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Maternal positions and mobility during first stage labour

  1. Annemarie Lawrence1,*,
  2. Lucy Lewis2,
  3. G Justus Hofmeyr3,
  4. Cathy Styles4

Editorial Group: Cochrane Pregnancy and Childbirth Group

Published Online: 9 OCT 2013

Assessed as up-to-date: 18 APR 2013

DOI: 10.1002/14651858.CD003934.pub4


How to Cite

Lawrence A, Lewis L, Hofmeyr GJ, Styles C. Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews 2013, Issue 10. Art. No.: CD003934. DOI: 10.1002/14651858.CD003934.pub4.

Author Information

  1. 1

    The Townsville Hospital and Health Service, Health & Well Being Service Group and Tropical Health Research Unit for Nursing and Midwifery Practice, Douglas, Queensland, Australia

  2. 2

    Department of Nursing and Midwifery Education Research, King Edward Memorial Hospital, School of Nursing and Midwifery, Curtin University, Perth, Australia

  3. 3

    University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of Health, Department of Obstetrics and Gynaecology, East London Hospital Complex, East London, Eastern Cape, South Africa

  4. 4

    Sunshine Coast Health Service District, Women's and Family Service Group, Nambour, Queensland, Australia

*Annemarie Lawrence, Health & Well Being Service Group and Tropical Health Research Unit for Nursing and Midwifery Practice, The Townsville Hospital and Health Service, Douglas, Queensland, 4810, Australia. annemarie_lawrence@health.qld.gov.au. maternalpositions@hotmail.com.au.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 9 OCT 2013

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Summary of findings    [Explanations]

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

 
Summary of findings for the main comparison. Summary of Outcomes

Comparison 1: Upright and ambulant positions versus recumbent positions and bed care

Outcomes showing significance

 Primary OutcomesSecondary Outcomes

Maternal1. Shorter duration of labour if upright. 

Subgroup analysis demonstrated this when:

  • women were nulliparous compared with multiparous
  • women had spontaneous labour compared with induction
  • women were sitting compared with recumbent/supine/lateral
  • women were walking compared with recumbent/supine/lateral
  • women were sitting, standing, squatting, kneeling or walking compared with recumbent/supine/lateral
  • women were siting, standing, squatting, kneeling or walking compared with a supine only position


Sensitivity analysis, which excluded lower quality trials, comparing sitting, standing, squatting, kneeling or walking with recumbent/supine/lateral did confirm this result.

 

2. More likely to have a vaginal birth if upright.

Subgroup analysis demonstrated this when:

  • women were walking compared with recumbent/supine/lateral
  • women were sitting, standing, squatting, kneeling or walking compared with recumbent/supine/lateral


Sensitivity analysis, which excluded lower quality trials, comparing sitting, standing, squatting, kneeling or walking with recumbent/supine/lateral did confirm this result.

3. Less likely to have operative birth if upright.

Subgroup analysis demonstrated this when:

  • women were sitting compared with recumbent/supine/lateral
  • women were walking compared with recumbent/supine/lateral
  • women were sitting, standing, squatting, kneeling or walking compared with recumbent/supine/lateral


Sensitivity analysis, which excluded lower quality trials, did confirm this result.

 

3. Less likely to have caesarean birth if upright.

Subgroup analysis demonstrated this when:

  • women were walking compared with recumbent/supine/lateral


Sensitivity analysis, which excluded lower quality trials, comparing sitting, standing, squatting, kneeling or walking with recumbent/supine/lateral did confirm this result.
1. Less likely to have an epidural if upright.

2. Lower pain scores if upright.

3. BUT More anxiety for nulliparous women if upright.

However this outcome is only from 1 study of 206 women.

 

 

Note: there were no data for: spontaneous rupture of membranes or hypotension requiring intervention.

Fetal / Neonatal 1. Less likely to have admission to NICU if mother is upright.

 

Comparison 2: Upright and ambulant positions versus recumbent positions and bed care (all women: epidural)

Outcomes showing significance

 Primary OutcomesSecondary Outcomes

Maternal1. More likely to have operative vaginal birth if multiparous and upright (subgroup analysis: parity only).

Note: there were no data for: duration of first stage labour; maternal satisfaction.
 

Note: there was no data for: artificial rupture of membranes; spontaneous rupture of membranes; estimated blood loss > 500 mL; perineal trauma.

Fetal / NeonatalNote: there were no data for: fetal distress requiring immediate birth or use of neonatal mechanical ventilation.Note: there were no data for: admission to the NICU.

 NICU: neonatal intensive care unit

 

Background

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

In cultures not influenced by Western society, women progress through the first stage of labour in upright positions and change position as they wish with no evidence of harmful effects to either the mother or the baby (Andrews 1990; Gupta 2012; Roberts 1989). Women in the developed world too, when encouraged, will choose a number of different positions as the first stage of labour progresses (Carlson 1986; Fenwick 1987; Roberts 1989; Rooks 1999), even though it is more common nowadays for them to labour in bed (Boyle 2000; Roberts 1989; Simkin 1989). Some studies have suggested that as a woman reaches five to six centimetres dilatation, there is a preference to lie down (Roberts 1980; Roberts 1984; Williams 1980). This may explain why women in randomised trials frequently have difficulty maintaining the position to which they have been assigned (Goer 1999), and suggests that there may not be a perfect universal position for women in the first stage of labour.

 

Description of the condition

Heralding the onset of second stage labour, first stage labour involves a co-ordinated series of complex physiological changes which results in full dilatation of the cervix. In readiness for birth of the baby (second stage) and separation and delivery of the placenta and membranes (third stage), the process of first stage labour may occur gradually over a period of days, or rapidly over a period of minutes. There are many factors which influence the duration and successful completion of first stage labour. These include the intensity and frequency of uterine contractions, whether the membranes have ruptured or not, the position and size of the baby or babies, the positioning and functioning of the placenta, the adequacy of the pelvis, and the physical and psychological well being of the mother.

 

Description of the intervention

Women who are in early labour are encouraged to remain in upright and mobile positions such as sitting, standing and walking until they are ready to give birth to their babies. There are many variations to being upright and mobile, but the key component is the ability for women to move and change position more quickly and easily as their labour progresses. Upright and mobile positions can be commenced and maintained in different places such as the home, shower or bath. They can be used with a variety of props such as a recliner chair or birthing ball. They can be alternated with other upright positions and can include comfort measures such as rocking the hips from side to side, leaning on a partner for support and intimacy and providing access to the lower back for massage or heat therapy.

 

How the intervention might work

Upright and mobile positions use gravity to aid descent of the fetal head into the pelvis. As the head is applied directly and evenly on the cervix, uterine contractions are intensified in strength, regularity and frequency. It is this uterine efficiency which aids cervical dilatation and successful completion of the first stage of labour. Study findings (Caldeyro-Barcia 1960; Lupe 1986; Mendez-Bauer 1980; Roberts 1983; Roberts 1984; Ueland 1969) have indicated that although contractions increased in strength in the upright or lateral position compared to the supine position, they were often negatively affected when a labouring woman lay down after being upright or mobile. This effect can often be reversed if the woman returns to an upright position. As effective contractions are vital to aid cervical dilatation and fetal descent, they have an important role in helping to reduce dystocia (slow progress in labour) (Roberts 1989; Rooks 1999; Walsh 2000).

Upright and mobile positions are also less likely to cause compression of the abdominal blood vessels by the pregnant uterus and this maximises uterine blood flow to the placenta and fetus during labour. Numerous studies show that a supine position in labour may have adverse physiological effects on the condition of the woman and her baby and on the progression of labour. The weight of the pregnant uterus can compress the abdominal blood vessels, compromising the mother's circulatory function including uterine blood flow (Abitbol 1985; Huovinen 1979; Marx 1982; Ueland 1969), and this may negatively affect the blood flow to the placenta (Cyna 2006; Roberts 1989; Rooks 1999; Walsh 2000). A recent study found an association between women who sleep supine during pregnancy and stillbirth (Stacey 2011). A related Cochrane review focuses on maternal position for fetal malpresentation in labour Hunter 2007.

Moving about can increase a woman's sense of control in labour by providing a self-regulated distraction from the challenge of labour (Albers 1997). Women who labour in water can move more easily than on land (Cluett 2009) and there is evidence to suggest immersion in water may reduce pain in labour (Jones 2012). Support from another person also appears to facilitate normal labour (Hodnett 2012). Increasing a woman's sense of control may have the effect of decreasing her need for analgesia (Albers 1997; Hodnett 2012; Lupe 1986; Rooks 1999) and it has also been suggested that upright positions in the first stage of labour may increase women's comfort (Simkin 2002).

 

Why it is important to do this review

Recumbent (lying down) positions in the first stage of labour are often promoted by care providers because they provide convenient access to the mother for abdominal palpation, fetal monitoring and vaginal examinations. Indeed some developments in technology such as fetal monitoring, epidurals for pain relief and the use of intravenous infusions have made it difficult and potentially unsafe for women to move about during labour. It is important, therefore, to assess the available evidence so that maternal positions which are shown to be safe and effective during first stage labour are actively encouraged. Clinicians providing care in first stage labour also need to provide clear, consistent, and evidence based explanation, so that women will understand both the risks and benefits of the positions they use and enable them to make informed decisions about the position choices they think will afford them most comfort.

 

Objectives

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

The purpose of this review is to assess the effects of different upright and recumbent positions and mobilisation for women in the first stage of labour on duration of labour, type of birth and other important outcomes for mothers and babies.

The primary objective is:

  • to compare the effects of upright (defined as walking and upright non-walking, e.g. sitting, standing, kneeling, squatting and all fours) positions with recumbent positions (supine, semi-recumbent and lateral) assumed by women in the first stage of labour on maternal, fetal and neonatal outcomes.

The secondary objectives are:

  • to compare the effects of semi-recumbent and supine positions with lateral positions assumed by women in the first stage of labour on maternal, fetal and neonatal outcomes;
  • to compare the effects of walking with upright non-walking positions (sitting, standing, kneeling, squatting, all fours) assumed by women in the first stage of labour on maternal, fetal and neonatal outcomes;
  • to compare the effects of walking with recumbent positions (supine, semi-recumbent and lateral) assumed by women in the first stage of labour on maternal, fetal and neonatal outcomes;
  • to compare allowing women to assume the position/s they choose with recumbent positions (supine, semi-recumbent and lateral) assumed by women in the first stage of labour on maternal, fetal and neonatal outcomes.

 

Methods

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Criteria for considering studies for this review

 

Types of studies

Randomised or quasi-randomised trials. We planned to include cluster randomised-trials which were otherwise eligible. Cross-over trials might be useful for short-term outcomes such as fetal heart rate patterns, but would not be appropriate for the main outcomes of this review and were not included.

 

Types of participants

Women in the first stage of labour.

 

Types of interventions

The type of intervention was the position or positions assumed by women in the first stage of labour. The positions assumed by a woman in the first stage of labour can be broadly categorised as being either upright or recumbent.

The positions considered recumbent were:

  • semi recumbent;
  • lateral;
  • supine;
  • dorsal (not prespecified in the protocol).
  • bed care (not prespecified in the protocol).

The positions considered upright included:

  • sitting;
  • standing;
  • walking;
  • kneeling;
  • squatting;
  • all fours (hands and knees).

 

Types of outcome measures

  • Maternal outcomes
  • Fetal outcomes
  • Neonatal outcomes

 

Primary outcomes

 
Primary maternal outcomes:

  • duration of first stage of labour;
  • mode of birth (spontaneous vaginal, operative vaginal or caesarean);
  • maternal satisfaction with positioning and with the childbirth experience.

 
Primary fetal and neonatal outcomes:

  • fetal distress requiring immediate birth;
  • use of neonatal mechanical ventilation.

 

Secondary outcomes

 
Secondary maternal outcomes:

  • pain as experienced by the woman;
  • use of analgesics (amount and type, e.g. epidural/opioid);
  • duration of second stage of labour;
  • augmentation of labour using oxytocin;
  • artificial rupture of membranes;
  • hypotension requiring intervention;
  • estimated blood loss > 500 mL;
  • perineal trauma (including episiotomy and third and fourth degree tears).

 
Secondary neonatal outcomes:

  • Apgar scores of less than seven at five minutes following birth; less than three at five minutes following birth and less than four at birth;
  • admission to the neonatal intensive care unit;
  • perinatal death (not prespecified in the protocol).

 

Search methods for identification of studies

 

Electronic searches

We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register by contacting the Trials Search Co-ordinator (31 January 2013).

The Cochrane Pregnancy and Childbirth Group’s Trials Register is maintained by the Trials Search Co-ordinator and contains trials identified from: 

  1. monthly searches of the Cochrane Central Register of Controlled Trials (CENTRAL);
  2. weekly searches of MEDLINE;
  3. weekly searches of Embase;
  4. handsearches of 30 journals and the proceedings of major conferences;
  5. weekly current awareness alerts for a further 44 journals plus monthly BioMed Central email alerts.

Details of the search strategies for CENTRAL, MEDLINE and Embase, the list of handsearched journals and conference proceedings, and the list of journals reviewed via the current awareness service can be found in the ‘Specialized Register’ section within the editorial information about the Cochrane Pregnancy and Childbirth Group

Trials identified through the searching activities described above are each assigned to a review topic (or topics). The Trials Search Co-ordinator searches the register for each review using the topic list rather than keywords.  

 

Searching other resources

We performed a manual search of the references of all retrieved articles and contacted expert informants.

We did not apply any language restrictions.

 

Data collection and analysis

We used methods described in the Cochrane Handbook for Systematic Reviews of Interventions for data collection, assessing study quality and analysing results (Higgins 2011).

 

Selection of studies

A minimum of two review authors independently assessed for inclusion all the potential studies identified as a result of the search strategy. We resolved any disagreement through discussion, or when required, we consulted an additional person.

 

Data extraction and management

For methods used in previous updates, please see Appendix 1.

For this update, we used the following methods.

We designed a form to extract data. At least two review authors extracted the data using the agreed form. We resolved discrepancies through discussion, or if required we consulted a third author. We entered data into Review Manager software (RevMan 2012), and checked for accuracy.

When information regarding any of the above was unclear, we attempted to contact authors of the original reports to provide further details.

 

Assessment of risk of bias in included studies

Two review authors independently assessed risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We resolved any disagreement by discussion or by involving a third assessor. Please see the 'Risk of bias' tables following the Characteristics of included studies tables for the assessment of bias for each study.

 

(1) Sequence generation (checking for possible selection bias)

We described for each included study the methods used to generate the allocation sequence to assess whether methods were truly random.

We assessed the methods as:

  • low risk of bias (any truly random process, e.g. random number table; computer random number generator);
  • high risk of bias (any non-random process, e.g. odd or even date of birth; hospital or clinic record number);
  • unclear risk of bias.

 

(2) Allocation concealment (checking for possible selection bias)

We described for each included study the method used to conceal the allocation sequence in sufficient detail and determined whether group allocation could have been foreseen in advance of, or during, recruitment, or changed afterwards.

