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Meta-Analysis
. 2017 May 25;5(5):CD002006.
doi: 10.1002/14651858.CD002006.pub4.

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

Janesh K Gupta  1 , Akanksha Sood  2 , G Justus Hofmeyr  3 , Joshua P Vogel  4
Affiliations
Meta-Analysis

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

Janesh K Gupta et al. Cochrane Database Syst Rev. .

Abstract

Background: For centuries, there has been controversy around whether being upright (sitting, birthing stools, chairs, squatting, kneeling) or lying down (lateral (Sim's) position, semi-recumbent, lithotomy position, Trendelenburg's position) have advantages for women giving birth to their babies. This is an update of a review previously published in 2012, 2004 and 1999.

Objectives: To determine the possible benefits and risks of the use of different birth positions during the second stage of labour without epidural anaesthesia, on maternal, fetal, neonatal and caregiver outcomes.

Search methods: We searched Cochrane Pregnancy and Childbirth's Trials Register (30 November 2016) and reference lists of retrieved studies.

Selection criteria: Randomised, quasi-randomised or cluster-randomised controlled trials of any upright position assumed by pregnant women during the second stage of labour compared with supine or lithotomy positions. Secondary comparisons include comparison of different upright positions and the supine position. Trials in abstract form were included.

Data collection and analysis: Two review authors independently assessed trials for inclusion and assessed trial quality. At least two review authors extracted the data. Data were checked for accuracy. The quality of the evidence was assessed using the GRADE approach.

Main results: Results should be interpreted with caution because risk of bias of the included trials was variable. We included eleven new trials for this update; there are now 32 included studies, and one trial is ongoing. Thirty trials involving 9015 women contributed to the analysis. Comparisons include any upright position, birth or squat stool, birth cushion, and birth chair versus supine positions.In all women studied (primigravid and multigravid), when compared with supine positions, the upright position was associated with a reduction in duration of second stage in the upright group (MD -6.16 minutes, 95% CI -9.74 to -2.59 minutes; 19 trials; 5811 women; P = 0.0007; random-effects; I² = 91%; very low-quality evidence); however, this result should be interpreted with caution due to large differences in size and direction of effect in individual studies. Upright positions were also associated with no clear difference in the rates of caesarean section (RR 1.22, 95% CI 0.81 to 1.81; 16 trials; 5439 women; low-quality evidence), a reduction in assisted deliveries (RR 0.75, 95% CI 0.66 to 0.86; 21 trials; 6481 women; moderate-quality evidence), a reduction in episiotomies (average RR 0.75, 95% CI 0.61 to 0.92; 17 trials; 6148 women; random-effects; I² = 88%), a possible increase in second degree perineal tears (RR 1.20, 95% CI 1.00 to 1.44; 18 trials; 6715 women; I² = 43%; low-quality evidence), no clear difference in the number of third or fourth degree perineal tears (RR 0.72, 95% CI 0.32 to 1.65; 6 trials; 1840 women; very low-quality evidence), increased estimated blood loss greater than 500 mL (RR 1.48, 95% CI 1.10 to 1.98; 15 trials; 5615 women; I² = 33%; moderate-quality evidence), fewer abnormal fetal heart rate patterns (RR 0.46, 95% CI 0.22 to 0.93; 2 trials; 617 women), no clear difference in the number of babies admitted to neonatal intensive care (RR 0.79, 95% CI 0.51 to 1.21; 4 trials; 2565 infants; low-quality evidence). On sensitivity analysis excluding trials with high risk of bias, these findings were unchanged except that there was no longer a clear difference in duration of second stage of labour (MD -4.34, 95% CI -9.00 to 0.32; 21 trials; 2499 women; I² = 85%).The main reasons for downgrading of GRADE assessment was that several studies had design limitations (inadequate randomisation and allocation concealment) with high heterogeneity and wide CIs.

Authors' conclusions: The findings of this review suggest several possible benefits for upright posture in women without epidural anaesthesia, such as a very small reduction in the duration of second stage of labour (mainly from the primigravid group), reduction in episiotomy rates and assisted deliveries. However, there is an increased risk blood loss greater than 500 mL and there may be an increased risk of second degree tears, though we cannot be certain of this. In view of the variable risk of bias of the trials reviewed, further trials using well-designed protocols are needed to ascertain the true benefits and risks of various birth positions.

PubMed Disclaimer

Conflict of interest statement

Janesh K Gupta: I am Editor‐in‐Chief for the European Journal of Obstetrics and Gynaecology (EJOG); I have received fees for consultancy from Femcare‐Nikodem Medicem and expert testimonies in relation to medicolegal reports; my institution has received money from Health Technology Assessment (HTA) grants; I have received royalties from core clinical cases undergraduate text books; and I am an author of a trial included in the systematic review (Gupta 1989) – trial assessment for inclusion, risk of bias, and data extraction were carried out by the other review authors (Justus Hofmeyr and Manjeet Shehmar (author in a previous version)), who were not directly involved in the study.

