Upright versus recumbent position in the second stage of labour in women with combined spinal-epidural analgesia

Birthing positions and mother`s satisfaction with childbirth: a cross-sectional study on the relevance of self determination

INTRODUCTION

Considering the inconclusive evidence regarding the clinical benefits of specific birthing positions, emphasis has been placed on adhering to women's preferences during the second stage of labour. Therefore, the present study aimed to assess the association between birthing position, the freedom to choose a birth position during the second stage of labour, and women's subjective satisfaction with childbirth.

METHODS

We performed a cross-sectional survey of women 8 or 12 months after a vaginal birth in a hospital. The women were recruited via two cooperating health insurance companies. Multivariate analyses were conducted to assess the strength of the association between birthing position and maternal satisfaction with childbirth, with a particular focus on interactions with self-determination.

RESULTS

In total, the data from 761 women were analysed. The supine position was the most frequently reported birthing position in the second stage of labour at 77.5%. Notably, 39.0% and 30.5% of the women who gave birth in the dorsal and lateral supine positions, respectively, stated that the birth position was not chosen voluntarily. The regression models show a significant negative association between supine birthing position and satisfaction with childbirth, which is significantly related to self-determination. The most common reason for the adoption of a specific birthing position was instructions from medical staff.

DISCUSSION

The data provide insight into the perceived satisfaction with childbirth depending on the birthing position, whereby the relevance of self-determination is particularly evident. At the same time, self-determination is often not given, which is associated with reduced birth satisfaction.

Influence of Laboring People's Mobility and Positional Changes on Birth Outcomes in Low-Dose Epidural Analgesia Labor: A Systematic Review with Meta-Analysis

INTRODUCTION

Freedom of movement has been identified as a key issue for pregnant individuals during the birthing process, even if they opt for epidural analgesia, which has relegated people to more static positions during birth for many years. The aims of this systematic review were to evaluate the influence of mobility and positional changes on perinatal and neonatal outcomes in people in labor with epidural analgesia, describe the range of movement interventions used during the first and second stage of labor, and describe the level of motor blockade among people with low-dose epidural analgesia.

METHODS

Bibliographic databases (Web of Science, Cochrane, CINAHL) were consulted from December 2020 to January 2021. The articles selected were clinical trials and observational or analytical studies, the subject of which was mobilization during labor in people with epidural analgesia. The outcome measures were mode of birth, duration of labor, and extrauterine adaptation after birth. A narrative synthesis was used to describe the types of movements interventions employed during the stages of labor and the level of motor blockade among people with low-dose epidural analgesia.

RESULTS

Ten articles were selected (8 clinical trials, one cross-sectional study, and one quasiexperimental study), with a total sample of 6086 individuals. A meta-analysis showed nonsignificant results between groups for mode of birth (relative risk [RR], 1.00; 95% CI, 0.87-1.14), duration of labor (RR, 1.64; 95% CI, -34.57 to 37.86), and extrauterine adaptation after birth (RR, 0.86; 95% CI, 0.39-1.93). There was heterogeneity among studies in the type of movement interventions used during the first and second stage of labor.

DISCUSSION

Although no clear benefit was observed for mobilization in epidural labor, no detrimental effects were found either, so perinatal care providers should encourage mobilization if the laboring person so desires, throughout the entire childbirth process.

Benefits and risks of upright positions during the second stage of labour: An overview of systematic reviews

BACKGROUND

Upright positions during the second stage of labour are assumed to have many physiological advantages that may facilitate normal birth. Clarifying the underlying benefits and risks of upright positions plays an important role in the implementation of upright positions. The benefits and risks of upright positions during the second stage of labour have been explored in several systematic reviews, but the results are divergent.

OBJECTIVE

To summarize the evidence on the underlying benefits and risks of upright positions during the second stage of labour by searching available systematic reviews to explore the best evidence for clinical practice and decision making.

DESIGN

Overview of systematic reviews.

DATA SOURCES

We systematically searched five English databases and four Chinese databases from inception to 15th March 2020 for any published and ongoing systematic reviews.

REVIEW METHODS

Two reviewers independently evaluated the methodological and the reporting quality of the included systematic reviews using the AMSTAR 2 tool and the PRISMA checklist. A descriptive synthesis was used by reporting the results of the highest quality reviews.

