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Meta-Analysis
. 2013 Oct 9;2013(10):CD003934.
doi: 10.1002/14651858.CD003934.pub4.

Maternal positions and mobility during first stage labour

Annemarie Lawrence  1 , Lucy Lewis, G Justus Hofmeyr, Cathy Styles
Affiliations
Meta-Analysis

Maternal positions and mobility during first stage labour

Annemarie Lawrence et al. Cochrane Database Syst Rev. .

Abstract

Background: It is more common for women in both high- and low-income countries giving birth in health facilities, to labour in bed. There is no evidence that this is associated with any advantage for women or babies, although it may be more convenient for staff. Observational studies have suggested that if women lie on their backs during labour this may have adverse effects on uterine contractions and impede progress in labour, and in some women reduce placental blood flow.

Objectives: To assess the effects of encouraging women to assume different upright positions (including walking, sitting, standing and kneeling) versus recumbent positions (supine, semi-recumbent and lateral) for women in the first stage of labour on duration of labour, type of birth and other important outcomes for mothers and babies.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2013).

Selection criteria: Randomised and quasi-randomised trials comparing women randomised to upright versus recumbent positions in the first stage of labour.

Data collection and analysis: We used methods described in the Cochrane Handbook for Systematic Reviews of Interventions for carrying out data collection, assessing study quality and analysing results. Two review authors independently evaluated methodological quality and extracted data for each study. We sought additional information from trial authors as required. We used random-effects analysis for comparisons in which high heterogeneity was present. We reported results using the average risk ratio (RR) for categorical data and mean difference (MD) for continuous data.

Main results: Results should be interpreted with caution as the methodological quality of the 25 included trials (5218 women) was variable.For Comparison 1: Upright and ambulant positions versus recumbent positions and bed care, the first stage of labour was approximately one hour and 22 minutes shorter for women randomised to upright as opposed to recumbent positions (average MD -1.36, 95% confidence interval (CI) -2.22 to -0.51; 15 studies, 2503 women; random-effects, T(2) = 2.39, Chi(2) = 203.55, df = 14, (P < 0.00001), I(2) = 93%). Women who were upright were also less likely to have caesarean section (RR 0.71, 95% CI 0.54 to 0.94; 14 studies, 2682 women) and less likely to have an epidural (RR 0.81, 95% CI 0.66 to 0.99, nine studies, 2107 women; random-effects, T(2) = 0.02, I(2) = 61%). Babies of mothers who were upright were less likely to be admitted to the neonatal intensive care unit, however this was based on one trial (RR 0.20, 95% CI 0.04 to 0.89, one study, 200 women). There were no significant differences between groups for other outcomes including duration of the second stage of labour, or other outcomes related to the well being of mothers and babies.For Comparison 2: Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women), there were no significant differences between groups for outcomes including duration of the second stage of labour, or other outcomes related to the well being of mothers and babies.

Authors' conclusions: There is clear and important evidence that walking and upright positions in the first stage of labour reduces the duration of labour, the risk of caesarean birth, the need for epidural, and does not seem to be associated with increased intervention or negative effects on mothers' and babies' well being. Given the great heterogeneity and high performance bias of study situations, better quality trials are still required to confirm with any confidence the true risks and benefits of upright and mobile positions compared with recumbent positions for all women. Based on the current findings, we recommend that women in low-risk labour should be informed of the benefits of upright positions, and encouraged and assisted to assume whatever positions they choose.

PubMed Disclaimer

Conflict of interest statement

None known.

