Maternal positions and mobility during first stage of labour
The duration of the first stage of labour may be reduced by about one hour in women who maintain the upright position and walk around; they are also likely to receive less epidural analgesia. Since the review did not find any adverse effects associated with remaining upright, health-care professionals and facilities may encourage labouring women to adopt positions that women are most comfortable with.
RHL Commentary by Makuch MY
More and more women in both developed and developing countries are giving birth in health-care facilities, usually in bed in recumbent positions. A woman’s position during labour has an important cultural imprint: in societies not influenced by Western culture, women progress through the first stage of labour in an upright position and change to other positions according to need (1, 2, 3).
In the 1960s, clinical studies on the upright position during labour assessed the benefits of this position for the woman and her fetus. In the 1980s, studies focused not only on the well-being of both the mother and her baby, but also compared the upright and supine positions with obstetrical variables. In the 1990, perhaps owing to the need to reduce unnecessary interventions and to focus on women's needs rather than the convenience of health-care providers, studies began to evaluate women’s perceptions of pain in different positions during labour (4). However, in spite of three decades of research, the ideal maternal position during labour and childbirth continues to be debated. The main purpose of the present review (5) was "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 length of labour, type of delivery and other important outcomes for mothers and babies".
2. METHODS OF THE REVIEW
Randomized or quasi-randomized trials registered in the Cochrane Pregnancy and Childbirth Group’s Trials Register up to 31 December 2008 were considered for inclusion. In these trials, women in labour had opted for positions categorized as upright or recumbent during the first stage of labour. The review authors assessed the quality of the studies and analysed the results according to the Cochrane Handbook for Systematic Reviews of Interventions (6). Outcomes were grouped as: (i) primary maternal outcomes: duration of the first stage of labour, type of delivery, maternal satisfaction with position and experience of childbirth; (ii) primary fetal and neonatal outcomes: fetal distress requiring immediate delivery and use of neonatal mechanical ventilation; (iii) secondary maternal outcomes: pain, use of analgesics, duration of the second stage of labour, augmentation of labour with oxytocin, spontaneous rupture of membranes, hypotension requiring intervention, estimated blood loss >500 ml, perineal trauma; and (iv) secondary neonatal outcomes: Apgar score less than seven at the 5th minute following delivery and admission to an intensive care unit.
Studies were assessed independently by two reviewers. Differences of opinion between the reviewers were settled through negotiation between the two reviewers, but when that failed, the studies were evaluated by another person. Data were entered into Review Manager Software, and checked for accuracy. Risk of bias was assessed by analysing the procedures for randomization and concealment of allocation. For each included study, the completeness of outcome data, including attrition and exclusions from the analysis, reasons for attrition/exclusion, and re-inclusion analyses were also examined and reported in the review.
The Review Manager Software was used for statistical analysis. Dichotomous data were presented as summary risk ratios, with 95% confidence intervals. For data measured as scores or on visual analogue scales, mean difference was used, and to combine trials measuring the same outcome using different methods, the standardized mean difference was used. When high levels of heterogeneity (more than 50%) were identified, data were processed through pre-specified subgroups and sensitivity analysis. Random effects meta-analysis was used to generate an overall summary for these comparisons.
Since some trials had recruited only nulliparous women and some had presented results separately for nulliparous and multiparous women, in order to use all available data, overall results are presented in the review by grouping the analysed data according to parity. Where there was a risk of bias associated with a particular aspect of the study quality, sensitivity analysis was used to explore its effect in the case of important outcomes. Characteristics of the included studies are clearly reported in tables, which present a well-elaborated summary of the quality of studies in terms of randomization, risk of bias, type of intervention, and main outcomes.
3. RESULTS OF THE REVIEW
Twenty-one studies with a total of 3706 women were included in the review. Results from 16 trials (2530 women) indicated that the first stage of labour was shorter by approximately one hour for women randomized to the upright position group compared with those in the supine and recumbent position groups. However, this finding should be interpreted with caution as there was a high level of heterogeneity between studies. Pooled results from nine trials (1677 women) showed a statistically significant difference between the groups (mean difference −0.99; 95% confidence interval −1.60 to −0.39). No difference between groups in the duration of the second stage of labour was found in the two trials reporting this outcome.