We assessed the methods as:

  • low risk of bias (e.g. telephone or central randomisation; consecutively numbered sealed opaque envelopes);
  • high risk of bias (open random allocation; unsealed or non-opaque envelopes; alternation; date of birth);
  • unclear risk of bias.

 

(3.1) Blinding of participants and personnel (checking for possible performance bias)

We described for each included study the methods used, if any, to blind study participants and personnel from knowledge of which intervention a participant received. We considered that studies were at low risk of bias if they were blinded, or if we judged that the lack of blinding would be unlikely to affect results. We assessed blinding separately for different outcomes or classes of outcomes.

We assessed the methods as:

  • low, high or unclear risk of bias for participants;
  • low, high or unclear risk of bias for personnel.

 

(3.2) Blinding of outcome assessment (checking for possible detection bias)

We described for each included study the methods used, if any, to blind outcome assessors from knowledge of which intervention a participant received. We assessed blinding separately for different outcomes or classes of outcomes.

We assessed methods used to blind outcome assessment as:

  • low, high or unclear risk of bias.

 

(4) Incomplete outcome data (checking for possible attrition bias through withdrawals, dropouts, protocol deviations)

We described for each included study the completeness of outcome data, including attrition and exclusions from the analysis. We state whether attrition and exclusions were reported, the numbers (compared with the total randomised participants), reasons for attrition/exclusion where reported, and any re-inclusions in analyses which we have undertaken.

We assessed the methods as:

  • low risk of bias (e.g. no missing outcome data; missing outcome data balanced across groups);
  • high risk of bias (e.g. numbers or reasons for missing data imbalanced across groups; ‘as treated’ analysis done with substantial departure of intervention received from that assigned at randomisation);
  • unclear risk of bias.

 

(5) Selective reporting (checking for reporting bias)

We described for each included study how we investigated the possibility of selective outcome reporting bias and what we found.

We assessed the methods as:

  • low risk of bias (where it is clear that all of the study’s pre-specified outcomes and all expected outcomes of interest to the review have been reported);
  • high risk of bias (where not all the study’s pre-specified outcomes have been reported; one or more reported primary outcomes were not prespecified; outcomes of interest are reported incompletely and so cannot be used; study fails to include results of a key outcome that would have been expected to have been reported);
  • unclear risk of bias.

 

(6) Other bias (checking for bias due to problems not covered by 1 to 5 above)

We described for each included study any important concerns we have about other possible sources of bias.

We assessed whether each study was free of other problems that could put it at risk of bias:

  • low risk of other bias;
  • high risk of other bias;
  • unclear whether there is risk of other bias.

 

(7) Overall risk of bias

We made explicit judgements about whether studies were at high risk of bias, according to the criteria given in the Handbook (Higgins 2011). With reference to (1) to (6) above, we assessed the likely magnitude and direction of the bias and whether we considered it is likely to impact on the findings. We explored the impact of the level of bias through undertaking sensitivity analyses - see 'Sensitivity analysis' below.

 

Measures of treatment effect

We carried out statistical analysis using the Review Manager software (RevMan 2012). We used fixed-effect meta-analysis for combining data in the absence of significant heterogeneity if trials were sufficiently similar. When significant heterogeneity was present, we used a random-effects meta-analysis.

 

Dichotomous data

For dichotomous data, we have presented results as summary risk ratio (RR) with 95% confidence intervals (CI).

 

Continuous data

For continuous data (e.g. maternal pain and satisfaction when measured as scores or on visual analogue scales) we used the mean difference (MD) if outcomes were measured in the same way between trials. We planned to use the standardised mean difference (SMD) to combine trials that measured the same outcome, but used different methods.  

 

Unit of analysis issues

 

Cluster-randomised trials

We intended to include cluster-randomised trials in the analyses along with individually-randomised trials, and to adjust sample sizes using the methods described in Gates 2005 and Higgins 2011.

We identified no cluster randomised trials in this version of the review, but if we identify such trials in future searches we will include them in updates.

 

Cross-over Trials

Cross-over trials might be useful for short-term outcomes such as fetal heart rate patterns, but would not be appropriate for the main outcomes of this review and were not included.

 

Dealing with missing data

For included studies, we noted levels of attrition. Where data were not reported for some outcomes or groups, we attempted to contact the study authors for further information. 

 

Intention-to-treat analysis (ITT)

We had intended to analyse data on all participants with available data in the group to which they were allocated, regardless of whether or not they received the allocated intervention. If in the original reports participants were not analysed in the group to which they were randomised, and there was sufficient information in the trial report, we attempted to restore them to the correct group (e.g. this applied to data from the Calvert 1982 study).

 

Assessment of heterogeneity

We assessed statistical heterogeneity in each meta-analysis using the T², I² and Chi² statistics. We regarded heterogeneity as substantial if the T² was greater than zero and either the I² was greater than 30% or there was a low P value (less than 0.10) in the Chi² test for heterogeneity. In such cases we took the following steps:

  1. we performed a sensitivity analysis, in which methodological weak trials were removed from the analyses and results compared for the primary outcomes;
  2. we visually inspected forest plots for evidence of inconsistency in results;
  3. we compared the results of fixed-effect and random-effects analyses.

 

Assessment of reporting biases

If there were 10 or more studies in the meta-analysis for any particular outcome, we investigated reporting biases (such as publication bias) using funnel plots. We assessed possible asymmetry visually. If asymmetry was suggested by a visual assessment, we performed exploratory analyses to investigate it.

 

Data synthesis

We carried out statistical analysis using the RevMan software (RevMan 2012). We used fixed-effect meta-analysis for combining data where it was reasonable to assume that studies were estimating the same underlying treatment effect: i.e. where trials examined the same intervention, and where we judged the trials’ populations and methods to be sufficiently similar. If we suspected clinical heterogeneity was sufficient to expect the underlying treatment effects differed between trials, or if substantial statistical heterogeneity was detected, we used random-effects meta-analysis to produce an overall summary. We only performed this analysis if we considered the average treatment effect across trials was clinically meaningful. We defined heterogeneity as substantial if a given meta-analysis resulted in an I² value greater than 30%, and there was inconsistency among trials in the direction or magnitude of effects (judged visually in the forest plot), or a low (less than 0.10) P value in the Chi² test for heterogeneity. The random-effects summary was treated as the average range of possible treatment effects and the clinical implications of treatment effects differing between trials is discussed. If the average treatment effect was not clinically meaningful, we did not combine trials. Where we used random-effects analyses, the results were presented as the average treatment effect with 95% confidence intervals, and the estimates of T² and I².

 

Subgroup analysis and investigation of heterogeneity

For the main outcomes of duration of first stage labour and method of birth, we performed subgroup analyses by:

  1. Parity: nulliparous women versus multiparous women;
  2. Onset of labour: spontaneous labour versus induction of labour;
  3. Position types: specific upright positions and or combinations versus specific recumbent positions:
    1. sitting versus recumbent/supine lateral;
    2. walking versus recumbent/supine lateral;
    3. sitting, standing, squatting, kneeling and/or walking (mixed) versus recumbent/supine lateral;
    4. sitting versus bed care;
    5. walking versus bed care;
    6. sitting, standing, squatting, kneeling and/or walking (mixed) versus bed care;
    7. sitting, standing, squatting, kneeling and/or walking versus supine only.

We had also planned subgroup analysis by women with a low-risk pregnancy (no complications, greater than or equal to 37 weeks' gestation, singleton with a cephalic presentation) versus high-risk pregnancy, but data were not available to carry out this analysis.

We assessed subgroup differences by interaction tests available within RevMan (RevMan 2012). We reported the results of subgroup analyses quoting the χ2 statistic and P value, and the interaction test I² value.

 

Sensitivity analysis

We carried out sensitivity analyses to explore the effect of trial quality for important outcomes in the review.  Where there was high or unclear risk of bias associated with allocation concealment, we excluded poor quality studies from the analyses in order to assess whether this made any difference to the overall result.

 

Results

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies

 

Results of the search

We identified a total of 84 reports representing 57 studies by the search strategy.

 

Included studies

We included 25 studies with a total of 5218 women in the review  Table 1.

Studies were carried out in 13 countries from 1963 to 2012 (almost 50 years): seven in the UK (Boyle 2002; Calvert 1982; Collis 1999; Fernando 1994; Flynn 1978; McManus 1978; Williams 1980); five in the USA (Andrews 1990; Bloom 1998; Mitre 1974; Nageotte 1997; Vallejo 2001); two in France (Frenea 2004; Karraz 2003); and one each in Australia (MacLennan 1994), Brazil (Miquelutti 2007), Finland (Haukkama 1982;), Hong Kong (Chan 1963), India (Mathew 2012), Iran (Taavoni 2011), Japan (Chen 1987), Sweden (Bundsen 1982), Taiwan (Gau 2011), Thailand (Phumdoung 2007) and Tunisia Ben Regaya 2010.

Most trials had small numbers of participants of between 40 to 300 women. Exceptions to this included Boyle 2002 (409 women); Nageotte 1997 (761 women) and Bloom 1998 (1067 women).

The majority of the trials included women at more than 36 weeks' gestation with no obstetric or medical complications (Andrews 1990; Ben Regaya 2010; Bloom 1998; Calvert 1982; Chen 1987; Collis 1999; Frenea 2004; Haukkama 1982; Karraz 2003; MacLennan 1994; Miquelutti 2007; Mitre 1974; Nageotte 1997; Phumdoung 2007; Taavoni 2011; Vallejo 2001).

Twelve studies included only nulliparous women (Andrews 1990; Ben Regaya 2010; Chan 1963; Collis 1999; Fernando 1994; Mathew 2012: Miquelutti 2007; Mitre 1974; Nageotte 1997; Phumdoung 2007; Taavoni 2011; Vallejo 2001);

There was considerable variation about the combinations of upright, mobile and recumbent used in the study protocols. Variations included:

  1. walking compared with lateral position (Flynn 1978); walking compared with dorsal or lateral positions (Ben Regaya 2010; Frenea 2004); walking compared with supine, semi supine or lateral position (Karraz 2003); walking compared with care in bed (Bloom 1998; Boyle 2002; Bundsen 1982; Nageotte 1997; Williams 1980);
  2. walking or sitting compared with supine or lateral positions (Chan 1963); walking or sitting compared with lateral position (McManus 1978; Vallejo 2001); walking or sitting compared with care in bed (Calvert 1982; Haukkama 1982; MacLennan 1994; Mathew 2012); walking, sitting or standing compared with care in bed (Collis 1999; Fernando 1994); walking, sitting, squatting, kneeling, or standing compared with supine, lateral or prone positions (Andrews 1990); walking, sitting, standing, crouching or kneeling compared with care in bed (Miquelutti 2007);
  3. sitting compared with supine position (Mitre 1974); sitting compared with dorsal or lateral position (Chen 1987); sitting, standing, kneeling or squatting compared with care in bed (Gau 2011); and sitting compared with care in bed (Taavoni 2011);
  4. kneeling compared with supine position (Phumdoung 2007).

 

Excluded studies

We excluded 32 studies from the review. Several of the studies were not randomised trials or it was not clear that there had been random allocation to groups (Allahbadia 1992; Asselineau 1996; Caldeyro-Barcia 1960; Li 2010; Solano 1982); three of the studies used cross-over designs (Melzack 1991; Molina 1997; Roberts 1984). One study (Diaz 1980 ) was excluded because more than 30% of the intervention group were excluded post-randomisation, as they did not comply with the protocol. This high rate of attrition meant it was difficult to interpret results. In the Hemminki 1983 study, women in the two groups received different packages of care, so it was not possible to separate out the treatment effect of maternal position on outcomes. It remains unclear if McCormick 2007 was successfully completed or not.

In some studies, the intervention did not compare mobility or upright positions with recumbent positions; for example, Cobo 1968 and Wu 2001 examined lying in bed on one side rather than the other, or lying supine. Liu 1989 compared semi-upright position with the lying flat position. These positions were both defined as recumbent positions for the purpose of this review. In some studies position/mobility was compared with an alternative intervention, for example the Hemminki 1985 study included women experiencing delay in labour and compared the use of immediate oxytocin with ambulation and delayed oxytocin. Similarly, Read 1981 examined oxytocin in labour. There were a couple of epidural studies, the COMET 2001 study compared women receiving different types of epidural, whereas, Ducloy-Bouthors 2006 compared epidural spread. One study (Weiniger 2009) compared walking to the toilet to void with using a bedpan in bed. In another (Hodnett 1982) the primary outcome was electronic fetal monitoring, with all women having bed care receiving an epidural, which was not the case for the ambulating women. Two studies focused on interventions in the second, rather than in the first stage of labour (Stewart 1983; Radkey 1991).

Several studies, which may otherwise have been eligible, focused on outcomes which had not been pre-specified in this review. For example, Danilenko-Dixon 1996 focused on cardiac output, while the study by Schmidt 2001 and those by Ahmed 1985; Cohen 2002; Divon 1985, and Schneider-Affeld 1982 (reported in brief abstracts) did not provide sufficient information on outcomes or present outcome data in a form that we were able to use in the review.

 

Risk of bias in included studies

The overall quality of the included studies was difficult to assess as many of the studies gave very little information about the methods used.

The methodological quality graph Figure 1 shows the review authors' judgements about each methodological quality item presented as percentages across all included studies.

 FigureFigure 1. Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.

The methodological quality summary Figure 2 shows the review authors' judgements about each methodological quality item for each included study.

 FigureFigure 2. Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

 

Allocation

The method of sequence generation was often not mentioned in the included studies. In the studies by Boyle 2002, Gau 2011, Miquelutti 2007 and Vallejo 2001, a computer-generated list of random numbers was used; MacLennan 1994 used variable blocks with stratification; six of the included studies utilised a quasi-randomised design, where the allocation to groups was according to hospital or case-note number or by alternate allocation (Calvert 1982; Chan 1963; Chen 1987; Mathew 2012; Taavoni 2011; Williams 1980); for the remaining 14 studies, the method of sequence generation was not stated.

The methods used to conceal group allocation from those recruiting women to the trials were also frequently not described. Eight studies referred to group allocation details being contained in envelopes. In the studies by Boyle 2002, Collis 1999, Gau 2011, MacLennan 1994, and Miquelutti 2007 the envelopes were described as sealed and opaque, and in the other studies envelopes were described as plain, numbered or sealed (Ben Regaya 2010, Frenea 2004; McManus 1978). In sensitivity analysis where studies of better and poorer quality have been separated, we regarded the eight studies that gave details of allocation concealment as the better quality studies, while we regarded those studies where allocation concealment was inadequate (e.g. in the quasi-randomised studies), or where methods were unclear as poorer quality.

 

Blinding

In the type of interventions we were considering (maternal positions and mobility), blinding women and their clinical carers to group allocation was not feasible. It was possible that partial blinding of outcome assessors could have been performed for some types of outcomes, but it was not clear that this was achieved in any of the included studies. The lack of blinding may introduce bias, and this should be kept in mind when interpreting the results.