RESULTS

Seven systematic reviews met the eligibility criteria, of which two Cochrane reviews had the highest methodological and reporting quality. In women without epidural analgesia, upright positions significantly reduced the rate of instrumental vaginal birth (moderate-quality evidence), shortened the second stage of labour (very low-quality evidence), reduced the rate of episiotomy (very low-quality evidence) and abnormal foetal heart rate patterns requiring intervention (very low-quality evidence), but significantly increased the risk of blood loss greater than 500 ml (moderate-quality evidence) and second-degree perineal trauma (low-quality evidence). However, no definite benefits or risks of upright positions were found in women with epidural analgesia based on the current evidence.

CONCLUSIONS

This overview demonstrates that upright positions have both benefits and risks but the quality of the current evidence is relatively low. It is necessary for the researchers to conduct robust studies to provide stronger evidence. In addition, upright positions are recommended to be used depending on women's preferences and labour progress, but should also be carefully monitored especially in women with epidural analgesia. Registration number: CRD42020175820.

Effects of flexible sacrum positions during the second stage of labour on maternal and neonatal outcomes: A systematic review and meta-analysis

AIMS AND OBJECTIVES

To assess the effects of flexible sacrum positions on mode of delivery, duration of the second stage of labour, perineal trauma, postpartum haemorrhage, maternal pain, abnormal foetal heart rate patterns and Apgar scores based on published literature.

BACKGROUND

Maternal positions served as a nonmedical intervention may facilitate optimal maternal and neonatal outcomes during labour. Flexible sacrum positions are conducive to expanding pelvic outlet. Whether flexible sacrum positions have positive effects on maternal and neonatal well-being is a controversial issue under heated discussion.

DESIGN

We performed a systematic review and meta-analysis based on PRISMA guidelines.

METHODS

Randomised controlled trials (RCTs) comparing any flexible sacrum position with non-flexible sacrum position in the second stage of labour were included. PubMed, EMBASE, Cochrane Library, CINAHL, CNKI (China National Knowledge Infrastructure), SinoMed and Wanfang databases were searched from inception to 11 March 2019 for published RCTs. Risk of bias was assessed by the Cochrane criteria, and random-effects meta-analyses were conducted by RevMan 5.3.

RESULTS

Sixteen studies (3,397 women) published in English were included. Flexible sacrum positions in the second stage of labour could reduce the incidence of operative delivery, instrumental vaginal delivery, caesarean section, episiotomy, severe perineal trauma, severe pain and shorten the duration of active pushing phase in the second stage of labour. However, flexible sacrum positions may increase the incidence of mild perineal trauma. There was no significant difference in the duration of the second stage of labour, maternal satisfaction and other outcomes.

CONCLUSIONS

Flexible sacrum positions are superior in promoting maternal well-being during childbirth. However, several results require careful interpretation. More rigorous original studies are needed to further explore their effects.

RELEVANCE TO CLINICAL PRACTICE

The results support the use of flexible sacrum positions. Flexible sacrum positions are recommended to apply flexibly or tailor to individual woman's labour progress.

Vertical Delivery as a Method of Prevention of Obstetric and Perinatal Complications

Currently, there are many points of view on management of physiological labor, in particular, it concerns the intrapartum position of a woman. Tactics of modern obstetrics should ensure the safety of motherhood, which in future ensures the prosperity of the state. One of the alternative methods of delivery is the vertical position of a woman in the intrapartum period. It is impossible to describe the whole range of possible positions of a woman in the intrapartum period, the common ones being: lying position (lateral, reclining, lithotomy, Trendelenburg’s, etc.) or upright position (sitting, using a chair for childbirth, standing, squatting, standing on the knees, etc.). Opinions about how the vertical position of a mother in the intrapartum period affects the outcome of childbirth are quite ambiguous. The conclusions of various authors on that matter often contradict each other.The aim of the research was to study the role of vertical delivery in reducing the frequency of obstetric and perinatal complications.Materials: publications of foreign and domestic authors within the period from 1989 to 2017.Methods: systematic analysis and synthesis of literature data.Conclusion: Despite a significant number of studies, it is not possible to determine the universality of the vertical position in childbirth, therefore, the selection of patients for the management of vertical childbirth should be approached carefully. In the presence of pregnancy complications, preference should be given to the classic version of the position in childbirth. In women who have a low risk of perinatal complications, an upright position can be a worthy alternative. To prevent the development of bleeding in the III stage of labor and the early postpartum period, a woman should take a horizontal position after the birth of the fetus. This condition must also be observed when examining the birth canal. Thus, the rational tactics of conducting childbirth is to determine the optimal combination of vertical and horizontal positions at different periods of the childbirth process, taking into account the convenience for the woman in labor. 

