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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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Characteristics of included studies [ordered by study ID]
Andrews 1990

MethodsRandomised trial: using a convenience sample over a 3-month period.


Participants40 women, Cleveland, U.S.A.

  • 20 study participants: nulliparous
  • 20 control participants nulliparous


Inclusion Criteria:

Parity: nulliparous,

Pluralty: single vertex fetus in an anterior position,

Gestation: 38 to 42 weeks

Onset of labour: spontaneous

Other: medically uncomplicated pregnancies; adequate pelvic measurements; intact amniotic membranes at the beginning of the maximum slope in their labour (4 to 9 cm dilatation).


InterventionsStudy group:

  • 20 women - upright: standing, ambulating, sitting, squatting, or kneeling.


15 women chose to lie down after receiving medication for rest: 5 of these women immediately returned to the upright position, stating that the contractions were more painful when they were lying down. The remaining 10 chose the lateral position to rest for up to 1 hour during the study period.

Control group:

  • 20 women - recumbent: supine, lateral, or prone - hands and knees.


All women:

- position assumed when cervical dilatation was from 4 to 9 cm,

- were free to choose several variations within each position group.
- were free to assume positions from the other group for routines of care or rest, these activities were documented.


OutcomesMaternal Outcomes:

  1. Duration of first stage of labour.
  2. Maternal Comfort.
  3. Analgesia amount.


Neonatal Outcomes:

Nil


Notes1. The length of maximum slope in labour was recorded. This is a subdivision of the first stage of labour, during which rapid cervical dilatation takes place (from 4 to 9 cm). The duration of the first stage was determined by the first recorded time that cervical dilatation was assessed to be 4 cm and on the first recorded time that dilatation was assessed to be 9 cm.

2. The Maternal Comfort Assessment Tool was used. The tool estimates the level of maternal comfort by measuring focus of attention; eye contact during contractions; breathing pattern and vocal behaviour during contractions; muscle tension and activity during contractions; and verbalisations regarding ability to continue with labour. In addition, vital signs; degree of cervical dilatation; duration, frequency, and intensity of contractions; medications; and use of monitoring apparatus were recorded. When the scores for each category of observable behaviour in the tool are added, the highest possible comfort score for each contraction was 14 and the lowest was 0. Comfort scores for a series of 3 contractions were recorded on an hourly basis during the phase of maximum slope, and averaged for mean hourly comfort scores. Hourly comfort scores where then average to obtain an overall mean comfort score for each woman.

3. The amount of narcotic and other analgesia.

The randomisation method is unclear.

Women in the recumbent position were monitored externally more often (n = 13) than women in the upright position (n = 1), which may have been an additional source of discomfort for women in the recumbent group.

Apgar scores were not included as outcome measures because only a mean Apgar at 1 minute for each group was provided.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskDescribed as 'randomly assigned'.

Allocation concealment (selection bias)Unclear riskNot stated.

Blinding (performance bias and detection bias)
Women
High riskNot feasible.

Blinding (performance bias and detection bias)
Clinical staff
High riskNot feasible.

Blinding (performance bias and detection bias)
Outcome assessor
Unclear riskNot stated.

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo stated losses to follow-up.

Selective reporting (reporting bias)Unclear riskUnclear.

Ben Regaya 2010

MethodsRandomised trial


Participants200 women, Sousse, Tunisia.

  • 100 study participants: nulliparous
  • 100 control participants: nulliparous


Inclusion Criteria:

Parity: nulliparous,

Pluralty: singleton,

Gestation: term,

Onset of labour: spontaneous

Other: less than 4 cm dilatation; cephalic presentation; no pathological antecedents; absence of fetal compromise; normal maternal examination; eligible for vaginal birth; consenting to participate.


InterventionsStudy group:

  • 100 women - authorised to ambulate until 6 cm of cervical dilatation.


Control group:

  • 100 women - confined to bed in dorsal or lateral recumbence


OutcomesMaternal Outcomes:

  1. Duration of first stage labour.
  2. Mode of birth.
  3. Maternal pain.
  4. Duration of second stage labour.
  5. Estimated blood loss > 500 mL.
  6. Perineal trauma.


Neonatal Outcomes:

  1. Admission to NICU


Notes1. Duration of first stage of labour: no standard deviation reported. Standard deviation calculated using the weighted average standard deviation reported for nulliparous women.

Unable to extract data for oxytocic use or Apgar scores - only mean scores provided.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot stated.

Allocation concealment (selection bias)Low riskSequentially numbered sealed envelopes.

Blinding (performance bias and detection bias)
Women
High riskNot feasible.

Blinding (performance bias and detection bias)
Clinical staff
High riskNot feasible.

Blinding (performance bias and detection bias)
Outcome assessor
Unclear riskNot stated.

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo stated losses to follow-up.

Selective reporting (reporting bias)Unclear riskUnclear.

Bloom 1998

MethodsRandomised trial: over a 12-month period.


Participants1067 women, Dallas, U.S.A.

  • 536 study participants: 272 primigravidae, 264 multigravida
  • 531 control participants: 272 primigravidae, 259 multigravida


Inclusion Criteria:

Parity: mixed,

Pluralty: not stated,

Gestation: between 36 and 41 weeks,

Onset of labour: spontaneous,

Other: cervical dilatation of 3 to 5 cm; in active labour; fetuses in cephalic presentation; uncomplicated pregnancies.


InterventionsStudy group:

  • 536 women assigned to walking (walking as desired).


Women were encouraged to walk but were instructed to return to their beds when they needed intravenous or epidural analgesia or when the second stage of labour began.

Nurses recorded the number of minutes spent walking.

If continuous electronic fetal heart rate monitoring was required, further walking was prohibited.

Of the 536 women assigned to the walking group: 380 actually walked; 30 had incomplete walking records; 8 had advanced cervical dilatation at the time of randomisation; and 2 had a fetus with unrecognised breech presentation.

Control group:

  • 531 women assigned to labour in bed (usual care - confined to a labour bed).


Women were permitted to assume their choice of supine, lateral or sitting positions during labour.

All women:

- routine surveillance using handheld a Doppler device was conducted every 30 mins.
- continuous electronic fetal heart rate monitoring was used for: fetal heart-rate abnormalities; meconium in the amniotic fluid; women in whom labour was augmented by the administration of oxytocin.
- pelvic examinations were performed approximately every 3 hours: ineffective labour was suspected if the cervix did not dilate progressively during the first two hours after admission.

- amniotomy was performed if the fetal membranes were intact,

- labour was augmented by intravenous oxytocin (initial dose 6 mU per min, increased every 40 mins by 6 mU per min to a maximum of 42 mU per min if a woman had hypotonic uterine contractions, and no further cervical dilatation after an additional 2-3 hours.

- Dystocia was diagnosed if labour had not progressed in 2-4 hours.
- positions permitted during birth included the lateral (Sims') position and the dorsal-lithotomy position, with or without obstetrical stirrups.

- all women wore pedometers


OutcomesMaternal Outcomes:

  1. Duration of first stage of labour.
  2. Mode of birth.
  3. Maternal pain.
  4. Analgesia type.
  5. Duration of second stage of labour.
  6. Augmentation of labour using oxytocin.
  7. Perineal trauma.


Neonatal Outcomes:

  1. Fetal distress.
  2. Use of neonatal mechanical ventilation.
  3. Apgar scores.
  4. Perinatal mortality.


NotesLimitations of the protocol: inability to mask walking; inability to extrapolate results to women with pregnancy complications, higher rates of caesarean birth or epidural analgesia; lack of objective methods to gauge maternal satisfaction with either walking or lying down during labour.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskDescribed as 'randomly assigned'.

Allocation concealment (selection bias)Unclear riskNot stated.

Blinding (performance bias and detection bias)
Women
High riskNot feasible.

Blinding (performance bias and detection bias)
Clinical staff
High riskNot feasible.

Blinding (performance bias and detection bias)
Outcome assessor
Unclear riskNot stated.