 

Incomplete outcome data

Some studies failed to report on the outcomes of the total population recruited.  An example of incomplete data is method of birth. The study by Miquelutti 2007 reported data for the number of women having spontaneous vaginal birth, but not for operative vaginal births or caesarean births. The study by Taavoni 2011 reported intention-to-treat data for the number of women having caesarean births, but no data were reported for the number having spontaneous vaginal or operative vaginal births.

 

Selective reporting

Several studies had limited outcomes to report, or claimed evidence of an outcome with little or no data to support it. For example, Bundsen 1982 concluded that telemetric monitoring (ambulation) had great value both psychologically and for medical reasons, but the only data provided was for the numbers of vacuum extractions and caesarean sections in each group. Mitre 1974 claimed that women in the sitting group had more comfort, but provided no supporting detail. In the study by Fernando 1994 no maternal outcomes were reported, and in many studies no neonatal outcomes were reported (Andrews 1990; Bundsen 1982; Karraz 2003; Mathew 2012; Phumdoung 2007; Taavoni 2011).

 

Other potential sources of bias

There was wide variation in the types of interventions tested in the included studies. Some authors gave very little information on the intervention employed, for example, how many centimetres dilated was the woman when the intervention was started, what exactly women were asked to do and what instructions were given to women in the control groups. Further, co-interventions in included studies also varied. This lack of detail means that the interpretation of results is not simple and readers should bear this variability in mind when reading the results of the review.

This review update includes pooled analyses for four comparisons with more than 10 studies. We constructed funnel plots for these comparisons (Figure 3; Figure 4; Figure 5; Figure 6). Visual assessment of the plots did not show asymmetry, suggesting there is no evidence of publication bias.

 FigureFigure 3. Funnel plot of comparison: 1 Upright and ambulant positions versus recumbent positions and bed care, outcome: 1.1 Duration of first stage labour (hours).
 FigureFigure 4. Funnel plot of comparison: 1 Upright and ambulant positions versus recumbent positions and bed care, outcome: 1.8 Mode of birth: spontaneous vaginal.
 FigureFigure 5. Funnel plot of comparison: 1 Upright and ambulant positions versus recumbent positions and bed care, outcome: 1.15 Mode of birth: operative vaginal: all women.
 FigureFigure 6. Funnel plot of comparison: 1 Upright and ambulant positions versus recumbent positions and bed care, outcome: 1.22 Mode of birth: caesarean birth.

 

Effects of interventions

See:  Summary of findings for the main comparison Summary of Outcomes

 

Comparison 1: Upright and ambulant positions versus recumbent positions and bed care (without epidural: all women) - 18 trials, 3337 women.

 

Primary outcomes

 

Duration of the first stage of labour

The duration of the first stage of labour varied considerably within and between trials. There were high levels of heterogeneity when studies were pooled (I2 = 93%). Hence, results need to be interpreted with caution. In view of the high levels of heterogeneity, we used a random-effects model for these analyses.

Overall the first stage of labour was approximately one hour and twenty-two minutes shorter for those randomised to upright compared with supine and recumbent positions. This analysis included pooled results from 15 trials (involving 2503 women) and the average effect between groups was statistically significant (average mean difference (MD) -1.36, 95% confidence interval (CI) -2.22 to -0.51; random-effects, T2 = 2.39, Chi2 = 203.55, df=14, (P < 0.00001), I2 = 93%) ( Analysis 1.1).

  • Subgroup analysis: Parity

The duration of first stage was approximately one hour and thirteen minutes shorter for nulliparous women randomised to upright positions compared with supine and recumbent positions (average MD -1.21, 95% CI -2.35 to -0.07; 12 trials, 1486 women; random-effects, T2 = 3.42, Chi2 = 195.59, df = 11, (P < 0.00001), I2 = 94%) ( Analysis 1.2). For multiparous women the duration of first stage was approximately half an hour shorter for those randomised to upright positions, but the evidence of a difference between groups did not reach statistical significance.

  • Subgroup analysis: Onset of labour

It was not possible to perform this subgroup analysis as there were no trials that reported that labour had been induced. For women with spontaneous labour, the duration of the first stage of labour was approximately one hour and twenty-five minutes shorter for those randomised to upright compared with supine and recumbent positions (average MD -1.43, 95% CI -2.35 to -0.50; 11 trials, 2114 women; random-effects, T2 = 2.08, Chi2 = 154.40, df = 10, (P < 0.00001), I2 = 94%) ( Analysis 1.3).

  • Subgroup analysis: Position types and combinations

For women who were randomised to sit, compared to those who were randomised to a recumbent, supine or lateral position, the duration of the first stage of labour was approximately two hours and twenty-three minutes shorter (average MD -2.39, 95% CI -4.06 to -0.72; three trials, 252 women; random-effects, T2 = 1.96, Chi2 = 26.07, df = 2, (P < 0.00001), I2 = 92%) ( Analysis 1.4).

For women who were randomised to walk, compared to those who were randomised to a recumbent, supine or lateral position, the duration of the first stage of labour was approximately three hours and fifty-seven minutes shorter (average MD -3.96, 95% CI -5.36 to -2.57; three trials, 302 women; random-effects, T2 = 1.04, Chi2 = 6.58, df = 2, (P < 0.04), I2 = 70%) ( Analysis 1.4).

For women who were randomised to sit, stand, squat, kneel or walk compared with those who were randomised to a recumbent, supine or lateral position, the duration of the first stage of labour was approximately two hours and eleven minutes shorter (average MD -2.19, 95% CI -3.49 to -0.89; eight trials, 849 women; random-effects, T2 = 3.24, Chi2 = 119.83, df = 7, (P < 0.00001), I2 = 94%) ( Analysis 1.5). For women who were randomised to sit, stand, squat, kneel or walk compared to those who were randomised to bed care, there was no difference in the duration of the first stage of labour. There was a difference between the two subgroups, those randomised to recumbent, supine or lateral position, compared with those randomised to bed care, and substantial heterogeneity was indicated (Chi2 = 10.17, df = 1, (P = 0.001), I2 = 90.2%) ( Analysis 1.5).

For women who were randomised to sit, stand, squat, kneel or walk compared to those who were randomised to a supine only position, the duration of the first stage of labour was approximately two hours and fourteen minutes shorter (average MD -2.24, 95% CI -3.23 to -1.26; two trials, 183 women; random-effects, T2 = 0.36, Chi2 = 3.32, df = 1, (P = 0.07), I2 = 70%) ( Analysis 1.6).

  • Sensitivity Analysis

When trials of lower quality were excluded, and women who were randomised to sit, stand, squat, kneel or walk were compared to those who were randomised to a recumbent, supine or lateral position, the duration of the first stage of labour was approximately five hours shorter. However, this analysis only included results from one trial of 200 women (average MD -5.00, 95% CI -6.05 to -3.95) ( Analysis 1.7).

 

Mode of birth

 
Spontaneous vaginal birth

Overall, more women had a spontaneous vaginal birth when randomised to upright versus recumbent positions, but these results were not quite statistically significant ( Analysis 1.8).

  • Subgroup analysis: Parity

More nulliparous women had a spontaneous vaginal birth when randomised to upright versus recumbent positions, but these results were not statistically significant ( Analysis 1.9). There were no differences between subgroups of nulliparous and multiparous women (test for subgroup differences: Chi² = 0.53, df = 1 (P = 0.46), I² = 0%).

  • Subgroup analysis: Onset of labour

More women with spontaneous onset of labour had a spontaneous vaginal birth when randomised to upright versus recumbent positions, but these results were not statistically significant ( Analysis 1.10). There were no differences between subgroups (test for subgroup differences: Chi² = 1.95, df = 1 (P = 0.16), I² = 48.8%).

  • Subgroup analysis: Position types and combinations

Women who were randomised to walk, compared to those who were randomised to a recumbent, supine or lateral position, were more likely to have spontaneous vaginal birth (risk ratio (RR) 1.26, 95% CI 1.11 to 1.42; three trials, 306 women; random-effects, T2 = 0.00, Chi2 = 1.05, df = 2, (P = 0.59), I2 = 0%) ( Analysis 1.11).

Women who were randomised to sit, stand, squat, kneel or walk compared to those who were randomised to a recumbent, supine or lateral position, were more likely to have spontaneous vaginal birth (RR 1.14, 95% CI 1.03 to 1.26; six trials, 746 women; random-effects,  T2 = 0.01, Chi2 = 8.33, df = 5, (P = 0.14), I2 = 40%) ( Analysis 1.12). For women who were randomised to sit, stand, squat, kneel or walk compared to those who were randomised to bed care, there was no difference in the number of women achieving spontaneous vaginal birth. There was a difference between the two subgroups, those randomised to recumbent, supine or lateral position, compared with those randomised to bed care, and substantial heterogeneity was indicated (Chi2 = 5.06, df = 1, (P=0.02), I2 = 80.2%) ( Analysis 1.12).

No trials comparing upright and mobile positions with supine only positions (Mitre 1974; Phumdoung 2007) reported mode of birth outcome data (Analysis 1.13).

  • Sensitivity Analysis

When trials of lower quality were excluded, and women who were randomised to sit, stand, squat, kneel or walk were compared to those who were randomised to a recumbent, supine or lateral position, women were more likely to have spontaneous vaginal birth (RR 1.20, 95% CI 1.05 to 1.38; two trials, 240 women; Chi2 = 0.42, df = 1, (P = 0.52), I2 = 0%) ( Analysis 1.14).

 
Operative vaginal birth

Overall, fewer women had operative vaginal birth when randomised to upright versus recumbent positions, however these results were not statistically significant ( Analysis 1.15).

  • Subgroup analysis: Parity

Fewer nulliparous women had operative vaginal birth when randomised to upright versus recumbent positions, however these results were not statistically significant ( Analysis 1.16). There were no differences between subgroups of nulliparous and multiparous women (test for subgroup differences: Chi² = 0.00, df = 1 (P = 0.95), I² = 0%).

  • Subgroup analysis: Onset of labour

Fewer women required operative vaginal birth when randomised to upright versus recumbent positions, irrespective of onset of labour, although results were not statistically significant ( Analysis 1.17). There were no differences between subgroups (test for subgroup differences: Chi² = 0.64, df = 1 (P = 0.42), I² = 0%).

  • Subgroup analysis: Position types and combinations

Women who were randomised to sit, compared to those who were randomised to a recumbent, supine or lateral position, were less likely to have operative vaginal birth (RR 0.18, 95% CI 0.04 to 0.75; two trials, 225 women; Chi2 = 0.10, df = 1, (P = 0.75), I2 = 0%) ( Analysis 1.18).

Women who were randomised to walk, compared to those who were randomised to a recumbent, supine or lateral position, were less likely to have operative vaginal birth (RR 0.50, 95% CI 0.28 to 0.89; three trials, 306 women; Chi2 = 2.32, df = 2, (P = 0.31), I2 = 14%) ( Analysis 1.18). There was a difference between subgroups, (Chi² = 12.06, df = 4 (P = 0.02), I² = 66.8%) ( Analysis 1.18).

Women who were randomised to sit, stand, squat, kneel or walk compared to those who were randomised to a recumbent, supine or lateral position, were less likely to have operative vaginal birth (RR 0.62, 95% CI 0.43 to 0.89; six trials, 746 women; Chi2 = 6.76, df = 5, (P = 0.24), I2 = 26%) ( Analysis 1.19). For women who were randomised to sit, stand, squat, kneel or walk compared to those who were randomised to bed care, there was no difference in the number of women having operative vaginal birth. There was a difference between the two subgroups, those randomised to recumbent, supine or lateral position, compared with those randomised to bed care, and substantial heterogeneity was indicated (Chi2 = 7.29, df = 1, (P=0.007), I2 = 86.3%) ( Analysis 1.19).

Neither of the two trials comparing upright and mobile positions with supine only positions (Mitre 1974; Phumdoung 2007) reported mode of birth outcome data (Analysis 1.20).

  • Sensitivity Analysis

When trials of lower quality were excluded, and women who were randomised to sit, stand, squat, kneel or walk were compared to those who were randomised to a recumbent, supine or lateral position, there was no statistically significant difference ( Analysis 1.21).

 
Caesarean birth

Overall, women encouraged to maintain upright and mobile positions had lower rates of caesarean birth compared with those in the comparison recumbent groups. The analysis included pooled results from 14 trials (including 2682 women) and the difference between groups was statistically significant (RR 0.71, 95% CI 0.54 to 0.94, Chi2 = 9.27, df = 12, (P = 0.68), I2 = 0%) ( Analysis 1.22).

Subgroup analysis: Parity

Fewer women required caesarean birth, regardless of parity, but these results were not statistically significant ( Analysis 1.23). There we no differences between nulliparous and multiparous women (test for subgroup differences: Chi² = 0.64, df = 1 (P = 0.42), I² = 0%).

  • Subgroup analysis: Onset of labour

Fewer women required caesarean birth, regardless of onset of labour, but these results were not statistically significant ( Analysis 1.24). There were no differences between subgroups (test for subgroup differences: Chi² = 0.45, df = 1 (P = 0.50), I² = 0%).

  • Subgroup analysis: Position types and combinations

For women who were randomised to walk, compared to those who were randomised to a recumbent, supine or lateral position, those who were randomised to upright compared with recumbent positions had less caesarean births (RR 0.31, 95% CI 0.12 to 0.79; three trials, 306 women; Chi2 = 0.00, df = 1, (P = 0.97), I2 = 0%) ( Analysis 1.25).

Women who were randomised to sit, stand, squat, kneel or walk compared to those who were randomised to a recumbent, supine or lateral position, were less likely to have caesarean birth, however this result did not reach significance ( Analysis 1.26). Women who were randomised to sit, stand, squat, kneel or walk compared to those who were randomised to bed care, were also less likely to have caesarean birth, however these results did not reach significance. For this outcome there was no difference between the two subgroups, those randomised to recumbent, supine or lateral position, compared with those randomised to bed care, (Chi2 = 0.09, df = 1, (P = 0.77), I2 = 0%) ( Analysis 1.26).

Neither of the trials comparing upright and mobile positions with supine only positions (Mitre 1974; Phumdoung 2007) reported mode of birth outcome data (Analysis 1.27).

  • Sensitivity Analysis

When trials of lower quality were excluded, women who were randomised to sit, stand, squat, kneel or walk compared to those who were randomised to a recumbent, supine or lateral position, were less likely to have caesarean birth (RR 0.35, 95% CI 0.14 to 0.86; two trials, 240 women; Chi2 = 0.63, df = 1, (P = 0.43), I2 = 0%) ( Analysis 1.28).

 

Maternal satisfaction

While some studies collected information on satisfaction with specific aspects of care (e.g. satisfaction with position, position preference and comfort score), the results were inconclusive. ( Analysis 1.30;  Analysis 1.31).

 

Fetal and neonatal outcomes

There were no significant differences between groups in terms of fetal distress requiring immediate delivery or use of neonatal mechanical ventilation ( Analysis 1.43;  Analysis 1.44).