Maternal position in the second stage of labour for women with epidural anaesthesia

BACKGROUND

Epidural analgesia in labour prolongs the second stage and increases instrumental delivery. It has been suggested that a more upright maternal position during all or part of the second stage may counteract these adverse effects. This is an update of a Cochrane Review published in 2017.

OBJECTIVES

To assess the effects of different birthing positions (upright or recumbent) during the second stage of labour, on maternal and fetal outcomes for women with epidural analgesia.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (5 June 2018), and the reference lists of retrieved studies.

SELECTION CRITERIA

All randomised or quasi-randomised trials including pregnant women (primigravidae or multigravidae) in the second stage of induced or spontaneous labour receiving epidural analgesia of any kind. Cluster-randomised controlled trials would have been eligible for inclusion but we found none. Studies published in abstract form only were also eligible.We assumed the experimental intervention to be maternal use of any upright position during the second stage of labour, compared with the control condition of remaining in any recumbent position.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, assessed risks of bias, and extracted data. We contacted study authors to obtain missing data. We assessed the quality of the evidence using the GRADE approach.We carried out a planned sensitivity analysis of the three studies with low risks of bias for allocation concealment and incomplete outcome data reporting, and further excluded one study with a co-intervention (this was not prespecified).

MAIN RESULTS

We include eight randomised controlled trials, involving 4464 women, comparing upright positions versus recumbent positions in this update. Five were conducted in the UK, one in France and two in Spain.The largest UK trial accounted for three-quarters of all review participants, and we judged it to have low risk of bias. We assessed two other trials as being at low risk of selection and attrition bias. We rated four studies at unclear or high risk of bias for both selection and attrition bias and one study as high risk of bias due to a co-intervention. The trials varied in their comparators, with five studies comparing different positions (upright and recumbent), two comparing ambulation with (recumbent) non-ambulation, and one study comparing postural changes guided by a physiotherapist to a recumbent position.Overall, there may be little or no difference between upright and recumbent positions for our combined primary outcome of operative birth (caesarean or instrumental vaginal): average risk ratio (RR) 0.86, 95% confidence interval (CI) 0.70 to 1.07; 8 trials, 4316 women; I² = 78%; low-quality evidence. It is uncertain whether the upright position has any impact on caesarean section (RR 0.94, 95% CI 0.61 to 1.46; 8 trials, 4316 women; I² = 47%; very low-quality evidence), instrumental vaginal birth (RR 0.90, 95% CI 0.72 to 1.12; 8 trials, 4316 women; I² = 69%) and the duration of the second stage of labour (mean difference (MD) 6.00 minutes, 95% CI -37.46 to 49.46; 3 trials, 456 women; I² = 96%), because we rated the quality of the evidence as very low for these outcomes. Maternal position in the second stage of labour probably makes little or no difference to postpartum haemorrhage (PPH), (PPH requiring blood transfusion): RR 1.20, 95% CI 0.83 to 1.72; 1 trial, 3093 women; moderate-quality evidence. Maternal satisfaction with the overall childbirth experience was slightly lower in the upright group: RR 0.95, 95% CI 0.92 to 0.99; 1 trial, 2373 women. Fewer babies were born with low cord pH in the upright group: RR 0.43, 95% CI 0.20 to 0.90; 2 trials, 3159 infants; moderate-quality evidence.The results were less clear for other maternal or fetal outcomes, including trauma to the birth canal requiring suturing (average RR 1.00, 95% CI 0.89 to 1.13; 3 trials, 3266 women; I² = 46%; low-quality evidence), abnormal fetal heart patterns requiring intervention (RR 1.69, 95% CI 0.32 to 8.84; 1 trial, 107 women; very low-quality evidence), or admission to neonatal intensive care unit (RR 0.54, 95% CI 0.02 to 12.73; 1 trial, 66 infants; very low-quality evidence). However, the CIs around some of these estimates were wide, and we cannot rule out clinically important effects.In our sensitivity analysis of studies at low risk of bias, upright positions increase the chance of women having an operative birth: RR 1.11, 95% CI 1.03 to 1.20; 3 trials, 3609 women; high-quality evidence. In absolute terms, this equates to 63 more operative births per 1000 women (from 17 more to 115 more). This increase appears to be due to the increase in caesarean section in the upright group (RR 1.29; 95% CI 1.05 to 1.57; 3 trials, 3609 women; high-quality evidence), which equates to 25 more caesarean sections per 1000 women (from 4 more to 49 more). In the sensitivity analysis there was no clear impact on instrumental vaginal births: RR 1.08, 95% CI 0.91 to 1.30; 3 trials, 3609 women; low-quality evidence.