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo stated losses to follow-up.

Selective reporting (reporting bias)Unclear riskUnclear

Boyle 2002

MethodsRandomisation was achieved by the use of sequentially numbered sealed envelopes. A computer-generated random number sequence was used.


Participants409 women, Hertfordshire, U.K.

  • 199 study participants:145 primigravidae, 54 multigravida
  • 210 control participants:151 primigravidae, 59 multigravida


Inclusion Criteria:

Parity: mixed,

Pluralty: not stated,

Gestation: greater than 34 weeks,

Onset of labour: spontaneous and induction of labour,

Other: cervical dilatation of 3 to 5 cm; in active labour; fetuses in cephalic presentation; uncomplicated pregnancies; women who chose to use a CSE between August 1st 1999 to December 31st 2000.

Exclusion Criteria: women who were physically unable to ambulate or could not understand English.


InterventionsStudy group:

  • 199 women were assigned to the ambulant group


Women in the experimental group were encouraged to ambulate for at least 15 mins in each hour.

Midwives used a modified Bromage scale in order to assess maternal mobility after the CSE had been cited and prior to ambulation.

The mean time of ambulation in the ambulant group was only 8.74 to 9.55 mins.

69 out of 199 women (34%) underwent induction of labour.

Control group:

  • 210 women were assigned to the non-ambulant group


Women in the control group received normal care in labour.

51 out of 210 (24%) women underwent induction of labour.

All women:

- pain was assessed with a visual analogue pain score.


OutcomesMaternal Outcomes:

  1. Mode of Birth
  2. Analgesia Amount


Neonatal Outcomes:

Nil


NotesNo durations of labour times, but author stated "there was no difference".

Mode of birth data totals differ from demographic data totals.

Apgar scores reported as means, therefore unable to be used.

Pooled data used from nulliparous and multiparous total dose of analgesia.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputer-generated random number sequence.

Allocation concealment (selection bias)Low riskSequentially numbered sealed envelopes.

Blinding (performance bias and detection bias)
Women
High riskNot feasible.

Blinding (performance bias and detection bias)
Clinical staff
High riskNot feasible.

Blinding (performance bias and detection bias)
Outcome assessor
Unclear riskNot stated.

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo stated losses to follow-up.

Selective reporting (reporting bias)Unclear riskUnclear.

Bundsen 1982

MethodsRandomised trial of women undergoing induction of labour.


Participants60 women, Goteborg, Sweden.

  • 40 study participants: mixed parity
  • 20 control participants: mixed parity


Inclusion Criteria:

Parity: mixed,

Pluralty: not stated,

Gestation: not stated,

Onset of labour: induced,

Other: nil stated.


InterventionsStudy group:

  • 40 women were assigned to ambulation (telemetry).


20 women were assigned to receive telemetry and transcutaneous electrical nerve stimulation (TNS), and 20 women were assigned to receive telemetry without TNS.

Control group:

  • 20 women were assigned to bed care, with conventional monitoring in bed.


All women:

- primary amniotomy,

- internal monitoring.


OutcomesMaternal Outcomes:

  1. Mode of birth.
  2. Artificial rupture of membranes


Neonatal Outcomes:

Nil


NotesInsufficient data to include total duration of labour (reported as 8 hours for primiparae and 4 hours for multipara in the study group; and 10 hours for primiparae and 6 hours for multipara in the control group).


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskDescribed as 'randomisation to three groups'.

Allocation concealment (selection bias)Unclear riskNot stated

Blinding (performance bias and detection bias)
Women
High riskNot feasible.

Blinding (performance bias and detection bias)
Clinical staff
High riskNot feasible.

Blinding (performance bias and detection bias)
Outcome assessor
Unclear riskNot stated.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNo stated losses to follow-up.

Selective reporting (reporting bias)High riskClaimed evidence of an outcome with little or no data to support it.

Calvert 1982

MethodsQuasi-randomised trial. Patients were randomly allocated based on whether the final digit of their hospital number was odd or even.


Participants200 women, Cardiff, U.K.

  • 100 study participants: 56 primigravidae, 44 multigravida
  • 100 control participants: 50 primigravidae, 50 multigravida


Inclusion Criteria:

Parity: mixed,

Pluralty: singleton,

Gestation: term (at least 37 weeks' gestation),

Onset of labour: spontaneous,

Other: vertex presentation; uterine contractions occurring at least every 10 mins; cervix at least 2.5 cm dilated; no contraindication to vaginal birth.

Exclusion criteria - women who had previously suffered a stillbirth or neonatal death or who had undergone a caesarean birth.


InterventionsStudy group:

  • 100 women were assigned to telemetry


Women were advised that they could get of bed to walk, sit in an easy chair or use the day room.

Only 45 women actually got out of bed. They remained out of bed between 3 mins, and 4 hours and 20 mins. The average time out of bed was 1 hour and 44 mins. 34 of those who left their beds initially, elected to stay in bed by the time they reached a cervical dilatation of 7 cm.

Control group:

  • 100 women were assigned to bed care and conventional bedside cardiotocography.


All patients in bed were nursed in the lateral position or with a lateral tilt.


OutcomesMaternal Outcomes:

  1. Duration of first stage of labour.
  2. Mode of birth.
  3. Maternal pain.
  4. Maternal anxiety.
  5. Analgesia type.
  6. Duration of second stage.


Neonatal Outcomes:

  1. Apgar scores.


Notes3. Within 24 hours of birth all patients were asked to complete a questionnaire to express their experience of pain, anxiety, comfort and restriction of mobility during the first stage of labour and the degree of induced anxiety or reassurance attributed to the monitor. Assessment was based on linear analogue scales. A score of 0 indicated nil and the score 100 indicated the maximum imaginable.

5. Duration of second stage only given for those who delivered spontaneously.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskDescribed as 'Final digit of hospital number (odd or even)'.

Allocation concealment (selection bias)High riskDescribed as 'Final digit of hospital number (odd or even)'.

Blinding (performance bias and detection bias)
Women
High riskNot feasible.

Blinding (performance bias and detection bias)
Clinical staff
High riskNot feasible.

Blinding (performance bias and detection bias)
Outcome assessor
Unclear riskNot stated.

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo stated losses to follow-up.

Selective reporting (reporting bias)Unclear riskUnclear.

Chan 1963

MethodsQuasi-randomised trial.


Participants200 women, Hong Kong.

  • 100 study participants: primigravidae.
  • 100 control participants: primigravidae.


Inclusion Criteria:

Parity: primigravidae,

Pluralty: not stated,

Gestation: not stated,

Onset of labour: not stated,

Other: nil stated.

Exclusion criteria - planned elective caesarean birth.


InterventionsStudy group:

  • 100 women were kept in the erect position (sit or walk).


Control group:

  • 100 women were kept in a supine or lateral position.


OutcomesMaternal Outcomes:

  1. Duration of first stage of labour.
  2. Mode of birth.
  3. Maternal pain.
  4. Analgesia type.
  5. Duration of second stage of labour.


Neonatal Outcomes:

  1. Fetal distress.
  2. Perinatal mortality.


Notes1. Duration of first stage of labour: no standard deviation or P values reported. Standard deviation calculated using the weighted average standard deviation reported for nulliparous women. Summary totals exclude number of L.S.C.S. cases.

2. Assisted breech births (2 upright, 4 recumbent) not included in spontaneous vaginal, operative vaginal or caesarean birth summary totals.

5. Duration of second stage of labour: no standard deviation or P values reported. Standard deviation calculated using the weighted average standard deviation reported. Summary totals exclude number of L.S.C.S. cases.

6. The summary total included one set of twins.

7. The summary total included one set of twins.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskAlternate group allocation.

Allocation concealment (selection bias)High riskNot stated.

Blinding (performance bias and detection bias)
Women
High riskNot feasible.

Blinding (performance bias and detection bias)
Clinical staff
High riskNot feasible.

Blinding (performance bias and detection bias)
Outcome assessor
Unclear riskNot stated.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNo stated losses to follow-up.