Figures

1
1
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
2
2
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
3
3
Funnel plot of comparison: 1 Upright and ambulant positions versus recumbent positions and bed care, outcome: 1.1 Duration of first stage labour (hours).
4
4
Funnel plot of comparison: 1 Upright and ambulant positions versus recumbent positions and bed care, outcome: 1.8 Mode of birth: spontaneous vaginal.
5
5
Funnel plot of comparison: 1 Upright and ambulant positions versus recumbent positions and bed care, outcome: 1.15 Mode of birth: operative vaginal: all women.
6
6
Funnel plot of comparison: 1 Upright and ambulant positions versus recumbent positions and bed care, outcome: 1.22 Mode of birth: caesarean birth.
1.1
1.1. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 1 Duration of first stage labour (hours).
1.2
1.2. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 2 Duration of first stage labour (hours): subgroup analysis: parity.
1.3
1.3. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 3 Duration of first stage labour (hours): subgroup analysis: onset of labour.
1.4
1.4. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 4 Duration of first stage labour (hours): subgroup analysis: position types.
1.5
1.5. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 5 Duration of first stage labour (hours): subgroup analysis: position types.
1.6
1.6. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 6 Duration of first stage labour (hours): subgroup analysis: position types.
1.7
1.7. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 7 Duration of first stage labour (hours): sensitivity analysis ‐ positions.
1.8
1.8. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 8 Mode of birth: spontaneous vaginal.
1.9
1.9. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 9 Mode of birth: spontaneous vaginal: subgroup analysis: parity.
1.10
1.10. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 10 Mode of birth: spontaneous vaginal: subgroup analysis: onset of labour.
1.11
1.11. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 11 Mode of birth: spontaneous vaginal: subgroup analysis: position types.
1.12
1.12. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 12 Mode of birth: spontaneous vaginal: subgroup analysis: position types.
1.14
1.14. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 14 Mode of birth: spontaneous vaginal: sensitivity analysis ‐ positions.
1.15
1.15. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 15 Mode of birth: operative vaginal: all women.
1.16
1.16. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 16 Mode of birth: operative vaginal: subgroup analysis: parity.
1.17
1.17. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 17 Mode of birth: operative vaginal: subgroup analysis: onset of labour.
1.18
1.18. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 18 Mode of birth: operative vaginal: subgroup analysis: position types.
1.19
1.19. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 19 Mode of birth: operative vaginal: subgroup analysis: position types.
1.21
1.21. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 21 Mode of birth: operative vaginal: sensitivity analysis ‐ positions.
1.22
1.22. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 22 Mode of birth: caesarean birth.
1.23
1.23. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 23 Mode of birth: caesarean birth: subgroup analysis: parity.
1.24
1.24. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 24 Mode of birth: caesarean birth: subgroup analysis: onset of labour.
1.25
1.25. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 25 Mode of birth: caesarean birth: subgroup analysis: position types.
1.26
1.26. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 26 Mode of birth: caesarean birth: subgroup analysis: position types.
1.28
1.28. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 28 Mode of birth: caesarean birth: sensitivity analysis ‐ positions.
1.29
1.29. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 29 Analgesia type.
1.30
1.30. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 30 Maternal satisfaction.
1.31
1.31. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 31 Maternal comfort.
1.32
1.32. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 32 Maternal pain.
1.33
1.33. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 33 Maternal pain.
1.34
1.34. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 34 Maternal pain.
1.35
1.35. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 35 Maternal anxiety.
1.36
1.36. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 36 Analgesia amount.
1.37
1.37. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 37 Duration of second stage of labour (minutes).
1.38
1.38. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 38 Augmentation of labour using oxytocin.
1.39
1.39. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 39 Artificial rupture of membranes.
1.41
1.41. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 41 Estimated blood loss > 500 mL.
1.42
1.42. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 42 Perineal trauma.
1.43
1.43. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 43 Fetal distress (requiring immediate delivery).
1.44
1.44. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 44 Use of neonatal mechanical ventilation.
1.45
1.45. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 45 Apgar scores.
1.46
1.46. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 46 Admission to NICU.
1.47
1.47. Analysis
Comparison 1 Upright and ambulant positions versus recumbent positions and bed care, Outcome 47 Perinatal mortality.
2.2
2.2. Analysis
Comparison 2 Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women), Outcome 2 Mode of birth: spontaneous vaginal.
2.3
2.3. Analysis
Comparison 2 Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women), Outcome 3 Mode of birth: spontaneous vaginal: subgroup analysis: parity.
2.4
2.4. Analysis
Comparison 2 Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women), Outcome 4 Mode of birth: spontaneous vaginal: subgroup analysis: onset of labour.
2.5
2.5. Analysis
Comparison 2 Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women), Outcome 5 Mode of birth: spontaneous vaginal: subgroup analysis: position types.
2.6
2.6. Analysis
Comparison 2 Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women), Outcome 6 Mode of birth: spontaneous vaginal: subgroup analysis: position types.
2.7
2.7. Analysis
Comparison 2 Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women), Outcome 7 Mode of birth: spontaneous vaginal: sensitivity analysis.
2.8
2.8. Analysis
Comparison 2 Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women), Outcome 8 Mode of birth: operative vaginal.
2.9
2.9. Analysis
Comparison 2 Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women), Outcome 9 Mode of birth: operative vaginal: subgroup analysis: parity.
2.10
2.10. Analysis
Comparison 2 Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women), Outcome 10 Mode of birth: operative vaginal: subgroup analysis: onset of labour.
2.11
2.11. Analysis
Comparison 2 Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women), Outcome 11 Mode of birth: operative vaginal: subgroup analysis: position types.
2.12
2.12. Analysis
Comparison 2 Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women), Outcome 12 Mode of birth: operative vaginal: subgroup analysis: position types.
2.13
2.13. Analysis
Comparison 2 Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women), Outcome 13 Mode of birth: operative vaginal: sensitivity analysis.
2.14
2.14. Analysis
Comparison 2 Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women), Outcome 14 Mode of birth: caesarean birth.
2.15
2.15. Analysis
Comparison 2 Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women), Outcome 15 Mode of birth: caesarean birth: subgroup analysis: parity.
2.16
2.16. Analysis
Comparison 2 Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women), Outcome 16 Mode of birth: caesarean birth: subgroup analysis: onset of labour.
2.17
2.17. Analysis
Comparison 2 Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women), Outcome 17 Mode of birth: caesarean birth: subgroup analysis: position types.
2.18
2.18. Analysis
Comparison 2 Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women), Outcome 18 Mode of birth: caesarean birth: subgroup analysis: position types.
2.19
2.19. Analysis
Comparison 2 Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women), Outcome 19 Mode of birth: caesarean birth: sensitivity analysis.
2.21
2.21. Analysis
Comparison 2 Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women), Outcome 21 Maternal pain.
2.22
2.22. Analysis
Comparison 2 Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women), Outcome 22 Analgesia amount.
2.23
2.23. Analysis
Comparison 2 Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women), Outcome 23 Duration of second stage of labour (minutes).
2.24
2.24. Analysis
Comparison 2 Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women), Outcome 24 Augmentation of labour using oxytocin.
2.26
2.26. Analysis
Comparison 2 Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women), Outcome 26 Hypotension requiring intervention.
2.31
2.31. Analysis
Comparison 2 Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women), Outcome 31 Apgar scores.
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