Akanksha Sood: None known.

G Justus Hofmeyr: GJH is conducting a study which may be considered for inclusion in this review (Hofmeyr 2015). He will not participate in decisions regarding the study.

Joshua P Vogel: JPV is conducting a study which may be considered for inclusion in this review (Hofmeyr 2015). He will not participate in decisions regarding the study.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Funnel plot of comparison: 1 Any upright versus supine position, outcome: 1.1 Duration of second stage of labour (minutes).
4
4
Funnel plot of comparison: 1 Any upright versus supine position, outcome: 1.4 Mode of birth: assisted birth.
5
5
Funnel plot of comparison: 1 Any upright versus supine position, outcome: 1.5 Mode of birth: caesarean section.
6
6
Funnel plot of comparison: 1 Any upright versus supine position, outcome: 1.6 Episiotomy.
7
7
Funnel plot of comparison: 1 Any upright versus supine position, outcome: 1.7 Second degree perineal tears.
8
8
Funnel plot of comparison: 1 Any upright versus supine position, outcome: 1.9 Blood loss > 500 mL.
1.1
1.1. Analysis
Comparison 1 Any upright versus supine position, Outcome 1 Duration of second stage of labour (minutes).
1.2
1.2. Analysis
Comparison 1 Any upright versus supine position, Outcome 2 Pain.
1.3
1.3. Analysis
Comparison 1 Any upright versus supine position, Outcome 3 Use of any analgesia/anaesthesia during second stage of labour.
1.4
1.4. Analysis
Comparison 1 Any upright versus supine position, Outcome 4 Mode of birth: assisted birth.
1.5
1.5. Analysis
Comparison 1 Any upright versus supine position, Outcome 5 Mode of birth: caesarean section.
1.6
1.6. Analysis
Comparison 1 Any upright versus supine position, Outcome 6 Episiotomy.
1.7
1.7. Analysis
Comparison 1 Any upright versus supine position, Outcome 7 Second degree perineal tears.
1.8
1.8. Analysis
Comparison 1 Any upright versus supine position, Outcome 8 Third/fourth degree tears.
1.9
1.9. Analysis
Comparison 1 Any upright versus supine position, Outcome 9 Blood loss > 500 mL.
1.10
1.10. Analysis
Comparison 1 Any upright versus supine position, Outcome 10 Need for blood transfusion.
1.11
1.11. Analysis
Comparison 1 Any upright versus supine position, Outcome 11 Manual removal of placenta.
1.12
1.12. Analysis
Comparison 1 Any upright versus supine position, Outcome 12 Abnormal fetal heart rate patterns.
1.13
1.13. Analysis
Comparison 1 Any upright versus supine position, Outcome 13 Admission to neonatal intensive care unit.
1.14
1.14. Analysis
Comparison 1 Any upright versus supine position, Outcome 14 Perinatal death.
1.15
1.15. Analysis
Comparison 1 Any upright versus supine position, Outcome 15 Subgroup analysis: duration of second stage of labour (parity).
2.1
2.1. Analysis
Comparison 2 Birth stool or squat stool versus supine position, Outcome 1 Duration of second stage all women (minutes).
2.2
2.2. Analysis
Comparison 2 Birth stool or squat stool versus supine position, Outcome 2 Use of any analgesia/anaesthesia during second stage of labour.
2.3
2.3. Analysis
Comparison 2 Birth stool or squat stool versus supine position, Outcome 3 Mode of birth: assisted birth.
2.4
2.4. Analysis
Comparison 2 Birth stool or squat stool versus supine position, Outcome 4 Mode of birth: caesarean section.
2.5
2.5. Analysis
Comparison 2 Birth stool or squat stool versus supine position, Outcome 5 Episiotomy.
2.6
2.6. Analysis
Comparison 2 Birth stool or squat stool versus supine position, Outcome 6 Second degree perineal tears.
2.7
2.7. Analysis
Comparison 2 Birth stool or squat stool versus supine position, Outcome 7 Third/fourth degree tears.
2.8
2.8. Analysis
Comparison 2 Birth stool or squat stool versus supine position, Outcome 8 Blood loss > 500 mL.
2.9
2.9. Analysis
Comparison 2 Birth stool or squat stool versus supine position, Outcome 9 Need for blood transfusion.
2.10
2.10. Analysis
Comparison 2 Birth stool or squat stool versus supine position, Outcome 10 Manual removal of placenta.
2.11
2.11. Analysis