Selective reporting (reporting bias)Unclear riskUnclear.

Chen 1987

MethodsQuasi-randomised trial: over a 2.5 year period.


Participants185 women, Oita, Japan.

  • 61 study participants: 33 primigravidae, 28 multigravida
  • 124 control participants: 68 primigravidae, 56 multigravida


Inclusion Criteria:

Parity: mixed,

Pluralty: singleton,

Gestation: full term,

Onset of labour: spontaneous,

Other: cephalic presentation; uneventful pregnancies.

Exclusion criteria - women received oxytocin augmentation; caesarean birth due to cephalo-pelvic disproportion or fetal distress; women requested and received epidural anaesthesia; child with congenital anomalies; tococardiogram records were unsuitable for reading (n = 67 exclusions after group allocation).


InterventionsStudy group:

  • 41 women were free to assume any comfortable position in home-like part of obstetric unit (furnished with desk, chair, sofa but no bed)(sitting) .


Most sat on a sofa (back of sofa at 65 degree angle from horizontal) with their knees flexed. When each woman's cervix became fully dilated, she was transferred to a birthing chair.

There were 20 post-randomisation exclusions from the study group. Reasons for exclusion included: oxytocin augmentation (n = 2); caesarean birth due to CPD (n = 2); caesarean birth due to fetal distress (n=3); epidural anaesthesia (n = 3); fetal anomaly (n = 1); unsatisfactory TCG record (n = 9).

Control group:

  • 75 women were assigned to maintain a dorsal or lateral recumbent position (supine): 32 women were assigned to a supine position in the first stage of labour and the birthing chair in the second stage of labour; 43 women were allocated to maintain a supine position throughout labour.


There were 49 post-randomisation exclusions from the control group: Reasons for exclusion included: oxytocin augmentation (n = 13); caesarean birth due to CPD (n = 8); caesarean birth due to fetal distress (n = 2); epidural anaesthesia (n = 9); fetal anomaly (n = 3); unsatisfactory TCG record (n = 14).

All women:

- no analgesia or anaesthesia was used except for pudendal nerve block or perineal infiltration of xylocaine.

- amniotomy was performed when cervical dilatation reached 3 to 4 cm.


OutcomesMaternal Outcomes:

  1. Duration of first stage of labour.
  2. Mode of birth.
  3. Analgesia type.
  4. Duration of second stage of labour.
  5. Augmentation of labour using oxytocin.
  6. Artificial rupture of membranes.


Neonatal Outcomes:

  1. Fetal distress requiring immediate birth.


Notes1. Duration recorded from 5 to 10 cm dilation only.

Pooled data used from nulliparous and multiparous durations of first stage labour.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskDescribed as 'Allocated following the order of their admission into the study'.

Allocation concealment (selection bias)High risk

Blinding (performance bias and detection bias)
Women
High riskNot feasible.

Blinding (performance bias and detection bias)
Clinical staff
High riskNot feasible.

Blinding (performance bias and detection bias)
Outcome assessor
Unclear riskNot stated.

Incomplete outcome data (attrition bias)
All outcomes
High risk67 participants were excluded after group allocation (37%). Some of the reasons for exclusion are unlikely to have related to the intervention (e.g. children born with congenital abnormalities) but other reasons may have related to group allocation (e.g. oxytocin augmentation, caesarean for fetal distress).

Selective reporting (reporting bias)Unclear riskUnclear

Collis 1999

MethodsRandomised trial of women receiving a CSE


Participants229 women, London, U.K.

  • 110 study participants: nulliparous
  • 119 control participants: nulliparous


Inclusion Criteria:

Parity: nulliparous,

Pluralty: singleton,

Gestation: 36 to 42 weeks,

Onset of labour: spontaneous or induced,

Other: cephalic presentation; requested regional analgesia (given CSE); no other pregnancy complications.


InterventionsStudy group:

  • 110 women were encouraged to spend at least 20 mins of each hour out of bed - walking, standing, sitting in a rocking chair.


51 women achieved at least 30% of time out of bed, 15 women spent no time out of bed, 44 spent 1 to 29%, 32 spent 30% to 59% and 19 women spent > 60% of time out of bed.

Reasons for not ambulating: 16 women developed motor block, 25 mothers were fatigued, 10 women were following instructions of the midwife.

Control group:

  • 119 women were encouraged to stay in bed - sitting up in bed or lying on either side.


16 women got out of bed: 15 between 1% to 29% of the time and 1 between 30% to 59% of the time.
Reasons for ambulating: to pass urine.

All women:

- continuous fetal monitoring,
- 500-1000 mL Hartmann's solution infused as a preload,

- CSE - 27-G Becton-Dickinson Whitacre 119 mm spinal needle and 16-G Tuohy needle'

- long spinal needle inserted through Tuohy needle into cerebrospinal fluid (needle-through-needle CSE),

- Subarachnoid injection of 25 g fentanyl and 2.5 mg bupivacaine

- Labours were managed according to the department's standard practice (cervical dilatation was assessed every 3 hours and if dilatation had not increased by 2 cm, amniotomy was performed. If the membranes were intact, this was followed 2 hours later (if progress of labour was still inadequate) by augmentation of labour with oxytocin. If the membranes were ruptured and inadequate progress of labour was noted, then oxytocin was started without waiting for another 2 hours.

- The mothers were allowed up to 2 hours in the second stage of labour. If at the end of the second hour, birth was not imminent, instrumental birth was performed.


OutcomesMaternal Outcomes:

  1. Mode of birth.
  2. Analgesia amount.
  3. Augmentation of labour using oxytocin.


Neonatal Outcomes:

  1. Apgar scores.


NotesDuration was recorded as the time between epidural insertion (highly variable) and birth (end of second stage). It was therefore not used as a comparable duration of first stage of labour.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot stated.

Allocation concealment (selection bias)Low riskDescribed as 'sealed opaque numbered envelopes'.

Blinding (performance bias and detection bias)
Women
High riskNot feasible.

Blinding (performance bias and detection bias)
Clinical staff
Unclear riskDescribed as 'Obstetrician was not aware which group the mother was in'.

Blinding (performance bias and detection bias)
Outcome assessor
Unclear riskNot stated.

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo stated losses to follow-up.

Selective reporting (reporting bias)Unclear riskUnclear.

Fernando 1994

MethodsRandomised trial of women receiving a CSE.


Participants40 women, London, U.K.

  • 20 study participants: nulliparous
  • 20 control participants: nulliparous


Inclusion Criteria:

Parity: nulliparous,

Pluralty: not stated,

Gestation: not stated,

Onset of labour: not stated,

Other: requesting regional analgesia.


InterventionsStudy group:

  • 20 women were allocated to be out of bed (sitting in rocking chair, stand by bed, walk about).


Control group:

  • 20 women were allocated to staying in bed.


All women:

- spinal injection of bupivacaine 2.5 mg and fentanyl 25 g using a 27 gauge, 1119 mm Becton-Dickinson Whitacre spinal needle through a 16-gauge Braun Tuohy needle, followed by epidural top ups of 10 mg bupivacaine in 10 mL with 2 g/mL of fentanyl.


OutcomesMaternal Outcomes:

Nil

Neonatal Outcomes:

  1. Apgar scores.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskDescribed as 'randomly allocated'.

Allocation concealment (selection bias)Unclear riskNot stated.

Blinding (performance bias and detection bias)
Women
High riskNot feasible.

Blinding (performance bias and detection bias)
Clinical staff
High riskNot feasible.

Blinding (performance bias and detection bias)
Outcome assessor
Unclear riskNot stated.

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo stated losses to follow-up.

Selective reporting (reporting bias)High riskNo maternal outcomes reported.

Flynn 1978

MethodsRandomised trial of patients who expressed an interest in ambulation when they were admitted in labour. During the antenatal period they had been informed that a certain number of patients could walk around while being continuously monitored in labour.


Participants68 women, Birmingham, U.K.

