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

 

Abstract

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 methods

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 September 2005). We updated this search on 12 June 2009 and added the results to the awaiting classification section.

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 20 included trials (6135 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 (9 trials: mean 4.28 minutes, 95% confidence interval (CI) 2.93 to 5.63 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 (19 trials: relative risk (RR) 0.80, 95% CI 0.69 to 0.92); a reduction in episiotomies (12 trials: RR 0.83, 95% CI 0.75 to 0.92); 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 1.63, 95% CI 1.29 to 2.05); 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).

Authors' 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.

[Note: The four citations in the awaiting assessment section of the review may alter the conclusions of the review once assessed.]

 

Plain language summary

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

Women should be encouraged to give birth in comfortable positions, which are usually upright.

In traditional cultures, women naturally give birth in upright positions like kneeling, standing etc. In western societies, doctors have influenced women to give birth on their backs, sometimes with their legs up in stirrups. The review of trials found the studies were not of good quality, but they showed that when women gave birth on their backs it was more painful for the mother and caused more problems with the baby's heartbeat. More women needed help from doctors using forceps and more had cuts to the birth outlet, but there was less blood loss. More research is needed.

 

摘要

背景

對於沒有接受硬脊膜外麻醉(epidural anaesthesia)的婦女而言，在分娩之第2階段中的姿勢

幾個世紀以來，對於正要生下嬰兒的婦女來說，到底是挺直(坐著、用產凳、用椅子、蹲下)或是躺下才會有好處，一直都爭論不休。

目標

在分娩的第2階段(自子宮頸完全擴張起)期間，要評估使用不同姿勢的優點與風險。

搜尋策略

我們搜尋了the Cochrane Pregnancy and Childbirth Group Trials Register(2005年九月30日)。

選擇標準

在分娩的第2階段，這些試驗使用了隨機或半隨機的分配與適當的後續追蹤，並比較了由懷孕婦女所認定的不同位置。

資料收集與分析

我們獨立地針對結論而評估了這些試驗，並擷取出資料。

主要結論

因為這20組(6135名參與者)被納入的試驗所涵蓋的方法品質不同，所以結果應該要以注意事項來進行加註。跟仰臥或是膀胱截石術姿勢比較起來，使用任何的直立或是側相位置時，曾出現了下列的現象：分娩的第2階段時程縮短(9 trials: mean 4.28 minutes, 95% confidence interval (CI) 2.93 to 5.63 minutes)這主要是因為在被指定分配到使用生產墊的婦女之中，人數大幅地下降；在接受輔助生產的情況當中，人數小幅地下降(19 trials: relative risk (RR) 0.80, 95% CI 0.69 to 0.92)；採取外陰切開術的人數降低了(12 trials: RR 0.83, 95% CI 0.75 to 0.92)；第2級會陰撕裂傷(perineal tears)的數目增加了(11 trials: RR 1.23, 95% CI 1.09 to 1.39)；預估血液流失量會超過500 ml的人數增加了(11 trials: RR 1.63, 95% CI 1.29 to 2.05)；在分娩的第二階段期間，關於嚴重疼痛的報告減少了(1 trial: RR 0.73, 95% CI 0.60 to 0.90)；胎兒心跳異常的狀況較少(1 trial: RR 0.31, 95% CI 0.08 to 0.98)。

作者結論

本篇回顧的試驗性發現認為，挺直的姿勢會有幾種可能的優點，但血液流失量會超過500毫升的風險也可能會提高。我們應該要鼓勵婦女們，以她們所發現最舒服的姿勢來進行生產。當我們可以取得以嚴格方法學所得的試驗資料時，就可以更為確定地估計不同之生產姿勢的好處及風險，但在這樣的時機出現之前，應該要讓婦女們在關於生產姿勢方面作出有憑有據的選擇(知情選擇獲取足夠的資訊再作出抉擇)，而這樣的位置或許是她們希望她們的寶寶能夠出生的方式。

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

我們應該要鼓勵婦女們，以各種舒服的姿勢來進行生產，而這些姿勢通常是挺直的。在傳統的文化中，婦女們通常都以挺直的姿勢來進行生產，像是跪姿、站姿等等。在西方社會中，醫生們已經影響了婦女們要以背躺式來進行生產，有時候還要她們將腳抬高放到腳蹬裡面。本篇試驗的回顧發現，這些研究的品質並不佳，但是它們卻證實了一件事，那就是當婦女以背躺式進行生產時，對於母親來說是更為疼痛的，而且還會造成更多嬰兒在心跳方面的問題。有更多的婦女們需要醫師們用產鉗來協助，並且有更多婦女需要切開產道出口，但是流失的血液量卻是比較少的。還需要有更多的研究。