AUTHORS' CONCLUSIONS

There may be little or no difference in operative birth between women who adopt recumbent or supine positions during the second stage of labour with an epidural analgesia. However, the studies are heterogeneous, probably related to differing study designs and interventions, differing adherence to the allocated intervention and possible selection and attrition bias. Sensitivity analysis of studies at low risk of bias indicated that recumbent positions may reduce the need for operative birth and caesarean section, without increasing instrumental delivery. Mothers may be more satisfied with their experience of childbirth by adopting a recumbent position. The studies in this review looked at left or right lateral and semi-recumbent positions. Recumbent positions such as flat on the back or lithotomy are not generally used due to the possibility of aorto-caval compression, although we acknowledge that these recumbent positions were not the focus of trials included in this review.

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.

Position in the second stage of labour for women with epidural anaesthesia

BACKGROUND

Epidural analgesia for pain relief in labour prolongs the second stage of labour and results in more instrumental deliveries. It has been suggested that a more upright position of the mother during all or part of the second stage may counteract these adverse effects. This is an update of a Cochrane review first published in 2013.

OBJECTIVES

To assess the effects of different birthing positions (upright and recumbent) during the second stage of labour, on important maternal and fetal outcomes for women with epidural analgesia.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (19 September 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

All randomised or quasi-randomised trials including pregnant women (either primigravidae or multigravidae) in the second stage of induced or spontaneous labour receiving epidural analgesia of any kind. Cluster-RCTs would have been eligible for inclusion in this review but none were identified. Studies published in abstract form only were eligible for inclusion.We assumed the experimental type of intervention to be the maternal use of any upright position during the second stage of labour, compared with the control intervention of the use of any recumbent position.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, assessed risk of bias, and extracted data. Data were checked for accuracy. We contacted study authors to try to obtain missing data.

MAIN RESULTS

Five randomised controlled trials, involving 879 women, comparing upright positions versus recumbent positions were included in this updated review. Four trials were conducted in the UK and one in France. Three of the five trials were funded by the hospital departments in which the trials were carried out. For the other three trials, funding sources were either unclear (one trial) or not reported (two trials). Each trial varied in levels of bias. We assessed all the trials as being at low or unclear risk of selection bias. None of the trials blinded women, staff or outcome assessors. One trial was poor quality, being at high risk of attrition and reporting bias. We assessed the evidence using the GRADE approach; the evidence for most outcomes was assessed as being very low quality, and evidence for one outcome was judged as moderate quality.Overall, we identified no clear difference between upright and recumbent positions on our primary outcomes of operative birth (caesarean or instrumental vaginal) (average risk ratio (RR) 0.97; 95% confidence interval (CI) 0.76 to 1.29; five trials, 874 women; I² = 54% moderate-quality evidence), or duration of the second stage of labour measured as the randomisation-to-birth interval (average mean difference -22.98 minutes; 95% CI -99.09 to 53.13; two trials, 322 women; I² = 92%; very low-quality evidence). Nor did we identify any clear differences in any other important maternal or fetal outcome, including trauma to the birth canal requiring suturing (average RR 0.95; 95% CI 0.66 to 1.37; two trials; 173 women; studies = two; I² = 74%; very low-quality evidence), abnormal fetal heart patterns requiring intervention (RR 1.69; 95% CI 0.32 to 8.84; one trial; 107 women; very low-quality evidence), low cord pH (RR 0.61; 95% CI 0.18 to 2.10; one trial; 66 infants; very low-quality evidence) or admission to neonatal intensive care unit (RR 0.54; 95% CI 0.02 to 12.73; one trial; 66 infants; very low-quality evidence). However, the CIs around each estimate were wide, and clinically important effects have not been ruled out. Outcomes were downgraded for study design, high heterogeneity and imprecision in effect estimates.There were no data reported on blood loss (greater than 500 mL), prolonged second stage or maternal experience and satisfaction with labour. Similarly, there were no analysable data on Apgar scores, and no data reported on the need for ventilation or for perinatal death.

