Upright or recumbent positions in late labour for women using an epidural for pain relief in labour

What is the issue?

We want to find out whether different birthing positions (upright or lying down) during the second stage of labour for women with epidurals affect outcomes for the women and babies. For the women this includes whether they need a caesarean section, instrumental birth or need suturing following tears to the perineum, and for the babies, whether they cope well with labour or need admission to special care baby unit. This is an update of a Cochrane review first published in 2013.

Why is this important?

An epidural is the most effective method for pain relief during labour. It is often used by women even though it can make labour longer and increase the need for forceps and ventouse (vacuum) birth. Instrumental deliveries are associated with the possibility of the woman developing prolapse, urinary incontinence, or painful sexual intercourse. Low-dose epidural techniques, also known as 'walking' epidurals, mean that women can still be mobile during their labour. Some experts have suggested that taking an upright position in late labour (such as standing, sitting, squatting) will reduce these negative effects of an epidural.

What evidence did we find?

We searched for evidence in September 2016. No new studies were included in this updated review as a result of the updated search.

Five randomised controlled trials, involving 879 women, comparing upright positions versus recumbent (lying down) positions were already included in the review. Four trials took place in the UK and one was conducted in France. Three of the five trials were funded by the hospital departments in which the trials were carried out. Funding sources for the other trials were either unclear (one trial) or not reported (two trials). All the trials were assessed as being at low or unclear risk of selection bias. None of the trials blinded women, staff or outcome assessors. The methodological quality of one trial was poor.

Overall, upright or recumbent position made no difference to which women had an operative birth (caesarean or instrumental vaginal) (moderate-quality evidence), or how long they had to push before the baby was born (very low-quality evidence). We did not find any clear differences in any other important maternal or fetal outcomes, including tears which needed suturing (very low-quality evidence), instrumental births due to abnormal heart patterns of the unborn baby (very low-quality evidence), too much acid in the cord blood (very low-quality evidence) or babies needing admission to neonatal intensive care unit (very low-quality evidence). However, due to the nature of the results, clinically important effects have not been ruled out.

There were no data reported on blood loss (greater than 500 mL), very long second stage or the women's experiences and satisfaction with labour. Similarly, there were no useful data on Apgar scores, and no data reported on babies dying or needing help to breathe.

What does this mean?

The five randomised controlled trials (involving 879 women) evaluated in this review do not show a clear effect of any upright position compared with a lying down position. The trials are small however, and cannot rule out any small important benefits or harms, so women should be encouraged to take up the position they prefer. More evidence is needed (two studies are ongoing and will be incorporated into this review in a subsequent update). Future, high-quality trials should involve larger numbers of women and ensure that the positions under study are acceptable to women.

Authors' conclusions: 

There are insufficient data to say anything conclusive about the effect of position for the second stage of labour for women with epidural analgesia. The GRADE quality assessment of the evidence in this review ranged between moderate to low quality, with downgrading decisions based on design limitations in the studies, inconsistency, and imprecision of effect estimates.

Women with an epidural should be encouraged to use whatever position they find comfortable in the second stage of labour.

More studies with larger sample sizes will need to be conducted in order for solid conclusions to be made about the effect of position on labour in women with an epidural. Two studies are ongoing and we will incorporate the results into this review at a future update.

Future studies should have the protocol registered, so that sample size, primary outcome, analysis plan, etc. are all clearly prespecified. The time or randomisation should be recorded, since this is the only unbiased starting time point from which the effect of position on duration of labour can be estimated. Future studies might wish to include an arm in which women were allowed to choose the position in which they felt most comfortable. Future studies should ensure that both compared positions are acceptable to women, that women can remain in them for most of the late part of labour, and report the number of women who spend time in the allocated position and the amount of time they spend in this or other positions.

Read the full abstract...
Background: 

Epidural analgesia for pain relief in labour prolongs the second stage of labour and results in more instrumental deliveries. It has been suggested that a more upright position of the mother during all or part of the second stage may counteract these adverse effects. This is an update of a Cochrane review first published in 2013.

Objectives: 

To assess the effects of different birthing positions (upright and recumbent) during the second stage of labour, on important maternal and fetal outcomes for women with epidural analgesia.

Search strategy: 

We searched Cochrane Pregnancy and Childbirth's Trials Register (19 September 2016) and reference lists of retrieved studies.

Selection criteria: 

All randomised or quasi-randomised trials including pregnant women (either primigravidae or multigravidae) in the second stage of induced or spontaneous labour receiving epidural analgesia of any kind. Cluster-RCTs would have been eligible for inclusion in this review but none were identified. Studies published in abstract form only were eligible for inclusion.

We assumed the experimental type of intervention to be the maternal use of any upright position during the second stage of labour, compared with the control intervention of the use of any recumbent position.

Data collection and analysis: 

Two review authors independently assessed trials for inclusion, assessed risk of bias, and extracted data. Data were checked for accuracy. We contacted study authors to try to obtain missing data.

Main results: 

Five randomised controlled trials, involving 879 women, comparing upright positions versus recumbent positions were included in this updated review. Four trials were conducted in the UK and one in France. Three of the five trials were funded by the hospital departments in which the trials were carried out. For the other three trials, funding sources were either unclear (one trial) or not reported (two trials). Each trial varied in levels of bias. We assessed all the trials as being at low or unclear risk of selection bias. None of the trials blinded women, staff or outcome assessors. One trial was poor quality, being at high risk of attrition and reporting bias. We assessed the evidence using the GRADE approach; the evidence for most outcomes was assessed as being very low quality, and evidence for one outcome was judged as moderate quality.

Overall, we identified no clear difference between upright and recumbent positions on our primary outcomes of operative birth (caesarean or instrumental vaginal) (average risk ratio (RR) 0.97; 95% confidence interval (CI) 0.76 to 1.29; five trials, 874 women; I² = 54% moderate-quality evidence), or duration of the second stage of labour measured as the randomisation-to-birth interval (average mean difference -22.98 minutes; 95% CI -99.09 to 53.13; two trials, 322 women; I² = 92%; very low-quality evidence). Nor did we identify any clear differences in any other important maternal or fetal outcome, including trauma to the birth canal requiring suturing (average RR 0.95; 95% CI 0.66 to 1.37; two trials; 173 women; studies = two; I² = 74%; very low-quality evidence), abnormal fetal heart patterns requiring intervention (RR 1.69; 95% CI 0.32 to 8.84; one trial; 107 women; very low-quality evidence), low cord pH (RR 0.61; 95% CI 0.18 to 2.10; one trial; 66 infants; very low-quality evidence) or admission to neonatal intensive care unit (RR 0.54; 95% CI 0.02 to 12.73; one trial; 66 infants; very low-quality evidence). However, the CIs around each estimate were wide, and clinically important effects have not been ruled out. Outcomes were downgraded for study design, high heterogeneity and imprecision in effect estimates.

There were no data reported on blood loss (greater than 500 mL), prolonged second stage or maternal experience and satisfaction with labour. Similarly, there were no analysable data on Apgar scores, and no data reported on the need for ventilation or for perinatal death.

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