approximately 3500 births per year. In midwife-led births, there were a total of 2.6% OASI and 18.9% intact perineum.

RESULTS

The sample consisted of 757 women, 12.7% suffered OASI and 87.3% of participating women had an intact perineum. This selected sample compares the most serious outcome (OASI), and the optimal outcome (intact perineum).In primiparous women, 61 women suffered OASI and 68 women had intact perineum, while for multipara women, 35 women suffered OASI and 593 women had intact perineum. There was an increased risk of OASI if women actively pushed when the head was crowning compared to breathing the head out (adjusted OR: 3.10; 95% CI: 1.75 to 5.47). The maternal birth position associated with the lowest risk of OASI was kneeling position (adjusted OR: 0.15; 95% CI: 0.03 to 0.70), supine maternal birth position (adjusted OR: 2.52; 95% CI: 1.04 to 4.90) and oxytocin augmentation more than 30 min in second stage (OR: 1.93; 95% CI: 1.68 to 15.63) were associated with an increased risk of OASI, when adjusting for maternal, foetal, and obstetric factors.

CONCLUSION

Our study suggests that actively pushing when the baby's head is crowning, a supine maternal birth position and oxytocin augmentation more than 30 min in second stage, were associated with increased risk of OASI when compared to intact perineum. A kneeling maternal birth position was associated with a decreased risk of OASI.

Position in the second stage of labour for women without epidural anaesthesia

BACKGROUND

For centuries, there has been controversy around whether being upright (sitting, birthing stools, chairs, squatting, kneeling) or lying down (lateral (Sim's) position, semi-recumbent, lithotomy position, Trendelenburg's position) have advantages for women giving birth to their babies. This is an update of a review previously published in 2012, 2004 and 1999.

OBJECTIVES

To determine the possible benefits and risks of the use of different birth positions during the second stage of labour without epidural anaesthesia, on maternal, fetal, neonatal and caregiver outcomes.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (30 November 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised, quasi-randomised or cluster-randomised controlled trials of any upright position assumed by pregnant women during the second stage of labour compared with supine or lithotomy positions. Secondary comparisons include comparison of different upright positions and the supine position. Trials in abstract form were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and assessed trial quality. At least two review authors extracted the data. Data were checked for accuracy. The quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

Results should be interpreted with caution because risk of bias of the included trials was variable. We included eleven new trials for this update; there are now 32 included studies, and one trial is ongoing. Thirty trials involving 9015 women contributed to the analysis. Comparisons include any upright position, birth or squat stool, birth cushion, and birth chair versus supine positions.In all women studied (primigravid and multigravid), when compared with supine positions, the upright position was associated with a reduction in duration of second stage in the upright group (MD -6.16 minutes, 95% CI -9.74 to -2.59 minutes; 19 trials; 5811 women; P = 0.0007; random-effects; I² = 91%; very low-quality evidence); however, this result should be interpreted with caution due to large differences in size and direction of effect in individual studies. Upright positions were also associated with no clear difference in the rates of caesarean section (RR 1.22, 95% CI 0.81 to 1.81; 16 trials; 5439 women; low-quality evidence), a reduction in assisted deliveries (RR 0.75, 95% CI 0.66 to 0.86; 21 trials; 6481 women; moderate-quality evidence), a reduction in episiotomies (average RR 0.75, 95% CI 0.61 to 0.92; 17 trials; 6148 women; random-effects; I² = 88%), a possible increase in second degree perineal tears (RR 1.20, 95% CI 1.00 to 1.44; 18 trials; 6715 women; I² = 43%; low-quality evidence), no clear difference in the number of third or fourth degree perineal tears (RR 0.72, 95% CI 0.32 to 1.65; 6 trials; 1840 women; very low-quality evidence), increased estimated blood loss greater than 500 mL (RR 1.48, 95% CI 1.10 to 1.98; 15 trials; 5615 women; I² = 33%; moderate-quality evidence), fewer abnormal fetal heart rate patterns (RR 0.46, 95% CI 0.22 to 0.93; 2 trials; 617 women), no clear difference in the number of babies admitted to neonatal intensive care (RR 0.79, 95% CI 0.51 to 1.21; 4 trials; 2565 infants; low-quality evidence). On sensitivity analysis excluding trials with high risk of bias, these findings were unchanged except that there was no longer a clear difference in duration of second stage of labour (MD -4.34, 95% CI -9.00 to 0.32; 21 trials; 2499 women; I² = 85%).The main reasons for downgrading of GRADE assessment was that several studies had design limitations (inadequate randomisation and allocation concealment) with high heterogeneity and wide CIs.