AUTHORS' CONCLUSIONS

There are insufficient data to say anything conclusive about the effect of position for the second stage of labour for women with epidural analgesia. The GRADE quality assessment of the evidence in this review ranged between moderate to low quality, with downgrading decisions based on design limitations in the studies, inconsistency, and imprecision of effect estimates.Women with an epidural should be encouraged to use whatever position they find comfortable in the second stage of labour.More studies with larger sample sizes will need to be conducted in order for solid conclusions to be made about the effect of position on labour in women with an epidural. Two studies are ongoing and we will incorporate the results into this review at a future update.Future studies should have the protocol registered, so that sample size, primary outcome, analysis plan, etc. are all clearly prespecified. The time or randomisation should be recorded, since this is the only unbiased starting time point from which the effect of position on duration of labour can be estimated. Future studies might wish to include an arm in which women were allowed to choose the position in which they felt most comfortable. Future studies should ensure that both compared positions are acceptable to women, that women can remain in them for most of the late part of labour, and report the number of women who spend time in the allocated position and the amount of time they spend in this or other positions.

Position in the second stage of labour and de novo onset of post-partum urinary incontinence

INTRODUCTION AND HYPOTHESIS

The aim of this study was to evaluate the role of the maternal position at the time of delivery on the onset of de novo symptoms of urinary incontinence (UI) in the post-partum period.

METHODS

This prospective study evaluated the data of consecutive women undergoing labour and delivery, between January 2014 and July 2014. We included only women with a singleton pregnancy undergoing vaginal delivery. During the study period, patients chose to deliver in the position that they considered the most comfortable. The onset of UI was evaluated according to the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-sf).

RESULTS

Overall, 716 primiparous women were included in the study. Sixty women refused the 12-week post-partum interview (8.4%). Women were divided in two groups: 296 women (45.1%) who chose an upright position during delivery (group 1) and 360 women (54.9%) who chose a supine position (group 2). Group 1 had a significantly lower episiotomy rate, but a higher rate of greater than second degree perineal tears. In group 1 we found a significantly lower rate of de novo UI (40.5% vs 48.9%, p = 0.03) and in particular of stress urinary incontinence. Via multivariate analysis, birth position was the only factor correlating with the occurrence of urinary incontinence in the post-partum period (OR: 1.52; 95%CI: 1.06, 2.18; p = 0.02).

CONCLUSIONS

Upright positions at delivery are related to a lower episiotomy rate and a higher rate of greater than second degree perineal tears. Supine positions are an independent risk factor for the onset of de novo UI.

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.

Position in the second stage of labour for women with epidural anaesthesia

BACKGROUND

Epidural analgesia for pain relief in labour prolongs the second stage of labour and results in more instrumental deliveries. It has been suggested that a more upright position of the mother during all or part of the second stage may counteract these adverse effects.

OBJECTIVES

To assess the effects of different birthing positions (upright versus recumbent) during the second stage of labour, on important maternal and fetal outcomes for women with epidural analgesia.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2012) and reference lists of retrieved studies

SELECTION CRITERIA

All randomised or quasi-randomised trials including pregnant women (either primigravidae or multigravidae) in the second stage of induced or spontaneous labour receiving epidural analgesia of any kind.We assumed the experimental type of intervention to be the maternal use of any upright position during the second stage of labour, compared with the control intervention of the use of any recumbent position.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, assessed risk of bias, and extracted data. Data were checked for accuracy. We contacted authors to try to obtain missing data.

MAIN RESULTS

Five randomised controlled trials, involving 879 women, were included in the review.Overall, we identified no statistically significant difference between upright and recumbent positions on our primary outcomes of operative birth (caesarean or instrumental vaginal) (average risk ratio (RR) 0.97; 95% confidence interval (CI) 0.76 to 1.29; five trials, 874 women), or duration of the second stage of labour measured as the randomisation to birth interval (average mean difference -22.98 minutes; 95% CI -99.09 to 53.13; two trials, 322 women). Nor did we identify any clear differences in the incidence of instrumental birth or caesarean section separately, nor in any other important maternal or fetal outcome, including trauma to the birth canal requiring suturing, operative birth for fetal distress, low cord pH or admission to neonatal intensive care unit. However, the CIs around each estimate were wide, and clinically important effects have not been ruled out.There were no data reported on excess blood loss, prolonged second stage or maternal experience and satisfaction with labour. Similarly, there were no analysable data on Apgar scores, and no data reported on the need for ventilation or for perinatal death.

AUTHORS' CONCLUSIONS

There are insufficient data to say anything conclusive about the effect of position for the second stage of labour for women with epidural analgesia. Women with an epidural should be encouraged to use whatever position they find comfortable in the second stage of labour. Future research should involve large trials of positions that women can maintain and predefined endpoints. One large trial is ongoing.