  • 34 study participants:17 primigravidae, 17 multigravida
  • 34 control participants:17 primigravidae, 17 multigravida


Inclusion Criteria:

Parity: mixed,

Pluralty: not stated,

Gestation: not stated,

Onset of labour: spontaneous,

Other: expressing an interest in ambulation.


InterventionsStudy group:

  • 34 women were allowed to walk around while being continuously monitored by telemetry.


When intravenous treatment was necessary (e.g. because of ketonuria or delay in labour) the women returned to bed.

Control group:

  • 34 women were nursed in the lateral position (recumbent) with conventional bedside monitoring of fetal heart and intrauterine pressure.


All women:

- were nursed in bed during the second and third stages of labour.
- Dilatation of the cervix and station of the presenting part were assessed at the start of monitoring and every two to three hours during labour.
- Analgesia was administered when the midwife thought the woman was becoming distressed with pain.
- Augmentation in labour with oxytocin or prostaglandin was given when indicated by delay in labour.

There was 33 cephalic and 1 breech presentation in each group.


OutcomesMaternal Outcomes:

  1. Duration of first stage of labour.
  2. Mode of birth.
  3. Maternal pain.
  4. Analgesia type.
  5. Augmentation of labour using oxytocin.


Neonatal Outcomes:

  1. Fetal distress requiring immediate birth.


NotesAssisted breech births (1 upright, 1 recumbent) not included as spontaneous vaginal, operative vaginal or caesarean births.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskDescribed as 'randomised prospective'.

Allocation concealment (selection bias)Unclear riskNot stated.

Blinding (performance bias and detection bias)
Women
High riskNot feasible.

Blinding (performance bias and detection bias)
Clinical staff
High riskNot feasible.

Blinding (performance bias and detection bias)
Outcome assessor
Unclear riskNot stated.

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo stated losses to follow-up.

Selective reporting (reporting bias)Unclear riskUnclear.

Frenea 2004

MethodsRandomised trial of women requesting epidural anaesthesia.


Participants61 women, Grenoble, France.

  • 30 study participants: 18 primigravidae, 12 multigravida
  • 31 control participants: 18 primigravidae, 13 multigravida


Inclusion Criteria:

Parity: mixed,

Pluralty: singleton,

Gestation: 37 to 42 weeks,

Onset of labour: spontaneous or admitted for elective induction,

Other: fixed cephalic uncomplicated presentation; 3 to 5 cm cervical dilatation at the time of epidural insertion; uncomplicated pregnancy; a normal fetal heart rate pattern.

Exclusion criteria - unfixed cephalic presentation, cervical dilatation more than 5 cm, a contraindication to epidural analgesia, or a systolic arterial blood pressure < 100 mmHg before epidural insertion, twin pregnancy, history of caesarean birth, and any known complications of pregnancy including breech presentation.


InterventionsStudy group:

  • 30 women were randomised to ambulation


Women were asked to walk at least 15 mins of each hour or for 25% of the duration of the first stage of labour.
Ambulation was permitted 15 to 20 mins after the initial injection, provided there was no postural hypotension, no motor block in lower limbs, no proprioception impairment and no fetal heart rate decelerations.
The women were asked to return to bed when they requested an epidural top-up or if they experienced weakness or sensory changes. Walking ended when examination by a midwife revealed full cervical dilatation.

Control group:

  • 31 women were allocated to be recumbent


Confined to bed in dorsal or lateral recumbent position.
Monitoring of labour was as for the ambulatory group, but without telemetry. Epidural analgesia of intermittent administrations of 0.08% bupivacaine-epinephrine plus 1 g/mL of sufentanil.


OutcomesMaternal Outcomes:

  1. Mode of birth.
  2. Analgesia amount.
  3. Augmentation of labour using oxytocin.
  4. Hypotension requiring intervention.


Neonatal Outcomes:

  1. Apgar scores.


NotesDuration was recorded as the time between epidural insertion (highly variable) and complete cervical dilatation. It was therefore not used as a comparable duration of first stage of labour.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot stated.

Allocation concealment (selection bias)Low riskDescribed as 'sealed numbered envelopes'.

Blinding (performance bias and detection bias)
Women
High riskNot feasible.

Blinding (performance bias and detection bias)
Clinical staff
High riskNot feasible.

Blinding (performance bias and detection bias)
Outcome assessor
Unclear riskNot stated.

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo stated losses to follow-up.

Selective reporting (reporting bias)Unclear riskUnclear.

Gau 2011

MethodsRandomised trial.


Participants188 women, Taiwan, Republic of China.

  • 94 study participants:33 primigravidae, 15 multigravida, 46 mixed parity.
  • 94 control participants: 22 primigravidae, 17 multigravida, 55 mixed parity.


Inclusion Criteria:

Parity: mixed,

Pluralty: singleton,

Gestation: unclear,

Onset of labour: spontaneous or admitted for elective induction,

Other: older than 18 years of age; no major obstetric or medical pregnancy complications; normal extremities and ability to undertake activities; a partner who was to be present during labour; and the ability to speak; read and write Chinese.


InterventionsStudy group:

  • 48 women were randomised to the birth ball exercise group


The birth ball exercise programme consisted of a 26 page booklet and a 19-minute videotape, with periodic follow-ups during prenatal checks. All women were asked to practise the exercises and positions at home for at least 20 mins three times a week for a period of 6-8 weeks. During labour, women in the study group were given a birth ball for use during labour and encouraged every hour to choose the most comfortable positions, movements and exercises.

There were 46 post-randomisation exclusions from the study group: Reasons for exclusion included: did not follow protocol (n = 3); epidural anaesthesia (n = 16); emergency caesarean (n = 18); preterm labour (n = 6); delivery at other hospital (n = 3).

Control group:

  • 39 women were randomised to the control group


There were 55 post-randomisation exclusions from the control group: Reasons for exclusion included: epidural anaesthesia (n = 25); emergency caesarean (n = 22); preterm labour (n = 6); delivery at other hospital (n = 2).


OutcomesMaternal Outcomes:

  1. Duration of first stage of labour.
  2. Mode of birth.
  3. Analgesia type.
  4. Maternal pain.
  5. Duration of second stage of labour.


Neonatal Outcomes:

  1. Apgar scores.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskA computer-generated block randomisation list (with block-sizes of four and eight varied randomly) was independently prepared by a statistician.

Allocation concealment (selection bias)Low riskSequentially numbered, sealed opaque envelopes contained allocation to the appropriate group.

Blinding (performance bias and detection bias)
Women
High riskNot feasible.

Blinding (performance bias and detection bias)
Clinical staff
High riskNot feasible.

Blinding (performance bias and detection bias)
Outcome assessor
Unclear riskNot stated.

Incomplete outcome data (attrition bias)
All outcomes
High riskThere was an attrition rate of 53.7%. The reasons 101 women were removed from the study included: emergency caesarean; epidural anaesthesia; preterm labour; delivery at other hospital; not following the protocol.

All outcome data for women excluded from the study were not included in the results.

Selective reporting (reporting bias)High riskStudy analysis which included the participants who did not follow the study protocol was repeated as ITT analysis. The authors stated there was no significant differences in effects based on ITT, but the outcome data for those and other excluded participants were not reported.

Haukkama 1982

MethodsQuasi-randomised trial.


Participants60 women, Helsinki, Finland.

  • 31 study participants:13 primigravidae, 18 multigravida
  • 29 control participants: 12 primigravidae, 17 multigravida


Inclusion Criteria:

Parity: mixed,

Pluralty: not stated,

Gestation: between 38 and 42 weeks,

Onset of labour: not stated,

Other: healthy, uneventful pregnancy.


InterventionsStudy group:

  • 31 women having cardiotocography by telemetry (upright).


Telemetry women were encouraged to sit or walk during the opening phase of labour.

Control group:

  • 29 women were randomised to have conventional cardiotocography (bed care).


All women:

- nitrous oxide-oxygen, pethidine (usual dose 75 mg given once or twice) or epidural block were used for analgesia when needed.