AUTHORS' CONCLUSIONS

The findings of this review suggest several possible benefits for upright posture in women without epidural anaesthesia, such as a very small reduction in the duration of second stage of labour (mainly from the primigravid group), reduction in episiotomy rates and assisted deliveries. However, there is an increased risk blood loss greater than 500 mL and there may be an increased risk of second degree tears, though we cannot be certain of this. In view of the variable risk of bias of the trials reviewed, further trials using well-designed protocols are needed to ascertain the true benefits and risks of various birth positions.

Midwife-led maternity care in Ireland - a retrospective cohort study

Background

Midwife-led maternity care is shown to be safe for women with low-risk during pregnancy. In Ireland, two midwife-led units (MLUs) were introduced in 2004 when a randomised controlled trial (the MidU study) was performed to compare MLU care with consultant-led care (CLU). Following study completion the two MLUs have remained as a maternity care option in Ireland. The aim of this study was to evaluate maternal and neonatal outcomes and transfer rates during six years in the larger of the MLU sites.

Methods

MLU data for the six years 2008–2013 were retrospectively analysed, following ethical approval. Rates of transfer, reasons for transfer, mode of birth, and maternal and fetal outcomes were assessed. Linear-by-Linear Association trend analysis was used for categorical data to evaluate trends over the years and one-way ANOVA was used when comparing continuous variables.

Results

During the study period, 3,884 women were registered at the MLU. The antenatal transfer rate was 37.4% and 2,410 women came to labour in the MLU. Throughout labour and birth, 567 women (14.6%) transferred to the CLU, of which 23 were transferred after birth due to need for suturing or postpartum hemorrhage. The most common reasons for intrapartum transfer were meconium stained liquor/abnormal fetal heart rate (30.3%), delayed labour progress in first or second stage (24.9%) and woman’s wish for epidural analgesia (15.1%). Of the 1,903 babies born in the MLU, 1,878 (98.7%) were spontaneous vaginal births and 25 (1.3%) were instrumental (ventouse/forceps). Only 25 babies (1.3%) were admitted to neonatal intensive care unit.

All spontaneous vaginal births from the MLU registered population, occurring in the study period in both the MLU and CLU settings (n = 2,785), were compared. In the MLU more often 1–2 midwives (90.9% vs 69.7%) cared for the women during birth, more women had three vaginal examinations or fewer (93.6% vs 79.9%) and gave birth in an upright position (standing, squatting or kneeling) (52.0% vs 9.4%), fewer women had an amniotomy (5.9% vs 25.9%) or episiotomy (3.4% vs 9.7%) and more women had a physiological management of third stage of labour (50.9% vs 4.6%).

Conclusions

Midwife-led care is a safe option that could be offered to a large proportion of healthy pregnant women. With strict transfer criteria there are very few complications during labour and birth. Maternity units without the option of MLU care should consider its introduction.

Principles of physiological breech birth practice: A Delphi study

OBJECTIVE

to establish a multi-professional consensus on shared principles underlying the practice of physiological breech birth.

DESIGN

three-round Delphi e-survey.

SETTING

multi-national.