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 have advantages for women delivering their babies.

OBJECTIVES

To assess the benefits and risks of the use of different positions during the second stage of labour (i.e. from full dilatation of the uterine cervix).

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (28 February 2012).

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials of any upright or lateral 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 lateral position.

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.

MAIN RESULTS

Results should be interpreted with caution as the methodological quality of the 22 included trials (7280 women) was variable.In all women studied (primigravid and multigravid) there was a non-significant reduction in duration of second stage in the upright group (mean difference (MD) -3.71 minutes; 95% confidence interval (CI) -8.78 to 1.37 minutes; 10 trials, 3485 women; random-effects, I(2) = 94%), a significant reduction in assisted deliveries (risk ratio (RR) 0.78; 95% CI 0.68 to 0.90; 19 trials, 6024 women, I(2)= 27%), a reduction in episiotomies (average RR 0.79, 95% CI 0.70 to 0.90, 12 trials, 4541 women; random-effects, I(2) = 7%), an increase in second degree perineal tears (RR 1.35; 95% CI 1.20 to 1.51, 14 trials, 5367 women), increased estimated blood loss greater than 500 ml (RR 1.65; 95% CI 1.32 to 2.60; 13 trials, 5158 women, asymmetric funnel plot indicating publication bias), fewer abnormal fetal heart rate patterns (RR 0.46; 95% CI 0.22 to 0.93; two trials, 617 women). In primigravid women the use of any upright compared with supine positions was associated with: non-significant reduction in duration of second stage of labour (nine trials: mean 3.24 minutes, 95% CI 1.53 to 4.95 minutes) - this reduction was largely due to women allocated to the use of the birth cushion.

AUTHORS' CONCLUSIONS

The findings of this review suggest several possible benefits for upright posture in women without epidural, but with the possibility of increased risk of blood loss greater than 500 mL. Until such time as the benefits and risks of various delivery positions are estimated with greater certainty, when methodologically stringent data from trials are available, women should be allowed to make choices about the birth positions in which they might wish to assume for birth of their babies.

Influência da posição de parto vaginal nas variáveis obstétricas e neonatais de mulheres primíparas

OBJETIVOS: determinar a prevalência de fatores obstétricos associados à posição de parto vaginal (PPV) - vertical ou horizontal; investigar correlações entre PPV e fatores obstétricos, bem como sua influência sobre as características neonatais. MÉTODOS: foi realizado um estudo de corte transversal. A amostra foi composta por 176 mulheres primíparas que realizaram parto vaginal, entre julho/2006 e fevereiro/2007. Foi investigada a correlação entre PPV e as seguintes variáveis obstétricas: ocorrência e grau de laceração perineal espontânea, episiotomia, sutura perineal, uso de ocitocina e instrumentação cirúrgica. Os neonatos foram classificados quanto à idade gestacional, peso, estatura, perímetro cefálico e Apgar 1º e 5º minutos. Teste qui quadrado foi aplicado para investigar correlação entre PPV e variáveis obstétricas e o teste t-student para investigar a influência da PPV nas características neonatais. RESULTADOS: não foi observada correlação entre PPV e sutura perineal, laceração perineal, uso de ocitocina, episiotomia e utilização de instrumentação cirúrgica (uso de fórceps ou vácuo-extrator). Houve correlação entre PPV e episiotomia e maior prevalência de episiotomia na posição horizontal. Não houve influência da PPV nas características neonatais. CONCLUSÕES: houve maior ocorrência de episiotomia na posição de parto horizontal, embora ambas as posições de parto tenham sido satisfatórias para os neonatos.

Risk factors for anal sphincter tears: the importance of maternal position at birth

OBJECTIVE

To assess the role of birth position in the occurrence of anal sphincter tears (AST).

DESIGN

Observational cohort study.

SETTING

South Hospital in Stockholm, a teaching hospital with around 5700 births per year.

POPULATION

Among all 19,151 women who gave birth at the South Hospital during the study period 2002-05, 12,782 women met the inclusion criteria of noninstrumental, vaginal deliveries.

METHODS

Data on birth position and other obstetric factors were analysed in relation to occurrence of AST.

MAIN OUTCOME MEASURE

Third- and fourth-degree AST.