 

Secondary outcomes

 

Maternal pain and analgesia

There were no statistically significant differences between the two trials reporting pain and anxiety outcomes for women in upright positions compared to those who received bed care ( Analysis 1.33;  Analysis 1.35), however women in recumbent positions reported higher pain scores at 4 cm and 8 cm dilatation using a Visual Analogue Scale (VAS) and the Verbal Response Scale (VRS) in one trial (87 women) ( Analysis 1.34).

There were no differences between groups in terms of complaints of discomfort (RR 0.68, 95% CI 0.12 to 3.72; three trials, 338 women; Chi2 = 9.15, df = 2, (P = 0.01), I2 = 78%) ( Analysis 1.32), although the results for this outcome were very inconsistent, with results strongly in both directions reflected in the very high I2 values. A random-effects analysis was used because of the heterogeneity, but it is important to note that the average treatment effect may not be a good summary. There were also no differences in the use of opioid analgesia ( Analysis 1.29). However, women randomised to upright positions were less likely to have epidural analgesia, with the difference reaching statistical significance (RR 0.81, 95% CI 0.66 to 0.99, nine studies, 2107 women; random-effects) ( Analysis 1.29).

The amount of analgesia received by women in the two groups was measured in one trial, but the difference between groups was not statistically significant ( Analysis 1.36).

 

Interventions in labour

 
Augmentation of labour using oxytocin

Women randomised to upright versus recumbent positions had less requirement for augmentation of labour, with the difference not quite reaching statistical significance (RR 0.89, 95% CI 0.76 to 1.05; eight studies, 1826 women) ( Analysis 1.38). In three studies, amniotomy was carried out routinely on all women (Bundsen 1982; Chen 1987; McManus 1978) and in two studies, all women's labours were induced (Bundsen 1982; McManus 1978) ( Analysis 1.39).

 

Duration of the second stage of labour

There was no difference between groups in the duration of the second stage of labour in the nine trials that reported this outcome ( Analysis 1.37).

 

Maternal outcomes

No studies reported outcomes for hypotension requiring intervention Analysis 1.40. There was no difference for estimated blood loss greater than 500 mL  Analysis 1.41. Women randomised to upright positions did have less use of episiotomy, but the difference did not reach statistical significance (RR 0.92, 95% CI 0.82 to 1.04; three studies, 1374 women)  Analysis 1.42. No studies reported outcomes for second or third degree perineal tears  Analysis 1.42.

 

Fetal and neonatal outcomes

There were no significant differences between groups in Apgar scores or admission to level I or II nursery ( Analysis 1.45;  Analysis 1.46).

Admission to neonatal intensive care units was reported in one study (200 women) as being less for babies born to mothers randomised to upright positions (RR 0.20, 95% CI 0.04 to 0.89) ( Analysis 1.46).

Five studies examined perinatal deaths; three deaths were reported in one study (Chan 1963). One less death occurred in the group where mothers were assigned to upright positions, but the results were not statistically significant ( Analysis 1.47).

 

Comparison 2: Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women) - seven trials, 1881 women

 

Primary outcomes

 

Duration of the first stage of labour

Duration of labour times were not used because they were recorded as either insertion of epidural time (which was highly variable) to 10 cm cervical dilatation (Frenea 2004; Vallejo 2001), or to delivery (at the end of second stage) (Collis 1999; Karraz 2003) (Analysis 2.1).

 

Mode of birth

Rates of spontaneous vaginal, operative vaginal and caesarean birth were similar for women randomised to upright versus recumbent positions ( Analysis 2.2;  Analysis 2.8;  Analysis 2.14).

  • Subgroup analysis: Parity

There were no differences between subgroups of multiparous women compared to nulliparous women in spontaneous vaginal births, operative vaginal births or caesarean sections ( Analysis 2.3;  Analysis 2.9;  Analysis 2.15).

  • Subgroup analysis: Onset of labour

Due to lack of data, it was not possible to perform subgroup analysis for onset of labour ( Analysis 2.4;  Analysis 2.10;  Analysis 2.16).

  • Subgroup analysis: Position types and combinations

For women who were randomised to sit, stand, squat, kneel or walk compared to those who were randomised to recumbent/supine/lateral or bed care, there was no differences between subgroups in spontaneous vaginal births, operative vaginal births or caesarean sections ( Analysis 2.6;  Analysis 2.12;  Analysis 2.18).

  • Sensitivity Analysis

There were no significant differences in the sensitivity analysis results relating to spontaneous vaginal births, operative vaginal births or caesarean births ( Analysis 2.7;  Analysis 2.13;  Analysis 2.19).

 

Secondary outcomes

 

Maternal pain and other outcomes

There were no differences between groups in terms of number of women requiring additional bupivacaine bolus doses for pain relief (RR 0.57, 95% CI 0.22 to 1.48; two trials, 720 women; Chi2 = 7.46, df = 1, (P = 0.006), I2 = 87%) ( Analysis 2.21), although the results for this outcome were very inconsistent, with results strongly in both directions reflected in the very high I2 values. A random-effects analysis was used because of the heterogeneity, but it is important to note that the average treatment effect may not be a good summary. There were no statistically significant differences between groups in terms of the amount of analgesia women required for pain relief ( Analysis 2.22), the number of women receiving oxytocin augmentation ( Analysis 2.24), and the number of women experiencing hypotension ( Analysis 2.26).

 

Neonatal outcomes

There was no information on perinatal mortality or admission to neonatal care units. There were no differences between groups in the incidence of Apgar scores of less than seven at one and five minutes ( Analysis 2.31).

 

Discussion

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

The objectives of this review were to assess the effects of positions and mobility during first stage of labour on duration of labour, type of birth and other important outcomes for mothers and babies.

The decision to treat trials comparing upright with recumbent positions (Comparison 1) differently from trials comparing upright with recumbent positions whereby all women have epidural at time of study entry (Comparison 2), was based on the opinion that epidurals are associated with prolonged labour, an increased requirement for augmentation and an increased incidence of operative vaginal birth (Anim-Somuah 2011; Kemp 2013; Simmons 2012). When mode of birth outcomes for both comparisons were pooled ( Table 2), we did find that women in the Comparison 1 group were more likely to have vaginal birth (83% compared to 59%), and women in Comparison 2 group were more likely to have operative vaginal birth (26% compared to 10%), and caesarean birth (16% compared to 7%). This demonstrated a difference in comparison characteristics and affirms our decision to treat the studies differently.

 

Summary of main results

We performed 80 meta-analyses in order to evaluate how a variety of maternal positions used during first stage labour affect the birth process and outcomes for mothers and babies.

For Comparison 1, women who were upright or mobile compared to those who were recumbent had a shorter first stage of labour ( Analysis 1.1); were less likely to have a caesarean birth ( Analysis 1.22); had less pain ( Analysis 1.34); were less likely to have an epidural ( Analysis 1.29); and their babies were less likely to be admitted to the neonatal intensive care unit ( Analysis 1.46).

Subgroup analysis demonstrated that nulliparous women and those who had spontaneous labour at trial entry were more likely to have a shorter duration of labour when upright or mobile ( Analysis 1.2;  Analysis 1.3). Women who laboured with sitting, standing, squatting, kneeling or walking positions, compared with supine, dorsal or lateral recumbent positions, had shorter durations of labour ( Analysis 1.4;  Analysis 1.5;  Analysis 1.6); more spontaneous vaginal births ( Analysis 1.11;  Analysis 1.12); less operative births ( Analysis 1.18;  Analysis 1.19); and less caesarean births ( Analysis 1.25).

Sensitivity analysis was performed to exclude those trials of lower quality. Comparison was made between women who used sitting, standing, squatting, kneeling or walking positions, and those who used supine, dorsal or lateral recumbent positions. This analysis confirmed that being upright or mobile during first stage labour was more likely to result in a shorter duration of first stage labour ( Analysis 1.7), more likely to result in spontaneous vaginal birth ( Analysis 1.14) and less likely to result in caesarean birth ( Analysis 1.28).

For Comparison 2, where all women had epidural at trial entry, subgroup analysis demonstrated that nulliparous women who were upright were more likely to have operative vaginal births, compared with multiparous women who were supine ( Analysis 2.9).

The outcomes of this review demonstrate benefit to the well being of mothers and babies. There is evidence that adopting an upright or mobile position during first stage labour reduces the duration of first stage, with no additional risk to mother or baby. Therefore, women in low-risk labour should be informed of the benefits of upright positions, and encouraged and assisted to assume whatever position they choose. Moving around in labour often requires continuous one-to-one support from a midwife/nurse, this reduces the need for pain medication and increases the likelihood of spontaneous vaginal delivery (Hodnett 2012).

 

Overall completeness and applicability of evidence

When considering the results of this review, it is important to consider the new evidence that women encouraged to maintain upright positions had lower rates of caesarean birth. This is an important finding as rates of caesarean birth continue to rise worldwide and most women and healthcare clinicians would like to see a reduction in caesarean birth as the procedure is not without risk for both mother and baby. Another new finding was that babies of mothers who were upright were less likely to be admitted to the neonatal unit. However, it would be prudent to treat this finding with caution as it is based on the results of one study only.

Most of the included studies collected information on mode of birth, but few had the statistical power to detect differences between groups. Few included studies collected outcome data on review outcomes such as pain, maternal satisfaction, and neonatal outcomes. Disappointingly, the many studies reporting Apgar scores, did so by different methods and at differing end points. Most reported the numbers of babies with Apgar scores less that seven at one and or five minutes (Calvert 1982; Haukkama 1982; MacLennan 1994; McManus 1978; Miquelutti 2007; Williams 1980), but Bloom 1998 reported scores less than three at five minutes, Gau 2011 reported scores less than eight at five minutes, and others only reported scores as means (Ben Regaya 2010; Boyle 2002; Mitre 1974), meaning that outcome data could not be pooled uniformly in these instances.

Studies were carried out over a long period: from the early 1960s (Chan 1963) through to 2012 (Mathew 2012); and in a number of different healthcare settings  Table 3. The cultural and healthcare context is likely to have been different at different times and in different settings, and there have also been changes in healthcare technologies. Within these changing contexts, the attitudes and expectations of healthcare staff, women and their partners towards pain, pain relief and appropriate behaviour during labour and childbirth have shifted. All of these factors are important in the interpretation of results.

 

Quality of the evidence

As labour is a dynamic and complex process with many physical and emotional variables, designing trials that examine interventions related to women in labour is challenging and it is difficult to avoid bias (Gupta 2000; Hollins Martin 2013; McNabb 1989; Stewart 1989). It is not possible to blind women or their caregivers to group allocation. In addition, it is difficult to standardise interventions. Due to the heterogeneity of trial interventions and participants, the inconsistencies within trials, and the variable trial quality, study findings are difficult to interpret, and the results of this review should be interpreted with caution.

For the main outcome, duration of first stage labour, there was considerable variation within and between studies in terms of average duration of first stage labour (hours). For nulliparous women means varied from 1.67 hours to 18.22 hours and for multiparous women means varied from 1.2 hours to 7.8 hours. Studies defined and measured the duration of the first stage of labour in different ways. For example, Chen 1987 recorded the duration as 5 to 10 cm, Taavoni 2011 as 4 to 8 cm, and Andrews 1990 as 4 to 9 cm.

The review included women from many countries around the world, all with differing ages, obstetric and medical histories, ethnicity, customs, beliefs and supports. There was considerable variation in the position interventions women received and how these positions were described. In the studies by Nageotte 1997 and Vallejo 2001, ambulation was defined as a minimum of five minutes of walking per hour, in the study by Frenea 2004 women were asked to walk 15 minutes each hour, and in the study by Andrews 1990 the position intervention was assumed when the woman was anywhere between 4 to 9 cm.

There was also variability in the amount of time women adhered to the protocol in terms of ambulation or staying in bed. In the study by Bloom 1998, of the 536 women assigned to the walking group only 380 women actually walked. In the study by Calvert 1982, of the 100 women assigned to telemetry, only 45 women actually got out of bed. In the study by MacLennan 1994, of the 96 women randomised to ambulate, only 37 women actually chose to ambulate for half an hour or more. In the study by Miquelutti 2007, women assigned to be upright only managed to achieve this for 57% of the time. It is clear that many of the women in these studies had difficulty maintaining the intervention position though out the whole duration of their first stage and preferred and often used alternative positions.

Further, there was also variation in the models of birth care, institutional procedures, and caregiver behaviour in relation to study protocols. In some studies, women were strongly encouraged by staff to mobilise (e.g. in the study by Miquelutti 2007 any woman in the intervention group that remained in bed for more than 30 minutes was asked to get out again) and in other studies, women had more choice and only gentle encouragement (Boyle 2002). In one study the intervention was only encouraged during the day as it was not felt that women would like to walk around at night (Karraz 2003), additionally women in the comparison group were not allowed out of bed even to walk to the toilet.

 

Potential biases in the review process

In order to minimise the potential for bias during the process of preparing this Cochrane Review, we have made every attempt to adhere to the study protocol (Lewis 2002). Any rationales for post hoc decisions to vary study protocol outcome data or methods of meta-analyses are clearly stated within the review.

 

Agreements and disagreements with other studies or reviews

The findings of this review should be considered alongside other related Cochrane reviews focusing on care during labour (e.g. Cluett 2009; Gupta 2012; Hodnett 2012; Hunter 2007; Kemp 2013). While position in the first stage of labour may have an independent effect, the position in second stage and other variables (e.g. the presence of a birth companion) are also important.

 

Authors' conclusions

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

 

Implications for practice

Upright positions and walking are associated with a reduction in the duration of the first stage of labour, use of epidural as a method of pain relief and caesarean birth. There is also evidence that there is less chance of babies being admitted to the neonatal unit. Despite many of the trials included in this review being of lesser quality, sensitivity analysis of the higher quality trials indicated that the main findings of this review were robust. It is likely that women's preferences for positioning change as the first stage of labour progresses (Gupta 2000) and, if given the opportunity, many women may choose an upright or ambulant position in early first stage labour and then choose to lie down as their labour progresses. Studies examining the physiology of maintaining a supine position in labour suggest adverse physiological effects on the labouring woman and her baby (Abitbol 1985; Huovinen 1979; Marx 1982; Roberts 1989; Rooks 1999; Stacey 2011; Walsh 2000). Therefore, we believe wherever possible, women should be informed of the benefits of upright positions, encouraged and supported to take up whatever positions they choose, they should not have their freedom of movement options restricted unless clinically indicated, and they should avoid spending long periods supine.

 
Implications for research

Overall, the quality of the studies included in the review was mixed and most studies provided little information on methods. Minimising risk of bias in trials on this topic is challenging, as blinding is not feasible and it is difficult to standardise interventions. At the same time, some aspects of study design can be controlled.

Some considerations for future research are as follows.