PARTICIPANTS

a panel of thirteen obstetricians and thirteen midwives, experienced in facilitating physiological breech births in varied settings, and involving varied maternal birthing positions, and two service user representatives.

METHODS

an initial survey contained open-ended questions. Answers were coded and amalgamated into 60 statements in Round 1 and a further 6 statements in Round 2. Participants considered statements in the following categories: first principles (14), maternal positioning (12), birth environment (18), fetal positions (14), safe progress (8). The panel indicated the extent of their agreement using a 5-point Likert scale. The pre-determined level of consensus was 70% of respondents indicating 4 or 5 on the Likert scale (agreement or strong agreement).

FINDINGS

the panel indicated consensus on 37 of 66 proposed statements concerning 'Principles of Practice.' Negative data (29/66 statements) are also reported, highlighting areas of divergent opinions. The findings suggest a paradigm shift away from risk management strategies based on prediction and control, and towards facilitation strategies based on relationship and response. Upright positions are a tool and not a rule of physiological breech birth.

CONCLUSION

the parameters of 'normal for breech' require further exploration to support professionals working within a paradigm of complex normality. The principles articulated in this research can be used to design further research exploring the influence of physiological breech practices on neonatal and maternal outcomes, including women's experiences of maternity care.

Swedish fathers' experiences of childbirth in relation to maternal birth position: a mixed method study

BACKGROUND

Fathers often want to be involved in labour and birth.

AIM

To investigate how maternal birth position during second stage of labour may influence fathers' experience of childbirth.

METHODS

Mixed method study with 221 Swedish fathers completing an on-line questionnaire. Descriptive statistics and qualitative content analysis were used.

RESULTS

In total 174 (78.7%) had a positive overall birth experience. The theme An emotional life-changing event influenced by the birth process and the structure of obstetrical care was revealed and included the categories; Midwives ability to be professional, The birth process' impact, and Being prepared to participate. The most frequently utilised birth position during a spontaneous vaginal birth was birth seat (n=83; 45.1%), and the fathers in this group were more likely to assess the birth position as very positive (n=40; 54.8%) compared to other upright and horizontal birth positions. Fathers with a partner having an upright birth position were more likely to have had a positive birth experience (p=0.048), to have felt comfortable (p=0.003) and powerful (p=0.019) compared to women adopting a horizontal birth position during a spontaneous vaginal birth. When the women had an upright birth position the fathers deemed the second stage of labour to have been more rapid (mean VAS 7.01 vs. 4.53) compared to women in a horizontal birth position.

CONCLUSION

An upright birth position enhances fathers' experience of having been positively and actively engaged in the birth process. Midwives can enhance fathers' feelings of involvement and participation by attentiveness through interaction and communicating skills.

Women's choice of positions during labour: return to the past or a modern way to give birth? A cohort study in Italy

Background. Childbirth medicalization has reduced the parturient's opportunity to labour and deliver in a spontaneous position, constricting her to assume the recumbent one. The aim of the study was to compare recumbent and alternative positions in terms of labour process, type of delivery, neonatal wellbeing, and intrapartum fetal head rotation. Methods. We conducted an observational cohort study on women at pregnancy term. Primiparous women with physiological pregnancies and single cephalic fetuses were eligible for the study. We considered data about maternal-general characteristics, labour process, type of delivery, and neonatal wellbeing at birth. Patients were divided into two groups: Group-A if they spent more than 50% of labour in a recumbent position and Group-B when in alternative ones. Results. 225 women were recruited (69 in Group-A and 156 in Group-B). We found significant differences between the groups in terms of labour length, Numeric Rating Scale score and analgesia request rate, type of delivery, need of episiotomy, and fetal occiput rotation. No differences were found in terms of neonatal outcomes. Conclusion. Alternative maternal positioning may positively influence labour process reducing maternal pain, operative vaginal delivery, caesarean section, and episiotomy rate. Women should be encouraged to move and deliver in the most comfortable position.