OutcomesMaternal Outcomes:

  1. Duration of first stage of labour.
  2. Mode of birth.
  3. Maternal pain.
  4. Analgesia type.
  5. Augmentation of labour using oxytocin.
  6. Artificial rupture of membranes.


Neonatal Outcomes:

  1. Apgar scores.
  2. Perinatal mortality.


NotesPooled data used from nulliparous and multiparous durations of first stage labour.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskDescribed as matched pairs 'allocated at random' to one of two groups. Patients were matched for age, parity and duration of pregnancy.

Allocation concealment (selection bias)Unclear riskNot stated.

Blinding (performance bias and detection bias)
Women
High riskNot feasible.

Blinding (performance bias and detection bias)
Clinical staff
High riskNot feasible.

Blinding (performance bias and detection bias)
Outcome assessor
Unclear riskNot stated.

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo stated losses to follow-up.

Selective reporting (reporting bias)Unclear riskUnclear.

Karraz 2003

MethodsRandomised trial.


Participants221 women, Evry, France

  • 144 study participants: 97 primigravidae, 47 multigravida
  • 77 control participants: 47 primigravidae, 30 multigravida


Inclusion Criteria:

Parity: mixed,

Pluralty: singleton,

Gestation: between 36 and 42 weeks,

Onset of labour: spontaneous or scheduled for induced labour,

Other: uncomplicated pregnancies.

Exclusion criteria - women with pre-eclampsia or previous caesarean.


InterventionsStudy group:

  • 144 women were assigned to the ambulatory group


Women could walk, sit in a chair or reclined in a semi-supine position (n = 141), as long as they demonstrated: acceptable analgesia; acceptable systolic blood pressure and ability to stand on one leg.

3 women in this group were excluded because they had a fast birth.

Control group:

  • 77 women were allocated to the non-ambulatory group


Women were not allowed to sit, walk or go to the toilet, they had to remain in the supine position or to lie in a semi-supine or lateral position (n = 74).

2 women in this group were excluded because they had a fast birth, and another 1 woman was excluded because of inadvertent dural puncture.

All women:

- Study conducted in daytime only (as women in labour at night are less inclined to walk).

- Received intermittent epidural injection of 0.1% ropivacaine with 0.6 µg/mL sufentanil.

- Repeat injections were given when the women requested additional pain relief.


OutcomesMaternal Outcomes:

  1. Mode of birth.
  2. Maternal pain.
  3. Analgesia amount.
  4. Augmentation using oxytocin.


Neonatal Outcomes:

Nil


NotesDuration was recorded as the time between epidural insertion (highly variable) and birth (end of second stage). It was therefore not used as a comparable duration of first stage of labour.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear risk'Randomly divided' in a 2:1 ratio.

Allocation concealment (selection bias)Unclear riskNot stated.

Blinding (performance bias and detection bias)
Women
High riskNot feasible.

Blinding (performance bias and detection bias)
Clinical staff
High riskNot feasible.

Blinding (performance bias and detection bias)
Outcome assessor
Unclear riskNot stated.

Incomplete outcome data (attrition bias)
All outcomes
High risk6 women were excluded after randomisation.

Selective reporting (reporting bias)Unclear riskUnclear.

MacLennan 1994

MethodsRandomised trial.


Participants196 women, Adelaide, Australia.

  • 96 study participants: 49 primigravidae, 47 multigravida
  • 100 control participants: 43 primigravidae, 57 multigravida


Inclusion Criteria:

Parity: mixed,

Pluralty: singleton,

Gestation: between 37 and 42 weeks,

Onset of labour: spontaneous,

Other: cephalic presentation; in established labour (presence of regular contractions less than 10 mins apart and cervical dilatation of 3 cm or more); able to ambulate in labour.

Exclusion criteria: women undergoing intravenous therapy, with hypertension (> 90 mmHg diastolic blood pressure), epidural or narcotic analgesia at or before entry to trial, evidence of possible fetal distress, previous prostaglandin treatment, induced labour and a physical inability to ambulate.


InterventionsStudy group:

  • 96 women were randomised to ambulate with fetal heart radiotelemetry


Women were encouraged to ambulate but were also given the option of sitting or lying down when they wished.

Only 37 women actually chose to ambulate for half an hour or more. The mean time they spent upright was 1.8 hrs, and the mean time they spent recumbent was 4.5 hrs.

Control group:

  • 100 women were randomised to recumbence with conventional fixed electronic fetal heart rate monitoring.


Most women chose a semi-recumbent posture with the head end of the bed at 45 degrees but they could also be on their side with lower elevation of the head.

All women:

After entry to the trial, all women had an artificial rupture of the membranes if they had not already spontaneously ruptured.


OutcomesMaternal Outcomes:

  1. Mode of birth.
  2. Analgesia type.
  3. Augmentation of labour using oxytocin.


Neonatal Outcomes:

  1. Apgar scores.
  2. Admission to NICU.
  3. Perinatal mortality.


NotesDuration was recorded as the time between entry (highly variable) and birth (end of second stage). It was therefore not used as a comparable duration of first stage of labour.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskDescribed as 'Balanced variable blocks with stratification by parity'.

Allocation concealment (selection bias)Low riskOpaque, sealed envelopes.

Blinding (performance bias and detection bias)
Women
High riskNot feasible.

Blinding (performance bias and detection bias)
Clinical staff
High riskNot feasible.

Blinding (performance bias and detection bias)
Outcome assessor
Unclear riskNot stated.

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo stated losses to follow-up.

Selective reporting (reporting bias)Unclear riskUnclear.

Mathew 2012

MethodsRandomised controlled trial approach with post test control group design.


Participants60 women, Magalore, India.

  • 40 study participants: nulliparous
  • 20 control participants: nulliparous


Inclusion Criteria:

Parity: nulliparous,

Pluralty: not stated,

Gestation: not stated,

Onset of labour: not stated,

Other: Nil stated.


InterventionsStudy group:

  • 20 women were asked to ambulate
  • 20 women were given a birthing ball and asked to use it


Control group:

  • 20 women were confined to bed in dorsal or lateral recumbence.


OutcomesMaternal Outcomes:

  1. Duration of first stage of labour.
  2. Mode of birth
  3. Duration of second stage of labour.


Neonatal Outcomes:

Nil.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskPurposive sampling technique was used for the selection of samples.

Allocation concealment (selection bias)Unclear riskRandom allocation of 20 samples to each of the three groups was achieved using a lottery method.

Blinding (performance bias and detection bias)
Women
High riskNot feasible.

Blinding (performance bias and detection bias)
Clinical staff
High riskNot feasible.

Blinding (performance bias and detection bias)
Outcome assessor
Unclear riskNot stated.

Incomplete outcome data (attrition bias)
All outcomes
High riskThere was missing data for the duration for 1st and 2nd stage labour: ambulation (n = 2), control (n = 4), but no missing data from the birthing ball group.

There was no explanation to explain the missing data.

In one table, 2 out of 24 women in the ambulation group are reported as having had a caesarean birth, but this is contradictory to the other reported data of zero caesarean births from 20 participants in the ambulation group.

Selective reporting (reporting bias)High riskAll methods of birth outcome data were reported, but not all durations of birth data were reported.

McManus 1978

MethodsRandomised trial of women undergoing induction of labour.


Participants40 women, Glasgow, U.K.

  • 20 study participants: 10 primigravidae, 10 multigravida
  • 20 control participants: 10 primigravidae, 10 multigravida


Inclusion Criteria:

Parity: mixed,

Pluralty: singleton,

Gestation: 38 weeks or more,

Onset of labour: induced,

Other: cervical score 6 or greater.

Exclusion criteria - multiple pregnancies or breech presentations.


InterventionsStudy group:

  • 20 women were allocated to an upright group.


Women were encouraged to "be up and about". If woman wished to go to bed, she was nursed in a sitting position with the aid of pillows.

Control group:

  • 20 women were allocated to a recumbent group.