The analysis of positions and mode of birth showed that: (i) for both nulliparous and multiparous women, spontaneous vaginal birth rates were similar; (ii) women remaining in the upright position had similar rates of assisted deliveries compared with women in the recumbent positions; and (iii) when women were encouraged to maintain an upright position, they had slightly lower rates of caesarean section. However, for all three findings, the strength of the evidence was weak and results did not reach statistical significance.
Even though some studies collected information about satisfaction with specific aspects of care, it was not possible to pool these results since none of the studies had collected information on women’s satisfaction with their general experience of childbirth. No differences were identified between the upright versus recumbent groups in terms of reported discomfort or requests for analgesia, although relatively few trials examined these outcomes, and findings were inconsistent. Results also showed similar rates of augmentation of labour for both groups.
There was little information in the included studies on maternal outcomes (rates of postpartum haemorrhage and perineal trauma); however, results from individual trials suggest no significant differences between groups. For neonatal outcomes, no significant differences for fetal distress and neonatal Apgar scores were observed between the groups.
Analysis for upright (including walking) versus recumbent positions with epidural analgesia was available from five trials, involving a total of 1176 women, irrespective of parity. Results on the duration of the first stage of labour, spontaneous vaginal delivery, assisted and caesarean delivery were similar for women randomized to either position. For neonatal outcomes no differences were observed between groups in the incidence of Apgar scores of less than seven at the 1st and 5th minute of life, and no information was available on perinatal mortality or admission to an intensive care unit.
4.1. Applicability of the results
The review authors conclude that the first stage of labour may be approximately one hour shorter for women who maintain the upright position and walk around and that women in these positions are likely to have less epidural analgesia. The results for other outcome variables, even though weak and inconclusive, tend to show that the vertical position is not harmful for both the woman and her baby. This review constitutes an important contribution to the discussion on upright versus recumbent positions during the first stage of labour. Even though only two of the 21 studies included were conducted in middle-income countries, there is no reason to believe that these findings will not be in principle applicable to all settings. Of course, the design of, and facilities in, labour wards is a challenge in many settings in both developed and developing countries, because many facilities may not be to conducive to women remaining in an upright position or walking around during labour.
4.2. Implementation of the intervention
Since the review did not suggest any adverse effects for the woman and her baby of maintaining the upright position during the first stage of labour, caregivers and policy-makers may consider implementing strategies that encourage the use of upright positions during the first stage of labour. However, any such strategies would need to take account of other needed interventions during first stage of labour, such as presence of a companion and free intake of fluids to avoid routine intravenous lines. More active promotion by health-care professionals of the various vertical positions that may be adopted during the first stage of labour as part of routine care can be a simple and inexpensive intervention, provided that facilities and personnel can adapt to its requirements. This guidance with respect to adoption of vertical positions during labour or the possibility to observe other women in these positions may stimulate labouring women to move more freely and adopt vertical positions according to their need.
4.3. Implications for research
A possible limitation of randomized controlled trials on women’s position during labour may be that women in the control group cannot be prevented from adopting an upright position any time during labour if they wish to do so. The opposite is also true in the case of women who are allocated to the vertical position group during labour. It would be neither ethical nor humane to prevent them from assuming the position they wish to be in for any length of time if they wanted to. However, it is necessary to continue to evaluate the effect of different positions on obstetrical variables, comfort and general well-being of labouring women. This poses a challenge for researchers conducting randomized trials to seek strategies to allocate women to control and intervention groups in order to minimize contamination.
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This document should be cited as: Makuch MY. Maternal positions and mobility during first stage of labour: RHL commentary (last revised: 1 February 2010). The WHO Reproductive Health Library; Geneva: World Health Organization.