RESULTS

AST occurred in 449 women (3.5%). The trauma was more frequent in primiparous (5.8%) than in multiparous women (1.7%). The highest proportion of AST was found among women who gave birth in lithotomy position (6.9%), followed by squatting position (6.4%). Logistic regression analyses showed that lithotomy (adjusted OR 2.02, 95% CI 1.58-2.59) and squatting positions (adjusted OR 2.05, 95% CI 1.09-3.82) were associated with a significantly increased risk for AST. Other major risk factors for anal sphincter trauma were primiparity (adjusted OR 3.29, 95% CI 2.55-4.25), prolonged second stage of labour >1 hour (adjusted OR 1.52, 95% CI 1.11-2.10), infant birthweight more than 4 kg (adjusted OR 2.12, 95% CI 1.64-2.72) and large infant head circumference (adjusted OR 1.57, 95% CI 1.23-1.99).

CONCLUSION

Lithotomy and squatting position at birth were associated with an increased risk for AST also after control for other risk factors.

Complication neurologique après posture obstétricale «en tailleur» lors d'un travail sous analgésie péridurale

Obstetrical positioning is used more and more often because of the supposed or proven benefits although side effects are not well known. We therefore report the case of a patient who presented with a postpartum neurological deficit after a seven hour hip-flexed posture during labour under epidural analgesia. The parturient did not complain of pain or discomfort during labour. The neurological injury was suspected because of delayed recovery of epidural analgesia induced-motor block. Neurological examination disclosed sensory and motor abnormalities in the left femoral and sciatic nerve distribution areas. The early performed lumbar CT scan did not show any complication and electromyographic evaluation performed on the ninth postpartum day was normal. Three months after delivery, some degree of neuropathic pain in the sciatic nerve distribution remained. The risk of neurological injury directly related to obstetrical positioning is discussed. Prolonged positioning using a posture which can induce nerve stretching should be avoided. This is especially true when the patient is receiving epidural analgesia which can mask pain or discomfort.

Complication neurologique après posture obstétricale «en tailleur» lors d'un travail sous analgésie péridurale

Obstetrical positioning is used more and more often because of the supposed or proven benefits although side effects are not well known. We therefore report the case of a patient who presented with a postpartum neurological deficit after a seven hour hip-flexed posture during labour under epidural analgesia. The parturient did not complain of pain or discomfort during labour. The neurological injury was suspected because of delayed recovery of epidural analgesia-induced motor block. Neurological examination disclosed sensory and motor abnormalities in the left femoral and sciatic nerve distribution areas. The early performed lumbar CT-scan did not show any complication and electromyographic evaluation performed on the ninth postpartum day was normal. Three months after delivery, some degree of neuropathic pain in the sciatic nerve distribution remained. The risk of neurological injury directly related to obstetrical positioning is discussed. Prolonged positioning using a posture which can induce nerve stretching should be avoided. This is especially true when the patient is receiving epidural analgesia which can mask pain or discomfort.

A meta-analysis of upright positions in the second stage to reduce instrumental deliveries in women with epidural analgesia

BACKGROUND

Epidural analgesia is associated with an increased risk of instrumental delivery. We, in this study, present a systematic review in order to assess the effectiveness of maintaining an upright position during the second stage of labor to reduce instrumental deliveries among women choosing epidural analgesia. The study population included women with uncomplicated pregnancies at term with epidural analgesia established in the first stage of labor.

METHODS

We searched MEDLINE, EMBASE, and CINAHL databases and the Cochrane Trials Register up to July 2003 and cross-checked the reference lists of published studies. Trial eligibility and outcomes were pre-specified. Group tabular data were obtained for each trial and were analyzed by using meta-analytic techniques.

RESULTS

Only two studies were included with data on 281 women (166 upright and 115 recumbent). Upright positions in the second stage were associated with a non-significant reduction in the risk of both instrumental delivery (relative risk (RR) = 0.77, 95% confidence interval (CI) = 0.46-1.28) and cesarean section (RR = 0.57, 95% CI = 0.28-1.16). Both studies reported a statistically significant reduction in labor duration associated with upright positions. Data on other outcomes, including perineal trauma, postpartum hemorrhage, maternal satisfaction, and infant well-being, were insufficient.

CONCLUSIONS

There were insufficient data to show a significant benefit from upright positions in the second stage of labor for women who choose epidural or to evaluate safety aspects. However the magnitude of the reductions in instrumental delivery and cesarean section warrants an adequately powered randomized, controlled trial to fully evaluate the practice of upright positions in the second stage for women with an epidural.