Women were nursed in the lateral position.

All women:

Labour was induced by forewater amniotomy and 0.5 mg PGE2 immediately after amniotomy and hourly thereafter until labour was considered to be established.
If labour was not established an hour after the 6th PGE2 tablet (i.e. 6 hours after amniotomy), intravenous oxytocin was given.


OutcomesMaternal Outcomes:

  1. Mode of birth.
  2. Analgesia type.
  3. Augmentation of labour using oxytocin.
  4. Artificial Rupture of Membranes.
  5. Estimated Blood loss > 500 mL.


Neonatal Outcomes:

  1. Fetal distress (requiring immediate birth).
  2. Use of neonatal mechanical ventilation
  3. Apgar scores.


NotesDuration was recorded as the time between induction (highly variable) and birth (end of second stage). It was therefore not used as a comparable duration of first stage of labour.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskDescribed as 'randomised prospective study'.

Allocation concealment (selection bias)Low riskDescribed as 'randomly allocated according to the contents of a plain envelope'.

Blinding (performance bias and detection bias)
Women
High riskNot feasible.

Blinding (performance bias and detection bias)
Clinical staff
High riskNot feasible.

Blinding (performance bias and detection bias)
Outcome assessor
Unclear riskNot stated.

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo stated losses to follow-up.

Selective reporting (reporting bias)Unclear riskUnclear.

Miquelutti 2007

MethodsRandomised trial.


Participants107 women, Campinas, Brazil

  • 54 study participants: nulliparous
  • 53 control participants: nulliparous


Inclusion Criteria:

Parity: nulliparous,

Pluralty: singleton,

Gestation: term,

Onset of labour: spontaneous,

Other: cephalic presentation; cervical dilation between 3 cm and 5 cm; in labour; low risk; aged 16 to 40 years.

Exclusion criteria - contraindications to upright position or booked for elective caesarean birth.


InterventionsStudy group:

  • 54 women were encouraged to adopt upright positions.


Women received written information/education involving the use of models on the benefits of maintaining an upright position and encouraged to stand, walk, sit, crouch or kneel. If women remained supine for more than 30 mins they were encouraged to return to an upright position.

Women remained upright for 57% of the time.

Control group:

  • 53 women were allocated to routine care group


Women remained upright for 28% of the time.

Women were not encouraged to adopt upright positions but were allowed to move around and adopt any position they chose.


OutcomesMaternal Outcomes:

  1. Duration of first stage of labour.
  2. Mode of birth.
  3. Maternal satisfaction.
  4. Maternal pain.
  5. Duration of second stage of labour.
  6. Augmentation of labour using oxytocin.
  7. Perineal trauma.


Neonatal Outcomes:

  1. Apgar scores.


Notes1. Duration of first stage labour only reported as median and P value. Symmetrical distribution assumed. Median value used as a mean to calculate standard deviation and utilise data.

2. No data for numbers of operative vaginal birth or caesarean births.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputer-generated.

Allocation concealment (selection bias)Low riskSealed, opaque envelopes opened sequentially.

Blinding (performance bias and detection bias)
Women
High riskNot feasible.

Blinding (performance bias and detection bias)
Clinical staff
High riskNot feasible

Blinding (performance bias and detection bias)
Outcome assessor
Unclear riskNot stated.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskFew women lost to follow-up but no data for numbers of operative vaginal birth or caesarean births.

Selective reporting (reporting bias)High riskReported data for the number of women having spontaneous vaginal birth, but not for operative births or caesarean births.

Mitre 1974

MethodsRandomised trial.


Participants100 women, Terre Haute, U.S.A.

  • 50 study participants: nulliparous
  • 50 control participants: nulliparous


Inclusion Criteria:

Parity: nulliparous,

Pluralty: not stated,

Gestation: term,

Onset of labour: spontaneous,

Other: cephalic presentation; latent phase of labour or the active phase with the cervix between 1 cm and 3 cm; admitted to the labour room; no evidence of cephalopelvic disproportion; no history of surgery or trauma to the cervix; normal prenatal course.


InterventionsStudy group:

  • 50 women were randomised the sitting group.


All women were allowed to sit up after the amniotomy had been performed and the presenting part was engaged. The women were allowed to lie down from time to time, if they desired.

Control group:

  • 50 women were allocated to the supine group.


Women were placed in the supine position and allowed to turn on their sides.
Direct fetal and maternal monitoring was performed randomly on several women in both groups, using a choriometric unit.


OutcomesMaternal Outcomes:

  1. Duration of first stage of labour.


Neonatal Outcomes:

Nil


Notes1. SD's from the mean time in active labour (time to birth) used for the active 'phase' of labour duration times.

Apgar scores only provided as a mean value.

It is not clear if all women in both groups had routine amniotomy.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskDescribed as 'divided randomly into two groups'.

Allocation concealment (selection bias)Unclear riskNot stated.

Blinding (performance bias and detection bias)
Women
High riskNot feasible.

Blinding (performance bias and detection bias)
Clinical staff
High riskNot feasible.

Blinding (performance bias and detection bias)
Outcome assessor
Unclear riskNot stated.

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo stated losses to follow-up.

Selective reporting (reporting bias)High riskClaimed evidence of an outcome with little or no data to support it.

Nageotte 1997

MethodsRandomised trial.


Participants761 women, California, U.S.A.

  • 253 study participants: nulliparous
  • 252 control participants:nulliparous
  • 256 participants not used for this review because they received a different epidural intervention: nulliparous.


Inclusion Criteria:

Parity: nulliparous,

Pluralty: not stated,

Gestation: 36 weeks or more,

Onset of labour: spontaneous or induced for spontaneous rupture of membranes at 36 weeks or more,

Other: fetus in the vertex position; requesting epidural analgesia.


InterventionsStudy group:

  • 253 women were encouraged to ambulate (n = 253).


Ambulation was defined as a minimum of five mins of walking per hour.

Control group:

  • 252 women were discouraged to ambulate.


All women:

- had CSE.
- received a minimum of 1000 mL of lactated Ringer's solution intravenously during the 30 mins preceding the placement of the epidural needle. CSE - intrathecal narcotic with a continuous low-dose epidural infusion. After the location of the epidural space with an 18-gauge Tuohy needle, a 11.9 cm 27-gauge Whitacre spinal needle was passed through the epidural needle into the subarachnoid space. Then 10 g of sufentanil in 2 mL of normal saline was infused and the spinal needle removed. An epidural catheter was advanced 3 cm into the epidural space and a continuous infusion of 0.0625 % bupivacaine with 2 g of fentanyl per millilitre was given at a rate of 12 mL per hour.
- Subsequent bolus doses of epidural solution were given as requested (12 mL of 0.0625% bupivacaine).


OutcomesMaternal Outcomes:

  1. Mode of birth.
  2. Maternal pain.
  3. Hypotension requiring intervention.


Neonatal Outcomes:

  1. Apgar scores.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskDescribed as 'randomly assigned'.

Allocation concealment (selection bias)Unclear riskNot stated.

Blinding (performance bias and detection bias)
Women
High riskNot feasible.

Blinding (performance bias and detection bias)
Clinical staff
High riskNot feasible.

Blinding (performance bias and detection bias)
Outcome assessor
Unclear riskNot stated.

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo stated losses to follow-up.

Selective reporting (reporting bias)Unclear riskUnclear.

Phumdoung 2007

MethodsRandomised trial. Randomised in blocks.


Participants204 women, Southern Thailand.

  • 40 study participants: primiparous
  • 43 control participants: primiparous
  • 121 participants not used for this review: primiparous


Inclusion Criteria:

Parity: nulliparous,

Pluralty: singleton,

Gestation: 38 - 42 weeks,

Onset of labour: spontaneous,

Other: cephalic presentation; in latent phase for > 10 hours; married; aged 18 - 35 years; fetal weight 2500 - 4000 g.

Exclusion criteria: had analgesia before recruitment; induced labour; membrane rupture > 20 hours previously; psychiatric problem; infection; asthma or objection to intervention.