Comparison 2 Birth stool or squat stool versus supine position, Outcome 11 Shoulder dystocia (not prespecified).
2.12
2.12. Analysis
Comparison 2 Birth stool or squat stool versus supine position, Outcome 12 Abnormal fetal heart rate patterns.
2.13
2.13. Analysis
Comparison 2 Birth stool or squat stool versus supine position, Outcome 13 Admission to neonatal intensive care unit.
2.14
2.14. Analysis
Comparison 2 Birth stool or squat stool versus supine position, Outcome 14 Perinatal death.
3.1
3.1. Analysis
Comparison 3 Birth cushion versus supine/lithotomy, Outcome 1 Duration of second stage of labour (minutes).
3.2
3.2. Analysis
Comparison 3 Birth cushion versus supine/lithotomy, Outcome 2 Mode of birth: assisted birth.
3.3
3.3. Analysis
Comparison 3 Birth cushion versus supine/lithotomy, Outcome 3 Mode of birth: caesarean section.
3.4
3.4. Analysis
Comparison 3 Birth cushion versus supine/lithotomy, Outcome 4 Episiotomy.
3.5
3.5. Analysis
Comparison 3 Birth cushion versus supine/lithotomy, Outcome 5 Second degree perineal tears.
3.6
3.6. Analysis
Comparison 3 Birth cushion versus supine/lithotomy, Outcome 6 Third/fourth degree tears.
3.7
3.7. Analysis
Comparison 3 Birth cushion versus supine/lithotomy, Outcome 7 Blood loss > 500 mL.
3.8
3.8. Analysis
Comparison 3 Birth cushion versus supine/lithotomy, Outcome 8 Perinatal death.
3.9
3.9. Analysis
Comparison 3 Birth cushion versus supine/lithotomy, Outcome 9 Subgroup analysis: duration of second stage of labour (parity).
4.1
4.1. Analysis
Comparison 4 Birth chair versus supine/lithotomy, Outcome 1 Duration of second stage of labour (minutes).
4.2
4.2. Analysis
Comparison 4 Birth chair versus supine/lithotomy, Outcome 2 Any analgesia/anaesthesia during second stage of labour.
4.3
4.3. Analysis
Comparison 4 Birth chair versus supine/lithotomy, Outcome 3 Mode of birth: assisted delivery.
4.4
4.4. Analysis
Comparison 4 Birth chair versus supine/lithotomy, Outcome 4 Mode of birth: caesarean section.
4.5
4.5. Analysis
Comparison 4 Birth chair versus supine/lithotomy, Outcome 5 Episiotomy.
4.6
4.6. Analysis
Comparison 4 Birth chair versus supine/lithotomy, Outcome 6 Second degree perineal tears.
4.7
4.7. Analysis
Comparison 4 Birth chair versus supine/lithotomy, Outcome 7 Blood loss > 500 mL.
4.8
4.8. Analysis
Comparison 4 Birth chair versus supine/lithotomy, Outcome 8 Need for blood transfusion.
4.9
4.9. Analysis
Comparison 4 Birth chair versus supine/lithotomy, Outcome 9 Manual removal of placenta.
4.10
4.10. Analysis
Comparison 4 Birth chair versus supine/lithotomy, Outcome 10 Admission to neonatal intensive care unit.
4.11
4.11. Analysis
Comparison 4 Birth chair versus supine/lithotomy, Outcome 11 Subgroup analysis: duration of second stage of labour (parity).
5.1
5.1. Analysis
Comparison 5 Sensitivity analysis based on trial quality (Comparison 1), Outcome 1 Duration of second stage of labour (minutes).
5.2
5.2. Analysis
Comparison 5 Sensitivity analysis based on trial quality (Comparison 1), Outcome 2 Mode of birth: assisted birth.
5.3
5.3. Analysis
Comparison 5 Sensitivity analysis based on trial quality (Comparison 1), Outcome 3 Mode of birth: caesarean section.
5.4
5.4. Analysis
Comparison 5 Sensitivity analysis based on trial quality (Comparison 1), Outcome 4 Second degree perineal tears.
5.5
5.5. Analysis
Comparison 5 Sensitivity analysis based on trial quality (Comparison 1), Outcome 5 Third/fourth degree tears.
5.6
5.6. Analysis
Comparison 5 Sensitivity analysis based on trial quality (Comparison 1), Outcome 6 Blood loss > 500 mL.
5.7
5.7. Analysis
Comparison 5 Sensitivity analysis based on trial quality (Comparison 1), Outcome 7 Admission to neonatal intensive care unit.
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References to ongoing studies

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Additional references

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References to other published versions of this review

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