Factors associated with spontaneous vaginal birth in nulliparous women: A descriptive systematic review

Abstract

Problem: Spontaneous vaginal birth (SVB) rates for nulliparous women are declining internationally.

Background: There is inadequate understanding of factors affecting this trend overall and limited large-scale responses to improve women's opportunity to birth spontaneously.

Aim: To undertake a descriptive systematic review identifying factors associated with spontaneous vaginal birth at term, in nulliparous women with a singleton pregnancy.

Methods: Quantitative studies of all designs, of nulliparous women with a singleton pregnancy and cephalic presentation, who experienced a SVB at term were included. Nine databases were searched (inception to October 2022). Two reviewers undertook quality appraisal; Randomised Controlled Trials (RCTs) with high risk of bias (ROB 2.0) and other designs with (QATSDD) scoring ≤ 50% were excluded.

Findings: Data were abstracted from 90 studies (32 RCTs, 39 cohort, 9 cross-sectional, 4 prevalence, 5 case control, 1 quasi-experimental). SVB rates varied (13%-99%). Modifiable factors associated with SVB included addressing fear of childbirth, low impact antenatal exercise, maternal positioning during second-stage labour and midwifery led care. Complexities arising during pregnancy and regional analgesia were shown to decrease SVB and other interventions, such as routine induction of labour were equivocal.

Discussion: Antenatal preparation (low impact exercise, childbirth education, addressing fear of childbirth) may increase SVB, as does midwifery continuity-of-care. Intrapartum strategies to optimise labour progression emerged as promising areas for further research.

Conclusion: Declining SVB rates may be improved through multi-factorial approaches inclusive of maternal, fetal and clinical care domains. However, the variability of SVB rates testifies to the complexity of the issue.

Keywords: Caesarean section; Nulliparous; Spontaneous vaginal birth; Systematic review; Vaginal delivery.