5 separate intervention groups (described below). In this review we have included data from two groups:


InterventionsStudy group:

  • 40 women were allocated to use the CAT position alternating half hourly with head high position (CAT position = facing towards bed head at 45 degrees with knees bent, taking weight on knees and elbows; head high position = lying at a 45-degree angle) (n = 40).


Control group:

  • 43 women were assigned to remain supine in bed.


OutcomesMaternal Outcomes:

  1. Duration of first stage of labour.


Neonatal Outcomes:

Nil.


NotesComplicated study design with five study groups:
1. CAT position alternating with head-high position with music (n = 40).
2. CAT position alternating with head-high position (n = 40).
3. CAT position alternating with supine position (n = 40).
4. Head-high position (lying in bed on back at 45 degrees) (n = 41).
5. Supine in bed (n = 43).

In this review we have used data for groups 2 and 5 in the analyses.

(It was not clear what 'CAT' signified)


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information.

Allocation concealment (selection bias)Unclear riskDescribed as 'random block design'.

Blinding (performance bias and detection bias)
Women
High riskNot feasible.

Blinding (performance bias and detection bias)
Clinical staff
High riskNot feasible.

Blinding (performance bias and detection bias)
Outcome assessor
Unclear riskNot stated.

Incomplete outcome data (attrition bias)
All outcomes
Low riskThree women were lost to follow-up as they had caesarean births during the first stage of labour. It was not clear whether this was before randomisation. No other loss to follow-up was apparent.

Selective reporting (reporting bias)Unclear riskUnclear.

Taavoni 2011

MethodsRandomised trial.


Participants62 women, Tehran, Iran.

  • 31 study participants: nulliparous
  • 31 control participants: nulliparous


Inclusion Criteria:

Parity: nulliparous,

Pluralty: singleton,

Gestation: 38 - 40 weeks,

Onset of labour: spontaneous,

Other: cephalic presentation; cervical dilatation between 4 to 8 cm; anticipation of a normal birth; no history of infertility; aged 18 to 25 years.


InterventionsStudy group:

  • 29 women were allocated to use a birth ball


There were two post randomisation exclusions from the study group. Reasons included: dissatisfied with sitting on the ball during birth ball movements (n = 1); caesarean birth because of lack of descent of the fetal head (n = 1).

Control group:

  • 31 women were allocated to usual care.


Routine care consists of the parturient lying on the bed without ambulating or any intervention.


OutcomesMaternal Outcomes:

  1. Duration of first stage labour.
  2. Mode of birth
  3. Maternal pain


Neonatal Outcomes:

Nil.


Notes1. Duration of first stage labour reported as duration of active phase.

2. No mode of birth outcomes for vaginal birth or operative vaginal birth were given.

If there was a need for analgesic medication, or if obstetric complications occurred, the participant was immediately referred to an obstetrician and other professionals as needed, then excluded from the study.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High risk60 volunteer women (convenience sample) were randomly allocated using a table of random numbers.

Allocation concealment (selection bias)High riskIf the number was even, women were assigned to the birth ball group, if the number was odd, women were assigned to control group.

Blinding (performance bias and detection bias)
Women
High riskNot feasible.

Blinding (performance bias and detection bias)
Clinical staff
High riskNot feasible.

Blinding (performance bias and detection bias)
Outcome assessor
Low riskThe individual responsible for data analysis was masked to the study purposes to minimise any bias that might arise from knowledge about the participants.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskThere were two post randomisation exclusions reported: dissatisfied with sitting on the ball during birth ball movements (n = 1); caesarean birth because of lack of descent of the fetal head (n = 1).

The total number of participants included for duration of labour and maternal pain data is not clearly stated. It is unclear if the number includes totals before or after exclusions. It is also not clear if the group numbers were even before or after the exclusions.

Selective reporting (reporting bias)Unclear riskUnclear.

Vallejo 2001

MethodsRandomised trial.


Participants160 women, Pennsylvania, U.S.A.

  • 75 study participants: nulliparous
  • 76 control participants nulliparous


Inclusion Criteria:

Parity: nulliparous,

Pluralty: singleton,

Gestation: 36 - 42 weeks,

Onset of labour: spontaneous or induction of labour,

Other: vertex position; 3-5 cm cervical dilatation at the time of epidural insertion; uncomplicated pregnancies.

Exclusion criteria - pre-eclampsia, diabetes mellitus, preterm gestation (< 36 weeks) and post-term gestation (> 42 weeks).


InterventionsStudy group:

  • 75 women were allocated to AEA with ambulation, sitting in a chair or both.


After 1 hour, women with a modified Bromage score of 5 who could stand on one foot (right and left) without assistance (all women in this group were able to do this) and without hypotension (systolic blood pressure < 100 mmHg or a decrease of 20 mmHg), were encouraged to ambulate with a support person (spouse or friend). If the woman could not comply with ambulation, she was encouraged to sit in a chair.
Ambulation was defined as a minimum of 5 min of walking per hour.
Women were not allowed to ambulate if there were persistent fetal decelerations and were not allowed to be out of bed in the second stage of labour when women were actively pushing.

Control group:

  • 76 women were assigned to AEA without ambulation or sitting in a chair.


Women were confined to bed, encouraged to stay recumbent in a lateral position, and were not allowed to raise the head of the bed more than 45 degrees from horizontal.

All women:

- AEA blocks initiated with 15 to 25 mL ropivacaine (0.07%) plus 100 g/mL fentanyl, no test dose, to achieve a T10 dermatome sensory level. After achieving adequate pain relief, a continuous infusion of 0.07% ropivacaine plus 2 g/mL fentanyl at 15 to 20 mL/hour was administered.


OutcomesMaternal Outcomes:

  1. Mode of birth.
  2. Analgesia amount.
  3. Duration of second stage of labour.
  4. Augmentation of labour using oxytocin.


Neonatal Outcomes:

  1. Apgar scores.


NotesDuration was recorded as the time between epidural insertion (highly variable) and complete cervical dilatation. It was therefore not used as a comparable duration of first stage of labour.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskDescribed as 'random number computer-generated program'.

Allocation concealment (selection bias)Unclear riskNot stated.

Blinding (performance bias and detection bias)
Women
High riskNot feasible.

Blinding (performance bias and detection bias)
Clinical staff
High riskNot feasible.

Blinding (performance bias and detection bias)
Outcome assessor
Unclear riskNot stated.

Incomplete outcome data (attrition bias)
All outcomes
High risk9 women were excluded.

Selective reporting (reporting bias)Unclear riskUnclear.

Williams 1980

MethodsQuasi-randomised trial.


Participants300 women, London, U.K.

  • 48 study participants: 25 primigravidae, 23 multigravida
  • 55 control participants: 30 primigravidae, 25 multigravida
  • 197 participants were excluded: short first stage (n = 84); at risk pregnancy (n = 29); induction (n = 24); refused ambulation (n = 30), elective caesarean birth (n = 13); stillbirths (n = 5); meconium-stained liquor (n = 5); breech (n = 3); twin pregnancy (n = 2); birth before arrival (n = 2).


Inclusion Criteria:

Parity: mixed,

Pluralty: singleton,

Gestation: 36-42 weeks,

Onset of labour: spontaneous,

Other: nil stated.


InterventionsStudy group:

  • 48 women were assigned to the ambulant group.


Women were informed about the possible benefits of ambulation and were encouraged to walk about during the first stage of labour
Women who refused ambulation or who requested to return to bed were allowed to do so.
Any woman who developed abnormalities of the fetal heart rate or fresh meconium staining of the amniotic fluid was returned to bed
Women who requested or who were advised to have an epidural also returned to bed but those requiring oxytocin augmentation of labour carried their intravenous infusions with them.

Control group:

  • 55 women were allocated to the non ambulant group.


