Position in the second stage of labour for women without epidural anaesthesia
Giving birth in an upright position appears to be associated with several benefits, including reduction in the duration of the second stage of labour. Pending further confirmation of these benefits women should be allowed to choose their birthing position.
RHL Commentary by Lavender T and Mlay R
1. EVIDENCE SUMMARY
This review (1) assesses the benefits and risks of different birthing positions adopted by women during the second stage of labour. It includes 20 trials involving 6136 women. Generally, the trials were of variable methodological quality. The authors performed a sensitivity analysis (by excluding trials of poor quality) to compare upright or lateral position with supine or lithotomy position. The findings showed that, in women who did not receive epidural anaesthesia, giving birth in upright or lateral position was associated with reduced duration of second stage of labour, small reduction in assisted deliveries, reduction in episiotomies, increase in second degree perineal tears, increased estimated blood loss greater than 500 ml, reduced reporting of severe pain during the second stage of labour and fewer abnormal fetal heart rate patterns.
The review suggests possible benefits of an upright birthing position, with the possibility of an increased risk of blood loss greater than 500 ml. The authors conclude that this finding should be regarded as tentative until better data become available. In the meantime women should be encouraged to adopt birthing positions they find most comfortable.
The search strategy was rigorous and all reports of studies that were identified as potentially eligible were assessed. Data extraction, analysis and presentation were clear and concise.
2. RELEVANCE TO UNDER-RESOURCED SETTINGS
2.1. Magnitude of the problem
The birthing position adopted by women is influenced by several factors, including instinctive behaviour and cultural norms. In parts of the developing world (such as parts of Asia, Africa and the Americas) squatting, for example, is a common sitting posture. In the United Republic United Republic of Tanzania, for example, women who deliver at home with the help of traditional birth attendants or relatives use squatting or other upright positions chosen by the woman. Contrary to this cultural practice, almost all women who give birth at health-care facilities do so in supine recumbent position. It is conceivable that the lack of birthing position options at health-care facilities could be contributing to women choosing to give birth at home with unskilled persons rather than delivering at a health-care facility. Only 47% of Tanzanian women give birth at a health-care facility. In developed countries, where childbirth is medicalized, maternal, monitoring and clinical interventions during labour are thought to limit women’s birthing position options. In the largest women’s hospital in Europe, for example, local audit data demonstrate that 86% of women give birth in either supine or semi-recumbent position. The identification of an optimum position with the possibility of improving clinical outcomes is therefore highly relevant to all women.
2.2. Applicability of the results
Studies included in this review were conducted in a wide range of developed and developing countries/regions (two in India, one in Hong Kong Special Administrative Region, one in Thailand, one in Kuwait, one in Ireland, five in England, two in Finland, one in Scotland, one in Australia, one in New Zealand, one in France, one in Canada and one in Sweden). Since there appear to be no differences in outcomes according to setting, the results of the systematic review can be expected to apply to all settings, including under-resourced settings.
2.3. Implementation of the intervention
Given the methodological limitations of the trials and the cautious interpretation of the authors, it is reasonable to recommend that each woman should be allowed to choose her preferred birthing position for the second stage of labour; there are no direct cost implications of this recommendation. In Africa, for example, where there is a critical shortage of skilled birth attendants, allowing women to deliver in an upright position has the potential to improve delivery outcomes; reduction in the duration of second stage of labour may help reduce overcrowding in labour wards and reduce the time health-care providers spends with each woman.
The real challenge for health-care professionals in all settings is to provide women with (i) unbiased information on which to base their birthing position choices, and (ii) advice on how to prepare for delivering in the chosen position. Training of certain health-care providers to support women in giving birth in different birthing positions may be required. Creating within the health system a culture supportive of giving women the freedom to choose their preferred birthing position would be a challenge. For example health-care providers in the United Republic of Tanzania are not comfortable with a woman squatting on the bed to deliver, because they fear the baby might fall on the floor.
A good-quality multicentre (involving both developing and developed countries) randomized controlled trial should be conducted on the short- and long-term outcomes of different birthing positions. In addition, qualitative research should be conducted to explore the impact of the birth environment on maternal birthing position. The beliefs of health-care providers with regard to birthing positions and their competency in advising women regarding birthing positions should also be investigated. Also, research should be conducted on the value of preparing women for different birthing positions.
- Gupta JK, Hofmeyr GJ, Smyth R. Position in the second stage of labour for women without epidural anaesthesia (Cochrane Review). The Cochrane Database of Systematic Reviews;2004, Issue 1.
This document should be cited as: Lavender T and Mlay R. Position in the second stage of labour for women without epidural anaesthesia: RHL commentary (last revised: 15 December 2006). The WHO Reproductive Health Library; Geneva: World Health Organization.