  • There is a need for larger high-quality multicentre trials, with particular attention given to allocation concealment (selection bias) and reporting of all pre-specified outcome criteria (reporting bias).
  • Researchers should clearly explain how they have defined the duration of first stage of labour and include full statistical details (e.g. P values and standard deviations (SDs)).
  • Mode of birth outcomes should include full intention-to-treat data.
  • More studies are needed that compare different upright positions (e.g. sitting upright versus walking) and different lying positions (e.g. lying on side versus back).
  • More studies are needed that include women who are not low risk (e.g. all women undergoing induction of labour; all women with gestational diabetes or obesity; all women planning to have epidural pain relief prior to labour).
  • There is a need to collect more detailed information on outcomes for mothers, such as the effect of position on complications (e.g. hypotension, precipitous birth, prolonged birth, post-partum haemorrhage).
  • There is a need to improve and standardise measurements of all outcome data, including maternal pain, control and satisfaction.
  • Few trials assessed comparable outcomes for babies and future studies need to focus on this.

 

Acknowledgements

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

We would like to acknowledge the technical and statistical advice provided by Philippa Middleton, Miranda Cumpston and Damien Jolley.

We would also like to thank Caroline Crowther, Lea Budden, Joan Webster and Therese Dowswell for their advice on early versions of this review.

As part of the pre-publication editorial process, this review has been commented on by two peers (an editor and referee who is external to the editorial team), a member of the Pregnancy and Childbirth Group's international panel of consumers and the Group's Statistical Adviser.

The National Institute for Health Research (NIHR) is the largest single funder of the Cochrane Pregnancy and Childbirth Group. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health.

 

Data and analyses

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
Download statistical data

 
Comparison 1. Upright and ambulant positions versus recumbent positions and bed care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Duration of first stage labour (hours)152503Mean Difference (IV, Random, 95% CI)-1.36 [-2.22, -0.51]

 2 Duration of first stage labour (hours): subgroup analysis: parity12Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 Nulliparous women
121486Mean Difference (IV, Random, 95% CI)-1.21 [-2.35, -0.07]

    2.2 Multiparous women
4662Mean Difference (IV, Random, 95% CI)-0.56 [-1.19, 0.06]

 3 Duration of first stage labour (hours): subgroup analysis: onset of labour11Mean Difference (IV, Random, 95% CI)Subtotals only

    3.1 Spontaneous labour: all women
112114Mean Difference (IV, Random, 95% CI)-1.43 [-2.35, -0.50]

   3.2 Induction of labour: all women
00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 4 Duration of first stage labour (hours): subgroup analysis: position types15Mean Difference (IV, Random, 95% CI)Subtotals only

    4.1 Sitting vs Recumbent / supine / lateral
3252Mean Difference (IV, Random, 95% CI)-2.39 [-4.06, -0.72]

    4.2 Walking vs Recumbent / supine / lateral
3302Mean Difference (IV, Random, 95% CI)-3.96 [-5.36, -2.57]

    4.3 Sitting, standing, squatting, kneeling or walking vs Recumbent / supine / lateral
3311Mean Difference (IV, Random, 95% CI)-1.02 [-3.36, 1.33]

    4.4 Sitting vs Bed care
160Mean Difference (IV, Random, 95% CI)0.11 [-0.29, 0.51]

    4.5 Walking vs Bed care
21170Mean Difference (IV, Random, 95% CI)-0.03 [-0.44, 0.38]

    4.6 Sitting, standing, squatting, kneeling or walking vs Bed care
4424Mean Difference (IV, Random, 95% CI)-0.52 [-1.49, 0.45]

 5 Duration of first stage labour (hours): subgroup analysis: position types15Mean Difference (IV, Random, 95% CI)Subtotals only

    5.1 Sitting, standing, squatting, kneeling or walking vs Recumbent / supine / lateral
8849Mean Difference (IV, Random, 95% CI)-2.19 [-3.49, -0.89]

    5.2 Sitting, standing, squatting, kneeling or walking vs Bed care
71654Mean Difference (IV, Random, 95% CI)-0.03 [-0.30, 0.25]

 6 Duration of first stage labour (hours): subgroup analysis: position types2Mean Difference (IV, Random, 95% CI)Subtotals only

    6.1 Sitting, standing, squatting, kneeling or walking vs supine only
2183Mean Difference (IV, Random, 95% CI)-2.24 [-3.23, -1.26]

 7 Duration of first stage labour (hours): sensitivity analysis - positions3364Mean Difference (IV, Fixed, 95% CI)-3.86 [-4.73, -2.99]

    7.1 Trials of better quality - Sitting, standing, squatting, kneeling or walking vs Recumbent / supine / lateral
1200Mean Difference (IV, Fixed, 95% CI)-3.00 [-6.05, -3.95]

    7.2 Trials of better quality - Sitting, standing, squatting, kneeling or walking vs Bed care
2164Mean Difference (IV, Fixed, 95% CI)-1.33 [-2.89, 0.23]

 8 Mode of birth: spontaneous vaginal142626Risk Ratio (M-H, Random, 95% CI)1.05 [0.99, 1.11]

 9 Mode of birth: spontaneous vaginal: subgroup analysis: parity8Risk Ratio (M-H, Random, 95% CI)Subtotals only

    9.1 Nulliparous women
81282Risk Ratio (M-H, Random, 95% CI)1.06 [0.96, 1.17]

    9.2 Multiparous women
4675Risk Ratio (M-H, Random, 95% CI)1.02 [0.99, 1.05]

 10 Mode of birth: spontaneous vaginal: subgroup analysis: onset of labour10Risk Ratio (M-H, Random, 95% CI)Subtotals only

    10.1 Spontaneous labour: all women
82124Risk Ratio (M-H, Random, 95% CI)1.04 [0.97, 1.12]

    10.2 Induction of labour: all women
2100Risk Ratio (M-H, Random, 95% CI)1.24 [0.98, 1.57]

 11 Mode of birth: spontaneous vaginal: subgroup analysis: position types14Risk Ratio (M-H, Random, 95% CI)Subtotals only

    11.1 Sitting vs Recumbent / supine / lateral
2225Risk Ratio (M-H, Random, 95% CI)1.20 [0.88, 1.64]

    11.2 Walking vs Recumbent / supine / lateral
3306Risk Ratio (M-H, Random, 95% CI)1.26 [1.11, 1.42]

    11.3 Sitting, standing, squatting, kneeling or walking vs Recumbent / supine / lateral
2235Risk Ratio (M-H, Random, 95% CI)1.00 [0.85, 1.17]

   11.4 Sitting vs Bed care
00Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    11.5 Walking vs Bed care
41426Risk Ratio (M-H, Random, 95% CI)1.01 [0.93, 1.11]

    11.6 Sitting, standing, squatting, kneeling or walking vs Bed care
4454Risk Ratio (M-H, Random, 95% CI)1.00 [0.92, 1.08]

 12 Mode of birth: spontaneous vaginal: subgroup analysis: position types14Risk Ratio (M-H, Random, 95% CI)Subtotals only

    12.1 Sitting, standing, squatting, kneeling or walking vs Recumbent / supine / lateral
6746Risk Ratio (M-H, Random, 95% CI)1.14 [1.03, 1.26]

    12.2 Sitting, standing, squatting, kneeling or walking vs Bed care
81880Risk Ratio (M-H, Random, 95% CI)1.00 [0.97, 1.04]

13 Mode of birth: spontaneous vaginal: subgroup analysis: position types0Risk Ratio (M-H, Random, 95% CI)Subtotals only

   13.1 Sitting, standing, squatting, kneeling or walking vs supine only
00Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

 14 Mode of birth: spontaneous vaginal: sensitivity analysis - positions5630Risk Ratio (M-H, Fixed, 95% CI)1.03 [0.94, 1.13]

    14.1 Trials of better quality - Sitting, standing, squatting, kneeling or walking vs Recumbent / supine / lateral
2240Risk Ratio (M-H, Fixed, 95% CI)1.2 [1.05, 1.38]

    14.2 Trials of better quality - Sitting, standing, squatting, kneeling or walking vs Bed care
3390Risk Ratio (M-H, Fixed, 95% CI)0.93 [0.83, 1.05]

 15 Mode of birth: operative vaginal: all women132519Risk Ratio (M-H, Fixed, 95% CI)0.91 [0.73, 1.14]

 16 Mode of birth: operative vaginal: subgroup analysis: parity7Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    16.1 Nulliparous women
71175Risk Ratio (M-H, Fixed, 95% CI)0.87 [0.65, 1.18]

    16.2 Multiparous women
4675Risk Ratio (M-H, Fixed, 95% CI)0.91 [0.24, 3.51]

 17 Mode of birth: operative vaginal: subgroup analysis: onset of labour9Risk Ratio (M-H, Random, 95% CI)Subtotals only

    17.1 Spontaneous labour: all women
72017Risk Ratio (M-H, Random, 95% CI)0.93 [0.62, 1.39]

    17.2 Induction of labour: all women
2100Risk Ratio (M-H, Random, 95% CI)0.61 [0.23, 1.58]

 18 Mode of birth: operative vaginal: subgroup analysis: position types13Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    18.1 Sitting vs Recumbent / supine / lateral
2225Risk Ratio (M-H, Fixed, 95% CI)0.18 [0.04, 0.75]

    18.2 Walking vs Recumbent / supine / lateral
3306Risk Ratio (M-H, Fixed, 95% CI)0.5 [0.28, 0.89]

    18.3 Sitting, standing, squatting, kneeling or walking vs Recumbent / supine / later
2235Risk Ratio (M-H, Fixed, 95% CI)0.94 [0.58, 1.52]

   18.4 Sitting vs Bed care
00Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    18.5 Walking vs Bed care
41426Risk Ratio (M-H, Fixed, 95% CI)1.19 [0.84, 1.68]

    18.6 Sitting, standing, squatting, kneeling or walking vs Bed care
3347Risk Ratio (M-H, Fixed, 95% CI)1.15 [0.67, 1.96]

 19 Mode of birth: operative vaginal: subgroup analysis: position types13Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    19.1 Sitting, standing, squatting, kneeling or walking vs Recumbent / supine / later
6746Risk Ratio (M-H, Fixed, 95% CI)0.62 [0.43, 0.89]

    19.2 Sitting, standing, squatting, kneeling or walking vs Bed care
71773Risk Ratio (M-H, Fixed, 95% CI)1.17 [0.88, 1.57]

20 Mode of birth: operative vaginal: subgroup analysis: position types0Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

   20.1 Sitting, standing, squatting, kneeling or walking vs supine only
00Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 21 Mode of birth: operative vaginal: sensitivity analysis - positions4523Risk Ratio (M-H, Fixed, 95% CI)0.98 [0.67, 1.45]

    21.1 Trials of better quality - Sitting, standing, squatting, kneeling or walking vs Recumbent / supine / lateral
2240Risk Ratio (M-H, Fixed, 95% CI)0.67 [0.34, 1.31]

    21.2 Trials of better quality - Sitting, standing, squatting, kneeling or walking vs Bed care
2283Risk Ratio (M-H, Fixed, 95% CI)1.22 [0.76, 1.97]

 22 Mode of birth: caesarean birth142682Risk Ratio (M-H, Fixed, 95% CI)0.71 [0.54, 0.94]

 23 Mode of birth: caesarean birth: subgroup analysis: parity8Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    23.1 Nulliparous women
81237Risk Ratio (M-H, Fixed, 95% CI)0.79 [0.52, 1.18]

    23.2 Multiparous women
4675Risk Ratio (M-H, Fixed, 95% CI)0.55 [0.22, 1.38]

 24 Mode of birth: caesarean birth: subgroup analysis: onset of labour10Risk Ratio (M-H, Random, 95% CI)Subtotals only

    24.1 Spontaneous labour: all women
82079Risk Ratio (M-H, Random, 95% CI)0.70 [0.49, 1.01]

    24.2 Induction of labour: all women
2100Risk Ratio (M-H, Random, 95% CI)0.29 [0.02, 3.86]

 25 Mode of birth: caesarean birth: subgroup analysis: position types14Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    25.1 Sitting vs Recumbent / supine / lateral
2225Risk Ratio (M-H, Fixed, 95% CI)1.02 [0.36, 2.84]

    25.2 Walking vs Recumbent / supine / lateral
3306Risk Ratio (M-H, Fixed, 95% CI)0.31 [0.12, 0.79]

    25.3 Sitting, standing, squatting, kneeling or walking vs Recumbent / supine / lateral
2235Risk Ratio (M-H, Fixed, 95% CI)1.30 [0.46, 3.63]

    25.4 Sitting vs Bed care
162Risk Ratio (M-H, Fixed, 95% CI)3.0 [0.13, 70.92]

    25.5 Walking vs Bed care
41426Risk Ratio (M-H, Fixed, 95% CI)0.70 [0.45, 1.09]

    25.6 Sitting, standing, squatting, kneeling or walking vs Bed care
3448Risk Ratio (M-H, Fixed, 95% CI)0.74 [0.46, 1.21]

 26 Mode of birth: caesarean birth: subgroup analysis: position types14Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    26.1 Sitting, standing, squatting, kneeling or walking vs Recumbent / supine / lateral
6746Risk Ratio (M-H, Fixed, 95% CI)0.67 [0.39, 1.15]

    26.2 Sitting, standing, squatting, kneeling or walking vs Bed care
81936Risk Ratio (M-H, Fixed, 95% CI)0.73 [0.53, 1.02]

27 Mode of birth: caesarean birth: subgroup analysis: position types0Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

   27.1 Sitting, standing, squatting, kneeling or walking vs supine only
00Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 28 Mode of birth: caesarean birth: sensitivity analysis - positions4624Risk Ratio (M-H, Fixed, 95% CI)0.72 [0.48, 1.09]

    28.1 Trials of better quality - Sitting, standing, squatting, kneeling or walking vs Recumbent
2240Risk Ratio (M-H, Fixed, 95% CI)0.35 [0.14, 0.86]

    28.2 Trials of better quality - Sitting, standing, squatting, kneeling or walking vs Bed care
2384Risk Ratio (M-H, Fixed, 95% CI)0.94 [0.59, 1.52]

 29 Analgesia type10Risk Ratio (M-H, Random, 95% CI)Subtotals only

    29.1 Opioid
71831Risk Ratio (M-H, Random, 95% CI)0.99 [0.85, 1.15]

    29.2 Epidural
92107Risk Ratio (M-H, Random, 95% CI)0.81 [0.66, 0.99]

    29.3 Entonox
3300Risk Ratio (M-H, Random, 95% CI)0.97 [0.72, 1.31]

 30 Maternal satisfaction1Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    30.1 Satisfaction with position reported at 6 cm
1107Risk Ratio (M-H, Fixed, 95% CI)1.31 [0.60, 2.85]