OutcomesMaternal Outcomes:

  1. Duration of first stage of labour.
  2. Mode of birth.
  3. Analgesia type.
  4. Duration of second stage of labour.


Neonatal Outcomes:

  1. Apgar scores.


NotesPooled data used from nulliparous and multiparous durations of first stage labour.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskDescribed as 'divided into two groups according to their hospital number'.

Allocation concealment (selection bias)High riskSee above.

Blinding (performance bias and detection bias)
Women
High riskNot feasible.

Blinding (performance bias and detection bias)
Clinical staff
High riskNot feasible.

Blinding (performance bias and detection bias)
Outcome assessor
Unclear riskNot stated.

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo stated losses to follow-up.

Selective reporting (reporting bias)Unclear riskUnclear.

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Ahmed 1985Brief abstract, data for the single result presented were not in a form we were able use in the review.

Allahbadia 1992Not clear that this was an RCT. States that 'patients were selected at random' but it was not clear that allocation to experimental and control groups was random. All primigravidae in the control group were subjected to prophylactic episiotomies, not all primigravidae in the intervention group were subjected to prophylactic episiotomies.

Asselineau 1996Not randomised.

Caldeyro-Barcia 19601. Observational - Not RCT.
2. Not all women were in the first stage of labour.

Cobo 1968Intervention not relevant. Study examining lying on side versus lying on back.

Cohen 2002The study group received a different amount of ropivacaine compared to the control group. No outcomes relevant to the review were reported.

COMET 2001The trial compared low-dose combined spinal epidural and low-dose infusion techniques and traditional epidural techniques. Therefore the study group received a different epidural type compared with the control group.

Danilenko-Dixon 1996The purpose of this study was to compare cardiac output after epidural analgesia in both left lateral and supine positions, which are both regarded as recumbent positions for the purposes of this review.

Delgado-Garcia 2012The study compared using exercise ball or not using an exercise ball. It did not compare upright positions with recumbent positions. Control group was allowed freedom of movement.

Diaz 1980This study uses quasi-randomised group allocation, but more than a third of the experimental group were excluded from the analysis; women that did not comply with the protocol were excluded post randomisation.

Divon 1985No data were presented. No outcomes relevant to the review were reported. Outcomes - BP, uterine work and beat-to-beat variability.

Ducloy-Bouthors 2006The purpose of the study was to compare epidural spread for supine compared with 3 hip-flexed postures. No outcomes relevant to the review were reported

Hemminki 1983In this study the comparison was between two management policies rather than two different treatments. One group was nursed in bed and one group was encouraged to mobilise but there were also other differences in the treatment the two groups received which may have had an effect on outcomes. Women nursed in bed had routine amniotomy, women in the ambulant group did not; monitoring was also different in the two groups. These differences in management mean that it is not possible to assess the effect of position on outcomes.

Hemminki 1985Compared ambulation with immediate oxytocin.

Hodnett 1982All bed-care patients had an epidural and not all ambulant patients did.

Li 2010Women were allocated to the treatment or control group according to personal preference. No other randomisation details were described.

Liu 1989Compares semi-upright position with lying flat position, which are both recumbent positions for the purposes of this review.

McCormick 2007Study not completed - no results reported.

Melzack 1991Cross-over design - women alternated between vertical and horizontal positions, then rated their level of pain at the end of each 20-minute period.

Molina 1997Cross-over design - women alternated between vertical and horizontal positions, then rated their level of pain at the end of each 15-minute period.

Radkey 1991Study position, squatting, assumed in second stage of labour only.

Read 1981Comparing ambulation with oxytocin.

Roberts 1984Cross-over design - women alternated between sitting and lateral recumbence positions, every 30 minutes.

Schmidt 2001Cross-over design - measures fetal oxygen saturations for different and successive maternal birth positions.

Schneider-Affeld 1982No quantitative outcome data presented.

Selby 2012The study participants were not in labour.

Solano 1982Not randomised.

Stewart 1983Compares positions used in the 2nd stage of labour.

Tussey 2011The study did not compare upright positions with recumbent positions.

Weiniger 2009Study compares walking to the toilet to void with using a bed pan in bed. No relevant outcomes are reported.

Wilson 2011The trial compared low-dose combined spinal epidural and low-dose infusion techniques and traditional epidural techniques. Therefore the study group received a different epidural type compared with the control group.

Wu 2001Intervention not relevant to review outcomes. Study examining lying on one side rather than the other to correct fetal malpresentation.

 
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]

 
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
 
Table 1. Trial and participant numbers

Trial and participant numbers, grouped by comparison and sorted alphabetically

Comparison 1: Upright and ambulant positions versus recumbent positions and bed careComparison 2: Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women)



No. of studiesAuthorYearNo.No. of studiesAuthorYearNo.

1Andrews1990401Boyle2002409

2Ben Regaya20102002Collis1999229

3Bloom199810673Fernando199440

4Bundsen1982604Frenea200461

5Calvert19822005Karraz2003221

6Chan19632006Nageotte1997761

7Chen19871857Vallejo2001160

8Flynn197868

9Gau2011188

10Haukkama198260

11MacLennan1994196

12Mathew201260

13McManus197840

14Miquelutti2007107

15Mitre1974100

16Phumduong2007204

17Taavoni201162

18Williams1980300


18333771881


Total number of studies for comparisons 1&2: 25


Total number of participants for comparisons 1&2: 5218

 
Table 2. Method of birth outcomes

Method of birth outcomes, grouped by comparison

 Comparison 1: Upright and ambulant positions versus recumbent positions and bed careComparison 2: Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women)



 UprightRecumbentComp. 1UprightRecumbent Comp. 2







 ntotal%ntotal%Totalntotal%ntotal%Total

Vaginal Birth1105130685%1084132082%83%47580859%44775859%59%

Operative Vaginal Birth125125210%135126711%10%20680825%19575826%26%

Caesarean Birth7213295%10613538%7%12780816%11675815%16%

 
Table 3. Characteristics of all studies

Characteristics of all studies, sorted by year of publication

AuthorYearUprightRecumbentCountryParityNo.All women: epiduralAll women: other

1Chan1963sit or walksupine or lateralHong Kongnulliparous200

2Mitre1974sitsupineU.S.A.nulliparous100

3Flynn1978walklateralU.K.mixed68External monitoring

4McManus1978walk or sitlateralU.K.mixed40Induction; Amniotomy

5Williams1980walkbed careU.K.mixed300

6Bundsen1982walkingbed careSwedenmixed60Induction; Amniotomy; Internal Monitoring

7Calvert1982walk or sitbed careU.K.mixed200External monitoring

8Haukkama1982sit or walkbed careFinlandmixed60External monitoring

9Chen1987sitdorsal or lateralJapanmixed185Amniotomy

10Andrews1990standing, walking, sitting, squatting, kneelingsupine, lateral, proneU.S.A.nulliparous40

11Fernando1994walking, standing, sittingbed careU.K.nulliparous40Epidural

12MacLennan1994walkbed careAustraliamixed196External monitoring

13Nageotte1997walkbed careU.S.A.nulliparous761Epidural

14Bloom1998walking as desiredbed careU.S.A.mixed1067

15Collis1999walking, standing,  sittingbed careU.K.nulliparous229EpiduralExternal Monitoring

16Vallejo2001walk or sitlateralU.S.A.nulliparous160EpiduralInduction; External Monitoring

17Boyle2002walkbed careU.K.mixed409Epidural

18Karraz2003walksupine, semi supine or lateralFrancemixed221EpiduralInduction

19Frenea2004ambulationdorsal or lateralFrancemixed61EpiduralExternal Monitoring

20Miquelutti2007stand, walk, sit, crouch, kneelbed careBrazilnulliparous107

21Phumduong2007kneelingsupineThailandnulliparous204

22Ben Regaya2010ambulationdorsal or lateralTunisia, North Africanulliparous200

23Gau2011sitting, standing, kneeling, squattingbed careTaiwanmixed188External Monitoring

24Taavoni2011sittingbed careIrannulliparous62

25Mathew2012walk or sitdorsal or lateralIndianulliparous60