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

  • Review
  • Intervention

Authors

  • Janesh K Gupta,

    Corresponding author
    1. University of Birmingham, Academic Department of Obstetrics and Gynaecology, Birmingham, UK
    • Janesh K Gupta, Academic Department of Obstetrics and Gynaecology, University of Birmingham, Birmingham Women's Hospital, Edgbaston, Birmingham, B15 2TG, UK. j.k.gupta@bham.ac.uk.

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  • Akanksha Sood,

    1. St Mary’s Hospital, CMFT, Department of Obstetrics and Gynaecology, Manchester, UK
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  • G Justus Hofmeyr,

    1. Walter Sisulu University, University of the Witwatersrand, Eastern Cape Department of Health, East London, South Africa
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  • Joshua P Vogel

    1. World Health Organization, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, Geneva, Switzerland
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Abstract

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.

Plain language summary

Women’s position for giving birth without epidural anaesthesia

What is the issue?

Women often give birth in upright positions like kneeling, standing or squatting. Some women give birth on their backs in what are known as ‘supine’ positions - including dorsal (the woman flat on her back), lateral (the woman lying on her side), semi-recumbent (where the woman is angled partly upright) or lithotomy (where the woman’s legs are held up in stirrups). Birth position can be influenced by many different factors including setting, mother's choice, caregiver preference, or medical intervention. This Cochrane review assessed the possible benefits and risks to the mother and baby, by giving birth in upright positions compared with supine positions and also looked at some individual upright positions for benefits and harms.

Why is this important?

Giving birth in the supine position may have been adopted to make it more convenient for midwives and obstetricians to assist the labour and birth. However, many women report that giving birth on their backs feels painful, uncomfortable and difficult. It is suggested that women in upright positions give birth more easily because the pelvis is able to expand as the baby moves down; gravity may also be helpful and the baby may benefit because the weight of the uterus will not be pressing down on the mother’s major blood vessels which supply oxygen and nutrition to the baby.

We looked at the upright positions such as: sitting (on an obstetric chair or stool); kneeling (either on all fours or kneeling up) and squatting (unaided or using a birth cushion or a squatting bar). We compared these with supine positions such as: dorsal; lateral; semi-recumbent and lithotomy. Our aim was to assess the effectiveness, benefits and possible disadvantages of the different positions for women without epidural, during the second stage of labour.

What evidence did we find?

We searched for evidence up to 30 November 2016. This review now includes data from 30 randomised controlled trials involving 9015 pregnant women who gave birth without epidural anaesthesia.

Overall, evidence was not of good quality. When women gave birth in an upright position, as compared with lying on their backs, the length of time they were pushing (second stage of labour) was reduced by around six minutes (19 trials, 5811 women; very low-quality evidence). Fewer women had an assisted delivery, for example with forceps (21 trials, 6481 women; moderate-quality evidence). The number of women having a caesarean section did not differ (16 trials, 5439 women; low-quality evidence). Fewer women had an episiotomy (a surgical cut to the perineum to enlarge the opening for the baby to pass through) although there was a tendency for more women to have perineal tears (low-quality evidence). There was no difference in number of women with serious perineal tears (6 trials, 1840 women; very low-quality evidence) between those giving birth upright or supine. Women were more likely to have a blood loss of 500 mL or more (15 trials, 5615 women; moderate-quality evidence) in the upright position but this may be associated with more accurate ways of measuring the blood loss. Fewer babies had problems with fast or irregular heart beats that indicate distress (2 trials, 617 women) when women gave birth in an upright position although the number of admissions to the neonatal unit was no different (4 trials, 2565 infants; low-quality evidence).

What does this mean?

This review found that there could be benefits for women who choose to give birth in an upright position. The length of time they had to push may be reduced but the effect was very small and these women might lose more blood. The results should be interpreted with caution because of poorly conducted studies, variations between trials and in how the findings were analysed.

More research into the benefits and risks of different birthing positions would help us to say with greater certainty which birth position is best for most women and their babies. Overall, women should be encouraged to give birth in whatever position they find comfortable.