    30.2 Preferred upright position
1107Risk Ratio (M-H, Fixed, 95% CI)1.25 [0.97, 1.61]

 31 Maternal comfort140Mean Difference (IV, Fixed, 95% CI)0.74 [-0.27, 1.75]

    31.1 Comfort score
140Mean Difference (IV, Fixed, 95% CI)0.74 [-0.27, 1.75]

 32 Maternal pain6Risk Ratio (M-H, Random, 95% CI)Subtotals only

    32.1 Complaints of discomfort/labour more uncomfortable
3338Risk Ratio (M-H, Random, 95% CI)0.68 [0.12, 3.72]

    32.2 Requiring analgesia
41536Risk Ratio (M-H, Random, 95% CI)0.95 [0.84, 1.08]

 33 Maternal pain2400Mean Difference (IV, Fixed, 95% CI)6.36 [-0.31, 13.03]

 34 Maternal pain2Mean Difference (IV, Fixed, 95% CI)Subtotals only

    34.1 Visual Analogue Scale (VAS) Score
160Mean Difference (IV, Fixed, 95% CI)-1.74 [-2.51, -0.97]

    34.2 Visual Analogue Scale (VAS) Score @ 4 cm
187Mean Difference (IV, Fixed, 95% CI)-2.0 [-2.70, -1.30]

    34.3 Visual Analogue Scale (VAS) Score @ 8 cm
187Mean Difference (IV, Fixed, 95% CI)-1.70 [-2.20, -1.20]

    34.4 Verbal Response Scale (VRS) Score @ 4 cm
187Mean Difference (IV, Fixed, 95% CI)-10.40 [-13.27, -7.53]

    34.5 Verbal Response Scale (VRS) Score@ 8 cm
187Mean Difference (IV, Fixed, 95% CI)-5.00 [-11.33, -2.67]

    34.6 Present Pain Intensity Scale (PPI) @ 4 cm
187Mean Difference (IV, Fixed, 95% CI)-1.40 [-3.61, 0.81]

    34.7 Present Pain Intensity Scale (PPI) @ 8 cm
187Mean Difference (IV, Fixed, 95% CI)-0.80 [-3.76, 2.16]

 35 Maternal anxiety1200Mean Difference (IV, Fixed, 95% CI)8.0 [-0.19, 16.19]

 36 Analgesia amount140Mean Difference (IV, Fixed, 95% CI)-17.5 [-36.89, 1.89]

    36.1 Narcotics and other analgesia
140Mean Difference (IV, Fixed, 95% CI)-17.5 [-36.89, 1.89]

 37 Duration of second stage of labour (minutes)92077Mean Difference (IV, Random, 95% CI)-3.71 [-9.37, 1.94]

 38 Augmentation of labour using oxytocin81826Risk Ratio (M-H, Fixed, 95% CI)0.89 [0.76, 1.05]

 39 Artificial rupture of membranes4276Risk Ratio (M-H, Fixed, 95% CI)1.02 [0.95, 1.10]

40 Hypotension requiring intervention00Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 41 Estimated blood loss > 500 mL2240Risk Ratio (M-H, Fixed, 95% CI)0.71 [0.14, 3.55]

 42 Perineal trauma3Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    42.1 Episiotomy
31374Risk Ratio (M-H, Fixed, 95% CI)0.92 [0.82, 1.04]

   42.2 Second-degree tears
00Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

   42.3 Third-degree tears
00Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 43 Fetal distress (requiring immediate delivery)61757Risk Ratio (M-H, Fixed, 95% CI)0.69 [0.35, 1.33]

 44 Use of neonatal mechanical ventilation21107Risk Ratio (M-H, Fixed, 95% CI)0.77 [0.19, 3.10]

    44.1 Intubation in delivery room
21107Risk Ratio (M-H, Fixed, 95% CI)0.77 [0.19, 3.10]

 45 Apgar scores8Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    45.1 Apgar < 4 at birth
140Risk Ratio (M-H, Fixed, 95% CI)0.2 [0.01, 3.92]

    45.2 Apgar < 7 at 1 min
6706Risk Ratio (M-H, Fixed, 95% CI)0.84 [0.54, 1.31]

    45.3 Apgar < 7 at 5 mins
4466Risk Ratio (M-H, Fixed, 95% CI)3.27 [0.34, 31.05]

    45.4 Apgar < 3 at 5 mins
11067Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    45.5 Apgar < 8 at 5 mins
187Risk Ratio (M-H, Fixed, 95% CI)0.12 [0.01, 2.19]

 46 Admission to NICU2396Risk Ratio (M-H, Fixed, 95% CI)0.58 [0.25, 1.36]

    46.1 Admission to NICU
1200Risk Ratio (M-H, Fixed, 95% CI)0.2 [0.04, 0.89]

    46.2 Admission to Level I or II nursery
1196Risk Ratio (M-H, Fixed, 95% CI)1.56 [0.45, 5.37]

 47 Perinatal mortality51564Risk Ratio (M-H, Fixed, 95% CI)0.50 [0.05, 5.37]

 
Comparison 2. Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women)

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

1 Duration of first stage labour: (minutes)00Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 2 Mode of birth: spontaneous vaginal61566Risk Ratio (M-H, Fixed, 95% CI)0.96 [0.89, 1.05]

 3 Mode of birth: spontaneous vaginal: subgroup analysis: parity4Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    3.1 Nulliparous women
41179Risk Ratio (M-H, Fixed, 95% CI)0.94 [0.84, 1.04]

    3.2 Multiparous women
1111Risk Ratio (M-H, Fixed, 95% CI)1.02 [0.81, 1.27]

 4 Mode of birth: spontaneous vaginal: subgroup analysis: onset of labour1Risk Ratio (M-H, Random, 95% CI)Subtotals only

    4.1 Spontaneous labour: all women
1505Risk Ratio (M-H, Random, 95% CI)0.94 [0.81, 1.09]

   4.2 Induction of labour: all women
00Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

 5 Mode of birth: spontaneous vaginal: subgroup analysis: position types6Risk Ratio (M-H, Random, 95% CI)Subtotals only

   5.1 Sitting vs Recumbent / supine / lateral
00Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    5.2 Walking vs Recumbent / supine / lateral
2276Risk Ratio (M-H, Random, 95% CI)1.02 [0.81, 1.28]

    5.3 Sitting, standing, squatting, kneeling or walking vs Recumbent / supine / lateral
1151Risk Ratio (M-H, Random, 95% CI)0.92 [0.75, 1.13]

   5.4 Sitting vs Bed care
00Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    5.5 Walking vs Bed care
2910Risk Ratio (M-H, Random, 95% CI)0.93 [0.83, 1.06]

    5.6 Sitting, standing, squatting, kneeling or walking vs Bed care
1229Risk Ratio (M-H, Random, 95% CI)1.00 [0.78, 1.27]

 6 Mode of birth: spontaneous vaginal: subgroup analysis: position types6Risk Ratio (M-H, Random, 95% CI)Subtotals only

    6.1 Sitting, standing, squatting, kneeling or walking vs Recumbent / supine / lateral
3427Risk Ratio (M-H, Random, 95% CI)0.99 [0.86, 1.15]

    6.2 Sitting, standing, squatting, kneeling or walking vs Bed care
31139Risk Ratio (M-H, Random, 95% CI)0.95 [0.85, 1.06]

 7 Mode of birth: spontaneous vaginal: sensitivity analysis3Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    7.1 Trials of better quality - Sitting, standing, squatting, kneeling or walking vs Recumbent / supine / lateral
161Risk Ratio (M-H, Fixed, 95% CI)0.85 [0.61, 1.20]

    7.2 Trials of better quality - Sitting, standing, squatting, kneeling or walking vs Bed care
2634Risk Ratio (M-H, Fixed, 95% CI)0.95 [0.81, 1.11]

 8 Mode of birth: operative vaginal61566Risk Ratio (M-H, Fixed, 95% CI)1.06 [0.90, 1.25]

 9 Mode of birth: operative vaginal: subgroup analysis: parity4Risk Ratio (M-H, Random, 95% CI)Subtotals only

    9.1 Nulliparous women
41084Risk Ratio (M-H, Random, 95% CI)1.36 [0.95, 1.94]

    9.2 Multiparous women
1111Risk Ratio (M-H, Random, 95% CI)1.09 [0.49, 2.42]

 10 Mode of birth: operative vaginal: subgroup analysis: onset of labour1Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    10.1 Spontaneous labour: all women
1505Risk Ratio (M-H, Fixed, 95% CI)1.18 [0.88, 1.59]

   10.2 Induction of labour: all women
00Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 11 Mode of birth: operative vaginal: subgroup analysis: position types6Risk Ratio (M-H, Random, 95% CI)Subtotals only

   11.1 Sitting vs Recumbent / supine / lateral
00Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    11.2 Walking vs Recumbent / supine / lateral
2276Risk Ratio (M-H, Random, 95% CI)1.17 [0.56, 2.44]

    11.3 Sitting, standing, squatting, kneeling or walking vs Recumbent / supine / lateral
1151Risk Ratio (M-H, Random, 95% CI)2.03 [0.73, 5.65]

   11.4 Sitting vs Bed care
00Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    11.5 Walking vs Bed care
2910Risk Ratio (M-H, Random, 95% CI)1.03 [0.81, 1.31]

    11.6 Sitting, standing, squatting, kneeling or walking vs Bed care
1229Risk Ratio (M-H, Random, 95% CI)1.00 [0.69, 1.45]

 12 Mode of birth: operative vaginal: subgroup analysis: position types6Risk Ratio (M-H, Random, 95% CI)Subtotals only

    12.1 Sitting, standing, squatting, kneeling or walking vs Recumbent / supine / lateral
3427Risk Ratio (M-H, Random, 95% CI)1.41 [0.77, 2.56]

    12.2 Sitting, standing, squatting, kneeling or walking vs Bed care
31139Risk Ratio (M-H, Random, 95% CI)1.02 [0.86, 1.20]

 13 Mode of birth: operative vaginal: sensitivity analysis3Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    13.1 Trials of better quality - Sitting, standing, squatting, kneeling or walking vs Recumbent / supine / lateral
161Risk Ratio (M-H, Fixed, 95% CI)1.55 [0.49, 4.95]

    13.2 Trials of better quality - Sitting, standing, squatting, kneeling or walking vs Bed care
2634Risk Ratio (M-H, Fixed, 95% CI)0.95 [0.77, 1.16]

 14 Mode of birth: caesarean birth61566Risk Ratio (M-H, Fixed, 95% CI)1.05 [0.83, 1.32]

 15 Mode of birth: caesarean birth: subgroup analysis: parity4Risk Ratio (M-H, Random, 95% CI)Subtotals only

    15.1 Nulliparous women
41084Risk Ratio (M-H, Random, 95% CI)1.14 [0.75, 1.73]

    15.2 Multiparous women
1206Risk Ratio (M-H, Random, 95% CI)1.31 [0.55, 3.09]

 16 Mode of birth: caesarean birth: subgroup analysis: onset of labour1Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    16.1 Spontaneous labour: all women
1505Risk Ratio (M-H, Fixed, 95% CI)0.95 [0.64, 1.40]

   16.2 Induction of labour: all women
00Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 17 Mode of birth: caesarean birth: subgroup analysis: position types6Risk Ratio (M-H, Random, 95% CI)Subtotals only

   17.1 Sitting vs Recumbent / supine / lateral
00Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    17.2 Walking vs Recumbent / supine / lateral
2276Risk Ratio (M-H, Random, 95% CI)0.74 [0.35, 1.56]

    17.3 Sitting, standing, squatting, kneeling or walking vs Recumbent / supine / lateral
1151Risk Ratio (M-H, Random, 95% CI)0.95 [0.49, 1.82]

   17.4 Sitting vs Bed care
00Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    17.5 Walking vs Bed care
2910Risk Ratio (M-H, Random, 95% CI)1.20 [0.74, 1.94]

    17.6 Sitting, standing, squatting, kneeling or walking vs Bed care
1229Risk Ratio (M-H, Random, 95% CI)1.01 [0.53, 1.95]

 18 Mode of birth: caesarean birth: subgroup analysis: position types6Risk Ratio (M-H, Random, 95% CI)Subtotals only

    18.1 Sitting, standing, squatting, kneeling or walking vs Recumbent / supine / lateral
3427Risk Ratio (M-H, Random, 95% CI)0.81 [0.52, 1.28]

    18.2 Sitting, standing, squatting, kneeling or walking vs Bed care
31139Risk Ratio (M-H, Random, 95% CI)1.15 [0.83, 1.59]

 19 Mode of birth: caesarean birth: sensitivity analysis3Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    19.1 Trials of better quality - Sitting, standing, squatting, kneeling or walking vs Recumbent / supine / lateral
161Risk Ratio (M-H, Fixed, 95% CI)1.29 [0.38, 4.35]

    19.2 Trials of better quality - Sitting, standing, squatting, kneeling or walking vs Bed care
2634Risk Ratio (M-H, Fixed, 95% CI)1.35 [0.93, 1.96]

20 Maternal satisfaction00Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 21 Maternal pain2Risk Ratio (M-H, Random, 95% CI)Subtotals only

    21.1 Requiring additional Bupivocaine bolus doses
2720Risk Ratio (M-H, Random, 95% CI)0.57 [0.22, 1.48]

 22 Analgesia amount5Mean Difference (IV, Random, 95% CI)Subtotals only

    22.1 Bupivocaine
3463Mean Difference (IV, Random, 95% CI)-0.24 [-2.32, 1.84]

    22.2 Ropivacaine
1151Mean Difference (IV, Random, 95% CI)19.70 [0.77, 38.63]

    22.3 Fentanyl
1229Mean Difference (IV, Random, 95% CI)-0.38 [-1.99, 1.23]

    22.4 Bupivocaine & Fentanyl
1409Mean Difference (IV, Random, 95% CI)-1.37 [-7.59, 4.85]

 23 Duration of second stage of labour (minutes)2204Mean Difference (IV, Fixed, 95% CI)2.35 [-15.22, 19.91]

 24 Augmentation of labour using oxytocin51161Risk Ratio (M-H, Fixed, 95% CI)0.98 [0.90, 1.07]

25 Artificial rupture of membranes00Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 26 Hypotension requiring intervention3781Risk Ratio (M-H, Fixed, 95% CI)1.12 [0.52, 2.45]

27 Estimated blood loss > 500 mL00Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

28 Perineal trauma0Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

   28.1 Episiotomy
0Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

   28.2 Second-degree tears
0Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

   28.3 Third-degree tears
0Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

29 Fetal distress (requiring immediate delivery)00Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

30 Use of neonatal mechanical ventilation00Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 31 Apgar scores5Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    31.1 Apgar < 7 at 1 min
2191Risk Ratio (M-H, Fixed, 95% CI)1.01 [0.37, 2.76]

    31.2 Apgar < 7 at 5 mins
4835Risk Ratio (M-H, Fixed, 95% CI)1.04 [0.21, 5.05]

32 Admission to NICU00Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

33 Perinatal mortality00Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 

Appendices

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Appendix 1. Data extraction and analysis - methods used in previous updates

We designed a form to extract data. At least two review authors extracted the data using the agreed form. We resolved discrepancies through discussion, or if required we consulted a third author. We entered data into Review Manager software (RevMan 2008), and checked for accuracy.

When information regarding any of the above was unclear, we attempted to contact authors of the original reports to provide further details.

 

Assessment of risk of bias in included studies  

Two review authors independently assessed risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We resolved any disagreement by discussion or by involving a third assessor. Please see the 'Risk of bias' tables following the Characteristics of included studies tables for the assessment of bias for each study.

 

(1) Sequence generation (checking for possible selection bias)

We described for each included study the methods used to generate the allocation sequence to assess whether methods were truly random.

