Maternal positions and mobility during first stage labour

Annemarie Lawrence1, Lucy Lewis2, G Justus Hofmeyr3, Therese Dowswell4, Cathy Styles5

1Institute of Women's and Children's Health (15), The Townsville Hospital, Douglas, Australia. 2The School of Women's and Infants' Health/The School of Paediatrics and Child Health, The University of Western Australia, Subiaco, Australia. 3Department of Obstetrics and Gynaecology, East London Hospital Complex, University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of Health, East London, South Africa. 4Cochrane Pregnancy and Childbirth Group, School of Reproductive and Developmental Medicine, Division of Perinatal and Reproductive Medicine, The University of Liverpool , Liverpool, UK. 5Institute of Women's and Children's Health, The Townsville Hospital, Douglas, Australia

Contact address: Annemarie Lawrence, Institute of Women's and Children's Health (15), The Townsville Hospital, 100 Angus Smith Drive, Douglas, Queensland, 4810, Australia. annemarie_lawrence@health.qld.gov.au. annielaw@bigpond.net.au. (Editorial group: Cochrane Pregnancy and Childbirth Group.)

Cochrane Database of Systematic Reviews, Issue 2, 2009 (Status in this issue: New)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DOI: 10.1002/14651858.CD003934.pub2
This version first published online: 15 April 2009 in Issue 2, 2009. Last assessed as up-to-date: 30 December 2008. (Help document - Dates and Statuses explained).

This record should be cited as: Lawrence A, Lewis L, Hofmeyr GJ, Dowswell T, Styles C. Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD003934. DOI: 10.1002/14651858.CD003934.pub2.

Abstract

Background
It is more common for women in the developed world, and those in low-income countries giving birth in health facilities, to labour in bed. There is no evidence that this is associated with any advantage for women or babies, although it may be more convenient for staff. Observational studies have suggested that if women lie on their backs during labour this may have adverse effects on uterine contractions and impede progress in labour.

Objectives
The purpose of the review is 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.

Search strategy
We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (November 2008).

Selection criteria
Randomised and quasi-randomised trials comparing women randomised to upright versus recumbent positions in the first stage of labour.

Data collection and analysis
We used methods described in the Cochrane Handbook for Systematic Reviews of Interventions for carrying out data collection, assessing study quality and analysing results. A minimum of two review authors independently assessed each study.

Main results
The review includes 21 studies with a total of 3706 women. Overall, the first stage of labour was approximately one hour shorter for women randomised to upright as opposed to recumbent positions (MD -0.99, 95% CI -1.60 to -0.39). Women randomised to upright positions were less likely to have epidural analgesia (RR 0.83 95% CI 0.72 to 0.96).There were no differences between groups for other outcomes including length of the second stage of labour, mode of delivery, or other outcomes related to the wellbeing of mothers and babies. For women who had epidural analgesia there were no differences between those randomised to upright versus recumbent positions for any of the outcomes examined in the review. Little information on maternal satisfaction was collected, and none of the studies compared different upright or recumbent positions.

Authors' conclusions
There is evidence that walking and upright positions in the first stage of labour reduce the length of labour and do not seem to be associated with increased intervention or negative effects on mothers' and babies' wellbeing. Women should be encouraged to take up whatever position they find most comfortable in the first stage of labour.

Plain language summary

Mothers' position during the first stage of labour
Women in the developed world and in health facilities in low-income countries usually lie in bed during the first stage of labour. Elsewhere, women progress through this first stage while upright, either standing, sitting, kneeling or walking around, although they may choose to lie down as their labour progresses. The attitudes and expectations of healthcare staff, women and their partners have shifted with regard to pain, pain relief and appropriate behaviour during labour and childbirth. A woman semi-reclining or lying down on the side or back during the first stage of labour may be more convenient for staff and can make it easier to monitor progression and check the baby. Fetal monitoring, epidurals for pain relief, and use of intravenous infusions also limit movement. Lying on the back (supine) puts the weight of the pregnant uterus on abdominal blood vessels and contractions may be less strong than when upright. Effective contractions help cervical dilatation and the descent of the baby.

The results of the review suggest that the first stage of labour may be approximately an hour shorter for women who are upright or walk around during the first stage of labour. The women’s body position did not affect the rate of interventions. The review authors identified 21 controlled studies from a number of countries that randomly assigned a total of 3706 women to upright or recumbent positions in the first stage of labour. Nine of the studies included only women who were giving birth to their first baby. The length of the second stage of labour and the numbers of women who achieved spontaneous vaginal deliveries or required assisted deliveries and augmentation were similar between groups, where reported. Use of opioid analgesia was no different, although women randomised to upright positions were less likely to have epidural analgesia. In those studies specifically examining position and mobility for women receiving epidural analgesia (five trials, 1176 women), an upright or recumbent position did not change the length of the first stage of labour (time from epidural insertion to complete cervical dilatation) or rates of spontaneous vaginal, assisted and caesarean delivery. Little information was given on maternal satisfaction or outcomes for babies.


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