Impact of first-stage ambulation on mode of delivery among women with epidural analgesia

BACKGROUND

New techniques for administering epidural analgesia allow increased mobility for labouring women with epidurals.

AIM

To determine the effect of ambulation or upright positions in the first stage of labour among women with epidural analgesia on mode of delivery and other maternal and infant outcomes.

METHODS

We undertook a systematic review and meta-analysis of randomised controlled trials (RCT) of ambulation or upright positions versus recumbency in the first stage of labour among women with effective first-stage epidural analgesia in an uncomplicated pregnancy. Trials were identified by searching Medline, Embase and CINAHL databases and the Cochrane Trials Register to March 2004. Trial eligibility and outcomes were prespecified. Group tabular data were obtained for each trial and analysed using meta-analytic techniques.

RESULTS

There were five eligible RCT, with a total of 1161 women. There was no statistically significant difference in the mode of delivery when women with an epidural ambulated in the first stage of labour compared with those who remained recumbent: instrumental delivery (relative risk (RR) = 1.16, 95% confidence interval (CI) 0.93-1.44) and Caesarean section (RR = 0.91, 95% CI 0.70-1.19). There were no significant differences between the groups in use of oxytocin augmentation, the duration of labour, satisfaction with analgesia or Apgar scores. There were no apparent adverse effects of ambulation, but data were reported by only a few trials.

CONCLUSIONS

Although ambulation in the first stage of labour for women with epidural analgesia provided no clear benefit to delivery outcomes or satisfaction with analgesia, neither were there are any obvious harms.

Position for women during second stage of labour

BACKGROUND

For centuries, there has been controversy around whether being upright (sitting, birthing stools, chairs, squatting) or lying down have advantages for women delivering their babies.

OBJECTIVES

To assess the benefits and risks of the use of different positions during the second stage of labour (i.e. from full dilatation of the cervix).

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (16 April 2003).

SELECTION CRITERIA

Trials that used randomised or quasi-randomised allocation and appropriate follow up and compared various positions assumed by pregnant women during the second stage of labour.

DATA COLLECTION AND ANALYSIS

We independently assessed the trials for inclusion and extracted the data.

MAIN RESULTS

Results should be interpreted with caution as the methodological quality of the 19 included trials (5764 participants) was variable. Use of any upright or lateral position, compared with supine or lithotomy positions, was associated with: reduced duration of second stage of labour (10 trials: mean 4.29 minutes, 95% confidence interval (CI) 2.95 to 5.64 minutes) - this was largely due to a considerable reduction in women allocated to the use of the birth cushion; a small reduction in assisted deliveries (18 trials: relative risk (RR) 0.84, 95% CI 0.73 to 0.98); a reduction in episiotomies (12 trials: RR 0.84, 95% CI 0.79 to 0.91); an increase in second degree perineal tears (11 trials: RR 1.23, 95% CI 1.09 to 1.39); increased estimated blood loss greater than 500 ml (11 trials: RR 1.68, 95% CI 1.32 to 2.15); reduced reporting of severe pain during second stage of labour (1 trial: RR 0.73, 95% CI 0.60 to 0.90); fewer abnormal fetal heart rate patterns (1 trial: RR 0.31, 95% CI 0.08 to 0.98).

REVIEWER'S CONCLUSIONS

The tentative findings of this review suggest several possible benefits for upright posture, with the possibility of increased risk of blood loss greater than 500 ml. Women should be encouraged to give birth in the position they find most comfortable. Until such time as the benefits and risks of various delivery positions are estimated with greater certainty, when methodologically stringent trials' data are available, women should be allowed to make informed choices about the birth positions in which they might wish to assume for delivery of their babies.

Obstetric epidural analgesia

PURPOSE OF THE REVIEW

There has recently been a growing interest in developing and modulating the techniques of neuraxial analgesia to meet the changing individual needs of parturients for pain relief during the course of labour and delivery.

RECENT FINDINGS

Neuraxial analgesia is now very safe. Modern low-dose spinal-epidural regimens provide efficacious analgesia, stable maternal haemodynamics and few tolerable side effects. Complications are possible, however, due to the invasive nature of the technique, patient characteristics or medical malpractice.

SUMMARY

Labour epidural analgesia still remains the 'gold standard' of obstetric pain management, although spinal analgesia with the single-injection technique is an attractive option due to its simplicity, reliability and efficacy. Up till now, there has been no single new drug to overcome the superiority of neuraxial analgesia in obstetrics.