We assessed the methods as:

  • adequate (e.g. random number table; computer random number generator);
  • inadequate (odd or even date of birth; hospital or clinic record number);
  • unclear.   

 

(2) Allocation concealment (checking for possible selection bias)

We described for each included study the method used to conceal the allocation sequence in sufficient detail and determined whether group allocation could have been foreseen in advance of, or during, recruitment, or changed afterwards.

We have assessed the methods as:

  • adequate (e.g. telephone or central randomisation; consecutively numbered sealed opaque envelopes);
  • inadequate (open random allocation; unsealed or non-opaque envelopes, alternation; date of birth);
  • unclear.   

 

(3) Blinding (checking for possible performance bias)

We have described for each included study the methods used to blind study personnel from knowledge of which intervention a participant received. We have described where there was any attempt at partial blinding (e.g. of outcome assessors). It is important to note that with the types of interventions described in this review, blinding participants to group assignment is generally not feasible. Similarly, blinding staff providing care is very difficult, and this may have the effect of increasing co-interventions, which in turn may affect outcomes. The lack of blinding in these studies may be a source of bias, and this should be kept in mind in the interpretation of results.

We assessed the methods as:

  • adequate, inadequate or unclear for participants;
  • adequate, inadequate or unclear for personnel;
  • adequate, inadequate or unclear for outcome assessors.

 

 (4) Incomplete outcome data (checking for possible attrition bias through withdrawals, dropouts, protocol deviations)

We have described for each included study the completeness of outcome data, including attrition and exclusions from the analysis. We state whether attrition and exclusions were reported, the numbers (compared with the total randomised participants), reasons for attrition/exclusion where reported, and any re-inclusions in analyses which we have undertaken.

We assessed the methods as:

  • adequate (e.g. where there was no missing data or low levels (less than 10%) and where reasons for missing data were balanced across groups);
  • inadequate (e.g. where there were high levels of missing data (more than 10%);
  • unclear (e.g. where there was insufficient reporting of attrition or exclusions to permit a judgement to be made).

 

(5) Other sources of bias and overall risk of bias

We described for each included study any important concerns we had about other possible sources of bias.

We have made explicit judgements about risk of bias for important outcomes both within and across studies. With reference to 1-4 above, we assessed the likely magnitude and direction of the bias and whether we considered it was likely to impact on the findings.  We have explored the impact of risk of bias through undertaking sensitivity analyses; see sensitivity analysis below.

 

Measures of treatment effect  

We carried out statistical analysis using the Review Manager software (RevMan 2008). We used fixed-effect meta-analysis for combining data in the absence of significant heterogeneity if trials were sufficiently similar. When significant heterogeneity was present, we used a random-effects meta-analysis.

 

Dichotomous data

For dichotomous data, we have presented results as summary risk ratio (RR) with 95% confidence intervals (CI).

 

Continuous data

For continuous data (e.g. maternal pain and satisfaction when measured as scores or on visual analogue scales) we used the mean difference (MD) if outcomes were measured in the same way between trials. We planned to use the standardised mean difference (SMD) to combine trials that measured the same outcome, but used different methods.  

 

Unit of analysis issues  

 

Cluster-randomised trials

We intended to include cluster-randomised trials in the analyses along with individually -randomised trials, and to adjust sample sizes using the methods described in Gates 2005 and Higgins 2011.

We identified no cluster-randomised trials in this version of the review, but if we identify such trials in future searches we will include them in updates.

 

Dealing with missing data  

For included studies, we noted levels of attrition. Where data were not reported for some outcomes or groups, we attempted to contact the study authors for further information. 

 

Intention-to-treat analysis (ITT)

We had intended to analyse data on all participants with available data in the group to which they were allocated, regardless of whether or not they received the allocated intervention. If in the original reports participants were not analysed in the group to which they were randomised, and there was sufficient information in the trial report, we attempted to restore them to the correct group (e.g. we did this for the data from the Calvert 1982 study). 

 

Assessment of heterogeneity  

We examined heterogeneity using the I² statistic. Where we identified high levels of heterogeneity among the trials (greater than 30%), we explored it by pre-specified subgroup analysis and by performing sensitivity analysis. A random-effects meta-analysis was used as an overall summary for these comparisons.

 

Subgroup analysis and investigation of heterogeneity  

Where data were available, we had planned subgroup analyses by:

  • nulliparous versus multiparous women;
  • spontaneous labour versus induction of labour;
  • sitting, walking or sitting, standing, squatting, kneeling or walking versus recumbent/supine/lateral or bedcare.

We had also planned subgroup analysis by:

  • women with a low-risk pregnancy (no complications, greater than or equal to 37 weeks' gestation, singleton with a cephalic presentation) versus high-risk pregnancy.

Data were not available to carry out this analysis.

 

Sensitivity analysis  

We carried out sensitivity analyses to explore the effect of trial quality for important outcomes in the review. Where there was risk of bias associated with a particular aspect of study quality (e.g. inadequate allocation concealment or high levels of attrition), we explored this by sensitivity analysis.

 

What's new

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Last assessed as up-to-date: 18 April 2013.


DateEventDescription

23 September 2013New citation required but conclusions have not changedThe comparisons in the main results of the abstract had been reported incorrectly in Issue 8, 2013. These have now been corrected.

23 September 2013AmendedFor Comparison 1: Upright and recumbent positions versus recumbent positions and bed care has been corrected to: Upright and ambulant positions versus recumbent positions and bed care.

For Comparison 2: Upright and recumbent positions versus recumbent positions and bed care (with epidural: all women) has been corrected to: Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women).



 

History

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Protocol first published: Issue 4, 2002
Review first published: Issue 2, 2009


DateEventDescription

18 April 2013New citation required and conclusions have changedWith the addition of new trial data, there is now evidence to suggest that upright positions in the first stage of labour reduce the risk of caesarean birth.

31 January 2013New search has been performedSearch updated. Five new trials included (Ben Regaya 2010; Boyle 2002; Gau 2011; Mathew 2012; Taavoni 2011).

One trial previously included (Broadhurst 1979) recognised as an already included study (Flynn 1978).

1 March 2009New search has been performedUpdate work to include trials with missing data, Cochrane Review Workshop, Melbourne.

11 November 2008AmendedConverted to new review format.



 

Contributions of authors

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

The review update has been conducted by Lucy Lewis and Annemarie Lawrence.

Data extraction and data entry for the review were carried out by Lucy Lewis and Annemarie Lawrence. The text of the review was drafted by Lucy Lewis and Annemarie Lawrence. Justus Hofmeyr and Cathy Styles commented on drafts.

 

Declarations of interest

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

None known.

 

Sources of support

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Internal sources

  • Griffith University, School of Nursing, Queensland, Australia.
  • Centre for Clinical Studies - Women's and Children's Health, Mater Hospital, Queensland, Australia.
  • The University of Liverpool, UK.
  • University of Adelaide, Australian Research Centre for Health of Women and Babies, South Australia, Australia.
  • James Cook University, School of Midwifery and Nutrition, Queensland, Australia.
  • University of Queensland, School of Nursing and Midwifery, Royal Brisbane and Women's Hospital, Queensland, Australia.
  • Institute of Women's and Children's Health, The Townsville Hospital, Queensland, Australia.
  • Tropical Health Research Unit for Nursing and Midwifery Practice (THRU), Queensland, Australia.

 

External sources

  • Department of Health and Ageing, Commonwealth Government, Australia.
  • National institute for Health Research, UK.
  • Monash Institute of Helath Services Research, Australia.
  • Australasian Cochrane Centre, Australia.
  • Tropical Health Research Unit for Nursing and Midwifery Practice (THRU), Queensland, Australia.

 

Differences between protocol and review

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

The methods section has been updated to reflect changes in methods and software. Perinatal death was not an outcome prespecified in the protocol. Subgroup and sensitivity analyses have been performed according to the updated methods.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. Abstract
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. Additional references
  23. References to other published versions of this review
Andrews 1990 {published data only}
  • Andrews CM, Chrzanowski M. Maternal position, labour and comfort. Applied Nursing Research 1990;3(1):7-13.
Ben Regaya 2010 {published data only}
  • Ben Regaya L, Fatnassi R, Khlifi A, Fekih M, Kebaili S, Soltan K, et al. Role of deambulation during labour: a prospective randomized study [Interet de la deambulation au cours du travail obstetrical: etude prospective randomisee de 200 cas]. Journal de Gynecologie, Obstetrique et Biologie de la Reproduction 2010;39(8):656-62.
Bloom 1998 {published data only}
  • Bloom SL, Kelly MA, Beimer H, Garcia M, Burpo B, McIntire DD, et al. A randomized trial of the effects of ambulation on active labor. American Journal of Obstetrics and Gynecology 1998;178(1 Pt 2):S98.
  • Bloom SL, McIntire DD, Kelly MA, Beimer HL, Burpo RH, Garcia MA, et al. Lack of effect of walking on labor and delivery. New England Journal of Medicine 1998;339(2):76-9.
  • Goer H. Does walking enhance labor progress?. Birth 1999;26(2):127-9.
Boyle 2002 {published data only}
  • Boyle S, Entwistle F, Hamilton C, Kulinska E. A randomised controlled trial examining the effect of ambulation on labour outcome in women who choose a Combined Spinal Epidural for pain relief in labour. International Confederation of Midwives. Midwives and women working together for the family of the world: ICM Proceedings; 2002; Vienna, Austria. 2002.
Bundsen 1982 {published data only}
  • Bundsen P, Lundberg J, Peterson LE. Telemetric versus conventional fetal monitoring in labour - a prospective randomized study [abstract]. Proceedings of 8th European Congress of Perinatal Medicine; 1982 Sept 7-10; Brussels, Belgium. 1982:Abstract no: 256.
Calvert 1982 {published data only}
Chan 1963 {published data only}
  • Chan DPC. Positions during labour. British Medical Journal 1963;1:100-2.
Chen 1987 {published data only}
Collis 1999 {published data only}
  • Collis R, Harding S, Davies L, Moore C, Baxendall M, Morgan B. Ambulation in labour with an epidural: the effect on analgesic requirements, outcome of labour and maternal satisfaction [abstract]. International Journal of Obstetric Anesthesia 1994;3:109.
  • Collis RE, Harding SA, Morgan BM. Effect of maternal ambulation on labour with low-dose combined spinal-epidural analgesia. Anaesthesia 1999;54(6):535-9.
Fernando 1994 {published data only}
  • Fernando R, Bonello E, Gill P, Urquhart J, Morgan B, Reynolds F. Placental and maternal plasma concentrations of fentanyl and bupivacaine after ambulatory combined spinal epidural (CSE) analgesia during labour. International Journal of Obstetric Anesthesia 1995;4:178-89.
  • Fernando R, Gill P, Urquhart J, Morgan BM. Neurobehavioural changes in neonates after ambulatory combined spinal epidural (CSE) analgesia during labour. International Journal of Obstetric Anesthesia 1994;3:174.
Flynn 1978 {published data only}
  • Broadhurst A, Flynn AM, Kelly J, Lynch PF. The effect of ambulation in labour on maternal satisfaction, analgesia and lactation. Proceedings of 5th International Congress on Psychosomatic Medicine in Obstetrics and Gynaecology, "Emotion and Reproduction";1977 Nov 13-19; Rome, Italy. 1979:943-6.
  • Flynn AM, Hollins G, Kelly J, Lynch PF. The effect of ambulation in labour on uterine action, analgesia and fetal well-being. Proceedings of 6th European Congress of Perinatal Medicine; 1978 Aug 29-Sept 1; Vienna, Austria. 1978:Abstract no: 344.
  • Flynn AM, Kelly J, Hollins G, Lynch PF. Ambulation in labour. British Medical Journal 1978;2:591-3.
Frenea 2004 {published data only}
Gau 2011 {published data only}
  • Gau ML, Chang CY, Tian SH, Lin KC. Effects of birth ball exercise on pain and self-efficacy during childbirth: a randomised controlled trial in Taiwan. Midwifery 2011;27(6):e293-300.
Haukkama 1982 {published data only}
Karraz 2003 {published data only}
MacLennan 1994 {published data only}
  • MacLennan AH, Crowther C, Derham R. Does the option to ambulate during spontaneous labour confer any advantage or disadvantage?. Journal of Maternal-Fetal Medicine 1994;3:43-8.
Mathew 2012 {published data only}
  • Mathew A, Nayak S, Vandana K. A comparative study on effect of ambulation and birthing ball on maternal and newborn outcome among primigravida mothers in selected hospitals in Mangalore. Nitte University Journal of Health Science 2012;2(2):2-5.
McManus 1978 {published data only}
  • McManus TJ, Calder AA. Upright posture and the efficiency of labour. Lancet 1978;1(8055):72-4.
Miquelutti 2007 {published data only}
Mitre 1974 {published data only}
  • Mitre IN. The influence of maternal position on duration of the active phase of labor. International Journal of Gynecology & Obstetrics 1974;12(5):181-3.
Nageotte 1997 {published data only}
  • Nageotte M, Larson D, Rumney P, Sidhu M, Hollenback K. A prospective randomized study of intrapartum epidural vs combination intrathecal/epidural anesthesia with or without ambulation. American Journal of Obstetrics and Gynecology 1997;176(1 Pt 2):S22.
  • Nageotte MP, Larson D, Rumney PJ, Sidhu M, Hollenbach K. Epidural analgesia compared with combined spinal-epidural analgesia during labor in nulliparous women. New England Journal of Medicine 1997;337(24):1715-9.
Phumdoung 2007 {published data only}
  • Phumdoung S, Youngvanichsate S, Jongpaiboonpatana W, Leetanaporn R. The effects of the PSU Cat position and music on length of time in the active phase of labor and labor pain. Thai Journal of Nursing Research 2007;11(2):96-105.
Taavoni 2011 {published data only}
  • Taavoni S, Abdolahian S, Haghani H. Effect of birth ball on active phase of physiologic labor: randomized control trial study [Abstract]. International Journal of Medicine 2010;40(Suppl 1):171.
  • Taavoni S, Abdolahian S, Haghani H, Neisani L. Effect of pelvic tilt by using birth ball on active phase of physiologic labor: A randomized control trial study. International Journal of Gynecology and Obstetrics 2012;119(Suppl 3):S496.
  • Taavoni S, Abdolahian S, Haghani H, Neysani L. Effect of birth ball usage on pain in the active phase of labor: a randomized controlled trial. Journal of Midwifery & Women's Health 2011;56(2):137-40.
Vallejo 2001 {published data only}
  • Vallejo M, Firestone L, Mandell G, Jaime F, Makishima S, Ramanathan S. The effect of sitting and ambulating on labor duration and maternal outcome [abstract]. Anesthesiology 2001;94(1A):Abstract no: A7.
  • Vallejo M, Mandell G, Jaime F, Ramanathan S. Ropivacaine for walking epidural analgesia during labor. Regional Anesthesia and Pain Medicine 1999;24(3 Suppl):74.
  • Vallejo MC, Firestone LL, Mandell GL, Jaime F, Makishima S, Ramanathan S. Effect of epidural analgesia with ambulation on labor duration. Anesthesiology 2001;95(4):857-61.
  • Vallejo MC, Mandell GL, Jaime F, Makishima S, Ramanathan S. Walking epidural analgesia: the effect of ambulation on labor duration and maternal outcome [abstract]. Anesthesiology 2000;93(3A):Abstract no: A1069.
Williams 1980 {published data only}

References to studies excluded from this review

  1. Top of page
  2. Abstract
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. Additional references
  23. References to other published versions of this review
Ahmed 1985 {published data only}
  • Ahmed LT, Bouchetara K. The influence of maternal position on duration of labor [abstract]. Archives of Gynecology 1985;237 Suppl:9.
Allahbadia 1992 {published data only}
Asselineau 1996 {published data only}
  • Asselineau D. Does ambulation under epidural analgesia during labour modify foetal extraction conditions? [La deambulation sous peridurale lors du travail modifie-t-elle les conditions d'extraction foetale?]. Contraception, Fertilité, Sexualité 1996;24(6):505-8.
Caldeyro-Barcia 1960 {published data only}
  • Caldeyro-Barcia R, Noriega-Guerra L, Cibils LA, Alvarez H, Poseiro JJ, Pose SV, et al. Effect of position changes on the intensity and frequency of uterine contractions during labor. American Journal of Obstetrics and Gynecology 1960;80(2):284-90.
Cobo 1968 {published data only}
  • Cobo E, De Bernal MM, Quintero CA, Cuadrado E. Neurohypophyseal hormone release in the human. III. Experimental study during labor. American Journal of Obstetrics and Gynecology 1968;101:479-89.
Cohen 2002 {published data only}
  • Cohen S, Ayers C, Zada Y, Trnovski S, Burley E, Maestrado P. A comparison of continuous epidural-PCA analgesia for labor pain with or without maternal ambulation [abstract]. Anesthesia & Analgesia 2002;94(2S):Abstract no: S195.
COMET 2001 {published data only}
  • COMET Study Group. The comparative obstetric mobile epidural trial (C.O.M.E.T.). Ambulatory epidural analgesia, delivery mode and pain relief: a randomized controlled trial. The C.O.M.E.T. Study Group. [abstract]. European Journal of Anaesthesiology 2000;17:782-3.
  • COMET Study Group. The comparative obstetric mobile epidural trial. Ambulatory epidural analgesia, delivery mode and pain relief: a randomised controlled trial [abstract]. Anesthesiology 2000;92 Suppl:Abstract no: A21.
  • COMET Study Group, Wilson MJ. A randomised controlled trial comparing traditional with two "mobile" epidural techniques: effect on urinary catheterisation in labor [abstract]. Anesthesiology 2002;96(Suppl 1):Abstract no: Z2.
  • Comparative Obstetric Mobile Epidural Trial (COMET) Study Group UK. Effect of low-dose mobile versus traditional epidural techniques on mode of delivery: a randomised controlled trial. Lancet 2001;358(9275):19-23.
  • Cooper GM, MacArthur C, Wilson MJ, Moore PA, Shennan A, on behalf of the COMET Study Group UK. Satisfaction, control and pain relief: short- and long-term assessments in a randomised controlled trial of low-dose and traditional epidurals and a non-epidural comparison group. International Journal of Obstetric Anesthesia 2010;19(1):31-7.
  • Duhig K, MacArthur C, Shennan AH, The COMET Study Group. The hypotensive and fetal heart rate response to low dose epidurals: analysis of an RCT data set [abstract]. Journal of Obstetrics and Gynaecology 2007;27(Suppl 1):S63-S64.
  • Elton C, Bharmal S, May AE, COMET Study Group. Does walking in labour with regional blockade affect the mode of delivery? [abstract]. International Journal of Obstetric Anesthesia 2002;11 Suppl:33.
  • Hussain for the COMET Study Group. Haemodynamic changes with 'mobile' epidurals in labour: is it safe for women to ambulate? [abstract]. Anesthesiology 2001;94(1A):Abstract no: A63.
  • Shennan AH, COMET Study Group. The effect of low-dose 'mobile' compared with traditional epidural techniques on mode of delivery: a randomised controlled trial [abstract]. Journal of Obstetrics and Gynaecology 2001;21 Suppl 1:S19.
  • Wilson MJ, COMET Study Group. The comparative obstetric mobile epidural trial (C.O.M.E.T.). A randomized controlled trial [abstract]. British Journal of Anaesthesia 2001;87(4):659P.
  • Wilson MJ, Cooper G, MacArthur C, Shennan A, Comparative Obstetric Mobile Epidural Trial (COMET) Study Group UK. Randomized controlled trial comparing traditional with two "mobile" epidural techniques: anesthetic and analgesic efficacy. Anesthesiology 2002;97(6):1567-75.
  • Wilson MJ, MacArthur C, Cooper GM, Bick D, Moore PA, Shennan A, et al. Epidural analgesia and breastfeeding: a randomised controlled trial of epidural techniques with and without fentanyl and a non-epidural comparison group. Anaesthesia 2010;65(2):145-53.
  • Wilson MJ, MacArthur C, Cooper GM, Shennan A, for the COMET Study Group UK. Ambulation in labour and delivery mode: a randomised controlled trial of high-dose vs mobile epidural analgesia. Anaesthesia 2009;  64(3):266-72.
  • Wilson MJ, Macarthur C, Shennan A, on behalf of the COMET Study Group (UK). Urinary catheterization in labour with high-dose vs mobile epidural analgesia: a randomized controlled trial. British Journal of Anaesthesia 2009;102(1):97-103.
Danilenko-Dixon 1996 {published data only}
  • Danilenko-Dixon DR, Tefft L, Cohen RA, Haydon B, Carpenter MW. Positional effects on maternal cardiac output during labor with epidural analgesia. American Journal of Obstetrics and Gynecology 1996;175:867-72.
Delgado-Garcia 2012 {published data only}
  • Delgado-Garcia BE, Orts-Cortes MI, Poveda-Bernabeu A, Caballero-Perez P. [Randomised controlled clinical trial to determine the effects of the use of birth balls during labour]. [Spanish]. Enfermeria Clinica 2012;22(1):35-40.
Diaz 1980 {published data only}
  • Diaz AG, Schwarcz R, Fescina R, Caldeyro-Barcia R. Vertical position during the first stage of the course of labor, and neonatal outcome. European Journal of Obstetrics & Gynecology and Reproductive Biology 1980;11(1):1-7.
Divon 1985 {published data only}
  • Divon MY, Mushkat Y, Sarna Z, Zimmer EZ, Vilensky A, Paldi E. The association between fetal heart rate patterns and maternal posture during labor. Archives of Gynecology 1985;237(Suppl 1):89.
Ducloy-Bouthors 2006 {published data only}
  • Ducloy-Bouthors AS, De Gasquet B, Davette M, Cuisse M. Maternal postures and epidural analgesia during labour [Postures maternelles pendant le travail: description et interference avec l'analgesie peridurale]. Annales Françaises d'Anesthesie et de Reanimation 2006;25(6):605-8.
Hemminki 1983 {published data only}
Hemminki 1985 {published data only}
  • Hemminki E, Lenck M, Saarikoski S, Henriksson L. Ambulation versus oxytocin in protracted labour: a pilot study. European Journal of Obstetrics & Gynecology and Reproductive Biology 1985;20:199-208.
Hodnett 1982 {published data only}
  • Hodnett ED. Patient control during labor: effects of two types of fetal monitors. Journal of Obstetric, Gynecologic and Neonatal Nursing 1982;2:94-9.
Li 2010 {published data only}
  • Li J, Ma QL, Chen RX, Li HN, Zhang HY. Effect of different pre-labor positions for premature rupture of membranes with vertex and engaged presentation on the maternal and neonatal outcomes. Chinese Journal of Evidence-Based Medicine 2010;10(12):1415-8.
Liu 1989 {published data only}
McCormick 2007 {published data only}
  • McCormick C. A randomised controlled trial of the effect of ambulation in the first stage of labour in terms of duration of labour of women with a previous caesarean section. controlled-trials.com (accessed 21 June 2007).
Melzack 1991 {published data only}
Molina 1997 {published data only}
Radkey 1991 {published data only}
  • Radkey AL, Liston RM, Scott KE, Young C. Squatting: preventive medicine in childbirth?. Proceedings of Annual Meeting of Society of Obstetricians and Gynaecologists of Canada; 1991; Toronto, Ontario, Canada. 1991:76.
Read 1981 {published data only}
  • Read JA, Miller FC, Paul RH. Randomized trial of ambulation vs oxytocin for labor enhancement: a preliminary report. American Journal of Obstetrics and Gynecology 1981;139:669-72.
Roberts 1984 {published data only}
  • Roberts JE, Mendez-Bauer C, Blackwell J, Carpenter ME, Marchese T. Effects of lateral recumbency and sitting on the first stage of labor. Journal of Reproductive Medicine 1984;29(7):477-81.
Schmidt 2001 {published data only}
  • Schmidt S, Sierra F, Hess C, Neubauer S, Kuhnert M, Heller G. Effect of modified labor posture on oxygenation of the fetus--a pulse oximetry study. Zeitschrift fur Geburtshilfe und Neonatologie 2001;205:49-53.
Schneider-Affeld 1982 {published data only}
Selby 2012 {published data only}
  • Selby C, Valencia S, Garcia L, Keep D, Overcash J, Jackson J. Activity level during a one-hour labor check evaluation: walking versus bed rest. MCN, American Journal of Maternal Child Nursing 2012;37(2):101-7.
Solano 1982 {published data only}
  • Solano F, Gallo M, Llamas C, Requena F, Arbues J. Perinatal effects of the maternal vertical position during dilatation period of the delivery. Effects on the mother-child couple [Efectos perinatales de la posición vertical materna durante el período de dilatación de parto. Efectos sobre el binomio madre-hijo]. Acta Obstétrica y Ginecológica Hispano-Lusitana 1982;30:81-104.
Stewart 1983 {published data only}
  • Hillan EM. The birthing chair trial. Research and the Midwife Conference; 1984; Manchester, UK. 1984:22-37.
  • Stewart P, Hillan E, Calder A. A study of the benefits of maternal ambulation during labour and the use of a birth chair for delivery. Proceedings of 8th European Congress of Perinatal Medicine; 1982 Sept 7-10; Brussels, Belgium. 1982:113.
  • Stewart P, Hillan E, Calder AA. A randomised trial to evaluate the use of a birth chair for delivery. Lancet 1983; Vol. 1:1296-8.
Tussey 2011 {published data only}
  • Tussey C, Botsios E. Use of a labor ball to decrease the length of labor in patients who receive an epidural. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing 2011;40:S105-6.
Weiniger 2009 {published data only}
Wilson 2011 {published data only}
Wu 2001 {published data only}
  • Wu X, Fan L, Wang Q. Correction of occipito-posterior by maternal postures during the process of labor. [Chinese]. Chung-Hua Fu Chan Ko Tsa Chih [Chinese Journal of Obstetrics & Gynecology] 2001;36(8):468-9.

Additional references

  1. Top of page
  2. Abstract
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. Additional references
  23. References to other published versions of this review
Abitbol 1985
Albers 1997
Anim-Somuah 2011
Boyle 2000
  • Boyle M. Childbirth in bed: the historical perspective. Practising Midwife 2000;3(11):21-4.
Broadhurst 1979
  • Broadhurst A, Flynn AM, Kelly J, Lynch PF. The effect of ambulation in labour on maternal satisfaction, analgesia and lactation. Proceedings of 5th International Congress on Psychosomatic Medicine in Obstetrics and Gynaecology, "Emotion and Reproduction";1977 Nov 13-19; Rome, Italy. 1979:943-6.
Carlson 1986
  • Carlson JM, Diehl JA, Sachtleben-Murray M, McRae M, Fenwick L, Friedman EA. Maternal position during parturition in normal labor. Obstetrics & Gynecology 1986;68(4):443-7.
Cluett 2009
Cyna 2006
Fenwick 1987
Gates 2005
  • Gates S. Methodological Guidelines. In: The Editorial Team. Pregnancy and Childbirth Group. About the Cochrane Collaboration (Collaborative Review Groups (CRGs)) 2005, Issue 2.
Goer 1999
Gupta 2000
Gupta 2012
Higgins 2011
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Hodnett 2012
Hollins Martin 2013
  • Hollins Martin CJ, Martin CR. A narrative review of maternal physical activity during labour and its effects upon length of first stage. Complementary Therapies in Clinical Practice 2013;19:44-9.
Hunter 2007
Huovinen 1979
Jones 2012
Kemp 2013
Lupe 1986
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Marx 1982
McNabb 1989
  • McNabb M. The science of Labour?. Nursing Times 1989;85(9):58-9.
Mendez-Bauer 1980
  • Mendez-Bauer C, Arroyo J, Freese U, Garcia-Ramos C, Hundsdorfer P, Izquierdo F, et al. The dynamics of labor in different positions. 7th European Congress Perinatal Medicine; 1980 Sept 14-17; Barcelona, Spain. 1980.
RevMan 2008
  • The Cochrane Collaboration. Review Manager (RevMan). 5.0. Copenhagen, The Nordic Cochrane Centre: The Cochrane Collaboration, 2008.
RevMan 2012
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Roberts 1980
Roberts 1983
Roberts 1989
  • Roberts J. Maternal position during the first stage of labour. In: Chalmers I, Enkin M, Keirse MJN editor(s). Effective Care in Pregnancy and Childbirth. Vol. 2, Oxford: Oxford University Press, 1989:883-92.
Rooks 1999
  • Rooks JP. Evidence-based practice and its application to childbirth care for low-risk women. Journal of Nurse Midwifery 1999;44(4):355-69.
Simkin 1989
  • Simkin P. Non-pharmacological methods of pain relief during labour. In: Chalmers I, Enkin M, Keirse MJN editor(s). Effective Care in Pregnancy and Childbirth. Vol. 2, Oxford: Oxford University Press, 1989:893-911.
Simkin 2002
  • Simkin P, Hara M. Nonpharmacological relief of pain during labor: systematic reviews of five methods. American Journal of Obstetrics and Gynecology 2002;186(5):5131-59.
Simmons 2012
Stacey 2011
  • Stacey T, Thompson JMD, Mitchell EA, Ekeroma AJ, Zuccollo JM, McCowan LME. Association between maternal sleep practices and risk of late stillbirth: a case-control study. BMJ 2011;342:d3403.
Stewart 1989
Ueland 1969
Walsh 2000
  • Walsh D. Part five: why we should reject the 'bed birth' myth. British Journal of Midwifery 2000;8(9):554-8.

References to other published versions of this review

  1. Top of page
  2. Abstract
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. Additional references
  23. References to other published versions of this review
Lawrence 2009
Lewis 2002
  • Lewis L, Webster J, Carter A, McVeigh CCM, Devenish-Meares PPDM. Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews 2002, Issue 4. [DOI: 10.1002/14651858.CD003934]